Dissociative detachment relates to psychotic symptoms and personality decompensation

The Indirect Effect of Peritraumatic Dissociation on the Relationship Between Childhood Maltreatment and Schizotypy

Schizotypy is a multidimensional personality construct that is understood as a vulnerability for schizophrenia, often manifesting as more subtle and attenuated symptoms, referred to as schizotypic psychopathology. It has many well-established environmental risk factors, including experiencing childhood maltreatment (CM), but the intermediary mechanisms that relate CM to schizotypic psychopathology are unclear. Prior studies have demonstrated that trait dissociation may indirectly affect the relationship between CM and schizotypic psychopathology. However, less is known about the importance of peritraumatic dissociative experiences during CM and how it relates to schizotypic symptom manifestations in young adulthood. Therefore, the present study explored the independent contributions of peritraumatic and trait dissociation in the relationship between CM and schizotypy. Participants (N = 346) were undergraduate students who completed online self-report measures on CM, trait dissociation, peritraumatic dissociation experienced during CM, and schizotypic symptoms. The indirect effect of peritraumatic dissociation and trait dissociation on the relationship between CM and schizotypy was examined using mediational analyses. Correlational analyses revealed significant associations between self-reported CM, schizotypy, trait dissociation, and peritraumatic dissociation. In addition, mediational analyses indicated a significant indirect effect of peritraumatic dissociation (β = .06, 95% confidence interval (CI) [0.01, 0.12]), but not trait dissociation (β = .05, 95% CI [-0.02, 0.12]), on CM and schizotypy. These results highlight peritraumatic dissociation as an important mechanism driving the expression of schizotypic symptoms among individuals with a history of CM. Understanding how trauma sequelae lead to schizotypic psychopathology may be crucial in assessing and treating individuals with maltreatment histories or those on the psychosis spectrum.

PTSD as a mediator of the relationship between trauma and psychotic experiences

BACKGROUND

Traumatic experiences are associated with a higher risk of psychotic illnesses, but little is known about potentially modifiable mechanisms underlying this relationship. This study aims to examine whether post-traumatic stress disorder (PTSD) symptoms mediate the relationship between trauma and psychotic experiences (PEs).

METHODS

We used data from the Avon Longitudinal Study of Parents and Children to examine whether: PTSD symptoms mediate the relationships between (a) childhood trauma and adolescent PEs (study of adolescent PEs; n = 2952), and (b) childhood/adolescent trauma and PEs in early adulthood (study of adult PEs; n = 2492). We examined associations between variables using logistic regression, and mediation using the parametric g-computation formula.

RESULTS

Exposure to trauma was associated with increased odds of PEs (adolescent PEs: OR_adjusted 1.48, 95% CI 1.23-1.78; adult PEs: OR_adjusted 1.57, 95% CI 1.25-1.98) and PTSD symptoms (adolescent PTSD: OR_adjusted 1.59, 95% CI 1.31-1.93; adult PTSD: OR_adjusted 1.50, 95% CI 1.36-1.65). The association between PTSD symptoms and PE was stronger in adolescence (OR_adjusted 4.63, 95% CI 2.34-9.17) than in adulthood (OR_adjusted 1.62, 95% CI 0.80-3.25). There was some evidence that PTSD symptoms mediated the relationship between childhood trauma and adolescent PEs (proportion mediated 14%), though evidence of mediation was weaker for adult PEs (proportion mediated 8%).

CONCLUSIONS

These findings are consistent with the hypothesis that PTSD symptoms partly mediate the association between trauma exposure and PEs. Targeting PTSD symptoms might help prevent the onset of psychotic outcomes.

The Association between Type of Dissociation and Psychotic Experiences in a Non-Psychotic Inpatient Sample

Robust evidence exists for the link between dissociation and psychotic positive symptoms. The extent to which various dissociative phenomena may contribute to this relationship is still unknown. This study aimed to investigate the association between different dissociative phenomena and psychotic experiences. For this purpose, we analyzed data from 118 consecutively admitted patients of an acute care unit for trauma-related disorders who completed the Childhood Trauma Questionnaire, the German version of the Dissociative Experiences Scale and the Symptom Check-List-90-Revised. Stepwise regression analyses revealed that derealization/depersonalization in combination with amnesia accounted for 44.5% of the variance of the psychoticism subscale of the Symptom Check-List-90-Revised. Absorption in combination with emotional abuse accounted for 24.9% of the variance of the paranoid ideation subscale of the Symptom Check-List-90-Revised. The results reveal that pathological and non-pathological types of dissociation that alter the perception of reality or memory procession may contribute to the development of psychotic experiences.

A Network Approach to Trauma, Dissociative Symptoms, and Psychosis Symptoms in Schizophrenia Spectrum Disorders

BACKGROUND

Dissociative experiences commonly occur in schizophrenia spectrum disorders (SSD). Yet little is known about how dissociative experiences in SSD are related to SSD symptoms. Accordingly, we investigated the relations between dissociative experiences and SSD symptoms, focusing on symptoms bridging these 2 symptom clusters as well as their relation to reported trauma history.

STUDY DESIGN

Network analyses were conducted on the responses of 248 individuals with an SSD who enrolled from multiple mental health centers in The Netherlands. Dissociative experiences were assessed via the Dissociative Experience Scale, SSD symptoms using the Positive and Negative Syndrome Scale, and trauma history through the Trauma History Questionnaire.

STUDY RESULTS

The results indicated that dissociative symptoms in SSD are mostly independent of other symptoms, but that emotional distress bridges between the dissociative and SSD symptom clusters. Furthermore, results revealed associations between positive and negative SSD symptoms and trauma through emotional distress, whereas dissociative symptoms remained relatively isolated.

CONCLUSION

Because SSD symptoms and dissociative experiences clustered relatively independent from each other, our findings promote the idea of tailored treatment approaches for individuals with an SSD with frequent dissociative experiences, specifically targeting these symptoms.

The moderation of maternal parenting on the association of trauma, dissociation, and psychosis in depressive inpatients

BACKGROUND

The effect of dissociation and parenting style on the relationship between psychological trauma and psychotic symptoms has not previously been investigated.

OBJECTIVE

The aim of this study was to develop a moderated mediation model to assess whether the association between psychological trauma and psychotic symptoms is mediated by dissociation and moderated by parental maltreatment.

METHODS

Inpatients with major depressive disorder (MDD) and bipolar depression (BP) were recruited. Self-reported and clinical rating scales were used to measure the level of dissociation, psychotic symptoms, history of psychological trauma and parental maltreatment. The PROCESS macro in SPSS was used to estimate path coefficients and adequacy of the moderated mediation model. High betrayal trauma (HBT), low betrayal trauma (LBT), paternal maltreatment, and maternal maltreatment were alternatively entered into the conceptual model to test the adequacy.

RESULTS

A total of 91 patients (59 with MDD and 32 with BP) were recruited, with a mean age of 40.59 ± 7.5 years. After testing with different variables, the moderated mediation model showed that the association between LBT and psychotic symptoms was mediated by dissociation and moderated by maternal maltreatment. A higher level of maternal maltreatment enhanced the effect of LBT on dissociation.

CONCLUSIONS

Healthcare workers should be aware of the risk of developing psychotic symptoms among depressive patients with a history of LBT and maternal maltreatment.

