Depersonalization/Derealization Disorder

Overview

Definition

• Depersonalization is a persistent or recurrent experience of unreality, detachment, or being an outside observer of one’s own thoughts, feelings, and sensations, usually associated with altered perception Perception The process by which the nature and meaning of sensory stimuli are recognized and interpreted. Psychiatric Assessment, emotional or physical numbness, and distorted sense of time. This perception Perception The process by which the nature and meaning of sensory stimuli are recognized and interpreted. Psychiatric Assessment might also make the patient feel like they are observing their own body. 
• Derealization is a persistent subjective sense of detachment or unreality of the surrounding world often described by the patient as unreal, dreamlike, foggy, lifeless, or visually distorted reality.

Epidemiology

• Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency in the general population: approximately 2%
  • Transient experiences of depersonalization or derealization occur in about 50% of individuals at least once in their lifetime, with symptoms lasting hours to days being common.
  • Depersonalization symptoms secondary to another pathology are more common.
• Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency is similar between sexes.
• Average age at onset: mean onset is 16 years, with less than 20% of cases starting after age 20 and only 5% after age 25
• Risk factors:
  • History of trauma
  • History of substance use disorder
  • Anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder or depressive disorders

Pathophysiology

• Trauma:
  • Thought to occur as a response to severe stressors
  • Survival mechanism to manage stressful situations without feeling overwhelmed
• Organic causes:
  • Seen in people with seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures and head injury (but the disorder is not directly caused by these)
  • It is thought that there is a genetic predisposition to developing depersonalization/derealization disorder (DDD).
• Neurobiology:
  • Several neurotransmitter systems (N-methyl-d-aspartate (NMDA), opioid Opioid Compounds with activity like opiate alkaloids, acting at opioid receptors. Properties include induction of analgesia or narcosis. Constipation, and serotonin Serotonin A biochemical messenger and regulator, synthesized from the essential amino acid l-tryptophan. In humans it is found primarily in the central nervous system, gastrointestinal tract, and blood platelets. Serotonin mediates several important physiological functions including neurotransmission, gastrointestinal motility, hemostasis, and cardiovascular integrity. Receptors and Neurotransmitters of the CNS) are associated with the disorder and involvement of the receptors Receptors Receptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell. Receptors leads to symptoms.
    • NMDA receptors Receptors Receptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell. Receptors are important in associative processes.
    • Ketamine Ketamine A cyclohexanone derivative used for induction of anesthesia. Its mechanism of action is not well understood, but ketamine can block NMDA receptors (n-methyl-d-aspartate receptors) and may interact with sigma receptors. Intravenous Anesthetics, an NMDA antagonist NMDA antagonist Alzheimer Disease, induces a dissociative state. 
  • Brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification regions, like the inferior parietal Parietal One of a pair of irregularly shaped quadrilateral bones situated between the frontal bone and occipital bone, which together form the sides of the cranium. Skull: Anatomy lobule (right hemisphere) are noted to have abnormal activity during a depersonalization experience.
  • Hypoactivation of the limbic system Limbic system The limbic system is a neuronal network that mediates emotion and motivation, while also playing a role in learning and memory. The extended neural network is vital to numerous basic psychological functions and plays an invaluable role in processing and responding to environmental stimuli. Limbic System: Anatomy (notably in the insula) has been also linked to depersonalization/derealization disorder.
• Conceptual models:
  • Cognitive behavioral models: Fear plays a central role, and the core components can be dissociation Dissociation Defense Mechanisms of affect (not feeling) and alexithymia (difficulty identifying and verbalizing emotions).
  • Psychodynamic theories: Immense stressors challenge the various aspects of one’s self-experience with the surrounding world.

Diagnosis and Clinical Features

Diagnosis

• Careful history taking, as well as neurologic exam, is essential for correct diagnosis. 
• Diagnosis is clinical by meeting specific criteria:
  • Presence of recurrent or persistent episodes of depersonalization, derealization, or both
  • Reality testing remains intact during episodes.
  • Episodes cause significant impairment in day-to-day function.
• Substance use (alcohol, lysergic acid diethylamide (LSD)), medical conditions ( seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures, head injury), and other psychiatric conditions must be ruled out.
• To rule out organic causes, initial evaluation must include:
  • EEG EEG Seizures
  • Basic metabolic panel Basic Metabolic Panel Primary vs Secondary Headaches and other blood work-up as clinically indicated
  • Urine toxicology screen
  • Brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification imaging

Clinical features

• Altered sense (misperception) of time: perceived as too fast or too slow 
• Problems with memory Memory Complex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory. Psychiatric Assessment consolidation Consolidation Pulmonary Function Tests and recall ( memory Memory Complex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory. Psychiatric Assessment impairment) 
• Nonpathologic dissociation Dissociation Defense Mechanisms:
  • Normal to experience dissociation Dissociation Defense Mechanisms during everyday daily activities 
  • Example: arriving at a destination in your vehicle without recalling the drive
  • In nonpathologic dissociation Dissociation Defense Mechanisms, the patient does not experience feelings of distress or functional impairment.

