Anxiety & Mood
Depersonalization and derealization: what they are
What depersonalization and derealization feel like, why they do not mean “going mad”, how they link to panic, when they become a disorder and what helps.
Depersonalization is the feeling of being cut off from yourself, that is, from your body, your thoughts or your feelings, as if you were watching your life from the outside. Derealization is the feeling that the world around you is not real, as if you were in a dream or a fog. Brief episodes are very common, especially under intense stress, anxiety or panic. In depersonalization-derealization disorder, the person always knows that it is a feeling and not reality, and this is what sets it apart from psychosis. When the symptoms persist or keep coming back and trouble you, an assessment is worthwhile.
What it feels like
Depersonalization concerns the self: the body, thoughts and feelings. People describe it as “like watching my life from the outside” or “like a robot”.
Derealization concerns the world around you. People describe it as “like a dream” or “as if a pane of glass separates me from the world”.
There may be only one of the two, or both together [1].
In depersonalization:
you feel that you are watching yourself like an outside observer,
you feel that you are not real, or that you are moving like a robot, on “autopilot”,
your emotions feel numb and you find it hard to tell what you feel,
you find it hard to recall memories clearly.
In derealization:
the world seems like a dream or a fog, as if a pane of glass or a veil separates you from it,
things seem lifeless, colourless or artificial, or distorted in size, blurred or flat,
sounds seem different and time seems to pass very slowly or very fast.
The experience is usually very unpleasant, and anxiety and depression often occur alongside it. Some people fear that they have brain damage or that they are “going mad”, and check again and again whether what they perceive is real [1].
The thought “I am going mad” is an anxiety thought, not a diagnosis. The feeling that you are not real, or that the world is not real, proves nothing about how things really are. We accept that the feeling is there and that it is unpleasant. We do not accept its catastrophic interpretation.
How common it is
Brief symptoms are very common. According to a systematic review, between 26% and 74% of the general population have experienced them at some point in their lives, and between 31% and 66% at the time of a traumatic event [3].
The disorder is much rarer: about 1 to 2 in 100. A more recent systematic review (2022) puts it at around 1% of the general population and finds it more common in teenagers and young adults [4].
It usually starts early. The average age of onset is 16, and it rarely begins after 40. In a series of 117 patients, men and women were about equal in number [5].
When it is a disorder
The diagnosis is clinical, meaning it is made through the interview. According to the DSM-5-TR criteria, there needs to be [1]:
persistent or recurrent episodes of depersonalization, derealization or both,
preserved awareness that the experience is not real,
significant distress or difficulty at work, in relationships or in other areas of life,
no better explanation by another condition, such as epileptic seizures, substance use, panic disorder, depression or another dissociative disorder.
To rule out other causes, a brain MRI and an electroencephalogram (EEG) may be needed, especially when the picture is atypical, for example when the symptoms start after the age of 40. A urine drug screen may also be needed [1].
Why it happens
Episodes are often linked with:
intense stress in relationships, finances or work,
depression, anxiety and panic attacks,
substances, especially cannabis, ketamine and hallucinogens.
In a series of 117 patients, the most common triggers at onset were intense stress, depression, panic, cannabis and hallucinogens [5]. Many patients also have a history of intense stress in childhood, most often emotional abuse or neglect [1]. This does not apply to everyone, however: in a German series of 223 patients, those with the disorder reported fewer traumatic experiences in childhood, and fewer current pressures, than patients with depression [6].
Depersonalization and panic
The link with panic is close. In the studies on panic disorder gathered in a systematic review, rates of depersonalization or derealization symptoms ranged from 7.8% to 82.6% [3]. The researchers note that the estimates are complicated by the different definitions and time periods that the studies use.
When the feeling appears only during panic attacks, the doctor considers whether it is part of panic disorder rather than a separate disorder. That is why the assessment matters: if the feeling is part of panic, depression or substance use, treatment targets that as well.
Does it pass?
The course differs from person to person. Symptoms usually come in episodes, with an intensity that rises and falls. An episode can last hours, days, weeks, months or even years, and in some people the symptoms are constant for years [1].
