Depersonalization Disorder: Directed Forgetting as a Function of Emotionality

There exists some evidence for a link between dissociation and emotionally avoidant information processing, yet studies to date have been contradictory. Our goal was to investigate emotionally avoidant processing in Depersonalization Disorder (DDD) using a directed forgetting (DF) paradigm. Thirty-two participants with DSM-IV DDD and 40 healthy controls performed an item-method DF task using positive, negative, and neutral words. Participants were also administered the Dissociative Experiences Scale (DES) and the Childhood Trauma Questionnaire (CTQ). The DDD group demonstrated significantly lower directed forgetting for negative, but not positive or neutral, words compared to controls. In the combined sample, DES total, depersonalization/derealization, and amnesia scores significantly inversely predicted explicit cued recall for to-be-forgotten negative words (higher dissociation, lower forgetting), while the CTQ was not predictive. The findings do not support emotionally avoidant processing in this paradigm; rather, DDD may be characterized by a diminished capacity to actively control attention and direct it away from emotionally disturbing material when instructed to do so.

The Multidimensional Inventory of Dissociation (MID) in Depersonalization Disorder: General Findings with a Clinical Emphasis on Memory and Identity Disturbances

The Multidimensional Inventory of Dissociation (MID) was administered to 23 participants diagnosed with DSM-IV-TR Depersonalization Disorder (DDD) by structured interview. The MID has not been previously examined in DDD and does not generate a diagnostic formula for the disorder. Mean MID score for the sample was modestly elevated at 18.54, and was significantly correlated with Dissociative Experiences Scale, Cambridge Depersonalization Scale, and Childhood Trauma Questionnaire scores. Criterion A (General Dissociation) Depersonalization and Depersonalization scale scores were markedly elevated (41.70 and 40.98 respectively), followed by moderate elevations in the Identity Confusion (36.01), Trance (25.44), and Memory Problems (23.30) scales. Criterion B (Intrusions from partly dissociated self-states) mean score was modestly elevated (19.13) and declined to 13.67 once items overlapping with the Depersonalization and Identity Confusion scales were excluded. Criterion C (fully dissociated manifestations of other self-states) mean score was minimally elevated (6.57). Of the 168 pathological dissociation items, 55 were clinically elevated in DDD. Closer examination of the Intrusions and Amnesia items that were modestly elevated in DDD revealed that these items did not reflect the presence of alters, but rather represented known depersonalization-related phenomena. We propose a preliminary formula, based on cutoff scores for Criterion A Depersonalization and/or Derealization, Criterion B, and Criterion C (≥20, ≤28, ≤11) for the sensitive diagnosis of DDD (82.6% of participants), which would require future investigation for replication and determination of specificity vis-à-vis the other dissociative disorders.

Attention and Memory in Depersonalization-Spectrum Dissociative Disorders: Impact of Selective-Divided Attentional Condition, Stimulus Emotionality, and Stress

We investigated cognition in depersonalization-spectrum dissociative disorders without comorbid posttraumatic stress disorder to explore evidence for emotionally avoidant information processing. Forty-eight participants with DSM-IV dissociative disorder (DD) (Depersonalization Disorder - 37, Dissociative Disorder NOS -11), 36 participants with Posttraumatic Stress Disorder (PTSD), and 56 healthy controls (HC) were administered the Weschler Adult Intelligence Scale-III (WAIS); the Weschler Memory Scale-III (WMS); and three Stroop tasks: the Standard Stroop, a selective-attention Emotional Stroop using neutral, dissociation, and trauma-related word categories, and a divided-attention Emotional Stroop using comparable words. Participants were also administered a paired-associates explicit and implicit memory test using emotionally neutral and negative words, before and after the Trier Social Stress Test. The DD and HC groups had comparable general intelligence and memory scores, though dissociation severity was inversely related to verbal comprehension and working memory. In the selective-attention condition, DD participants showed greater incidental recall across word categories with comparable interference. However in the divided-attention condition, DD participants significantly favored lesser attentional interference at the expense of remembering words. Across attentional conditions, DD participants had better recall for disorder-related than neutral words. Pre-stress, the DD group demonstrated better explicit memory for neutral versus negative words with reversal after stress, whereas the HC group demonstrated the opposite pattern; implicit memory did not differ. Cognition in the PTSD control group was generally dissimilar to the DD group. The findings in toto provide substantial evidence for emotionally avoidant information processing in DD, vulnerable to the impact of stress, at the level of both attention and memory.

Pathological Dissociation in The National Comorbidity Survey Replication (NCS-R): Prevalence, Morbidity, Comorbidity, and Childhood Maltreatment

Our aim was to examine U.S. national prevalence of pathological dissociation (PD) likely indicative of dissociative disorder, and associated morbidity, comorbidity, and childhood maltreatment. PD was assessed in 6,644 participants in the National Comorbidity Survey Replication, a nationally representative adult survey. Seven of the eight pathological dissociation taxon items were inquired about over the past month and scored on a 4-point scale. A conservative PD cutoff score was applied, with 100% specificity against healthy individuals and 84% sensitivity for Depersonalization Disorder which lies at the less severe end of the dissociative disorder spectrum; it yielded a national PD prevalence of 4.1%. The PD group had diminished physical and mental health, marked comorbidity with most major psychiatric disorders, and high likelihood of psychiatric hospitalization. Over half of PD members had attempted suicide, significantly more than individuals with lifetime major depression. Childhood maltreatment was quantified for physical abuse, witnessing domestic violence, physical neglect, emotional abuse, and emotional neglect. Total childhood trauma significantly positively predicted PD severity, as well as severity of all three pathological dissociative experiences (amnesia, depersonalization / derealization, identity alteration). Furthermore, each childhood trauma category significantly predicted PD severity uniquely and additively. Childhood maltreatment in the PD group was significantly greater than in lifetime major depression, except for similar emotional neglect, and was comparable to lifetime PTSD. The study reinforces the validity of prior PD findings across clinical and community samples, and highlights the need for increased attention toward diagnosing and treating these quite common and highly morbid disorders and their traumatic antecedents.

