1
|
Savard MA, Merlo R, Samithamby A, Paas A, Coffey EBJ. Approaches to studying emotion using physiological responses to spoken narratives: A scoping review. Psychophysiology 2024:e14642. [PMID: 38961524 DOI: 10.1111/psyp.14642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 06/07/2024] [Accepted: 06/12/2024] [Indexed: 07/05/2024]
Abstract
Narratives are effective tools for evoking emotions, and physiological measurements provide a means of objectively assessing emotional reactions - making them a potentially powerful pair of tools for studying emotional processes. However, extent research combining emotional narratives and physiological measurement varies widely in design and application, making it challenging to identify previous work, consolidate findings, and design effective experiments. Our scoping review explores the use of auditory emotional narratives and physiological measures in research, examining paradigms, study populations, and represented emotions. Following the PRISMA-ScR Checklist, we searched five databases for peer-reviewed experimental studies that used spoken narratives to induce emotion and reported autonomic physiological measures. Among 3466 titles screened and 653 articles reviewed, 110 studies were included. Our exploration revealed a variety of applications and experimental paradigms; emotional narratives paired with physiological measures have been used to study diverse topics and populations, including neurotypical and clinical groups. Although incomparable designs and sometimes contradictory results precluded general recommendations as regards which physiological measures to use when designing new studies, as a whole, the body of work suggests that these tools can be valuable to study emotions. Our review offers an overview of research employing narratives and physiological measures for emotion study, and highlights weaknesses in reporting practices and gaps in our knowledge concerning the robustness and specificity of physiological measures as indices of emotion. We discuss study design considerations and transparent reporting, to facilitate future using emotional narratives and physiological measures in studying emotions.
Collapse
Affiliation(s)
- Marie-Anick Savard
- Department of Psychology, Concordia University, Montreal, Quebec, Canada
- International Laboratory for Brain, Music and Sound Research (BRAMS), Montreal, Quebec, Canada
- Centre for Research on Brain, Language and Music (CRBLM), Montreal, Quebec, Canada
| | - Raphaëlle Merlo
- International Laboratory for Brain, Music and Sound Research (BRAMS), Montreal, Quebec, Canada
- Centre for Research on Brain, Language and Music (CRBLM), Montreal, Quebec, Canada
- École de Psychologie, Université Laval, Québec, Quebec, Canada
| | - Abiraam Samithamby
- Department of Psychology, Concordia University, Montreal, Quebec, Canada
- International Laboratory for Brain, Music and Sound Research (BRAMS), Montreal, Quebec, Canada
- Centre for Research on Brain, Language and Music (CRBLM), Montreal, Quebec, Canada
| | - Anita Paas
- Department of Psychology, Concordia University, Montreal, Quebec, Canada
- International Laboratory for Brain, Music and Sound Research (BRAMS), Montreal, Quebec, Canada
- Centre for Research on Brain, Language and Music (CRBLM), Montreal, Quebec, Canada
| | - Emily B J Coffey
- Department of Psychology, Concordia University, Montreal, Quebec, Canada
- International Laboratory for Brain, Music and Sound Research (BRAMS), Montreal, Quebec, Canada
- Centre for Research on Brain, Language and Music (CRBLM), Montreal, Quebec, Canada
- Montreal Neurological Institute (MNI), McGill University, Montreal, Quebec, Canada
| |
Collapse
|
2
|
Callus E, Gallina E, Fernandez I. EMDR: dispelling the false memory creation myth in response to Otgaar et al. (2022a). Front Psychol 2024; 15:1366137. [PMID: 38689725 PMCID: PMC11058937 DOI: 10.3389/fpsyg.2024.1366137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/03/2024] [Indexed: 05/02/2024] Open
Affiliation(s)
- Edward Callus
- Clinical Psychology Service, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Eugenio Gallina
- Centro di Ricerca e Studi in Psicotraumatologia (CRSP), Milan, Italy
| | - Isabel Fernandez
- Centro di Ricerca e Studi in Psicotraumatologia (CRSP), Milan, Italy
- Associazione EMDR Italia, Varedo, Italy
| |
Collapse
|
3
|
Boysen GA. Dissociative Identity Disorder: A Review of Research From 2011 to 2021. J Nerv Ment Dis 2024; 212:174-186. [PMID: 38412243 DOI: 10.1097/nmd.0000000000001764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
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.
Collapse
Affiliation(s)
- Guy A Boysen
- Department of Psychology, McKendree University, Lebanon, Illinois
| |
Collapse
|
4
|
Kieran K, Morse B, Margolis A. Dissociative Identity Disorder in Schools Part I. NASN Sch Nurse 2024:1942602X231223938. [PMID: 38246892 DOI: 10.1177/1942602x231223938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
Dissociation is a normal life adaptation that can become pronounced and disruptive in the setting of repeated or extreme exposure to trauma. Children and adolescents may experience dissociation due to a trauma or stressor-related disorder, anxiety, or depressive disorders. Children and adolescents also may mimic behavior they see online as a way of expressing internally painful and intolerable experiences. Myth and misinformation surround the diagnosis of dissociative identity disorder (DID), formerly multiple personality disorder. The purpose of this article is to provide school nurses with evidence-based information on DID and resources for practice regarding how to provide a secure, consistent approach to students who are being traumatized, misunderstood, or excluded at home or at school. Part 1 of this two-part series describes DID foundations and DID in school-aged children, reviews controversy spurred by social media representation, and presents the Trauma-Informed Care (TIC) model. TIC offers useful perspectives regardless of a student's presentation or diagnostic status. Part 2 will discuss recommendations for managing dissociative presentations using a team-based approach, focusing on the school nurse's roles and responsibilities.
Collapse
Affiliation(s)
- Kathryn Kieran
- Instructor MGH Institute of Health Professions, Boston, MA
| | - Brenna Morse
- Associate Professor, MGH Institute of Health Profession
| | | |
Collapse
|
5
|
Strouza AI, Lawrence AJ, Vissia EM, Kakouris A, Akan A, Nijenhuis ERS, Draijer N, Chalavi S, Reinders AATS. Identity state-dependent self-relevance and emotional intensity ratings of words in dissociative identity disorder: A controlled longitudinal study. Brain Behav 2023; 13:e3208. [PMID: 37721528 PMCID: PMC10570477 DOI: 10.1002/brb3.3208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 07/20/2023] [Accepted: 07/22/2023] [Indexed: 09/19/2023] Open
Abstract
INTRODUCTION Dissociative identity disorder (DID) is characterized by, among others, amnesic episodes and the recurrence of different dissociative identity states. While consistently observed in clinical settings, to our knowledge, no controlled research study has shown the degree to which different identity states report autobiographical knowledge over time. Hence, the current study investigates self-relevance and emotional intensity ratings of words longitudinally. METHODS Data of 46 participants were included: 13 individuals with DID, 11 DID-simulating actors, and a control group of 22 paired individuals. Individuals with DID and DID simulators participated once in the neutral identity state (NIS) and once in the trauma-related dissociative identity state (TIS). The control group paired 11 healthy controls with 11 participants with posttraumatic stress disorder (PTSD) as a NIS-TIS pair. Self-relevance ratings of different word types were collected in a baseline and a follow-up session, on average 6 weeks apart. A mixed ANOVA design was used to assess the effects of group, session, word type, and dissociative identity state. RESULTS All participants in TIS and individuals with DID in NIS rated self-relevant trauma-related words more negatively. In the NIS, the control group rated self-relevant trauma-related words as less negative, whereas the ratings of simulating actors were intermediate. There was no group-dependent longitudinal effect for intensity ratings. CONCLUSIONS This study was the first to confirm clinical observations that self-relevant and emotional processing are different between individuals with DID and controls, but consistent over time. Actors were unable to perfectly simulate DID. The finding that ratings of self-relevant trauma-related words differ between subgroups as included in the study is in line with clinical observations.
Collapse
Affiliation(s)
- Aikaterini I. Strouza
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & NeuroscienceKing's College LondonLondonUK
- Department of Psychiatry, Amsterdam UMC, Location VUmcVU University AmsterdamAmsterdamThe Netherlands
| | - Andrew J. Lawrence
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & NeuroscienceKing's College LondonLondonUK
| | | | - Andreana Kakouris
- Department of Psychosis Studies, Institute of PsychiatryKing's College LondonLondonUK
| | - Ayse Akan
- Department of Psychosis Studies, Institute of PsychiatryKing's College LondonLondonUK
- North East London NHS Foundation TrustLondonUK
| | - Ellert R. S. Nijenhuis
- Clienia Littenheid AGPrivate Clinic for Psychiatry and PsychotherapyLittenheidSwitzerland
| | - Nel Draijer
- Department of PsychiatryVU University Medical CenterAmsterdamThe Netherlands
| | - Sima Chalavi
- Movement Control and Neuroplasticity Research Group, Department of Movement SciencesKU LeuvenLeuvenBelgium
| | - Antje A. T. S. Reinders
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & NeuroscienceKing's College LondonLondonUK
| |
Collapse
|
6
|
Lanfranco RC, Martínez-Aguayo JC, Arancibia M. Assessing malingering and personality styles in dissociative identity disorder: a case study. Neurocase 2023; 29:141-150. [PMID: 38704614 DOI: 10.1080/13554794.2024.2348218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 04/15/2024] [Indexed: 05/06/2024]
Abstract
Dissociative Identity Disorder (DID), formerly Multiple Personality Disorder, involves two or more distinct identities controlling behaviour, stemming from trauma-related dissociation. Understanding DID's cognitive, neural, and psychometric aspects remains a challenge, especially in distinguishing genuine cases from malingering. We present a case of a DID patient with nine identities, evaluated to rule out malingering. Using the Millon Index of Personality Styles, we assessed the primary and two alternate identities, revealing marked differences. High consistency scores support validity. We suggest employing personality inventories beyond symptomatology to characterise dissociative identities' consistency and adaptation styles, aiding in malingering assessments in future studies.
