Let's now take a brief moment to review Depersonalization/Derealization disorder. It's the
persistent or recurrent feeling of detachment from one's self, environment, or social situation in
the presence of intact reality testing. People with this disorder are very aware of it and they
often will fear that they're going crazy. It's frequently associated, therefore, with anxiety and
panic. Consider this clinical case example. A 28-year-old man is sitting in a coffee shop. He's
watching other people and it looks as if they are not real and are actually part of a dream. He
thinks this is odd and wonders to himself if he's going crazy. What do you think he's experiencing?
Well, the answer is a derealization disorder.
The gender ration is 1:1. The average age of onset is 16-years-old.
There's an increased incidence of
comorbid anxiety and depression and severe stress is a predisposing factor.
The lifetime prevalence across the US, Canada and Europe is about 2.8 %.
So here are few questions about the pathology. What does trauma have to do with it? Well, we actually
think that depersonalization/derealization is a quintessential response to acute trauma. How
about organic precursors? Do you know of any that could be involved? Seizures, head injury
and substance abuse can all lead to the depersonalization/derealization symptoms and need to be
ruled out before making a diagnosis of a dissociative disorder. In terms of neurobiology, what's
associated with depersonalization? Well, actually we think several neurotransmitter systems
are involved: NMDA, opioid and serotonin, also brain regions like the parietal lobe and the right
hemisphere. Functional brain circuits are also important and we think there may be hypoactivation
of the limbic system that's associated with depersonalization and conceptual models. What about
cognitive behavioral models? Well, fear is a central component and the core components can be
dissociation of affect, meaning not feeling, along with alexithymia (difficulty identifying and
verbalizing emotions) and this can happen during the depersonalized state. According to psychodynamic
theories, there can be an inability to integrate various aspects of one's self-experience with
the world around them. So how do you diagnose depersonalization/derealization disorder? So
you're looking for persistent or recurrent experiences of either depersonalization or derealization
and they meet 1 or 2 of the following criteria: Depersonalization which is unreality, detachment,
or feeling like being an outside observer or derealization, the unreality or detachment with
respect to surroundings. So for example, individuals are objects and experience this unreal,
dreamlike, foggy, or visually distorted. Reality testing is actually intact during the episode. The
symptoms cause significant distress and impair social and occupational functioning. The disturbance
is not due to substances or general medical condition and also the symptoms cannot be better
attributed to another psychiatric illness. The differential diagnosis includes schizophrenia, panic
disorder, acute stress disorder, PTSD, other dissociative disorders and also personality disorders
such as borderline and avoidant personalities and of course in your differential you've ruled
out substances in general medical conditions. This is often chronic but it can remit without any
intervention at all so in fact a lot of these individuals never end up seeing a physician for their
symptoms but when there is comorbid anxiety or depression, that might bring an individual in
to meet a doctor and in that case you want to treat it with therapy and also medications specifically
anxiolytics, maybe a very brief brief trial of a benzodiazepine or a first line medication for
anxiety such as an antidepressant like an SSRI. Now, here's a question to kind of end things up.
Have you ever arrived at a destination in your vehicle and had absolutely no recollection of
what happened while you were driving there? Well, this is an example of a non-pathologic
dissociation. In other words, it's a very common human experience. When we talk about
depersonalization and derealization, we are interested in the people who find their symptoms
so distressing that it's really interfering with their life and that's what sprained them in for
an evaluation and for treatment and help.