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Deutsches Arzteblatt International Jun 2020The pathological feigning of disease can be seen in all medical disciplines. It is associated with variegated symptom presentations, self-inflicted injuries, forced but... (Review)
Review
BACKGROUND
The pathological feigning of disease can be seen in all medical disciplines. It is associated with variegated symptom presentations, self-inflicted injuries, forced but unnecessary interventions, unusual and protracted recoveries, and frequent changes of treating physician. Factitious illness is often difficult to distinguish from functional or dissociative disorders on the one hand, and from malingering on the other. Many cases, even fatal ones, probably go unrecognized. The suspicion that a patient's problem may be, at least in part, factitious is subject to a strong taboo and generally rests on supportive rather than conclusive evidence. The danger of misdiagnosis and inappropriate treatment is high.
METHODS
On the basis of a selective review of current literature, we summarize the phenomenology of factitious disorders and present concrete strategies for dealing with suspected factitious disorders.
RESULTS
Through the early recognition and assessment of clues and warning signs, the clinician will be able to judge whether a factitious disorder should be considered as a differential diagnosis, as a comorbid disturbance, or as the suspected main diagnosis. A stepwise, supportive confrontation of the patient with the facts, in which continued therapeutic contact is offered and no proofs or confessions are demanded, can help the patient set aside the sick role in favor of more functional objectives, while still saving face. In contrast, a tough confrontation without empathy may provoke even more elaborate manipulations or precipitate the abrupt discontinuation of care-seeking.
CONCLUSION
Even in the absence of systematic studies, which will probably remain difficult to carry out, it is clearly the case that feigned, falsified, and induced disorders are underappreciated and potentially dangerous differential diagnoses. If the entire treating team successfully maintains an alert, transparent, empathic, and coping-oriented therapeutic approach, the patient will, in the best case, be able to shed the pretense of disease. Above all, the timely recognition of the nature of the problem by the treating team can prevent further iatrogenic harm.
Topics: Diagnosis, Differential; Factitious Disorders; Humans
PubMed: 32897184
DOI: 10.3238/arztebl.2020.0452 -
Molecules (Basel, Switzerland) Dec 2020Ketamine is a versatile agent primarily utilized as a dissociative anesthetic, which acts by blocking the excitatory receptor -methyl-d-aspartate receptor (NMDA). It... (Review)
Review
Ketamine is a versatile agent primarily utilized as a dissociative anesthetic, which acts by blocking the excitatory receptor -methyl-d-aspartate receptor (NMDA). It functions to inhibit the current of both Na and K voltage-gated channels, thus preventing serotonin and dopamine reuptake. Studies have indicated that administering a single subanesthetic dose of ketamine relieves depression rapidly and that the effect is sustained. For decades antidepressant agents were based on the monoamine theory. Although ketamine may not be the golden antidepressant, it has opened new avenues toward mechanisms involved in the pathology of treatment-resistant depression and achieving rapid antidepressant effects. Thus, preclinical studies focusing on deciphering the molecular mechanisms involved in the antidepressant action of ketamine will assist in the development of a new antidepressant. This review was conducted to elucidate the emerging pathways that can explain the complex dose-dependent mechanisms achieved by administering ketamine to treat major depressive disorders. Special attention was paid to reviewing the literature on hydroxynorketamines, which are ketamine metabolites that have recently attracted attention in the context of depression.
Topics: Animals; Antidepressive Agents; Biomarkers; Depressive Disorder, Major; Disease Susceptibility; Humans; Ketamine; Receptors, N-Methyl-D-Aspartate
PubMed: 33297563
DOI: 10.3390/molecules25235777 -
Indian Journal of Psychological Medicine Nov 2021There is a gap in understanding the pathogenesis of dissociative conversion disorder (DCD), despite the disorder having a strong historical root. The role of personality...
BACKGROUND
There is a gap in understanding the pathogenesis of dissociative conversion disorder (DCD), despite the disorder having a strong historical root. The role of personality and neurocognitive factors are now highlighted; however, inconsistencies are reported. This study explores the personality disposition, arousability, and decision-making ability of patients with DCD, in reference to a healthy control group (HCG).
