• Depersonalisation disorder is characterised by a sense of unreality and feeling severely disconnected from yourself 

  • Jeffrey Abugel, who has experience of the condition and supports others, explains further

  • We have therapists available who specialise in working with dissociation – find them here


Depersonalisation. The very word suggests a loss of personhood. But that’s only part of the story of a complex and understudied condition that affects literally millions of people. And even after a century of investigation, most of these people still have never heard the term. 

Depersonalisation can be a fleeting symptom of many disorders. But when it is chronic and unrelenting it becomes a syndrome in its own right— Depersonalisation Derealisation Disorder (DDD). It is marked by an overwhelming sense of unreality and detachment from one’s normal sense of self.

Depersonalisation affects a person’s inner world of feelings, identity and thought processes. Derealisation affects one’s perception of the outer world which can seem foreign and visually unsettling. Both are part of the same condition, appearing more or less at the opposite end of a fairly broad spectrum of symptoms that may include:

  • Feelings of loss of self and embodiment

  • Excessive self-observation

  • Sensation of watching one’s self in a movie

  • Feelings of unreality

  • Unreality of surroundings

  • Emotional numbing

  • Perceptual/sensory alterations

  • Lost sense of time

  • Existential rumination/obsessiveness


For many years, DDD, also known as DPD or dpdr has been categorised under dissociative disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Yet on the surface it shares little in common with the other dissociative disorders—dissociative fugue, dissociative identity disorder, and out-of-body experiences. However, the distinct feeling of detachment between mind and body, or that one’s consciousness resides outside of the head are distinctly dissociative.

Dissociation is a normal reaction following a catastrophic event, designed to distance a person from trauma. DDD is often perceived as a dysfunction of this fight or flight reaction—a normal defence mechanism gone awry.

Importantly, “reality testing remains in tact,” for DDD sufferers. They know that something is dreadfully wrong and often obsess about their own state of mind and existential questions about the nature of reality itself. While other diagnostic manuals have placed the condition in other categories in the past, i.e. anxiety, neuroses etc., most have come to the conclusion that DDD is in fact a dissociative disorder, albeit a unique disorder in its own right.


Not so obscure

The actual number of people suffering from chronic, ongoing depersonalisation disorder is difficult to calculate. But efforts to do so have arrived at figures ranging from 1.7 to 2.4 percent of the overall U.S. and U.K. populations. That number surpasses those for schizophrenia and bipolar disorder. Estimates also indicate that up to 75 percent of the population have experience brief, fleeting episodes of depersonalisation at some point in their lives. Still, the condition remains largely misdiagnosed and under-researched. 

No doubt, the difficulty in describing the symptoms plays a role, along with its appearance as a symptom of other syndromes. The waters are also muddied by the fact that DDD can be observed, experienced or interpreted from different perspectives. While it has been studied from psychiatric and psychological angles since the late 1800s, it has also been viewed through the lenses of philosophy, literature and spirituality. 

The very term depersonalisation was drawn from Swiss philosopher Frederic Amiel’s Journal Intime, the lifelong diary of a man stricken by chronic detachment and perception of life as through “a veil.”  Jean Paul Sartre’s novel Nausea is widely considered the philosophic “bible” of depersonalisation with it’s chilling first-person account of intense feelings of unreality. 

Spiritually, DDD has been linked to “ego death” and eastern religious traditions that involve the dissolution of the self as part of the path to spiritual enlightenment. Others have used the term “enlightenment’s evil twin” to describe a mental state that mimics part of the path to spiritual growth but in fact leads only to mental inertia.


Sources of onset

Research now shows that DDD can be triggered by several factors including ongoing stress and early life trauma. But unlike post-traumatic stress disorder (PTSD), such traumas are usually lower level and ongoing. This may involve family dysfunction, verbal abuse or childhood neglect. DDD can also be triggered by certain drugs such as marijuana, LSD, and Ketamine. Whatever the trigger, the end result is the same and likely involves a genetic predisposition to the disorder.

Despite a century of quiet investigation and commentary, dpdr remained largely unknown until the advent the internet. For the first time, web pages and discussion groups revolved around this unique disorder and drew kindred spirits together. This new interest prompted the establishment of specialised research clinics in New York and London. 

In 2006, the first book on the subject, Feeling Unreal—Depersonalisation Disorder and the Loss of the Self written by Daphne Simeon, MD, and myself was published by Oxford University Press and touted as an important seminal work. (The, updated and revised edition appeared in February 2023).


Current treatment

Research conducted around the world in the last two decades has pointed the way toward effective treatments through medication and/or therapy. The complexity of depersonalisation is evidenced by the fact that despite the consistency of symptoms among patients, no single medication or treatment predominates. This is likely because no single mechanism within the brain or body can claim to be the solitary source of onset. To date, however, some somatic approaches have proven more successful than others. 

