Understanding Derealization Disorder: Symptoms, Causes, and Management Strategies

Derealization, a mental state characterized by a detached and unreal perception of one’s surroundings, is a distressing experience that can significantly disrupt daily life. People going through derealization often describe feeling like they are living in a dream or observing themselves from outside their body. This dissociative disorder, known as depersonalization-derealization disorder, causes a persistent or recurrent sense of detachment from reality, self, and environment.

While brief episodes of derealization are relatively common, with over 50% of individuals experiencing them at some point, around 2% of the population suffers from frequent and distressing bouts that warrant clinical intervention. This article delves into the definition, symptoms, potential causes, and various treatment approaches for managing derealization, shedding light on this often misunderstood and underdiagnosed condition.

Derealization Definition and Symptoms

What is Derealization Disorder?

Derealization is a mental health symptom characterized by a persistent or recurrent feeling of detachment from one’s surroundings and reality. People experiencing derealization often describe the world around them as unreal, dreamlike, or resembling a movie. It is a dissociative experience where the individual’s perception of their environment becomes distorted, leading to a sense of disconnection.

Key Symptoms of Derealization

1. Feeling disconnected from reality:
   • The world appears lifeless, muted, or fake, as if separated by a veil or glass wall.
   • Surroundings seem artificial, lacking depth or meaningfulness.
2. Altered perception of surroundings:
   • Distortions in the perception of time, distance, and the size or shape of objects.
   • Sounds may seem muffled or distorted.
3. Emotional numbness:
   • Feeling emotionally disconnected from loved ones or unable to experience emotions fully.
   • A sense of emotional detachment or numbness towards the environment.
4. Dreamlike state:
   • The experience of being in a dream or fog, with a surreal or unreal quality to the surroundings.
   • Recent events may feel like distant memories or vice versa.
5. Intact reality testing:
   • Despite the distorted perceptions, individuals with derealization disorder are aware that their experiences are not real and recognize that something is off.

It’s important to note that while derealization can be a standalone experience, it often co-occurs with depersonalization, a related dissociative symptom involving a detachment from one’s sense of self, body, or thoughts.

Derealization is distinct from depersonalization, although the two are often grouped together as depersonalization-derealization disorder. While derealization involves a distorted perception of the external world, depersonalization refers to a detachment from one’s internal experiences, such as thoughts, emotions, and bodily sensations.

Prevalence and Onset

Prevalence of Derealization Disorder

Derealization disorder, often occurring alongside depersonalization, is a relatively rare but potentially debilitating condition. According to research studies:

1. The current prevalence rate of depersonalization-derealization syndrome is approximately 1% in the general population.
2. Depersonalization episodes are more common, with about half of all Americans experiencing at least one or two episodes during their lifetime. However, the full-blown depersonalization-derealization disorder itself is much rarer, with an estimated prevalence of 2% of the population, though it is likely underdiagnosed.
3. The prevalence of derealization disorder in a UK population-based birth cohort study was 0.95% (95% CI 0.56 to 1.34).
4. Previous studies have found prevalence rates ranging from 0.5-2% in UK and US samples, up to 23.4% in a US telephone survey.

Onset and Age of Occurrence

The onset of derealization disorder typically occurs during specific life stages:

1. The disorder typically starts before age 25, with 63.7% of patients having onset before age 25, 17.9% between ages 26 and 40, and 4.9% after age 40.
2. Symptoms of depersonalization-derealization disorder usually begin showing in early childhood, with the average age of onset being 16 years old.
3. Most diagnoses happen during adolescence, with only 5% of cases developing after the age of 25, and cases starting after age 40 being extremely rare.
4. Those with earlier ages of onset tend to have more severe cases of the disorder.
5. The typical onset of derealization disorder is reported to be in late adolescence or early adulthood.

Comorbidities and Associated Factors

Derealization disorder often co-occurs with other mental health conditions and is associated with certain risk factors:

1. Derealization disorder has a very high comorbidity with depressive disorders (84.8% in the study).
2. Derealization disorder patients have a higher comorbidity with anxiety disorders, while somatoform disorders and PTSD are more prevalent in the depression-only group.
3. Derealization disorder is more common in people who experience trauma, such as violence, abuse, or other kinds of extreme stress.
4. The only significant childhood risk factor identified was teacher-rated anxiety at age 13, which was a strong independent predictor of adult derealization disorder.
5. A family history of anxiety disorders is more common in derealization disorder patients.

