Depersonalization-derealization disorder

Essential Features:

• Persistent or recurrent experiences of either or both depersonalization or derealization:
• Depersonalization is characterized by experiencing the self as strange or unreal, or feeling detached from, or as though one were an outside observer of, one’s thoughts, feelings, sensations, body, or actions. Depersonalization may take the form of emotional and/or physical numbing, a sense of watching oneself from a distance or ‘being in a play’, or perceptual alterations (e.g., a distorted sense of time).
• Derealization is characterized by experiencing other persons, objects, or the world as strange or unreal (e.g., dreamlike, distant, foggy, lifeless, colourless, or visually distorted) or feeling detached from one’s surroundings.
• During experiences of depersonalization or derealization, reality testing remains intact. The experiences are not associated with delusions or beliefs that the individual is being controlled by external persons or forces.
• The symptoms are not better accounted for by another mental disorder (e.g., Post-Traumatic Stress Disorder, an Anxiety or Fear-Related Disorder, another Dissociative Disorder, Personality Disorder).
• The symptoms are not due to the effects of a substance or medication on the central nervous system, including withdrawal effects, and are not due to a Disease of the Nervous System (e.g., temporal lobe epilepsy), head trauma, or another medical condition.
• The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

Additional Clinical Features:

• A common associated symptom in Depersonalization-Derealization Disorder is an altered sense of time, such as the subjective experience of time slowing down or speeding up.
• Catastrophic cognitions (e.g., frequent fears of ‘going crazy’) may occur, along with a lack of vividness in autobiographical memories. Loss of the sense of ‘ownership’ of some memories or physiological hyporeactivity to emotional stimuli may also be present.
• Episodes of depersonalization and derealization in Depersonalization-Derealization Disorder may be associated with adverse life events or interpersonal conflicts.

Boundary with Normality (Threshold):

• Transient feelings of depersonalization or derealization may be experienced when under stress, during extreme emotional states or exhaustion, when physically ill, or under the influence of substances. Unlike Depersonalization-Derealization Disorder, such experiences typically remit when these emotional or physical states change.

Course Features:

• Onset of Depersonalization-Derealization Disorder can occur in childhood but more typically has its onset in mid-adolescence, with a mean age at onset of approximately 16 years of age. Onset after 25 years of age is very rare.
• The onset of Depersonalization-Derealization Disorder can vary from acute to gradual and insidious, with initial episodes of limited severity and frequency followed by those that are more extreme and persistent.
• Discrete episodes of Depersonalization-Derealization Disorder can vary in duration, ranging from brief (e.g., hours or days) to prolonged (e.g., weeks, months or years). The course of the disorder is typically chronic and persistent.
• Most patients experience either continuous symptoms or an initially episodic course that becomes continuous over time. A persistent episodic course is less common, affecting about one-third of cases. Intensity of symptoms may differ between episodes or remain constant for years or even decades.
• Internal and external factors such as emotional stress, anxiety or negative affect, sensory overstimulation, sleep deprivation or substance use can exacerbate symptom intensity. Some individuals with Depersonalization-Derealization Disorder report that physical stimulation (e.g., exercise, mild self-injury) or comforting interpersonal interactions can reduce symptom intensity.
• Depersonalization-Derealization Disorder often co-occurs with Mood Disorders, Anxiety or Fear-Related Disorders or Personality Disorder. However, co-occurrence of these diagnoses does not appear to alter the severity of depersonalization or derealization symptoms.
• Although a history of verbal or emotional abuse, neglect and other forms of childhood interpersonal trauma are associated with the development of Depersonalization-Derealization Disorder, the association is not as strong as for other Dissociative Disorders (e.g., Dissociative Amnesia, Dissociative Identity Disorder). Some cases of Depersonalization-Derealization Disorder develop with what appears to be an out-of-the-blue onset that cannot be linked to any identifiable triggers.
• Psychoactive substance use, especially of marijuana or hallucinogens, is a common precipitant of depersonalization and derealization symptoms. However, Depersonalization-Derealization Disorder diagnosis can only be assigned if the symptoms persist beyond the period of intoxication or withdrawal.

