Depersonalisation and Dissociative Disorders

One of the most disconcerting symptoms people might experience when stressed is depersonalisation.

Depersonalisation involves a sense of being detached from yourself, such as feeling as though your body does not belong to you. It may be accompanied by derealisation or a sense of being detached from one’s surroundings.

Depersonalisation is a form of dissociation.

Dissociative symptoms involve a subjective experience of detachment from one’s body, thoughts, memories, emotions, actions, sense of identity and/or connection with the world. This contrasts with a person feeling well connected with themselves and the world around them and having a more integrated sense of their experience.

Correspondingly, dissociative experiences are often associated with feelings of a loss of control.

They may lead people to question the soundness of their own mind. Dissociative states can be temporary, as is typically the case with panic attacks, but patterns or habits of dissociative behaviours can become more entrenched over time. When dissociative reactions are more disruptive and persistent, they might be diagnosable as a Dissociative Disorder. Depersonalisation symptoms can be associated with anxiety, depression, trauma reactions and especially with Dissociative Disorders, such as Dissociative Identity Disorder (DID).

Types of Depersonalisation

Common depersonalisation symptoms include feeling detached from your body, such as feeling as though your body does not belong to you, or viewing yourself from a distance as though viewing another person.

You may experience yourself as being on autopilot, or feel as though you are in a dream. It also includes having difficulty relating to the image of yourself in the mirror. Parts of your body may feel distorted, such as your hands seeming larger or smaller than usual.

Depersonalisation also often involves a sense of emotional numbing or a sense of emotional detachment.

Neurobiological studies show that people with more entrenched patterns of depersonalisation have reduced activity in the brain’s limbic system in response to emotional stimuli.

Depersonalisation is commonly associated with disruptions to memory, feeling disconnected from one’s memories or having uncommon difficulty remembering recent or past events. People may feel as though their memories do not truly belong to them. Memories may otherwise seem distorted in their time frame so that recent events feel more distant.

The experience of depersonalisation can be especially disruptive when combined with feelings of derealisation.

Derealisation means having a sense of detachment from your surroundings, perhaps by feeling as though the world is not real. People may feel as though they are looking at the world through a fog. Especially when people are highly distressed, they may misinterpret this experience and fear that they are losing their mind. In such cases, the person’s anxiety and distress about experiencing depersonalisation symptoms can become just as disruptive as the depersonalisation itself.

Even though approximately half the population experiences depersonalisation or derealisation at some point in life, approximately 2% of people experience it so often or in such a disruptive fashion that they could be diagnosed as having a Depersonalisation/ Derealisation Disorder (DDD). During such episodes, the person is still aware of their surroundings and knows that what they are experiencing is not normal.

Other dissociative conditions include Dissociative Amnesia.

The associated memory loss can relate to a particular event or a discrete period of time, or more rarely can be generalised to the point of forgetting almost all of one’s life history.

Dissociative Identity Disorder (DID), formerly called multiple personality disorder, is most commonly associated with repeated severe abuse or trauma in childhood.

It occurs where the person has developed two or more distinct identity or personality states, combined with gaps in memory about recent or past events. This likely applies to approximately 1% of the population and around 4% of psychiatric inpatients. People with DID commonly experience depersonalisation and periods of missing time, consistent with their sense of identity shifting from one personality state to another.

Those who suffer from dissociative disorders will often suffer from other conditions including depression, post-traumatic stress disorder and perhaps Borderline Personality Disorder. Sometimes they will have been diagnosed with a milder form of Bipolar Disorder (Bipolar II), even if a dissociative disorder later seems to be a more fitting diagnosis.

Case examples of depersonalisation in dissociative disorders

To have a greater understanding of depersonalisation, it helps to appreciate other people’s subjective experiences.

The following descriptions are from people who kindly gave permission for this material to be used to illustrate how depersonalisation and other dissociative symptoms might be experienced. Their names have been changed and they have given permission for their descriptions to be used.

Case example 1 – Jason

Jason presented in his early 20s with a long history of depersonalisation.

This included watching himself play sport from outside his body. He had come to believe that the world was literally a simulation. He experienced repeated traumatic experiences during his childhood associated with disturbing experiences in his family.

Jason grasped the concept of dissociative experience so well and related his understanding and progress in such an articulate manner that his case well illustrates how depersonalisation can develop and how it can be constructively addressed.

Jason referred himself after encountering our practice podcast episode and clinical handout on dissociative disorders. He found the psychoeducation about dissociation and depersonalisation especially helpful to him as it was “relatable” and “validated a lot of things that were going on in my head that weren’t being spoken about … it was not just created in my mind… it made the issue feel real… in the real world – I almost wasn’t aware of it for a long time. I thought that was how everyone perceived reality.”

