Sertraline, commonly known by the brand name Zoloft, is a widely prescribed selective serotonin reuptake inhibitor (SSRI) used to treat conditions such as major depressive disorder, obsessive-compulsive disorder, panic disorder, and social anxiety disorder. The primary function of an SSRI is to increase the level of serotonin in the brain, a neurotransmitter that regulates mood, sleep, and appetite. While sertraline is effective for many, some individuals may experience unsettling side effects, including feeling detached from oneself or the world—a state clinically known as depersonalization-derealization (DPDR). Though a distressing symptom, this experience is not uncommon, especially during the initial weeks of treatment as the brain adjusts to the medication.
The Serotonin Connection: A Neurological Hypothesis
To understand why sertraline might trigger feelings of unreality, it is crucial to examine its mechanism of action. Sertraline works by blocking the reabsorption of serotonin by neurons, which increases the concentration of serotonin in the synapse. While the exact link between increased serotonin and dissociation is not fully understood, research suggests a possible connection through specific serotonin receptors, particularly the $5-HT_2$ receptors.
Serotonergic systems are known to be involved in sensory processing, and studies suggest that an excessive activation of these systems, potentially in the thalamus or hippocampus, could interfere with the normal transmission and integration of sensory information. This interference could disrupt the brain's ability to create a coherent sense of reality, leading to the dissociative symptoms of depersonalization and derealization. Additionally, emotional blunting, a related side effect of SSRIs, involves the inability to fully experience emotions. This can make the world feel less vivid and real by dampening both positive and negative emotional responses, which is distinct from but can contribute to the overall feeling of detachment.
The Adjustment Period: A Temporary Phenomenon
For many individuals, experiencing feelings of unreality is a transient side effect that occurs during the first few weeks of starting or adjusting a sertraline dosage. As the brain's neurochemistry adapts to the new levels of serotonin, these initial disturbances can subside. This phenomenon is a part of the process where the brain finds a new chemical balance. Some patients report that the dissociative sensations become less intense or disappear entirely over time. Patience and communication with your healthcare provider are essential during this initial phase, as abruptly stopping the medication can lead to withdrawal symptoms.
Identifying Depersonalization vs. Derealization
While the terms are often used together, it is helpful to distinguish between depersonalization and derealization. Understanding the difference can help you better communicate your symptoms to your doctor.
| Feature | Depersonalization | Derealization |
|---|---|---|
| Focus | Inner experience | External world |
| Sensation | Feeling detached from one's own body, thoughts, or emotions; observing oneself from a distance | Feeling that the external world is unreal, foggy, or dreamlike; objects may seem distorted or lifeless |
| Examples | A feeling of being an automaton or robot; watching your life play out on a screen; an unexplainable numbness | The feeling that familiar places seem foreign; seeing the world as if through a pane of glass; experiencing distorted perception of time or size |
Strategies for Managing Feelings of Unreality
If you are experiencing depersonalization or derealization, several strategies can help manage the symptoms:
- Grounding Techniques: These focus on engaging your senses to bring your mind back to the present moment. Examples include: gripping a piece of ice, holding a strong-scented item, or focusing on the textures of objects around you.
- Mindfulness and Awareness: Practice focusing on your immediate thoughts, feelings, and sensations without judgment. Activities like mindful walking, listening to music, or engaging in a hobby can be beneficial.
- Avoid Abrupt Cessation: Never stop taking sertraline cold turkey. This can cause severe withdrawal symptoms, which can intensify anxiety and dissociative feelings.
- Maintain a Healthy Lifestyle: Regular exercise can stimulate serotonin production and help balance mood. Adequate sleep and hydration are also crucial for overall mental stability.
- Avoid Stimulants and Alcohol: Substances like caffeine and alcohol can exacerbate feelings of derealization and interact negatively with your medication.
- Open Communication with Your Doctor: Keep a journal of your symptoms and discuss them honestly with your healthcare provider. They can help determine if the medication is the cause and suggest appropriate adjustments.
When to Consult Your Doctor
It is important to seek medical advice if feelings of unreality are severe, persistent, or cause significant distress. Your doctor may consider several alternatives, including:
- Dose Adjustment: A lower dose of sertraline may be enough to manage your primary symptoms while reducing the intensity of side effects.
- Switching Antidepressants: If dose adjustment is ineffective, your doctor may suggest switching to a different antidepressant. Switching strategies can vary (e.g., cross-tapering) and depend on the medications involved. A non-SSRI, such as a norepinephrine-dopamine reuptake inhibitor (NDRI), might be an option, as they are less likely to cause emotional blunting.
- Combination Therapy: In some cases, adding another medication might help counteract the dissociative symptoms. For instance, combining an SSRI with a mood stabilizer like lamotrigine has shown effectiveness in some patients.
Conclusion
Discovering that a prescribed medication could be causing the disorienting feeling of not being real can be frightening. However, it's a recognized side effect that is often manageable and can improve with time. By understanding the potential neurological underpinnings of why sertraline makes you feel not real, you can work collaboratively with your healthcare provider to find the right balance of treatment and relief. Never hesitate to discuss these sensitive side effects, as open communication is the most important step toward successful treatment. For more detailed information on sertraline, including other potential side effects, consult authoritative medical resources like the National Institutes of Health.
Support Systems
Connecting with others who have similar experiences can also be beneficial. Online patient communities and mental health support groups offer a space to share stories, learn coping mechanisms, and find comfort in knowing you are not alone. Additionally, therapy, particularly Cognitive Behavioral Therapy (CBT), can provide effective strategies for managing dissociative symptoms and the underlying anxiety.
