Basal activity of the hypothalamic-pituitary-adrenal axis in patients with depersonalization disorder

The role of the immune system in depersonalisation disorder

OBJECTIVES

Depersonalisation-derealization disorder (DPD) is a dissociative disorder that impairs cognitive function and occupational performance. Emerging evidence indicate the levels of tumour necrosis factor-α and interleukin associated with the dissociative symptoms. In this study, we aimed to explore the role of the immune system in the pathology of DPD.

METHODS

We screened the protein expression in serum samples of 30 DPD patients and 32 healthy controls. Using a mass spectrometry-based proteomic approach, we identified differential proteins that were verified in another group of 25 DPD patients and 30 healthy controls using immune assays. Finally, we performed a correlation analysis between the expression of differential proteins and clinical symptoms of patients with DPD.

RESULTS

We identified several dysregulated proteins in patients with DPD compared to HCs, including decreased levels of C-reactive protein (CRP), complement C1q subcomponent subunit B, apolipoprotein A-IV, and increased levels of alpha-1-antichymotrypsin (SERPINA3). Moreover, the expression of CRP was positively correlated with visuospatial memory and the ability to inhibit cognitive interference of DPD. The expression of SERPINA3 was positively correlated with the ability to inhibit cognitive interference and negatively correlated with the perceptual alterations of DPD.

CONCLUSIONS

The dysregulation of the immune system may be the underlying biological mechanism in DPD. And the expressions of CRP and SERPINA3 can be the potential predictors for the cognitive performance of DPD.

Biomarkers of Pathological Dissociation: A Systematic Review

Pathological dissociation is a severe, debilitating and transdiagnostic psychiatric symptom. This review identifies biomarkers of pathological dissociation in a transdiagnostic manner to recommend the most promising research and treatment pathways in support of the precision medicine framework. A total of 205 unique studies that met inclusion criteria were included. Studies were divided into four biomarker categories, namely neuroimaging, psychobiological, psychophysiological and genetic biomarkers. The dorsomedial and dorsolateral prefrontal cortex, bilateral superior frontal regions, (anterior) cingulate, posterior association areas and basal ganglia are identified as neurofunctional biomarkers of pathological dissociation and decreased hippocampal, basal ganglia and thalamic volumes as neurostructural biomarkers. Increased oxytocin and prolactin and decreased tumor necrosis factor alpha (TNF-α) are identified as psychobiological markers. Psychophysiological biomarkers, including blood pressure, heart rate and skin conductance, were inconclusive. For the genetic biomarker category studies related to dissociation were limited and no clear directionality of effect was found to warrant identification of a genetic biomarker. Recommendations for future research pathways and possible clinical applicability are provided.

Symptoms of depersonalisation/derealisation disorder as measured by brain electrical activity: A systematic review

Depersonalisation/derealisation disorder (DPD) refers to frequent and persistent detachment from bodily self and disengagement from the outside world. As a dissociative disorder, DPD affects 1-2 % of the population, but takes 7-12 years on average to be accurately diagnosed. In this systematic review, we comprehensively describe research targeting the neural correlates of core DPD symptoms, covering publications between 1992 and 2020 that have used electrophysiological techniques. The aim was to investigate the diagnostic potential of these relatively inexpensive and convenient neuroimaging tools. We review the EEG power spectrum, components of the event-related potential (ERP), as well as vestibular and heartbeat evoked potentials as likely electrophysiological biomarkers to study DPD symptoms. We argue that acute anxiety- or trauma-related impairments in the integration of interoceptive and exteroceptive signals play a key role in the formation of DPD symptoms, and that future research needs analysis methods that can take this integration into account. We suggest tools for prospective studies of electrophysiological DPD biomarkers, which are urgently needed to fully develop their diagnostic potential.

Understanding and treating depersonalisation disorder

Depersonalisation disorder involves an unpleasant, chronic and disabling alteration in the experience of self and environment. In addition to these classic features of depersonalisation and derealisation, symptoms may also encompass alterations in bodily sensation and a loss of emotional reactivity. Primary depersonalisation disorder is probably more common than previously thought, and here we discuss the diagnosis, assessment and treatment of the condition, with particular reference to our experiences in a specialist depersonalisation clinic. We also consider psychological and biological aspects of the condition. Although there is as yet no recognised treatment for this disorder, various pharmacological interventions, particularly a combination of lamotrigine and a selective serotonin reuptake inhibitor, have shown promise. We discuss these drug treatments, together with psychological approaches, in particular a recent cognitive–behavioural conceptualisation and treatment approach.

