Emotion and the unreal self: depersonalization disorder and de-affectualization

Depersonalization disorder is a psychiatric condition in which there is a pervasive change in the quality of subjective experience, in the absence of psychosis. The core complaint is a persistent and disturbing feeling that experience of oneself and the world has become empty, lifeless, and not fully real. A greatly reduced emotional responsivity, or ‘de-affectualization’, is frequently described. This article examines the phenomenology and neurobiology of DPD with a particular emphasis on the emotional aspects. It is argued that the study of DPD may provide valuable insights into the relationship between emotion, experience, and identity

Emotional modulation of visual cortex activity: A functional nearinfrared spectroscopy study

Functional neuroimaging and electroencephalography reveal emotional effects in early visual cortex. Here, we used fNIRS to examine haemodynamic responses evoked by neutral, positive and negative emotional pictures, matched for brightness, contrast, hue, saturation, spatial frequency and entropy. Emotion content modulated amplitude and latency of oxy-, deoxy- and total haemoglobin response peaks, and induced peripheral autonomic reactions. The processing of positive and negative pictures enhanced haemodynamic response amplitude, and this effect was paralleled by blood pressure changes. The processing of positive pictures was reflected in reduced haemodynamic response peak latency. Together these data suggest early visual cortex holds amplitude-dependent representation of stimulus salience and latency-dependent information regarding stimulus valence, providing new insight into affective interaction with sensory processing

Case report: Clinical lycanthropy in Huntington's disease

We describe the case of a patient diagnosed with Huntington's disease (HD), who, following a two-year history of anxiety with obsessional preoccupations, developed psychosis with clinical lycanthropy: a prominent delusional idea that he was a werewolf. Although there was no benefit from various antidepressants and antipsychotics, there was remarkable improvement of his symptoms following prescription of Clozapine. His choreiform movement disorder also improved as his mental state settled. Although some reported cases of clinical lycanthropy are related to neurological conditions, this is the first case in a patient with HD. We also discuss the relevance of cultural and personal factors in the expression of a delusion that incorporates disgust, and the potential role of somatosensory aberrations and misidentification of self

Case report: Clinical lycanthropy in Huntington's disease

We describe the case of a patient diagnosed with Huntington's disease (HD), who, following a two-year history of anxiety with obsessional preoccupations, developed psychosis with clinical lycanthropy: a prominent delusional idea that he was a werewolf. Although there was no benefit from various antidepressants and antipsychotics, there was remarkable improvement of his symptoms following prescription of Clozapine. His choreiform movement disorder also improved as his mental state settled. Although some reported cases of clinical lycanthropy are related to neurological conditions, this is the first case in a patient with HD. We also discuss the relevance of cultural and personal factors in the expression of a delusion that incorporates disgust, and the potential role of somatosensory aberrations and misidentification of self

Fractionating the unitary notion of dissociation:disembodied but not embodied dissociative experiences are associated with exocentric perspective-taking

It has been argued that hallucinations which appear to involve shifts in egocentric perspective (e.g., the out-of-body experience, OBE) reflect specific biases in exocentric perspective-taking processes. Via a newly devised perspective-taking task, we examined whether such biases in perspective-taking were present in relation to specific dissociative anomalous body experiences (ABE) - namely the OBE. Participants also completed the Cambridge Depersonalization Scale (CDS; Sierra and Berrios, 2000) which provided measures of additional embodied ABE (unreality of self) and measures of derealization (unreality of surroundings). There were no reliable differences in the level of ABE, emotional numbing, and anomalies in sensory recall reported between the OBE and control group as measured by the corresponding CDS subscales. In contrast, the OBE group did provide significantly elevated measures of derealization ("alienation from surroundings" CDS subscale) relative to the control group. At the same time we also found that the OBE group was significantly more efficient at completing all aspects of the perspective-taking task relative to controls. Collectively, the current findings support fractionating the typically unitary notion of dissociation by proposing a distinction between embodied dissociative experiences and disembodied dissociative experiences - with only the latter being associated with exocentric perspective-taking mechanisms. Our findings - obtained with an ecologically valid task and a homogeneous OBE group - also call for a re-evaluation of the relationship between OBEs and perspective-taking in terms of facilitated disembodied experiences

Impairment of perceptual metacognitive accuracy and reduced prefrontal grey matter volume in first-episode psychosis

