Depersonalization and derealization are two of the most common symptoms associated with dissociation. While depersonalization refers to a temporary loss of sense of self, derealization is characterized with a temporary detachment from reality.
Depersonalization/Derealization Disorder (Depersonalization Derealization Disorder) is defined as “persistent or recurring symptoms of depersonalization, or derealization, or both.” The key factor of the aforementioned definition is “persistence”, since episodes of dissociation are very common, with up to 74% of the general population experiencing them transiently at least once in their lifetime. However, when symptoms become persistent, severe, and interfere with normal functioning, Depersonalization Derealization Disorder may be diagnosed.
People experiencing Depersonalization Derealization Disorder symptoms may feel like they are floating above their own body, or perceiving reality from a different perspective. Contrary to psychotic episodes, reality testing (the ability to distinguish the external world compared to internal perception) remains intact during depersonalization or derealization.
Episodes may be triggered by severe stress or trauma, and can manifest in adulthood as an adaptive measure. Studies involving brain imaging have shown evidence of abnormal responses to emotional stimulation, which links to weak or blunt experiences of emotions reported in Depersonalization Derealization Disorder.
The lack of epidemiological surveys concerning Depersonalization Derealization Disorder has led to contrasting data on its prevalence. While the lifetime prevalence of the disorder is estimated to be 1-2% of the population with an equal ratio of men and women, recent data suggests a slight male preponderance.
While there is often a comorbidity of Depersonalization Derealization Disorder and mood or anxiety disorders, the symptoms of depersonalization can be present in patients diagnosed with schizophrenia, panic disorder, posttraumatic stress disorder, personality disorders, and other dissociative disorders, making them plausible differential diagnoses. This is also a likely cause of the under-diagnosis of Depersonalization Derealization Disorder.
Symptoms of Depersonalization Derealization Disorder can be alleviated and managed effectively through psychotherapy.
Signs and Symptoms
Depersonalization/Derealization Disorder requires a medical diagnosis.
The symptoms of this disorder expand over two conditions.
Characterized by a feeling of unfamiliarity with oneself or one’s being, depersonalization is often described as feeling subjectively detached from aspects of the self. This can include:
1. Hypo-emotionality, a detachment from one’s feelings: “I know I have feelings, but I cannot feel them.”
2. Detachment from thoughts: “My thoughts don’t feel like my own.”
3. Detachment from whole body or body parts.
4. Diminished sensation (such as touch, hunger, libido, etc.).
5. Lack of agency: feeling robotic, loss of control over speech or movement.
6. Out-of-body experiences, in severe cases.
7. Gaps in memory, difficulty in subjective recall.
Characterized by a feeling of detachment from reality, derealization is described as a sensation that one’s surroundings are not real. This can include:
1. Feeling of unfamiliarity with surroundings, objects, and/or individuals.
2. Feelings of being in a dream-like state, or in a fog or bubble.
3. An artificial experience of surroundings.
Derealization is also commonly accompanied by:
1. Subjective visual distortions: blurred vision, flatness or exaggerated depth, altered distance or size of objects.
2. Auditory distortions: voices can sound muted or heightened.
3. Significant clinical distress: feelings of panic or anxiety over states of derealization.
Individuals with Depersonalization/Derealization Disorder often report their own feelings of “going crazy”, accompanied by a fear of irreversible brain damage. Physiological symptoms such as light-headedness or tingling are common.
While there is little epidemiological survey data concerning dissociative disorders, recent studies have shown a slight male preponderance in the prevalence of Depersonalization/Derealization Disorder, with patients having higher education level but also higher rate of unemployment. The mean age of onset is 16 years, and only a minority of people develop it after the age of 25. In most cases there, the disorder presents a chronic course.
Existing data points towards a 1% prevalence rate of Depersonalization/Derealization Disorder among the general population, though it is important here to note that it is severely underdiagnosed owing to its high comorbidity with several mental illnesses.
Temperamental factors associated with Depersonalization/Derealization Disorder include harm-avoidant traits, insecurity and immature tendencies. This is further highlighted with a comorbidity of the disorder among those with insecure, depressive personalities.
However, the most well-known risk factors of Depersonalization/Derealization Disorder are environmental, with clear associations between the disorder and childhood trauma in a large proportion of patients. Emotional abuse or neglect is consistently observed to be a factor, while other forms of trauma include physical abuse, witnessing domestic violence, unexpected death, or growing up with a severely mentally ill parent. There is also evidence of the presence of Depersonalization/Derealization Disorder symptoms in former drug addicts.
Comorbidities include unipolar depression, anxiety disorders, and personality disorders (commonly seen in borderline, avoidant, and obsessive-compulsive disorders).
Healthcare providers must ensure that symptoms presented are not better explained by a range of phenomena such as alcohol or drug abuse or other pre-existing mental health issues, such as schizophrenia, posttraumatic stress disorder (PTSD), major depressive disorder, acute stress disorder, panic disorder, or other dissociative disorders. Medical conditions such as seizures can also be a potential reason for symptoms associated with Depersonalization/Derealization Disorder.
