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Schizophrenia and dissociation: Its relation with severity, self-esteem and awareness of illness
SCHRES-07722; No of Pages 6 Schizophrenia Research xxx (2018) xxx–xxx
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Schizophrenia and dissociation: Its relation with severity, self-esteem and awareness of illness Ania Justo a,⁎, Alicia Risso b, Andrew Moskowitz c, Anabel Gonzalez d a
Department of Psychiatry and Psychology of the Polyclinic Assistens, Calle Urzáiz, 28, 2 C, 36201, Vigo, Spain Department of Psychology, Universidade da Coruña, Spain Touro College Berlin, Germany d Complexo Hospitalario Universitario A Coruña, Spain b c
a r t i c l e
i n f o
Article history: Received 22 October 2017 Received in revised form 16 February 2018 Accepted 17 February 2018 Available online xxxx Keywords: Schizophrenia Dissociation Self-esteem Awareness Trauma PTSD
a b s t r a c t This article describes the conclusions of an investigation done with 120 Spanish patients: the finding of a new psychopathological profile within a subgroup of patients suffering from schizophrenia. The patients were evaluated through different questionnaires about sociodemographic data, traumatic events, the severity index (both clinical and psychopathological), self-esteem and consciousness of the illness. From the scores obtained on a scale of dissociative experiences, they were classified into two groups: high dissociative symptomatology or HD, and low dissociative symptomatology or LD. The HD group contained 44 patients (36.7% of the total population). The groups LD and HD show meaningful differences with respect to dissociative symptomatology levels, general psychopathology and level of traumatic events suffered. The percentage of patients with low self-esteem was higher in group HD than in group LD (M = 25.52 front 28.76 of group LD; t (118) = 2.94, p = .00). In addition, the group HD was more conscious of having a mental disorder, of the beneficial effects of medication and of the social consequences of their illness: F (1) = 10.929, p = .001; ƞ2pt = 0.083; 1-β = 0.907. The results show the existence of a subgroup of schizophrenic patients with higher levels of dissociation and trauma that were related with higher levels of symptomatology, lower self-esteem and higher consciousness of the illness, building a population of higher severity in which it would make sense to implement coadjutant treatments specifically oriented to these variables and, in addition, opening a therapeutic possibility for the patients with refractory schizophrenia. © 2018 Elsevier B.V. All rights reserved.
1. Introduction Schizophrenia is a severe mental disorder, which despite the proliferation of therapeutic strategies, continues generating very significant personal, family and social consequences. Healthcare programs traditionally have been structured based on levels of functional impairment of the patients, but also to its clinical features. An example is the programs of dual pathology, which have been oriented to schizophrenic patients with addictive behaviors, since this population requires a different therapeutic strategy. Over the last decade, several studies have found that patients suffering from schizophrenia experience dissociative phenomena with more frequency and at higher levels than the general population (Braehler et al., 2013; Vogel et al., 2006). In recent years, the possible role of trauma in the development of schizophrenia has been raised
⁎ Corresponding author. E-mail address: [email protected] (A. Justo).
(Kilcommons and Morrison, 2005; Şar et al., 2009; Schäfer et al., 2006; Schäfer et al., 2012; Vogel et al., 2009) and its presence has been related to greater severity. Given that trauma-based disorders improve with specific psychotherapies (Bisson et al., 2007) and these treatments have been shown to be beneficial in schizophrenia (de Bont et al., 2013), finding a group of more severely traumatized patients within those diagnosed with schizophrenia is not only of nosological interest, but is also important for the planning of health care resources. In support of this, Achim et al. (2009) found, in an analysis of 20 studies, that the prevalence of PTSD in psychosis was approximately 12.4%; comorbid PTSD in the psychosis patients was associated with poorer functioning and more severe psychotic symptoms. In recent investigations, dissociative symptoms in schizophrenia were related to levels of post-traumatic stress, which could imply a potential influence of posttraumatic events on dissociation in the pathogenesis of the schizophrenia (Bob and Mashou, 2011; Kilcommons and Morrison, 2005; Read et al., 2005). Thus, in order to select a subset of schizophrenic patients with more severe traumatization, dissociative symptoms seem to be a relevant indicator.
https://doi.org/10.1016/j.schres.2018.02.029 0920-9964/© 2018 Elsevier B.V. All rights reserved.
Please cite this article as: Justo, A., et al., Schizophrenia and dissociation: Its relation with severity, self-esteem and awareness of illness, Schizophr. Res. (2018), https://doi.org/10.1016/j.schres.2018.02.029
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A. Justo et al. / Schizophrenia Research xxx (2018) xxx–xxx
The interrelationship between schizophrenia and dissociation goes back to Bleuler, and raises further issues of differential diagnosis still not well demarcated. Some characteristic symptoms of schizophrenia such as auditory hallucinations (Perona Garcelán et al., 2012; Varese et al., 2011) are also very common in dissociative disorders, giving rise to possible diagnostic confusion. Some authors have proposed a link between the two psychopathological groups, and a relationship that goes beyond a simple comorbidity (Álvarez et al., 2015). Even the symptoms described by Kurt Schneider as pathognomonic for schizophrenia have been proposed to be more characteristic of dissociative disorders (Kluft, 1987; Moskowitz and Corstens, 2007). To address these issues, some authors (Ross and Keyes, 2004; Şar et al., 2009) have proposed a dissociative subtype of schizophrenia, characterized by relevant dissociative symptomatology related to comorbidity and severe trauma during childhood. These investigations open the door to a new conceptualization of the relationships between schizophrenia, dissociation and trauma. There remain many questions to answer. This investigation tries to address some of them and has two objectives. The first objective is to look for evidence for a dissociative subtype in a Spanish sample where there are schizophrenic patients with different levels of severity and symptomatic profiles. The second objective is to characterize this subtype, if found, considering its clinical and psychopathological features in general, also analyzing its relationship to self-esteem and consciousness of illness, which have been related to severity and poorer quality of life in schizophrenic patients (Eack and Newhill, 2007; Read and Dillon, 2013). These variables have never been studied in this group of patients. However, in our clinic experience with this kind of patients, we have observed that high dissociation levels could be associated, paradoxically, with a higher awareness of the illness (of the suffering and of its functional and social consequences) and with lower self-esteem levels. In this study, these hypotheses are tested to try to find out the adequacy of these clinical observations and to see if they could be generalized in the different assistance centers. 2. Methods 2.1. Participants This study examined 120 voluntary patients who had a schizophrenia diagnosis. Patients were from both genders (77.2% male) and were between 20 and 75 years old (M = 43.52; SD = 11.28). All participants signed an informed consent form to cover the requirements of the Helsinki 2000 Declaration. All patients were in treatment at various inpatient and outpatient state and privately owned facilities in Galicia, including the penitentiary. The objective was to gain a heterogeneous sample to maximize the representability regarding the general schizophrenia population. All patients who had the diagnosis of schizophrenia were informed of the study, twelve people were deemed not capable of giving informed consent. In addition, the diagnosis of schizophrenia was reviewed by two clinicians. There were three patients who were excluded on this basis because they didn't meet the diagnostic criteria of DSM-5 schizophrenia in the past or currently. 2.2. Instruments The basic data was gathered with questionnaire designed specifically for this investigation that included socio-demographic and health variables (suicide attempts, consults at hospitals, relatives diagnosed with psychosis and other disorders and drug use). The additional questionnaires used were as follows: 2.2.1. Dissociative Experiences Scale – DES (Bernstein and Putnam, 1986) This instrument is the most common screening instrument for dissociative symptomatology. It has 28 items scored on a scale from 0 to 100
