Derealization and Depersonalization: Symptoms, Causes and What Helps

In depersonalization people describe feeling “like a robot” or “behind a glass wall,” not feeling their body or emotions, hearing their own voice as foreign, or seeing their hands as different. Emotional numbness and a feeling of watching your life as a spectator are also typical. In derealization the sensations concern the surroundings: walls and people seem unreal, distorted, distant or “painted,” time flows strangely, and familiar places look strange. The two phenomena often occur together and are frequently grouped under a single diagnosis.

The DSM-5 criteria for depersonalization/derealization disorder require persistent or recurrent episodes of depersonalization and/or derealization, intact reality testing (the person knows it is an impression), significant distress or impairment, and that the symptoms cannot be better explained by a substance (such as a drug or medication), a medical condition or another mental disorder such as schizophrenia, panic disorder, acute stress disorder or depression. The ICD-11 classification describes the disorder in a similar way. Two conditions are therefore key: duration and distress. A single episode lasting minutes or hours that passes by itself does not meet the criteria.

Both reviews give a consistent picture: the experience of unreality is part of the normal repertoire of the human nervous system, while the disorder in which it becomes entrenched and makes life difficult is rare but not exceptional — it affects roughly one person in a hundred. At the same time the prevalence data should be read with caution: they are based mainly on cross-sectional studies, and differences in definitions cause wide variation in results.

The most frequently cited model treats depersonalization and derealization as a form of protective detachment from overwhelming stimuli. When a threat or tension is very strong and neither flight nor fight is possible, the nervous system may “turn down” the processing of emotions and bodily sensations, which is subjectively experienced as numbness and unreality. Imaging studies in people with the disorder have described altered activity in areas of the prefrontal cortex and limbic system and a blunted autonomic response to emotional stimuli. These are, however, mechanistic findings from small samples with no unequivocal conclusions — there is no test that confirms the diagnosis.

Such a model explains well why episodes appear at the worst moments: during an accident, a panic attack or intense stress, when some people describe a “fog” and a feeling that it is happening to someone else. It also explains the vicious circle that maintains the disorder: after the first episode a person starts checking carefully whether they “still feel unreal,” fears that it is a sign of mental illness or brain damage, and anxiety and excessive self-monitoring intensify the symptoms. From a cognitive perspective, it is not unreality itself but its catastrophic interpretation that decides whether the episode passes or becomes entrenched.

The most frequently described triggers are severe or chronic stress, panic attacks and generalized anxiety, lack of sleep and extreme fatigue, trauma (especially childhood abuse), depression, and psychoactive substances. The list does not end with psychology: similar sensations can accompany migraine with aura, some epileptic seizures (especially temporal lobe), dehydration, severe sleep deprivation, hypoglycaemia, and the use or withdrawal of certain medications. For this reason a first episode with no obvious cause is worth discussing with a doctor rather than just “waiting out.”

The practical conclusion: in some people a single, even modest use of cannabis or hallucinogens is enough to set off symptoms that then persist despite complete abstinence. It is not known who is particularly susceptible, so there is no ‘safe’ dose, and people with earlier episodes of unreality, anxiety or trauma should treat cannabis and psychedelic substances with particular caution. The same goes for sleep: chronic sleep deficit and insomnia intensify dissociative and anxiety symptoms, as we describe in our knowledge-base entry on sleep and mental health.

The most important difference concerns preserved reality testing. In depersonalization and derealization the person knows the impression is strange and ‘as if’ — they say the world seems unreal, not that it is unreal. In psychosis the person is convinced of the reality of hallucinations or delusions and has no distance from their experiences. Unreality alone, without delusions and hallucinations, therefore does not signal the onset of schizophrenia — although any doubt requires assessment by a psychiatrist.

In practice the initial assessment includes a history (when it started, what preceded it, which substances and medicines), a physical examination and, depending on the picture, blood tests, an EEG if seizures are suspected (see our knowledge-base entry on electroencephalography) and a psychiatric or psychological assessment using dissociation questionnaires. Brain imaging is rarely needed if there are no neurological symptoms.

This is the most important and least comfortable piece of information: for this disorder we have few reliable studies. Four randomized trials with 300 participants in total across the whole literature is a volume that other fields would classify as preliminary. No method can therefore be considered proven to the degree we know from the treatment of depression or anxiety, and promises of a quick ‘cure’ with a supplement or a breathing technique should be treated sceptically.

A concrete example of caution: lamotrigine has been studied in depersonalization disorder. A double-blind, placebo-controlled crossover study of nine patients (Sierra et al., 2003) showed no advantage over placebo — none of the participants was a responder. A randomized study with a strongly positive result was also published, but it was later retracted by the journal and should therefore not be cited as evidence of efficacy. Likewise, the Wang review did not identify any drug with unequivocally proven efficacy.

What is done in practice, then? The foundation is explaining what these experiences are (psychoeducation reduces fear of them), treating coexisting depression or anxiety — because these are the conditions that can most often be treated effectively — improving sleep and limiting triggers, including complete abstinence from cannabis and psychoactive substances. Specialized forms of cognitive behavioural therapy that target catastrophic interpretations of symptoms and excessive self-monitoring are being developed, but the evidence for their efficacy is still limited. The choice of method is worth discussing with a psychiatrist or clinical psychologist experienced in dissociative disorders.

Physical activity and a regular daily rhythm have no proven effect on the disorder itself, but they improve sleep and mood, which are factors that genuinely affect the severity of symptoms. We also do not recommend supplements ‘for dissociation’ — such studies simply do not exist.

What this text does not cover: dissociation in the context of complex trauma and dissociative identity disorder (these require a separate, specialist assessment), depersonalization in the course of neurological diseases, and the pharmacology of individual drugs. We also do not describe neuromodulation methods, because the evidence is too preliminary to draw practical conclusions.

The most helpful message for someone who has just had a first episode of unreality is also a simple one: the experience is common, it does not mean brain damage or madness, and in most cases it passes once the cause subsides. At the same time it is worth saying honestly that once the symptom becomes entrenched, we have little hard evidence for specific treatments — and that it is better to look for a specialist who works with dissociative disorders than to buy more promises.