Altered patterns of heartbeat-evoked potentials in depersonalization/derealization disorder: neurophysiological evidence for impaired cortical representation of bodily signals

OBJECTIVE

Core features of depersonalization/derealization disorder (DPD) are emotional numbing and feelings of disembodiment. Although there are several neurophysiological findings supporting subjective emotional numbing, the psychobiology of disembodiment remains unclear.

METHODS

Heartbeat-evoked potentials (HEPs), which are considered psychophysiological indicators for the cortical representation of afferent signals originating from the cardiovascular system, were assessed in 23 patients with DPD and 24 healthy control individuals during rest and while performing a heartbeat perception task.

RESULTS

Absolute HEP amplitudes did not differ between groups. Nevertheless, healthy individuals showed higher HEPs during the heartbeat perception task than during rest, whereas no such effect was found in patients with DPD (p = .031). Patients with DPD had higher total levels of salivary α-amylase than did healthy individuals (9626.6 [8200.0] versus 5344.3 [3745.8] kU min/l; p = .029), but there were no group differences in cardiovascular measures (heart rate = 76.2 [10.1] versus 74.3 [7.5] beats/min, p = .60; normalized low-frequency heart rate variability = 0.63 [0.15] versus 0.56 [0.15] normalized units, p = .099; low frequency/high frequency ratio = 249.3 [242.7] versus 164.8 [108.8], p = .10), salivary cortisol (57.5 [46.7] versus 55.1 [43.6] nmol min/l, p = .86), or cortisone levels (593.2 [260.3] versus 543.8 [257.1] nmol min/l, p = .52).

CONCLUSIONS

These results suggest altered cortical representation of afferent signals originating from the cardiovascular system in patients with DPD, which may be associated with higher sympathetic tone. These findings may reflect difficulties of patients with DPD to attend to their actual bodily experiences.

Avaliação do funcionamento do eixo HPA em deprimidos por meio de medidas basais: revisão sistemática da literatura e análise das metodologias utilizadas

Objetivo Realizar revisão sistemática da literatura para conhecer a atividade do eixo hipotálamo-pituitária-adrenal (HPA) em deprimidos considerando-se as medidas basais dos hormônios e analisar criticamente as metodologias utilizadas. Métodos Foi realizada busca de artigos nas bases de dados PubMed e SciELO. Na primeira base de dados, introduziram-se as palavras-chave “depressive disorder” e “HPA axis”, e na segunda utilizaram-se os termos “depression” ou “depressão” e “HHA” ou “HPA axis”. Optou-se por pesquisa realizada em humanos adultos, em inglês e português, do ano 2000 até 2011. Resultados Dos 27 artigos selecionados, obtiveram-se como resposta do eixo HPA tanto hiperatividade como atividade desregulada, hipoatividade ou não alteração. Tais resultados dependem das variáveis e dos hormônios estudados, do fluido coletado – plasma, urina, saliva, líquido cefalorraquidiano – do horário de coleta, do número de coletas, da análise estatística utilizada, do subtipo de doença depressiva, entre outros. Conclusão: Os resultados não apresentam consenso em relação à atividade do eixo HPA. Considerando as variáveis estudadas, o eixo HPA, na maioria das vezes, apresenta-se disfuncional na presença da depressão.

Salivary cortisol in depressed patients versus control persons: a systematic review and meta-analysis

