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Depersonalization/Derealization Disorder

Dissociation Image courtesy of Super OfficeOpens in new window
  • Depersonalization is defined by a sense of being detached from one’s self (e.g., being an observer outside one’s body).
  • Derealization is defined by a sense of detachment from one’s surroundings, such that the surroundings seem unreal.

Depersonalization/derealization is found in both adolescents and adults often in response to acute stress.

  • In depersonalization the focus is on oneself. It is an extremely uncomfortable feeling of being an observer of one’s own body or mental processes.
  • In derealization the focus is on the outside world. It is the recurring feeling that one’s surroundings are unreal or distant.

The person may feel mechanical, dreamy, or detached from the body. Some people suffer episodes of these problems that come and go while others have episodes that begin with stressors and eventually become constant. Patients describe these experiences as very distressing.

Individuals with depersonalization or derealization disorder may have the impression that they are outside their body, viewing themselves from a distance or looking at the world through a fog. They often report feeling physically and emotionally numb. Although more than a third of college students report that they have experienced at least fleeting moments of depersonalization or realization in the past year (Hunter, Sierra, & David, 2004), these mild and intermittent symptoms are rarely of concern.

A diagnosis of depersonalization/derealization disorder is considered only when the symptoms are persistent or recurrent. Unlike the other dissociative disordersOpens in new window, this disorder involves no disturbance of memory.

The following quotes, drawn from a 1953 medical textbook, capture some of the experience of this disorder:

The world appears strange, peculiar, foreign, dream-like. Objects appear at time strangely diminished in size, at times flat. Sound appear to come from a distance. . . . The emotions likewise undergo marked alteration. Patients complain that they are capable of experiencing neither pain nor pleasure; love and hate have perished with them. They experience a fundamental change in their personality, and the climax is reached with their complaints that they have become stranges to themselves. It is as though they were dead, lifeless, mere automations. (Schilder, 1953, pp. 304 – 305)
Elizabeth, a 42-year-old executive, gasps as she looks in the mirror. She can’t believe the changes in her appearance. She thinks that her body looks wavy and out of focus. She says that it feels as though she is floating in a fog and her feet are not actually touching the ground. “I wonder if I am really awake or if my life is a dream.” As she is admitted to the stress-management unit, Elizabeth confides to the nurse that her son has recently charged with insider trading in the stock market and that he may be facing a lengthy jail sentence.
Mrs. A. was a 43-year-old woman who lived with her mother and son and worked in a clerical job. She had experienced symptoms of depersonalization several times per year for as long as she could remember. “It’s as if the real me is taken out and put on a shelf or stored somewhere inside of me. Whatever makes me me is not there. It is like an opaque curtain… like going through the motions. . .” She had found these symptoms to be extremely distressing. She had experienced panic attacks for 1 year when she was 35. She described a childhood trauma history that included nightly sexual abuse by her mother from her earliest memory to age 10. (Simeon, Gross, et al., 1997, p. 1109)

The symptoms of depersonalization and derealization are usually triggered by stress.

Depersonalization/derealization disorder usually begins in adolescence, and it can start either abruptly or gradually. Most people who experience depersonalization also experience derealization, and the course is similar for both symptoms.

Symptoms are often continuously present for years (Simeon, 2009). Comorbid personality disorders are frequently present, and during their lifetime, about 90% of people with this disorder will experience anxiety disordersOpens in new window or depressionOpens in new window (Simeon, Knutelska, et al., 2003). As in the clinical case of Mrs. A., childhood trauma is often reported (Michal, Adler, et al., 2016).

The DSM-5 diagnostic criteria for depersonalization/derealization disorder specify that the symptoms can co-occur with other disorders but should not be entirely explained by those disorders.

It is important to rule out disorders that commonly involve these symptoms, including schizophreniaOpens in new window, acute stress disorderOpens in new window, posttraumatic stress disorderOpens in new window, and borderline personality disorderOpens in new window. Depersonalization is also relatively common during panic attacksOpens in new window and during marijuana, ketamine, or hallucinogen intoxication (Lynn, Berg, et al., 2018).

Etiology of Depersonalization/Derealization Disorder

Some research findings indicate that some experiences of depersonalization/derealization may relate to problems in the way that the brain integrates information from different sensory and bodily soruces (Lynn et al., 2018).

In a small PET study, eight patients with depersonalization/derealization disorder showed atypical activity in regions involved in integrating information from sensory cortex areas (e.g., visual, auditory, and somatosensory) and bodily cues (Simeon, Guralnick, et al., 2000).

Other research has shown that brief symptoms of depersonalization and derealization can be induced in individuals who do not have depersonalization/derealization disorder by providing mismatched or unexpected sensory experiences. For example, asking participants to wear goggles that distort visual information about where a person is being touched can produce temporary experiences of depersonalization and derealization.

Among those with depersonalization/derealization disorder, brain regions that are involved in processing bodily cues related to emotion experience, such as the anterior cingulate cortex, appear to be underactive when viewing emotionally evocative images, which could contribute to the sense of feeling affectively numb (Medford, 2012). Taken together, depersonalization/derealization symptoms may be triggered when neural signals from various bodily or sensory cues are mismatched (Lynn et al., 2018).

See also:
  1. Baker, D., Hunter, E., Lawrence, E. et al. (2003). Depersonalization disorder: clinical featurs of 204 cases. British Journal of Psychiatry, 182, 428 – 433.
  2. Brauer, R., Harrow, M., Tucker, G.J. (1970). Depersonalization phenomena in psychiatric patients. British Journal of Psychiatry, 117, 509 – 515.
  3. Brock, S., Wiesel, B. (1942). Derealization and depersonalization: their occurrence in orgnic and psychogenic states. Diseases of the Nervous System, 3, 139 – 149.
  4. Edwards, J.G., Angusm, J.W. (1972). Depersonalization. British Journal of Psychiatry, 120. 242 – 244.
  5. Hunter, E.C., Phillips, M.L., Chalder, T. Sierra, M. David, A.S. (2003). Depersonalization disorder: a cognitive-behavioral conceptualization. Behavior Research and Therapy, 41, 1451 – 1467
  6. Hunter, E.C., Sierra, M., David, A.S. (2004). The epidemiology of depersonalization and derealization. A systematic review. Social Psychiatric Epidemiology, 39, 9 – 18.
  7. Johnson, J.G., Cohen, P., Kasen, S., Brook, J.S. (2006). Dissociative disorders among adults in the community, impaired functioning, and axis I and II comorbidity. Journal of Psychiatry Research, 40, 131 – 140.
  8. Mula, M., Pini, S., Cassano, G.B. (2007). The neurobiology and clinical significance of depersonalization in mood and anxiety disorders: a critical reappraisal. Journal of Affective Disorders, 99, 91 – 99.
  9. Phillips, M.L., Sierra, M. (2003). Depersonalizaton disorder: a functional neuroanatomical perspective, Stress, 6, 157 – 165.
  10. Roth, M. (1959). The phobic anxiety-depersonalization syndrome. Proceedings of the Royal Society of Medicine, 52, 587 – 595.
  11. Shorvon, H.J. (1946). The depersonalization syndrome. Proceedings of the Royal Society of Medicine, 39, 779 – 792.
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