The anti-seizure medication lamotrigine has been shown helpful as it inhibits glutamate release and lessens dissociation feelings in many patients. Selective Serotonin Reuptake Inhibitors (SSRIs) are largely ineffective against depersonalisation by themselves but are sometimes helpful in enhancing mood and are often coupled with lamotrigine. Early tests of the tricyclic antidepressant clomipramine showed promising results, while later trials showed mixed results. Anecdotally, however, it remains in the forefront of options as it impacts levels of norepinephrine and serotonin in the brain. The jury is still out on other medicines such as naltrexone, an opioid receptor antagonist said to decrease dissociation symptoms. For some patients, transcranial magnetic imagining has shown positive results when specific brain regions are targeted. 

In recent decades, various therapies have proven to be helpful as well, with or without medication. And, the fact that what works for one person may not for another still surfaces. Every course of treatment must be personalised, depending on which symptoms are prevalent. Is panic or anxiety a major factor? Are there feelings of a separation of mind and body? Does the inner world seem strange? Or is it the outer world that seems foreign? 

The Cambridge Depersonalization Scale is a good starting point for assessing symptoms. Time has shown that for some patients, cognitive behavioural therapy (CBT) can be quite effective. For others, acceptance and commitment therapy (ACT) is preferable. Grounding and mindfulness techniques can be particularly helpful and the latter has been shown to actually increase the brain’s grey matter. 

Psychotherapy may also be effective, particularly when the source of onset is unknown, or ongoing childhood traumas are not easily identified. 

The last few decades have shown increasing interest in depersonalisation. With this, new research is ongoing and promising in terms of unlocking its mysteries. Societal pressures, the breakdown of traditional institutions and support systems, as well as the legalisation of marijuana in many states in the U.S. will no doubt fuel the reporting of new cases, particularly among young people. If there is a positive side to this scenario the term “depersonalisation” may make its way into popular culture enough to prompt serious ongoing investigation.

Jeffrey Abugel has first-hand experience of DDD and is the founder of the Initiative for Depersonalisation Studies


Further reading

Depersonalisation and childhood trauma: A psychoanalytic perspective

Dissociation: Understanding the impact of relational trauma

How to help someone who is dissociating

Schema therapy: How damaging beliefs develop in childhood

How to support yourself through trauma


References

https://www.psychiatrist.com/jcp/lamotrigine-treatment-depersonalization-disorder/

https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/fluoxetine-therapy-in-depersonalisation-disorder-randomised-controlled-trial/35440276385E5FE7CB90E84CC8796E61

Sierra M, Phillips ML, Lambert MV, et al. Lamotrigine in the treatment of depersonalization disorder. J Clin Psychiatry 2001 Oct; 62 (10): 826-7

Sierra, M., Baker, D., Medford, N., Lawerence, E., Patel, M., Phillips, M.L., & David, A.S. (2006). Lamotrigine as an add-on treatment for depersonalization disorder: a retrospective study of 32 cases.  Clinical Neuropharmacol 29(5), 253-258.

Aliyev NA, Aliyev ZN. Lamotrigine in the immediate treatment of outpatients with depersonalization disorder without psychiatric comorbidity: randomized, double-blind, placebo-controlled study. J Clin Psychopharmacol. 2011 Feb;31(1):61-5. doi: 10.1097/JCP.0b013e31820428e1. Retraction in: Shader RI, Greenblatt DJ. J Clin Psychopharmacol. 2014 Dec;34(6):671. PMID: 21192145.

Fichtner CG, Horevitz RP, Braun BG. Fluoxetine in depersonalization disorder. Am J Psychiatry 1992 Dec; 149 (12): 1750-1

Simeon D, Guralnik O, Schmeidler J, Knutelska M:  Fluoxetine therapy in depersonalisation disorder: randomised controlled trial.  Br J Psychiatry 2004;185:31-36

Sierra, M., Baker, D., Medford, N., Lawerence, E., Patel, M., Phillips, M.L., & David, A.S. (2006). Lamotrigine as an add-on treatment for depersonalization disorder: a retrospective study of 32 cases.  Clinical Neuropharmacol 29(5), 253-258.

Simeon D, Stein DJ, Hollander E:  Treatment of depersonalization disorder with clomipramine.  Biol Psychiatry 44:302-303, 1998

Bohus MJ, Landwehrmeyer B, Stiglmayr CE, et al. Naltrexone in the treatment of dissociative symptoms in patients with borderline personality disorder: a open-label trial. J Clin Psychiatry 1999 Sep; 60 (9): 598-603

Christopeit M, Simeon D, Urban N, Gowatsky J, Lisanby SH, Mantovani A. (2014). Effects of repetitive transcranial magnetic stimulation (rTMS) on specific symptom clusters in depersonalization disorder. Brain Stimulation, 7(1), 141-143.

Jay, E.-L., Sierra, M., Van den Eynde, F., Rothwell, J.C., & David, A.S. (2014). Testing a neurobiological model of Depersonalization Disorder using repetitive transcranial magnetic stimulation.  Brain Stimulation, 7, 252-259

Jay, E.-L., Nestler, S., Sierra, M., McClelland, J., Kekic, M. & David, A.S. (2016). Ventrolateral prefrontal cortex repetitive transcranial magnetic stimulation in the treatment of depersonalization disorder: a consecutive case series.  Psychiatry Research, 240, 118-122.