Dissociative disorders in DSM-5

Sleep and dream disturbances associated with dissociative experiences

Some dissociative experiences may be related, in part, to REM intrusion into waking consciousness. If so, some aspects of dream content may be associated with daytime dissociative experiences. We tested the hypothesis that some types of dream content would predict daytime dissociative symptomology. As part of a longitudinal study of the impact of dreams on everyday behavior we administered a battery of survey instruments to 219 volunteers. Assessments included the Dissociative Experiences Scale (DES), along with other measures known to be related to either REM intrusion effects or dissociative experiences. We also collected dream reports and sleep measures across a two-week period from a subgroup of the individuals in the baseline group. Of this subgroup we analyzed two different subsamples; 24 individuals with dream recall for at least half the nights in the two-week period; and 30 individuals who wore the DREEM Headband which captured measures of sleep architecture. In addition to using multiple regression analyses to quantify associations between DES and REM intrusion and dream content variables we used a split half procedure to create high vs low DES groups and then compared groups across all measures. Participants in the high DES group evidenced significantly greater nightmare distress scores, REM Behavior Disorder scores, paranormal beliefs, lucid dreams, and sleep onset times. Validated measures of dreamed first person perspective and overall dream coherence in a time series significantly predicted overall DES score accounting for 26% of the variance in dissociation. Dream phenomenology and coherence of the dreamed self significantly predicts dissociative symptomology as an individual trait. REM intrusion may be one source of dissociative experiences. Attempts to ameliorate dissociative symptoms or to treat nightmare distress should consider the stability of dream content as a viable indicator of dissociative tendencies.

Dissociative Amnesia: Remembrances Under Cover

The existence or questionability of "repressed memories" can be discussed as being a matter of definition. It seems, however, far-fetched to consider all "lost" memories as caused by encoding problems, brain damage, forgetfulness, failure to disclose events, and so on. We argue that dissociative amnesia (DA) (or "psychogenic amnesia," or "functional amnesia," or, as we favor to call it, "mnestic block syndrome") is caused by psychic alterations, but ultimately they can be traced to changes in the physiology of the brain, as we are of the opinion that all memory processes-positive or negative-alter brain functions, sometimes more permanently, sometimes transiently. We have proven this idea using functional imaging techniques, in particular fluoro-deoxy-d-glucose positron emission tomography. Having investigated dozens of patients with severe and long-lasting DA conditions, we believe it to be disrespectful to many (but not to all) of the affected patients to question their disease condition, which can be proven to be not caused by feigning, malingering, or direct brain damage.

Treatment of dissociative identity disorder: leveraging neurobiology to optimize success

INTRODUCTION

Dissociative identity disorder (DID) is a treatable mental health condition that is associated with a range of psychobiological manifestations. However, historical controversy, modern day misunderstanding, and lack of professional education have prevented accurate treatment information from reaching most clinicians and patients. These obstacles also have slowed empirical efforts to improve treatment outcomes for people with DID. Emerging neurobiological findings in DID provide essential information that can be used to improve treatment outcomes.

AREAS COVERED

In this narrative review, the authors discuss symptom characteristics of DID, including dissociative self-states. Current treatment approaches are described, focusing on empirically supported psychotherapeutic interventions for DID and pharmacological agents targeting dissociative symptoms in other conditions. Neurobiological correlates of DID are reviewed, including recent research aimed at identifying a neural signature of DID.

EXPERT OPINION

Now is the time to move beyond historical controversy and focus on improving DID treatment availability and efficacy. Neurobiological findings could optimize treatment by reducing shame, aiding assessment, providing novel interventional brain targets and guiding novel pharmacologic and psychotherapeutic interventions. The inclusion of those with lived experience in the design, planning and interpretation of research investigations is another powerful way to improve health outcomes for those with DID.

A Systematic Review and Narrative Analysis of the Evidence for Individual Psychodynamically Informed Psychotherapy in the Treatment of Dissociative Identity Disorder in Adults

Dissociative Identity Disorder (DID) is a highly disabling diagnosis, characterized by the presence of two or more personality states which impacts global functioning, with a substantial risk of suicide. The International Society for the Study of Trauma and Dissociation (ISSTD) published guidelines for treating DID in 2011 that noted individual Psychodynamically Informed Psychotherapy (PDIP) was a cornerstone of treatment. This paper systematically reviews the evidence base for PDIP in the treatment of adults with DID according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Thirty-five articles were located and reviewed: seven prospective longitudinal publications, 13 case series and 15 case studies. Results suggested that PDIP has been widely deployed in DID to reported good effect with a range of treatment protocols and using multiple theoretical models. Despite the positive findings observed, the evidence base remains at the level of observational-descriptive design. Creative approaches in recent years have been developed, which add empirical weight to the use of PDIP as an effective treatment. The elevation to observational-analytic designs in the Evidence-Based Medicine hierarchy has yet to take place. Bearing in mind the challenges of research in PDIP, suggestions are offered for how the evidence base might develop.

Dissociative Identity Disorder: A Review of Research From 2011 to 2021

ABSTRACT

Dissociative identity disorder (DID) has historically been one of the most controversial topics in the study of psychopathology. Building on a previous review of empirical research on DID from 2000 to 2010, the present review examined DID research from 2011 to 2021. The research output included 56 case studies and 104 empirical studies. Within the empirical studies, approximately 1354 new cases of DID emerged, which resulted in an average samples of approximately 20. Reanalysis of previous samples was standard in the literature with only 40% of reported cases being new. Studies emerged from dozens of countries across the world, but the majority of cases were from Western counties, especially the United States. Diagnosis primarily relied upon validated measures, but 74% of all new cases came from six research groups. Overall, research on DID is steady but methodologically limited in ways that make generalization, especially about etiology, difficult.

Acute amnestic syndrome in fornix lesions: a systematic review of reported cases with a focus on differential diagnosis

Introduction

Acute amnestic syndrome is an uncommon clinical presentation of neurological disease. Differential diagnosis encompasses several syndromes including Wernicke-Korsakoff and transient global amnesia (TGA). Structural lesions of the fornix account for a minority of cases of acute amnestic syndromes. Etiology varies from iatrogenic injury to ischemic, inflammatory, or neoplastic lesions. A prompt diagnosis of the underlying pathology is essential but challenging. The aim of this review is to systematically review the existing literature regarding cases of acute amnestic syndrome associated with non-iatrogenic lesions of the fornix.

Methods

We performed a systematic literature search on PubMed, Scopus, and Web of Science up to September 2023 to identify case reports and case series of patients with amnestic syndrome due to fornix lesions. The systematic review was conducted according to PRISMA guidelines. The research was limited to articles written in English. Cases of fornix damage directly ascribable to a surgical procedure were excluded.

Results

A total of 52 publications reporting 55 cases were included in the review. Focusing on acute/subacute onset, vascular etiology was highly prevalent, being responsible for 78% of cases, 40/55 (74%) of which were due to acute ischemic stroke. The amnestic syndrome was characterized by anterograde amnesia in all patients, associated with retrograde amnesia in 27% of cases. Amnesia was an isolated presentation in most cases. Up to two thirds of patients had persistent memory deficits of any severity at follow-up.

Discussion

Acute amnestic syndrome can be rarely caused by fornix lesions. In most cases of acute/subacute presentation, the etiology is ischemic stroke, mainly caused by strokes involving the subcallosal artery territory. The differential diagnosis is challenging and a distinction from common mimics is often difficult on a clinical basis. A high index of suspicion should be maintained to avoid misdiagnosis and provide adequate acute treatment to patients with time-dependent disease, also employing advanced neuroimaging. More research is needed to better understand the outcome and identify prognostic factors in patients with amnestic syndrome due to fornix lesions.

