Hippocampal and amygdalar volumes in dissociative identity disorder

Multiple mediation of the association between childhood emotional abuse and adult obesity by anxiety and bulimia - a sample from bariatric surgery candidates and healthy controls

Bulimia, which means a person has episodes of eating a very large amount of food (bingeing) during which the person feels a loss of control over their eating, is the most primitive reason for being overweight and obese. The extended literature has indicated that childhood emotional abuse has a close relationship with adverse mood states, bulimia, and obesity. To comprehensively understand the potential links among these factors, we evaluated a multiple mediation model in which anxiety/depression and bulimia were mediators between childhood emotional abuse and body mass index (BMI). A set of self-report questionnaires, including the Childhood Trauma Questionnaire (CTQ), Beck Anxiety Inventory, Beck Depression Inventory (BDI), and Eating Disorder Inventory (EDI), was sent out. Clinical data from 37 obese patients (age: 29.65 ± 5.35, body mass index (BMI): 37.59 ± 6.34) and 37 demographically well-matched healthy people with normal body weight (age: 31.35 ± 10.84, BMI: 22.16 ± 3.69) were included in the investigation. We first performed an independent t-test to compare all scales or subscale scores between the two groups. Then, we conducted Pearson correlation analysis to test every two variables' pairwise correlation. Finally, multiple mediation analysis was performed with BMI as the outcome variable, and childhood emotional abuse as the predictive variable. Pairs of anxiety, bulimia, and depression, bulimia were selected as the mediating variables in different multiple mediation models separately. The results show that the obese group reported higher childhood emotional abuse (t = 2.157, p = 0.034), worse mood state (anxiety: t = 5.466, p < 0.001; depression: t = 2.220, p = 0.030), and higher bulimia (t = 3.400, p = 0.001) than the healthy control group. Positive correlations were found in every pairwise combination of BMI, childhood emotional abuse, anxiety, and bulimia. Multiple mediation analyses indicate that childhood emotional abuse is positively linked to BMI (β = 1.312, 95% CI = 0.482-2.141). The model using anxiety and bulimia as the multiple mediating variables is attested to play roles in the relationship between childhood emotional abuse and obesity (indirect effect = 0.739, 95% CI = 0.261-1.608, 56.33% of the total effect). These findings confirm that childhood emotional abuse contributes to adulthood obesity through the multiple mediating effects of anxiety and bulimia. The present study adds another potential model to facilitate our understanding of the eating psychopathology of obesity.

Childhood adversity severity modulates the associations between adaptive psychological changes and amygdala volumetric changes in response to behavioral interventions

Background

Adverse Childhood Experience (ACE) has been shown to have detrimental impact on amygdala structure. Prior research found that adaptive psychological changes after Mindfulness-Based Interventions (MBI) were associated with amygdala volumetric changes. The present study aims to further investigate whether such effects also occur among ACE survivors and whether the effects are unique to MBI.

Methods

A total of 64 young adult childhood adversity survivors were randomized to an eight-week MBI or Stress Management Education (SME) as an active control condition. Anatomical MRI and questionnaires on mindfulness, stress and psychological health were collected at baseline and post-intervention. Due to subject dropout, the final sample included 39 subjects (MBI:20, SME:19).

Results

Both groups showed increased mindfulness levels, reduced stress, and improved psychological symptoms (depression, anxiety, and somatization), with no significant group by time interaction effect. There was no significant group difference on amygdala volumetric changes. Within the MBI group, childhood maltreatment severity was a significant mediator between changes of mindfulness levels and right amygdala volumetric changes. Across pooled sample of both groups, childhood maltreatment was a significant moderator for the effect of trait anxiety level changes on left amygdala volumetric changes.

Limitations

Modest sample size, relatively low retention rates, suboptimal monitoring of home practice.

Conclusions

MBI did not demonstrate overall better clinical effects than SME. Psychological-change-dependent amygdala volumetric change was not specific to MBI. Childhood maltreatment severity modulated the relationships between adaptive psychological changes and amygdala volumetric changes.

Social Stigmatization and Late Treatment of Dissociative Disorder: A Case Report on Trance and Possession Disorder

Dissociative disorders have been present in our society since time immemorial, with culture, society, and spiritual beliefs playing a major part. It went through many changes from its name and what it constituted. Diagnosis can be made based on the International Classification of Diseases (ICD) 10, Diagnostic and Statistical Manual of Mental Disorders (DSM) 5, and now the current International Classification of Diseases (ICD) 11 criteria. One of its constituents is trance and possession disorder which is one of the main obstacles faced by psychiatrists in Indian society. Through this case, we can assume that there are many factors involved that lead to delays in diagnosing and managing a case of dissociative disorder, most importantly the social and cultural factors. Even now cultural-socio-spiritual beliefs add to the challenge of dissociative disorders. This case reveals that individuals first consult a general physician before visiting a psychiatrist; so, the need for consultation liaison psychiatry (CLP) and its role today in diagnosis and further management is emphasized. There still exists a need for awareness to be made regarding the mind-body relationship and psychosocial support to both patients and their relatives keeping in mind their beliefs.

Hippocampal volume mediates the relationship of parental rejection in childhood with social cognition in healthy adults

Childhood abuse reduces hippocampal and amygdala volumes and impairs social cognition, including the ability to recognize facial expressions. However, these associations have been studied primarily in individuals with a history of severe abuse and psychiatric symptoms; researchers have not determined whether these associations can also be observed in healthy adults. In the present study, we analyzed data from 400 healthy adults (208 men and 192 women) at Tamagawa University. Parental rejection reflecting childhood abuse was assessed using the short form of Egna Minnen Beträffande Uppfostran, while social cognition was assessed using the "Fake Smile Detection Task." Hippocampal and amygdala volumes were extracted from T1-weighted magnetic resonance imaging data using FreeSurfer. We found that greater parental rejection resulted in smaller hippocampal and amygdala volumes and poorer performance in the Fake Smile Detection Task. Structural equation modeling analysis supported the model that hippocampal volume mediates maternal rejection effect on performance on the Fake Smile Detection Task, with involvement of the amygdala. These findings are in line with the structural and functional connectivity found between the hippocampus and amygdala and their joint involvement in social cognition. Therefore, parental rejection may affect hippocampal and amygdala volumes and social cognitive function even in symptom-free adults.

Assessing malingering and personality styles in dissociative identity disorder: a case study

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.

What are the neural correlates of dissociative amnesia? A systematic review of the functional neuroimaging literature

AIM

Dissociative amnesia is an emblematic psychiatric condition in which patients experience massive memory loss ranging from focal to global amnesia. This condition remains poorly understood and this review aims to investigate the neuroanatomical feature of this disease.

