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Mazinan RG, Dudek C, Warkentin H, Finkenstaedt M, Schröder J, Musil R, Kratzer L, Fuss J, Biedermann SV. Borderline personality disorder and sexuality: causes and consequences of dissociative symptoms. Borderline Personal Disord Emot Dysregul 2024; 11:8. [PMID: 38500169 PMCID: PMC10949637 DOI: 10.1186/s40479-024-00251-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/05/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Sexual risk behavior in patients diagnosed with borderline personality disorder (BPD) is supposed to be associated with traumatic experiences and dissociative symptoms. Nevertheless, scientific research thereon is scarce which might be due to the high prevalence of sexual trauma and fear of overwhelming patients with explicit sexual content. METHODS We investigated a clinical sample of patients diagnosed with BPD (n = 114) and compared them to a sample of matched healthy controls (HC) (n = 114) concerning the dissociative symptoms derealization, depersonalization, and conversion in sexual situations. In a subgroup of patients with BPD (n = 41) and matched HC (n = 40) dissociative symptoms after exposure to an acoustically presented erotic narrative were assessed in the lab. Regression analyses were used to examine the associations between sexual trauma, post-traumatic stress disorder (PTSD), dissociation in sexual situations, and risky sexual behavior. RESULTS Patients diagnosed with BPD endorsed higher dissociative symptoms in sexual situations retrospectively and in the lab compared to HC. Regression analyses revealed that depersonalization and conversion symptoms in sexual situations were explained by severity of BPD, while derealization was explained by PTSD symptomatology. Impulsive and sexual behavior with an uncommitted partner were higher in the BPD group and explained by derealization, while conversion showed an inverse association. CONCLUSION Our findings highlight the importance of addressing distinct dissociative symptoms in sexual situations when counselling and treating women with BPD. In the long term, this could contribute to a reduction in sexual risk behavior in patients with BPD. TRIAL REGISTRATION This analysis is part of a larger ongoing study and was registered prior to accessing the data (Registration trial DRKS00029716).
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Affiliation(s)
- Rose Gholami Mazinan
- Social and Emotional Neuroscience Group, Department of Psychiatry and Psychotherapy, Center of Psychosocial Medicine, University Medical Center Hamburg- Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Christina Dudek
- Department of Psychiatry and Psychotherapy, Psychiatric Clinic of LMU, Munich Ludwig Maximilians-Universität München, München, Germany
| | - Hannah Warkentin
- Social and Emotional Neuroscience Group, Department of Psychiatry and Psychotherapy, Center of Psychosocial Medicine, University Medical Center Hamburg- Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Maja Finkenstaedt
- Social and Emotional Neuroscience Group, Department of Psychiatry and Psychotherapy, Center of Psychosocial Medicine, University Medical Center Hamburg- Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Institute of Forensic Psychiatry and Sex Research, Center for Translational Neuro- and Behavioral Sciences, University of Duisburg-Essen, Essen, Germany
| | - Johanna Schröder
- Institute for Clinical Psychology and Psychotherapy, Department for Psychology, Medical School Hamburg, Hamburg, Germany
| | - Richard Musil
- Department of Psychiatry and Psychotherapy, Psychiatric Clinic of LMU, Munich Ludwig Maximilians-Universität München, München, Germany
- Oberberg Fachklinik Bad Tölz, Bad Tölz, Germany
| | - Leonhard Kratzer
- Department of Psychotraumatology, Clinic St Irmingard, Osternacher Strasse 103, 83209, Prien am Chiemsee, Germany
| | - Johannes Fuss
- Institute of Forensic Psychiatry and Sex Research, Center for Translational Neuro- and Behavioral Sciences, University of Duisburg-Essen, Essen, Germany
| | - Sarah V Biedermann
- Social and Emotional Neuroscience Group, Department of Psychiatry and Psychotherapy, Center of Psychosocial Medicine, University Medical Center Hamburg- Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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Černis E, Loe BS, Lofthouse K, Waite P, Molodynski A, Ehlers A, Freeman D. Measuring dissociation across adolescence and adulthood: developing the short-form Černis Felt Sense of Anomaly scale (ČEFSA-14). Behav Cogn Psychother 2024; 52:163-177. [PMID: 37926868 PMCID: PMC7615643 DOI: 10.1017/s1352465823000498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