Collapse
Affiliation(s)
- Renzo C Lanfranco
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Psychology, University of Edinburgh, Edinburgh, UK
- Center for Research in Cognition & Neurosciences, Université libre de Bruxelles, Brussels, Belgium
| | | | - Marcelo Arancibia
- Center of Translational Studies in Stress and Mental Health (C-ESTRES), Faculty of Sciences, Universidad de Valparaíso, Valparaíso, Chile
- Department of Psychiatry, School of Medicine, Faculty of Medicine, Universidad de Valparaíso, Valparaíso, Chile
| |
Collapse
|
7
|
Reinders AATS, Dimitrova LI, Schlumpf YR, Vissia EM, Dean SL, Jäncke L, Chalavi S, Veltman DJ, Nijenhuis ERS. The elusive search for a biomarker of dissociative amnesia: an overstated response to understated findings? Psychol Med 2022; 52:2837-2845. [PMID: 35855668 DOI: 10.1017/s0033291722001660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Antje A T S Reinders
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Lora I Dimitrova
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Department of Psychiatry, Amsterdam UMC, Location VUmc, VU University Amsterdam, Amsterdam, The Netherlands
| | - Yolanda R Schlumpf
- Division of Neuropsychology, Department of Psychology, University of Zurich, Zurich, Switzerland
- Clienia Littenheid AG, Private Clinic for Psychiatry and Psychotherapy, Sirnach, Switzerland
| | - Eline M Vissia
- Heelzorg, Centre for Psychotrauma, Zwolle, The Netherlands
| | - Sophie L Dean
- Department of Psychosis Studies, Institute of Psychiatry, King's College London, London, UK
| | - Lutz Jäncke
- Division of Neuropsychology, Department of Psychology, University of Zurich, Zurich, Switzerland
- Research Unit for Plasticity and Learning of the Healthy Aging Brain, University of Zurich, Zurich, Switzerland
| | - Sima Chalavi
- Movement Control and Neuroplasticity Research Group, Department of Movement Sciences, KU Leuven, Leuven, Belgium
| | - Dick J Veltman
- Department of Psychiatry, Amsterdam UMC, Location VUmc, VU University Amsterdam, Amsterdam, The Netherlands
| | - Ellert R S Nijenhuis
- Clienia Littenheid AG, Private Clinic for Psychiatry and Psychotherapy, Sirnach, Switzerland
| |
Collapse
|
8
|
Modesti MN, Rapisarda L, Capriotti G, Del Casale A. Functional Neuroimaging in Dissociative Disorders: A Systematic Review. J Pers Med 2022; 12:jpm12091405. [PMID: 36143190 PMCID: PMC9502311 DOI: 10.3390/jpm12091405] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 08/21/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Dissociative disorders encompass loss of integration in essential functions such as memory, consciousness, perception, motor control, and identity. Nevertheless, neuroimaging studies, albeit scarce, have suggested the existence of particular brain activation patterns in patients belonging to this diagnostic category. The aim of this review is to identify the main functional neuroimaging correlates of dissociative disorders. Methods: we searched the PubMed database to identify functional neuroimaging studies conducted on subjects with a diagnosis of a dissociative disorder, following the PRISMA guidelines. In the end, we included 13 studies in this systematic review, conducted on 51 patients with dissociative identity disorder (DID), 28 subjects affected by depersonalization disorder, 24 with dissociative amnesia, and 6 with other or not specified dissociative disorders. Results: Prefrontal cortex dysfunction seems prominent. In addition, changes in the functional neural network of the caudate are related to alterations of identity state and maintenance of an altered mental status in DID. Another role in DID seems to be played by a dysfunction of the anterior cingulate gyrus. Other regions, including parietal, temporal, and insular cortices, and subcortical areas were reported to be dysfunctional in dissociative disorders. Conclusions: Prefrontal dysfunction is frequently reported in dissociative disorders. Functional changes in other cortical and subcortical areas can be correlated with these diagnoses. Further studies are needed to clarify the neurofunctional correlations of each dissociative disorder in affected patients, in order to identify better tailored treatments.
Collapse
Affiliation(s)
- Martina Nicole Modesti
- Faculty of Medicine and Psychology, Sapienza University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Ludovica Rapisarda
- Faculty of Medicine and Psychology, Sapienza University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Gabriela Capriotti
- Unit of Nuclear Medicine, Department of Medical-Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sant’Andrea University Hospital, Sapienza University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Antonio Del Casale
- Unit of Psychiatry, Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, Sant’Andrea University Hospital, Sapienza University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
- Correspondence:
| |
Collapse
|
9
|
Schlumpf YR, Nijenhuis ERS, Klein C, Jäncke L, Bachmann S. Functional connectivity changes in the delta frequency band following trauma treatment in complex trauma and dissociative disorder patients. Front Psychiatry 2022; 13:889560. [PMID: 35966482 PMCID: PMC9364934 DOI: 10.3389/fpsyt.2022.889560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Phase-oriented trauma treatment is efficacious in the treatment of complex trauma and dissociative disorder patients. However, the neural correlates of this therapeutic effect are not yet well-understood. In the current study we investigated whether patients show a strengthening in functional network connectivity in the delta frequency band (1-3.5 Hz) over the course of phase-oriented inpatient trauma treatment while they performed an emotion regulation task. Further, we examined whether neural changes were associated with symptom reduction and improvement in emotion regulation skills. Methods Before and after 8 weeks of treatment, electroencephalography (EEG) was acquired in patients (n = 28) with a complex posttraumatic stress disorder (cPTSD) or complex dissociative disorder (CDD). They also completed clinical and emotion regulation questionnaires. To delimit data variability, patients participated as one dissociative part that is referred to as Apparently Normal Part (ANP). Patients' data were compared to a matched healthy control croup (n = 38), also measured twice. Results Prior to treatment, functional connectivity was significantly lower in patients compared to controls during cognitive reappraisal of unpleasant pictures and passive viewing of unpleasant and neutral pictures. These hypoconnected networks largely overlapped with networks typically activated during the recall of (emotional) autobiographical memories. Functional connectivity strength within these networks significantly increased following treatment and was comparable to controls. Patients showed symptom reduction across various clinical domains and improvement in the use of cognitive reappraisal as emotion regulation strategy. Treatment-related network normalizations were not related to changes in questionnaire data. Conclusion Phase-oriented treatment may strengthen connections between regions that are activated during autobiographical recall. These findings encourage further investigation of this circuitry as a therapeutic target in cPTSD and CDD patients. Clinial trial registration www.ClinicalTrials.gov, identifier: NCT02459340, https://www.kofam.ch/de/studienportal/suche/149284/studie/26681.
Collapse
Affiliation(s)
- Yolanda R. Schlumpf
- Division of Neuropsychology, Department of Psychology, University of Zurich, Zurich, Switzerland
- Clienia Littenheid AG, Hospital for Psychiatry and Psychotherapy, Littenheid, Switzerland
| | - Ellert R. S. Nijenhuis
- Clienia Littenheid AG, Hospital for Psychiatry and Psychotherapy, Littenheid, Switzerland
| | - Carina Klein
- Division of Neuropsychology, Department of Psychology, University of Zurich, Zurich, Switzerland
| | - Lutz Jäncke
- Division of Neuropsychology, Department of Psychology, University of Zurich, Zurich, Switzerland
- Research Unit for Plasticity and Learning of the Healthy Aging Brain, University of Zurich, Zurich, Switzerland
| | - Silke Bachmann
- Clienia Littenheid AG, Hospital for Psychiatry and Psychotherapy, Littenheid, Switzerland
- Department of Psychiatry, Psychotherapy, and Psychosomatics, University Hospitals and University of Halle (Saale), Halle, Germany
- Department of Psychiatry, University Hospitals of Geneva, Geneva, Switzerland
| |
Collapse
|
10
|
Vissia EM, Lawrence AJ, Chalavi S, Giesen ME, Draijer N, Nijenhuis ERS, Aleman A, Veltman DJ, Reinders AATS. Dissociative identity state-dependent working memory in dissociative identity disorder: a controlled functional magnetic resonance imaging study. BJPsych Open 2022; 8:e82. [PMID: 35403592 PMCID: PMC9059616 DOI: 10.1192/bjo.2022.22] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Memory function is at the core of the psychopathology of dissociative identity disorder (DID), but little is known about its psychobiological correlates. AIMS This study aims to investigate whether memory function in DID differs between dissociative identity states. METHOD Behavioural data and neural activation patterns were assessed in 92 sessions during an n-back working memory task. Participants were people with genuine diagnosed DID (n = 14), DID-simulating controls (n = 16) and a paired control group (post-traumatic stress disorder (n = 16), healthy controls (n = 16)). Both DID groups participated as authentic or simulated neutral and trauma-related identity states. Reaction times and errors of omission were analysed with repeated measures ANOVA. Working memory neural activation (main working memory and linear load) was investigated for effects of identity state, participant group and their interaction. RESULTS Identity state-dependent behavioural performance and neural activation was found. DID simulators made fewer errors of omission than those with genuine DID. Regarding the prefrontal parietal network, main working memory in the left frontal pole and ventrolateral prefrontal cortex (Brodmann area 44) was activated in all three simulated neutral states, and in trauma-related identity states of DID simulators, but not those with genuine DID or post-traumatic stress disorder; for linear load, trauma-related identity states of those with genuine DID did not engage the parietal regions. CONCLUSIONS Behavioural performance and neural activation patterns related to working memory in DID are dependent on the dissociative identities involved. The narrowed consciousness of trauma-related identity states, with a proneness to re-experiencing traumatising events, may relate to poorer working memory functioning.
