Functional connectivity of the auditory cortex in women with trauma-related disorders who hear voices.

BACKGROUND: 'Voice-hearing' (VH) is a transdiagnostic experience that is common in trauma-related disorders (trauma-D). However, the neural substrates underlying trauma-related VH remain largely unexplored. While auditory perceptual dysfunction is among the abnormalities implicated in schizophrenia VH, whether VH in trauma-D also involves auditory perceptual alterations is unknown. METHODS: We investigated auditory cortex (AC)-related functional connectivity (FC) in n=65 women with trauma-D related to childhood abuse with varying severities of VH. Using a novel, computationally-driven and individual-specific method of functionally parcellating the brain, we calculated the FC of two distinct AC subregions-Heschl's gyrus (HG, corresponding to primary AC) and lateral superior temporal gyrus (lSTG, in non-primary AC)- with both the cerebrum and cerebellum. We then measured the association between VH severity and FC using leave-one-out cross validation within the cerebrum, and voxel-wise multiple regression analyses in the cerebellum. RESULTS: We found that VH severity positively correlated with left lSTG-frontoparietal network FC, while it negatively correlated with FC between left lSTG and both cerebral and cerebellar representations of the default mode network. VH severity was not predicted by FC of left HG or right AC subregions. CONCLUSIONS: Our findings point to altered interactions between auditory perceptual processing and higher-level processes related to self-reference and executive functioning. This is the first study to show alterations in auditory cortical connectivity in trauma-related VH. While VH in trauma-D appears to be mediated by brain networks that are also implicated in schizophrenia VH, the results suggest a unique mechanism that could distinguish VH in trauma-D.

Treatment of dissociative identity disorder: leveraging neurobiology to optimize success.

INTRODUCTION: Dissociative identity disorder (DID) is a treatable mental health condition that is associated with a range of psychobiological manifestations. However, historical controversy, modern day misunderstanding, and lack of professional education have prevented accurate treatment information from reaching most clinicians and patients. These obstacles also have slowed empirical efforts to improve treatment outcomes for people with DID. Emerging neurobiological findings in DID provide essential information that can be used to improve treatment outcomes. AREAS COVERED: In this narrative review, the authors discuss symptom characteristics of DID, including dissociative self-states. Current treatment approaches are described, focusing on empirically supported psychotherapeutic interventions for DID and pharmacological agents targeting dissociative symptoms in other conditions. Neurobiological correlates of DID are reviewed, including recent research aimed at identifying a neural signature of DID. EXPERT OPINION: Now is the time to move beyond historical controversy and focus on improving DID treatment availability and efficacy. Neurobiological findings could optimize treatment by reducing shame, aiding assessment, providing novel interventional brain targets and guiding novel pharmacologic and psychotherapeutic interventions. The inclusion of those with lived experience in the design, planning and interpretation of research investigations is another powerful way to improve health outcomes for those with DID.

Deconstructing dissociation: a triple network model of trauma-related dissociation and its subtypes.

Trauma-related pathological dissociation is characterized by disruptions in one's sense of self, perceptual, and affective experience. Dissociation and its trauma-related antecedents disproportionately impact women. However, despite the gender-related prevalence and high individual and societal costs, dissociation remains widely underappreciated in clinical practice. Moreover, dissociation lacks a synthesized neurobiological model across its subtypes. Leveraging the Triple Network Model of psychopathology, we sought to parse heterogeneity in dissociative experience by examining functional connectivity of three core neurocognitive networks as related to: (1) the dimensional dissociation subtypes of depersonalization/derealization and partially-dissociated intrusions; and, (2) the diagnostic category of dissociative identity disorder (DID). Participants were 91 women with and without: a history of childhood trauma, current posttraumatic stress disorder (PTSD), and varied levels of dissociation. Participants provided clinical data about dissociation, PTSD symptoms, childhood maltreatment history, and completed a resting-state functional magnetic resonance imaging scan. We used a novel statistical approach to assess both overlapping and unique contributions of dissociation subtypes. Covarying for age, childhood maltreatment and PTSD severity, we found dissociation was linked to hyperconnectivity within central executive (CEN), default (DN), and salience networks (SN), and decreased connectivity of CEN and SN with other areas. Moreover, we isolated unique connectivity markers associated with depersonalization/derealization in CEN and DN, to partially-dissociated intrusions in CEN, and to DID in CEN. This suggests dissociation subtypes have robust functional connectivity signatures that may serve as targets for PTSD/DID treatment engagement. Our findings underscore dissociation assessment as crucial in clinical care, in particular, to reduce gender-related health disparities.

