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Ross Hauser, MD.

Many of the patients who we see in our neck center have conditions of anxiety, depression, and dissociation. They may also have been diagnosed with personality disorders. These challenges can be termed psychiatric-like because, in some people, these problems are a manifest of cervical spine and craniocervical instability and are symptoms of nerve, vein, and arterial compression caused by the unstable bones of the neck pressing and compressing these vital structures. Here is a story from someone reaching out for more information. It has been edited for clarity.

I feel like my neck is tired all the time, like it needs some type of support to hold my head up. When I turn my neck to the side I feel a dull pain and I cannot hold my head in this position for more than five seconds. Sometimes I feel like blood is rushing to my head and there is a throbbing feeling. I feel weakness in my arms and legs, sometimes numbness in my arms. The brain fog is always there. My blood pressure is very high and very low sometimes. Anxiety and dissociation have become almost constant, am struggling to write this because my concentration is off. When I face upwards the pain in my neck eases a bit, most times I feel a throbbing at the base of my skull. I have suffered from chronic neck pain that comes from poor posture.  I ignored the pain for so long because mostly pain killers took it away for days but I have now avoided the poor posture but my neck still hurts, now pain killers are not working anymore and the brain fog, anxiety and fatigue are too much.

We see many people at our center who suffer from a vast myriad of symptoms related to neurologic-type and vascular-type symptoms and conditions. These health challenges can be traced to their problems with their neck, cervical spine, and craniocervical instability. For a comprehensive review of these symptoms please refer to my article Symptoms and conditions of Craniocervical Instability. In this article and videos, I will focus on the problems of personality disorder, dissociation, anxiety, and depression.

Article Summary:

Part 1: Personality changes and emotional health problems often seen in patients with cervical spine instability 

• Negative changes in personality and psychological status could be due to ligamentous cervical instability or cervical dysstructure.
• Symptomology of disassociation discussed by Ross Hauser, M.D.
• Another patient story example: ” disconnected from the family and everything I love. . .”

Part 2: Part 2: Cervical spine and craniocervical instability patients can be seen as having psychiatric-like, or neurologic-like, or vascular-like conditions

• Whiplash and Dissociation – attachment avoidance (avoiding need of relationship or family support) and attachment anxiety (the fear of not having a relationship or family support).
• Type D Personality.
• Psychiatric Depersonalization/Derealization and a connection to the inner ear.
• Arterial and venous obstruction of fluid into and out of the brain: One explanation for the problems of emotional detachment, anxiety, depression, memory, cognitive function, and brain fog described by some patients with cervical spine instability.

Part 3: Treating the physical aspect of pain in dissociation 

• Research on cervical instability. A mechanical approach to Dissociation, Anxiety, and Depression.

Part 1: Personality changes and emotional health problems often seen in patients with cervical spine instability

Ross Hauser, MD discusses emotional symptoms and personality changes that may have a structural link to the neck in some cases.

Video summary and highlights:

This video is on one of the most important topics we see in patients. How ligamentous cervical instability, that is how weak and damaged neck ligaments are not able to support and hold the neck and head in place, allowing the neck bones to compress on the neurologic (nerve) processes that run trough the neck and cervical spine. This affects a person’s emotion stability and personality. Many patients have shared with us how psychological diagnosis such as bipolar disorders or personality disorders have been radically changed for the better once their neck and cervical spine instability or “dysstructure” a broken down neck structure, has been treated and natural structure, curvature, and stability has been restored.

Anyone who’s had a change in emotional status or change in personality, that in some cases seems to have happened overnight, has to wonder why did this happen? What can happen is that a person’s brain pressure can reach certain levels where certain parts of the brain will no longer function correctly or the brain’s nerve impulses and messages are not reaching other parts of the body, or when those messages do arrive, they are jumbled and distorted and nothing makes sense. They will have a sudden change in emotional stability, for instance they could have new onset of anxiety. If know somebody whose personality is absolutely changed, almost overnight,  more irritability or lack of interest in things, they don’t care about the future, all of a sudden they’re very depressed or all of a sudden they have bipolar disorder, you have to think, this is night right? What is going on? It could be cervical spine instability.

This is the background slide in the introduction of the video. A brief summary is given below.

