Daphne Simeon

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.

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.

The detection and measurement of depersonalization disorder

Depersonalization disorder comprises one of the four major dissociative disorders and yet remains poorly studied. There are no reports describing the application of dissociation scales to this population. Our goal was to investigate the applicability of four such scales to depersonalization disorder and to establish screening criteria for the disorder. Two general dissociation scales and two depersonalization scales were administered to 50 subjects with DSM-III-R depersonalization disorder and 20 healthy control subjects. The depersonalization disorder group scored significantly higher than the normal control group in all scales and subscales. Factor analysis of the Dissociative Experiences Scale (DES) yielded three factors as proposed previously, absorption, amnesia, and depersonalization/derealization. A DES cutoff score of 12, markedly lower than those previously proposed for the screening of other dissociative disorders, is required for the sensitive detection of depersonalization disorder. Alternatively, the DES pathological dissociation taxon (DES-taxon) score recently generated in the literature appears more sensitive to the detection of depersonalization disorder and is better recommended for screening purposes. The other three scales were fairly strongly correlated to the DES, suggesting that they may measure similar but not identical concepts, and cutoff scores are proposed for these scales also. General implications for the screening and quantification of depersonalization pathology are discussed.

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.

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.

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.

Serotonergic function in social phobia: comparison to normal control and obsessive–compulsive disorder subjects

Eighteen patients with social phobia, 21 normal control subjects, and 42 obsessive-compulsive disorder (OCD) control subjects were challenged with single doses of the partial serotonin agonist oral m-chlorophenylpiperazine (m-CPP) and placebo. Social phobics did not significantly differ from normal or OCD control subjects in prolactin response to m-CPP. There was a significant difference across groups in cortisol response to m-CPP, such that female social phobics had more robust cortisol responses to the m-CPP challenge. Pairwise comparisons only reached trend significance, perhaps due to the relatively small sample sizes. This study offers preliminary evidence for serotonin dysfunction in social phobia, particularly in female social phobics, but needs to be replicated in a larger sample size.

Cognitive Functioning in Depersonalization Disorder

Depersonalization disorder (DPD) is a dissociative disorder characterized by a subjective sense of unreality and detachment, and has been associated with deficits in perception and short-term memory. In this study, 21 DPD and 17 healthy comparison participants free of psychiatric disorders were administered a comprehensive neuropsychologic battery. The groups did not differ in full-scale, verbal, and performance IQ (Wechsler Adult Intelligence Scale), in working memory (Paced Auditory Serial Addition Test), or in selective attention (Digit Span with Distracters). The DPD group performed significantly worse on immediate visual and verbal recall (Wechsler Memory Scale, Revised), but not on delayed recall. Dissociation severity was significantly correlated with processing slowness and distractibility. We conclude that DPD is associated with cognitive disruptions in early perceptual and attentional processes.

Cognitive-Affective Neuroscience of Depersonalization

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

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.