Many people recover fully, especially when the symptoms are linked to stress that is dealt with or passes, or when they do not last long. In some people they subside even without treatment. In others they become chronic and hard to treat. Some people have very little difficulty in daily life when they stay busy and turn their attention to other activities [1]. In the German series of 223 patients at a specialist clinic, the course tended to be long-lasting. The researchers note, however, that their sample does not represent everyone who has the symptoms [6].
What helps
Psychotherapy. Cognitive and behavioural techniques, “grounding” techniques that turn attention to the five senses, and psychodynamic therapy are used. In some patients they are successful. Therapy also needs to address the pressures that triggered the symptoms, as well as earlier difficult experiences [1].
Cognitive behavioural therapy. In an open study with 21 patients, therapy helped patients interpret the symptoms as non-threatening and reduce avoidance, “safety behaviours” and constant checking of the symptoms. There was significant improvement, still visible at six months, and at the end of treatment 29% no longer met the criteria for the disorder. The study was small, and the researchers note that larger and more rigorous studies are needed [7].
Medication. Various medicines have been tried, but none has clearly proven effective for the disorder itself. Some patients may benefit, probably mainly because co-occurring anxiety or depression is treated. Whether medication is needed, and which, is decided after the assessment [1].
In 117 patients, the symptoms often got worse with negative emotions, stress, social situations experienced as threatening and unfamiliar surroundings. In contrast, they eased with comforting contact with other people, intense emotional or physical stimulation and relaxation [5].
During an episode:
Name it: “what I feel is a sensation, not reality”.
Turn your attention to your senses: what you see, what you hear, what you touch.
Try not to interrupt what you are doing to check again and again whether you are “real”. Constant checking is one of the things therapy targets.
When avoidance keeps the problem going, we do not wait for the feeling to go away before you go back to living normally. You gradually return to what you avoid, with the feeling present, and test in practice whether what you fear actually happens. Each such step is a small behavioural experiment.
When to ask for help
The feeling persists or keeps coming back and causes you distress, or makes work, studies or relationships harder.
It comes with panic attacks, low mood or intense anxiety.
It started or got worse after using cannabis or other substances.
You constantly check whether you are “real”, or avoid places and people so that it does not come on.
It started for the first time after the age of 40. In that case a medical check for other causes is needed too.
Safety: If you stop being sure that it is a feeling and start to believe that the world, or you, have actually changed, ask for a psychiatric assessment without delay. If you have thoughts that life is not worth living or thoughts of harming yourself, ask for help immediately: 166 (ambulance, EKAV), 112, or the Suicide Prevention Line 1018.
How I can help
Book a psychiatric assessment, at the practice in Trikala or online. See also the page on anxiety and panic attacks. If the symptoms make you avoid travelling or unfamiliar places, the first conversation can take place from your home: see how working with an online psychiatrist works, or book an appointment.
This article is educational and does not replace individual clinical assessment. Do not change or stop any treatment you are already taking without talking to your doctor.
Sources
Spiegel D. Depersonalization/Derealization Disorder. MSD Manual, Professional Version. Fully reviewed June 2025, modified January 2026. https://www.msdmanuals.com/professional/psychiatric-disorders/dissociative-disorders/depersonalization-derealization-disorder
Spiegel D. Depersonalization/Derealization Disorder. MSD Manual, Consumer Version. Fully reviewed June 2025, modified January 2026. https://www.msdmanuals.com/home/mental-health-disorders/dissociative-disorders/depersonalization-derealization-disorder
Hunter EC, Sierra M, David AS. The epidemiology of depersonalisation and derealisation. A systematic review. Soc Psychiatry Psychiatr Epidemiol. 2004. https://doi.org/10.1007/s00127-004-0701-4
Yang J, et al. The Prevalence of Depersonalization-Derealization Disorder: A Systematic Review. J Trauma Dissociation. Published online 2022. https://doi.org/10.1080/15299732.2022.2079796
Simeon D, et al. Feeling unreal: a depersonalization disorder update of 117 cases. J Clin Psychiatry. 2003. https://doi.org/10.4088/jcp.v64n0903
Michal M, et al. A case series of 223 patients with depersonalization-derealization syndrome. BMC Psychiatry. 2016. https://doi.org/10.1186/s12888-016-0908-4
Hunter EC, et al. Cognitive-behaviour therapy for depersonalisation disorder: an open study. Behav Res Ther. 2005. https://doi.org/10.1016/j.brat.2004.08.003