Collapse
Affiliation(s)
- Eline M Vissia
- Cognitive Neuroscience Centre, University Medical Centre Groningen, University of Groningen, The Netherlands; and Centre for Psychotrauma, Heelzorg, The Netherlands
| | - Andrew J Lawrence
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| | - Sima Chalavi
- Cognitive Neuroscience Centre, University Medical Centre Groningen, University of Groningen, The Netherlands; and Research Centre for Movement Control and Neuroplasticity, Department of Movement Sciences, Katholieke Universiteit Leuven, Belgium
| | - Mechteld E Giesen
- Cognitive Neuroscience Centre, University Medical Centre Groningen, University of Groningen, The Netherlands
| | - Nel Draijer
- Department of Psychiatry, VU University Medical Center, Amsterdam University Medical Center, The Netherlands
| | | | - André Aleman
- Cognitive Neuroscience Centre, University Medical Centre Groningen, University of Groningen, The Netherlands
| | - Dick J Veltman
- Department of Psychiatry, VU University Medical Center, Amsterdam University Medical Center, The Netherlands
| | - Antje A T S Reinders
- Cognitive Neuroscience Centre, University Medical Centre Groningen, University of Groningen, The Netherlands; and Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| |
Collapse
|
11
|
Gauld C, Espi P, Revol O, Fourneret P. Explanatory hypotheses of the ecology of new clinical presentations of Dissociative Identity Disorders in youth. Front Psychiatry 2022; 13:965593. [PMID: 36299545 PMCID: PMC9589448 DOI: 10.3389/fpsyt.2022.965593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 09/15/2022] [Indexed: 11/13/2022] Open
Abstract
Dissociative Identity Disorders (DIDs) are controversial psychiatric conditions encountered in clinical practice and nosology. DID as described in the international classifications has little similarity with the clinical picture of "DID" met in current youth psychiatry. From this Perspective, we hypothesize that this current clinical presentation does not satisfy the categorical criteria of the international classifications. Based on the two terminological challenges related to the definition of DID (i.e., the notion of dissociative disorders and the different meanings of the term identity), we propose to differentiate two distinct entities from each other. The first is medical and listed in diagnostic criteria of international classifications; the second comes from popular culture and refers to the vast majority of clinical presentations received in daily clinical practice-presented under the term Dissociative Identity Conditions (DIC). Since the status of DIC is a hot topic in current clinical psychiatry, we aim to identify eight possible explanations that can be provided to support its occurrence: (1) impact of iatrogenicity; (2) factors of suggestibility and desire for social acceptability; (3) psychoanalytic explanations; (4) neuropsychological explanations; (5) socio-cognitive explanations; (6) emotional labeling; (7) narrative explanations; (8) and transient illnesses explanations. In conclusion, we sustain that DIC results from a narrative interpretation of medical discourse by popular culture, developing in patients presenting undeniable distress. Such a transient disease fits in an ecological niche, which echoes the values of society, persisting under the action of a need for narrative continuity of the self.
Collapse
Affiliation(s)
- Christophe Gauld
- Service de Psychopathologie de l'enfant et de l'adolescent, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France.,UMR CNRS 8590 IHPST, Université de la Sorbonne, Paris, France
| | - Pauline Espi
- Service de Psychopathologie de l'enfant et de l'adolescent, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France
| | - Olivier Revol
- Service de Psychopathologie de l'enfant et de l'adolescent, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France
| | - Pierre Fourneret
- Service de Psychopathologie de l'enfant et de l'adolescent, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France.,Laboratory of Social Neuroscience and Comparative Development, Institut des Sciences Cognitives, UMR5229, Université Lyon 1, Lyon, France
| |
Collapse
|
12
|
Boulet C, Lopez-Castroman J, Mouchabac S, Olié E, Courtet P, Thouvenot E, Abbar M, Conejero I. Stress response in dissociation and conversion disorders: A systematic review. Neurosci Biobehav Rev 2021; 132:957-967. [PMID: 34740754 DOI: 10.1016/j.neubiorev.2021.10.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/14/2021] [Accepted: 10/28/2021] [Indexed: 12/28/2022]
Abstract
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.
Collapse
Affiliation(s)
- Charlotte Boulet
- Department of Psychiatry, Nîmes University Hospital, Nîmes, France
| | - Jorge Lopez-Castroman
- Department of Psychiatry, Nîmes University Hospital, Nîmes, France; IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France
| | - Stéphane Mouchabac
- Saint-Antoine Hospital Center APHP, Department of Psychiatry, iCRIN Psychiatry (Infrastructure of Clinical Research in Neurosciences-Psychiatry), Brain and Spine Institute (ICM), Sorbonne University, INSERM, CNRS, 75013, Paris, France
| | - Emilie Olié
- Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital CHU Montpellier, IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France
| | - Philippe Courtet
- Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital CHU Montpellier, IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France
| | - Eric Thouvenot
- Department of Neurology, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Mocrane Abbar
- Department of Psychiatry, Nîmes University Hospital, Nîmes, France
| | - Ismael Conejero
- Department of Psychiatry, Nîmes University Hospital, Nîmes, France; IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France; Centre de Biochimie Structurale, University of Montpellier, Montpellier, France.
| |
Collapse
|
13
|
Abstract
Dissociative identity disorder (DID) is a severely debilitating disorder. Despite recognition in the current and past versions of the DSM, DID remains a controversial psychiatric disorder, which hampers its diagnosis and treatment. Neurobiological evidence regarding the aetiology of DID supports clinical observations that it is a severe form of post-traumatic stress disorder.
Collapse
Affiliation(s)
- Antje A T S Reinders
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Dick J Veltman
- Department of Psychiatry, Amsterdam University Medical Centers, Vrije Universiteit (VU) Medical Center, VU Amsterdam, The Netherlands
| |
Collapse
|
14
|
Schlumpf YR, Nijenhuis ERS, Klein C, Jäncke L, Bachmann S. Resting-state functional connectivity in patients with a complex PTSD or complex dissociative disorder before and after inpatient trauma treatment. Brain Behav 2021; 11:e02200. [PMID: 34105902 PMCID: PMC8323038 DOI: 10.1002/brb3.2200] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 04/30/2021] [Accepted: 05/09/2021] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Recent research suggests that traumatized patients are characterized by disrupted resting-state functional connectivity. We examined whether neural networks involved in resting-state change over the course of a phase-oriented inpatient treatment for complex traumatized and dissociative disorder patients. We also investigated associations between these network alterations and clinical symptoms and emotion regulation skills. METHODS Pre- and post-treatment, electroencephalography (EEG) was recorded during resting-state in patients (n = 23) with a complex dissociative disorder (CDD) or complex posttraumatic stress disorder (cPTSD). Patients also completed clinical and emotion regulation questionnaires. To reduce variance in the collected data, patients were exclusively tested as one prototypical dissociative part referred to as Apparently Normal Part (ANP). Functional network connectivity was examined and compared with a matched healthy control group (n = 37), also measured twice. RESULTS Prior to treatment and compared with controls, patients had a significantly lower functional connectivity strength within eyes-open and eyes-closed resting-state networks in the theta and alpha frequency band. Following treatment, functional connectivity strength within these networks was comparable to the control group and comprised areas belonging to the default mode network (DMN) and prefrontal as well as anterior cingulate control regions. Treatment-related network normalizations in the theta frequency band were associated with a self-reported increase in the use of cognitive reappraisal strategies and reduction in emotion regulation difficulties. CONCLUSION Phase-oriented trauma treatment can strengthen resting-state network connectivity and can increase the capacity of complex traumatized and dissociative patients as ANP to handle emotional challenges effectively.
Collapse
Affiliation(s)
- Yolanda R. Schlumpf
- Division of Neuropsychology, Department of PsychologyUniversity of ZurichZurichSwitzerland
- Clienia Littenheid AGHospital for Psychiatry and PsychotherapyLittenheidSwitzerland
| | | | - Carina Klein
- Division of Neuropsychology, Department of PsychologyUniversity of ZurichZurichSwitzerland
| | - Lutz Jäncke
- Division of Neuropsychology, Department of PsychologyUniversity of ZurichZurichSwitzerland
- Research Unit for Plasticity and Learning of the Healthy Aging BrainUniversity of ZurichZurichSwitzerland
| | - Silke Bachmann
- Department of Psychiatry, Psychotherapy, and PsychosomaticsUniversity Hospitals and University of Halle (Saale)HalleGermany
- Department of PsychiatryUniversity Hospitals of GenevaGenevaSwitzerland
| |
Collapse
|
15
|
Piedfort-Marin O, Rignol G, Tarquinio C. Le trouble dissociatif de l’identité : les mythes à l’épreuve des recherches scientifiques. ANNALES MEDICO-PSYCHOLOGIQUES 2021. [DOI: 10.1016/j.amp.2021.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
16
|
Dorahy MJ, Huntjens RJC, Marsh RJ, Johnson B, Fox K, Middleton W. The Sense of Self Over Time: Assessing Diachronicity in Dissociative Identity Disorder, Psychosis and Healthy Comparison Groups. Front Psychol 2021; 12:620063. [PMID: 33633645 PMCID: PMC7902028 DOI: 10.3389/fpsyg.2021.620063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/04/2021] [Indexed: 11/17/2022] Open
Abstract
Dissociative experiences have been associated with diachronic disunity. Yet, this work is in its infancy. Dissociative identity disorder (DID) is characterized by different identity states reporting their own relatively continuous sense of self. The degree to which patients in dissociative identity states experience diachronic unity (i.e., sense of self over time) has not been empirically explored. This study examined the degree to which patients in dissociative identity states experienced diachronic unity. Participants were DID adults (n=14) assessed in adult and child identity states, adults with a psychotic illness (n=19), adults from the general population (n=55), children from the general population (n=26) and adults imagining themselves as children (n=23). They completed the Diachronic Disunity Scale (DDS), the Dissociative Experiences Scale (DES), and the Self-Concept Clarity Scale (SCCS). Diachronic disunity was not limited to psychiatric groups, but evident to some degree in all adult and child samples. The DID adult sample experienced more dissociation and self-confusion than the psychosis and adult comparison groups, but did not differ on the diachronic measure. DID patients in their child identity states and child comparisons showed disunity and were significantly different from child simulators, who showed relatively more unity. Results suggest that DID patients in either adult or child dissociative identity states, like those in other samples, do not universally experience themselves as having a consistent sense of self over time.
