The development of the somatoform dissociation questionnaire (SDQ-5) as a screening instrument for dissociative disorders

Association Between Psychotic and Dissociative Symptoms: Further Investigation Using Network Analysis

The association and overlap between psychotic and dissociative phenomena have been increasingly recognized. Previous studies found that psychotic symptoms are closely associated with post-traumatic and dissociative symptoms and that these trauma-related phenomena may mediate the relationship between trauma and psychotic symptoms. It remained less explored which specific post-traumatic and dissociative symptom clusters are particularly associated with psychotic symptoms. This cross-sectional study used a data-driven approach (network analysis) to explore the associations among different psychotic and post-traumatic/dissociative symptom clusters in an online convenience predominantly female sample (N = 468)(59.2% had ever seen a psychiatrist). Participants completed well-established multidimensional measures that assessed different symptom clusters of psychosis, dissociation, and PTSD. In addition, multiple mediation analysis was conducted to examine which post-traumatic/dissociative symptoms could mediate the relationship between childhood and adulthood trauma and different psychotic symptoms. Our results confirmed previous findings that PTSD and dissociative symptoms are closely associated with psychotic symptoms. More importantly, both data-driven and multiple mediation analysis results indicated that identity dissociation was particularly associated with perceptual anomalies and bizarre experiences, while emotional constriction was particularly associated with negative symptoms. It is important to screen for trauma and dissociation and provide trauma-and dissociation-informed care when working with people at risk of or experiencing psychosis. Further longitudinal studies using more representative samples are needed.

Dissociative Symptoms in Complex Posttraumatic Stress Disorder: A Systematic Review

The 11th revision of the International Classification of Diseases (ICD-11) introduced Complex Posttraumatic Stress Disorder (CPTSD) as a sibling disorder to PTSD. Dissociative symptoms have been implicated in the severity of ICD-11 CPTSD; however, no reviews have investigated how dissociation has been measured in studies investigating CPTSD, nor the relationship between CPTSD and dissociation. This systematic review aimed to identify measures used to assess dissociative symptoms in studies that have assessed CPTSD according to ICD-11 criteria and to synthesize the relationship between these constructs. PsycINFO, PubMed, Scopus and Web of Science were searched on March 31, 2021. Seventeen articles met inclusion criteria. CPTSD was most frequently measured by a version of the International Trauma Questionnaire. Twelve measures were used to assess for dissociative symptoms, the most common being the Dissociative Symptoms Scale and the Dissociative Experiences Scale. The relationship between CPTSD and dissociative symptoms was moderate-to-strong, but inconsistently reported. Further research is needed to determine the most appropriate measure(s) of dissociation in CPTSD.

Borderline personality disorder features and their relationship with trauma and dissociation in a sample of community health service users

BACKGROUND

Previous studies have indicated that borderline personality disorder (BPD) is closely associated with trauma and dissociation. Nevertheless, BPD is a heterogeneous condition, and not all people with BPD have severe dissociation. This study examined whether the relationship of BPD features with trauma and dissociation would remain significant after controlling for some general non-specific mental health distress. We also made the first attempt to explore which specific BPD features would be particularly associated with dissociation.

METHODS

We analyzed survey data from a sample of community health service users in Hong Kong (N = 376). Hierarchical multiple regression and data-driven network analysis were used.

RESULTS

The lifetime prevalence of DSM-5 BPD was 16.0% in our sample. Of participants who met criteria for BPD, 43.3% scored above cutoff on the dissociation measures, thus possibly having clinically significant dissociative symptoms. BPD features were associated with adulthood trauma and psychoform dissociation even after controlling for age, depression and self-esteem. Network analysis showed that some BPD features - including impulsivity, identity disturbance and suicidal/self-mutilation behaviors - were particularly associated with dissociation; other BPD features such as interpersonal-related problems had relatively weak to no connection with dissociation.

CONCLUSIONS

Our results suggested that some particular BPD features might be dissociative in nature, although further longitudinal research is required. We argue that a trauma-informed perspective should be employed when working with clients presenting with BPD features despite these features being commonly stigmatized. Further research on the intervention needs of the people with BPD who suffer from high levels of dissociation is required.

Prevalence and correlates of dissociative symptoms among people with depression

BACKGROUND

To improve the outcomes of depression treatment, personalized treatments that take individual needs into account are recommended. Recent research suggests that a subgroup of depressed people who suffer from co-occurring dissociation may be more likely to have encountered traumatic or stressful experiences and they may also have more psychosocial intervention needs.

METHODS

This study examined the prevalence and correlates of dissociative symptoms in an online convenience sample of people (N = 410) from 18 different countries/regions who reported clinically significant levels of depressive symptoms (indicated by Patient Health Questionnaire-9 score ≥10).

RESULTS

Over 60% of participants exhibited clinically significant levels of dissociative symptoms (indicated by a Multiscale Dissociation Inventory total score >66). Compared with those with low levels of dissociative symptoms, participants with high levels of dissociative symptoms reported more traumas, interpersonal stress, depression and trauma-related symptoms. Emotional constriction in particular had a weak but significant negative correlation with the level of perceived medication benefits.

LIMITATIONS

The use of an online convenience sample could limit the generalizability of our findings. Our cross-sectional data could not demonstrate causal relationships between the study variables.

CONCLUSIONS

The findings highlight a need for complex health interventions for depressed people with co-occurring dissociative symptoms, focusing not only on depressive symptoms but also addressing trauma and dissociation-related symptoms.

A study in University of Ruhuna for investigating prevalence, risk factors and remedies for psychiatric illnesses among students

There is no comprehensive study on the mental health of Sri Lankan undergraduate in higher education, as most existing studies have been done for medical students only. It is unknown how academic and environmental factors contribute for the prevalence of psychiatric illnesses. Further, there is no sufficient information on the student/university based remedies to reduce the psychological distress of students. This research is carried out to find the overall psychological distress, well-being, prevalence percentages of psychiatric illnesses, associated risk factors, and student/university remedies to overcome them. We use standard questionnaires to screen for psychiatric illnesses, and we analyze the responses for our own questionnaire using Binary logistic regression analysis to identify demographic factors, academic factors, and environmental factors causing each mental disorder. We use Pearson correlation coefficient to identify correlation between prevalence of each psychiatric illnesses. All 13 psychiatric illnesses were found with a moderate correlation among diseases having a mean prevalence percentage of 28 and a standard deviation of 14.36, despite the prevalence of well-being factors among students and only 8% are clinically diagnosed. 89% of the students were suffering from at least one psychiatric illness and 68% were found to be psychologically distressed. Sets of overall and individual demographic, academic, and environmental risk factors contributing for the prevalence of a psychiatric illness in general and in particular were identified respectively after a binary logistic regression analysis. 61% of the students don’t receive psychiatric help from the university and are using their own remedies. The universities must consider the environmental and academic risk factors associated with psychiatric illnesses and design curriculum, expand resources, and provide counseling services to reduce the impact of risk factors.

