The relationship between dissociation and panic symptoms in adolescence and the exploration of potential mediators.

Background: Dissociative experiences have been linked to panic symptoms in adolescents, yet the nature of the association remains unclear. Methods: In the present study, we investigated the longitudinal relationship between dissociative experiences (focusing on the felt sense of anomaly subtype) and panic, as well as the potential mediating roles of emotion regulation strategies (expressive suppression and cognitive reappraisal), alexithymia, and cognitive appraisals of dissociation. Four thousand five hundred one adolescents aged 13-18 years were recruited via social media advertising to take part in an online survey at two timepoints, 1 month apart. Results: Analysis of 421 datasets found a significant positive relationship between initial dissociative experiences and panic symptoms reported 1 month later. This was mediated by the emotion regulation strategy of cognitive reappraisal, and cognitive appraisals of dissociation. These two variables were no longer significant mediators when controlling for panic symptoms at the first time point, likely due to the stability of panic symptoms across both assessments. Neither alexithymia nor expressive suppression were significant mediators. Conclusions: Thus, dissociative experiences that are persistently misinterpreted in a catastrophic manner may lead to escalating anxiety and panic symptoms, which could in turn heighten and maintain the feared dissociation sensation. These results indicate that dissociative experiences are associated with panic symptoms in adolescence, with cognitive appraisals of dissociation and cognitive reappraisal playing a role in this relationship.

Measuring dissociation across adolescence and adulthood: developing the short-form Cernis Felt Sense of Anomaly scale (CEFSA-14).

BACKGROUND: Dissociation may be important across many mental health disorders, but has been variously conceptualised and measured. We introduced a conceptualisation of a common type of dissociative experience, 'felt sense of anomaly' (FSA), and developed a corresponding measure, the Cernis Felt Sense of Anomaly (CEFSA) scale. AIMS: We aimed to develop a short-form version of the CEFSA that is valid for adolescent and adult respondents. METHOD: Data were collected from 1031 adult NHS patients with psychosis and 932 adult and 1233 adolescent non-clinical online survey respondents. Local structural equation modelling (LSEM) was used to establish measurement invariance of items across the age range. Ant colony optimisation (ACO) was used to produce a 14-item short-form measure. Finally, the expected test score function derived from item response theory modelling guided the establishment of interpretive scoring ranges. RESULTS: LSEM indicated 25 items of the original 35-item CEFSA were age invariant. They were also invariant across gender and clinical status. ACO of these items produced a 14-item short-form (CEFSA-14) with excellent psychometric properties (CFI=0.992; TLI=0.987; RMSEA=0.034; SRMR=0.017; Cronbach's alpha=0.92). Score ranges were established based on the expected test scores at approximately 0.7, 1.25 and 2.0 theta (equivalent to standard deviations above the mean). Scores of 29 and above may indicate elevated levels of FSA-dissociation. CONCLUSIONS: The CEFSA-14 is a psychometrically valid measure of FSA-dissociation for adolescents and adults. It can be used with clinical and non-clinical respondents. It could be used by clinicians as an initial tool to explore dissociation with their clients.

Self-stigma predicts post-traumatic and depressive symptoms in traumatized individuals seeking interventions for dissociative symptoms: a preliminary investigation.

