Depersonalization Derealization Disorder

Depersonalization derealization disorder is persistent or recurrent experiences of feeling detached from one's self (depersonalisation) and/or surroundings (derealisation) with intact reality testing.

• Lifetime prevalence 1 to 2%; transient episodes occur in about 50% of people; onset in adolescence.
• Triggers: cannabis and hallucinogens, severe anxiety, panic, trauma, emotional neglect, sleep deprivation.
• Neurobiology includes prefrontal inhibition of limbic responses.
• Comorbid anxiety, depression, personality disorders.

• Feeling like an automaton, observing oneself from outside, numbness, emotional blunting, distorted body perception; world seems unreal, foggy or dreamlike.
• Preserved insight; distress, rumination, fear of "going mad".
• Symptoms continuous or episodic, often worsened by stress.

• Clinical; Cambridge Depersonalisation Scale, DES.
• Exclude substance related, epilepsy (temporal lobe), migraine aura, vestibular disease, brain tumour, psychosis (loss of insight), panic disorder, PTSD.
• Review drugs (cannabis, ketamine, SSRIs), EEG or MRI if atypical.

• Psychoeducation and reassurance; avoid cannabis, alcohol and stimulants; sleep regularisation.
• CBT adapted for depersonalisation (reducing rumination, behavioural experiments), mindfulness, grounding techniques.
• Medication evidence limited: SSRIs for comorbid anxiety or depression; lamotrigine 100 to 250 mg daily as augmentation; naltrexone 50 to 250 mg daily in some; clomipramine.
• Avoid benzodiazepines.
• Treat panic, depression, trauma; transcranial magnetic stimulation under study.