It’s important to note that while derealization can be a standalone experience, it often co-occurs with depersonalization, a related dissociative symptom involving a detachment from one’s sense of self, body, or thoughts.

Suggestion for read: How to Identify and Handle Emotional Damage

Potential Causes

The precise cause of derealization disorder is not well understood, but it is believed to arise from a combination of genetic, environmental, and trauma-related factors. Several potential causes and risk factors have been identified:

Traumatic Experiences

1. Emotional abuse, neglect, or other severe trauma in childhood are common triggers for derealization disorder.
2. Witnessing domestic violence, physical abuse, or the unexpected death of a loved one can also contribute to the development of the disorder.
3. Traumatic events, such as accidents, natural disasters, or combat experiences, can increase the risk of derealization episodes.

Chronic Stress and Mental Health Conditions

1. Prolonged exposure to high levels of stress can lead to derealization as a coping mechanism.
2. Derealization often co-occurs with mental health disorders like depression, anxiety, and post-traumatic stress disorder (PTSD).
3. Individuals with certain personality traits, such as high neuroticism or emotional instability, may be more susceptible to derealization.

Neurological and Physiological Factors

1. Imprecise interoceptive predictions (the ability to perceive internal bodily signals) relative to predictions in other modalities may lead to over-integration of exteroceptive (external sensory) and proprioceptive (body position and movement) information, resulting in derealization and depersonalization.
2. Derealization may represent an attempt to account for imprecise interoceptive predictions, potentially progressing to mixed derealization/depersonalization and eventually depersonalization as interoceptive prediction precision further declines.
3. Certain medical conditions, such as seizures, dementia, or substance abuse, can also trigger derealization as a symptom.

Substance Use and Withdrawal

1. The use of certain substances, such as marijuana, hallucinogens, or dissociative drugs, can induce derealization episodes.
2. Withdrawal from substances like alcohol or benzodiazepines can also lead to derealization experiences.

It is essential to note that derealization disorder must be differentiated from other conditions, such as illness anxiety, obsessive-compulsive disorder (OCD), and psychotic disorders, which may present with similar symptoms.

Diagnosis and Evaluation

Diagnostic Process

Diagnosing derealization disorder involves a comprehensive evaluation process to rule out potential underlying physical or mental health conditions that may be causing the symptoms. The diagnostic process typically includes the following steps:

1. Physical Examination and Laboratory Tests
   • A thorough physical examination is conducted to identify any potential medical conditions that could contribute to the symptoms of derealization.
   • Laboratory tests, such as blood tests, urine analysis, and brain imaging techniques like MRI or EEG, may be performed to rule out physical causes or the presence of substances that could induce derealization episodes.
2. Mental Health Evaluation
   • A mental health professional, such as a psychiatrist or psychologist, will conduct a detailed assessment of the patient’s symptoms, thoughts, feelings, and behavior patterns.
   • Structured interviews and questionnaires, such as the Dissociative Experiences Scale (DES) and the DES Taxon Calculator, are commonly used to evaluate the severity and nature of the dissociative symptoms.
3. Personal and Medical History
   • Patients will be asked to provide detailed information about their personal and medical history, including any traumatic experiences, substance use, medications, and family history of mental health conditions.
4. Differential Diagnosis
   • The evaluation process involves ruling out other potential disorders that may present with similar symptoms, such as schizophrenia, bipolar disorder, post-traumatic stress disorder (PTSD), substance use disorders, or medication side effects.

During the diagnostic process, patients should be prepared to provide comprehensive information about their symptoms, personal history, medications, and any questions or concerns they may have. The healthcare provider will use this information, along with the results of the physical examination and laboratory tests, to make an accurate diagnosis and develop an appropriate treatment plan.