Prevalence and risk factors of airflow obstruction in a Caribbean population

SETTING: The prevalence of airflow obstruction (AO) in the Caribbean population is unknown.OBJECTIVE: To measure the prevalence of and risk factors for AO (post-bronchodilator ratio of forced expiratory volume in 1 sec to forced vital capacity of <0.7) in the Trinidad and Tobago general population using the Burden of Obstructive Lung Disease methodology.DESIGN: National cross-sectional, stratified, cluster sampling of adults aged ≥40 years.RESULTS: AO prevalence was 9.5% among 1104 participants, most of whom were unaware of this. Compared to those aged 40-49 years, the adjusted odds ratio of AO by age group was 2.73 (60-69 years) and 3.30 (≥70 years). Risk factors for AO were unemployment (OR 4.31), being retired (OR 2.17), smoking ≥20 pack-years (OR 1.88) and exposure to dusty jobs for more than 1 year (OR 2.06). Related symptoms were history of wheezing, unscheduled visits to the doctor or admission to hospital for breathing problems and in subjects with at least one respiratory symptom (OR 1.90), at least one risk factor (OR 2.81), either symptoms or risk factors (OR 3.71) and both symptoms and risk factors (OR 5.78) (P < 0.05 in all cases).CONCLUSION: AO prevalence in the general population of Trinidad and Tobago aged ≥40 years was 9.5%, almost all of which was undiagnosed. AO was associated with smoking, age >59 years, lack of employment and working in a dusty job.

Should OCD leave the anxiety disorders in DSM-V? The case for obsessive compulsive-related disorders

Recently in 2006, a group of experts in obsessive compulsive disorder (OCD) and obsessive compulsive-related disorders (OCRDs) convened in Washington, DC, to review existing data on the relationships between these various disorders, and to suggest approaches to address the gaps in our knowledge, in preparation for the upcoming Diagnostic and Statistical Manual (Fifth Edition) (DSM-V). As a result of this meeting, the Research Planning Agenda for DSM-V: OCRD Work Group suggested removing OCD from the anxiety disorders, where it is currently found. This proposal is in accordance with the current International Classification of Mental Disorders (ICD-10) classification of OCD as a separate category from the anxiety disorders. Although the ICD-10 places both OCD and the anxiety disorders under the umbrella category of "neurotic, stress-related, and somatoform disorders," they are two separate categories, distinct from one another. As OCD and other putative OCRDs share aspects of phenomenology, comorbidity, neurotransmitter/peptide systems, neurocircuitry, familial and genetic factors, and treatment response, it was proposed to create a new category in DSM-V entitled OCRDs. Alternatively, the OCRDs might be conceptualized as a new category within the broader category of anxiety disorders. Future studies are needed to better define the relationships among these disorders, and to study boundary issues for this proposed category. There are both advantages and disadvantages in creating a new diagnostic category in DSM-V, and these are discussed in this article.

Face processing in depersonalization: an fMRI study of the unfamiliar self

Depersonalization disorder (DPD) is characterized by a core sense of unfamiliarity. Nine DPD participants and 10 healthy controls underwent functional magnetic resonance imaging while viewing self and unfamiliar faces. Compared with control subjects, the DPD group exhibited significantly greater activation in several brain regions in response to self vs. stranger faces. Implications are discussed.

Preliminary physiological evidence for impaired emotion regulation in depersonalization disorder

Depersonalization disorder is associated with emotional responding deficits. Ability to regulate emotion was measured by heart rate, skin conductance, and subjective responses to pictures. Compared to controls, depersonalized participants were better able to suppress, but not enhance, emotions irrespective of valence (heart rate). Emotion regulation in depersonalization merits further study.

Early emotional processing deficits in depersonalization: an exploration with event-related potentials in an undergraduate sample

Emotional stimuli may draw attention to such an extent that they hamper the processing of subsequent signals, a phenomenon termed emotion-induced blindness (EIB). As depersonalization is associated with self-reported attenuated emotional responses, the present study explored whether individuals scoring high on the Cambridge Depersonalization Scale (CDS; n=15) exhibit a diminished EIB effect relative to low CDS scoring individuals (n=15), and whether attentional processes reflected in event-related potentials (ERPs) are implicated in this effect. We obtained an EIB effect such that emotional distractors that preceded targets with a lag of 200ms reduced correct detection of targets. Although the magnitude of this effect was similar for high and low CDS participants, high CDS participants exhibited a significantly lower ERP amplitude at the frontal lead in the 200-300ms window than did low CDS individuals to targets that followed emotional versus neutral distractors. This latter effect was significantly related to the Alienation factor of the CDS. This pattern suggests that difficulties in the discrimination between emotional and neutral stimuli relate to the feeling of unreality in depersonalization.

A double-blind, placebo-controlled trial of topiramate for pathological gambling

OBJECTIVES

Pathological gambling (PG) is an impulse control disorder characterized by recurrent gambling thoughts and behaviours that impair social functioning. Earlier studies suggested that topiramate may be effective in treating some impulse control disorders. We conducted the first randomized, controlled trial of topiramate in PG.

METHODS

PG patients were randomized to topiramate (N = 20) or placebo (N = 22) in this 14-week, double-blind, placebo-controlled, parallel-group trial. The primary outcome measure was change in the obsessions subscale of the Yale-Brown Obsessive-Compulsive Scale Modified for Pathological Gambling.