The process of emotion identification: Considerations for psychiatric disorders

Emotional regulation is important for mental health and behavioral regulation. A relevant precursor to emotional regulation may involve identification of one's emotions. Here, we propose a model of seven components that may provide a foundation for emotion identification. These factors include baseline mood, monitoring, physiological responses, interoception, past personal experiences regarding emotions/metacognition, context, and labeling. We additionally examine how deficits in different components may contribute to the concept of alexithymia, which is defined by difficulty identifying and describing one's own emotions. Ultimately, we explore how the model may support a relationship between specific psychiatric disorders and alexithymia. The proposed model may help explain emotional identification impairment in multiple psychiatric disorders and guide future research and treatment development efforts.

Therapist-Assisted Web-Based Intervention for Prolonged Grief Disorder After Cancer Bereavement: Randomized Controlled Trial

BACKGROUND

Bereavement due to cancer increases the risk of prolonged grief disorder. However, specialized treatment options for prolonged grief after a loss due to illness are still scarce.

OBJECTIVE

The aim of this study is to extend previous findings by evaluating a web-based cognitive behavioral intervention with asynchronous therapist support, consisting of structured writing tasks adapted specifically for prolonged grief after cancer bereavement.

METHODS

The intervention was evaluated in a purely web-based randomized waitlist-controlled trial. Open-access recruitment of participants was conducted on the web. Prolonged grief (Inventory of Complicated Grief), depression, anxiety, posttraumatic stress, posttraumatic growth, somatization, sleep quality, and mental and physical health were assessed on the web via validated self-report measures.

RESULTS

A total of 87 participants were randomized into the intervention group (IG; 44/87, 51%) or the waitlist control group (43/87, 49%). Of the participants, 7% (6/87) dropped out of the study (5/44, 11%, in the IG). Of the 39 completers in the IG, 37 (95%) completed all intervention tasks. The intervention reduced symptoms of prolonged grief (intention-to-treat: P<.001; η²=0.34; Cohen d=0.80) to a clinically significant extent. It had favorable effects on depression, anxiety, posttraumatic stress, posttraumatic growth, and overall mental health but not on somatization, sleep quality, or physical health.

CONCLUSIONS

The web-based intervention for prolonged grief after cancer bereavement is effective in reducing symptoms of prolonged grief disorder and accompanying syndromes in a timely, easily realizable manner and addresses specific challenges of bereavement to illness. Considering web-based approaches in future mental health care policy and practice can reduce health care gaps for those who are bereaved to cancer.

TRIAL REGISTRATION

German Clinical Trial Register U1111-1186-6255; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011001.

Investigating post-traumatic stress disorder (PTSD) and complex PTSD among people with self-reported depressive symptoms

BACKGROUND

Trauma has been increasingly linked to depression. Previous studies have suggested that comorbid post-traumatic stress disorder (PTSD) may be associated with poor outcomes in depression treatment. However, the prevalence and correlates of ICD-11 PTSD and complex PTSD (CPTSD) in people with depression remain unclear.

METHODS

This study examined the prevalence and correlates of ICD-11 PTSD and CPTSD in an online convenience sample of 410 adults from 18 different countries/regions who reported clinically significant levels of depressive symptoms (indicated by a Patient Health Questionnaire-9 score ≥10).

RESULTS

According to the International Trauma Questionnaire results, 62.68% of participants met the ICD-11 criteria for PTSD/CPTSD (5.6% PTSD, 57.1% CPTSD). Participants with CPTSD reported more types of trauma and higher levels of interpersonal stress than those without PTSD. Participants with CPTSD also reported higher levels of mental health problems, including depressive, dissociative and psychotic symptoms, than those without PTSD. Only disturbances in self-organization (DSO) symptoms but not classical PTSD symptoms had a significant relationship with depressive symptoms, when other major variables (including trauma, interpersonal stress, and comorbid psychotic and dissociative symptoms) were controlled for.

CONCLUSIONS

Trauma-related symptoms should be regularly screened for in clients who report depressive symptoms. Depressed clients who have comorbid trauma disorders have more trauma and interpersonal stress and exhibit more severe mental health problems. They may require specific trauma-focused interventions in addition to standard depression treatments.

Dissociation and emotion regulation strategies: A meta-analytic review

OBJECTIVE

Clinical and neurobiological models posited that dissociative mechanisms might affect processes involved in emotional generation and regulation. However, there is a lack of a comprehensive theoretical framework that systematically includes dissociation within emotional functioning.

METHODS

The current study aims at conducting a meta-analytic review on the relationship between dissociation and emotion regulation in order to empirically estimate to what extent dissociation is related to emotion regulation processes. The meta-analysis was based on r coefficient as effect size measure, using a random-effect approach.

RESULTS

The meta-analysis included 57 independent studies for a total of 11596 individuals. Findings showed an overall moderate relationship between dissociation and emotion regulation (r_w = .32; p < .05). The association between dissociation and emotion regulation was the same among clinical samples than non-clinical ones. Furthermore, dissociation showed moderate to large relationships with maladaptive domains of emotion regulation, namely disengagement (r_w = 0.34; p < .01) (i.e., behavioral avoidance, experiential avoidance, thought and emotional suppression) and aversive cognitive perseveration (r_w = 0.38; p < .001) (i.e., rumination, worry and nonacceptance). The analysis did not find significant relationship between dissociation and adaptive domain of emotional regulation (i.e., problem solving, mindfulness).

CONCLUSION

Dissociation in the context of emotion regulation might be viewed as a basic neuro-mental mechanism that automatically contribute to the over-modulation of emotional states through avoidance reactions from internal and external reality. Future longitudinal studies are needed to clarify the causal relationships between dissociation and emotion regulation.

