Depersonalization-derealization disorder (DPDR) is a dissociative disorder in which the person experiences or has persistent or recurrent feelings of depersonalization or derealization. Depersonalization is a feeling of being disconnected or detached from oneself. Individuals may report feeling as if they are an outside observer of their own thoughts or body, and often report feeling a loss of control over their thoughts or actions. Derealization is described as detachment from one's surroundings. Individuals experiencing derealization may report perceiving the world around them as foggy, dreamlike, surreal, detached or visually distorted.
Depersonalization-derealization disorder is thought to be caused largely by interpersonal trauma such as early childhood abuse or intense amounts of trauma experienced within a short period of time. Adverse childhood experiences, specifically emotional abuse and neglect, have been linked to the development of depersonalization symptoms. Feelings of depersonalization and derealization are common from significant stress, anxiety, or panic attacks. Individuals may remain in a depersonalized state for the duration of a typical panic or stress attack. However, in some cases, the dissociative state may last for hours, days, weeks, or even months. In rare cases, symptoms of a single episode can last for years. Cases like these are caused by severe amounts of abuse, trauma and stress.
Diagnostic criteria include persistent or recurrent feelings of detachment from one's mental or bodily processes or from one's surroundings. A diagnosis is made when the dissociation is persistent, interferes with the social or occupational functions of daily life, or causes marked distress in the patient. While brief episodes of depersonalization or derealization are common in the general population, the disorder is only diagnosed when these symptoms cause substantial distress or impair functioning.
While once considered rare, about 1–2% of the general population are affected at some point. The long-term form of the disorder affects about 0.8 to 1.9%.
Signs and symptoms The core symptoms of depersonalization-derealization disorder are the subjective experience of "unreality in one's self", or detachment from one's surroundings. Individuals who are diagnosed with depersonalization also often experience an urge to question and think critically about the nature of reality and existence often leading to extended periods of contemplation.
Individuals with depersonalization describe feeling disconnected from their physicality; feeling as if they are not completely occupying their own body; feeling as if their speech or physical movements are out of their control; feeling detached from their own thoughts or emotions; and experiencing themselves and their lives from a distance. While depersonalization involves detachment from one's self, individuals with derealization feel detached from their surroundings, as if the world around them is foggy, dreamlike, or visually distorted. Individuals with the disorder commonly describe a feeling that time is passing them by and that they are not in the present. In some cases, individuals may be unable to accept their reflection as their own, or they may have out-of-body experiences. Additionally some individuals experience difficulty concentrating and problems with memory retrieval. These individuals sometimes lack the "feeling" of a memory, recalling it but feeling as if they did not personally experience it. These experiences which strike at the core of a person's identity and consciousness may cause a person to feel uneasy or anxious. The inner turmoil created by the disorder can also result in depression.
First experiences with depersonalization may be frightening, with patients fearing loss of control, dissociation from the rest of society, and functional impairment. The majority of people with depersonalization-derealization disorder misinterpret the symptoms, thinking that they are signs of serious psychosis or brain dysfunction. This commonly leads to an increase in anxiety and obsession, which contributes to the worsening of symptoms.
Factors that tend to diminish symptoms are comforting personal interactions, intense physical or emotional stimulation, and relaxation. Distracting oneself (by engaging in conversation or watching a movie, for example) may also provide temporary relief. Some other factors that are identified as relieving symptom severity are diet or exercise, while alcohol and fatigue are listed by some as worsening their symptoms.
Many members of the general population can experience occasional, brief moments of mild depersonalization; however, depersonalization-derealization disorder occurs when these feelings are strong, severe, persistent, or recurrent and when these feelings interfere with daily functioning. DPDR is most commonly experienced as chronic and continuous. However, for a minority who have DPDR as an episodic condition, the duration of these episodes is highly variable, with some lasting as long as, or longer than, several weeks.
Causes The exact cause of depersonalization is unknown, although biopsychosocial correlations and triggers have been identified. It has been thought that depersonalization can result from a biological response to dangerous or life-threatening situations, leading to heightened senses and emotional numbing. Trauma such as witnessing or experiencing domestic violence, accidents or natural disasters, sudden death of a loved one, or having a parent with severe mental illness can cause DPDR.
Recreational substance use, particularly cannabis, ketamine, and other hallucinogens, has also been identified as a trigger for episodes of depersonalization and derealization, precipitating a form of the disorder called hallucinogen persisting perception disorder.