Somatic Symptom Disorder and Health Anxiety: Assessment and Management

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Somatic Symptom Disorder (SSD) and Illness Anxiety Disorder (IAD) replaced the diagnostic entities of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) somatoform disorders and hypochondriasis. SSD turns away from specifying the presence or absence of a medical condition for presented symptoms and instead focuses on excessive symptom-related affects, cognitions, and behaviors. People with pathological health anxiety can be diagnosed with SSD or IAD, depending on the intensity of accompanying somatic symptoms. Cognitive-behavioral therapy shows the best empirical evidence for an effective treatment of SSD and IAD.

Diagnostic Efficacy and Clinical Relevance of Artificial Intelligence in Detecting Cognitive Decline

Cognitive impairment is an age-associated disorder of increasing prevalence as the aging population continues to grow. Classified based on the level of cognitive decline, memory, function, and capacity to conduct activities of daily living, cognitive impairment ranges from mild cognitive impairment to dementia. When considering the insidious nature of the etiologies responsible for varying degrees of cognitive impairment, early diagnosis may provide a clinical benefit through the facilitation of early treatment. Typical diagnosis relies heavily on evaluation in a primary care setting. However, there is evidence that other diagnostic tools may aid in an earlier diagnosis of the different underlying pathologies responsible for cognitive impairment. Artificial intelligence represents a new intersecting field with healthcare that may aid in the early detection of neurodegenerative disorders. When assessing the role of AI in detecting cognitive decline, it is important to consider both the diagnostic efficacy of AI algorithms and the clinical relevance and impact of early interventions as a result of early detection. Thus, this review highlights promising investigations and developments in the space of artificial intelligence and healthcare and their potential to impact patient outcomes.

The integrative process promoted by EMDR in dissociative disorders: neurobiological mechanisms, psychometric tools, and intervention efficacy on the psychological impact of the COVID-19 pandemic

Dissociative disorders (DDs) are characterized by a discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, bodily representation, motor control, and action. The life-threatening coronavirus disease 2019 (COVID-19) pandemic has been identified as a potentially traumatic event and may produce a wide range of mental health problems, such as depression, anxiety disorders, sleep disorders, and DD, stemming from pandemic-related events, such as sickness, isolation, losing loved ones, and fear for one's life. In our conceptual analysis, we introduce the contribution of the structural dissociation of personality (SDP) theory and polyvagal theory to the conceptualization of the COVID-19 pandemic-triggered DD and the importance of assessing perceived safety in DD through neurophysiologically informed psychometric tools. In addition, we analyzed the contribution of eye movement desensitization and reprocessing (EMDR) to the treatment of the COVID-19 pandemic-triggered DD and suggest possible neurobiological mechanisms of action of the EMDR. In particular, we propose that, through slow eye movements, the EMDR may promote an initial non-rapid-eye-movement sleep stage 1-like activity, a subsequent access to a slow-wave sleep activity, and an oxytocinergic neurotransmission that, in turn, may foster the functional coupling between paraventricular nucleus and both sympathetic and parasympathetic cardioinhibitory nuclei. Neurophysiologically informed psychometric tools for safety evaluation in DDs are discussed. Furthermore, clinical and public health implications are considered, combining the EMDR, SDP theory, and polyvagal conceptualizations in light of the potential dissociative symptomatology triggered by the COVID-19 pandemic.

Dialectical Core Schemas Mediate the Relationships Between Dissociative Experiences and Symptomatology in a Community Sample

BACKGROUND

Maladaptive cognitions about the self and others are associated with a wide array of dysfunctional responses and psychopathological symptoms in non-clinical and clinical samples. Dissociative experiences (e.g., depersonalization and derealization) as a coping response to stressful situations lie on a continuum from healthy to unhealthy but are generally elevated in individuals experiencing mental illness. However, the extent to which Dialectical Core Schemas explain the relationship between dissociative experiences and symptomatology is unclear. Therefore, this study aimed to investigate the mediating role of Dialectical Core Schemas on the relationship between dissociative experiences and symptomatology.

METHODS

A community sample of 179 participants were recruited (M_age = 21.2 years, SD = 8.2). Data were gathered through self-report questionnaires using a cross-sectional design.

RESULTS

Maladaptive core schemas about self and others correlated positively with all dissociative experiences (e.g., depersonalization/derealization, amnesia), while adaptive core schemas about the self correlated negatively with depersonalization/derealization and distractibility. Maladaptive core schemas mediated the relationship between dissociative experiences and symptomatology.

CONCLUSIONS

The relationships between dissociative experiences and symptomatology are bi-directional. Exploring the mediating factors may help clinicians and researchers better understand how to enhance case conceptualization and clinical decision-making.

The importance of organic screening, regarding a clinical case

INTRODUCTION

Before cataloguing a morbid process as a "mental disorder", it is essential to bear in mind the importance of early diagnosis of causes of non-psychiatric origin for a possible clinical presentation. For this reason, we will try to reflect this fact, which it seems necessary to remember even though it is well known, since it can be overlooked in emergency situations in the hospital setting, with the consequences derived from an incomplete diagnosis and with the potential life-threatening risk for the patient.

CASE PRESENTATION

A 13-year-old female adolescent, who presented an acute clinical picture suggestive of dissociative disorder. She required hospital admission for diagnostic-therapeutic clarification, and neuroimaging findings led to an initial diagnosis of a neoplastic lesion in the brain stem and, finally, as ischaemic lesion of vasculitic origin in said location.

DISCUSSION

A differential diagnosis was proposed through the different psychic and non-psychic aetiologies of the clinical picture, but the intervention of the hospital's paediatric service was necessary for orientation and definitive affiliation, given the suspicion of non-psychiatric illness after a torpid evolution in spite of psychotherapeutic and psychopharmacological interventions.

CONCLUSIONS

Through the presentation and review of a clinical case that happened in our hospital, we must insist on an adequate comprehensive approach to the patient, especially with the child-adolescent population, when faced with an acute clinical presentation and without previous studies at a relevant physical level.

Treatment of Comorbid Disorders, Syndromes, and Symptoms of Posttraumatic Stress Disorder Related to Childhood Maltreatment with STAIR-NT

Abstract. Background: Early interpersonal traumatic events, such as childhood maltreatment, increase the risk of developing complex posttraumatic stress symptoms. The biphasic treatment program STAIR-NT (Skills Training for Affective and Interpersonal Regulation with Narrative Therapy), developed specifically for this patient group, combines interventions to improve emotion regulation and interpersonal skills with narrative therapy. Objective: Many affected patients with PTSD after childhood maltreatment also suffer from various comorbid mental disorders and symptoms that can affect and impede the course and outcome of treatment with STAIR-NT. Method: Based on experience from a current treatment study, we provide recommendations for integrating treatment of comorbid mental symptoms into STAIR-NT. Results / Conclusion: Training affective and interpersonal regulation skills in the first treatment phase offers various interventions to efficiently adapt transdiagnostic mechanisms such as emotion dysregulation. In cases of severe comorbid mental disorders or symptoms, adding disorder-specific interventions to STAIR-NT may be indicated.

