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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.

Olivia Carelli earned her PsyD in Clinical Psychology at Nova Southeastern University. She received her masters degree in Clinical Psychology at Nova Southeastern University and her undergraduate degree in Psychology from Flagler College. Dr. Carelli completed her Predoctoral Internship at The Renfrew Center for Eating Disorders in Coconut Creek, Fl. She is currently completing her Postdoctoral Residency at Dr. Yudell & Associates, a group practice with locations in Plantation and Coral Springs, Florida. Dr. Carelli was previously the coordinator for the Help Desk at the Sidran Institute for Traumatic Stress, where she directed survivors from across the US to competent, trauma-informed care. Dr. Carelli is establishing a niche for herself in treating C-PTSD, dissociation, poor self-esteem and body image, and eating disorders. Dr. Carelli practices from a relational model and most often uses emotion-focused and feminist approaches. Her other clinical and research interests include Depersonalization/Derealization Disorder, group therapy, and psychological assessment.

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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  1. Geoffrey Guenther

    DPDD exhibits some of the traits of other phenomena resulting from the presence of an autonomous and semi-sentient (at a minimum) region of the “unconscious.” Examples of these phenomena include:
    Bipolar Disorder
    Transient Global Amnesia
    Deja vu
    Alcoholic blackouts
    This hints that DPDD may have a similar cause. The feelings of being merely an observer, of being detached from body control, are entirely accurate. This might explain DPDD’s resistance to therapy. The visual phenomena may also be explicable, but that’s much more speculative.
    I’m wondering if hypnotherapy has been tried.

    Information on the underlying hypothesis can be found here:

  2. Laura Steinbring

    Toxic mold causes a physiological dysregulation of the brain, and many who have been exposed to toxic mold have depersonalization. The emotionally flat feeling is also caused by toxic mold which blocks production of the “happy” hormones dopamine and seratonin. This is often overlooked in diagnosing depression and anxiety but needs to be considered as it is, according to mold toxicity experts, pervasive in the population but unknown to traditional medicine, so it is rarely diagnosed. I know this because I suffer with mold toxicity and have been living with it for 5 years. It’s a very complex disorder with equally complex treatments. Once snubbed by the medical community as non-existent, it is now becoming more accepted and there’s a large amount of evidence of mold toxicity from reputable sources available online and in books. I know it is real bc I live with it every day. I was first dx as delusional and with SSD because traditional diagnostic tests couldn’t discover a root cause for my symptoms. It took me 2 1/2 years to find a mold MD and get the correct dx.


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