Negative changes in personality and psychological status could be due to ligamentous cervical instability or cervical dysstructure

Negative changes in personality and psychological status could be due to ligamentous cervical instability or cervical dysstructure.

1. Definite change in personality or emotional stability.
   1. Article for further resources please see Ross Hauser, MD Reviews Cervical Spine Instability and Potential Effects on Brain Physiology
2. Other signs of cervical instability: popping clicking and grinding of neck
   1. neck pain
   2. muscle spasms
   3. muscle fatigue
   4. numbness in arms or hands
3. Other symptoms suggestive of intracranial hypertension.
   1. blurred vision
   2. head pressure
   3. headaches
      1. Article for further understanding and information: Cervical Spine Instability, fluid build up and intracranial hypertension.
4. Other symptoms suggestive of vagus nerve degeneration.
   1. swallowing difficulty – Cervical disc disease and difficulty swallowing – cervicogenic dysphagia
   2. increase stress – Emotional stress: Anxiety, Depression and Panic Attacks: A neurologic and psychiatric like condition caused by cervical spine instability.
   3. emotional lability – offered described as an “emotional roller coaster.”
   4. Digestive. See articles:
      1. How neck pain and cervical spine instability cause nausea, gastroparesis and other digestive problems
      2. Cervical spine instability and digestive disorders: Indigestion and irritable bowel syndrome caused by cervical spondylosis
5. Symptoms of Anhedonia – the inability to feel pleasure
   1. reduce motivation
   2. diminished pleasure derived from daily activities
   3. social withdrawal
6. Loss of libido. Also see Sexual function and cervical spine instability.

Symptomology of disassociation discussed by Ross Hauser, M.D.

The word dissociation often presents a problem for people who suffer from it and are trying to research help for it. The problem is that the word dissociation is often used to describe, and accurately so, the displacement between the bones of the cervical spine. If a C3 has slipped well in front of a C4 for example it could be said that the C3 is in a position of dissociation with C4. It is out of place, it doesn’t belong where it is. Many of you reading this article may be thinking, “I am like the C3, sometimes I feel out of place like I don’t belong in my space.” For many of you, you are like the C3, sometimes you do feel out of place.

Let’s briefly look at some research studies to help reassure you that this is not a made-up diagnosis to try to explain your episodes.

Here is a study in the journal Current Psychiatry Reports (1) that looks for a cause of dissociation. The study does not mention cervical spine instability, it talks about the problem from a psychiatric viewpoint, but we can make some connections. First here is what the study highlights:

• “Dissociation involves disruptions of usually integrated functions of consciousness, perception, memory, identity, and affect (e.g., depersonalization, derealization, numbing, amnesia, and analgesia).”
• “While the precise neurobiological underpinnings of dissociation remain elusive, neuroimaging studies in disorders, characterized by high dissociation have provided valuable insight into brain alterations possibly underlying dissociation.”

Another patient story example: ” disconnected from the family and everything I love. . .”

“My worst symptom is an intense desire to sleep. I have suffered from it for eight years. All the drugs doctors have tried, stimulants, antidepressants, did not work and some gave me severe  side-effects like sobbing, shaking, feeling hopeless, disconnected from the family and everything I love. . . “

We see many people with terrible brain fog, excessive sleepiness, the desire to take naps, sometimes incapacitating fatigue, most of the day they feel horrible or terribly depressed. These emotions can come upon them instantly, without warning, they start sobbing, shaking, a feeling of hopelessness has come over them. They feel like they are disconnected from themselves, they feel dissociation. They feel psychologically that you are not even yourself. Like you’re not even in your own body.

Part 2: Cervical spine and craniocervical instability patients can be seen as having psychiatric-like, or neurologic-like, or vascular-like conditions

In the patient cases discussed here, a person’s list of symptoms is so extensive that a problem of dissociation episodes comes last even though it may be just as impactful as their other symptoms.

I have already scheduled surgery for cervical spine fusion. I am having fusion from C2-C4. It is the only way, according to my doctors, to handle my upper cervical instability. As my surgical date approaches, I am researching what I hope would be a better approach to my extensive list of symptoms.

I can’t drive, I can’t look down, I have significant occipital neuralgia, migraines, cervical stenosis, vertigo and dizziness, concentration and memory problems, cervical neck-related insomnia, digestive disorders, Trigeminal neuralgia, and dissociation episodes.