BACKGROUND Dissociation may be important across many mental health disorders, but has been variously conceptualised and measured. We introduced a conceptualisation of a common type of dissociative experience, 'felt sense of anomaly' (FSA), and developed a corresponding measure, the Černis Felt Sense of Anomaly (ČEFSA) scale. AIMS We aimed to develop a short-form version of the ČEFSA that is valid for adolescent and adult respondents. METHOD Data were collected from 1031 adult NHS patients with psychosis and 932 adult and 1233 adolescent non-clinical online survey respondents. Local structural equation modelling (LSEM) was used to establish measurement invariance of items across the age range. Ant colony optimisation (ACO) was used to produce a 14-item short-form measure. Finally, the expected test score function derived from item response theory modelling guided the establishment of interpretive scoring ranges. RESULTS LSEM indicated 25 items of the original 35-item ČEFSA were age invariant. They were also invariant across gender and clinical status. ACO of these items produced a 14-item short-form (ČEFSA-14) with excellent psychometric properties (CFI=0.992; TLI=0.987; RMSEA=0.034; SRMR=0.017; Cronbach's alpha=0.92). Score ranges were established based on the expected test scores at approximately 0.7, 1.25 and 2.0 theta (equivalent to standard deviations above the mean). Scores of 29 and above may indicate elevated levels of FSA-dissociation. CONCLUSIONS The ČEFSA-14 is a psychometrically valid measure of FSA-dissociation for adolescents and adults. It can be used with clinical and non-clinical respondents. It could be used by clinicians as an initial tool to explore dissociation with their clients.
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Affiliation(s)
- Emma Černis
- School of Psychology, University of Birmingham, Edgbaston,
Birmingham, B15 2TT
- Institute for Mental Health, University of Birmingham, Edgbaston,
Birmingham, B15 2TT
- Department of Psychiatry, University of Oxford, Warneford Lane,
Oxford, OX3 7JX
| | - Bao S. Loe
- The Psychometrics Centre, University of Cambridge, Cambridge Judge
Business School, Trumpington Street, Cambridge CB2 1AG
| | - Katie Lofthouse
- Department of Experimental Psychology, University of Oxford, New
Radcliffe House, Oxford, OX2 6GG
- University of East Anglia, Norwich Medical School, Chancellors
Drive, Norwich, NR4 7TJ
| | - Polly Waite
- Department of Psychiatry, University of Oxford, Warneford Lane,
Oxford, OX3 7JX
- Department of Experimental Psychology, University of Oxford, New
Radcliffe House, Oxford, OX2 6GG
| | - Andrew Molodynski
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, OX3
7JX
| | - Anke Ehlers
- Department of Experimental Psychology, University of Oxford, New
Radcliffe House, Oxford, OX2 6GG
- Oxford Centre for Anxiety Disorders and Trauma, Department of
Experimental Psychology, University of Oxford, The Old Rectory, Paradise Square,
Oxford, OX1 1TW
| | - Daniel Freeman
- Department of Experimental Psychology, University of Oxford, New
Radcliffe House, Oxford, OX2 6GG
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, OX3
7JX
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Shipp L, Musatova A, Černis E, Waite P. The relationship between dissociation and panic symptoms in adolescence and the exploration of potential mediators. JCPP ADVANCES 2024; 4:e12202. [PMID: 38486953 PMCID: PMC10933600 DOI: 10.1002/jcv2.12202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 09/12/2023] [Indexed: 03/17/2024] Open
Abstract
Background Dissociative experiences have been linked to panic symptoms in adolescents, yet the nature of the association remains unclear. Methods In the present study, we investigated the longitudinal relationship between dissociative experiences (focusing on the felt sense of anomaly subtype) and panic, as well as the potential mediating roles of emotion regulation strategies (expressive suppression and cognitive reappraisal), alexithymia, and cognitive appraisals of dissociation. Four thousand five hundred one adolescents aged 13-18 years were recruited via social media advertising to take part in an online survey at two timepoints, 1 month apart. Results Analysis of 421 datasets found a significant positive relationship between initial dissociative experiences and panic symptoms reported 1 month later. This was mediated by the emotion regulation strategy of cognitive reappraisal, and cognitive appraisals of dissociation. These two variables were no longer significant mediators when controlling for panic symptoms at the first time point, likely due to the stability of panic symptoms across both assessments. Neither alexithymia nor expressive suppression were significant mediators. Conclusions Thus, dissociative experiences that are persistently misinterpreted in a catastrophic manner may lead to escalating anxiety and panic symptoms, which could in turn heighten and maintain the feared dissociation sensation. These results indicate that dissociative experiences are associated with panic symptoms in adolescence, with cognitive appraisals of dissociation and cognitive reappraisal playing a role in this relationship.