RESULTS

Mixed regression models (time [weeks] × treatment) revealed no significant treatment effect of topiramate on the primary or secondary outcome measures. The most statistically robust findings involved reducing the Barratt Impulsiveness Scale (BIS) total score and Motor and Non-Planning subscale scores, for which topiramate outperformed placebo at merely a trend level (P < 0.1).

CONCLUSIONS

The observed trend in BIS score reductions may warrant further investigation to study whether topiramate reduces clinically important impulsivity in PG. Treatment studies with larger samples and less stringent exclusion criteria are needed to produce results that can be generalized to pathological gamblers in the community.

Dissociative disorders in DSM-5

BACKGROUND

We present recommendations for revision of the diagnostic criteria for the Dissociative Disorders (DDs) for DSM-5. The periodic revision of the DSM provides an opportunity to revisit the assumptions underlying specific diagnoses and the empirical support, or lack of it, for the defining diagnostic criteria.

METHODS

This paper reviews clinical, phenomenological, epidemiological, cultural, and neurobiological data related to the DDs in order to generate an up-to-date, evidence-based set of DD diagnoses and diagnostic criteria for DSM-5. First, we review the definitions of dissociation and the differences between the definitions of dissociation and conceptualization of DDs in the DSM-IV-TR and the ICD-10, respectively. Also, we review more general conceptual issues in defining dissociation and dissociative disorders. Based on this review, we propose a revised definition of dissociation for DSM-5 and discuss the implications of this definition for understanding dissociative symptoms and disorders.

RESULTS

We make the following recommendations for DSM-5: 1. Depersonalization Disorder (DPD) should include derealization symptoms as well. 2. Dissociative Fugue should become a subtype of Dissociative Amnesia (DA). 3. The diagnostic criteria for DID should be changed to emphasize the disruptive nature of the dissociation and amnesia for everyday as well as traumatic events. The experience of possession should be included in the definition of identity disruption. 4. Dissociative Trance Disorder should be included in the Unspecified Dissociative Disorder (UDD) category.

CONCLUSIONS

There is a growing body of evidence linking the dissociative disorders to a trauma history, and to specific neural mechanisms.

Oxytocin administration attenuates stress reactivity in borderline personality disorder: a pilot study

Oxytocin has known stress-reducing and attachment-enhancing effects. We thus hypothesized that oxytocin would attenuate emotional and hormonal responses to stress in borderline personality disorder (BPD). Fourteen BPD and 13 healthy control (HC) adults received 40 IU intranasal oxytocin or placebo in double-blind randomized order followed by the Trier Social Stress Test. Subjective dysphoria (Profile of Mood Changes) and plasma cortisol levels were measured. Childhood trauma history, attachment style, and self-esteem were also rated. A significant "Group × Drug × Time" interaction effect for dysphoria (p=.04) reflected a proportionately greater attenuation of stress-induced dysphoria in the BPD group after oxytocin administration. Additionally, a marginally significant "Group × Drug" interaction effect for cortisol (p=.10) reflected a tendency toward greater attenuation of the stress-induced cortisol surge in the BPD group after oxytocin administration. In the combined sample, the oxytocin-placebo difference in the emotional stress reactivity was significantly predicted by childhood trauma alone (p=.037) and combined with self-esteem (p=.030), whereas the oxytocin-placebo difference in cortisol stress reactivity was predicted only by insecure attachment (p=.013). Results suggest that oxytocin may have a beneficial impact on emotional regulation in BPD, which merits further investigation and could have important treatment implications.

Dissociative disorders in DSM-5

BACKGROUND

We present recommendations for revision of the diagnostic criteria for the Dissociative Disorders (DDs) for DSM-5. The periodic revision of the DSM provides an opportunity to revisit the assumptions underlying specific diagnoses and the empirical support, or lack of it, for the defining diagnostic criteria.

METHODS

This paper reviews clinical, phenomenological, epidemiological, cultural, and neurobiological data related to the DDs in order to generate an up-to-date, evidence-based set of DD diagnoses and diagnostic criteria for DSM-5. First, we review the definitions of dissociation and the differences between the definitions of dissociation and conceptualization of DDs in the DSM-IV-TR and the ICD-10, respectively. Also, we review more general conceptual issues in defining dissociation and dissociative disorders. Based on this review, we propose a revised definition of dissociation for DSM-5 and discuss the implications of this definition for understanding dissociative symptoms and disorders.

RESULTS

We make the following recommendations for DSM-5: 1. Depersonalization Disorder (DPD) should derealization symptoms as well. 2. Dissociative Fugue should become a subtype of Dissociative Amnesia (DA). 3. The diagnostic criteria for DID should be changed to emphasize the disruptive nature of the dissociation and amnesia for everyday as well as traumatic events. The experience of possession should be included in the definition of identity disruption. 4. Should Dissociative Trance Disorder should be included in the Unspecified Dissociative Disorder (UDD) category.

CONCLUSIONS

There is a growing body of evidence linking the dissociative disorders to a trauma history, and to specific neural mechanisms.

Temporo-parietal junction stimulation in the treatment of depersonalization disorder

This is the first clinical trial of repetitive Transcranial Magnetic Stimulation (rTMS) in depersonalization disorder (DPD). After 3weeks of right temporo-parietal junction (TPJ) rTMS, 6/12 patients responded. Five responders received 3 more weeks of right TPJ rTMS showing 68% DPD symptoms improvement. Right TPJ rTMS was safe and effective.