Background: Previous studies showed that self-stigma is associated with poor clinical outcomes in people with serious mental illness, and is associated with post-traumatic stress disorder (PTSD). However, less is known about self-stigma in people with dissociative symptoms, which are often related to psychological trauma. This study examined whether baseline self-stigma would be associated with dissociative, PTSD and depressive symptoms at post-intervention, after controlling for treatment usage and baseline symptom severity, in a sample of traumatized Chinese adults undertaking a psychoeducation intervention for dissociative symptoms.Methods: We conducted a secondary analysis of data from a 60-day web-based psychoeducation programme. A total of 58 participants who provided data before and after the intervention were included for analysis. Hierarchical regression analyses were conducted.Results: In this highly traumatized, dissociative, and symptomatic help-seeking sample, baseline self-stigma was associated with PTSD (ß = .203, p = .032) and depressive (ß = .264, p = .025) symptoms at post-intervention, even after controlling for baseline symptom severity, age, location, number of sessions attended in the web-based psychoeducation programme, and use of psychological treatments for PTSD/dissociative symptoms. However, self-stigma was not associated with dissociative symptoms (p = .108).Conclusions: This is the first study showing that self-stigma is a significant predictor of comorbid symptoms (i.e. PTSD and depressive symptoms) in people seeking interventions for dissociative symptoms. The findings that post-traumatic and dissociative symptoms have different relationships to self-stigma also highlight the possibility dissociation might be an independent psychological construct closely associated with trauma, but not merely a PTSD symptom, although further studies are necessary. The preliminary findings call for more efforts to understand, prevent, and address self-stigma in people with trauma-related mental health issues such as dissociative symptoms.

Little is known about the clinical impacts of self-stigma in people with trauma and dissociation.Self-stigma predicted post-traumatic and depressive symptoms in people seeking interventions for dissociative symptoms.More efforts to understand and prevent self-stigma in people with trauma-related symptoms are needed.

A targeted psychological treatment for sleep problems in young people at ultra-high risk of psychosis in England (SleepWell): a parallel group, single-blind, randomised controlled feasibility trial.

BACKGROUND: Sleep disturbance is common and problematic for young people at ultra-high risk of psychosis. Sleep disruption is a contributory causal factor in the occurrence of mental health problems, including psychotic experiences, anxiety, and depression. The implication is that treating sleep problems might have additional benefits on mental health outcomes in individuals at high risk. The present study had two aims: first, to establish the feasibility and acceptability of a randomised controlled trial to treat sleep problems with the aim of reducing psychotic experiences in young people at ultra-high risk of psychosis; and second, to provide proof of concept of the clinical efficacy of the treatment. METHODS: We did a parallel group, single-blind, randomised controlled feasibility trial in two National Health Service trusts in England. Eligible participants were aged 14-25 years, a patient of mental health services, assessed as being at ultra-high risk of psychosis on the Comprehensive Assessment of At-Risk Mental States, and having current sleep problems (score of ≥15 on the self-report Insomnia Severity Index [ISI]). Participants were randomly assigned (1:1) to either a targeted psychological therapy for sleep problems (SleepWell) plus usual care or usual care alone via an automated online system, with non-deterministic minimisation that balanced participants for ISI score and referring service. The SleepWell therapy was delivered on an individual basis in approximately eight 1-h sessions over 12 weeks. Assessments were done at 0, 3, and 9 months, with trial assessors masked to treatment allocation. The key feasibility outcomes were the numbers of patients identified, recruited, and retained, treatment uptake, and data completion. Treatment acceptability was measured with the Abbreviated Acceptability Rating Profile (AARP). In preliminary clinical assessments, the primary clinical outcome was insomnia at 3 and 9 months assessed with the ISI, reported by randomised group (intention-to-treat analysis). Safety was assessed in all randomly assigned participants. The trial was prospectively registered on ISRCTN, 85601537, and is completed. FINDINGS: From Nov 18, 2020, to Jan 26, 2022, 67 young people were screened, of whom 40 (60%) at ultra-high risk of psychosis were recruited. Mean age was 16·9 years (SD 2·5; range 14-23), and most participants identified as female (n=19 [48%]) or male (n=19 [48%]) and as White (n=32 [80%]). 21 participants were randomly assigned to SleepWell therapy plus usual care and 19 to usual care alone. All participants provided data on at least one follow-up visit. 39 (98%) of 40 participants completed the primary outcome assessment at 3 and 9 months. 20 (95%) of 21 participants assigned to SleepWell therapy received the prespecified minimum treatment dose of at least four sessions. The median treatment acceptability score on the AARP was 48 (IQR 46 to 48; n=17; maximum possible score 48). At the post-intervention follow-up (3 months), compared with the usual care alone group, the SleepWell therapy group had a reduction in insomnia severity (ISI adjusted mean difference -8·12 [95% CI -11·60 to -4·63]; Cohen's d=-2·67 [95% CI -3·81 to -1·52]), which was sustained at 9 months (ISI adjusted mean difference -5·83 [-9·31 to -2·35]; Cohen's d=-1·91 [-3·06 to -0·77]). Among the 40 participants, eight adverse events were reported in six participants (two [11%] participants in the usual care group and four [19%] participants in the SleepWell therapy group). One serious adverse event involving hospital admission for a physical health problem was reported in the SleepWell therapy group, and one patient in the usual care alone group transitioned to psychosis. None of these events were classed as being related to trial treatment or procedures. INTERPRETATION: A randomised controlled trial of a targeted psychological sleep therapy for young people at ultra-high risk of psychosis is feasible. Patients can be retained in the trial and assessments done by masked assessors. Uptake of the sleep therapy was high, and we found preliminary evidence of sustained reductions in sleep problems. A definitive multicentre trial is now needed. FUNDING: NIHR Research for Patient Benefit and NIHR Oxford Health Biomedical Research Centre.

