What is depersonalization and derealization?

by Dr. Melissa Shepard, MD

by Dr. Melissa Shepard, MD

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Depersonalization and derealization (DPDR) happen to many people (up to 50% in some studies) at some point in their lives (Hunter, 2004). These experiences are usually mild, transient, and not bothersome. However, in some people, DPDR can take on a life of its own, spiraling into a terrifying and all-consuming experience.

DPDR is often a symptom of a psychiatric disorder such as an anxiety disorder, mood disorder, or post-traumatic stress disorder. It can also arise from substance use, most commonly marijuana use. DPDR that is severe or exists outside of these other disorders is referred to as depersonalization/derealization disorder (DDD). DDD appears to be present in about 2% of people (Hunter, 2004).

Usually, our brains integrate each facet of our experience, expertly combining our thoughts, memories, feelings, surroundings, and sensations into a seamless experience of the world around us. We classify chronic DPDR and DDD as dissociative disorders because they disrupt this integration of experiences, causing our view of ourselves and the world to feel disconnected and abnormal.

Many people with chronic DPDR and DDD have both depersonalization and derealization, but it is possible to have only one of the two. Depersonalization refers to feeling detached from yourself, and people describe it as feeling like you are in a dream, robotic, watching yourself in a movie, or observing yourself from above or outside your body. People with depersonalization may fear losing control.

Derealization is similar but refers more to your sense of the world around you. For example, feeling detached from the world or feeling like objects, people, or other things around you are not real. Sometimes people describe the world around them as feeling foggy, flat, distorted, blurry, like a dream, or otherwise strange or unreal.

Why do people develop depersonalization and derealization?

Some common risk factors for DPDR include experiencing severe stress, trauma, severe anxiety, depression, and substance use. Some individuals experience their first episode of DPDR after using certain substances, most commonly marijuana, hallucinogens, ketamine, and salvia (especially if they have an anxiety-provoking or otherwise negative experience taking the drug).

People who have seizure disorders, traumatic brain injuries, or other medical conditions may also experience DPDR.

Illustration of woman with a wound in her chest in a dream-like world
Image courtesy of Shutterstock

There are several biological factors that increase the likelihood that someone will develop chronic DPDR and DDD after being exposed to one or more of these risk factors, but more research is needed to understand these biological factors. Thus far, research has suggested that people who are less able to suppress emotional responses and people who have more difficulty describing their emotions are more likely to develop chronic DPDR. It is also possible for someone to have no risk factors and still develop depersonalization or derealization.

Why would DPDR develop in response to stress or trauma, even in people without risk factors? Depersonalization and derealization may be helpful in stressful or traumatic situations. In these situations, dissociating through DPDR allows someone to take quick and decisive action to navigate the traumatic or stressful experience without being overwhelmed or distracted by emotions. For example, you may have heard stories of people in scary situations who take heroic actions without thinking. In most people, DPDR resolves after the stressful or traumatic event is over. But for some, this initially adaptive response can persist long after the risk is gone, taking on a life of its own.

How are depersonalization and derealization treated?

Many people experience DPDR at some point in their lives, and treatment is unnecessary unless the symptoms are persistent and bothersome. If they are (as in the case of chronic DPDR and DDD), several treatment approaches can be helpful:

1. Understand DPDR and know that it not dangerous

These conditions can feel very scary, so it’s important to know that depersonalization and derealization are not dangerous. These experiences will not cause permanent brain damage or cause someone to develop a psychotic disorder like schizophrenia. People can feel a lot of shame about their condition, especially if it started after an episode of drug use. People suffering from DPDR must remember that while substance use is associated with the development of DPDR, most people who use substances do not develop these issues. Adding layers of guilt and shame to DPDR symptoms is never helpful.

2. Get treatment for mood, anxiety, or substance use disorders.

If someone has a mood disorder (such as major depression or bipolar disorder), anxiety disorder or other psychiatric condition, treatment of that co-occurring condition may be all that is needed to improve their DPDR symptoms. When chronic DPDR or DDD has developed after substance use, it is crucial to avoid future substance use. In general, treating related disorders earlier improves DPDR recovery, so it is essential to seek help from a trained mental health professional (who can also rule out other potentially treatable causes).

3. Consider therapy to target DPDR symptoms

DPDR symptoms generally respond well to therapy, although there have been no randomized controlled trials to determine whether one form of therapy is more effective than another. Many clinicians find that Cognitive Behavioral Therapy (CBT) helps challenge some of the negative thoughts associated with DPDR. CBT can also help people with DPDR learn grounding techniques that can bring them back to the present when they feel disconnected.

Mindfulness and Acceptance and Commitment Therapy (ACT) can also be helpful for people suffering from DPDR. ACT helps sufferers allow DPDR symptoms to be there without pushing them away or resisting them. Paradoxically, this acceptance makes the DPDR symptoms less prominent, allowing them to fade away over time. Research suggests that trauma-focused therapeutic interventions are also crucial for DPDR treatment (Brand, 2012).

4. Consider medications or other interventions

Medications may help in chronic DPDR and DDD even if there are no other co-occurring mental health conditions. Lamotrigine has shown efficacy in one randomized, double-blind, placebo-controlled study (Aliyev, 2011). Naltrexone has also shown some promise in studies, but the data is not as robust as the data for lamotrigine (Simeon, 2005). Clomipramine and SSRIs may also be helpful (Gentile, 2014).

Antidepressants, including SSRIs and SNRIs, are particularly beneficial if chronic DPDR is associated with anxiety or depression, as noted above. However, people with DPDR are more likely to have emotional blunting on these medications. If emotional blunting develops and becomes problematic, there are alternatives such as clomipramine that may be helpful.

Regardless of the severity, cause, or presence of other related mental health conditions, we can successfully manage derealization and depersonalization. If this is something that you suffer from, please reach out to your doctor, therapist, or other mental health professional. You are not alone, and things can get better!

References and Further Reading

Aliyev NA, Aliyev ZN. Lamotrigine in the immediate treatment of outpatients with depersonalization disorder without psychiatric comorbidity: randomized, double-blind, placebo-controlled study. J Clin Psychopharmacol 2011; 31:61.

Brand BL, Lanius R, Vermetten E, et al. Where are we going? An update an assessment, treatment, and neurobiological research in dissociative disorders as we move toward the DSM-5. J Trauma Dissociation. 2012;13(1):9–31.

Gentile JP, Snyder M, Marie Gillig P. Stress and trauma: Psychotherapy and pharmacotherapy for depersonalization/derealization disorder. Innov Clin Neurosci. 2014;11(7-8):37-41.

Hunter EC, Baker D, Phillips ML, et al. Cognitive-behaviour therapy for depersonalisation disorder: an open study. Behav Res Ther 2005; 43:1121.

Hunter, E.C.M., Sierra, M. & David, A.S. The epidemiology of depersonalisation and derealisation. Soc Psychiatry Psychiatr Epidemiol 39, 9–18 (2004). https://doi-org.proxy1.library.jhu.edu/10.1007/s00127-004-0701-4

Mantovani A, Simeon D, Urban N, et al. Temporo-parietal junction stimulation in the treatment of depersonalization disorder. Psychiatry Res 2011; 186:138.

Simeon D, Guralnik O, Schmeidler J, Knutelska M. Fluoxetine therapy in depersonalisation disorder: randomised controlled trial. Br J Psychiatry 2004; 185:31.

Simeon D, Knutelska M. An open trial of naltrexone in the treatment of depersonalization disorder. J Clin Psychopharmacol 2005; 25:267.

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