Derealization syndrome

It is believed that more than half of the human population, at least once for a short time, experiencing acute stress, include such a psychological defense mechanism as perceiving what happened to someone else and/or in another reality, which allows one to abstract from emotions, analyze the situation and find a way out of it. However, impressionable and emotional people, with hyperbolic perception, vulnerable and unstable psyche can linger in such a state for a long time, and this is already a pathology. Such manifestations are found in symptom complexes of many mental and organic diseases, however, they can exist for a long time as a separate syndrome of depersonalization/derealization outside of mental diseases.

The state of perceiving the surrounding reality, relationships with other people as from an auditorium or a dream, detachedly, in psychiatric practice is called derealization. It is mainly considered as one of the types of depersonalization - allopsychic. In this case, the emotional component of the perception of the environment, nature, music, works of art is partially or completely dulled.

During derealization, the individual almost always controls himself and his actions, is completely sane and adequate, understands that he is not healthy, therefore, it is much more difficult for him to endure such a state for a long time than for “real psychos” who are characterized by an imaginary worldview.

Is derealization dangerous?

Short-term detachment from current events apparently happens to many people, passes by itself and does not pose a danger, since it does not have a significant impact on life activities.

Depersonalization/derealization syndrome acts as a kind of shield, protecting the human psyche from more serious damage, however, a prolonged distorted perception of the world leads to memory impairment, the development of depression and more serious consequences. Moreover, a person is aware of his condition and is not always able to return to reality on his own, which often makes him assume that he has a mental illness or damage to the central nervous system.

The manifestation of most cases of this nervous disorder, according to foreign studies, occurs at a young age, mainly at 14-16 years old and coincides with the formation of personality, sometimes this happens in early childhood. Gender does not matter. People who have crossed the 25-year mark (one in twenty) extremely rarely seek help with such problems, isolated cases occur in adulthood. Such an early manifestation also represents a certain danger for the adaptation of the individual in society.

Causes derealizations

Depersonalization/derealization syndrome develops against the background of mental exhaustion, usually caused by a whole complex of reasons against the background of a strong or long-term stress factor.

This is facilitated by certain personality traits. People prone to this syndrome often have inflated claims, overestimate their capabilities, do not take into account any objective circumstances, and, having not received what they want and not feeling the strength to continue the fight, they fence themselves off from reality. True, not by their own will. An exhausted psyche creates a protective barrier to prevent more serious mental health disorders or the development of vascular crises.

Constant dissatisfaction of needs, seeming or real underestimation of their successes by teachers, management, relatives, awareness of the impossibility of reaching a certain level contribute to the fact that derealization occurs in depression. The tendency to long-term fixation on negative events, suspiciousness increases the likelihood of developing the syndrome.

This condition is often associated with neurasthenia, anxiety neurosis and other neurotic disorders. Long-term exposure to stressful circumstances, chronic fatigue and the inability to restore strength, psychotraumatic situations in childhood (indifference or, conversely, excessive severity of parents; bullying in the family or among peers; the death of a loved one to whom the individual was very attached), forced or conscious loneliness can lead to the development of derealization in neurosis as a defensive reaction.

Vegetative-vascular dystonia, which affects the central nervous system, disrupts vascular tone and the functioning of internal organs, is a factor that increases the likelihood of derealization. A person suffering from a disorder of the vegetative nervous system can isolate themselves from reality due to even a banal everyday problem. Derealization in VSD leads the patient to deep stress, usually after the first attack he begins to expect the next one, and this expectation is justified. The disease necessarily requires treatment to break this vicious circle.

Sometimes derealization occurs due to lack of sleep, especially regular sleep. In this case, you should not panic ahead of time, you need to organize your daily routine. The attacks should pass.

The same applies to the development of symptoms of the syndrome when sitting in front of a computer monitor for a long time on forums, in social networks, playing computer games. Usually, such a pastime is complicated by lack of sleep, visual and nervous fatigue, stress during games, a sedentary lifestyle and banal hypoxia from insufficient time spent in the fresh air. In addition, young people often lead such a lifestyle, replacing the real world and relationships with fictitious ones. Derealization from the Internet, from the computer is a very real threat to the mental health of young people who spend a lot of time in front of the monitor, having fun and communicating in the virtual world with the indifferent connivance of adults (if only they don’t pester!).