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

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

Listening to and Believing Derogatory and Threatening Voices.

BACKGROUND AND HYPOTHESIS: A plausible cause of distress for voice hearers is listening to and believing the threats and criticisms heard. Qualitative research indicates that patients have understandable reasons to listen. This study aimed to develop the understanding of distress using this listening and believing framework. Measures were developed of listening and believing voices and the reasons, and associations with distress tested. STUDY DESIGN: A cross-sectional study of patients hearing derogatory and threatening voices (N = 591). Listening and Believing-Assessment and Listening and Believing-Reasons item pools were completed, and assessments of distress. Exploratory and confirmatory factor analyses and structural equation modeling (SEM) were conducted. STUDY RESULTS: 52% (n = 307) of participants believed their voices most or all the time. Listening and believing had 4 factors: active listening, passive listening, believing, and disregarding. Higher levels of believing, active listening, and particularly passive listening were associated with higher levels of anxiety, depression, and voice distress. Reasons for listening and believing formed 7 factors: to better understand the threat; being too worn down to resist; to learn something insightful; being alone with time to listen; voices trying to capture attention; voices sounding like real people; and voices sounding like known people. Each type of reason was associated with active listening, passive listening, and believing. SEM showed that feeling worn down in particular accounted for listening and believing. Test-retest reliability of measures was excellent. CONCLUSIONS: A framework of listening and believing negative voices has the potential to inform the understanding and treatment of voice distress.

Psychological mechanisms connected to dissociation: Generating hypotheses using network analyses.

A large number of mechanisms, many relating to the processing of affect, have been proposed to cause dissociation. The aim of this study was to use network analyses to identify psychological processes most closely connected with 'felt sense of anomaly' dissociative experiences. Both an undirected model and a partially directed network model were estimated using data from 6161 general population respondents collected online. The networks were used to identify relationships between dissociation and ten candidate mechanisms: cognitive appraisals, behavioural responses to dissociation, affect intolerance, alexithymia, attentional control, body vigilance, anxiety sensitivity, general self-efficacy, perseverative thinking, and beliefs regarding stress. Both models indicated a highly connected network in which dissociation had direct connections with six psychological processes: cognitive appraisals, behavioural responses, perseverative thinking, alexithymia, general self-efficacy, and beliefs about being overwhelmed. The strongest connection in both networks was between dissociation and cognitive appraisals (causal effect 0.73). The causal direction of connections could not be statistically determined with confidence, apart from the strong probability that dissociation causes meta-cognitions about being overwhelmed (98.54% of 50,000 sampled directed acyclic graphs). Both networks suggest that cognitive appraisals and factors relating to heightened (negative) sensitivity to affect are closely connected to dissociation. Dissociative experiences may arise from a high sensitivity to affect leading to threat-based appraisals that are ruminated upon and maintained by unhelpful behaviours such as avoidance. Investigation of these relationships in clinical groups, and direct causal tests, are required.