indicating the percentage of time that the patient reports having had specific dissociative experiences. It has a reliability of 0.78 and a validity of 0.76. For this study, we used the Spanish translation of Icarán and Colon (1996). The internal consistency reliability for the study sample is α = 0.93. 2.2.2. Structured Clinical Interview for the Dissociative Disorders – SCID-D (Steinberg, 1993) It is a structured interview done specifically for the diagnosis of dissociative disorders (DD). It explores five areas of manifestation of dissociative disorders: amnesia, depersonalization, derealization, identity confusion and identity alteration. In it, obligatory questions can be found in each subscale that allows an initial evaluation to be made, and to decide for which subjects it would be necessary to utilize the full scale. It has a reliability of 0.88 and a good validity. 2.2.3. Traumatic Experiences Questionnaire - TQ (Davidson et al., 1990) For this study, we used the translation of Bobes et al. (2000). It has 46 yes or no items regarding whether an experience was suffered and also gathers information about the age and duration of the traumatic event. The third section is a list of 18 symptoms that explore the three symptomatic clusters of PTSD. The items are of dichotomous answer Yes/No and the temporal frame of reference is very broad and open: any time after the event. Its psychometric properties have only been calculated for the general and the clinical population. The internal consistency reliability for the study sample is α = 0.69. 2.2.4. Derogatis Symptom Checklist Revised - SCL 90-R (Derogatis et al., 1975) The objective of this instrument is to detect general psychiatric symptomatology. For this study, the translation of González de Rivera et al. (1989) was used. It has a reliability of 0.79–0.90 and a validity of 0.73–0.80. It has a list of 90 items that are scored on a scale from 0 (“nothing” or “not at all”) to 4 (“a lot”), representing the extent to which the patient is bothered by a particular symptom. The internal consistency reliability for the study sample is α = 0.97. 2.2.5. Rosenberg self-esteem scale- RSES (Rosenberg, 1965) It includes 10 items whose contents are centered on the feelings of respect and acceptance of yourself. Half of the items are scored positively and the other half negatively. The score follows a Likert scale that goes from 1 = agree to 4 = totally disagree. It has a reliability of 0.74 and a validity of 0.87. The internal consistency reliability for the study sample is α = 0.86. 2.2.6. Scale to assess Unawareness of Mental Health - SUMD (Amador and Strauss, 1990) It has the goal of evaluating the patient's consciousness of the disorder and its social consequences, and the perceived effectiveness of medication. It has 3 general items and 17 items dedicated to specific symptoms. The scale used in this investigation is the Spanish adaptation of Ruiz et al. (2008). It has a validity of 0.84. In this study, the results of the three general items were analyzed and scored independently of their specific symptomatology. The internal consistency reliability for the study sample is α = 0.91. 2.3. Procedure The data gathering was done by two psychiatrists and two psychologists. The DES scale was administered orally to ensure that patients' responded to the questions as they were intended, and were not describing experiences better classified as psychotic than as dissociative. To this end, when a patient scored positively on any item of the DES they were asked for examples of the phenomena enquired about. The study had the approval of the Regional Ethical Committee of Galicia.
Please cite this article as: Justo, A., et al., Schizophrenia and dissociation: Its relation with severity, self-esteem and awareness of illness, Schizophr. Res. (2018), https://doi.org/10.1016/j.schres.2018.02.029
A. Justo et al. / Schizophrenia Research xxx (2018) xxx–xxx
2.4. Statistical analysis First, an exploratory and descriptive analysis of the sociodemographic variables and of clinical significance (independent variables) was carried out, together with the determination of the optimal cut-off point in the DES dependent variable (Magder and Fix, 2003; Williams, 2006). This procedure consisted of determining, for a range of values of the independent variable (DES = 20–30), the value that best separates patients according to the association test X2 with respect to the Gold Standard (SCID-D), being the lowest p-value indicative of the optimum cut-off point. In addition, the Youden index and the odds ratio are calculated for each of the cut points analyzed (see Table 1). To control the type I error derived from the multiple comparisons, the correction proposed by Altman et al. (1994) was used. Secondly, to verify the degree of relationship between the dependent variable DES and the independent variables, a logistic regression analysis was applied step by step. In a first phase, a screening was carried out on those variables that showed significant differences at baseline, using a univariate logistic regression model. In a second phase, and on those independent variables that showed a significant relationship with the dependent variable, a multivariate logistic regression analysis was performed. The goodness of fit of the final model was verified by the analysis of the ROC curve and the statisticians of Hosmer-Lemeshow and Nagelkerke. The processing of the data was carried out using the statistical software SPSS 20 and G * Power 3.1 (Mayr et al., 2007). 3. Results The DES results show that it is possible to discriminate two differentiated groups of people: one with low dissociative symptomatology (LD) and another with high dissociative symptomatology (HD) [LD: n = 76; M = 6.98, SD = 5.27; DES-HD: n = 44; M = 34.20, SD = 11.55; t (53.52) = −14.77, p = .00, d = 3.03. Previous research (Achim et al., 2009; Bernstein and Putnam, 1986; Ross and Keyes, 2004) recommended cutoff scores of 20, 25 or 30 but we decided to statistically investigate the best possible cutoff. A type of procedure that takes as reference the comparison of the DES variable with another reference variable (in this case the presence-absence of dissociative disorder valued through the SCID-D) has been followed. Within this group, two procedures have been performed: calculation of the Youden index and minimum p-value (Fluss et al., 2005), yielding the same result, establishing the cut-off point in the value 20. There were statistically significant differences in the age variable [DES-LD: M = 45.88, SD = 12.17; DES-HD: M = 39.45, SD = 8.18; t (115.25) = 3.45, p = .01, d = 0.62]. For the rest of the Table 1 Results of the optimal cut-off point estimation for the DES scale. Cut point (DES)
Youden indexa
20 21 22 23 24 25 26 27 28 29 30
0,37 0,30 0,26 0,28 0,28 0,25 0,20 0,17 0,09 0,09 0,09
X2 11,29 7,59 6,37 7,24 7,24 6,05 4,17 3,20 1,09 1,27 1,27
O. R.b 5,24 3,93 3,57 3,91 3,91 3,58 2,95 2,67 1,88 2,13 2,13
pc 0,02 0,11 0,18 0,12 0,12 0,21 0,43 0,62 0,90 0,92 0,92
a Youden index: the optimal cut-off point is the one that reaches the highest value in the index b O.R: Odds Ratio c p-Minimum value method: the optimum cut-off point is the one that obtains the lowest p-value.
