Exacerbation of central serous chorioretinopathy during trauma-confronting psychotherapy- a case report.

BACKGROUND: Psychotherapy for post-traumatic stress disorder, in particular trauma-confronting psychotherapy, can be associated with increased stress. However, research on the somatic impact and psychosomatic interactions of these psychological stress reactions is lacking. We report on a 43-year old man whose central serous chorioretinopathy exacerbated upon trauma-confronting psychotherapy. CASE PRESENTATION: We report on a man with pre-diagnosed, asymptomatic central serous chorioretinopathy who underwent inpatient psychosomatic therapy. He disclosed a history of sexual abuse by a family member and consequently showed intrusions, flashbacks, nightmares, avoidance behavior, and hyperarousal. Thus, we diagnosed post-traumatic stress disorder. After a stabilization phase, he underwent trauma-focused psychotherapy including trauma confrontation. In the course of this treatment, acute vision loss with blurred vision and image distortion of his right eye occurred. An ophthalmologic visit confirmed a relapse of a pre-diagnosed central serous chorioretinopathy. The analysis of stress biomarkers showed a decrease in testosterone levels and a noon peak in diurnal cortisol secretion, which is indicative of a stress reaction. CONCLUSION: Central serous chorioretinopathy may exacerbate upon psychotherapeutic treatment. In this case, an exacerbation of chorioretinopathy was observed in direct relation to the therapeutic intervention. Psychotherapists and ophthalmologists should collaborate in the psychotherapeutic treatment of patients with chorioretinopathy. Our case demonstrates the need to consider the possible increased stress levels during psychotherapy and resulting physical side effects, such as exacerbation of an existing condition. It is advisable to adjust the level of generated stress particularly well in the presence of stress-inducible physical diseases. Our case is a good example of the interplay between psychological and physical stress.

Paradoxical effect of anti-inflammatory drugs on IL-6 mRNA expression in patients with PTSD during treatment.

The pathophysiology of posttraumatic stress disorder (PTSD) is associated with the activation of the innate immune system, including cytokines like interleukin 6 (IL-6). However, the role of IL-6 in the etiology and treatment of PTSD still remains elusive. We conducted a prospective controlled trial to investigate the development of IL-6 during psychosomatic treatment in individuals with PTSD in comparison with individuals without PTSD. We assessed IL-6 mRNA expression before and after 2 months of psychosomatic treatment in individuals with and without PTSD. Severities of PTSD and depressive symptoms were assessed in parallel. Linear mixed regression was applied for statistical analysis, including the factors diagnosis PTSD and pre-post treatment after subgrouping for intake of anti-inflammatory drugs. The development of IL-6 mRNA expression during treatment was affected by the use of anti-inflammatory drugs. In the subgroup without intake of anti-inflammatory drugs, no significant statistical treatment effect in individuals with and without PTSD emerged. In the subgroup of individuals taking anti-inflammatory drugs, a significant interaction effect of the factors pre-post treatment and diagnosis PTSD was observed. Whereas IL-6 mRNA expression in individuals without PTSD decreased according to amelioration of symptoms, IL-6 mRNA expression in individuals with PTSD increased significantly during treatment, in opposite direction to symptom severity. Anti-inflammatory drugs might affect IL-6 mRNA expression in individuals with PTSD in a paradoxical way. This study offers a further piece of evidence that IL-6 could be involved in the pathophysiology of PTSD and PTSD-specific immunologic molecular mechanisms.

Autopilot functionality and self-destructive behavior in patients with complex dissociative disorders-A qualitative study.

OBJECTIVE: Dissociative disorders are common in psychiatric patients and severely impact patients' lives. They are, however, underdiagnosed, thus preventing patients from accessing timely and adequate therapy. Identifying how patients with dissociative disorders relate to themselves could improve diagnostics. However, this question has not been explored in detail. The aim of the study was to gain insights into how people with complex dissociative disorders relate to themselves. METHOD: We conducted semistructured qualitative interviews with ten women diagnosed with complex dissociative disorders who had previously completed trauma-focused therapy. Data were analyzed through reflexive thematic analysis. RESULTS: Participants described their behavior toward themselves before the start of the therapy as "autopilot-functional" and "self-destructive." The "autopilot functionality" was characterized by being outward-oriented and ignoring one's own needs. Hence, participants only appeared to be functional. "Self-destructive behavior" was described as a spectrum of various destructive behaviors (e.g., eating disorders, self-harm, excessive exercise, and substance abuse) that participants perceived as a cohesive complex. The participants illustrated that both behaviors were driven by a lack of self-empathy and connected to suppression and poor perception of bodily stimuli. CONCLUSIONS: "Autopilot functionality" seems to be a hallmark in patients with complex dissociative disorders. With patients hiding their self-destructive behavior, health personnel may misjudge the severity of these patients' mental illness. Neither "autopilot functionality" nor "self-destructive behavior" should be judged (neither negatively nor positively), but one should understand both as a coping mechanism for trauma-related disorders. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Long-term follow-up of a multimodal day clinic, group-based treatment program for patients with very high risk for complex posttraumatic stress disorder, and for patients with non-complex trauma-related disorders.