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Affiliation(s)
- Lottie Shipp
- Department of Experimental PsychologyUniversity of OxfordOxfordUK
| | - Alisa Musatova
- Department of Experimental PsychologyUniversity of OxfordOxfordUK
| | - Emma Černis
- School of PsychologyUniversity of BirminghamBirminghamUK
- Department of PsychiatryUniversity of OxfordOxfordUK
| | - Polly Waite
- Department of Experimental PsychologyUniversity of OxfordOxfordUK
- Department of PsychiatryUniversity of OxfordOxfordUK
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Beals K, Torregrossa LJ, Smith R, Lane RD, Sheffield JM. Impaired emotional awareness is associated with childhood maltreatment exposure and positive symptoms in schizophrenia. Front Psychiatry 2024; 14:1325617. [PMID: 38283891 PMCID: PMC10811959 DOI: 10.3389/fpsyt.2023.1325617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 12/14/2023] [Indexed: 01/30/2024] Open
Abstract
Objectives Evidence suggests that emotional awareness-the ability to identify and label emotions-may be impaired in schizophrenia and related to positive symptom severity. Exposure to childhood maltreatment is a risk factor for both low emotional awareness and positive symptoms. Methods The current investigation examines associations between a performance-based measure of emotional awareness, positive symptom severity, and childhood maltreatment exposure in 44 individuals with a schizophrenia-spectrum disorder and 48 healthy comparison participants using the electronic Levels of Emotional Awareness Scale (eLEAS), Positive and Negative Syndrome Scale (PANSS) and Childhood Trauma Questionnaire (CTQ). Results Patients demonstrated significant deficits in emotional awareness overall, which was true for both self and others. In patients, lower emotional awareness was significantly associated with more severe positive symptoms. Emotional awareness was significantly impaired in patients with schizophrenia with self-reported maltreatment exposure, relative to other groups. Severity of maltreatment was not significantly associated with emotional awareness or positive symptoms when looking continuously, and there was no significant indirect effect. Conclusion These data suggest that emotional awareness impairments observed in schizophrenia may be exacerbated by exposure to childhood maltreatment, possibly putting individuals at greater risk for experiencing positive symptoms of psychosis.
