Dissociative disorders among Chinese inpatients diagnosed with schizophrenia

Trauma and dissociation among inpatients diagnosed with schizophrenia spectrum disorders in Taiwan

Background: The overlapping symptoms of schizophrenia and dissociation have been increasingly recognized. This paper explains why it is reasonable to expect that there would be a substantial subgroup of patients diagnosed with schizophrenia spectrum disorders (SSDs) who suffer from pathological dissociation. Objective: As little is known about the prevalence of dissociative disorders and symptoms among patients with SSDs, we investigated the prevalence of dissociative disorders and symptoms among patients with SSDs. Method: We used both self-report measures and structured interviews to examine dissociative disorders and symptoms in a randomly recruited sample of inpatients with a clinical diagnosis of SSDs in Taiwan (N = 100). Results: Over 60% of participants exhibited pathological dissociation, and 54% had a dissociative disorder according to structured interview data; three participants met the DSM-5 diagnostic criteria for dissociative identity disorder. The concurrent validity of pathological dissociation in this sample was similar to that of depression among patients with schizophrenia reported in the literature. Participants with a dissociative disorder were more likely to report high-betrayal traumas and meet DSM-5 criteria for post-traumatic stress disorder; they also reported more psychotic symptoms than those without a dissociative disorder. Conclusions: This was one of very few studies that used structured interviews to examine pathological dissociation in patients with SSDs. The results indicate that pathological dissociation in SSDs is not uncommon. Clinical assessment should include measures of dissociation to facilitate early identification.

Clinical Features of a Chinese Sample with Self-Reported Symptoms of Pathological Dissociation

People with pathological dissociation should receive proper clinical attention and timely support. Recent studies have shown that pathological dissociation is common in the Chinese context. However, little is known about the clinical features of Chinese people with pathological dissociation. This paper reports the first data regarding trauma histories, mental health symptoms, clinical diagnoses, service usages, stigma and psychosocial needs in a convenience sample of Chinese people who screened positive for pathological dissociation on a self-report measure (N = 72). This sample was characterized by a history of trauma and high levels of trauma-related symptoms and depression. Medication treatments were the most common interventions for them; many participants did not receive psychotherapy. We found no clinical differences between participants who had and had not received psychotherapy for post-traumatic/dissociative symptoms. This implies that many participants did not have the chance of receiving specific psychotherapy even though their trauma histories and clinical symptoms were as severe as those who were receiving specific psychotherapy. Stigma and unmet psychosocial needs were common in this sample and should receive more attention in the field. Implications for research and practice are highlighted. More dissociation-informed services are required for Chinese-speaking populations.

Biomarkers of Pathological Dissociation: A Systematic Review

Pathological dissociation is a severe, debilitating and transdiagnostic psychiatric symptom. This review identifies biomarkers of pathological dissociation in a transdiagnostic manner to recommend the most promising research and treatment pathways in support of the precision medicine framework. A total of 205 unique studies that met inclusion criteria were included. Studies were divided into four biomarker categories, namely neuroimaging, psychobiological, psychophysiological and genetic biomarkers. The dorsomedial and dorsolateral prefrontal cortex, bilateral superior frontal regions, (anterior) cingulate, posterior association areas and basal ganglia are identified as neurofunctional biomarkers of pathological dissociation and decreased hippocampal, basal ganglia and thalamic volumes as neurostructural biomarkers. Increased oxytocin and prolactin and decreased tumor necrosis factor alpha (TNF-α) are identified as psychobiological markers. Psychophysiological biomarkers, including blood pressure, heart rate and skin conductance, were inconclusive. For the genetic biomarker category studies related to dissociation were limited and no clear directionality of effect was found to warrant identification of a genetic biomarker. Recommendations for future research pathways and possible clinical applicability are provided.

Voices: Are They Dissociative or Psychotic?

