The depersonalization disorder is a personality disorder characterized by experiencing severe feelings of unreality that dominate the life of the person and that prevent normal functioning in life.
The sensations of depersonalization and derealization can be part of various disorders -as in acute stress disorder-, although when they are the main problem, the person meets the criteria for this disorder.
People with this disorder may have a cognitive profile with deficits in attention, short-term memory , or spatial reasoning. They may be easily distracted and have difficulty perceiving three-dimensional objects.
Although it is not known precisely how these perceptual and cognitive deficits develop, it seems that they are related to tunnel vision (perceptual distortions) and mental emptiness (difficulties in capturing new information).
In addition to the symptoms of depersonalization and derealization, the inner turmoil created by the disorder can lead to depression, self-harm, low self-esteem, anxiety attacks, panic attacks, phobias …
Although the disorder is an alteration in the subjective experience of reality, it is not a form of psychosis, since people who suffer from it maintain the ability to distinguish between their own internal experiences and external objective reality.
The chronic form of this disorder has a prevalence of 0.1 to 1.9%. While episodes of derealization or depersonalization can occur commonly in the general population, the disorder is only diagnosed when symptoms cause significant discomfort or problems in work, family, or social life.
Persistent episodes of depersonalization and derealization can lead to discomfort and functioning problems at work, at school, or in other areas of life.
During these episodes, the person is aware that their sense of detachment is just sensations, not reality.
Symptoms of depersonalization
- Feelings of being an outside observer of thoughts, feelings, or floating sensation.
- Sensations of being a robot or of not being in control of speech or other movements.
- Feeling that the body, legs or arms are distorted or elongated.
- Emotional or physical numbness of the senses or responses to the external world.
- Feelings that the memories are unemotional, and that they may not be the memories themselves.
- Feelings of unfamiliarity with the external environment, such as living in a movie.
- Feeling emotionally disconnected from close people.
- The external environment appears distorted, artificial, colorless or unclear.
- Distortions in the perception of time, such as recent events felt like the distant past.
- Distortions about the distance, size and shape of objects.
- Episodes of depersonalization or derealization can last for hours, days, weeks, or even months.
In some people, these episodes turn into permanent emotions of depersonalization or derealization that can get better or worse.
In this disorder, the sensations are not caused directly by drugs, alcohol, mental disorders, or another medical condition.
Diagnostic criteria according to DSM-IV
A) Persistent or recurring experiences of distancing or being an external observer of one’s own mental processes or of the body (for example, feeling as if one were in a dream).
B) During the depersonalization episode, the sense of reality remains intact.
C) Depersonalization causes clinically significant distress or impairment in social, occupational, or other important areas of life.
D) The depersonalization episode appears exclusively in the course of another mental disorder, such as schizophrenia, anxiety disorders, acute stress disorder or other dissociative disorders, and is not due to the direct physiological effects of a substance (for example , drugs, or drugs) or a general medical condition (for example, temporal lobe epilepsy ).
In ICE-10, this disorder is called depersonalization-derealization disorder. The diagnostic criteria is:
- One of the following:
- symptoms of depersonalization. For example, the individual feels that their feelings or experiences are distant.
- derealization symptoms. For example, objects, people, or the environment seem unreal, distant, artificial, colorless or lifeless.
- An acceptance that it is a spontaneous or subjective change, not imposed by outside forces or by other people.
The diagnosis should not be given in certain specific conditions, for example alcohol or drug intoxication, or in conjunction with schizophrenia, mood or anxiety disorders.
The exact cause of this disorder is not known, although biopsychosocial risk factors have been identified. The most common immediate precipitators of the disorder are:
- Severe stress
- Emotional abuse in childhood is a significant predictor for its diagnosis.
- Major depressive disorder.
- Ingestion of hallucinogens.
- Death of a close person.
- Severe trauma, such as a car accident.
Not much is known about the neurobiology of this disorder, although there is evidence that the prefrontal cortex could inhibit neural circuits that normally form the emotional substrate of experience.
This disorder may be associated with dysregulation of the hypothalamic-pituitary-adrenal axis, the area of the brain involved in the “fight or flight” response. Patients demonstrate abnormal baseline cortisol and activity levels.
In some cases, the use of cannabis can lead to dissociative states such as depersonalization and derealization. Sometimes these effects can remain persistent and result in this disorder.
When cannabis is consumed in a high dose during adolescence, it increases the risk of developing this disorder, especially in cases where the person is predisposed to psychosis.
Cannabis-induced depersonalization disorder typically occurs in adolescence and is most common in boys and ages 15-19.
Depersonalization disorder lacks effective treatment, in part because the psychiatric community has focused on research into other illnesses, such as alcoholism.
A variety of psychotherapeutic techniques are currently used, such as cognitive behavioral therapy. In addition, the effectiveness of drugs such as selective serotonin reuptake inhibitors (SSRIs), antivonvulsants or opioid antagonists are being investigated.
Cognitive behavioral therapy
It is intended to help patients reinterpret symptoms in a non-threatening way.
Neither antidepressants, benzodiazepines, nor antipsychotics have been found to be helpful. There is some evidence to support naloxone and naltrexone.
A combination of SSRIs and a benzodiazepine has been proposed to treat people with this disorder and anxiety. In a 2011 study with lamotrigine it was found to be effective in treating depersonalization disorder.
Modafinil has been effective in a subgroup of people with depersonalization, attention problems, and hypersomnia.
When to visit a professional?
Momentary feelings of depersonalization or derealization are normal and are not causes for concern. However, when they are frequent, they can be a sign of this disorder or of another mental illness.
It is advisable to visit a professional when you have feelings of depersonalization or derealization that:
- They are annoying or emotionally disturbing.
- Are frequent.
- They interfere with work, relationships, or daily activities.
- Episodes of derealization or depersonalization can lead to:
- Difficulty concentrating on tasks or remembering things.
- Interference with work and other daily activities.
- Problems in family and social relationships.
- “Depersonalization derealization disorder: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis”.
- Depersonalization Disorder, (DSM-IV 300.6, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition).
- Simeon D, Guralnik O, Schmeidler J, Sirof B, Knutelska M (2001). “The role of childhood interpersonal trauma in depersonalization disorder”. The American Journal of Psychiatry 158 (7): 1027–33. doi: 10.1176 / appi.ajp.158.7.1027. PMID 11431223.
- Mauricio Sierra (August 13, 2009). Depersonalization: A New Look at a Neglected Syndrome. Cambridge, UK: Cambridge University Press. p. 120. ISBN 0-521-87498-X