Depersonalisation Derealisation Disorder: The Forgotten Condition

A mental health condition that has been abandoned by the healthcare world and yet millions face its terrible effects every day.

Imagine feeling like an outsider of your own body. You can observe your own actions, feelings, and thoughts from a distance. You feel like the world is unreal and your surroundings feel strange. You feel like you are living in a dream, but you are awake. These are symptoms that are experienced by individuals with Depersonalisation-derealisation disorder (DPRD).

Depersonalisation is the subjective experience of feeling detached from one’s self which causes the individual to feel like an outsider of their own cognitions or body. It can be accompanied by derealisation which can cause the individual to view the world as unreal or unfamiliar (American Psychiatric Association, 2013; Spiegel et al., 2013). Depersonalisation and Derealisation symptoms can present as a transient occurrence particularly during substance use or as a response to a stress-inducing situation (Noyes & Kletti, 1977). If these symptoms persist for a period of time and are clinically significant (defined by distress and functional impairment) individuals can be diagnosed with Depersonalisation-derealisation disorder (APA, 2013). DPRD is categorised as a dissociative disorder in the DSM-V and can present as a primary disorder in the context of other psychiatric disorders, particularly major depression or anxiety (Baker et al., 2003; Medford et al., 2005).

It is estimated that the worldwide prevalence rate for DPRD is 1 – 2% in the general population (Hunter, Sierra, & David, 2004). This means around 1.3 million people in the UK. This mirrors the prevalence rate of psychiatric conditions such as Obsessive-Compulsive Disorder and even higher than conditions such as Schizophrenia which has a prevalence rate estimated as low as 0.28% (Charlson et al., 2018; Kessler et al., 2005).

Despite this high prevalence rate, DPRD is rarely diagnosed. Specifically, in Germany, a study investigating how often DPRD is diagnosed in the general population found that the 1-year prevalence rate was as low as 0.007% for the diagnosis of DPRD (Michal, Beutel, & Grobe, 2010). This can exacerbate the burden of the disorder as underdiagnoses can lead to fewer people being treated appropriately which may increase hospitalisation rates (Myrick et al., 2017). To the best of my knowledge, this study has not been replicated in the UK.

It has also been identified that individuals with clinically significant Depersonalisation and/or Derealisation symptoms experience a diagnostic delay (Baker et al., 2003; Michal et al., 2016). Using similar methodology, these studies conducted large case series in which individuals provided the nature of their DPRD to aid in describing the clinical phenomenology of the condition. A clinical diagnosis was made by a clinician according to the DSM-IV (Baker et al., 2003) and ICD-10 (Michal et al., 2016). Both studies found that the mean duration of clinically significant DP/DR symptoms was between 7 – 14 years from the onset of symptoms before receiving a diagnosis of DPRD from this clinician, with the UK study reporting a longer duration of 13.9 years (Baker et al., 2003). This is supported by recent anecdotal reports of individuals within the general population waiting between 8 and 12 years before receiving a diagnosis of DPRD (Victoria Derbyshire, 2017).

Research has proposed several possible explanations for the long and complicated paths to diagnosis for individuals with DPRD. One being that clinicians are unfamiliar with the symptomatology of DPRD (Coons, 1998; Leonard et al., 2005). This means that DP/DR symptoms may be misinterpreted as other psychiatric conditions (Hunter et al., 2017). Clinicians are advised to not diagnose DPRD if symptoms may be accounted for by another disorder (APA, 2013). Thus, this may contribute to the delay in diagnosis for DPRD. Equally, due to the unfamiliarity with DPRD among clinicians’, patients may feel misunderstood as their symptoms are misinterpreted. This may result in some patients seeking help from several clinicians in order to be understood or some may stop seeking help (Shorvon, 1946). Subsequently, this impacts the time taken to receive a diagnosis.

At present, medical training concerning mental health conditions is limited with little to no training surrounding DPRD (Victoria Derbyshire, 2017). Given that DPRD is severely underdiagnosed, it is imperative that clinicians are trained in its presentation as a chronic disorder. Training may improve clinicians confidence in detecting and treating DPRD, which subsequently decreases the economic burden on the NHS, as resources are not wasted and the burden on individuals with DPRD is decreased as they are diagnosed in a timely manner and treated appropriately (Langeland et al., 2020).

