The empirical exploration of - PowerPoint Presentation

1. The empirical exploration of dissociative identity disorder (DID): Voices, shame and autobiographical memoryMartin DorahyUniversity of CanterburyChristchurch, New Zealand

2. PlanDID and voice hearing – study near completionAutobiographical memory in DID – study under wayEmbarrassment/shame and dissociation (just completed)

3. Core features of DIDThe existence of 2 or more personalities/ identities that take recurrent control of behaviourPsychogenic amnesia for seemingly unforgettable autobiographical events

4. Aetiology“DID is probably due to a complex combination of traumatic experiences, dissociative processes, psychosocial mediators and socially constructed understandings of self.” Dorahy et al., 2014DID is a disorder of self or personhoodChild abuse and neglect“Every study that has systematically Examined aetiology has found that antecedent severe, chronic childhood trauma is present in the histories of almost all individuals with DID”.Attachment – frightened & frightening Vs containingBiological capacity to dissociateSociocultural variablesWest: self as separate, autonomous, self-contained and independent (Cross and Markus, 1999) – separate selvesEast: Self as entwined and interdependent – outside forces – possession

5. CA&N by attachment figureEmotional part of the personality (EP)Apparently normal part of the personality (ANP): e.g.,Van der Hart et al., 2006; Nijenhuis, Van der Hart & Steele, 2002Fight flightFreezeSubmit__________________________ functions dedicated to the survival of the species & daily life________________________________functions dedicated tothe survival of the individualMotherWorkerLoverD-type attachmentFamily dynamicsBiological capacity to dissociateCultural influences

6. Emotional part of the personality (EP)Apparently normal part of the personality (ANP): e.g.,Fight flightFreezeSubmitMotherWorkerLoverPsychosomatic symptoms e.g. *Amnesia *Emotional numbing *Flashbacks *Ego observing *Auditory halls *Ego-alien experiences *Conversion blindness/deafness *Dissociative identitiesAttach. cry

7. Process, structure, symptoms?Process Phenomena/symptoms (e.g., continuum)StructureTrauma in presence of other contributing variables

8. DID appears to be difficult to diagnosis and prone to misdiagnosis

9. Overlapping symptomsSeveral symptoms domains typically evident in DID overlap with other disorders: e.g.,BPD (Dorahy et al., 2015) Schneiderian first-rank symptoms (Middleton & Butler, 1998; Ross et al, 1995): Auditory hallucinations

10. AH (or voice hearing) definedPercept-like experience in the absence of appropriate stimuli, which manifest asA human vocalisation (verbal), which is experienced inA conscious state and is Not organic in originLongden et al., 2011Typically experienced as ego-dystonic (alien)

11. Voices & the general populationPrevalence rates of AH in general population:5% (Eaton et al., 1991) – 41% (Pearson et al., 2008) (L/T)Influenced by:Age ( adolescents, college aged)Nature of Qs (e.g., “troubled by hearing voices in your head”; “voices of absent relative”)Complexity (e.g., conversations vs single phrases)Affective valence (distress vs non-distress)Longden et al., 2011

12. Voices in psychopathologyAH evident in a considerable number of DSM-5 non psychotic disorders, eg.,Substance-related disorders (e.g., Berglund, 2006)BPD & Schiz PD (e.g., Yee et al., 2005)Bipolar disorder (e.g., Baethge et al., 2005)Dissociative disorders (Honig et al., 1998) ASD/PTSD (e.g., Anketell, Dorahy et al., 2010; Brewin & Patel, 2010; Scott et al., 2007; “Voices unreliable discriminator”)

13. AH as psychologicalThere is a growing movement towards viewing AH as psychological and dissociative, rather than biogenetic and psychotic (Longden et al., 2011; Moskowtiz & Corsten, 2007).