Comparing predictive validity in a community sample: High–dimensionality and traditional domain–and–facet structures of personality variation

Prediction of outcomes is an important way of distinguishing, among personality models, the best from the rest. Prominent previous models have tended to emphasize multiple internally consistent “facet” scales subordinate to a few broad domains. But such an organization of measurement may not be optimal for prediction. Here, we compare the predictive capacity and efficiency of assessments across two types of personality–structure model: conventional structures of facets as found in multiple platforms, and new high–dimensionality structures emphasizing those based on natural–language adjectives, in particular lexicon–based structures of 20, 23, and 28 dimensions. Predictions targeted 12 criterion variables related to health and psychopathology, in a sizeable American community sample. Results tended to favor personality–assessment platforms with (at least) a dozen or two well–selected variables having minimal intercorrelations, without sculpting of these to make them function as indicators of a few broad domains. Unsurprisingly, shorter scales, especially when derived from factor analyses of the personality lexicon, were shown to take a more efficient route to given levels of predictive capacity. Popular 20th–century personality–assessment models set out influential but suboptimal templates, including one that first identifies domains and then facets, which compromise the efficiency of measurement models, at least from a comparative–prediction standpoint. © 2020 European Association of Personality Psychology

Validity of A Web-based Measure of Borderline Personality Disorder: A Preliminary Study

PURPOSE

Early identification of borderline personality disorder (BPD) is important as timely interventions are beneficial and cost-effective. Unrecognized BPD not only results in suffering for individuals and their families, but also leads to considerable social costs. Although web-based measures have the potential to facilitate screening assessment of BPD for research and clinical purposes, little is known about whether the results of web-based measures of BPD are valid. This preliminary study aims to examine the validity of a web-based measure of BPD.

METHOD

We analyzed data from five independent samples (N = 828 in total).

RESULTS

The web-based BPD measure had a consistent relationship with relevant variables, including trauma exposure, mental well-being, depression, post-traumatic stress, dissociation and psychotic features across samples. It was also strongly correlated with another BPD measure. The web-based BPD measure could discriminate between participants with and without BPD and the discrimination performance was excellent (area under the curve =.853).

DISCUSSION

The initial findings suggest that the web-based BPD measure used in the present study is valid and may be helpful for research and screening purposes, although it should be followed up with a more comprehensive assessment in clinical settings. Implications are discussed. Given the limitations in this study, further studies are needed.

Shame, dissociative seizures and their correlation among traumatised female Yazidi with experience of sexual violence

BACKGROUND

Survivors of Islamic State of Iraq and Syria (ISIS) captivity are at high risk of developing mental disorders such as post-traumatic stress disorder (PTSD).

AIMS

This study looks at the correlation between sexual abuse, shame, somatoform or bodily distress disorders, and dissociative seizures (psychogenic non-epileptic seizures).

METHOD

The psychological effects of traumatic events and dissociative seizure were assessed in Yazidi women who were held captive by ISIS in Northern Iraq between 2014 and 2018. These effects were examined comparing 64 women who were held captive and sexually abused by ISIS with 60 women suffering from PTSD who were not held captive and sexually abused by ISIS. Structured clinical-psychological interviews and established psychometric questionnaires were used to assess mental disorders especially dissociative seizures and somatoform disorders, and shame related to trauma.

RESULTS

Women who were held captive by ISIS showed a significantly higher prevalence of dissociative seizures (43.7%; P = 0.02) and somatisation disorder (38.7%; P = 0.02), as well as depressive (75.0%; P = 0.42) and anxiety disorders (62.5%; P = 0.44), than women who were not held captive and sexually abused by ISIS. Dissociative disorders were identified in 40.6% (P = 0.36) of those female Yazidi who experienced sexual violence while being held captive.

CONCLUSIONS

Shame in connection with sexual violence seems to play an important role in negative self-perception after rape. Dissociation not only plays an important role in unprocessed childhood trauma with feelings of shame, but also in more recent trauma experiences with shame.

Demographic and mental health correlates of childhood emotional abuse and neglect in a Hong Kong sample

BACKGROUND

Adverse childhood experiences are an important public health issue. It is well documented that they are associated with many health problems. Nevertheless, little is known about childhood emotional abuse and neglect (CEA and CEN) among Hong Kong people.

OBJECTIVE

This study aimed to explore the demographic and mental health correlates of CEA and CEN in a Hong Kong sample.

METHODS

A total of N = 418 Hong Kong adults completed an online survey that included questions regarding demographic information and measures of adverse childhood experiences, depression, anxiety, borderline personality disorder, post-traumatic stress disorder and somatoform dissociation.

RESULTS

The rates of CEA and CEN were 43.3 % and 44.5 % respectively in this convenience sample. Both CEA and CEN were associated with poor socioeconomic status. They were also associated with psychiatric service usage and all five types of mental health problems. Both CEA and CEN increased the chance of having mental health problems even after taking into account the effects of other forms of childhood abuse and neglect.

CONCLUSIONS

This study is the first to show that CEA and CEN are significantly associated with poor socioeconomic status and mental health problems in the Hong Kong context. Implications are discussed. Further studies are needed.

A preliminary study of the clinical differences between dissociative and nondissociative depression in Hong Kong: implications for mental health practice

Depression is a serious public health issue, but not all patients with depression respond well to pharmaceutical treatments. Some scholars suggested that dissociation could be a marker indicating the types of patients with depression that may benefit more from psychosocial interventions than from pharmaceutical treatments. This study explored the possibility to differentiate dissociative depression and nondissociative depression in a clinical sample (N = 68) in the Chinese context, and discusses the potential implications for treatment considerations. Compared with the nondissociative group, the dissociative group reported higher occurrences of psychosocial etiological risk factors (e.g., childhood physical abuse, lack of help from family) and psychosocial-related symptoms (e.g., unstable relations, fear of abandonment, trauma-related flashbacks, somatization symptoms). Our initial findings revealed that patients with dissociative depression appeared to have distinct clinical features and might require more psychosocial interventions. Implications for health care research and practice are discussed.

Adverse childhood experiences and dissociation among Hong Kong mental health service users

Adverse childhood experiences (ACEs) have become a major concern in the mental health field. The literature suggests that ACEs could be associated with various mental health problems. Yet, ACEs require further investigation in Chinese cultures, especially in Hong Kong. Both the frequency of ACEs and their relationships with dissociation remain unknown in clinical settings in Hong Kong. In this study, we administered the Dissociative Experiences Scale (DES), the Somatoform Dissociation Questionnaire (SDQ) and the 10-item Adverse Childhood Experiences (ACEs) Questionnaire to 202 community mental health service users in Hong Kong. The frequency of ACEs and dissociation is reported and the trauma model of dissociation can be observed in this sample. Consistent with the Western literature, we found that ACEs are associated with mental health problems and that participants with childhood abuse and/or neglect report a significantly higher level of dissociation. While this study is preliminary, we suggest that ACEs and dissociation should receive more attention in the Chinese mental health field. Implications for practice are highlighted. Further studies are warranted.

