Identity state-dependent self-relevance and emotional intensity ratings of words in dissociative identity disorder: A controlled longitudinal study.

INTRODUCTION: Dissociative identity disorder (DID) is characterized by, among others, amnesic episodes and the recurrence of different dissociative identity states. While consistently observed in clinical settings, to our knowledge, no controlled research study has shown the degree to which different identity states report autobiographical knowledge over time. Hence, the current study investigates self-relevance and emotional intensity ratings of words longitudinally. METHODS: Data of 46 participants were included: 13 individuals with DID, 11 DID-simulating actors, and a control group of 22 paired individuals. Individuals with DID and DID simulators participated once in the neutral identity state (NIS) and once in the trauma-related dissociative identity state (TIS). The control group paired 11 healthy controls with 11 participants with posttraumatic stress disorder (PTSD) as a NIS-TIS pair. Self-relevance ratings of different word types were collected in a baseline and a follow-up session, on average 6 weeks apart. A mixed ANOVA design was used to assess the effects of group, session, word type, and dissociative identity state. RESULTS: All participants in TIS and individuals with DID in NIS rated self-relevant trauma-related words more negatively. In the NIS, the control group rated self-relevant trauma-related words as less negative, whereas the ratings of simulating actors were intermediate. There was no group-dependent longitudinal effect for intensity ratings. CONCLUSIONS: This study was the first to confirm clinical observations that self-relevant and emotional processing are different between individuals with DID and controls, but consistent over time. Actors were unable to perfectly simulate DID. The finding that ratings of self-relevant trauma-related words differ between subgroups as included in the study is in line with clinical observations.

Dissociative identity state-dependent working memory in dissociative identity disorder: a controlled functional magnetic resonance imaging study.

BACKGROUND: Memory function is at the core of the psychopathology of dissociative identity disorder (DID), but little is known about its psychobiological correlates. AIMS: This study aims to investigate whether memory function in DID differs between dissociative identity states. METHOD: Behavioural data and neural activation patterns were assessed in 92 sessions during an n-back working memory task. Participants were people with genuine diagnosed DID (n = 14), DID-simulating controls (n = 16) and a paired control group (post-traumatic stress disorder (n = 16), healthy controls (n = 16)). Both DID groups participated as authentic or simulated neutral and trauma-related identity states. Reaction times and errors of omission were analysed with repeated measures ANOVA. Working memory neural activation (main working memory and linear load) was investigated for effects of identity state, participant group and their interaction. RESULTS: Identity state-dependent behavioural performance and neural activation was found. DID simulators made fewer errors of omission than those with genuine DID. Regarding the prefrontal parietal network, main working memory in the left frontal pole and ventrolateral prefrontal cortex (Brodmann area 44) was activated in all three simulated neutral states, and in trauma-related identity states of DID simulators, but not those with genuine DID or post-traumatic stress disorder; for linear load, trauma-related identity states of those with genuine DID did not engage the parietal regions. CONCLUSIONS: Behavioural performance and neural activation patterns related to working memory in DID are dependent on the dissociative identities involved. The narrowed consciousness of trauma-related identity states, with a proneness to re-experiencing traumatising events, may relate to poorer working memory functioning.

Differentiating Dissociative from Non-Dissociative Disorders: A Meta-Analysis of the Structured Clinical Interview for DSM Dissociative Disorders (SCID-D).