Derealization may occur with cervical osteochondrosis. This is due to the fact that the disorders occurring in this section of the spine disrupt the blood supply to the brain and the innervation of the arteries. Pathological processes in the vertebral structures lead to complications such as vegetative-vascular dystonia, which occurs with depersonalization/derealization syndrome and panic attacks. Treatment of the underlying disease significantly improves the patient's condition and allows one to get rid of painful symptoms.

Alcoholism and derealization are closely related. More than 13% of alcoholics are subject to this syndrome. Even with a single alcohol intoxication, ion exchange suffers, the sensitivity of serotonergic receptors changes, the metabolism of γ-aminobutyric acid, and other processes in the cortex and subcortical structures of the brain are disrupted. And chronic alcohol intoxication causes irreversible changes in the structures of the brain.

Other psychoactive substances can also induce symptoms of depersonalization/derealization syndrome. These include caffeine, antihistamines, hypnotics and sedatives, antipsychotics and antidepressants (selective serotonin reuptake inhibitors), anticonvulsants and hallucinogenic drugs, even drugs such as indomethacin and minocycline have been noted to have similar properties.

Therefore, derealization after smoking weed or using other drugs – LSD, opiates, during the period of recovery from anesthesia – is not at all surprising.

In addition to those already listed, risk factors for the development of this disorder are:

• sluggish and paroxysmal-progressive schizophrenia;
• circular psychosis;
• epileptic parksism;
• dissociative disorders;
• organic pathologies of the brain;
• adolescence, pregnancy;
• physical or psycho-emotional abuse in childhood;
• witnessing scenes of violence;
• rejection in the family, among peers;
• low stress resistance;
• hereditary predisposition to pathological anxiety.

[ 1 ]

Pathogenesis

There are still many "blank spots" in the mechanism of development of depersonalization/derealization syndrome. In the prodromal period, patients always experience increased anxiety, worry, and mental stress. The syndrome affects individuals who are hypersensitive to emotional situations, anxious individuals who react sharply to stressful situations. The loss or reduction of the emotional component of mental activity develops as a defensive reaction to events that threaten to disorganize the mental process or cause vascular catastrophes. When the defense takes a protracted course, it itself becomes the basis of the pathological process.

It is assumed that in response to stress, the synthesis of β-endorphins (endogenous opiates) increases in the neurons of the pituitary gland. Increased activation of opioid receptors disrupts the neurochemical balance and triggers a cascade of changes in other receptor systems. This leads to disturbances in the production of γ-aminobutyric acid, changes in the activity of neurotransmitters that regulate positive emotions and mood. It has been established that derealization and serotonin, norepinephrine, and dopamine are associated. In patients, it is assumed that the pleasure center (anhedonia) and the limbic system responsible for organizing emotional and motivational behavior are switched off.

[ 2 ], [ 3 ]

Symptoms derealizations

In all known cases of seeking help from specialists, patients noted during the survey that the development of the disorder was preceded by an intensification of nervous tension and feelings of anxiety.

The first signs of such a condition appear suddenly and can be expressed in such sensations as perceiving the surrounding world in one plane, seeing it as in a picture or photograph, often black and white or cloudy. The acuity of color and sound sensations is lost. The surrounding environment seems “flat”, “dead”, or is perceived dull, as if through glass, in the head - the absence of thoughts, in the soul - emotions. In general, it is difficult for the patient to grasp what mood he is in, because there is none - neither bad nor good.

Memory problems may arise, the patient often does not remember recent events - where he went, who he met, what he ate, and whether he ate at all. Paroxysms occur when the patient feels that he has already seen or experienced everything that is happening (déjà vu), or has never seen (jemez vu).

The present time for such patients usually flows slowly, some complain of the feeling that it has stopped altogether. But the past is perceived as one short moment, since the emotional coloring of past events is erased from memory.

Difficulty may arise when it comes to thinking abstractly.

Derealization rarely occurs in its pure form; it is almost always accompanied by symptoms of depersonalization, that is, a disorder of the perception of one's own personality and/or one's own body. These phenomena are similar in that in both cases the perception of the surrounding world is disrupted, but the emphasis is placed somewhat differently.