Oxytocin can hinder trust and cooperation in borderline personality disorder

We investigated the effects of intranasal oxytocin (OXT) on trust and cooperation in borderline personality disorder (BPD), a disorder marked by interpersonal instability and difficulties with cooperation. Although studies in healthy adults show that intranasal OXT increases trust, individuals with BPD may show an altered response to exogenous OXT because the effects of OXT on trust and pro-social behavior may vary depending on the relationship representations and expectations people possess and/or altered OXT system functioning in BPD. BPD and control participants received intranasal OXT and played a social dilemma game with a partner. Results showed that OXT produced divergent effects in BPD participants, decreasing trust and the likelihood of cooperative responses. Additional analyses focusing on individual differences in attachment anxiety and avoidance across BPD and control participants indicate that these divergent effects were driven by the anxiously attached, rejection-sensitive participants. These data suggest that OXT does not uniformly facilitate trust and pro-social behavior in humans; indeed, OXT may impede trust and pro-social behavior depending on chronic interpersonal insecurities, and/or possible neurochemical differences in the OXT system. Although popularly dubbed the 'hormone of love', these data suggest a more circumspect answer to the question of who will benefit from OXT.

Skin conductance and memory fragmentation after exposure to an emotional film clip in depersonalization disorder

It is often assumed that when confronted with an emotional event, patients with DPD inhibit information processing. It is also thought that this fosters memory fragmentation. This hypothesis has not been tested in chronic depersonalization. The aim of this study was to investigate the temporal pattern of autonomic responding to emotional material in depersonalization disorder, along with concomitant deficits in subjective and objective memory formation (i.e., difficulties to form a coherent narrative consisting of an ordered sequence of events). Participants with depersonalization disorder (n=14) and healthy control participants (n=14) viewed an emotional video clip while their skin conductance (SC) levels were measured. Peritraumatic dissociation was measured before and after the clip, and memory performance was measured 35 min after viewing. Compared to controls, depersonalized participants exhibited a distinctly different temporal pattern of autonomic responding, characterized by an earlier peak and subsequent flattening of SCLs. Maximum SCLs did not differ between the two groups. Moreover, unlike the control group, depersonalized participants showed no SC recovery after clip offset. In terms of memory performance, patients exhibited objective memory fragmentation, which they also reported subjectively. However, they did not differ from controls in free recall performance. Apparently, emotional responding in DPD is characterized by a shortened latency to peak with subsequent flattening and is accompanied by memory fragmentation in the light of otherwise unremarkable memory functioning.

Medical problems among dental patients at the school of dentistry, the university of the West Indies

This study ascertained demographic information and prevalence rates of medical problems among 571 new and consecutive dental patients attending the emergency clinic of the School of Dentistry, The University of the West Indies. Patients were interviewed by specially trained and calibrated dental students and interns. Various medical problems of patients were recorded in individual open-ended case sheets, maintaining their privacy and confidentiality. This information was then transcribed into a specially designed and pretested form. The data were entered into a Microsoft Excel spreadsheet and analyzed using the SPSS statistical package to obtain the prevalence rates of medical conditions, which were then cross-tabulated with gender, age, ethnicity, and other variables. Significance of differences, if any, was evaluated by chi-square test. In all, 303 medical conditions were encountered in 239 individuals, giving a prevalence rate of 42 percent. Hypertension (12.6 percent), diabetes (6.1 percent), asthma (5.8 percent), arthritis (4.7 percent), and various allergies (8.3 percent) constituted an important segment of the problems. Gender, ethnic, and age differences were also evident for some diseases. In this study-which was the first of this kind in the West Indies-vital information on medical problems among dental patients was obtained by interviews conducted by dental students and interns, forming an important part of their dental education.

Is depersonalization disorder initiated by illicit drug use any different? A survey of 394 adults

OBJECTIVE

Previous studies have documented that in a substantial minority of individuals with depersonalization disorder, onset is first triggered by illicit drug ingestion. The goal of this study was to systematically compare a large sample of individuals with drug-initiated (D) versus non-drug-initiated (ND) chronic depersonalization.

METHOD

We conducted an internet survey of 394 adults endorsing DSM-IV-TR depersonalization and/or derealization symptoms. Sixty-four questions were utilized to inquire about demographic and clinical characteristics, illness course, substance use history, and treatment response. The Cambridge Depersonalization Scale (CDS) was administered. The study was conducted from September 2005 to January 2006.

RESULTS

Compared to the ND group (n = 198), the D group (n = 196) included more male and younger individuals. The 2 most common precipitating drugs were cannabis and hallucinogens, followed by ecstasy. The majority of participants had modest use histories prior to onset and never ingested subsequently. The 2 groups endorsed similar illness course, impairment, suicidality, and limited treatment response. The D group showed significantly greater improvement over time than the ND group (P = .002), although the groups did not differ in reported psychotherapy or pharmacotherapy effectiveness. The groups did not differ in CDS total score or on the 4 subscale scores of unreality of self, perceptual alterations, unreality of surroundings, and temporal disintegration. On the numbing subscale of the CDS, the ND group scored higher (P = .009) only prior to controlling for age and gender.

CONCLUSION

The study strongly supports a uniform syndrome for chronic depersonalization/derealization regardless of precipitant.

Relationships between obsessive-compulsive symptomatology and severity of psychosis in schizophrenia: a systematic review and meta-analysis

OBJECTIVE

The presence of obsessive-compulsive symptoms (OCS) or obsessive-compulsive disorder (OCD) is common in patients with schizophrenia. The impact of OCS and OCD on severity of psychotic symptoms has been assessed in several past studies yielding inconclusive results. In this report, we aim to integrate the findings of prior studies by means of a systematic review followed by a meta-analysis.

