Today I’m talking about Derealization, Depersonalization, and Dissociation – terms related to feeling detached or untethered to their life at some point. Here’s a super fast definition for each of these terms. Depersonalization is where students have the feeling of being outside themself and observing their actions, feelings or thoughts from a distance. Derealization is where they feel the world is unreal. People and things around them may seem “lifeless” or “foggy.” Disassociation is experiencing a loss of connection between thoughts, memories, feelings, surroundings, behavior and identity. 

Now – I want to move from these definitions to brain regions for just a bit to provide some structural context. You won’t be tested on this material but my goal is to reinforce to the parents and clinicians listening out there that all of the symptoms we’re talking about reside in one or more parts of the brain which theoretically means there’s an opportunity for effective interventions and treatment. 

I think we can all agree that Dissociative disorders involve disruptions in the normal integration of consciousness, memory, identity, or perception. While the exact neurobiological mechanisms underlying dissociative disorders are not fully understood, research has suggested involvement of various and specific brain regions and neural networks. Here are some of those brain regions and networks that have been implicated or studied in association with dissociative disorders:

• Hippocampus (region deep inside the brain that hugs the top of the brain stem)
  • The hippocampus is involved in memory formation and retrieval. Alterations in hippocampal function have been noted in individuals with dissociative disorders, particularly regarding traumatic memories.
• Amygdala (little almond sized blob at the end of the hippocampus)
  • The amygdala plays a key role in processing emotions, particularly fear and threat detection. Dysregulation of the amygdala has been observed in individuals with trauma-related dissociative symptoms.
• Prefrontal Cortex (very front of our brains above the eyes):
  • The prefrontal cortex is responsible for executive functions, decision-making, and self-regulation. Disruptions in prefrontal cortex activity have been linked to difficulties in emotion regulation seen in dissociative disorders.
• Default Mode Network (DMN):
  • The DMN is a network of brain regions associated with self-referential thinking, mind-wandering, and autobiographical memory. Changes in DMN connectivity have been observed in individuals with depersonalization/derealization disorder.
• Thalamus (one of the center-most regions of the brain above the brain stem)
  • The thalamus acts as a relay station for sensory information. Abnormalities in thalamic function have been suggested in dissociative disorders, contributing to disruptions in sensory perception.
• Hypothalamus (lower part of the thalamus):
  • The hypothalamus is involved in regulating the autonomic nervous system and stress responses. Dysregulation in hypothalamic function may contribute to heightened stress responses seen in dissociative disorders.
• Corpus Callosum (hugs all of the central brain regions and connects left and right hemisphere):
  • The corpus callosum connects the two hemispheres of the brain and is involved in communication between them. Changes in the corpus callosum have been observed in individuals with dissociative identity disorder (DID).

It’s important to emphasize that these associations are not universally applicable to everyone with dissociative disorders, and the exact neural mechanisms vary among different subtypes of dissociation. Additionally, environmental factors, such as exposure to trauma or stress, can play a significant role in the development and expression of dissociative symptoms.

Now, let’s move towards the more clinical language and breakdown of these different dissociative disorders and talk about symptoms. 

Symptoms of a Dissociative Disorder

Symptoms of dissociative disorder can vary but might include:

• Feeling disconnected from themself and the world around them
• Forgetting about certain time periods, events and personal information
• Feeling uncertain about who they are
• Having multiple distinct identities
• Feeling little or no physical pain
• Some people with dissociative disorder also have seizures 

What are the Causes of Dissociative Disorder?

Dissociation is a way the mind copes with too much stress. Periods of dissociation can last for a relatively short time (hours or days) or for much longer (weeks or months). Many people with a dissociative disorder have had a traumatic event during childhood. Dissociation can happen as a way of coping with it. Someone with a dissociative disorder may have experienced physical, sexual or emotional abuse during childhood. Some people dissociate after experiencing war, kidnapping or even an invasive medical procedure. Switching off from reality is a normal defense mechanism that helps the person cope during a traumatic time. It’s a form of denial, as if “this is not happening to me.” It becomes a problem when the environment is no longer traumatic but the person still acts and lives as if it is, and has not dealt with or processed the event.

Specific types of dissociative disorders

There are several different types of dissociative disorder. The 3 main types are:

• Depersonalization-Derealization Disorder
• Dissociative Amnesia
• Dissociative Identity Disorder

Depersonalization-Derealization Disorder

Depersonalization is where someone may have the feeling of being outside themself and observing their actions, feelings or thoughts from a distance. Derealization is where they feel the world is unreal. People and things around them may seem “lifeless” or “foggy”. People can have depersonalisation or derealisation, or both together. It may last only a few moments or come and go over many years. 

