Have you ever felt detached from yourself or your surroundings, as if watching your life unfold from a distance? A recent study published in BMC Psychiatry sheds light on these lesser-known symptoms — depersonalization and derealization — and their profound impact on individuals with depression. The findings reveal that those experiencing these symptoms alongside depression face a more severe illness course, less response to treatment, and overall poorer health outcomes.
Depersonalization refers to a state of feeling detached from oneself, where individuals may experience themselves as if they are an outside observer of their own thoughts, body, or sensations. This often manifests as a sense of estrangement or detachment from one’s own being, as if they are watching their life unfold from a distance without being able to fully participate in it.
Derealization, on the other hand, pertains to the external world, casting a veil of unreality over one’s surroundings. People experiencing derealization might describe the world around them as foggy, dreamlike, or visually distorted, as though they are living in a movie or a bubble from which they cannot escape. Unlike depersonalization, which affects one’s sense of self, derealization distorts one’s perception of the environment, making the world appear unreal and distant.
Depersonalization and derealization symptoms have been reported in 30-80% of various mental disorders and affect a significant portion of the general population to varying degrees. Despite their prevalence, these symptoms are often overlooked in clinical settings, particularly in the context of depression, where they are not currently recognized as diagnostic criteria. Given their potential to complicate treatment and prognosis, understanding the role of depersonalization and derealization in depression is crucial for improving patient care.
“I have been researching the symptoms of depersonalization and derealization for many years. These symptoms are largely neglected in mental health care, although they carry important prognostic and treatment-relevant information,” said study author Matthias Michal, a specialist for psychosomatic medicine and psychotherapy at University Medical Center Mainz.
For their study, the researchers utilized data from the Gutenberg Health Study (GHS), a comprehensive, population-based cohort study conducted in the Rhine-Main-Region of Germany. This study’s design was observational and prospective, aiming to capture a wide array of health-related data from a large sample of the population, specifically targeting individuals aged 35 to 74 years.
Upon recruitment, participants underwent a detailed baseline examination between 2007 and 2012, with follow-up assessments five years later. These examinations incorporated clinical evaluations, computer-assisted personal interviews, laboratory tests from venous blood samples, and measurements of blood pressure and body metrics. Out of over 15,000 initial participants who underwent extensive baseline examinations between 2007 and 2012, this analysis focused on 10,422 individuals.
Among the study’s participants, a subset of individuals with clinically significant depression also exhibited depersonalization and derealization symptoms. This group faced a notably more severe disease trajectory compared to their depressed counterparts without depersonalization and derealization symptoms.
Depressed individuals with depersonalization and derealization symptoms reported higher levels of distress across various measures, including higher scores on the PHQ-9 for depression, indicating more severe depressive symptoms. They also exhibited greater anxiety, social anxiety, and personality distress, alongside poorer self-rated physical and mental health.
These findings suggest that depersonalization and derealization symptoms compound the burden of depression, amplifying its severity and the associated health impacts. Additionally, this group experienced more pronounced interpersonal problems, such as issues within the family and feelings of loneliness, and were more likely to be taking antidepressants and to have sought psychiatric consultation in the past month.
When examining outcomes over a five-year follow-up period, the study revealed a stark prognosis for individuals with depression. Only 15.9% of those with depression achieved remission.
“This is a somewhat disillusioning result because in Germany, health care is fully covered by statutory health insurance (mental health care: psychotherapy up to 300 hours, inpatient psychotherapy, psychiatric treatment, etc.),” Michal told PsyPost. “Mainz and the surrounding area, where the Gutenberg Health Study is conducted, is well-supplied with health care facilities and psychotherapists.”
An even smaller fraction of those with depersonalization and derealization symptoms achieved remission (6.9%), underlining the detrimental impact of these symptoms on the likelihood of recovery from depression. Michal was particularly surprised by the low remission rates. “The aim of depression treatment is remission,” he noted.
The study also found that depersonalization and derealization symptoms not only affect mental health outcomes but also have implications for physical health. Despite similar rates of chronic physical illnesses between depressed individuals with and without depersonalization and derealization symptoms, those experiencing depersonalization and derealization reported worse self-rated physical health.
This suggests that the perception and impact of physical health conditions may be exacerbated by the presence of depersonalization and derealization symptoms, further complicating the health profile of these individuals. Interestingly, the researchers also observed that depersonalization and derealization symptoms were associated with prolonged hospital stays, although they did not increase the overall likelihood of hospitalization for physical health reasons.
“Symptoms of depersonalization and derealization are predictors of worse outcomes for persons suffering from depression,” Michal said. “These symptoms are easy to assess. The study might motivate healthcare professionals to increase efforts to identify depersonalization and derealization symptoms and improve treatment rates and outcomes.”
While the study’s insights are invaluable, the authors acknowledge certain limitations, including the reliance on self-reported data and the potential for selection bias. Additionally, the study’s demographic focus on a specific region in Germany may limit the generalizability of the findings to broader populations. Finally, there was only limited data regarding treatment.
“We had no comprehensive information about treatment rates and treatment dosages,” Michal explained. “We do not know how many depressed persons have received adequate treatment.”
Looking ahead, the researchers call for further studies to explore the underlying mechanisms linking depersonalization and derealization symptoms with depression’s prognosis. There’s a particular interest in investigating the role of early identification and targeted treatment strategies for depersonalization and derealization symptoms in improving depressive disorder outcomes.
“I want to contribute to the improvement of mental healthcare for disadvantaged persons,” Michal said.
The study, “Impact of depersonalization on the course of depression: longitudinal observations from the gutenberg health study,” was authored by Matthias Michal, Jörg Wiltink, Ana N. Tibubos, Philipp S. Wild, Thomas Münzel, Karl Lackner, Norbert Pfeiffer, Jochem König, Alexander Gieswinkel, Manfred Beutel, and Jasmin Ghaemi Kerahrodi.
