This post includes descriptions of sensations (and the lack of them) associated with depersonalization/derealization (DPDR), which may be triggering if you are in a DPDR episode or have had one in the past. Those who come out of prolonged DPDR episodes sometimes experience a high level of fear about entering another episode, so if this is the case, please take some time to notice your surroundings to the best of your ability, monitor your reactions and take the precautions you need to take care of yourself while reading this.
Introduction
I decided to make this post because I was compiling scattered research about DPDR that I have gathered over the years for my own use as a clinician. If you have also looked for solid information and resources for DPDR you probably know they are few and far between, so I thought this compilation may be helpful to other folks on a similar search. I also describe my own approach to working with DPDR, and provide a free exercise. At the bottom I include a video that goes into practical tools in more depth, and I give some information about accessing resources for support.
Definitions
Depersonalization and derealization (DPDR) are perceptual disturbances that about 23% of individuals will experience as short-lived symptoms at some point in their lives (Simeon, 2004), but they can also last for long periods of time and present in chronic episodes. Depersonalization and derealization are often described in conjunction with each other, although not always. The brief experience of DPDR is gaining more visibility within the mental health field, especially as a passing symptom of traumatic experiences, but its prolonged, chronic presentation is still under-researched and understood. Even though it is under-researched, research is picking up and there are approaches to treating and effectively coping with DPDR that I describe in this post.
The Diagnostic Statistical Manual of mental disorders (DSM-V) defines the chronic experience of DPDR as depersonalization/derealization disorder. Depersonalization is defined as “experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional or physical numbing.)”
Derealization is defined as: “Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted)” (American Psychiatric Association, 2013). Put more simply, depersonalization involves the sense that the self isn't real, and derealization involves the sense that surroundings or the outside world is not real.
Self-reports
Because there is so little knowledge about DPDR in its prolonged state among the general public, most people have no idea what to call the experience when they go through it. In fact, in a study conducted by Baker et al. (2003), they found the average duration of symptoms was over 12 years by the time of first contact with a depersonalization specialist. This is largely because there are so few depersonalization specialists in the first place, but many individuals also believe they are the only ones who see themselves and the world this way, which only adds to the already-present sense of isolation and detachment (Simeon, 2004). Online communities for individuals going through this have developed over time which can help ease some isolation, such as https://www.dpselfhelp.com/forum/. There is also a growing youtube community.
Although those experiencing prolonged DPDR often feel totally alone in their experience, their descriptions of the disturbing and difficult-to-express sensations have remained remarkably similar and consistent throughout the last century. As early as 1935, Mayer-Gross collected self-reports of those experiencing DPDR and they are closely comparable to reports given at present day. This consistency in description despite isolation is extremely fascinating especially because the sensations are so difficult to describe, even to yourself. If you have experienced it, you know what I’m talking about.
Some of the most specific and common perceptual experiences involve looking at your hands and feeling they do not belong to you, feeling like everyone is acting out a role on stage and you are just a spectator, feeling surrounded by a metaphorical fog, and the image of yourself being isolated in the back of your own brain. Physical experiences include a decreased ability to feel bodily pleasure and/or pain, and general numbness. DPDR involves a sense of detachment from self and surroundings, but still involves a clear grasp of reality. Basically, you know there is a real world and you exist, but your body does not believe you. These are incredibly conflicting ideas to hold simultaneously, and are often described in “as if” language: "as if I were an automaton,” / “as if the world is not real,” / “as if I do not really exist.” Here we list more self-reports for different facets of the experience.
Self-reports for the internal experience:
Feeling “like a robot,” / “separate from myself,” / “head full of cotton wool.”
Self-reports of detachment from bodily feelings: “as if I were a phantom body” / “my emotions are gone, nothing affects me”
“everything is detached from me” (Medford, Sierra, Baker, & David, 2005) / “feel like
the walking dead” (Simeon, 2004).
Self-reports for perception of surroundings:
- “painted, not natural,” / “two-dimensional,” (Medford et al., 2005).
