Why Aren’t We Talking About Depersonalization and Derealization?
Despite being common symptoms of anxiety, depersonalization and derealization have flown under the radar
It’s 2:00 in the afternoon, and I’m hurtling down the highway, hoping the body I’m puppeteering will listen to me. Despite having driven hundreds of times before, and knowing that my arms indeed belong to me and are wired into my motor neurons, I can’t seem to convince myself I am in control. I fear that at any moment I could float out of my body; that the only way I’m able to stay on this planet, in this physical form, is through sheer willpower alone.
You’re here, I tell myself. You’re driving. But I’m not so sure I’m not just watching a movie of the road projected onto a windshield-shaped screen. The path before me is losing dimension and depth.
The sun delivers a searing brightness as the light reflects off the asphalt, washing out my field of vision. The trees lining the highway shimmer, seeming to blend into one another in a haze. I recognize everything, and yet none of it appears to be what it seems.
I can feel my clammy hands shaking as I grip the wheel with white-knuckled force. A cold sweat prickles the back of my neck as I struggle to stave off a panic attack, audibly repeating to myself you are in control you are in control.
From an outside perspective, I know I’m driving perfectly fine, and I’m fully aware of my surroundings. I’m in my lane, following the curves of the road with no problem, staying out of the surrounding cars’ way. I know that if I tell my arms to turn the wheel or my foot to tap the brake pedal, they will do so. However, I’m finding it nearly unfathomable to think that the hands in front of me are my hands, and it’s me controlling them.
Driving can make me feel like I’m living a nightmare, but I power through it anyway, because I refuse to allow my symptoms to rob me of my independence, my career, or my ability to live my life as I want to live it.
The persistent detachment from reality I experience is hard to put into words, but I’ve had nearly a decade to pick the right way to describe it. And I’m far from being alone in dealing with these symptoms.
I experience states of depersonalization (DP) and derealization (DR), both of which entail an array of dissociative symptoms. DP and DR are considered to be similar but distinct from one another, with the former referring to a detachment from one’s body and mind, and the latter describing a disconnect between oneself and one’s surroundings.
Though these differences are recognized in medical literature, the DSM-5 specifies that there is no evidence of one occurring without the other.
The experience of DP and DR is often described as a “threatening sense of unreality” in one’s environment. A sufferer may feel as though they are living in a dream, and perceive a disconnection from their body, such that they fear they are not in control of their movements and can hardly recognize their own reflection. They may feel cut off from their surroundings to the extent that it seems as though they are “observing the world from behind glass”.
People who are facing these symptoms may experience their life like they’re watching themselves from a distance, feel disconnected from their own thoughts and memories, and have dulled or muted emotional responses.
As the symptoms can feel quite surreal, sufferers often have to resort to using abstract language to illustrate what’s going on in their heads. Descriptors such as “the sense that your head is wrapped in cotton” are commonplace.
DP and DR are common symptoms of panic attacks and depressive disorders, and can also occur as their own disorder — Depersonalization-Derealization (DPDR) Disorder. Transient DP/DR states occur even in the general population, in individuals with no history of mental illness. If you’ve ever been sleep deprived or under extreme stress and felt “spaced out”; not quite able to participate in reality like you normally can, like your surroundings were hazy and somehow detached from you, you could call that derealization.
One overview of six studies exploring the prevalence of DP/DR symptoms reported a rate “between 26 and 74%” for these experiences among the general population. Yet, until I myself was confronted with a sense of unreality and began searching for answers, I had never heard of the existence of these mental changes.
Many who deal with DP and DR have similar stories to mine; they had no explanation for the onset of their symptoms, so they feared they were losing their sanity or suffering from some sort of serious neurological issue.
An estimated 1–2% of the population has DPDR Disorder, but studies have shown it is severely under-diagnosed. An analysis published in 2010 of all medical diagnoses in 1.567 million Germans over a period of 1 year showed that DPDR Disorder was diagnosed at a rate of .007%.
For people who do get a diagnosis, it takes an average of 7–12 years to receive it.
There is a dearth of research on how and why DP and DR occur, and potential avenues of treatment for it, especially when it occurs as DPDR Disorder independently of any other mental health condition. DP and DR are often considered to be negligible symptoms of anxiety that will disappear with treatment, and the potentially debilitating impact of the estrangement from reality they cause is severely understated.
In her TEDx Talk titled “Living in a Dream”, Laura Weinstein brought the audience through her harrowing 6-year journey of trying to understand why she felt like an outsider in her own body, beginning the summer before she started 2nd grade. One criterion for panic attacks listed in the DSM-5 is “feeling unreal”, so the psychologist her parents brought her to went off of that, giving her the diagnosis of panic disorder and prescribing breathing exercises.
“My episodes encapsulated much more than just feeling unreal,” she poured out to listeners. “I was feeling unreal all the time, and “unreal” was only a part of it.” She described her state of being as “living in a purgatory between life and death”.
The breathing exercises only worsened the feelings of “spacing out” she was enduring, because she wasn’t panicking. She only discovered the term “depersonalization” through her own research, as a 7th grader. It seems that online content creators she found discussing the subject were more helpful to her than any mental health professional she was ever in the care of growing up.