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sociodemographic variables considered, no statistically significant differences were found between the two groups. As for the independent variables, there were no statistically significant differences in suicide attempts, emergency consultations and hospitalizations. For the remaining variables, statistically significant differences were obtained (see Table 2). Very significant were the results obtained in the variable “number of traumas”, where a very high number of traumatic events was found in the HD group vs the LD group (80% vs LD 30%) psychopathological indices in the SCL scale - the most interesting result is
Table 2 Descriptive Analysis and results of the comparison between groups in the independent variables. Variables
Age Groups LD/HD RSES SDQ 20 SCL-90-R Somatization Obsessive-compulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic Anxiety Paranoid Ideation Psychoticism Global severity index Positive discomfort index Total positive symptoms
Groups LD (n = 76)
HD (n = 44)
M
SD
M
SD
T
p
d
45.88 6.98 28.76 1.28
12.17 5.27 5.48 0.79
39.45 34.20 25.52 1.77
8.18 11.55 6.33 1.29
3.45 −14.77 2.94 −2.31
.01* .00* .00 .02
0.62# 3.03## 0.55 0.46
0.51 0.84 0.88 1.00 0.79 0.52 0.55 1.08 0.69 0.78 1.99 32.97
0.62 0.77 0.81 0.78 0.71 0.64 0.59 1.00 0.70 0.57 0.69 19.68
1.26 1.88 1.77 1.76 1.66 1.16 1.35 1.88 1.62 1.62 2.48 58.11
0.81 0.76 0.86 0.89 0.86 0.97 0.93 0.97 0.71 0.71 0.64 17.41
−5.26 −7.11 −5.61 −4.87 −5.93 −3.93 −5.18 −4.26 −6.70 −6.67 −3.84 −7.26
.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00
1.04 1.36 1.06 0.91 1.10 0.78 1.03 0.81 1.32 1.30 0.74 1.35
Variables
Centers of Origin Outpatients Rehabilitation hospitals Exclusion centers and prisons Mental illness awareness Clear Intermediate None Drug consumption awareness Clear Intermediate None Awareness of social consequences Clear Intermediate None Suicide attempts No Yes Hospital emergency room visits Low High Hospitalizations Low High Number of traumas Low High PTSD Yes No
Groups LD (n = 76)
HD (n = 44)
N
N
%
%
20 28 28
26.3% 36.8% 36.8%
9 15 20
20.5% 34.1% 45.5%
24 12 40
31.6 15.8 52.6
22 11 11
50.0 25.0 25.0
24 20 32
31.6 26.3 42.1
25 7 12
56.8 15.9 27.3
12 15 49
15.8 19.7 64.5
21 8 15
47.7 18.2 34.1
57 19
75.0 25.0
26 18
59.1 40.9
46 30
60.5 39.5
21 23
47.7 52.3
47 29
61.8 38.2
23 21
52.3 47.7
53 23
69.7 30.3
9 35
20.5 79.5
15 61
19.7 80.3
15 29
65.9 24.2
X2
p
V
0.97
.61
0.09
8.71
.01
0.27
7.36
.02
0.25
15.19
.00
0.36
3.31
.07
0.17
1.85
.17
0.12
1.05
.31
0.09
27.10
.00
0.47
25.58
.00
0.46#
Note: *p b .05; d: Cohen's d. v: v de Cramer. #: Sizes of the moderate effect; M: Average; PTSD: Posttraumatic Stress Disorder; RSES: Self-esteem scale of Rosenberg; SCL 90-R: Derogatis Symptom Checklist Revised; SD: Standard Deviation; SDQ 20: Somatoform Dissociation Questionnaire; t: Student; X2: Chi squared.
Please cite this article as: Justo, A., et al., Schizophrenia and dissociation: Its relation with severity, self-esteem and awareness of illness, Schizophr. Res. (2018), https://doi.org/10.1016/j.schres.2018.02.029
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A. Justo et al. / Schizophrenia Research xxx (2018) xxx–xxx
that the largest difference between the groups seems to be on SCL Psychoticism-, levels of self-esteem - significant differences are observed between the groups, with scores being lower in group HD (M = 25.52 versus 28.76 of group LD); t (118) = 2.94, p = .00) and illness conscience - where group HD shows more consciousness of having a mental disorder, of the beneficial effects of the medication and of the social consequences of their illness - (high scores indicate lower levels of awareness of illness). In the Table 3 the results of the univariate regression logistic analysis are shown controlling the age variable and excluding those independent variables that were not significant in the previous step. In the Table 4 the final results of the multivariate logistic regression model final results are shown. The model associates the ownership relationship to the dissociation group (LD vs. HD) using three significant variables: number of traumas (Zwald = 15.93, p = .00, OR = 8.37, C.I. = 2.95–23.75), psychoticism (Zwald = 6.02, p = .01, OR = 2.42, C.I. = 1.19–4.90) and obsession (Zwald = 3.63, p = .05, OR = 2.17, C.I. = .98–4.83). The rest of the variables introduced in the model did not have a significant contribution. This final model has a specificity of the 89.5% and a sensitivity of the 72.7%. The percentage of global classification is 83.3% with an area below the ROC curve over 90% (Area = 0.90, p = .00, C.I. = 0.85– 0.95) (See Fig. 1). The test Hosmer-Lemeshow does not show significant differences in the calculated model [X2 (8) = 12.93, p = .11] indicating a good adjustment of the final model. The test Nagelkerke (R2 = 0.57) shows that the 57% of the variation in the dissociation variable is explained by the three variables included in the final model. 4. Discussion The prevalence of dissociative symptoms among patients with a diagnosis of schizophrenia found in this study is consistent with other studies (Braehler et al., 2013; Schäfer et al., 2006; Schäfer et al., 2006). Nevertheless, possibly, at least some of the persons in the HD group might be better or more accurately diagnosed with PTSD, C-PTSD or a Table 3 Logistic univariate logistic regression analysis. Variables
Β
S.E.
Zwald
p
OR
.00 0.95 .01 0.91 .08 4.44
0.91 0.98 0.85 0.98 0.82 24.08
1.45 1.54 1.18 1.48 1.32 0.88 1.36 0.84 1.56 1.93 1.20 0.06
0.34 0.31 0.27 0.39 0.29 0.27 0.32 0.22 0.30 0.40 0.33 0.01
.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00
2.17 2.53 1.90 2.07 2.10 1.42 2.10 1.50 2.62 3.17 1.73 1.04
2.50
0.47 28.12 .00 12.17 4.83 30.64
−0.48 0.23 4.40 −0.42 0.23 3.31 −0.73 0.24 9.28 2.03
4.26 4.68 3.25 4.40 3.75 2.42 3.91 2.31 4.77 6.91 3.33 1.06
.03 0.04 .07 0.65 .00 0.48
0.44 20.86 .00 7.62
SCL-90-R Obsessive-compulsive Psychoticism TQ Number of traumas
Β
S.E.
Zwald
p
OR
C.I. OR 95% Inf.
Sup.
0.78 0.88
0.41 0.36
3.63 6.02
.05 .01
2.17 2.42
0.98 1.19
4.83 4.90
2.12
0.53
15.93
.00
8.37
2.95
23.75
Note: β: Beta Coefficient; C.I. OR 95%: Confidence interval at a 95%. Inf.: Inferior limit. Sup.: Higher limit; OR: Odds Ratio; p: Signification threshold b.05; SCL 90-R: Derogatis Symptom Checklist Revised; S.E.: Standard error; TQ: Traumatic Experiences Questionnaire; Zwald: Wald.
dissociative disorder. That would be a question to be addressed by a future study. One difference in our study is that it gathers patients from many different settings, including ambulatories and medium/long stay units and even those with criminal conduct. In contrast, all studies done previously have examined subsamples of patients with an acute outbreak of schizophrenia mostly in ambulatory and hospital settings. These differences must be taken into account when interpreting and comparing the results. The strong relationship between dissociation and trauma coincides with that described in patients with other disorders. In addition to the number of adverse events, the higher presence of post-traumatic symptomatology in the HD sample could correspond simply to the higher presence of trauma in this group (Vogel et al., 2006) or to an influence of these post-traumatic symptoms in the development of the psychotic condition (Kilcommons and Morrison, 2005; Vogel et al., 2011). Independent of the interpretation as a mediator or etiological variable, this result fits with other studies that support the relationship between dissociative and post-traumatic symptomatology (Murray et al., 2002; Panasetis and Bryant, 2003). It is also interesting to note that the high percentage of PTSD found in the global sample is higher than in previous investigations, although this may be due to the higher clinical severity of the patients evaluated in our study, as this is also noted in the Kilcommons and Morrison (2005) study.
Sup.
