Depersonalization/Derealization Disorder

Depersonalization/derealization disorder (DDD) is a type of dissociative disorder characterized by a persistent experience of depersonalization (the feeling of being detached from oneself, like watching oneself from an external viewpoint) and derealization (the feeling of being detached from the real world, like the world is distant or hazy). Crisis intervention therapy during the acute episodes, combined with psychodynamic therapy during the asymptomatic period, is 1st-line treatment for this disorder.

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Overview

Definition

  • Depersonalization is a persistent or recurrent experience of unreality, detachment, or being an outside observer of one’s own thoughts, feelings, and sensations, usually associated with altered perception, emotional or physical numbness, and distorted sense of time. This perception might also make the patient feel like they are observing their own body. 
  • Derealization is a persistent subjective sense of detachment or unreality of the surrounding world often described by the patient as unreal, dreamlike, foggy, lifeless, or visually distorted reality.

Epidemiology

  • Prevalence in the general population: approximately 2%
    • Transient feelings of depersonalization or derealization occur much more frequently (approximately 19%).
    • Depersonalization symptoms secondary to another pathology are more common.
  • Prevalence is similar between sexes.
  • Average age at onset: 16 years
  • Risk factors:
    • History of trauma
    • History of substance abuse
    • Anxiety or depressive disorders

Pathophysiology

  • Trauma: 
    • Thought to occur as a response to severe stressors
    • Survival mechanism to manage stressful situations without feeling overwhelmed
  • Organic causes: 
    • Seen in people with seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures and head injury (but the disorder is not directly caused by these)
    • It is thought that there is a genetic predisposition to developing depersonalization/derealization disorder (DDD).
  • Neurobiology: 
    • Several neurotransmitter systems are thought to be involved (N-methyl-d-aspartate (NMDA), opioid, and serotonin) because administration of these causes a depersonalization experience. 
    • Brain regions like the parietal lobe and the right hemisphere are noted to have abnormal activity during a depersonalization experience.
    • Hypoactivation of the limbic system Limbic system The limbic system is a neuronal network that mediates emotion and motivation, while also playing a role in learning and memory. The extended neural network is vital to numerous basic psychological functions and plays an invaluable role in processing and responding to environmental stimuli. Limbic System, in particular the insula, has been also linked to depersonalization/derealization disorder.
  • Conceptual models:
    • Cognitive behavioral models: Fear is a central component, and the core components can be dissociation of affect (not feeling) and alexithymia (difficulty identifying and verbalizing emotions).
    • Psychodynamic theories: an inability to integrate various aspects of one’s self-experience with the surrounding world

Diagnosis and Clinical Features

Diagnosis

  • Careful history taking, as well as neurologic exam, is essential for correct diagnosis. 
  • Diagnosis is clinical by meeting specific criteria:
    • Presence of recurrent or persistent episodes of depersonalization, derealization, or both
    • Reality testing remains intact during episodes.
    • Episodes cause significant impairment in day-to-day function.
  • Substance use (alcohol, lysergic acid diethylamide (LSD)), medical conditions ( seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures, head injury), and other psychiatric conditions must be ruled out.
  • To rule out organic causes, initial evaluation must include:
    • EEG
    • Basic metabolic panel 
    • Urine toxicology screen

Clinical features

  • Altered sense (misperception) of time: perceived as too fast or too slow 
  • Problems with memory consolidation and recall (memory impairment) 
  • Nonpathologic dissociation: 
    • Normal to experience dissociation during everyday daily activities 
    • Example: arriving at a destination in your vehicle without recalling the drive
    • In nonpathologic dissociation, the patient does not experience feelings of distress or functional impairment.

Management

Treatment must include psychoeducation as well as supportive psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy.

Psychotherapy

  • Main treatment option, especially for those without other psychiatric comorbidities 
  • CBT: Goal is to develop techniques to reframe dissociative symptoms as less threatening. 
  •  Psychodynamic psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy: Goal is to uncover intolerable emotions that may lead to the dissociative symptoms and create better ways to process them.