Targeting dissociation using cognitive behavioural therapy in voice hearers with psychosis and a history of interpersonal trauma: A case series

OBJECTIVES

Previous studies have suggested that dissociation might represent an important mechanism in the maintenance of auditory verbal hallucinations (i.e., voices) in people who have a history of traumatic life experiences. This study investigated whether a cognitive behavioural therapy (CBT) intervention for psychosis augmented with techniques specifically targeting dissociative symptoms could improve both dissociation and auditory hallucination severity in a sample of voice hearers with psychosis and a history of interpersonal trauma (e.g., exposure to sexual, physical, and/or emotional abuse).

DESIGN

Case series.

METHODS

A total of 19 service users with psychosis were offered up to 24 therapy sessions over a 6-month intervention window. Participants were assessed four times over a 12-month period using measures of dissociation, psychotic symptoms severity, and additional secondary mental-health and recovery measures.

RESULTS

Sixteen participants engaged in the intervention and were included in last-observation-carried-forward analyses. Dropout rates were in line with those of other CBT for psychosis trials (26.3%). Repeated measures ANOVAs revealed large and significant improvements in dissociation (d_rm  = 1.23) and hallucination severity (d_rm  = 1.09) by the end of treatment; treatment gains were maintained 6 months following the end of therapy. Large and statistically significant gains were also observed on measures of post-traumatic symptoms, delusion severity, emotional distress, and perceived recovery from psychosis.

CONCLUSIONS

The findings of this case series suggest that the reduction of dissociation represents a valuable and acceptable treatment target for clients with auditory verbal hallucinations and a trauma history. Future clinical trials might benefit from considering targeting dissociative experiences as part of psychological interventions for distressing voices.

PRACTITIONER POINTS

Practitioners should consider the role of dissociation when assessing and formulating the difficulties of voice hearers with a history of trauma. Techniques to reduce dissociation can be feasibly integrated within psychological interventions for voices. Voice hearers with histories of trauma can benefit from psychological interventions aimed at reducing dissociation.

Psychotic-like experiences? Trajectories and typologies of hallucinations and delusions from early adolescence to early adulthood in a population-based sample of Irish youth

OBJECTIVES

Hallucinations and delusions that occur in the absence of a psychotic disorder are common in children and adolescents. Longitudinal phenomenological studies exploring these experiences are notably lacking. The objective of the current paper was to explore the phenomenology and characteristics of hallucinations and delusions from early adolescence to early adulthood.

METHODS

Participants were 17 young people aged 18-21 years from the general population, all of whom had a history of childhood hallucinations and/or delusions. Longitudinal data on the phenomenological characteristics and attributions of reported hallucinatory and delusional phenomena spanning nine years were explored using content analysis.

RESULTS

Hallucinatory and delusional phenomena were transient for two-thirds of the sample. The remaining one-third reported reoccurring hallucinatory and delusional phenomena into early adulthood. In those, two typologies were identified: (1) Paranormal typology and (2) Pathological typology. The former was characterised by hallucinatory and delusional phenomena that were exclusively grounded in subcultural paranormal or spiritual belief systems and not a source of distress. The latter was characterised by delusion-like beliefs that were enmeshed with individuals' mood states and a source of distress. The perceived source, the subcultural context and how young people appraised and integrated their experiences differentiated the Paranormal and Pathological typologies.

CONCLUSIONS

Not all hallucinatory and delusion-like experiences are psychotic-like in nature. To reliably differentiate between pathological and non-pathological hallucinations and delusions, assessments need to explore factors including the phenomenology of individuals' experiences, how people make sense and appraise them, and the subcultural contexts within which they are experienced.

Psychological processes mediating the association between developmental trauma and specific psychotic symptoms in adults: a systematic review and meta-analysis

Experiencing psychological trauma during childhood and/or adolescence is associated with an increased risk of psychosis in adulthood. However, we lack a clear knowledge of how developmental trauma induces vulnerability to psychotic symptoms. Understanding the psychological processes involved in this association is crucial to the development of preventive interventions and improved treatments. We sought to systematically review the literature and combine findings using meta-analytic techniques to establish the potential roles of psychological processes in the associations between developmental trauma and specific psychotic experiences (i.e., hallucinations, delusions and paranoia). Twenty-two studies met our inclusion criteria. We found mediating roles of dissociation, emotional dysregulation and post-traumatic stress disorder (PTSD) symptoms (avoidance, numbing and hyperarousal) between developmental trauma and hallucinations. There was also evidence of a mediating role of negative schemata, i.e. mental constructs of meanings, between developmental trauma and delusions as well as paranoia. Many studies to date have been of poor quality, and the field is limited by mostly cross-sectional research. Our findings suggest that there may be distinct psy-chological pathways from developmental trauma to psychotic phenomena in adulthood. Clinicians should carefully ask people with psychosis about their history of developmental trauma, and screen patients with such a history for dissociation, emotional dysregulation and PTSD symptoms. Well conducted research with prospective designs, including neurocognitive assessment, is required in order to fully understand the biopsychosocial mechanisms underlying the association between developmental trauma and psychosis.

Dissociative Symptoms in Bipolar Disorder: Impact on Clinical Course and Treatment Response

Background: Dissociative symptoms are under recognized and scarcely studied by clinicians and researchers in patients with bipolar disorder (BD). We examined the relationship between dissociative symptoms and the psychotic features in patients with BD and assessed clinical and socio-demographic characteristics more frequently associated with dissociative symptoms and treatment response. Methods: Participants were 100 adult outpatients with BD. They were screened with semi-structured interview to collect socio-demographic and clinical characteristics; the Dissociative Experiences Scale-II (DES-II) and the ALDA scale were used to assess dissociative psychopathologies and response to treatment with mood stabilizers, respectively. Results: DES score (mean 31.7 ± 21.7) correlated with clinical variables, BD features, and course of illness. Psychotic symptoms, mixed features, and previous suicide attempts significantly predicted DES score [F _{(3, 47)} = 39.880, p < 0.001, R ² corrected = 0.713]. Dissociative symptoms were inversely correlated with poor response to treatment (r = -0.593; p < 0.001). Limitations: Cross-sectional design with a small sample and backward clinical assessment of psychotic symptoms. Conclusions: Dissociative phenomena are closely related to the presence of psychotic symptoms, mixed features, and previous suicide attempts in BD, especially in BD-I. Given the close association between dissociative and psychotic symptoms, this association could represent a diagnostic indicator of BD-I that may guide the clinician to plan the most appropriate treatment.

The Relationship Between Dissociation and Symptoms of Psychosis: A Meta-analysis

Evidence suggests that dissociation is associated with psychotic experiences, particularly hallucinations, but also other symptoms. However, until now, symptom-specific relationships with dissociation have not been comprehensively synthesized. This is the first prospectively registered (CRD42017058214) meta-analysis to quantify the magnitude of association between dissociative experiences and all symptoms of psychosis. MEDLINE, PsycINFO, PubMed, and Scopus databases were searched using exhaustive terms denoting dissociation and psychotic symptoms. We included both nonclinical (58 studies; 16 557 participants) and clinical (46 studies; 3879 patient participants) samples and evaluated study quality. Ninety-three eligible articles considering 20 436 participants were retained for analysis. There was a robust association between dissociation and clinical and nonclinical positive psychotic symptoms (r = .437; 95%CI: .386 -.486), with the observed effect larger in nonclinical studies. Symptom-specific associations were also evident across clinical and nonclinical studies, and included significant summary effects for hallucinations (r = .461; 95%CI: .386 -.531), delusions (r = .418; 95%CI: .370 -.464), paranoia (r = .447; 95%CI: .393 -.499), and disorganization (r = .346; 95%CI: .249 -.436). Associations with negative symptoms were small and, in some cases, not significant. Overall, these findings confirm that dissociative phenomena are not only robustly related to hallucinations but also to multiple positive symptoms, and less robustly related to negative symptoms. Our findings are consistent with proposals that suggest certain psychotic symptoms might be better conceptualized as dissociative in nature and support the development of interventions targeting dissociation in formulating and treating psychotic experiences.