Evaluation Methods

Several evaluation methods may be employed to assess the presence and severity of derealization disorder, including:

1. Structured Interviews: Clinicians may use standardized interviews, such as the Structured Clinical Interview for DSM-5 Dissociative Disorders (SCID-D), to gather detailed information about the patient’s symptoms and experiences.
2. Questionnaires and Rating Scales: Self-report measures like the Dissociative Experiences Scale (DES) and the Cambridge Depersonalization Scale (CDS) can help quantify the severity of dissociative symptoms and track changes over time.
3. Psychological Testing: Neuropsychological tests and cognitive assessments may be used to evaluate the patient’s cognitive functioning, memory, attention, and other mental processes that could be affected by derealization disorder.
4. Medical Tests: In addition to laboratory tests, medical imaging techniques like MRI, CT scans, or EEG may be employed to rule out neurological or structural abnormalities that could contribute to the symptoms.
5. Urine Toxicology Screening: Urine tests may be conducted to detect the presence of substances that could induce or exacerbate derealization episodes, such as recreational drugs or certain medications.

By combining information from various evaluation methods, healthcare professionals can make an accurate diagnosis and develop an appropriate treatment plan tailored to the individual’s needs.

Treatment Approaches

Psychotherapy

The primary treatment approach for derealization disorder is psychotherapy, particularly cognitive-behavioral therapy (CBT) and psychodynamic therapy. These talk therapies aim to help individuals understand and manage their symptoms effectively.

1. Cognitive-Behavioral Therapy (CBT)
   • CBT helps patients identify and challenge negative thought patterns and beliefs contributing to their derealization experiences.
   • Through CBT, patients learn coping techniques, such as mindfulness, grounding exercises, and relaxation strategies, to reduce dissociative episodes and regain a sense of reality.
   • CBT also addresses any co-occurring conditions like anxiety or depression that may exacerbate derealization symptoms.
2. Psychodynamic Therapy
   • This form of therapy explores the underlying emotional factors and past traumas that may be triggering derealization episodes.
   • By understanding and processing unresolved emotions, patients can develop healthier coping mechanisms and reduce dissociative symptoms.
   • Psychodynamic therapy is particularly helpful for individuals with a history of traumatic experiences or childhood adversity.

Medication Management

While no medications have been specifically approved for treating derealization disorder, certain medications may be prescribed to manage co-occurring conditions or specific symptoms:

1. Antidepressants
   • Selective serotonin reuptake inhibitors (SSRIs) or other antidepressants may be prescribed to treat co-occurring depression or anxiety disorders.
   • These medications can help regulate mood and reduce the emotional distress associated with derealization episodes.
2. Anti-anxiety Medications
   • Benzodiazepines or other anti-anxiety medications may be prescribed on a short-term basis to alleviate severe anxiety symptoms that can exacerbate derealization.
3. Mood Stabilizers
   • In some cases, mood stabilizers like lamotrigine or valproic acid may be prescribed to help regulate mood and reduce dissociative symptoms.
4. Antipsychotics
   • Atypical antipsychotics, such as risperidone or olanzapine, may be used in severe cases to alleviate persistent derealization symptoms.

It’s important to note that medication should always be used in conjunction with psychotherapy and under the close supervision of a healthcare professional. Medications can have side effects, and their effectiveness in treating derealization disorder may vary from individual to individual.

Integrated Treatment Approach

Derealization disorder often co-occurs with other mental health conditions, such as depression, anxiety, or substance abuse disorders. In these cases, an integrated treatment approach that addresses all co-occurring conditions simultaneously is recommended for optimal outcomes.

1. Psychotherapy and Medication Management
   • Combining psychotherapy techniques like CBT or psychodynamic therapy with appropriate medication management can effectively treat derealization and co-occurring conditions like depression or anxiety.
2. Substance Abuse Treatment
   • If derealization is associated with substance abuse, treatment should include substance abuse counseling, rehabilitation programs, and strategies to prevent relapse.
3. Trauma-Focused Therapy
   • For individuals with a history of trauma, trauma-focused therapies like eye movement desensitization and reprocessing (EMDR) may be incorporated into the treatment plan to address underlying traumatic experiences.

