What is causing my feeling of unreality and how can it be treated?

Feelings of Unreality: Depersonalization-Derealization

You are most likely experiencing depersonalization-derealization symptoms, which manifest as feelings of detachment from yourself (depersonalization) or a sense that your surroundings are unreal (derealization), and this requires immediate evaluation to determine if this represents panic disorder, depersonalization-derealization disorder (DPD), or another underlying condition.

Immediate Diagnostic Considerations

Rule Out Panic Disorder First

• Feelings of unreality (derealization) or being detached from oneself (depersonalization) are core symptoms of panic attacks, occurring alongside other symptoms like palpitations, sweating, trembling, shortness of breath, chest pain, nausea, dizziness, fear of losing control, or fear of dying 1
• If you experience these unreality feelings in discrete episodes lasting minutes with four or more panic symptoms, panic disorder is the primary diagnosis to consider 1
• Sertraline (an SSRI) is FDA-approved and effective for treating panic disorder with derealization/depersonalization symptoms 1

Assess for Primary Depersonalization-Derealization Disorder

• If feelings of unreality are persistent or recurrent rather than episodic, and occur without prominent panic attacks, memory disturbances, or identity confusion, you likely have depersonalization-derealization disorder 2, 3
• DPD typically begins around age 16 and follows a chronic, continuous course 4
• The disorder affects approximately 1% of the general population but is more common (3-20%) in those with anxiety disorders 3

What Triggers These Symptoms

Common Precipitants

• Severe stress, depression, panic attacks, marijuana use, and hallucinogen ingestion are the most frequent immediate triggers 4
• Childhood emotional maltreatment and interpersonal trauma are strongly associated, with prevalence rates of 25-53.8% in abuse survivors 3, 4
• Substance abuse, particularly cannabis and hallucinogens, can precipitate persistent symptoms 4

Medical Causes to Exclude

• Rule out delirium if you have cognitive changes, confusion, or altered consciousness—this requires urgent medical evaluation 5
• Assess for depression, as approximately 50% of depressed patients experience depersonalization-derealization symptoms 3
• Consider anxiety disorders, which show DPD prevalence of 3.3-20.2% 3

Treatment Approach

For Panic Disorder with Derealization/Depersonalization

• Start sertraline (SSRI) as first-line treatment if panic disorder is diagnosed 1
• Cognitive-behavioral therapy targeting catastrophic misinterpretations of unreality symptoms is essential 6
• The combination of medication and psychotherapy provides optimal outcomes 1

For Primary Depersonalization-Derealization Disorder

• Cognitive-behavioral therapy should be the foundation of treatment, specifically targeting catastrophic misinterpretations that these symptoms indicate severe mental illness or brain dysfunction 6
• The vicious cycle operates as follows: you experience transient unreality symptoms → you catastrophically misinterpret them as dangerous → this increases anxiety → which paradoxically intensifies the unreality feelings 6
• Address safety behaviors and avoidances that maintain the disorder by preventing disconfirmation of feared outcomes 6

Pharmacotherapy Options for DPD

• Clomipramine, fluoxetine (SSRIs), lamotrigine, and opioid antagonists have been reported in case series, though none demonstrate potent anti-dissociative effects 4
• A 2024 systematic review identified 30 treatment methods but found generally low-quality evidence, suggesting combination approaches may be necessary 2
• Medication should target comorbid conditions (depression, anxiety) rather than expecting direct resolution of unreality symptoms 4

Critical Pitfalls to Avoid

Do Not Dismiss as "Just Anxiety"

• While depersonalization-derealization commonly occurs with anxiety, persistent symptoms warrant specific evaluation and treatment rather than generic anxiety management 3, 4
• The disorder causes significant distress and functional impairment despite appearing "less severe" than other psychiatric conditions 2

Avoid Benzodiazepines

• Benzodiazepines are not recommended as they can worsen dissociative symptoms and create dependence 5
• They should only be used for acute crisis intervention in severe distress, not as ongoing treatment 5

Address Trauma History

• Specifically inquire about childhood emotional maltreatment and interpersonal trauma, as this strongly predicts DPD and requires trauma-focused therapy 3, 4
• Standard anxiety treatment without addressing underlying trauma will likely fail 4

When to Seek Urgent Evaluation

• If unreality feelings are accompanied by confusion, disorientation, or inability to recognize familiar people or places, seek immediate medical attention to rule out delirium or acute neurological conditions 5
• If symptoms include suicidal thoughts, severe depression, or inability to function, urgent psychiatric evaluation is required 5
• New onset after age 40 or with neurological symptoms (weakness, vision changes, speech difficulties) requires medical workup to exclude organic causes 4