Collapse
Affiliation(s)
- Martin J Dorahy
- School of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand.,The Cannan Institute, Belmont Private Hospital, Brisbane, QLD, Australia
| | - Rafaële J C Huntjens
- Department of Clinical Psychology, University of Groningen, Groningen, Netherlands
| | - Rosemary J Marsh
- School of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand.,Department of Clinical Psychology, University of Groningen, Groningen, Netherlands
| | - Brooke Johnson
- School of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand
| | - Kate Fox
- School of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand
| | - Warwick Middleton
- School of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand.,The Cannan Institute, Belmont Private Hospital, Brisbane, QLD, Australia
| |
Collapse
|
17
|
Blihar D, Delgado E, Buryak M, Gonzalez M, Waechter R. A systematic review of the neuroanatomy of dissociative identity disorder. EUROPEAN JOURNAL OF TRAUMA & DISSOCIATION 2020. [DOI: 10.1016/j.ejtd.2020.100148] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
18
|
Moskowitz A, van der Hart O. Historical and contemporary conceptions of trauma-related dissociation: A neo-Janetian critique of models of divided personality. EUROPEAN JOURNAL OF TRAUMA & DISSOCIATION 2020. [DOI: 10.1016/j.ejtd.2019.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
19
|
Smith GP, Hartelius G. Resolution of Dissociated Ego States Relieves Flashback-Related Symptoms in Combat-Related PTSD: A Brief Mindfulness Based Intervention. MILITARY PSYCHOLOGY 2020; 32:135-148. [PMID: 38536266 PMCID: PMC10013259 DOI: 10.1080/08995605.2019.1654292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 08/07/2019] [Indexed: 10/25/2022]
Abstract
A novel understanding and therapeutic approach to the treatment of PTSD-related flashback triggers are described. Triggered responses are conceptualized as the result of latent dissociative structures of neural organization and psychodynamic functioning activated by current events. The dissociative structure - here described as a dissociated ego state (DES) - reflects a fracturing of executive functioning resulting in a delimited aspect of self that is not under cognitive control or subject to cognitive inhibition by the self of daily experience, and is the psychological construct behind intrusive PTSD symptoms. Use of a mindful attentional state permits regulated access to the DES (therapeutic engagement without risk of emotional dysregulation) so that dissociated cognitive resources can be recovered and the dissociated structure deactivated. This may relieve maladaptive responses and behaviors associated with the DES in a profound and durable way, without the need for exposure to or recovery of traumatic memories. Based on this understanding, a 9-step intervention is introduced with a case example of a Vietnam veteran suffering PTSD symptoms for 49 years with significant gains maintained at 21 months follow up. These findings demonstrate rapid and durable resolution of chronic PTSD symptoms through a mindfulness-based approach that focused on deactivation of dissociated ego states, in contrast to targeting trauma memories. If proven efficacious, this novel approach may result in reduced treatment costs and improved outcomes for veterans suffering with PTSD.
Collapse
Affiliation(s)
- Genine P. Smith
- Department of Integral and Transpersonal Psychology, California Institute of Integral Studies, San Francisco, California, USA
| | - Glenn Hartelius
- Department of Integral and Transpersonal Psychology, California Institute of Integral Studies, San Francisco, California, USA
| |
Collapse
|
20
|
Huntjens RJC, Rijkeboer MM, Arntz A. Schematherapy in DID: treatment length and related studies on dissociative amnesia. Eur J Psychotraumatol 2020; 11:1711638. [PMID: 32002144 PMCID: PMC6968667 DOI: 10.1080/20008198.2020.1711638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- R J C Huntjens
- Department of Experimental Psychotherapy and Psychopathology, University of Groningen, Groningen, Netherlands
| | - M M Rijkeboer
- Department of Clinical Psychological Science, Maastricht University, Maastricht, Netherlands
| | - A Arntz
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
21
|
Dimitrova L, Fernando V, Vissia EM, Nijenhuis ERS, Draijer N, Reinders AATS. Sleep, trauma, fantasy and cognition in dissociative identity disorder, post-traumatic stress disorder and healthy controls: a replication and extension study. Eur J Psychotraumatol 2020; 11:1705599. [PMID: 32082509 PMCID: PMC7006753 DOI: 10.1080/20008198.2019.1705599] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/14/2019] [Accepted: 11/13/2019] [Indexed: 10/26/2022] Open
Abstract
Background: Two aetiology models for dissociative identity disorder (DID) have been proposed, namely a childhood Trauma Model and an iatrogenic or Fantasy model. A recent study indicated that sleep disturbances underlie dissociative symptomatology. Objective: Our current study aims to test whether this finding can be replicated in an independent sample and to investigate if this finding still holds after correcting for childhood and adult traumatization. An experimental working memory task is included to investigate how sleep disturbance, traumatization, dissociation, and fantasy proneness impact cognitive functioning. Methods: Three groups of participants were included - individuals with DID, individuals with post-traumatic stress disorder (PTSD), and matched healthy controls. Sleep disturbances were measured and compared between the groups along with measures of childhood and adult traumatization, psychoform and somatoform [psychological and somatic] dissociative symptoms, and fantasy proneness. Cognitive capacity was assessed using a working memory task. Results: When controlled for traumatic experiences, sleep disturbances did not predict dissociative symptoms. When controlled for sleep disturbance and fantasy proneness, childhood traumatization did predict dissociative symptoms. Psychoform dissociative symptoms correlated with traumatic experiences more than with fantasy proneness. Working memory performance was similar among the participating groups. Propensity to fantasy did not discriminate individuals with DID and PTSD, and was a weak predictor of dissociative symptoms. Conclusion: Whereas DID and PTSD are associated with sleep disturbances, these features do not statistically predict dissociative symptoms in these disorders when traumatic experiences are taken into account. Fantasy proneness is not excessive in DID and PTSD. Hence, we found no evidence that sleep disturbances, propensity to fantasy and abnormal working memory capacity explain dissociative symptoms in DID and PTSD. In sum, the relationship between sleep and dissociative symptoms disappeared when potentially traumatizing events were controlled for.
Collapse
Affiliation(s)
- Lora Dimitrova
- Department of Psychosis Studies, Institute of Psychiatry, King's College London, London, UK.,Department of Psychiatry, Amsterdam UMC, location VUMC, VU University Amsterdam, Amsterdam, the Netherlands
| | - Vinuri Fernando
- Department of Psychosis Studies, Institute of Psychiatry, King's College London, London, UK.,Department of Psychiatry, Amsterdam UMC, location VUMC, VU University Amsterdam, Amsterdam, the Netherlands
| | - Eline M Vissia
- Heelzorg, Centre for Psychotrauma, Zwolle, The Netherlands
| | - Ellert R S Nijenhuis
- Clienia Littenheid AG, Private Clinic for Psychiatry and Psychotherapy, Littenheid, Switzerland
| | - Nel Draijer
- Department of Psychiatry, VU University Medical Center, Amsterdam, The Netherlands
| | - Antje A T S Reinders
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| |
Collapse
|
22
|
Paris J. Dissociative identity disorder: validity and use in the criminal justice system. BJPSYCH ADVANCES 2019. [DOI: 10.1192/bja.2019.12] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SUMMARYThis 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 OBJECTIVESAfter reading this article you will be able to:
•understand the history of the DID diagnosis•evaluate the validity of the DID diagnosis•appreciate, from case law, use of DID in support of an insanity defence.DECLARATION OF INTERESTNone.
Collapse
|
23
|
Nijenhuis ERS, van der Hart O, Schlumpf YR, Vissia EM, Reinders AATS. Considerations regarding treatment efficiency, dissociative parts and dissociative amnesia for Huntjens et al.'s Schema Therapy for Dissociative Identity Disorder. Eur J Psychotraumatol 2019; 10:1687081. [PMID: 31762956 PMCID: PMC6853204 DOI: 10.1080/20008198.2019.1687081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Ellert R S Nijenhuis
- Clienia Littenheid AG, Hospital for Psychiatry and Psychotherapy, Littenheid, Switzerland
| | - Onno van der Hart
- Department of Clinical and Health Psychology, Utrecht University, Utrecht, The Netherlands
| | - Yolanda R Schlumpf
- Clienia Littenheid AG, Hospital for Psychiatry and Psychotherapy, Littenheid, Switzerland.,Division of Neuropsychology, Institute of Psychology, University of Zurich, Switzerland
| | - Eline M Vissia
- GGZ centraal, Top Referent Trauma Centrum, Ermelo, The Netherlands
| | - Antje A T S Reinders
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, London, UK
| |
Collapse
|
24
|
Trauma-Related Dissociation Is No Fantasy: Addressing the Errors of Omission and Commission in Merckelbach and Patihis (2018). PSYCHOLOGICAL INJURY & LAW 2018. [DOI: 10.1007/s12207-018-9336-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
|
25
|
Schiavone FL, McKinnon MC, Lanius RA. Psychotic-Like Symptoms and the Temporal Lobe in Trauma-Related Disorders: Diagnosis, Treatment, and Assessment of Potential Malingering. CHRONIC STRESS 2018; 2:2470547018797046. [PMID: 32440584 PMCID: PMC7219949 DOI: 10.1177/2470547018797046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 07/30/2018] [Indexed: 11/17/2022]
Abstract
Objective To overview the phenomenology, etiology, assessment, and treatment of psychotic-like symptoms in trauma-related disorders focusing on the proposed role of temporal lobe dysfunction. Method We describe the literature pertaining to (i) psychotic-like symptoms and temporal lobe dysfunction in trauma-related disorders and (ii) psychological testing profiles in trauma-related disorders. We define trauma-related disorders as borderline personality disorder, post-traumatic stress disorder, and the dissociative disorders. Our search terms were dissociative disorders, temporal lobe, trauma, post-traumatic stress disorder, borderline personality disorder, psychosis, and malingering. Results Trauma-related psychotic-like symptoms are common and can differ in phenomenology from primary psychotic symptoms. Hallucinations consist of auditory and nonauditory content that may or may not relate to traumatic content. Child voices are highly suggestive of complex dissociative disorders. Critically, not only do these symptoms resemble those seen in temporal lobe epilepsy, but the temporal lobe is implicated in trauma-related disorders, thus providing a plausible neurobiological explanation. Despite such evidence, these symptoms are frequently considered atypical and misdiagnosed. Indeed, common structured psychological assessment tools categorize these symptoms as possible indicators of invalid testing profiles. Conclusion Psychotic-like symptoms are common in trauma-related disorders, may be related to temporal lobe dysfunction, and are frequently misinterpreted. This may lead to ineffective treatment and inappropriate determinations of malingering in the forensic system.
