Depersonalization/derealization disorder involves a persistent or recurring feeling of being detached from one’s body or mental processes, like an outside observer of one's life (depersonalization), and/or a feeling of being detached from one's surroundings (derealization).
The disorder is usually triggered by severe stress, particularly emotional abuse or neglect during childhood, or other major stresses (such as experiencing or witnessing physical abuse).
Feelings of detachment from self or the surroundings may occur periodically or continuously.
After tests are done to rule out other possible causes, doctors diagnose the disorder based on symptoms.
Psychotherapy, especially cognitive-behavioral therapy, is often helpful.
(See also Overview of Dissociative Disorders.)
Temporary feelings of depersonalization and/or derealization are common. About one half of people have felt detached from themselves (depersonalization) or from the surroundings (derealization) at one time or another. This feeling often occurs after people
Experience life-threatening danger
Take certain drugs (such as marijuana, hallucinogens, , or methylenedioxymethamphetamine [ecstasy])
Become very tired
Are deprived of sleep or sensory stimulation (as may occur when they are in an intensive care unit)
Depersonalization or derealization can also occur as a symptom in many other mental health disorders, as well as in general medical disorders, such as seizure disorders.
Depersonalization/derealization feelings are considered a disorder when the following occur:
Depersonalization or derealization occurs on its own (that is, it is not caused by drugs or another mental health disorder), and it persists or recurs.
The symptoms are very distressing to the person or make it difficult for the person to function at home or at work.
Depersonalization/derealization disorder occurs in about 2% of the population and affects men and women equally.
The disorder may begin during early or middle childhood. It rarely begins after age 40.
Causes of Depersonalization/Derealization Disorder
Depersonalization/derealization disorder often develops in people who have experienced severe stress, including the following:
Emotional abuse or neglect during childhood
Physical abuse
Experiencing or witnessing domestic violence
Having a severely impaired or mentally ill parent
Unexpected death of a loved one
Symptoms can be triggered by severe stress (for example, due to relationships, finances, or work), depression, anxiety, or use of illicit drugs. However, in 25 to 50% of cases, the causes of stress are relatively minor or cannot be identified.
Symptoms of Depersonalization/Derealization Disorder
Symptoms of depersonalization/derealization disorder may start gradually or suddenly. Episodes may last for only hours or days or for weeks, months, or years. Episodes may involve depersonalization, derealization, or both.
The intensity of symptoms often waxes and wanes. But when the disorder is severe, symptoms may be present and remain at the same intensity for years or even decades.
Depersonalization symptoms involve
Feeling detached from one's body, mind, feelings, and/or sensations
People may also say they feel unreal or like an automaton, with no control over what they do or say. They may feel emotionally or physically numb. Such people may describe themselves as an outside observer of their own life or the “walking dead.”
Derealization symptoms involve
Feeling detached from the surroundings (people, objects, or everything), which seem unreal
People may feel as if they are in a dream or a fog, or as if a glass wall or veil separates them from their surroundings. The world seems lifeless, colorless, or artificial. The world may appear distorted to them. For example, objects may appear blurry or unusually clear, or they may seem flat or smaller or larger than they are. Sounds may seem louder or softer than they are. Time may seem to be going too slow or too fast.
The symptoms almost always cause great discomfort. Some people find them intolerable. Anxiety and depression are common. Many people are afraid that the symptoms result from irreversible brain damage. Many worry about whether they really exist or repeatedly check to determine whether their perceptions are real.
Stress, worsening depression or anxiety, new or overstimulating surroundings, and lack of sleep can make symptoms worse.
Symptoms are often persistent. People may have symptoms all the time, or symptoms may come and go with periods of time with no symptoms.
People often have great difficulty describing their symptoms and may fear or believe that they are going crazy. However, people always remain aware that their experiences of detachment are not real but rather are just the way that they feel. This awareness is what separates depersonalization/derealization disorder from a psychotic disorder. People with a psychotic disorder, such as schizophrenia, have thoughts that are not consistent with reality, but they do not realize these are different from usual thoughts.
Diagnosis of Depersonalization/Derealization Disorder
A doctor's evaluation, based on specific diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)
Sometimes tests to rule out other possible causes
Doctors suspect the disorder based on symptoms:
People have episodes of depersonalization, derealization, or both that last a long time or recur.
People know that their dissociative experiences are not real.
People are very distressed by their symptoms or their symptoms make them unable to function in social situations or at work.
A physical examination and sometimes tests are done to rule out other disorders that could cause the symptoms, including other mental health disorders, seizure disorders, and substance use disorders. Tests may include magnetic resonance imaging (MRI), computed tomography (CT), electroencephalography (EEG), and blood and urine tests to check for use of illicit drugs.
Psychologic tests and special structured interviews and questionnaires can also help doctors with the diagnosis.
Treatment of Depersonalization/Derealization Disorder
Psychotherapy
Sometimes antianxiety medications and antidepressants
Depersonalization/derealization disorder may disappear without treatment. People are treated only if the disorder persists, recurs, or causes distress.
Various psychotherapy methods have been effective for some people. Depersonalization/derealization disorder is often associated with or triggered by other mental health disorders (such as anxiety or depression), which require treatment. Any stresses that triggered the symptoms or that may have contributed to development of depersonalization/derealization disorder must also be addressed.
Techniques that can help include the following:
Cognitive techniques can help block obsessive thinking about the unreal state of being.
Behavioral techniques can help people become absorbed in tasks that distract them from the depersonalization.
Grounding techniques use the five senses (hearing, touch, smell, taste, and sight) to help people feel more connected to themselves and the world. For example, loud music is played or a piece of ice is put in the hand. These sensations are difficult to ignore, making people aware of themselves in the present moment.
Psychodynamic techniques focus on helping people work through intolerable conflicts, negative feelings, and experiences from which people feel they must detach themselves.
Moment-to-moment tracking and labeling of dissociation and affect (the outward expression of emotions and thoughts) teaches people to recognize and identify their feelings of dissociation. Such recognition helps some people. This technique also helps people focus on what is actually happening in the moment.
Various medications have been used to treat depersonalization/derealization disorder, but none have proven to be effective. Antianxiety medications and antidepressants sometimes help, mainly by relieving anxiety or depression, which are present in many people with depersonalization/derealization disorder. However, antianxiety medications may also increase depersonalization or derealization, so doctors carefully monitor use of these medications.
Prognosis for Depersonalization/Derealization Disorder
Complete recovery is possible for many people with depersonalization/derealization disorder, especially if the symptoms result from stresses that can be dealt with during treatment. Other people do not respond well to treatment, and the disorder becomes chronic. In some people, depersonalization/derealization disorder disappears on its own.
Symptoms, even those that persist or recur, may cause only minor problems if people can keep their mind busy and focus on other thoughts or activities, rather than think about their sense of self. However, some people become disabled because they feel so disconnected from their self and their surroundings or because they also have anxiety or depression.