Being in this state for a prolonged period of time has profound impacts. On top it being incredibly difficult to describe, because there is a sense of detachment from the self and/or surroundings, there is also a common feeling of not controlling one's own actions and rather watching oneself act from the background. Because of this, those experiencing DPDR often appear totally normal to those around them which only adds to the feelings of alienation. The knowledge of what constitutes “reality” is also difficult to hold because although those experiencing DPDR know what is real and what is not, there is a common and often intense fear of having permanent brain damage, or eventually losing touch with reality entirely (Simeon, 2004). This fear is absolutely understandable, but DPDR very rarely leads to an actual break in reality, which may provide some comfort.
DPDR in the Mental Health Field
These were common self-reported experiences of DPDR. Because of the isolation involved in these episodes, having the experience validated can go a long way, likely more so than some other mental health struggles that are somewhat understood and acknowledged by the general public. It's also important to note that just because there is little acknowledgment among the general public, that does not mean there is nowhere to turn. DPDR is being researched more all the time, effective therapeutic approaches are being studied, and many people do come out of their prolonged episodes and/or learn to manage symptoms. I will now briefly take you through how the mental health field has approached this topic over time.
Symptomatic of Trauma
DPDR is usually discussed in its symptomatic form and as a natural freeze response to threatening events. When facing threatening events, our body goes into fight-flight-freeze mode and a near-instant sequence of physiological responses helps us fight off the threat, flee for safety, or freeze. The freeze response comes from the ancient strategy of ‘playing dead’ so a predator will lose interest and go away (Van der Kolk, 2012, cited in The Trauma Toolkit, 2013). Freezing can result in temporary DPDR, and in this case, it is tied to a clear circumstance in the environment. This clarity of cause is not granted for prolonged and/or chronic episodes that seemingly have no context or seemed to appear out of nowhere (Simeon, 2004).
In 1935, Mayer-Gross theorized that DPDR is a “preformed response of the brain” that is a normal response to threat that becomes fixed and maladaptive in some individuals. Seventy years later, this is still an attractive idea (Medford et al., 2005). Even though a prolonged episode may have seemed to appear out nowhere, it may still be tied to a freeze response that was internalized but was not immediately experienced.
It is possible for an out-of-body experience to occur due to traumatic events, especially when they're chronic, and this can result in structural dissociation. This means that the part of ourselves that experienced a trauma can become compartmentalized, and feel separate from our present self, which does not feel the full effects or impact of the traumatic experience. Our bodies do this to protect us from bearing the full emotional weight of the experience(s). When this happens, the dissociated part can feel stuck in the experience, and the emotional impacts can come out when exposed to triggers that remind us of the original event(s). This dissociation can involve the experience of depersonalization, where it may feel like the event happened to "someone else." Treatment in this case involves building internal communication between parts of self, then processing the trauma. While DPDR can involve structural dissociation, it does not always, and it is important not to assume so. Because DPDR is described as a trauma symptom, it is a common misconception that it is always tied to this kind of detachment/traumatic response. Each scenario includes its own approach to treatment and healing, and while both presentations are forms of dissociation, they contain many differences (Van der Hart, Nijenhuis, & Steele, 2006).
Experienced with Other Disorders/Challenges
The theory of internalized freeze responses contributing to chronic DPDR is further supported by the high level of emotional abuse that is experienced among those experiencing DPDR. Simeon, Gurainik, & Schmeidler (as cited in Simeon, 2004) found that when compared to those who did not experience DPDR, there was a significantly high experience of childhood trauma, particularly tied to emotional abuse. Physical and sexual abuse were reported as well but were more likely to be present in more severe forms of dissociation like dissociative identity disorder (DID). Other common experiences preceding DPDR episodes include prolonged periods of severe stress or adjustment. When we face prolonged severe stress and have not been given the tools or do not have the capacity to hold and regulate associated emotions, the body essentially shuts off to protect itself, which explains the sense of detachment from self and/or surroundings. Some people experience waves of coming in and out of presence as their nervous system works through the stress, and some have prolonged episodes of shutdown. If this is the case, and especially if the DPDR is tied to emotional abuse where the person did not have their feelings validated, welcomed or regulated by caregivers, treatment involves gradually helping the person to notice, hold, and validate their own emotions so their body can learn how to regulate them.