Developmental Presentations:

• Children often have significant difficulty verbalizing their subjective experiences of depersonalization or derealization. They are also less likely than adults to experience unease or distress caused by these symptoms.
• Depersonalization in adolescents may lead to poor academic achievement.

Culture-Related Features:

• Intentionally induced experiences of depersonalization and derealization can be desired objectives of spiritual or meditative practices that are common in many religions and cultures and should not be assigned a diagnosis of Depersonalization-Derealization Disorder. Transient distressing experiences of depersonalization and derealization may emerge initially during these practices but abate as the person acquires proficiency.
• However, some individuals who initially induce these states intentionally or experience them as part of their religious practice may lose control over them and develop persistent symptoms that warrant assigning the diagnosis.

Sex- and/or Gender-Related Features:

• Depersonalization-Derealization Disorder occurs with similar frequency among men and women.
• There are no significant gender differences in the clinical characteristics or the co-occurrence patterns of the disorder.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with other Dissociative Disorders: Experiences of depersonalization and derealization are common in other Dissociative Disorders, particularly Dissociative Identity Disorder, Partial Dissociative Identity Disorder, Trance Disorder, and Possession Trance Disorder. If the diagnostic requirements for another Dissociative Disorder are met, an additional diagnosis of Depersonalization-Derealization Disorder should not be assigned.
• Boundary with Schizophrenia or Other Primary Psychotic Disorders: In Schizophrenia or Other Primary Psychotic Disorders, non-transient experiences of depersonalization or derealization are common during psychotic episodes, and may be accompanied by delusional interpretations of this experience. If depersonalization and/or derealization are limited to periods of psychotic symptoms in an individual with Schizophrenia or Other Primary Psychotic Disorder, an additional diagnosis of Depersonalization-Derealization Disorder should not be assigned.
• Boundary with Depressive Disorders: Depersonalization and derealization are common during Depressive Episodes and may be persistent. An additional diagnosis of Depersonalization-Derealization Disorder should not be assigned if the symptoms occur only during Depressive Episodes or are otherwise better accounted for by a Depressive Disorder.
• Boundary with panic attacks: Panic attacks in the context of Panic Disorder or other mental disorders may be associated with marked experiences of depersonalization-derealization, which may persist for a time after the panic episode subsides. If depersonalization-derealization symptoms occur exclusively during panic attacks or continue only for a brief period afterwards, a separate diagnosis of Depersonalization-Derealization Disorder is not warranted.
• Boundary with other Anxiety or Fear-Related Disorders: Transient experiences of depersonalization or derealization are also common in other Anxiety or Fear-Related Disorders such as Social Anxiety Disorder and Generalized Anxiety Disorder. If depersonalization and/or derealization is better accounted for by an Anxiety or Fear-Related Disorder (for example, these experiences occur only in the context of confrontation with the corresponding focus of apprehension), an additional diagnosis of Depersonalization-Derealization Disorder should not be assigned.
• Boundary with Post-Traumatic Stress Disorder and Complex Post-Traumatic Stress Disorder: Experiences of depersonalization and derealization are common in Post-Traumatic Stress Disorder, particularly during re-experiencing episodes such as flashbacks. If depersonalization or derealization is limited to episodes of re-experiencing in an individual with Post-Traumatic Stress Disorder or Complex Post-Traumatic Stress Disorder, an additional diagnosis of Depersonalization-Derealization Disorder should not be assigned. However, if clinically significant depersonalization and derealization occurs outside of or is persistent following re-experiencing episodes and the diagnostic requirements of both disorders are met, an additional diagnosis of Depersonalization-Derealization Disorder may be assigned.
• Boundary with Personality Disorder: Experiences of depersonalization or derealization may occur in Personality Disorder, especially when the person is under stress. If the symptoms are better accounted for by Personality Disorder, an additional diagnosis of Depersonalization-Derealization Disorder should not be assigned.