Collapse
Affiliation(s)
| | - Margaret C McKinnon
- Mood Disorders Program, St. Joseph's Healthcare, Hamilton, Ontario, Canada.,Department of Psychiatry and Behavioural Neuroscience, McMaster University, Hamilton, Ontario, Canada.,Homewood Research Institute, Guelph, Ontario, Canada
| | - Ruth A Lanius
- Department of Psychiatry, University of Western Ontario, London, Ontario, Canada.,Department of Neuroscience, University of Western Ontario, London, Ontario, Canada
| |
Collapse
|
26
|
Stevanovic D, Brajkovic L, Srivastava MK, Krgovic I, Jancic J. Widespread cortical PET abnormalities in an adolescent related to a PNES dissociative state, PTSD, ADHD, and domestic violence exposure. Scand J Child Adolesc Psychiatr Psychol 2018; 6:98-106. [PMID: 33520757 PMCID: PMC7703842 DOI: 10.21307/sjcapp-2018-011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Accumulated evidence indicates that exposure to trauma is associated with the development of cognitive impairments and psychiatric symptoms in children and adolescents. OBJECTIVE In this case study of a female adolescent of 17 years, we aimed to evaluate how cortical positron emission tomography (PET) abnormalities relate to psychogenic non-epileptic seizure (PNES) dissociative state, post-traumatic stress disorder (PTSD), attention-deficit/hyperactivity disorder (ADHD), and domestic violence exposure. METHODS Detailed psychiatric and neuropsychological assessment was performed initially, followed by a PET study. The PET imaging was carried out in the resting-state and in the dissociative-state. RESULTS The adolescent was suffering from multiple episodes of unconsciousness, all found to be psychogenic; thus, PNES was diagnosed. However, at the psychopathology symptom level, the adolescent had heightened impulsivity, hyperactivity, hyperarousal, anxiety, somatic, and dissociative/ functional neurological symptoms present separately or concurrently at some point during her life; thus, the criteria for PTSD and ADHD were also fulfilled. In the resting state, significant hypometabolism was observed in the occipital, occipitotemporal, polar, and mesial parts of the temporal regions bilaterally, fronto-parietal medial and lateral pericental regions, and fronto-temporal and insular region on the left. The most intense metabolism was observed in the posterior cingulate gyrus and the medial parts of the posterior parietal lobe. In the dissociative state, there was a slight increase in the metabolism of the brain globally compared with the resting state, but with identical distribution of the regional changes observed. CONCLUSIONS Widespread cortical PET abnormalities were found, possibly indicating alterations in large-scale brain networks, in a patient with PNES and a dissociative state, PTSD, and ADHD, who was exposed to chronic domestic violence.
Collapse
Affiliation(s)
- Dejan Stevanovic
- Clinic of Neurology and Psychiatry for Children and Youth, Belgrade, Serbia
| | - Leposava Brajkovic
- University of Belgrade Center for Nuclear Medicine, Clinical Center of Serbia, Belgrade, Serbia
| | | | - Ivan Krgovic
- Clinic of Neurology and Psychiatry for Children and Youth, Belgrade, Serbia
| | - Jasna Jancic
- Clinic of Neurology and Psychiatry for Children and Youth, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| |
Collapse
|
27
|
Gupta MA, Pur DR. Obstructive Sleep Apnea Severity in Dissociative Identity Disorder can Vary Significantly Depending Upon the Autonomic Activation Status of the Personality That Has Executive Control. J Clin Sleep Med 2018; 14:1633. [PMID: 30176981 DOI: 10.5664/jcsm.7356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 06/22/2018] [Indexed: 11/13/2022]
Affiliation(s)
- Madhulika A Gupta
- Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Daiana R Pur
- Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| |
Collapse
|
28
|
Gerge A. REVISITING THE SAFE PLACE:Method and Regulatory Aspects in Psychotherapy when Easing Allostatic Overload in Traumatized Patients. Int J Clin Exp Hypn 2018; 66:147-173. [PMID: 29601274 DOI: 10.1080/00207144.2018.1421356] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Safe-place inductions are considered important altered states of consciousness (ASC) to be (re)installed during trauma-informed psychotherapy. Coregulation aimed at changing implicit relational knowing and increasing integration and coherence through relational work and hypnotic techniques is crucial, as clients' abilities to self-soothe and regulate have become seriously impaired. Thus, resource-oriented metaphors as inner strength imagery is advocated. Also, methods such as creative-arts therapy and neurofeedback will induce ASCs, as most methods used with complex traumatized clients, due to their high hypnotizability. When positive or soothing imagery or relationally held suggestions for changed attentional focus are added to both psychodynamic psychotherapy and CBT, a hetero-hypnosis will be induced-a prerequisite for phase-specific trauma therapy aimed at changing inner schemas and scripts.
Collapse
|
29
|
Reinders AATS, Chalavi S, Schlumpf YR, Vissia EM, Nijenhuis ERS, Jäncke L, Veltman DJ, Ecker C. Neurodevelopmental origins of abnormal cortical morphology in dissociative identity disorder. Acta Psychiatr Scand 2018; 137:157-170. [PMID: 29282709 DOI: 10.1111/acps.12839] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To examine the two constitutes of cortical volume (CV), that is, cortical thickness (CT) and surface area (SA), in individuals with dissociative identity disorder (DID) with the view of gaining important novel insights into the underlying neurobiological mechanisms mediating DID. METHODS This study included 32 female patients with DID and 43 matched healthy controls. Between-group differences in CV, thickness, and SA, the degree of spatial overlap between differences in CT and SA, and their relative contribution to differences in regional CV were assessed using a novel spatially unbiased vertex-wise approach. Whole-brain correlation analyses were performed between measures of cortical anatomy and dissociative symptoms and traumatization. RESULTS Individuals with DID differed from controls in CV, CT, and SA, with significantly decreased CT in the insula, anterior cingulate, and parietal regions and reduced cortical SA in temporal and orbitofrontal cortices. Abnormalities in CT and SA shared only about 3% of all significantly different cerebral surface locations and involved distinct contributions to the abnormality of CV in DID. Significant negative associations between abnormal brain morphology (SA and CV) and dissociative symptoms and early childhood traumatization (0 and 3 years of age) were found. CONCLUSIONS In DID, neuroanatomical areas with decreased CT and SA are in different locations in the brain. As CT and SA have distinct genetic and developmental origins, our findings may indicate that different neurobiological mechanisms and environmental factors impact on cortical morphology in DID, such as early childhood traumatization.
Collapse
Affiliation(s)
- A A T S Reinders
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,Department of Neuroscience, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - S Chalavi
- Department of Neuroscience, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Biomedical Kinesiology, Research Center for Movement Control and Neuroplasticity, KU Leuven, Leuven, Belgium
| | - Y R Schlumpf
- Division of Neuropsychology, Institute of Psychology, University of Zurich, Zurich, Switzerland.,Private Clinic for Psychiatry and Psychotherapy, Clienia Littenheid AG, Littenheid, Switzerland
| | - E M Vissia
- Department of Neuroscience, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - E R S Nijenhuis
- Private Clinic for Psychiatry and Psychotherapy, Clienia Littenheid AG, Littenheid, Switzerland
| | - L Jäncke
- Division of Neuropsychology, Institute of Psychology, University of Zurich, Zurich, Switzerland.,Research Unit for Plasticity and Learning of the Healthy Aging Brain, University of Zurich, Zurich, Switzerland
| | - D J Veltman
- Department of Psychiatry, VU University Medical Center, Amsterdam, The Netherlands
| | - C Ecker
- Department of Child & Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, Goethe University, Frankfurt am Main, Germany.,Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK
| |
Collapse
|
30
|
Brand BL, Schielke HJ, Brams JS. Assisting the Courts in Understanding and Connecting with Experiences of Disconnection: Addressing Trauma-Related Dissociation as a Forensic Psychologist, Part I. PSYCHOLOGICAL INJURY & LAW 2017. [DOI: 10.1007/s12207-017-9304-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
|
31
|
Ribáry G, Lajtai L, Demetrovics Z, Maraz A. Multiplicity: An Explorative Interview Study on Personal Experiences of People with Multiple Selves. Front Psychol 2017; 8:938. [PMID: 28659840 PMCID: PMC5468408 DOI: 10.3389/fpsyg.2017.00938] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 05/22/2017] [Indexed: 11/13/2022] Open
Abstract
Background and aims: Personality psychology research relies on the notion that humans have a single self that is the result of the individual's thoughts, feelings, and behaviors that can be reliably described (i.e., through traits). People who identify themselves as "multiple" have a system of multiple or alternative, selves, that share the same physical body. This is the first study to explore the phenomenon of multiplicity by assessing the experiences of people who identify themselves as "multiple." Methods: First, an Internet forum search was performed using the terms "multiplicity" and "multiple system." Based on that search, people who identified themselves as multiple were contacted. Interviews were conducted by a consultant psychiatrist, which produced six case vignettes. Results: Multiplicity is discussed on Twitter, Tumblr, Google+ and several other personal websites, blogs, and forums maintained by multiples. According to the study's estimates, there are 200-300 individuals who participate in these forums and believe they are multiple. Based on the six interviews, it appears that multiples have several selves who are relatively independent of each other and constitute the personality's system. Each "resident person" or self, has their own unique behavioral pattern, which is triggered by different situations. However, multiples are a heterogeneous group in terms of their system organization, memory functions, and control over switching between selves. Conclusions: Multiplicity can be placed along a continuum between identity disturbance and dissociative identity disorder (DID), although most systems function relatively well in everyday life. Further research is needed to explore this phenomenon, especially in terms of the extent to which multiplicity can be regarded as a healthy way of coping.