Inaccurate diagnosis of dissociative disorders (DDs) remains a frequent problem. Misdiagnoses may lead to delayed or ineffective treatment, and subsequently poorer quality of life for those struggling with DDs, who frequently utilize mental health treatment and evidence high rates of self-harm and suicidality. This study's objective was to examine the magnitude of the effects with which the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) and revised version (SCID-D-R) - henceforth referred to as the "SCID-D interviews" - provide diagnoses of DDs and differentiate them from nondissociative disorders as well as factitious and simulated dissociative presentations. For inclusion, studies had to be empirical investigations comparing SCID-D data of DD populations with other populations. Using combined methods of searching for "SCID-D" in electronic indexing databases, seeking recommendations from experts, and reviewing reference sections of identified studies, 15 studies were identified and subjected to meta-analytic review. Analyses showed that the overall SCID-D interview score (effect size 3.12) as well as each of the five subscales - particularly amnesia and identity alteration (effect sizes 2.16 and 2.87, respectively) - significantly differentiated DD from non-DD. Findings suggest that the SCID-D interviews show good validity identifying and differentiating those with DDs as compared to those without DDs. The SCID-D interviews are valid instruments for diagnosing and differentiating DD from other psychiatric disorders and feigned presentations of DD. Clinicians, researchers, and forensic experts can use the SCID-D interviews with confidence to make differential diagnoses of DDs. Future research using the SCID-D interviews is discussed.

The Association Between Childhood Trauma and Attachment Functioning in Patients With Personality Disorders.

Attachment (mal)functioning and a history of childhood trauma (CT) are both considered psychological determinants of personality disorders (PDs). Their interaction, however, remains largely uninvestigated. In this study, the authors assessed adult and childhood attachment style in a sample of patients with diverse PDs (N = 75) and determined the relation with both occurrence and severity of CT. The authors found that the sample was characterized by severe attachment malfunctioning and high levels of CT. Using cross-tabulations and analysis of variance, the authors showed that patients with a fearful or dismissive attachment style experienced more severe CT than patients with a preoccupied attachment style. Patients reporting an affectionless control bonding style to either parent suffered frequent and severe CT. Although temporal causality cannot be determined, these findings stress the necessity to screen for CT in PDs and suggest that attachment-centered psychotherapy for these patients may benefit from preceding or concurrent trauma treatment.

The course of (comorbid) trauma-related, dissociative and personality disorders: two year follow up of the Friesland study cohort.

Background: There is substantial comorbidity between trauma-related disorders (TRDs), dissociative disorders (DDs) and personality disorders (PDs), especially in patients who report childhood trauma and emotional neglect. However, little is known about the course of these comorbid disorders, despite the fact that this could be of great clinical importance in guiding treatment. Objective: This study describes the two-year course of a cohort of patients with (comorbid) TRDs, DDs and PDs and aims to identify possible predictors of course. Possible gender differences will be described, as well as features of non-respondents. Method: Patients (N = 150) referred to either a trauma treatment program or a PD treatment program were assessed using five structured clinical interviews for diagnosing TRDs, DDs, PDs and trauma histories. Three self-report questionnaires were used to assess general psychopathology, dissociative symptoms and personality pathology in a more dimensional way. Data on demographics and received treatment were obtained using psychiatric records. We described the cohort after a two-year follow-up and used t-tests or chi-square to test possible differences between respondents and non-respondents and between women and men. We used regression analysis to identify possible course predictors. Results: A total of 85 (56.7%) of the original 150 patients participated in the follow-up measurement. Female respondents reported more sexual abuse than female non-respondents. Six patients (4.0%; all women) died because of suicide. Levels of psychopathology significantly declined during the follow-up period, but only among women. Gender was the only significant predictor of change. Conclusions: Comorbidity between TRDs, DDs and PDs was more the rule than the exception, pleading for a more dimensional and integrative view on pathology following childhood trauma and emotional neglect. Courses significantly differed between men and women, advocating more attention to gender in treatment and future research.