METHODS

We conducted a systematic review of the scientific literature available on PubMed, up to December 1, 2022, using a combination of keywords referring to dissociative amnesia. We included every scientific report involving patients undergoing a functional imaging procedure.

RESULTS

Twenty-two studies met our inclusion criteria (gathering 49 patients). Only one was a controlled study with a large sample. The other 21 were case reports and case series. In resting state, neuroimaging studies mostly showed a hypo-activated right inferolateral prefrontal cortex, associated with limbic hypoactivity and lesser activation of the hippocampal and para-hippocampal structures. The patients also presented abnormal patterns of cerebral activation when performing memory tasks. When testing recognition of memories from the amnestic period, patients showed increased activation across temporal areas (hippocampal and para-hippocampal gyri) and the limbic network. When trying to recollect memories from an amnestic period compared to a non-amnestic period, patients failed to activate these structures efficiently. Most of these patterns tended to return to normal when symptoms resolved.

CONCLUSION

This review identified a paucity of controlled studies in the field of dissociative amnesia neuroimaging, which restricts the extrapolation of results. Patients with dissociative amnesia present a broad prefronto-temporo-limbic network dysfunction. Some of the brain areas implicated in this network might represent potential targets for innovative treatments.

Clinical Manifestations of Body Memories: The Impact of Past Bodily Experiences on Mental Health

Bodily experiences such as the feeling of touch, pain or inner signals of the body are deeply emotional and activate brain networks that mediate their perception and higher-order processing. While the ad hoc perception of bodily signals and their influence on behavior is empirically well studied, there is a knowledge gap on how we store and retrieve bodily experiences that we perceived in the past, and how this influences our everyday life. Here, we explore the hypothesis that negative body memories, that is, negative bodily experiences of the past that are stored in memory and influence behavior, contribute to the development of somatic manifestations of mental health problems including somatic symptoms, traumatic re-experiences or dissociative symptoms. By combining knowledge from the areas of cognitive neuroscience and clinical neuroscience with insights from psychotherapy, we identify Clinical Body Memory (CBM) mechanisms that specify how mental health problems could be driven by corporeal experiences stored in memory. The major argument is that the investigation of the neuronal mechanisms that underlie the storage and retrieval of body memories provides us with empirical access to reduce the negative impact of body memories on mental health.

Normal amygdala morphology in dissociative identity disorder

Studies investigating the structure of the amygdala in relation to dissociation in psychiatric disorders are limited and have reported normal or preserved, increased or decreased global volumes. Thus, a more detailed investigation of the amygdala is warranted. Amygdala global and subregional volumes were compared between individuals with dissociative identity disorder (DID: n = 32) and healthy controls (n = 42). Analyses of covariance did not show volumetric differences between the DID and control groups. Although several unknowns make it challenging to interpret our findings, we propose that the finding of normal amygdala volume is a genuine finding because other studies using this data-set have presented robust morphological aberrations in relation to the diagnosis of DID.

A Meta-Analysis of Hippocampal and Amygdala Volumes in Patients Diagnosed With Dissociative Identity Disorder

Dissociative Identity Disorder (DID), an illness characterized by multiple personality states, has long been a controversial diagnosis within the psychiatric community. Demonstrating a neuroanatomical basis for the disorder may help to resolve the controversy. Current literature on the neuroanatomy associated with DID has focused on the hippocampus and amygdala and are inconclusive. This meta-analysis pools the results from n = 3 studies to compare the mean size of these two structures between DID patients, non-DID patients, and healthy controls. Patients diagnosed with both DID & PTSD were found to have smaller hippocampi bilaterally (p< .001) compared to healthy controls; no significant difference was seen in the amygdala. When comparing DID to PTSD patients, the left hippocampus was smaller (p< .001), with a trend for a smaller right hippocampus (p = .06). A comparison of the amygdala was not possible due to a lack of data. These findings suggest that a smaller hippocampus is seen in DID patients beyond what is seen for PTSD, provides neuroanatomical evidence for the memory impairment often seen in DID patients (i.e., amnesia experienced by the host and alters), and presents a potentially novel means to understand this disorder.

Inter-identity amnesia for neutral episodic self-referential and autobiographical memory in Dissociative Identity Disorder: An assessment of recall and recognition

Amnesia is a core diagnostic criterion for Dissociative Identity Disorder (DID), however previous research has indicated memory transfer. As DID has been conceptualised as being a disorder of distinct identities, in this experiment, behavioral tasks were used to assess the nature of amnesia for episodic 1) self-referential and 2) autobiographical memories across identities. Nineteen DID participants, 16 DID simulators, 21 partial information, and 20 full information comparison participants from the general population were recruited. In the first study, participants were presented with two vignettes (DID and simulator participants received one in each of two identities) and asked to imagine themselves in the situations outlined. The second study used a similar methodology but with tasks assessing autobiographical experience. Subjectively, all DID participants reported amnesia for events that occurred in the other identity. On free recall and recognition tasks they presented a memory profile of amnesia similar to simulators instructed to feign amnesia and partial information comparisons. Yet, on tests of recognition, DID participants recognized significantly more of the event that occurred in another identity than simulator and partial information comparisons. As such, results indicate that the DID performance profile was not accounted for by true or feigned amnesia, lending support to the idea that reported amnesia may be more of a perceived than actual memory impairment.

Biomarkers of Pathological Dissociation: A Systematic Review

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

Structural and functional brain alterations in psychiatric patients with dissociative experiences: A systematic review of magnetic resonance imaging studies

INTRODUCTION

There is currently no general agreement on how to best conceptualize dissociative symptoms and whether they share similar neural underpinnings across dissociative disorders. Neuroimaging data could help elucidate these questions.

OBJECTIVES

The objective of this review is to summarize empirical evidence for neural aberrations observed in patients suffering from dissociative symptoms.

METHODS

A systematic literature review was conducted including patient cohorts diagnosed with primary dissociative disorders, post-traumatic stress disorder (PTSD), or borderline personality disorder.

RESULTS

Results from MRI studies reporting structural (gray matter and white matter) and functional (during resting-state and task-related activation) brain aberrations were extracted and integrated. In total, 33 articles were included of which 10 pertained to voxel-based morphology, 2 to diffusion tensor imaging, 10 to resting-state fMRI, and 11 to task-related fMRI. Overall findings indicated aberrations spread across diverse brain regions, especially in the temporal and frontal cortices. Patients with dissociative identity disorder and with dissociative PTSD showed more overlap in brain activation than each group showed with depersonalization/derealization disorder.

CONCLUSION

In conjunction, the results indicate that dissociative processing cannot be localized to a few distinctive brain regions but rather corresponds to differential neural signatures depending on the symptom constellation.

