Recurrent Papillary Thyroid Carcinoma to the Cervical Lymph Nodes: Outcomes of Compartment-Oriented Lymph Node Resection.

INTRODUCTION: Recurrence of papillary thyroid carcinoma after initial treatment is challenging. Surgical reintervention is recommended, but cure after surgery in uncertain and surgical morbidity may be high. This study evaluates the effect of compartment-oriented lymph node dissection (LND) on clinical and biochemical cure rate as well as the related complications. PATIENTS AND METHODS: All patients who underwent LND for recurrent papillary thyroid carcinoma between 2000 and 2015 were included. Demography, the extent of the initial surgery, usage of 131I, the pattern of recurrence, diagnosis, details of the surgical reintervention, histological findings, surgical morbidity, and clinical and biochemical outcomes were analyzed. RESULTS: There were 11 (12.7%) males and 75 (87.2%) females with a mean age of 42.8 ± 14.6 years. Seventy-seven patients had undergone total thyroidectomy and in 67 (77.9%) some type of LN resection. In 76 (88.3%), 131I was administered after the initial surgery. We localized suspicious lymph nodes by US in all patients, and metastases were documented before surgery by FNA in 63. Seven (8.13%) patients underwent central LND, 63 (73.2%) lateral LND and 16 (18.6%) both, central and lateral LND. Major complications occurred in 6 patients (6.9%). Sixty-two (72.0%) patients received 131I after surgery. A second surgical re-exploration was performed in 30 (34.8%) patients, and 7 patients required 3 or more additional LND. In a mean follow-up of 59.4 ± 39 months, 51 (59.3%) patients are clinically, radiologically and biochemically free of disease. CONCLUSIONS: In this series, compartment-oriented lymph node resection of recurrent papillary thyroid carcinoma leads to a final clinical and biochemical disease-free status of 59.3% with 6.9% of major complications.

Hypoparathyroidism After Total Thyroidectomy: Importance of the Intraoperative Management of the Parathyroid Glands.

BACKGROUND: Total thyroidectomy is the most common surgical procedure for the treatment of thyroid diseases. Postoperative hypocalcemia/hypoparathyroidism is the most frequent complication after total thyroidectomy. The aim of this study was to evaluate the rate of postoperative hypocalcemia and permanent hypoparathyroidism after total thyroidectomy in order to identify potential risk factors and to evaluate the impact of parathyroid autotransplantation. PATIENTS AND METHODS: We performed a retrospective analysis of 1018 patients who underwent total thyroidectomy at our institution between 2000 and 2016. Medical records were reviewed to analyze patient features, clinical presentation, management and postoperative complications. Descriptive and inferential statistics were employed based on the natural scaling of each included variable. Statistical significance was set at p ≤ 0.05. RESULTS: Mean ± SD age was 46.79 ± 15.9 years; 112 (11.7%) were males and 844 (88.3%) females. A total of 642 (67.2%) patients underwent surgery for malignant disease. The rate of postoperative hypocalcemia, transient, protracted and permanent hypoparathyroidism was 32.8%, 14.43%, 18.4% and 3.9%, respectively. Permanent hypoparathyroidism was significantly associated with the number of parathyroid glands remaining in situ (4 glands: 2.5%, 3 glands: 3.8%, 1-2 glands: 13.3%; p ˂ 0.0001) [OR for 1-2 glands in situ = 5.32, CI 95% 2.61-10.82]. Other risk factors related to permanent hypoparathyroidism were obesity (OR 3.56, CI 95% 1.79-7.07), concomitant level VI lymph node dissection (OR 3.04, CI 95% 1.46-6.37) and incidental parathyroidectomy without autotransplantation (OR 3.6, CI 95% 1.85-7.02). CONCLUSIONS: Identification and in situ preservation of at least three parathyroid glands were associated with a lower rate of postoperative hypocalcemia (30.4%) and permanent postoperative hypoparathyroidism (2.79%).

Correction to: Hypoparathyroidism After Total Thyroidectomy: Importance of the Intraoperative Management of the Parathyroid Glands.

In the original version of the article, the last three column headings in Table 3 were mislabeled. The original article has been corrected. Following is the corrected table.

Absence of an Additional Metabolic Effect of Body Contour Surgery in Patients With Massive Weight Loss After Laparoscopic Roux-En-Y Gastric Bypass.

