Approach to treating depersonalization/derealization disorder
- Daphne Simeon, MD
Daphne Simeon, MD
- Associate Clinical Professor
- Mount Sinai School of Medicine
Depersonalization/derealization disorder (DDD) is characterized by persistent or recurrent depersonalization and/or derealization that causes clinically significant distress. Reality testing remains intact, and no medical causes can be identified . Depersonalization and/or derealization can be precipitated by acute and chronic traumatic experiences.
DDD has a prevalence of approximately 1 to 2 percent and is associated with significant morbidity, yet often goes undetected or misdiagnosed, leading to delays in treatment. DDD has high rates of comorbidity with depression and anxiety disorders, as well as avoidant and borderline personality disorders.
This topic discusses our approach to selecting treatments for DDD, including psychotherapy and pharmacotherapy. The epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis of DDD are discussed separately. Information on the components, efficacy, and administration of individual psychotherapies for DDD are also described separately. Information on the efficacy, dosing, and side effects of individual medications for DDD are also described separately. (See "Depersonalization/derealization disorder: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis" and "Psychotherapy of depersonalization/derealization disorder" and "Pharmacotherapy of depersonalization/derealization disorder".)
Depersonalization — Depersonalization is a persistent or recurrent feeling of detachment or estrangement from one’s self. An individual experiencing depersonalization may report feeling like an automaton or as if in a dream or as if watching him- or herself in a movie. Depersonalized individuals may report the sense of being an outside observer of their mental processes or their body, or at its extreme, lacking a sense of self. Another common feature is hypoemotionality (emotional numbing or blunting) specifically detachment from feelings that an individual knows they have. They often report feeling a loss of agency over their thoughts, perceptions, and actions.
Derealization — Derealization is a subjective sense of detachment or unreality regarding the world around them (eg, individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, seen through a glass, bubble, or veil, or visually distorted).
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- GENERAL PRINCIPLES
- INITIAL TREATMENT
- Choosing between psychotherapy and medication
- Selecting a psychotherapy
- Patient subgroups
- - Affect intolerance
- - Co-occurring depression or anxiety
- Intense, disabling anxiety
- TREATMENT RESPONSE
- Poor or partial response
- - Longer-term psychotherapy
- - Hypnotizable patients
- - Medication strategies
- Noncomorbid patients
- Emotional numbing
- TREATMENT RESISTANCE
- Chronic DDD with severe impairment
- SUMMARY AND RECOMMENDATIONS