Depersonalisation and derealisation: assessment and management

Who experiences depersonalisation and derealisation?

Otherwise healthy people—Transient symptoms of depersonalisation and derealisation are very common in the general population, often during periods of stress or fatigue. One US phone study of more than 1000 people found that nearly a quarter reported a brief episode over the previous one year period.1

Those with a range of physical and mental health conditions—Such symptoms are also commonly associated with several medical conditions, such as migraine and temporal lobe epilepsy,2 and with psychiatric conditions, particularly anxiety disorders, such as panic, depression, or in those with complex post-traumatic stress or personality disorders who report a history of childhood abuse or trauma.3

Those with depersonalisation and derealisation disorder as a primary diagnosis—Less well known is that the symptoms of depersonalisation and derealisation can also occur as a chronic primary mental health disorder called depersonalisation derealisation disorder (DPRD). These symptoms can cause distress and affect quality of life and function. Case series from the UK,4 Germany,5 and the US6 find the primary disorder of DPRD affects men and women roughly equally. Several robust epidemiological surveys indicate prevalence rates over the past month of clinically significant DPRD at around 1% of the general population3 and at 5% within psychiatric outpatient samples.7 Data suggest that DPRD can be underdiagnosed, or the diagnosis is delayed, with patients typically waiting between seven and 12 years for a diagnosis.45 If left untreated the disorder can have an unremitting course lasting years. Patients report that early diagnosis and information-giving help alleviate the distress typically associated with this condition and promote recovery.

The infographic that accompanies this article summarises the main categories of people who experience depersonalisation and derealisation.

What symptoms do people describe?

Patients might use the language in Box 1 and infographic (see appendix files) when putting their experience into words. Such phrases used by patients might suggest the need for further questioning.

Alongside the core symptoms of unreality and detachment, people with depersonalisation and derealisation can describe emotional numbing of positive and negative emotions, and experiences affecting specific parts, or all, of their body. They might report that parts of their body (their reflection, voice, or hands) don’t feel like they belong to them and that their actions feel robotic. They might experience blurred vision or perceptual distortions, such as seeing the world in two dimensions. Obsessive existential thoughts about the meaning of life might be present. The person might complain about difficulty concentrating or remembering but these problems are typically not accompanied by clear-cut objective cognitive deficits such as memory or attention impairments on formal testing.8

Patients with depersonalisation and derealisation are aware that their experiences are subjective and do not reflect reality, but might present urgently seeking help because of fears that their symptoms indicate incipient psychosis or brain dysfunction. However, the “as if . . .”quality to their descriptions helps to distinguish those with depersonalisation and derealisation from those experiencing psychosis, as the former will not have accompanying hallucinations or delusional beliefs. In US psychiatric classification systems,9 depersonalisation derealisation disorder is categorised as a dissociative disorder due to the sense of detachment experienced. However it is distinguishable from other dissociative disorders in that discontinuities of memory and identity are rare.

What triggers depersonalisation and derealisation

Current evidence is insufficient to fully characterise or quantify associations with life events or other diagnoses, or to predict who will or won’t develop symptoms. However, what data exist suggest that there are some life events and diagnoses that are associated with transient or intermittent symptoms and with the more chronic disorder.

There is a strong association of depersonalisation or derealisation symptoms starting during a period of acute stress. This has led to the current understanding that DP DR is part of a normal physiological or psychological coping mechanism (“like a circuit breaker”) that is designed to protect us from overwhelming anxiety by creating a sense of detachment and numbing.1011 However, in some cases this normally transient coping mechanism can become maintained, leading to the chronic disorder of DPRD.11

How to assess and manage someone with symptoms

The suggested key principles for when someone presents with symptoms of depersonalisation or derealisation are laid out in the infographic (appendix files). This guide is compiled based on research evidence and clinical experience from authors based at the specialist London based NHS Depersonalisation Disorder Clinic. Try to distinguish between transient or intermittent symptoms; those that might be suggestive of a concurrent physical or mental health problem where the DP DR is secondary; or symptoms that are suggestive of the chronic disorder of DPRD. Remember DPRD can be a primary disorder or it can be a comorbid problem in the context of substantial history of trauma or a primary mental health disorder. If the latter, then address this history. If there is no significant history of trauma then treat as a primary disorder by following the guidance in this article.

Assessing symptoms of DP DR—The hardest differential diagnosis is when both an anxiety disorder and depersonalisation derealisation disorder are present and distressing. In these cases it is worthwhile monitoring both conditions on a monthly basis, and if the DP DR does not resolve within a few months, to assume that this is primary DPRD, and to follow the recommendations for this. Box 2 shows a scoring system to assist with assessment of DP DR symptoms.

Management of DP DR symptoms—In all cases, when there are DP DR symptoms present, normalise these symptoms by explaining the common association with acute stress and fatigue, as well as giving hope that these symptoms are likely to resolve in time. Signpost patients to sources of support (see Box ‘Patient resources’).

Treatment for primary depersonalisation derealisation disorder—The evidence base for empirically validated treatments for DPRD is extremely limited. Small open studies suggest some interventions may be promising, but need to be treated with caution. Psychotherapeutic approaches such as cognitive behavioural therapy, specifically adapted for DPRD, have shown good results but are only available in specialist settings.13 Mindfulness approaches could be beneficial.14 A study of lamotrigine as an adjunct therapy reported dose related benefits,15 as did studies using opiate antagonists.1617 Repetitive transcranial magnetic stimulation has also been tried and the results show promise.1819

The older literature confirms the large number of treatments tried but ineffective, including anticonvulsants, stimulants, and even electroconvulsive therapy.20 A recent systematic review21 found only three double blind randomised control trials (RCTs), with inconsistent results. One RCT involved lamotrigine, which blocks ketamine induced depersonalisation.22 The second trial had no effect, albeit approaching statistical significance.23 An RCT of fluoxetine found it no more efficacious than placebo,24 although with a trend for efficacy in those with a comorbid anxiety disorder. An RCT using biofeedback found no significant therapeutic benefit.25