Psychosocial There is growing evidence linking physical and sexual abuse in childhood with the development of dissociative disorders. Childhood interpersonal trauma – emotional abuse in particular – is a significant predictor of a diagnosis of DPDR. Compared to other types of childhood trauma, emotional abuse has been found to be the most significant predictor both of a diagnosis of depersonalization-derealization disorder and of depersonalization scores, but not of general dissociation scores. Some studies suggest that greater emotional abuse and lower physical abuse predict depersonalization in adult women with post-traumatic stress disorder (PTSD). Patients with high interpersonal abuse histories (HIA) show significantly higher scores on the Cambridge Depersonalization Scale, when compared to a control group. Earlier age of abuse, increased duration and parental abuse tend to correlate with severity of dissociative symptoms. Besides traumatic experiences, other common precipitators of the disorder include severe stress, major depressive disorder or panic attacks.Simeon D: Depersonalisation disorder: a contemporary overview . CNS Drugs. 2004. People who live in highly individualistic cultures may be more vulnerable to depersonalization due to a hypersensitivity towards threats and fears of losing control.
A 2010 study found evidence that some users participating in virtual reality (VR) may be more likely to experience dissociation after use. Users reportedly experienced higher levels of a lessened sense of presence in reality after exposure to VR. However, it was noted that the effects of exposure were likely to rapidly disappear after returning to objective reality. Additionally, individuals who reported higher preexisting dissociation levels, as well as being more easily immersed or absorbed in imagination overall, were found to be linked to higher increases in dissociative symptoms after the VR exposure. This study offered evidence towards a link between imaginative processes of the brain and dissociative experiences.
Neurobiology
There is converging evidence that the prefrontal cortex may inhibit neural circuits that normally form the basis of emotional experience. In an fMRI study of DPDR patients, emotionally aversive scenes activated the right ventral prefrontal cortex. Participants demonstrated a reduced neural response in emotion-sensitive regions, as well as an increased response in regions associated with emotional regulation. In a similar test of emotional memory, depersonalization-derealization disorder patients did not process emotionally salient material in the same way as did healthy controls. In a test of skin conductance responses to unpleasant stimuli, the subjects showed a selective inhibitory mechanism on emotional processing.
Studies are beginning to show that the temporoparietal junction has a role in multisensory integration, embodiment, and self-other distinction. Several studies analyzing brain MRI findings from DPDR patients found decreased cortical thickness in the right middle temporal gyrus, reduction in grey matter volume in the right caudate, thalamus, and occipital gyri, as well as lower white matter integrity in the left temporal and right temporoparietal regions. However, no structural changes in the amygdala were observed.
A PET scan found functional abnormalities in the visual, auditory, and somatosensory cortex, as well as in areas responsible for an integrated body schema.
One study examining EEG readings found frontal alpha-wave overactivation and increased theta activity waves in the temporal region of the left hemisphere.
It is unclear whether genetics plays a role; however, there are many neurochemical and hormonal changes in individuals with depersonalization-derealization disorder. DPDR may be associated with dysregulation of the hypothalamic-pituitary-adrenal axis, the area of the brain involved in the "fight-or-flight" response. Patients demonstrate abnormal cortisol levels and basal activity. Studies found that patients with DPDR could be distinguished from patients with clinical depression and posttraumatic stress disorder.
The vestibular system may also play a role in DPDR. The vestibular system helps control balance, spatial orientation, and motor coordination, but also plays a role in self-awareness. Disruption to this system can potentially cause a feeling of detachment from surroundings. Several studies have shown that patients with peripheral vestibular disease are also more likely to have dissociative symptoms when compared to healthy individuals.
Dissociative symptoms are sometimes described by those with neurological diseases, such as amyotrophic lateral sclerosis, Alzheimer's, multiple sclerosis (MS), etc., that directly affect brain tissue.
Diagnosis Assessment Diagnosis is based on the self-reported experiences of the person followed by a clinical assessment. Psychiatric assessment includes a psychiatric history and some form of mental status examination. Since some medical and psychiatric conditions mimic the symptoms of DPDR, clinicians must differentiate between and rule out the following to establish a precise diagnosis: temporal lobe epilepsy, panic disorder, acute stress disorder, schizophrenia, migraine, drug use, brain tumor or lesion. No laboratory test for depersonalization-derealization disorder currently exists.Depersonalization Disorder, (DSM-IV 300.6, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) As patients with dissociative disorders likely experienced intense trauma in the past, concomitant dissociative disorders should be considered in patients diagnosed with a stress disorder (i.e. PTSD or acute stress disorder).
The diagnosis of depersonalization-derealization disorder can be made with the use of the following interviews and scales: The Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) is widely used, especially in research settings. This interview takes about 30 minutes to 1.5 hours, depending on the individual's experiences.