Anxiety sensitivity predicts depression severity in individuals with dissociative identity disorder.

BACKGROUND: Anxiety sensitivity involves the fear of anxiety-related symptoms and can exacerbate both major depressive disorder and posttraumatic stress disorder (PTSD) symptoms. However, it is unclear if anxiety sensitivity plays a similar role in dissociative identity disorder (DID) where symptoms of depression and PTSD commonly co-occur. We examined the association between anxiety sensitivity, depression, PTSD and dissociative symptoms in DID, hypothesizing a positive association between all symptoms and anxiety sensitivity. METHOD: Participants were 21 treatment-seeking adult females with histories of childhood trauma, current PTSD, and DID. Participants completed the Anxiety Sensitivity Index (ASI), Beck Depression Inventory-II, Childhood Trauma Questionnaire, Multidimensional Inventory of Dissociation, and PTSD Checklist for DSM-5. The ASI included subscales that assessed anxiety sensitivity in cognitive, physical, and social domains. RESULTS: Participants reported high levels of anxiety sensitivity. A multiple regression analysis demonstrated that the ASI cognitive subscale was the strongest predictor of depressive symptoms. No direct associations were identified between anxiety sensitivity and PTSD or dissociative symptoms. We conducted a mediation analysis to test an indirect relationship between cognitive anxiety sensitivity and dissociative symptoms, and found a significant indirect effect through depressive symptoms. CONCLUSIONS: Our results suggest that cognitive anxiety sensitivity or the fear of cognitive dyscontrol is linked with symptom severity in DID. These findings emphasize the need to assess for and utilize interventions that target anxiety sensitivity, which may in turn alleviate symptoms of depression and dissociation in DID.

Unravelling psychiatric heterogeneity and predicting suicide attempts in women with trauma-related dissociation using artificial intelligence.

Background: Suicide is a leading cause of death, and rates of attempted suicide have increased during the COVID-19 pandemic. The under-diagnosed psychiatric phenotype of dissociation is associated with elevated suicidal self-injury; however, it has largely been left out of attempts to predict and prevent suicide.Objective: We designed an artificial intelligence approach to identify dissociative patients and predict prior suicide attempts in an unbiased, data-driven manner.Method: Participants were 30 controls and 93 treatment-seeking female patients with posttraumatic stress disorder (PTSD) and various levels of dissociation, including some with the PTSD dissociative subtype and some with dissociative identity disorder (DID).Results: Unsupervised learning models identified patients along a spectrum of dissociation. Moreover, supervised learning models accurately predicted prior suicide attempts with an F1 score up to 0.83. DID had the highest risk of prior suicide attempts, and distinct subtypes of dissociation predicted suicide attempts in PTSD and DID.Conclusions: These findings expand our understanding of the dissociative phenotype and underscore the urgent need to assess for dissociation to identify individuals at high-risk of suicidal self-injury.

Dissociation, feelings of detachment and disruption in one's sense of self and surroundings, is associated with an elevated risk of suicidal self-injury; however, it has largely been left out of attempts to predict and prevent suicide.Using machine learning techniques, we found dissociative identity disorder had the highest risk of prior suicide attempts, and distinct subtypes of dissociation predicted suicide attempts in posttraumatic stress disorder and dissociative identity disorder.These findings underscore the urgent need to assess for dissociation to identify individuals at high-risk of suicidal self-injury.

Higher integration scores are associated with facial emotion perception differences in dissociative identity disorder.