Auditory hallucinations are widely regarded as symptoms of brain disease treated with medications. In an alternative paradigm, voices are understood as trauma-driven dissociated, disowned, or disavowed aspects of self; the goal is not to suppress them but to integrate them during psychotherapy. Auditory hallucinations are common in dissociative identity disorder, borderline personality disorder, and complex posttraumatic stress disorder and are not specific to psychosis. The features that differentiate psychotic from dissociative voices include the qualities of the voices themselves, as well as other symptoms: for example, compared with dissociative voices, psychotic voices are accompanied by less sociability, more formal thought disorder, more negative symptoms including blunted affect, and more delusions. The author proposes that the psychotherapy of dissociative voices can be indicated trans-diagnostically, including in a subgroup of individuals with diagnoses of schizophrenia. Psychotherapeutic strategies are illustrated with a case example.

Investigating the prevalence of dissociative disorders and severe dissociative symptoms in first episode psychosis

AIM

Increasing evidence suggests that childhood trauma and dissociation are associated with psychotic symptoms and disorders. Significant rates of dissociative disorders and clinical levels of dissociative symptoms are found in chronic schizophrenia. To date, no studies have examined the prevalence of these in a first episode psychosis (FEP) group. This study aimed to investigate the prevalence of dissociative disorders and symptoms in a FEP sample as well as the prevalence of severe dissociative symptoms in those with or without experiences of childhood trauma.

METHODS

Sixty-six young people with FEP completed a research interview which included the structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Axis I Disorders, Childhood Trauma Questionnaire and the Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised.

RESULTS

Dissociative symptoms at clinical levels were found in 36.4% of the sample. Furthermore, 13.6% of the sample met diagnostic criteria for a lifetime dissociative disorder. Significant differences in the frequency of clinical dissociative symptoms between those with or without childhood trauma were also found.

CONCLUSIONS

Dissociative symptoms should be routinely assessed for in early intervention settings, especially in cases where childhood trauma is disclosed or suspected. Where present, dissociative symptoms should also be incorporated into subsequent case formulation and treatment planning.

Dissociation debates: everything you know is wrong

Controversy about dissociation and the dissociative disorders (DD) has existed since the beginning of modern psychiatry and psychology. Even among professionals, beliefs about dissociation/DD often are not based on the scientific literature. Multiple lines of evidence support a powerful relationship between dissociation/DD and psychological trauma, especially cumulative and/or early life trauma. Skeptics counter that dissociation produces fantasies of trauma, and that DD are artefactual conditions produced by iatrogenesis and/or socio-cultural factors. Almost no research or clinical data support this view. DD are common in general and clinical populations and represent a major underserved population with a substantial risk for suicidal and self-destructive behavior. Prospective treatment outcome studies of severely ill DD patients show significant improvement in symptoms including suicidal/self-destructive behaviors, with reductions in treatment cost. A major public health effort is needed to raise awareness about dissociation/DD, including educational efforts in all mental health training programs and increased funding for research.

A utilização do Método de Rorschach no diagnóstico diferencial da Esquizofrenia e Transtorno Dissociativo de Identidade

RESUMO O objetivo deste artigo foi investigar a prevalência do Transtorno Dissociativo de Identidade (TDI) em dez pacientes diagnosticados com esquizofrenia com característica paranóide, com base no Método de Rorschach. Foram registrados indicadores ou sintomas psicológicos que caracterizaram o diagnóstico diferencial desses pacientes, analisadas diferenças clínicas específicas e verificado o enquadramento dos dados obtidos, com a aplicação da Técnica de Rorschach. Para fins de diagnóstico diferencial, observou-se que dois pacientes apresentaram sintomas diferenciais aos da esquizofrenia, sendo que um deles apresentou sintomas dissociativos, não sendo confirmada a prevalência do TDI entre os esquizofrênicos. No caso da esquizofrenia e do TDI, devido às características similares que apresentam, avaliações multidisciplinares são indicadas para se fazer o diagnóstico diferencial entre eles.