Management

Treatment must include psychoeducation Psychoeducation Psychotherapy as well as supportive psychotherapy Supportive psychotherapy Psychotherapy.

Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy

• First-line: combined CBT and exploratory psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy with the following goals:
  • Address acute symptoms and stressors
  • Normalize symptoms, minimize repetitive thoughts, and use grounding strategies effectively
• Alternative approach:
  • Psychodynamic psychotherapy Psychodynamic psychotherapy Forms of psychotherapy falling within or deriving from the psychoanalytic tradition, that view individuals as reacting to unconscious forces (e.g., motivation, drive), that focus on processes of change and development, and that place a premium on self understanding and making meaning of what is unconscious. Psychotherapy: the goal is to uncover intolerable emotions that may lead to dissociative symptoms and create better ways to process them.

Pharmacotherapy

• Treat comorbid conditions (depression, anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder).
• Lamotrigine Lamotrigine A phenyltriazine compound, sodium and calcium channel blocker that is used for the treatment of seizures and bipolar disorder. Second-Generation Anticonvulsant Drugs ( anticonvulsant Anticonvulsant Anticonvulsant drugs are pharmacological agents used to achieve seizure control and/or prevent seizure episodes. Anticonvulsants encompass various drugs with different mechanisms of action including ion-channel (Na+ and Ca+2) blocking and GABA reuptake inhibition. First-Generation Anticonvulsant Drugs): used in individuals without co-occurring mental health conditions (e.g., anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder, depression, etc ETC The electron transport chain (ETC) sends electrons through a series of proteins, which generate an electrochemical proton gradient that produces energy in the form of adenosine triphosphate (ATP). Electron Transport Chain (ETC).), who haven’t responded to cognitive-behavioral therapy Cognitive-behavioral therapy Cognitive-behavioral therapy corrects faulty assumptions and tries to replace maladaptive behavior with healthier alternatives. Psychotherapy (CBT) or psychodynamic psychotherapy Psychodynamic psychotherapy Forms of psychotherapy falling within or deriving from the psychoanalytic tradition, that view individuals as reacting to unconscious forces (e.g., motivation, drive), that focus on processes of change and development, and that place a premium on self understanding and making meaning of what is unconscious. Psychotherapy.
• SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants/ SNRIs SNRIs Serotonin Reuptake Inhibitors and Similar Antidepressants: used for co-occurring depression or anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder; less evidence for direct impact on DDD symptoms.
• Clomipramine Clomipramine A tricyclic antidepressant similar to imipramine that selectively inhibits the uptake of serotonin in the brain. It is readily absorbed from the gastrointestinal tract and demethylated in the liver to form its primary active metabolite, desmethylclomipramine. Tricyclic Antidepressants (tricyclic antidepressant Antidepressant Antidepressants encompass several drug classes and are used to treat individuals with depression, anxiety, and psychiatric conditions, as well as those with chronic pain and symptoms of menopause. Antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and many other drugs in a class of their own. Serotonin Reuptake Inhibitors and Similar Antidepressants) and Naltrexone Naltrexone Derivative of noroxymorphone that is the n-cyclopropylmethyl congener of naloxone. It is a narcotic antagonist that is effective orally, longer lasting and more potent than naloxone, and has been proposed for the treatment of heroin addiction. Opioid Analgesics (opioid-receptor antagonist):
  • Preferred in cases of inadequate response to psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy and SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants
  • Naltrexone Naltrexone Derivative of noroxymorphone that is the n-cyclopropylmethyl congener of naloxone. It is a narcotic antagonist that is effective orally, longer lasting and more potent than naloxone, and has been proposed for the treatment of heroin addiction. Opioid Analgesics: second-line option if clomipramine Clomipramine A tricyclic antidepressant similar to imipramine that selectively inhibits the uptake of serotonin in the brain. It is readily absorbed from the gastrointestinal tract and demethylated in the liver to form its primary active metabolite, desmethylclomipramine. Tricyclic Antidepressants is ineffective or contraindicated
  • Both may help with hypoemotionality or emotional numbing
• Antipsychotics: used for DDD with overvalued ideas or psychosis-like symptoms.
• Stimulants Stimulants Stimulants are used by the general public to increase alertness and energy, decrease fatigue, and promote mental focus. Stimulants have medical uses for individuals with ADHD and sleep disorders, and are also used in combination with analgesics in pain management. Stimulants (eg, methylphenidate Methylphenidate A central nervous system stimulant used most commonly in the treatment of attention deficit disorder in children and for narcolepsy. Its mechanisms appear to be similar to those of dextroamphetamine. Stimulants, atomoxetine, etc ETC The electron transport chain (ETC) sends electrons through a series of proteins, which generate an electrochemical proton gradient that produces energy in the form of adenosine triphosphate (ATP). Electron Transport Chain (ETC).): occasionally used for cognitive symptoms (e.g., attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment or memory Memory Complex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory. Psychiatric Assessment complaints)