A systematic review on mediators between adversity and psychosis: potential targets for treatment

Various psychological and biological pathways have been proposed as mediators between childhood adversity (CA) and psychosis. A systematic review of the evidence in this domain is needed. Our aim is to systematically review the evidence on psychological and biological mediators between CA and psychosis across the psychosis spectrum. This review followed PRISMA guidelines. Articles published between 1979 and July 2019 were identified through a literature search in OVID (PsychINFO, Medline and Embase) and Cochrane Libraries. The evidence by each analysis and each study is presented by group of mediator categories found. The percentage of total effect mediated was calculated. Forty-eight studies were included, 21 in clinical samples and 27 in the general population (GP) with a total of 82 352 subjects from GP and 3189 from clinical studies. The quality of studies was judged as 'fair'. Our results showed (i) solid evidence of mediation between CA and psychosis by negative cognitive schemas about the self, the world and others (NS); by dissociation and other post-traumatic stress disorder symptoms; and through an affective pathway in GP but not in subjects with disorder; (iii) lack of studies exploring biological mediators. We found evidence suggesting that various overlapping and not competing pathways involving post-traumatic and mood symptoms, as well as negative cognitions contribute partially to the link between CA and psychosis. Experiences of CA, along with relevant mediators should be routinely assessed in patients with psychosis. Evidence testing efficacy of interventions targeting such mediators through cognitive behavioural approaches and/or pharmacological means is needed in future.

Early risk and protective factors and young adult outcomes in a longitudinal sample of young people with a history of psychotic-like experiences

AIM

Psychotic-like experiences (PEs) have been associated with childhood adversity and psychopathology. However, few studies have examined the dynamic interplay between risk and protective factors and later life outcomes in people with PEs. This study aimed to explore and compare patterns of early adverse and protective experiences and young adult outcomes in a sample of young people with a history of PEs.

METHOD

Longitudinal qualitative data spanning nine years were collected from a general population sample of seventeen young adults who had reported PEs in early adolescence. A qualitative comparative case study design was used to explore patterns of early life experiences and young adult outcomes.

RESULTS

Four archetypal profiles of early life experiences and later outcomes were identified. Qualitative differences between types of early adverse experiences and the quality of attachment relationships were dominant discriminating factors between low-risk and at-risk archetypes for poor young adult outcomes. Experiences of multiple adversities, which included childhood trauma and occurred in the absence of secure attachment relationships was associated with the poorest young adult outcomes. The presence of secure attachment relationships was protective, even among individuals who had experienced adversity.

CONCLUSIONS

Not all young people who report PEs have high levels of adversity. Those who experience multiple early adversities, childhood trauma and insecure attachment relationships are at highest risk for reoccurring PEs and poor young adult outcomes. Developing trusted attachment relationships and engaging in corrective experiences may be protective and could promote positive outcomes in youth with PEs.

Exploring the relationship between auditory hallucinations, trauma and dissociation

BACKGROUND

It is clinically imperative to better understand the relationship between trauma, auditory hallucinations and dissociation. The personal narrative of trauma has enormous significance for each individual and is also important for the clinician, who must use this information to decide on a diagnosis and treatment approach.

AIMS

To better understand whether dissociation contributes in a significant way to hallucinations in individuals with and without trauma histories.

METHOD

Three groups of participants with auditory hallucinations were recruited, with diagnoses of: schizophrenia (without trauma) (n = 18), post-traumatic stress disorder (PTSD, n = 27) and comorbid schizophrenia and PTSD (SCZ+PTSD), n = 26). Clinician-administered measures included the PTSD Symptoms Scale Interview (PSSI-5), the Clinician-Administered Dissociative States Scale (CADSS) and the Psychotic Symptom Rating Scales (PSYRATS).

RESULTS

Dissociative symptoms were significantly higher in participants with trauma histories (PTSD and SCZ+PTSD groups) and significantly correlated with hallucinations in trauma-exposed participants, but not in participants with schizophrenia (without trauma history). Hallucination severity was correlated with the CADSS amnesia subscale score, but depersonalisation and derealisation were not.

CONCLUSIONS

Dissociation may be a mechanism in trauma-exposed individuals who hear voices, but it does not explain all hallucinatory experiences. The SCZ+PTSD group were in an intermediary position between schizophrenia and PTSD on dissociative and hallucination measures. The PTSD and SCZ+PTSD groups experienced dissociative phenomena much more frequently than the schizophrenia group, with a significant trend towards the amnesia subtype of dissociation.

Assessing Voice Hearing in Trauma Spectrum Disorders: A Comparison of Two Measures and a Review of the Literature

Voice hearing (VH) can occur in trauma spectrum disorders (TSD) such as posttraumatic stress disorder (PTSD) and dissociative disorders. However, previous estimates of VH among individuals with TSD vary widely. In this study, we sought to better characterize the rate and phenomenology of VH in a sample of 70 women with TSD related to childhood abuse who were receiving care in a specialized trauma program. We compared the rate of VH within our sample using two different measures: 1) the auditory hallucination (AH) item in the Structured Clinical Interview for DSM-IV-TR (SCID), and 2) the thirteen questions involving VH in the Multidimensional Inventory of Dissociation (MID), a self-report questionnaire that comprehensively assesses pathological dissociation. We found that 45.7% of our sample met threshold for SCID AH, while 91.4% met criteria for MID VH. Receiver operating characteristics (ROC) analyses showed that while SCID AH and MID VH items have greater than chance agreement, the strength of agreement is only moderate, suggesting that SCID and MID VH items measure related but not identical constructs. Thirty-two patients met criteria for both SCID AH and at least one MID VH item ("unequivocal VH"), 32 for at least one MID VH item but not SCID AH ("ambiguous VH"), and 6 met criteria for neither ("unequivocal non-VH"). Relative to the ambiguous VH group, the unequivocal VH group had higher dissociation scores for child voices, and higher mean frequencies for child voices and Schneiderian voices. Our findings suggest that VH in women with TSD related to childhood abuse is common, but that the rate of VH depends on how the question is asked. We review prior studies examining AH and/or VH in TSD, focusing on the measures used to ascertain these experiences, and conclude that our two estimates are consistent with previous studies that used comparable instruments and patient samples. Our results add to growing evidence that VH-an experience typically considered psychotic or psychotic-like-is not equivalent to having a psychotic disorder. Instruments that assess VH apart from psychotic disorders and that capture their multidimensional nature may improve identification of VH, especially among patients with non-psychotic disorders.

Severe childhood trauma and clinical and neurocognitive features in schizotypal personality disorder

OBJECTIVE

Literature suggests that childhood trauma increases vulnerability for schizophrenia-spectrum disorders, including schizotypal personality disorder (SPD). Yet, it remains unexplored whether childhood trauma predicts symptom load and the level of neurocognitive functioning in SPD.

METHOD

We included 225 individuals with SPD and 127 healthy controls. Childhood trauma was evaluated using the Childhood Trauma Questionnaire, and schizotypal traits were assessed using the Schizotypal Personality Questionnaire. Standard neurocognitive assessments covered six cognitive domains.