Antecedentes: existe una comorbilidad sustancial entre trastornos relacionados con el trauma (TRDs por sus siglas en inglés), trastornos disociativos (DDs por sus siglas en inglés) y trastornos de personalidad (PDs por sus siglas en inglés), especialmente en pacientes que reportan trauma infantil y negligencia emocional. Sin embargo, se conoce muy poco sobre el curso de estos trastornos comórbidos, pese al hecho de que esto pudiese ser de gran importancia clínica para guiar el tratamiento.Objetivo: Este estudio describe el curso de dos años de una cohorte de pacientes con TRDs, DDs, y PDs (comórbidos) y tiene como objetivo identificar posibles predictores de curso. Se describirán posibles diferencias de género, así como características de los no encuestados.Métodos: Pacientes (N=150) que fueron referidos ya sea a un centro de tratamiento de trauma o a un programa de tratamiento para trastorno de personalidad fueron evaluados usando cinco entrevistas clínicas estructuradas para diagnosticar TRDs, DDs, PDs e historias de trauma. Tres cuestionarios de auto-reporte fueron usados para evaluar psicopatología general, síntomas disociativos y patología de la personalidad de una forma más dimensional. Se obtuvo información sobre la demografía y el tratamiento recibido usando registros psiquiátricos. Describimos la cohorte después de un seguimiento de dos años y usamos Test-T o chi cuadrado para evaluar posibles diferencias entre encuestados y no encuestados, así como entre hombres y mujeres. Usamos análisis de regresión para identificar posibles predictores de curso.Resultados: Un total de 85 (56.7%) de los 150 pacientes originales participaron en las mediciones de seguimiento. Las encuestadas femeninas reportaron más abuso sexual que las mujeres no encuestadas. Seis pacientes (4%, todas mujeres) fallecieron por suicidio. Los niveles de psicopatología declinaron significativamente durante el período de seguimiento, pero solo entre mujeres. El género fue el único predictor de cambio.Conclusiones: la comorbilidad entre TRDs, DDs y PDs fue más la regla que la excepción, haciendo necesaria una visión más integrativa y dimensional de la patología posterior al trauma infantil y la negligencia emocional. Los cursos difieren significativamente entre hombres y mujeres, advocando por más atención al género en el tratamiento y futura investigación.

Sleep, trauma, fantasy and cognition in dissociative identity disorder, post-traumatic stress disorder and healthy controls: a replication and extension study.

Background: Two aetiology models for dissociative identity disorder (DID) have been proposed, namely a childhood Trauma Model and an iatrogenic or Fantasy model. A recent study indicated that sleep disturbances underlie dissociative symptomatology. Objective: Our current study aims to test whether this finding can be replicated in an independent sample and to investigate if this finding still holds after correcting for childhood and adult traumatization. An experimental working memory task is included to investigate how sleep disturbance, traumatization, dissociation, and fantasy proneness impact cognitive functioning. Methods: Three groups of participants were included - individuals with DID, individuals with post-traumatic stress disorder (PTSD), and matched healthy controls. Sleep disturbances were measured and compared between the groups along with measures of childhood and adult traumatization, psychoform and somatoform [psychological and somatic] dissociative symptoms, and fantasy proneness. Cognitive capacity was assessed using a working memory task. Results: When controlled for traumatic experiences, sleep disturbances did not predict dissociative symptoms. When controlled for sleep disturbance and fantasy proneness, childhood traumatization did predict dissociative symptoms. Psychoform dissociative symptoms correlated with traumatic experiences more than with fantasy proneness. Working memory performance was similar among the participating groups. Propensity to fantasy did not discriminate individuals with DID and PTSD, and was a weak predictor of dissociative symptoms. Conclusion: Whereas DID and PTSD are associated with sleep disturbances, these features do not statistically predict dissociative symptoms in these disorders when traumatic experiences are taken into account. Fantasy proneness is not excessive in DID and PTSD. Hence, we found no evidence that sleep disturbances, propensity to fantasy and abnormal working memory capacity explain dissociative symptoms in DID and PTSD. In sum, the relationship between sleep and dissociative symptoms disappeared when potentially traumatizing events were controlled for.