Collapse
Affiliation(s)
- Gergő Ribáry
- Department of Clinical Psychology and Addiction, Institute of Psychology, Eötvös Loránd UniversityBudapest, Hungary
| | - László Lajtai
- Department of Clinical Psychology and Addiction, Institute of Psychology, Eötvös Loránd UniversityBudapest, Hungary
| | - Zsolt Demetrovics
- Department of Clinical Psychology and Addiction, Institute of Psychology, Eötvös Loránd UniversityBudapest, Hungary
| | - Aniko Maraz
- Department of Clinical Psychology and Addiction, Institute of Psychology, Eötvös Loránd UniversityBudapest, Hungary
| |
Collapse
|
32
|
Bailey TD, Brand BL. Traumatic dissociation: Theory, research, and treatment. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/cpsp.12195] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
33
|
Şar V, Dorahy MJ, Krüger C. Revisiting the etiological aspects of dissociative identity disorder: a biopsychosocial perspective. Psychol Res Behav Manag 2017; 10:137-146. [PMID: 28496375 PMCID: PMC5422461 DOI: 10.2147/prbm.s113743] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Dissociative identity disorder (DID) is a chronic post-traumatic disorder where developmentally stressful events in childhood, including abuse, emotional neglect, disturbed attachment, and boundary violations are central and typical etiological factors. Familial, societal, and cultural factors may give rise to the trauma and/or they may influence the expression of DID. Memory and the construction of self-identity are cognitive processes that appear markedly and centrally disrupted in DID and are related to its etiology. Enduring decoupling of psychological modes may create separate senses of self, and metamemory processes may be involved in interidentity amnesia. Neurobiological differences have been demonstrated between dissociative identities within patients with DID and between patients with DID and controls. Given the current evidence, DID as a diagnostic entity cannot be explained as a phenomenon created by iatrogenic influences, suggestibility, malingering, or social role-taking. On the contrary, DID is an empirically robust chronic psychiatric disorder based on neurobiological, cognitive, and interpersonal non-integration as a response to unbearable stress. While current evidence is sufficient to firmly establish this etiological stance, given the wide opportunities for innovative research, the disorder is still understudied. Comparison of well-selected samples of DID patients with non-dissociative subjects who have other psychiatric disorders would further delineate the neurobiological and cognitive features of the disorder, whereas genetic research on DID would further illuminate the interaction of the individual with environmental stress. As such, DID may be seen as an exemplary disease model of the biopsychosocial paradigm in psychiatry.
Collapse
Affiliation(s)
- Vedat Şar
- Department of Psychiatry, Koç University School of Medicine, Istanbul, Turkey
| | - Martin J Dorahy
- Department of Psychology, University of Canterbury, Christchurch, New Zealand
| | - Christa Krüger
- Department of Psychiatry, University of Pretoria, Pretoria, South Africa
| |
Collapse
|
34
|
Research and clinical issues in trauma and dissociation: Ethical and logical fallacies, myths, misreports, and misrepresentations. EUROPEAN JOURNAL OF TRAUMA & DISSOCIATION 2017. [DOI: 10.1016/j.ejtd.2017.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
35
|
Chiu CD, Chang JH, Hui CM. Self-concept integration and differentiation in subclinical individuals with dissociation proneness. SELF AND IDENTITY 2017. [DOI: 10.1080/15298868.2017.1296491] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Chui-De Chiu
- Department of Psychology, The Chinese University of Hong Kong, Hong Kong SAR, The People’s Republic of China
| | - Jen-Ho Chang
- Institute of Ethnology, Academia Sinica, Taipei, Taiwan
| | - Chin Ming Hui
- Department of Psychology, The Chinese University of Hong Kong, Hong Kong SAR, The People’s Republic of China
| |
Collapse
|
36
|
Nijenhuis ER. Ten reasons for conceiving and classifying posttraumatic stress disorder as a dissociative disorder. EUROPEAN JOURNAL OF TRAUMA & DISSOCIATION 2017. [DOI: 10.1016/j.ejtd.2017.01.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
37
|
Dorahy MJ. Using the past to fertilize but not determine the future: Reflections on dissociation in the International Society for the Study of Trauma and Dissociation. J Trauma Dissociation 2017; 18:1-10. [PMID: 27429395 DOI: 10.1080/15299732.2016.1213779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Martin J Dorahy
- a Department of Psychology , University of Canterbury , Christchurch , New Zealand.,b The Cannan Institute, Belmont Private Hospital , Brisbane , Australia
| |
Collapse
|
38
|
McKinnon MC, Boyd JE, Frewen PA, Lanius UF, Jetly R, Richardson JD, Lanius RA. A review of the relation between dissociation, memory, executive functioning and social cognition in military members and civilians with neuropsychiatric conditions. Neuropsychologia 2016; 90:210-34. [DOI: 10.1016/j.neuropsychologia.2016.07.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 06/16/2016] [Accepted: 07/16/2016] [Indexed: 01/01/2023]
|
39
|
Vissia EM, Giesen ME, Chalavi S, Nijenhuis ERS, Draijer N, Brand BL, Reinders AATS. Is it Trauma- or Fantasy-based? Comparing dissociative identity disorder, post-traumatic stress disorder, simulators, and controls. Acta Psychiatr Scand 2016; 134:111-28. [PMID: 27225185 DOI: 10.1111/acps.12590] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2016] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The Trauma Model of dissociative identity disorder (DID) posits that DID is etiologically related to chronic neglect and physical and/or sexual abuse in childhood. In contrast, the Fantasy Model posits that DID can be simulated and is mediated by high suggestibility, fantasy proneness, and sociocultural influences. To date, these two models have not been jointly tested in individuals with DID in an empirical manner. METHOD This study included matched groups [patients (n = 33) and controls (n = 32)] that were compared on psychological Trauma and Fantasy measures: diagnosed genuine DID (DID-G, n = 17), DID-simulating healthy controls (DID-S, n = 16), individuals with post-traumatic stress disorder (PTSD, n = 16), and healthy controls (HC, n = 16). Additionally, personality-state-dependent measures were obtained for DID-G and DID-S; both neutral personality states (NPS) and trauma-related personality states (TPS) were tested. CONCLUSION For Trauma measures, the DID-G group had the highest scores, with TPS higher than NPS, followed by the PTSD, DID-S, and HC groups. The DID-G group was not more fantasy-prone or suggestible and did not generate more false memories. Malingering measures were inconclusive. Evidence consistently supported the Trauma Model of DID and challenges the core hypothesis of the Fantasy Model.
Collapse
Affiliation(s)
- E M Vissia
- Department of Neuroscience, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - M E Giesen
- Department of Neuroscience, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - S Chalavi
- Department of Neuroscience, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Biomedical Kinesiology, Research Center for Movement Control and Neuroplasticity, KU Leuven, Leuven, Belgium
| | - E R S Nijenhuis
- Clienia Littenheid, Psychiatrische Klinik, Littenheid, Switzerland
| | - N Draijer
- Department of Psychiatry, VU University Medical Center, Amsterdam, The Netherlands
| | - B L Brand
- Psychology Department, Towson University, Towson, MD, USA
| | - A A T S Reinders
- Department of Neuroscience, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| |
Collapse
|
40
|
Brand BL, Sar V, Stavropoulos P, Krüger C, Korzekwa M, Martínez-Taboas A, Middleton W. Separating Fact from Fiction: An Empirical Examination of Six Myths About Dissociative Identity Disorder. Harv Rev Psychiatry 2016; 24:257-70. [PMID: 27384396 PMCID: PMC4959824 DOI: 10.1097/hrp.0000000000000100] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 01/27/2015] [Accepted: 05/22/2015] [Indexed: 01/08/2023]
Abstract
Dissociative identity disorder (DID) is a complex, posttraumatic, developmental disorder for which we now, after four decades of research, have an authoritative research base, but a number of misconceptualizations and myths about the disorder remain, compromising both patient care and research. This article examines the empirical literature pertaining to recurrently expressed beliefs regarding DID: (1) belief that DID is a fad, (2) belief that DID is primarily diagnosed in North America by DID experts who overdiagnose the disorder, (3) belief that DID is rare, (4) belief that DID is an iatrogenic, rather than trauma-based, disorder, (5) belief that DID is the same entity as borderline personality disorder, and (6) belief that DID treatment is harmful to patients. The absence of research to substantiate these beliefs, as well as the existence of a body of research that refutes them, confirms their mythical status. Clinicians who accept these myths as facts are unlikely to carefully assess for dissociation. Accurate diagnoses are critical for appropriate treatment planning. If DID is not targeted in treatment, it does not appear to resolve. The myths we have highlighted may also impede research about DID. The cost of ignorance about DID is high not only for individual patients but for the whole support system in which they reside. Empirically derived knowledge about DID has replaced outdated myths. Vigorous dissemination of the knowledge base about this complex disorder is warranted.
Collapse
Affiliation(s)
- Bethany L Brand
- From Towson University (Dr. Brand); Koç University School of Medicine (Istanbul) (Dr. Sar); Blue Knot Foundation, Sydney, Australia (Dr. Stavropoulos); University of Pretoria (Dr. Krüger); McMaster University (Dr. Korzekwa); Carlos Albizu University (San Juan) (Dr. Martínez-Taboas); Latrobe University, University of New England, University of Canterbury (New Zealand), and University of Queensland (Australia) (Dr. Middleton)
| | | | | | | | | | | | | |
Collapse
|
41
|
Abstract
The etiology of dissociative identity disorder (DID) remains a topic of debate. Proponents of the fantasy model and the trauma model of DID have both called for more empirical research. To this end, the current study presents new and extended data analyses of a previously published H2O positron emission tomography imaging study. This study included 29 subjects: 11 patients with DID and 10 high- and 8 low-fantasy-prone DID-simulating mentally healthy control subjects. All subjects underwent an autobiographical memory script-driven (neutral and trauma related) imagery paradigm in 2 (simulated) dissociative personality states (neutral and trauma related). Psychobiological and psychophysiological data were obtained. Results of the new post-hoc tests on the psychophysiological responses support the trauma model. New results of the brain imaging data did not support the fantasy model. This study extends previously published results by offering important new supporting data for the trauma model of DID.
