JOURNAL READING

Brain Functional Integration:

An Epidemiologic Study On Stress-producing
Dissociative Phenomena

March 22th, 2018

ABSTRACT
Personality disorder+prolonged stress Dissociative
phenomena  worsening prognosis mental disorder., ex: ↑
suicidal ideation.
Methods: 933 psychiatric outpatients  screening
DES (dissociative), SCL-90-R(psikopatologis)
Result: All psychopathologic traits detected with the symptom
checklist-90-revised had a significant correlation with the total
score on the DES
Conclusion: This study, confirming Janet’s theory, explains that,
mental disorders and psychopathologic experiences of patients
can configure the chronic stress condition that produces
functional damage to the adaptive executive system
BACKGROUND
DSM-5 + ICD-10 provide an unsatisfactory description for
dissociative disorders (DDs).
DSM-5 somatoform disorders and symptoms related to stress
and trauma
ICD-10 codes DD within conversion disorders
The aims of this study were the following:
1. evaluating the presence and extent of dissociative
symptoms experienced by participants (psychiatric
outpatients and control healthy subjects);
2. analyzing the relevance of these phenomena in the context
of different mental disorders and personality disorders
3. proposing an explanatory model for the development of
dissociative symptoms in subjects suffering from other
mental disorders.
PATIENTS AND METHODS
Population
We included 933 (413 males and 520 females) psychiatric
outpatients (mean age 34.7±11.48 years) consecutively recruited
from a private practice office.

Psychiatric Evaluation
We evaluated:
The presence of mental disorders using the mini international
neuropsychiatric interview (MINI) interview ver 5.0;
The presence of personality disorders using the structured clinical
interview for DSM-II (SCID-II) interview;
Psychopathologic characteristics and clinical severity using the
symptom checklist-90-revised (SCL-90-R) test and
The presence of dissociative phenomena with the DES.
We excluded:
Trauma/dissociative subtype of PTSD
Acute psychotic
Manic episode
A severe depressive episode
A stress-related disorder
A DD
Somatic symptom disorder.
Clinical Test Evaluation
The DES is a self-report instrument for rapid
compilation and processing that assesses the
presence, quantity and type of dissociative
experiences without considering specific diagnosis. It
is composed of 28 items arranged on an analog
scale. The cut-off value indicating the presence of
pathologic dissociation regards scores $20: scores
.20 are associated, in general, to a DD diagnosis.
SCL-90
The SCL-90 is a self-
administered scale for the
evaluation of psychiatric
symptomatology. It consists of
90 items representing nine
usually frequent clinical
dimensions in outpatients
MINI is a semi-structured diagnostic
assessment scale to identify the
DES pathologic psychiatric symptoms
according to ICD-10 and DSM-IV. The
interview modules include 14 Axis I
disorders, 1 Axis II disorder
MINI
The SCID-II is used to diagnose the personality disorders, both
in categorical terms (present or absent criteria) and
SCIID-II quantitative terms. The SCID II consists of 119 items, with
dichotomous answers (Yes/No). A score of “3” on an item of
the SCID-II, provided by the clinician, indicates that there is
sufficient evidence that the feature described by the item is
“pathologic”, “persistent” and “widespread”.
Collection and Analysis of Data
We evaluated the descriptive statistics of the data:
The distribution of dissociative symptoms seen with DES in
the sample
The frequency and type of diagnosed mental disorders
The frequency and type of personality disorders diagnosed
and sociodemographic characteristics of the subjects.
Statistical methods

ANOVA

T-Test

Spearman

ANOVA
Regresi Logistik
RESULT
Total sample  933 subjects

118 713
no mental Mental
disorder disorder
296
Personality
disorder

the most frequent

personality disorder
 did not show any correlation

So, young age seems to be associated with more severe dissociative symptoms
except for amnesic symptoms.
All scores significantly higher amongunmarried or celibate participants
10% 50% 100% 90%
Dissociative symptoms were significantly
more severe in the first group than the second group
This psychopathologic traits
detected with SCL-90-R  if
signifficant  total score on DES
scale correlated with Spearmen,
and results are : • Maximum

• Minimum
Significantly on :
Subjects affected by major depressive disorder or hypomanic disorder,
patients under pharmacologic treatment, patients affected by generalized
anxiety disorder or psychotic disorders presented average total DES
scores higher than controls (p <0.001)
DISCUSSION
- Symptoms of DD are suggested as generated by the psychic
mechanism of “separation”
- Amnestic symptoms  generated by the
compartmentalization of painful memory contents, are
unanimously considered typical pathologic manifestations
related to trauma more serious than other dissociative
events.
- Absorption and depersonalization symptoms are linked to the
semi-physiologic nature of the detachment mechanism itself
The positive result of the univariate ANOVA for these two personality disorders (but not
for the other personality disorders) suggests the existence of a specific link between these
disorders of personality and DDs.