Psychiatric Impact of Organized and Ritual Child Sexual Abuse: Cross-Sectional Findings from Individuals Who Report Being Victimized

Organized and ritual child sexual abuse (ORA) is often rooted in the child’s own family. Empirical evidence on possible associations between ORA and trauma-related symptoms in those who report this kind of extreme and prolonged violence is rare. The aim of our study was to explore socio-demographic and clinical characteristics of the individuals reporting ORA experiences, and to investigate protective as well as promotive factors in the link between ORA and trauma-related symptom severity. Within the framework of a project of the Independent Inquiry into Child Sexual Abuse in Germany, we recruited 165 adults who identified themselves as ORA victims via abuse- and trauma-specific networks and mailing lists, and they completed an anonymous online survey. We used variance analyses to examine correlations between several variables in the ORA context and PTSD symptoms (PCL-5) as well as somatoform dissociation (SDQ-5). Results revealed a high psychic strain combined with an adverse health care situation in individuals who report experiences with ORA. Ideological strategies used by perpetrators as well as Dissociative Identity Disorders experienced by those affected are associated with more severe symptoms (η²_p = 0.11; η²_p = 0.15), while an exit out of the ORA structures is associated with milder symptoms (η²_p = 0.11). Efforts are needed to improve health care services for individuals who experience severe and complex psychiatric disorders due to ORA in their childhood.

A New Measure for Assessing Substance-Related and Addictive Disorders: The Addictive Behavior Questionnaire (ABQ)

This article evaluates the psychometric properties of a new measure for assessing Substance-Related and Addictive Disorders: the Addictive Behavior Questionnaire (ABQ). The ABQ is a self-report measure composed of two sections: the Severity Index (SI) and the Seven Domains Addiction Scale (7DAS). Materials and methods. A total sample of 698 subjects divided into two groups (515 subjects in the clinical sample and 183 subjects in the control sample), participated in this study. We applied Exploratory Factor Analysis (EFA) to examine features of ABQ construct validity, we used Cronbach’s alpha coefficient to assess its internal reliability, and explored some aspects of its concurrent validity by examining its associations with other measures assessing addictive behaviors and psychopathology. Results and conclusions: results of EFA indicated that all the scales of the ABQ are unidimensional and showed good internal consistency. The correlations between the sections of the ABQ and the other measures used in the current study were significant and in the expected directions. These results suggest that the ABQ has good psychometric properties and allows researchers and clinicians to gather relevant information regarding behaviors, psychopathology and severity of symptoms, for the best clinical reasoning and for planning tailored treatment for each patient.

The Effects of an Internet-Based Imagery Rehearsal Intervention: A Randomized Controlled Trial

BACKGROUND

Nightmares are extremely dysphoric dreams, which are prevalent and associated with psychological strain. This study investigated (a) the efficacy of an internet-based imagery rehearsal therapy (IRT), (b) the role of imagery rescription, and (c) the role of guidance during internet-based IRT.

METHODS

A total of 127 patients suffering from mainly idiopathic nightmares were randomly assigned to 1 of 2 IRT internet-based groups (guided IRT; unguided IRT) or to 1 of 2 active control groups (frequency control group; narrative control group).

RESULTS

IRT was more effective than a nightmare frequency control condition with respect to nightmare frequency and nightmare distress. Compared to the narrative control group, IRT was only superior in improving nightmare distress but not in nightmare frequency because the narrative control group also improved regarding nightmare frequency. Guidance by a nightmare coach did not affect efficacy, compliance, or dropout.

CONCLUSION

Internet-based IRT seems to be an effective treatment even when offered with minimal guidance by a nightmare coach. Describing the nightmare narrative in detail already decreased nightmare frequency. However, with regard to inducing decreases in nightmare frequency and nightmare distress, IRT was superior to the narrative control group. The results are discussed with reference to the mastery hypothesis.

Internet-based grief therapy for bereaved individuals after loss due to Haematological cancer: study protocol of a randomized controlled trial

BACKGROUND

Approximately 10% of the individuals experiencing the death of a loved one develop prolonged grief disorder (PGD) after bereavement. Family members of haematological cancer patients might be particularly burdened since their loss experience is preceded by a very strenuous time of disease and aggressive treatment. However, support needs of relatives of cancer patients often remain unmet, also after the death of the patient. Therapeutic possibilities are enhanced by providing easily available and accessible Internet-based therapies. This study will adapt and evaluate an Internet-based grief therapy for bereaved individuals after the loss of a significant other due to haematological cancer.

METHODS

The efficacy of the Internet-based grief therapy is evaluated in a randomized controlled trial with a wait-list control group. Inclusion criteria are bereavement due to hematological cancer and meeting the diagnostic criteria for PGD. Exclusion criteria are severe depression, suicidality, dissociative tendency, psychosis, posttraumatic stress disorder, substance use disorder, and current psychotherapeutic or psychopharmacological treatment. The main outcome is PGD severity. Secondary outcomes are depression, anxiety, somatization, posttraumatic stress, quality of life, sleep quality, and posttraumatic growth. Data is collected pre- and posttreatment. Follow-up assessments will be conducted 3, 6, and 12 months after completion of the intervention. The Internet-based grief therapy is assumed to have at least moderate effects regarding PGD and other bereavement-related mental health outcomes. Predictors and moderators of the treatment outcome and PGD will be determined.

DISCUSSION

Individuals bereaved due to haematological cancer are at high risk for psychological distress. Tailored treatment for this particularly burdened target group is missing. Our study results will contribute to a closing of this healthcare gap.

TRIAL REGISTRATION

German Clinical Trial Register UTN: U1111-1186-6255 . Registered 1 December 2016.

Dissociation in patients with dissociative seizures: relationships with trauma and seizure symptoms

BACKGROUND

This study aimed to extend the current understanding of dissociative symptoms experienced by patients with dissociative (psychogenic, non-epileptic) seizures (DS), including psychological and somatoform types of symptomatology. An additional aim was to assess possible relationships between dissociation, traumatic experiences, post-traumatic symptoms and seizure manifestations in this group.