Objective: The present study examined the follow-up of a multimodal day clinic group-based therapy program for patients with trauma-related disorders and investigated potential differences for patients with classic PTSD versus cPTSD. Method: Sixty-six patients were contacted 6 and 12 months after discharge of our 8-week program and completed various questionnaires (Essen Trauma Inventory (ETI), Beck Depression Inventory-Revised (BDI-II), Screening scale of complex PTSD (SkPTBS), Patient Health Questionnaire (PHQ)-Somatization, as well as single items to therapy utilization and life events in the interim period). Due to organizational reasons a control group could not be included. Statistical analyses included repeated-measures ANOVA with cPTSD as between-subject factor. Results: The reduction of depressive symptoms at discharge was persistent at 6 and 12 months follow-up. Somatization symptoms were increased at discharge, but were leveled out at 6 months follow-up. The same effect was found for cPTSD symptoms in those patients with non-complex trauma-related disorders: Their increase of cPTSD symptoms was flattened at 6 months follow-up. Patients with a very high risk for cPTSD showed a strong linear reduction of cPTSD symptoms from admission to discharge and 6 months follow-up. cPTSD patients had a higher symptom load compared to patients without cPTSD on all time points and scales. Conclusion: Multimodal, day clinic trauma-focused treatment is associated with positive changes even after 6 and 12 months. Positive therapy outcomes (reduced depression, reduced cPTSD symptoms for patients with a very high risk for cPTSD) could be maintained. However, PTSD symptomatology was not significantly reduced. Increases in somatoform symptoms were leveled out and can therefore be regarded as side effects of treatment, which may be connected with actualization of trauma in the intensive psychotherapeutic treatment. Further analyses should be applied in larger samples and a control group.

Altered frontal electroencephalography as a potential correlate of acute dissociation in dissociative disorders: novel findings from a mirror confrontation study.

People suffering from chronic dissociation often experience stress and detachment during self-perception. We tested 18 people with dissociative disorders not otherwise specified (DDNOS; compared with a matched sample of 18 healthy controls) undergoing a stress-inducing facial mirror confrontation paradigm, and measured acute dissociation and frontal electroencephalography (measured with a four-channel system) per experimental condition (e.g. confrontation with negative cognition). Linear mixed models indicated a significant group×time×condition effect, with DDNOS group depicting less electroencephalography power than healthy controls at the beginning of mirror confrontation combined with negative and positive cognition. This discrepancy - most prominent in the negative condition - diminished in the second minute. Correlational analyses depicted a positive association between initial electroencephalography power and acute dissociation in the DDNOS group. These preliminary findings may indicate altered neural processing in DDNOS, but require further investigation with more precise electroencephalography measures.

Disconnected - Impaired Interoceptive Accuracy and Its Association With Self-Perception and Cardiac Vagal Tone in Patients With Dissociative Disorder.

Patients suffering from dissociative disorders are characterized by an avoidance of aversive stimuli. This includes the avoidance of emotions and, in particular, bodily perceptions. In the present pilot study, we explored the potential interoceptive accuracy deficit of patients suffering from dissociative disorders in a heartbeat detection task. Moreover, we investigated the impact of facial mirror-confrontation on interoceptive accuracy and the potential association between cardiac vagal tone derived from heart rate variability and interoceptive accuracy. Eighteen patients suffering from dissociative disorders and 18 healthy controls were assessed with the Mental Tracking Paradigm by Schandry for heartbeat detection at baseline and after confrontations exposing them to their own faces in a mirror (2 min each, accompanied by a negative or positive cognition). During the experiment, cardiac vagal tone was assessed. We used Pearson correlations to calculate potential associations between cardiac vagal tone and interoceptive accuracy. Patients performed significantly worse than the healthy controls in the heartbeat detection task at baseline. They displayed no significant increase in interoceptive accuracy following facial mirror-confrontation. In the patient group, higher cardiac vagal tone was associated with a more precise heartbeat detection performance. Dissociative disorder patients showed a considerable deficit in interoceptive accuracy. Our results fit with the assumption that highly dissociative patients tend to tune out the perceiving of bodily signals. To the extent that bodily signal perception may play a causal role in these disorders, therapeutic approaches enhancing interoceptive accuracy and cardiac vagal tone may be considered important and practicable steps to improve the therapy outcome of this patient group.

The enemy in the mirror: self-perception-induced stress results in dissociation of psychological and physiological responses in patients with dissociative disorder.

Background: Patients suffering from dissociative disorders (DD) are characterized by an avoidance of aversive stimuli. Clinical experience has shown that DD patients typically avoid the confrontation with their own faces in a mirror (CFM). Objective: To investigate potential CFM-associated self-reported and psychophysiological stress reactions of DD patients, which most likely inform on the still unknown pathophysiology of dysfunctional self-perception in DD. Method: Eighteen DD patients and 18 healthy controls (HCs) underwent CFM. They were assessed for CFM-induced subjective self-reported stress, acute dissociative symptoms and sympathetic and parasympathetic drive using impedance cardiography. Results: DD patients experienced more subjective stress and acute dissociation than HCs upon CFM. Their psychological stress response did not activate the sympathetic and parasympathetic nervous system. Conclusions: In DD patients, CFM constitutes serious self-reported stress and is associated with a blunted autonomic reactivity. Therapeutic approaches promoting self-perception and self-compassion, in particular by using CFM, might serve as goal-oriented diagnostic and therapeutic tools in DD.

