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Feeling Detached from Oneself, Symptoms and Therapeutic Interventions
Abnormal Psychology · Chapter 15: Dissociative Disorders: Fragmentation of Identity and MemorySection 15.3 · lesson 57 of 9712 min · free with a free account
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In this lesson
Depersonalization and derealization - common, often misdiagnosed, and treatable.
- Define depersonalization and derealization
- Explain why intact reality testing is the central diagnostic point
- Describe the maintenance cycle and why monitoring backfires
- Describe psychoeducation and treatment
Transcript
Everything said in the video, section by section (1,519 words). Read along, or search it.
Dissociative Disorders: Fragmentation of Identity and Memory
Feeling Detached from Oneself
This final section of the chapter covers experiences of detachment. Depersonalization, and derealization. We define them, and explain the single diagnostic point everything depends on. We look at why these experiences are so hard to describe, and so often misdiagnosed. And we look at the cycle that maintains them, and why simply understanding them is itself a treatment.
Read This First
Described From the Outside, on Purpose
A few things first. Brief experiences of this kind are common. And reading about them can make them more noticeable for a while. If any of this is difficult, it is reasonable to pause, and anyone affected should speak with a qualified professional. The experience is described here clinically, from the outside, rather than in an immersive way. That is deliberate. A vivid, evocative description could induce or intensify the experience in a viewer, which would be unpleasant, and counterproductive. Two facts frame everything that follows. Transient experiences of this kind are common, and not pathological. And the standalone condition is frequently misdiagnosed, with people often waiting years to be recognized.
Definitions
Unreality of Self, Unreality of the World
Depersonalization refers to experiences of unreality or detachment from oneself. From one's own thoughts, feelings, sensations, body, or actions. Derealization refers to experiences of unreality or detachment from one's surroundings. The environment seems unreal, distant, or altered. The two often occur together, and either can occur alone. People describe both through metaphor. Observing rather than doing. Surroundings that feel flat, distant, or changed in a way that is hard to specify. The fears that come with them are similar. That the experience means brain damage, or losing one's mind. And in both, reality testing is intact. The person knows the experience is not literally the case. That last point is the most important line in this whole section.
Common and Ordinary
Brief Episodes Are Everyday Experience
Brief episodes of depersonalization or derealization are common in the general population. They are especially common under fatigue, sustained stress, sleep deprivation, or intense anxiety. That places them at the ordinary end of the dissociative continuum. They need no explanation, and no concern. Saying this plainly does two things. It prevents viewers from over-identifying with a condition, just because they recognize a brief experience in themselves. And it is a therapeutic fact in its own right. A large part of the distress in the clinical condition comes from believing the experience is rare, ominous, and a sign of something catastrophic. Learning that brief versions are common is often a relief.
The Disorder
Persistent - With Reality Testing Intact
The disorder involves persistent or recurrent experiences of depersonalization, derealization, or both. Throughout, reality testing remains intact. The experiences cause significant distress or impairment, and are not due to a substance, another medical condition, or another mental condition. Here is the central diagnostic point. The person knows the experience is not literally the case. They say as if, and they mean it. As if watching themselves. As if the world were not real. As if behind glass. That is what separates this from a psychotic presentation. A person who holds that they have literally left their body, or that the world is literally a fabrication, is describing something different. Chapter nineteen covers that. And this distinction cannot be made from how vivid or distressing the account sounds, because the language is nearly identical either way. It has to be asked about directly.
The Difficulty of Description
No Words for a Missing Sense
People with this condition characteristically struggle to describe what they are experiencing. Ordinary language has no words for the absence of a sense of reality. That sense is normally so reliable that it goes unnoticed, so its loss has no name. So people reach for metaphor. Glass, fog, film, distance, dreaming, acting. They are not being vague. It is the only language available. And metaphor delivered by a distressed person is easily misheard. Feeling unreal may be recorded as a psychotic experience. Feeling nothing may be recorded as depressive numbing. Frightening and physical may be recorded as anxiety alone. People also fear the words themselves, since saying I feel unreal sounds like admitting to losing one's mind. So they often soften it, or stop mentioning it altogether. Delays of years before recognition are common. The practical lesson is to ask about it in ordinary terms, and then separately ask whether they think it is actually so. And recognition itself brings substantial relief.
