Can stimulants be given to a patient with Attention Deficit Hyperactivity Disorder (ADHD) and depersonalization/derealization syndrome?

Stimulant Use in ADHD Patients with Depersonalization/Derealization Syndrome

Stimulants can be cautiously used in patients with ADHD who also have depersonalization/derealization syndrome, as there is emerging evidence suggesting they may actually improve both conditions simultaneously.

Decision Algorithm for Treatment

1. Assessment Phase

   • Confirm ADHD diagnosis using validated rating scales (Wender Utah Rating Scale, Brown Attention-Deficit Disorder Scale, Conners Adult ADHD Rating Scale) 1
   • Document severity of depersonalization/derealization symptoms
   • Rule out psychosis, which is an absolute contraindication to stimulant use 1

2. Treatment Approach

   • For patients with both ADHD and depersonalization/derealization:
     • Begin with a stimulant medication (methylphenidate or amphetamine-based)
     • Start at low doses and titrate gradually while monitoring both ADHD symptoms and depersonalization effects
     • Monitor for any worsening of dissociative symptoms

Evidence Supporting This Approach

The AACAP Practice Parameters for stimulant use indicate that ADHD with comorbid conditions, including anxiety disorders, can be effectively treated with stimulants 1. While depersonalization/derealization syndrome is not specifically mentioned in the contraindications, psychosis is listed as an absolute contraindication 1.

Recent case reports have shown promising results:

• A 2020 case report showed reduction in depersonalization/derealization symptoms after treatment with mixed amphetamine salts 2
• A 2025 report of three cases demonstrated that methylphenidate extended release helped reduce dissociative symptoms in patients with comorbid ADHD and dissociative disorders, including depersonalization-derealization disorder 3
• A 2011 case report described a "spectacular" response to methylphenidate in a patient with primary depersonalization disorder 4

Important Considerations

• Start with long-acting formulations which are associated with better medication adherence and lower risk of rebound effects 1

• Monitor closely for adverse effects including:

  • Common side effects: decreased appetite, sleep disturbances, increased blood pressure and pulse, headaches, irritability 1
  • Any worsening of depersonalization symptoms
  • Any emergence of psychotic symptoms (which would necessitate discontinuation)

• Dosing considerations:

  • Doses for patients with dissociative symptoms may need to be lower than standard ADHD doses 3
  • Methylphenidate extended release may be particularly beneficial based on case reports 3

Clinical Pitfalls to Avoid

• Don't mistake depersonalization for psychosis - Depersonalization involves feeling detached from oneself while maintaining reality testing, unlike psychosis which involves loss of reality testing 5
• Don't overlook substance use - Screen for substance use as marijuana and hallucinogens can precipitate or worsen depersonalization 5
• Don't ignore treatment response timing - Some patients report immediate improvement in both conditions, which should be documented to support continued treatment 3
• Don't miss childhood trauma history - Depersonalization disorder has been associated with childhood interpersonal trauma, particularly emotional maltreatment 5

The evidence base for treating depersonalization disorder remains limited, with no FDA-approved treatments 2, 6. However, the emerging case reports of stimulant benefits in patients with both conditions provide a reasonable basis for a cautious therapeutic trial in appropriate patients.