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Affiliation(s)
- Kendall Beals
- Sheffield Lab, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
- Social Cognition and Recovery in Schizophrenia Lab, Department of Psychology, The University of Southern Mississippi, Hattiesburg, MS, United States
| | - Lénie J. Torregrossa
- Sheffield Lab, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Ryan Smith
- Laureate Institute for Brain Research, Tulsa, OK, United States
| | - Richard David Lane
- Department of Psychiatry, University of Arizona, Tucson, AZ, United States
| | - Julia M. Sheffield
- Sheffield Lab, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
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Freeman D, Loe BS. Explaining paranoia: cognitive and social processes in the occurrence of extreme mistrust. BMJ MENTAL HEALTH 2023; 26:e300880. [PMID: 37945313 PMCID: PMC10649488 DOI: 10.1136/bmjment-2023-300880] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Paranoia-incorrectly thinking that others are deliberating trying to harm you-causes distress, undermines social interactions and leads to withdrawal. It presents across multiple psychiatric diagnoses. OBJECTIVE The primary aim was to determine the extent that cognitive and social processes may explain paranoia. The secondary aim was to identify explanatory factors that distinguished paranoia and social anxiety. METHODS 10 382 UK adults, quota sampled to match the population for age, gender, ethnicity, income and region, participated in a non-probability survey. All participants completed a paranoia measure and assessments of cognitive and social processes. Structural equation modelling was conducted. FINDINGS 2586 (24.9%) participants described being mistrustful of other people. 1756 (16.9%) participants wanted help to trust more. 66.7% of variance in paranoia was explained by a model comprising (in descending order of importance): within-situation defence behaviours, negative images, negative self-beliefs, discrimination, dissociation, aberrant salience, anxiety sensitivity, agoraphobic distress, worry, less social support, agoraphobic avoidance, less analytical reasoning and alcohol use. All explanatory factors were associated with paranoia and social anxiety. Ten factors were more closely associated with paranoia than social anxiety, including discrimination, hallucinations, negative images, aberrant salience and alcohol use. Nine factors were more closely associated with social anxiety, including less positive self-belief, an external locus of control, worry and less analytical reasoning. CONCLUSIONS Multiple causes are likely to be involved in paranoia. Cognitive and social processes may explain a high degree of paranoia. CLINICAL IMPLICATIONS Multiple clear targets for intervention to reduce paranoia are identified.
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Affiliation(s)
- Daniel Freeman
- Department of Experimental Psychology, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
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Waite F, Černis E, Kabir T, Iredale E, Johns L, Maughan D, Diamond R, Seddon R, Williams N, Yu LM, Freeman D. A targeted psychological treatment for sleep problems in young people at ultra-high risk of psychosis in England (SleepWell): a parallel group, single-blind, randomised controlled feasibility trial. Lancet Psychiatry 2023; 10:706-718. [PMID: 37562423 DOI: 10.1016/s2215-0366(23)00203-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/31/2023] [Accepted: 06/07/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Sleep disturbance is common and problematic for young people at ultra-high risk of psychosis. Sleep disruption is a contributory causal factor in the occurrence of mental health problems, including psychotic experiences, anxiety, and depression. The implication is that treating sleep problems might have additional benefits on mental health outcomes in individuals at high risk. The present study had two aims: first, to establish the feasibility and acceptability of a randomised controlled trial to treat sleep problems with the aim of reducing psychotic experiences in young people at ultra-high risk of psychosis; and second, to provide proof of concept of the clinical efficacy of the treatment. METHODS We did a parallel group, single-blind, randomised controlled feasibility trial in two National Health Service trusts in England. Eligible participants were aged 14-25 years, a patient of mental health services, assessed as being at ultra-high risk of psychosis on the Comprehensive Assessment of At-Risk Mental States, and having current sleep problems (score of ≥15 on the self-report Insomnia Severity Index [ISI]). Participants were randomly assigned (1:1) to either a targeted psychological therapy for sleep problems (SleepWell) plus usual care or usual care alone via an automated online system, with non-deterministic minimisation that balanced participants for ISI score and referring service. The SleepWell therapy was delivered on an individual basis in approximately eight 1-h sessions over 