In Depersonalization-Derealization Disorder, someone feels detached from themself (depersonalization) and disconnected from their environment (derealization). While feelings like this may come and go for many people, in people with depersonalization-derealization disorder, they tend to last a long time (persist) or go away and come back (recur).

Depersonalization affects an individual’s ability to recognize their thoughts, feelings and body as their own. It might feel like they’re watching themself play a role in a movie rather than living their life. For example, if they’re grocery shopping, they might feel like they’re watching someone else push their cart, select food from the shelves and go through the check-out line. Or they might not recognize their reflection in the glass doors of the frozen section.

Derealization affects an individual’s ability to see their surroundings accurately. Things might not seem real. Or they might feel like they’re looking through a clouded window or in black-and-white rather than full color. Objects might look distorted in shape or size, or they may feel like they change while they look at them.

In Depersonalization-Derealization Disorder, individuals may experience depersonalization, derealization or both. But they haven’t lost touch with reality. They understand that their perceptions aren’t real, which can be frustrating and cause anxiety. Psychiatrists classify Depersonalization-Derealization Disorder as a dissociative disorder in the DSM-V. Dissociative Identity Disorder and Dissociative Amnesia are also in this category.

How common is Depersonalization-Derealization Disorder?

Most people know what it’s like to feel disconnected from time to time. This is called transient depersonalization. But Depersonalization-Derealization Disorder is long-lasting, sometimes you could even say it’s chronic. It generally happens to 1% to 2% of people, though it’s more common in adolescents, young adults, and people with other mental health conditions.

What are the symptoms of Depersonalization-Derealization Disorder?

People with Depersonalization-Derealization Disorder sometimes find it hard to put their symptoms into words. Others feel like they have words to describe their experience but that people don’t seem to understand them or take them seriously. But the main symptom of depersonalization-derealization disorder is feeling disconnected. They might feel:

• Disconnected from their thoughts, feelings and body (depersonalization)
• Disconnected from their surroundings or environment (derealization)
• Robot-like or that those around them are robotic
• Emotionally numb
• Like they’re observing themself from outside their body
• Like they’re living in a dream world
• Sad or anxious

These symptoms can cause significant distress, as they might start to wonder if there’s something terribly wrong with them. They might focus on the symptoms, think about their symptoms or past events over and over again (rumination) or try to control them. This can increase their feelings of anxiety and worry, which in turn may make their symptoms worse.

What causes Depersonalization-Derealization Disorder?

The very unsatisfying answer is that researchers and clinicians don’t know exactly what causes Depersonalization-Derealization Disorder, though it’s often linked to intense stress or trauma, like:

• Physical abuse
• Domestic violence (either witnessing or experiencing it)
• Accidents or natural disasters
• Life-threatening danger
• The sudden death of a loved one
• A parent with severe mental illness

What are the risk factors?

Some people may be at higher risk for developing a dissociative disorder due to:

• A decreased awareness of emotions
• Certain personality or other mental health disorders
• Physical conditions (mostly neurological) like a seizure disorder

Dissociative Amnesia

Someone with Dissociative Amnesia will have periods where they cannot remember information about themselves or events in their past life. They may also forget a learned talent or skill. These gaps in memory are much more severe than normal forgetfulness and are not the result of another medical condition. Some people with Dissociative Amnesia find themselves in a strange place without knowing how they got there. They may have traveled there on purpose, or wandered in a confused state. These blank episodes may last minutes, hours or days. In rare cases, they can last months or years.

Dissociative Identity Disorder

Dissociative Identity Disorder used to be called Multiple Personality Disorder. Someone diagnosed with DID may feel uncertain about their identity and who they are. They may feel the presence of other identities, each with their own names, voices, personal histories and mannerisms.

The main symptoms of DID are:

• Memory gaps about everyday events and personal information
• Having several distinct identities

Diagnosis and Tests

How is depersonalization, derealization, and dissociation tested and/or diagnosed?

During a clinical intake assessment, a student’s therapist, psychologist, or psychiatrist will look for other mental health conditions (also known as co-morbidities) like:

• Depression
• Anxiety
• Obsessive-compulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)
• Personality disorders

If they don’t have another diagnosis that more clearly or accurately fits with symptoms, they’re not coming off medication, and their experiences aren’t related to mood-altering substances like drugs or alcohol, the clinician may diagnose them with Depersonalization-Derealization Disorder or Dissociative Disorder.

What tests will be done to more accurately diagnose it?