Whiplash and Dissociation – attachment avoidance (avoiding need of relationship or family support) and attachment anxiety (the fear of not having a relationship or family support).

Symptoms of dissociation found in people with cervical spine instability are often documented in the medical literature about people with whiplash injuries. As people with untreated or mistreated whiplash injury often fall into the problem of long-term chronic symptomology, or post-traumatic osteoarthritis, also they are sometimes considered as suffering from Post Traumatic Stress Disorder (PTSD) they share symptoms with those non-whiplash associated cervical spine instability caused by degenerative wear and tear.  Let’s make a connection.

We are going to start by looking at a 2013 paper in the journal Clinical Practice and Epidemiology in Mental Health. (2)

“With PTSD symptoms and somatization representing important features of the whiplash associated disorder, traditional pain management may miss important features. Clinicians may be misguided in their interventions, because patients with symptoms of whiplash, may primarily seek treatment for pain complaints. In relation to affect regulation, factors such as PTSD, somatization, and attachment insecurity may be overlooked despite being highlighted as potential vulnerabilities.”

A brief note: The quoted research suggests that people with Whiplash Associated Disorder are seeking medical treatment for pain. Doctors should not ignore however the fact that some of these people may need counseling. In our office, we feel it’s critically important that the patient have a good support system behind them, whether family or partner or friend or support group.

A brief note:  Attachment insecurity is a disorder where people lash out or have widely varying emotions towards some in close relationship with them, family member, loved one, partner). A 2019 study updated by the same lead researcher as the 2013 study just noted, and published in the Journal of Psychosomatic Research (3) wrote: “when attachment avoidance (avoiding need of relationship or family support) and attachment anxiety (the fear of not having a relationship or family support) were high there was a significant positive relationship between depression and disability.”

Let me stress again: In our office, we feel it’s critically important that the patient have a good support system behind them, whether family or partner or friend or support group.

In October 2020 a team of Italian university research and medical hospital doctors writing in the journal Frontiers in Psychology. (4) investigated whether chronic pain patients with somatization reported higher alexithymic (isolation, the inability to make an emotional connection with others) traits than those without somatization and to study the different relationships between psychological characteristics, pain, health-related quality of life, and somatization.

• One hundred thirty-four chronic pain patients were evaluated for alexithymia (feelings of isolation and emotional detachment), somatization, distress, health-related quality of life, and pain.

Results: Patients with somatization (37.04%) reported significantly higher feelings of isolation and emotional detachment and difficulty in identifying feelings than those without somatization. The somatizer group had also a significantly higher disease duration, severity, and interference of pain, distress, and lower health-related quality of life than the non-somatizer group.

People who have chronic pain for long-duration can shut themselves off emotionally if they feel that no one understands that they have more pain than they should.

Type D Personality

Someone who is considered a type D personality is someone who is considered chronically distressed. Many studies exploring type D personality find that in many patients, the same symptoms of cervical spine instability occur.

A December 2021 paper (5) looked at 240 physiotherapy students, 120 of them having type D personalities and 120 considered as control subjects. In students with type D personality symptoms, temporomandibular disorders occurred significantly more often and in greater number than in those without stress personalities.

• Among the 240 respondents, depression was found in 128 people (53.3%).
• In the group of students with type D personalities, depression was significantly more frequent than in the group without type D personalities. In participants with depression, TMD symptoms were more common, i.e., headaches, neck, and shoulder girdle pain, TMJ acoustic symptoms, increased masticatory muscle tension, teeth clenching, and teeth grinding.

I make the connection between TMJ disorders and cervical spine instability in my article: TMJ and Tinnitus: Should we explore the ligament chain from the cervical spine through the neck to the jaw to the ear?

Psychiatric Depersonalization/Derealization and a connection to the inner ear.

In the TMJ article above, I point out the close anatomical association between the temporomandibular joint and the upper cervical vertebrae is demonstrated in the image below. As stated in the caption, the close relationship between the structures can be used to illustrate to sufferers how injury to the cervical spine ligaments supporting the proper position and movement of the C1 (atlas) and C2 (axis) could cause pain that would travel throughout the head, face, and TMJ area and cause issues in the inner ear.

