Depersonalization / Derealization Disorder
Depersonalization/derealization disorder is an altered state of self-awareness and identity that results in a feeling of dissociation, or disconnection, from oneself, one’s surroundings, or both. It is often felt as a sense of unreality or detachment from one’s body.
Feelings of dissociation can be triggered by intense stress or by experiencing or witnessing disturbing events, and under such circumstances, they can be normal, especially when they are transient. A majority of adults have experienced at least one such episode, and such episodes are considered a normal response to overwhelming threat. Episodes of depersonalization/derealization (DP/DR) also occur in many psychiatric conditions, notably panic disorder and social anxiety disorder, and may also occur as side effects of recreational drugs such as cannabis.
Depersonalization/derealization disorder is usually diagnosed only if such feelings of detachment frequently recur or are chronic, cause anguish, and interfere with an individual's quality of life. Studies indicate that .8 to 2.8 percent of the population in the United States and elsewhere has had the disorder at some point in the course of their life.
The symptoms of Depersonalization/Derealization disorder are completely invisible, involving alterations only in subjective experience. The primary symptom is an unpleasant sense of experiencing one's own behavior, thoughts, and feelings from a dreamlike distance. According to DSM-5, symptoms include:
- Feeling emotionally numb, or as if the person is not controlling his or her words and actions
- Feeling detached from ordinary sensations, such as touch, thirst, hunger, and libido
Derealization is a sense of distance from activities going on in the world or feeling that one's surroundings are distorted or somewhat unrecognizable. This may include:
- Feeling as if objects are the wrong size or color
- Feeling as though time is speeding up or slowing down
- Experiencing sounds as louder or softer than expected
- Feeling as though one is watching events and activities unfold in a movie or on a computer screen, rather than actually participating
Depersonalization/derealization disorder is diagnosed when such episodes cause a person clinically significant distress and/or make it difficult for the person to function normally at work, in school, or in a social setting. They must also not be attributable to another psychological condition such as schizophrenia. Individuals with depersonalization/derealization disorder may start showing signs in early childhood; symptoms rarely occur for the first time in adults over the age of 40, and only 5 percent occur in adults over the age of 25.
Episodes of depersonalization and/or derealization may last for hours or days at a time and recur for weeks, months, or even years. At all times, the individual is typically aware of both their inner thoughts and what is going on around them; as a result, they are conscious of the fact that they feel detached from their body and/or their surroundings. It’s common for people with depersonalization/derealization disorder to fear that they don’t really exist, or that their symptoms are the result of irreversible brain damage.
No one knows for sure how common DP/DR is; it is not a well-studied condition. Data that exist suggest that as a stand-alone condition, Depersonalization/Derealization Disorder affects 1 percent of the population, about the same prevalence as schizophrenia. That may be a vast underestimate, as psychiatrists rarely screen for the condition and people are either reluctant to describe their experiences of DP/DR or have difficulty doing so. People typically experience symptoms for many years before their disorder is diagnosed.
Among psychiatric populations, depersonalization is far more common, occurring in up to 80 percent of patients. Clinicians who screen for the disorder observe that depersonalization may be the third most common psychiatric symptoms, after anxiety and depressed mood.
People with DP/DR feel like strangers to themselves. Depersonalization and derealization involve a sense of alienation from experience—feelings of unreality and detachment from the self and/or surroundings. Researchers identify several distinct components of the depersonalization/derealization experience. First and perhaps foremost are feelings of unreality, feeling detached from one’s mental processes and body—sometimes, patients report, as an observer or “as if in a dream” or a movie, or “separate from myself.”. People feel a sense of disembodiment, as if their body doesn’t belong to them. Their own voice may sound remote and not real. They feel a diminished sense of self, “as if I were an automaton.”
At the same time, there is an emotional numbing; they do not feel anxiety or any emotions at all; they experience no emotional reactivity: “My emotions are gone, nothing affects me.” There is also a distorted sense of presence. People with DP/DR also report feelings of alienation from the surroundings; the world doesn’t look unreal but it feels artificial” or “painted, not natural” or “two-dimensional”; other people may seem “like actors in a play.” Time can also seem to bend, so that experiences in the recent past feel like they happened much longer ago.
DP/DR can also give rise to existential unease. Patients may wonder: “If I’m not really me, then who am I?”
After undergoing a full psychiatric assessment, patients can be identified through administration of the Cambridge Depersonalization Scale, a 29-item questionnaire on which people self-rate the intensity and frequency of symptoms of depersonalization.
• Out of the blue, I feel strange, as if I were not real or as if I were cut off from the world.
• What I see looks 'flat' or 'lifeless', as if I were looking at a picture.
• Parts of my body feel as if they didn't belong to me.
• I have found myself not being frightened at all in situations which normally I would find frightening or distressing.
• Whilst doing something I have the feeling of being a "detached observer" of myself.
• When I weep or laugh, I do not seem to feel any emotions at all.
• Whilst fully awake I have "visions" in which I can see myself outside, as if I were looking my image in a mirror. • I feel detached from memories of things that have happened to me - as if I had not been involved in them.
• Out of the blue, I find myself not feeling any affection towards my family and close friends.
• I have to touch myself to make sure that I have a body or a real existence.
While DP/DR is classed as a dissociative disorder, there are important ways in which it differs from dissociative disorders. Notably, in contrast to dissociative disorders, people who experience DP/DR are aware of the change in experience of themselves, and they find it disturbing.
