depersonalization-derealization disorder depersonalization-derealization disorder depersonalization-derealization disorder (dpdr, dpd) is a mental disorder in which the person has persistent or recurrent feelings of depersonalization and/or derealization. depersonalization is described as feeling disconnected or detached from one's self. individuals may report feeling as if they are an outside observer of their own thoughts or body, and often report feeling a loss of control over their thoughts or actions. derealization is described as detachment from one's surroundings. individuals experiencing derealization may report perceiving the world around them as foggy, dreamlike/surreal, or visually distorted. depersonalization-derealization disorderspecialtypsychiatry, clinical psychologysymptomsdepersonalization, derealizationusual onsetyoung adulthooddurationchronic, episodictreatmentpsychotherapyfrequency1–2% (general population) depersonalization-derealization disorder is thought to be caused largely by interpersonal trauma such as childhood abuse. adverse early childhood experiences, specifically emotional abuse and neglect have been linked to the development of depersonalization symptoms. triggers may include significant stress, panic attacks, and drug use. individuals with the disorder may remain in a depersonalized state for the duration of a typical panic attack. however, in some situations the dissociated state may last for hours, days, or even weeks at a time. in rare cases, symptoms can last for years. diagnostic criteria for depersonalization-derealization disorder includes persistent or recurrent feelings of detachment from one's mental or bodily processes or from one's surroundings. a diagnosis is made when the dissociation is persistent and interferes with the social or occupational functions of daily life. while depersonalization-derealization disorder was once considered rare, lifetime experiences with it occur in about 1–2% of the general population. the chronic form of the disorder has a reported prevalence of 0.8 to 1.9%. while brief episodes of depersonalization or derealization can be common in the general population, the disorder is only diagnosed when these symptoms cause substantial distress or impair social, occupational, or other important areas of functioning. signs and symptoms the core symptoms of depersonalization-derealization disorder is the subjective experience of "unreality in one's self", or detachment from one's surroundings. people who are diagnosed with depersonalization also often experience an urge to question and think critically about the nature of reality and existence. individuals with depersonalization describe feeling disconnected from their physicality; feeling as if they are not completely occupying their own body; feeling as if their speech or physical movements are out of their control; feeling detached from their own thoughts or emotions; and experiencing themselves and their lives from a distance. while depersonalization involves detachment from one's self, individuals with derealization feel detached from their surroundings, as if the world around them is foggy, dreamlike, or visually distorted. individuals with the disorder commonly describe a feeling as though time is passing them by and they are not in the notion of the present. in some cases, individuals may be unable to accept their reflection as their own, or they may have out-of-body experiences. additionally some individuals experience difficulty concentrating and problems with memory retrieval. these individuals sometimes lack the "feeling" of a memory where they are able to recall a memory but feel as if they did not personally experience it. these experiences which strike at the core of a person's identity and consciousness may cause a person to feel uneasy or anxious. the inner turmoil created by the disorder can also result in depression. first experiences with depersonalization may be frightening, with patients fearing loss of control, dissociation from the rest of society and functional impairment. the majority of people with depersonalization-derealization disorder misinterpret the symptoms, thinking that they are signs of serious psychosis or brain dysfunction. this commonly leads to an increase of anxiety and obsession, which contributes to the worsening of symptoms. factors that tend to diminish symptoms are comforting personal interactions, intense physical or emotional stimulation, and relaxation. distracting oneself (by engaging in conversation or watching a movie, for example) may also provide temporary relief. some other factors that are identified as relieving symptom severity are diet or exercise, while alcohol and fatigue are listed by some as worsening their symptoms. occasional, brief moments of mild depersonalization can be experienced by many members of the general population; however, depersonalization-derealization disorder occurs when these feelings are strong, severe, persistent, or recurrent and when these feelings interfere with daily functioning. dpdr episodes tend to be transient but duration is highly variable with some lasting as long as several weeks. a growing number of users participating in virtual reality (vr) are facing the hazard of dpdr with dissociative experiences after use. higher levels of a lessened sense of reality and being easily immersed can occur. causes the exact cause of depersonalization is unknown, although biopsychosocial correlations and triggers have been identified. it has been thought that depersonalization can be caused by a biological response to dangerous or life-threatening situations which causes heightened senses and emotional numbing. psychosocial there is growing evidence linking physical and sexual abuse in childhood with the development of dissociative disorders. childhood interpersonal trauma – emotional abuse in particular – is a significant predictor of a diagnosis of dpdr. compared to other types of childhood trauma, emotional abuse has been found to be the most significant predictor both of a diagnosis of depersonalization disorder and of depersonalization scores, but not of general dissociation scores. some studies suggest that greater emotional abuse and lower physical abuse predict depersonalization in adult women with post-traumatic stress disorder (ptsd). patients with high interpersonal abuse histories (hia) show significantly higher scores on the cambridge depersonalization scale, when compared to a control group. earlier age of abuse, increased duration and parental abuse tend to correlate with severity of dissociative symptoms. besides traumatic experiences, other common precipitators of the disorder include severe stress, major depressive disorder, panic attacks, and psychoactive substances. people who live in highly individualistic cultures may be more vulnerable to depersonalization, due to threat hypersensitivity and an external locus of control. neurobiology animated image showing prefrontal cortex, which is thought to play a role in dpdr there is converging evidence that the prefrontal cortex may inhibit neural circuits that normally form the basis of emotional experience. in an fmri study of dpdr patients, emotionally aversive scenes activated the right ventral prefrontal cortex. participants demonstrated a reduced neural response in emotion-sensitive regions, as well as an increased