RESULTS

All types of reported childhood trauma were significantly associated with SPD, in a linear fashion. Severe sexual abuse showed the greatest magnitude of association with higher cognitive-perceptual load (e.g., ideas of reference, odd belief or magical thinking); severe emotional neglect was associated with interpersonal scores (e.g., excessive social anxiety, constricted affect) within the SPD group. SPD individuals who reported severe trauma showed worse cognitive functioning (i.e., working memory, verbal/visual learning and memory, as well as verbal fluency).

CONCLUSIONS

Particular severe childhood trauma types were associated with higher cognitive-perceptual and interpersonal symptoms in SPD, along with worse cognitive functioning. These findings highlight the need for clinicians to enquire about childhood trauma in SPD patients, since unaddressed early adverse experiences may carry long-term negative consequences.

Insight and Dissociation in Lucid Dreaming and Psychosis

Dreams and psychosis share several important features regarding symptoms and underlying neurobiology, which is helpful in constructing a testable model of, for example, schizophrenia and delirium. The purpose of the present communication is to discuss two major concepts in dreaming and psychosis that have received much attention in the recent literature: insight and dissociation. Both phenomena are considered functions of higher order consciousness because they involve metacognition in the form of reflective thought and attempted control of negative emotional impact. Insight in dreams is a core criterion for lucid dreams. Lucid dreams are usually accompanied by attempts to control the dream plot and dissociative elements akin to depersonalization and derealization. These concepts are also relevant in psychotic illness. Whereas insightfulness can be considered innocuous in lucid dreaming and even advantageous in psychosis, the concept of dissociation is still unresolved. The present review compares correlates and functions of insight and dissociation in lucid dreaming and psychosis. This is helpful in understanding the two concepts with regard to psychological function as well as neurophysiology.

Prevalence of auditory pseudohallucinations in adult survivors of physical and sexual trauma with chronic post-traumatic stress disorder (PTSD)

Auditory Verbal Hallucinations (AVHs) are commonly associated with psychosis but are also reported in post-traumatic stress disorder (PTSD). Hearing voices after the experience of stress has been conceptualised as a dissociative experience. Brewin and Patel's (2010) seminal study reported that hearing voices is relatively common in PTSD, as hearing voices was associated with PTSD in half and two thirds of military veterans and survivors of civilian trauma, respectively. The authors conceptualised these voices as "auditory pseudohallucinations." To build upon this work, we administered Brewin and Patel's' interview to adult survivors (n = 40) of physical and sexual trauma with chronic PTSD, and healthy controls (n = 39). In contrast to previous findings, only 5% (n = 2) of our PTSD sample reported recently hearing a voice that was consistent with an auditory pseudohallucination, with no reports in our control group. Thus, no support was provided for auditory pseudohallucinations as a significant symptom in this population.

Trauma-intrusive hallucinations and the dissociative state

BACKGROUND

Research has supported a model of dissociation mediating the experience of hearing voices in traumatised individuals.

AIMS

To further understand this model by examining subtypes of the dissociative experience involved in trauma-intrusive hallucinations.

METHOD

The study involved four hospitals, 11 psychiatrists and 69 participants assessed using the Psychotic Symptoms Rating scale, the PTSD Symptoms Scale Interview and the Dissociative Subtype of PTSD Score.

RESULTS

In total, 59% (n = 41) of the participants heard voices and they were compared with the 41% (n = 28) who did not. The severity of PTSD symptoms did not predict experience of hearing voices. Regression analysis indicated that two scales of dissociation (derealisation/depersonalisation and loss of awareness) were equally good predictors of the extent of hearing voices. Adding other possible predictors (age of trauma <18, sexual violence) was relevant but did not enhance the prediction.

CONCLUSIONS

This research supports the proposal that trauma-intrusive voices are mediated by symptoms of dissociation. The supported model describes general, rather than trauma specific, symptoms of dissociation mediating the experience of hearing voices. The concept of anchoring is discussed and suggests a potential treatment strategy, which could be useful in the clinical management of hearing voices.

DECLARATION OF INTEREST

None.

Does dissociation mediate the relationship between childhood trauma and hallucinations, delusions in first episode psychosis?

BACKGROUND

Childhood trauma has been linked to the presence of delusions and hallucinations in psychosis, although the mechanisms underlying this relationship require elucidation. Dissociation, characterized by disruptions to the integrative functioning of several core mental domains, has emerged as a potential mechanism. There is a paucity of research using a clinician-rated measure of dissociation to test the indirect effect of dissociation on the relationship between childhood trauma and psychotic symptoms. This study aimed to investigate whether dissociation mediated both the relationships between childhood trauma and hallucinations, and childhood trauma and delusions utilizing a clinician-administered measure of dissociation, namely the Structured Clinical Interview for DSM-IV Dissociative Disorders - Revised (SCID-D-R).

METHOD

Sixty-six first-episode psychosis (FEP) participants completed a research interview and questionnaires. Information about experiences of childhood trauma, psychosis, dissociation, general psychopathology and demographics were collected.

RESULTS

When using the SCID-D-R, childhood trauma positively correlated with dissociation. Further, dissociation mediated the relationship between childhood trauma and delusions. Contrary to previous findings, we found no relationship between dissociation and hallucinations and no mediating effect of dissociation on the association between childhood trauma and hallucinations. The results of the SCID-D-R differed significantly from those of the Dissociative Experiences Scale-II (DES-II) which were consistent with previous research.

CONCLUSIONS

Our findings are the first to use a clinician-rated measure to test the mediating effect of dissociation on the relationship between childhood trauma and positive symptoms (i.e., hallucinations and delusions). Given the discrepancies in results between the SCID-D-R and DES-II, how dissociation is measured in future research is an important consideration. The results add to a body of work that increasingly recognizes the importance of dissociative symptoms on the relationship between childhood trauma and psychosis. The results suggest that dissociative symptoms should be part of routine assessment in those with a history of trauma and present to FEP services.

Auditory hallucinations and PTSD in ex-POWS

Literature has suggested that auditory hallucinations might be prevalent in the general population and could be linked to the experience of trauma. This prospective study examines the prevalence of auditory hallucinations in trauma survivors and its association with posttraumatic stress disorder (PTSD) symptoms, over time. Former prisoners of war (ex-POWs) from the 1973 Yom Kippur War (n = 99) with and without PTSD and comparable veterans (n = 103) were assessed twice, in 1991 (T1) and 2003 (T2) in regard to auditory hallucinations and PTSD symptoms. Findings indicated that ex-POWs who suffered from PTSD reported higher levels of auditory hallucinations at T2 as well as increased hallucinations over time, compared to ex-POWs without PTSD and combatants who did not endure captivity. The relation between PTSD and auditory hallucinations was unidirectional, so that the PTSD overall score at T1 predicted an increase in auditory hallucinations between T1 and T2, but not vice versa. Assessing the role of PTSD clusters in predicting hallucinations revealed that intrusion symptoms had a unique contribution, compared to avoidance and hyperarousal symptoms. The findings suggest that auditory hallucinations might be a consequence of the posttraumatic reaction among veterans.

Where pseudo-hallucinations meet dissociation: a cluster analysis

OBJECTIVES

The possible link between cognitive areas of perception and integration of consciousness was examined using assessments of hallucinations and derealisation/depersonalization.

METHODS

Sixty-five subjects in three main diagnostic groups - posttraumatic stress disorder (PTSD), borderline personality disorder (BPD) and schizophrenia - identified by their treating psychiatrist as hearing voices were surveyed regarding characteristics of hallucinations, derealisation/depersonalization, delusions and childhood/adult trauma.