14. Trauma, dissociation and psychosisRecent empirical work linking trauma to psychosis.Childhood relational trauma as pathway to psychosis (e.g., Arseneault et al., 2011; Read et al., 2005).Empirical link between trauma (especially early relational trauma) and AH (e.g., Read et al., 2003; Shevlin, Dorahy, Adamson, 2007; Whitfield et al., 2005) Long history linking trauma to dissociation (rel. trauma) (e.g., Dalenberg et al., 2012)

15. Voices, dissociation & traumaDissociation strongly linked to AH (e.g., Anketell, Dorahy et al., 2010; Brewin & Patel, 2010; Kilcommons et al., 2008; Schäfer et al., 2008)Contemporary clinical and empirical work AH common in traumatised & dissociative samples (e.g., Kluft, 1987; Middleton & Butler, 1998; Ross et al., 1995; Ross, 2004; Scott et al., 2007).

16. Starting pointDO AH LOOK DIFFERENT BTW DID AND SCHIZOPHRENIA WITH AND WITHOUT MALTREATMENT?EG, Honig et al. (1998) found no difference in location of voices in schizophrenia and dissociative disorders Both experienced voices inside and outside the head.

17. Method: AH in DID & schizophreniaN = 6529 DID (all F)16 schizophrenia with child maltreatment (4 F)18 schizophrenia without child maltreat (3 F)Later two groups had persistent AVHNo age differences; but more males in psychosis groupsDorahy et al., 2010

18. AssessmentMental Health Research Institute Unusual Perceptions Schedule (MUPS; Carter, MacKinnon, Howard, Zeegers, & Copolov, 1995)The Childhood Trauma Questionnaire (CTQ; Bernstein & Fink, 1998) The Dissociative Experiences Scale - Taxon (DES-T; Waller, Putnam, & Carlson, 1996) DID Section of Dissociative Disorders Interview Schedule (DDIS; Ross et al., 1989).

19. Mental Health Research Institute Unusual Perceptions ScheduleExamining many aspects of ‘voice hearing’ across 7 domainsPhysical chc (e.g., frequency, location, duration)Personal chc (e.g., gender)Relationship/emotion (e.g., assoc. feelings, rel to voice)Form/content (e.g., content, repetition)Cognitive processes (e.g., rel. btw memory and voices)Perceptions of experience (e.g., sense of reality)Psychosocial issues (e.g., coping mechanisms)

20. CTQ & DESSamples differed linearly on dissociation (DES-T) and child maltreatment (CTQ)

21. VH, dissociation and psychosis (Dorahy et al., 2009)Sw/oM (n=18)SwMN=16DIDN=29Sig (2)Below 18 when started28%38%90%*Hear constantly50%47%86%*Location: Inside Outside Both56%28%17%63%19%19%52%3%45%NS**More than 2 voices33%25%89%*Both adult and child voices0%13%97%*Voices comment about you24%20%62%*Voices tell you what to do44%81%72%*Linked to person in past22%38%76%*

22. Accompanying sensations and other hallucinationsSw/oM (n=18)%SwM (n=16)%DID (n=29)%Sign voice/s were coming172576Experienced accompanying physical sensation with voices505097Headaches111948Experienced visual hallucinations444483Experienced tactile hallucinations331990Experienced olfactory hallucinations223876Experienced gustatory hallucinations62555Other hallucinations happen around same time as auditory halls.285679

23. Does child maltreatment or dissociation best predict central aspects of AH?Backwards likelihood-ratio logistic regression (all p’s < .01) Voices started before 18:CTQ (Exp B = 1.1) & CTQ  DES-T (Exp B=1.01)More than 2 voices: DES-T (Exp B = 1.05)Voice told what to do: DES-T (Exp B = 1.1)Feel controlled by voices: DES-T (Exp B = 1.04)Voices replay past memories: DES-T (Exp B = 1.03)

24. DiscussionSchizophrenia voice experience looks somewhat different from DID. DID more likely to:Start before 18Hear constantlyHear both internally and externallyHear more than 2 voicesHear both child and adult voices