INTRODUCTION: Body contour surgery (BCS) is a combination of soft tissue resections that have proven to be an effective treatment for the aesthetic and functional problems related to massive weight loss (MWL). There are no studies analyzing the metabolic effect of large volume adipose tissue flap resection in patients with MWL after bariatric surgery. METHODS: This study was a retrospective review of adults who underwent BCS after gastric bypass. Preoperative clinical and laboratory data were compared with 1- and 2-year postoperative follow-up. RESULTS: A total of 62 patients with a mean age of 41 years were analyzed. Seventy-nine percent of them were women. Most procedures included abdominal flap resection alone or in combination with other areas. Mean resected tissue weight was 6.2 kg. We found that weight and body mass index (BMI) were lower 1 year after BCS (P < 0.05), but this was not maintained after 2 years. There were no differences for systolic or diastolic blood pressure, total cholesterol, triglycerides, high-density lipoprotein, low-density lipoprotein, or fasting glucose after 1 and 2 years of the BCS. A subgroup analysis showed that the transient weight and BMI improvement was only apparent 1 year after BCS in those patients with flap resections more than 8 kg. CONCLUSIONS: There are no differences in blood pressure, total cholesterol, triglycerides, high-density lipoprotein, low-density lipoprotein, or fasting glucose 1 and 2 years after BCS in patients who experienced MWL after gastric bypass. Although weight and BMI were transiently lower in those patients with tissue flap resections more than 8 kg, this effect disappeared after 2 years.

Dissociable brain correlates for depression, anxiety, dissociation, and somatization in depersonalization-derealization disorder.

OBJECTIVE: The cerebral mechanisms of traits associated with depersonalization-derealization disorder (DPRD) remain poorly understood. METHOD: Happy and sad emotion expressions were presented to DPRD and non-referred control (NC) subjects in an implicit event-related functional magnetic resonance imaging (fMRI) design, and correlated with self report scales reflecting typical co-morbidities of DPRD: depression, dissociation, anxiety, somatization. RESULTS: Significant differences between the slopes of the two groups were observed for somatization in the right temporal operculum (happy) and ventral striatum, bilaterally (sad). Discriminative regions for symptoms of depression were the right pulvinar (happy) and left amygdala (sad). For dissociation, discriminative regions were the left mesial inferior temporal gyrus (happy) and left supramarginal gyrus (sad). For state anxiety, discriminative regions were the left inferior frontal gyrus (happy) and parahippocampal gyrus (sad). For trait anxiety, discriminative regions were the right caudate head (happy) and left superior temporal gyrus (sad). Discussion The ascertained brain regions are in line with previous findings for the respective traits. The findings suggest separate brain systems for each trait. CONCLUSION: Our results do not justify any bias for a certain nosological category in DPRD.

Symptom profiles in depersonalization and anxiety disorders: an analysis of the Beck Anxiety Inventory.

BACKGROUND: Depersonalization disorder (DPD) entails distressing alterations in self-experiencing. However, it has long been recognized that depersonalisation symptoms occur in other disorders, particularly anxiety and panic. One strand of research proposes that depersonalization phenomenology arises through altered autonomic arousal in response to stress. SAMPLING AND METHODS: We sought to examine profiles of anxiety symptoms through a secondary data analysis of individual items and factor subscales on the Beck Anxiety Inventory (BAI), comparing two relatively large patient samples with DPD or with a variety of anxiety conditions, respectively. The DPD sample (n = 106) had a lower overall BAI score than the combined anxiety disorders group (n = 525). RESULTS: After controlling for this as well as for potential confounders such as age and gender, the DPD group presented significantly lower scores on the panic subscale, marginally lower scores on the autonomic subscale and significantly higher scores on the neurophysiological subscale of the BAI. CONCLUSIONS: These differences imply similarities between the cognitive components of DPD and anxiety disorders while physiological experiences diverge. The findings encourage future research looking at direct physiological measures and longitudinal designs to confirm the mechanisms underlying different clinical manifestations of anxiety.

Rabies virus in white-nosed coatis (Nasua narica) in Mexico: what do we know so far?

