Do you have Brain Fog? Why it may be more than you think.

In my integrative psychiatry and neurologic health practice, I frequently encounter patients who describe feeling "foggy" or "not quite themselves," often attributing these sensations to "brain fog." However, I have found that for many, these experiences reflect something completely different: Dissociation! More specifically, depersonalization and derealization (DP/DR), two forms of dissociation that are distinct from the cognitive cloudiness of brain fog. Mislabeling DP/DR as brain fog can obscure underlying conditions like anxiety, post-traumatic stress disorder (PTSD), or chronic stress, delaying effective treatment. This post explores DP/DR, their neurophysiological underpinnings, and their connections to these conditions, emphasizing the importance of accurate diagnosis.

What Are Depersonalization and Derealization?

Depersonalization involves a sense of detachment from oneself, where individuals feel disconnected from their body, emotions, or thoughts. Patients might describe feeling like they’re observing themselves from outside or living on autopilot (American Psychiatric Association, 2013). Derealization, conversely, manifests as a sense that the external world is unreal, dreamlike, or distant, as if life is a movie or objects lack vibrancy (Simeon & Abugel, 2006). Both are dissociative phenomena, often co-occurring, and can be profoundly distressing, yet they’re frequently mistaken for brain fog—a term typically associated with cognitive difficulties like poor concentration or memory (Ocon, 2016).

Unlike brain fog, which is often linked to fatigue or medical conditions like long COVID (Ceban et al., 2022), DP/DR involve a perceptual and emotional disconnect. For instance, a patient with depersonalization might say, “I feel like a robot,” while someone with derealization might note, “The world looks flat, like I’m not really here.” These experiences can be transient or persistent, particularly when tied to mental health conditions.

Connections to Anxiety, PTSD, and Chronic Stress

DP/DR are strongly associated with anxiety disorders, PTSD, and chronic stress. Anxiety can trigger dissociation as a coping mechanism, where the mind distances itself from overwhelming emotions (Spiegel et al., 2011). Studies estimate that 66% of individuals with anxiety disorders experience some form of dissociation, with DP/DR being common presentations (Sierra & Berrios, 1998). For example, during a panic attack, someone might feel detached from their body to buffer intense fear, a process that can persist beyond the acute episode.

In PTSD, DP/DR are hallmark symptoms, often arising as a response to trauma. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) recognizes a dissociative subtype of PTSD, where depersonalization and derealization are prominent (American Psychiatric Association, 2013). Research shows that up to 30% of PTSD patients experience these symptoms, which may serve to emotionally numb individuals from traumatic memories (Lanius et al., 2010). A veteran, for instance, might describe feeling “outside” themselves when triggered by a loud noise, reflecting depersonalization.

Chronic stress also plays a role. Prolonged activation of the stress response can disrupt emotional regulation, leading to dissociative states. Studies suggest that chronic stress alters connectivity in brain networks involved in self-perception and reality testing, increasing DP/DR risk (van der Kolk, 2014). Patients with demanding jobs or caregiving roles often report feeling “disconnected” as stress accumulates, mistaking this for brain fog.

Neurophysiology of DP/DR

The neurophysiology of DP/DR offers insight into why these experiences feel so distinct. Research points to dysregulation in the brain’s limbic system, particularly the amygdala, which processes fear and emotional salience. In DP/DR, heightened amygdala activity, often seen in anxiety and PTSD, may trigger a shutdown response in the prefrontal cortex, dampening emotional awareness and creating a sense of detachment (Sierra & Berrios, 1998). Neuroimaging studies reveal reduced connectivity between the prefrontal cortex and insula in depersonalization, impairing integration of bodily and emotional states (Lemche et al., 2016).

Derealization, meanwhile, is linked to altered activity in the temporoparietal junction, a region involved in spatial awareness and reality perception. This disruption can make the environment feel “off” or unreal (Hunter et al., 2003). Chronic stress and PTSD exacerbate these changes by flooding the brain with cortisol, which impairs neural plasticity and heightens dissociation (van der Kolk, 2014). In long COVID, neuroinflammation may further disrupt these circuits, potentially explaining why some patients report DP/DR-like symptoms mislabeled as brain fog (Ceban et al., 2022).