The Relationship Between Acute Dissociative Effects Induced by Ketamine and Treatment Response in Adolescent Patients with Treatment-Resistant Depression

Objective: Ketamine has proven effective as a rapid-acting antidepressant agent. Several adult studies have investigated the association between ketamine's acute dissociative effects and depression response, but no studies have examined the association in adolescents with treatment-resistant depression (TRD). Methods: We conducted a secondary data analysis of 16 adolescent participants who participated in a randomized, single-dose, midazolam-controlled crossover trial of ketamine in adolescents with depression. We examined the association between the acute dissociative symptoms (measured at 60 minutes following start of infusion using the Clinician-Administered Dissociative States Scale [CADSS], and its three subscales: depersonalization, derealization, amnesia) and response and depression symptom improvement at 1'day (using the Montgomery-Åsberg Depression Rating Scale). Results: Within the ketamine group, there were no significant associations between dissociation symptoms or CADSS subscale scores and magnitude of depression symptom improvement or likelihood of ketamine response. When receiving midazolam, there was no significant association between overall dissociation symptoms and magnitude or likelihood of response of depressive symptoms. Higher levels of symptoms on the 'depersonalization' CADSS subscale when receiving midazolam were associated with less improvement in depression symptoms at 1 day following infusion. Conclusions: In contrast to some adult literature, the current data do not show a relationship between acute dissociative effects and antidepressant response to ketamine in pediatric patients with TRD. Interpretation may be limited by the small sample size, reducing the power to detect small or medium associations. Future research should utilize larger samples to more definitively measure the magnitude of association between acute dissociative symptoms and later antidepressant response to ketamine and to assess the relationship to trial design (e.g., crossover vs. parallel trial, comparison condition utilized and number of infusions) within both adult and pediatric populations. ClinicalTrials.gov identifier: NCT02579928.

The brain-body disconnect: A somatic sensory basis for trauma-related disorders

Although the manifestation of trauma in the body is a phenomenon well-endorsed by clinicians and traumatized individuals, the neurobiological underpinnings of this manifestation remain unclear. The notion of somatic sensory processing, which encompasses vestibular and somatosensory processing and relates to the sensory systems concerned with how the physical body exists in and relates to physical space, is introduced as a major contributor to overall regulatory, social-emotional, and self-referential functioning. From a phylogenetically and ontogenetically informed perspective, trauma-related symptomology is conceptualized to be grounded in brainstem-level somatic sensory processing dysfunction and its cascading influences on physiological arousal modulation, affect regulation, and higher-order capacities. Lastly, we introduce a novel hierarchical model bridging somatic sensory processes with limbic and neocortical mechanisms regulating an individual's emotional experience and sense of a relational, agentive self. This model provides a working framework for the neurobiologically informed assessment and treatment of trauma-related conditions from a somatic sensory processing perspective.

The Association between Type of Dissociation and Psychotic Experiences in a Non-Psychotic Inpatient Sample

Robust evidence exists for the link between dissociation and psychotic positive symptoms. The extent to which various dissociative phenomena may contribute to this relationship is still unknown. This study aimed to investigate the association between different dissociative phenomena and psychotic experiences. For this purpose, we analyzed data from 118 consecutively admitted patients of an acute care unit for trauma-related disorders who completed the Childhood Trauma Questionnaire, the German version of the Dissociative Experiences Scale and the Symptom Check-List-90-Revised. Stepwise regression analyses revealed that derealization/depersonalization in combination with amnesia accounted for 44.5% of the variance of the psychoticism subscale of the Symptom Check-List-90-Revised. Absorption in combination with emotional abuse accounted for 24.9% of the variance of the paranoid ideation subscale of the Symptom Check-List-90-Revised. The results reveal that pathological and non-pathological types of dissociation that alter the perception of reality or memory procession may contribute to the development of psychotic experiences.

Persistent Dissociation and Its Neural Correlates in Predicting Outcomes After Trauma Exposure

OBJECTIVE

Dissociation, a disruption or discontinuity in psychological functioning, is often linked with worse psychiatric symptoms; however, the prognostic value of dissociation after trauma is inconsistent. Determining whether trauma-related dissociation is uniquely predictive of later outcomes would enable early identification of at-risk trauma populations. The authors conducted the largest prospective longitudinal biomarker study of persistent dissociation to date to determine its predictive capacity for adverse psychiatric outcomes following acute trauma.

METHODS

All data were part of the Freeze 2 data release from the Advancing Understanding of Recovery After Trauma (AURORA) study. Study participants provided self-report data about persistent derealization (N=1,464), a severe type of dissociation, and completed a functional MRI emotion reactivity task and resting-state scan 2 weeks posttrauma (N=145). Three-month follow-up reports were collected of posttraumatic stress, depression, pain, anxiety symptoms, and functional impairment.

RESULTS

Derealization was associated with increased ventromedial prefrontal cortex (vmPFC) activation in the emotion reactivity task and decreased resting-state vmPFC connectivity with the cerebellum and orbitofrontal cortex. In separate analyses, brain-based and self-report measures of persistent derealization at 2 weeks predicted worse 3-month posttraumatic stress symptoms, distinct from the effects of childhood maltreatment history and current posttraumatic stress symptoms.

CONCLUSIONS

The findings suggest that persistent derealization is both an early psychological and biological marker of worse later psychiatric outcomes. The neural correlates of trauma-related dissociation may serve as potential targets for treatment engagement to prevent posttraumatic stress disorder. These results underscore dissociation assessment as crucial following trauma exposure to identify at-risk individuals, and they highlight an unmet clinical need for tailored early interventions.

Primiparous and Multiparous Women's Mode of Birth and Negative Emotions

Negative childbirth experiences may result in negative emotions that may lead to negative outcomes, such as post-traumatic stress disorder. We aimed to examine the differences in emotions between primiparous and multiparous women and mode of birth. We used a retrospective cross-sectional study design with three hundred and fifty women. Primiparous women reported higher levels of fear, lack of control, and dissociation emotions compared to multiparous women. The EmCs (emergency cesarean section) group experienced the most fear, lack of control, anger, and conflict emotions. It is important to conduct follow up work with women who underwent unplanned birth procedures since negative childbirth experiences may lead to further negative effects on women's psychosocial health and well-being.

Consistency of inclusion criteria for functional movement disorder clinical research studies: A systematic review

BACKGROUND: Functional movement disorders (FMDs) are a common cause of disability. With an increasing research interest in FMD, including the emergence of intervention trials, it is crucial that research methodology be examined, and standardized protocols be developed. OBJECTIVE: To characterize the current inclusion criteria used to select patients for FMD research studies and review the consistency and appropriateness of these criteria. METHODS: We identified studies of potential biomarkers for FMD that were published over the last two decades and performed a qualitative analysis on the finally included studies. RESULTS: We identified 79 articles and found inconsistent inclusion criteria. The Fahn-Williams and DSM-IV criteria were the most commonly applied, but neither accounted for the majority (Fahn-Williams 46%, DSM-IV 32% of the total). The selection of the inclusion criteria depended in part on the phenotype of FMD under investigation. We also identified inclusion methodologies that were not appropriate, such as the inclusion of low-certainty diagnoses and diagnosing by excluding specific biomarkers rather than including patients based on clinical characteristics that commonly are thought to suggest FMD. CONCLUSIONS: Significant variability exists with the inclusion criteria for FMD research studies. This variability could limit reproducibility and the appropriate aggregation of data for meta-analysis. Advancing FMD rehabilitation research will need standardized inclusion criteria. We make some suggestions.