Pharmacotherapy

  • Treat comorbid conditions (depression, anxiety).
  • Lamotrigine ( anticonvulsant Anticonvulsant Anticonvulsant drugs are pharmacological agents used to achieve seizure control and/or prevent seizure episodes. Anticonvulsants encompass various drugs with different mechanisms of action including ion-channel (Na+ and Ca+2) blocking and GABA reuptake inhibition. First-Generation Anticonvulsant Drugs) might be helpful as adjunct therapy to psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy.
  • Opioid-receptor antagonists (naltrexone) might help.

Differential Diagnosis

  • Acute stress disorder Acute stress disorder Acute stress disorder describes stress reactions displayed after an individual has experienced a traumatic event. Symptoms last more than 3 days but less than 1 month and include re-experiencing the event as flashbacks or nightmares, avoidance of reminders of the event, irritability, hyperarousal, and poor memory and concentration. Acute Stress Disorder: stress reactions displayed after an individual has experienced a traumatic event. Symptoms last > 3 days, but < 1 month and include reexperiencing the event as flashbacks or nightmares, avoidance of reminders of the event, irritability, hyperarousal, and poor memory and concentration. Those with DDD experience only the dissociative aspects and, therefore, do not qualify for the diagnosis of acute stress disorder. 
  • Hallucinogen use disorder Hallucinogen use disorder Hallucinogen use disorder is defined by the pathologic consumption of hallucinogenic substances that cause perceptual distortions (visual or auditory). Examples include psilocybin (mushrooms), lysergic acid diethylamide (LSD), and phencyclidine (PCP). These drugs are used for their psychedelic effects. Hallucinogen Use Disorder: pathologic consumption of hallucinogenic substances that cause perceptual distortions (visual or auditory). Examples of substances ingested include psilocybin (mushrooms), LSD, and phencyclidine ( PCP PCP Pneumocystis jiroveci is a yeast-like fungus causing pneumocystis pneumonia (PCP) in immunocompromised patients. Pneumocystis pneumonia is spread through airborne transmission and classically affects patients with AIDS, functioning as an AIDS-defining illness. Patients may present with insidious onset of fever, chills, dry cough, chest pain, and shortness of breath. Pneumocystis jiroveci/Pneumocystis Pneumonia (PCP)). These drugs are used for their psychedelic effects—a temporary altered state of consciousness. During acute intoxication, patients may experience depersonalization or derealization. Thorough history taking and toxicology screening can differentiate hallucinogen intoxication from DDD. 
  • Schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia: chronic mental health disorder that is characterized by positive symptoms (delusions, hallucinations, and disorganized speech or behavior) and negative symptoms (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia is associated with a decline in functioning lasting > 6 months. Those with DDD may experience similar alterations in realities; however, reality testing remains intact, with no other positive/negative symptoms. 

References

  1. Sadock BJ, Sadock VA, Ruiz P. (2014). Anxiety disorders. In Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 11th ed. Philadelphia: Lippincott Williams and Wilkins, pp. 451–464.
  2. Aderibigbe YA, Bloch RM, Walker WR. (2001). Prevalence of depersonalization and derealization experiences in a rural population. Soc Psychiatry Psychiatr Epidemiol. https://pubmed.ncbi.nlm.nih.gov/11355447/ 
  3. Simeon D, Knutelska M, Nelson D, Guralnik O. (2003). Feeling unreal: a depersonalization disorder update of 117 cases. J Clin Psychiatry. https://pubmed.ncbi.nlm.nih.gov/14628973/
  4. Grigsby J, Kaye K. (1993). Incidence and correlates of depersonalization following head trauma Head trauma Head trauma occurs when external forces are directed to the skull and brain structures, resulting in damage to the skull, brain, and intracranial structures. Head injuries can be classified as open (penetrating) or closed (blunt), and primary (from the initial trauma) or secondary (indirect brain injury), and range from mild to severe and life-threatening. Head Trauma. https://pubmed.ncbi.nlm.nih.gov/8260954/ 

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