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

Depersonalisation disorder may occur during severe anxiety or following a traumatic event, suggesting a possible role of stress hormones. This study investigated basal activity of the hypothalamic-pituitary-adrenal (HPA) axis in patients with depersonalisation disorder. Salivary cortisol levels were measured at four time points over 12 h in patients with depersonalisation disorder (N=13), major depressive disorder (MDD, N=14) and healthy controls (N=13). Beck Depression Inventory scores were significantly higher in depersonalised subjects than controls, while MDD subjects demonstrated higher scores than both groups. Basal cortisol levels of depersonalised subjects were significantly lower than those of MDD subjects but not healthy controls. These results point to reduced basal activity of the HPA axis in depersonalisation disorder. This pilot study supports the distinction between depersonalisation disorder and major depressive disorder which should be examined in a larger sample.     

The relationship of akathisia with suicidality and depersonalization among patients with schizophrenia

An association of suicidality and depersonalization with akathisia has been reported, but it is not clear whether these phenomena are specific to akathisia or are nonspecific manifestations of distress. The authors used the Barnes Akathisia Rating Scale, Brief Psychiatric Rating Scale, and Hamilton Rating Scale for Depression (Ham-D) to examine the relationships between suicidality, depersonalization, dysphoria, and akathisia in 68 patients with schizophrenia or schizophreniform disorder. Akathisia was associated with higher scores on the Ham-D ratings of suicidality, depersonalization, and agitation. In a logistic regression model, depressive mood and subjective awareness of akathisia appeared to be the only predictors of suicidality and depersonalization, respectively. These findings support the association between akathisia and both suicidality and depersonalization. However, these symptoms appear to be nonspecific responses to accompanying depressive mood and the subjective awareness of the akathisia syndrome, respectively.     

Fear reduction in patients with chronic pain: a learning theory perspective

Acute pain informs the individual that there is an imminent threat of body damage, and is associated with the urge to escape and avoid. Fear learning takes place when neutral stimuli receive the propensity to predict the occurrence of pain, and when defensive responses are initiated in anticipation of potential threats to the integrity of the body. Fear-avoidance models have been put forward featuring the role of individual differences in catastrophic interpretations of pain in the modulation of learning and avoidance. Based on extensive literature on fear reduction in anxiety disorders; cognitive-behavioral treatments have been developed and applied to patients with chronic pain reporting substantial pain-related fear. In this article, we discuss mechanisms underlying the acquisition, the assessment and extinction of pain-related fear through the cognitive-behavioral treatment of pain-related fear. Finally, we provide a number of critical notes and directions for future research in the field of chronic pain and pain-related fear.     

Grey matter alterations in patients with depersonalization disorder: a voxel-based morphometry study

Background

To our knowledge, no whole brain investigation of morphological aberrations in dissociative disorder is available to date. Previous region-of-interest studies focused exclusively on amygdalar, hippocampal and parahippocampal grey matter volumes and did not include patients with depersonalization disorder (DPD). We therefore carried out an explorative whole brain study on structural brain aberrations in patients with DPD.

Methods

We acquired whole brain, structural MRI data for patients with DPD and healthy controls. Voxel-based morphometry was carried out to test for group differences, and correlations with symptom severity scores were computed for grey matter volume.

Results

Our study included 25 patients with DPD and 23 controls. Patients exhibited volume reductions in the right caudate, right thalamus and right cuneus as well as volume increases in the left dorsomedial prefrontal cortex and right somatosensory region that are not a direct function of anxiety or depression symptoms.

Limitations

To ensure ecological validity, we included patients with comorbid disorders and patients taking psychotropic medication.

Conclusion

The results of this first whole brain investigation of grey matter volume in patients with a dissociative disorder indentified structural alterations in regions subserving the emergence of conscious perception. It remains unknown if these alterations are best understood as risk factors for or results of the disorder.     

Treating traumatized patients and victims of violence

This chapter presents a thorough exposition of treating traumatized patients and victims of violence, addressing many aspects of trauma and victimization critical to a vast proportion of the work that mental health professionals find themselves doing.     