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

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

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

BACKGROUND: Dissociative experiences occur across a range of mental health disorders. However, the term 'dissociation' has long been argued to lack conceptual clarity and may describe several distinct phenomena. We therefore aimed to conceptualise and empirically establish a discrete subset of dissociative experiences and develop a corresponding assessment measure. METHODS: First, a systematic review of existing measures was carried out to identify themes across dissociative experiences. A theme of 'Felt Sense of Anomaly' (FSA) emerged. Second, assessment items were generated based on this construct and a measure developed using exploratory (EFA) and confirmatory (CFA) factor analyses of 8861 responses to an online self-report survey. Finally, the resulting measure was validated via CFA with data from 1031 patients with psychosis. RESULTS: 'Felt sense of anomaly' (FSA) was identified as common to many dissociative experiences, affecting several domains (e.g. body) and taking different forms ('types'; e.g. unfamiliarity). Items for a novel measure were therefore systematically generated using a conceptual framework whereby each item represented a type-by-domain interaction (e.g. 'my body feels unfamiliar'). Factor analysis of online responses found that FSA-dissociation manifested in seven ways: anomalous experiences of the self, body, and emotion, and altered senses of familiarity, connection, agency, and reality (Χ2 (553) = 4989.435, p<0.001, CFI = 0.929, TLI = 0.924, RMSEA = 0.052, SRMR = 0.047). Additionally, a single-factor 'global FSA' scale was produced (Χ2 (9) = 312.350, p<0.001, CFI = 0.970, TLI = 0.950, RMSEA = 0.107, SRMR = 0.021). Model fit was adequate in the clinical (psychosis) group (Χ2 (553) = 1623.641, p<0.001, CFI = 0.927, TLI = 0.921, RMSEA = 0.043, SRMR = 0.043). The scale had good convergent validity with a widely used dissociation scale (DES-II) (non-clinical: r = 0.802), excellent internal reliability (non-clinical: Cronbach's alpha = 0.98; clinical: Cronbach's alpha = 0.97), and excellent test-retest reliability (non-clinical: ICC = 0.92). Further, in non-clinical respondents scoring highly on a PTSD measure, CFA confirmed adequate model fit (Χ2 (553) = 4758.673, CFI = 0.913, TLI = 0.906, RMSEA = 0.052, SRMR = 0.054). CONCLUSIONS: The Cernis Felt Sense of Anomaly (CEFSA) scale is a novel measure of a subset of dissociative experiences that share a core feature of FSA. It is psychometrically robust in both non-clinical and psychosis groups.

Catastrophic cognitions about coronavirus: the Oxford psychological investigation of coronavirus questionnaire [TOPIC-Q].

BACKGROUND: Cognitive therapies are developed on the principle that specific cognitive appraisals are key determinants in the development and maintenance of mental health disorders. It is likely that particular appraisals of the coronavirus pandemic will have explanatory power for subsequent mental health outcomes in the general public. To enable testing of this hypothesis we developed a questionnaire assessing coronavirus-related cognitions. METHODS: 12 285 participants completed online a 46-item pool of cognitions about coronavirus and six measures of different mental health problems. The sample was randomly split into derivation and validation samples. Exploratory factor analyses determined the factor structure, selection of items, and model fit in the derivation sample. Confirmatory factor analysis (CFA) then tested this model in the validation sample. Associations of the questionnaire with mental health outcomes were examined. RESULTS: The 26-item, seven-factor, Oxford Psychological Investigation of Coronavirus Questionnaire [TOPIC-Q] was developed. CFA demonstrated a good model fit (χ2 = 2108.43, df = 278, p < 0.001, comparative fit index (CFI) = 0.950, Tucker-Lewis index (TLI) = 0.942, root mean square error of approximation (RMSEA) = 0.033, standardized root mean square residual (SRMR) = 0.038). The factors were: cognitions about (1) safety and vulnerability, (2) negative long-term impact, (3) having the virus, (4) spreading the virus, (5) social judgment, (6) negative self, and (7) being targeted. The questionnaire explained significant variance in depression (45.8%), social anxiety (37.3%), agoraphobia (23.2%), paranoia (27.3%), post-traumatic stress disorder (57.1%), and panic disorder (31.4%). Cognitions about negative long-term impact had the greatest explanatory power across disorders. CONCLUSIONS: TOPIC-Q provides a method to assess appraisals of the pandemic, which is likely to prove helpful both in longitudinal studies assessing mental health outcomes and in delivery of psychological therapy.