12 weeks. Assessments were done at 0, 3, and 9 months, with trial assessors masked to treatment allocation. The key feasibility outcomes were the numbers of patients identified, recruited, and retained, treatment uptake, and data completion. Treatment acceptability was measured with the Abbreviated Acceptability Rating Profile (AARP). In preliminary clinical assessments, the primary clinical outcome was insomnia at 3 and 9 months assessed with the ISI, reported by randomised group (intention-to-treat analysis). Safety was assessed in all randomly assigned participants. The trial was prospectively registered on ISRCTN, 85601537, and is completed. FINDINGS From Nov 18, 2020, to Jan 26, 2022, 67 young people were screened, of whom 40 (60%) at ultra-high risk of psychosis were recruited. Mean age was 16·9 years (SD 2·5; range 14-23), and most participants identified as female (n=19 [48%]) or male (n=19 [48%]) and as White (n=32 [80%]). 21 participants were randomly assigned to SleepWell therapy plus usual care and 19 to usual care alone. All participants provided data on at least one follow-up visit. 39 (98%) of 40 participants completed the primary outcome assessment at 3 and 9 months. 20 (95%) of 21 participants assigned to SleepWell therapy received the prespecified minimum treatment dose of at least four sessions. The median treatment acceptability score on the AARP was 48 (IQR 46 to 48; n=17; maximum possible score 48). At the post-intervention follow-up (3 months), compared with the usual care alone group, the SleepWell therapy group had a reduction in insomnia severity (ISI adjusted mean difference -8·12 [95% CI -11·60 to -4·63]; Cohen's d=-2·67 [95% CI -3·81 to -1·52]), which was sustained at 9 months (ISI adjusted mean difference -5·83 [-9·31 to -2·35]; Cohen's d=-1·91 [-3·06 to -0·77]). Among the 40 participants, eight adverse events were reported in six participants (two [11%] participants in the usual care group and four [19%] participants in the SleepWell therapy group). One serious adverse event involving hospital admission for a physical health problem was reported in the SleepWell therapy group, and one patient in the usual care alone group transitioned to psychosis. None of these events were classed as being related to trial treatment or procedures. INTERPRETATION A randomised controlled trial of a targeted psychological sleep therapy for young people at ultra-high risk of psychosis is feasible. Patients can be retained in the trial and assessments done by masked assessors. Uptake of the sleep therapy was high, and we found preliminary evidence of sustained reductions in sleep problems. A definitive multicentre trial is now needed. FUNDING NIHR Research for Patient Benefit and NIHR Oxford Health Biomedical Research Centre.
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Affiliation(s)
- Felicity Waite
- Department of Experimental Psychology, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK; Psychological Therapies Theme, NIHR Oxford Health Biomedical Research Centre, Oxford, UK.
| | - Emma Černis
- Department of Experimental Psychology, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK
| | | | - Ellen Iredale
- Department of Experimental Psychology, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK
| | - Louise Johns
- Early Intervention in Psychosis Service, Oxford Health NHS Foundation Trust, Oxford, UK
| | - Daniel Maughan
- Early Intervention in Psychosis Service, Oxford Health NHS Foundation Trust, Oxford, UK
| | - Rowan Diamond
- Department of Experimental Psychology, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK
| | - Rebecca Seddon
- Oxford Primary Care Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nicola Williams
- Oxford Primary Care Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ly-Mee Yu
- Oxford Primary Care Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Daniel Freeman
- Department of Experimental Psychology, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK; Psychological Therapies Theme, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
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Lofthouse MK, Waite P, Černis E. Developing an understanding of the relationship between anxiety and dissociation in adolescence. Psychiatry Res 2023; 324:115219. [PMID: 37119790 DOI: 10.1016/j.psychres.2023.115219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 04/06/2023] [Accepted: 04/22/2023] [Indexed: 05/01/2023]
Abstract
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.
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Affiliation(s)
- Miss Katie Lofthouse
- University of Oxford, Department of Experimental Psychology, Anna Watts Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, United Kingdom; University of East Anglia, Norwich Medical School, Chancellors Drive, Norwich NR4 7TJ, United Kingdom
| | - Polly Waite
- University of Oxford, Department of Experimental Psychology, Anna Watts Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, United Kingdom; University of Oxford, Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, United Kingdom.