Introduction: Metacognition, or “thinking about thinking”, is a higher-order thought process that allows for the evaluation of perceptual processes for accuracy. Metacognitive accuracy is associated with the grey matter volume (GMV) in the prefrontal cortex (PFC), an area also impacted in schizophrenia. The present study set out to investigate whether deficits in metacognitive accuracy are present in the early stages of psychosis. Methods: Metacognitive accuracy in first-episode psychosis (FEP) was assessed on a perceptual decision making task and their performance compared to matched healthy control participants (N = 18). A novel signal detection theory approach was used to model metacognitive sensitivity independently from objective perceptual performance. A voxel-based morphometry investigation was also conducted on GMV. Results: We found that the FEP group demonstrated significantly worse metacognitive accuracy compared to controls (p = .039). Importantly, GMV deficits were also observed in the superior frontal gyrus. The findings suggest a specific deficit in this processing domain to exist at first episode; however, no relationship was found between GMV and metacognitive accuracy. Conclusions: Our findings support the notion that an inability to accurately scrutinise perception may underpin functional deficits observed in later schizophrenia; however, the exact neural basis of metacognitive deficits in FEP remains elusive

Reflections on the CODES trial for adults with Dissociative Seizures: what we found and considerations for future studies

The COgnitive behavioural therapy versus standardised medical care for adults with Dissociative non-Epileptic Seizures (CODES) multi-centre randomised controlled trial is the largest, fully-powered study to test the clinical and cost effectiveness of a psychotherapeutic intervention in this population. We also explored predictors or moderators of outcomes and investigated mechanisms of change in therapy. In this current review of findings, we discuss issues related to the design of the trial and consider the study’s nested qualitative studies which were done not only to shed light on the original research questions but to provide insights and recommendations for other researchers in the field of functional neurological disorder. Finally, we consider issues relating to the possible clinical application of our study findings

How does cognitive behaviour therapy for dissociative seizures work? A mediation analysis of the CODES Trial

Background We compared dissociative seizure specific cognitive behaviour therapy (DS-CBT) plus standardised medical care (SMC) to SMC alone in a randomised controlled trial. DS-CBT resulted in better outcomes on several secondary trial outcome measures at the 12-month follow-up point. The purpose of this paper is to evaluate putative treatment mechanisms. Methods We carried out a secondary mediation analysis of the CODES trial. 368 participants were recruited from the National Health Service in secondary / tertiary care in England, Scotland and Wales. Sixteen mediation hypotheses corresponding to combinations of important trial outcomes and putative mediators were assessed. Twelve-month trial outcomes considered were final-month seizure frequency, Work and Social Adjustment Scale (WSAS), and the SF-12v2, a quality-of-life measure providing physical (PCS) and mental component summary (MCS) scores. Mediators chosen for analysis at six months (broadly corresponding to completion of DS-CBT) included: a) beliefs about emotions, b) a measure of avoidance behaviour, c) anxiety and d) depression. Results All putative mediator variables except beliefs about emotions were found to be improved by DS-CBT. We found evidence for DS-CBT effect mediation for the outcome variables dissociative seizures, WSAS and SF-12v2 MCS scores by improvements in target variables avoidance behaviour, anxiety and depression. The only variable to mediate the DS-CBT effect on the SF-12v2 PCS score was avoidance behaviour. Conclusions Our findings largely confirmed the logic model underlying the development of CBT for patients with dissociative seizures. Interventions could be additionally developed to specifically address beliefs about emotions to assess whether it improves outcomes. <br/

Six-month outcomes of the CODES randomised controlled trial of cognitive behavioural therapy for dissociative seizures: A secondary analysis

PURPOSE: The CODES Trial for adults with dissociative seizures had a predesignated 12-month post-randomisation follow-up point for outcome evaluation. We undertook an exploratory, unplanned, secondary analysis to evaluate the effectiveness of cognitive behavioural therapy plus standardised medical care (CBT+SMC) compared to SMC alone at 6 months post-randomisation, i.e., closer to the end of treatment. METHODS: The analysis of 6-month data followed our previous method of using multiple imputation and an intention-to-treat approach to analyse variables 12 months post-randomisation. RESULTS: The original trial primary outcome of monthly seizure frequency showed greater benefit from CBT+SMC than SMC-alone at 6 months (at p < 0.05). Of 13 comparable previously-defined secondary outcomes, 12 showed a significant between group effect (p < 0.05) in favour of the CBT intervention at 6 months. The average effect size of the comparable previously-defined primary and secondary continuous outcomes was 0.33 at 6 months vs 0.26 at 12 months. The estimated Incidence Rate Ratio (IRR) quantifying monthly seizure reduction was IRR = 0.72 (95%CI from 0.55 to 0.93) at 6 months compared to IRR = 0.78 at 12 months. CONCLUSION: DS-specific CBT (plus SMC) produced evidence of significant benefits at 6 months post- randomisation (around which time CBT was complete) compared to SMC alone; for the majority of these outcomes, better results following CBT (plus SMC) had previously been reported at 12 months. Our pattern of results suggests that short- and longer-term follow-ups are necessary to understand treatment effects in this disorder. Studies only providing short-term follow-up data should be interpreted with caution