Additional Insights into the Relationship Between Brain Network Architecture and Susceptibility and Resilience to the Psychiatric Sequelae of Childhood Maltreatment

Childhood maltreatment is associated with increased risk for psychiatric and substance use disorders. However, some maltreated individuals appear resilient to these consequences while manifesting the same array of brain changes as maltreated individuals with psychopathology. Hence, a critical issue has been to identify compensatory brain alterations in these resilient individuals. We recently reported that maltreatment is associated with a more vulnerable structural brain network architecture. Resilient individuals have this same vulnerability but appeared to be able to effectively compensate due to reduced nodal efficiency (ability of a node to influence the global network) in 9 specific brain regions that moderate the relationship between maltreatment and psychopathology. Following up we now report that network vulnerability increases progressively during late adolescence to plateau at about 21 years of age, which may help to explain age of onset of psychopathology. Further, we found that network vulnerability was most significantly affected by parental verbal abuse between 16-18 years of age and number of types of maltreatment during childhood. Asymptomatic individuals with no history of psychopathology had more prominent alterations in nodal efficiency than asymptomatic individuals with prior history, who specifically showed reduced nodal efficiency in right amygdala and right subcallosal gyrus. Experiencing inadequate financial sufficiency during childhood increased risk of susceptibility versus resilience by 2.98-fold (95% CI 1.49-5.97, p = 0.002) after adjusting for differences in exposure to maltreatment. Interestingly, adequate-to-higher financial sufficiency appeared to be protective and was associated with reduced nodal efficiency in the right postcentral gyrus and subcallosal gyrus 'resilience' nodes.

Is There an Ace Up Our Sleeve? A Review of Interventions and Strategies for Addressing Behavioral and Neurobiological Effects of Adverse Childhood Experiences in Youth

Exposure to early life adversity (ELA) is a major public health crisis posing as a significant risk of immediate and sustained mental and physical health consequences. While a remarkable body of knowledge has been amassed showing psychological, cognitive, social, developmental, and neurobiological consequences of ELA exposure, little has been done to improve the long-term mental and physical health outcomes for youth exposed to ELA. Furthermore, neurobiological processes underlying poor outcomes in this population have been largely left out of prevention and intervention target efforts. In this review, we first describe ELA-related alterations across psychological and neurobiological systems in children and adolescents. Next, we describe existing evidence-based interventions targeting ELA-related outcomes. We then turn to experimental studies examining individual differences in mechanistic functioning consequent to ELA exposure, and strategies that target these mechanisms and modulate disrupted functioning. Finally, we highlight areas of future research that may be promising in engaging behavioral and neurobiological targets through novel preventive interventions or augmentation of existing interventions, thereby reducing negative mental and physical health outcomes later in life.

Confederates in the Attic: Posttraumatic Stress Disorder, Cardiovascular Disease, and the Return of Soldier's Heart

Da Costa originally described Soldier's Heart in the 19th Century as a syndrome that occurred on the battlefield in soldiers of the American Civil War. Soldier's Heart involved symptoms similar to modern day posttraumatic stress disorder (PTSD) as well as exaggerated cardiovascular reactivity felt to be related to an abnormality of the heart. Interventions were appropriately focused on the cardiovascular system. With the advent of modern psychoanalysis, psychiatric symptoms became divorced from the body and were relegated to the unconscious. Later, the physiology of PTSD and other psychiatric disorders was conceived as solely residing in the brain. More recently, advances in psychosomatic medicine led to the recognition of mind-body relationships and the involvement of multiple physiological systems in the etiology of disorders, including stress, depression PTSD, and cardiovascular disease, has moved to the fore, and has renewed interest in the validity of the original model of the Soldier's Heart syndrome.

Stress, the brain, and trauma spectrum disorders

This chapter reviews the relationship between stress and brain function in patients with neuropsychiatric disorders, with an emphasis on disorders that have most clearly been linked to traumatic stress exposure. These disorders, which have been described as trauma spectrum disorders, include posttraumatic stress disorder (PTSD), a subgroup of major depression, borderline personality disorder (BPD) and dissociative disorders; they share in common a neurobiological footprint, including smaller hippocampal volume, and are distinguished from other disorders that may share symptom similarities, like some of the anxiety disorders, but are not as clearly linked to stress. The relationship between environmental events such as stressors, especially in early childhood, and their effects on brain and neurobiology is important to understand in approaching these disorders as well as the development of therapeutic interventions. Addressing patients with stress-related disorders from multiple developmental (age at onset of trauma) as well as levels of analysis (cognitive, cultural, neurobiological) approaches will provide the most complete picture and result in the most successful treatment outcomes.

A systematic review of structural MRI investigations within borderline personality disorder: Identification of key psychological variables of interest going forward

Existing models of Borderline Personality Disorder (BPD) suggest that a combination of genetic vulnerability, childhood trauma, and disrupted attachment can lead to the marked emotional lability, impulsivity and interpersonal difficulties observed clinically. Brain structural differences in frontal, limbic and hippocampal regions have been reported in BPD. Less clear is how specific psychological factors relate to these structural differences, and how consistently this is found across studies. This was the focus of the present review. Eighteen studies published between 2004 and 2018 met inclusion criteria encompassing 990 participants. Study quality was assessed using the Nottingham-Ottawa Scale. We also introduce a newly devised scale to assess MRI reporting quality. The most frequently investigated psychological variable were impulsivity (9 studies), depression (8), trauma (6), aggression (6), severity of symptoms (3), global functioning, abuse and dissociation (2). Study quality varied, however, a trend was observed where newer studies were higher in reporting quality. Impulsivity demonstrated greater association with frontal structures, trauma related to the hypothalamus and limbic systems, and aggression with hippocampal and frontal structures. The present review recommends greater exploration of neurocognitive and psychosis-related features such as delusions, paranoia and voice-hearing in future studies, and to investigate cortical changes in longitudinal designs.

Macro- and microstructural gray matter alterations in sexually assaulted women

BACKGROUND

Studies with trauma survivors documented structural alterations in brain regions involved in posttraumatic stress disorder (PTSD) neurocircuitry. Nonetheless, whether such alterations exist in women who were sexually assaulted in adulthood is not clear. We investigated the macro- and microstructure of key regions implicated in PTSD pathophysiology, namely the amygdala, hippocampus, anterior cingulate cortex (ACC), and insula, in this population.

METHODS

Thirty-eight sexually assaulted women (PTSD, n = 25; non-PTSD, n = 13) and 24 non-exposed controls (NEC) were studied with T1- and diffusion-weighted MRI. Gray matter volume, mean diffusivity (MD), and fractional anisotropy (FA) were calculated for each region. Between-group comparisons and correlations with PTSD symptom severity were performed.