Rabies is a neglected disease that affects all mammals. To determine the appropriate sanitary measures, the schedule of preventive medicine campaigns requires the proper identification of the variants of the virus circulating in the outbreaks, the species involved, and the interspecific and intraspecific virus movements. Urban rabies has been eradicated in developed countries and is being eradicated in some developing countries. In Europe and North America, oral vaccination programs for wildlife have been successful, whereas in Latin America, Asia, and Africa, rabies remains a public health problem due to the habitation of a wide variety of wild animal species that can act as rabies virus reservoirs in their environment. After obtaining recognition from the WHO/PAHO as the first country to eliminate human rabies transmitted by dogs, Mexico faces a new challenge: the control of rabies transmitted by wildlife to humans and domestic animals. In recent years, rabies outbreaks in the white-nosed coati (Nasua narica) have been detected, and it is suspected that the species plays a significant role in maintaining the wild cycle of rabies in the southeast of Mexico. In this study, we discussed cases of rabies in white-nosed coatis that were diagnosed at InDRE (in English: Institute of Epidemiological Diagnosis and Reference; in Spanish: Instituto de Diagnostico y Referencia Epidemiologicos) from 1993 to 2022. This study aimed to determine whether white-nosed coatis might be an emergent rabies reservoir in the country. A total of 13 samples were registered in the database from the Rabies laboratories of Estado de Mexico (n = 1), Jalisco (n = 1), Quintana Roo (n = 5), Sonora (n = 1), and Yucatan (n = 5). Samples from 1993 to 2002 from Estado de Mexico, Jalisco, and Sonora were not characterized because we no longer had any samples available. Nine samples were antigenically and genetically characterized. To date, coatis have not been considered important vectors of the rabies virus. The results from our research indicate that the surveillance of the rabies virus in coatis should be relevant to prevent human cases transmitted by this species.

Depersonalization disorder and anxiety: a special relationship?

A significant association between anxiety and depersonalization has been found in healthy controls and psychiatric patients irrespective of underlying conditions. Although patients with depersonalization disorder (DPD) often have a history of severe anxiety symptoms, clinical observations suggest that the relation between anxiety and depersonalization is complex and poorly understood. Using relevant rating scales, levels of anxiety and depersonalization were assessed in 291 consecutive DPD cases. 'High' and 'low' depersonalization groups, were compared according to anxiety severity. Correlation and multivariate regression analyses were also used to assessed the contribution of anxiety to the phenomenology and natural course of depersonalization. A low but significant association between depersonalization and anxiety (as measured by Beck's Anxiety Inventory) was only apparent in those patients with low intensity depersonalization, but not in those with severe depersonalization. Levels of anxiety did not seem to make specific contributions to the clinical features of depersonalization itself, although DPD patients with high anxiety seem characterised by additional non-specific perceptual symptoms. The presence of a 'statistical dissociation' between depersonalization and anxiety adds further evidence in favour of depersonalization disorder being an independent condition and suggests that its association with anxiety has been overemphasized.

Psychophysiological investigations in depersonalization disorder and effects of electrodermal biofeedback.

Previous studies investigating depersonalization disorder (DPD) report a lower baseline skin conductance level (SCL) and attenuated skin conductance response (SCR) to emotive stimuli. We hypothesized that increasing physiological arousal levels via electrodermal biofeedback may ameliorate disembodiment and emotional numbing symptomatology. Real-time versus sham biofeedback yielded a significant SCL increase after just 3 real-time biofeedback sessions in healthy volunteers. Subsequently, a randomized controlled biofeedback trial was administered with DPD patients. Findings were not replicated as SCL tended to fall, curiously more substantially in the real-time condition, concomitant with increased low- and high-frequency heart rate variability. To further investigate abnormal autonomic regulation in DPD, we compared basal autonomic activity between patients and healthy volunteers and found the former to be significantly more labile, indexed by greater nonspecific SCRs and higher resting SCLs. Rather than low sympathetic arousal, DPD might be better characterized by abnormal autonomic regulation affecting emotional and physiological responsivity.

[Primary adrenal malignacies]. / Tumores suprarrenales malignos primarios.

