Depersonalization: The Disappearing Body

Paul M. was in nursing school, in the midst of intense stress and social pressure, when he had the panic attack that changed the course of his life. When the worst of it subsided, he knew something was wrong. He felt a complete sense of disconnection from his hands, as though they belonged to someone else. He felt estranged from the rest of his body. People and places he knew well felt suddenly unfamiliar, even alien. And when he looked in the mirror, a stranger looked back at him. “I felt as if I’d lost my soul,” Paul explained. “Everything appeared dreamlike, as though I was watching a movie of my life.” He was utterly terrified.

For two years, Paul had no respite from his suffering. He sought help from both a family doctor and a mental health counselor. Each attributed his symptoms to anxiety, which made him feel even more adrift and hopeless. Yet as he tells it, he was one of the lucky ones. Thanks to his mental health training, he recognized his symptoms as the distressing shift in self-awareness known as depersonalization.

A staggering 75 percent of us will experience transient feelings of depersonalization at some points in our lives. In fact, symptoms of depersonalization rank as the third most reported psychological symptom after anxiety and depression, particularly in young people.

Just as they did for Paul, the symptoms of depersonalization often constellate suddenly and rapidly, as you might imagine in the case of traumatic events. But the triggers are often more subtle. Symptoms can begin during periods of intense stress or sleep deprivation. And they often occur alongside depression and anxiety, which leads mental health professionals to overlook them. They can also be exacerbated by derealization, the sense that objects, other people, and the world around us are artificial and unreal.

Sometimes, symptoms persist and interfere with daily functioning, as they did for Paul. In this case, they classify as full-blown Depersonalization and Derealization Disorder (DDD), which occurs in up to 2.5 percent of the general population. The disorder begins as young as 16 and usually before age 25.

Triggers for the disorder DDD include traumatic or stressful events, severe depression, marijuana or hallucinogenic drug use, interpersonal abuse, or even intense meditation practice.

The clinical picture of depersonalization has remained consistent for over a century. In fact, fully 80 percent of psychiatric inpatients experience it. Despite this, most mental health professionals have little familiarity with it. They often misdiagnose the condition as anxiety or depression—or, as Ginnie, a woman whom I spoke with for this article lamented, a completely unrelated condition, in her case hives. Sadly, the average length of time it takes to receive a diagnosis of DDD is a whopping 7-12 years.

Why might this be, and what can we as a society do about it? One reason that clinicians and patients alike, including Ginnie, cite for this is that patients find it difficult to describe their symptoms—and that this leads clinicians down other diagnostic paths.  

And yet, the responsibility for misdiagnosis feels displaced to me.

As I delved into emerging research on depersonalization, I began to sense another reason why.

Diagnosing Depersonalization

In the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, the canonical text used by psychologists and psychiatrists to diagnose patients, and by insurance companies to authorize treatment.

The manual lists the following criteria for diagnosis:

The presence of persistent or recurrent experiences of depersonalization, derealization, or both:

• Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing)

• Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, life less, or visually distorted)

The DSM-V lists additional requirements for diagnosis, including:

• intact reality testing

• distress or impairment in social, occupational, or other key areas of functioning

• the disturbance is not due to the physiological effects of a substance (e.g., a drug of abuse, medication) or another medical condition

• and it is not better explained by another mental disorder, such as schizophrenia, panic disorder, major depressive disorder, acute stress disorder, posttraumatic stress disorder, or other dissociative disorder

But as it turns out, this achingly common disorder may be an anomaly of embodiment, a factor that its current diagnostic profile virtually buries with just two words: “sensations” and “body.”

What’s more, most mental health professionals don’t ask about the body in clinical interviews, which leads to a scarcity of language and concepts that aid in self-inquiry for people suffering from depersonalization. Accordingly, most patients describe the disorder in predominantly cognitive terms. To my mind, mental health professionals don’t just receive very little training in how to assess bodily awareness and functioning in mental health issues, but they’re taught not to ask about the body in a diagnostic interview or in treatment.

The absence of the body in traditional mental health settings and its absence in the diagnostic criteria mean that most people lack the concepts, language, and even permission to include the body in self-evaluation, clinical diagnosis, and treatment.

Looking at depersonalization through the lens of embodiment, I began to see it less as a “mental” health issue and more as a sudden, pervasive loss of the body.