Cognitive and neural facets of dissociation in a traumatized population

Dissociative phenomena are frequently experienced by psychologically traumatized people. However, little is known about the cognitive profiles of highly dissociative traumatized individuals, and corresponding patterns of neural connectivity when attentional networks are engaged in the context of emotion. One hundred seventeen traumatized women completed the multiscale dissociation inventory (MDI) and neuropsychological testing; MDI scores were used to classify high- and low-dissociative participants. Forty-six participants also underwent fMRI during performance of an attentional control task that incorporates emotionally distracting images (Affective Number Stroop; ANS). Compared to low-dissociative participants, high-dissociative participants demonstrated better performance on an executive functioning task (F1,111 = 4.64, p = .03), worse performance on a task of visual memory (F1,111 = 9.52, p = .003), and similar performance on all other neuropsychological measures. In addition, dissociative symptoms were negatively correlated with functional connectivity between the amygdala and right anterior insula in response to trauma-related ANS trials. These findings indicate that highly dissociative traumatized people experience difficulties with attentional control in the context of emotionally evocative stimuli, but in a neutral context, their overall cognitive profiles are similar to low-dissociative people. Highly dissociative participants also demonstrated weaker connectivity between the amygdala and insula in response to trauma-relevant images. Evocative, trauma-relevant stimuli appear to disrupt neutral networks involved with attention to salient cues and interoception in highly dissociative traumatized individuals. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The link between dissociation and both suicide attempts and non-suicidal self-injury: Meta-analyses

Dissociative disorders (DD) are frequently associated with suicidal behaviors. We performed the first meta-analysis of studies comparing rates of suicide attempts (SA) and non-suicidal self-injury (NSSI) in psychiatric individuals with and without DD. We included: 1) studies comparing SA and NSSI rates in psychiatric individuals with and without DD; 2) studies comparing Dissociative Experiences Scale (DES) scores in both SA and NSSI psychiatric patients versus non SA and non NSSI ones. Cochrane Collaboration Review Manager Software and STROBE statement were used. Nineteen studies were included in the analyses. DD patients were more likely to report both previous SA and NSSI in comparison to non DD patients. Importantly, results remained highly significant in both outcomes but with no more heterogeneity when including studies using a DSM-based method to diagnose DD. Both SA and NSSI patients reported higher DES scores in comparison to non SA and non NSSI patients. The presence of DD diagnosis or higher DES scores seems to be related to both SA and NSSI in psychiatric patients. Hence, it may be reasonable to hypothesize the presence of a dissociative subtype in a subset of these patients, which should be considered as a transdiagnostic factor and should be carefully assessed.

The self-report Dissociative Disorders Interview Schedule: A preliminary report

A self-report version of the Dissociative Disorders Interview Schedule (SR-DDIS) was administered to 100 inpatients in a hospital-based trauma program. All participants had previously completed the interviewer-administered version of the DDIS. When we compared the overall results on the DDIS and SR-DDIS for the 100 inpatients, the findings were very consistent for both symptom clusters and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), diagnoses. The agreement rate between the 2 versions for DSM-5 diagnoses was fair to substantial using Cohen's kappa, with agreement being substantial for 4 out of the 7 diagnoses made by the DDIS. It appears likely that the SR-DDIS can be used instead of the DDIS, at least in clinical populations, with no clinically or conceptually significant differences between the results obtained with the 2 versions.

Separating Fact from Fiction: An Empirical Examination of Six Myths About Dissociative Identity Disorder

Dissociative identity disorder (DID) is a complex, posttraumatic, developmental disorder for which we now, after four decades of research, have an authoritative research base, but a number of misconceptualizations and myths about the disorder remain, compromising both patient care and research. This article examines the empirical literature pertaining to recurrently expressed beliefs regarding DID: (1) belief that DID is a fad, (2) belief that DID is primarily diagnosed in North America by DID experts who overdiagnose the disorder, (3) belief that DID is rare, (4) belief that DID is an iatrogenic, rather than trauma-based, disorder, (5) belief that DID is the same entity as borderline personality disorder, and (6) belief that DID treatment is harmful to patients. The absence of research to substantiate these beliefs, as well as the existence of a body of research that refutes them, confirms their mythical status. Clinicians who accept these myths as facts are unlikely to carefully assess for dissociation. Accurate diagnoses are critical for appropriate treatment planning. If DID is not targeted in treatment, it does not appear to resolve. The myths we have highlighted may also impede research about DID. The cost of ignorance about DID is high not only for individual patients but for the whole support system in which they reside. Empirically derived knowledge about DID has replaced outdated myths. Vigorous dissemination of the knowledge base about this complex disorder is warranted.