The DSM classifies DP/DR as a dissociative disorder; it is, in fact, a specific type of dissociation, or disconnection or estrangement from one’s thoughts and feelings. The thoughts and feelings do not seem to be real or to belong to oneself. Like other dissociative disorders it is a perturbation of consciousness. There is a disruption in self-awareness. But it is unlike other dissociative disorders in one very important way: People who experience DP/DR are aware of the change in experience of themselves—they recognize that the world around them is intact—and they find it disturbing. That can make them fear they are losing their mind.
In DP/DR, people feel disconnected from themself and the world around them. In an out-of-body experience, people feel not simply a sense of disconnection from themselves and the world around them but experience a visual hallucination that involves seeing their physical body in an external visual space. They perceive their environment from a perspective outside their physical body.
DP/DR is not well understood. Like other dissociative disorders, depersonalization/derealization reflects a disruption in the normal integration of consciousness, memory, identity, perception, motor control, and behavior. And like them, it often occurs in the aftermath of acute stress or trauma. Some experts believe it initially occurs as a shield, a form of mental protection from injury.
A history of severe stress, neglect, or physical or emotional abuse can lead to depersonalization/derealization disorder. Acute moments of stress anxiety, or trauma, may also trigger symptoms in individuals without a history of such experiences. Studies have shown that poor sleep quality is associated with an increase in the severity of symptoms of dissociation. Depersonalization/derealization disorder occurs with equal frequency in men and women.
Some studies identify emotional numbing and loss of emotional reactivity as the core feature of depersonalization/derealization. Depersonalization is thought to reflect an impairment in emotional processing; patients seem to have great difficulty in identifying their own feelings. Some neuroimaging studies indicate that depersonalization experiences are accompanied by involuntary inhibition of emotional response. Researchers also find that people with DP/DR have a low skin electrical conductance response to unpleasant stimuli that would normally give rise to a response; the test is considered a measure of emotional reactivity. The evidence suggests that suppression of emotional processing results from abnormalities in functioning of the autonomic nervous system, perhaps due to some defect in the stress-response system. The processing of feeling states takes place in the same part of the brain (the insula) that senses interior body states and may be the seat of self-awareness.
Research suggests that DP/DR is a disruption in interoception, the processing of internal body signals essential to self-awareness. DP/DR most often occurs under conditions of acute stress or trauma, as is the case with other dissociative states, and the relationship with acute stress suggests that stress hormones play a role in some capacity.
Being tired, anxious, or intoxicated (with alcohol or other substances, notably cannabis and ketamine) can be triggers, and in most cases DP/DR experiences are transient. But in some cases, DP/DR may persist for days, weeks, or months, with episodic or continuous symptoms. Individuals with DP/DR are fully aware of the abnormal nature of the DP/DR experience and find the alterations in experience of themselves so disturbing that they typically worry about their mental state and wonder whether they are losing their mind.
The most frequent predisposing factors are acute stress or trauma, illicit use of certain drugs, the presence of an anxiety disorder, and a childhood history of emotional abuse. People with a major psychiatric disorder, including severe anxiety or panic disorder, depression, post traumatic stress disorder, obsessive compulsive disorder and schizophrenia, and people with neurological conditions such as migraine and epilepsy, can experience depersonalization as a symptom.
Typically, the disorder starts with symptoms occurring episodically. Over time, the episodes become longer-lasting and more severe.
Most of the time, DP/DR is a transient response to an unusual experience when people are stressed or fatigued. However, it also occurs with more frequency or severity among people with psychiatric disorders, including severe anxiety, panic disorder, depression, post-traumatic stress disorder, obsessive compulsive disorder, and schizophrenia. People with migraine or epilepsy can experience depersonalization as a symptom. There’s some evidence that more frequent or sustained episodes of DP/DR can be an early sign of psychosis.
Often, people with depersonalization find the episodes so disturbing that they obsessively monitor themselves, on the lookout for symptoms. Such reactions can intensify episodes, so that it is often difficult to distinguish what is cause and what is effect.
Depersonalization and anxiety are separate conditions that often co-exist, but exactly how they are related is not quite clear. Clinicians have known for a long time that patients complaining of feelings of unreality also frequently suffer from panic attacks. Even among the general population, anxiety is the single biggest predictor of the depersonalization/derealization experience and, up to a point, contributes to the severity of such experiences. Anxiety is also an effect of DP/DR experiences; people who experience episodes worry about their mental state, and are frightened that they are losing their mind
There is no recognized drug treatment for DP/DR and patients are primarily treated with psychotherapy, although medications may be used to treat co-existing mental health problems such as anxiety and depression. Recently, a variation of Cognitive and Behavioral Therapy (CBT) has been developed that addresses depersonalization.
One aim of psychotherapy is to help patients understand DP/DR and the nature of their experiences. Another is to help patients manage DP/DR symptoms when they do occur so they do not set off anxiety and other responses that amplify the problem. For that reason, behavioral techniques such as grounding exercises (touching a wall, chanting, turning on music) are often part of a treatment plan. The therapy also helps patients reinterpret their symptoms in a non-threatening way and reduce avoidant responses and symptom monitoring.
Interestingly, clinicians find that diagnosing the disorder can have therapeutic effects by itself. It reassures patients that their symptoms are a recognizable phenomenon and that they are not unique in experiencing them.
Early clinical trials suggest that drug therapy combining the anticonvulsant drug lamotrigine with a selective serotonin reuptake inhibitor (SSRI) may benefit patients with DP/DR. Several studies have shown that the SSRIs alone have little to no effect on depersonalization symptoms.