Dissociative Symptoms and Disorders in Patients With Bipolar Disorders: A Scoping Review

Dissociative disorders are an important group of trauma-related disorders associated with significant disability. The co-occurrence of dissociative disorders (DD) and symptoms (DS) in bipolar disorder has been relatively understudied, but there is some evidence that this comorbidity may have significant mechanistic and clinical implications. This paper presents the results of a scoping review of the frequency and correlates of DS and DD in bipolar disorder. Based on the available evidence, DS/DD are more common in bipolar disorder than in healthy controls or in unipolar depression, are related to childhood trauma, and are associated with psychotic symptoms, suicide attempts, and a poorer response to treatment in patients with bipolar disorder. The implications of these findings, and possible mechanistic pathways underlying them, are discussed based on the current literature. Clinicians should be aware of the frequent occurrence of significant DS or DD when treating patients with bipolar disorder. A tentative future research agenda for this field, based on clinical, risk factor-related and neurobiological considerations, is outlined.

Stress response in dissociation and conversion disorders: A systematic review

Dissociative disorders (DD) and conversion disorders (CD) are frequent in general and psychiatric populations. Some evidence suggest that the hypothalamic-pituitary axis (HPA) and autonomic nervous system (ANS) are dysregulated in both disorders. We carried out a systematic review of the literature to summarize the existing knowledge on the stress response, via HPA and/or ANS, in patients with DD, CD, or dissociative symptoms. We systematically searched Medline and Web of Science using the Medical Subject Headings related to stress axis, CD, DD, and dissociative symptoms following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results suggest that in participants without psychiatric history, high cortisol secretion is related to high dissociation scores. Conversely the stress system might be blunted in patients with post-traumatic stress disorder who develop dissociative symptoms. Stress response changes seem to be associated with the emergence and persistence of dissociative and conversion disorders. Hence, monitoring the stress response and examining closely the history of stress exposure in DD and CD should be encouraged in future larger studies.

Dissociative Identity Disorder: Diagnostic Accuracy and DSM-5 Criteria Change Implications

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) revised the diagnostic criteria for dissociative identity disorder (DID) to more accurately reflect the symptom profile of DID patients. No study has examined how this change affects clinical diagnosis of DID. The present study examined clinician reports of patient symptoms in relation to DSM-IV-TR and DSM-5 DID diagnostic criteria. Data were analyzed from 169 clinicians who participated in the Treatment of Patients with Dissociative Disorders Network Study with a patient they assigned a DID diagnosis. Clinicians evaluated their patients with respect to DSM-IV-TR and DSM-5 DID diagnostic criteria. Researchers determined a clinician-assigned DID diagnosis as "accurate" when the patient's reported dissociative symptoms matched DSM-IV-TR and/or DSM-5 criteria for DID. Most of the clinicians (95.27%) accurately diagnosed DID. Of those accurately diagnosed, 83.85% of patients met DSM-IV-TR and DSM-5 DID criteria, 9.94% only met DSM-IV-TR DID criteria, and 6.21% only met DSM-5 DID criteria. Further examination of responses suggested that possible idiomatic responses to the negative wording of the DSM-5 exclusionary criteria might have accounted for the DSM-IV-TR appearing to fit for a greater number of cases in this study. Changes in the DSM criteria for DID did not substantially change the frequency or accuracy of assigned DID diagnoses, but the removal of the requirement in DSM-5 that self-states regularly take control of an individual's behavior slightly increased the number of individuals meeting criteria for DID.

Believing in dissociative amnesia relates to claiming it: a survey of people's experiences and beliefs about dissociative amnesia

Dissociative amnesia is one of the most controversial categories in the field of psychiatry and clinical psychology. Self-reports of dissociative amnesia in the general population, and beliefs about this topic, have so far not been subjected to empirical scrutiny. Here, we surveyed a sample from the general population (N = 1017), revealing that about a tenth (n = 102) claimed to have experienced dissociative amnesia. Some claims pertained to amnesia for traumatic autobiographical experiences (e.g., sexual assault), while other claims reflected memory loss for experiences that can be regarded as non-traumatic or non-stressful (e.g., dissociative amnesia for an anniversary). Importantly, many participants believed in the existence of dissociative amnesia, and those who claimed dissociative amnesia indicated even more belief in this phenomenon than the rest of the sample. Finally, many participants indicated to have at least once claimed to have feigned memory loss in their life, and that they experienced some form of forgetting when trying to retrieve events for which they lied upon. Overall, our findings suggest that claiming dissociative amnesia goes hand in hand with believing in dissociative amnesia.

Childhood abuse experiences, depression and dissociation symptoms in relation to suicide attempts and suicidal ideation

This study aimed to examine associations between suicide attempts (SA), suicidal ideation (SI), depression, dissociative symptoms, emotional abuse, physical abuse and sexual abuse, and to explore predictors of SA and SI, as well as possible mediating factors. We also aimed to examine support for a dissociative depression subgroup. Participating in this study were 342 adults, of these were 138 respondents with a diagnosis of depression (DG), and 204 respondents comprising a community sample (CS). Respondents completed the Center for Epidemiologic Studies Depression Scale - Revised (CESD-R), Childhood Trauma Questionnaire - Short Form (CTQ-SF), and Dissociative Experience Scale (DES). All but two (DES-Absorption and DES - Depersonalization/Derealization) of the study variable mean scores were higher in the DG than in the CS group. Regression analysis showed that SA was predicted by sexual abuse and DES-Amnesia in the CS group. Structural equation modeling revealed that in both groups the types of abuse were reciprocally correlated, emotional abuse was linked to dissociation, which in turn was related to depression, which is turn was predictive of suicide ideation. Depression had a full mediating effect between dissociation and suicide ideation in the CS, and a partial mediating effect in the DG. Sexual abuse had a direct effect upon depression and suicide ideation in the DG. Cluster analysis provided support for a dissociative depression subtype.

Interpersonal Trauma and Posttraumatic Stress in Autistic Adults

Background

Many autistic adults report interpersonal traumas (IPTs) such as physical or sexual assault, which are often associated with posttraumatic stress and dissociation. Factors such as gender might make autistic individuals particularly vulnerable to experiencing IPT and negative posttraumatic symptoms.

Methods

In this study, 687 self-identified autistic adults completed an online survey on their traumatic experiences and mental health symptoms.

Results

Seventy-two percent of participants reported experiencing sexual assault, other unwanted or uncomfortable sexual experiences, or physical assault. Forty-four percent of participants met the criteria for posttraumatic stress disorder (PTSD), including 50% of those who had experienced IPT and 28% of those who had not (odds ratio = 2.50; 95% confidence interval 1.74-3.60). IPT was also significantly associated with higher levels of psychoform (p < 0.001) and somatoform (p < 0.001) dissociation. Autistic cisgender women and gender minorities experienced a significantly higher number of traumas (p = 0.004) and were significantly more likely than cisgender men to experience sexual IPT (p < 0.001) and meet the criteria for PTSD (p < 0.001). There were no significant differences between autistic individuals with and without a professional autism spectrum disorder (ASD) diagnosis.

Conclusions

IPT is associated with potentially severe mental health outcomes for autistic adults. Autistic women and gender minorities may be particularly vulnerable to sexual IPT and adverse outcomes. Increased screening for a history of IPT and posttraumatic symptoms is recommended for all autistic adults regardless of ASD diagnosis status.