Jason described that as a child during tumultuous episodes of threatening behaviour in his family he would hide under the table, “not in that situation, but observing it”. He consciously appreciated that he had found a way to not experience the situation (emotionally). He thought to himself, “This is awesome”, as he felt that he had discovered a “cheat code” in life.

Jason increasingly used this strategy to avoid other emotional experiences, such as if he were bored at school.

He then recognised, “If I don’t want to be there I don’t have to be”. He described that on many occasions after feeling bored sitting in a classroom, “It was like – I’m gone. Sitting outside the classroom or whatever”. Not surprisingly, he came to draw on the strategy so frequently that it “became my reality more often than not”. For a long time, this approach seemed to pay off as “Nothing would bother me. Everything would bounce off. I wouldn’t have to experience it.”

Jason described his subjective experience was like “the real version of me gets pushed to the back of my mind. It leaves my body.”

Pointing to the potential genesis of DID, he then described that he would go into character or a role, into an alternate reality or an altered state.

Reflecting his increased detachment from his memory and perception he described remembering leaving his body during a distressing incident at home and then wondering whether the previous night’s disturbing events had actually occurred. Given that his family did not later discuss or acknowledge these disturbing incidents, he described that it “seemed to be only in my head.”

At times Jason described having a sense of different voices, which he related to the idea of an “identity split.”

In such situations, including at work, he would “switch persona – being louder, more confident, and cocky.”

Jason tellingly described that “The only association I had with reality was pain and argument”, seemingly acknowledging the motivation for his avoidant or dissociative reactions. At times he tried to “integrate” himself “back into reality”. But he described that “I needed a few little bits of reality… because more than that was too much. I felt that I would overdose on reality”.

Jason seemed to acknowledge that his reactions were like being in a trance when he described that whilst in such states, “nothing else seemed to hit (me).”

He added, “I so badly want to switch off. I so badly want to give back control to that part that used to have control. I so badly want to surrender myself and dissociate. I so badly want to stop feeling again. I avoided it for a long time. I thought I could avoid it forever. I kind of loved it, however, it was detrimental to my relationships and the way I interacted with others.”

Jason recognised enduring limitations of this approach including feeling that his emotional maturity had been “trapped at a 10-year-old [level]”.

When he did connect more with reality and experienced painful emotions, he might ask himself, “Why am I suddenly myself, crying my room?”

Jason at times seemed “spaced out” to friends. He found it disconcerting to see himself in the mirror as he described, “You know it is you theoretically, but you just don’t really recognise who you are”. His derealisation experiences included seeing people “like they were in slow motion, like in some game or movie”.

Perhaps of most significance, Jason had started a new relationship, which he valued, but found it distressing to notice that his newfound pleasurable feelings of being in a relationship were accompanied by more frequent feelings of uncomfortable emotions as well. He felt that he needed to separate from his partner to address his underlying difficulties. He was severely depressed at the time of his referral.

Like many other people with dissociative experiences, Jason was initially harshly self-critical about his reactions.

He would say to himself, “How did I allow myself to dissociate? I know it’s a natural brain response, but I believe I should’ve been smart enough to stop it from happening. The fact that I allowed myself to live like that makes me angry at myself…”

He conveyed his previous sense of instability by saying, “The way I used to live was like the ‘real me’ having one finger on the steering wheel. I could make tiny, slight adjustments, but I was never able to drive the car… the car being my body of course. I’m surprised I didn’t crash more often in this out-of-control state. Without [experiencing the] feelings involved, I behaved in a way that I would never choose to behave like when I am in control.”

Jason progressed extremely well as he came to understand the nature of his dissociative experience and its avoidant function of protecting him from pain. He was ready to allow himself to experience himself and his feelings more directly and fully, as well as the world. He understood this would put him in a better position to connect with others and to potentially enjoy being in a more healthy relationship in future.

Being a quick learner, Jason grasped the importance of learning to deal with discomfort more directly, “within his own skin”, so to speak.

He described that he had “felt more present and engaged” in the intervening weeks and “didn’t need to switch off”. He was “there more often than not”.

When Jason inevitably lapsed back into a dissociative state he described, “Now when I go into a dissociated state it is disconcerting”. This contrasted with his earlier views as a child when he “felt special” that he could use this strategy, stating that, “It was “kinda fun for a while”. Even as a young adult, he felt that he had “figured out what others haven’t… We are not in base reality. The world was a simulation. None of it was real.”

Jason gradually felt increased satisfaction from trying to come back in touch with reality.

He exclaimed, “I exist now!” Jason’s awareness has reached such a point that he cannot return to his previous perspective. He described, “You can’t go back to the place you lived. You do not realise the place you were was wrong until you realise (there is) another side to it”.

Jason made further progress by developing useful personal grounding techniques. He described that “Now I take a bit of time each day to get everything out of mind. I look around for a few minutes and think, “It’s pretty cool there’s something rather than nothing.” He seemingly expressed a sense of awe and wonder in describing that he looked up at the sky and thought, “There’s so much out there that we don’t know. We are in a little bubble and let things penetrate.”

