By Heather Sheaffer, MA, LCSW
Introduction
Depersonalization/derealization disorder is a dissociative disorder during which the patient feels as though he or she is detached from the self or from the environment. These episodes can come on suddenly, or persist for months or years. Several areas of the brain have been implicated in depersonalization/derealization disorder, suggesting that it is a brain disorder. According to the DSM-5, depersonalization/derealization disorder is a fairly common disorder, with as many as half of all adults experiencing at least 1 episode at some point during the lifespan, although less than 2% of the population experience pervasive symptoms (American Psychiatric Association, 2013). Symptoms of depersonalization and realization are common during a traumatic experience. Therefore, individuals with a history of trauma or abuse have an increased risk of depersonalization/derealization disorder. Treating depersonalization/derealization disorder includes the treatment of the preceding stressor, as well as development of coping skills that challenge depersonalization/derealization disorder symptoms.
Symptoms of Depersonalization/Derealization Disorder
The primary symptom of depersonalization/derealization disorder is the persistent or recurring experience of either depersonalization or derealization. The DSM-5 describes depersonalization as a sense of detachment or outside of one’s feelings, thoughts or actions. Derealization is described as a dreamlike or foggy state of feeling detached from surroundings. These states can manifest in many ways. Some patients experience an altered sense of time. Others feel as though they are not human. Many complain of their head feeling foggy, feeling lightheaded or tingly. Many patients think they are going crazy. For diagnosis, both of these experiences must cause distress or impairment. The symptoms cannot be caused by any drug, medication or other disorder (American Psychiatric Association, 2013).
Presentation
The way episodes of depersonalization/derealization disorder present vary greatly among patients. Some patients find that episodes come on suddenly with no warning. For some patients, the sense of depersonalization of derealization are continuous and do not end. Some recognize triggers that precede episodes and some patients are able to willfully induce episodes (Guralnik and Simon, 2010).
Prevalence
The DSM-5 estimates that half of all adults have experienced at least one episode of depersonalization or derealization. However, less than 2% of adults experience persistent or recurring episodes. The average age of oneset is 16 years old, although symptoms can begin in childhood. Less than 5% of adults experience onset of depersonalization/derealization disorder after age 25 (American Psychiatric Association, 2013).
Social Consequences of Depersonalization/Derealization Disorder
The DSM-5 explains that symptoms of depersonalization/derealization disorder can interfere with work, school and relationships. Feeling disconnected from self or surroundings can lead to difficulty in focusing, learning and performing. Emotional disconnectedness can impair relationships (American Psychiatric Association, 2013).
Comorbidity
Depersonalization/derealization disorder often occurs with anxiety, depression or both (American Psychiatric Association, 2013). Patients diagnosed with post traumatic stress disorder and panic disorders are also likely to experience symptoms of depersonalization/derealization disorder (Weiner and McKay, 2013). Avoidant personality disorder, borderline personality disorder and obsessive-compulsive disorder are the most common comorbid personality disorders (American Psychiatric Association, 2013).
Depersonalization/Derealization Disorder and Trauma
Although Trauma and history of abuse are not diagnostic features of depersonalization/derealization disorder, they are common predictors. During traumatic events, such as abuse, assault, or an accident, it is common for people to experience symptoms associated with depersonalization/derealization disorder. It is believed that depersonalization or derealization can protect the psyche from the pain of the trauma. Similarly, adults with a history of childhood abuse are more likely than the general population to meet diagnostic criteria for depersonalization/derealization disorder (Guralnik and Simon, 2010). Although physical and sexual abuses are traumatic and can lead to dissociative symptoms, emotional abuse is the most common factor associated with depersonalization/derealization disorder. Specifically, childhood experiences of rejection, terror, exploitation, isolation and denial of emotional response are associated with adulthood depersonalization/derealization disorder (Hunt, 2010). The DSM-5 explains that although trauma is a factor in the development of depersonalization/derealization disorder, tempermental factors such as being harm-avoidant, or emotionally immature also contribute.
Depersonalization/Derealization Disorder and the Brain
Several regions of the brain have been implicated in depersonalization/derealization disorder. The sensory cortex is responsible for gathering and relaying information to areas of the brain that process sensory information. During episodes of depersonalization or derealization, the sensory cortex is overactive. The amygdala, which regulates emotional response in the brain, has been found to be underactive in individuals with depersonalization/derealization disorder. This can result in the sense of emotional numbness common among depersonalization/derealization disorder patients. The insula, which registers sensation within the body, is also under active in depersonalization/derealization disorder patients. The hippocampus is responsible for narrative memory. Sometimes, such as in trauma situations the hippocampus fails to store information. Several theories aim to explain how the brain works during a depersonalization/derealization episode. The overall belief is that the parts of the brain responsible for sensory information, emotions and memory are not working together, and that overactivity in some regions and simultaneous under activity in others can create symptoms and sensations associated with depersonalization/derealization disorder (Hunt, 2010).
Treatment of Depersonalization/Derealization Disorder
Treatment of depersonalization/derealization disorder varies greatly depending on the theoretical approach of the therapist. Because certain brain functions are implicated in depersonalization/derealization disorder, many doctors find that medications, such as antidepressants and anticonvulsants are helpful. These drugs change the way the brain responds to emotional and sensational stimuli. Still, no medication can resolve the symptoms of depersonalization/derealization disorder without therapy. The psychoanalytical model approaches depersonalization/derealization disorder as a defense against internal conflict or threat of the self, usually the result of childhood abuse. From this approach, depersonalization/derealization disorder is treated by exploring and overcoming averse childhood circumstances (Medford, et al., 2005).
In addition to treating past trauma that may have triggered depersonalization/derealization disorder, many therapists approach treatment by establishing and strengthening coping skills. Important skills to challenge depersonalization/derealization disorder symptoms include emotional regulation, adapting to life post-trauma, interpersonal skills and development of a healthy self-identity. Although developing coping skills is important, it should never replace dealing with the trauma or series of traumatic experiences that preceded depersonalization/derealization disorder. Depersonalization/derealization disorder symptoms are a method of avoiding painful feelings and can only be treated when the patient can face the feelings associated with the trauma (Medford, et al, 2005).
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Guralnik, O. & Simeon, D.(2010). Depersonalization: standing in the spaces between recognition and interpellation. Psychoanalytic Dialogues. 20(4) (2010): 400-416
Hunt, G, (2010).Existence in a Shambles: Examining the Curious Case of Depersonalization Disorder. Colonial Academic Alliance.
Medford, N., Sierra, M., Baker, D. & David, A.S.(2005). Understanding and treating depersonalisation disorder. Advances in Psychiatric Treatment. 11: 92-100
Weiner, E. & McKay, D. (2013). A preliminary evaluation of repeated exposure for depersonalization and derealization. Behavior Modification. 37(2): 226-42
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