Lay summary

Why was this study done?: Many autistic people experience interpersonal traumas (IPTs) such as sexual or physical assault. These can lead to mental health challenges such as posttraumatic stress disorder (PTSD) or dissociation (a disconnection between individuals and aspects of their perceptions or sense of self). We wanted to better understand what might make autistic adults more likely to experience trauma and how it affects them.What was the purpose of this study?: The purpose was to understand what might make autistic people more at risk of experiencing IPT and PTSD. We also wanted to know if IPT is associated with a higher risk of PTSD or dissociation.What did the researchers do?: Six hundred eighty-seven autistic adults filled out an online survey about their traumatic experiences, PTSD symptoms, and dissociation symptoms. We analyzed their responses to see how often participants reported experiencing different types of trauma and whether they met the criteria for PTSD and clinical dissociation. We then compared trauma experiences and PTSD rates across genders and those with and without a professional autism spectrum disorder (ASD) diagnosis and compared PTSD rates and dissociation rates across participants who had versus had not experienced IPT.What were the results of the study?: Seventy-two percent of autistic adults in this study reported having experienced sexual assault, another unwanted sexual experience, or physical assault. Almost half (44%) met the criteria for PTSD. Most participants (93%) also reported high levels of mind-based dissociation, and 32% reported high levels of body-based dissociation (dissociation that causes negative emotions to be experienced as physical problems such as headaches or trouble moving). Participants who had experienced IPT were almost twice as likely to meet the criteria for PTSD and scored higher on both measures of dissociation. Cisgender women and gender minorities were more likely to experience IPT and meet the criteria for PTSD than cisgender men. Participants with and without a professional ASD diagnosis did not differ.What do these findings add to what was already known?: Most previous research on trauma and PTSD for autistic people was done on children and did not look at IPT specifically or compare people based on their gender or ASD diagnosis. As far as we know, this is the first study on posttraumatic dissociation in autistic adults.What are potential weaknesses in the study?: The findings of this study may not apply to autistic adults as a whole. People who could have participated may not have been interested in the topic, may not have seen study advertisements and so been unaware of the study, or may not have had the time or energy to participate. Findings might have been different if different groups of autistic people participated more.How will these findings help autistic adults now or in the future?: If professionals who help autistic people do not talk to them about trauma, traumatized autistic adults may not get the right support. This study could encourage professionals to screen more autistic people, especially women and gender minorities, for trauma.

The importance of organic screening, regarding a clinical case

INTRODUCTION

Before cataloguing a morbid process as a "mental disorder", it is essential to bear in mind the importance of early diagnosis of causes of non-psychiatric origin for a possible clinical presentation. For this reason, we will try to reflect this fact, which it seems necessary to remember even though it is well known, since it can be overlooked in emergency situations in the hospital setting, with the consequences derived from an incomplete diagnosis and with the potential life-threatening risk for the patient.

CASE PRESENTATION

A 13-year-old female adolescent, who presented an acute clinical picture suggestive of dissociative disorder. She required hospital admission for diagnostic-therapeutic clarification, and neuroimaging findings led to an initial diagnosis of a neoplastic lesion in the brain stem and, finally, as ischaemic lesion of vasculitic origin in said location.

DISCUSSION

A differential diagnosis was proposed through the different psychic and nonpsychic aetiologies of the clinical picture, being the intervention of the hospital's paediatric service necessary for orientation and definitive affiliation, given the suspicion of non-psychiatric illness after a torpid evolution in spite of psychotherapeutic and psychopharmacological interventions.

CONCLUSIONS

Through the presentation and review of a clinical case that happened in our hospital, we must insist on an adequate comprehensive approach to the patient, especially with the child-adolescent population, when faced with an acute clinical presentation and without previous studies at a relevant physical level.

Dissociation among individuals receiving cancer care: a scoping review

PROBLEM IDENTIFICATION

Dissociation is a common presentation of trauma, distinguishable from classic post-traumatic stress disorder (PTSD) symptoms. While pre-cancer and cancer-related traumatic experiences are prevalent among cancer-affected individuals, the specific impact of traumatic dissociation is unclear.

LITERATURE SEARCH

This scoping review includes a search of English articles published between 1980 and 2019 referencing dissociation in the context of cancer-affected adults.

DATA EVALUATION/SYNTHESIS

Articles assessed how dissociation was addressed in relation to pre-cancer and cancer-related trauma exposure and treatment. Out of 1,265 articles, 71 met inclusion criteria, and 15 underwent a full review. Two studies addressed dissociation related to pre-cancer trauma, nine in regard to cancer-related trauma only, and four in relation to both trauma types. No studies included experimental designs or described interventions.

CONCLUSIONS

Despite high rates of trauma exposure among cancer-affected adults, limited studies specifically address the impact of dissociation. Further inquiry on this topic is needed, especially on treatment implications.

Posttraumatic cognitions predict distorted body perceptions in women with dissociative identity disorder

BACKGROUND

Dissociative identity disorder (DID) is a psychobiological syndrome associated with a history of exposure to childhood abuse and neglect. The consequences of these traumatic events often include a profound impact on the way individuals inhabit and experience their bodies. Despite this, there is a paucity of empirical research on the subject. The aim of this study was to systematically document the occurrence of distorted body perceptions in DID and examine childhood maltreatment, posttraumatic stress disorder (PTSD) symptom severity, and posttraumatic cognitions as predictors of distorted body perceptions in DID.

METHODS

Participants were adult women with histories of childhood abuse and neglect and a current DID diagnosis receiving treatment at a psychiatric care facility. Data were obtained through a battery of self-report measures, including the Body Uneasiness Test, Childhood Trauma Questionnaire, PTSD Checklist for DMS-5, and Posttraumatic Cognitions Inventory.

RESULTS

A series of unpaired t-tests documented elevated levels of weight phobia, body image concerns, body avoidance, compulsive self-monitoring, and depersonalization in DID compared to published non-clinical data on the Body Uneasiness Test. A series of multiple regression models including measures of childhood trauma, PTSD symptoms, and posttraumatic cognitions demonstrated that over and above childhood trauma and PTSD symptom severity, posttraumatic cognitions significantly predicted distorted body perceptions.

CONCLUSIONS

In a treatment-seeking sample of women with DID, distorted body perceptions were elevated. Furthermore, posttraumatic cognitive distortions significantly predicted distorted body perceptions when controlling for childhood maltreatment and PTSD symptom severity. This suggests that distorted cognitions are a key target for therapeutic intervention.

Perceptions of Child Abuse as Manifested in Drawings and Narratives by Children and Adolescents

Child abuse is an underreported phenomenon despite its high global prevalence. This study investigated how child abuse is perceived by children and adolescents as manifested in their drawings and narratives, based on the well-established notion that drawings serve as a window into children's mental states. A sample of 97 Israeli children and adolescents aged 6-17 were asked to draw and narrate what child abuse meant to them. The drawings and narratives were coded quantitatively. The results indicated that participants did not perceive a distinction between abuse and violence and referred to them interchangeably. Almost half of the participants focused on emotional abuse. The most frequent type of abuse within the family was between parents and children, and the most frequent abuse outside the family was peer victimization. Most of the drawings were figurative and realistic and half of the drawings included words suggestive of the participants' attempts to be heard and fully understood. The vast majority of drawings did not include the figure of the artist, about a third of the drawings employed dissociative techniques (i.e., included positive objects, were unrelated to abuse, used words alone, or did not follow the instructions), and almost half of the narratives were dissociative or characterized by negative resolution, describing feelings such as sadness, humiliation, and loneliness. These findings suggest the emotional pain associated with the abuse or violence and the use of dissociative mechanisms to bypass the pain. The findings are discussed in light of the literature on children's disclosure.