Jason highlighted his newfound confidence in dealing with uncomfortable emotions.

He stated, “In the past, I could switch away from my reactions. Now I might feel angry and have an emotional response, but it’s healthier.”

He was also more ready to more directly deal with challenging situations rather than seek to avoid them or put them off, describing that previously when facing a difficult situation, he would “constantly want to run the other way…”

He added, “But it’s a hurdle you want to jump over if you eventually want to feel good within yourself. If you want to be in a healthy place you are going to end up going back to that hurdle. So there’s no point putting it off. The barrier stays there until you process it and feel things. You can [then] be on the other side of it.”

Case example 2 – Ryan

Another client, Ryan, presented in a severely depressed state.

He described how he would “look at life with emotional detachment”, explaining that had “spent a lot of time in my head”.

Ryan directly acknowledged that he had “put a lot of trust in my ability to dissociate”. He described that he was “on autopilot through most of my days. I don’t remember the things I’ve said or done. I feel like I’m not a real person. I disappear into the crowd.”

Ryan described having different “versions” of himself that he gave different names.

One would come out when things needed to get done, as a “more clinical version of myself”. He would then be able to identify emotions, but not feel them. Ryan acknowledged having periods of missing time when he “may lose an hour”.

Ryan descriptively referred to certain depersonalisation experiences as, “like back seating… I will not be present and will run on autopilot.” Seemingly describing a self-hypnosis strategy, he explained “it’s like I’m focusing my eyes… it’s a gateway to the back seat… the final stage of dissociating”. Ryan’s depersonalization also occurred at times in conjunction with panic symptoms including heart palpitations, feeling shaky and scared and feeling that he was losing control.

Ryan was very articulate and quick to understand more about his reactions. He explained that “the more I sit with things the easier it is to remember things. An understanding of not [needing to have] an instant shut down.”

Ryan described having a sense of achievement from his increased awareness of what was happening around him.

He described being more aware of when he was tuning out and noticed that it often occurred when he was more agitated.

Ryan had started to develop more direct alternate strategies to deal with stressful situations, including telling someone when he did not want to discuss a topic further or choosing to step outside. Rather than aggressively defend a position he was taking, he now felt more able to choose how he might react or respond.

Ryan described that his main goal was “to recognise and feel all the emotions involved and choose (how to respond) based on everything.” He described previously identifying parts of himself, including one who holds anger, representing a shadow side of himself with darkness and depression. Another part was very clinical and emotionally detached, but often communicated with other parts of himself in a way that was often cruel. Ryan gradually learned other ways of helping different parts of himself communicate, along the lines of conducting an internal committee meeting. He recently described, “The other version of me has hope, and feels happy.”

Unhelpful consequences of depersonalisation

When people have experienced a long-term pattern of depersonalisation since childhood, this often suggests that they have overused a hypnotic-like strategy to buffer the emotional experience of pain.

Jason and Ryan both described deliberately having induced such states so they did not have to experience the situation they were in. Or at least they didn’t feel that they were in their body with the associated painful feelings. They both reported experiences of amnesia or detachment from memories, which can also be readily induced in a hypnotic state.

People are more likely to dissociate if they have high levels of absorption, a normal personality attribute that correlates with hypnotic potential. Absorption involves a capacity to focus one’s attention intently on an aspect of experience, which can influence one’s state of mind. It is also associated with having a more active imagination and proneness to fantasy. These characteristics are commonly associated with creativity. However, this propensity can complicate matters when people face repeated stress or trauma, as it also increases their capacity to dissociate from the experience.

If this becomes a more entrenched habit, it interferes with more direct processing of emotions in challenging situations.

This in turn may interfere with the development of more adaptive coping skills.

Depersonalisation accompanied by panic feelings is often associated with hypervigilance and agitation, combined with a specific type of increased frontal lobe activity that suppresses subjective emotional states and distress. Whereas this might be somewhat adaptive in reducing one’s subjective distress whilst you have to focus on a challenge or task, if it becomes an entrenched habit it leads people to be more detached from their emotions. They are then less able to be helpfully informed by their emotions and the guidance they might provide in responding to a particular situation. This would predictably interfere with how people deal with conflict as well as their capacity to relate to other people in more consistent and healthy ways.

In my view, depersonalisation experiences, just as dissociative experiences more generally, often represent one of two different types of reactions.

One is a more passive and automatic reaction to feeling overwhelmed, involving a degrading of people’s perceptual awareness and memory, often combined with a sense of agitation and losing control. It may also involve numbing.

