Describing the indescribable: A qualitative study of dissociative experiences in psychosis

Associations between disturbed sleep and attenuated psychotic experiences in people at clinical high risk for psychosis

BACKGROUND

Pre-diagnostic stages of psychotic illnesses, including 'clinical high risk' (CHR), are marked by sleep disturbances. These sleep disturbances appear to represent a key aspect in the etiology and maintenance of psychotic disorders. We aimed to examine the relationship between self-reported sleep dysfunction and attenuated psychotic symptoms (APS) on a day-to-day basis.

METHODS

Seventy-six CHR young people completed the Experience Sampling Methodology (ESM) component of the European Union Gene-Environment Interaction Study, collected through PsyMate® devices, prompting sleep and symptom questionnaires 10 times daily for 6 days. Bayesian multilevel mixed linear regression analyses were performed on time-variant ESM data using the brms package in R. We investigated the day-to-day associations between sleep and psychotic experiences bidirectionally on an item level. Sleep items included sleep onset latency, fragmentation, and quality. Psychosis items assessed a range of perceptual, cognitive, and bizarre thought content common in the CHR population.

RESULTS

Two of the seven psychosis variables were unidirectionally predicted by previous night's number of awakenings: every unit increase in number of nightly awakenings predicted a 0.27 and 0.28 unit increase in feeling unreal or paranoid the next day, respectively. No other sleep variables credibly predicted next-day psychotic symptoms or vice-versa.

CONCLUSION

In this study, the relationship between sleep disturbance and APS appears specific to the item in question. However, some APS, including perceptual disturbances, had low levels of endorsement amongst this sample. Nonetheless, these results provide evidence for a unidirectional relationship between sleep and some APS in this population.

Anxious distress in people with major depressive episodes: a cross-sectional analysis of clinical correlates

OBJECTIVE

Most people with major depressive episodes meet the criteria for the anxious distress (AD) specifier defined by DSM-5 as the presence of symptoms such as feelings of tension, restlessness, difficulty concentrating, and fear that something awful may happen. This cross-sectional study was aimed at identifying clinical correlates of AD in people with unipolar or bipolar depression.

METHODS

Inpatients with a current major depressive episode were included. Data on socio-demographic and clinical variables were collected. The SCID-5 was used to diagnose depressive episodes and relevant specifiers. The Montgomery-Åsberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS) were used to assess the severity of depressive and manic (mixed) symptoms, respectively. Multiple logistic regression analyses were carried out to identify clinical correlates of AD.

RESULTS

We included 206 people (mean age: 48.4 ± 18.6 yrs.; males: 38.8%) admitted for a major depressive episode (155 with major depressive disorder and 51 with bipolar disorder). Around two-thirds of the sample (N = 137; 66.5%) had AD. Multiple logistic regression models showed that AD was associated with mixed features, higher YMRS scores, psychotic features, and a diagnosis of major depressive disorder (p < 0.05).

CONCLUSION

Despite some limitations, including the cross-sectional design and the inpatient setting, our study shows that AD is likely to be associated with mixed and psychotic features, as well as with unipolar depression. The identification of these clinical domains may help clinicians to better contextualize AD in the context of major depressive episodes.

Conceptualizing multiplicity spectrum experiences: A systematic review and thematic synthesis

BACKGROUND

Dissociative identity disorder and depersonalization-derealization have attracted research and clinical interest, facilitating greater understanding. However, little is known about the experience of multiplicity of self outside of traumagenic or illness constructs. Consequently, this systematic review explored how people identifying as having multiple selves conceptualize their experiences and identity.

METHODS

A comprehensive search of qualitative studies reporting lived experiences of multiplicity was conducted through PsycINFO, PubMed and Scopus (PROSPERO ID: CRD42021258555). Thirteen relevant studies were retrieved (N = 98, 16-64 years, conducted in the United Kingdom, the United States, Hungary and Poland).

RESULTS

Using line-by-line thematic synthesis, four analytical themes were developed: multiplicity: disorder versus experience; impact of understanding multiplicity; importance of supporting multiplicity; and continuum of experiences.

DISCUSSION

This review highlights heterogeneity within multiplicity-spectrum experiences, emphasizing the need for person-centred, individualized understanding, separate from mental health conceptualizations. Therefore, training in person-centred individualized care to promote self-concept clarity is needed across health, education and social care. This systematic review is the first to synthesize voices of people with lived experience across the multiplicity spectrum, demonstrating how qualitative research can contribute to advancing our understanding of this complex phenomena with the community, acknowledging reciprocal psychosocial impacts of multiplicity and providing valuable recommendations for services.