References

American Psychiatric Association. (2013). Dissociative Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596.dsm08

Baker, D., Hunter, E., Lawrence, E., Medford, N., Patel, M., Senior, C., Sierra, M., Lambert, M.V., Phillips, M.L., & David, A.S. (2003). Depersonalisation disorder: clinical features of 204 cases. The British Journal of Psychiatry, 182 (5), 428-433. doi: https://doi.org/10.1192/bjp.182.5.428.

Charlson, F.J., Ferrari, A.J., Santomauro, D.F., Diminic, S., Stockings, E., Scott, J.G., McGrath, J.J., &Whiteford, H.A. (2018). Global Epidemiology and Burden of Schizophrenia: Findings From the Global Burden of Disease Study 2016. Schizophrenia Bulletin, 44 (6), 1195-1203. doi: https://doi.org/10.1093/schbul/sby058.

Coons, P.M. (1998). The Dissociative Disorders: Rarely considered and underdiagnosed. Psychiatric Clinics of North America, 21 (3), 637-648. doi: https://doi.org/10.1016/S0193-953X(05)70028-9.

Hunter, E.C.M., Charlton, J., & David, A.S. (2017). Depersonalisation and derealisation: assessment and management. British Medical Journal, 356 (745). doi: 10.1136/bmj.j745.

Kessler, R.C., Berglund, P., Demler, O., Jin, R., Merikangas, K.R., & Walters, E.E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of general psychiatry, 62 (6), 593-602. doi: 10.1001/archpsyc.62.6.593.

Langeland, W., Jepsen, E.K.K., Brand, B.L., Kleven, L., Loewenstein, R.J., Putnam, F.W., Schielke, H.J., Myrick, A., Lanius, R.A., & Heir, T. (2020). The Economic Burden of Dissociative Disorders: A Qualitative Systematic Review of Empirical Studies. Psychological Trauma Theory Research Practice and Policy. Advanced online publication. 10.1037/tra0000556.

Leonard, D., Brann, S., & Tiller, J. (2005). Dissociative Disorders: Pathways to Diagnosis, Clinician Attitudes and Their Impact. Austalian & New Zealand Journal of Psychiatry, 39 (10), 940-946. doi: 10.1080/j.1440-1614.2005.01700.x.

Medford, N., Sierra, M., Baker, D., & David, A.S. (2005). Understanding and treating depersonalisation disorder. Advances in Psychiatric Treatment, 11 (2), 92-100. doi: 10.1192/apt.11.2.92.

Michal, M., Adler, J., Wiltink, J., Reiner, I., Tschan, R., Wolfling, K., Weimert, S., Tuin, I., Subic-Wrana, C., Beutel, M.E., & Zwerenz, R. (2016). A case series of 223 patients with depersonalization-derealization syndrome. BMC Psychiatry, 16 (203). doi: 10.1186/s12888-016-0908-4.

Michal, M., Beutel, M., & Grobe, T. (2010). Wie oft wird die Depersonalisations-Derealisationsstörung (ICD-10: F48.1) in der ambulanten Versorgung diagnostiziert? [How often is the depersonalisation derealisation disorder (ICD-10: F48.1) diagnosed in outpatient care?]. Zeitschrift für Psychosomatische Medizin und Psychotherapie, 56 (1), 74-83. doi: 10.13109/zptm.2010.56.1.74.

Myrick, A.C., Webermann, A.R., Langeland, W., Putnam, F.W., & Brand, D.L. (2017). Treatment of dissociative disorders and reported changes in inpatient and outpatient cost estimates. European Journal of Psychotraumatology, 8 (1). doi: 10.1080/20008198.2017.1375829.

Noyes, R., & Kletti, R. (1977). Depersonalization in response to life-threatening danger. Comprehensive Psychiatry, 18 (4), 375-384. doi: https://doi.org/10.1016/0010-440X(77)90010-4.

Shorvon, H.J. (1946). The Depersonalization Syndrome. Proceedings of the Royal Society of Medicine, 39, 779-792.

Spiegel, D., Lewis-Fernandez, R., Lanius, R., Vermetten, E., Simeon, D., & Friedman, M. (2013). Dissociative Disorders in DSM-5. Annual Review of Clinical Psychology, 9, 299-326. doi: 10.1146/annurev-clinpsy-050212-185531.

Victoria Derbyshire (2017, September, 26). The disorder that makes people unable to feel love [Video file]. Retrieved from https://www.bbc.co.uk/programmes/p05h8drf.