response in regions associated with emotional regulation. in a similar test of emotional memory, depersonalization disorder patients did not process emotionally salient material in the same way as did healthy controls. in a test of skin conductance responses to unpleasant stimuli, the subjects showed a selective inhibitory mechanism on emotional processing. studies are beginning to show that the temporoparietal junction has a role in multisensory integration, embodiment, and self-other distinction. several studies analyzing brain mri findings from dpdr patients found decreased cortical thickness in the right middle temporal gyrus, reduction in grey matter volume in the right caudate, thalamus, and occipital gyri, as well as lower white matter integrity in the left temporal and right temporoparietal regions. however, no structural changes in the amygdala were observed. a pet scan found functional abnormalities in the visual, auditory, and somatosensory cortex, as well as in areas responsible for an integrated body schema. one study examining eeg readings found frontal alpha wave overactivation and increased theta activity waves in the temporal region of the left hemisphere. image showing temporoparietal junction, a portion of the brain also thought to play a role in dpdr it is unclear whether genetics plays a role; however, there are many neurochemical and hormonal changes in individuals with depersonalization disorder. dpdr may be associated with dysregulation of the hypothalamic-pituitary-adrenal axis, the area of the brain involved in the "fight-or-flight" response. patients demonstrate abnormal cortisol levels and basal activity. studies found that patients with dpdr could be distinguished from patients with clinical depression and posttraumatic stress disorder. the vestibular system may also play a role in dpdr. the vestibular system helps control balance, spatial orientation, motor coordination, but also plays a role in self-awareness. disruption to this system can potentially cause a feeling of detachment from surroundings. several studies have shown that patients with peripheral vestibular disease are also more likely to have dissociative symptoms when compared to healthy individuals. dissociative symptoms are sometimes described by those with neurological diseases, such as amyotrophic lateral sclerosis, alzheimer's, multiple sclerosis (ms), etc., that directly affect brain tissue. diagnosis assessment diagnosis is based on the self-reported experiences of the person followed by a clinical assessment. psychiatric assessment includes a psychiatric history and some form of mental status examination. since some medical and psychiatric conditions mimic the symptoms of dpdr, clinicians must differentiate between and rule out the following to establish a precise diagnosis: temporal lobe epilepsy, panic disorder, acute stress disorder, schizophrenia, migraine, drug use, brain tumor or lesion. no laboratory test for depersonalization-derealization disorder currently exists. as patients with dissociative disorders likely experienced intense trauma in the past, concomitant dissociative disorders should be considered in patients diagnosed with a stress disorder (i.e. ptsd or acute stress disorder). the diagnosis of depersonalization disorder can be made with the use of the following interviews and scales: the structured clinical interview for dsm-iv dissociative disorders (scid-d) is widely used, especially in research settings. this interview takes about 30 minutes to 1.5 hours, depending on individual's experiences. the dissociative experiences scale (des) is a simple, quick, self-administered questionnaire that has been widely used to measure dissociative symptoms. it has been used in hundreds of dissociative studies, and can detect depersonalization and derealization experiences. the dissociative disorders interview schedule (ddis) is a highly structured interview which makes dsm-iv diagnoses of somatization disorder, borderline personality disorder and major depressive disorder, as well as all the dissociative disorders. it inquires about positive symptoms of schizophrenia, secondary features of dissociative identity disorder, extrasensory experiences, substance abuse and other items relevant to the dissociative disorders. the ddis can usually be administered in 30–45 minutes. the cambridge depersonalization scale (cds) is a method for determining the severity of depersonalization disorder. it has been proven and accepted as a valid tool for the diagnosis of depersonalization disorder in a clinical setting. it is also used in a clinical setting to differentiate minor episodes of depersonalization from actual symptoms of the disorder. due to the success of the cds, a group of japanese researchers underwent the effort to translate the cds into the j-cds or the japanese cambridge depersonalization scale. through clinical trials, the japanese research team successfully tested their scale and determined its accuracy. one limitation is that the scale does not allow for the differentiation between past and present episodes of depersonalization. it may be difficult for the individual to describe the duration of a depersonalization episode, and thus the scale may lack accuracy. the project was conducted in the hope that it would stimulate further scientific investigations into depersonalization disorder. diagnostic and statistical manual of mental disorders, 5th edition (dsm-5) in the dsm-5, the word "derealization" was added to "depersonalization disorder" and renamed "depersonalization/derealization disorder" ("dpdr"). it remains classified as a dissociative disorder. patients must meet the following criteria to be diagnosed per the dsm-5: presence of persistent/recurrent episodes of depersonalization/derealization ability to distinguish between reality and dissociation during an episode (i.e. patient is aware of a perceptual disturbance) symptoms are severe enough to interfere with social, occupational, or other areas of functioning symptoms are not due to a substance or medication symptoms are not due to another psychiatric disorder international classification of diseases 11th revision (icd-11) the icd-11 has relisted dpdr as a disorder rather than a syndrome as previously, and has also reclassified it as a dissociative disorder from its previous listing as a neurotic disorder. the description used in the icd-11 is similar to the criteria found in the dsm-5. individuals with dpdr are described as having persistent/recurrent symptoms of depersonalization/derealization, have intact reality testing, and symptoms are not better explained by another psychiatric/neural disorder, substance, medication, or head trauma. symptoms are severe enough to cause distress or impairment in functioning. differential diagnoses dpdr differentials include neurologic and psychiatric conditions as well as side effects from illicit substances or medications. neurologic seizures brain tumor post-concussion syndrome metabolic abnormalities migraines vertigo meniere's disease psychiatric panic attack phobias ptsd acute stress syndrome depression schizophrenia borderline personality disorder other dissociative disorders consequence of psychoactive substance use marijuana hallucinogens mdma ketamine hallucinogen persisting perception disorder prevention depersonalization-derealization disorder may be prevented by