Derealization disorder

Depersonalization derealization disorder is a chronic and distressing condition characterized by detachment from oneself and/or the external world ¹. Depersonalization refers to the sensation of being detached from one’s body, often associated with feelings of loss of control over one’s own body, actions, or thoughts ². During depersonalization patients report to be detached from and often associated with feelings of loss of control over one’s own body. These sensations may or may not be associated with an altered perception of one’s surroundings that is experienced as unreal, for example derealization ³. Derealization refers to the altered perception of one’s surroundings (the external world) that is experienced as unreal ². Other clinical phenomena of depersonalization derealization disorder include emotional numbing and somatosensory distortions ⁴. Symptoms of depersonalization derealization disorder are highly distressing and are associated with major morbidity. The affectively flattened and robotic demeanor that these individuals often demonstrate may appear incongruent with the extreme emotional pain reported by those with the disorder. Impairment is often experienced in both interpersonal and occupational spheres, largely due to the hypoemotionaHty with others, subjective difficulty in focusing and retaining information, and a general sense of disconnectedness from life.

Although depersonalization and derealization are often reported by psychiatric patients suffering from depression ⁵ or anxiety ⁶ and even though DSM‐5 specifies that depersonalization derealization disorder should “not be attributable to another medical condition” ⁷, single case reports and small case series have described depersonalization‐ and derealization‐like symptoms in the context of epilepsy ², after cortical electrical stimulation ⁸ and in patients following traumatic brain injury ⁹. However, these reports were in majority single case studies ¹⁰ or small case series ¹¹. Moreover, due to the lack of studies applying quantitative lesion analysis, to date the phenomenological distinction between depersonalization and derealization as well as any potential distinct brain mechanisms remain poorly understood ¹². Shorter episodes of depersonalization or derealization can also occur in the context of other disorders, such as temporal lobe epilepsy ¹³, schizophrenia ¹⁴ or posttraumatic stress disorder (PTSD) ¹⁵.

Historically, it has been proposed that depersonalization and derealization constitute two distinct phenomena ¹¹. However, currently depersonalization derealization disorder has been classified as a single dissociative disorder, requiring persistent and/or recurrent episodes of depersonalization and/or derealization ⁷.

Depersonalization derealization disorder is a dissociative disorder ⁷. Transient depersonalization derealization symptoms lasting hours to days are common in the general population with estimated lifetime prevalence in U.S. and non-U.S. countries is approximately 2% (range of 0.8% to 2.8%) of the general population ¹⁶.The 12-month prevalence of depersonalization derealization disorder is thought to be markedly less than for transient symptoms, although precise estimates for the disorder are unavailable. In general, approximately one-half of all adults have experienced at least one lifetime episode of depersonalization derealization. However,
symptomatology that meets full criteria for depersonalization derealization disorder is markedly less common than transient symptoms. The gender ratio for the disorder is 1:1 ⁷.

The mean age at onset of depersonalization/derealization disorder is 16 years, although the disorder can start in early or middle childhood; a minority cannot recall ever not having had the symptoms. Less than 20% of individuals experience onset after age 20 years and only 5% after age 25 years. Onset in the fourth decade of life or later is highly unusual. Onset can range from extremely sudden to gradual. Duration of depersonalization/derealization disorder episodes can vary greatly, from brief (hours or days) to prolonged (weeks, months, or years). Given the rarity of disorder onset after age 40 years, in such cases the individual should be examined more closely for underlying medical conditions (e.g., brain lesions, seizure disorders, sleep apnea). The course of the depersonalization derealization disorder is often persistent. About one-third of cases involve discrete episodes; another third, continuous symptoms from the start; and still another third, an initially episodic course that eventually becomes continuous.

While in some individuals the intensity of symptoms can wax and wane considerably, others report an unwavering level of intensity that in extreme cases can be constantly present for years or decades. Internal and external factors that affect symptom intensity vary between individuals, yet some typical patterns are reported. Exacerbations can be triggered by stress, worsening mood or anxiety symptoms, novel or overstimulating settings, and physical factors such as lighting or lack of sleep.

The best treatment for depersonalization and derealization disorder is talk therapy, since there are no medications specifically designed for this disorder. Though, certain medications designed to treat depression and anxiety such as Prozac, Klonopin and Anafranil may help.

Derealization disorder causes

The exact cause of depersonalization-derealization disorder isn’t well-understood. Some people may be more vulnerable to experiencing depersonalization and derealization than others, possibly due to genetic and environmental factors. Heightened states of stress and fear may trigger episodes.

