Depersonalization-Derealization Syndrome
ICD-10: F48.1
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Depersonalization and Derealization (DDS) WHAT IS IT? Depersonalization and derealization are states in which the perception of one's own person or the environment is altered and experienced as unreal.
- People who suffer from depersonalization experience their mental activity or their body as foreign or distant, as if they were outside their body.
- In derealization, the surroundings appear altered, often as if in the distance, blurred, or as if in a dream. Both phenomena can create the feeling that the world and one's own self seem automated or unreal.
[Translate to English:] Depersonalisation
[Translate to English:] Das Gefühl, weit entfernt oder "nicht wirklich hier" zu sein, beschreibt eine Empfindung der Entfremdung von sich selbst und der eigenen Umgebung. Eigene Gefühle und Erfahrungen erscheinen dabei losgelöst, fern und nicht als die eigenen. Es kann sich so anfühlen, als würden die eigenen Emotionen und Bewegungen zu jemand anderem gehören. Oft entsteht der Eindruck, als ob man in einem Schauspiel mitspielen würde, ohne wirklich Teil der Realität zu sein.
Derealization
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The sensation of unreality is a state in which the world around one appears strange and alienated. Objects, people, or the entire environment often seem oddly artificial or distorted. It is as if everything has lost its luster: colors appear pale and lifeless, and things seem uninteresting and monotonous.
This state can also include the feeling that the surroundings seem like a stage on which everyone is merely playing a role. The people around one seem like actors in a theatrical play, and everything feels staged and unreal. One has the impression of being disconnected from real life and being merely a spectator in a strange performance.
What Depersonalization-Derealization is NOT
Why Depersonalization and Derealization are neither psychotic disorders nor classified as part of dissociative disorders (conversion disorders):
- No change in personality: People who suffer from depersonalization or derealization do not experience a fundamental change in their personality. Although they feel alienated from themselves or their environment, they continue to recognize who they are and have no profound personality changes.
- Insight into the cause: Those affected recognize that their perceptual disturbances, such as the feeling of being distanced from themselves or reality, are not caused by external forces or other people. Therefore, these are not delusions or externally controlled experiences.
- Intact reality testing: Despite the feelings of alienation, those affected are able to distinguish between their inner experience and external reality. They know that their sensations do not correspond to the actual situation, which is often not the case with psychotic disorders.
- Non-psychotic and not a precursor: Depersonalization and derealization are not considered psychotic disorders and do not herald such a disorder either. This means that these experiences do not indicate that a person will develop psychosis in the near future.
- Not part of dissociative disorders: These phenomena are not counted among dissociative disorders (also called conversion disorders) because they typically affect only certain aspects of identity. In contrast, dissociative disorders can involve more severe impairments, such as in perception, memory, or motor ability. Depersonalization and derealization primarily affect the experience of one's own identity without resulting in more comprehensive impairments.
Although depersonalization and derealization are distressing, they are not profound or psychotic disorders and therefore should not be classified as such.
Symptoms of Derealization-Depersonalization
Out of the blue, a feeling of strangeness overcomes me, as if I don't really exist or am cut off from the world. The things I see appear "flat" and lifeless to me, as if I'm merely looking at a picture. Parts of my body seem foreign to me, as if they don't belong to me.
In situations that would normally trigger fear or stress, I feel no anxiety. Activities that once brought me joy, I can no longer enjoy. While doing something, I often have the feeling of being merely a distant observer of my own actions.
The taste of food leaves me with neither pleasure nor aversion. My body sometimes seems so light, as if it were floating in the air. Even when I cry or laugh, it seems as if I'm not experiencing any real emotions. It seems to me as if I have no thoughts at all, and when I speak, it sounds as if a "robot" is uttering the words.
Familiar voices, including my own, suddenly sound distant and unreal. I have the feeling as if my hands or feet have changed their size, as if they have become smaller or larger. My surroundings sometimes appear so unreal to me, as if there were a veil between me and the outside world.
It feels as if recently occurred events already lie far in the past. Things I did this morning seem to me as if I experienced them weeks ago. Sometimes I see "dream images" in which I observe myself from the outside, as if I were seeing myself in a mirror.
I feel disconnected from my own memories of events in my life, as if I hadn't really been involved in them. New situations seem strangely familiar to me, as if I had already experienced them before. Suddenly I notice that I'm losing all emotional connection to my family members and close friends.
Objects in my surroundings appear smaller or more distant to me. It feels as if I can't properly feel the things I touch, as if I weren't really the one touching them. I have the feeling of not being able to imagine things visually, such as the face of a familiar friend or a familiar place.
When a part of my body hurts, I perceive this pain as strangely detached, "as if it were someone else's pain." Sometimes I have the feeling of being outside my body. When I move, it seems as if I'm not controlling my movements myself, so that I seem "automaton-like" and mechanical, like a "robot."
Smells evoke in me neither pleasant sensations nor disgust. My thoughts seem to me as if they were independent of me, and I feel detached from them. Sometimes I have to touch myself to make sure that I have a body and really exist.