Psychiatrists are urged to screen for depersonalization and derealization symptoms regularly, as these can be quite common and lead to significant distress in patients.
The Diagnostic Statistical Manual 5 (DSM-5) mentions the diagnostic criteria to be persistent or recurrent experiences of either depersonalization or derealization, or both. The persistence of episodes of depersonalization or derealization is a key factor in qualifying for a diagnosis. Transient symptoms of the same can be common in the general population.
The major mode of treatment for Depersonalization/Derealization Disorder is psychotherapy. Psychotherapists work on building a reliable alliance over time and facilitating change. The expectation from the patient is to work on their own coping strategies and self-efficacy.
There are no established psychopharmacological treatment routes for Depersonalization Derealization Disorder. Very few trials have been carried out to find medication efficacies, with available evidence proving inconclusive.
The course of therapy is usually complicated and depends on each individual. Patients often benefit from an eclectic approach. Supportive interventions and coping strategies are used during extreme stress, while self-reflection and self-evaluation may prove helpful for mild symptoms. Upon improvement, the patient may be asked to purposefully create a state of depersonalization in order to make use of coping strategies. This can prove helpful in case of relapse.
The onus of maintaining effective coping strategies and working on relationship patterns falls on the patient. It is important to keep working on helpful mechanisms even outside the therapeutic setting.
Additionally, grounding techniques (for e.g. placing ice in the hand or lighting incense to occupy the sense of smell) and mindfulness can also be effective in combating out-of-body experiences and help individuals feel more connected to reality.
MedicationThere is no known medication that conclusively helps with symptoms of Depersonalization/Derealization Disorder. A study that targeted dissociative symptoms comorbid with posttraumatic stress disorder and bipolar disorder showed modest efficacies of Paroxetine (SSRI) and Naloxone (anti-opioid) in controlling depersonalization symptoms. Patients may also find some relief through SSRIs, lamotrigine, anti-opioids and anxiolytics, but that is likely due to their effect on underlying symptoms of depression or anxiety. Psychotherapists must be careful while prescribing benzodiazepine as they may aggravate depersonalization.
1. Illness anxiety disorder: Individuals with depersonalization/derealization disorder can present with vague somatic complaints and fear of brain damage. However, the diagnosis of depersonalization/derealization disorder is characterized by the presence of typical depersonalization/derealization symptoms and the absence of other manifestations of illness anxiety disorder.i
2. Major depressive disorder: Feelings of numbness, deadness, apathy, and being in a dreams are common in major depressive episodes and depersonalization/ derealization disorder, But in depersonalization/ derealization disorder such symptoms are associated with further symptoms of the disorder.
3. Obsessive-compulsive disorder: Some individuals with depersonalization/derealization disorder can become obsessively preoccupied with their subject or develop habits of checking on the status of their symptoms. However, the other symptoms of obsessive-compulsive disorder are not present in depersonalization/derealization disorder.
4. Other dissociative disorders: In order to diagnose depersonalization/derealization disorder, the symptoms should not occur in the context of another dissociative disorder, such as dissociative identity disorder. Differentiation from dissociative amnesia and conversion disorder is simpler, as the symptoms of these disorders do not overlap with those of depersonalization/derealization disorder.
5. Anxiety disorders: Depersonalization/derealization disorder should not be diagnosed when the symptoms occur only during panic attacks that are part of panic disorder, social anxiety disorder, or specific phobia. In addition, it is not uncommon for depersonalization/derealization symptoms to first begin with panic attacks.
6. Psychotic disorders: Rarely, positive-symptom schizophrenia can be a difficult diagnosis nihilistic delusions are present.
7. Substance/medication-induced disorders: Depersonalization/derealization associated with the physiological effects of substances during acute intoxication or withdrawal is not diagnosed as depersonalization/derealization disorder. The most common substances are marijuana, hallucinogens, ketamine, ecstasy, and salvia. Only if the symptoms persist for some time in the absence of any further substance or medication use, the diagnosis of depersonalization/derealization disorder applies.
8. Mental disorders due to another medical condition: Features such as onset after age40 years or the presence of atypical symptoms in any individual suggest thepossibility of an underlying medical condition. In such cases, it is essential to conduct a thorough medical and neurological evaluation, which may include standard laboratory studies before a confirmed diagnosis.
Comorbidities were high for unipolar depressive disorder and anxiety disorders, along with low comorbidity for posttraumatic stress disorder. The three most commonly comorbid
personality disorders were avoidant, borderline, and obsessive-compulsive.
Depersonalization or derealization symptoms that pass quickly are common and usually not cause for alarm. Depersonalization-derealization disorder or any physical or mental health condition, however, can be indicated by persistent or severe feelings of detachment and distortion of your environment.
Depersonalization-derealization disorder episodes might linger for several hours, days, weeks, or even months. Some persons experience these events as recurring episodes of derealization or depersonalization, which may occasionally get better or worse.
If you have symptoms of depersonalization or derealization that bother you, are emotionally upsetting, persist or keep returning, or interfere with your everyday activities, relationships, or employment, see a doctor.
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