Reliability and validity of a Japanese version of the Cambridge depersonalization scale as a screening instrument for depersonalization disorder

Aims:  The Cambridge Depersonalization Scale (CDS) is an instrument that has obtained reliability and validity in some countries for use in detecting depersonalization disorder under clinical conditions, but not yet in Japan under non-psychiatric conditions. The purposes of this study were to develop a Japanese version of the CDS (J-CDS) and to examine its reliability and validity as an instrument for screening depersonalization disorder under non-clinical conditions.
Methods:  The CDS was translated from English into Japanese and then back-translated into English by a native English-speaking American. After making the J-CDS, we examined its reliability and validity. Questionnaires that were composed of J-CDS, the Dissociative Experience Scale (DES), the Zung self-rating scale and the Maudsley Obsessional–Compulsive Inventory were administrated to 59 participants (12 patients with depersonalization disorder, 11 individuals who had recovered from depersonalization and 36 healthy controls).
Results:  Cronbach's alpha and split-half reliability were 0.94 and 0.93, respectively. The J-CDS score in the depersonalization group was significantly higher than in the healthy control group. The J-CDS score was significantly correlated with scores of total DES, and DES-depersonalization. The best compromise between the true positive and false negative rate was at a cut-off point of 60, yielding a sensitivity of 1.00 and a specificity of 0.96.
Conclusions:  In this study, J-CDS showed good reliability and validity. The best cut-off point, when we use this for distinguishing individuals with depersonalization disorder from individuals without psychiatric disorders, is 60 points.     

The development of the client-therapist bond through the lens of attachment theory

The bond between client and therapist, a component of the global alliance, is widely believed to play a crucial role in supporting the work of therapy. However, we know little about how the client-therapist bond becomes established and have few theoretical tools to conceptualize its development. Attachment theory, with its focus on the development and dynamics of intimate relationships, is a lens through which we can expand our understanding of the client-therapist bond. I argue that the therapeutic bond may be usefully viewed as an in-progress attachment to therapists. Using Bowlby (1969/1982) and Ainsworth's (Ainsworth et al., 1978) ideas about normative attachment development, I present a phase model of attachment to the therapist and include behavioral, cognitive, emotional, and physiological markers of each phase. I draw empirical support from the psychotherapy process and alliance literatures and discuss research considerations and clinical implications of the model. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

Review of the relationship between obsession and depersonalization

Depersonalization is discussed and a brief outline of the primary symptoms is presented. The relationship between obsessionalism and depersonalization is reviewed in the literature, and subsequent similarities are presented. The intellectual obsessive depersonalization syndrome is postulated as a variant, and also as an exposition of what might occur in many other cases of depersonalization. Finally, a picture is presented which takes into account a strong component of obsessionalism in both the etiology and course of depersonalization.     

Integrating systems theory and attachment theory: the use of radio communication to modify attachments in a patient with psychogenic vomiting

A case is presented that shows the usefulness of integrating systems theory and attachment theory in the formulation and treatment of a clinical problem. The 5 year old son of East Indian immigrants presented with persistent psychogenic vomiting associated with pathological family attachments. It was evident that the precarious family equilibrium was stabilized by the child's psychogenic vomiting. The therapeutic team suggested to the family that their problems might be more satisfactorily resolved if the mother and child maintained their link by two-way radio. Three weeks later the vomiting had ceased, the child no longer felt that he needed the radio and both parents had established new patterns of relating to their child, whose attendance and peer socialization at school showed marked improvement. To some extent the rapid resolution of the problems was facilitated by the cultural strengths of the family.     

Borderline personality disorder and the search for meaning: an attachment perspective

OBJECTIVE: To explore the links between the attachment theory-derived concept of disorganized attachment, and the psychiatric diagnosis of borderline personality disorder (BPD). METHOD: Literature search for characteristics of disorganized attachment. Clinical case material from psychotherapeutic work with patients suffering from BPD. RESULTS: Disorganized attachment can be understood in terms of an approach-avoidance dilemma for infants for whom stressed or traumatized/traumatizing caregivers are simultaneously a source of threat and a secure base. Interpersonal relationships in BPD including those with caregivers is similarly seen in terms of an approach-avoidance dilemma, which manifests itself in disturbed transference/countertransference interactions between therapists and BPD sufferers. Borderline personality disorder sufferers lack meaning in their lives because they are unable to play 'language games' with their potential intimates, resorting to actions rather than words to express feelings. CONCLUSIONS: Possible ways of handling these phenomena are suggested, based on Main's (1995) notion of 'meta-cognitive monitoring', in the hope of re-instating meaning and more stable self-structures, in these patients' lives.