METHOD

A total of 40 patients with DS were compared with a healthy control group (n = 43), matched on relevant demographic characteristics. Participants completed several self-report questionnaires, including the Multiscale Dissociation Inventory (MDI), Somatoform Dissociation Questionnaire-20, Traumatic Experiences Checklist and the Post-Traumatic Diagnostic Scale. Measures of seizure symptoms and current emotional distress (Hospital Anxiety and Depression Scale) were also administered.

RESULTS

The clinical group reported significantly more psychological and somatoform dissociative symptoms, trauma, perceived impact of trauma, and post-traumatic symptoms than controls. Some dissociative symptoms (i.e. MDI disengagement, MDI depersonalization, MDI derealization, MDI memory disturbance, and somatoform dissociation scores) were elevated even after controlling for emotional distress; MDI depersonalization scores correlated positively with trauma scores while seizure symptoms correlated with MDI depersonalization, derealization and identity dissociation scores. Exploratory analyses indicated that somatoform dissociation specifically mediated the relationship between reported sexual abuse and DS diagnosis, along with depressive symptoms.

CONCLUSIONS

A range of psychological and somatoform dissociative symptoms, traumatic experiences and post-traumatic symptoms are elevated in patients with DS relative to healthy controls, and seem related to seizure manifestations. Further studies are needed to explore peri-ictal dissociative experiences in more detail.

The Scoring and Interpretation of the SDQ-20 and SDQ-5

The 20-item Somatoform Dissociation Questionnaire (SDQ-20; Nijenhuis, Spinhoven, Van Dyck, Van der Hart, & Van-derlinden, 1996) evaluates the severity of somatoform dissociation. The SDQ-20 items were derived from a pool of 75 items describing clinically observed somatoform dissociative symptoms that in clinical settings had appeared upon reactivation of particular dissociative parts of the personality and that could not be medically explained. The SDQ-20 scores were best predicted by self-reported physical and sexual traumatization in patients with dissociative disorders and psychiatric controls (Nijenhuis et al., 1998c), even after statistically controlling for self-reported emotional traumatization (emotional neglect and emotional abuse). These traumatization scores were composed of four factors, i.e. presence of trauma, duration of trauma, relationship to perpetrator, and subjectively rated impact of trauma.

Pain and self-harm: A systematic review

BACKGROUND

A growing body of research has explored altered physical pain threshold and tolerance in non-suicidal self-injury (NSSI) and suicidal self-harm. The evidence, however, is inconsistent such that the nature of the relationship is unclear, and whether or not this effect is also present in suicidal self-harm is equivocal.

METHODS

A keyword search of three major psychological and medical databases (PsycINFO, Medline and Web of Knowledge) was conducted, yielding 1873 records. Following duplicate removal and screening, 25 articles were quality assessed, and included in the final systematic review.

RESULTS

There is strong evidence for increased pain tolerance in NSSI, and some evidence for this in suicidal individuals, but notably, there were no prospective studies. The review found a lack of substantive focus on psychological correlates of altered pain tolerance in this population. Several candidate explanatory mechanisms were proposed within the reviewed studies.

LIMITATIONS

The current review was a narrative systematic review; methods used to assess pain were considered too heterogeneous to conduct a meta-analysis.

CONCLUSIONS

The evidence suggests that there is elevated pain tolerance among those who engage in NSSI. Future prospective research should determine if altered pain tolerance is a cause or a consequence of the behaviour. The identification of psychological correlates of increased pain tolerance is a neglected area of research. It could provide opportunities for treatment/intervention development, if mediating or moderating pathways can be identified. Too few studies have directly investigated candidate explanatory mechanisms to draw definitive conclusions.

Is it Trauma- or Fantasy-based? Comparing dissociative identity disorder, post-traumatic stress disorder, simulators, and controls

OBJECTIVE

The Trauma Model of dissociative identity disorder (DID) posits that DID is etiologically related to chronic neglect and physical and/or sexual abuse in childhood. In contrast, the Fantasy Model posits that DID can be simulated and is mediated by high suggestibility, fantasy proneness, and sociocultural influences. To date, these two models have not been jointly tested in individuals with DID in an empirical manner.

METHOD

This study included matched groups [patients (n = 33) and controls (n = 32)] that were compared on psychological Trauma and Fantasy measures: diagnosed genuine DID (DID-G, n = 17), DID-simulating healthy controls (DID-S, n = 16), individuals with post-traumatic stress disorder (PTSD, n = 16), and healthy controls (HC, n = 16). Additionally, personality-state-dependent measures were obtained for DID-G and DID-S; both neutral personality states (NPS) and trauma-related personality states (TPS) were tested.

CONCLUSION

For Trauma measures, the DID-G group had the highest scores, with TPS higher than NPS, followed by the PTSD, DID-S, and HC groups. The DID-G group was not more fantasy-prone or suggestible and did not generate more false memories. Malingering measures were inconclusive. Evidence consistently supported the Trauma Model of DID and challenges the core hypothesis of the Fantasy Model.

Traumatic Experience and Somatoform Dissociation Among Spirit Possession Practitioners in the Dominican Republic

Recent studies in African contexts have revealed a strong association between spirit possession and severe trauma, with inclusion into a possession cult serving at times a therapeutic function. Research on spirit possession in the Dominican Republic has so far not included quantitative studies of trauma and dissociation. This study evaluated demographic variables, somatoform dissociative symptoms, and potentially traumatizing events in the Dominican Republic with a group of Vodou practitioners that either do or do not experience spirit possession. Inter-group comparisons revealed that in contrast to non-possessed participants (n = 38), those experiencing spirit possession (n = 47) reported greater somatoform dissociation, more problems with sleep, and previous exposure to mortal danger such as assaults, accidents, or diseases. The two groups did not differ significantly in other types of trauma. The best predictor variable for group classification was somatoform dissociation, although those items could also reflect the experience of followers during a possession episode. A factor analysis across variables resulted in three factors: having to take responsibility early on in life and taking on a professional spiritual role; traumatic events and pain; and distress/dissociation. In comparison with the non-possessed individuals, the possessed ones did not seem to overall have a remarkably more severe story of trauma and seemed to derive economic gains from possession practice.