BACKGROUND: Primary adrenal malignancies are rare and have a dismal prognosis. We report our experience in both adrenocortical carcinomas and malignant pheochromocytomas who received medical care at our Institution between 1994 and 2009. MATERIAL AND METHODS: The data bases of hospital discharges, surgery and pathology were reviewed looking for patients with diagnosis of primary adrenal malignant tumors. Clinical presentation, laboratory and image characteristics, surgical details, histopathology findings and outcome were analyzed. RESULTS: A total of eight patients were identified, two men and six women with a mean age of 48.1 +/- 15.7 years (31-80). Six patients presented with adrenocortical carcinomas and two had malignant pheochromocytomas. Of the six cortical tumors four were functioning. Five were stage II, two were stage III and one was stage IV. All patients underwent surgery as initial treatment. Six patients underwent open and two, laparoscopic adrenalectomy. Three patients received adjuvant chemotherapy. In a mean follow up of 32 +/- 27 months, only three patients with stage II were alive and free of the disease. CONCLUSIONS: As in other series, primary adrenal carcinoma in our population proved to be a rare endocrine neoplasm with poor prognosis despite complete surgical resection. Treatment at initial stages provides better outcome.

Rabies Virus Variants Detected from Cougar (Puma concolor) in Mexico 2000-2021.

In 2019, the World Health Organization (WHO) and the Pan-American Health Organization (PAHO) recognized Mexico as a country free of human rabies transmitted by dogs. Nevertheless, the sylvatic cycle remains as a public health concern in the country. Although cougars (Puma concolor) are not reservoirs of any rabies virus variant (RVV), these felines could act as vectors at the top of the food chain, and their relationships with other organisms must be considered important for the regulatory effect on their prey's populations. In this study, genetic and antigenic characterization was performed on all cougar rabies cases diagnosed at the Rabies Laboratory Network of the Ministry of Health (RLNMH) in Mexico from 2000 to 2021. Samples from other species, a skunk, a horse (Equus caballus) (attacked by a cougar), and a gray fox (Urocyon cineroargenteus), were included as reference. Rabies cases in cougars were restricted to two Northern states of Mexico (Sonora and Chihuahua). Five out of six samples of cougars were RVV7 (Arizona gray fox RVV) and one from Sonora was RVV1. Interestingly, there is no evidence of RVV1 in dogs in the Northern states since the 1990s but skunk species now harbor this RVV1 in this region of the country.

Depersonalization: a selective impairment of self-awareness.

Depersonalization is characterised by a profound disruption of self-awareness mainly characterised by feelings of disembodiment and subjective emotional numbing. It has been proposed that depersonalization is caused by a fronto-limbic (particularly anterior insula) suppressive mechanism--presumably mediated via attention--which manifests subjectively as emotional numbing, and disables the process by which perception and cognition normally become emotionally coloured, giving rise to a subjective feeling of 'unreality'. Our functional neuroimaging and psychophysiological studies support the above model and indicate that, compared with normal and clinical controls, DPD patients show increased prefrontal activation as well as reduced activation in insula/limbic-related areas to aversive, arousing emotional stimuli. Although a putative inhibitory mechanism on emotional processing might account for the emotional numbing and characteristic perceptual detachment, it is likely, as suggested by some studies, that parietal mechanisms underpin feelings of disembodiment and lack of agency feelings.

Public Veterinary Medicine: Public Health Rabies virus variants identified in Nuevo Leon State, Mexico, from 2008 to 2015.

OBJECTIVE: To identify rabies virus variants (RVVs) isolated from bats and terrestrial mammals in Nuevo Leon between 2008 and 2015 and Coahuila in 2006. SAMPLE: RVVs isolated from 15 bats and terrestrial mammals in Nuevo Leon and from a cow (Bos taurus) in Coahuila, along with 46 reference rabies virus sequences. PROCEDURES: Antigenic characterization of the 16 isolates was performed with an indirect fluorescent antibody technique. Genomic sequencing of the nucleoprotein gene in the 16 isolates was performed with a reverse transcription PCR assay. Phylogenetic reconstruction of the 62 sequences was performed by means of Bayesian inference. RESULTS: 9 isolates from bats and 1 isolate from a domestic cat that became infected as a result of contact with a Mexican free-tailed bat all clustered in the lineage associated with Lasiurus spp in the Americas or the lineage associated with Tadarida brasiliensis mexicana. An isolate from a domestic dog was identified as a variant associated with the dog-coyote lineage. The RVV isolated from a fox clustered in an Arizona fox lineage. The 3 RVVs from skunks (Mephitis macroura) were placed in a lineage with variants isolated from spotted skunks (Spilogale putorius). The RVV isolated from the cow was clustered in a lineage associated with foxes in Texas and separate from the lineage for the fox from Nuevo Leon. CONCLUSIONS AND CLINICAL RELEVANCE: Results reinforced the need for Mexico to implement rabies surveillance and monitoring programs for bats and wild-living terrestrial carnivores.