Symptoms of depersonalization-derealization disorder may be related to childhood trauma or other experiences or events that cause severe emotional stress or trauma.

Risk factors for depersonalization-derealization disorder

Factors that may increase the risk of depersonalization-derealization disorder include:

• Certain personality traits that make you want to avoid or deny difficult situations or make it hard to adapt to difficult situations
• Severe trauma, during childhood or as an adult, such as experiencing or witnessing a traumatic event or abuse
• Severe stress, such as major relationship, financial or work-related issues
• Depression or anxiety, especially severe or prolonged depression, or anxiety with panic attacks
• Using recreational drugs, which can trigger episodes of depersonalization or derealization

Temperamental

Individuals with depersonalization derealization disorder are characterized by harm-avoidant temperament, immature defenses, and both disconnection and overconnection schemata. Immature defenses such as idealization/devaluation, projection and acting out result in denial of reality and poor adaptation. Cognitive disconnection schemata reflect defectiveness and emotional inhibition and subsume themes of abuse, neglect, and deprivation. Overconnection schemata involve impaired autonomy with themes of dependency, vulnerability, and incompetence.

Environmental

There is a clear association between the disorder and childhood interpersonal traumas in a substantial portion of individuals, although this association is not as prevalent or as extreme in the nature of the traumas as in other dissociative disorders, such as dissociative identity disorder. In particular, emotional abuse and emotional neglect have been most strongly and consistently associated with the disorder. Other stressors can include physical abuse; witnessing domestic violence; growing up with a seriously impaired, mentally ill parent; or unexpected death or suicide of a family member or close friend. Sexual abuse is a much less common antecedent but can be encountered. The most common proximal précipitants of the disorder are severe stress (interpersonal, financial, occupational), depression, anxiety (particularly panic attacks), and illicit drug use. Symptoms may be specifically induced by substances such as tetrahydrocannabinol, hallucinogens, ketamine, MDMA (3,4-methylenedioxymethamphetamine; “ecstasy”) and salvia. Marijuana use may precipitate new-onset panic attacks and depersonalization derealization symptoms simultaneously.

Culture-reiated issues

Volitionally induced experiences of depersonalization/derealization can be a part of meditative practices that are prevalent in many religions and cultures and should not be diagnosed as a disorder. However, there are individuals who initially induce these states intentionally but over time lose control over them and may develop a fear and aversion for related practices.

Derealization disorder symptoms

The person has persistent or recurrent experiences (episodes) of feeling detached from one’s surroundings, mental processes, or body (e.g., feeling like one is in a dream, or as if one is looking at themselves as an outside observer). Episodes of depersonalization-derealization disorder may last hours, days, weeks or even months at a time. In some people, these episodes turn into ongoing feelings of depersonalization or derealization that may periodically get better or worse. Persistent and recurrent episodes of depersonalization or derealization or both cause distress and problems functioning at work or school or in other important areas of your life. During these episodes, you are aware that your sense of detachment is only a feeling and not reality.

The experience and feelings of the disorder can be difficult to describe. Worry about “going crazy” can cause you to become preoccupied with checking that you exist and determining what’s actually real.

Symptoms usually begin in the mid- to late teens or early adulthood. Depersonalization-derealization disorder is rare in children and older adults.

In the case of depersonalization, the individual may feel detached from his or her entire being (e.g., “I am no one,” “I have no self”). He or she may also feel subjectively detached from aspects of the self, including feelings (e.g., hypoemotionality: “I know I have feelings but I don’t feel them”), thoughts (e.g., “My thoughts don’t feel like my own,” “head filled with cotton”), whole body or body parts, or sensations (e.g., touch, proprioception, hunger, thirst, libido). There may also be a diminished sense of agency (e.g., feeling robotic, like an automaton; lacking control of one’s speech or movements).

Episodes of derealization are characterized by a feeling of unreality or detachment from, or unfamiliarity with, the world, be it individuals, inanimate objects, or all surroundings. The individual may feel as if he or she were in a fog, dream, or bubble, or as if there were a veil or a glass wall between the individual and world around. Surroundings may be experienced as artificial, colorless, or lifeless. Derealization is commonly accompanied by subjective visual distortions, such as blurriness, heightened acuity, widened or narrowed visual field, two-dimensionality or flatness, exaggerated three-dimensionality, or altered distance or size of objects, termed macropsia or micropsia.