Sometimes when someone enters a prolonged DPDR episode, they find themselves racking their brain for a particular abusive event that could have caused the episode, and if nothing comes to mind, it could feel like there is no basis for the experience. This is a complicated topic to approach, but there does not have to be a dramatic, singular, or visibly overwhelming event in your past to provide a basis for this experience. Experiencing prolonged stress can mean many things to many people, and it has very real effects on your mind and body whether the events appear "severe" to outside observers or not. Your body only cares about your own experience.
DPDR can be a primary experience or a secondary one when associated with other mental struggles/disorders. This means that, if you are experiencing DPDR along with another disorder, it is common to feel like one experience is dominant, and the other is symptomatic. You may experience depression primarily, and experience depersonalization symptoms in stressful circumstances, or DPDR may feel like the main experience which leads to feelings of depression or anxiety. Common disorders/struggles experienced with DPDR include anxiety (Baker et al., 2003), depression, phobias, and obsession-compulsive disorder (WHO, 1992, p. 179). Prolonged episodes can develop gradually, or acutely (instantly). In acute cases, someone may recall the exact moment of onset. An episode can also be triggered by drug use, especially marijuana (Simeon, 2003).
Hyper-reflection
I have already written about the remarkably similar description of DPDR sensations over time and despite isolation. To me, this consistency shows how self-aware those of us who have experienced DPDR are towards our own sense of detachment, even if that awareness does not translate into integration with our surroundings initially. I absolutely believe this is a strength that can be harnessed if re-directed. While introspection can be healthy to practice because it teaches us about our internal experience, it can become detrimental if we focus only on our inner world and therefore reinforce further detachment from the outside world.
Among those in prolonged DPDR episodes there can be a tendency to philosophically ruminate, ie. thinking “if I’m not really me, then who am I? How can I be real but seem not real?” These thoughts are absolutely understandable. For an experience that involves a feeling of unreality while also knowing that what feels fake is actually real, philosophical questions centred around the meaning of life and existence in the first place is totally logical.
If you have gone to this place during a DPDR episode, you likely know how circular and fruitless these explorations can be. They can become repetitive and sometimes intrusive. These self-explorations can also involve self-monitoring and self-observation that become obsessive, usually in a desperate attempt to scan the body and mind for some sign of attachment to surroundings. Again, this is all understandable when feeling stuck in an experience that doesn’t make sense and is so frightening. The problem is, participating in too much self-monitoring or circular existential questions can actually perpetuate the condition by heightening the sense of unreality and existential unease (Medford et al., 2005).
Victor Frankl termed a phenomenon that he called hyper-reflection. From what I have seen this concept has not been tied directly to DPDR before, but it closely fits the description of what I just described. He described it as a kind of hyper-awareness of an issue, that ends up exacerbating the issue. He used a story about a "centipede who ran very well until he decided one day to observe just how he ran. The more he became conscious of the process, the more difficult it was to function, and finally he could only lie in a ditch in despair" (Frankl, 1986/2019). He also wrote about hyper-intention, which involves fixating on getting rid of an issue, which in the same way, ends up exacerbating it. He wrote that the antidote to hyper-reflection and hyper-intention is "dereflection," which involves redirecting attention away from oneself (Frankl, 1946). In terms relevant to DPDR, this involves noticing when you hyper-reflecting on the sense of detachment, and redirecting your attention towards the outside world or other activities.
My Approach
As is the case for all my specializations, I tailor my approach to your unique presentation and needs. Below I give some examples of how I approach DPDR and how it matches my therapeutic modalities and training.
