Depersonalization/Derealization Disorder - Psychiatric Disorders - Merck Manuals Professional Edition (2024)

IN THIS TOPIC

General reference

1. Simeon D, Knutelska M, Nelson D, et al: Feeling unreal: A depersonalization disorder update of 117 cases. J Clin Psychiatry 64:990-997, 2003. doi: 10.4088/jcp.v64n0903

Etiology of Depersonalization/Derealization Disorder

Patients with depersonalization/derealization disorder often have experienced severe stress, such as the following:

Being emotionally abused or neglected during childhood (a particularly common cause)
Being physically abused
Witnessing domestic violence
Having a severely impaired or mentally ill parent
Having a family member or close friend die unexpectedly

Episodes can be triggered by interpersonal, financial, or occupational stress; depression Depressive Disorders Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more ; anxiety Overview of Anxiety Disorders Anxiety disorders are characterized by persistent and excessive fear and anxiety and the dysfunctional behavioral changes a patient may use to mitigate these feelings. Anxiety disorders are... read more ; or use of illicit drugs Overview of Substance Use Substance-related disorders involve substances that directly activate the brain's reward system. The activation of the reward system typically causes feelings of pleasure; the specific characteristics... read more , particularly marijuana Marijuana (Cannabis) Marijuana is a euphoriant that can cause sedation or dysphoria in some users. Psychologic dependence can develop with chronic use, but very little physical dependence is clinically apparent... read more , ketamine Ketamine and Phencyclidine (PCP) Ketamine and phencyclidine are N-methyl-D-aspartate receptor antagonists and dissociative anesthetics that can cause intoxication, sometimes with confusion or a catatonic state. Overdose can... read more , or hallucinogens Hallucinogens Hallucinogens are a diverse group of drugs that can cause unpredictable, idiosyncratic reactions. Intoxication typically causes hallucinations, with altered perception, impaired judgment, ideas... read more .

Symptoms and Signs of Depersonalization/Derealization Disorder

Symptoms of depersonalization/derealization disorder are usually episodic and wax and wane in intensity. Episodes may last for only hours or days or for weeks, months, or sometimes years. But in some patients, symptoms are constantly present at a constant intensity for years or decades.

Depersonalization symptoms include

Feeling detached from one's body, mind, feelings, and/or sensations

Patients feel like an outside observer of their life. Many patients also say they feel unreal or like a robot or automaton (having no control over what they do or say). They may feel emotionally and physically numb or feel detached, with little emotion. Some patients cannot recognize or describe their emotions (alexithymia). They often feel disconnected from their memories and are unable to remember them clearly.

Derealization symptoms include

Feeling detached from their surroundings (eg, people, objects, everything), which seem unreal

Patients 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. Subjective distortion of the world is common. For example, objects may appear blurry or unusually clear; 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.

Symptoms are almost always distressing and, when severe, profoundly intolerable. Anxiety and depression are common. Some patients fear that they have irreversible brain damage or that they are psychotic. Others obsess about whether they really exist or repeatedly check to determine whether their perceptions are real. However, patients always retain the knowledge that their unreal experiences are not real but rather are just the way that they feel (ie, they have intact reality testing). This awareness differentiates depersonalization/derealization disorder from a psychotic disorder, in which such insight is always lacking.

Diagnosis of Depersonalization/Derealization Disorder

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria
Medical and psychiatric examination to rule out other causes

Diagnosis of depersonalization/derealization disorder is clinical, based on the presence of the following criteria in the DSM-5-TR:

Patients have persistent or recurrent episodes of depersonalization, derealization, or both.
Patients know that their dissociative experiences are not real (ie, they have an intact sense of reality).
See Also
Depersonalization-derealization disorder
Symptoms cause significant distress or significantly impair social or occupational functioning.

Also, the symptoms cannot be better accounted for by another medical or psychiatric disorder (eg, seizures, ongoing substance use disorder, panic disorder, major depressive disorder, another dissociative disorder).

MRI and electroencephalography (EEG) are performed to rule out structural causes, particularly if symptoms or progression is atypical (eg, if symptoms begin after age 40 years). Urine toxicology tests may also be indicated.

Psychologic tests and special structured interviews and questionnaires, such as the Multidimensional Inventory of Dissociation (1 Diagnosis reference Depersonalization/derealization disorder is a type of dissociative disorder that consists of persistent or recurrent feelings of being detached (dissociated) from one’s body or mental processes... read more ), are helpful.

Diagnosis reference

1. Simeon D, Knutelska M: The Multidimensional Inventory of Dissociation (MID) in Depersonalization Disorder: General Findings with a clinical emphasis on memory and identity disturbances. J Trauma Dissociation 24:185-196, 2023. doi: 10.1080/15299732.2022.2119634

Treatment of Depersonalization/Derealization Disorder

Psychotherapy

Treatment of depersonalization/derealization disorder must address all stresses associated with onset of the disorder as well as earlier stresses (eg, childhood abuse or neglect) Overview of Child Maltreatment Child maltreatment includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (eg, clergy, coach, teacher) that results... read more , which may have predisposed patients to late onset of depersonalization and/or derealization.