"I Have No Hope": The Experience of Mothers in Polygamous Families as Manifested in Drawings and Narratives

Polygamy is associated with lower marital satisfaction and is known to involve sexual, physical, and emotional abuse on the part of the husband. Less is known about the experience of mothers in polygamous families. This study was designed to shed light on the experiences of women in polygamous families in a sample of 80 Israeli Arab mothers living in polygamous families who use social services, domestic violence agencies, and health centers. Mothers were asked to draw their experiences in their families and to provide narratives for the drawings. A phenomenological approach was used to analyze the drawings, and yielded five different pictorial phenomena: (1) pseudo-sweetness, (2) houses, (3) the absentee father and the estranged mother, (4) incorporation of graphic symbols and lettering that represented distress, and (5) growth and development. Most of the drawings were restricted and shallow, indicating a complex emotional state of despair and distress. The central feelings that emerged from the drawings were negative emotions of anger, sadness, loneliness, and powerlessness. While some women longed for romantic relationships with their husbands, others expressed the desire for revenge and justice. Dissociation and parentification, as central coping strategies, emerged from the drawings and the narratives. The findings are discussed theoretically and clinically.

Poor sleep efficiency and daytime napping are risk factors of depersonalization disorder in female university students

Objectives

Depersonalization is characterized by feelings of detachment from reality and has been associated with anxiety and depression, both of which have a bi-directional relationship with sleep. To date, few studies have directly examined the potential relationship between sleep and depersonalization, which was the primary objective of our study.

Design/methods

A cross-sectional study of female, Emirati, university students (n = 100) was conducted. Participants completed the Pittsburgh Sleep Quality Index (PSQI), the Cambridge Depersonalization Scale (CDS) and the Hospital Anxiety and Depression Scale (HADS). Additionally, 36 of the 100 participants wore wrist actigraphy for two consecutive weekdays. Average sleep duration, and average sleep efficiency (SE; %) across the two nocturnal sleep episodes were calculated. Total number of sleep episodes were obtained from wrist actigraphy and sleep logs.

Results

A significant, positive relationship was observed between PSQI global score and CDS total score (r = 0.21, p = 0.04). Actigraphy-estimated average nocturnal sleep duration was not significantly associated with the CDS. Compared to nocturnal sleepers only, those who undertook daytime naps had almost three times the risk of meeting the criteria for depersonalization disorder (OR = 2.95, 95% CI: 1.04–8.41), after adjustment. For each 1% increase in SE a 23% decreased risk of depersonalization was observed (OR = 0.77, 95% CI: 0.61–0.96), after adjustment.

Conclusions

Sleep screening in young adults may help to ensure better detection and management of psychological health outcomes. Our findings need to be confirmed prospectively in larger samples and amongst different populations but reiterate the importance of sleep habits pertaining to mental health.

•

We show a novel relationship between depersonalization and sleep in a non-clinical sample.

•

Actigraphy determined poor sleep efficiency was significantly associated with subjective reports of depersonalization.

•

Daytime nappers were ~3 times more likely to report depersonalization symptoms and meet the diagnositic criteria.

Firebug! Dissociative Identity Disorder? Malingering? Or …? An Intensive Case Study of an Arsonist

Courts struggle with questions of how to assess competency to stand trial (CTS) and not guilty by reason of insanity (NGRI) in dissociative identity disorder (DID). Concerns about CTS include dissociative amnesia and unpredictable switching behaviors that could cause inconsistent information transfer across self states, with the defendant unable to access important legal information about his/her defense and to collaborate with his/her attorney; DID defendants could not conform their conduct to the law or know right from wrong due to dissociative amnesia, the seemingly independent actions of self states, and the disruption of reality testing by switching. The author presents the case of a woman charged with both a witnessed and an unwitnessed burglary and arson, the latter at the home of her former therapist. The author was the fourth forensic evaluator in the case. Disagreements included whether the defendant met diagnostic criteria for DID or was malingering, and whether she was CTS and/or NGRI. In clinical work with DID, “the whole human being” is held responsible for all behavior, despite reported amnesia or lack of subjective agency. The Discrete Behavioral States (DBS) model of DID avoids reification of the DID self states and their conflation as separate “people.” This model supports evaluating the defendant at the level of specific self states, the self-state system, and that of the whole human being. The author concluded that the defendant met diagnostic criteria for DID and also was malingering its severity. She was competent to stand trial and legally sane.

Validity and reliability of a Persian version of the Dissociative Experiences Scale II (DES-II) on Iranian patients diagnosed with schizophrenia and mood disorders

Dissociative Experiences Scale (DES) is a valid self-reported tool to evaluate both non-pathological and pathological dissociative experiences. This study aims at evaluating the psychometric properties of a Persian version of the DES-II on both non-clinical samples and patients with schizophrenia and mood disorders. The back-translated DES-II was administered to 370 individuals being divided into three groups (270 healthy subjects, 50 patients with mood disorders, and 50 patients with schizophrenia) recruited from Shahid Beheshti Hospital of Kerman Medical University. The results showed a good reliability (Cronbach's alpha = 0.95), a very high item-total correlation, and a good internal consistency of 0.892 measured by split half. Moreover, the Persian version of the DES-II questionnaire demonstrated convergent validity of the scale. Analyses of the DES-II subscales revealed significant differences for amnesic experiences, absorption/imaginative involvement, and depersonalization/derealization among healthy individuals, and patients with mood disorders as well as schizophrenia. We also found significant differences among only schizophrenia group but not mood disorders group in comparison with healthy individuals (p value = .0001, and 0.70, respectively), and between patients with schizophrenia and patients with mood disorders (p value = .03) using DES-T. As a conclusion, the Persian version of the DES-II is an appropriate, reliable, and valid tool to screen dissociative experiences and discriminate subcomponents of dissociative disorders in the Iranian population.

Acute amnestic syndromes

Acute amnestic syndromes are usually rare clinical events occurring in emergency situations. Etiological diagnosis can be challenging and underlying causes diverse. They can be transient and totally reversible, or accompanied by other neurological symptoms resulting in serious and irreversible brain damage. Pathophysiology of these syndromes mainly corresponds to structural or functional alteration of memory circuits, including those in the hippocampus. One of the most frequent forms is transient global amnesia (TGA), characterized by sudden onset of anterograde amnesia lasting less than 24  hours, in the absence of other neurological signs or symptoms. Another acute and transient memory disorder is transient epileptic amnesia (TEA), due to focal crisis activity. Stroke injuries occurring at strategic memory-related sites can also present as sudden episodes of amnesia. In addition to neurological etiologies, amnesia may be a symptom of a psychiatric disorder (dissociative amnesia). Traumatic brain injuries, autoimmune encephalitis and acute toxic metabolic disorders can also cause amnesia and should be included among the differential diagnoses. In this review, we summarize the most relevant clinical findings in acute amnestic syndromes, and discuss the different ancillary tests needed to establish a correct diagnosis and management as well the best treatment options. Relevant anatomical and pathophysiological aspects underlying these conditions will be also be presented.