Adjunctive Therapies and Coping Strategies

In addition to psychotherapy and medication management, various adjunctive therapies and coping strategies can be beneficial for managing derealization symptoms:

1. Mindfulness and Grounding Techniques
   • Practicing mindfulness meditation, deep breathing exercises, and grounding techniques can help individuals stay present and connected to their surroundings during derealization episodes.
2. Lifestyle Changes
   • Adopting a healthy lifestyle, including regular exercise, a balanced diet, and adequate sleep, can reduce stress levels and improve overall well-being, potentially alleviating derealization symptoms.
3. Support Groups
   • Joining support groups or connecting with others who have experienced derealization can provide a sense of community, validation, and shared coping strategies.
4. Stress Management
   • Learning stress management techniques, such as relaxation exercises, time management strategies, or seeking support from loved ones, can help prevent or reduce the frequency and severity of derealization episodes.

Effective treatment for derealization disorder often involves a combination of psychotherapy, medication management (if necessary), and adjunctive therapies tailored to the individual’s specific needs and circumstances. Regular follow-up with a mental health professional is essential to monitor progress, adjust treatment plans as needed, and ensure long-term symptom management.

Psychotherapy Techniques

Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy (CBT) is the psychological treatment approach with the strongest research support for managing derealization disorder. CBT aims to help individuals identify and modify the negative thought patterns and behaviors that contribute to their dissociative experiences. The key elements of CBT for derealization disorder include:

1. Developing a Personalized Model of Symptoms
   • Collaboratively creating a comprehensive understanding of the individual’s specific derealization symptoms, triggers, and maintaining factors.
2. Self-Monitoring
   • Encouraging patients to track their derealization episodes, thoughts, emotions, and behaviors to gain insight into patterns and potential triggers.
3. Grounding Strategies
   • Teaching techniques like mindfulness exercises, sensory awareness, and grounding techniques to help patients stay present and connected to their surroundings during derealization episodes.
4. Psychoeducation
   • Providing education about the nature of derealization, how the brain and body respond to stress, and the role of dissociation as a coping mechanism.
5. Attention Experiments
   • Guiding patients to experiment with different levels of attention to their derealization symptoms, helping them understand the impact of their focus on symptom intensity.
6. Cognitive Restructuring
   • Identifying and challenging unhelpful or catastrophic thinking patterns associated with derealization, such as “I’m going crazy” or “I’ll never feel normal again.”
7. Behavioral Experiments
   • Designing and conducting experiments to test the validity of negative beliefs or assumptions related to derealization, promoting more adaptive perspectives.
8. Therapy Blueprint
   • Developing a comprehensive plan for managing derealization symptoms, incorporating various CBT techniques and strategies tailored to the individual’s needs.

CBT for Derealization in Psychosis

Recent research has explored the potential of CBT interventions for addressing derealization symptoms in individuals with psychotic disorders. Depersonalization is common in psychosis and is associated with more severe psychotic symptoms. A brief CBT intervention aims to reduce the distress associated with derealization by:

1. Altering catastrophic attributions about the symptoms.
2. Enhancing coping strategies for managing derealization episodes.
3. Modifying unhelpful appraisals and beliefs related to the symptoms.

These interventions are typically evaluated through randomized controlled trials, assessing feasibility, acceptability, and effectiveness in reducing derealization, psychotic symptoms, depression, anxiety, and post-traumatic stress.

Overall, CBT is the most evidence-based psychological treatment for derealization and depersonalization, focusing on developing a personalized understanding of the symptoms, self-monitoring, and challenging unhelpful thoughts and behaviors through various cognitive and behavioral techniques.

Medications

While no medications have been specifically approved for treating derealization disorder, certain medications may be prescribed to manage co-occurring conditions or specific symptoms associated with the disorder.

Selective Serotonin Reuptake Inhibitors (SSRIs)

1. SSRIs, such as sertraline (Zoloft), fluoxetine (Prozac), and citalopram (Celexa), are commonly prescribed to individuals with derealization disorder.
2. These antidepressants can help alleviate symptoms like flat affect, blunted emotions, and co-occurring depression and anxiety, which often accompany derealization episodes.
3. Research suggests that combining an SSRI with the mood stabilizer lamotrigine may be an effective treatment approach for derealization disorder.