Why Misdiagnosis Matters

Confusing DP/DR with brain fog can lead to misdirected treatment. Brain fog might prompt lifestyle changes like better sleep or diet, which, while helpful, don’t address dissociation’s roots in anxiety, trauma, or stress. DP/DR often respond to targeted therapies, such as cognitive-behavioral therapy (CBT), mindfulness, or trauma-focused approaches like eye movement desensitization and reprocessing (EMDR) (Simeon et al., 2004). For example, grounding techniques can help patients reconnect with their body during depersonalization episodes, while addressing anxiety or PTSD can reduce symptom frequency.

Misdiagnosis also risks overlooking serious conditions. Persistent DP/DR may signal depersonalization-derealization disorder, a standalone condition requiring specialized care (Simeon & Abugel, 2006). In my practice, I’ve seen patients with long COVID attribute dissociation to cognitive impairment, delaying treatment for underlying anxiety or stress-related disorders.

Moving Forward

If you feel detached from yourself or the world feels unreal, don’t assume it’s just brain fog. These could be signs of depersonalization or derealization, especially if you’re navigating anxiety, PTSD, chronic stress, or even long COVID. Consult a mental health professional to explore these symptoms—they’re more common than you might think, and naming them is the first step toward relief.

About the Author

Dr. David George is the founder of Neuregen in Scottsdale, Arizona, where he specializes in integrative psychiatry and neurologic health. With a clinical focus at the intersection of psychiatry and neurology, Dr. George addresses conditions like anxiety, PTSD, depression, and brain injuries by integrating evidence-based treatments—such as psychotherapy and medication—with innovative approaches like ketamine therapy, stellate ganglion block, and regenerative medicine. Neuregen emphasizes integrative approaches, combining therapy, stress management, and other therapies to address DP/DR’s root causes.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.

Ceban, F., Ling, S., Lui, L. M. W., Lee, Y., Gill, H., Teopiz, K. M., ... & McIntyre, R. S. (2022). Fatigue and cognitive impairment in post-COVID-19 syndrome: A systematic review and meta-analysis. Brain, Behavior, and Immunity, 100, 93-102. https://doi.org/10.1016/j.bbi.2021.12.020

Hunter, E. C. M., Phillips, M. L., Chalder, T., Sierra, M., & David, A. S. (2003). Depersonalisation disorder: A cognitive-behavioural conceptualisation. Behaviour Research and Therapy, 41(12), 1451-1467. https://doi.org/10.1016/S0005-7967(03)00066-4

Lanius, R. A., Vermetten, E., Loewenstein, R. J., Brand, B., Schmahl, C., Bremner, J. D., & Spiegel, D. (2010). Emotion modulation in PTSD: Clinical and neurobiological evidence for a dissociative subtype. American Journal of Psychiatry, 167(6), 640-647. https://doi.org/10.1176/appi.ajp.2009.09081168

Lemche, E., Surguladze, S. A., Brammer, M. J., Phillips, M. L., Sierra, M., David, A. S., ... & Giampietro, V. (2016). Dissociable brain correlates for depression, anxiety, dissociation, and somatisation in depersonalization-derealization disorder. CNS Spectrums, 21(1), 35-42. https://doi.org/10.1017/S1092852915000588

Ocon, A. J. (2016). Caught in the thickness of brain fog: Exploring the cognitive symptoms of chronic fatigue syndrome. Frontiers in Physiology, 7, 113. https://doi.org/10.3389/fphys.2016.00113

Sierra, M., & Berrios, G. E. (1998). Depersonalization: Neurobiological perspectives. Biological Psychiatry, 44(9), 898-908. https://doi.org/10.1016/S0006-3223(98)00015-8

Simeon, D., & Abugel, J. (2006). Feeling unreal: Depersonalization disorder and the loss of the self. Oxford University Press.

Simeon, D., Guralnik, O., Schmeidler, J., & Knutelska, M. (2004). Cognitive-behavioral therapy for depersonalization disorder: An open study. Journal of Clinical Psychopharmacology, 24(6), 657-660. https://doi.org/10.1097/01.jcp.0000144897.18674.39

Spiegel, D., Loewenstein, R. J., Lewis-Fernández, R., Sar, V., Simeon, D., Vermetten, E., ... & Dell, P. F. (2011). Dissociative disorders in DSM-5. Depression and Anxiety, 28(12), E17-E45. https://doi.org/10.1002/da.20923

van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Viking.