Persistent Depersonalization/Derealization Disorder Induced by Synthetic Cannabinoids

To the Editor: Depersonalization/derealization disorder is characterized in DSM-5 by persistent or recurrent depersonalization symptoms in the presence of intact reality testing, not better accounted for by other psychiatric or medical disorders. Its prevalence is around 2% in the general population (1). Depersonalization/derealization disorder is underdiagnosed by clinicians and is particularly resistant to pharmacological treatments (2). In a substantial number of cases, the onset is triggered by cannabis, hallucinogens, 3,4-methylenedioxymethamphetamine (Ecstasy), LSD, and ketamine consumption (1, 3). We report the case of Mr. A, a 20-year-old male student who used cannabis on a weekly basis from ages 18 to 19 and who was without a history of substance use disorder or other psychiatric disorders.

In November 2014, following a single dose of the synthetic cannabinoid K2, without any other associated drug, Mr. A immediately presented with symptoms reflective of depersonalization/derealization disorder. He described a detachment from his own thoughts, body, and feelings and his impression “of not being there.” He also reported the feeling of being disconnected from his own body, “as if his mind were outside his body,” without reaching out-of-body experience. The emotional numbing was paradoxically associated with very painful feelings. Derealization was also reported as he had the impression “of being in a dream.” The patient was aware of a disturbing change in his experience of himself and his surroundings. His sense of reality was intact.

The patient asked for help nearly 6 months later, noting continuing unrest even though he immediately stopped using K2 and cannabis. He fulfilled the DSM-5 criteria for depersonalization/derealization disorder.

The patient’s results on the Cambridge depersonalization scale (1) were scored as 220/290. His symptoms caused significant distress and impairment in social and occupational functioning and were not better categorized under another mental disorder. There were no symptoms of a psychotic disorder, anxiety, or depressive mood disorder, as classified by DSM-5. Results of an electroencephalogram and brain imaging were normal, and results of a subsequent urine analysis were negative. He received fluoxetine treatment for 6 months without any improvement. The symptoms remained persistent for more than 17 months.