RESULTS

Volumetric analyses revealed lower amygdala and insula volumes in the PTSD compared with the non-PTSD group. In contrast, altered microstructure was observed in both traumatized groups compared with NEC, including higher MD and lower FA in the right amygdala, and higher FA in the ACC bilaterally. Finally, the non-PTSD group had higher FA in the right insula compared with the PTSD group. PTSD symptom severity was correlated with amygdala and insula volumes, as well as with hippocampal FA and MD.

LIMITATIONS

Sample size may have led to reduced statistical power.

CONCLUSIONS

Sexual assault and the development of PTSD in women are linked with structural alterations in key regions implicated in PTSD following other trauma types (e.g., combat), though hippocampal and ACC volumes were preserved. Further studies are needed to disentangle the unique contribution of trauma type and of sex/gender to these observations.

Fibromyalgia and dissociative symptoms

BACKGROUND

Fibromyalgia (FM) is a chronic pain syndrome with a controversial etiopathogenesis. Patients with FM usually complain of cognitive symptoms, which are described as "fibrofog." These cognitive complaints might be caused partially by dissociative disorders (DD). The aim of this research is to determine the association between FM and DD.

METHODS

The authors conducted a case-control study for this purpose, integrated by 3 groups: control (C), patients with rheumatic disorders (R), and patients with FM (FM), who were compared through the Dissociative Experiences Scale (DES).The findings are as follows: 42% were taking medications in the FM group, and their differences in scores with those who were not under medications were then considered. In terms of the results, the FM group showed higher scores than both C and R groups (p < 0.05). Patients with FM who were taking antidepressants had lower scores than those who were not (Z-score -8.03; p < 0.05); and finally, 5.71% had a score over 30 (χ2 = 3.73, p = 0.15).

CONCLUSION

Patients with FM had higher scores, which might be related to the association of dissociative experiences, lifetime trauma, and victimization. Antidepressants might have some role on dissociative symptoms as well.

During infant maltreatment, stress targets hippocampus, but stress with mother present targets amygdala and social behavior

Infant maltreatment increases vulnerability to physical and mental disorders, yet specific mechanisms embedded within this complex infant experience that induce this vulnerability remain elusive. To define critical features of maltreatment-induced vulnerability, rat pups were reared from postnatal day 8 (PN8) with a maltreating mother, which produced amygdala and hippocampal deficits and decreased social behavior at PN13. Next, we deconstructed the maltreatment experience to reveal sufficient and necessary conditions to induce this phenotype. Social behavior and amygdala deficits (volume, neurogenesis, c-Fos, local field potential) required combined chronic high corticosterone and maternal presence (not maternal behavior). Hippocampal deficits were induced by chronic high corticosterone regardless of social context. Causation was shown by blocking corticosterone during maltreatment and suppressing amygdala activity during social behavior testing. These results highlight (1) that early life maltreatment initiates multiple pathways to pathology, each with distinct causal mechanisms and outcomes, and (2) the importance of social presence on brain development.

Women's Auto/Biography and Dissociative Identity Disorder: Implications for Mental Health Practice

Dissociative Identity Disorder (DID) is an uncommon disorder that has long been associated with exposure to traumatic stressors exceeding manageable levels commonly encompassing physical, psychological and sexual abuse in childhood that is prolonged and severe in nature. In DID, dissociation continues after the traumatic experience and produces a disruption in identity where distinct personality states develop. These personalities are accompanied by variations in behaviour, emotions, memory, perception and cognition. The use of literature in psychiatry can enrich comprehension over the subjective experience of a disorder, and the utilisation of 'illness narratives' in nursing research have been considered a way of improving knowledge about nursing care and theory development. This research explores experiences of DID through close textual reading and thematic analysis of five biographical and autobiographical texts, discussing the lived experience of the disorder. This narrative approach aims to inform empathetic understanding and support the facilitation of therapeutic alliances in mental healthcare for those experiencing the potentially debilitating and distressing symptoms of DID. Although controversies surrounding the biomedical diagnosis of DID are important to consider, the lived experiences of those who mental health nurses encounter should be priority.

Dissociation debates: everything you know is wrong

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

Susceptibility or Resilience to Maltreatment Can Be Explained by Specific Differences in Brain Network Architecture

BACKGROUND

Childhood maltreatment is a major risk factor for psychopathology. However, some maltreated individuals appear remarkably resilient to the psychiatric effects while manifesting the same array of brain abnormalities as maltreated individuals with psychopathology. Hence, a critical aim is to identify compensatory brain alterations that enable resilient individuals to maintain mental well-being despite alterations in stress-susceptible regions.

METHODS

Network models were constructed from diffusion tensor imaging and tractography in physically healthy unmedicated 18- to 25-year-old participants (N = 342, n = 192 maltreated) to develop network-based explanatory models.

RESULTS

First, we determined that susceptible and resilient individuals had the same alterations in global fiber stream network architecture using two different definitions of resilience: 1) no lifetime history of Axis I or II disorders, and 2) no clinically significant symptoms of anxiety, depression, anger-hostility, or somatization. Second, we confirmed an a priori hypothesis that right amygdala nodal efficiency was lower in asymptomatic resilient than in susceptible participants or control subjects. Third, we identified eight other nodes with reduced nodal efficiency in resilient individuals and showed that nodal efficiency moderated the relationship between maltreatment and psychopathology. Fourth, we found that models based on global network architecture and nodal efficiency could delineate group membership (control, susceptible, resilient) with 75%, 82%, and 80% cross-validated accuracy.

CONCLUSIONS

Together these findings suggest that sparse fiber networks with increased small-worldness following maltreatment render individuals vulnerable to psychopathology if abnormalities occur in specific nodes, but that decreased ability of certain nodes to propagate information throughout the network mitigates the effects and leads to resilience.

Psycho-Neurobiology and Its Potential Influence on Psychotherapy: Being, Doing, and the Risk of Scientism

Neuroscientific information may transform the modern practice of psychotherapy. Still we must pay heed to the most salient of the common factors generating therapeutic change: the relationship between patient and therapist. Likewise, brain and body are both part of mind and we ignore this at our clinical peril. Research on affective, cognitive, mnemic, somatic, psychophysiologic, developmental, and integrative mental processes, amongst others, must hold to a high standard of translation from basic scientific findings or we risk practicing a psychotherapy enslaved to an authoritarian scientism as a substitute for the creation of unfettered intimacy and engagement. A balanced approach is required if in trauma treatment, for example, we are to be both potential beneficiaries of understanding what is in our human heads while not losing track of our very human hearts. Each clinician need develop a basic knowledge of neuroscience in order to critically assess the meanings of new findings and their proper place in the practice of all the psychotherapies.