−0.05 0.02 8.52 −0.09 0.04 6.18 1.49 0.86 2.98 17.64 24.35 18.49 14.74 20.12 10.68 18.37 15.00 26.30 23.57 12.96 24.07
Variables
C.I. OR 95% Inf.
Age RSES SDQ20 SCL-90-R Somatizations Obsessive-compulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic Anxiety Paranoid Ideation Psychoticism Global severity index Positive discomfort index Total positive symptoms TQ Number of traumas SUMD Mental disorder awareness Drug consumption awareness Awareness of social consequences PTSD
Table 4 Final results of the multivariate regression logistic model.
8.38 8.64 5.55 9.39 6.69 4.11 7.29 3.54 8.66 15.07 6.40 1.09
0.40 0.97 0.41 1.03 0.30 0.77 3.19 18.20
Note: β: Beta Coefficient; C.I. OR 95%: Confidence interval at a 95%. Inf.: Inferior limit. Sup.: Higher limit; OR: Odds Ratio; p: Signification threshold b0.05; RSES: Self-esteem Scale of Rosenberg; SCL 90-R: Derogatis Symptom Checklist Revised; SDQ 20: Somatoform Dissociation Questionnaire; S.E.: Standard error; SUMD: Scale to assess Unawareness of Mental Health; TQ: Traumatic Experiences Questionnaire; Zwald: Wald.
Fig. 1. Curve ROC. The closeness to the top-left corner shows the level of discrimination of the logistic regression model.
Please cite this article as: Justo, A., et al., Schizophrenia and dissociation: Its relation with severity, self-esteem and awareness of illness, Schizophr. Res. (2018), https://doi.org/10.1016/j.schres.2018.02.029
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The most telling general psychopathology (SCL-90-R) finding increases the knowledge of this dissociative subtype, overtaking previous identification and psychopathological descriptions. Therefore, it is not only understood as a subgroup with higher levels of dissociation, trauma and different psychiatric comorbidities (Ross and Keyes, 2004; Şar et al., 2009) but also as a complex clinical picture featured by the existence of high levels of general and specific psychopathological severity. That symptomatology varies from symptomatology more related to the nuclear aspects of the definition of psychosis (such as psychoticism, paranoid ideation and hostility) to symptomatology external to the formal definition of schizophrenia (such as anxiety, depression, obsession and somatization). Besides, is added the related central dissociative symptoms (amnesia, depersonalization/derealization and confusion/identity alteration). The appearance of high rates of psychopathologic comorbidity have been demonstrated in others studies (Achim et al., 2009; Buckley et al., 2008; Vogel et al., 2006; Vogel et al., 2009). However, those investigations did not separate patients with schizophrenia on the basis of dissociation. In addition, in the last decade, different meta-analysis has supported the relationship between general psychopathology and quality of life in schizophrenic patients (Eack and Newhill, 2007; Siris, 2000). Continuing with the psychopathologic characterization, the association of lower scores of self-esteem with the HD group is suggestive. Low self-esteem has been related to severity and content of hallucinations (Romm et al., 2011; Smith et al., 2006) and has been proposed as a mediator variable of interactions the patient has with the voices that they hear (Paulik, 2011). In addition, in different investigations of the general population, it has been observed that low self-esteem preceded the development of psychosis (Krabbendam et al., 2002), and this has been associated with an increase of the propensity to hallucinate (Gaweda et al., 2012; Gracie et al., 2007). The fact that auditory verbal hallucinations are also present in dissociative disorders could be relevant to this association between hallucinations and self-esteem previously not contemplated. It has been proposed that dissociation plays a role in the aetiology of hallucinatory experiences (Varese et al., 2011), one hypothesis that could explain the relationship between dissociation, schizophrenia, hallucinations and self-esteem could be that at higher levels of dissociation, the greater the dissociated aversive content that occurs in voices. This hypothesis must be investigated in future research. The result that the HD group shows a lower self-esteem is consistent with the higher ratio of general psychopathology. The correlations obtained between the RSES and all the dimensions of the SCL-90-R coincide with the results of different authors (Eack and Newhill, 2007; Malla et al., 2004), indicating a lower self-esteem with diverse psychopathology disorders. In addition, it is especially interesting that this finding is comparable with a heterogeneous sample of the Spanish population diagnosed with schizophrenia (Vázquez Morejón et al., 2004). Therefore, you can observe the average in the RSES of our group LD exceed self-esteem levels in the general Spanish population, whereas the group HD has a lower average in both. Increased awareness of illness in the HD group supports the second of our hypothesis. Traumatic history and dissociative symptoms could lead to a greater subjective suffering, and a minor adaptation to symptoms, which would imply an increase in the awareness of the disease and its consequences. It is interesting to note that in our study, this subgroup of patients exhibited a high correlation between high general psychopathology, low self-esteem and high consciousness of the illness. These results could help in understanding the discrepancy between the sign of the relations of the variables, self-esteem, psychopathology and consciousness of the illness found in previous studies (Amador et al., 1994; David et al., 1992; David, 2004; Simeon, 2006). If we take the logistic regression model and variables that have been shown to be most relevant, we see that traumatic background and the psychopathological profile are the factors that seem to be more discriminant. Regarding clinical aspects, patients with more dissociative symptoms have more obsessive symptoms and psychoticism.
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The obsessive symptoms have been studied in schizophrenia (Swets et al., 2014) but a possible relationship with trauma or dissociative symptoms has not been explored. It is important to note that items describing obsessive-compulsive symptoms in the SLC-90 refer in part to difficulties of memory and concentration, which are one of the areas affected in the dissociative disorders (Dorahy et al., 2014) and some of the items have to do with intrusive thoughts, also characteristic of dissociative pictures (Dell, 2006). Therefore, these symptoms may reflect dissociative rather than actual obsessive psychopathology. However, this fact raises potential hypothesis to be explored, relating to the relationship between obsessive symptoms and dissociation in schizophrenia. Especially interesting are the highest levels of psychoticism in the group of patients with more dissociative symptoms. Similarly, to the obsessive-compulsive symptoms, items from the SLC-90 that describe the factor psychoticism cover aspects as feeling that the own thoughts are controlled by someone and auditory hallucinations, both phenomenologically related to dissociative disorders. This greater presence of positive symptoms in the proposed diagnostic group of dissociative schizophrenia has been described by other studies (Ross and Keyes, 2004). This finding may represent a diagnostic confusion due to the similarity of some symptoms of both pictures, which has important therapeutic implications. For example, the non-response of these symptoms to medication could be interpreted as a resistance to the pharmacological drugs, rising its dose or changing medications in an unnecessary way, probably with little result (Misiak and Frydecka, 2016). On the other hand, if these symptoms are identified as dissociative, therapeutic strategy would treat them with a specific psychotherapeutic approach 5. Conclusion The group of schizophrenic patients with more dissociative symptoms presents differential elements that support a specific study. They are younger patients, with more awareness of their disease, especially with regard to its psychosocial impact, more general psychiatric symptomatology, and more number of traumatic events, worse self-esteem and greater suicidalidality. The more relevant factors are traumatic antecedents, obsessive-compulsive symptoms and psychoticism. An adequate identification of dissociative symptoms can help the planning of resources and the optimization of therapeutic strategies. Role of funding source He has received no funding. Contributors Author Ania Justo designed the study and wrote the protocol. Authors Andrew Moskowitz and Anabel González managed the literature searches and analyses. Author Alicia Risso undertook the statistical analysis. All authors contributed to and have approved the final manuscript. Conflicts of interest All authors declare that they have no conflicts of interest. Acknowledgements We would like to thank Dra. Pena, Dra. Gómez, Dra. Cibeira and Dr. Martin who kindly helped us select patients for the study.