METHODS
In this cross-sectional study, the sample comprised ten adult psychiatric patients with DCD. Ten participants of the HCG were matched according to age, gender, education, economic status, domicile, religious background, and handedness. The study assessed personality disposition with Temperament and Character Inventory, arousability with reaction time task, and decision-making ability with the Iowa Gambling Task (IGT PEBL version).
RESULTS
The DCD group differed significantly on personality disposition related to both temperament and character. There was also evidence of easy arousability and frustration along with deficit in executive function related to decision-making ability.
CONCLUSION
This study highlights the presence of both temperamental and characterological factors associated with DCD. Moreover, this study identifies the role of cognitive arousability and decision-making or feedback utilization ability in the psychopathology of DCD.
PubMed: 35210676
DOI: 10.1177/0253717620981555 -
BJPsych Open Mar 2022Studies investigating the structure of the amygdala in relation to dissociation in psychiatric disorders are limited and have reported normal or preserved, increased or...
Studies investigating the structure of the amygdala in relation to dissociation in psychiatric disorders are limited and have reported normal or preserved, increased or decreased global volumes. Thus, a more detailed investigation of the amygdala is warranted. Amygdala global and subregional volumes were compared between individuals with dissociative identity disorder (DID: n = 32) and healthy controls (n = 42). Analyses of covariance did not show volumetric differences between the DID and control groups. Although several unknowns make it challenging to interpret our findings, we propose that the finding of normal amygdala volume is a genuine finding because other studies using this data-set have presented robust morphological aberrations in relation to the diagnosis of DID.
PubMed: 35287776
DOI: 10.1192/bjo.2022.36 -
Frontiers in Psychiatry 2023
PubMed: 36926462
DOI: 10.3389/fpsyt.2023.1115357 -
BMJ Neurology Open 2024Dissociative seizures often occur in the context of dysregulated affective arousal and entail dissociative symptoms such as a disintegration of bodily awareness....
INTRODUCTION
Dissociative seizures often occur in the context of dysregulated affective arousal and entail dissociative symptoms such as a disintegration of bodily awareness. However, the interplay between affective arousal and changes in interoceptive processing at the onset of dissociative seizures is not well understood.
METHODS
Using retrospective routine data obtained from video-electroencephalography telemetry in a university hospital epilepsy monitoring unit, we investigate ictal changes in cardiac indices of autonomic arousal and heartbeat evoked potentials (HEPs) in 24 patients with dissociative seizures.
RESULTS
Results show autonomic arousal during seizures with increased heart rate and a shift towards sympathetic activity. Compared with baseline, ictal HEP amplitudes over central and right prefrontal electrodes (F8, Fz) were significantly less pronounced during seizures, suggesting diminished cortical representation of interoceptive information. Significant correlations between heart rate variability measures and HEPs were observed at baseline, with more sympathetic and less parasympathetic activity related to less pronounced HEPs. Interestingly, these relationships weakened during seizures, suggesting a disintegration of autonomic arousal and interoceptive processing during dissociative seizures. In a subgroup of 16 patients, MRI-based cortical thickness analysis found a correlation with HEP amplitudes in the left somatosensory association cortex.
CONCLUSIONS
These findings possibly represent an electrophysiological hint of how autonomic arousal could negatively impact bodily awareness in dissociative seizures, and how these processes might be related to underlying brain structure.
PubMed: 38860229
DOI: 10.1136/bmjno-2024-000665 -
Alcoholism, Clinical and Experimental... Feb 2022Up to 50% of individuals with posttraumatic stress disorder (PTSD) endorse problematic alcohol use. Typically, these individuals present with more complex and often more...
BACKGROUND
Up to 50% of individuals with posttraumatic stress disorder (PTSD) endorse problematic alcohol use. Typically, these individuals present with more complex and often more severe PTSD symptoms than those who do not report problematic alcohol use. Emerging literature suggests that heightened symptoms of dissociation are likewise associated with greater PTSD symptom severity. Despite this knowledge, the role of dissociation in the relation between PTSD severity and alcohol-related problems has yet to be examined. Here, we explore the mediating role of dissociative symptomatology on the association between PTSD severity and alcohol-related problems within a PTSD treatment-seeking sample.