Antecedentes: Se han propuesto dos modelos etiológicos para el trastorno de identidad disociativo (TID), a sabre, un modelo de trauma infantil y un modelo iatrogénico o de fantasía. Un estudio reciente indicó que las alteraciones del sueño subyacen en la sintomatología disociativaObjetivo: Nuestro actual estudio tiene como objetivo evaluar si este hallazgo se puede replicar en una muestra independiente e investigar si este hallazgo aún se mantiene después de corregir la traumatización en niños y adultos. Se incluye una tarea experimental de memoria de trabajo para investigar cómo la alteración del sueño, la traumatización, la disociación y la propensión a la fantasía afectan el funcionamiento cognitivo.Métodos: Se incluyeron tres grupos de participantes: individuos con TID, individuos con trastorno de estrés postraumático (TEPT) y controles sanos pareados. Las alteraciones del sueño se midieron y compararon entre los grupos junto con medidas de traumatización infantil y adulta, síntomas disociativos psicomorfos y somatomorfos [psicológicos y somáticos] y propensión a la fantasía. La capacidad cognitiva se evaluó mediante una tarea de memoria de trabajoResultados: Cuando se controlaron las experiencias traumáticas, los trastornos del sueño no predijeron síntomas disociativos. Cuando se controlaron las alteraciones del sueño y la propensión a la fantasía, la traumatización infantil predijo los síntomas disociativos. Los síntomas disociativos psicomorfos se correlacionan más con las experiencias traumáticas que con la propensión a la fantasía. El rendimiento de la memoria de trabajo fue similar entre los grupos participantes. La propensión a la fantasía no discriminaba a los individuos con TID y TEPT, y era un predictor débil de síntomas disociativosConclusión: Mientras que el TID y el TEPT están asociados con trastornos del sueño, estas características no predicen estadísticamente los síntomas disociativos en estos trastornos cuando se tienen en cuenta las experiencias traumáticas. La propensión a la fantasía no es excesiva en DID y PTSD. Por lo tanto, no encontramos evidencia de que los trastornos del sueño, la propensión a la fantasía y la capacidad anormal de la memoria de trabajo expliquen los síntomas disociativos en el TID y el TEPT. En resumen, la relación entre el sueño y los síntomas disociativos desapareció cuando se controlaron los eventos potencialmente traumáticos.

An Emotional Neglect-Personality Disorder Approach: Quantifying a Dimensional Transdiagnostic Model of Trauma-Related and Personality Disorders.

Are personality disorders (PDs) associated with emotional neglect? Draijer (2003) developed a dimensional model of trauma-related disorders and PD. The first dimension consists of the severity of the trauma endured. The second dimension consists of emotional neglect, which is assumed to be related primarily to personality pathology. In this article, we investigate whether an association between retrospective reports of emotional neglect and the presence and severity of PD exists. A sample of 150 patients was systematically assessed. Results indicate that there is little evidence to support a link between emotional neglect and problematic personality functioning at the disorder level; however, there might be a link between emotional neglect and problematic personality functioning in a dimensional way. Findings indicate a relationship between lack of parental warmth and problematic personality functioning, supporting the existence of the emotional neglectaxis of the proposed model in a dimensional framework of viewing personality pathology.

Dissociative subtype of posttraumatic stress disorder or PTSD with comorbid dissociative disorders: Comparative evaluation of clinical profiles.

INTRODUCTION: The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) introduced a dissociative subtype for patients with posttraumatic stress disorder (PTSD) and depersonalization and/or derealization symptoms. Despite high comorbidity rates between PTSD and dissociative disorders (DDs), research has not paid attention to the differentiation or overlap between the dissociative subtype of PTSD and DDs. This raises a question: To what extent do patients with dissociative PTSD differ from patients with PTSD and comorbid DDs? METHOD: We compared three groups of complex patients with trauma-related disorders and/or personality disorders (n = 150): a dissociative PTSD, a nondissociative PTSD, and a non-PTSD group of patients with mainly personality disorders. We used structured clinical interviews and self-administered questionnaires on dissociative symptoms and disorders, personality disorders, trauma histories, depression, anxiety, and general psychopathology. The Dissociative Experiences Scale (DES; ≥20) and the depersonalization/derealization subscale of the DES were used for differentiating dissociative PTSD from nondissociative PTSD. RESULTS: Of all patients, 33% met criteria for dissociative PTSD. More than half of the dissociative PTSD patients (54%) met criteria for one or more DDs; using the depersonalization/derealization subscale of the DES, even 66% had a comorbid DD. But also of the non-PTSD patients, 24% had a mean DES score of ≥20. There were no symptomatic differences (e.g., depression and anxiety) between dissociative PTSD with and without comorbid DDs. CONCLUSION: Overlap between dissociative PTSD and DD is large and we recommend replication of previous studies, using structured clinical assessment of DDs. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Profiling psychopathology of patients reporting early childhood trauma and emotional neglect: Support for a two-dimensional model?