Trauma-related pathological dissociation in a case with cerebral palsy

This article provides a case report of a Chinese-Cantonese female with both cerebral palsy and dissociative identity disorder. To my knowledge, this is the first report of a case with dissociative identity disorder from Hong Kong, as well as the first report of a case with both dissociative identity disorder and cerebral palsy in the literature. Large-sample studies should be undertaken in the future to investigate the prevalence of dissociative disorders in a variety of populations in Hong Kong, including individuals with diagnosed brain diseases.

Misattributing the Source of Self-Generated Representations Related to Dissociative and Psychotic Symptoms

Objective: An intertwined relationship has been found between dissociative and psychotic symptoms, as the two symptom clusters frequently co-occur, suggesting some shared risk factors. Using a source monitoring paradigm, previous studies have shown that patients with schizophrenia made more errors in source monitoring, suggesting that a weakened sense of individuality may be associated with psychotic symptoms. However, no studies have verified a relationship between sense of individuality and dissociation, and it is unclear whether an altered sense of individuality is a shared sociocognitive deficit underlying both dissociation and psychosis.

Method: Data from 80 acute psychiatric patients with unspecified mental disorders were analyzed to test the hypothesis that an altered sense of individuality underlies dissociation and psychosis. Behavioral tasks, including tests of intelligence and source monitoring, as well as interview schedules and self-report measures of dissociative and psychotic symptoms, general psychopathology, and trauma history, were administered.

Results: Significant correlations of medium effect sizes indicated an association between errors attributing the source of self-generated items and positive psychotic symptoms and the absorption and amnesia measures of dissociation. The associations with dissociative measures remained significant after the effects of intelligence, general psychopathology, and trauma history were excluded. Moreover, the relationships between source misattribution and dissociative measures remained marginally significant and significant after controlling for positive and negative psychotic symptoms, respectively.

Limitations: Self-reported measures were collected from a small sample, and most of the participants were receiving medications when tested, which may have influenced their cognitive performance.

Conclusions: A tendency to misidentify the source of self-generated items characterized both dissociation and psychosis. An altered sense of individuality embedded in self-referential representations appears to be a common sociocognitive deficit of dissociation and psychosis.

Sleep loss increases dissociation and affects memory for emotional stimuli

BACKGROUND AND OBJECTIVES

Because of their dreamlike character, authors have speculated about the role that the sleep-wake cycle plays in dissociative symptoms. We investigated whether sleep loss fuels dissociative symptoms and undermines cognitive efficiency, particularly memory functioning.

METHODS

Fifty-six healthy undergraduate students were randomly assigned to an experimental group (n = 28) and a control group (n = 28). The experimental group was deprived of sleep for 36 h in a sleep laboratory; the control group had a regular night of sleep. Sleepiness, mood, and dissociative symptoms were assessed 6 times in the experimental group (control group: 4 times). Several cognitive tasks were administered.

RESULTS

Sleep deprivation led to an increase in dissociative symptoms, which was mediated by levels of general distress. Feelings of sleepiness preceded an increase of dissociative symptoms and deterioration of mood. Finally, sleep loss also undermined memory of emotional material, especially in highly dissociative individuals.

LIMITATIONS

Limitations included moderate reliability of the mood scale, limited generalizability due to student sample, and a relatively short period of intensive sleep deprivation rather than lengthy but intermittent sleep loss, representative of a clinical population.

CONCLUSIONS

We found that sleep deprivation had significant effects on dissociation, sleepiness, and mood. Specifically, sleepiness and dissociation increased during the night, while mood deteriorated. Our findings stress the importance of sleep deficiencies in the development of dissociative symptoms. They support the view that sleep disruptions fuel distress, but also degrade memory and attentional control. It is against this background that dissociative symptoms may arise.