DATA SOURCES

A search of studies in PubMed (from 1950 to September 2006) and PsycINFO (from 1966 to September 2006) databases was performed to assess the influence of OCS and OCD on severity of psychotic symptoms in patients with schizophrenia using as syntax ("schizophrenia" OR "psychosis" OR "psychotic") AND ("obsessive-compulsive disorder" OR "OCD" OR "obsession*" OR "compulsion*" OR "obsessiv*" OR "compulsiv*"). Reference lists of all retrieved articles were also hand-searched.

STUDY SELECTION

Twenty-three studies were included in the systematic review, and 18 articles provided usable data for the meta-analysis.

DATA EXTRACTION

All relevant data were extracted using a standardized report form by 2 investigators. Effect sizes and pooled estimates were calculated. Data were analyzed separately for studies using an OCS or OCD definition.

DATA SYNTHESIS

The presence of OCS was significantly associated with greater severity of global psychotic symptoms (standardized mean difference [95% CI], 0.39 [0.14 to 0.64]), positive psychotic symptoms (0.28 [0.00 to 0.56]), and negative psychotic symptoms (0.36 [0.11 to 0.62]). In contrast, no differences in the severity of global psychotic symptoms (0.19 [-0.14 to 0.51]), positive psychotic symptoms (-0.01 [-0.20 to 0.19]), or negative psychotic symptoms (-0.11 [-0.30 to 0.08]) were found for the OCD versus non-OCD subgroups.

CONCLUSION

This first meta-analysis revealed that the presence of obsessive-compulsive symptoms in schizophrenia is associated with higher global, positive, and negative psychotic symptoms. This association was not found when a categorical definition of obsessive-compulsive disorder was used.

Acute dissociation predicts rapid habituation of skin conductance responses to aversive auditory probes

The present study examined how acute dissociation, trait-like dissociative symptoms, and physiological reactivity relate to each other. Sixty-nine undergraduate students were exposed to 14 aversive auditory probes, while their skin conductance responses were measured. A combination of self-reported anxiety and trait-like dissociation was found to predict variability in peritraumatic dissociation levels induced by the aversive probes. Furthermore, high levels of acute dissociation were associated with faster habituation of skin conductance responding, while trait-like dissociation was unrelated to habituation. Interestingly, individuals who reported childhood trauma displayed elevated skin conductance responses. Our findings contribute to the growing body of evidence indicating that subjective feelings of acute dissociation have their objective concomitants, notably fast habituation of physiologic responses.

De-constructing depersonalization: further evidence for symptom clusters

Depersonalization disorder is defined in the DSM-IV-TR using a single symptom criterion, which does not do justice to the phenomenological complexity of the disorder. In 394 affected adults, the Cambridge Depersonalization Scale yielded five factors (numbing, unreality of self, perceptual alterations, unreality of surroundings, and temporal disintegration), put forth as symptom criteria for a better diagnosis of depersonalization disorder.

Somatoform dissociation in depersonalization disorder

Along with psychoform dissociation, somatoform dissociation has been put forth as a core aspect of dissociative states, possibly as reliable as psychoform dissociation in the screening for dissociative disorders. The goal of this study was to investigate the prominence and correlates of somatoform dissociation in one of the major Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) dissociative disorders, depersonalization disorder (DPD). A total of 54 adults with DPD and 47 healthy control participants free of lifetime Axis I and II disorders were administered the 20-item Somatoform Dissociation Questionnaire (SDQ) as well as the Dissociative Experiences Scale, the Cambridge Depersonalization Scale, and the Childhood Trauma Questionnaire-Short Form. Somatoform dissociation scores were statistically significantly, but clinically only modestly, elevated in the DPD as compared to the healthy control group. SDQ items significantly elevated in the DPD group were mostly perceptual in nature. Depersonalization scores were significantly correlated with somatoform dissociation in the DPD group, whereas absorption and amnesia scores were not. With respect to childhood interpersonal trauma, although emotional abuse was significantly associated with depersonalization severity, none of the 5 categories of trauma were significantly associated with somatoform dissociation in the DPD group. In conclusion, somatoform dissociation is modest in DPD, and the SDQ is a weak instrument for the screening of dissociation in this disorder, detecting only one third of the sample when using the traditional SDQ cutoff score of 30.

Factors associated with resilience in healthy adults

Mature defenses comprise one well-validated indicator of resilience. We investigated the relationships of resilience to trauma, attachment, temperament, cortisol, and cognitive performance in adult healthy volunteers. Participants were administered the Defense Style Questionnaire; the Relationship Questionnaire; the Childhood Trauma Questionnaire, and the Tridimensional Personality Questionnaire. Cortisol determinations included 24-h urinary, mean hourly plasma, response to low-dose dexamethasone suppression, and reactivity to the Trier social stress test (TSST). Mathematical performance during the TSST was quantified. Twenty-five women and 29 men participated. Resilience was significantly negatively correlated with childhood interpersonal trauma and with harm avoidance. Resilience was significantly positively correlated with urinary cortisol, secure attachment, reward dependence, and superior performance. In a linear regression analysis, the strongest predictor of resilience was childhood trauma, followed by math performance under stress and harm avoidance. We conclude that in young adults without manifest psychiatric disorder, resilience was associated with developmental, biological, and cognitive measures which merit further investigation.

An open-label trial of divalproex extended-release in the treatment of borderline personality disorder

INTRODUCTION

Borderline personality disorder (BPD) is associated with several symptoms, including impulsivity, aggression, and intense unstable affect, which can be targeted with anticonvulsant agents. Divalproex extended-release (ER) is used widely in clinical practice, which leads to the question of its efficacy and tolerability in treating BPD.