| | - Emma Černis
- University of Oxford, Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, United Kingdom; Oxford Health NHS Foundation Trust, Oxford OX3 7JX, United Kingdom; University of Birmingham School of Psychology, Edgbaston, Birmingham B15 2TT, United Kingdom
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Fung HW, Černis E, Shum MHY. Self-stigma predicts post-traumatic and depressive symptoms in traumatized individuals seeking interventions for dissociative symptoms: a preliminary investigation. Eur J Psychotraumatol 2023; 14:2251778. [PMID: 37682581 PMCID: PMC10494730 DOI: 10.1080/20008066.2023.2251778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/23/2023] [Accepted: 07/31/2023] [Indexed: 09/09/2023] Open
Abstract
Background: Previous studies showed that self-stigma is associated with poor clinical outcomes in people with serious mental illness, and is associated with post-traumatic stress disorder (PTSD). However, less is known about self-stigma in people with dissociative symptoms, which are often related to psychological trauma. This study examined whether baseline self-stigma would be associated with dissociative, PTSD and depressive symptoms at post-intervention, after controlling for treatment usage and baseline symptom severity, in a sample of traumatized Chinese adults undertaking a psychoeducation intervention for dissociative symptoms.Methods: We conducted a secondary analysis of data from a 60-day web-based psychoeducation programme. A total of 58 participants who provided data before and after the intervention were included for analysis. Hierarchical regression analyses were conducted.Results: In this highly traumatized, dissociative, and symptomatic help-seeking sample, baseline self-stigma was associated with PTSD (β = .203, p = .032) and depressive (β = .264, p = .025) symptoms at post-intervention, even after controlling for baseline symptom severity, age, location, number of sessions attended in the web-based psychoeducation programme, and use of psychological treatments for PTSD/dissociative symptoms. However, self-stigma was not associated with dissociative symptoms (p = .108).Conclusions: This is the first study showing that self-stigma is a significant predictor of comorbid symptoms (i.e. PTSD and depressive symptoms) in people seeking interventions for dissociative symptoms. The findings that post-traumatic and dissociative symptoms have different relationships to self-stigma also highlight the possibility dissociation might be an independent psychological construct closely associated with trauma, but not merely a PTSD symptom, although further studies are necessary. The preliminary findings call for more efforts to understand, prevent, and address self-stigma in people with trauma-related mental health issues such as dissociative symptoms.
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Affiliation(s)
- Hong Wang Fung
- Department of Social Work, Hong Kong Baptist University, Kowloon Tong, Hong Kong
| | - Emma Černis
- School of Psychology, University of Birmingham, Birmingham, UK
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Mertens YL, Daniels JK. The Clinician-Administered Dissociative States Scale (CADSS): Validation of the German Version. J Trauma Dissociation 2022; 23:366-384. [PMID: 34670474 DOI: 10.1080/15299732.2021.1989111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The Clinician-Administered Dissociative States Scale (CADSS) is a structured clinical interview to assess state dissociation rated by clinicians. The current study aimed to validate the German version of CADSS by comparing it to the established self-report measures for dissociation and exploring its underlying factor structure. Severity of within-session state dissociation was assessed directly following a standard psychotherapy session in a trauma-exposed patient sample (N= 105; 81.9% female). Internal consistency, convergent validity with other dissociation measures, and the factorial structure of the instrument were analyzed. The German version exhibited excellent internal consistency (Cronbach's α = .94) and correlated significantly with self-report measures of state dissociation (r = .86) and trait dissociation (r = .77) indicative of high convergent validity. Exploratory factor analysis revealed a three-factor solution with the factors (1) Depersonalization/Derealization, (2) Identity Confusion/Alteration, and (3) Amnesia. Results support the CADSS as a useful instrument to assess state dissociation, conceptualized as a multidimensional construct, in clinical practice.
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Affiliation(s)
- Yoki L Mertens
- Department of Clinical Psychology, University of Groningen, Groningen, Netherlands
| | - Judith K Daniels
- Department of Clinical Psychology, University of Groningen, Groningen, Netherlands
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Černis E, Ehlers A, Freeman D. Psychological mechanisms connected to dissociation: Generating hypotheses using network analyses. J Psychiatr Res 2022; 148:165-173. [PMID: 35124396 PMCID: PMC8968218 DOI: 10.1016/j.jpsychires.2022.01.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 01/18/2022] [Accepted: 01/26/2022] [Indexed: 11/26/2022]
Abstract
A large number of mechanisms, many relating to the processing of affect, have been proposed to cause dissociation. The aim of this study was to use network analyses to identify psychological processes most closely connected with 'felt sense of anomaly' dissociative experiences. Both an undirected model and a partially directed network model were estimated using data from 6161 general population respondents collected online. The networks were used to identify relationships between dissociation and ten candidate mechanisms: cognitive appraisals, behavioural responses to dissociation, affect intolerance, alexithymia, attentional control, body vigilance, anxiety sensitivity, general self-efficacy, perseverative thinking, and beliefs regarding stress. Both models indicated a highly connected network in which dissociation had direct connections with six psychological processes: cognitive appraisals, behavioural responses, perseverative thinking, alexithymia, general self-efficacy, and beliefs about being overwhelmed. The strongest connection in both networks was between dissociation and cognitive appraisals (causal effect 0.73). The causal direction of connections could not be statistically determined with confidence, apart from the strong probability that dissociation causes meta-cognitions about being overwhelmed (98.54% of 50,000 sampled directed acyclic graphs). Both networks suggest that cognitive appraisals and factors relating to heightened (negative) sensitivity to affect are closely connected to dissociation. Dissociative experiences may arise from a high sensitivity to affect leading to threat-based appraisals that are ruminated upon and maintained by unhelpful behaviours such as avoidance. Investigation of these relationships in clinical groups, and direct causal tests, are required.