25. DiscussionNo difference in internal voicesWith reference to voice location, locus lacks both “conceptual clarity and clinical utility” (Copolov et al., 2004, p. 5)DID and schiz. with maltreatment more likely to experience command hallucination

26. Laddis & Dell, 2012DID (40), schiz in remission (20), schiz active (20)DID higher incidence of: child voicesvoices that converse or argue Angry & persecutory voicesDID lower incidence of:delusions

27. Current study Further explored voice hearing in DID and schizophrenia, and delusionsTwo DID groups:Abuse ended before 18Sexual abuse after 18 (often/v.often) (growing interest in ongoing abuse, Middleton, 2013)To pick up potential differences in DID groupings(Palmer, 2015)

28. MeasuresDES; DES-TInterpretation of Voices Inventory (IVI; 26 itemsMeta-physical beliefs about voices (e.g., They mean that I am close to God).Positive beliefs (e.g., They help me keep control).Loss of control (e.g., They control the way I think).Peter’s et al. Delusional Inventory (21 items); e.g., “Do you ever feel as if some people are not what they seem to be?” Psychotic Symptom Rating Scale (11 & 6 items)Auditory Hallucinations (e.g., frequency, location)Delusions (e.g, conviction)

29. Dissociation as putative mechanismsSampleAge: F(2,63) = .36, p = .69Child abuseAll participants reported a history of child abuse/neglect except 1 person with schizophreniaLow Path Diss DIDHigh Path Diss DIDSchizophreniaN25 (9 adult SA)25(12 SA)16(0 adult SA)age44.8445.4442.56SexM=1F=24M=1F=24M=14F=2

30. Child and adult abuseSchizophrenia(n=16)Low DES-T DID (n=25)High DES-T DID (n=25) Total CTQRange: 28-14051*(SD=22.43)85* (SD=17.78)100*(SD=12.74)Adult Phy&Sex ab.Range: 1-41.16*(SD=.30)2.06 (SD=1.1)2.71 (SD=1.2)

31. Child and adult abuseSchizophrenia(n=16)Low DES-T DID (n=25)High DES-T DID (n=25) Total CTQRange: 28-14051*(SD=22.43)85* (SD=17.78)100*(SD=12.74)

32. Pathological DissociationAll groups differ on pathol. Dissociation, F(2,63) = 79.25, p < .001

33. “Have you ever heard voices that you suspect others don’t hear”1(never) – 5 (always)Schizophrenia(n=16)Low DES-T DID (n=25)High DES-T DID (25)Frequency3.33^3.884.50^F(2,57) = 5.62, p = .006; High DES-T DID differed from Schiz, p < .05

34. Hallucination CharacteristicsSchizophrenia(n=16)Low DES-T DID (n=25)High DES-T DID (25)Continuous voices25%40%52%Voices solely or largely internal20%71%88%Belief voices solely or largely external47%25%12%

35. AH characteristics^^^^^^^^

36. Interpretation of Voices Inventory*

37. Peter’s et al. Delusional Inventory

38. DiscussionWith DID differentiated by dissociative symptom, High path diss DID higher than 2 other groups on:Metaphysical and loss of control explanations for voicesGroups did not differ on: positive beliefs about voicesGeneral Delusions (other studies show differences in delusion, Laddis & Dell, 2012)

39. Discussion - IIHigh path dissociation DID looked different from schizophrenia on:FrequencyLoudnessAmount of negative contentAmount of distressBut the low path. dissociation DID looked similar to schizophrenia on nearly all auditory hallucination characteristicsThus, while markers of AH appears to be more severe in DID, their presence or severity should NOT be used to differentiate DID from schizophrenia.Though some markers might point towards DID, such as: Solely or largely internal voiceChild and adult voicesMore than two voicesSeverity of pathological dissociative symptoms in DID is a marker of more severe ‘psychotic’ symptom profile – all DID is not equal and pathological dissociation may create difference.