If a student’s provider suspects some type of dissociative disorder, they may ask a series of questions that help identify their symptoms, how often they occur and how much they interfere with the student’s well-being. They may also ask them to complete some psychological assessments (also known as batteries or tests). Although finding the right words to describe their feelings may be hard, it’s important for the student to be as specific as possible about what life is like for them so the clinician can most accurately diagnose and recommend effective treatment.

Management and Treatment

How is all this dissociative stuff treated if it’s just some form of detachment from reality?

Researchers still aren’t sure about the best way to treat depersonalization-derealization disorder. When considering treatment options, clinicians will talk with the student about their medical history, symptoms and treatment goals. They may recommend medication and talk therapy like cognitive behavioral therapy (CBT) or even eye movement desensitization processing (EMDR). 

Medications

Though talk therapy is the most effective treatment, clinicians may recommend a medication (or combination of medications) as part of their treatment, especially if the dissociative symptoms are proving to be what clinicians refer to as ‘treatment resistant.’ Some of the typical categories of effective medications for dissociation include:

• Selective serotonin reuptake inhibitors (SSRIs)
• Anti-anxiety medications
• Mood-stabilizing medications
• Antipsychotic medications

There is recent research pointing to use of SSRI’s and antipsychotics as the most effective combination of medications to treat dissociation 

How long does depersonalization-derealization disorder last?

Again, there’s not a lot of research on what to expect if someone has dissociation or depersonalization stuff going on. Left untreated, depersonalization and derealization can last for years. Sometimes it resolves on its own, but it might negatively impact their relationships or work life. With treatment, people commonly start to see an improvement in their symptoms within a few months.

How can students take care of themselves?

If a student has lasting symptoms of depersonalization-derealization disorder, their priority should be to seek treatment from a therapist for behavioral and psychological tools and psychiatrist for medication and medical advice. They’ll likely need several visits weekly initially, and then regular follow-ups throughout the semester with occasional follow-ups with the psychiatrist. A good psychiatrist will help find the right treatment for their specific situation and ensure that the side effects are manageable. The therapist will use talk therapy to teach skills to cope with symptoms and gain insight into their symptom triggers.

In the meantime, the best things students can do is to take their medications as prescribed and try to be gentle with themself as possible while not ignoring daily assignments and obligations. It’s OK if they can’t find words to accurately describe their experience. And, while it’s natural to worry about one’s health, encourage them not to dwell on it. Paced breathing that involves a long exhale or meditation can calm a racing brain.

What’s Not so good to eat, drink or take?

If someone has depersonalization-derealization disorder, it’s a good idea to avoid substance use. Drugs and alcohol can bring about symptoms of depersonalization and derealization. They may also interact with medications. It’s important for students to be honest with their mental healthcare team about when and how they use substances. 

It’s also not a great idea to binge on caffeine. The relationship between caffeine and dissociative disorders is not well-researched, and individual responses obviously can vary but here are some considerations:

• Stimulant Effects: Caffeine is a stimulant, and for some individuals, especially those with anxiety or dissociative symptoms, stimulants may exacerbate feelings of jitteriness, restlessness, or even anxiety.
• Increased Arousal: Caffeine can increase arousal and alertness. In some cases, heightened arousal may be counterproductive for individuals with dissociative disorders who may benefit from a calmer and more relaxed state.
• Sleep Disturbances: Caffeine can interfere with sleep, leading to difficulties falling asleep or staying asleep. Quality sleep is crucial for mental health, and disruptions in sleep patterns may impact dissociative symptoms.

Alright, now I want to talk about what parents can do to best support their college student if they suspect they’re struggling with any of these mental health challenges. 

First, get some psychological testing scheduled. As I’ve mentioned in previous podcasts and blog posts, psych testing is a solid starting point to establishing what’s going on and what some effective interventions may look like on or around campus. 

Next, provide regular check-ins about their symptoms but also about practical day-to-day stuff. While I don’t want students to ignore any of these dissociative symptoms, I also don’t want it to be the ONLY topic they refer to when talking to friends and family. This can lead to a self-fulfilling prophecy 

Next, Don’t assume fine means fine. If you sense that something is wrong or off, say something. Promoting transparent, consistent communication about uncomfortable topics like this leads to more opportunity for change. 

Finally, validate feelings and thoughts, but always come back to behavior. It’s the one thing we can control. Dissociative symptoms make us feel like we can’t control a lot. Encouraging your son or daughter to identify even seemingly small things in their grasp can pull them through tough days. 

Derealization, depersonalization, and dissociation are more common than ever among college students, but with some consistent clinical support and lifestyle changes, their symptoms don’t have to ruin their life.