It seems as if I have lost physical sensations such as hunger and thirst, and eating or drinking appears to me like an automatic routine. Previously familiar places suddenly seem foreign to me, as if I had never seen them before. When I look in the mirror, I don't recognize myself.
Possible predisposing conditions:
- Anxiety.
- Avoidance tendency.
- Low tolerance for uncertainty.
- Inadequacy.
Possible triggers of Depersonalization Derealization:
- Stressful experiences.
- Psychosocial burdens.
- Traumatic experiences (death, separation, loss, accident).
Possible function of Depersonalization-Derealization Syndrome
DDS-Funktionsanalyse
Depersonalization-Derealization Syndrome can be understood as a psychological protective response that helps the affected person cope with overwhelming or threatening situations. In people with DDS, the experience of one's own person (depersonalization) or the environment (derealization) is altered, which is often described as a feeling of alienation. This feeling can represent a form of avoidance behavior that serves as an escape mechanism.
Through depersonalization, the affected person unconsciously distances themselves from themselves, which results in intense emotional experiences or distressing thoughts being perceived in a diminished way. Similarly, derealization can lead to the outside world being experienced as unreal or alienated, making threatening or painful aspects of the environment appear less distressing.
In this sense, DDS can be interpreted as an unconscious strategy for avoiding the full experience of reality. Those affected attempt to gain a certain control or protection from overwhelming feelings, stress, or trauma through this distancing. This can have a relieving effect in the short term, but in the long term often leads to further problems, as it prevents confrontation with the actual triggers of internal tensions.
What does someone experiencing depersonalization do?
A person experiencing depersonalization (i.e., "someone depersonalizing") often perceives themselves as alienated from themselves. This feeling affects both one's own self and the body and can appear detached, unreal, or like an "observer" of one's own life.
Typical behaviors of a person with depersonalization: Passive observation of one's own behavior: Many experience themselves as spectators of their own lives, as if they were observing their actions from the outside rather than actively controlling them. Avoidance behavior: Those affected frequently withdraw, avoid social situations or situations they perceive as too overwhelming. They may be afraid that others will notice their alienation or perceive them as "strange." Increased self-focus: Those affected often reflect intensively on their symptoms and try to understand or control the experience of depersonalization. This fixation on their own sensations can intensify the feeling of alienation. Emotional numbing: Many people report having no or only very diminished emotional reactions to things that previously moved them. As a result, they often appear apathetic or indifferent. Physical distancing: One's own body feels foreign or unreal. Some pay increased attention to unusual physical sensations and repeatedly check whether they still have control over their body. Others, on the other hand, avoid actively engaging with their body. Reality doubts: In combination with derealization, someone depersonalizing may doubt the reality of their surroundings, which can lead to repeated "reality checks" (e.g., whether things feel real or how they appear to others). Automated behavior: Everyday life can be experienced as "autopilot-like." The person performs actions routinely without really feeling connected to them or present. Why does he do this? Depersonalization is often a protective response of the brain to stress, trauma, or overwhelm. These mechanisms arise to protect the individual from intense emotions or dangerous situations by creating distance from what is experienced. Therefore, many of these behaviors (withdrawal, passive behavior, emotional numbing) are an attempt to cope with overwhelming feelings or burdens.
How does the person experiencing depersonalization do it?
How a person experiencing depersonalization enters into or maintains the experience of depersonalization can be described through the interplay of psychological, cognitive, and physical processes. There are both unconscious and conscious mechanisms that promote the alienation.
How does he do it – on the cognitive level: Dissociation as an automatic response: Depersonalization often occurs without conscious control. When the person experiencing depersonalization is confronted with intense stressors or traumatic memories, the brain can automatically trigger a dissociative reaction. This conscious "splitting off" serves as a protective mechanism to reduce painful feelings or overwhelm. Mental distancing: A person experiencing depersonalization often thinks repeatedly about their sensations, which is referred to as "ruminating." This constant focus on the feeling of not being real or separate from oneself intensifies the experience. Through the continuous observation of one's own thoughts and feelings, the person remains trapped in a cycle of self-alienation. Avoidance of intense emotions: Through the splitting off from intense emotions – often unconsciously – the emotional connection to experiences is suppressed. This process leads to a feeling of emotionlessness or emotional numbness. The person experiencing depersonalization does this as an unconscious protective strategy to avoid emotional pain or overload. How does he do it – on the physical level: Reduced body awareness: A person experiencing depersonalization can diminish the conscious perception of their own body. This often happens involuntarily and can appear as a feeling of "fogging" of the body. The body may feel foreign, difficult to control, or unreal, as if it doesn't really "belong to me." Automated actions: A person experiencing depersonalization often does things without actively focusing on their own body. Movements and actions can feel automatic and mechanical, as if the person is operating in "autopilot mode." There is a disconnection between inner perception and outer action. Intensification through stress responses: Physical reactions such as rapid heartbeat, muscle tension, or shallow breathing triggered by stress can intensify the feeling of depersonalization. These physical symptoms reinforce the perception that "something is wrong" or the body is not under one's own control. How does he do it – through maintenance: Fixation on symptoms: A person experiencing depersonalization often fixates on the unusual experience. Through constant thinking about one's own symptoms (for example: "Why do I feel so unreal?"), the condition persists or even worsens. This fixation keeps attention on the feeling of alienation. Avoidance of triggers: Often a person experiencing depersonalization avoids situations that could evoke stress or intense emotions. Although this brings short-term relief, it strengthens the tendency toward dissociation in the long term, as emotional processing is impeded. Psychological withdrawal: A person experiencing depersonalization may withdraw from interpersonal relationships or activities that previously brought joy. This leads to further alienation, as the person builds fewer connections to their environment or sense of self. Overall, the person experiencing depersonalization does this unconsciously or as an automated protective response to cope with overwhelming feelings or traumatic experiences. The maintenance of the condition is often reinforced by mental, physical, and emotional reactions that culminate in a cycle.