Antipsychotic Medications

1. Antipsychotic medications can provide mood stabilization, anxiety reduction, and an improved range of affect, potentially targeting and reducing depersonalization and derealization symptoms.
2. These medications may be prescribed in severe cases of derealization disorder when other treatment approaches have been ineffective.

Addressing Co-occurring Conditions

Derealization disorder frequently co-occurs with conditions like depression, anxiety, and substance abuse disorders. In such cases, an integrated treatment approach that addresses all co-occurring conditions simultaneously is recommended for optimal outcomes. Medications may be prescribed to treat these co-occurring conditions, which can indirectly alleviate derealization symptoms.

Off-Label Use and Limitations

It’s important to note that no specific medication has been proven to effectively treat derealization disorder as a primary condition. Medications are often used off-label to address related symptoms or co-occurring conditions. Major health organizations do not currently recommend specific medications for derealization disorder due to limited research and inconsistent results.

While medications can provide symptomatic relief, they should be used cautiously and under the close supervision of a healthcare professional. Common side effects of medications used for derealization disorder include constipation, dizziness, drowsiness, dry mouth, increased appetite, and potential interactions with other medications, recreational drugs, or alcohol.

Prognosis and Outlook

The prognosis and outlook for individuals with derealization disorder can vary significantly, depending on factors such as the severity and duration of symptoms, the presence of co-occurring conditions, and the individual’s response to treatment.

Symptom Patterns

1. Derealization symptoms tend to be episodic, with periods of remission and exacerbation.
2. Episodes can last for hours, days, weeks, months, or even years, with some individuals experiencing constant symptoms at a consistent intensity for prolonged periods.
3. The intensity of derealization experiences often fluctuates, with symptoms waxing and waning over time.

Long-Term Outlook

1. Without proper treatment, derealization disorder can persist for years, potentially resolving on its own in some cases.
2. However, untreated derealization disorder may negatively impact an individual’s relationships, work life, and overall quality of life.
3. With appropriate treatment, many individuals experience significant improvement in their derealization symptoms over time, although a complete cure is not guaranteed.

Factors Influencing Prognosis

Several factors can influence the long-term prognosis and outlook for individuals with derealization disorder:

1. Duration of Symptoms: Individuals with more recent onset or shorter duration of symptoms generally have a better prognosis compared to those with chronic, long-standing symptoms.
2. Underlying Causes: Derealization resulting from treatable or transient stressors, such as acute trauma or substance use, may have a more favorable prognosis compared to cases with complex or unresolved underlying causes.
3. Co-occurring Conditions: The presence of co-occurring mental health conditions, such as depression, anxiety, or substance abuse disorders, can complicate the treatment process and potentially impact the prognosis.
4. Treatment Adherence: Consistent engagement with evidence-based treatment approaches, such as cognitive-behavioral therapy (CBT) and appropriate medication management, can significantly improve the prognosis and reduce symptom severity over time.
5. Support System: A strong support system, including family, friends, and access to mental health resources, can positively influence the treatment process and overall prognosis.

Treatment Considerations

While current treatments for derealization disorder lack strong evidence for efficacy, seeking professional help and adhering to a comprehensive treatment plan is crucial for managing symptoms and improving the long-term outlook. Regular follow-up with a mental healthcare provider is recommended to monitor progress, adjust treatment strategies as needed, and provide ongoing support.

It is important to note that complete recovery is possible for many individuals, especially those who seek treatment early and address any underlying contributing factors. However, for some individuals, derealization may become a more chronic and refractory condition, requiring ongoing management and support.

Coping Strategies

Seeking Professional Support

One of the most crucial steps in coping with derealization disorder is seeking professional support from qualified mental health practitioners. Working closely with a therapist or counselor can provide invaluable guidance and access to evidence-based coping strategies tailored to individual needs.

1. Psychotherapy: Engaging in psychotherapy, particularly cognitive-behavioral therapy (CBT) or psychodynamic therapy, can help individuals understand and manage their derealization symptoms more effectively.
2. Support Groups: Joining support groups or connecting with others who have experienced derealization can provide a sense of community, validation, and shared coping strategies.
3. Helplines and Organizations: Reaching out to organizations like No Panic, The Mix, and Childline can offer valuable resources, information, and support for managing derealization episodes.