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

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

The challenges and opportunities of social connection when hearing derogatory and threatening voices: A thematic analysis with patients experiencing psychosis.

OBJECTIVES: Relationships with other people are important determinants of the course of psychosis, yet social isolation is common. This study sought to learn about the patient experience of being around other people when hearing derogatory and threatening voices (DTVs). DESIGN: A qualitative interview study. METHODS: Fifteen participants with experience of hearing DTVs in the context of non-affective psychosis were recruited from NHS services. Data were obtained by semi-structured interviews and analysed using thematic analysis. RESULTS: Three themes were identified: (1) reasons why interacting with people is difficult when hearing DTVs; (2) the relationship between social connection and DTVs; and (3) factors which enable voice hearers to connect with others. A further ten sub-themes are outlined as reasons why hearing DTVs led to lower social connection, including difficulties during conversations (e.g., the concentration required is hard), negative expectations of interactions (e.g., fearing negative judgement from others), and difficulties sharing experiences of voices (e.g., people will be hurt or upset if I tell them about the voices). Isolation was a common response to hearing DTVs but also a time of vulnerability for hearing voices. Managing the challenges of interacting with people led to some improvements in DTVs. CONCLUSIONS: There are understandable reasons why hearing DTVs leads to lower social connection. Yet isolating oneself can also be a time of vulnerability for DTVs. Social connection might be one vehicle for disengaging from and disputing derogatory and threatening voice content. The effect on voice hearing of social recovery interventions warrants further investigation. PRACTITIONER POINTS: Participants shared 10 reasons why being around people is challenging when hearing derogatory and threatening voices. These typically affected both daily social experiences and contact with clinicians. Common initial responses to hearing DTVs were to reduce contact with people, experience difficulties connecting during conversations and to avoid sharing the experience of voice hearing. However, social isolation was a time of vulnerability to DTVs, and hence, increasing social connection might be a target for interventions. A range of factors enabled voice hearers to manage social situations, for example: the fostering of trust, self-acceptance, learning when it is better to stay at home, and developing a narrative to explain voice hearing to others. Addressing the barriers to connecting with others might have an important role in personal recovery from voice hearing.

Treating sleep problems in young people at ultra-high-risk of psychosis: study protocol for a single-blind parallel group randomised controlled feasibility trial (SleepWell).

