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Depersonalization/Derealization Disorder

Theory, Treatment, and Advocacy

Depersonalization/Derealization Disorder (DPDD) is identified as a dissociative disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Revision (DSM-5) and a neurotic disorder in the International Classification of Diseases, Tenth Revision (ICD-10). Although a consistent definition has been accepted by the psychology community since the late 1800’s, the disorder is still misunderstood and understudied, potentially because of the difficulty of non-sufferers to conceptualize the pathology and difficulty for individuals with these traits to verbalize their experiences. Depersonalization is defined in the DSM-5 as “longstanding or recurring feelings of being detached from one's mental processes or body, as if one is observing themselves from the outside or in a dream,” and derealization as “the longstanding or recurring feeling of the external world of the individual being unreal”. Available data suggest the prevalence of DPDD is between 1.7 to 2.4% of the general population (Hunter et al., 2004), and prevalence studies have indicated that between 40 to 80% of psychiatric inpatients suffer from comorbid secondary depersonalization (Brauer et al., 1970; Hunter at al., 2005; Hunter et al., 2004).

DPDD is differentiated from psychotic disorders due to its theoretical conceptualization being grounded in trauma and because reality testing remains unimpaired, meaning sufferers fully understand the difference between their internal world and the external world. Optical disturbances associated with the disorder include macropsia and micropsia (objects looking larger and smaller), visual snow, teleopsia (objects looking distant), metamorphosia (distortions in shapes and colors), blurry vision, and rapid fluctuations in light (Simeon et al., 2001). There is currently no medical cure for DPDD and a minimal knowledge base on its neurological underpinnings. The lack of empirically supported treatment and limited understanding of this disorder— even amongst mental health practitioners— leaves sufferers feeling hopeless, alone, and misunderstood. To add to this frustration, empirical studies to date have shown DPDD to be mostly refractory to current available psychotherapies and pharmacotherapies (Sierra, 2008; Hunter at al., 2005). Antipsychotic medications have often been associated with negative outcomes (Medford et al., 2005).

Although there is no definitive and universal conceptualization of the origin of the disorder,  DPDD is most commonly associated with traumatic experiences and extreme stress.  It is hypothesized that DPDD may be caused by multilevel deficits in the complex interaction between emotional, affective and cognitive processing (Gerrans, 2019). Many studies have replicated the idea that DPDD is intimately related to emotional abuse above other types of abuse (Aponte-Soto et al., 2019; Simeon et al., 2001). Many sufferers report a history of childhood emotional abuse with the absence of other types of abuse (Ó Laoide et al., 2019). A possible theory is that DPDD emerges when emotions are invalidated so systematically that victims come to eventually perceive themselves as both physically and mentally unreal. Literature has also tied DPDD to hallucinogen and marijuana use (Simeon, Kozin, et al., 2009) and some defensive personality characteristics (Simeon et al., 2002).

Alterations in Perception, Sensation, and Emotional Processing

DPDD is associated with a wide range of perceptual, cognitive, attentional, and emotional regulation disturbances in addition to the primary presentation of a disturbed sense of self and others (Guralnik et al., 2007). Although many theories exist, it is not clear as of yet if the development of DPDD is associated with all types of trauma, trauma intensity, or length of exposure to trauma. Given that sufferers often cite perceptual/sensory disturbances as the most terrifying aspect of the disorder (Simeon et al., 1997) and the disorder’s association with high rates of suicidality, (Kenny at al., 2008), it is imperative that we begin to isolate the aspects of perception and sensation that are altered or compromised in DPDD. Given that “dampened” emotions are also at the core of this diagnosis, understanding the process by which emotions are experienced is also crucial to clinical intervention.

Many theories have been proposed regarding how suffers of DPDD experience emotion, yet only one has enough empirical backing to stand alone. That theory suggests that individuals with DPDD experience emotions differently and have deficits in identifying their own emotions. Multiple studies have replicated these findings (Giesbrecht et al., 2010; Lemche et al., 2008; Michal et al., 2013). This is clinically relevant because it helps speak to why Cognitive Behavioral Therapy (CBT) has been found to have only moderate effects for this population (Hunter et al. 2005). Patients may have difficulty understanding the relationship between their feelings and thoughts because they are not “feeling” the way non suffers typically do.

It is unclear at this point whether individuals with DPDD are experiencing an emotional “dampening” effect or if their struggle lies solely in identifying emotion, as the existing literature is too variable. Some studies suggest an increased emotional sensitivity towards negative stimuli, while others do not (Simeon, Giesbrecht, et al.,2009; Montagne at al., 2007).  Similar to the variability in the findings on sensory perception within this population (smell, sound, taste all having varying degrees of perceived bluntness), it is possible emotional stimuli may have different effects depending on the mode via which those stimuli are communicated (movie clips, musical sounds, faces, etc.). Therein also lies the possibility that emotional processing differences may be just as time-variable as sensory and perceptual deficits seem to be for DPDD sufferers.

