Schizophrenia and Derealization

Derealization is a dissociative disorder born of anxiety and is often seen co-existing alongside depersonalization disorder and as a symptom of schizophrenia. Derealization is often confused with or used interchangeably with depersonalization, however there is a clear difference. While depersonalization disorder is characterized by perceptually separating the body and consciousness, derealization disorder involves the distortion of the external environment. A patient suffering from both derealization and depersonalization would experience perceptual detachment from the body as well as the environment.

Symptoms of Derealization

Derealization disorder, like depersonalization disorder, is a highly perceptual condition and as such, it is often seen as a symptom of a more severe mental condition such as schizophrenia. However, the disorder stands as a mental condition in its own right given that it has its own symptoms. In this way, it is also distinguished from depersonalization disorder. Patients diagnosed with derealization disorder often experience the outside world as an abstract entity that is confusing and disorienting. Input from the immediate environment is perceived as overstimulating, especially settings that are crowded or brightly lit. This perceptual distortion causes the individual to see the world as ‘flat’ or two-dimentional. Distorted visual stimuli cause the patient to become disoriented as spatial perception becomes foggy and imprecise.

Researchers know extremely little about derealization disorder and what they do know is that it almost never manifests itself in isolation of depersonalization disorder. This finding has even been used to challenge the separation of the two disorders in the Diagnostic and Statistical Manual for Mental Disorders (DSM). As it stands now, depersonalization disorder and derealization disorder are co-symptoms, therefore patients suffering from the latter may experience additionally the symptoms of the former disorder.

The Etiology of Derealization Disorder

Depersonalization and derealization are very similar etiologically. Although the exact cause of dissociative disorders such as these are not known with the highest level of certainty, research suggests that neurobiological causes, specifically having to do with neurotransmitter dysfunction and abnormalities in neurological structure. Neurochemically, derealization as well as depersonalization are tied to deficits in norepinephrine as demonstrated by studies of urinary output. Neurostructually, damage to the temporal lobe is linked to both derealization and depersonalization, as well as schizophrenia. Studies also suggest that depersonalization/derealization disorders can be experienced as ‘normal’ or ‘abnormal’. This difference comes from different levels of cause. For example, derealization and depersonalization have been experienced as a result of substance abuse, extreme levels of stress, meditation, sleep and sensory deprivation, and residual hallucinations due to hypnosis. It is the individual’s perception of the experience and the duration of the experience that classify it as a disorder. While some individuals experience derealization temporarily, as a result of meditation or hypnosis and enjoy the sensory experience they gain from it, others may experience stress-induced derealization that is chronic and invasive and describe it as a negative experience. Therefore, derealization may occur as both a transient experience or a clinical illness.

Regardless of diagnosis based on subjective experience, derealization is not a homeostatic state of being because it involves disruption of neurobiological function. A chronic case of derealization, and one that is diagnosed as a disorder is most likely caused by neurostructural and biochemical damage. If we look at the fact that derealization is often a co-symptom of depersonalization and both are often symptoms of major mental disorders like schizophrenia, we can see that neurobiological dysfunction overlaps in all three cases. Therefore, we can look at the disorders as indicators of the severity of neurological damage. For example, and individual with derealization disorder alone will have significantly less organic damage than an individual with both derealization and depersonalization, and that individual will have less damage than someone diagnosed with schizophrenia. Keep in mind also that schizophrenia has been linked to reduced gray matter volume, a case that is chronic and progressive. This means that as structural damage increases, so does the likelihood of more severe mental disorders which can stem from derealization/depersonalization.

Treatment of Derealization

Since derealization is generally a co-symptom of depersonalization, both are treated in a similar manner. The limited amount of knowledge we have of the etiology of derealization and depersonalization dictate how we treat it and so far, treatment is purely pharmacological. Derealization is often treated with selective serotonin reuptake inhibitors (SSRIs) either alone or combined with an anticonvulsive medication such as lamotrigine. SSRIs prevent certain neurotransmitters (either serotonin, dopamine, or norepinephrine) from being collected back into the synaptic cleft of certain neurons and thus allow more of it to remain active. Lamotrigine is an anticonvulsive and its function is to reduce the amount of glutamate released by presynaptic cells.

Derealization may also be treated with psychotherapy, however this involves an acceptance of symptoms and success with this sort of treatment depends on the patient’s perception of his/her own experience. Usually, a combination of both psychotherapy and medication can significantly reduce symptoms.

Derealization and Schizophrenia

Derealization is often seen as a symptom of schizophrenia and this is mainly do to the fact that both are etiologically similar. The severity of schizophrenia symptoms depend on the amount of neurobiological dysfunction. While derealization symptoms may occur without a diagnosis of schizophrenia, it is very likely that someone diagnosed with schizophrenia will suffer from derealization as well as depersonalization.

In psychiatric literature, disorders like derealization and depersonalization are almost always categorized as precursors for more severe mental illnesses. This is why we often relate derealization and schizophrenia, however according to classification by the DMS, both may exist independently of each other.