Understanding, identifying and managing severe dissociative disorders in general psychiatric settings

The severe dissociative disorders of dissociative identity disorder (DID) and dissociative disorder not otherwise specified (DDNOS) are complex, not uncommon presentations associated with severe symptoms, high rates of comorbidity, high service use compared with other psychiatric disorders, and high suicidality. They exact high personal and socioeconomic burdens and show poor response to standard treatments, with high levels of treatment attrition and ‘revolving-door’ out-patient and in-patient service use; patients are often misdiagnosed or labelled ‘untreatable’. DID and DDNOS diagnoses remain controversial, but they have been repeatedly validated internationally over the past 20 years and the disorders can be accurately identified using screening tools and structured clinical interviews. Neurobiological understanding of the disorders is increasing; findings are consistent with a trauma origin and have commonality with features seen in other trauma-related disorders. Specialist treatment that addresses the dissociative symptoms alongside their trauma origins shows promise in early evidence. Working knowledge of these disorders among non-specialist psychiatrists and psychologists in the UK remains poor, resulting in long delays before diagnosis and treatment.

LEARNING OBJECTIVES

•

DECLARATION OF INTEREST

None.

Psychotic-Like Symptoms and the Temporal Lobe in Trauma-Related Disorders: Diagnosis, Treatment, and Assessment of Potential Malingering

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.

Dissociative Experience in Unipolar and Bipolar Depression: Exploring the Great Divide

Objective

Unipolar and bipolar depression (UD and BD) differ strikingly in respect to neurobiology, course and management, but their apparent clinical similarity often leads to misdiagnosis resulting in chronicity of course and treatment failure. In this study we have tried to assess whether UD and BD can be differentiated on the basis of their dissociative symptoms.

Methods

Thrty-six UD patients and 35 BD patients in active episodes, without any psychiatric comorbidity were selected from outpatient department and compared for depressive and dissociative symptoms using Hamilton Depression Rating Scale and Dissociative Experience Scale-II (DES-II).

Results

We found that thought the two groups didn’t differ in terms of the socio-demographic or clinical variables, BD group had significantly higher dissociative experience (U=343, p=0.001) than UD and the difference remained significant even after adjusting for the confounding factors.

Conclusion

Our study shows that dissociative symptoms are significantly more prevalent in the depressive episodes of bipolar affective disorder as compared to the UD and can be an important tool in differentiating between the two disorders with very similar clinical profile. The difference can be measured using a simple self-report questionnaire like DES-II.

Childhood Trauma, Perceived Stress, and Hair Cortisol in Adults With and Without Cardiovascular Disease

OBJECTIVE

Childhood trauma has been associated with greater psychological and physical morbidity, including a greater risk of developing cardiovascular disease (CVD). This may partially reflect trauma-induced disturbances in how stress is later perceived and regulated. This study evaluated the associations of childhood trauma with perceived stress and hair cortisol concentrations (HCC) in a large sample of adults with coronary artery disease (CAD) and in non-CVD patients experiencing other nonfatal illnesses. Whether sex, age, or CVD status influenced these associations was also examined.

METHODS

A total of 1124 men and women (aged 65.2 [6.9] years) recruited from a hospital cohort completed the Childhood Trauma and Perceived Stress Questionnaires, whereas hair samples were obtained from 598 participants. Health status was confirmed via medical records.

RESULTS

Moderate to severe childhood trauma was experienced by 359 participants. Childhood trauma was associated with greater perceived stress levels for the past 2 years (r = .308, p = .01; β = 0.263, p < .001), but not 3-month cortisol secretion in hair. Perceived stress correlated negatively with age (r = -.241, p < .001). In secondary analyses, age moderated the relation between sexual abuse and perceived stress (β = -0.067, p = .016). Although sexual abuse was associated with greater levels of perceived stress among all participants, this relation was strongest in younger individuals.

CONCLUSIONS

Participants who experienced trauma in their youth reported greater levels of perceived stress, but not HCC, in late adulthood. Whether this suggests intact hypothalamic-pituitary-adrenal regulation in those exposed to childhood trauma or whether this reflects the characteristics of our sample requires further investigation.

REVISITING THE SAFE PLACE:Method and Regulatory Aspects in Psychotherapy when Easing Allostatic Overload in Traumatized Patients

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.

Neurodevelopmental origins of abnormal cortical morphology in dissociative identity disorder

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.

Lateralization of Neurobiological Response in Adolescents with Post-Traumatic Stress Disorder Related to Severe Childhood Sexual Abuse: the Tri-Modal Reaction (T-MR) Model of Protection

This study inquires into neurobiological response to stress and its clinical correlates among adolescents with post-traumatic stress disorder (PTSD). Structural magnetic resonance imaging (MRI) measures of cerebral anatomy were carried out on 23 female adolescents with PTSD related to severe childhood sexual abuse and 21 matched healthy controls. Clinician Administered PTSD Scale for Children and Adolescents, Adolescent Dissociative Experiences Scale, Childhood Trauma Questionnaire, Schedule for Affective Disorders and Schizophrenia for School Age Children, Beck Depression Scale, and a set of neuro-cognitive tests were administered to all participants. Compared to controls, PTSD group bilaterally had smaller amygdala, hippocampus, anterior cingulate, and thinner prefrontal cortex but normal thalamus. Further analyses within the PTSD group suggested an association between symptoms of PTSD and sizes of right brain structures including smaller amygdala but larger hippocampus and anterior cingulate. Thinner right prefrontal cortex and larger right thalamus seemed to be related to denial and response prevention, respectively. Being related to both hemispheres, dissociative amnesia was negatively associated with proportion of the right amygdala to right thalamus and to both left and right prefrontal cortex. Suggesting a neuro-protective effect against traumatic stress at least through adolescence, depersonalization-derealization and identity alteration were correlated with thicker left prefrontal cortex. Unlike the lateralization within PTSD group, correlations between regions of interest were rather symmetrical in controls. The graded response to stress seemed to be aimed at mental protection by lateralization of brain functions and possibly diminished connection between two hemispheres. A Tri-Modal Reaction (T-MR) Model of protection is proposed.

