Sciences Participating with Arts & Culture in Education

Real Eyes, Realize, Real Lies: An Exploration of Derealization and Education in Mental Health

We’re in a small conference room, tucked away behind key-card-locked doors with anti-ligature handles. The nurse educator is clarifying some terms used in the Mental Status Exam, a tool she promises will soon become intuitive to all of us.

“Derealization is a weird one. Let me know if you ever encounter a patient with it. Personally, I have never seen it in the clinical setting.”

Oh, I have that, I think of saying, an unwelcome sense of belonging telling me to speak up. I stop myself, though, gauging that my first-hand knowledge of this symptom isn’t the kind of response that is being prompted.

When teachers speak about psychiatry, they tend to emphasize how special it is, as if assuming that students won’t enjoy it and will need to be coaxed into speaking to patients. I wish they would preface every internship the same way, as my lackluster experiences on cardiac and geriatric units have made me doubt whether I belong in nursing at all. That’s why I have been looking forward to this mental health internship so much. I will get to spend more time with patients and help them achieve a type of recovery I have never facilitated before.

Biting down on my reply in this sterile environment, I can’t yet know whether or not I’ll end up loving psych. Nor can I know that adapting to this new environment will have me questioning the difference between sanity and the insanity, or the impact of these labels on the way we are taught to care for patients with mental illness.

Although derealization can be a symptom of other mental illnesses, the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) recognizes it as a disorder of its own. The condition is explained as “[e]xperiences of unreality or detachment with respect to surroundings,” making “individuals or objects… [seem] unreal, dreamlike, foggy, lifeless, or visually distorted” (American Psychiatric Association, 2013). In my experience, these symptoms come in waves and are triggered by fatigue and anxiety, which heighten during the unpredictable moments of my life. Exam periods coupled with wanting to maintain the semblance of a social life result in day-long dream states that make me question if I’m really present in my surroundings.

These changes in the perception of my environment don’t affect my cognition or ability to care for patients, which makes them easy to conceal. In psychiatry, a person’s functionality is commonly used as an indicator of their mental health status. Whether a patient can independently perform their activities of daily living is key in deciding if they get admitted or discharged. But how can behaviour that passes for normal be an indicator of wellbeing? In my experience, passing classes and going out with friends certainly isn’t the full picture, as I could be acutely derealized throughout.

While functionality isn’t the only factor in the diagnosis of mental illness, “a preference for self-reliance [is one of] the most important barriers to help-seeking” (Gulliver, 2010). However, by valuing performance and productivity, we burden patients with both the task of healing and that of maintaining the appearance of health, focusing on their ability to compensate for their illness rather than improve their quality of life. Talcott Parsons, the sociologist who theorized what he called “the sick role,” proposed that people who are sick are granted the right by society to deviate from their usual productive roles in order to heal. In this case, productivity is synonymous to economic contribution, which when lost seems to warrant the person’s removal from social systems altogether. However, society also attempts to push the person back to normalcy by sanctioning those who remain unable to financially contribute to it. These sanctions could range from unemployment to outright institutionalization in psychiatric units, which is where health care professionals like me come in. From what I’ve witnessed in the clinical setting, the scary part of psychiatric illness isn’t the inability to cope but losing fundamental freedoms because of it.

With these sanctions in mind, it makes sense that people would want to avoid “the sick role” for too long, and even avoid a reason to be labelled sick to begin with. But that very thought sets a vicious circle in motion, as the ill are productive enough to withhold suspicion, while simultaneously making their condition worse by hiding it.

Psychotherapeutic intervention is one of the treatments offered to those who can’t maintain functionality or who need help developing healthy coping strategies. An example of this type of counselling is Acceptance and Commitment Therapy (ACT), which follows the “fundamental premise that pain… and anxiety are inevitable features of human life” (Dindo, 2017). One must therefore “adapt to these types of challenges” instead of “engaging in counterproductive attempts to eliminate or suppress undesirable experiences.” ACT proposes the “committed pursuit of valued life areas and directions, even in the face of the natural desire to escape or avoid painful and troubling experiences,” as a way of living with symptoms of mental illness.

This concept of radical acceptance could also be applied to the education nurses receive about mental health. In order to provide competent care, we must first accept that our patients’ lived experiences differ greatly from ours and often don’t follow the same logic that may be instinctive to us. As caregivers, we can also go a step beyond acceptance and work through the implicit biases we carry about psychological disorders, leading to self-reflection and allowing us to be more compassionate towards our patients’ reality.

Unfortunately, the way we’re often taught about mental illness lacks the sense of acceptance and questioning of biases that ACT proposes. Yet the nature of psychiatry requires that our training go beyond banal techniques like speaking in a calm voice and maintaining appropriate eye contact. Using a framework that accepts all aspects of mental illness instead of othering those who are diagnosed with these conditions should be an essential outcome for anyone who works in this specialty.