BACKGROUND: Effective interventions, targeting key contributory causal factors, are needed to prevent the emergence of severe mental health problems in young people. Insomnia is a common clinical issue that is problematic in its own right but that also leads to the development and persistence of psychotic experiences. The implication is that treating sleep problems may prevent the onset of psychosis. We collected initial case series data with 12 young people at ultra-high-risk of psychosis. Post-intervention, there were improvements in sleep, depression and psychotic experiences. Now we test the feasibility of a randomised controlled trial, with a clinical aim to treat sleep problems and hence reduce depression, psychotic experiences, and prevent transition to psychosis. METHODS AND ANALYSIS: A randomised controlled feasibility trial will be conducted. Forty patients aged 14 to 25 years who are at ultra-high-risk of psychosis and have sleep disturbance will be recruited from National Health Service (NHS) mental health services. Participants will be randomised to receive either a novel, targeted, youth-focussed sleep intervention in addition to usual care or usual care alone. Assessor-blinded assessments will be conducted at baseline, 3 months (post-intervention) and 9 months (follow-up). The eight-session psychological intervention will target the key mechanisms which disrupt sleep: circadian rhythm irregularities, low sleep pressure, and hyperarousal. To gain an in-depth understanding of participants' views on the acceptability of the intervention and study procedures, 16 participants (n=10 intervention, n=6 control) will take part in qualitative interviews. Analyses will focus on feasibility outcomes (recruitment, retention, and treatment uptake rates) and provide initial CI estimates of intervention effects. Thematic analysis of the qualitative interviews will assess the acceptability of the intervention and trial procedures. ETHICS AND DISSEMINATION: The trial has received ethical approval from the NHS Health Research Authority. Findings will be disseminated through peer-reviewed publications, conference presentations, and lay networks. TRIAL REGISTRATION NUMBER: ISRCTN85601537.

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

BACKGROUND: Despite its long history, dissociation remains under-recognised clinically, partly due to difficulties identifying dissociative symptoms. Qualitative research may support its recognition by providing a lived experience perspective. In non-affective psychosis, identification of dissociation may be particularly important given that such experiences have been implicated its development and maintenance. Therefore, this study aimed to understand in the context of psychosis: what it is like to experience dissociation; the impact dissociation might have; what factors begin, maintain or end dissociative experiences; and what beliefs people hold about dissociation. METHODS: Qualitative interviews were carried out with twelve NHS patients with non-affective psychosis diagnoses and experience of dissociation. Data were analysed using Thematic Analysis. RESULTS: Dissociation involves subjective strangeness, unreality, disconnection, and shifts in perception. It impacts on mental health (including psychotic experiences), daily functioning, emotional connection, and can lead to social withdrawal. Stress, fatigue, and excessive internal focus may be involved in development and maintenance. Participants found it very difficult to describe the experience of dissociation, and, as a result, often did not mention it to others. Even when shared, interviewees reported that their descriptions were misunderstood and therefore they did not receive information or support specific to dissociation. The consensus was that experiences of dissociation are negative, but that understanding them better helped to enable coping. CONCLUSIONS: The core subjective experience of dissociation appears to be a felt sense of anomaly (FSA), and we therefore suggest clinicians proactively enquire about such experiences. Dissociation is distressing, and has multiple impacts, but can easily be overlooked due to difficulties describing it and behavioural similarities to negative psychotic symptoms such as withdrawal.

Cognitive appraisals of dissociation in psychosis: a new brief measure.

BACKGROUND: Catastrophic cognitive appraisals, similar to those in anxiety disorders, are implicated in depersonalisation, a form of dissociation. No scales exist to measure appraisals of dissociative experiences. Dissociation is common in psychosis. Misinterpretations of dissociative experiences may maintain psychotic symptoms. Therefore, assessing appraisals in this context may be valuable. AIMS: The primary aim was to develop a measure of key appraisals of dissociation in psychosis. Secondary aims were to test the relationship between appraisals and psychotic experiences (paranoia and hallucinations), and determine whether appraisals explain additional variance in psychotic symptoms above dissociative symptoms. METHOD: Fifty items were generated from transcripts of interviews with patients. The measure was developed and psychometrically validated via factor analysis of data from 9902 general population participants and 1026 patients with psychosis. Convergent validity, test-re-test reliability, and internal reliability were assessed. Regression analyses tested relationships with psychotic symptoms. RESULTS: A 13-item single-factor measure was developed. Factor analysis indicated good model fit [χ2(65) = 247.173, comparative fit index (CFI) = 0.960, root mean square error of approximation (RMSEA) = 0.052]. The scale had good convergent validity with a rumination (non-clinical: r = 0.71; clinical: r = 0.73) and dissociation measure (r = 0.81; r = 0.80), high internal consistency (α = 0.93; α = 0.93), and excellent 1-week test-re-test reliability [intraclass correlation (ICC) = 0.90]. It explained variance in psychotic symptoms (paranoia: 36.4%; hallucinations: 35.0%), including additional variance compared with dissociation alone (paranoia: 5.3%; hallucinations: 2.3%). CONCLUSIONS: The Cognitive Appraisals of Dissociation in Psychosis (CAD-P) measure is a psychometrically robust scale identifying appraisals of dissociative experiences in psychosis and is associated with the presence of psychotic experiences. It is likely to prove useful for clinical assessment and research.