Similar cortical but not subcortical gray matter abnormalities in women with posttraumatic stress disorder with versus without dissociative identity disorder

Neuroanatomical evidence on the relationship between posttraumatic stress disorder (PTSD) and dissociative disorders is still lacking. We acquired brain structural magnetic resonance imaging (MRI) scans from 17 patients with dissociative identity disorder (DID) and co-morbid PTSD (DID-PTSD) and 16 patients with PTSD but without DID (PTSD-only), and 32 healthy controls (HC), and compared their whole-brain cortical and subcortical gray matter (GM) morphological measurements. Associations between GM measurements and severity of dissociative and depersonalization/derealization symptoms or lifetime traumatizing events were evaluated in the patient groups. DID-PTSD and PTSD-only patients, compared with HC, had similarly smaller cortical GM volumes of the whole brain and of frontal, temporal and insular cortices. DID-PTSD patients additionally showed smaller hippocampal and larger pallidum volumes relative to HC, and larger putamen and pallidum volumes relative to PTSD-only. Severity of lifetime traumatizing events and volume of the hippocampus were negatively correlated. Severity of dissociative and depersonalization/derealization symptoms correlated positively with volume of the putamen and pallidum, and negatively with volume of the inferior parietal cortex. Shared abnormal brain structures in DID-PTSD and PTSD-only, small hippocampal volume in DID-PTSD, more severe lifetime traumatizing events in DID-PTSD compared with PTSD-only, and negative correlations between lifetime traumatizing events and hippocampal volume suggest a trauma-related etiology for DID. Our results provide neurobiological evidence for the side-by-side nosological classification of PTSD and DID in the DSM-5.

Somatoform dissociation among Swedish adolescents and young adults: the psychometric properties of the Swedish versions of the SDQ-20 and SDQ-5

BACKGROUND

Somatoform dissociation is supposed to be a vital aspect of the general concept of dissociation. The Somatoform Dissociation Questionnaire-20 (SDQ-20) and the brief version SDQ-5 are self-report instruments constructed to identify somatic dissociation.

AIM

In the present study, the psychometric qualities of the Swedish version of the SDQ-20 and its brief version, the SDQ-5, were examined among adolescents and young adults. Reliability and concurrent validity were investigated.

METHODS

A total of 512 adolescents and young adults participated in the study: 461 adolescents from a non-clinical sample and 50 adolescents and young adults from a clinical eating disorder outpatient unit. They completed the self-report instruments the SDQ-20, the SDQ-5 (part of SDQ-20), the Linköping Youth Life Experience Scale (LYLES, a trauma history scale) and the Dissociation Questionnaire-Sweden (Dis-Q-Sweden).

RESULTS

Both internal consistency and test-retest reliability of the Swedish version of SDQ-20 were good in both the non-clinical (α = 0.83) and the clinical groups (α = 0.84); the reliability for the SDQ-5 was, however, lower (non-clinical α = 0.50, clinical α = 0.64). Significant differences were found between the clinical and non-clinical groups on both somatoform and psychoform dissociation. Correlations between the Dis-Q-Sweden, SDQ-20 and SDQ-5 were generally high. The criterion and convergent validity was acceptable for both scales but somewhat better for SDQ-20 than for SDQ-5.

CONCLUSION

The advantage with both the SDQ-20 and the SDQ-5 is that they are short questionnaires, but the results suggests that SDQ-20 is preferable based on the higher-quality psychometric properties of the SDQ-20.

Abnormal hippocampal morphology in dissociative identity disorder and post-traumatic stress disorder correlates with childhood trauma and dissociative symptoms

Smaller hippocampal volume has been reported in individuals with post-traumatic stress disorder (PTSD) and dissociative identity disorder (DID), but the regional specificity of hippocampal volume reductions and the association with severity of dissociative symptoms and/or childhood traumatization are still unclear. Brain structural magnetic resonance imaging scans were analyzed for 33 outpatients (17 with DID and 16 with PTSD only) and 28 healthy controls (HC), all matched for age, sex, and education. DID patients met criteria for PTSD (PTSD-DID). Hippocampal global and subfield volumes and shape measurements were extracted. We found that global hippocampal volume was significantly smaller in all 33 patients (left: 6.75%; right: 8.33%) compared with HC. PTSD-DID (left: 10.19%; right: 11.37%) and PTSD-only with a history of childhood traumatization (left: 7.11%; right: 7.31%) had significantly smaller global hippocampal volume relative to HC. PTSD-DID had abnormal shape and significantly smaller volume in the CA2-3, CA4-DG and (pre)subiculum compared with HC. In the patient groups, smaller global and subfield hippocampal volumes significantly correlated with higher severity of childhood traumatization and dissociative symptoms. These findings support a childhood trauma-related etiology for abnormal hippocampal morphology in both PTSD and DID and can further the understanding of neurobiological mechanisms involved in these disorders.

An Internet-based program to enhance motivation to change in females with symptoms of an eating disorder: a randomized controlled trial

BACKGROUND

Previous research has demonstrated an association between low motivation to change and an unfavorable treatment outcome in patients with an eating disorder. Consequently, various studies have examined the effects of motivational enhancement therapy (MET) on motivation to change and treatment outcome in eating disorders. In each of these studies, MET was administered in a face-to-face setting. However, because of its anonymity and ease of access, the internet provides several advantages as the format for such an intervention. Therefore, the current study investigated the effects of an internet-based program ('ESS-KIMO') to enhance motivation to change in eating disorders.

METHOD

In total, 212 females were accepted for participation and assigned randomly to the intervention condition (n = 103) or waiting-list control condition (n = 109). The intervention consisted of six online MET sessions. Before and after the intervention or waiting period respectively, participants completed the Eating Disorder Examination Questionnaire (EDE-Q), the Stages of Change Questionnaire for Eating Disorders (SOCQ-ED), the Pros and Cons of Eating Disorders Scale (P-CED), the Self-Efficacy Scale (SES), and the Rosenberg Self-Esteem Scale (RSES). A total of 125 participants completed the assessment post-treatment. Completer analyses and intent-to-treat analyses were performed.

RESULTS

Significant time × group interactions were found, indicating a stronger increase in motivational aspects and self-esteem, in addition to a stronger symptom reduction on some measures from pre- to post-treatment in the intervention group compared to the control group.

CONCLUSIONS

Internet-based approaches can be considered as useful for enhancing motivation to change in eating disorders and for yielding initial symptomatic improvement.

