I am experiencing derealization (out‑of‑body feeling) with persistent dysgeusia (lingering taste); what could be causing this?

Derealization and Persistent Dysgeusia: Likely Causes and Management

Your symptoms of feeling "out of body" (derealization) combined with persistent taste in your mouth most likely represent either a post-viral syndrome (particularly COVID-19), a dissociative response to anxiety/stress, or less commonly, a neurological condition requiring evaluation.

Most Probable Causes

Post-Viral Syndrome (Highest Priority to Rule Out)

• COVID-19 remains the leading infectious cause, affecting 59-86% of infected patients with taste/smell alterations, and can present as the initial or sole symptom in 11.9-22% of cases 1
• Post-viral olfactory and taste dysfunction accounts for 11% of community cases and 20-25% of specialist presentations 1
• The persistent taste (dysgeusia) you're experiencing is commonly caused by viral upper respiratory infections, which damage the olfactory neuroepithelium 1
• Critical pitfall: Never overlook COVID-19 as a potential cause, especially when taste/smell symptoms present without traditional nasal congestion 1

Dissociative Symptoms Related to Anxiety/Mood Disorders

• Derealization (the "out of body" feeling you describe) occurs in 0.9% of the general population and is strongly associated with combined mood and anxiety disturbance 2
• Derealization is significantly more likely when both mood and anxiety symptoms coexist, rather than occurring with a single disorder 2
• The combination of unreality experiences with sensory disturbances (like persistent taste) may indicate greater disruption to your usual sense of self 2
• Depersonalization/derealization disorder is severely underdiagnosed and often misattributed to other conditions 3

Neurological Causes (Less Common but Important)

• Temporal lobe dysfunction can cause both derealization-like symptoms and taste disturbances, as taste perception can be affected by pathology involving cranial nerve pathways 4
• Derealization of epileptic origin occurs in temporal lobe epilepsy and presents with altered perception of surroundings 5
• However, most patients with olfactory and taste symptoms do not require imaging unless history or physical examination warrants it 4

Immediate Assessment Steps

Clinical Evaluation You Need

• Document COVID-19 exposure history and testing status, including timeline of symptom onset relative to any viral illness 4
• Perform thorough nasal and neurological examination focusing on cranial nerve function 4
• Assess for "red flag" neurological symptoms: sudden onset, progressive worsening, associated weakness, speech changes, or visual disturbances that would necessitate urgent imaging 4
• Evaluate for anxiety and mood symptoms, particularly the combination of both, which strongly predicts derealization 2

When Imaging IS Indicated

• MRI is the mainstay for examining olfactory apparatus and taste pathways if there are concerning neurological findings on examination 4
• Do NOT order neuroimaging if there is a clear temporal relationship to viral infection with otherwise normal neurological exam 1
• Consider MRI only if symptoms include other concerning features beyond derealization and taste disturbance 4

Management Approach

If Post-Viral Etiology

• Provide olfactory training through organizations like AbScent/Fifth Sense 4
• Ensure safety precautions including gas alarms, smoke alarms, and careful attention to food expiration dates 4
• Avoid oral steroids due to potential worsening of viral conditions, though intranasal steroids are unlikely to be harmful if already taking them 4
• Arrange rhinology follow-up after acute phase resolves 4

If Dissociative/Anxiety-Related

• Cognitive behavioral therapy is beneficial for derealization symptoms, as reassurance and education are crucial 6
• Address underlying mood and anxiety symptoms, as derealization is more likely with combined mood/anxiety disturbance 2
• Consider evaluation by psychiatry if symptoms persist despite treatment of underlying anxiety/mood disorders 3, 7

For Persistent Metallic/Altered Taste

• Alpha-lipoic acid 200-600 mg daily in divided doses is first-line treatment for burning mouth syndrome and persistent taste alterations 6
• Detailed oral examination to assess for dental restorations, gum disease, or other oral pathology 6
• Consider laboratory testing including serum zinc, vitamin B12, and thyroid function if symptoms persist 1, 6

Critical Pitfalls to Avoid

• Do not rely on patient self-assessment of severity alone—objective testing reveals much higher dysfunction rates than patients report 1
• Never assume psychiatric origin without excluding organic causes through appropriate neurological examination 1
• Avoid premature attribution to psychiatric causes without ruling out nutritional deficiencies and viral etiologies 6
• Do not dismiss normal-appearing oral mucosa as excluding pathology, as many taste disorders present without visible abnormalities 6

When to Seek Urgent Care

• If derealization is accompanied by difficulty swallowing both solids and liquids, this may indicate acute stroke and requires immediate evaluation 8
• Any sudden onset of neurological symptoms including weakness, speech changes, or visual disturbances warrants urgent neuroimaging 4
• Progressive worsening of symptoms or development of new neurological signs requires prompt medical attention 4