The Dunn Worry Questionnaire and the Paranoia Worries Questionnaire: new assessments of worry.

BACKGROUND: The cognitive process of worry, which keeps negative thoughts in mind and elaborates the content, contributes to the occurrence of many mental health disorders. Our principal aim was to develop a straightforward measure of general problematic worry suitable for research and clinical treatment. Our secondary aim was to develop a measure of problematic worry specifically concerning paranoid fears. METHODS: An item pool concerning worry in the past month was evaluated in 250 non-clinical individuals and 50 patients with psychosis in a worry treatment trial. Exploratory factor analysis and item response theory (IRT) informed the selection of scale items. IRT analyses were repeated with the scales administered to 273 non-clinical individuals, 79 patients with psychosis and 93 patients with social anxiety disorder. Other clinical measures were administered to assess concurrent validity. Test-retest reliability was assessed with 75 participants. Sensitivity to change was assessed with 43 patients with psychosis. RESULTS: A 10-item general worry scale (Dunn Worry Questionnaire; DWQ) and a five-item paranoia worry scale (Paranoia Worries Questionnaire; PWQ) were developed. All items were highly discriminative (DWQ a = 1.98-5.03; PWQ a = 4.10-10.7), indicating small increases in latent worry lead to a high probability of item endorsement. The DWQ was highly informative across a wide range of the worry distribution, whilst the PWQ had greatest precision at clinical levels of paranoia worry. The scales demonstrated excellent internal reliability, test-retest reliability, concurrent validity and sensitivity to change. CONCLUSIONS: The new measures of general problematic worry and worry about paranoid fears have excellent psychometric properties.

The weeks before 100 persecutory delusions: the presence of many potential contributory causal factors.

BACKGROUND: The period before the formation of a persecutory delusion may provide causal insights. Patient accounts are invaluable in informing this understanding. AIMS: To inform the understanding of delusion formation, we asked patients about the occurrence of potential causal factors - identified from a cognitive model - before delusion onset. METHOD: A total of 100 patients with persecutory delusions completed a checklist about their subjective experiences in the weeks before belief onset. The checklist included items concerning worry, images, low self-esteem, poor sleep, mood dysregulation, dissociation, manic-type symptoms, aberrant salience, hallucinations, substance use and stressors. Time to reach certainty in the delusion was also assessed. RESULTS: Most commonly it took patients several months to reach delusion certainty (n = 30), although other patients took a few weeks (n = 24), years (n = 21), knew instantly (n = 17) or took a few days (n = 6). The most frequent experiences occurring before delusion onset were: low self-confidence (n = 84); excessive worry (n = 80); not feeling like normal self (n = 77); difficulties concentrating (n = 77); going over problems again and again (n = 75); being very negative about the self (n = 75); images of bad things happening (n = 75); and sleep problems (n = 75). The average number of experiences occurring was high (mean 23.5, s.d. = 8.7). The experiences clustered into six main types, with patients reporting an average of 5.4 (s.d. = 1.0) different types. CONCLUSIONS: Patients report numerous different experiences in the period before full persecutory delusion onset that could be contributory causal factors, consistent with a complex multifactorial view of delusion occurrence. This study, however, relied on retrospective self-report and could not determine causality. DECLARATION OF INTEREST: None.

The comments of voices on the appearance of patients with psychosis: 'the voices tell me that I am ugly'.