Alienation of the sense of one's own "I" or depersonalization is divided into autopsychic (disturbances of personal identification) and somatopsychic (complete or partial rejection of one's own body and its vital functions).

For example, with autopsychic depersonalization, a person stops discovering his or her inherent personality traits and does not recognize his or her essence. He or she notices the disappearance of warm feelings toward loved ones and friends, hostility and anger toward enemies, stops being offended, empathizing, yearning, nothing pleases or upsets him or her. The patient defines his or her actions as automatic. Events in which he or she is a participant are felt as if they were happening to someone else. The person becomes an outside observer of his or her own life. In severe cases, a split personality may occur, the patient complains that two people live inside him or her, thinking and acting differently. The alienation of one's own personality is realized and usually frightens the patient very much.

Somatic depersonalization is manifested by decreased sensitivity to pain, hunger, heat and cold, touch. A person does not feel the weight of his body, does not feel how his muscles and joints work.

Derealization is also a type of depersonalization, in which the subjective perception of the external environment of the individual is disrupted. Each type of syndrome practically does not exist in isolation, the symptoms in the same patient usually alternate. Derealization and depersonalization are not in vain combined into one syndrome, since it is usually impossible to distinguish them from each other in one patient. Some symptoms are simply more pronounced, while others may not be present. Dulling or loss of emotions is observed in all cases, is fully recognized by the individual, causes him suffering and fear of complete loss of reason.

Anxious individuals who get stuck in anticipation of negative events are more susceptible to developing the syndrome. Such people often develop vegetative-vascular dystonia, which also increases the likelihood of detachment, "dropping out" of life. Anxiety and derealization are two accompanying symptoms.

Against the background of strong anxiety, expectation of some negative development of events, even a completely mentally healthy person may develop such a syndrome. In people with mental illnesses, derealization disorder can be a symptom in the structure of mental pathology, both minor and dominant.

Derealization and schizophrenia have similar symptoms. In both cases, contact with reality is disrupted, and its subjective perception changes. Schizophrenics, as a rule, often perceive everything as brighter and more colorful, music sounds more expressive to them, and real events are perceived as a play with colorful decorations. Some, sometimes quite insignificant, properties of familiar things are often singled out by them and perceived as very important. Nevertheless, depersonalization and/or derealization cause a lot of unpleasant sensations in the patient. Schizophrenics often feel themselves outside of time, outside of their body, having moved into another body. Sometimes it is difficult to distinguish the symptoms of schizophrenia from the manifestations of the syndrome.

Depersonalization/derealization in schizophrenics is more severe and pronounced, often in combination with delirium and hallucinations. The delusional form of the phenomenon can be expressed in reincarnation, division into physical and mental units, splitting of the personality, disappearance of the external world or the patient's personality.

Depersonalization/derealization can be a symptom of many mental illnesses and can persist for many years.

Derealization syndrome, considered a neurotic disorder, can be short-term, paroxysmal, or permanent.

Short-term manifestations of derealization develop after an acute psychotraumatic situation, under the influence of fatigue, lack of sleep and other factors. They last for several minutes and their protective role is undeniable. They may never recur and are not considered pathologies.

Pathological derealization can be paroxysmal or prolonged and permanent.

In the first case, a short-term attack of derealization is a separate attack of spatial disorientation and is replaced by a normal state. During the attack, visual distortions of reality usually appear (blurred contours of objects; tunnel vision - everything is clearly visible in front of the eyes, peripheral vision is blurry; diverging circles of irregular shape in front of the eyes; colors disappear, everything becomes gray or black and white); auditory distortions (ringing in the ears, sounds are heard as if through cotton wool, ears are blocked, the tempo of sounds slows down, individual sounds are perceived too sharply); spatial orientation is disturbed (you can forget a familiar road, not recognize a familiar place, etc.). These are the most common symptoms, however, distortions of various external aspects can be observed, sometimes hallucinatory phenomena occur. During the attack, which begins and recedes suddenly, a person gets lost, gets upset, begins to choke, loses coordination.