BACKGROUND: Recovery from dissociative identity disorder (DID) is associated with the process of integration, which includes an increasing sense of self-cohesion and ownership over one's own emotions. Emotion perception is a construction based on interplay between stored knowledge (past experience), and incoming sensory inputs, suggesting changes in emotion perception might occur at different levels of integration - but this remains unexplored. Therefore, we examined the association between integration, psychiatric symptoms, and facial emotion perception. We hypothesized higher integration would be associated with fewer psychiatric symptoms, and differences in the perception of emotions. METHODS: Participants were 82 respondents to a cross-sectional web-based study. All participants met self-report cutoff scores for posttraumatic stress disorder (PTSD) and DID using the PTSD Checklist for DSM-5 and Multiscale Dissociation Inventory, respectively. Participants completed a psychometrically-matched test of facial emotion perception for anger, fear, and happiness called the Belmont Emotion Sensitivity Test. Participants also completed the Beck Depression Inventory II, Childhood Trauma Questionnaire, and Integration Measure, a validated measure of self-cohesion. RESULTS: Higher integration scores were associated with lower depression, PTSD, and autobiographical memory disturbance scores. Repeated-measures ANCOVA confirmed integration significantly interacted with emotion category on the facial emotion perception task. Specifically, higher integration scores were associated with greater accuracy to fearful and angry faces. CONCLUSIONS: While acknowledging the limitations of a cross-sectional design, our results suggest that the process of integration is associated with fewer psychiatric symptoms, and more accurate facial emotion perception. This supports treatment guidelines regarding integration as a therapeutic goal for DID.

Can the Trauma Symptom Inventory-2 distinguish coached simulators from dissociative disorder patients?

OBJECTIVE: The first objective was to understand how individuals with complex dissociative disorders (CDD) score on the Trauma Symptom Inventory-2 (TSI-2). These individuals have high elevations on many psychological measures' validity and clinical scales because of the severe traumatic reactions they experience; thus, creating a challenge for clinicians who seek to determine whether these individuals are exaggerating reported symptoms. The second objective was to compare coached CDD simulators to CDD profiles on the TSI-2s clinical and validity scales. The third objective was to examine the utility rates of the TSI-2s Atypical Response Scale (ATR) in distinguishing feigned CDD from clinical CDD. METHOD: This study compared 39 CDD inpatients to 51 coached CDD simulators on the TSI-2. A profile analysis compared the CDD group and coached simulators on the TSI-2 scales, and post hoc 1-way analysis of covariances (ANCOVAS) examined significant differences between the groups. RESULTS: The CDD patients elevated on most of the TSI-2 clinical scales and factors. There were significant differences between CDD patients' and CDD simulators' TSI-2 profiles, with simulators failing to endorse some of the co-occurring symptoms common in CDD. The ATR correctly classified only 60-73% of participants and its specificity scores were low. CONCLUSIONS: It is important to understand how CDD individuals score on the TSI-2 so that their results can be recognized and meaningfully interpreted. The TSI-2 may not be a useful measure for distinguishing feigned CDD from CDD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

MMPI-2 Item Endorsements in Dissociative Identity Disorder vs. Simulators.

Elevated scores on some MMPI-2 (Minnesota Multiphasic Inventory-2) validity scales are common among patients with dissociative identity disorder (DID), which raises questions about the validity of their responses. Such patients show elevated scores on atypical answers (F), F-psychopathology (Fp), atypical answers in the second half of the test (FB), schizophrenia (Sc), and depression (D) scales, with Fp showing the greatest utility in distinguishing them from coached and uncoached DID simulators. In the current study, we investigated the items on the MMPI-2 F, Fp, FB, Sc, and D scales that were most and least commonly endorsed by participants with DID in our 2014 study and compared these responses with those of coached and uncoached DID simulators. The comparisons revealed that patients with DID most frequently endorsed items related to dissociation, trauma, depression, fearfulness, conflict within family, and self-destructiveness. The coached group more successfully imitated item endorsements of the DID group than did the uncoached group. However, both simulating groups, especially the uncoached group, frequently endorsed items that were uncommonly endorsed by the DID group. The uncoached group endorsed items consistent with popular media portrayals of people with DID being violent, delusional, and unlawful. These results suggest that item endorsement patterns can provide useful information to clinicians making determinations about whether an individual is presenting with DID or feigning.