METHODS
Structural equation modeling was used to test the mediating role of dissociative symptomatology between PTSD severity and alcohol-related problems. Participants [N = 334; mean age (SD) = 44.29 (9.77), 50% female] were drawn from a clinical intake battery database for PTSD in-patient treatment services at Homewood Health Care, Guelph, ON, Canada. A subset of battery measures assessing PTSD severity, dissociative symptomatology, and alcohol-related problems were submitted to analysis.
RESULTS
A significant positive association emerged between PTSD severity and alcohol-related problems (β = 0.127, p < 0.05) in the absence of dissociative symptomatology. Critically, however, when added to this model, dissociative symptomatology (six unique facets of dissociation assessed by the Multiscale Dissociation Inventory) mediated the relation between PTSD severity and alcohol-related problems. Specifically, greater PTSD severity was associated with greater dissociative symptomatology (β = 0.566, p < 0.0001), which was in turn associated with greater alcohol-related problems (β = 0.184, p < 0.05).
CONCLUSIONS
These results suggest that dissociative symptomatology plays a key role in explaining the relation between PTSD severity and alcohol-related problems. Future studies should examine the impact of targeting dissociative symptomatology specifically in treating individuals with PTSD who endorse alcohol-related problems.
Topics: Adult; Alcohol-Related Disorders; Cross-Sectional Studies; Dissociative Disorders; Emotional Regulation; Female; Humans; Male; Middle Aged; Severity of Illness Index; Stress Disorders, Post-Traumatic
PubMed: 35179786
DOI: 10.1111/acer.14764 -
Neuropharmacology Nov 2022The N-methyl-d-aspartate receptor (NMDAR) antagonist (R,S)-ketamine causes rapid onset and sustained antidepressant actions in treatment-resistant patients with major... (Review)
Review
The N-methyl-d-aspartate receptor (NMDAR) antagonist (R,S)-ketamine causes rapid onset and sustained antidepressant actions in treatment-resistant patients with major depressive disorder (MDD) and other psychiatric disorders, such as bipolar disorder and post-traumatic stress disorder. (R,S)-ketamine is a racemic mixture consisting of (R)-ketamine (or arketamine) and (S)-ketamine (or esketamine), with (S)-enantiomer having greater affinity for the NMDAR. In 2019, an esketamine nasal spray by Johnson & Johnson was approved in the USA and Europe for treatment-resistant depression. In contrast, an increasing number of preclinical studies show that arketamine has greater potency and longer-lasting antidepressant-like effects than esketamine in rodents, despite the lower binding affinity of arketamine for the NMDAR. Importantly, the side effects, i.e., psychotomimetic and dissociative effects and abuse liability, of arketamine are less than those of (R,S)-ketamine and esketamine in animals and humans. An open-label study demonstrated the rapid and sustained antidepressant effects of arketamine in treatment-resistant patients with MDD. A phase 2 clinical trial of arketamine in treatment-resistant patients with MDD is underway. This study was designed to review the brief history of the novel antidepressant arketamine, the molecular mechanisms underlying its antidepressant actions, and future directions.
Topics: Animals; Antidepressive Agents; Depression; Depressive Disorder, Major; Depressive Disorder, Treatment-Resistant; Humans; Ketamine; Receptors, N-Methyl-D-Aspartate
PubMed: 35977629
DOI: 10.1016/j.neuropharm.2022.109219 -
Psychiatric Research and Clinical... Dec 2020Studies on maladaptive daydreaming have shown that it has a number of comorbidities including dissociative disorders, yet no studies have examined the reciprocal...
OBJECTIVE
Studies on maladaptive daydreaming have shown that it has a number of comorbidities including dissociative disorders, yet no studies have examined the reciprocal relationship. The aim of this study was to determine the frequency of maladaptive daydreaming in a sample of psychiatric inpatients with high levels of dissociation.