Adverse Childhood Experiences and the Consequences on Neurobiological, Psychosocial, and Somatic Conditions Across the Lifespan

Introduction: Adverse childhood experiences (ACE) such as sexual and physical abuse or neglect are frequent in childhood and constitute a massive stressor with long-lasting adverse effects on the brain, mental and physical health.The aim of this qualitative review is to present a concise overview of the present literature on the impact of ACE on neurobiology, mental and somatic health in later adulthood. Methods: The authors reviewed the existing literature on the impact of ACE on neurobiology, mental and somatic health in later adulthood and summarized the results for a concise qualitative overview. Results: In adulthood, the history of ACE can result in complex clinical profiles with several co-occurring mental and somatic disorders such as posttraumatic stress disorder, depression, borderline personality disorder, obesity and diabetes. Although a general stress effect in the development of the disorders and neural alterations can be assumed, the role of type and timing of ACE is of particular interest in terms of prevention and treatment of ACE-related mental and somatic conditions. It has been suggested that during certain vulnerable developmental phases the risk for subsequent ACE-related disorders is increased. Moreover, emerging evidence points to sensitive periods and specificity of ACE-subtypes in the development of neurobiological alterations, e.g., volumetric and functional changes in the amygdala and hippocampus. Conclusion: Longitudinal studies are needed to investigate complex ACE-related characteristics and mechanisms relevant for mental and somatic disorders by integrating state of the art knowledge and methods. By identifying and validating psychosocial and somatic risk factors and diagnostic markers one might improve the development of innovative somatic and psychological treatment options for individuals suffering from ACE-related disorders.

Cortical thickness alterations linked to somatoform and psychological dissociation in functional neurological disorders

BACKGROUND

Links between dissociation and functional neurological disorder (FND)/conversion disorder are well-established, yet the pathophysiology of dissociation remains poorly understood. This MRI study investigated structural alterations associated with somatoform and psychological dissociation in FND. We hypothesized that multimodal, paralimbic cingulo-insular regions would relate to the severity of somatoform dissociation in patients with FND.

METHODS

FreeSurfer cortical thickness and subcortical volumetric analyses were performed in 26 patients with motor FND and 27 matched healthy controls. Patients with high dissociation as measured by the Somatoform Dissociation Questionnaire-20 (SDQ) or Dissociative Experiences Scale (DES) were compared to controls in stratified analyses. Within-group analyses were also performed with SDQ and DES scores in patients with FND. All cortical thickness analyses were whole-brain corrected at the cluster-wise level.

RESULTS

Patients with FND and high somatoform dissociation (SDQ > 35) showed reduced left caudal anterior cingulate cortex (ACC) cortical thickness compared to controls. In within-group analyses, SDQ scores inversely correlated with left caudal ACC cortical thickness in patients with FND. Depersonalization/derealization scores positively correlated with right lateral occipital cortical thickness. Both within-group findings remained statistically significant controlling for trait anxiety/depression, borderline personality disorder and post-traumatic stress disorder, adverse life events, and motor FND subtypes in post-hoc analyses.

CONCLUSION

Using complementary between-group and within-group analyses, an inverse association between somatoform dissociation and left caudal ACC cortical thickness was observed in patients with FND. A positive relationship was also appreciated between depersonalization/derealization severity and cortical thickness in visual association areas. These findings advance our neuropathobiological understanding of dissociation in FND. Hum Brain Mapp 39:428-439, 2018. © 2017 Wiley Periodicals, Inc.

A resting-state fMRI study in borderline personality disorder combining amplitude of low frequency fluctuation, regional homogeneity and seed based functional connectivity

BACKGROUND

This resting-state fMRI study investigated thebrain function in patients with borderline personality disorder (BPD) with three data-driven algorithms.

METHODS

Forty BPD patients and thirty-five controls were enrolled and scanned with a 3.0T Philips Ingenia scanner. Rs-fMRI and structural images were preprocessed by DPARSF based on SPM8 on the MATLAB platform. To evaluate BPD related brain function alterations comprehensively, we analyzed the amplitude of low frequency fluctuations (ALFF), regional homogeneity (ReHo), and seed based functional connectivity (seed-based FC), three data-driven algorithms of rs-fMRI. Results were multiply corrected by REST AlphaSim program at the level of p<0.05. Meanwhile, the correlation between imaging and psychological data was also performed in BPD patients.

RESULTS

Compared with control group, BPD group showed decreased ALFF and ReHo both in the right posterior cingulate cortex (PCC) and adjacent precuneus. With these two areas as seeds, disturbed functional connectivity mainly distributed in the frontotemporal and limbic structure in BPD group. There were no significant correlations found between imaging variables and psychological data.

LIMITATIONS

The sample size was relatively small, and no significant correlations were found between imaging variables and psychological data, which might limit the clinical application of these results.

CONCLUSIONS

Based on data-driven analysis, we discovered that the right PCC and precuneus were altered in resting state function in BPD. Combining with our previous Voxel Based Morphometry (VBM) study which has found increased gray matter volume (GMV) in the right PCC and precuneus, we confirmed that these two areas were core brain regions altered both in structure and function in BPD.

Revisiting the etiological aspects of dissociative identity disorder: a biopsychosocial perspective

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.

Childhood maltreatment, psychopathology, and the development of hippocampal subregions during adolescence

INTRODUCTION

It is well established that childhood maltreatment has a detrimental impact on the brain, particularly the hippocampus. However, the hippocampus is a functionally and structurally heterogeneous region, and little is known about how maltreatment might affect hippocampal subregion development throughout important periods of plasticity. This study investigated whether childhood maltreatment was associated with the development of hippocampal subregion volumes from early to late adolescence. It also investigated associations between onset of psychiatric disorder and hippocampal subregion volume development.

METHODS

One hundred and sixty-six (85 male) adolescents took part in three magnetic resonance imaging assessments during adolescence (mean age at each assessment: 12.79 [SD 0.43] years, 16.70 [SD 0.52] years, and 19.08 [SD 0.46] years), provided a self-report of childhood maltreatment, and were assessed for Axis I psychopathology.

RESULTS

Childhood maltreatment was associated with the development of right total and left cornu ammonis 4 (CA4-DG) volumes from early to late adolescence. Early and late onset psychopathology was associated with the development of right presubiculum and right cornu ammonis 1 (CA1) volumes, respectively. Maltreatment findings appeared to be specific to males, whereas psychopathology findings appeared to be specific to females.

CONCLUSIONS

These findings provide evidence for possible deleterious effects of childhood maltreatment and early onset psychiatric disorder on the development of different subregions of the hippocampus. Altered development of the right CA1, on the other hand, might precede the development of late-adolescent onset psychopathology. Our results highlight the importance of considering development in research examining associations between stress, mental illness, and hippocampal morphology.

