Depersonalization and derealization: dissociative symptoms

In the current Statistical Diagnostic Manual of Mental Disorders (DSM-5, APA 2013), the Depersonalization and Derealization Disorder (DDD) is inserted within the Dissociative Disorders.  It consists of an altered state of self-awareness that results in persistent or recurrent episodes of detachment or separation from oneself ( depersonalization ), from the surrounding environment ( derealization ) or both, during which the reality examination remains intact.

Considering the lifetime prevalence estimate of approximately 2% of the world population (Sierra, 2009), it undoubtedly represents a clinical condition of some relevance. Nonetheless, most psychiatrists believe that depersonalization and derealization are extremely rare or even non-existent (Sierra, 2009). This may also be attributable to the insufficient training clinicians receive on the evaluation of Dissociative Disorders .

After all, it is important to remember that dissociative psychopathology is a hidden psychopathology (Kluft, 2009). Usually the patient comes to the psychological consultation with other issues (for example, panic disorder , post-traumatic stress disorder , major depression, just to name a few) and thus certain symptoms can be hidden or minimized (Gonzalez, 2013). Furthermore, the subjective characteristic according to which people feel estranged and separated from their own self (depersonalization) and their surroundings (derealization) makes detection complex. Their behavior may appear strange but there are no specific behaviors that would lead an outside observer to suspect this disorder simply by observing people or interacting with them.

Dissociation, depersonalization and derealization

With reference to dissociative symptoms , Holmes et al. (2005) suggested distinguishing it into two broad categories: detachment and compartmentalization. Symptoms of compartmentalization have to do with the disintegration of higher mental functions induced by the traumatic event. So for example they concern dissociative amnesia (ie the inability to remember important autobiographical information). The dissociative symptoms of detachment instead all refer to the experience of feeling alienated from one’s emotions, from one’s body, from the usual sense of one’s identity (Liotti and Farina, 2011).

Dissociative symptoms of detachment include depersonalization and derealization .

Dissociative symptoms of detachment

  • By depersonalizationwe mean a subjective experience of unreality, detachment or estrangement from one’s own identity, one’s thoughts, feelings, emotions, as well as from one’s body. It induces disturbing sensations that include a sense of non-existence, of feeling out of one’s body, as an external observer of oneself (Sierra, 2009). Depersonalization is associated with a decrease or loss of emotional reactivity, as a kind of physical and emotional numbness (APA, 2013). This emotionally numb condition can range from relatively bearable forms that patients describe as feeling ‘distant from things’, or emotionally uninvolved, to extreme forms of total annihilation and inner death. People report experiencing a strange feeling ofdisconnection from their body , something they have never experienced before: they feel as if they are living an out-of-body experience, of total detachment, as if they were in a dream or watching each other in a film. The person may feel detached from their whole being (” I am nobody “), as well as from aspects of their Self, such as feelings (” I know I have emotions but I don’t feel them “), thoughts (” My thoughts don’t seem mine ” ), body or parts of the body (“ I look in the mirror and I don’t recognize myself ”).
  • The derealisationhas characteristics similar to depersonalization but refers to the feeling of unreality, detachment or alienation from the world, be it represented by people, inanimate objects or the whole surrounding environment. The person may feel as if he is in the fog, or as if there is a veil or glass wall between himself and the surrounding world. In this state you have the feeling of being separated from the outside world to the point that this can appear distorted and unreal, not recognizable: objects can be of different shapes and sizes, the perception of time changes as if it were flowing too fast or too slowly; sounds may be louder or softer than expected. Perceptual alterations emerge as if you are not familiar with the surrounding reality which can appear flat,

From normal phenomenon to mental disorder

The depersonalization and derealization can be transient and common phenomena in the general population (among others, Seth, Suzuki & Critchley, 2012). They can occasionally emerge as side effects of medications or drug use, particularly cannabis (Madden & Einhorn, 2018).

Even serious events, such as the unexpected death of a loved one, a serious car accident, or any traumatic event (i.e. an event that overwhelms the individual’s stamina), can involve a response that includes depersonalization and derealization.. These responses, by themselves, are not necessarily abnormal or unusual in serious situations; rather they are normal reactions of normal people to abnormal events. Just think of what it might feel like to witness a terrible car accident or to receive devastating news. It is now clear that there is a first shock phase in which you feel a sense of confusion, alienation, unreality, disorientation, as if what we are experiencing was not real, as if it were a dream or in any case something lived from a perspective external to ourselves. The feeling of not being connected to one’s body or to the surrounding reality at that moment is therefore an acute physiological reaction to stress useful for maintaining a certain detachment from the event,

This consideration opens to the reflection on whether the dissociative symptoms of detachment  represent a defense mechanism of the brain from the mental pain evoked by the traumatic event or if, taking up Janet’s (1907) idea, dissociative symptoms are nothing more than the consequence devastating ( désagrégation ) of the dissolution of the functions of consciousness induced by the vehement emotions of the trauma.