Losing the Body: When Life Goes Grayscale

And yet, depersonalization has at its root a profound estrangement from parts of the body—often at first the hands—and from the body as a whole. Nearly 70 percent of patients with depersonalization feel as though their bodies do not belong to them. This is a marked loss of body ownership, which some researchers call body disownership.

The disorder also features a loss of the sense of agency and pervasive feelings of disembodiment. This can make people feel as though they’re ghosting through life, on the margins of society.

On an online forum for depersonalization, one member put words to this loss:

“It’s like my mind lives in a shadowland, as though I co-exist in different realities, where my mind or soul is only partially connected to my body or bodies,” they wrote. “It seems that my body could disappear altogether, and I’d still remain as a vacuous entity—a ghost, if you will.”

Depersonalization features not just a loss of perceived connection with the body, but disengagement from sensory life itself. Sensations and emotions become blunted, as though they’re happening at a distance. One’s sense of self takes on a transparent, hollow quality.

Perceptual distortions often occur, such as the impression that parts of the body are growing or shrinking. Research has revealed anomalies in brain regions responsible for somatic (bodily) processing and vestibular function, which provides maintains balance and provides information about the body’s position in space and allows for refined adjustments to a variety of forces.

Depersonalization often leads people to feel as though they’ve devolved from a full-color to a grayscale existence. Together, these factors make it impossible to immerse oneself fully in life, and lead to an absence of vitality and aliveness. As one therapy patient described,

“I feel as though I'm not alive, as though my body is an empty, lifeless shell. I seem to be standing apart from the rest of the world, as though I am not really here… I seem to be walking in a world I recognize but don't feel.”

Recovering the Body

Given the absence of the body in the treatment of most mental health conditions, depersonalization included, most therapies focus on the mental symptoms. These include distressing, catastrophic thoughts about what’s happening, bleak predictions about the future, and negative self-referential thinking—as Ginnie described, the thought “Something is deeply wrong with me,” occurring as though on a loudspeaker, hundreds of times in a day.

At present, cognitive-behavioral therapy (CBT) is one of the most commonly prescribed treatments for depersonalization. It entails the painstaking process of identifying negative thoughts about one’s mind and existence and replacing them with neutral or positive ones, over and over again. Over the course of many years, Ginnie said, it helped somewhat.

But CBT and MCBT (Mindfulness-Based Cognitive Therapy), she said, may have minimal impact. A 2023 study seemed to corroborate her reflection, showing modest improvement in adults with CBT. But the sample size (36 adults) was small, the control group was on a waiting list (with no other intervention given), and participants were not randomly assigned to the groups.  

When I asked Ginnie what helped the most, every answer Ginnie gave involved doing something deeply physical in her body: training for and running half marathons, caring for a sister’s young children, and having sex with her partner.

Perhaps it was the centrality of the body in our discussion that prompted these insights, but I don’t think that’s the case.

Paul, the psychiatric nurse whom we met at the beginning of this piece, said the most helpful intervention that lifted him out of his yearslong bout of depersonalization was spinning classes: The bright lights, social setting, loud music, and intensely physical activity, he said, brought him back into his body.

And on many depersonalization forums, over and over again, people shared their beneficial experiences—usually with intense physical exercise, and often using some form of resistance.

This led me to wonder about the merits of interoception (mindful awareness of the body), the bodyscan awareness from MBSR, slow proprioceptive movement, and other body-based contemplative practices. Such interventions are, after all, the staples of many yoga and somatic therapist. But, it turns out, they may be contraindicated in depersonalization.

Ginnie explained that even the thought of mindful awareness of the body (think interoception) or other contemplative body-based practices would frighten many people with depersonalization. "Why would we want to go inward,” she asked, “when what’s happening inside is so frightening?”

Ginnie also does nonprofit work with people who suffer from depersonalization and talks with numerous other sufferers. She explained that contemplative body-based practices may be contraindicated, at least during active episodes of depersonalization. Because the disorder involves over-thinking, and the body feels absent, it would be too easy, she said, to engage in catastrophic thinking about being in one’s body. In fact, a substantial body of work led by researcher Willoughby Britton has shown that meditation can lead to a host of adverse experiences, including depersonalization.

Body Loss Approaches Pandemic Proportions

What’s the big deal, we might wonder, about a disorder that affects only 2 percent of the population?

The actual number, I think, may far exceed that.

Throughout several decades as a psychologist and yoga therapist, I’ve encountered a growing number of people who report not a bout of depersonalization but something else altogether: a chronic, low-grade version that feels just as debilitating over time.