METHODS

This study assessed the efficacy and tolerability of divalproex ER in 20 adult outpatients with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition BPD via a 12-week open-label trial. Primary outcome measures included the Clinical Global Impression-Improvement (CGI-I) scale and the Global Assessment Scale. Secondary outcome measures assessed aggression (Aggression Questionnaire, Overt Aggression Scale-Modified); affective disturbance (Affective Intensity Measure, Affective Lability Scale); dissociation (Dissociative Experiences Scale); and general psychopathology (Symptom-Checklist 90-Revised).

RESULTS

Thirteen subjects were male and seven were female with a mean age of 37.0+/-11.3 years. Treatment was associated with statistically significant improvement on the CGI-I, the Global Assessment Scale, the Overt Aggression Scale-Modified irritability subscale, and the Aggression Questionnaire. A trend toward significant improvement was observed on the Affective Intensity Measure. Seven out of 10 completers (70%) were treatment responders, with an endpoint CGI-I of 2 (much improved) or 1 (very much improved). There was no significant decline in affective lability or in dissociation. One participant discontinued treatment due to adverse events.

CONCLUSION

These findings support that divalproex ER is an efficacious and well-tolerated pharmacologic agent for BPD, with the additional advantage of single daily dosing at bedtime. Placebo-controlled trials are needed for replication.

Hypothalamic-pituitary-adrenal axis function in dissociative disorders, post-traumatic stress disorder, and healthy volunteers

BACKGROUND

This study investigated basal and stress-induced hypothalamic-pituitary-adrenal (HPA)-axis alterations in dissociative disorders (DDs).

METHODS

Forty-six subjects with DD without lifetime post-traumatic stress disorder (PTSD), 35 subjects with PTSD, and 58 healthy comparison (HC) subjects, free of current major depression, were studied as inpatients. After a 24-hour urine collection and hourly blood sampling for ambient cortisol determination, a low-dose dexamethasone suppression test was administered, followed by the Trier Social Stress Test.

RESULTS

The DD group had significantly elevated urinary cortisol compared with the HC group, which was more pronounced in the absence of lifetime major depression, whereas the PTSD and HC groups did not differ. The DD group demonstrated significantly greater resistance to, and faster escape from, dexamethasone suppression compared with the HC group, whereas the PTSD and HC groups did not differ. The three groups did not differ in cortisol stress reactivity, but both psychiatric groups demonstrated a significant inverse correlation between dissociation severity and cortisol reactivity, after controlling for all other symptomatology. The PTSD subgroup with comorbid DD tended to have blunted stress reactivity compared with the HC group.

CONCLUSIONS

The study demonstrates a distinct pattern of HPA-axis dysregulation in DDs, emphasizing the importance of further study of stress-response systems in dissociative psychopathology.

A preliminary study of cortisol and norepinephrine reactivity to psychosocial stress in borderline personality disorder with high and low dissociation

The goal of the current study was to investigate subjective and neurohormonal reactivity to acute psychosocial stress in borderline personality disorder (BPD) as a function of dissociative symptoms. Five BPD subjects with high dissociation, 8 BPD subjects with low dissociation, and 11 healthy control subjects were compared in basal urinary cortisol and norepinephrine, as well as in plasma cortisol and norepinephrine reactivity to the Trier Social Stress Test (TSST). Subjective stress rating and emotional response to the TSST were also measured. The three groups differed significantly in cortisol stress reactivity, with the high-dissociation BPD group demonstrating the most robust response. The three groups did not significantly differ in norepinephrine stress reactivity. In the combined BPD sample, dissociation severity tended to be inversely correlated with basal urinary norepinephrine, was positively correlated with norepinephrine stress reactivity. Childhood trauma was inversely correlated with basal urinary cortisol. In conclusion, despite its small sample size this pilot study suggests that dissociative symptomatology may be a marker of heightened biological vulnerability to stress in BPD, and merits further study.

Temporal disintegration in depersonalization disorder

Distortions of the experience of time are central to some types of dissociative experiences. In this study, we investigated the relationship between a self-report measure of temporal disintegration and symptoms of dissociation in depersonalization disorder (DPD). Fifty-two DPD and thirty non-clinical control participants were administered the Dissociative Experience Scale (DES) and Temporal Integration Inventory (TII). The DPD group had significantly higher TII scores than the control group. Within the DPD group, there was a significant positive correlation between DES total score and TII total score, and between TII-time distinction subscale score and TII-agency subscale score. In the DPD group, TII scores were not associated with age of onset or duration of illness. Of the three dissociative domains of absorption, amnesia, and depersonalization/derealization, only absorption was a significant predictor of TII total and subscale scores by stepwise linear regression analyses. We conclude that the experience of temporal disintegration in DPD is not directly related to the core symptoms of depersonalization/derealization, but exists when the depersonalized experience involves more prominent absorption.

The oral health and treatment needs of schoolchildren in Trinidad and Tobago: findings of a national survey

OBJECTIVE

To describe the oral health and treatment need of schoolchildren in Trinidad and Tobago.

DESIGN AND METHOD

Cross-sectional survey using stratified cluster sampling. Participants were children in primary (aged 6-8 years) and secondary school (aged 12 and 15 years). Main outcome measures were DMFT/dmft, treatment need, and fluorosis.

RESULTS

Examinations were completed on 1064 children. The dmft of the 6-8-year-olds was 2.54 (95% CI = 2.32, 2.76). For 12-year-olds, the DMFT was 0.61 (95% CI = 0.51, 0.71), whereas for 15-year-olds, the DMFT was 1.06 (95% CI = 0.87, 1.25). Most of the caries experience in 6-8-year-olds was from decayed teeth. Sixty-seven per cent of the sample (95% CI = 64%, 69%) had some type of treatment need. Most frequently occurring need was for fillings at 42% (95% CI = 40%, 44%) with 28% (95% CI = 26%, 31%) of the total sample needing two or more surface fillings, followed by fissure sealants at 33% (95% CI = 30%, 36%) and caries-arresting care at 12% (95% CI = 10%, 14%). Extraction of one or more teeth was needed in 13% (95% CI = 11%, 15%) of children. Rates of fluorosis were negligible.

