Dissociative Identity Disorder in Schools Part II.

Dissociation is a well-established outcome of early life trauma, but school nurses may not be aware of resources and recommendations available to support students who experience it. If dissociation or behaviors consistent with dissociation are present, trauma-informed care (TIC) principles can guide individualized care of the student. Part I of this two-part article provided a pertinent background on dissociation, dissociative identity disorder (DID), the effects of social media, and TIC. Part II offers specific recommendations for implementing these principles in school nursing practice and follows the student vignette through the school year. Due to their holistic approach to care and long-standing leadership in providing TIC, nurses can significantly affect health, safety, and access to learning for students expressing dissociative experiences at school.

Dissociative Identity Disorder in Schools Part I.

Dissociation is a normal life adaptation that can become pronounced and disruptive in the setting of repeated or extreme exposure to trauma. Children and adolescents may experience dissociation due to a trauma or stressor-related disorder, anxiety, or depressive disorders. Children and adolescents also may mimic behavior they see online as a way of expressing internally painful and intolerable experiences. Myth and misinformation surround the diagnosis of dissociative identity disorder (DID), formerly multiple personality disorder. The purpose of this article is to provide school nurses with evidence-based information on DID and resources for practice regarding how to provide a secure, consistent approach to students who are being traumatized, misunderstood, or excluded at home or at school. Part 1 of this two-part series describes DID foundations and DID in school-aged children, reviews controversy spurred by social media representation, and presents the Trauma-Informed Care (TIC) model. TIC offers useful perspectives regardless of a student's presentation or diagnostic status. Part 2 will discuss recommendations for managing dissociative presentations using a team-based approach, focusing on the school nurse's roles and responsibilities.

Bipolar mood state reflected in cortico-amygdala resting state connectivity: A cohort and longitudinal study.

BACKGROUND: Using resting-state functional magnetic resonance imaging (rsfMRI), we previously compared cohorts of bipolar I subjects in a manic state to those in a euthymic state to identify mood state-specific patterns of cortico-amygdala connectivity. Our results suggested that mania is reflected in the disruption of emotion regulation circuits. We sought to replicate this finding in a group of subjects with bipolar disorder imaged longitudinally across states of mania and euthymia METHODS: We divided our subjects into three groups: 26 subjects imaged in a manic state, 21 subjects imaged in a euthymic state, and 10 subjects imaged longitudinally across both mood states. We measured differences in amygdala connectivity between the mania and euthymia cohorts. We then used these regions of altered connectivity to examine connectivity in the longitudinal bipolar group using a within-subjects design. RESULTS: Our findings in the mania vs euthymia cohort comparison were replicated in the longitudinal analysis. Bipolar mania was differentiated from euthymia by decreased connectivity between the amygdala and pre-genual anterior cingulate cortex. Mania was also characterized by increased connectivity between amygdala and the supplemental motor area, a region normally anti-correlated to the amygdala in emotion regulation tasks. LIMITATIONS: Stringent controls for movement effects limited the number of subjects in the longitudinal sample. CONCLUSIONS: In this first report of rsfMRI conducted longitudinally across mood states, we find that previously observed between-group differences in amygdala connectivity are also found longitudinally within subjects. These results suggest resting state cortico-amygdala connectivity is a biomarker of mood state in bipolar disorder.

Differential brain network activity across mood states in bipolar disorder.

BACKGROUND: This study aimed to identify how the activity of large-scale brain networks differs between mood states in bipolar disorder. The authors measured spontaneous brain activity in subjects with bipolar disorder in mania and euthymia and compared these states to a healthy comparison population. METHODS: 23 subjects with bipolar disorder type I in a manic episode, 24 euthymic bipolar I subjects, and 23 matched healthy comparison (HC) subjects underwent resting state fMRI scans. Using an existing parcellation of the whole brain, we measured functional connectivity between brain regions and identified significant differences between groups. RESULTS: In unbiased whole-brain analyses, functional connectivity between parietal, occipital, and frontal nodes within the dorsal attention network (DAN) were significantly greater in mania than euthymia or HC subjects. In the default mode network (DMN), connectivity between dorsal frontal nodes and the rest of the DMN differentiated both mood state and diagnosis. LIMITATIONS: The bipolar groups were separate cohorts rather than subjects imaged longitudinally across mood states. CONCLUSIONS: Bipolar mood states are associated with highly significant alterations in connectivity in two large-scale brain networks. These same networks also differentiate bipolar mania and euthymia from a HC population. State related changes in DAN and DMN connectivity suggest a circuit based pathology underlying cognitive dysfunction as well as activity/reactivity in bipolar mania. Altered activities in neural networks may be biomarkers of bipolar disorder diagnosis and mood state that are accessible to neuromodulation and are promising novel targets for scientific investigation and possible clinical intervention.

State dependent cortico-amygdala circuit dysfunction in bipolar disorder.

BACKGROUND: Existing models of the pathophysiology of bipolar disorder posit disruption in neural circuits of emotion regulation and reward processing. However, few fMRI studies have compared regional brain activity and connectivity in different mood states in bipolar disorder to determine if manic symptomatology is reflected in specific circuit abnormalities. The purpose of this study was to test the hypothesis that bipolar mania is associated with altered connectivity between cortical regions thought to regulate subcortical structures such as the amygdala and striatum. METHODS: 28 subjects with bipolar disorder in a manic state, 24 different bipolar subjects in a euthymic state, and 23 matched healthy comparison subjects underwent resting state fMRI scans. Several cortical and sub-cortical structures implicated in the pathogenesis of bipolar disorder were selected for study. We conducted a whole-brain analysis of functional connectivity of these regions. RESULTS: Bipolar mania was differentiated from euthymia by decreased functional connectivity between the amygdala and anterior cingulate cortex (ACC). Mania was also characterized by increased connectivity between amygdala and dorsal frontal cortical structures that are normally anti-correlated in emotion regulation tasks. LIMITATIONS: Both groups of bipolar subjects were prescribed medications. The study was not longitudinal in design. CONCLUSIONS: Compared to bipolar subjects in a euthymic state, subjects in the manic state demonstrate disrupted functional connectivity between brain regions involved in the regulation of emotion and the amygdala. This disruption of activity in neural circuits involved in emotion may underlie the emotional dysregulation inherent to a bipolar manic episode.