Existential therapy
If philosophical rumination loops are part of your DPDR experience, I approach treatment through the lens of existential therapy. I believe it lends very well to the space of existential questioning (and often full-blown crisis) that can lie at the core of chronic DPDR. Because circular existential questions can perpetuate episodes, my approach is about channelling the energy clients feel within their own self-monitoring towards the external world, in accessible steps. Actively focussing on the external world can be incredibly scary. Many people experiencing DPDR become more isolated because being in the outside world is so upsetting, but doing this too much perpetuates the cycle. Existential therapy (specifically existential analysis) is not about dwelling on questions of meaning, it is about striving for a life of felt authenticity and personal meaning, and finding a way of living that enables us to give inner consent to our actions. Inner consent essentially means finding the “yes” in life, instead of feeling controlled by circumstance (Laengle & Wurm, 2016). Obviously this takes practice and time, and the existential analysis framework is about honouring the existential crisis at the core of DPDR, containing the drive for existential exploration in fruitful ways, and eventually applying inner sources of meaning into surroundings.
Trauma Processing with EMDR and Ego State Therapy
EMDR stands for "Eye movement desensitization and reprocessing," and is used to process traumatic memories. When we go through experiences that are overwhelming to our system and that are perceived as a threat, we go into fight-flight-freeze mode and as a result do not process the memory fully. When this happens, we continue to experience unexpected emotions when coming into contact with triggers that hold similarities to the original memory. These symptoms can involve sudden and confusing emotions/sensations, or flashbacks. EMDR targets the memories driving these symptoms and allows us to process the memory properly, which can help resolve the symptoms (Shapiro, 2018). Since DPDR often develops because of going through prolonged stress to the point of detaching from surroundings and/or sense of self, using EMDR to process memories tied to those stressors may be a way of getting to the root.
Ego state therapy involves exploring the various parts and identities that exist within our inner world. Just like it is important to foster gradual connection with surroundings through DPDR work, it is also important to address internal conflicts and integrate internal disconnections. Sometimes when we go through periods of trauma or severe stress, parts of our identity can get left behind within us without receiving the nurturance they need. Ego state therapy is about identifying these parts of yourself, and finding ways to nurture them in a way that is tied to the present and not the past. While this approach can be helpful for anyone, it may be particularly helpful if structural dissociation is part of the person's experience, as it helps to foster internal communication and strengthen a sense of self (Shapiro, 2016).
Cognitive-Behavioural Therapy
Research has shown that breaking the circular cycles of self-monitoring can have a significant effect on DPDR by using cognitive-behavioural therapy (CBT). One study used CBT with individuals reporting severe and chronic DPD with an average duration of 14 years, and dissociative symptoms significantly decreased after treatment (Hunter, Phillips, Chalder, Sierra, & David, 2003). I use CBT as symptom-management and as a way to build capacity.
I wholeheartedly believe that anyone experiencing DPDR is actively exhibiting a huge amount of strength and resilience already. Living life while experiencing DPDR is an emotionally and sometimes existentially exhausting experience. It takes so much courage to just go out into the world and perform daily tasks all the while experiencing a totally indescribable fear and alienation that is not perceived by those around you. The strength needed for re-integration is already there.
Free Exercise
I made an exercise that you are free to try out. The idea is to develop a practice of observing the world around you. When first starting, it should feel uncomfortable but not debilitating. It’s natural to avoid certain settings when experiencing DPDR because it feels disheartening to be confronted with your sense of disconnection head-on, but avoidance feeds the isolation. The first step is to pick a location where you have felt connected to in the past, either during your episode or beforehand.
You don’t want to pick a place that is debilitating in its grief – if you were to rate it on a scale of 1-10, 1 being not uncomfortable at all and 5 being barely uncomfortable, pick a 6. Other examples of locations may be art museums, cafes, etc. If you feel your DPDR symptoms particularly triggered in some locations, rule those out. Common triggers are artificial light and crowded places. You know your own triggers best.