CONCLUSION

The caries experience of 12- and 15-year-old children were low but was high for schoolchildren aged 6-8 years, in terms of prevalence and severity. Effective oral health promotion strategies need to be implemented to improve the oral health of primary schoolchildren in Trinidad and Tobago.

An open trial of naltrexone in the treatment of depersonalization disorder

Depersonalization disorder (DPD) remains one of the few disorders in modern psychiatry for which no treatments are established that are even partially effective, whether pharmacological or psychotherapeutic. Depersonalization disorder is a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition dissociative disorder characterized by a pervasive subjective sense of unreality and detachment with intact reality testing. Two recent controlled medication trials, one with lamotrigine and one with fluoxetine, failed to show efficacy. There is some evidence for dysregulation of endogenous opioid systems in depersonalization, and a few studies have suggested that opioid antagonists may have efficacy in the treatment of dissociation and depersonalization symptoms. In this prospective open treatment trial, 14 subjects were recruited and treated with naltrexone for 6 weeks to a maximum dose of 100 mg/d (first 7 subjects) or 10 weeks to a maximum dose of 250 mg/d (next 7 subjects). Mean naltrexone dose was 120 mg/d. There was an average 30% reduction of symptoms with treatment, as measured by 3 validated dissociation scales. Three patients were very much improved, and 1 patient was much improved with naltrexone treatment. These findings are potentially promising in a highly treatment-refractory disorder for which no treatment guidelines exist and warrant a randomized controlled trial.

Dissociation and posttraumatic stress 1 year after the World Trade Center disaster: follow-up of a longitudinal survey

BACKGROUND

We conducted a 1-year follow-up of an original mail survey of early reactions to the World Trade Center disaster.

METHOD

Of the 75 subjects originally surveyed, 58 (77%) responded. The survey included measures of dissociation (Dissociative Experiences Scale, Cambridge Depersonalization Scale, Clinician-Administered Dissociative States Scale), post-traumatic stress (Impact of Event Scale-Revised), social support (Interpersonal Support Evaluation List-short form), and a life quality measure (Quality of Life Enjoyment and Satisfaction Questionnaire-short form). We hypothesized that dissociative versus posttraumatic symptoms at follow-up could be dissected on the basis of early reactions.

RESULTS

Responders and nonresponders did not differ in baseline characteristics. Exposure was not associated with dissociation or posttraumatic stress at follow-up. Of distress, dissociation, and posttraumatic stress at baseline, baseline dissociation was the strongest predictor of outcome dissociation while baseline posttraumatic stress was the strongest predictor of outcome posttraumatic stress. Of 4 peritraumatic distress factors generated in the original survey, "loss of control" and "guilt/shame" were significantly related to dissociation and posttraumatic stress at outcome, while "helplessness/anger" was only associated with posttraumatic stress at outcome. Lesser improvement in posttraumatic stress over the first year was significantly related to less social support and greater comorbid dissociation. Interim social support was associated with better life quality and fewer symptoms at outcome.

CONCLUSION

There was evidence for partly independent pathways toward dissociation versus posttraumatic stress 1 year after the disaster. Feelings of guilt and shame, and persistent dissociation, were poor prognostic factors, while social support had a powerful ameliorating influence.

Depersonalisation disorder: a contemporary overview

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

Fluoxetine therapy in depersonalisation disorder: randomised controlled trial

BACKGROUND

Despite anecdotal reports that serotonin reuptake inhibitors may improve depersonalisation, there is no proven efficacious treatment for depersonalisation disorder.

AIMS

To investigate the efficacy of fluoxetine in the treatment of depersonalisation disorder.

METHOD

Fifty-four people who met DSM-IV criteria for depersonalisation disorder were recruited through newspaper advertisements, and 50 were randomised to a 10-week, double-blind trial of fluoxetine 10-60 mg/day or placebo. Primary outcome measures were the Dissociative Experiences Scale-Depersonalisation Factor, the Depersonalization Severity Scale and the Clinical Global Impression-Improvement (CGI-I) scale.

RESULTS

Intention-to-treat analysis revealed that fluoxetine (mean dosage 48 mg/day) was not superior to placebo except for a clinically minimal but statistically significantly greater improvement in CGI-I score in the fluoxetine group prior to covarying for anxiety and depression (2.9 v. 3.6). Depersonalisation was significantly more likely to improve if comorbid anxiety disorder improved.

CONCLUSIONS

Fluoxetine was not efficacious in treating depersonalisation disorder, despite the commonly reported clinical use of serotonin reuptake inhibitors for this condition.

Examination of the pathological dissociation taxon in depersonalization disorder

In recent years, the pathologic dissociation taxon developed by Waller, Putnam, and Carlson (Psychological Methods 1:300-321, 1996) from a Dissociative Identity Disorder (DID) sample has been increasingly used in studies of dissociation in general. However, the taxon's convergence with dissociative diagnoses other than DID, as well as the taxon's central premise that pathologic dissociation is a categorical rather than a dimensional construct, remain areas of exploration. This report examines the applicability of the pathologic dissociation taxon to Depersonalization Disorder (DPD). The Dissociative Experiences Scale was administered to 100 consecutively recruited DPD subjects diagnosed by semistructured clinical interview and by the SCID-D. Taxon membership probability was calculated using the recommended SAS scoring program. Approximately 2/3 of subjects (N = 64) had a very high probability (>.80) of belonging to the taxon, while 1/3 of subjects had a very low probability (<.10) of belonging to the taxon. A taxon cutoff score of 13 yielded an 81% sensitivity in detecting the presence of DPD. The modest convergence between taxonic membership and clinical dissociative disorder diagnosis suggests that the taxon may have important limitations in its use, at least when applied to DPD in its current form. As previously, we continue to recommend a low taxon cutoff score (13) for the sensitive detection of depersonalization disorder. The inference that pathologic dissociation is a unitary and categorical entity is also discussed.