Associated Features and Course
Beyond the Detachment
Several features commonly accompany the detachment. Emotional numbing, a reduced sense of emotional response, which is often more distressing than the detachment itself. An altered sense of time, and a distorted experience of one's own body. And subjective difficulty with memory and concentration, which is often more feared than objectively demonstrable. Onset is typically in adolescence or early adulthood. The course may be episodic, or continuous, with intensity that fluctuates. But much of the suffering in this condition does not come from the experience itself. It comes from the interpretation. The fear that it means brain damage, permanent change, or impending insanity. And that is the opening for treatment.
Triggers vs. Maintenance
What Started It Isn't What Keeps It Going
Onset commonly follows severe stress, a panic episode, sleep deprivation, or substance use, which is named here only at the level of substance class. But the onset context does not determine what keeps the experience going. This is clinically important, and frequently missed. Whatever began it, what sustains it is a maintenance cycle. And treatment addresses that cycle, not the original trigger. A person still searching for what caused it is often searching in the wrong place. As for mechanism, one account proposes a disconnection between perception and its usual emotional coloring. The world is perceived accurately, but does not feel real. Reduced autonomic responsiveness to emotional material has been reported in this group. That is an association, not an established cause. The cognitive-behavioral account does not try to explain onset. It explains maintenance, which is what treatment needs.
Figure 15.3.3
The Maintenance Cycle
Here is the maintenance cycle. The experience occurs. It is interpreted catastrophically. This means brain damage. This means I am going mad. This will be permanent. That interpretation is the first intervention point. Anxiety rises, which makes the experience more likely. The person monitors, checking whether it is there, and how bad it is now. That turns attention inward, away from the world. That monitoring is the second intervention point. And attention turned inward is exactly the condition under which detachment is most prominent. So the loop turns again. Avoidance and safety behaviors also keep it going, by preventing the person from discovering that the experience is tolerable and self-limiting. Monitoring is a target of treatment, not a coping strategy.
Differential Diagnosis
Standalone - or Part of Something Else?
Before the standalone diagnosis is made, several alternatives must be considered. A psychotic presentation is ruled in or out, by asking directly whether the person thinks the experience is actually so. Panic disorder is the commonest reason the standalone diagnosis is wrongly given. If the experience occurs only within attacks, and resolves with them, it is a feature of panic disorder. A depressive presentation is considered by asking whether the full depressive picture is met. Post-traumatic dissociation comes with the wider post-traumatic picture. Seizures and other neurological causes, often brief and stereotyped, come first in assessment, following the exclusion pathway. And substance effects are considered by asking whether onset and offset track use.
Treatment
Psychoeducation Is the Treatment
In most conditions, psychoeducation prepares the ground for treatment. Here, it is treatment. Much of the distress comes from the interpretation. And the facts are both reassuring and true. The experience has a name. Brief versions are common. And it is not a sign of brain damage. It is not psychosis, and it does not become psychosis. And it is treatable. Reducing the catastrophic interpretation lowers anxiety, which reduces both the experience and the monitoring. It weakens the whole loop. Cognitive-behavioral approaches then target the interpretation, the self-monitoring, and the avoidance. Grounding approaches, which redirect attention outward, are taught only by a clinician. Used as a way of checking whether the experience has gone, they become part of the cycle. Treating co-occurring anxiety and depression is often among the most effective steps. The evidence for medication for this condition specifically is limited, and prescribing decisions rest with a prescriber. And outcomes are better than people expect. The belief that it is permanent follows from the very interpretation that sustains it.
2 Composite Cases
Ellis and Yolanda
Two composite cases show the contrast. They describe no real people. Ellis, twenty-eight, told a new doctor he had never felt properly real since his late teens. For ten years he had been given other diagnoses, and at one point a psychosis was queried. Asked directly, he was clear that he knows everything is real. That, he said, is exactly what frightens him. Reality testing is intact. Neurological assessment was normal, and the experience persists outside any panic or low mood. This is the standalone disorder. Simply learning that it has a name, is common in brief form, and is not brain damage or psychosis, brought him substantial relief before treatment began. Yolanda, thirty-five, has panic attacks, and asked whether she had a dissociative condition. During attacks, she experiences marked detachment and unreality. Between attacks, she feels entirely herself. The detachment begins and ends with each attack. So it is a feature of her panic disorder, not a separate condition, and treating the panic is the priority.
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