Grounding Techniques

Grounding techniques are practical strategies that can help individuals stay present and connected to their surroundings during derealization episodes. These techniques involve engaging the five senses to anchor oneself in the present moment.

1. Sensory Awareness: Focusing on tactile sensations, such as touching objects with different textures, can help ground individuals in their physical environment.
2. Auditory Grounding: Listening to familiar or calming sounds, like music or nature sounds, can provide a sense of familiarity and connection to the present.
3. Olfactory Anchors: Engaging the sense of smell by inhaling pleasant scents, such as essential oils or familiar fragrances, can be a powerful grounding tool.
4. Mindful Observation: Mindfully observing and describing the details of one’s surroundings, including colors, shapes, and textures, can help individuals stay anchored in the present moment.

Lifestyle Adjustments

Adopting a healthy lifestyle can play a significant role in managing derealization symptoms and promoting overall well-being.

1. Stress Management: Practicing stress-reducing techniques, such as deep breathing exercises, yoga, or meditation, can help prevent or reduce the frequency and severity of derealization episodes.
2. Regular Exercise: Engaging in regular physical activity can improve mood, reduce stress, and promote a sense of connection with one’s body.
3. Balanced Diet: Maintaining a nutritious and balanced diet can support overall mental and physical health, potentially alleviating derealization symptoms.
4. Adequate Sleep: Prioritizing quality sleep and establishing a consistent sleep routine can help regulate mood and improve overall functioning.

Creative Outlets and Mindfulness

Engaging in creative activities and practicing mindfulness can provide a sense of grounding and self-expression, which can be beneficial for individuals coping with derealization disorder.

1. Art, Music, or Writing: Exploring creative outlets, such as painting, playing an instrument, or journaling, can offer a means of self-expression and a way to connect with one’s emotions and experiences.
2. Mindfulness Meditation: Practicing mindfulness meditation can cultivate present-moment awareness and help individuals observe their thoughts and sensations with a non-judgmental attitude.
3. Yoga or Tai Chi: Engaging in mind-body practices like yoga or tai chi can promote relaxation, mindfulness, and a sense of connection with one’s physical self.

Support System and Education

Building a strong support system and educating oneself about derealization disorder can empower individuals and enhance their ability to cope with the condition effectively.

1. Family and Friends: Seeking support and understanding from loved ones can provide a sense of validation and encouragement during challenging times.
2. Educational Resources: Accessing reliable information about derealization disorder, its causes, and treatment options can help individuals better understand and manage their condition.
3. Self-Help Groups: Joining self-help groups or online communities can offer a supportive environment for sharing experiences, coping strategies, and encouragement with others who understand the challenges of derealization disorder.

It’s important to remember that coping with derealization disorder is an ongoing process, and different strategies may work better for different individuals. Seeking professional guidance and exploring various coping techniques can help individuals find the approach that works best for them, ultimately improving their overall well-being and quality of life.

FAQs

What approaches can be taken to manage derealization? To manage derealization, it is advisable to avoid fixating on experiences that feel unreal. Engaging in activities that serve as a distraction can be beneficial. One can also use their five senses to stay anchored in reality, such as listening to loud music or holding an object with a very cold temperature. Additionally, confronting and understanding negative emotions and identifying the triggers of derealization symptoms can aid in dealing with the condition.

What typically causes derealization? The onset of derealization may be linked to both genetic predispositions and environmental influences. High levels of stress and intense fear are known to trigger episodes of the condition. Furthermore, symptoms of depersonalization-derealization disorder have been associated with childhood trauma or other severely distressing experiences or events.

Can you describe the four stages of derealization? Derealization and its related condition, depersonalization, are believed to develop through four distinct stages: the vital stage, the allopsychic stage, the somatopsychic stage, and the autopsychic stage.

What types of therapy are effective for derealization? The primary therapeutic intervention for depersonalization-derealization disorder is talk therapy, which aims to reduce or eliminate symptoms. Cognitive-behavioral therapy and psychodynamic therapy are two forms of talk therapy that are commonly used to treat this disorder.

Here are few certified therapists who you can get in touch and book a therapy session with:

Jennifer Campbel Kirk

Wenna Chen

Tommaso Palumbo