Differential Diagnosis

• Acute stress disorder Acute stress disorder Acute stress disorder describes stress reactions displayed after an individual has experienced a traumatic event. Symptoms last more than 3 days but less than 1 month and include re-experiencing the event as flashbacks or nightmares, avoidance of reminders of the event, irritability, hyperarousal, and poor memory and concentration. Acute Stress Disorder: stress reactions displayed after an individual has experienced a traumatic event Traumatic event An emotionally painful, shocking, stressful, and sometimes life-threatening experience. It can result from witnessing distressing events such as natural disasters, physical or sexual abuse, and terrorism or other acts of violence. Posttraumatic Stress Disorder (PTSD). Symptoms last > 3 days, but < 1 month and include reexperiencing the event as flashbacks or nightmares, avoidance of reminders of the event, irritability, hyperarousal, and poor memory Memory Complex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory. Psychiatric Assessment and concentration. Those with DDD experience only the dissociative aspects and, therefore, do not qualify for the diagnosis of acute stress disorder Acute stress disorder Acute stress disorder describes stress reactions displayed after an individual has experienced a traumatic event. Symptoms last more than 3 days but less than 1 month and include re-experiencing the event as flashbacks or nightmares, avoidance of reminders of the event, irritability, hyperarousal, and poor memory and concentration. Acute Stress Disorder. 
• Hallucinogen Hallucinogen Drugs capable of inducing illusions, hallucinations, delusions, paranoid ideations, and other alterations of mood and thinking. Despite the name, the feature that distinguishes these agents from other classes of drugs is their capacity to induce states of altered perception, thought, and feeling that are not experienced otherwise. Hallucinogen Use Disorder use disorder: pathologic consumption of hallucinogenic substances that cause perceptual distortions (visual or auditory). Examples of substances ingested include psilocybin ( mushrooms Mushrooms Mycology), LSD, and phencyclidine ( PCP PCP Pneumocystis jiroveci is a yeast-like fungus causing pneumocystis pneumonia (PCP) in immunocompromised patients. Pneumocystis pneumonia is spread through airborne transmission and classically affects patients with AIDS, functioning as an AIDS-defining illness. Patients may present with insidious onset of fever, chills, dry cough, chest pain, and shortness of breath. Pneumocystis jirovecii/Pneumocystis Pneumonia (PCP)). These drugs are used for their psychedelic effects—a temporary altered state of consciousness. During acute intoxication, patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship may experience depersonalization or derealization. Thorough history taking and toxicology screening Screening Preoperative Care can differentiate hallucinogen intoxication Hallucinogen intoxication Hallucinogen Use Disorder from DDD. 
• Schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia: chronic mental health disorder that is characterized by positive symptoms (delusions, hallucinations Hallucinations Subjectively experienced sensations in the absence of an appropriate stimulus, but which are regarded by the individual as real. They may be of organic origin or associated with mental disorders. Schizophrenia, and disorganized speech or behavior) and negative symptoms (flat affect, avolition Avolition Lack of initiative. Schizophrenia, anhedonia Anhedonia Inability to experience pleasure due to impairment or dysfunction of normal psychological and neurobiological mechanisms. It is a symptom of many psychotic disorders (e.g., depressive disorder, major; and schizophrenia). Schizophrenia, poor attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment, and alogia Alogia Poverty of speech. Schizophrenia). Schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia is associated with a decline in functioning lasting > 6 months. Those with DDD may experience similar alterations in realities; however, reality testing remains intact, with no other positive/negative symptoms.