OBJECTIVE: Profiling patients who report early childhood trauma and emotional neglect may be useful for treatment planning. This study attempts to quantify a two-dimensional "trauma-neglect model" (Draijer, 2003) proposed to distinguish clinical profiles in terms of trauma-related, dissociative, and personality pathology. METHOD: A sample of patients referred to a trauma program (n = 49) and a personality disorders program (n = 101) was extensively assessed. Cluster analysis was used to discriminate patients in terms of "psychiatric disease burden," based on symptom severity scores, type of disorder, and level of maladaptive personality functioning. Clusters that differed in psychiatric disease burden were mapped in the trauma-neglect space and their positions were evaluated. RESULTS: We found three clusters and labeled them as "mildly impaired" (26% of patients), "moderately impaired" (43% of patients), and "severely impaired" (31% of patients). The mean scores on trauma and neglect for the mild and severe groups differed significantly. CONCLUSIONS: These findings indicate that further investigation of the validity of the model, which may be used to plan treatment, is useful. Patients experiencing a wide range of trauma-related disorders, dissociative disorders (DD), and personality disorders (PD), combined with a high level of psychiatric symptoms and a maladaptive style of personality functioning, report a range of traumatic experiences in combination with a lack of maternal care, and can be profiled as "severely impaired." (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The clinical course of trauma-related disorders and personality disorders: study protocol of two-year follow-up based on structured interviews.

BACKGROUND: Trauma-related disorders and personality disorders are prevalent in survivors of chronic childhood trauma and neglect. Both conditions have serious consequences for patients, their families, society and public health and a high risk of development of chronicity. However, information on the long term course trajectories is lacking and predictors of course outcome in survivors of chronic childhood traumatization are unknown. The first aim of the current study is to identify two-year course trajectories of pathology in patients with trauma-related disorders and personality disorders. The second aim is to examine predictors of the course, including demographics, clinical characteristics and comorbidities. METHODS/DESIGN: The study is a naturalistic two-year follow-up of 150 patients consecutively admitted to the trauma treatment program and the personality disorder treatment program respectively at GGZ Friesland, a regular Dutch mental health care center. The only exclusion criterion is insufficient mastery of the Dutch language. Participants will be assessed after 2 years of treatment through measures that have been completed at baseline, including structured clinical interviews to measure childhood histories of trauma and neglect, (symptoms of) trauma-related disorders and personality disorders, and psychological questionnaire measures (e.g., general psychopathology, depressive symptoms and personality features). In addition, participants will complete an evaluation questionnaire to assess medication prescribed and treatment (s) received outside GGZ Friesland between baseline and follow-up. Information about (psychological and pharmacological) treatment received at GGZ Friesland during the follow-up period will be collected from patient files. DISCUSSION: This study provides insight in the two-year course of (comorbid) trauma-related disorders and personality disorders. Identifying predictors of the course of trauma-related and personality disorders will allow to differentiate clinical profiles and will offer indicators for treatment.

Childhood sexual abuse by representatives of the Roman Catholic Church: a prevalence estimate among the Dutch population.