RESULTS

A cluster analysis produced two clusters predominantly determined by variables of hallucinations measures, childhood sexual abuse and derealisation/depersonalization scores.

CONCLUSIONS

History of childhood trauma and variability in derealisation/depersonalization scores were better predictors of external, negative, uncontrollable voices than diagnosis of BPD or PTSD. The potential links between dissociative states and pseudo-hallucinations are discussed.

Hearing voices, dissociation, and the self: A functional-analytic perspective

In the current article, we review existing models of the etiology of voice hearing. We summarize the argument and evidence that voice hearing is primarily a dissociative process involving critical aspects of self. We propose a complementary perspective on these phenomena that is based on a modern behavioral account of complex behavior known as relational frame theory. This type of approach to voice hearing concerns itself with the functions served for the individual by this voice hearing; the necessary history, such as trauma, that establishes these functions; and the relevant dissociative processes involving self and others. In short, we propose a trauma-dissociation developmental trajectory in which trauma impacts negatively on the development of self through the process of dissociation. Using the relational frame theory concept of relations of perspective taking, our dissociation model purports that trauma gives rise to more coordination than distinction relations between self and others, thus weakening an individual's sense of a distinct self. Voice hearing experiences, therefore, reflect an individual's perceptions of self and others and may indicate impairments in the natural psychological boundaries between these critical related concepts. One clinical implication suggested by this model is that therapeutic intervention should understand the behaviors associated with a sense of self that is fragile and threatened by others. Relations with self and others should be a key focus of therapy as well as interventions designed to enhance a coherent distinct sense of self.

Dissociative Experiences and Psychopathology Among Inmates in Italian and Portuguese Prisons

The association between dissociation and psychopathological symptoms is well established, yet studies with inmates are lacking. If higher rates of dissociation and psychiatric symptoms are reported in inmate samples, it is not clear whether they represent two separate, albeit related, characteristics. We examined the association between dissociation and psychopathological symptoms among 320 Italian subjects (122 inmates and 198 community participants) and a Portuguese inmate sample ( n = 67). Then, we tested whether dissociation and psychopathology levels were higher among inmates. Both hypotheses were supported, confirming the relevance of dissociative, paranoid, and psychotic symptoms among inmates, as well as their interrelations. Notably, the group difference in dissociation remained significant after partialing out the variance associated with other psychopathological symptoms. Conversely, only the difference in paranoid symptoms remained-marginally-significant when controlling for the influence of dissociation. This finding suggests that dissociation may have unique relevance for the psychological functioning of inmates.

Child death and maternal psychosis-like experiences in 44 low- and middle-income countries: The role of depression

BACKGROUND

Studies on the effect of child death on the mental wellbeing of women in low- and middle-income countries (LMICs) are scarce despite the high child mortality rates. Thus, the aim of the current study was to assess the association between child death and psychosis-like experiences (PLEs), as well as the role of depression in this association.

METHODS

Data from 44 LMICs which participated in the World Health Survey (WHS) were analyzed. A total of 59,444 women who ever gave birth, aged 18-49years, without a self-reported lifetime psychosis diagnosis, were included in the analysis. The World Mental Health Survey version of the Composite International Diagnostic Interview (CIDI) was used to establish the diagnosis of past 12-month DSM-IV depression, and assess four positive psychotic symptoms. Depression was defined as self-reported lifetime depression diagnosis and/or past 12-month depression. Multivariable logistic regression analyses were performed.

RESULTS

After adjustment for potential confounders, women who experienced child death had higher odds for all types of PLEs (when unadjusted for depression) (OR 1.20-1.71; p<0.05) and depression (OR=1.64; 95%CI=1.39-1.93). When adjusted for depression, only delusion of control was strongly associated with child death (OR=1.54; 95%CI=1.20-1.97).

CONCLUSIONS

Child death may be an important determinant of mental wellbeing among women in LMICs. Given the known adverse health outcomes associated with PLEs and depression, as well as the co-occurrence of these symptoms, mental health care may be particularly important for mothers who have experienced child loss in LMICs.

Unique and Overlapping Symptoms in Schizophrenia Spectrum and Dissociative Disorders in Relation to Models of Psychopathology: A Systematic Review

Schizophrenia spectrum disorders (SSDs) and dissociative disorders (DDs) are described in the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) and tenth edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) as 2 categorically distinct diagnostic categories. However, several studies indicate high levels of co-occurrence between these diagnostic groups, which might be explained by overlapping symptoms. The aim of this systematic review is to provide a comprehensive overview of the research concerning overlap and differences in symptoms between schizophrenia spectrum and DDs. For this purpose the PubMed, PsycINFO, and Web of Science databases were searched for relevant literature. The literature contained a large body of evidence showing the presence of symptoms of dissociation in SSDs. Although there are quantitative differences between diagnoses, overlapping symptoms are not limited to certain domains of dissociation, nor to nonpathological forms of dissociation. In addition, dissociation seems to be related to a history of trauma in SSDs, as is also seen in DDs. There is also evidence showing that positive and negative symptoms typically associated with schizophrenia may be present in DD. Implications of these results are discussed with regard to different models of psychopathology and clinical practice.

The relation of dissociation and mind wandering to unresolved/disorganized attachment: an experience sampling study

Individuals with unresolved/disorganized representations of childhood trauma (U/d attachment) report more psychological distress than others, but little is known about their everyday mentation. In the present study adults with childhood trauma (N = 45) completed the Berkeley-Leiden Adult Attachment Questionnaire-Unresolved (BLAAQ-U) and the Adult Attachment Interview (AAI), and reported everyday mentation during 5 days of experience sampling. The BLAAQ-U and the AAI showed a medium association with each other, but only the former significantly predicted negative affect, dissociation, and low control/awareness of mentation. Contrary to our predictions, U/d attachment did not significantly predict mind wandering, but the BLAAQ-U predicted endorsements of a negative mind wandering style. U/d attachment, as assessed by both instruments, was associated with the Poor attentional control style and beliefs in anomalous mental phenomena. Experience sampling is a valuable way to investigate everyday experiences in individuals with U/d attachment.

Dissociation mediates the relationship between peer victimization and hallucinatory experiences among early adolescents

Peer victimization increases the risk of experiencing psychotic symptoms among clinical and general populations, but the mechanism underlying this association remains unclear. Dissociation, which is related to peer victimization and hallucinatory experiences, has been demonstrated as a significant mediator in the relation between childhood victimization and hallucinatory experience among adult patients with psychosis. However, no studies have examined the mediating effect of dissociation in a general early adolescent population. We examined whether dissociation mediates the relationship between peer victimization and hallucinatory experiences among 10-year-old adolescents using a population-based cross-sectional survey of early adolescents and their main parent (Tokyo Early Adolescence Survey; N = 4478). We examined the mediating effect of dissociation, as well as external locus of control and depressive symptoms, on the relationship between peer victimization and hallucinatory experiences using path analysis. The model assuming mediation effects indicated good model fit (comparative fit index = .999; root mean square error of approximation = .015). The mediation effect between peer victimization and hallucination via dissociation (standardized indirect effect = .038, p < .001) was statistically significant, whereas the mediation effects of depressive symptoms (standardized indirect effect = -.0066, p = 0.318) and external locus of control (standardized indirect effect = .0024, p = 0.321) were not significant. These results suggest that dissociation is a mediator in the relation between peer victimization and hallucinatory experiences in early adolescence. For appropriate intervention strategies, assessing dissociation and peer victimization as they affect hallucinatory experiences is necessary.