METHODS
The Dissociative Experiences Scale (DES), Self-Report Dissociative Disorders Interview Schedule, Maladaptive Daydreaming Scale-16 (MDS-16), Structured Clinical Interview for Maladaptive Daydreaming, and the Obsessive Compulsive Inventory were administered to a sample of 100 inpatients in a psychiatric hospital program specializing in dissociative disorders.
RESULTS
Of the 100 participants, 93 reported childhood physical and/or sexual abuse, 33 met criteria for dissociative identity disorder; 56 met criteria for other specified dissociative disorder, 49 met criteria for maladaptive daydreaming disorder, and 23 met criteria for unspecified maladaptive daydreaming. The average score on the DES was 39.1 and the average score on the MDS-16 was 33.9. Individuals with maladaptive daydreaming disorder scored significantly higher than those without on many different symptom clusters.
CONCLUSIONS
This sample of 100 highly traumatized and dissociative inpatients reported high levels of maladaptive daydreaming along with many other forms of comorbidity. Maladaptive daydreaming is a previously under-recognized aspect of complex dissociative disorders and requires further attention in both research and clinical practice.
PubMed: 36101866
DOI: 10.1176/appi.prcp.20190050 -
Journal of Translational Autoimmunity 2021Complex regional pain syndrome (CRPS) purports to explain extremity pain accompanied by a variety of subjective complaints, including sensitivity to touch, fatigue,... (Review)
Review
Complex regional pain syndrome (CRPS) purports to explain extremity pain accompanied by a variety of subjective complaints, including sensitivity to touch, fatigue, burning sensations, allodynia and signs consistent with voluntary immobilization, including skin changes, edema and trophic changes. By its own definition, CRPS pain is disproportionate to any inciting event or underlying pathology, which means that the syndrome describes non-anatomic and exaggerated symptoms. Although CRPS was coined in the early 1990s, physicians have described unexplained exaggerated pain for centuries. Before a small group of researchers assigned this historical phenomenon with the name CRPS, other physicians in various subspecialties investigated the existence of a common pathophysiologic mechanism but found none. The literature was searched for evidence of a reproducible pathologic mechanism for CRPS. Although some have suggested that CRPS is an autoimmune disease, there is a paucity of evidence to support this. While cytokines such as IL-1β, IL-6 and TNF-α have been detected during the early phases of CRPS, this cannot lead to the conclusion that CRPS is an autoimmune disease, nor that it is an autoinflammatory disorder. Moreover, intravenous immunoglobulin has showed inconsistent results in the treatment of CRPS. On the other hand, CRPS has been found to meet at least three out of four criteria of malingering, which was previously a DSM-IV diagnosis; and its diagnostic criteria are virtually identical to current DSM-5 Functional Neurological Disorder ("FND"), and proposed ICD-11 classification, which includes FND as a distinct neurological diagnosis apart from any psychiatric condition. Unfortunately, the creation of CPRS is not merely misguided brand marketing. It has serious social and health issues. At least in part, the existence of CRPS has led to the labeling of many patients with a diagnosis that allows the inappropriate use of invasive surgery, addictive opioids, and ketamine. The CRPS hypothesis also ignores the nature and purpose of pain, as a symptom of some organic or psychological process. Physicians have long encountered patients who voice symptoms that cannot be biologically explained. Terminology historically used to describe this phenomenon have been medically unexplained symptoms ("MUS"), hysterical, somatic, non-organic, psychogenic, conversion disorder, or dissociative symptoms. The more recent trend describes disorders where there is a functional, rather than structural cause of the symptoms, as "functional disorders." Physicians report high success treating functional neurological symptoms with reassurance, physiotherapy, and cognitive behavior therapy measured in terms of functional improvement. The CRPS label, however, neither leads to functional improvement in these patients nor resolution of symptoms. Under principles of evidence-based medicine, the CRPS label should be abandoned and the syndrome should simply be considered a subset of FNDs, specifically Functional Pain Disorder; and treated appropriately.
PubMed: 33490941
DOI: 10.1016/j.jtauto.2020.100080