And I’ve witnessed much more of it in recent years.

With the chronic overuse of technology, social media, and artificial intelligence, many of us are becoming untethered from our bodily existence—or finding that it takes more and more time in our bodies to keep us tethered.

Consider the following:

In 2022, a group of researchers examined the impact of Covid-19 on levels of depersonalization in a large sample of people in predominantly European countries. as well as Mexico, South Africa, Chile, Canada, Australia, and the U.S. They compared lifestyle habits pre-pandemic and during the lockdown. They found that participants who increased their use of digital-based media activities (especially television, movies, and computer games) and online social e-meetings had higher symptoms of depersonalization. And those with higher experiences of depersonalization also reported enhanced vividness of negative emotions in comparison to positive emotions.

How many of us have increased our use of digital entertainment and online meetings since the pandemic began? Likely, the answer is most of us.

We are all vulnerable to a chronic loss of embodiment and loss of self that occurs not in the blink of an eye, as the traditional disorder does, but slowly and imperceptibly over time. This low-grade version may echo the theme of keeping us imprisoned amid our thoughts and, as James Joyce said about the protagonist of one of his stories, living at a distance from our bodies.

We might lose time, almost as though days or even months go by with nothing to mark them. Even worse, we might not even recognize that it’s happening.

Another 2022 study examined the effects of virtual reality and computer gaming on depersonalization. The researchers found significantly higher spikes in depersonalization and derealization experiences immediately after virtual reality gaming compared with computer gaming. This makes sense, because in virtual reality, we abandon our bodies in exchange for the life of someone else.

As we become more dependent on these technologies, I believe that the chances of “losing our bodies” in ways both small and large will continue to rise.

And the same kind of body loss we see in depersonalization also occurs, although in different forms and shadings, in anxiety, depression, chronic pain, substance use disorders, posttraumatic stress disorder, and many other conditions that are also “diseases of disembodiment.”

Finding artful, creative, and diverse ways to include the presence of the body in our lives, and doing so together with others, might be not a luxury but rather a biological, psychological, social, and spiritual imperative.

Sources:

Paul M. was in nursing school, in the midst of intense stress and social pressure, when he had the panic attack: Episode 188: Depersonalization and Derealization. (n.d.). Psychiatry & Psychotherapy Podcast. Retrieved March 20, 2024, from https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-188-depersonalization-and-derealization

A staggering 75 percent of us will experience transient feelings of depersonalization: Yang, J., Millman, L. S. M., David, A. S., & Hunter, E. C. M. (2023). The Prevalence of Depersonalization-Derealization Disorder: A Systematic Review. Journal of Trauma & Dissociation: The Official Journal of the International Society for the Study of Dissociation (ISSD), 24(1), 8–41. https://doi.org/10.1080/15299732.2022.2079796 See also: Hunter, E. C. M., Sierra, M., & David, A. S. (2004). The epidemiology of depersonalisation and derealisation. A systematic review. Social Psychiatry and Psychiatric Epidemiology, 39(1), 9–18. https://doi.org/10.1007/s00127-004-0701-4

In fact, symptoms of depersonalization rank as the third most: Simeon, D., Knutelska, M., Nelson, D., & Guralnik, O. (2003). Feeling unreal: A depersonalization disorder update of 117 cases. The Journal of Clinical Psychiatry, 64(9), 990–997. https://doi.org/10.4088/jcp.v64n0903

Triggers for the disorder DDD include traumatic or stressful events: Hunter, E. C., Sierra, M., & David, A. S. (2004). The epidemiology of depersonalisation and derealisation. A systematic review. Social psychiatry and psychiatric epidemiology, 39(1), 9–18. https://doi.org/10.1007/s00127-004-0701-4

Despite this, most mental health professionals have little familiarity with it: 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: The Journal of Mental Science, 182, 428–433. See also: Michal, M., Adler, J., Wiltink, J., Reiner, I., Tschan, R., Wölfling, 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(1), 203. https://doi.org/10.1186/s12888-016-0908-4. See also: Simeon, D., Knutelska, M., Nelson, D., & Guralnik, O. (2003). Feeling unreal: A depersonalization disorder update of 117 cases. The Journal of Clinical Psychiatry, 64(9), 990–997. https://doi.org/10.4088/jcp.v64n0903

Sadly, the average length of time it takes to receive a diagnosis of DDD is a whopping: Depersonalization—An overview | ScienceDirect Topics. (n.d.). Retrieved September 5, 2024, from https://www.sciencedirect.com/topics/neuroscience/depersonalization