The pathophysiology of depression has been associated to dysregulation of the hypothalamic-pituitary-adrenal axis and the use of salivary cortisol measures is increasingly being incorporated into research. The aim of the present study was to investigate whether salivary cortisol differs for patients with depression and control persons. We did a systematic review with sequential meta-analysis and meta-regression according to the PRISMA Statement based on comprehensive database searches for studies of depressed patients compared to control persons in whom salivary cortisol was measured. Twenty case-control studies, including 1354 patients with depression and 1052 control persons were identified. In a random-effects meta-analysis salivary cortisol was increased for depressed patients as compared to control persons on average 2.58 nmol/l (95% C.I.: 0.95-4.21) p=0.002 in the morning and on average 0.27 nmol/l (95% C.I.: 0.03-0.51) p=0.03 in the evening. In a fixed-effects model the mean difference was 0.58 nmol/l (95% C.I.). Study sequential cumulative meta-analyses suggested random error for the finding of this rather small difference between groups. The reference intervals for morning salivary cortisol in depressed patients (0-29 nmol/l) and control persons (1-23 nmol/l) showed substantial overlap suggesting lack of discriminative capacity. These results should be interpreted with caution as the heterogeneity for the morning analysis was large and a funnel plot, suggested presence of bias. Further, in meta-regression analyses higher intra-assay coefficients of variation in cortisol kits (p=0.07) and mean age (p=0.08) were associated with a higher mean difference of morning salivary cortisol between depressed and controls, while gender and depression severity were not. Based on the available studies there is not firm evidence for a difference of salivary cortisol in depressed patients and control persons and salivary cortisol is unable to discriminate between persons with and without depression.

Depersonalization disorder

PURPOSE OF REVIEW

There is increasing interest in depersonalization disorder, in part because of the increased community awareness of the condition via the Internet. The disorder may be more prevalent than schizophrenia but is often misdiagnosed; hence, an update is timely.

RECENT FINDINGS

Recent research has included characterization of the nosology and phenomenology of the disorder, whereas emerging evidence demonstrates a neurophysiological dampening down in addition to psychological dampening in the face of emotional stimulation.

SUMMARY

Greater understanding of the clinical characteristics of this disorder will improve the reliability of diagnosis and aid the development of neurobiological and psychological models for empirical testing. Although response to current treatments has been disappointing, recent research has identified the basis for the development of new pharmacological and psychological treatments.

Cognitive-affective neuroscience of depersonalization

Depersonalization disorder (DPD) is characterized by a subjective sense of detachment from one's own being and a sense of unreality. An examination of the psychobiology of depersonalization symptoms may be useful in understanding the cognitive-affective neuroscience of embodiment. DPD may be mediated by neurocircuitry and neurotransmitters involved in the integration of sensory processing and of the body schema, and in the mediation of emotional experience and the identification of feelings. For example, DPD has been found to involve autonomic blunting, deactivation of sub-cortical structures, and disturbances in molecular systems in such circuitry. An evolutionary perspective suggests that attenuation of emotional responses, mediated by deactivation of limbic structures, may sometimes be advantageous in response to inescapable stress.

[Depersonalisation/derealization - clinical picture, diagnostics and therapy]

The present state of knowledge about depersonalization (DP) and derealization (DR) is reviewed with respect to classification, epidemiology, etiology, and therapy. Mild and transient DP-DR are considered to be common phenomena. The prevalence of depersonalization-derealization disorder (DP-DR-D) is estimated to be approx. 1-2% of the general population in the Western hemisphere. DP-DR-D is probably severely underdiagnosed. DP-DR-D is strongly associated with depression and anxiety disorders. It is suggested that symptoms of DP-DR indicate disease severity and negatively predict therapy outcome. Neurobiological and psychological models have shown that a disordered body schema and emotional and autonomic blunting are essential components of the disorder. Despite the frequency of DPDR and its clinical relevance, there is a considerable lack of empirical research on DP-DR with respect to the health-care situation of depersonalized patients and with regard to treatment options.

Depersonalization experiences in undergraduates are related to heightened stress cortisol responses

The relationship between dissociative tendencies, as measured with the Dissociative Experiences Scale and its amnesia, absorption/imaginative involvement, and depersonalization/derealization subscales, and HPA axis functioning was studied in 2 samples of undergraduate students (N = 58 and 67). Acute stress was induced by means of the Trier Social Stress Test. Subjective and physiological stress (i.e., cortisol) responses were measured. Individuals high on the depersonalization/derealization subscale of the Dissociative Experiences Scale exhibited more pronounced cortisol responses, while individuals high on the absorption subscale showed attenuated responses. Interestingly, subjective stress experiences, as indicated by the Tension-Anxiety subscale of the Profile of Mood States, were positively related to trait dissociation. The present findings illustrate how various types of dissociation (i.e., depersonalization/derealization, absorption) are differentially related to cortisol stress responses.