A January 2023 paper in the Journal of the neurological sciences (6) Psychiatric Depersonalization/Derealization symptoms in patients and possible causes are explored. Here are the highlights of that research:

“Psychiatric Depersonalization/Derealization (DPDR) symptoms were demonstrated in patients with peripheral vestibular disorders. However, only semicircular canals dysfunction was evaluated, therefore, otoliths’ contribution to Psychiatric Depersonalization/Derealization is unknown.”

Let’s stop for explanatory notes.

What has been evaluated: Semicircular canals dysfunction is missing or abnormally thin temporal bone in the semicircular canal.

What has been not been evaluated: The semicircular canal contain the vestibular end organs (two pairs of otolith (ear stones) organs (the utricle and saccule)) within the inner ear. These ear stones help sense rotational movements of the head and keep us “up right.” Dysfunction of this process would therefore trigger vertigo, disequilibrium and other balance issues in addition to healing loss and hearing problems. Further patients who suffer from this problem hear an exaggerated or amplified heartbeat.

Also, Psychiatric Depersonalization/Derealization symptoms in patients with central vestibular dysfunction (a possible problem of the central nervous system, i.e, nerve injury or compression) are presently unknown. Psychiatric Depersonalization/Derealization was also studied in the context of spatial disorientation and anxiety, but the relation of these cognitive and emotional functions to vestibular dysfunction requires clarification.

After testing, the researchers found:  Psychiatric Depersonalization/Derealization develops in association with sacculi dysfunction, either with or without missing or abnormally thin temporal bone in the semicircular canal. Spatial disorientation and anxiety seem to mediate the transformation of vestibular dysfunction (a possible problem with nerve injury or compression) into Psychiatric Depersonalization/Derealization symptoms.

Arterial and venous obstruction of fluid into and out of the brain: One explanation for the problems of emotional detachment, anxiety, depression, memory, cognitive function, and brain fog described by some patients with cervical spine instability.

At 3:15 in the video above with Dr. Hauser, Dr. Hauser describes the arterial and venous obstruction of fluid into and out of the brain. In explaining to patients this vital component of their brain health, the analogy of a Brain Toilet Obstruction seemed to resonate with our patients as the best way to understand fluid in and fluid out.

In this split image, the image to the left shows a stable neck with a normal cervical spine curvature. Everything is in its proper place. Cerebrospinal fluid drains and refills within the brain.

In the image to the right, we see cervical dysstructure, a condition of cervical spine instability. The displacement of the C1 is now exerting pressure on the arteries and veins leading into and out of the brain. The Cerebrospinal fluid is now backing up into the brain. In this situation, frontal lobe damage can occur.

To reiterate: The brain needs to drain out or flush out toxins and refill itself with fresh fluids. In the image to the right, it is pointed out that obstruction of the veins and arteries will cause a “clogged toilet.” What happens when the toilet clogs?

• The arteries that bring fresh oxygen, nutrients, and clean fluids to the brain will be impeded.
• The veins that help flush out toxic buildup will clog.

Cerebrospinal fluid and intracranial blood levels need to be maintained at all times, think of it as the water in your toilet bowl. That level is always maintained and does not fluctuate until the time the toilet is flushed. When the toilet is flushed the water goes down the drain and as soon as the dirty water is flushed, freshwater now drains in from the toilet tank to the toilet bowl.

If the drain is clogged the toilet overflows, if there is no water in the tank, the fluid in the brain does not refill.

Ultimately this will result in an accumulation of cerebrospinal fluid in various parts of the brain including the frontal lobe. This will destroy neurons and brain tissue. This can be one explanation for the problems of emotional detachment, anxiety, depression, memory, cognitive function, and brain fog described by some patients with cervical spine instability.

For a more comprehensive discussion on these topics please see our articles:

• Spontaneous intracranial hypotension – lumbar epidurals and cervical spine instability
• Cervical Spine Instability, Vein blockage, fluid build up, and intracranial hypertension
• Brain Toilet Obstruction (BTO)

Above we talked about various tests that could show pressure within the brain. The toilet analogy is one way to understand this pressure buildup. Testing is of course the documented way to demonstrate pressure within the brain.

One way we document that the venous outflow from the brain is obstructed by extracranial Doppler ultrasound examinations. This will help reveal if internal jugular veins and other veins are being blocked. We also do ultrasounds of the eye which will show that the optic nerve sheaths are swollen which is a sign that the pressure inside the brain is high. Together with the information gleaned from a digital motion x-ray we then come up with a treatment regime to help get the brain functioning back to normal.