Stress- and trauma-related blockade of episodic-autobiographical memory processing

Memory disorders without a direct neural substrate still belong to the riddles in neuroscience. Although they were for a while dissociated from research and clinical arenas, risking becoming forgotten diseases, they sparked novel interests, paralleling the refinements in functional neuroimaging and neuropsychology. Although Endel Tulving has not fully embarked himself on exploring this field, he had published at least one article on functional amnesia (Schacter et al., 1982) and ignited a seminal article on amnesia with mixed etiology (Craver et al., 2014). Most importantly, the research of Endel Tulving has provided the researchers and clinicians in the field of dissociative or functional amnesia with the best framework for superiorly understanding these disorders through the lens of his evolving concept of episodic memory and five long term memory systems classification, which he developed and advanced. Herein we use the classification of long-term memory systems of Endel Tulving as well as his concepts and views on autonoetic consciousness, relationships between memory systems and relationship between episodic memory and emotion to describe six cases of dissociative amnesia that put a challenge for researchers and clinicians due to their atypicality. We then discuss their possible triggering and maintaining mechanisms, pointing to their clinical heterogeneity and multifaceted causally explanatory frameworks.

A novel theory on the predictive value of variation in the β-endorphin system on the risk and severity of PTSD

Despite growing interest in genetic and psychosocial indicators of heightened susceptibility to posttraumatic stress disorder (PTSD), a predictive model, which explains why some individuals develop PTSD in response to life-threatening traumatic events, while others, when faced with the same or similar experiences, do not, has thus far remained out of reach. In this paper, we review the literature on gene-environment interactions in β-endorphin system functioning with regard to PTSD and suggest that variation, both genetic and with regard to environmental stimuli, in systems which, like the β-endorphin system, distort human perception of life-threatening traumatic experiences may account for some of the variance in resilience to the disorder. Given the role of β-endorphin in both social connections and physical exercise, this becomes especially relevant with regard to military selection, training, and leadership processes.

The Return of the Repressed: The Persistent and Problematic Claims of Long-Forgotten Trauma

Can purely psychological trauma lead to a complete blockage of autobiographical memories? This long-standing question about the existence of repressed memories has been at the heart of one of the most heated debates in modern psychology. These so-called memory wars originated in the 1990s, and many scholars have assumed that they are over. We demonstrate that this assumption is incorrect and that the controversial issue of repressed memories is alive and well and may even be on the rise. We review converging research and data from legal cases indicating that the topic of repressed memories remains active in clinical, legal, and academic settings. We show that the belief in repressed memories occurs on a nontrivial scale (58%) and appears to have increased among clinical psychologists since the 1990s. We also demonstrate that the scientifically controversial concept of dissociative amnesia, which we argue is a substitute term for memory repression, has gained in popularity. Finally, we review work on the adverse side effects of certain psychotherapeutic techniques, some of which may be linked to the recovery of repressed memories. The memory wars have not vanished. They have continued to endure and contribute to potentially damaging consequences in clinical, legal, and academic contexts.

The Dissociative Subtype of PTSD Interview (DSP-I): Development and Psychometric Properties

The inclusion of the dissociative subtype of post-traumatic stress disorder (PTSD-DS) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) reflects the importance of assessing PTSD-DS. We developed the Dissociative Subtype of PTSD Interview (DSP-I). This clinician-administered instrument assesses the presence and severity of PTSD-DS (i.e., symptoms of depersonalization or derealization) and contains a supplementary checklist that enables assessment and differentiation of other trauma-related dissociative symptoms (i.e., blanking out, emotional numbing, alterations in sensory perception, amnesia, and identity confusion). The psychometric properties were tested in 131 treatment-seeking individuals with PTSD and histories of multiple trauma, 17.6 % of whom met criteria for PTSD-DS in accordance with the DSP-I. The checklist was tested in 275 treatment-seeking individuals. Results showed the DSP-I to have high internal consistency, good convergent validity with PTSD-DS items of the CAPS-5, and good divergent validity with scales of somatization, anxiety and depression. The depersonalization and derealization scales were highly associated. Moreover, the DSP-I accounted for an additional variance in PTSD severity scores of 8% over and above the CAPS-5 and number of traumatic experiences. The dissociative experiences of the checklist were more strongly associated with scales of overall distress, somatization, depression, and anxiety than scales of depersonalization and derealization. In conclusion, the DSP-I appears to be a clinically relevant and psychometrically sound instrument that is valuable for use in clinical and research settings.

The Detachment and Compartmentalization Inventory (DCI): An assessment tool for two potentially distinct forms of dissociation

While evidence suggests a division between two qualitatively distinct forms of dissociation, no scale has been specifically designed to differentiate between them. This study describes the development and validation of the Detachment and Compartmentalization Inventory (DCI). The DCI was developed from dissociation theory, 29 existing dissociation scales and expert opinion. An initial pilot study was conducted which assessed readability, explored validity and reduced items before the DCI was administered online to 89 nonclinical and 105 clinical participants. The Dissociative Experiences Scale (DES), Somatoform Dissociation Questionnaire (SDQ), and Mindfulness Attention Awareness Scale (MAAS) were included in the survey battery. The DCI exhibited good internal reliability, discriminant validity, convergent validity, construct validity and concurrent validity. The final version containing 22-items, is self-administered, grounded in the theoretical literature and supported by initial psychometric evaluation. It has 10 items assessing compartmentalization, 10 items assessing detachment and two items examining valid responding. The DCI could detect compartmentalization and detachment, and was designed for clinical research and for screening patients.

Dissociation debates: everything you know is wrong

Controversy about dissociation and the dissociative disorders (DD) has existed since the beginning of modern psychiatry and psychology. Even among professionals, beliefs about dissociation/DD often are not based on the scientific literature. Multiple lines of evidence support a powerful relationship between dissociation/DD and psychological trauma, especially cumulative and/or early life trauma. Skeptics counter that dissociation produces fantasies of trauma, and that DD are artefactual conditions produced by iatrogenesis and/or socio-cultural factors. Almost no research or clinical data support this view. DD are common in general and clinical populations and represent a major underserved population with a substantial risk for suicidal and self-destructive behavior. Prospective treatment outcome studies of severely ill DD patients show significant improvement in symptoms including suicidal/self-destructive behaviors, with reductions in treatment cost. A major public health effort is needed to raise awareness about dissociation/DD, including educational efforts in all mental health training programs and increased funding for research.

Dissociative identity disorder: validity and use in the criminal justice system

This review examines whether the diagnosis of dissociative identity disorder (DID) could be used to support a defence of ‘not guilty by reason of insanity’ (NGRI, or the insanity defence). The problem is that DID has doubtful validity and can easily be malingered. However, the diagnosis is listed in standard psychiatric manuals. If accepted as valid, DID would have problematic forensic implications.

LEARNING OBJECTIVES

After reading this article you will be able to: •

DECLARATION OF INTEREST

None.

An Online Educational Program for Individuals With Dissociative Disorders and Their Clinicians: 1-Year and 2-Year Follow-Up

Individuals with dissociative disorders (DDs) are underrecognized, underserved, and often severely psychiatrically ill, characterized by marked dissociative and posttraumatic stress disorder (PTSD) symptoms with significant disability. Patients with DD have high rates of nonsuicidal self-injury (NSSI) and suicide attempts. Despite this, there is a dearth of training about DDs. We report the outcome of a web-based psychoeducational intervention for an international sample of 111 patients diagnosed with dissociative identity disorder (DID) or other complex DDs. The Treatment of Patients with Dissociative Disorders Network (TOP DD Network) program was designed to investigate whether, over the course of a web-based psychoeducational program, DD patients would exhibit improved functioning and decreased symptoms, including among patients typically excluded from treatment studies for safety reasons. Using video, written, and behavioral practice exercises, the TOP DD Network program provided therapists and patients with education about DDs as well as skills for improving emotion regulation, managing safety issues, and decreasing symptoms. Participation was associated with reductions in dissociation and PTSD symptoms, improved emotion regulation, and higher adaptive capacities, with overall sample |d|s = 0.44-0.90, as well as reduced NSSI. The improvements in NSSI among the most self-injurious patients were particularly striking. Although all patient groups showed significant improvements, individuals with higher levels of dissociation demonstrated greater and faster improvement compared to those lower in dissociation |d|s = 0.54-1.04 vs. |d|s  = 0.24-0.75, respectively. These findings support dissemination of DD treatment training and initiation of treatment studies with randomized controlled designs.