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Schizophrenia Research journal homepage: www.elsevier.com/locate/schres
Schizophrenia and dissociation: Its relation with severity, self-esteem and awareness of illness Ania Justo a,⁎, Alicia Risso b, Andrew Moskowitz c, Anabel Gonzalez d a
Department of Psychiatry and Psychology of the Polyclinic Assistens, Calle Urzáiz, 28, 2 C, 36201, Vigo, Spain Department of Psychology, Universidade da Coruña, Spain Touro College Berlin, Germany d Complexo Hospitalario Universitario A Coruña, Spain b c
a r t i c l e
i n f o
Article history: Received 22 October 2017 Received in revised form 16 February 2018 Accepted 17 February 2018 Available online xxxx Keywords: Schizophrenia Dissociation Self-esteem Awareness Trauma PTSD
a b s t r a c t This article describes the conclusions of an investigation done with 120 Spanish patients: the finding of a new psychopathological profile within a subgroup of patients suffering from schizophrenia. The patients were evaluated through different questionnaires about sociodemographic data, traumatic events, the severity index (both clinical and psychopathological), self-esteem and consciousness of the illness. From the scores obtained on a scale of dissociative experiences, they were classified into two groups: high dissociative symptomatology or HD, and low dissociative symptomatology or LD. The HD group contained 44 patients (36.7% of the total population). The groups LD and HD show meaningful differences with respect to dissociative symptomatology levels, general psychopathology and level of traumatic events suffered. The percentage of patients with low self-esteem was higher in group HD than in group LD (M = 25.52 front 28.76 of group LD; t (118) = 2.94, p = .00). In addition, the group HD was more conscious of having a mental disorder, of the beneficial effects of medication and of the social consequences of their illness: F (1) = 10.929, p = .001; ƞ2pt = 0.083; 1-β = 0.907. The results show the existence of a subgroup of schizophrenic patients with higher levels of dissociation and trauma that were related with higher levels of symptomatology, lower self-esteem and higher consciousness of the illness, building a population of higher severity in which it would make sense to implement coadjutant treatments specifically oriented to these variables and, in addition, opening a therapeutic possibility for the patients with refractory schizophrenia. © 2018 Elsevier B.V. All rights reserved.
1. Introduction Schizophrenia is a severe mental disorder, which despite the proliferation of therapeutic strategies, continues generating very significant personal, family and social consequences. Healthcare programs traditionally have been structured based on levels of functional impairment of the patients, but also to its clinical features. An example is the programs of dual pathology, which have been oriented to schizophrenic patients with addictive behaviors, since this population requires a different therapeutic strategy. Over the last decade, several studies have found that patients suffering from schizophrenia experience dissociative phenomena with more frequency and at higher levels than the general population (Braehler et al., 2013; Vogel et al., 2006). In recent years, the possible role of trauma in the development of schizophrenia has been raised
⁎ Corresponding author. E-mail address: [email protected] (A. Justo).
(Kilcommons and Morrison, 2005; Şar et al., 2009; Schäfer et al., 2006; Schäfer et al., 2012; Vogel et al., 2009) and its presence has been related to greater severity. Given that trauma-based disorders improve with specific psychotherapies (Bisson et al., 2007) and these treatments have been shown to be beneficial in schizophrenia (de Bont et al., 2013), finding a group of more severely traumatized patients within those diagnosed with schizophrenia is not only of nosological interest, but is also important for the planning of health care resources. In support of this, Achim et al. (2009) found, in an analysis of 20 studies, that the prevalence of PTSD in psychosis was approximately 12.4%; comorbid PTSD in the psychosis patients was associated with poorer functioning and more severe psychotic symptoms. In recent investigations, dissociative symptoms in schizophrenia were related to levels of post-traumatic stress, which could imply a potential influence of posttraumatic events on dissociation in the pathogenesis of the schizophrenia (Bob and Mashou, 2011; Kilcommons and Morrison, 2005; Read et al., 2005). Thus, in order to select a subset of schizophrenic patients with more severe traumatization, dissociative symptoms seem to be a relevant indicator.
https://doi.org/10.1016/j.schres.2018.02.029 0920-9964/© 2018 Elsevier B.V. All rights reserved.
Please cite this article as: Justo, A., et al., Schizophrenia and dissociation: Its relation with severity, self-esteem and awareness of illness, Schizophr. Res. (2018), https://doi.org/10.1016/j.schres.2018.02.029
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The interrelationship between schizophrenia and dissociation goes back to Bleuler, and raises further issues of differential diagnosis still not well demarcated. Some characteristic symptoms of schizophrenia such as auditory hallucinations (Perona Garcelán et al., 2012; Varese et al., 2011) are also very common in dissociative disorders, giving rise to possible diagnostic confusion. Some authors have proposed a link between the two psychopathological groups, and a relationship that goes beyond a simple comorbidity (Álvarez et al., 2015). Even the symptoms described by Kurt Schneider as pathognomonic for schizophrenia have been proposed to be more characteristic of dissociative disorders (Kluft, 1987; Moskowitz and Corstens, 2007). To address these issues, some authors (Ross and Keyes, 2004; Şar et al., 2009) have proposed a dissociative subtype of schizophrenia, characterized by relevant dissociative symptomatology related to comorbidity and severe trauma during childhood. These investigations open the door to a new conceptualization of the relationships between schizophrenia, dissociation and trauma. There remain many questions to answer. This investigation tries to address some of them and has two objectives. The first objective is to look for evidence for a dissociative subtype in a Spanish sample where there are schizophrenic patients with different levels of severity and symptomatic profiles. The second objective is to characterize this subtype, if found, considering its clinical and psychopathological features in general, also analyzing its relationship to self-esteem and consciousness of illness, which have been related to severity and poorer quality of life in schizophrenic patients (Eack and Newhill, 2007; Read and Dillon, 2013). These variables have never been studied in this group of patients. However, in our clinic experience with this kind of patients, we have observed that high dissociation levels could be associated, paradoxically, with a higher awareness of the illness (of the suffering and of its functional and social consequences) and with lower self-esteem levels. In this study, these hypotheses are tested to try to find out the adequacy of these clinical observations and to see if they could be generalized in the different assistance centers. 2. Methods 2.1. Participants This study examined 120 voluntary patients who had a schizophrenia diagnosis. Patients were from both genders (77.2% male) and were between 20 and 75 years old (M = 43.52; SD = 11.28). All participants signed an informed consent form to cover the requirements of the Helsinki 2000 Declaration. All patients were in treatment at various inpatient and outpatient state and privately owned facilities in Galicia, including the penitentiary. The objective was to gain a heterogeneous sample to maximize the representability regarding the general schizophrenia population. All patients who had the diagnosis of schizophrenia were informed of the study, twelve people were deemed not capable of giving informed consent. In addition, the diagnosis of schizophrenia was reviewed by two clinicians. There were three patients who were excluded on this basis because they didn't meet the diagnostic criteria of DSM-5 schizophrenia in the past or currently. 2.2. Instruments The basic data was gathered with questionnaire designed specifically for this investigation that included socio-demographic and health variables (suicide attempts, consults at hospitals, relatives diagnosed with psychosis and other disorders and drug use). The additional questionnaires used were as follows: 2.2.1. Dissociative Experiences Scale – DES (Bernstein and Putnam, 1986) This instrument is the most common screening instrument for dissociative symptomatology. It has 28 items scored on a scale from 0 to 100