During the depersonalization or derealization experience, the person remains somewhat in touch with their present reality.

The depersonalization causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The depersonalization experience does not occur exclusively during the course of another mental disorder, such as schizophrenia, panic disorder, acute stress disorder, or another dissociative disorder, and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy).

Depersonalization symptoms

Symptoms of depersonalization include:

• Feelings that you’re an outside observer of your thoughts, feelings, your body or parts of your body — for example, as if you were floating in air above yourself
• Feeling like a robot or that you’re not in control of your speech or movements
• The sense that your body, legs or arms appear distorted, enlarged or shrunken, or that your head is wrapped in cotton
• Emotional or physical numbness of your senses or responses to the world around you
• A sense that your memories lack emotion, and that they may or may not be your own memories.

Signs that you may have depersonalization disorder:

• You Feel Like a Completely Separate Entity from Your Body: Your body feels like a stranger to you. Your head may feel like it’s been wrapped in cotton, and your body hollow and lifeless. Some people lose their sense of touch, taste and smell, and may feel the need to pinch, poke or hit themselves just to try to feel normal again.
• You Don’t Feel Any Connection to the Person You See in the Mirror: You feel a sense of profound detachment when you see your reflection, so you try to avoid it. In fact, you avoid other things in addition to mirrors, like leaving the house or being with people.
• You Experience a Sense of Detachment From Your Environment: Often times, depersonalization is accompanied by derealization, and you not only feel disconnected from the world but you’re also unfamiliar with it, individuals, inanimate objects, and/or all surroundings. Derealization often involves subjective visual distortions such as fuzziness, heightened sensitivity, a larger or smaller visual field, two-dimensionality or flatness, and exaggerated 3D visions or altered size of objects.
• You Feel Like a Robot: When experiencing depersonalization, people sometimes feel like they are an observer of their own body and mental process. Their voice may sound unfamiliar and their thoughts, the way they speak, and the things they do no longer feel spontaneous. Instead, they feel as if they’re just going through the motions. Another major factor sufferers describe is the inability to feel emotion, even to those closest to them.
• You Think Your Memories Belong to Someone Else: You may struggle with attention and memory, and have trouble remembering everyday things, have trouble taking in new information, and experience thoughts that are accelerated or confused. Your memories may lack an emotional core or you may feel as if they’re so far away from you that they can’t possibly be your own.
• You Know That There’s Something Wrong: You aren’t delusional; you know that something isn’t right with you and the way you view the world.

Derealization symptoms

Symptoms of derealization include:

• Feelings of being alienated from or unfamiliar with your surroundings — for example, like you’re living in a movie or a dream
• Feeling emotionally disconnected from people you care about, as if you were separated by a glass wall
• Surroundings that appear distorted, blurry, colorless, two-dimensional or artificial, or a heightened awareness and clarity of your surroundings
• Distortions in perception of time, such as recent events feeling like distant past
• Distortions of distance and the size and shape of objects.

Derealization disorder complications

Episodes of depersonalization or derealization can be frightening and disabling. They can cause:

• Difficulty focusing on tasks or remembering things
• Interference with work and other routine activities
• Problems in relationships with your family and friends
• Anxiety or depression
• A sense of hopelessness

Derealization disorder diagnosis

Your doctor may determine or rule out a diagnosis of depersonalization-derealization disorder based on:

• Physical exam. In some cases, symptoms of depersonalization or derealization may be linked to an underlying physical health problem, medications, recreational drugs or alcohol.
• Lab tests. Some lab tests may help determine whether your symptoms are related to medical or other issues.
• Psychiatric evaluation. Your mental health professional asks about your symptoms, thoughts, feelings and behavior patterns, which can help determine if you have depersonalization-derealization disorder or other mental health disorders.
• DSM-5. Your mental health professional may use the criteria for depersonalization-derealization disorder listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Derealization disorder diagnostic criteria

Depersonalization Dereallzation disorder diagnostic criteria (DSM 5) ¹⁷:

• A. The presence of persistent or recurrent experiences of depersonalization, derealization, or both:
  1. Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing).
  2. Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted).
• B. During the depersonalization or derealization experiences, reality testing remains intact.
• C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication) or another medical condition (e.g., seizures).
• E. The disturbance is not better explained by another mental disorder, such as schizophrenia, panic disorder, major depressive disorder, acute stress disorder, post-traumatic stress disorder, or another dissociative disorder.