The Concept of Peritraumatic Dissociation: A Qualitative Approach

Peritraumatic dissociation has been considered an important feature for the development of post-traumatic stress disorders, but this concept remains widely unclear. To explore the peritraumatic experience, we interviewed eight victims of urban violence shortly after their traumatic events. The data collected were compared and analyzed according to the systematic set of procedures of Grounded Theory (GT). The alterations reported by participants were coded and categorized according to their perceptions of their inner and outer world, and the impressions of others involved, including the examiner's observations. The theoretical perspective for interpreting this study has parallels with Jaspers' psychopathology. Peritraumatic dissociation was conceived as a failure of synthesis among emerging stimuli from the internal and the external world, including the time-space flow structure, even when cognitive-perceptual tools remain intact. This synthesis qualifies the totality of the perceptual experience as coherent and meaningful to conscience, enabling possibilities for being/existing.

Association of Ego Defense Mechanisms with Academic Performance, Anxiety and Depression in Medical Students: A Mixed Methods Study

BACKGROUND

 Ego defense mechanisms are unconscious psychological processes that help an individual to prevent anxiety when exposed to a stressful situation. These mechanisms are important in psychiatric practice to assess an individual's personality dynamics, psychopathologies, and modes of coping with stressful situations, and hence, to design appropriate individualized treatment. Our study delineates the relationship of ego defense mechanisms with anxiety, depression, and academic performance of Pakistani medical students.

METHODS

 This cross-sectional study was done at CMH Lahore Medical College and Fatima Memorial Hospital Medical and Dental College, both in Lahore, Pakistan, from December 1, 2014 to January 15, 2015. Convenience sampling was used and only students who agreed to take part in this study were included. The questionnaire consisted of three sections: 1) Demographics, documenting demographic data and academic scores on participants' most recent exams; 2) Hospital Anxiety and Depression Scale (HADS); and 3) Defense Style Questionnaire-40 (DSQ-40). The data were analyzed with SPSS v. 20. Mean scores and frequencies were calculated for demographic variables and ego defense mechanisms. Bivariate correlations, one-way ANOVA, and multiple linear regression were used to identify associations between academic scores, demographics, ego defense mechanisms, anxiety, and depression.

RESULTS

 A total of 409 medical students participated, of whom 286 (70%) were females and 123 (30%) were males. Mean percentage score on the most recent exams was 75.6% in medical students. Bivariate correlation revealed a direct association between mature and neurotic ego defense mechanisms and academic performance, and an indirect association between immature mechanisms and academic performance. One-way ANOVA showed that moderate levels of anxiety (P < .05) and low levels of depression (P < .05) were associated with higher academic performance.

CONCLUSION

 There was a significant association between academic performance and ego defense mechanisms, anxiety, and depression levels in our sample of Pakistani medical students.

Trauma and psychosis: The mediating role of self-concept clarity and dissociation

Childhood trauma (CT) and psychosis may be associated. Drawing on the dissociation and social psychological literature, the current study examined the mediating role of structural aspects of self in explaining the relationship between childhood trauma and psychosis. Twenty-nine individuals with psychosis were compared with 31 healthy volunteers regarding childhood trauma, dissociation and self-concept clarity (SCC). High rates of maltreatment were found in the psychosis sample. Additionally, clinical participants reported more dissociation and less self-concept clarity. Mediational analyses were carried out on pooled data from across both clinical and non-clinical samples. These suggested that the influence of physical neglect in increasing the likelihood of experiencing psychosis was explicable through the effects of increased dissociation. Self-concept clarity mediated the relationship between psychosis and total childhood trauma, emotional abuse, physical abuse, emotional and physical neglect. Furthermore, dissociation and self-concept clarity were strongly correlated providing evidence that they may form a unitary underlying concept of 'self-concept integration'. The study provides further evidence of the link between childhood trauma and psychosis. Self-concept integration may be adversely affected by negative childhood experiences, which increases psychosis risk. Methodological limitations, clinical implications and suggestions for future research are considered.

Ethnic variation in whether dissociation mediates the relation between traumatic life events and attenuated positive psychotic symptoms

The present study sought to determine whether dissociative experiences mediated the relationship between traumatic life events and attenuated positive psychotic symptoms in a non-treatment-seeking sample of racial and ethnic minority young adults. Participants (n = 549) completed a self-report inventory for psychosis risk (i.e., the Prodromal Questionnaire; R. L. Loewy, C. E. Bearden, J. K. Johnson, A. Raine, & T. D. Cannon, 2005), from which a total number of attenuated positive psychotic symptoms was assessed. Participants also completed a checklist of potentially traumatic life events and a traumatic dissociation scale. Hierarchical linear regression models and bootstrapping results indicated that dissociation mediated the relationship between traumatic life events and attenuated positive psychotic symptoms. Stratified analyses of Black, Asian, and Hispanic subgroups revealed that full mediation was only evident in the Black subgroup of young adults. Partial mediation was found among the Hispanic group, and no mediation occurred in the Asian subgroup. For the latter, traumatic life events were not significantly associated with dissociative experiences. A dissociative response style may be particularly relevant to trauma-exposed Black young adults exhibiting subclinical psychotic experiences and less so for Asian young adults. Trauma-induced dissociative experiences should be assessed further in clinical high-risk studies, especially among Black traumatized youth.

Depersonalization in patients with persecutory delusions

Delusions are, in part, attempts to explain confusing anomalous experience. Depersonalization, a key subset of anomalous experience, has been little studied in relation to persecutory delusions. The aims of this study were to assess the presence of depersonalization in patients with persecutory delusions and to examine associations with levels of paranoia and worry. Fifty patients with a current persecutory delusion completed measures of depersonalization, psychotic symptoms, and worry. Depersonalization experiences were common: 30 patients (60%) each reported at least 10 different depersonalization symptoms occurring often. A greater number of depersonalization experiences were associated with higher levels of paranoia and worry. The positive association of worry and paranoia became nonsignificant when controlling for depersonalization. Overall, depersonalization may be common in patients with persecutory delusions and is associated with the severity of paranoia. The results are consistent with the view that worry may cause depersonalization experiences that contribute to the occurrence of paranoid thoughts.

Sexual trauma increases the risk of developing psychosis in an ultra high-risk "prodromal" population

Studies indicate a high prevalence of childhood trauma in patient cohorts with established psychotic disorder and in those at risk of developing psychosis. A causal link between childhood trauma and development of psychosis has been proposed. We aimed to examine the association between experience of childhood trauma and the development of a psychotic disorder in a large "Ultra High Risk" (UHR) for psychosis cohort. The data were collected as part of a longitudinal cohort study of all UHR patients recruited to research studies at the Personal Assessment and Clinical Evaluation clinic between 1993 and 2006. Baseline data were collected at recruitment to these studies. The participants completed a comprehensive follow-up assessment battery (mean time to follow-up 7.5 years, range 2.4-14.9 years), which included the Childhood Trauma Questionnaire (CTQ), a self-report questionnaire that assesses experience of childhood trauma. The outcome of interest was transition to a psychotic disorder during the follow-up period. Data were available on 233 individuals. Total CTQ trauma score was not associated with transition to psychosis. Of the individual trauma types, only sexual abuse was associated with transition to psychosis (P = .02). The association remained when adjusting for potential confounding factors. Those with high sexual abuse scores were estimated to have a transition risk 2-4 times that of those with low scores. The findings suggest that sexual trauma may be an important contributing factor in development of psychosis for some individuals.