Dissociative disorders and possession experiences in Israel: a comparison of opiate use disorder patients, Arab women subjected to domestic violence, and a nonclinical group

This study examined the association between exposure to domestic violence and dissociative symptoms. A sample of 68 Israeli opiate use disorder patients in recovery, 80 battered Arab Israeli women, and 103 respondents from a community sample participated in structured interviews that included the Dissociative Disorders Interview Schedule (DDIS), the Dissociative Trance Disorder Interview Schedule (DTDIS), and the Dissociative Experiences Scale (DES). As predicted, community participants reported significantly less exposure to traumatizing events and lower levels of dissociative psychopathology than individuals sampled from specialized treatment centers. In all, 91% of battered female participants were taxon-positive for dissociative disorder with 1 of every 2 respondents reporting symptoms corresponding to dissociative amnesia and depersonalization disorder, suggesting that this group may be particularly vulnerable to dissociative psychopathology. Extrasensory and paranormal experiences (ESP) and dissociative trance disorder experiences were strongly related to dissociative experiences and features of dissociative identity disorder (DID). These statistical associations suggest that dissociative disorders and ESP/trance experiences may share an underlying construct. Further research is needed on trauma and dissociation among female victims of domestic abuse in patriarchal, collectivist societies, particularly in the Arab world.

Reliability and Validity of the Dissociative Experiences Scale Among South Korean Patients With Schizophrenia

The Dissociative Experiences Scale (DES) is the most widely used self-report tool for use with the general population and various clinical entities, including those with schizophrenia. This preliminary study tested the reliability of the DES, especially temporal stability and validity, in patients diagnosed with schizophrenia receiving inpatient or outpatient treatment. The DES was administered at a university-affiliated training hospital in South Korea to a total of 68 patients (39 inpatients and 29 outpatients) whose diagnosis of schizophrenia was confirmed using the Structured Clinical Interview for DSM-IV Axis Disorders. Internal consistency, 4-week test-retest reliability, and validity were calculated. Participants also completed the Childhood Trauma Questionnaire, the Beck Depression Inventory, and the Symptom Checklist-Posttraumatic Stress Disorder Scale. Four-week test-retest reliability was moderate (r = .69) and internal consistency was good (Cronbach's α = .95). Total score on the DES was correlated with childhood trauma (r = .69, p < .001), posttraumatic symptoms (r = .50, p < .001), and depression (r = .52, p < .001), demonstrating the convergent validity of the scale. Our study confirms the psychometric soundness of the DES among patients with schizophrenia after the acute stage of illness (e.g., 3 weeks after admission), supporting use of the scale for screening and evaluating dissociative symptoms within this population.

Self-reported sleep disturbances in patients with dissociative identity disorder and post-traumatic stress disorder and how they relate to cognitive failures and fantasy proneness

Sleep disturbances, fantasy proneness, cognitive failures, and dissociative symptoms are related to each other. However, the co-occurrence of these phenomena has been primarily studied in non-clinical samples. We investigated the correlations between these phenomena in dissociative identity disorder (DID) patients, post-traumatic stress disorder (PTSD) patients, and healthy controls. Both patient groups reported more sleep problems and lower sleep quality and displayed higher levels of fantasy proneness and cognitive failures than controls. However, the two patient groups did not differ with regard to these variables. Moreover, a higher level of unusual sleep experiences tended to predict participants belonging to the DID group, while specifically a lower sleep quality and more cognitive failures tended to predict participants belonging to the PTSD group.

Dissociative symptoms and sleep parameters--an all-night polysomnography study in patients with insomnia

BACKGROUND

Dissociative disorders encompass a range of symptoms varying from severe absent-mindedness and memory problems to confusion about one's own identity. Recent studies suggest that these symptoms may be the by-products of a labile sleep-wake cycle.

METHODS

In the current study, we explored this issue in patients suffering from insomnia (N=46). We investigated whether these patients have raised levels of dissociative symptoms and whether these are related to objective sleep parameters. Patients stayed for at least one night in a specialized sleep clinic, while sleep EEG data were obtained. In addition, they completed self-report measures on dissociative symptoms, psychological problems, and sleep characteristics.