A multi-site single-blind clinical study to compare the effects of STAIR Narrative Therapy to treatment as usual among women with PTSD in public sector mental health settings: study protocol for a randomized controlled trial

BACKGROUND

This article provides a description of the rationale, design, and methods of a multisite clinical trial which evaluates the potential benefits of an evidence-based psychosocial treatment, STAIR Narrative Therapy, among women with posttraumatic stress disorder (PTSD) related to interpersonal violence who are seeking services in public sector community mental health clinics. This is the first large multisite trial of an evidence-based treatment for PTSD provided in the context of community settings that are dedicated to the treatment of poverty-level patient populations.

METHODS

The study is enrolling 352 participants in a minimum of 4 community clinics. Participants are randomized into either STAIR Narrative Therapy or Treatment As Usual (TAU). Primary outcomes are PTSD, emotion management and interpersonal problems. The study will allow a flexible application of the protocol determined by patient need and preferences. Secondary analyses will assess the relationship of outcomes to different patterns of treatment implementation for different levels of baseline symptom severity.

DISCUSSION

The article discusses the rationale and study issues related to the use of a flexible delivery of a protocol treatment and of the selection of treatment as it is actually practiced in the community as the comparator.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT01488539.

Physical and social pains in borderline disorder and neuroanatomical correlates: a systematic review

Borderline personality disorder (BPD) is a common psychiatric disorder, the core features of which are affective dysregulation, identity disturbances, and problems in social interaction, with an intense fear of loss, abandonment, or rejection by social partners. Self-injurious behaviors (SIB), such as superficial cutting, occur in 70-80 % of BPD patients, which are associated with emotional relief. Intriguingly, the majority of BPD patients report reduced or no pain associated with SIB, whereas BPD patients are over-represented in chronic pain patients. Thus, studying pain perception in such patients may help to understand the pathophysiology of BPD, but also the interaction between affective and physical dimensions of pain. We conducted a systematic review dealing with physical and social pains in BPD patients, with a special focus on neuroimaging data. SIB appear to be an inadequate strategy to regulate negative emotions that may be related to social/psychological pain, by increasing dorsolateral prefrontal cortex activation in order to regulate amygdala activation. In addition, abnormal hyperactivation of the insula is a possible trait marker of BPD, and might contribute to modified pain sensitivity. When considering psychological pain in BPD patients, neuroanatomical studies have shown a hyper-responsive subcortical limbic network and a deficient regulatory control system operating through anterior brain regions. Promising therapeutic strategies should target neuroanatomical and neurobiological dysfunctions, which lead to altered pain perception in BPD patients.

Internet-based motivation program for women with eating disorders: eating disorder pathology and depressive mood predict dropout

BACKGROUND

One of the main problems of Internet-delivered interventions for a range of disorders is the high dropout rate, yet little is known about the factors associated with this. We recently developed and tested a Web-based 6-session program to enhance motivation to change for women with anorexia nervosa, bulimia nervosa, or related subthreshold eating pathology.

OBJECTIVE

The aim of the present study was to identify predictors of dropout from this Web program.

METHODS

A total of 179 women took part in the study. We used survival analyses (Cox regression) to investigate the predictive effect of eating disorder pathology (assessed by the Eating Disorders Examination-Questionnaire; EDE-Q), depressive mood (Hopkins Symptom Checklist), motivation to change (University of Rhode Island Change Assessment Scale; URICA), and participants' age at dropout. To identify predictors, we used the least absolute shrinkage and selection operator (LASSO) method.

RESULTS

The dropout rate was 50.8% (91/179) and was equally distributed across the 6 treatment sessions. The LASSO analysis revealed that higher scores on the Shape Concerns subscale of the EDE-Q, a higher frequency of binge eating episodes and vomiting, as well as higher depression scores significantly increased the probability of dropout. However, we did not find any effect of the URICA or age on dropout.

CONCLUSIONS

Women with more severe eating disorder pathology and depressive mood had a higher likelihood of dropping out from a Web-based motivational enhancement program. Interventions such as ours need to address the specific needs of women with more severe eating disorder pathology and depressive mood and offer them additional support to prevent them from prematurely discontinuing treatment.

Dissociative disorders in medical settings

Despite the challenges of conducting research on dissociation and the dissociative disorders, our understanding has grown greatly over the past three decades, including our knowledge of the often overlooked sensorimotor manifestations of dissociation, more commonly referred to as somatoform dissociation. This article will first review the definitions and presentations of dissociation in general along with recent research on the concept of somatoform dissociation. Then, each of the dissociative disorders and conversion disorder will be discussed in further detail as well as how they might present in a medical setting. Current recommendations for diagnosis and treatment will also be provided.

Fact or factitious? A psychobiological study of authentic and simulated dissociative identity states

BACKGROUND

Dissociative identity disorder (DID) is a disputed psychiatric disorder. Research findings and clinical observations suggest that DID involves an authentic mental disorder related to factors such as traumatization and disrupted attachment. A competing view indicates that DID is due to fantasy proneness, suggestibility, suggestion, and role-playing. Here we examine whether dissociative identity state-dependent psychobiological features in DID can be induced in high or low fantasy prone individuals by instructed and motivated role-playing, and suggestion.

METHODOLOGY/PRINCIPAL FINDINGS

DID patients, high fantasy prone and low fantasy prone controls were studied in two different types of identity states (neutral and trauma-related) in an autobiographical memory script-driven (neutral or trauma-related) imagery paradigm. The controls were instructed to enact the two DID identity states. Twenty-nine subjects participated in the study: 11 patients with DID, 10 high fantasy prone DID simulating controls, and 8 low fantasy prone DID simulating controls. Autonomic and subjective reactions were obtained. Differences in psychophysiological and neural activation patterns were found between the DID patients and both high and low fantasy prone controls. That is, the identity states in DID were not convincingly enacted by DID simulating controls. Thus, important differences regarding regional cerebral bloodflow and psychophysiological responses for different types of identity states in patients with DID were upheld after controlling for DID simulation.

CONCLUSIONS/SIGNIFICANCE

The findings are at odds with the idea that differences among different types of dissociative identity states in DID can be explained by high fantasy proneness, motivated role-enactment, and suggestion. They indicate that DID does not have a sociocultural (e.g., iatrogenic) origin.

Online cognitive-behavioural treatment of bulimic symptoms: a randomized controlled trial

BACKGROUND

Manualized cognitive-behavioural treatment (CBT) is underutilized in the treatment of bulimic symptoms. Internet-delivered treatment may reduce current barriers.

OBJECTIVE

This study aimed to assess the efficacy of a new online CBT of bulimic symptoms.