Estimates of the extent of childhood sexual abuse (CSA) within in the Roman Catholic Church (RCC) in the general population are difficult to find. The independent Commission of Inquiry into sexual abuse of minors in the RCC in the Netherlands collected population-based data to estimate its prevalence. A large random online population sample was surveyed using a two-phase stratified sampling procedure. In Phase 1, 34,267 subjects aged 40 years and older were screened for childhood exposure to sexual abuse by non-family members, a history of institutionalization and a Roman Catholic upbringing. In Phase 2, a stratified subset of 2,462 subjects was assessed to obtain more detailed target information about sexual abuse reports within the RCC. We employed multiple imputation for the estimation of RCC CSA in the original Phase 1 sample. The prevalence of non-familial CSA in general (14.0%) was higher among women (17.2%) than among men (10.6%). The prevalence of CSA within the Dutch RCC (1.7%) was higher among men (2.7%) than among women (0.7%). As expected, older subjects reported more often CSA in the RCC than their younger counterparts. Respondents who stayed for some time in RCC run institutions for education or child protection had a higher risk to report sexual abuse. Although sexual abuse of minors by representatives of the RCC was a structural problem during a period that the Church was highly influential in the Netherlands, the estimated prevalence of the phenomenon is only a fraction of the prevalence rate of non-familial CSA.

Similar cortical but not subcortical gray matter abnormalities in women with posttraumatic stress disorder with versus without dissociative identity disorder.

Neuroanatomical evidence on the relationship between posttraumatic stress disorder (PTSD) and dissociative disorders is still lacking. We acquired brain structural magnetic resonance imaging (MRI) scans from 17 patients with dissociative identity disorder (DID) and co-morbid PTSD (DID-PTSD) and 16 patients with PTSD but without DID (PTSD-only), and 32 healthy controls (HC), and compared their whole-brain cortical and subcortical gray matter (GM) morphological measurements. Associations between GM measurements and severity of dissociative and depersonalization/derealization symptoms or lifetime traumatizing events were evaluated in the patient groups. DID-PTSD and PTSD-only patients, compared with HC, had similarly smaller cortical GM volumes of the whole brain and of frontal, temporal and insular cortices. DID-PTSD patients additionally showed smaller hippocampal and larger pallidum volumes relative to HC, and larger putamen and pallidum volumes relative to PTSD-only. Severity of lifetime traumatizing events and volume of the hippocampus were negatively correlated. Severity of dissociative and depersonalization/derealization symptoms correlated positively with volume of the putamen and pallidum, and negatively with volume of the inferior parietal cortex. Shared abnormal brain structures in DID-PTSD and PTSD-only, small hippocampal volume in DID-PTSD, more severe lifetime traumatizing events in DID-PTSD compared with PTSD-only, and negative correlations between lifetime traumatizing events and hippocampal volume suggest a trauma-related etiology for DID. Our results provide neurobiological evidence for the side-by-side nosological classification of PTSD and DID in the DSM-5.

Inconsistent retrospective self-reports of childhood sexual abuse and their correlates in the general population.

PURPOSE: Epidemiological research on childhood sexual abuse (CSA) and its consequences in adult life mainly relies on retrospective reports. This study explores their consistency and the correlates of inconsistent CSA self-reports in a random population sample. METHOD: A stratified subsample of 2,462 subjects (selected from a large-scale (N = 34,267) representative sample of Dutch adults aged 40 and beyond) participated in a two-phase online questionnaire survey on extra-familial CSA which was conducted on a four- to six-week interval. Subjects reporting CSA were overrepresented. Participants with consistent and inconsistent responses were compared with regard to demographics, family background, abuse severity, and clinical characteristics. Potential correlates of inconsistency were identified using logistic regression analysis. An additional questionnaire (Phase III) administered to inconsistent respondents explored possible reasons for their inconsistency. RESULTS: Of the 1,992 respondents who had reported extra-familial CSA during Phase I, 707 (35.5%) denied this in Phase II. Of the 2,462 respondents in Phase II, 727 (29.5%; 9.2% when considering sample stratification) gave a discrepant answer to the extra-familial sexual abuse item compared to their answers given in Phase I. Reports of less severe abuse, intra-familial CSA, and early parental separation predicted inconsistency. Reasons provided for inconsistency varied from misunderstanding (e.g., reporting intra-familial CSA rather than extra-familial CSA) to emotional motives (e.g., embarrassment, being overwhelmed) or practical considerations (e.g., lack of privacy while filling out the questionnaire). CONCLUSIONS: Inconsistent self-reports of extra-familial sexual abuse occur on a substantial scale and are associated with less severe forms of abuse (lack of salience) or classification difficulties (perpetrator being a family member or not). Consistency tests and probing for clarifications or corrections should be routinely conducted in order to increase the quality of CSA epidemiological research.

