Derealization & Depersonalization
What is derealization/depersonalization?
What are the symptoms?
Causes and risk factors
Examples of disorders they occur in
Associated regions of the brain
1. What is derealization/depersonalization?
Psychosensory symptoms - specifically derealization and depersonalization - are a common occurrence in mental disorders in which patients have been exposed to trauma, prolonged stress or depression (e.g. PTSD, Bipolar, anxiety, depression, etc…). These symptoms may develop as a coping mechanism for past trauma, or as a means of detaching from a stressful situation that they may feel unable to handle. While both include feelings of unreality and are both dissociative/psychosensory symptoms, they differ slightly. Derealization involves an altered perception of the external world (Mayoclinic, 2011), whereas depersonalization involves a feeling of disconnection or detachment from one’s own body and thoughts (Mayoclinic, 2017).
Symptoms of derealization include: feeling emotionally disconnected, surroundings appearing distorted, artificial, colorless, surreal, or two-dimensional, or a heightened hypervigilance of your surroundings, distortions in time, or in distance, size and shape of objects. (Fritscher, 2019)
Symptoms of depersonalization include: out-of-body experiences, feeling as if you are an outside observer of your thoughts and body (Mayoclinic, 2017), feeling a loss of control with your actions, a feeling of numbness, difficulty attaching emotion to memories, feeling detached from yourself (as if you have no self), and feeling as if your bodily proportions are incorrect. (NCBI, 1997).
If ongoing or severe, these symptoms may be diagnosed as depersonalization-derealization disorder - one of four dissociative disorders in the DSM-5. (Fritscher, 2019). Patients with this disorder - unlike those with psychotic disorders - know that they’re experiences aren’t real, and therefore may feel as if they’re “going crazy”; (Krause-Utz, 2017) this is also a common symptom in anxiety disorders.
.3. Causes and risk factors
Severe stress, prolonged anxiety, and depression are common triggers for derealization/depersonalization, with those who have experienced trauma (such as witnessing loved ones dying, neglect during childhood, emotional or physical abuse) being especially prone to developing these symptoms. Increased anxiety, unhealthy sleep cycles, lack of stimulation from the external world, caffeine, and drug use may worsen symptoms. (NCBI, 2008)
Depending on the individual, certain characteristics may put them at a higher risk for developing these symptoms or disorder (Krause-Utz, 2017); issues adapting to or a tendency to avoid new/difficult situations, severe stress in any area of life, depression & anxiety (as a diagnosed disorder), especially prolonged depression or anxiety accompanied by panic attacks, and a history of using recreational drugs. Genetic predispositions have had little research but those with a family history of anxiety disorders are at a higher risk of developing these symptoms.
4. Examples of disorders they occur in
Patients with lifetime DPDR symptoms were associated with an early onset of Bipolar, and those during periods of depression in Bipolar II reported having more psychosensory symptoms in comparison to Bipolar I patients. This is the same for bipolar patients with a history of rapid cycling (presumably as a response to stress). (NCBI, 1997) Derealization in an early onset of both Bipolar subtypes also correlated with a panic disorder comorbidity. (NCBI, 2008)
Up to 30% of individuals diagnosed with PTSD experience depersonalization/derealization (this is classified as a separate subtype - dissociative PTSD), with those who developed this disorder in response to recurrent traumas or childhood adversity being most vulnerable. In people with the dissociative subtype of PTSD, their brain’s emotional responses are over-regulated, in turn causing emotional detachment and depersonalization/derealization symptoms, a contrast to the most common form of PTSD which involves under modulation of emotions. In D-PTSD, the thalamus may play a role in dissociative states of altered consciousness. (Psychology today, 2020)
There is a significant correlation between depersonalization/derealization and anxiety disorders. Levels of anxiety have been observed to make no contribution towards the clinical features of the symptoms themselves, albeit DPD patients with increased anxiety seemed to display more non-specific perceptual symptoms. (Star, 2019) These symptoms have also been associated with panic disorder and may occur together. (WebMD, 2020)
5. Associated brain regions
Note: This is a summary of several past neuroimaging studies done on derealization/depersonalization and disorders with dissociative symptoms. (Sierra, 2011)
During an investigation of brain activity during the presentation of ‘aversive vs neutral images’ in patients with chronic depersonalization disorder, patients displayed less activity in the occipito-temporal cortex, ACC, and insula (in some ways similar to the amygdala, this structure controls attention modulation and other responses).
Neuroimaging studies on disorders characterized by high dissociation &
depersonalization/derealization display a link between the disconnection of a
cortico-limbic brain system, involving the amygdala, anterior cingulate cortex (ACC), and prefrontal structures, specifically increased activity in the medial prefrontal cortex and dorsolateral prefrontal cortex, ACC, regions of the brain implicated in attention, cognitive control, and arousal modulation.
Reduced ability in emotion processing or the attenuation of automatic responses maybe due to dampened activity in the amygdala from increased use of the PFC via the ACC. This is because the amygdala controls ‘salience detection’ and the initiation of stress and fear responses to threat; this structure is also responsible for fight-or-flight responses.
Altered glucose metabolism in tempo-parietal regions may also cause feelings of unreality in DPD.
Structural abnormalities are correlated with the severity of dissociation. Reduced GMV (gray matter volumes) in the right thalamus, caudate, and ceneus, and increased GMV in the left dorsomedial PFC and the right somato-sensoric regions were observed to contribute to depersonalization disorder symptoms. Volumes in the right middle frontal gyrus were also found to be positively correlated with severity of depersonalization and derealization, as well as significantly lower fractional anisotropy in white matter of the right anterior corona radiata.
fMRI research on other structures of the brain associated with derealization/depersonalization have been done but excluded in this article.