Basal norepinephrine in depersonalization disorder

In contrast to the noradrenergic dysregulation described in PTSD, little is known regarding noradrenergic function in dissociative disorders. The purpose of this preliminary study was to investigate basal norepinephrine in depersonalization disorder (DPD). Nine subjects with DSM-IV DPD, without lifetime PTSD, were compared to nine healthy comparison (HC) subjects. Norepinephrine was measured via 24-h urine collection and three serial plasma determinations. Groups did not differ significantly in plasma norepinephrine levels. Compared to the HC group, the DPD group demonstrated significantly higher urinary norepinephrine, only prior to covarying for anxiety. The DPD group also demonstrated a highly significant inverse correlation between urinary norepinephrine and depersonalization severity (r=-0.88). Norepinephrine and cortisol levels (reported in a prior study) were not intercorrelated. We concluded that although dissociation accompanied by anxiety was associated with heightened noradrenergic tone, there was a marked basal norepinephrine decline with increasing severity of dissociation. The findings are in concordance with the few reports on autonomic blunting in dissociation and merit further investigation.

Relationship of personality to dissociation and childhood trauma in borderline personality disorder

BACKGROUND

Dissociation is a prominent feature in some individuals with borderline personality disorder (BPD), yet our understanding of the meanings and implications of prominent dissociation in BPD remains limited. The purpose of this study was to investigate the relationship between dissociation and childhood trauma in BPD and to explore the relationships of dissociation and trauma to various personality features of BPD.

METHODS

Twenty BPD subjects and 24 healthy comparison subjects of similar age and gender were administered the Dissociative Experiences Scale, the Childhood Trauma Questionnaire-short form, the Tridimensional Personality Questionnaire, the Defense Style Questionnaire, the Relationship Style Questionnaire, and the Schema Questionnaire.

RESULTS

The BPD group exhibited greater dissociation and childhood trauma, as well as greater pathology in most personality variables, compared with the healthy group. Dissociation in BPD was not significantly related to total childhood trauma, but only to emotional neglect, which accounted for 23% of the variance in dissociation scores.

CONCLUSION

Within the BPD group, dissociation was associated with fearful attachment and immature defenses, while total childhood trauma and emotional neglect were associated with overconnection and disconnection schemata. This is a preliminary study with a small sample size, yet the correlates of dissociation in BPD merit further investigation.

Feeling unreal: a depersonalization disorder update of 117 cases

BACKGROUND

Despite a surge of interest and literature on depersonalization disorder in recent years, a large series of individuals with the disorder has not been described to date. In this report, we systematically elucidate the phenomenology, precipitants, antecedents, comorbidity, and treatment history in such a series.

METHOD

117 adult subjects with depersonalization disorder (DSM-III-R/DSM-IV criteria) consecutively recruited to a number of depersonalization disorder research studies were administered structured and semistructured diagnostic interviews and the Dissociative Experiences Scale. Data were gathered from 1994 to 2000.

RESULTS

The illness had an approximately 1:1 gender ratio with onset around 16 years of age. The course was typically chronic and often continuous. Illness characteristics such as onset, duration, and course were not associated with symptom severity. Mood, anxiety, and personality disorders were frequently comorbid, but none predicted depersonalization severity. The most common immediate precipitants of the disorder were severe stress, depression, panic, marijuana ingestion, and hallucinogen ingestion, and none of these predicted symptom severity. Negative affects, stress, perceived threatening social interaction, and unfamiliar environments were some of the more common factors leading to symptom exacerbation. Conversely, comforting interpersonal interactions, intense emotional or physical stimulation, and relaxation tended to diminish symptom intensity. There were no significant gender differences in the clinical features of the disorder. In this sample, depersonalization tended to be refractory to various medication and psychotherapy treatments.

CONCLUSION

The characteristics of depersonalization disorder found in this sample, the largest described to date, are in good accord with previous literature. The study highlights the need for novel therapeutic approaches to treat depersonalization disorder. Novel medication classes, as well as novel psychotherapeutic techniques that build on the reported symptom fluctuation factors, may prove helpful in the future.

Peritraumatic reactions associated with the World Trade Center disaster

OBJECTIVE

The World Trade Center disaster was of unprecedented magnitude and impact in U.S. history. The authors conducted a pilot survey investigating these effects.

METHOD

A questionnaire regarding the disaster was sent to responders to an advertisement. It included demographic and disaster-exposure questions and three scales applied to "during and shortly after" the disaster.

RESULTS

Despite widely ranging exposure, scores for distress (Peritraumatic Distress Inventory), dissociation (Peritraumatic Dissociative Experiences Questionnaire), and posttraumatic stress (Impact of Event Scale-Revised) were markedly elevated (N=75). After covariance for exposure, the distress factor of loss of control most strongly predicted both early dissociation and posttraumatic stress. Life threat specifically contributed to arousal. Dissociation did not contribute beyond distress to posttraumatic stress, with the exception of re-experiencing.

CONCLUSIONS

This survey of reactions to the World Trade Center disaster revealed high levels of early symptoms and suggested similar but independent pathways toward dissociation and posttraumatic stress.