Core features

• Depersonalization: subjective sense of detachment from one’s thoughts, feelings, body or actions (“like an outside observer”).
• Derealization: perception that the external world is unreal, foggy, colourless or visually distorted.
• Symptoms are ego‑dystonic (distressing), often accompanied by anxiety or depressed mood, and typically preserve reality testing (the person knows the sensation is unusual).

Common precipitants & associations

• Acute stress, panic attacks, severe fatigue, sleep deprivation, cannabis or hallucinogen use, and trauma (especially early life adversity) are common triggers.
• DPDR frequently co‑occurs with anxiety disorders, depression, PTSD and other dissociative disorders.

Assessment checklist

1. History: onset, duration, frequency, context (stress/panic), substance use (cannabis, hallucinogens), suicidal ideation, impact on function and coping strategies.
2. Evaluate reality testing (patients usually recognise experiences are not objective changes), assess comorbid psychiatric disorders and inquire about trauma history.
3. Medical and neurological screen: exclude seizures, migraine aura, vestibular disorders, and medication or substance effects—consider targeted investigations (EEG, MRI) only if red flags present.
4. Use validated measures where helpful (Cambridge Depersonalisation Scale) to quantify severity and track treatment response.

Differential diagnosis

• Substance‑induced dissociative states (cannabis, hallucinogens), neurological conditions (temporal lobe epilepsy, migraine), psychotic disorders with derealisation, depersonalisation as part of PTSD, and other dissociative disorders.
• Clarify by temporal relation to substances/medical events and by presence/absence of reality testing impairment.

Management principles

1. Validate the distressing nature of symptoms and normalise them as a stress response when appropriate—avoid dismissive language.
2. Address precipitants and comorbidities: treat panic attacks, improve sleep, reduce substance use and manage trauma where present.
3. Psychological therapies are first‑line: CBT adapted for DPDR, mindfulness strategies, grounding techniques and trauma‑informed therapies if PTSD coexists.
4. Pharmacotherapy: no medications are specifically approved; SSRIs may help comorbid anxiety/depression and some evidence suggests lamotrigine or naltrexone in small studies—use cautiously and usually within specialist settings.

Practical interventions & skills

• Grounding techniques: sensory grounding (5‑4‑3‑2‑1), holding a textured object, cold water on the face, naming colours/objects to re‑anchor to the present.
• Reduce physiological arousal: breathing retraining, paced breathing, sleep hygiene and graded return to activity.
• Mindfulness & acceptance: practice noticing sensations without catastrophic interpretation and commit to valued activities despite symptoms.

Key takeaways

• DPDR causes distressing detachment experiences with preserved reality testing; identify and address triggers (panic, substances, sleep deprivation) and comorbidities.
• First‑line management is psychological (CBT, grounding, mindfulness); pharmacotherapy targets comorbidity and is adjunctive.
• Escalate urgently for red flags suggesting neurologic disease or severe psychiatric risk; coordinate care and offer psychoeducation and practical skills early.