The second type is a more deliberate, albeit somewhat unconscious, hypnotic mechanism designed to buffer people from painful emotions. As the case examples described, sometimes people might initially feel some sort of increased choice or control in these situations. It may seem to start as a somewhat deliberate strategy to avoid pain or to take some action without being distracted by painful feelings. However, if it functions as a kind of emotional bypass, it is likely to have longer-term costs in terms of less well-integrated thoughts, feelings, behaviour and sense of identity and purpose.

Either way, the key is to learn more direct coping and arousal management strategies to enable a person to bear with their painful experience within their own skin.

As their confidence to manage with this improves, they may have less need to induce a different state of mind to buffer themselves from painful feelings or an unwelcome reality.

Key strategies to counter depersonalisation

[Also see our clinical handout on Dealing with Dissociative Experiences]

• Psychoeducation: as with other dissociative symptoms, it helps to understand the nature and function of depersonalisation. It is typically a sign of feeling overwhelmed as well as an attempt to buffer oneself from painful experience. It relates in part to trance states and other hypnotic mechanisms to reduce pain. It helps to recognise the adaptive aspects of dissociation and depersonalisation as well as the complications associated with them.

• Arousal Management: It is important to learn alternative and more direct coping strategies to reduce arousal, such as breathing, relaxation or mindfulness techniques.

• Grounding techniques: It helps to practise being grounded in the present moment, drawing on your senses to connect with your immediate surroundings. This can include describing things to yourself in your immediate environment using each of your senses or looking at and feeling your feet in your shoes on the floor. This directly contrasts with the experience of dissociating from one’s current experience.

• Practise experiencing discomfort “within your own skin” with your “frontal lobes switched on”. In other words, at least in less threatening or overwhelming situations, allow yourself to feel your uncomfortable emotions and notice that they will vary rather than remain constant. They do not last forever. Painful feelings are not dangerous in themselves. Uncomfortable emotions will tend to peak and then reduce in intensity over time, and usually within no more than hours. Allowing yourself to experience your emotions can help to gain understanding and guidance from them.

• Practise exercising appropriate boundaries in relationships. It helps to be discerning about whom you choose to trust. It can also help to have some more direct strategies for dealing with conflict situations, such as developing appropriate ways of asserting yourself.

• Any activity that focuses on furthering the constructive roles in your life, in relationships, caregiving, work or study, can enhance your sense of constructive purpose and identity.

• If your depersonalisation is associated with panic attacks, past trauma, depression or other psychological difficulties it can be worth seeking psychological therapy.

• Psychological therapy may help with all of the above strategies. Therapy would typically include some objective assessment of dissociative symptoms as well as accompanying anxiety and/or depressive symptoms and some assessment of potential trauma reactions.

• The judicious use of medication may help, even though there is no specific medication that directly treats dissociative symptoms or depersonalisation. However, medication such as antidepressants might help, especially with accompanying depressive symptoms. It helps to have a longer-term relationship with a general medical practitioner who knows you well.

• If people have experienced unresolved past trauma, it often helps to undertake trauma-informed therapy with a therapist very well experienced in post-traumatic stress disorder (PTSD) and other trauma-related reactions. This might focus in part on recognising situations or cues that may trigger trauma memories and accompanying anxiety and dissociative symptoms.

• Some deliberate exposure to trauma-related memories may help defuse their impact, but this might best be attempted in a therapy setting when your life circumstances are more stable. People with strong dissociative tendencies may react more unpredictably to trauma memories, and extra care is called for when eliciting them. Direct exposure strategies are not always indicated, required or helpful. If in doubt, it is perhaps best not to use them. Dealing with triggered emotions can help process underlying trauma memories in at least an indirect manner.

• If raising children after having been raised in a harsh, abusive or invalidating environment yourself, aim to “turn things around in a generation”. This is as noble a quest as any.

• Show self-compassion: Dissociative Disorders are amongst the more disruptive psychological conditions for which people seek help. They typically involve complex and longer-term difficulties and are commonly accompanied by depression, trauma reactions, anxiety reactions and somatic symptoms. People can and often do make very considerable progress, but this tends to be gradual. Acknowledge your positive motivation for change, courage and progress, however gradual it might seem. Treating yourself kindly helps counter some of the impact of past abuse and trauma.

For a related article on dissociative experiences, see our clinical handout, Dealing with dissociative symptoms.

Listen to our practice podcast, Psych Spiels and Silver Linings, for the episodes on depersonalisation (ep. 43), Dissociative Identity Disorder (ep. 44), and on dissociative experiences more generally (ep. 9).

You can listen to the episodes in the players below or on your favourite podcast player.

If depersonalisation happens in the context of panic attacks, listen to the episode on that – Depersonalisation in Panic Attacks.

Our clinical handout on dissociation and panic attacks can be found here.

For a further explanation of the topics discussed in this article, listen to episode 43 below.

For a more general overview of dissociation and strategies for managing it, listen to episode 9 below.