Depersonalisation-derealisation disorder

Depersonalisation-Derealisation Disorder (DDD) is a dissociative disorder characterised by periods of feeling disconnected from the body and thoughts (depersonalisation or derealisation). Derealisation is a sense of unreality, alienation, separation from reality and distance. The experience of depersonalisation has been described as observing oneself from outside the body or being in a dream. Although individuals do not lose contact with reality, depersonalisation/derealisation disorder causes significant distress and disruption to daily functioning. An episode of depersonalisation-derealisation can last from a few minutes to many years.

Which symptoms are characteristic of depersonalisation and derealisation?

Short experiences of depersonalisation or derealisation are quite common. However, prolonged and recurrent episodes of these symptoms can cause problems at work, school or in other important areas of life. The experience and feelings associated with this condition can be difficult to describe. Worrying about 'losing your mind' can make you focus on constantly checking what is real. Symptoms usually begin in middle or late adolescence or early adulthood. Depersonalisation-derealisation disorder is rare in children and the elderly.

Symptoms of depersonalisation include:

• The feeling that you observe your thoughts, feelings, body or parts of it from the outside. For example, you may feel like you are floating in the air above you.
• A feeling of being robotic or having no control over what you say or how you move.
• A feeling that your body, legs or arms seem twisted or are the wrong shape. They may also seem bigger or smaller than usual. You may also feel like your head is wrapped in wool/ cotton.
• Emotional or physical numbing of your senses or reactions to the world around you.
• A feeling that memories are stripped of emotion and may or may not be your own memories. Not trusting your memories.

Symptoms of derealisation include:

• A feeling that people and surroundings are not real, as if you are living in a film or dream.
• A feeling of emotional disconnection from people you care about, as if you were separated by a glass wall.
• Distorted surroundings, perception of time, space and distance.
• Environments that look different from usual, blurry or colourless. Places can also appear as if they have only two dimensions and are therefore flat and lacking in depth. You may also be more aware of your surroundings, which may seem clearer than usual.
• Thoughts about time that are not real, such as recent events that seem like the distant past.
• Unrealistic thoughts about distance and the size and shape of objects.

Depersonalisation-derealisation episodes can last for hours, days, weeks or months. In some people, these episodes develop into continuous feelings of depersonalisation or derealisation, which may periodically improve or become exacerbated.

What is the difference between derealisation and depersonalisation?

Depersonalisation is the feeling of being disconnected or detached from one's own body, thoughts or feelings. Unlike psychotic disorders, people experiencing depersonalisation do not lose touch with reality. They recognise that their feelings are not in line with reality.

Derealisation, on the other hand, refers to a disconnection from one's surroundings and external environment. Other objects or people may seem unreal, as if from a dream. You are aware that you are in an altered state (so it is not a disconnection from reality), but the experience can be unsettling and disorientating.

Depersonalisation-derealisation disorder and others disorders

Depersonalisation/derealisation can co-occur in some psychiatric disorders such as schizophrenia, but can also result from neurological disorders such as migraine, or epilepsy (epilepsy).

In order to make a diagnosis of depersonalisation disorder, the symptoms must not only occur together with another disorder (e.g. epilepsy). A differential diagnosis for dissociative disorders is important here.

What is the impact of depersonalisation - derealisation on daily functioning?

Having episodes of depersonalisation or derealisation can be frightening and make it difficult for the person suffering from the disorder to function.

• It makes it difficult to focus on tasks or remember things.
• it interferes with work and other routine activities.
• Causes problems in relationships with family and friends.
• Makes you feel anxious, depressed or hopeless.

What are the causes of depersonalisation-derealisation disorder? What increases the risk of occurrence?

The cause of depersonalisation-derealisation disorder is not well understood. Some people may be more prone to depersonalisation and derealisation than others. This is probably due to genetic and environmental factors. High levels of stress and anxiety can trigger attacks. Symptoms of depersonalisation-derealisation disorder may be related to childhood trauma or other experiences or events that cause severe emotional stress or trauma.

Factors that may increase the risk of depersonalisation-derealisation syndrome are:

• Serious trauma in childhood or adulthood, such as experiencing or witnessing a traumatic event such as violence or abuse.
• Intense stress, such as serious relationship problems, financial or work-related problems.
• Depression or anxiety, especially severe depression, long-term depression or anxiety with panic attacks.
• Use of substances that can cause attacks of depersonalisation or derealisation

     - ketamine
     - hallucinogens
     - mdma
     - cannabis
  

Depersonalisation: when to seek professional help?

Transient feelings of depersonalisation are not always a cause for concern. However, continuous or severe feelings of detachment and distortion of the environment may be a sign of depersonalisation-derealisation disorder or another disorder. In these case, differential diagnosis and treatment carried out by a specialist is important.

Contact your physician if you experience symptoms of depersonalisation or derealisation that:

• are persistent or recurrent
• interfere with work, relationships or daily activities.

Depersonalisation - test

The most common tool for assessing the severity of symptoms of depersonalisation-derealisation disorder is the DES. It should be borne in mind that tests in themselves do not constitute a basis for a definite diagnosis. They are only a diagnostic tool, the results of which should always be analysed by a specialist and the diagnosis should be further supported by a medical history and the overall symptoms.

The physician determines the treatment based on the medical history, symptoms and underlying cause. The following can be recommend:

• medication (pharmacotherapy)
• psychotherapy such as cognitive behavioural therapy (CBT) or EMDR (Eye Movement Desensitisation and Reprocessing) therapy.
• Stress regulation exercises, including Biofeedback training, can help manage anxiety and stress, which can contribute to depersonalisation-derealisation symptoms.
• Neurostimulation: Studies on repetitive transcranial magnetic stimulation (rTMS) have shown a 44-68% reduction in depersonalisation-derealisation disorder symptoms, and rTMS has the potential to provide treatment without significant side effects.

• Neurostimulation therapy by means of TMS (transcranial magnetic stimulation)
• Pharmacotherapy

• Hunter, E. C. M., Phillips, M. L., Chalder, T., Sierra, M., & David, A. S. (2003). Depersonalisation disorder: a cognitive–behavioural conceptualisation. Behaviour Research and Therapy, 41(12), 1451-1467.
• Medford, N., Sierra, M., Baker, D., & David, A. S. (2005). Understanding and treating depersonalisation disorder. Advances in Psychiatric Treatment, 11(2), 92-100.
• Mantovani A, Simeon D, Urban N, Bulow P, Allart A, Lisanby S. Temporo-parietal junction stimulation in the treatment of depersonalization disorder. Psychiatry Res. 2011 Mar 30;186(1):138-40. doi: 10.1016/j.psychres.2010.08.022. Epub 2010 Sep 15. PMID: 20837362.
• Jay EL, Nestler S, Sierra M, McClelland J, Kekic M, David AS. Ventrolateral prefrontal cortex repetitive transcranial magnetic stimulation in the treatment of depersonalization disorder: A consecutive case series. Psychiatry Res. 2016 Jun 30;240:118-122. doi: 10.1016/j.psychres.2016.04.027. Epub 2016 Apr 13. PMID: 27104926; PMCID: PMC4906152.
• Wulf L, Palm U, Padberg F. Combined Therapies—rTMS meets CBT. Novel approach for the treatment of Derealization/Depersonalization Syndrome. L'Encéphale. 2019;45:S82
• Gatus A, Jamieson G and Stevenson B (2022) Past and Future Explanations for Depersonalization and Derealization Disorder: A Role for Predictive Coding. Front. Hum. Neurosci. 16:744487. doi: 10.3389/fnhum.2022.744487