RESULTS

Dissociative symptom levels were elevated in patients suffering from insomnia, and were correlated with unusual sleep experiences and poor sleep quality. Longer REM sleep periods and less time spent awake during the night were predictive of dissociation.

CONCLUSIONS

This is the first study to show that insomnia patients have raised dissociative symptom levels and that their dissociative symptoms are related to objective EEG parameters. These findings are important because they may inspire sleep-related treatment methods for dissociative disorders.

A review of published research on adult dissociative identity disorder: 2000-2010

The purpose of this study was to assess the scientific and etiological status of dissociative identity disorder (DID) by examining cases published from 2000 to 2010. In terms of scientific status, DID is a small but ongoing field of study. The review yielded 21 case studies and 80 empirical studies, presenting data on 1171 new cases of DID. A mean of 9 articles, each containing a mean of 17 new cases of DID, emerged each year. In terms of etiological status, many of the central criticisms of the disorder's validity remain unaddressed. Most cases of DID emerged from a small number of countries and clinicians. In addition, documented cases occurring outside treatment were almost nonexistent. Finally, people simulating DID in the laboratory were mostly indistinguishable from individuals with DID. Overall, DID is still a topic of study, but the research lacks the productivity and focus needed to resolve ongoing controversies surrounding the disorder.

Fragmented Sleep, Fragmented Mind

In psychopathology, dissociation typically refers to a disturbance in the normal integration of thoughts, feelings, and experiences into consciousness and memory. In this article, we review the literature on how sleep disturbances relate to dissociative symptoms and memory failure. We contend that this body of research offers a fresh perspective on dissociation. Specifically, we argue that dissociative symptoms are associated with a labile sleep–wake cycle, in which dreamlike mentation invades the waking state, produces memory failures, and fuels dissociative experiences. The research domain of sleep and dissociation can accommodate the dominant idea in the clinical literature that trauma is the distal cause of dissociation, and it holds substantial promise to inspire new treatments for dissociative symptoms (e.g., interventions that focus on normalization of the sleep-wake cycle). We conclude with worthwhile paths for further investigations and suggest that the sleep–dissociation approach may help reconcile competing interpretations of dissociative symptoms.

What we know and what we need to learn about the treatment of dissociative disorders

In this editorial, I briefly review research design issues and the current treatment research for dissociative disorders (DD), discuss the limitations and challenges of conducting treatment studies for patients with DD, and conclude by describing what I see as the first wave and second wave in the field of dissociation. Insurers and federally funded programs are increasingly requiring that treatment be empirically supported in order for treatment to be reimbursed. For example, psychoanalysis will no longer be reimbursed in The Netherlands because of what is perceived as a lack of empirical support. Other countries have also established standards about the treatments that have sufficient empirical support to merit government payment. I believe it is only a matter of time before it is common for patients with DD to be required to seek out empirically supported treatment if they want treatment to be reimbursed. We need to financially support treatment studies in order to develop a more solid empirical basis for the treatment of DD.

Teaching Chinese psychiatrists to make reliable dissociative disorder diagnoses

The aim of the study was to assess the outcome of an educational effort by two North American experts in dissociative disorders to teach Chinese psychiatrists to make reliable dissociative disorder diagnoses. In the final phase of the educational effort, 569 patients at Shanghai Mental Health Center completed the Chinese version of the Dissociative Experiences Scale (DES). Patients were then randomly selected in different proportions according to their DES scores: 96 selected patients were then assessed with the Dissociative Disorders Interview Schedule (DDIS) and clinical diagnostic interviews based on DSM-IV criteria. According to the clinical diagnostic interviews, 28 (4.9%) patients were diagnosed as having dissociative disorders. Agreement between the American experts and Chinese psychiatrists for presence or absence of a dissociative disorder was 0.75 using Cohen's kappa. Dissociative disorders can be diagnosed in China with good inter-rater reliability. The authors describe the steps taken to achieve this outcome.