BORDERLINE PERSONALITY NARCISSIST

DISORDER PERSONALITY DISORDER

- Individuals affected by borderline personality - the narcissist hypervigilant try to maintain their
disorder, reports of traumatic events or of long self-esteem by preventing situations of
periods of overwhelming stress are common. vulnerability
- experiences difficulties in integrating positive
and negative views of self and others by creating
a division between segregated positive and
negative feelings.
- According to psychodynamic vision, the obsessiveness is based on the “separation of
affections” defense mechanism, which can be considered as an emotional
desensitization mechanism.
- Patients defend themselves from these feelings through reactive formation and isolation
of affection, as they find rage and addiction as consciously inacceptable concepts
- Psychotic disorders are considered as:
 a disorder of the self,
 deficit in awareness of somatosensory experiences,
 these processes may involve the same frontal neural network able to disconnect
experiences, feeling and consciousness in dissociative phenomena

Finally, anxiety disorders and affective disorders may be

linked to DDs through nonspecific stressful effects
- According to Janet, an adaptive executive system ensures
mental efficiency if it is developed properly over time
- The functional integrity of the adaptive processes would be
maintained by two mechanisms:
1. Compartmentalizing painful experience
 Result in amnesia only if the dissociated contents of
consciousness are not excessively broad
2. Reducing somatic–emotional sensitivity
 Result in depersonalization/derealization only if
intense to interrupt the continuity of conscious
experiences
CONCLUSION
CONCLUSION
ACKNOWLEDGE AUTHOR
CONTRIBUTIONS DISCLOSURE
MENTS

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functional firstdegree all aspects of the
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adaptive
executive system.
STROBE CHECKLIST
1 (a) Indicate the study’s design with a commonly used term in the title or the
abstract  NO

(b) Provide in the abstract an informative and balanced summary of what

was done and what was found  YES
2. Explain the scientific background and rationale for the
investigation being reported  YES
3. State specific objectives, including any prespecified hypotheses  YES

4. Present key elements of study design early in the paper  NO

5. Describe the setting, locations, and relevant dates, including periods of

recruitment, exposure, follow-up, and data collection  NO
6 (a) Give the eligibility criteria, and the source and methods of
selection of participants. Describe methods to follow up  YES

(b) For the matched studies, give matching criteria and number of
exposed and exposed  NO
7. Clearly define all outcomes, exposures, predictors, potential confounders,
and effect modifiers. Give diagnostic criteria, if applicable  YES

8. For each variable of interest, give sources of data and details of methods of
assessment (measurement). Describe comparability of assessment
methods if there is more than one group  YES
9. Describe any efforts to address potential sources of bias  NO
10. Explain how the study size was arrived at  NO
11. Explain how quantitative variables were handled in the analyses. If
applicable, describe which groupings were chosen and why  NO
12 (a) Describe all statistical methods, including those used to control for
confounding  YES
(b) Describe any methods used to examine subgroups and interactions  YES

(c) Explain how missing data were addressed  NO

(d) If applicable, explain how loss to follow-up was addressed  NO
(e) Describe any sensitivity analyses  NO
13 (a) Report numbers of individuals at each stage of study—eg numbers
potentially eligible, examined for eligibility, confirmed eligible, included in
the study, completing follow-up, and analysed  YES
ON TABLE 1.

(b) Give reasons for non-participation at each stage  NO

(c) Consider use of a flow diagram  NO

14 (a) Give characteristics of study participants (eg demographic, clinical,
social) and information on exposures and potential confounders  YES
ON TABLE 1 & 2
(b) Indicate number of participants with missing data for each variable of
interest  NO
(c) Cohort study—Summarise follow-up time (eg, average and total
amount)  NO

15. Report numbers of outcome events or summary measures over time 

YES
ON TABLE 7 & 8
16. (a) Give unadjusted estimates and, if applicable, confounder-adjusted
estimates and their precision (eg, 95% confidence interval). Make clear
which confounders were adjusted for and why they were included  NO
(b) Report category boundaries when continuous variables were
categorized  NO
(c) If relevant, consider translating estimates of relative risk into absolute
risk for a meaningful time period  NO

17. Report other analyses done—eg analyses of subgroups and interactions,

and sensitivity analyses  YES
ON TABLE 8.
18. Summarise key results with reference to study objectives  YES
19. Discuss limitations of the study, taking into account sources of potential
bias or imprecision. Discuss both direction and magnitude of any potential
bias  NO

20. Give a cautious overall interpretation of results considering objectives,

limitations, multiplicity of analyses, results from similar studies, and other
relevant evidence  NO

21. Discuss the generalisability (external validity) of the study results  NO

22. Give the source of funding and the role of the funders for the present
study and, if applicable, for the original study on which the present article
is based  NO
THANK
YOU