Psychospiritual Resiliency: Enhancing Mental Health and Ecclesiastical Collaboration in Caring for Those Experiencing Dissociative Phenomena

Trauma can oftentimes be a catalyst for changes in an individual's religious and spiritual beliefs. Beliefs about the cause of the trauma, for instance, may include attributions of possessing spirits, and are to be found in an increasingly pluralistic and multicultural society. Such preternatural explanations may be referred to as dissociative identity disorder, possession form. Unwittingly, an overreliance on neurobiological explanations and relegation of cultural idioms of distress may diminish effective collaboration with ecclesiastical authorities. Concomitantly, ecclesiastical experts are confronted with bewildering posttrauma dissociative symptomatology, and may not be prepared as diagnosticians to rule out psychobiological explanations. In both instances, client care may be compromised. Noteworthy, the current investigation integrates the author's participant observation research at the Vatican's school of Exorcism in Rome, Italy.

Unique and Overlapping Symptoms in Schizophrenia Spectrum and Dissociative Disorders in Relation to Models of Psychopathology: A Systematic Review

Schizophrenia spectrum disorders (SSDs) and dissociative disorders (DDs) are described in the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) and tenth edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) as 2 categorically distinct diagnostic categories. However, several studies indicate high levels of co-occurrence between these diagnostic groups, which might be explained by overlapping symptoms. The aim of this systematic review is to provide a comprehensive overview of the research concerning overlap and differences in symptoms between schizophrenia spectrum and DDs. For this purpose the PubMed, PsycINFO, and Web of Science databases were searched for relevant literature. The literature contained a large body of evidence showing the presence of symptoms of dissociation in SSDs. Although there are quantitative differences between diagnoses, overlapping symptoms are not limited to certain domains of dissociation, nor to nonpathological forms of dissociation. In addition, dissociation seems to be related to a history of trauma in SSDs, as is also seen in DDs. There is also evidence showing that positive and negative symptoms typically associated with schizophrenia may be present in DD. Implications of these results are discussed with regard to different models of psychopathology and clinical practice.

Protective Prevention Effects on the Association of Poverty With Brain Development

IMPORTANCE

This study was designed to determine whether a preventive intervention focused on enhancing supportive parenting could ameliorate the association between exposure to poverty and brain development in low socioeconomic status African American individuals from the rural South.

OBJECTIVE

To determine whether participation in an efficacious prevention program designed to enhance supportive parenting for rural African American children will ameliorate the association between living in poverty and reduced hippocampal and amygdalar volumes in adulthood.

DESIGN, SETTING, AND PARTICIPANTS

In the rural southeastern United States, African American parents and their 11-year-old children were assigned randomly to the Strong African American Families randomized prevention trial or to a control condition. Parents provided data used to calculate income-to-needs ratios when children were aged 11 to 13 years and 16 to 18 years. When the participants were aged 25 years, hippocampal and amygdalar volumes were measured using magnetic resonance imaging.

EXPOSURES

Household poverty was measured by income-to-needs ratios.

MAIN OUTCOMES AND MEASURES

Young adults' whole hippocampal, dentate gyrus, and CA3 hippocampal subfields as well as amygdalar volumes were assessed using magnetic resonance imaging.

RESULTS

Of the 667 participants in the Strong African American Families randomized prevention trial, 119 right-handed African American individuals aged 25 years living in rural areas were recruited. Years lived in poverty across ages 11 to 18 years forecasted diminished left dentate gyrus (simple slope, -14.20; standard error, 5.22; P = .008) and CA3 (simple slope, -6.42; standard error, 2.42; P = .009) hippocampal subfields and left amygdalar (simple slope, -34.62; standard error, 12.74; P = .008) volumes among young adults in the control condition (mean [SD] time, 2.04 [1.88] years) but not among those who participated in the Strong African American Families program (mean [SD] time, 2.61 [1.77] years).

CONCLUSIONS AND RELEVANCE

In this study, we described how participation in a randomized clinical trial designed to enhance supportive parenting ameliorated the association of years lived in poverty with left dentate gyrus and CA3 hippocampal subfields and left amygdalar volumes. These findings are consistent with a possible role for supportive parenting and suggest a strategy for narrowing social disparities.

Dissociation and Alterations in Brain Function and Structure: Implications for Borderline Personality Disorder

Dissociation involves disruptions of usually integrated functions of consciousness, perception, memory, identity, and affect (e.g., depersonalization, derealization, numbing, amnesia, and analgesia). While the precise neurobiological underpinnings of dissociation remain elusive, neuroimaging studies in disorders, characterized by high dissociation (e.g., depersonalization/derealization disorder (DDD), dissociative identity disorder (DID), dissociative subtype of posttraumatic stress disorder (D-PTSD)), have provided valuable insight into brain alterations possibly underlying dissociation. Neuroimaging studies in borderline personality disorder (BPD), investigating links between altered brain function/structure and dissociation, are still relatively rare. In this article, we provide an overview of neurobiological models of dissociation, primarily based on research in DDD, DID, and D-PTSD. Based on this background, we review recent neuroimaging studies on associations between dissociation and altered brain function and structure in BPD. These studies are discussed in the context of earlier findings regarding methodological differences and limitations and concerning possible implications for future research and the clinical setting.

Hippocampal and amygdala volumes in adults with posttraumatic stress disorder secondary to childhood abuse or maltreatment: A systematic review

We systematically reviewed differences in hippocampal and amygdala volumes between adults with childhood maltreatment-related posttraumatic stress disorder (PTSD) and healthy controls. Using the terms "adults", "MRI", "magnetic resonance imaging", with "posttraumatic stress disorder" "PTSD", "child abuse", and "child maltreatment", we conducted searches on several electronic databases. We identified 10 studies that met our inclusion criteria; 7 of which were included in a meta-analysis of hippocampal volume and 4 that were included in a meta-analysis of amygdala volume. Mean hippocampal and amygdala volumes were used to determine effect sizes. We found bilateral reduction of both the hippocampus and amygdala in the PTSD group compared to healthy controls, with effect sizes of -0.66 and -0.67 for the left and right hippocampus (p<0.00001 and p=0.002) and -1.08 and -1.15 for the left and right amygdala, (p=0.013 and p=0.003), respectively. Confidence intervals were -0.93,-0.39 and -1.26,-0.29 for the left and right hippocampus, respectively. For the amygdala, confidence intervals were -1.92,-0.23 and -1.19, -0.39 for the left and right amygdala. The relatively few studies available for analysis is a limitation. Additionally, sex diverse MRI studies in PTSD are needed to determine whether sex plays a significant role in the hippocampal effects associated with childhood-onset trauma.

Legion Theory

William James and many other early pioneers of psychology and psychiatry endorsed the notion of parallel rational conscious streams in the human mind and suggested that an understanding of multiple personalities, in what is now known as Dissociative Identity Disorder (DID), was the key to developing an appropriate model of the mind. A new meta-theory of psychology, Legion Theory, developed from an inductive study of the specific characteristics of DID, is presented. Legion Theory proposes the mind to encompass two major sets of mechanisms. The first is a set of parallel conscious streams which form the self. The second is a set of internal mental models representing the physical and other worlds. The interaction of these two sets of processes is shown to provide a model for many psychological phenomena, including abstract logical thinking and intelligence, dreams, implicit and explicit memory, state-dependent memory, psychogenic fugues, and body dysmorphia.