The next step is to follow the prompts and observe your surroundings. You may feel upset and not want to bother because you’ll mainly notice the sense of disconnection. Try working through this frustration as best as you can and only focus on the physical aspects of the objects. Describe/document these observations. If you do notice sensations arise in your body or your body react to the environment in any way, write that down as well. It is okay and healthy to acknowledge your feelings of grief, anger, or sadness towards the disconnection, but do it briefly and only in one word, then move back to the physical aspects of the surroundings.
Some people struggle with differentiating feelings from sensations. Put simply, feelings are what usually come to mind when we think of emotions (ie. joy, happiness, sadness, anger etc.) and sensations refer to the way these emotions affect our bodies. Some sensation words include: fuzzy, shaky, tense, open, radiating, etc., and they are usually present in specific parts of our bodies (ie. shoulders, forehead, legs, stomach, etc.). I have included a list of these words. Of course DPDR often involves a lack of bodily sensations, and the point is not to fixate on your body in hopes of finding something – this part of the exercise is more about simply noticing if something does come up, and may be more useful after doing this practice for a while.
The activity may feel contrived at first. Any new practice aimed towards changing your experience does. The key is repetition. The more you fight your urge to avoid the world, and the more you continue interacting with it instead of falling into yourself, the more you will break those cycles that often perpetuate DPDR episodes. The idea is for this practice to become habitual. Using the sheet is helpful at first, and use it as long as you like, but the goal is for it to become common practice when interacting with your surroundings.
This exercise addresses a few aspects of DPDR, and you may be looking for practices that target a different aspect. Dr. Elaine Hunter (who was a part of the CBT study that had some promising results) wrote a book called Overcoming Depersonalisation and Feelings of Unreality: A self-help guide using cognitive-behavioural techniques that has other exercises that may cover what you are looking for.
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References
Aderibigbe YA, Bloch RM, Waler WR. (2001). Prevalence of depersonalization and derealization experiences in a rural population. Soc Psychiatry Psychiatr Epidemiol; 36: 63-9
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Baker, D., Hunter, E., Lawrence, E., & David, A. (2018). Overcoming depersonalisation and feelings of unreality: A self-help guide (2nd ed.). Robinson.
Baker, D., Hunter, E., Lawrence, E., et al (2003). Depersonlisation disorder: clinical features of 204 cases. British Journal of Psychiatry, 182, 428-433.
Frankl, V. E. (1946). Man's search for meaning. Beacon Press.
Frankl, V. E. (1986/2019). The doctor and the soul: From psychotherapy to logotherapy, Trans. Clara Winston and Richard Winston, (New York: Vintage Books, A division of Penguin Random House LLC, 2019).
Hunter, E. C. M., Baker, D., Phillips, M. L., Sierra, M., David, A. S. (2004). Cognitive-behaviour therapy for depersonalisation disorder: an open study. Behaviour Research and Therapy, 43, 1121-1130.
Laengle, S., & Wurm, C. (Ed.). (2016) Living your own life: Existential analysis in action. Routledge.
Medford, N., Sierra, M., Baker, D., & David, A. S. (2005). Understanding and treating depersonalisation disorder. Advances in Psychiatric Treatment, 11, 92-100.
Shapiro, F. (2018). Eye movement desensitization and reprocessing (EMDR) therapy. (3rd ed.). The Guilford Press.
Shapiro, R. (2016). Easy ego state interventions: Strategies for working with parts. NY: W. Norton & Company
Simeon, D. (2004). Depersonalisation disorder: A contemporary overview. Therapy in Practice, 18(6), 343-354.
Trauma-informed (2013). The Trauma Toolkit, Second Edition. Klinic Community Health Centre.
Trauma-Informed Practice Guide. 2013. BC Provincial Mental Health and Substance Use Planning Council.
Van der Hart, O., Nijenhuis, E. R. S., Steele, K. (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. NY: W. Norton & Company.
World Health Organization (1992). The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: WHO.