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Affiliation(s)
- Emma Černis
- University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, OX3 7JX, UK.
| | - Anke Ehlers
- Oxford Centre for Anxiety Disorders and Trauma, Department of Experimental Psychology, University of Oxford, The Old Rectory, Paradise Square, Oxford, OX1 1TW, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, OX3 7JX, UK
| | - Daniel Freeman
- University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, OX3 7JX, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, OX3 7JX, UK
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High dissociatives, nature versus nurture? CURRENT PSYCHOLOGY 2022. [DOI: 10.1007/s12144-021-02663-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AbstractNon-pathological dissociative experiences are common among the general population, and anyone may experience them to some degree. Thus, the aim of this study was to assess the degree of dissociative experiences such as fantasy proneness, imagination, and absorption in fine arts undergraduates prior to beginning their artistic studies, and at the end of their studies at the faculty of fine arts. Moreover, education undergraduates were used as a comparison group. The sample consisted of 440 undergraduates (204 fine arts, and 236 education undergraduates; 224 first-year undergraduates, and 216 fourth-year undergraduates), who were administered three dissociative experiences tests: Dissociative Ability Scale, Dissociative Experiences Scale, and Questionnaire of Experiences of Dissociation. The working hypotheses were substantiated with dissociative experiences being a distinctive personality trait of fine arts undergraduates. We have found a grade level difference between first-year and fourth-year fine arts undergraduates, although the study does not examine the nature of the change itself. The results are discussed in the light of previous studies, and new lines of research proposed.
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Černis E, Molodynski A, Ehlers A, Freeman D. Dissociation in patients with non-affective psychosis: Prevalence, symptom associations, and maintenance factors. Schizophr Res 2022; 239:11-18. [PMID: 34800911 PMCID: PMC8765411 DOI: 10.1016/j.schres.2021.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/27/2021] [Accepted: 11/07/2021] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Emma Černis
- University of Oxford Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, United Kingdom.
| | - Andrew Molodynski
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford OX3 7JX, United Kingdom.
| | - Anke Ehlers
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford OX3 7JX, United Kingdom; Oxford Centre for Anxiety Disorders and Trauma, Department of Experimental Psychology, University of Oxford, The Old Rectory, Paradise Square, Oxford OX1 1TW, United Kingdom.
| | - Daniel Freeman
- University of Oxford Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, United Kingdom; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford OX3 7JX, United Kingdom.