I’ve heard both teachers and students joke about how all psych nurses are ultimately psych patients. This is an extension of the stigma that perfuses mental health. But does the caregiver have to live through the same struggles as their patient in order to value their humanity? Sympathizing with a patient’s experiences shouldn’t require us to identify with their issues. Medical units tailor their care to patients’ pathologies, their diagnoses often standing in for their names. One of the reasons psychiatry is so stimulating is because it calls for care to be adapted to each patient’s personality. At least that’s what I’ve found most exciting about this type of work.

My new prescription glasses have only magnified how disconnected I feel from what’s around me. Going down the stairs seems an impossible task. My feet don’t feel like they’re making contact with the steps under them, but I somehow make it down and end up at my locker, which has soaked up the smell of weed that lingers in that section of the school. I meet my friends and explain how panicked I feel, and then laugh at how ridiculous I must sound.

“You’ll get used to it,” they tell me.

And I do. I’m surprised at how well my brain adapts to this feeling. A literature review on The Neurobiology of Depersonalization and Derealization explains how our brain’s “ability to automatically adapt to recurring patterns of activation” is one of its “most fascinating characteristics” (Thiel, 2017). It questions whether the “recurring dissociative symptoms” of the disorder change cerebral structure, or if those symptoms are caused by the structural changes themselves. They label it a “chicken or the egg dilemma,” which sums up most under-researched mental disorders pretty well.

How much does the answer to this question really matter? Engaging in these nature-versus-nurture-type conversations makes me feel like a pretentious film student debating the ending of American Psycho. I do understand research is a gateway to finding treatment, which is why it’s so disheartening to read that most articles I find about derealization are the first of their kind. Only recently have studies looked into seemingly obvious research questions about this condition, an omission from academic research that seems ignorant of all the blog posts and message boards about derealization I’ve found over the years.

Discussing with others my experience as a nursing student in psychiatry has brought to light the assumption often held about people who are diagnosed with a mental illness: that they’re less functional and more dangerous than people with physiological conditions. While it’s important to understand the severity of mental illness, imagining people with psychiatric conditions as nothing but vulnerable is harmful. Picturing them excelling at their job or in relationships shouldn’t be groundbreaking. It seems the diagnosis of physical disease offers validation to patients, while the diagnosis of mental illness is a catalyst for social exclusion. If functionality is a primary goal of all treatment, perhaps the resilience of people with mental illnesses should be addressed when nursing students are learning how to care for these patients. My thriving while having symptoms of derealization can indeed be a strength, allowing me to approach patients with greater empathy toward their situations. Being proactive about my condition and finding effective coping mechanisms has armed me with skills that are essential to supporting people who are in distress.

“What does it feel like?” a friend asks me, sipping her piña colada. We’re sitting on bar stools painted like coconuts, being served by a bartender wearing a Hawaiian shirt that has the Tiki Bar’s logo printed on the back. He looks about as spaced out as I am, but he makes our drinks strong and we’re happy.

“I guess at its worst, it’s kind of like feeling tipsy without the good parts.” I don’t really know what the good parts are, but she seems to get what I mean, which is oddly reassuring.

Ultimately, I feel most grounded when assisting people in their healing. I help them feel real, which I believe is the core of caring. It is a feeling most professionals in my field chase and that I’m happy to have discovered. This feeling may be elusive, but so is the haze of derealization. In learning to accept its fleeting nature, I’ve realized that comfort and uncertainty aren’t mutually exclusive. Guiding others through the fog may be the key to clearing it altogether.

Works Cited

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American Psychiatric Publishing, 2013.

Dindo, Lilian et al. “Acceptance and Commitment Therapy: A Transdiagnostic Behavioral Intervention for Mental Health and Medical Conditions.” Neurotherapeutics: The Journal of the American Society for Experimental NeuroTherapeutics, vol. 14, no. 3, Jul 2017, pp. 546-553, doi:10.1007/s13311-017-0521-3

Gulliver, Amelia et al. “Perceived Barriers and Facilitators to Mental Health Help-Seeking in Young people: A Systematic Review.” BMC Psychiatry, vol. 10, no. 113, Dec 2010, doi:10.1186/1471-244X-10-113

Thiel, Freya et al. “The Neurobiology of Depersonalization and Derealization.” Mental Health: Services, Assessments and Perspectives, edited by Cindy Carlson, Nova Science Publishers, Jul 2017, pp. 99-124.

Photograph, Dissociation by madamepsychosis distributed by CC BY-NC-ND 2.0 DEED.