indicating the percentage of time that the patient reports having had specific dissociative experiences. It has a reliability of 0.78 and a validity of 0.76. For this study, we used the Spanish translation of Icarán and Colon (1996). The internal consistency reliability for the study sample is α = 0.93. 2.2.2. Structured Clinical Interview for the Dissociative Disorders – SCID-D (Steinberg, 1993) It is a structured interview done specifically for the diagnosis of dissociative disorders (DD). It explores five areas of manifestation of dissociative disorders: amnesia, depersonalization, derealization, identity confusion and identity alteration. In it, obligatory questions can be found in each subscale that allows an initial evaluation to be made, and to decide for which subjects it would be necessary to utilize the full scale. It has a reliability of 0.88 and a good validity. 2.2.3. Traumatic Experiences Questionnaire - TQ (Davidson et al., 1990) For this study, we used the translation of Bobes et al. (2000). It has 46 yes or no items regarding whether an experience was suffered and also gathers information about the age and duration of the traumatic event. The third section is a list of 18 symptoms that explore the three symptomatic clusters of PTSD. The items are of dichotomous answer Yes/No and the temporal frame of reference is very broad and open: any time after the event. Its psychometric properties have only been calculated for the general and the clinical population. The internal consistency reliability for the study sample is α = 0.69. 2.2.4. Derogatis Symptom Checklist Revised - SCL 90-R (Derogatis et al., 1975) The objective of this instrument is to detect general psychiatric symptomatology. For this study, the translation of González de Rivera et al. (1989) was used. It has a reliability of 0.79–0.90 and a validity of 0.73–0.80. It has a list of 90 items that are scored on a scale from 0 (“nothing” or “not at all”) to 4 (“a lot”), representing the extent to which the patient is bothered by a particular symptom. The internal consistency reliability for the study sample is α = 0.97. 2.2.5. Rosenberg self-esteem scale- RSES (Rosenberg, 1965) It includes 10 items whose contents are centered on the feelings of respect and acceptance of yourself. Half of the items are scored positively and the other half negatively. The score follows a Likert scale that goes from 1 = agree to 4 = totally disagree. It has a reliability of 0.74 and a validity of 0.87. The internal consistency reliability for the study sample is α = 0.86. 2.2.6. Scale to assess Unawareness of Mental Health - SUMD (Amador and Strauss, 1990) It has the goal of evaluating the patient's consciousness of the disorder and its social consequences, and the perceived effectiveness of medication. It has 3 general items and 17 items dedicated to specific symptoms. The scale used in this investigation is the Spanish adaptation of Ruiz et al. (2008). It has a validity of 0.84. In this study, the results of the three general items were analyzed and scored independently of their specific symptomatology. The internal consistency reliability for the study sample is α = 0.91. 2.3. Procedure The data gathering was done by two psychiatrists and two psychologists. The DES scale was administered orally to ensure that patients' responded to the questions as they were intended, and were not describing experiences better classified as psychotic than as dissociative. To this end, when a patient scored positively on any item of the DES they were asked for examples of the phenomena enquired about. The study had the approval of the Regional Ethical Committee of Galicia.
Please cite this article as: Justo, A., et al., Schizophrenia and dissociation: Its relation with severity, self-esteem and awareness of illness, Schizophr. Res. (2018), https://doi.org/10.1016/j.schres.2018.02.029
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2.4. Statistical analysis First, an exploratory and descriptive analysis of the sociodemographic variables and of clinical significance (independent variables) was carried out, together with the determination of the optimal cut-off point in the DES dependent variable (Magder and Fix, 2003; Williams, 2006). This procedure consisted of determining, for a range of values of the independent variable (DES = 20–30), the value that best separates patients according to the association test X2 with respect to the Gold Standard (SCID-D), being the lowest p-value indicative of the optimum cut-off point. In addition, the Youden index and the odds ratio are calculated for each of the cut points analyzed (see Table 1). To control the type I error derived from the multiple comparisons, the correction proposed by Altman et al. (1994) was used. Secondly, to verify the degree of relationship between the dependent variable DES and the independent variables, a logistic regression analysis was applied step by step. In a first phase, a screening was carried out on those variables that showed significant differences at baseline, using a univariate logistic regression model. In a second phase, and on those independent variables that showed a significant relationship with the dependent variable, a multivariate logistic regression analysis was performed. The goodness of fit of the final model was verified by the analysis of the ROC curve and the statisticians of Hosmer-Lemeshow and Nagelkerke. The processing of the data was carried out using the statistical software SPSS 20 and G * Power 3.1 (Mayr et al., 2007). 3. Results The DES results show that it is possible to discriminate two differentiated groups of people: one with low dissociative symptomatology (LD) and another with high dissociative symptomatology (HD) [LD: n = 76; M = 6.98, SD = 5.27; DES-HD: n = 44; M = 34.20, SD = 11.55; t (53.52) = −14.77, p = .00, d = 3.03. Previous research (Achim et al., 2009; Bernstein and Putnam, 1986; Ross and Keyes, 2004) recommended cutoff scores of 20, 25 or 30 but we decided to statistically investigate the best possible cutoff. A type of procedure that takes as reference the comparison of the DES variable with another reference variable (in this case the presence-absence of dissociative disorder valued through the SCID-D) has been followed. Within this group, two procedures have been performed: calculation of the Youden index and minimum p-value (Fluss et al., 2005), yielding the same result, establishing the cut-off point in the value 20. There were statistically significant differences in the age variable [DES-LD: M = 45.88, SD = 12.17; DES-HD: M = 39.45, SD = 8.18; t (115.25) = 3.45, p = .01, d = 0.62]. For the rest of the Table 1 Results of the optimal cut-off point estimation for the DES scale. Cut point (DES)
Youden indexa
20 21 22 23 24 25 26 27 28 29 30
0,37 0,30 0,26 0,28 0,28 0,25 0,20 0,17 0,09 0,09 0,09
X2 11,29 7,59 6,37 7,24 7,24 6,05 4,17 3,20 1,09 1,27 1,27
O. R.b 5,24 3,93 3,57 3,91 3,91 3,58 2,95 2,67 1,88 2,13 2,13
pc 0,02 0,11 0,18 0,12 0,12 0,21 0,43 0,62 0,90 0,92 0,92
a Youden index: the optimal cut-off point is the one that reaches the highest value in the index b O.R: Odds Ratio c p-Minimum value method: the optimum cut-off point is the one that obtains the lowest p-value.