The neurobiology and clinical significance of depersonalization in mood and anxiety disorders: a critical reappraisal

Depersonalization and derealization occur on a continuum of situations, from healthy individuals to a severely debilitating disorder where the symptoms can persist chronically. Since 1960s, different neurobiological models have been hypothesized and they have been associated with the temporal lobes. Recent advances in the functioning of the limbic system and the application of Geschwind's concept of disconnection in the cortico-limbic networks, pointed the role of the amygdala and its connections with medial prefrontal cortex and anterior cingulate cortex, the same structures that are strictly interlinked with the neurobiology of emotions and affective disorders. In this paper, we hypothesize that depersonalization may represent a clinical index of disease severity, poorer response to treatment and high level of comorbidity, in mood and anxiety disorders, discussing the neurobiology of depersonalization and the available clinical evidence.

[Depersonalization--current data]

OBJECTIVE

Depersonalization is a fascinating clinical phenomenon referring to a self-consciousness disorder, characterized by emotional detachment from one's own feelings, thoughts, or actions. This article intends to summarize the current literature in this area.

METHOD

Using the Medline data base, we reviewed literature addressing the clinical, etiology, nosology, physiopathology, and treatment of depersonalization.

CONCLUSIONS

Derealization means that perception of the world and of external reality are altered. These 2 phenomena are often associated. They are not specific to any psychiatric entity and are reported in many different psychiatric syndromes. Many factors, including use of different substances, are involved in their onset. The physiopathology is still little known. However, some conceptual models suggest partial amygdala inhibition combined with activation of other amygdaloid structures. A serotoninergic functioning impairment is indicated in different pharmacologic studies. Different psychotropic drugs, especially serotoninergic antidepressants, have been proposed for pharmacotherapy; however, there are no conclusive randomized studies, and the contribution of psychotherapy in treating these patients is still questioned.

Depersonalisation disorder: a contemporary overview

Depersonalisation disorder is characterised by prominent depersonalisation and often derealisation, without clinically notable memory or identity disturbances. The disorder has an approximately 1 : 1 gender ratio with onset at around 16 years of age. The course of the disorder is typically long term and often continuous. Mood, anxiety and personality disorders are often comorbid with depersonalisation disorder but none predict symptom severity. The most common immediate precipitants of the disorder are severe stress, depression and panic, and marijuana and hallucinogen ingestion. Depersonalisation disorder has also been associated with childhood interpersonal trauma, in particular emotional maltreatment. Neurochemical findings have suggested possible involvement of serotonergic, endogenous opioid and glutamatergic NMDA pathways. Brain imaging studies in depersonalisation disorder have revealed widespread alterations in metabolic activity in the sensory association cortex, as well as prefrontal hyperactivation and limbic inhibition in response to aversive stimuli. Depersonalisation disorder has also been associated with autonomic blunting and hypothalamic-pituitary-adrenal axis dysregulation. To date, treatment recommendations and guidelines for depersonalisation disorder have not been established. There are few studies assessing the use of pharmacotherapy in this disorder. Medication options that have been reported include clomipramine, fluoxetine, lamotrigine and opioid antagonists. However, it does not appear that any of these agents have a potent anti-dissociative effect. A variety of psychotherapeutic techniques has been used to treat depersonalisation disorder (including trauma-focused therapy and cognitive-behavioural techniques), although again none of these have established efficacy to date. Overall, novel therapeutic approaches are clearly needed to help individuals experiencing this refractory disorder.

Relationship between baseline cortisol, social functioning and depression: a mediation analysis

Both elevated cortisol secretion and low social support have been commonly found in depressed patients, but their respective roles in depression remain unclear. In fact, it may not be a lack of social support but a failure to obtain it that is important. The present study used mediation analysis to study the interrelationships among cortisol, social functioning and depression. Sixty healthy volunteers were recruited from the community. Depression and social functioning were measured by the Beck Depression Inventory and the Social Adaptation Self-evaluation Scale, respectively. Salivary samples were collected to measure the cortisol. Using mediation analysis, it was found that elevated cortisol secretion was a vulnerability factor for low social functioning, leading to higher depression scores. Hypercortisolaemia may be a predisposing factor and may interact with a low level of social functioning leading to depression.