Depersonalization & Derealization (DPDR): Causes, Symptoms & Treatment

In DPDR, reality may remain intact, but the felt connection with reality can become disrupted. In this page Dr Millia Begum explains DPDR. Professional help and treatment for DPDR is informed by the underlying cause of the symptoms. 

What is depersonalisation?

Depersonalization is one of the many symptoms of dissociation whereby one experiences a sense of being disconnected from one’s own body, feelings, thoughts, or observing themselves from a distance, rather than fully inhabiting their own experience.

What is derealisation?

Derealization is one of many symptoms of dissociation whereby one experiences a sense of disconnection from the outside world either expericienng it as distant, unreal, dreamlike, flat or strangely unfamiliar.

Some people describe the outside world as feeling like a theatre or film in which they can see other people and understand what is happening, but cannot fully feel connected to it.

What is the difference between depersonalisation and derealisation?

Depersonalization and derealization commonly occur together. Both are dissociative experiences, but the emphasis is slightly different.

Depersonalisation involves a disruption in the felt connection with the self.

Derealisation involves a disruption in the felt connection with the external world.

A person may experience one more strongly than the other, or move between both.

Is DPDR a psychotic symptom?

Usually, no.

One of the important differences between DPDR and psychosis is reality testing.

In depersonalisation and derealisation, the person generally knows that the world has not literally become unreal and that they have not actually left their body.

What has changed is their felt sense of connection with reality.

For example, someone may say:

“I know this is my family. I know this is my home. But it does not feel real.”

In psychosis, reality testing itself may become impaired.

This distinction is important, although persistent or unusual symptoms should always be assessed carefully. A psychiatrist would help in differentiating if these are psychotic or DPDR symptoms. 

What causes depersonalisation and derealisation?

There is no single cause of DPDR. A useful way of understanding it is as a disturbance in the felt sense of connection — with oneself, with other people, or with the surrounding world.

This can arise for different reasons.

Possible contributors include:

• severe anxiety or panic
• traumatic experiences
• developmental or attachment trauma
• substance-related experiences
• some neurological or medical conditions
• prolonged stress or emotional overwhelm
• other dissociative or mental health conditions

Understanding why DPDR developed in a particular person is important because the treatment may be different depending on the underlying cause.

Can panic attacks trigger DPDR?

Yes. Panic attacks can trigger depersonalization or derealization, particularly when the person becomes frightened by changes in perception, bodily sensations or consciousness.

But the relationship can also work in the opposite direction.

A sudden episode of derealisation may itself feel frightening:

“Why does everything suddenly feel unreal?”

That fear can then trigger panic.

This can create a self-perpetuating cycle:

DPDR → fear → panic → increased DPDR → more fear

Understanding this cycle can itself be helpful because the person may begin to recognise that the experience, although extremely unsettling, does not necessarily mean that they are losing touch with reality.

Can cannabis or other substances trigger persistent DPDR?

Cannabis and other mind-altering substances can trigger depersonalisation and derealisation in some people.

For some, the experience resolves when the effects of the substance wear off. For others, symptoms may persist. The mechanisms are not fully understood.

In some cases, a substance may intensify an existing tendency towards dissociation.

In others, an altered state of consciousness may trigger intense fear or panic, after which the person becomes highly vigilant to changes in perception and continues to experience DPDR.

Persistent symptoms following substance use should be clinically assessed rather than assumed to have one particular cause.

What is trauma-related DPDR?

Depersonalisation and derealisation can occur during or after overwhelming traumatic experiences.

When an experience feels unbearable, the brain may reduce the intensity of emotional, bodily or perceptual experience.

This can function as a form of protective psychological and neurobiological distancing.

The person may remain aware of what is happening but feel strangely detached from it.

For example:

“I knew it was happening, but it felt as though it was happening to somebody else.”

or:

“I could see everything around me, but nothing felt real.”

In this sense, DPDR may reduce the immediate impact of shock, fear, pain or overwhelm.

The difficulty is that a response that was protective during the original experience can sometimes persist long after the danger has passed.

Can early attachment trauma contribute to DPDR?

Some people with longstanding depersonalisation or derealisation describe a history not of one single traumatic event, but of chronic developmental or relational difficulties.

When connection itself has repeatedly been associated with fear, rejection, unpredictability, emotional neglect or loss, distancing from internal and relational experience may become protective.

For some people, derealisation can therefore involve more than the world simply “looking unreal”.

There may also be a deeper disruption in the felt sense of connection, familiarity and belonging.

What happens in the brain during DPDR?

The neuroscience of depersonalisation and derealisation is still developing.

Research has suggested alterations in networks involved in emotional processing, interoception, attention, threat processing and the integration of bodily and perceptual experience.

Some studies have described reduced emotional responsivity alongside increased involvement of prefrontal regulatory systems.

Changes involving areas such as the amygdala, insula and prefrontal cortex have also been studied.

However, it is unlikely that DPDR can be explained by one brain region alone.

It is better understood as involving changes across networks responsible for how we integrate:

body sensation, emotion, perception, attention and our sense of self and reality.

How is DPDR treated?

Treatment should begin by understanding why the DPDR is occurring.

Depersonalisation and derealisation are symptoms that can occur in several different conditions, rather than representing one single process in everyone.

Assessment may therefore explore:

• panic and anxiety
• trauma and dissociation
• developmental and attachment experiences
• substance use
• mood symptoms
• neurological or medical factors
• neurodevelopmental conditions
• sleep and stress

Psychoeducation can be very helpful, particularly when fear of the symptoms is perpetuating a panic-DPDR cycle.

Grounding, orienting and present-moment awareness may also help some people reconnect with their body and environment.

Where trauma is contributing, treatment may involve careful stabilisation followed by gradual trauma processing.

For some people, treatment of persistent anxiety, depression or another underlying mental health condition may also be important.

Medication does not specifically “switch off” DPDR, but medication may sometimes be considered when other conditions such as anxiety or depression are contributing significantly.

Can trauma therapy help DPDR?

Where depersonalisation or derealisation is linked to trauma, treatment may sometimes include trauma-focused approaches such as EMDR, Deep Brain Reorienting (DBR), or Internal Family Systems (IFS). These approaches work in different ways and are not automatically appropriate for every person with DPDR. Assessment is important, particularly where dissociation is prominent, because trauma processing may need to proceed gradually and with careful attention to stability, orientation and tolerance.

• EMDR may be considered when DPDR is linked to specific traumatic memories or triggers, but pacing and dissociation assessment are important.
• DBR may be relevant where overwhelming shock, orienting responses or very early threat responses appear central to the presentation.
• IFS may be useful when DPDR is connected with protective distancing, internal conflict, attachment-related pain or parts that fear emotional contact.

When should I seek professional help?

Occasional brief experiences of depersonalisation or derealisation can occur during periods of intense stress, fatigue or anxiety.

Professional assessment becomes particularly important when DPDR is:

• persistent or recurrent
• causing significant distress
• affecting work, study or daily functioning
• making relationships or social connection difficult
• associated with panic attacks
• accompanied by depression or increasing withdrawal
• difficult to distinguish from other mental or neurological symptoms

Persistent DPDR can become very isolating.

People may begin withdrawing from relationships or activities because connection no longer feels meaningful or because they fear the symptoms themselves.

A careful assessment can help identify what may be driving the symptoms and what form of treatment is most appropriate.