The manual lists the following criteria for diagnosis: American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

The condition manifests as a pervasive disruption of self-awareness: Sierra, M., & David, A. S. (2011). Depersonalization: A selective impairment of self-awareness. Consciousness and Cognition, 20(1), 99–108. https://doi.org/10.1016/j.concog.2010.10.018

The disorder also features a loss of the sense of agency and: Vignemont, F. de. (2018). Mind the Body: An Exploration of Bodily Self-Awareness (1st edition). Oxford University Press. See also: Sierra, M., & David, A. S. (2011). Depersonalization: A selective impairment of self-awareness. Consciousness and Cognition, 20(1), 99–108. https://doi.org/10.1016/j.concog.2010.10.018

Nearly 70 percent of patients with depersonalization feel as though their bodies: Vignemont, F. de. (2018). Mind the Body: An Exploration of Bodily Self-Awareness (1st edition). Oxford University Press. See also: Sierra, M., & David, A. S. (2011). Depersonalization: A selective impairment of self-awareness. Consciousness and Cognition, 20(1), 99–108. https://doi.org/10.1016/j.concog.2010.10.018

As one therapy patient described: Phillips, M. L., & Sierra, M. (2003). Depersonalization Disorder: A Functional Neuroanatomical Perspective. Stress, 6(3), 157–165. https://doi.org/10.1080/1025389031000138538.

People with severe levels of depersonalization can suffer from illeism, a: Billon, A. (2017). Basic Self-Awareness. European Journal of Philosophy, 25(3), 732–763. https://doi.org/10.1111/ejop.12168

And people with depersonalization show lowered levels of trust in their bodies’ internal: Gwyther, M. P. D., Lenggenhager, B., Windt, J. M., Aspell, J. E., & Ciaunica, A. (2024). Examining the association between depersonalisation traits and the bodily self in waking and dreaming. Scientific reports, 14(1), 6107. https://doi.org/10.1038/s41598-024-56119-w

On an online forum for depersonalization, one member put words to this loss: Randy » Initiative for Depersonalization Studies (IDS). (2020, March 30). https://depersonalization.info/personal-stories/randy/

Research has revealed anomalies in brain regions responsible for somatic (bodily) processing and vestibular: Symptoms. Multisensory research, 28(5-6), 637–651. https://doi.org/10.1163/22134808-00002480 See also: Ferrè, E. R., & Haggard, P. (2016). The vestibular body: Vestibular contributions to bodily representations. Cognitive neuropsychology, 33(1-2), 67–81. https://doi.org/10.1080/02643294.2016.1168390 See also: Elyoseph, Z., Geisinger, D., Zaltzman, R., Gordon, C. R., & Mintz, M. (2023). How vestibular dysfunction transforms into symptoms of depersonalization and derealization?. Journal of the neurological sciences, 444, 120530. https://doi.org/10.1016/j.jns.2022.120530

As one therapy patient described: Phillips, M. L., & Sierra, M. (2003). Depersonalization Disorder: A Functional Neuroanatomical Perspective. Stress, 6(3), 157–165. https://doi.org/10.1080/1025389031000138538.

A 2023 study seemed to corroborate her reflection: Hunter, E. C. M., Wong, C. L. M., Gafoor, R., Lewis, G., & David, A. S. (2023). Cognitive Behaviour Therapy (CBT) for Depersonalization Derealization Disorder (DDD): a self-controlled cross-over study of waiting list vs. active treatment. Cognitive behaviour therapy, 52(6), 672–685. https://doi.org/10.1080/16506073.2023.2255744

A group of researchers examined the impact of Covid-19 on levels of depersonalization: Ciaunica, A., McEllin, L., Kiverstein, J., Gallese, V., Hohwy, J., & Woźniak, M. (2022). Zoomed out: digital media use and depersonalization experiences during the COVID-19 lockdown. Scientific reports, 12(1), 3888. https://doi.org/10.1038/s41598-022-07657-8

A 2022 study examined the effects of virtual reality and computer gaming: Peckmann, C., Kannen, K., Pensel, M. C., Lux, S., Philipsen, A., & Braun, N. (2022). Virtual reality induces symptoms of depersonalization and derealization: A longitudinal randomised control trial. Computers in Human Behavior, 131, 107233. https://doi.org/10.1016/j.chb.2022.107233