Lived experience of psychosis: challenges and perspectives for research and care

PURPOSE OF REVIEW

There is currently a recognition of the first-personal knowledge of people with lived experience of schizophrenia as an epistemic privilege that can influence and improve the quality of research and care. This review aims to identify and better understand the actual challenges and perspectives of this field.

RECENT FINDINGS

Two main themes are present in the recent literature: first, the direct involvement of persons with lived experience of psychosis both in research (first person accounts, lived experience and participatory research) and care with the development of new professional positions such as expert patients and peer workers ; second, the field of research on lived experience of psychosis based mostly on phenomenological psychiatry and qualitative research.

SUMMARY

Both involvement of persons with lived experience in care and research, and research on lived experience of psychosis have direct impact and outcomes such as leading to a better understanding of psychotic phenomena and to reduced stigma and providing more person-centered and holistic care and better social support. This review also highlights the conceptual and ethical challenges to overcome, especially the risk of tokenism.

Developing an understanding of the relationship between anxiety and dissociation in adolescence

Anxiety is a common problem in adolescence which is hypothesised to be associated with dissociation, a range of distressing symptoms linked to reduced psychosocial functioning. Yet, to date, research into the mechanisms of dissociation in adolescents has been limited. The present study investigated the link between trait anxiety and dissociative experiences (depersonalisation and 'felt sense of anomaly') using an online survey. Cognitive appraisals of dissociation, perseverative thinking, and body vigilance were assessed as potential mediating factors of this relationship. 1211 adolescents aged 13-18 years were recruited via social media advertisements and local schools. Linear regression showed a moderate positive relationship between trait anxiety and both dissociation constructs. Hierarchical regression indicated that cognitive appraisals of dissociation and perseverative thinking mediated the relationship between trait anxiety and both dissociation constructs, but trait anxiety was a significant predictor for felt sense of anomaly but not depersonalisation after including the mediators. The final models accounted for 58.7% of variance in depersonalisation and 68.4% of variance in felt sense of anomaly. These results support the hypothesis that dissociation is associated with anxiety in adolescence. They also demonstrate that cognitive-behavioural conceptualisations may be valid for understanding dissociation in adolescence.

Adult Survivors of Child Sexual Abuse Draw and Describe Their Experiences of Dissociation

The paper examined how dissociation is experienced and manifested in the drawings and narratives of female survivors of childhood sexual abuse (CSA) diagnosed with dissociative identity disorder. Fifteen Israeli women filled out a self-report questionnaire consisting of demographics, traumatic events, and dissociation severity. Then, they were asked to draw a dissociation experience and provide a narrative. The results indicated that experiencing CSA was highly correlated with indicators such as the level of fragmentation, the figurative style, as well as with the narrative. Two main themes emerged: a constant movement between internal and external worlds, and distorted perceptions of time and space.

Can We Predict Dissociative Experiences Based on Inner Speech in Nonclinical Population by Mediating Role of Sleep Disturbance?

ABSTRACT

Dissociative experiences include various experiences and behaviors that can cause people to feel disturbed and disconnected from reality. Individuals with dissociative experiences may exhibit various symptoms, particularly in their inner speech. The present study examined how we can predict dissociative experiences based on inner speech in nonclinical populations by mediating the role of sleep disturbance. In this cross-sectional study, data were collected from university students aged 18 to 40 years ( N = 400). They were asked to complete online self-report questionnaires: Varieties of the Inner Speech Questionnaire, Dissociative Experiences Scale, and Pittsburgh Sleep Quality Index. Results showed that there was a relationship between dissociative experiences and sleep disturbance ( r = 0.29, p < 0.001), dialogic inner speech ( r = 0.39, p < 0.001), condensed inner speech ( r = 0.31, p < 0.001), other people's inner speech ( r = 0.46, p < 0.001), evaluative/motivational inner speech ( r = 0.28, p < 0.001), and total inner speech score ( r = 0.48, p < 0.001). Thus, the current study showed a significant relationship among inner speech, dissociative experiences, and sleep disturbances. Inner speech was found to predict dissociative experiences by mediating sleep disturbances in the nonclinical population. Individuals with strong dissociative experiences had high scores for inner speech and sleep disturbance. The present study highlights a new area of research and its relationship to inner speech and dissociation. Future studies could further explore this new area to validate the findings reported here and support the authors' theoretical interpretation.