Fear of happiness among college students: The role of gender, childhood psychological trauma, and dissociation

AIMS

This study aimed to evaluate the fear of happiness among college students and its relationship to gender, childhood psychological trauma, and dissociation.

SETTING AND DESIGN

College students were addressed as study population, and a relational screening method was implemented.

MATERIALS AND METHODS

Among 184 participants, 93 (50.5%) were women. The Fear of Happiness Scale (FHS), the Childhood Trauma Questionnaire (CTQ), and the Dissociative Experiences Scale (DES) were administered to all participants.

STATISTICAL ANALYSIS USED

Mann-Whitney-U and Student's t-tests were implemented for comparison of groups. Pearson correlation and stepwise multiple regression analyses were conducted to identify associations between variables.

RESULTS

There were no differences on DES, FHS, and CTQ total scores between genders. DES was associated with CTQ total scores in both genders. Women had higher scores than men on childhood emotional abuse and fear of "cheerfulness ends up with bad faith." Compared to nonmembers, female dissociative taxon members had higher scores on all childhood trauma types except sexual abuse, and on all types of fear of happiness except "good fortune ends up with disaster" which was the only type of fear significantly elevated among male dissociative taxon members. A stepwise regression analysis revealed that depersonalization, childhood emotional neglect, and physical abuse predicted fear of happiness among women which was predicted by absorption among men.

CONCLUSIONS

There is a relationship between childhood psychological trauma, dissociation, and fear of happiness. Women seem to be more vulnerable in this path of obsessional thinking which affects different realms in male and female genders.

No Time Like the Present: Thinking About the Past and the Future Is Related to State Dissociation Among Individuals With High Levels of Psychopathological Symptoms

Several short-term pathways have been implicated in relation to dissociative experiences, among them are daily stress, sleepiness, and rumination. In addition, it has been claimed that mechanisms contributing to dissociative experiences may differ, according to specific psychopathological symptoms. Accordingly, this study had two aims. The first was to sample moment-to-moment increases or decreases in current stress, sleepiness, and rumination, in order to assess their temporal relations with state dissociation. Rumination was broken down to its basic two subcomponents: the negative value of the thoughts and thinking about the past (in comparison to present or future), in order to differentiate it from other repetitive thought patterns (e.g., worry). The second goal was to explore whether depression, anxiety, and obsessive–compulsive symptoms may moderate the links between the three mechanisms and specific state dissociation scales [specifically, depersonalization-derealization (DEP-DER) and absorption (ABS)]. Ninety-nine undergraduate students completed trait questionnaires and then answered state items four times a day for 4 days. These experience sampling data were analyzed using multilevel linear modeling (MLM) with Level 1 state measurements and Level 2 demographic and trait variables of the participants. Moments of stress, sleepiness, thinking about the past and negative thoughts were all associated both with state DEP-DER and with state ABS. Dissociation, negative thinking, stress, and sleepiness were positively associated with moments of thinking about the past and the future but inversely associated with moments of thinking about the present. Finally, in accordance with our expectations, the links between DEP-DER and hypothesized mechanisms were mostly moderated by depression and anxiety symptoms, whereas the links between ABS and hypothesized mechanisms were moderated mainly by obsessive–compulsive symptoms. Our findings are in accordance with literature on the efficacy of mindfulness as well as the maladaptive correlates of mind-wandering, as they suggest that dissociative detachment from one’s present occupation is associated with decreased well-being.

State-Dependent Memory: Neurobiological Advances and Prospects for Translation to Dissociative Amnesia

In susceptible individuals, overwhelming traumatic stress often results in severe abnormalities of memory processing, manifested either as the uncontrollable emergence of memories (flashbacks) or as an inability to remember events (dissociative amnesia, DA) that are usually, but not necessarily, related to the stressful experience. These memory abnormalities are often the source of debilitating psychopathologies such as anxiety, depression and social dysfunction. The question of why memory for some traumatic experiences is compromised while other comparably traumatic experiences are remembered perfectly well, both within and across individuals, has puzzled clinicians for decades. In this article, we present clinical, cognitive, and neurobiological perspectives on memory research relevant to DA. In particular, we examine the role of state dependent memory (wherein memories are difficult to recall unless the conditions at encoding and recall are similar), and discuss how advances in the neurobiology of state-dependent memory (SDM) gleaned from animal studies might be translated to humans.

Using New Approaches in Neurobiology to Rethink Stress-Induced Amnesia

Purpose of Review

Psychological stress can impact memory systems in several different ways. In individuals with healthy defense and coping systems, stress results in the formation of negatively valenced memories whose ability to induce emotional and somatic distress subsides with time. Vulnerable individuals, however, go on to develop stress-related disorders such as post-traumatic stress disorder (PTSD) and suffer from significant memory abnormalities. Whether expressed as intrusive trauma memories, partial amnesia, or dissociative amnesia, such abnormalities are thought to be the core source of patients' symptoms, which are often debilitating and implicate an entire socio-cognitive-affective spectrum.

Recent Findings

With this in mind, and focusing on stress-responsive hippocampal microcircuits, this article highlights recent advances in the neurobiology of memory that allow us to (1) isolate and visualize memory circuits, (2) change their activity using genetic tools and state-dependent manipulations, and (3) directly examine their impact on socio-affective circuits and global network connectivity. By integrating these approaches, we are now in a position to address important questions that have troubled psychiatry for a long time-questions such as are traumatic memories special, and why are stress effects on memory diverse.

Summary

Furthering our fundamental understanding of memory in the framework of adaptive and maladaptive stress responses has the potential to boost the development of new treatments that can benefit patients suffering from psychological trauma.

Brain functional integration: an epidemiologic study on stress-producing dissociative phenomena

Dissociative phenomena are common among psychiatric patients; the presence of these symptoms can worsen the prognosis, increasing the severity of their clinical conditions and exposing them to increased risk of suicidal behavior. Personality disorders as long duration stressful experiences may support the development of dissociative phenomena. In 933 psychiatric outpatients consecutively recruited, presence of dissociative phenomena was identified with the Dissociative Experience Scale (DES). Dissociative phenomena were significantly more severe in the group of people with mental disorders and/or personality disorders. All psychopathologic traits detected with the symptom checklist-90-revised had a significant correlation with the total score on the DES. Using total DES score as the dependent variable, a linear regression model was constructed. Mental and personality disorders which were associated with greater severity of dissociative phenomena on analysis of variance were included as predictors; scores from the nine scales of symptom checklist-90-revised, significantly correlated to total DES score, were used as covariates. The model consisted of seven explanatory variables (four factors and three covariates) explaining 82% of variance. The four significant factors were the presence of borderline and narcissistic personality disorder, substance abuse disorders and psychotic disorders. Significant covariates were psychopathologic traits of anger, psychoticism and obsessiveness. This study, confirming Janet's theory, explains that, mental disorders and psychopathologic experiences of patients can configure the chronic stress condition that produces functional damage to the adaptive executive system. The symptoms of dissociative depersonalization/derealization and dissociative amnesia can be explained, in large part, through their current and previous psychopathologic experiences.