In the second case, derealization is persistent and may be accompanied by a variety of symptoms. Visual impairment usually becomes the main symptom, to which sensory impairment and sound distortion are added. Constant derealization is usually combined with symptoms of depersonalization - there is detachment from the body shell, emotional essence, sensations disappear. The patient observes himself and his life from the outside. Over time, the symptoms may worsen, memory impairment, control over one's words and actions are added.

Derealization is almost never detected in children before adolescence, but the rudiments of depersonalization can be detected in children over three years of age. It manifests itself in playful reincarnation, for example, into animals, into other people. Children want to be fed animal feed, say that they have a tail and paws, walk on all fours, ask to be called by other people's names. A healthy child can also play like this, and the difference is that it is almost impossible to distract a sick child from such a game. He completely reincarnates.

More often in children, the somatopsychic form of the syndrome is observed - children do not feel hunger or thirst, they feel that their body parts live their own lives. Usually, such rudiments of symptoms are observed in children with schizophrenia or epilepsy.

Derealization in childhood can already be detected in its infancy from the age of ten. It manifests itself in attacks of déjà vu or jème vu. Such attacks are also characteristic of epileptics or epileptoid conditions.

"Adult" symptoms of derealization in adolescents are formed by late puberty and are manifested mainly by visual and auditory disturbances. Much less frequently observed are disorders of taste and tactile sensations, the phenomena of déjà vu and jème vu.

Teenagers often experience a personal transformation with alienation of emotions, the somatopsychic form of the phenomenon is represented by feelings of loss of unity of one's own body, changes in its proportions, absence of any parts. Depersonalization and derealization disorders are typical for adolescence due to the fact that during this period the personality is formed, rapid physical growth and physiological changes of the body occur, emotions are seething. During this period, the tendency to get stuck and introspection increases. Experts believe that such disorders are quite common in adolescence, it is just difficult for teenagers to express their feelings.

Some consider depersonalization/derealization syndrome in adolescence to be the first warning signs of progressive schizophrenia.

In adolescents with epilepsy, derealization attacks often occur before or instead of a seizure.

[ 4 ], [ 5 ], [ 6 ]

Complications and consequences

Derealization significantly complicates a person's life, exerting a significant negative impact on their interaction with others, ability to work, performance of daily duties, and contributes to the development of the patient's isolation. They are critical of the situation, realize its unnaturalness, and sometimes lose their perception of reality. Persistent, long-term derealization causes a lot of suffering to the patient and can lead to depression and suicide.

Does derealization go away on its own? Sometimes it does, however, if attacks are repeated or persistent derealization develops, it is better to seek help from competent specialists. Full recovery is possible if derealization was a consequence of stress, arose against the background of neurosis, and treatment was started in a timely manner.

Derealization, which manifests itself as a symptom of a serious progressive mental illness, has consequences and complications of this disease, and in most cases it is attributed to negative symptoms and manifestations of the disease's resistance to treatment. However, even in this case, timely treatment can improve the situation.

[ 7 ], [ 8 ]

Diagnostics derealizations

Patients usually seek medical attention with complaints of sudden changes in perception of the surroundings, lack of recognition of familiar surroundings, loss of feelings, and loss of trust in their sensations. They usually find it difficult to describe the symptoms, since the sensations are often vague and fantastic, while the patient is aware of the bias of his own sensations.

The patient may be prescribed clinical laboratory tests to determine the general level of his health, urine analysis to detect traces of toxic substances.

Ultrasound examination, electroencephalography, magnetic resonance imaging are done to identify organic disorders, especially if some complaints do not fit into the clinical picture of the syndrome, or if the manifestation of the disease occurred late, for example, after the patient's fortieth birthday.

In diagnostics, a derealization test is almost always used, which is a list of all possible signs of the syndrome. The patient is asked to answer questions about what symptoms he is experiencing. The most famous questionnaire (Nuller scale), which includes various symptoms of derealization and depersonalization, was compiled by famous psychiatrists Yu. L. Nuller and E. L. Genkina. The test is conducted by a specialist, evaluating the patient's answers in points. When the patient scores more than 32 points, the doctor may suspect that he has a disorder.

The diazepam test allows for a more precise diagnosis. This method is considered reliable for distinguishing depersonalization/derealization syndrome from anxiety disorder and depression. Developed by Professor Nuller, it involves the patient's reaction to a jet injection of diazepam into a vein. The dose of the drug varies from 20 to 40 mg and depends on the patient's age and the severity of the disorder.