Childhood trauma and dissociation in first-episode psychosis, chronic schizophrenia and community controls

Increasing evidence supports the role of childhood trauma in the etiology of psychosis but underlying mechanisms are poorly understood. Early maltreatment has been linked to dissociative symptoms in psychosis patients. We explored associations between childhood trauma (Childhood Trauma Questionnaire) and dissociation (Dissociative Experiences Scale) in first-episode psychotic patients (n=62), chronic psychotic patients (n=43), and non-psychotic community controls (n=66). Multivariate analyses of covariance were used to test associations between childhood trauma and dissociation by group while controlling for sex. Chronic patients reported the highest level of dissociation. More severe childhood trauma was associated with greater dissociative symptoms in all groups although most strongly in chronic patients. Emotional abuse showed the strongest associations with dissociation, with these being strongest for chronic patients, followed by first-episode patients--and least for controls. Men showed a stronger association between physical neglect and dissociation than women, irrespective of group. There were no significant group by sex interactions. Our findings replicate the strong association between childhood trauma and dissociative symptoms in chronic and first-episode psychotic patients relative to non-psychotic control subjects. We also demonstrate the salience of emotional abuse in explaining variance in dissociation, especially in chronic patients.

Pathways between childhood victimization and psychosis-like symptoms in the ALSPAC birth cohort

BACKGROUND

Several large population-based studies have demonstrated associations between adverse childhood experiences and later development of psychotic symptoms. However, little attention has been paid to the mechanisms involved in this pathway and the few existing studies have relied on cross-sectional assessments.

METHODS

Prospective data on 6692 children from the UK Avon Longitudinal Study of Parents and Children (ALSPAC) were used to address this issue. Mothers reported on children's exposure to harsh parenting and domestic violence in early childhood, and children self-reported on bullying victimization prior to 8.5 years. Presence of children's anxiety at 10 years and their depressive symptoms at 9 and 11 years were ascertained from mothers, and children completed assessments of self-esteem and locus of control at 8.5 years. Children were interviewed regarding psychotic symptoms at a mean age of 12.9 years. Multiple mediation analysis was performed to examine direct and indirect effects of each childhood adversity on psychotic symptoms.

RESULTS

The association between harsh parenting and psychotic symptoms was fully mediated by anxiety, depressive symptoms, external locus of control, and low self-esteem. Bullying victimization and exposure to domestic violence had their associations with psychotic symptoms partially mediated by anxiety, depression, locus of control, and self-esteem. Similar results were obtained following adjustment for a range of confounders and when analyses were conducted for boys and girls separately.

CONCLUSIONS

These findings tentatively suggest that specific cognitive and affective difficulties in childhood could be targeted to minimize the likelihood of adolescents exposed to early trauma from developing psychotic symptoms.

Affinities in the phenomenological perspective of schizophrenia and recent cognitive research: Towards mutual enrichment

This work presents affinities existing between the phenomenological view of schizophrenia and recent cognitive research on this disorder. We postulate that the core abnormality in schizophrenia is a particular kind of disturbance of the sense of self, which has two main aspects, an enhanced sense of awareness or hyperreflexivity, and diminished self-affection. Noticeable parallels are shown between “hyperreflexivity” and some cognitive models and research that concentrate on attentional processes in schizophrenia patients. It is also argued that “diminished self-affection” may be related to certain factors recently dealt with in cognitive research, such as “beliefs about superstition and responsibility related to one’s own thoughts” and “dissociation.” Furthermore, certain points which, in our opinion, could be of mutual enrichment to both viewpoints are briefly analyzed. Finally, several limitations and problems that such mutual sharing may have are also described, and some possible lines of future research are suggested.

Dissociative experiences as mediators between childhood trauma and auditory hallucinations

The purpose of this work was to study the relationship between reported traumatic experiences in childhood and positive psychotic symptoms. We hypothesized that dissociative experiences were potential mediators between childhood trauma and hallucinations, but not delusions. The sample comprised 71 patients diagnosed with psychoses. They were assessed with the Dissociative Experiences Scale (DES-II; Carlson & Putnam, 1993), a questionnaire on trauma (TQ; Davidson, Hughes, & Blazer, 1990), and the Positive and Negative Syndrome Scale (PANSS; Kay, Opler, & Lindenmayer, 1988) delusions and hallucinations items. The results showed that childhood trauma was positively associated with the dissociation scale scores (r = .40) and also the hallucination (r = .36) and delusions scale scores (r = .32). Furthermore, it was demonstrated that the dissociation variable was a potential mediator between childhood trauma and hallucinations, but not between childhood trauma and delusions. Of the 3 DES-II factors, only depersonalization showed a mediating relationship between childhood trauma and hallucinations. The main conclusion is that the impact of childhood trauma on hallucinations may not simply be direct, but mediated by dissociative experiences, especially depersonalization. Clinical implications are also briefly discussed.

Dissociative symptoms in patients with schizophrenia: relationships with childhood trauma and psychotic symptoms

OBJECTIVE

This study sought to examine the stability of dissociative symptoms in patients with schizophrenia spectrum disorders as well as relationships between psychotic symptoms, childhood trauma, and dissociation.

METHOD

One hundred forty-five patients with schizophrenia spectrum disorders (72% schizophrenia, 67% men) were examined at admission to inpatient treatment and 3 weeks later using the Positive and Negative Syndrome Scale, the Childhood Trauma Questionnaire, and the Dissociative Experiences Scale.

RESULTS

Dissociative symptoms significantly decreased over time (mean, 19.2 vs 14.1; P < .001). The best predictor of dissociative symptoms at admission was the Positive and Negative Syndrome Scale positive subscale (F(inc)(3,64) = 3.66, P = .017), whereas childhood sexual abuse best predicted dissociation when patients were stabilized (F(inc)(10,80) = 2.00, P = .044).

CONCLUSION

Dissociative symptoms in patients with schizophrenia spectrum disorders are related to childhood trauma. Dissociation seems to be state dependent in this diagnostic group. Moreover, diagnostic interviews, in addition to the Dissociative Experiences Scale, should be considered to avoid measurement artifacts.

Dissociation mediates the relationship between childhood trauma and hallucination-proneness

BACKGROUND

It has been proposed that the relationship between childhood trauma and hallucinations can be explained by dissociative processes. The present study examined whether the effect of childhood trauma on hallucination-proneness is mediated by dissociative tendencies. In addition, the influence of dissociative symptoms on a cognitive process believed to underlie hallucinatory experiences (i.e. reality discrimination; the capacity to discriminate between internal and external cognitive events) was also investigated.

METHOD

Patients with schizophrenia spectrum disorders (n=45) and healthy controls (with no history of hallucinations; n=20) completed questionnaire measures of hallucination-proneness, dissociative tendencies and childhood trauma, as well as performing an auditory signal detection task.

RESULTS

Compared to both healthy and non-hallucinating clinical controls, hallucinating patients reported both significantly higher dissociative tendencies and childhood sexual abuse. Dissociation positively mediated the effect of childhood trauma on hallucination-proneness. This mediational role was particularly robust for sexual abuse over other types of trauma. Signal detection abnormalities were evident in hallucinating patients and patients with a history of hallucinations, but were not associated with pathological dissociative symptoms.

CONCLUSIONS

These results are consistent with dissociative accounts of the trauma-hallucinations link. Dissociation, however, does not affect reality discrimination. Future research should examine whether other cognitive processes associated with both dissociative states and hallucinations (e.g. deficits in cognitive inhibition) may explain the relationship between dissociation and hallucinatory experiences.