Pancreatic insulinoma: a surgical experience.

BACKGROUND: Small size, high benignity rate, and sporadic nature make insulinomas suitable for laparoscopic resection. On the other hand, occult location or multicentricity mandate open surgery. This study was designed to analyze a series of patients who had pancreatic insulinomas and underwent initial treatment at our institution. METHODS: Clinical records of the 34 patients with pancreatic insulinomas who underwent surgical resection between 1995 and 2007 were reviewed. Main variables for analysis were cure of the disease and surgical complications. RESULTS: There were 20 women and 14 men with a mean age of 40 +/- 13 years. Mean size of the tumors was 2.2 +/- 1 cm. Laparoscopic resection was completed in 14 of 21 patients. Most tumors that were resected by laparoscopy were solitary, benign, and located in the body and tail of the pancreas. Open surgery was selected for 13 patients, including 7 sporadic (5 in the head), 4 related to the MEN syndrome, and 2 malignant tumors. Surgical morbidity occurred in 23 patients. The most common complication was pancreatic fistula (3/13 in open, 4/14 in laparoscopic, and 6/7 in conversions). One patient in the open group died 15 days after surgery from massive PTE. Postoperative normoglycemia was achieved in all patients and persisted for a follow-up period of 4 +/- 3.7 years. CONCLUSIONS: Most insulinomas in our series were small and benign. Tumors that were located in the body and tail were more often amenable for laparoscopic resection. The cure rate was very high. Pancreatic fistula was the most frequent complication.

Development of an Interactive Outcome Estimation Tool for Laparoscopic Roux-en-Y Gastric Bypass in Mexico Based on a Cohort of 1002 Patients.

BACKGROUND: Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is one of the most commonly performed bariatric procedures. Considering significant differences between populations around the world, surgical outcomes may vary widely. The aim of the study was to develop an educational patient-specific interactive application that may estimate the potential outcomes of LRYGB in the Mexican population. METHODS: A database with 76 different variables from 1002 patients who underwent LRYGB at two Mexican Institutions between 1992 and 2014 and had a minimum of 6-month follow-up was analyzed. Descriptive and inferential statistics, as well as a multivariate regression analysis, were performed for the primary analysis. Results were based on four statistical models obtained from the cohort outcomes. A tool was designed to provide estimates of absolute weight loss (AWL) and resolution of four major comorbidities: type 2 diabetes (T2D), high blood pressure (HBP), hypercholesterolemia, and the obstructive syndrome of sleep apnea (OSAS). RESULTS: There were 353 males (35.2%) and 649 females (64.8%) with a mean age of 41.9 ± 12.1 years and a mean preoperative BMI of 45.3 ± 7.9 kg/m2. Mean AWL at 2 years was 39.02 ± 12.7 kg. Mean accumulative percentage of resolution for T2D, HBP, and dyslipidemias at the same time period was 78%, 66.2%, and 84.7%, respectively. Based on these results, the educational tool was developed. CONCLUSIONS: We were able to develop an interactive estimation application to provide a population-based guidance for potential outcomes of LRYGB. This might be useful not only for health professionals but also for patients interested in learning potential outcomes in specific circumstances.

Laparoscopic Roux-en-Y gastric bypass as a revision procedure after restrictive bariatric surgery.

BACKGROUND: Adjustable gastric banding (AGB) and vertical banded gastroplasty (VBG) have been extensively used to treat morbid obesity. Patients with insufficient weight loss or complications may require surgical revision. The laparoscopic Roux-en-Y gastric bypass (LRYGBP) is one of the most common procedures currently used for revision. The aim of the study was to analyze surgical outcomes of 30 consecutive patients who underwent revision to LRYGBP in a 2-year period. METHODS: The prospectively constructed database and the medical records of all patients undergoing revision to LRYGBP were reviewed. Demographics, surgical details, results, and complications were analyzed. RESULTS: There were 23 women and seven men with a mean age of 41.1+/-9.7 years (r=25-61). Mean body mass index (BMI) was 40.0+/-7.5 kg/m(2) (r=27.2-65.2). Initial operation was AGB in 24, VBG in five, and both in one patient. In ten patients, the band had been removed before revision, in 13 cases, band removal and LRYGBP were performed in one surgical intervention, and in two patients, it was performed in a two-step surgery. There were two conversions to open surgery. Five patients presented major surgical complications. Hospital stay averaged 5.1 days (r=3-25). Mean percent excess body weight loss at 6 and 12 months was 61.7+/-27.5 and 81.2+/-20.5 kg/m(2), respectively. Mean percent low body mass index at 6 and 12 months was 22.5+/-9.1 and 29.1+/-11.4 kg/m(2), respectively. CONCLUSIONS: LRYGBP as a revision procedure is feasible in most patients. Surgical complications are more frequent.