The essential features of depersonalization/derealization disorder are persistent or recurrent episodes of depersonalization, derealization, or both ¹⁷. Episodes of depersonalization are characterized by a feeling of unreality or detachment from, or unfamiliarity with, one’s whole self or from aspects of the self (Criterion A1). The individual may feel detached from his or her entire being (e.g., “I am no one,” “I have no self”). He or she may also feel subjectively detached from aspects of the self, including feelings (e.g., hypoemotionality: “I know I have feelings but I don’t feel them”), thoughts (e.g., “My thoughts don’t feel like my own,” “head^filled with cotton”), whole body or body parts, or sensations (e.g., touch, proprioception, hunger, thirst, libido). There may also be a diminished sense of agency (e.g., feeling robotic, like an automaton; lacking control of one’s speech or movements). The depersonalization experience can sometimes be one of a split self, with one part observing and one participating, known as an “out-of-body experience” in its most extreme form. The unitary symptom of “depersonalization” consists of several symptom factors: anomalous body experiences (i.e., unreality of the self and perceptual alterations); emotional or physical numbing; and temporal distortions with anomalous subjective recall.

Episodes of derealization are characterized by a feeling of unreality or detachment from, or unfamiliarity with, the world, be it individuals, inanimate objects, or all surroundings (Criterion A2). The individual may feel as if he or she were in a fog, dream, or bubble, or as if there were a veil or a glass wall between the individual and world around. Surroundings may be experienced as artificial, colorless, or lifeless. Derealization is commonly accompanied by subjective visual distortions, such as blurriness, heightened acuity, widened or narrowed visual field, two-dimensionality or flatness, exaggerated three-dimensionality, or altered distance or size of objects (i.e., macropsia or micropsia). Auditory distortions can also occur, whereby voices or sounds are muted or heightened. In addition. Criterion C requires the presence of clinically significant distress or impairment in social, occupational, or other important areas of fimctioning, and Criteria D and E describe exclusionary diagnoses.

Associated features supporting diagnosis

Individuals with depersonalization/derealization disorder may have difficulty describing their symptoms and may think they are “crazy” or “going crazy”. Another common experience is the fear of irreversible brain damage. A commonly associated symptom is a subjectively altered sense of time (i.e., too fast or too slow), as well as a subjective difficulty in vividly recalling past memories and owning them as personal and emotional. Vague somatic symptoms, such as head fullness, tingling, or lightheadedness, are not uncommon. Individuals may suffer extreme rumination or obsessional preoccupation (e.g., constantly obsessing about whether they really exist, or checking their perceptions to determine whether they appear real). Varying degrees of anxiety and depression are also common associated features. Individuals with the disorder have been found to have physiological hyporeactivity to emotional stimuli. Neural substrates of interest include the hypothalamic-pituitary-adrenocortical axis, inferior parietal lobule, and prefrontal cortical-limbic circuits.

Derealization disorder treatment

Treatment of depersonalization-derealization disorder is primarily psychotherapy. However, sometimes medications may be added to your treatment plan.

Psychotherapy

Psychotherapy, also called counseling or talk therapy, is the main treatment. The goal is to gain control over the symptoms so that they lessen or go away. Two such psychotherapies include cognitive behavioral therapy and psychodynamic therapy.

Psychotherapy can help you:

• Understand why depersonalization and derealization occur
• Learn techniques that distract from your symptoms and make you feel more connected to your world and feelings
• Learn coping strategies to deal with stressful situations and times of extreme stress
• Address the emotions related to past trauma you’ve experienced
• Address other mental health conditions such as anxiety or depression

Medications

There are no medications specifically approved to treat depersonalization-derealization disorder. However, medications may be used to treat specific symptoms or to treat depression and anxiety that are often associated with the disorder.

Coping and support

While depersonalization and derealization disorder can feel frightening, realizing that it’s treatable may be reassuring. To help you cope with depersonalization-derealization disorder:

• Follow your treatment plan. Psychotherapy may involve practicing certain techniques on a daily basis to help resolve feelings of depersonalization and derealization. Seeking treatment early can improve your chances of successfully using these techniques.
• Learn about the condition. Books and internet resources are available that discuss why depersonalization and derealization occur and how to cope. Ask your mental health professional to suggest educational materials and resources.
• Connect with others. Stay connected with supportive and caring people — family, friends, faith leaders or others.

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