Disorganized attachment in infancy predicts greater amygdala volume in adulthood

Early life stress in rodents is associated with increased amygdala volume in adulthood. In humans, the amygdala develops rapidly during the first two years of life. Thus, disturbed care during this period may be particularly important to amygdala development. In the context of a 30-year longitudinal study of impoverished, highly stressed families, we assessed whether disorganization of the attachment relationship in infancy was related to amygdala volume in adulthood. Amygdala volumes were assessed among 18 low-income young adults (8M/10F, 29.33±0.49years) first observed in infancy (8.5±5.6months) and followed longitudinally to age 29. In infancy (18.58±1.02mos), both disorganized infant attachment behavior and disrupted maternal communication were assessed in the standard Strange Situation Procedure (SSP). Increased left amygdala volume in adulthood was associated with both maternal and infant components of disorganized attachment interactions at 18 months of age (overall r=0.679, p<0.004). Later stressors, including childhood maltreatment and attachment disturbance in adolescence, were not significantly related to left amygdala volume. Left amygdala volume was further associated with dissociation and limbic irritability in adulthood. Finally, left amygdala volume mediated the prediction from attachment disturbance in infancy to limbic irritability in adulthood. Results point to the likely importance of quality of early care for amygdala development in human children as well as in rodents. The long-term prediction found here suggests that the first two years of life may be an early sensitive period for amygdala development during which clinical intervention could have particularly important consequences for later child outcomes.

Structural brain aberrations associated with the dissociative subtype of post-traumatic stress disorder

OBJECTIVE

One factor potentially contributing to the heterogeneity of previous results on structural grey matter alterations in adult participants suffering from post-traumatic stress disorder (PTSD) is the varying levels of dissociative symptomatology. The aim of this study was therefore to test whether the recently defined dissociative subtype of PTSD characterized by symptoms of depersonalization and derealization is characterized by specific differences in volumetric brain morphology.

METHOD

Whole-brain MRI data were acquired for 59 patients with PTSD. Voxel-based morphometry was carried out to test for group differences between patients classified as belonging (n = 15) vs. not belonging (n = 44) to the dissociative subtype of PTSD. The correlation between dissociation (depersonalization/derealization) severity and grey matter volume was computed.

RESULTS

Patients with PTSD classified as belonging to the dissociative subtype exhibited greater grey matter volume in the right precentral and fusiform gyri as well as less volume in the right inferior temporal gyrus. Greater dissociation severity was associated with greater volume in the right middle frontal gyrus.

CONCLUSION

The results of this first whole-brain investigation of specific grey matter volume in dissociative subtype PTSD indentified structural aberrations in regions subserving the processing and regulation of emotional arousal. These might constitute characteristic biomarkers for the dissociative subtype PTSD.

Annual Research Review: Enduring neurobiological effects of childhood abuse and neglect

BACKGROUND

Childhood maltreatment is the most important preventable cause of psychopathology accounting for about 45% of the population attributable risk for childhood onset psychiatric disorders. A key breakthrough has been the discovery that maltreatment alters trajectories of brain development.

METHODS

This review aims to synthesize neuroimaging findings in children who experienced caregiver neglect as well as from studies in children, adolescents and adults who experienced physical, sexual and emotional abuse. In doing so, we provide preliminary answers to questions regarding the importance of type and timing of exposure, gender differences, reversibility and the relationship between brain changes and psychopathology. We also discuss whether these changes represent adaptive modifications or stress-induced damage.

RESULTS

Parental verbal abuse, witnessing domestic violence and sexual abuse appear to specifically target brain regions (auditory, visual and somatosensory cortex) and pathways that process and convey the aversive experience. Maltreatment is associated with reliable morphological alterations in anterior cingulate, dorsal lateral prefrontal and orbitofrontal cortex, corpus callosum and adult hippocampus, and with enhanced amygdala response to emotional faces and diminished striatal response to anticipated rewards. Evidence is emerging that these regions and interconnecting pathways have sensitive exposure periods when they are most vulnerable.

CONCLUSIONS

Early deprivation and later abuse may have opposite effects on amygdala volume. Structural and functional abnormalities initially attributed to psychiatric illness may be a more direct consequence of abuse. Childhood maltreatment exerts a prepotent influence on brain development and has been an unrecognized confound in almost all psychiatric neuroimaging studies. These brain changes may be best understood as adaptive responses to facilitate survival and reproduction in the face of adversity. Their relationship to psychopathology is complex as they are discernible in both susceptible and resilient individuals with maltreatment histories. Mechanisms fostering resilience will need to be a primary focus of future studies.

Impact of childhood emotional abuse on neocortical neurometabolites and complex emotional processing in patients with generalized anxiety disorder

BACKGROUND

The rostral prefrontal cortex (RPFC) is involved in reflective thought processes such as self-knowledge and person perception. We hypothesized that childhood emotional abuse, which is disruptive of emotional regulation, would differentially impact neurometabolite concentrations of the RPFC, and related neocortical areas, in adults with generalized anxiety disorder (GAD) versus healthy controls.

METHODS

GAD patients (n=16; females=11) and medically healthy volunteers (n=16; F=10) were assessed using the Childhood Trauma Questionnaire (CTQ), specifically the emotional abuse category. Proton magnetic resonance spectroscopy imaging examined 3 regions of interest (ROI) from the most rostral slice from the Duyn et al. (1993) multivoxel imaging modality: rostral prefrontal cortex (BA 10,9), premotor cortex (BA 6,8) and secondary somatosensory and associated parietal cortex (BA 5,7). Metabolites included N-acetyl-aspartate, creatine, and choline.

RESULTS

GAD patients reported higher emotional abuse scores versus controls. An omnibus general linear model including 3 ROI, 3 metabolites, and laterality as dependent variables revealed a significant diagnosis by CTQ emotional abuse score interactive effect. In controls, all 3 ROI for all 3 metabolites on both sides demonstrated a significant inverse relationship with emotional abuse scores; none were significant in GAD patients.

LIMITATIONS

A major limitation is the uneven distribution of emotional abuse scores between the controls and GAD patients, with GAD patients reporting higher scores.

CONCLUSION

Unlike controls, GAD patients appear compromised in forming a molecular representation reflective of magnitude of childhood emotional abuse. The neurometabolites in GAD patients appear non-aligned to childhood emotional abuse, suggesting potential consequences for normative "theory of mind" processes and emotional function in certain anxiety disorders.