Abnormal hippocampal morphology in dissociative identity disorder and post-traumatic stress disorder correlates with childhood trauma and dissociative symptoms.

Smaller hippocampal volume has been reported in individuals with post-traumatic stress disorder (PTSD) and dissociative identity disorder (DID), but the regional specificity of hippocampal volume reductions and the association with severity of dissociative symptoms and/or childhood traumatization are still unclear. Brain structural magnetic resonance imaging scans were analyzed for 33 outpatients (17 with DID and 16 with PTSD only) and 28 healthy controls (HC), all matched for age, sex, and education. DID patients met criteria for PTSD (PTSD-DID). Hippocampal global and subfield volumes and shape measurements were extracted. We found that global hippocampal volume was significantly smaller in all 33 patients (left: 6.75%; right: 8.33%) compared with HC. PTSD-DID (left: 10.19%; right: 11.37%) and PTSD-only with a history of childhood traumatization (left: 7.11%; right: 7.31%) had significantly smaller global hippocampal volume relative to HC. PTSD-DID had abnormal shape and significantly smaller volume in the CA2-3, CA4-DG and (pre)subiculum compared with HC. In the patient groups, smaller global and subfield hippocampal volumes significantly correlated with higher severity of childhood traumatization and dissociative symptoms. These findings support a childhood trauma-related etiology for abnormal hippocampal morphology in both PTSD and DID and can further the understanding of neurobiological mechanisms involved in these disorders.

Phase-based treatment of a complex severely mentally ill case involving complex posttraumatic stress disorder and psychosis related to Dandy Walker syndrome.

UNLABELLED: For patients with comorbid complex posttraumatic stress disorder (PTSD) and psychotic disorder, trauma-focused therapy may be difficult to endure. Phase-based treatment including (a) stabilization, (b) trauma-focused therapy, and (c) integration of personality with recovery of connection appears to be the treatment of choice. OBJECTIVE: The objective of this article is to describe and evaluate the therapeutic process of a single case from a holistic perspective. METHOD: We present a case report of a 47-year-old woman treated for severe complex PTSD resulting from repeated sexual and physical abuse in early childhood and moderate psychotic symptoms stemming from Dandy Walker Syndrome with hydrocephalus. RESULTS: The patient was treated with quetiapine (600-1,000 mg) and citalopram (40 mg). Stabilization consisted of intensive psychiatric nursing care in the home and stabilizing group treatment for complex PTSD. After stabilization, the following symptom domains showed improvement: self-regulation, self-esteem, assertiveness, avoidance of social activities, and negative cognitions. However, intrusions and arousal persisted and were therefore subsequently treated with prolonged imaginary exposure that also included narrative writing assignments and a final closing ritual. This intensive multidisciplinary, phase-based approach proved effective: All symptoms of complex PTSD were in full remission. Social integration and recovery were promoted with the reduction of polypharmacy and the provision of social skills training and lifestyle training. CONCLUSION: The present case shows a phase-based treatment approach with multidisciplinary collaborative care to be effective for the treatment of a case of complex PTSD with comorbid psychotic disorder stemming from severe neurological impairment. Replication of this promising approach is therefore called for.

The addition of STEPPS in the treatment of patients with bipolar disorder and comorbid borderline personality features: a protocol for a randomized controlled trial.

