Depersonalisation-derealisation disorder

Patients with depersonalisation-derealisation disorder can experience either symptoms of depersonalisation, derealisation or both.

(Read more: Mental health)

Presentation of depersonalisation

• Out of body experiences or often feeling as if the person is looking down upon themself from above or observing themself as an outsider.
• Experiencing a sense of detachment from one’s physical being, as if the patient does not possess a body.
• The senses may feel muted or turned off altogether and a feeling of numbness may ensue.
• Experiencing a lack of control over one’s own thoughts, words and/or actions.
• Perception of one's body parts being disproportionately larger or smaller.
• Inability to emote upon recalling memories that now feel too alien or foreign.

Presentation of derealisation

• Inability to recognise familiar surroundings or feelings as though they are or have become visually distorted, hazy, imaginary or dreamt up.
• Feeling like a glass wall separates one from the world; as if one can watch but not interact with it.
• Believing that one's surroundings are not real and experiencing them as distorted. Often the sense of depth perception feels lost and objects may appear unnaturally flat, too far or too close. Things can also appear disproportionate in size.
• Sense of time can seem distorted to the individual; occurrences of the past can appear like recent happenings and current events can feel like old news.

While the exact cause of depersonalisation-derealisation disorder remains unclear, research has made it evident that an interplay of factors, including genetics, predisposing personality traits and environmental elements like emotional or sexual abuse are to blame for it.

It is believed that emotional trauma to the psyche in early childhood is the most significant predictor of future development of depersonalisation-derealisation disorder. Coping mechanisms and escapist tendencies developed to further oneself from traumatic, abusive and violent environments can later on manifest as derealisation or depersonalisation. Furthermore, certain stressful events, traumatic incidents or drug and substance abuse can trigger episodes of depersonalisation and derealisation. Lastly, newer evidence has been uncovered that suggests anatomical variations in the structures of the brain that control emotions are linked to depersonalisation-derealisation disorder.

Following can be the causes, risk factors and triggers of depersonalisation-derealisation disorder:

• Early childhood abuse: Growing up in an abusive or violent environment can precipitate tendencies in children to separate themselves from their traumatic circumstances. These tendencies can later, with age, manifest as depersonalisation and derealisation. Emotional abuse has been found to be strongly associated with depersonalisation derealisation disorder. The earlier the age of onset of abuse and greater the duration, the more severe the dissociative symptoms are.
• Post traumatic stress disorder (PTSD): Dissociative subtype of post traumatic stress disorder is known to occur in a section of people who have undergone or experienced extreme violence, wars, kidnappings or sexual abuse. Dissociative symptoms of depersonalisation and derealisation arise in response to triggers that make the individual remember and mentally relive the initial traumatic episode. While not all suffering from post traumatic stress disorder present this way, dissociative symptoms are not unheard of.
• Severe stress: Periods of undue emotional or mental stress can act as a trigger for already susceptible people to experience depersonalisation-derealisation disorder. In a subconscious attempt to escape the mental duress caused by the situation at hand, such individuals often develop dissociative symptoms. (Read more: Home remedies for stress)
• Major depressive disorder: In addition to classical symptoms, such as hopelessness, suicidal thoughts, loss of motivation and pleasure (anhedonia), that define major depressive disorder (MDD), dissociative symptoms too are suggested to play a role in depression. Hopelessness is found to induce tendencies in patients to segregate themselves from distressing thoughts and feelings that can be too hard for them to accept. Derealisation and depersonalisation can arise in a small subset of depressed persons.
• Panic attacks: Although not all individuals experiencing panic attacks display dissociative signs, derealisation is a common occurrence in youth undergoing an episode. Symptoms of derealisation like dissociating from time, place and person, can further overwhelm the child.
• Psychoactive substance use: Many recreationally abused drugs act on the principle of delivering the taker a “high” or momentary sensation of departure from the realities of life. With chronic misuse, dissociative symptoms set in, making it increasingly difficult to distinguish the real from the imagined. Drugs associated with dissociative disorders include:
  • Marijuana
  • Hallucinogens
  • MDMA
  • Ketamine
  • Salvia
• Highly individualistic societies: Some evidence exists that in societies that foster the culture of individualism, depersonalisation-derealisation disorder may be more common.
• Brain anatomy: Various neurobiological models have hypothesised, some even supported by different brain imaging studies, that variations in structures of certain areas of the brain may be associated with depersonalisation-derealisation disorder. A recent study suggests the importance of the amygdala and its connections with the medial prefrontal cortex in controlling emotions can play a crucial role in dissociative mental disorders.