BACKGROUND: There are high rates of obesity and low self-esteem in patients with psychosis. The occurrence of negative voice content directly about appearance is therefore plausible. Derogatory comments about appearance are likely to be distressing, increase depression and contribute to social withdrawal. AIMS: To systematically assess the occurrence of voice content regarding appearance and identify correlates. METHOD: Sixty patients experiencing verbal auditory hallucinations at least once a week in the context of non-affective psychosis completed a measure assessing positive and negative voice content about appearance. They also completed assessments about body image, self-esteem, psychiatric symptoms and well-being. RESULTS: Fifty-five (91.7%) participants reported hearing voices comment on their appearance. A total of 54 (90%) patients reported negative voice content about their appearance with 30 (50%) patients experienced negative appearance comments on a daily basis. The most common negative comment was 'the voices tell me that I am ugly' (n = 48, 80%). There were 39 (65%) patients who reported positive voice content on appearance. The most frequent positive comment was 'I look as nice as other people' (n = 26, 43.3%). Negative voice content about appearance was associated with body image concerns, paranoia, voice hearing severity, depression, worry, negative self-beliefs and safety-seeking behaviours. Positive appearance voice content was associated with greater body esteem and well-being and lower levels of depression and insomnia. CONCLUSIONS: Voice content about appearance is very common for patients seen in clinical services. Negative voice content may reflect - and subsequently reinforce - negative beliefs about one's appearance, low self-esteem, worry and paranoia. DECLARATION OF INTEREST: None.

Suicidal ideation and behaviour in patients with persecutory delusions: Prevalence, symptom associations, and psychological correlates.

BACKGROUND: To determine the prevalence of suicidal ideation and behaviour - and their correlates - in patients with persecutory delusions. METHODS: 110 patients with persecutory delusions in the context of non-affective psychosis were assessed for suicidal thoughts and behaviours over the past month. Symptom and psychological assessments were also completed. RESULTS: The severity of suicidal ideation was: no suicidal ideation (n = 26, 23.6%); wish to be dead (n = 21, 19.1%); nonspecific active suicidal thoughts (n = 14, 12.7%); suicidal thoughts with methods but no intent (n = 29, 26.4%); suicidal thoughts with intent but no specific plan (n = 13, 11.8%); and suicidal intent with plan (n = 7, 6.4%). In the past month, five patients (4.5%) had made an actual, interrupted, or aborted suicide attempt. The severity of suicidal ideation was associated with higher levels of depression, paranoia, hallucinations, anger, insomnia, negative beliefs about the self and others, pessimism, worry, and delusion safety-seeking behaviours and lower levels of psychological well-being and reward responsiveness. Severity of ideation was not associated with cannabis or alcohol use, working memory, pain, or meaningful activity levels. CONCLUSIONS: Patients with persecutory delusions are typically in a severe state of psychological stress, and at risk of suicide, as indicated by very high levels of suicidal ideation. This exploratory study also identifies correlates of suicidal ideation that could be investigated in causal research designs.

What is the relationship between dissociation and self-harming behaviour in adolescents?

Deliberate self-harm in adolescents is an increasing clinical problem, but there is a limited understanding of the mechanisms causing or maintaining this behaviour. One proposed mechanism is that of dissociation. However, the role this mechanism may play is unclear: although some suggest that adolescents engage in self-harm to end the aversive experience of dissociation, others propose that self-harm is used to purposefully trigger a dissociative state to avoid emotional pain. This systematic review is the first to evaluate the available evidence regarding the relationship between dissociation and deliberate self-harm in adolescents (aged 18 or younger). Nineteen relevant studies were identified. These studies were limited by cross-sectional design and poor methods of measurement, but some important conclusions could be drawn. The majority of studies found a positive correlation between the severity of dissociation and the severity and frequency of deliberate self-harm in adolescents, and a small number of results suggest that dissociation mediates the relationship between childhood trauma and adolescent self-harm.