Differences in Body Composition in Patients with Obesity 1 Year After Roux-En-Y Gastric Bypass: Successful Vs. Unsuccessful Weight Loss.

AIM: The aim of this study is to compare the differences in body composition in patients with obesity with successful weight loss (SWL) and unsuccessful (USWL) 1 year after Roux-en-Y gastric bypass (RYGB). METHODS: We included 36 women and 22 men. After stratifying patients according with SWL (defined as ≥ 50% of excess weight loss), fat-free mass (FFM) and fat mass (FM) trajectories were analyzed in each group. RESULTS: The %FM in SWL women (78%) was lower than USWL (36 vs. 44, p < 0.001). The %FM in SWL men (77%) was lower than USWL (27 vs. 38, p < 0.05). A lower %FM before surgery increased the probability of success (p < 0.05). CONCLUSIONS: SWL patients have a lower %FM, and those with lower pre-surgical %FM are more likely to have SWL 1 year after RYGB.

Safety assessment of the use of ultrasonic energy in the proximity of the recurrent laryngeal nerve in a porcine model.

BACKGROUND: Advanced bipolar and ultrasonic energy have demonstrated reduction of operating time and blood loss in thyroidectomy. However, these devices generate heat and thermal dispersion that may damage adjacent structures such as the recurrent laryngeal nerve (RLN). This study was designed to evaluate the safety profile of the Harmonic Focus+® (HF+) device through the evaluation of thermal injury to the RLN using different algorithms of distance and time with state of the art technology. METHODS: 25 Vietnamese pigs underwent activation of HF+ in the proximity of their RLN. They were divided into 4 groups according to activation distance (3 mm, 2 mm, 1 mm and on the RLN). Time of activation, time between tones of the ultrasonic generator, changes in the electromyographic signal using continuous nerve neuromonitoring, vocal fold mobility assessed by direct laryngoscopy and histological thermal damaged were evaluated. RESULTS: None of the pigs had loss of signal in the electromyography during the procedure; only one pig had isolated transient decrease in amplitude and one increase in latency. One pig had transient vocal fold paresis in the group with activation on the nerve. Evaluation of the nerves by histology and immunohistochemistry did not show significant changes attributed to thermal injury. CONCLUSIONS: The use of ultrasonic energy close to the RLN is safe, provided that activation time does not exceed the necessary time to safely transect the tissue.

Genome Sequence of a Rabies Virus Isolated from a Dog in Chiapas, Mexico, 2013.

Rabies virus (RABV), a member of the genus Lyssavirus, causes encephalitis that is almost always fatal following the onset of clinical signs. Here, we report the complete codifying sequence of an RABV isolated from a dog in Mexico. Molecular data showed that this strain belongs to the Chiapas lineage.

Limbic and prefrontal responses to facial emotion expressions in depersonalization.

Depersonalization disorder, characterized by emotional detachment, has been associated with increased prefrontal cortical and decreased autonomic activity to emotional stimuli. Event-related fMRI with simultaneous measurements of skin conductance levels occurred in nine depersonalization disorder patients and 12 normal controls to neutral, mild and intense happy and sad facial expressions. Patients, but not controls, showed decreases in subcortical limbic activity to increasingly intense happy and sad facial expressions, respectively. For both happy and sad expressions, negative correlations between skin conductance measures in bilateral dorsal prefrontal cortices occurred only in depersonalization disorder patients. Abnormal decreases in limbic activity to increasingly intense emotional expressions, and increases in dorsal prefrontal cortical activity to emotionally arousing stimuli may underlie the emotional detachment of depersonalization disorder.