Unfortunately, her story is not out of the ordinary among individuals who deal with DP and DR. A 2015 article from The Guardian told the stories of three individuals who have been coping with DPDR Disorder for years. One of them is the daughter of a physician, but even with her father’s medical training he was wholly unaware of the condition — he had to learn about it on the Internet.
Gila Lyons wrote an article for Healthline about her anxiety-induced depersonalization, and how her explanation of her symptoms to her psychiatrist was a tearful one, as she was scared he would tell her she was insane. However, he wasn’t phased.
Her psychiatrist explained that traumatic events or high anxiety can foster these symptoms due to the human body’s physiologic response to fear. Stress activates the body’s fight-or-flight response wherein adrenaline directs blood away from the brain to your core and your larger muscles so you have the ability to flee from danger faster.
Studies of the neurological activity of patients with DPDR Disorder saw reduced activity in the areas of the brain responsible for emotional responses. Blunting emotions in the face of short-term danger may have an evolutionary advantage, but if it becomes chronic, it only causes problems.
It’s no wonder that DP and DR are associated with anxiety disorders; one 2007 study of DPDR Disorder patients showed that 45% of the subjects were also diagnosed with an anxiety disorder, and another found a comorbidity rate of 41–64%. DP is a symptom of anxiety, but DPDR Disorder can also exist as its own condition, alongside an anxiety disorder or not.
Though the symptoms seem worrying, from a medical perspective they’re considered relatively harmless. Experiencing depersonalization and derealization is not a sign of psychosis, as sufferers will pass “reality checks” and understand that their altered sensations are not real.
Despite the apparent innocuousness of this warped sense of reality, actually having to cope with it on a daily basis can be seriously troubling. DP and DR symptoms can cause significant distress; your once-familiar surroundings becoming alien and your life losing the meaning it once had can be quite debilitating.
With how unearthly the sensations associated with DP/DR can become, and the lack of awareness surrounding the condition, those who deal with these symptoms may believe their illness is more severe than it actually is, and feel they are doomed. Patients might interpret the slower cognition and inability to engage with the world that comes with DP/DR as the result of physical brain issues. The aforementioned 2007 study of DPDR patients found that over 50% of subjects believed they had permanent brain damage or loss of brain function.
When I first noticed my life had turned to grayscale and was devoid of meaning, I distantly wondered if I had a brain tumor, though my thoughts seemed to be awash in a sea of nothingness. I had difficulty holding onto any particular notion, not only because of my impenetrable brain fog, but also because no thoughts could issue an emotional response from me, and therefore were essentially meaningless.
DP and DR symptoms have long been regarded as secondary to anxiety and depressive disorders, and DPDR Disorder on its own was thought to be quite rare. A study of 223 patients with this disorder seems to indicate otherwise.
Researchers compared the DPDR patients’ symptoms and course of treatment with a sample of patients diagnosed with a depressive disorder, to better understand how these two types of disorders differ. Even though DPDR Disorder and depressive disorders are frequently comorbid, the clinical picture DPDR patients presented with was distinct.
As compared to the depressed patients, DPDR patients had been dealing with their symptoms for longer, had a higher level of functional impairment socially and at work/school, and had high rates of previous inpatient treatment. They almost universally expressed a need for counseling specific to their symptoms.
The clearly significant distress these patients were under flies in the face of the idea that DP should be regarded as a minor symptom of another primary disorder and highlights the gaps in care many with DP and DR symptoms encounter when seeking treatment.
The study also considered both patient groups’ history of trauma to try and understand risk factors for developing DPDR Disorder, and the results didn’t quite align with the common assumption that DPDR Disorder arises from severe long-term trauma. It seems that, according to this study, DPDR Disorder may not ride on the coattails of a traumatic event after all. This is an unexpected result because short-term episodes of DP and DR are often triggered by unbearable stress. There are clearly other factors at play here.
The way DPDR Disorder originates in individuals who have it is poorly understood, and current treatments are limited, with many medications having shown little success in getting symptoms under control.
I have found comfort in Internet forums over the years. Seeing others with DP and DR explain their strategies for coping and mitigation of symptoms helps me live a better life, and understand that I don’t need to be afraid. The less I fear the symptoms, the less of a hold they have on me.
Hopeful musings aside, I can’t help but consider how my perceptions of my mental state would have changed had I known about DP when it first appeared.
There is absolutely a need for more, larger studies on DPDR Disorder, and DP and DR should more frequently be a part of mental health discourse. Frankly, I’m surprised they’re not, especially since they’re commonly tied into anxiety and depression.
I want to highlight the lack of awareness of DP and DR, and how difficult it can be to manage, while also instilling hope in those who deal with it. I have absolutely improved since this all started when I was a teenager, and it’s possible for you too.
Accepting my symptoms rather than fearing them has been key for me because it helps me realize that they are not harmful, and my life can continue despite them. I encourage anyone who is struggling to reach out to friends, family, and any mental health resource that is accessible.