In patients with depression, the clinical picture remains virtually unchanged with diazepam; the drug causes drowsiness and lethargy.

In case of anxiety disorder, the symptoms of the disorder disappear almost immediately, even during the administration, and sometimes even mild euphoria appears.

In depersonalization/derealization syndrome, the reaction occurs 20 minutes or half an hour later after the drug is administered. Symptoms are completely or partially eliminated: patients experience the emergence of feelings and perception of a colorful real world.

The patient is examined for depression, the preservation of intelligence and ability to think, character accentuations. Using psychodiagnostic methods, family history, relationships with relatives, psychotraumatic situations in the patient's life, resistance to stress and anxiety level are studied.

[ 9 ], [ 10 ]

Differential diagnosis

Based on the examination data, a final diagnosis is made. The predominant symptoms of the syndrome are determined: derealization or depersonalization, its type. Organic and somatic pathologies, alcohol and drug use, and the consequences of drug therapy are excluded. The main diagnostic criterion for the disorder is that patients do not lose the ability to realize that their sensations are subjective, that objective reality does not correspond to their perception, and are fully conscious.

Delirium of any etiology resembles severe derealization disorder in its symptoms. However, delirium is characterized by confusion, although at the very beginning, patients may be adequate for a short time. In general, episodes of delirium are characterized by such vivid symptoms of excitement with hallucinations and delusions that their diagnosis is not difficult. The greatest difficulty is presented by cases of hypokinetic delirium, when the patient is relatively calm.

Cotard's syndrome is characterized by symptoms that are more similar to depersonalization, but the central place in it is occupied by nihilism in relation to both one's own life and everything around. Individuals with derealization are aware that they exist.

This disorder is also differentiated from pseudoreminiscence (time shift of real events) and confabulation (memories of things that never happened in the patient’s life).

Senestopathia (unfounded symptoms of organic pathologies, felt on nervous grounds or in mental illnesses) is differentiated from somatopsychic depersonalization.

Patients with depersonalization/derealization syndrome are often misdiagnosed as having schizophrenia or schizoid personality disorder. This is facilitated by the emotional coldness of patients, the loss of warm feelings even towards close people, the difficulty in putting their feelings and experiences into words, which can be mistaken for fruitless, complex, ornate speech patterns.

Oneiroid, in which the patient lacks a critical attitude towards his own condition, and amentia, which is similar to derealization in its state of confusion, but is distinguished by significant disturbances in thinking and speech, and the inability to contact the patient, are also differentiated from derealization, in which coherent thinking, speech, and contact are preserved.

Treatment derealizations

If a patient is diagnosed with a mental illness or somatic pathology, against the background of which symptoms of depersonalization/derealization have appeared, the only way out is to treat the underlying disease. When it is cured or a therapeutic effect or stable remission is achieved, the symptoms of derealization disappear, and usually they are the first to disappear.

For more information on methods of treating derealization, read this article.

Prevention

To prevent the occurrence of the syndrome and its relapses, those who have already encountered a similar condition are usually recommended to lead a healthy and open lifestyle; in some cases, it would be good to change their place of residence and circle of friends.

However, the main thing is to change yourself, make your view of the world more positive, soberly assess your capabilities and set realistic goals. Do something for the soul - yoga, winter swimming, cross-stitching... New acquaintances will appear, there will be more interesting meetings, and there will be no time to accumulate grievances against life and feel deprived and unhappy loser.

[ 11 ], [ 12 ], [ 13 ]

Forecast

There are known cases when depersonalization/derealization syndrome passed by itself, and the patients' health improved. After all, this is just a protective reaction of the body. However, you should not delay the situation, sometimes a few conversations with a psychotherapist are enough to fully recover. Of course, people who seek help in the first days of the pathological condition have a better chance of getting out of the situation without consequences.

In some cases, usually advanced ones, the syndrome becomes chronic and resistant to treatment. Much depends on the patient himself, if he wants to get rid of psychological discomfort, tries to distract himself, focusing his attention on rational thoughts and actions, then his prognosis is much more favorable. In some, the syndrome becomes recurrent.

[ 14 ], [ 15 ]