Dissociative and psychotic experiences of adolescents admitted to a psychiatric inpatient unit

A positive correlation between the incidences of dissociative and psychotic experiences has been consistently reported in a variety of adult populations. The present study was a preliminary investigation of the association between dissociative and psychotic experiences in adolescents requiring inpatient mental health care. No previous research has investigated this relationship in an adolescent cohort. Adolescents currently under inpatient care (n = 18) completed questionnaires assessing their experience of dissociative and psychotic phenomena. In line with previous research, a significant positive correlation was found between dissociative and psychotic experiences that remained highly significant once similarities between measures were taken into account. Recognizing the relationship between psychotic and dissociative experiences may be important in developing appropriate and effective treatment for young people experiencing mental health difficulties. Although the study is cross-sectional in nature and has a small sample, the results offer further evidence of the robust relationship between dissociative and psychotic experiences.

Voices from the storm: a critical review of quantitative studies of auditory verbal hallucinations and childhood sexual abuse

Although an association between hallucinations and sexual abuse has been documented, the relation between specifically auditory verbal hallucinations (AVHs) and childhood sexual abuse (CSA) is less clear. This study reviewed quantitative studies of AVHs and CSA. 36% of psychiatric patients with AVHs, and 22% of non-psychiatric patients with AVHs, reported CSA. At least 16% of the general population with auditory hallucinations also reported CSA. The majority of studies reviewed found that those with AVHs were more likely to be survivors of CSA than individuals without AVHs. 56% of psychiatric patients with CSA reported AVHs, and at least 21% of the general population with CSA reported auditory hallucinations. A majority of studies found survivors of CSA were more likely to report AVHs than individuals without CSA. Ability to impute a causal role for CSA was impaired by such studies' failures to control for potentially confounding variables. Yet, studies of AVH content showed links between the content of voices and the content of CSA in some voice-hearers. It is concluded that although a clear association between CSA and AVHs exists, there is not yet reliable quantitative evidence of a causal relation. Implications for mental health professionals and for future research, are discussed.

Dissociative and metacognitive factors in hallucination-proneness when controlling for comorbid symptoms

INTRODUCTION

Recent studies have linked hallucination-proneness to dysfunctional metacognitive beliefs, dissociation, and disrupted capacity to discriminate between internal and external cognitive events (reality discrimination). This study addressed a number of methodological limitations of previous research by investigating the relationship between hallucination-proneness and the aforementioned variables while controlling for comorbid symptoms.

METHOD

A large sample of nonclinical participants was screened on measures of hallucination-proneness, cognitive intrusions, paranoid ideation, metacognitive beliefs, and dispositional mindfulness (including measures of dissociation-like experiences). In addition, a signal detection task was used to investigate reality discrimination in four subgroups of participants selected on the basis of their scores on hallucination-proneness and intrusions.

RESULTS

Regression analyses for the self-report data were conducted to investigate the predictors of hallucination-proneness and paranoia when controlling for comorbid symptoms. Also, between-group differences on the behavioural data were tested to determine whether perturbed reality discrimination is specifically associated with hallucination-proneness rather than cognitive intrusions. Results revealed that metacognitive beliefs are more strongly associated with intrusions and paranoia than hallucination-proneness, whereas hallucination-proneness is related to perturbed reality discrimination and dissociation.

CONCLUSIONS

These results clarify previous research on metacognitive dysfunction in hallucination-proneness, and highlight the importance of controlling for the covariation among symptoms when investigating the cognitive processes underlying psychotic experiences.

[Does dissociative schizophrenia exist?]

On a phenomenological level, there's an important overlap between dissociative and psychotic symptoms. Furthermore, traumatic etiology, recognized in dissociative disorders, is also increasingly considered in psychosis. These similarities create confusion in clinical settings with important repercussions for individuals suffering from these disorders. Indeed, difficulties encountered in differential diagnoses could result in an erroneous diagnosis or in an undetected comorbidity. Some authors are going further in suggesting that there is a sub-type of schizophrenia having dissociation behind the expression of psychotic symptoms.

Psychotic symptoms with sexual content in the "ultra high risk" for psychosis population: frequency and association with sexual trauma

Individuals at "ultra high risk" (UHR) for psychosis have been found to experience high rates of sexual trauma. An aetiological role for sexual trauma has been proposed for psychotic disorders and may influence psychotic symptom content. We aimed to investigate the relationship between previous sexual trauma and reported psychotic-like experiences, in particular psychotic symptoms with a sexual content in a UHR sample. We investigated the prevalence of "attenuated" or "subthreshold" psychotic symptoms with a sexual content in a consecutive series of patients recruited to a specialist UHR clinic. Patient's experience of general and sexual trauma was rated separately using a trauma questionnaire based on the list of events qualifying as traumas under DSM IV. The sample consisted of 92 patients, 14 (15.2%) had experienced an attenuated psychotic symptom with sexual content. The most common symptom was overvalued ideas/delusions of being watched in the shower/toilet or undressing. A considerable proportion of the sample (36.2%) had experienced sexual trauma (sexually molested or raped). Presence of attenuated psychotic symptoms with sexual content was related to history of previous sexual trauma (OR 7.17, P<0.01). This relationship remained significant when other traumatic experiences, PTSD diagnosis, age and sex were adjusted for. Further research into this relationship with regard to outcome and treatment is warranted.

Childhood abuse and psychosis; a critical review of the literature

Childhood trauma has long been recognised as a potential cause for a range of affective mental health problems arising in adulthood. Only in recent years has the association between childhood abuse and psychosis begun to be investigated. This paper provides a critical review of the literature addressing the relationship between childhood abuse and psychosis. Implications for practitioners are discussed, including practice, policy, treatment and child protection issues. A significant proportion of people develop psychosis in adulthood following all types of childhood abuse, including people diagnosed with schizophrenia, major depressive disorders, dissociative identity disorder and post-traumatic stress disorder. Evidence suggests the possibility of a causal relationship between childhood abuse and psychosis in adulthood. Mental health nurses are ideally placed to offer help, care and support to those individuals who experience psychosis by acknowledging and listening to their life events, including experiences of childhood abuse.

Prodromal unfolding: the validation of the Schizotypic Syndrome Questionnaire model in a sample of first-episode schizophrenic patients

AIM

Validation of Van Kampen's Schizotypic Syndrome Questionnaire (SSQ) model of schizophrenic prodromal unfolding. The SSQ model comprises 12 negative, asocial and psychotic-like symptoms that are hypothesized to determine each other in terms of cause and effect.

METHOD

Use was made of the Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS)-dependent retrospective data assembled in the Mannheim Age-Beginning-Course Study sample of first-episode schizophrenic patients to measure the SSQ symptoms. Both the mean positions of the IRAOS-assessed symptoms on a continuum representing the proportion of total time of pre-psychotic disturbance and the outcome of a series of LISREL analyses conducted on the IRAOS-dependent data were addressed.

RESULTS

Both kinds of data supported the validity of the SSQ model; however, this was after introducing some (relatively minor or demonstrable ineffective) changes in the model as the 'translation' of the SSQ symptoms by means of the IRAOS was not always easy, or proved even impossible in the case of one symptom.

CONCLUSIONS

The conclusion seems warranted that the present investigation supports the validity of the SSQ model as a model of pre-psychotic and prodromal unfolding in patients diagnosed as suffering from schizophrenia. From a theoretical perspective, arguments are presented to interpret the SSQ model as a model of the core or principal symptoms of schizophrenia, including their temporal unfolding.