3
sociodemographic variables considered, no statistically significant differences were found between the two groups. As for the independent variables, there were no statistically significant differences in suicide attempts, emergency consultations and hospitalizations. For the remaining variables, statistically significant differences were obtained (see Table 2). Very significant were the results obtained in the variable “number of traumas”, where a very high number of traumatic events was found in the HD group vs the LD group (80% vs LD 30%) psychopathological indices in the SCL scale - the most interesting result is
Table 2 Descriptive Analysis and results of the comparison between groups in the independent variables. Variables
Age Groups LD/HD RSES SDQ 20 SCL-90-R Somatization Obsessive-compulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic Anxiety Paranoid Ideation Psychoticism Global severity index Positive discomfort index Total positive symptoms
Groups LD (n = 76)
HD (n = 44)
M
SD
M
SD
T
p
d
45.88 6.98 28.76 1.28
12.17 5.27 5.48 0.79
39.45 34.20 25.52 1.77
8.18 11.55 6.33 1.29
3.45 −14.77 2.94 −2.31
.01* .00* .00 .02
0.62# 3.03## 0.55 0.46
0.51 0.84 0.88 1.00 0.79 0.52 0.55 1.08 0.69 0.78 1.99 32.97
0.62 0.77 0.81 0.78 0.71 0.64 0.59 1.00 0.70 0.57 0.69 19.68
1.26 1.88 1.77 1.76 1.66 1.16 1.35 1.88 1.62 1.62 2.48 58.11
0.81 0.76 0.86 0.89 0.86 0.97 0.93 0.97 0.71 0.71 0.64 17.41
−5.26 −7.11 −5.61 −4.87 −5.93 −3.93 −5.18 −4.26 −6.70 −6.67 −3.84 −7.26
.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00
1.04 1.36 1.06 0.91 1.10 0.78 1.03 0.81 1.32 1.30 0.74 1.35
Variables
Centers of Origin Outpatients Rehabilitation hospitals Exclusion centers and prisons Mental illness awareness Clear Intermediate None Drug consumption awareness Clear Intermediate None Awareness of social consequences Clear Intermediate None Suicide attempts No Yes Hospital emergency room visits Low High Hospitalizations Low High Number of traumas Low High PTSD Yes No
Groups LD (n = 76)
HD (n = 44)
N
N
%
%
20 28 28
26.3% 36.8% 36.8%
9 15 20
20.5% 34.1% 45.5%
24 12 40
31.6 15.8 52.6
22 11 11
50.0 25.0 25.0
24 20 32
31.6 26.3 42.1
25 7 12
56.8 15.9 27.3
12 15 49
15.8 19.7 64.5
21 8 15
47.7 18.2 34.1
57 19
75.0 25.0
26 18
59.1 40.9
46 30
60.5 39.5
21 23
47.7 52.3
47 29
61.8 38.2
23 21
52.3 47.7
53 23
69.7 30.3
9 35
20.5 79.5
15 61
19.7 80.3
15 29
65.9 24.2
X2
p
V
0.97
.61
0.09
8.71
.01
0.27
7.36
.02
0.25
15.19
.00
0.36
3.31
.07
0.17
1.85
.17
0.12
1.05
.31
0.09
27.10
.00
0.47
25.58
.00
0.46#
Note: *p b .05; d: Cohen's d. v: v de Cramer. #: Sizes of the moderate effect; M: Average; PTSD: Posttraumatic Stress Disorder; RSES: Self-esteem scale of Rosenberg; SCL 90-R: Derogatis Symptom Checklist Revised; SD: Standard Deviation; SDQ 20: Somatoform Dissociation Questionnaire; t: Student; X2: Chi squared.
Please cite this article as: Justo, A., et al., Schizophrenia and dissociation: Its relation with severity, self-esteem and awareness of illness, Schizophr. Res. (2018), https://doi.org/10.1016/j.schres.2018.02.029
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A. Justo et al. / Schizophrenia Research xxx (2018) xxx–xxx
that the largest difference between the groups seems to be on SCL Psychoticism-, levels of self-esteem - significant differences are observed between the groups, with scores being lower in group HD (M = 25.52 versus 28.76 of group LD); t (118) = 2.94, p = .00) and illness conscience - where group HD shows more consciousness of having a mental disorder, of the beneficial effects of the medication and of the social consequences of their illness - (high scores indicate lower levels of awareness of illness). In the Table 3 the results of the univariate regression logistic analysis are shown controlling the age variable and excluding those independent variables that were not significant in the previous step. In the Table 4 the final results of the multivariate logistic regression model final results are shown. The model associates the ownership relationship to the dissociation group (LD vs. HD) using three significant variables: number of traumas (Zwald = 15.93, p = .00, OR = 8.37, C.I. = 2.95–23.75), psychoticism (Zwald = 6.02, p = .01, OR = 2.42, C.I. = 1.19–4.90) and obsession (Zwald = 3.63, p = .05, OR = 2.17, C.I. = .98–4.83). The rest of the variables introduced in the model did not have a significant contribution. This final model has a specificity of the 89.5% and a sensitivity of the 72.7%. The percentage of global classification is 83.3% with an area below the ROC curve over 90% (Area = 0.90, p = .00, C.I. = 0.85– 0.95) (See Fig. 1). The test Hosmer-Lemeshow does not show significant differences in the calculated model [X2 (8) = 12.93, p = .11] indicating a good adjustment of the final model. The test Nagelkerke (R2 = 0.57) shows that the 57% of the variation in the dissociation variable is explained by the three variables included in the final model. 4. Discussion The prevalence of dissociative symptoms among patients with a diagnosis of schizophrenia found in this study is consistent with other studies (Braehler et al., 2013; Schäfer et al., 2006; Schäfer et al., 2006). Nevertheless, possibly, at least some of the persons in the HD group might be better or more accurately diagnosed with PTSD, C-PTSD or a Table 3 Logistic univariate logistic regression analysis. Variables
Β
S.E.
Zwald
p
OR
.00 0.95 .01 0.91 .08 4.44
0.91 0.98 0.85 0.98 0.82 24.08
1.45 1.54 1.18 1.48 1.32 0.88 1.36 0.84 1.56 1.93 1.20 0.06
0.34 0.31 0.27 0.39 0.29 0.27 0.32 0.22 0.30 0.40 0.33 0.01
.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00
2.17 2.53 1.90 2.07 2.10 1.42 2.10 1.50 2.62 3.17 1.73 1.04
2.50
0.47 28.12 .00 12.17 4.83 30.64
−0.48 0.23 4.40 −0.42 0.23 3.31 −0.73 0.24 9.28 2.03
4.26 4.68 3.25 4.40 3.75 2.42 3.91 2.31 4.77 6.91 3.33 1.06
.03 0.04 .07 0.65 .00 0.48
0.44 20.86 .00 7.62
SCL-90-R Obsessive-compulsive Psychoticism TQ Number of traumas
Β
S.E.
Zwald
p
OR
C.I. OR 95% Inf.
Sup.
0.78 0.88
0.41 0.36
3.63 6.02
.05 .01
2.17 2.42
0.98 1.19
4.83 4.90
2.12
0.53
15.93
.00
8.37
2.95
23.75
Note: β: Beta Coefficient; C.I. OR 95%: Confidence interval at a 95%. Inf.: Inferior limit. Sup.: Higher limit; OR: Odds Ratio; p: Signification threshold b.05; SCL 90-R: Derogatis Symptom Checklist Revised; S.E.: Standard error; TQ: Traumatic Experiences Questionnaire; Zwald: Wald.
dissociative disorder. That would be a question to be addressed by a future study. One difference in our study is that it gathers patients from many different settings, including ambulatories and medium/long stay units and even those with criminal conduct. In contrast, all studies done previously have examined subsamples of patients with an acute outbreak of schizophrenia mostly in ambulatory and hospital settings. These differences must be taken into account when interpreting and comparing the results. The strong relationship between dissociation and trauma coincides with that described in patients with other disorders. In addition to the number of adverse events, the higher presence of post-traumatic symptomatology in the HD sample could correspond simply to the higher presence of trauma in this group (Vogel et al., 2006) or to an influence of these post-traumatic symptoms in the development of the psychotic condition (Kilcommons and Morrison, 2005; Vogel et al., 2011). Independent of the interpretation as a mediator or etiological variable, this result fits with other studies that support the relationship between dissociative and post-traumatic symptomatology (Murray et al., 2002; Panasetis and Bryant, 2003). It is also interesting to note that the high percentage of PTSD found in the global sample is higher than in previous investigations, although this may be due to the higher clinical severity of the patients evaluated in our study, as this is also noted in the Kilcommons and Morrison (2005) study.
Sup.
−0.05 0.02 8.52 −0.09 0.04 6.18 1.49 0.86 2.98 17.64 24.35 18.49 14.74 20.12 10.68 18.37 15.00 26.30 23.57 12.96 24.07
Variables
C.I. OR 95% Inf.