Collapse
|
42
|
Chalavi S, Vissia EM, Giesen ME, Nijenhuis ER, Draijer N, Cole JH, Dazzan P, Pariante CM, Madsen SK, Rajagopalan P, Thompson PM, Toga AW, Veltman DJ, Reinders AA. Abnormal hippocampal morphology in dissociative identity disorder and post-traumatic stress disorder correlates with childhood trauma and dissociative symptoms. Hum Brain Mapp 2015; 36:1692-704. [PMID: 25545784 PMCID: PMC4400262 DOI: 10.1002/hbm.22730] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 12/09/2014] [Accepted: 12/15/2014] [Indexed: 01/17/2023] Open
Abstract
Smaller hippocampal volume has been reported in individuals with post-traumatic stress disorder (PTSD) and dissociative identity disorder (DID), but the regional specificity of hippocampal volume reductions and the association with severity of dissociative symptoms and/or childhood traumatization are still unclear. Brain structural magnetic resonance imaging scans were analyzed for 33 outpatients (17 with DID and 16 with PTSD only) and 28 healthy controls (HC), all matched for age, sex, and education. DID patients met criteria for PTSD (PTSD-DID). Hippocampal global and subfield volumes and shape measurements were extracted. We found that global hippocampal volume was significantly smaller in all 33 patients (left: 6.75%; right: 8.33%) compared with HC. PTSD-DID (left: 10.19%; right: 11.37%) and PTSD-only with a history of childhood traumatization (left: 7.11%; right: 7.31%) had significantly smaller global hippocampal volume relative to HC. PTSD-DID had abnormal shape and significantly smaller volume in the CA2-3, CA4-DG and (pre)subiculum compared with HC. In the patient groups, smaller global and subfield hippocampal volumes significantly correlated with higher severity of childhood traumatization and dissociative symptoms. These findings support a childhood trauma-related etiology for abnormal hippocampal morphology in both PTSD and DID and can further the understanding of neurobiological mechanisms involved in these disorders.
Collapse
Affiliation(s)
- Sima Chalavi
- Department of NeuroscienceUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
- Research Center for Movement Control and NeuroplasticityDepartment of Biomedical KinesiologyKU LeuvenLeuvenBelgium
| | - Eline M. Vissia
- Department of NeuroscienceUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Mechteld E. Giesen
- Department of NeuroscienceUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | | | - Nel Draijer
- Department of PsychiatryVU University Medical CenterAmsterdamThe Netherlands
| | - James H. Cole
- Computational, Cognitive, and Clinical Neuroimaging LaboratoryDivision of Brain Sciences, Imperial College London, Burlington Danes Building, Hammersmith HospitalLondonUnited Kingdom
| | - Paola Dazzan
- Department of Psychosis StudiesInstitute of Psychiatry, King's College LondonLondonUnited Kingdom
- National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College LondonUnited Kingdom
| | - Carmine M. Pariante
- Department of Psychological MedicineInstitute of Psychiatry, King's College LondonLondonUnited Kingdom
| | - Sarah K. Madsen
- Imaging Genetics Center, Institute for Neuroimaging and Informatics, Laboratory of Neuro ImagingKeck School of Medicine, University of Southern CaliforniaLos AngelesCalifornia
| | - Priya Rajagopalan
- Imaging Genetics Center, Institute for Neuroimaging and Informatics, Laboratory of Neuro ImagingKeck School of Medicine, University of Southern CaliforniaLos AngelesCalifornia
- Indiana University‐Purdue UniversityIndianapolisIndiana
| | - Paul M. Thompson
- Imaging Genetics Center, Institute for Neuroimaging and Informatics, Laboratory of Neuro ImagingKeck School of Medicine, University of Southern CaliforniaLos AngelesCalifornia
| | - Arthur W. Toga
- Imaging Genetics Center, Institute for Neuroimaging and Informatics, Laboratory of Neuro ImagingKeck School of Medicine, University of Southern CaliforniaLos AngelesCalifornia
| | - Dick J. Veltman
- Department of PsychiatryVU University Medical CenterAmsterdamThe Netherlands
| | - Antje A.T.S. Reinders
- Department of NeuroscienceUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
- Department of Psychosis StudiesInstitute of Psychiatry, King's College LondonLondonUnited Kingdom
| |
Collapse
|
43
|
Similar cortical but not subcortical gray matter abnormalities in women with posttraumatic stress disorder with versus without dissociative identity disorder. Psychiatry Res 2015; 231:308-19. [PMID: 25670646 DOI: 10.1016/j.pscychresns.2015.01.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 11/21/2014] [Accepted: 01/13/2015] [Indexed: 11/21/2022]
Abstract
Neuroanatomical evidence on the relationship between posttraumatic stress disorder (PTSD) and dissociative disorders is still lacking. We acquired brain structural magnetic resonance imaging (MRI) scans from 17 patients with dissociative identity disorder (DID) and co-morbid PTSD (DID-PTSD) and 16 patients with PTSD but without DID (PTSD-only), and 32 healthy controls (HC), and compared their whole-brain cortical and subcortical gray matter (GM) morphological measurements. Associations between GM measurements and severity of dissociative and depersonalization/derealization symptoms or lifetime traumatizing events were evaluated in the patient groups. DID-PTSD and PTSD-only patients, compared with HC, had similarly smaller cortical GM volumes of the whole brain and of frontal, temporal and insular cortices. DID-PTSD patients additionally showed smaller hippocampal and larger pallidum volumes relative to HC, and larger putamen and pallidum volumes relative to PTSD-only. Severity of lifetime traumatizing events and volume of the hippocampus were negatively correlated. Severity of dissociative and depersonalization/derealization symptoms correlated positively with volume of the putamen and pallidum, and negatively with volume of the inferior parietal cortex. Shared abnormal brain structures in DID-PTSD and PTSD-only, small hippocampal volume in DID-PTSD, more severe lifetime traumatizing events in DID-PTSD compared with PTSD-only, and negative correlations between lifetime traumatizing events and hippocampal volume suggest a trauma-related etiology for DID. Our results provide neurobiological evidence for the side-by-side nosological classification of PTSD and DID in the DSM-5.
Collapse
|
44
|
Farina B, Speranza AM, Imperatori C, Quintiliani MI, Della Marca G. Change in heart rate variability after the adult attachment interview in dissociative patients. J Trauma Dissociation 2015; 16:170-80. [PMID: 25492425 DOI: 10.1080/15299732.2014.975309] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The aim of this study was to assess heart rate variability (HRV) in individuals with dissociative disorders (DD) before and after the Adult Attachment Interview (AAI). Electrocardiograms were recorded before, during, and after the AAI in 13 individuals with DD and 13 healthy participants matched for age and gender. Significant change in HRV was observed only in the DD group. After the AAI, those with DD showed significant increases in the low frequency/high frequency ratio (pre-AAI = 1.91 ± 1.19; post-AAI = 4.03 ± 2.40; Wilcoxon test = -2.76, p = .005). Our results suggest that the retrieval of childhood attachment experiences in individuals with DD is associated with a change in HRV patterns that could reflect the emotion dysregulation of dissociative psychopathological processes.
Collapse
Affiliation(s)
- Benedetto Farina
- a Department of Human Sciences , European University of Rome , Rome , Italy
| | | | | | | | | |
Collapse
|
45
|
Şar V. The many faces of dissociation: opportunities for innovative research in psychiatry. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2014; 12:171-9. [PMID: 25598819 PMCID: PMC4293161 DOI: 10.9758/cpn.2014.12.3.171] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 04/07/2014] [Accepted: 04/09/2014] [Indexed: 01/10/2023]
Abstract
It has been claimed that the progress of psychiatry has lagged behind that of other medical disciplines over the last few decades. This may suggest the need for innovative thinking and research in psychiatry, which should consider neglected areas as topics of interest in light of the potential progress which might be made in this regard. This review is concerned with one such field of psychiatry: dissociation and dissociative disorders. Dissociation is the ultimate form of human response to chronic developmental stress, because patients with dissociative disorders report the highest frequency of childhood abuse and/or neglect among all psychiatric disorders. The cardinal feature of dissociation is a disruption in one or more mental functions. Dissociative amnesia, depersonalization, derealization, identity confusion, and identity alterations are core phenomena of dissociative psychopathology which constitute a single dimension characterized by a spectrum of severity. While dissociative identity disorder (DID) is the most pervasive condition of all dissociative disorders, partial representations of this spectrum may be diagnosed as dissociative amnesia (with or without fugue), depersonalization disorder, and other specified dissociative disorders such as subthreshold DID, dissociative trance disorder, acute dissociative disorders, and identity disturbances due to exposure to oppression. In addition to constituting disorders in their own right, dissociation may accompany almost every psychiatric disorder and operate as a confounding factor in general psychiatry, including neurobiological and psycho-pharmacological research. While an anti- dissociative drug does not yet exist, appropriate psychotherapy leads to considerable improvement for many patients with dissociative disorders.
Collapse
Affiliation(s)
- Vedat Şar
- Department of Psychiatry, V.K.V. American Hospital, Istanbul, Turkey
| |
Collapse
|
46
|
Şar V. The many faces of dissociation: opportunities for innovative research in psychiatry. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE : THE OFFICIAL SCIENTIFIC JOURNAL OF THE KOREAN COLLEGE OF NEUROPSYCHOPHARMACOLOGY 2014. [PMID: 25598819 DOI: 10.9758/cpn.2014.12.3.171)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
It has been claimed that the progress of psychiatry has lagged behind that of other medical disciplines over the last few decades. This may suggest the need for innovative thinking and research in psychiatry, which should consider neglected areas as topics of interest in light of the potential progress which might be made in this regard. This review is concerned with one such field of psychiatry: dissociation and dissociative disorders. Dissociation is the ultimate form of human response to chronic developmental stress, because patients with dissociative disorders report the highest frequency of childhood abuse and/or neglect among all psychiatric disorders. The cardinal feature of dissociation is a disruption in one or more mental functions. Dissociative amnesia, depersonalization, derealization, identity confusion, and identity alterations are core phenomena of dissociative psychopathology which constitute a single dimension characterized by a spectrum of severity. While dissociative identity disorder (DID) is the most pervasive condition of all dissociative disorders, partial representations of this spectrum may be diagnosed as dissociative amnesia (with or without fugue), depersonalization disorder, and other specified dissociative disorders such as subthreshold DID, dissociative trance disorder, acute dissociative disorders, and identity disturbances due to exposure to oppression. In addition to constituting disorders in their own right, dissociation may accompany almost every psychiatric disorder and operate as a confounding factor in general psychiatry, including neurobiological and psycho-pharmacological research. While an anti- dissociative drug does not yet exist, appropriate psychotherapy leads to considerable improvement for many patients with dissociative disorders.