Please see my article:

• Cervical spine compression causes internal jugular vein stenosis

It may be possible to visualize a cause of dissociation through brain-blood flow tests.

In other words, it may be possible to visualize a cause of dissociation through brain-blood flow tests. Let’s continue with the study.

“Dissociation is a complex heterogeneous phenomenon. (It is diverse in its cause, its symptoms, and the conditions it may cause). It has been defined as a “disruption of and/or discontinuity in the normal, subjective integration of one or more aspects of psychological functioning, including – but not limited to – memory, identity, consciousness, perception, and motor control.” Here the world of psychiatry and the world of cervical spine instability share many symptoms that can be applied to both fields.

Here is one more area that is shared, the ability to visualize the problem with certain testing. Back to the study:

Over the past decades, neuroimaging has become one of the most important tools in clinical neurobiology. Techniques such as magnetic resonance imaging (MRI), MR spectroscopy (MRS), positron emission tomography (PET), and diffusion tensor imaging (DTI) are used to study abnormalities in the brain.”

What the researchers of this study are suggesting is that this problem of dissociation may have something to do with blood flow to the brain and it should be explored. Let’s be clear problems of dissociation can be caused by many problems, the problems of blood flow in and out of the brain may be the primary cause in some, not all.

Part 3: Treating the physical aspect of pain in dissociation

These are all physical manifestations that may lead to the emotional challenges we have described above. In patients, we see they recognize changes in their emotional and mental state. They have become anxious all the time, they can’t focus, they have obsessive tendencies, depression, alienation from the family.

At our center, the many problems, including dissociation that we see in our cervical spine and craniocervical instability patients can be seen as psychiatric-like, or neurologic-like, or vascular-like, but, in our world of neck pain, these conditions and symptoms may be a manifestation of nerve, vein, and arterial compression caused by instability in the neck, from C0-C7.

At our center, we offer diagnostic testing to check for blood flow in and out of the brain. These tests are done in real-time while the patient moves and rotates his/her head. As you may suffer from many of the conditions already highlighted in this article, you may know first hand that when you turn your head to the right, for example, your symptoms get worse, when you turn you had all the way to the left or up or down or back and forth you can manipulate the severity of your symptoms simply by repositioning your head. Motion is the key to finding the root cause of cervical spine instability.

Please refer to the following articles:

• Dynamic Analysis of Blood Flow Measurements to the Brain, Brainstem, Cervical Spinal Cord, and Cranial Nerves
• Using Transcranial Doppler & Extracranial Doppler Ultrasound Testing at the Hauser Neck Center

What are we seeing in this image?

Dr. Hauser is using ultrasound to examine the blood flow through the carotid artery. Blood in and out of the brain has to pass through the neck in its journey back and forth to the heart.

For a more comprehensive review please see our articles:

• How cervical spine instability disrupts blood flow into the brain and causes many neurological problems
• Cervical Spine Instability, Vein blockage, fluid build up, and intracranial hypertension.

 

What are we seeing in this image? Ultrasound measurement of the optic nerve.

Digital motion X-Ray C1 – C2

• Digital Motion X-ray can show instability at the C1-C2 Facet Joints
• The amount of misalignment or “overhang” between the C1-C2 demonstrates the degree of instability in the upper cervical spine which may lead to an understanding of why the patient is not responding to conventional treatments for post-concussion syndrome.

You can also visit this page on our site for more information on Digital Motion X-ray (DMX)

Research on cervical instability. A mechanical approach to Dissociation, Anxiety, and Depression

In the research above, a case is laid out for the treatment of cervical spine instability in patients with dissociation, anxiety, and depression. As also stated, not every case of these psychiatric-like disorders can be attributed to cervical spine instability. Certainly, at our center, we see many people with this connection because this is what we treat.

Prolotherapy is an injection technique that stimulates the repair of unstable, torn or damaged ligaments. When the cervical ligaments are unstable, they allow for excessive movement of the vertebrae, which can stress tendons, atrophy muscles, pinch on nerves and cause other symptoms associated with cervical instability including neurologic-type, vascular-type, and psychiatric-like symptoms and conditions.