Age RSES SDQ20 SCL-90-R Somatizations Obsessive-compulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic Anxiety Paranoid Ideation Psychoticism Global severity index Positive discomfort index Total positive symptoms TQ Number of traumas SUMD Mental disorder awareness Drug consumption awareness Awareness of social consequences PTSD
Table 4 Final results of the multivariate regression logistic model.
8.38 8.64 5.55 9.39 6.69 4.11 7.29 3.54 8.66 15.07 6.40 1.09
0.40 0.97 0.41 1.03 0.30 0.77 3.19 18.20
Note: β: Beta Coefficient; C.I. OR 95%: Confidence interval at a 95%. Inf.: Inferior limit. Sup.: Higher limit; OR: Odds Ratio; p: Signification threshold b0.05; RSES: Self-esteem Scale of Rosenberg; SCL 90-R: Derogatis Symptom Checklist Revised; SDQ 20: Somatoform Dissociation Questionnaire; S.E.: Standard error; SUMD: Scale to assess Unawareness of Mental Health; TQ: Traumatic Experiences Questionnaire; Zwald: Wald.
Fig. 1. Curve ROC. The closeness to the top-left corner shows the level of discrimination of the logistic regression model.
Please cite this article as: Justo, A., et al., Schizophrenia and dissociation: Its relation with severity, self-esteem and awareness of illness, Schizophr. Res. (2018), https://doi.org/10.1016/j.schres.2018.02.029
A. Justo et al. / Schizophrenia Research xxx (2018) xxx–xxx
The most telling general psychopathology (SCL-90-R) finding increases the knowledge of this dissociative subtype, overtaking previous identification and psychopathological descriptions. Therefore, it is not only understood as a subgroup with higher levels of dissociation, trauma and different psychiatric comorbidities (Ross and Keyes, 2004; Şar et al., 2009) but also as a complex clinical picture featured by the existence of high levels of general and specific psychopathological severity. That symptomatology varies from symptomatology more related to the nuclear aspects of the definition of psychosis (such as psychoticism, paranoid ideation and hostility) to symptomatology external to the formal definition of schizophrenia (such as anxiety, depression, obsession and somatization). Besides, is added the related central dissociative symptoms (amnesia, depersonalization/derealization and confusion/identity alteration). The appearance of high rates of psychopathologic comorbidity have been demonstrated in others studies (Achim et al., 2009; Buckley et al., 2008; Vogel et al., 2006; Vogel et al., 2009). However, those investigations did not separate patients with schizophrenia on the basis of dissociation. In addition, in the last decade, different meta-analysis has supported the relationship between general psychopathology and quality of life in schizophrenic patients (Eack and Newhill, 2007; Siris, 2000). Continuing with the psychopathologic characterization, the association of lower scores of self-esteem with the HD group is suggestive. Low self-esteem has been related to severity and content of hallucinations (Romm et al., 2011; Smith et al., 2006) and has been proposed as a mediator variable of interactions the patient has with the voices that they hear (Paulik, 2011). In addition, in different investigations of the general population, it has been observed that low self-esteem preceded the development of psychosis (Krabbendam et al., 2002), and this has been associated with an increase of the propensity to hallucinate (Gaweda et al., 2012; Gracie et al., 2007). The fact that auditory verbal hallucinations are also present in dissociative disorders could be relevant to this association between hallucinations and self-esteem previously not contemplated. It has been proposed that dissociation plays a role in the aetiology of hallucinatory experiences (Varese et al., 2011), one hypothesis that could explain the relationship between dissociation, schizophrenia, hallucinations and self-esteem could be that at higher levels of dissociation, the greater the dissociated aversive content that occurs in voices. This hypothesis must be investigated in future research. The result that the HD group shows a lower self-esteem is consistent with the higher ratio of general psychopathology. The correlations obtained between the RSES and all the dimensions of the SCL-90-R coincide with the results of different authors (Eack and Newhill, 2007; Malla et al., 2004), indicating a lower self-esteem with diverse psychopathology disorders. In addition, it is especially interesting that this finding is comparable with a heterogeneous sample of the Spanish population diagnosed with schizophrenia (Vázquez Morejón et al., 2004). Therefore, you can observe the average in the RSES of our group LD exceed self-esteem levels in the general Spanish population, whereas the group HD has a lower average in both. Increased awareness of illness in the HD group supports the second of our hypothesis. Traumatic history and dissociative symptoms could lead to a greater subjective suffering, and a minor adaptation to symptoms, which would imply an increase in the awareness of the disease and its consequences. It is interesting to note that in our study, this subgroup of patients exhibited a high correlation between high general psychopathology, low self-esteem and high consciousness of the illness. These results could help in understanding the discrepancy between the sign of the relations of the variables, self-esteem, psychopathology and consciousness of the illness found in previous studies (Amador et al., 1994; David et al., 1992; David, 2004; Simeon, 2006). If we take the logistic regression model and variables that have been shown to be most relevant, we see that traumatic background and the psychopathological profile are the factors that seem to be more discriminant. Regarding clinical aspects, patients with more dissociative symptoms have more obsessive symptoms and psychoticism.
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The obsessive symptoms have been studied in schizophrenia (Swets et al., 2014) but a possible relationship with trauma or dissociative symptoms has not been explored. It is important to note that items describing obsessive-compulsive symptoms in the SLC-90 refer in part to difficulties of memory and concentration, which are one of the areas affected in the dissociative disorders (Dorahy et al., 2014) and some of the items have to do with intrusive thoughts, also characteristic of dissociative pictures (Dell, 2006). Therefore, these symptoms may reflect dissociative rather than actual obsessive psychopathology. However, this fact raises potential hypothesis to be explored, relating to the relationship between obsessive symptoms and dissociation in schizophrenia. Especially interesting are the highest levels of psychoticism in the group of patients with more dissociative symptoms. Similarly, to the obsessive-compulsive symptoms, items from the SLC-90 that describe the factor psychoticism cover aspects as feeling that the own thoughts are controlled by someone and auditory hallucinations, both phenomenologically related to dissociative disorders. This greater presence of positive symptoms in the proposed diagnostic group of dissociative schizophrenia has been described by other studies (Ross and Keyes, 2004). This finding may represent a diagnostic confusion due to the similarity of some symptoms of both pictures, which has important therapeutic implications. For example, the non-response of these symptoms to medication could be interpreted as a resistance to the pharmacological drugs, rising its dose or changing medications in an unnecessary way, probably with little result (Misiak and Frydecka, 2016). On the other hand, if these symptoms are identified as dissociative, therapeutic strategy would treat them with a specific psychotherapeutic approach 5. Conclusion The group of schizophrenic patients with more dissociative symptoms presents differential elements that support a specific study. They are younger patients, with more awareness of their disease, especially with regard to its psychosocial impact, more general psychiatric symptomatology, and more number of traumatic events, worse self-esteem and greater suicidalidality. The more relevant factors are traumatic antecedents, obsessive-compulsive symptoms and psychoticism. An adequate identification of dissociative symptoms can help the planning of resources and the optimization of therapeutic strategies. Role of funding source He has received no funding. Contributors Author Ania Justo designed the study and wrote the protocol. Authors Andrew Moskowitz and Anabel González managed the literature searches and analyses. Author Alicia Risso undertook the statistical analysis. All authors contributed to and have approved the final manuscript. Conflicts of interest All authors declare that they have no conflicts of interest. Acknowledgements We would like to thank Dra. Pena, Dra. Gómez, Dra. Cibeira and Dr. Martin who kindly helped us select patients for the study.
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Please cite this article as: Justo, A., et al., Schizophrenia and dissociation: Its relation with severity, self-esteem and awareness of illness, Schizophr. Res. (2018), https://doi.org/10.1016/j.schres.2018.02.029