Dissociation and Dissociative Disorders Reconsidered: Beyond Sociocognitive and Trauma Models Toward a Transtheoretical Framework

For more than 30 years, the posttraumatic model (PTM) and the sociocognitive model (SCM) of dissociation have vied for attention and empirical support. We contend that neither perspective provides a satisfactory account and that dissociation and dissociative disorders (e.g., depersonalization/derealization disorder, dissociative identity disorder) can be understood as failures of normally adaptive systems and functions. We argue for a more encompassing transdiagnostic and transtheoretical perspective that considers potentially interactive variables including sleep disturbances; impaired self-regulation and inhibition of negative cognitions and affects; hyperassociation and set shifts; and deficits in reality testing, source attributions, and metacognition. We present an overview of the field of dissociation, delineate uncontested and converging claims across perspectives, summarize key multivariable studies in support of our framework, and identify empirical pathways for future research to advance our understanding of dissociation, including studies of highly adverse events and dissociation. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Dissociation in patients with non-affective psychosis: Prevalence, symptom associations, and maintenance factors

Dissociation is problematic in its own right for patients with psychosis but may also contribute to the occurrence of psychotic experiences. We therefore set out to estimate in a large cohort of patients with psychosis the prevalence of dissociative experiences, and assess using network models the relationships between dissociation, its potential maintenance mechanisms, and mental health symptoms. 902 patients with non-affective psychosis attending UK mental health services participated. Both an undirected model and a partially directed network model were estimated to identify potential relationships between 'felt sense of anomaly' dissociative experiences, paranoia, hallucinations, psychological wellbeing, sleep, and six potential maintenance mechanisms (affect intolerance, perseverative thinking, general self-efficacy, alexithymia, cognitive appraisals, and cognitive-behavioural responses to dissociation). 617 patients (65.4%) had experienced at least one dissociative symptom regularly over the past fortnight, with the average number experienced being 8.9 (SD = 8.0). Dissociation had direct relationships with paranoia, hallucinations, low psychological wellbeing, cognitive appraisals, cognitive-behavioural responses to dissociation, perseverative thinking, and low alexithymia. Dissociation was a probable cause of hallucinations (94.21% of 50,000 sampled directed acyclic graphs), with a trend towards also being a cause of paranoia (86.25% of 50,000 sampled directed acyclic graphs). Approximately two-thirds of patients with psychosis experience regular dissociative experiences. Dissociation is associated with low psychological wellbeing, and it is likely to have a direct causal influence on psychotic symptoms. Catastrophic cognitive appraisals, cognitive-behavioural responses to dissociation, factors related to affect sensitivity, and perseverative thinking may contribute to the occurrence of dissociation.

Dissociation in relation to other mental health conditions: An exploration using network analysis

Dissociative experiences, traditionally studied in relation to trauma and PTSD, may be important phenomena across many different psychological conditions, including as a contributory causal factor for psychotic experiences. In this study, the aim was to explore, using network approaches, how dissociative experiences taking the form of a Felt Sense of Anomaly (FSA) relate to both common mental health conditions and psychotic experiences. 6941 individuals from the general population completed online assessments of FSA-dissociation, post-traumatic stress symptoms (PTSS), anxiety, depression, insomnia, worry, distress tolerance, hallucinations, grandiosity, paranoia, and cognitive disorganization. An undirected partial correlation network analysis was used to explore the network structure, then Bayesian inference with Directed Acyclic Graphs (DAGs) was used to identify potential directions of relationships between dissociation and mental health symptoms. Dissociation was found to be highly connected in both network models. Both networks found direct relationships between dissociation and hallucinations, grandiosity, paranoia, cognitive disorganization, anxiety, depression, and PTSS. In the DAGs analysis, the direction of influence between dissociation and hallucinations, PTSS, anxiety and depression was unclear, however it was found to be probable that dissociation influences paranoia (97.66% of sampled DAGs found the direction dissociation to paranoia, versus 2.34% finding the reverse direction), cognitive disorganization (99.74% vs. 0.26%), and grandiosity (93.49% vs. 6.51%). Further, dissociation was found to be a probable influence of insomnia and distress tolerance via indirect pathways. In summary, dissociation is connected to many mental health disorders, and may influence a number of presentations, particularly psychotic experiences. The importance of dissociation in mental health may therefore currently be under-recognised.

Feelings, Thoughts, and Behaviors During Disaster

Thoughts, feelings, and behaviors during traumatic events, that is, peritraumatic reactions, are key to post-trauma psychopathology development. Qualitative research is required to investigate whether existing quantitative methods capture the range and complexity of peritraumatic reactions as described by survivors. Semi-structured interviews were conducted with 104 earthquake survivors. Participants reported experiencing various peritraumatic reactions (M = 21, range = 6-43). The survivors' accounts confirmed presence and overall phenomenological characteristics of commonly studied peritraumatic reactions such as dissociation, distress, mental defeat, and immobility. In addition, novel and understudied reactions were identified: cognitive overload, hyperfocus, and emotion regulation, as well as positive affect. Finally, a number of cross-cutting phenomena were identified such as the social nature of many reactions and survivors evaluating their reactions as difficult to put into words. These findings have implications for the conceptualization of peritraumatic reactions, for trauma-focused psychotherapeutic interventions, and for the wellbeing of disaster survivors.