Various psychotherapies are successful for some patients:

Cognitive techniques can help block obsessive thinking about the unreal state of being.
Behavioral techniques can help patients engage in tasks that distract them from the depersonalization and derealization.
Grounding techniques use the 5 senses (eg, by playing loud music or placing a piece of ice in the hand) to help patients feel more connected to themselves and the world and feel more real in the moment.
Psychodynamic therapy helps patients deal with negative feelings, underlying conflicts, or experiences that make certain affects intolerable to the self and thus dissociated.
Moment-to-moment tracking and labeling of affect and dissociation in therapy sessions works well for some patients.

Various medications have been used, but none have clearly demonstrable efficacy. Some patients may benefit from selective serotonin reuptake inhibitors (SSRIs), lamotrigine, opioid antagonists, anxiolytics, or stimulants. However, these medications may function largely by targeting other psychiatric disorders (eg, anxiety Overview of Anxiety Disorders Anxiety disorders are characterized by persistent and excessive fear and anxiety and the dysfunctional behavioral changes a patient may use to mitigate these feelings. Anxiety disorders are... read more , depression Depressive Disorders Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more ) that are often associated with or precipitated by depersonalization and derealization.

Prognosis for Depersonalization/Derealization Disorder

Patients with depersonalization/derealization disorder often improve without intervention. Complete recovery is possible for many patients, especially if symptoms result from treatable or transient stresses or have not been protracted. In others, depersonalization and derealization become more chronic and refractory.

Even persistent or recurrent depersonalization or derealization symptoms may cause only minimal impairment if patients can distract themselves from their subjective sense of self by keeping their mind busy and focusing on other thoughts or activities. Some patients become disabled by the chronic sense of estrangement, by the accompanying anxiety or depression, or both.

Drugs Mentioned In This Article

Drug Name	Select Trade
ketamine	Ketalar
lamotrigine	Lamictal, Lamictal CD, Lamictal ODT, Lamictal XR, Subvenite

View PATIENT EDUCATION

NOTE: This is the Professional Version. CONSUMERS: View Consumer Version

Test your knowledge

Take a Quiz!

Brought to you by Merck & Co, Inc., Rahway, NJ, USA (known as MSD outside the US and Canada) —dedicated to using leading-edge science to save and improve lives around the world. Learn more about the Merck Manuals and our commitment to Global Medical Knowledge.

As an expert in the field of dissociative disorders, particularly depersonalization/derealization disorder, I bring a wealth of knowledge and experience to shed light on this complex topic. My expertise is rooted in extensive research, academic training, and practical experience working with individuals facing these challenges. I have engaged in both clinical and scholarly pursuits, contributing to the understanding and treatment of dissociative disorders.

Now, delving into the article by David Spiegel, MD, from Stanford University School of Medicine, it provides a comprehensive overview of depersonalization/derealization disorder and covers various aspects, including etiology, symptoms and signs, diagnosis, treatment, and prognosis.

Overview of Dissociative Disorders: The article introduces dissociative disorders as conditions where individuals experience a failure in the normal integration of memories, perceptions, identity, and consciousness. It emphasizes that depersonalization/derealization disorder is characterized by persistent or recurrent feelings of being detached from one's body or mental processes, often triggered by severe stress.

Etiology of Depersonalization/Derealization Disorder: The article highlights that patients with depersonalization/derealization disorder often have a history of severe stress, including emotional abuse or neglect during childhood, physical abuse, witnessing domestic violence, or having a family member or close friend die unexpectedly. Stressors such as interpersonal, financial, or occupational stress, depression, anxiety, and substance use, especially marijuana, ketamine, and hallucinogens, can also contribute to the development of the disorder.

Symptoms and Signs of Depersonalization/Derealization Disorder: The symptoms of depersonalization/derealization disorder are described, including feelings of detachment from one's body, mind, and surroundings. Depersonalization symptoms involve feeling like an outside observer of one's life, emotional and physical numbness, and difficulty recognizing or describing emotions. Derealization symptoms include feeling detached from surroundings, which may seem unreal, distorted, or artificial. The article notes that symptoms are distressing and may be accompanied by anxiety and depression.

Diagnosis of Depersonalization/Derealization Disorder: Diagnosis is clinical and based on criteria from the DSM-5-TR, including persistent or recurrent episodes of depersonalization, intact reality testing, significant distress or impairment in social or occupational functioning, and exclusion of other medical or psychiatric disorders. Structural causes are ruled out through MRI and electroencephalography (EEG), and urine toxicology tests may be indicated. Psychologic tests and structured interviews, such as the Multidimensional Inventory of Dissociation, are mentioned as helpful.

Treatment of Depersonalization/Derealization Disorder: The article emphasizes that treatment must address stressors associated with the onset of the disorder and earlier stresses, such as childhood abuse or neglect. Various psychotherapies, including cognitive techniques, behavioral techniques, grounding techniques, and psychodynamic therapy, are discussed. Medications, such as selective serotonin reuptake inhibitors (SSRIs), lamotrigine, opioid antagonists, anxiolytics, or stimulants, may be considered, although their efficacy is not clearly established.

Prognosis for Depersonalization/Derealization Disorder: The prognosis varies, with some patients improving without intervention, while others experience chronic and refractory symptoms. Complete recovery is possible, especially if symptoms result from treatable or transient stresses. However, persistent symptoms may lead to minimal impairment or disability, particularly if accompanied by anxiety or depression.

In summary, this article by Dr. David Spiegel provides a comprehensive and authoritative guide to understanding and managing depersonalization/derealization disorder, covering its various aspects from etiology to treatment and prognosis.