In any case, regardless of the explanation of the dissociative phenomenon, the individual’s response becomes pathological when the symptoms of depersonalization-derealization either generalize to other situations, manifest themselves in an uncontrollable way, or persist beyond the immediate threat. Hence the emergence of the DDD.

The causes of depersonalization-derealization disorder

As in the case of other Dissociative Disorders , DDD is mostly the consequence of having lived through multiple and / or chronic traumatic experiences, protracted over time, in large spans of individual development (van der Kolk, 2005). It is important to underline that by traumatic experiences we mean not only the traumatization in terms of physical, emotional and sexual abuse but also the condition of parental neglect.

As previously said, the main criterion of DDD consists of persistent or recurrent episodes in which the person experiences a sense of unreality and a profound detachment from himself and the surrounding world , to the point of perceiving himself as an external observer, an automaton, inside a a dream.

The feeling of detachment associated with depersonalization and derealization is similar to watching events and activities as if they were unfolding in a movie or computer screen. However, at all times, the person remains aware of both their thoughts and what is happening around them. Unlike psychotic disorders , in fact, patients with DDD are generally aware that their perception is altered and that their experiences of detachment are not real. However, since these sensations are very intense and likely to generate confusion, patients with DDD can fear the risk of going crazy when they experience the feelings of detachment typical of depersonalization / derealization.. In this regard, it may happen that the symptoms of depersonalization / derealization act as a trigger for a panic attack in which the person interprets the symptoms of unreality and detachment as a sign of a threat to their cognitive safety (for example, the fear of going crazy) . These persistent and recurring episodes of strangeness can cause extreme distress and make normal daily functioning difficult at work, school, or in a social setting.

Treatment of depersonalization and derealization disorders

Somer, Amos-Williams & Stein (2013), analyzing all randomized controlled trials of pharmacotherapy and psychotherapy for the treatment of Depersonalization-Derealization Disorder , showed inconsistent evidence for pharmacological efficacy and no efficacy for other interventions.

Pharmacologically, most drugs prescribed to patients with DDD fall into the categories of antidepressants and anxiolytics and are administered primarily for the purpose of relieving comorbid anxiety and mood symptoms , but do not appear to treat dissociative disease. . To date, in fact, despite the fact that the literature includes some trials on the administration of clomipramine, serotonin reuptake inhibitors (SSRIs), and lamotrigine (Somer et al., 2013), no pharmacological treatment has been found to reduce dissociation by itself. .

At the psychotherapeutic level, the standard treatment model, now widely recognized for Dissociative Disorders, is the so-called phase-oriented model (van der Hart, Nijenhuis & Steele, 2011) structured in 3 phases:

  1. The first stage is the so-called stabilization and reduction of symptoms. In this phase, the main task of the therapy is to obtain conditions of safety for the patient both within the therapeutic relationship and outside the therapy with the stabilization of the most disabling symptoms (for example, symptoms of dissociative detachment, impulsive acts and risky behaviors, dysregulated emotions). In this phase, the goal of helping the person to manage dissociative symptoms becomes central thanks to emotional stabilization exercises, the creation of skills and the increase of positive experiences and emotions in the patient’s life, in addition to grounding(anchoring to the present moment) useful to allow a form of grounding in reality. For example, stimulating orientation reflexes in the present by passing an object (for example, a stuffed toy ball) or asking to describe some elements of the surrounding environment helps the person to feel more in touch with reality.
  2. The second phase involves the processing of the traumatic memories underlying the Depersonalization-Derealization Disorder. An effective approach to the work of desensitization and re-processing of traumatic events is the Eye Movementt Desensitization and Reprocessing (EMDR, Shapiro 2001).
  3. Finally, the third phase involves the integration of the personality, that is, the consolidation of resources and of what the person has achieved in the previous phases until a unified sense of self is reached.

This successive phase path almost never follows a linear trend. More often it has been described in the form of a spiral, in which it is necessary to circle the previous stages.

Obviously, the success of any psychotherapy intervention passes through an accurate assessment of the clinical specificity and the choice of interventions that may be more suitable for that person at that time.


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