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Piazza GG, Iskandar G, Hennessy V, Zhao H, Walsh K, McDonnell J, Terhune DB, Das RK, Kamboj SK. Pharmacological modelling of dissociation and psychosis: an evaluation of the Clinician Administered Dissociative States Scale and Psychotomimetic States Inventory during nitrous oxide ('laughing gas')-induced anomalous states. Psychopharmacology (Berl) 2022; 239:2317-2329. [PMID: 35348804 PMCID: PMC9205822 DOI: 10.1007/s00213-022-06121-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 03/15/2022] [Indexed: 12/13/2022]
Abstract
RATIONALE A significant obstacle to an improved understanding of pathological dissociative and psychosis-like states is the lack of readily implemented pharmacological models of these experiences. Ketamine has dissociative and psychotomimetic effects but can be difficult to use outside of medical and clinical-research facilities. Alternatively, nitrous oxide (N2O) - like ketamine, a dissociative anaesthetic and NMDAR antagonist - has numerous properties that make it an attractive alternative for modelling dissociation and psychosis. However, development and testing of such pharmacological models relies on well-characterized measurement instruments. OBJECTIVES To examine the factor structures of the Clinician Administered Dissociative States Scale (CADSS) and Psychotomimetic States Inventory (PSI) administered during N2O inhalation in healthy volunteers. METHODS Secondary analyses of data pooled from three previous N2O studies with healthy volunteers. RESULTS Effect sizes for N2O-induced dissociation and psychotomimesis were comparable to effects reported in experimental studies with sub-anaesthetic ketamine in healthy volunteers. Although, like ketamine, a three-factor representation of N2O-induced dissociation was confirmed, and a more parsimonious two-factor model might be more appropriate. Bayesian exploratory factor analysis suggested that N2O-induced psychosis-like symptoms were adequately represented by two negative and two positive symptom factors. Hierarchical cluster analysis indicated minimal item overlap between the CADSS and PSI. CONCLUSION N2O and ketamine produce psychometrically similar dissociative states, although parallels in their psychosis-like effects remain to be determined. The CADSS and PSI tap largely non-overlapping experiences under N2O and we propose the use of both measures (or similar instruments) to comprehensively assess anomalous subjective states produced by dissociative NMDAR antagonists.
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Affiliation(s)
- Giulia G. Piazza
- grid.83440.3b0000000121901201Clinical Psychopharmacology Unit, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Georges Iskandar
- grid.83440.3b0000000121901201Clinical Psychopharmacology Unit, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK ,grid.439749.40000 0004 0612 2754Department of Anaesthesia and Perioperative Medicine, University College London Hospital, London, UK
| | - Vanessa Hennessy
- grid.83440.3b0000000121901201Clinical Psychopharmacology Unit, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Hannah Zhao
- grid.83440.3b0000000121901201Clinical Psychopharmacology Unit, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Katie Walsh
- grid.83440.3b0000000121901201Clinical Psychopharmacology Unit, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Jeffrey McDonnell
- grid.83440.3b0000000121901201Clinical Psychopharmacology Unit, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Devin B. Terhune
- grid.4464.20000 0001 2161 2573Department of Psychology, Goldsmiths, University of London, London, UK
| | - Ravi K. Das
- grid.83440.3b0000000121901201Clinical Psychopharmacology Unit, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Sunjeev K. Kamboj
- grid.83440.3b0000000121901201Clinical Psychopharmacology Unit, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
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Černis E, Evans R, Ehlers A, Freeman D. Dissociation in relation to other mental health conditions: An exploration using network analysis. J Psychiatr Res 2021; 136:460-467. [PMID: 33092867 PMCID: PMC8039185 DOI: 10.1016/j.jpsychires.2020.08.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/07/2020] [Accepted: 08/14/2020] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Emma Černis
- University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, OX3 7JX, UK.
| | - Robin Evans
- University of Oxford Department of Statistics, 24-29 St Giles', Oxford, OX1 3LB, UK
| | - Anke Ehlers
- Oxford Centre for Anxiety Disorders and Trauma, Department of Experimental Psychology, University of Oxford, The Old Rectory, Paradise Square, Oxford, OX1 1TW, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, OX3 7JX, UK
| | - Daniel Freeman
- University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, OX3 7JX, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, OX3 7JX, UK
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Černis E, Bird JC, Molodynski A, Ehlers A, Freeman D. Cognitive appraisals of dissociation in psychosis: a new brief measure. Behav Cogn Psychother 2020; 49:1-13. [PMID: 33446299 PMCID: PMC8293624 DOI: 10.1017/s1352465820000958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/17/2020] [Accepted: 11/20/2020] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Emma Černis
- Oxford Cognitive Approaches to Psychosis, Department of Psychiatry, University of Oxford, Oxford, UK
| | - Jessica C. Bird
- Oxford Cognitive Approaches to Psychosis, Department of Psychiatry, University of Oxford, Oxford, UK
| | | | - Anke Ehlers
- Oxford Health NHS Foundation Trust, Oxford, UK
- Oxford Centre for Anxiety Disorders and Trauma, Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Daniel Freeman
- Oxford Cognitive Approaches to Psychosis, Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
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