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Before a diagnosis of depersonalisation-derealisation disorder is made, the following things are considered:

• Medical history: The doctor will begin assessment by taking a proper medical history, with special emphasis on childhood trauma and possible substance abuse. Additionally, other medical illnesses that can produce symptoms that mimic those of depersonalisation-derealisation disorder may also be uncovered.
• Physical examination: Afterwards, a neurological examination will be conducted to rule out other brain related conditions. This may require the aid of laboratory and radiological imaging studies.
• Laboratory investigations:
  • Complete blood count: Altered ratio of blood cells can indicate possible infection, including that of the brain and its covering.
  • Blood glucose levels: Abnormally low (hypoglycaemia) or high (hyperglycaemia) levels can bring about psychological symptoms.
  • Blood levels of drugs, alcohol and other substances: To rule out intoxication or even withdrawal.
  • Kidney function tests: Toxin buildup due to failing kidneys or electrolyte imbalance can alter mental status.
  • Liver function tests: Liver disease can at times produce encephalopathy of the brain, which presents with mental symptoms.
  • Lumbar puncture and cerebrospinal fluid (CSF) analysis: This might indicate meningitis or brain infection, which can produce similar symptoms.
• Imaging studies:
  • EEG: An electroencephalogram reads the brain waves and helps diagnose epilepsy.
  • MRI: An MRI proves useful in visualising a space occupying lesion or tumour that could be producing the symptoms by compressing key structures.
  • CT scan: Another imaging modality used for a similar purpose as MRI.
  • Psychiatric evaluation: The doctor will interview the patient about their thoughts, feelings, memories, actions and identity. Alongside this, the patient’s mental status will also be evaluated. Self-reported questionnaires, like the Cambridge Depersonalisation Scale, are filled out by patients. Lastly, reality testing is carried out to differentiate between psychosis (where it’s impaired) and dissociation (wherein it’s intact).

The above information is compiled and then matched with the standard DSM-5 diagnostic criteria to arrive at a diagnosis.

Many other conditions, including similar mental disorders, can mimic depersonalisation-derealisation disorder and must be ruled out first before labelling as such and beginning definitive treatment. 

• Major depressive disorder
• Illness anxiety disorder: Also called hypochondria, illness anxiety disorder causes the patient to believe minor or wholly perceived physical symptoms are due to a serious illness.
• Obsessive compulsive disorder: Some patients with depersonalisation-derealisation disorder might obsessively check on their symptoms. However, other criteria of obsessive compulsive disorder (OCD) are absent.
• Other dissociative disorders
• Anxiety disorders (especially panic disorders and panic attacks)
• Psychotic disorders: The major difference between the two is that in a dissociative disorder, the patient is aware that something is “off” and that their symptoms of depersonalisation and derealisation are not normal. However, with psychotic disorders, all sense of reality is lost.
• Substance/medicine-induced disorders: Illicit substances like marijuana, ecstasy, ketamine and MDMA are the usual culprits.
• Neurological diseases: In cases that present atypically, for example with a late onset after 40 years of age, brain diseases may be culpable:
  • Metabolic derangement (for example, hypoglycaemia)
  • Epilepsy
  • Other causes of seizures
  • Migraines
  • Vertigo
  • Ménière’s disease
  • Brain tumours
  • Substance intoxication or withdrawal

Depersonalisation-derealisation disorder is mostly managed with psychotherapy. Adjunct medication can be prescribed to assuage the symptoms of linked mental conditions. 

Psychotherapy: Commonly called talk therapy or counselling, psychotherapy is employed to help patients under the guidance of qualified professionals, gain control over the distressing symptoms until they go away entirely or become easier to manage. Two kinds of psychotherapy are available:

• Cognitive behavioural therapy
• Psychodynamic therapy

The aim of counselling is to:

• Understand why symptoms arise
• Develop coping strategies to deal with stressful situations
• Address past psychological trauma
• Manage associated depression or anxiety
• Learn methods to distract you from the symptoms and regain a connection to the world and oneself by using grounding techniques (employing the five senses, playing loud music or holding an ice cube) amongst others

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Medical therapy: No specific drug therapy for depersonalisation-derealisation disorder exists yet. However, associated major depressive disorder or anxiety disorders can be treated or managed with medication.

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Depersonalisation-derealisation disorder can usually be effectively managed with correct diagnosis and proper psychotherapy, allowing the individual to lead a healthy and meaningful life.