Experience of Self › Disturbance of Awareness of Self-Activity

Depersonalisation

Depersonalisation is a distressing sense of being detached from one's own self, feelings, or body, as though observing oneself from a distance or acting on autopilot rather than being fully present. The person usually knows perfectly well that they still exist and are themselves; what has changed is the felt quality of that existence, not the belief in it.

It is traditionally paired with derealisation, its outward-facing counterpart, in which the surrounding world rather than the self feels flat, distant, or unreal; the two frequently occur together and share the same underlying quality of detachment.

Recognition features

• A subjective feeling of unreality or detachment from one's own thoughts, feelings, body, or actions
• Usually described as unpleasant, unlike the more neutral or pleasant quality of some altered states such as absorption or ecstasy
• Insight is retained: the person is describing a change in how things feel, not stating a delusional belief
• Often worsens with fatigue, severe stress, or as part of another underlying condition

Eliciting it at interview

• Ask in ordinary language before offering the clinical term: "Have you ever felt as though you're not quite real, or as if you're watching yourself from outside your body?"
• Check for retained insight directly: "Do you still know that you exist and that this is you, even though it feels strange?"
• Distinguish it from a nihilistic delusion by asking plainly whether the person believes they have actually stopped existing, or whether it simply feels that way

Distinguishing features

• Differs from a nihilistic delusion (such as the belief that one is dead or does not exist), which is held with delusional conviction rather than described as a feeling
• Differs from derealisation in that the sense of unreality is directed at the self rather than at the external environment, though the two often co-occur
• Differs from the emotional flattening seen in depression, although a loss of normal emotional responsiveness in depression can shade into a depersonalisation-like experience

Common misconceptions

• That depersonalisation is rare; brief, mild versions of it are common in the general population, especially under extreme tiredness or acute stress, and do not by themselves indicate a psychiatric disorder
• That the experience means someone is 'going mad'; the retained insight is itself a reassuring sign that reality testing is intact

Related phenomena

Dissociation of Affect · Derealisation · Loss of Emotional Resonance · Nihilistic Delusion · Autoscopy · Disturbance of Awareness of Self-Activity · Schizoid Personality Disorder · Schizotypal Personality Disorder

Practice this

A 22-year-old university student says that for the past few days it has felt like she is watching herself walk around campus instead of actually being there. She is clear that she still knows it is her and that she has not stopped existing — it just doesn't feel like it. What is this experience? · A 19-year-old man under heavy exam pressure and sleeping poorly describes feeling "like I'm on autopilot, watching myself from a few feet behind my own head" for the past several days. He finds it unpleasant and says he knows, rationally, that this is just how it feels rather than what's actually happening. Before revealing the answer: what is this, and what feature of his account rules out a nihilistic delusion? · A patient describes an unsettling sense of being detached from themselves. Before revealing the answer, decide what single question distinguishes autoscopy from depersonalisation. · Two patients each describe, in their own way, 'not really existing.' Before revealing the answer, decide what single question best separates depersonalisation from a nihilistic delusion. · A patient describes a pervasive sense of unreality but hasn't specified exactly what feels unreal. Before revealing the answer, decide what single question separates derealisation from depersonalisation. · A person describes feeling emotionally cut off from others. Before revealing the answer, decide what distinguishes schizoid personality disorder from depersonalisation. · A patient seems withdrawn and is hard to read. You want to check specifically for depersonalisation without leading them into an answer. Before revealing the answer, decide what you would actually ask. · Explain why retained insight is considered such an important feature of depersonalisation, both for recognising it and for reassuring a distressed patient.

Illustration

A 22-year-old university student says, "For the past few days, it's like I'm watching myself walk around campus instead of actually being there. I know it's me, I'm not confused about that, it just doesn't feel like it." She has been under significant exam pressure and has slept poorly for the past week, and finds the experience distressing enough that she has started avoiding lectures.

References

• Casey, P. & Kelly, B. (2019). Fish's Clinical Psychopathology, 4th ed. Ch. 7, 'Disorders of the Experience of Self'.