Article Title: Depersonalization/Derealization Disorder
Author Name: Leen Sawalha
Editor: Ihdaa Mahmoud Bani Khalaf, Sadeen Eid
Reviewer: Ethar Hazaimeh

Keywords: Depersonalization, derealization, dissociation, detachment

Overview

Picture being trapped in a dreamlike trance forever – an eternal curse. This is what those suffering from depersonalization/derealization disorder experience. It is a psychiatric illness in which the person feels as if they are detached from their body (in depersonalization) and as if their surrounding environment is fake (in derealization). ^[1]

Epidemiology and Risk Factors

Depersonalization/derealization disorder is quite uncommon; it affects 0.76% – 1.9% of the population. The prevalence in those with other specified mental disorders ranges from 1.8% – 53.8%, and 4.4% – 41.9% in those with unspecified/mixed disorders. ^[1] It does not have a gender predilection. ^[2]

It usually happens in those with chemical and psychological risk factors. Traumatic events such as dealing with childhood emotional or sexual abuse could unshackle the gates open for the disorder, making it present as a defense mechanism of sorts. It can be imagined as a dam, holding back the riptide. It acts to provide sanctuary to the person, shielding them from the overwhelming emotions that come with such distressing situations. ^[3]

Generally, risk factors include:^[4]

• Life stressors and trauma
• Neglect in childhood
• Abuse in childhood
• Use of illicit drugs
• Psychiatric condition or growing up with a parent with a psychiatric condition 

Pathophysiology

There are many neurotransmitters affiliated with the disorder. NMDA glutamatergic pathways, endogenous opioids, and serotonergic pathways all show a possible involvement. ^[3]

The NMDA antagonist ketamine can induce a dissociative episode, even in those without the disorder. ^[5] K opioid agonists produce the same effect; ^[6] so do cannabinoids. A prominent theory suggests that cannabinoids block specific areas on NMDA receptors (different from the portion blocked via non-competitive antagonists), and this is what causes dissociative symptoms. ^[3]  Serotonin receptor agonists, such as LSD (lysergide) and DMT (dimethyltryptamine), have also been implicated in the production of dissociative states. ^[2]

A novel study states that there is a strong inverse correlation between the amount of 24-hour urine noradrenaline and the degree of depersonalization, suggesting that the lack of noradrenaline could also aid a hand in its pathophysiology. ^[7]

Lastly, the hypothalamic-pituitary axis may have a role in its pathogenesis; however, studies show inconsistent and conflicting evidence. ^[3]

Clinical Presentation

‘I no longer exist; I am living in a movie; I am looking at myself from the outside’ – these are all common phrases uttered by the patients. This can be a petrifying experience causing immense agony, making them feel as though they are losing their mind; however, these seemingly alarming declarations are masked by their flat effect, making it puzzling for physicians to correctly identify the cause. ^[4] They are more prone to attempt suicide, however, since they usually have other mental illnesses (such as major depressive disorder), the exact cause of increased suicidal ideations is unclear whether it is due to comorbid mental illnesses or as a direct result of the disorder. ^[2]

Five specific symptoms were found to be consistent in patients with the disorder:^[8]

• Feeling detached from one’s body
• Perceptual distortions
• Numbing of emotions
• Disrupted experiences of time and related imagery
• Feeling as though surroundings are fake 

Diagnosis of depersonalization

The use of questionnaires aids in the identification of depersonalization/derealization disorder. One of the most popular scales is the Dissociative Experiences Scale.^[9] It is important to note that this scale is not used for diagnosis, rather, it provides extra data concerning the treatment and episodes of the dissociative disorder. ^[9] It screens for 3 items: amnesia, depersonalization, and absorption. ^[10] A more specific scale used for distinguishing depersonalization/derealization disorder from other diseases is the Cambridge Depersonalization Scale. ^[10] This scale is reliable and valid; it has even been able to distinguish Temporal lobe epilepsy (TLE) and anxiety (both of which present with depersonalization) from the disorder itself. A score of 70 suggests the most likely disorder to be depersonalization/derealization disorder. ^[10]

DSM 5 Criteria

To diagnose depersonalization/derealization disorder, the following DSM-5 criteria must be met:^[11]

• Recurring/persisting either depersonalization, derealization, or both.
• During an episode, reality testing remains unchanged
• Social/occupational distress due to the symptoms
• Not due to another medical illness, other psychiatric illness, or drug use 

Treatment

In a pilot study by Nuller et al, Naloxone was administered to 14 patients. 7 of the 14 patients had a significant decrease in the depersonalization symptoms, while the symptoms of another 3 completely disappeared. ^[12]

Unfortunately, no medication has shown any efficacy. Fluoxetine has been tried; however, it was of no avail. ^[3]

Behavioral therapy can also be used. Blue described a case of a 50-year-old woman suffering from the disease. She was given a rather astonishing number of 16 different drugs, all of which failed miserably in treating her. She only responded to behavioral therapy. This indicates its potential efficacy – even over pharmacotherapy. ^[13]

In those with a history of depersonalization due to adverse events, the use of therapy targeting the causative trauma can help the individual better process it, leading to better coping with the dissociation. ^[3]

Prognosis

Depersonalization disorder has a chronic course in 2/3^rd of patients, starting in adolescents. It greatly impairs the individual’s ability to function day to day in social settings and work. Any future traumatic event, or even an elevation in stress levels, can amplify symptoms, stripping away the individual’s ability to function. ^[14]

Conclusion

To say we are close to understanding this complex disorder would be a great leap in optimism; it is greatly under-researched, thus, is usually confused with other disorders. With more studies, we could hopefully be able to rid this world of this debilitating, but rather silent, nightmare.

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