These terms refer to a set of symptoms that may occur either as brief, recurrent episodes or as phases, that is, prolonged periods, and may even become a continuous, long-lasting background condition. When these symptoms are the predominant and constant feature in a person’s history, the term “depersonalization/derealization disorder” is used, whereas the symptoms may also occur in a variety of otherwise definable disorders (panic, mood disorders, psychosis). These symptoms are also referred to as “dissociative symptoms,” but it should be clarified that this term (dissociative, dissociation) does not have the same meaning as the term used in psychiatry several decades ago, which is still sometimes employed. The old “dissociative crisis” or “dissociative state” referred more or less to psychotic episodes, perhaps without continuous or well-defined delusions, but this was essentially the meaning. The “dissociative” symptoms being referred to here, however, are something different and therefore do not automatically imply psychosis.
Being “derealized” means feeling outside reality, as though on a different plane, with a sense that what one does or says does not belong to oneself. Identity feels as though it were frozen, fixed at a point that does not coincide or correspond with what is happening, what one remembers, or what one says. One may feel as though one were watching or experiencing oneself from the outside, as though the world in front of oneself were a kind of giant screen or an illusion. The ordinary, automatic sense of words, things, and time becomes loosened; it is as though the overall meaning were no longer there. For this reason, when the person speaks and acts in these circumstances, they may feel like a puppet, an automaton, someone playing a role, saying certain things without actually perceiving their meaning, finding them funny or meaningless. This can interfere with communication, especially emotional communication and expressiveness.
Depersonalization refers to a sense of estrangement from one’s own body, that is, feeling outside the body, or as though inside a shell, an armor, or behind a mask. Mental functions are also involved, so that the spontaneity of the flow of thoughts is no longer perceived; one remembers things but has difficulty relating them to oneself, almost as though one were remembering a version of oneself in the third person. When depersonalization increases or begins, there may be a fear of losing contact with reality or with oneself, of no longer being able to know fundamental things such as one’s own identity, the time and space in which one is acting, the emotional meaning of things, and the meaning of relationships.
Derealization is common during depressive episodes; the term “affective depersonalization” is used to describe the emotional impoverishment or blunting of a depressed patient. It is also common during or after panic attacks and may persist for hours or days, together with fear of another attack or with a state of weakness and demoralization. It may be a condition preceding psychotic episodes, particularly when it is associated with a state of perplexity, in which the person is absorbed by the idea that they must bring something into focus: reality seems to break apart in order to make room for a new configuration, and the person remains suspended, like someone waiting for the right moment to understand something.
It is very common for a continuous state of derealization to develop as an expression of an obsessive disorder. In states of obsessive concern about one’s own mental functions, or about aspects concerning one’s emotions, one’s relationships with others, and the correctness of one’s actions, the person may gradually come to live on a kind of obsessive “track” that keeps them separated from reality. At first, this may be a position of detachment that is necessary in order to think, rationalize, reflect, and analyze things in search of the best order or the most convincing answer. Eventually, however, it becomes a condition of distance and fluctuation, like that of someone who has become unaccustomed to immediate and intuitive contact with reality and therefore examines it even before having absorbed it: from their own breathing to the words spoken by others, to the things that appear before them, to the actions they have to perform.
People experiencing obsessive derealization may feel, or actually become, slowed down, awkward, and frozen. They may feel exiled into a parallel reality from which everything can be seen and everything can be felt, and in which they can even do everything if they want to, but only in an unnatural way, having to “act” or being unable to behave naturally. The whole process therefore entails an unsustainable effort, in the sense that the person thinks about themselves while thinking, acting, and speaking, as though they had to “edit” or review their own existence second by second before allowing it to emerge, or before allowing messages from outside to enter.
Obsessive derealization is usually accompanied by absolute and meaningless questions such as “right or wrong,” “good or bad,” “is it part of me or is it not part of me,” and so on, applied to virtually any external stimulus, from the façades of buildings to the people one encounters.
Treatment of depersonalization symptoms must begin with diagnosis. Once treatment for the underlying diagnosis has been established, it is advisable to wait a certain number of weeks, because these symptoms tend to resolve slowly. In obsessive forms, psychotherapy may be particularly useful. Some medications may initially worsen these sensations. Conversely, some medications may alleviate them while producing greater emotional blunting over time.