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Depersonalization disorder consists of persistent or recurrent feelings of being detached from one's body or mental processes, usually with a feeling of being an outside observer of one's life. The disorder is often triggered by severe stress. Diagnosis is based on symptoms after other possible causes are ruled out. Treatment consists of psychotherapy.

About 20 to 40% of the general population have had a transient experience of depersonalization, frequently occurring in connection with life-threatening danger, acute drug intoxication (marijuana, hallucinogens, ketamine Some Trade Names
KETALAR
Click for Drug Monograph
, Ecstasy), sensory deprivation, or sleep deprivation. Depersonalization can also occur as a symptom in many other mental disorders as well as in physical disorders such as seizure disorders (ictal or postictal). When depersonalization occurs independently of other mental or physical disorders and is persistent or recurrent, depersonalization disorder is present. It is estimated to occur in about 2% of the general population.

Symptoms and Signs

Patients feel detached from their body, mind, feelings, or sensations. Most patients also say they feel unreal (derealization), like an automaton, or as if they were in a dream or in some other way detached from the world. Some patients cannot recognize or describe their emotions (alexithymia). Patients may describe themselves as the "walking dead." Symptoms are almost always distressing and, when severe, profoundly intolerable. Anxiety and depression are common.

Symptoms are often chronic; about ¹/₃ of patients have recurrent episodes, and ²/₃ have continuous symptoms. Episodic symptoms sometimes become continuous.

Patients often have great difficulty describing their symptoms and may fear or believe they are going crazy. They always retain the knowledge that their unreal experiences are not real but rather are just the way that they feel. This awareness differentiates depersonalization disorder from a psychotic disorder, in which such insight is always lacking.

Diagnosis

Diagnosis is based on symptoms after ruling out physical disorders, ongoing substance abuse, and other mental disorders (especially anxiety, depression, and other dissociative disorders). Initial evaluation should include MRI and EEG to rule out physical causes, particularly if symptoms or progression are atypical. Urine toxicology tests may also be indicated.

Psychologic tests and special structured interviews and questionnaires are helpful.

Prognosis

Patients often improve without intervention. Complete recovery is possible for many patients, especially if symptoms result from treatable or transient stresses or have not been protracted. In others, depersonalization becomes more chronic and refractory.

Even persistent or recurrent depersonalization symptoms may cause only minimal impairment if patients can distract themselves from their subjective sense of self by keeping their mind busy and focusing on other thoughts or activities. Some patients become disabled by the chronic sense of estrangement, by the accompanying anxiety or depression, or both.

Treatment

Treatment must address all stresses associated with onset of the disorder as well as earlier stresses (eg, childhood emotional abuse or neglect), which may have predisposed patients to late onset of depersonalization.

Various psychotherapies (eg, psychodynamic psychotherapy, cognitive-behavioral therapy) are successful for some patients:

• Cognitive techniques can help block obsessive thinking about the unreal state of being.
• Behavioral techniques can help patients engage in tasks that distract them from the depersonalization.
• Grounding techniques use the 5 senses (eg, by playing loud music or placing a piece of ice in the hand) to help patients feel more connected to themselves and the world and more real in the moment.
• Psychodynamic therapy focuses on underlying conflicts that make certain affects intolerable to the self and thus dissociated.
• Moment-to-moment tracking and labeling of affect and dissociation in therapy sessions works well for some patients.

Various drugs have been used, but none have clearly demonstrable efficacy. However, some patients are apparently helped by serotonin reuptake inhibitors, lamotrigine Some Trade Names
LAMICTAL
Click for Drug Monograph
, opioid antagonists, anxiolytics, and stimulants. However, these drugs may largely be targeting other mental disorders (eg, anxiety, depression) that are often associated with or precipitated by depersonalization.

Last full review/revision June 2008 by Daphne Simeon, MD

Content last modified June 2008