Collapse
Affiliation(s)
- Vedat Şar
- Department of Psychiatry, V.K.V. American Hospital, Istanbul, Turkey
| |
Collapse
|
47
|
Reinders AATS, Willemsen ATM, den Boer JA, Vos HPJ, Veltman DJ, Loewenstein RJ. Opposite brain emotion-regulation patterns in identity states of dissociative identity disorder: a PET study and neurobiological model. Psychiatry Res 2014; 223:236-43. [PMID: 24976633 DOI: 10.1016/j.pscychresns.2014.05.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 04/27/2014] [Accepted: 05/13/2014] [Indexed: 11/19/2022]
Abstract
Imaging studies in posttraumatic stress disorder (PTSD) have shown differing neural network patterns between hypo-aroused/dissociative and hyper-aroused subtypes. Since dissociative identity disorder (DID) involves different emotional states, this study tests whether DID fits aspects of the differing brain-activation patterns in PTSD. While brain activation was monitored using positron emission tomography, DID individuals (n=11) and matched DID-simulating healthy controls (n=16) underwent an autobiographic script-driven imagery paradigm in a hypo-aroused and a hyper-aroused identity state. Results were consistent with those previously found in the two PTSD subtypes for the rostral/dorsal anterior cingulate, the prefrontal cortex, and the amygdala and insula, respectively. Furthermore, the dissociative identity state uniquely activated the posterior association areas and the parahippocampal gyri, whereas the hyper-aroused identity state uniquely activated the caudate nucleus. Therefore, we proposed an extended PTSD-based neurobiological model for emotion modulation in DID: the hypo-aroused identity state activates the prefrontal cortex, cingulate, posterior association areas and parahippocampal gyri, thereby overmodulating emotion regulation; the hyper-aroused identity state activates the amygdala and insula as well as the dorsal striatum, thereby undermodulating emotion regulation. This confirms the notion that DID is related to PTSD as hypo-aroused and hyper-arousal states in DID and PTSD are similar.
Collapse
Affiliation(s)
- Antje A T S Reinders
- Department of Psychosis Studies, Institute of Psychiatry, King׳s College London, United Kingdom; Department of Neuroscience, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Antoon T M Willemsen
- Department of Nuclear Medicine & Molecular Imaging, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Johan A den Boer
- Department of Nuclear Medicine & Molecular Imaging, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Herry P J Vos
- Outpatient Department Addiction Clinic Groningen/Drenthe, The Netherlands
| | - Dick J Veltman
- Department of Psychiatry, VU University Medical Center, Amsterdam, The Netherlands
| | - Richard J Loewenstein
- Sheppard Pratt Health System, Department of Psychiatry, University of Maryland, Baltimore, MD, USA
| |
Collapse
|
48
|
Schlumpf YR, Reinders AATS, Nijenhuis ERS, Luechinger R, van Osch MJP, Jäncke L. Dissociative part-dependent resting-state activity in dissociative identity disorder: a controlled FMRI perfusion study. PLoS One 2014; 9:e98795. [PMID: 24922512 PMCID: PMC4055615 DOI: 10.1371/journal.pone.0098795] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 05/06/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In accordance with the Theory of Structural Dissociation of the Personality (TSDP), studies of dissociative identity disorder (DID) have documented that two prototypical dissociative subsystems of the personality, the "Emotional Part" (EP) and the "Apparently Normal Part" (ANP), have different biopsychosocial reactions to supraliminal and subliminal trauma-related cues and that these reactions cannot be mimicked by fantasy prone healthy controls nor by actors. METHODS Arterial spin labeling perfusion MRI was used to test the hypotheses that ANP and EP in DID have different perfusion patterns in response to rest instructions, and that perfusion is different in actors who were instructed to simulate ANP and EP. In a follow-up study, regional cerebral blood flow of DID patients was compared with the activation pattern of healthy non-simulating controls. RESULTS Compared to EP, ANP showed elevated perfusion in bilateral thalamus. Compared to ANP, EP had increased perfusion in the dorsomedial prefrontal cortex, primary somatosensory cortex, and motor-related areas. Perfusion patterns for simulated ANP and EP were different. Fitting their reported role-play strategies, the actors activated brain structures involved in visual mental imagery and empathizing feelings. The follow-up study demonstrated elevated perfusion in the left temporal lobe in DID patients, whereas non-simulating healthy controls had increased activity in areas which mediate the mental construction of past and future episodic events. CONCLUSION DID involves dissociative part-dependent resting-state differences. Compared to ANP, EP activated brain structures involved in self-referencing and sensorimotor actions more. Actors had different perfusion patterns compared to genuine ANP and EP. Comparisons of neural activity for individuals with DID and non-DID simulating controls suggest that the resting-state features of ANP and EP in DID are not due to imagination. The findings are consistent with TSDP and inconsistent with the idea that DID is caused by suggestion, fantasy proneness, and role-playing.
Collapse
Affiliation(s)
- Yolanda R. Schlumpf
- Division of Neuropsychology, Institute of Psychology, University of Zurich, Zurich, Switzerland
- * E-mail:
| | - Antje A. T. S. Reinders
- Department of Neuroscience, University Medical Center Groningen, and BCN Neuroimaging Center, University of Groningen, Groningen, The Netherlands
- Department of Psychosis Studies, Institute of Psychiatry, King's College London, London, United Kingdom
| | | | - Roger Luechinger
- Institute for Biomedical Engineering, University and ETH Zurich, Zurich, Switzerland
| | - Matthias J. P. van Osch
- Department of Radiology, C. J. Gorter Center for High-Field MRI, Leiden University Medical Center, Leiden, The Netherlands
| | - Lutz Jäncke
- Division of Neuropsychology, Institute of Psychology, University of Zurich, Zurich, Switzerland
- International Normal Aging and Plasticity Imaging Center, University of Zurich, Zurich, Switzerland
| |
Collapse
|
49
|
Dorahy MJ, Brand BL, Sar V, Krüger C, Stavropoulos P, Martínez-Taboas A, Lewis-Fernández R, Middleton W. Dissociative identity disorder: An empirical overview. Aust N Z J Psychiatry 2014; 48:402-17. [PMID: 24788904 DOI: 10.1177/0004867414527523] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Despite its long and auspicious place in the history of psychiatry, dissociative identity disorder (DID) has been associated with controversy. This paper aims to examine the empirical data related to DID and outline the contextual challenges to its scientific investigation. METHODS The overview is limited to DID-specific research in which one or more of the following conditions are met: (i) a sample of participants with DID was systematically investigated, (ii) psychometrically-sound measures were utilised, (iii) comparisons were made with other samples, (iv) DID was differentiated from other disorders, including other dissociative disorders, (v) extraneous variables were controlled or (vi) DID diagnosis was confirmed. Following an examination of challenges to research, data are organised around the validity and phenomenology of DID, its aetiology and epidemiology, the neurobiological and cognitive correlates of the disorder, and finally its treatment. RESULTS DID was found to be a complex yet valid disorder across a range of markers. It can be accurately discriminated from other disorders, especially when structured diagnostic interviews assess identity alterations and amnesia. DID is aetiologically associated with a complex combination of developmental and cultural factors, including severe childhood relational trauma. The prevalence of DID appears highest in emergency psychiatric settings and affects approximately 1% of the general population. Psychobiological studies are beginning to identify clear correlates of DID associated with diverse brain areas and cognitive functions. They are also providing an understanding of the potential metacognitive origins of amnesia. Phase-oriented empirically-guided treatments are emerging for DID. CONCLUSIONS The empirical literature on DID is accumulating, although some areas remain under-investigated. Existing data show DID as a complex, valid and not uncommon disorder, associated with developmental and cultural variables, that is amenable to psychotherapeutic intervention.
Collapse
Affiliation(s)
- Martin J Dorahy
- 1Department of Psychology, University of Canterbury, Christchurch, New Zealand
| | | | | | | | | | | | | | | |
Collapse
|
50
|
Barlow MR, Chu JA. Measuring fragmentation in dissociative identity disorder: the integration measure and relationship to switching and time in therapy. Eur J Psychotraumatol 2014; 5:22250. [PMID: 24396569 PMCID: PMC3880957 DOI: 10.3402/ejpt.v5.22250] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 10/20/2013] [Accepted: 11/20/2013] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Some people with dissociative identity disorder (DID) have very little communication or awareness among the parts of their identity, while others experience a great deal of cooperation among alternate identities. Previous research on this topic has been sparse. Currently, there is no empirical measure of integration versus fragmentation in a person with DID. In this study, we report the development of such a measure. OBJECTIVE The goal of this study was to pilot the integration measure (IM) and to address its psychometric properties and relationships to other measures. The IM is the first standardized measure of integration in DID. METHOD Eleven women with DID participated in an experiment that included a variety of tasks. They filled out questionnaires about trauma and dissociation as well as the IM. They also provided verbal results about switching among alternate identities during the study sessions. RESULTS Participants switched among identities an average of 5.8 times during the first session, and switching was highly correlated with trauma. Integration was related to switching, though this relationship may be non-linear. Integration was not related to time in psychotherapy. CONCLUSIONS The IM provides a useful beginning to quantify and study integration and fragmentation in DID. Directions for future research are also discussed, including expanding the IM from this pilot. The IM may be useful in treatment settings to assess progress or change over time.
Collapse
Affiliation(s)
- M Rose Barlow
- Psychology Department, Boise State University, Boise, ID, USA
| | - James A Chu
- McLean Hospital, Belmont, MA, USA ; Harvard Medical School, Department of Psychiatry, Boston, MA, USA
| |
Collapse
|