METHOD

Participants with bulimic symptoms (n = 105) were randomly allocated to online CBT, bibliotherapy or waiting list/delayed treatment condition. Data were gathered at pre-treatment, post-treatment and 1-year follow-up.

OUTCOME MEASURES

The primary outcome measures were the Eating Disorder Examination Questionnaire (EDE-Q) and the frequency of binge eating and purging episodes. The secondary outcome measure was the Body Attitude Test.

RESULTS

Dropout from Internet treatment was 26%. Intention-to-treat ANCOVAs of post-test data revealed that the EDE-Q scores and the frequency of binging and purging reduced more in the online CBT group compared with the bibliotherapy and waiting list groups (pooled between-group effect size: d = 0.9). At 1-year follow-up, improvements in the online CBT group had sustained.

CONCLUSION

This study identifies online CBT as a viable alternative in the treatment of bulimic symptoms.

Psychoform and somatoform dissociation and PTSD in deaf adults

Both deafness and dissociation disconnect people from certain aspects of the external environment. Dissociation among the deaf population has been largely neglected as an area of scientific investigation. The purpose of this study was twofold: first, to examine the psychometrics of 2 dissociation measures--the Dissociation scale of the Trauma Symptom Inventory (TSI) and the Somatoform Dissociation Questionnaire-20 (SDQ-20); and second, to evaluate the relationship between dissociation and posttraumatic stress disorder (PTSD) in deaf adults. A diverse sample of 79 deaf adults was assessed using the Clinician-Administered PTSD Scale, the TSI, and the SDQ-20. Results provided support for the concept of psychoform dissociation, as measured by the TSI Dissociation scale, in deaf adults. However, somatoform dissociation, as measured by the SDQ-20, showed lower internal consistency. The SDQ-5, a shortened version of the SDQ-20, was unreliable in the current sample. Deaf adults were significantly higher on psychoform dissociation than the norm samples of hearing adults. As in hearing samples, dissociation--both psychoform and somatoform--was significantly related to PTSD symptoms. In addition, those with dissociative PTSD displayed significantly more symptoms of depression, anger, impaired self-reference, tension reduction behavior, and somatoform dissociation than did the nondissociative PTSD group.

Efficacy of cognitive behavioral internet-based therapy in parents after the loss of a child during pregnancy: pilot data from a randomized controlled trial

The loss of a child during pregnancy can be a traumatic event associated with long-lasting grief and psychological distress. This study examined the efficacy of an internet-based cognitive behavioral therapy program for mothers after pregnancy loss. In a randomized controlled trial with a waiting list control group, 83 participants who had lost a child during pregnancy were randomly allocated either to 5 weeks of internet therapy or to a 5-week waiting condition. Within a manualized cognitive behavioral treatment program, participants wrote ten essays on loss-specific topics. Posttraumatic stress, grief, and general psychopathology, especially depression, were assessed pretreatment, posttreatment, and at 3-month follow-up. Intention-to-treat analyses and completer analyses were performed. Relative to controls, participants in the treatment group showed significant improvements in posttraumatic stress, grief, depression, and overall mental health, but not in anxiety or somatization. Medium to large effect sizes were observed, and the improvement was maintained at 3-month follow-up. This internet-based cognitive behavioral therapy program represents an effective treatment approach with stable effects for women after pregnancy loss. Implementation of the program can thus help to improve the health care provision for mothers in this traumatic loss situation.

A Stabilization Group Approach for Heterogeneous Populations of Trauma Clients

High prevalence and long-lasting implications of human-inflicted trauma call for effective treatment approaches reaching clients in need of trauma-specific treatment. Numerous approaches exist, but often with limited empirical support. There is also a tendency toward segregating treatment approaches depending on type of exposure history and presenting symptoms. This might exclude clients in need of trauma-specific treatment; therefore, treatment approaches that can reach more heterogeneous groups of clients are needed. In this article, a group-based treatment approach adjusted to include clients with a wide range of trauma-related problems and traumatic experiences will be presented. A brief outline of the approach is presented, together with the theoretical and empirical background, to facilitate implementation by practitioners and empirical testing.

Hypnotically induced dissociation (HID) as a strategic intervention for enhancing OCD treatment

To date, cognitive behavioral therapy has been designated the most efficient evidence-based psychotherapeutic approach for OCD management. This is mainly due to its ability to effectively address the constitutional and developmentally acquired emotional and cognitive deficiencies of OCD, which express themselves through behavioral compulsions and intrusive thoughts. Yet some reports indicate that from 30 to 60 percent of OCD patients are not responsive to psychotherapeutic interventions. As a consequence, broader therapeutic models have been considered. These models encompass multifactorial etiologies of OCD and take intrapsychic stressogenic factors into consideration as well. Some of these models have adopted hypnotherapeutic approaches. In the present article, we introduce a therapeutic tool that utilizes hypnotically induced dissociation (HID) to identify and address the intrapsychic etiology of OCD. The result is a therapeutic intervention that complements existing OCD treatment strategies. Clinical cases are presented to illustrate implementation of the approach.

Standardized web-based cognitive behavioural therapy of mild to moderate depression: a randomized controlled trial with a long-term follow-up

Depression is common but undertreated. Web-based self-help provides a widely accessible treatment alternative for mild to moderate depression. However, the lack of therapist guidance may limit its efficacy. The authors assess the efficacy of therapist-guided web-based cognitive behavioural treatment (web-CBT) of mild to moderate depression. Fifty-four individuals with chronic, moderate depression participated in a randomized wait-list controlled trial, with an 18-month follow-up (immediate treatment: n = 36, wait-list control: n = 18). Primary outcome measures were the Beck Depression Inventory (BDI-IA) and the Depression scale of the Symptom Checklist-90-Revised (SCL-90-R. DEP). Secondary outcome measures were the Depression Anxiety Stress Scales and the Well-Being Questionnaire. Five participants (9%) dropped out. Intention-to-treat analyses of covariance revealed that participants in the treatment condition improved significantly more than those in the wait-list control condition (.011 < p < .015). With regard to the primary measures, between-group effects (d) were 0.7 for the BDI-IA and 1.1 for the SCL-90-R DEP. Posttest SCL-90- R DEP scores indicated recovery of 49% of the participants in the treatment group compared with 6% in the control group (odds ratio = 14.5; p < .004). On average, the effects were stable up to 18 months (n = 39), although medication was a strong predictor of relapse. The results demonstrate the efficacy of web-CBT for mild to moderate depression and the importance of therapist guidance in psychological interventions.