40. Future workDelusions: real or pseudo.Can phenomenology (e.g., of depersonalisation) explain AH or is a dissociative structure required? Phenomenology can’t explain the elaborate relationship the person has with voices, as if it was another self (Dorahy & Palmer, in press)Structure can.Questionnaire under development (Butler, 2015)

41. Clinical ImplicationsAssess for dissociation when person describes VHAssessing for child and adult voices may have some discriminatory utilityAssessing for multiple voices and them starting in childhood may have some discriminatory utility‘Psychotic’ symptoms in DID should reduce in therapy as dissociation is dealt with.Assessing the severe of pathological dissociation in DID is important

42. Dissociative identitiesIdentities: cognitions, emotions, behaviours, defenses -Trauma fixated & trauma avoidant.Two-way (symmetric) amnesiaA I BOne-way (asymmetric) amnesia A I BMutual awarenessA B(Janet, 1907; Dorahy, 2001; Ellenberger,1970; Putnam, 1989; Huntjens et al., 2003, 2012)

43. Existing LiteratureDorahy (2001) Semantically rich and data-driven content of a memory influence transfer in DIDHuntjens et al. (2003, 2005a,b, 2007, 2012) Similar memory transfer recorded between DID and DID controls, despite DID group reporting amnesiaProcedural memoriesNewly acquired emotional memoriesSemantic memoryAutobiographical semantic memoryPrebble, Addis & Tippett (2013) Episodic memory - autobiographicalAutonoetic and noetic consciousness

44. To assess episodic autobiographical memory in dissociative identity disorder (DID), with regard to transfer across identities that report having no awareness of each other (two-way amnesia). To assess autobiographical memory differences across groups with DID, non-clinical controls, and people simulating DID. To assess how the emotional content of a memory influences retrieval in the identity that experienced the event and the identity that did not experience the event (specifically, the emotion of embarrassment/shame).

45. Experimental Task 1Presentation of narratives (through head phones):Embarrassing & neutral – identity AEmbarrassing & neutral – identity BSecond person (‘You’) to first person (‘I’) transformation when repeating (autobio, internalised)Counterbalanced

46. Embarrassment/shame

47. Control script

48. Previous work: Embarrassment/shame induction and dissociationScripts given to students (McKendry, 2013) and patients in counselling (Scott, 2014)Assessing internal and external shame (Gilbert)Internal: perception of self as inferior, less than, useless External: perception of self as object of scorn, contempt or ridicule from others 3 conditionsSelf (Internal shame)Experimenter (External shame)Neutral (looking at white dots on black screen)

49. Apparatus

50. Dissociation increased after shame inductionPDEQ – for peri-experimental dissociationNo difference across conditionsBut difference across emotion (shame/Emb. Vs neutral), McKendry: Students, F (1, 75) = 13.58, p = <0.001, p2 = 0.15 Scott: patients, F (1, 30) = 11.21, p = .002, p2= .27

51. discussionDissociation is not related to specific kind on shame/embarrassment-inducing context. Rather, it seems to operate with a general increase in shame/embarrassment, regardless of whether one is in the company of others or not.Because the scripts have been found to heighten affect, we decided to use them in DID study investigating autobiographical memory

52. Participants for that study20 DID (currently 18, but some unuseable)40 Controls (20 amnesic, 20 non-amnesic) (currently 32, one ?DD)20 DID Simulators (currently 12)

53. Participants for that studyRecruitmentDID via Belmont Private Hospital and private practices in ChristchurchControls via University of Canterbury participant pool, ‘Subjects Wanted’ website, leaflets in Psychology Department, public libraries. churchesDID Simulators via Drama department at University of Canterbury and contacts in BrisbaneSimulator trainingIndependent of education and development sessionInformation sheets, videos, working with research assistantResearcher blind to DID and simulatorsDID/Simulators asked to chose two identities, one aware of painful life events, one unaware of them.

54. Rafaele will no doubt report back on the outcomes Thank you for listening