Behavioral therapy treatment
Bewältigungsstrategien bei Depersonalisations-Derealisations-Syndrom
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[Translate to English:]
- Strong, very familiar therapeutic rapport.
- Grounding.
- Mindfulness meditation. Self-awareness of symptom-free periods.
- Deepening in the perceptual dynamics of this axis: Externally visible versus Internally visible.
- Intrusive thought stopping.
- Attention redirection: Away from symptom focus/anxious self-observation.
- Reduction of negative (catastrophic) meaning of symptoms.
- Reduction of avoidance behaviors and thoughts.
- Improvement of emotion perception, naming, and expression (group therapy). Promotion of emotional experience, away from self-observing experience.
- Restructuring of associated dysfunctional beliefs about oneself and the behavior of other people.
- Symptom diary recording associated fears.
- Mental hygiene. Healthy lifestyle.
- Reduction of excessive safety behavior in relationships/fear of loss of control.
- Enhancement of self-confidence.
- Improvement of functional self-perception and perception of others.
Behavioral therapy steps for treating Depersonalization-Derealization Syndrome (DDS)
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Here is a description of the first seven behavioral therapy steps for treating Depersonalization-Derealization Syndrome (DDS)
Today I would like to introduce you to our approach to specifically treat your symptoms of depersonalization and derealization. Here are the steps we will go through together:
- Psychoeducation We begin by having me explain to you in detail what depersonalization and derealization are, how they develop, and what role they play in your life. You will learn that these symptoms are often a response to stress or anxiety and that they are not dangerous. We will discuss how the brain activates these experiences as a protective mechanism and how you can better understand the symptoms.
- Goal: Through this knowledge, we want to reduce your fear of the symptoms and give you a sense of control.
- Cognitive Restructuring In this step, we will look at your automatic thoughts that may be intensifying your symptoms. For example, you might think: "I'm losing my mind" or "This is the end." Together we will question these thoughts and replace them with more realistic and less threatening thoughts. To do this, we use techniques such as cognitive restructuring, where we examine the reality of your thoughts and make adjustments.
- Goal: You will learn to change your thought patterns to reduce your anxiety and better cope with the symptoms.
- Exposure Therapy We will systematically confront situations or thoughts that typically trigger your symptoms. This initially takes place in a safe setting, sometimes also in your imagination. We begin with less anxiety-provoking situations and gradually increase. The goal is for you to learn that these situations and your symptoms are not as threatening as you might assume.
- Goal: Through repeated confrontation, we will reduce your fear of the triggers and improve your ability to cope with the symptoms.
- Mindfulness Training I will teach you techniques with which you can learn to observe your thoughts, feelings, and physical sensations without judgment. This includes mindfulness exercises such as conscious breathing and body scan exercises. These methods help you experience the symptoms as temporary and non-threatening by learning to remain present in the moment.
- Goal: You will learn to observe your symptoms neutrally instead of evaluating them or fighting against them.
- Behavioral Experiments We will plan experiments together to test your assumptions about the symptoms. For example, we could recreate a specific situation that normally triggers your symptoms to see how that situation actually unfolds. This helps you better understand the reality of your fears and check whether your beliefs about the symptoms are accurate.
- Goal: Through these experiments, we can test and reduce your fears and misconceptions.
- Reinforcement Management We will identify which activities and behaviors bring you joy and promote your well-being. We will focus on integrating these positive activities into your daily life and rewarding your successes. The goal is for you to have more positive experiences again, which can indirectly alleviate your symptoms.
- Goal: Increasing your joy in life through positive activities and rewards.
- Self-Monitoring and Progress Tracking You will keep a diary in which you record your symptoms, thoughts, and progress. We will regularly review these records together to evaluate your progress and adjust the therapy accordingly. This helps us identify patterns or triggers and ensure that we are working effectively.
- Goal: Through continuous monitoring and adjustment of the therapy, we can ensure that you are on the right path and can better control your symptoms.
We will go through these steps systematically and at your pace. Each step is designed to help you better cope with your symptoms and improve your quality of life.