Treatment Recommendations

While not organized or explicitly denoted, the research on sensory and emotional deficits within individuals with a DPDD diagnosis provides a breadth of information in terms of ways to clinically understand and approach clients with DPDD. Clinicians should be mindful that individuals with DPDD may not believe themselves, the therapist, or even the therapy room are “real”. Patients often report “feeling like a robot,” describe the world as “painted, not natural,” “two-dimensional,” or as if “as if everyone is acting out a role on a stage, and I’m just a spectator.” Clients may also be overwhelmed with philosophical ruminations, e.g., “How can things be real but seem not real?” (Medford et al., 2005).

Clients may be present as distant and emotionally detached, and yet be very frustrated by this. Given that the individual was at one point likely fully able to experience and express emotion, this bluntedness may be experienced as frightening. They may also be likely to ask questions like, “Do you think there is something wrong with my brain?” Or “Could I have a brain tumor?”. Questions like this may best be met with a definitive explanation that feeling like one is “losing [their] mind” is a common thought someone with DPDD can have.  It may help to explain to the client that although it may be scary, in many ways, there is a better prognosis due to them having such awareness of these deficits, as opposed to the typical presentation of psychotic disorders. Clients may be validated by the therapist asking them specific questions related to their sensory deficits, i.e. “Are you able to feel your body right now?” or “What is your vision like right now?”. Even being provided a proper explanation of their diagnosis may be very validating for individuals with DPDD as they are unlikely to have heard of the disorder outside of the therapy room and may feel very alone. In terms of intervention, emotion-focused and interpersonal therapy may have the biggest impact, given the small effect sizes for improvement from CBT in the literature. Beyond this, the therapeutic relationship is likely to play a large part in the client’s recovery, as the development of the illness may have originated from attachment related issues or interpersonally abusive relationships. Interestingly, to date, there are no studies examining the efficacy of group therapy for individuals with DPDD or the impact of the therapeutic alliance on symptom remission. Given the origins of the diagnosis often being in ineffective relationships and that sufferers report feeling very alone in their diagnosis, a strong therapeutic alliance and/or group process therapy may prove to be very effective.

Recommendations for Future Research

Interestingly, there are no studies to date looking at the relationship between DPDD and emotions within interpersonal relationships. As interpersonal relationships are characteristically far more complex than exposure to musical sounds and video clips—the emotional stimuli typical of most studies— understanding how relationships are developed and maintained for people with DPDD is critical to acquiring a realistic view of their emotional differences compared to control groups. Understanding these differences would also inform treatment in terms of what is to be expected within the therapeutic relationship. Future research may want to qualitatively explore the therapeutic relationship between individuals with DPDD and therapist, as this may bring light to what is occurring outside the therapy room. It may also be clinically meaningful to quantitatively examine whether levels of DPDD change depending on whom the patient is interacting with. It is unclear if comfortability with an individual or level of relaxation within the client can change severity of symptoms.

Interestingly, most studies also do not provide information on participant drug use or panic attacks immediately prior to onset of DPDD. Being that DPDD is often brought on by either drug use, a severe panic attack, or extreme emotional stress or abuse, there may be variability in sensory, perception, and emotional deficits between these three groups which is contributing to the overall variability in study findings. Future studies should collect information regarding the events occurring prior to the onset of the disorder and further, employ factor analysis to see if there are different subsets of symptoms within DPDD based on these variables.

Visibility and Research

Finally, perhaps the biggest barrier to creating better forms of treatment for people with DPDD is the lack of visibility and research. As of now, web searches point to only a few groups of individuals publishing research on DPDD. DPDD is rarely spoken about in the media and it is not uncommon to find a mental health practitioner entirely unfamiliar with the disorder. This lack of knowledge on the part of mental health professionals in practice may also further contribute to the fear and confusion individuals with DPDD experience over their perceptual and emotional deficits. As there is a bidirectional relationship between public knowledge of a disorder and quantity of research, education and further funding to study DPDD are both crucial to understanding this phenomenon more accurately. It is also imperative the available research is disseminated in platforms accessible to lay individuals, such as blogs and news sources. Sufferers may not be sure of what they are experiencing and subsequently where to access proper mental healthcare. The first step for clinicians and researchers should be to propagate information on DPDD to unknowing mental health professionals and the general public. A proper diagnosis and thus ability to identify with a group can often be healing in itself. By validating the lived experience of those with DPDR through our language and dedication to disseminating information, individuals may begin to feel empowered to use their own voices to bring this disorder to the public’s knowledge.

Cite This Article

Carelli, O., Ellis, A. E., (2021, March). Depersonalization/Derealization disorder: Theory, treatment, and advocacy. [Web article]. Retrieved from http://www.societyforpsychotherapy.org/depersonalization-derealization-disorder-theory-treatment-and-advocacy

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