Antecedentes: Los pacientes que sufren trastornos disociativos (DD en su sigla en inglés) se caracterizan por evitar los estímulos aversivos. La experiencia clínica ha mostrado que los pacientes con DD típicamente evitan la confrontación con sus propias caras en un espejo (CFM en su sigla en inglés). Objetivo: Investigar las potenciales reacciones de estrés psicofisiológicas y autoinformadas asociadas a CFM de pacientes con DD, las que muy probablemente informan sobre la fisiopatología todavía desconocida de la autopercepción disfuncional en los DD. Método: Dieciocho pacientes con DD y 18 controles sanos (HCs en sus siglas en inglés) se sometieron a CFM. Fueron evaluados en cuanto al estrés subjetivo auto-informado inducido por CFM, síntomas disociativos agudos e impulso simpático y parasimpático, usando cardiografía de impedancia. Resultados: Los pacientes con DD experimentaron más estrés subjetivo y disociación aguda que los HCs en CFM. Su respuesta de estrés psicológico no activó el sistema nervioso simpático y parasimpático. Conclusiones: En pacientes con DD, el CFM constituye un estrés grave auto-informado y se asocia con una reactividad autonómica limitada. Los enfoques terapéuticos que promueven la autopercepción y la autocompasión, en particular mediante el uso de CFM, podrían servir como herramientas diagnósticas y terapéuticas orientadas a objetivos en los DD.

Expanding the mutational spectrum in Johanson-Blizzard syndrome: identification of whole exon deletions and duplications in the UBR1 gene by multiplex ligation-dependent probe amplification analysis.

BACKGROUND: Johanson-Blizzard syndrome (JBS, MIM #243800) is a very rare autosomal recessive disorder characterized by exocrine pancreatic insufficiency, nasal wing hypoplasia, hypodontia, and other abnormalities. JBS is caused by mutations of the UBR1 gene (MIM *605981), encoding a ubiquitin ligase of the N-end rule pathway. METHODS: Molecular findings in a total of 65 unrelated patients with a clinical diagnosis of JBS who were previously screened for UBR1 mutations by Sanger sequencing were reviewed and cases lacking a disease-causing UBR1 mutation on either one or both alleles were included in this study. In order to discover mutations that are not detectable by Sanger sequencing, we designed a probe set for multiplex ligation-dependent probe amplification (MLPA) analysis of the UBR1 gene and analyzed the copy number status of all 47 UBR1 exons. RESULTS: Our previous studies using Sanger sequencing could detect mutations in 93.1% of 130 disease-associated UBR1 alleles. Six patients with a highly suggestive clinical diagnosis of JBS and unsolved genotype were included in this study. MLPA analysis detected six alleles harboring exon deletions/duplications, thereby raising the mutation detection rate in the entire cohort to 97.7% (127/130 alleles). CONCLUSION: We conclude that single or multi-exon deletions or duplications account for a substantial proportion of JBS-associated UBR1 mutations.

[Extensive interactions between eating and weight disorder, major depression, pain, and sarcoidosis - case 5/2012]. / Komplexe Wechselwirkung von Ess- und Gewichtsstörung, Depression, Schmerzstörung und Sarkoidose - Fall 5/2012.

HISTORY AND ADMISSION FINDINGS: We report on a 41-year-old female patient suffering from obesity, binge eating more than twice a week with loss of control, eating rapidly and feeling guilty after eating, dyspnoea and chronic pain in the whole body, especially in her arms, legs and in both ankles. Furthermore, subdued mood, loss of interest and pleasure, fatigue and impaired concentration could be recognized. In the past, weight increase had been observed when corticosteroids were given against exacerbations of sarcoidosis. INVESTIGATIONS: In the case of our patient, the beginning of sarcoidosis and increase of weight and pain correlated with augmentation of depression and psychosocial stress. Dysfunctional behavioral features and multiple interactions between diseases could be observed. DIAGNOSIS, TREATMENT AND COURSE: We diagnosed obesity, binge eating disorder, major depression, chronic pain disease with somatic and psychical components and sarcoidosis. The patient was treated in a multimodal therapy program including psychotherapy, pharmacotherapy and psychopharmacotherapy, nutritionist advice and therapeutic exercise. A weight loss of 7.9 kg (5.9 %), well-balanced diet, reduction of binge eating and of pain intensity, mood stabilization as well as perception and expression of emotions and coping strategies in chronic diseases were achieved. CONCLUSION: Interdisciplinary treatment of patients suffering from psychosomatic, somatic and mental diseases is crucial for a good outcome.