A new perspective and assessment measure for common dissociative experiences: 'Felt Sense of Anomaly'

BACKGROUND

Dissociative experiences occur across a range of mental health disorders. However, the term 'dissociation' has long been argued to lack conceptual clarity and may describe several distinct phenomena. We therefore aimed to conceptualise and empirically establish a discrete subset of dissociative experiences and develop a corresponding assessment measure.

METHODS

First, a systematic review of existing measures was carried out to identify themes across dissociative experiences. A theme of 'Felt Sense of Anomaly' (FSA) emerged. Second, assessment items were generated based on this construct and a measure developed using exploratory (EFA) and confirmatory (CFA) factor analyses of 8861 responses to an online self-report survey. Finally, the resulting measure was validated via CFA with data from 1031 patients with psychosis.

RESULTS

'Felt sense of anomaly' (FSA) was identified as common to many dissociative experiences, affecting several domains (e.g. body) and taking different forms ('types'; e.g. unfamiliarity). Items for a novel measure were therefore systematically generated using a conceptual framework whereby each item represented a type-by-domain interaction (e.g. 'my body feels unfamiliar'). Factor analysis of online responses found that FSA-dissociation manifested in seven ways: anomalous experiences of the self, body, and emotion, and altered senses of familiarity, connection, agency, and reality (Χ2 (553) = 4989.435, p<0.001, CFI = 0.929, TLI = 0.924, RMSEA = 0.052, SRMR = 0.047). Additionally, a single-factor 'global FSA' scale was produced (Χ2 (9) = 312.350, p<0.001, CFI = 0.970, TLI = 0.950, RMSEA = 0.107, SRMR = 0.021). Model fit was adequate in the clinical (psychosis) group (Χ2 (553) = 1623.641, p<0.001, CFI = 0.927, TLI = 0.921, RMSEA = 0.043, SRMR = 0.043). The scale had good convergent validity with a widely used dissociation scale (DES-II) (non-clinical: r = 0.802), excellent internal reliability (non-clinical: Cronbach's alpha = 0.98; clinical: Cronbach's alpha = 0.97), and excellent test-retest reliability (non-clinical: ICC = 0.92). Further, in non-clinical respondents scoring highly on a PTSD measure, CFA confirmed adequate model fit (Χ2 (553) = 4758.673, CFI = 0.913, TLI = 0.906, RMSEA = 0.052, SRMR = 0.054).

CONCLUSIONS

The Černis Felt Sense of Anomaly (ČEFSA) scale is a novel measure of a subset of dissociative experiences that share a core feature of FSA. It is psychometrically robust in both non-clinical and psychosis groups.

Cognitive appraisals of dissociation in psychosis: a new brief measure

BACKGROUND

Catastrophic cognitive appraisals, similar to those in anxiety disorders, are implicated in depersonalisation, a form of dissociation. No scales exist to measure appraisals of dissociative experiences. Dissociation is common in psychosis. Misinterpretations of dissociative experiences may maintain psychotic symptoms. Therefore, assessing appraisals in this context may be valuable.

AIMS

The primary aim was to develop a measure of key appraisals of dissociation in psychosis. Secondary aims were to test the relationship between appraisals and psychotic experiences (paranoia and hallucinations), and determine whether appraisals explain additional variance in psychotic symptoms above dissociative symptoms.

METHOD

Fifty items were generated from transcripts of interviews with patients. The measure was developed and psychometrically validated via factor analysis of data from 9902 general population participants and 1026 patients with psychosis. Convergent validity, test-re-test reliability, and internal reliability were assessed. Regression analyses tested relationships with psychotic symptoms.

RESULTS

A 13-item single-factor measure was developed. Factor analysis indicated good model fit [χ2(65) = 247.173, comparative fit index (CFI) = 0.960, root mean square error of approximation (RMSEA) = 0.052]. The scale had good convergent validity with a rumination (non-clinical: r = 0.71; clinical: r = 0.73) and dissociation measure (r = 0.81; r = 0.80), high internal consistency (α = 0.93; α = 0.93), and excellent 1-week test-re-test reliability [intraclass correlation (ICC) = 0.90]. It explained variance in psychotic symptoms (paranoia: 36.4%; hallucinations: 35.0%), including additional variance compared with dissociation alone (paranoia: 5.3%; hallucinations: 2.3%).

CONCLUSIONS

The Cognitive Appraisals of Dissociation in Psychosis (CAD-P) measure is a psychometrically robust scale identifying appraisals of dissociative experiences in psychosis and is associated with the presence of psychotic experiences. It is likely to prove useful for clinical assessment and research.