BACKGROUND: Bipolar disorder (BD) and borderline personality disorder (BPD) both are severe and chronic psychiatric disorders. Both disorders have overlapping symptoms, and current research shows that the presence of a BPD has an adverse effect on the course of BD. The limited research available shows an unfavorable illness course, a worse prognosis and response to medication, longer treatment duration, more frequent psychiatric admissions, higher drop-out, increased risk of substance abuse, increased risk of suicide, and more impairment of social and occupational functioning. However, there is no research available on the effect of specific psychotherapeutic treatment for this patients. METHODS/DESIGN: This paper presents the protocol of a RCT to investigate the presence of borderline personality features in patients treated for BD (study part 1) and the effectiveness of STEPPS (Systems Training for Emotional Predictability and Problem Solving) added to treatment as usual (TAU) for BD compared to TAU in patients with BD and comorbid borderline personality features (study part 2). STEPPS is a validated and effective intervention for BPD. The study population consists of patients treated for BD at specialized outpatient clinics for BD in the Netherlands. At first the prevalence of comorbid borderline personality features in outpatients with BD is investigated. Inclusion criteria for study part 2 is defined as having three or more of the DSM-IV-TR diagnostic criteria of BPD, including impulsivity and anger bursts. Primary outcomes will be the frequency and severity of manic and depressive recurrences as well as severity, course and burden of borderline personality features. Secondary outcomes will be quality of life, utilizing mental healthcare and psychopathologic symptoms not primarily related to BD or BPD. Assessment will be at baseline, at the end of the intervention, and at 12 and 18 months follow-up. DISCUSSION: This will be the first randomized controlled trial of a specific intervention in patients with BD and comorbid BPD or borderline personality features. There are no recommendations in the guideline of treatment of bipolar disorders for patients with this complex comorbidity. We expect that a combined treatment aimed at mood disorder and emotion regulation will improve treatment outcomes for these patients.

Survivors of early childhood trauma: evaluating a two-dimensional diagnostic model of the impact of trauma and neglect.

BACKGROUND: A two-dimensional diagnostic model for (complex) trauma-related and personality disorders has been proposed to assess the severity and prognosis of the impact of early childhood trauma and emotional neglect. An important question that awaits empirical examination is whether a distinction between trauma-related disorders and personality disorders reflects reality when focusing on survivors of early childhood trauma. And, is a continuum of trauma diagnoses a correct assumption and, if yes, what does it look like? OBJECTIVE: We describe the design of a cross-sectional cohort study evaluating this two-dimensional model of the impact of trauma and neglect. To provide the rationale of our study objectives, we review the existing literature on the impact of early childhood trauma and neglect on trauma-related disorders and personality disorders. Aims of the study are to: (1) quantify the two-dimensional model and test the relation with trauma and neglect; and (2) compare the two study groups. METHOD: A total of 200 consecutive patients referred to two specific treatment programs (100 from a personality disorder program and 100 from a trauma-related disorder program) in the north of Holland will be included. Data are collected at the start of treatment. The assessments include all DSM-5 trauma-related and personality disorders, and general psychiatric symptoms, trauma history, and perceived emotional neglect. DISCUSSION: The results will provide an evaluation of the model and an improvement of the understanding of the relationship between trauma-related disorders and personality disorders and early childhood trauma and emotional neglect. This may improve both diagnostic as well as indication procedures. We will discuss possible strengths and limitations of the design.

Symptom overreporting obscures the dose-response relationship between trauma severity and symptoms.

We investigated whether symptom overreporting affects the dose-response relationship between self-reported abuse severity and psychiatric symptoms in two samples. The first sample (N=599) consisted of adults who had previously reported to a public commission that they had been witnesses to or victims of childhood sexual abuse by Roman Catholic Church representatives. The second sample (N=1756) consisted of general population respondents who indicated that they had been victims of non-familial childhood sexual abuse. Using a web-based data collection procedure, both samples completed the Brief Symptom Inventory (BSI-18), items addressing abuse severity, and items flagging symptom overreporting. Adjusting for overreporting reduced the proportion of participants with clinically raised BSI-18 scores from 60% to 47% in sample 1 and from 26% to 22% in sample 2. Also, in both samples, normal range reporting participants exhibited the typical dose-response relationship between trauma severity and BSI-18 scores, whereas this pattern was largely non-significant in overreporting participants. Our findings show that symptom overreporting has a psychometric impact that may obscure relationships between clinically relevant variables and should therefore preferably be monitored in surveys.