What Is Derealization?

Derealization is an experience of feeling separated from your immediate surroundings, without an associated change of consciousness or impaired awareness. It is a major component of depersonalization/derealization disorder, a condition that’s diagnosed based on criteria in the fifth edition of the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5).

Derealization can also occur with a number of medical or psychiatric disorders, as an effect of a substance, or it can occur without an identifiable reason. The experience of derealization is not usually distressing, but it can be.

Often, derealization is fleeting, lasting for a few minutes, without frequent recurrence. However, it can recur or last for prolonged periods of time, especially when it is caused by a psychiatric or medical condition.

Characteristics

Derealization can be described as a sense that your environment and the events happening around you seem to be part of another world. You might feel that you are not part of your surroundings or that your surroundings seem like a dream or like a movie that you are watching. 

A key component of derealization is that a person who has this symptom typically feels aware of the situation and has insight. Someone who is experiencing derealization knows that the reality around them is happening and that everything around them is real, but they don’t feel part of what is going on around them.

Characteristics of derealization include: 

• A sense of dissociation from the environment
• A feeling that events are not happening in real time
• A sense that colors or sounds are not as they normally would be

Derealization is not the same as being disengaged, which is a sense of being emotionally detached. It is also different from feeling left out. Derealization is also distinct from having a vivid imagination, dreaming, or hallucinations.

Diagnosis

When it is part of a psychiatric issue, derealization might recur, but when it’s a medication effect or if it occurs in association with a medical condition, it can resolve when the medical situation is resolved, and it is unlikely to recur. 

If you experience repeated or distressing episodes of derealization, or your derealization is associated with other medical, psychiatric, or psychological symptoms, it’s important that you seek medical help. With a professional evaluation, you can receive a diagnosis and treatment of the condition that is causing you to experience derealization.

Your healthcare provider would ask about your symptoms, any associated symptoms or triggers, your medical and psychiatric history, and medications you are taking, and your family medical history. You would also have a physical examination to include a neurological and mental status examination.

If your diagnosis is not clear based on this assessment, you might have additional tests that could include:

• Blood tests
• Urine tests
• Brain imaging studies
• Electroencephalogram (EEG)

Your blood and urine tests might include tests that can detect substances that could be causing your symptoms.

Causes 

There are a number of causes of derealization. It can be caused by psychiatric disorders, neurological disorders, or reactions to overwhelming stress. It can also be associated with fatigue.

Derealization is a major component of derealization/depersonalization disorder, a dissociative disorder that is characterized by a recurring feeling of derealization and/or depersonalization (a sense of being outside your self or your body). Derealization and depersonalization don’t necessarily have to occur at the same time for a diagnosis of this disorder.

Conditions associated with derealization include:

• Depression
• Anxiety
• Panic disorder
• Post-traumatic stress disorder (PTSD)
• Migraine
• Epilepsy
• Anesthesia medications, such as ketamine 
• Recreational drugs, such as hallucinogens 
• Inner ear disorders
• Fatigue
• Psychiatric disorders 
• Borderline personality disorder 

While derealization is not a change in consciousness, it can sometimes occur with conditions that affect your level of consciousness. For example, it can occur before or during a migraine or a seizure, or when you are given anesthetic medication.

Derealization can result from temporary or underlying changes in brain function. And it can be an unconscious way of defending against anxiety, conflict, and trauma.

Physiology 

There is more than one physiological cause of derealization. It can result from alterations in the activity of certain areas of the brain.

For example, derealization can occur with vertigo (a sense that the room is spinning) that’s caused by dysfunction of the inner ear. And stimulation of the semicircular canals in the ear can briefly trigger symptoms of derealization.

Derealization can also be associated with disruption of cerebral dysfunction, such as before a seizure or a result of drug effects on the brain. However, derealization is not always associated with an identifiable disruption of brain functions.

Treatment 

The treatment of derealization may be necessary if it’s recurrent and if it causes distress. Sometimes treatment of derealization is part of the comprehensive management of conditions like anxiety, PTSD, or other psychiatric conditions, or medical issues such as an inner ear disorder.

Generally, the symptom isn’t specifically treated with medication beyond the medication that might be used to treat an associated underlying disorder—like depression or epilepsy. 

Depersonalization/derealization disorder is managed with approaches that include psychotherapy and behavioral management.

Therapy

Psychotherapy can include a variety of techniques and may include cognitive, behavioral, and psychodynamic approaches.

When derealization develops as a response to severe stress, such as in the setting of PTSD, it can be considered a method of “self-treatment” as a way to cope and dissociate—such as from the recollection of traumatic events or from ongoing experiences of traumatic events.

In these types of situations, therapy may be focused on gaining more effective ways of managing the underlying trauma. And sometimes treatment can involve getting away from an ongoing harmful situation, such as in cases of abuse.

Coping

If you are experiencing distress due to recurrent or prolonged episodes of derealization, it’s important that you seek medical help. Once you have a diagnostic evaluation and understand the cause of your problem, you can work with your medical team to get the best treatment. 

If your symptoms of derealization become well controlled and then reappear again, you should call your healthcare provider and revisit or potentially revise your treatment plan.