In 2014, we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments in The Open Orthopaedics Journal. (7) We are honored that this research has been used in at least 6 other medical research papers by different authors exploring our treatments and findings and cited, according to Google Scholar, in more than 40 articles.

In our clinical and research observations, we have documented that Prolotherapy can offer answers for sufferers of cervical instability, as it treats the problem at its source. Prolotherapy to the various structures of the neck can eliminate the instability and the sympathetic symptom including sympathetic dominance. We concluded that in many cases of chronic neck pain, the cause may be underlying joint instability and capsular ligament laxity. Furthermore, we contend that the use of comprehensive Prolotherapy appears to be an effective treatment for chronic neck pain and cervical instability, especially when due to ligament laxity. The technique is safe and relatively non-invasive as well as efficacious in relieving chronic neck pain and its associated symptoms.

Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult-to-treat musculoskeletal disorders.

A Digital Motion X-Ray or DMX is a tool we use to help understand a patient’s neck instability and how we may be able to help the patients with our treatments. In the illustration below a patient who suffered from upper cervical instability demonstrated hypermobility of the C1-C2. This hypermobility can result in common symptoms of neck pain, headaches, dizziness, vertigo, tinnitus, concentration difficulties, anxiety, TMJ, and other symptoms.

The curvatures of the neck -What are we seeing in this image?

In our practice, we see problems of cervical spine instability caused by damaged or weakened cervical spine ligaments. With ligament weakness or laxity, the cervical vertebrae move out of place and progress into problems of chronic pain and neurological symptoms by distorting the natural curve of the spine. This illustration demonstrates the progression from Lordotic to Military to Kyphotic to “S” shape curve.

What are we seeing in this image? Restoration of normal curvature in one of our patients

In this video, a demonstration of a Prolotherapy treatment is given

Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative healing process can rebuild and repair damaged soft tissue structures. It is a simple injection treatment that addresses very complex issues.

This video jumps to 1:05 where the actual treatment begins.

This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

Many of the patients who we see in our neck center have conditions of anxiety, depression, and dissociation. These challenges can be termed psychiatric-like because, in some people, these problems are manifest of cervical spine and craniocervical instability and are symptoms of nerve, vein, and arterial compression caused by the unstable bones of the neck pressing and compressing these vital structures. By identifying cervical spine instability, disruption of blood flow into and out of the brain, disruption of normal Cerebrospinal fluid flow and by treating the damaged cervical spine ligaments and addressing the problems of the cervical spinal curvature, we hope to be able to help the right candidate get back to a better lifestyle.

We hope you found this article informative and it helped answer many of the questions you may have surrounding cervical spine instability and anxiety, depression, and dissociation. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form

References

1 Krause-Utz A, Frost R, Winter D, Elzinga BM. Dissociation and alterations in brain function and structure: implications for borderline personality disorder. Current psychiatry reports. 2017 Jan 1;19(1):6. [Google Scholar]
2 Andersen TE, Elklit A, Brink O. PTSD symptoms mediate the effect of attachment on pain and somatization after a whiplash injury. Clinical practice and epidemiology in mental health: CP & EMH. 2013;9:75. [Google Scholar]
3 Andersen TE, Sterling M, Maujean A, Meredith P. Attachment insecurity as a vulnerability factor in the development of chronic whiplash-associated disorder–A prospective cohort study. Journal of psychosomatic research. 2019 Mar 1;118:56-62. [Google Scholar]
4 Lanzara R, Conti C, Camelio M, Cannizzaro P, Lalli V, Bellomo RG, Saggini R, Porcelli P. Alexithymia and Somatization in Chronic Pain Patients: A Sequential Mediation Model. Frontiers in Psychology. 2020 Oct 27;11:2929. [Google Scholar]
5 Gębska M, Dalewski B, Pałka Ł, Kołodziej Ł, Sobolewska E. The importance of type d personality in the development of temporomandibular disorders (TMDs) and depression in students during the COVID-19 pandemic. Brain Sciences. 2021 Dec 27;12(1):28. [Google Scholar]
6 Elyoseph Z, Geisinger D, Zaltzman R, Gordon CR, Mintz M. How vestibular dysfunction transforms into symptoms of depersonalization and derealization?. Journal of the Neurological Sciences. 2023 Jan 15;444:120530. [Google Scholar]
7 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326. [Google Scholar]

This article was updated March 23, 2023

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