Psychopatological severity index and dissociative symptomatology ...

Original articlePsychopatological severity index and dissociative symptomatologyin a group of non-psychotic outpatientsIndici di gravità psicopatologica e sintomatologia dissociativa in una popolazione di pazientiambulatoriali non psicoticiF. Macrì, M. Salviati, A. Provenzano, C. Melcore, S. Terlizzi, S. Campi, M.M. Moscariello, M. BiondiDipartimento di Neurologia e Psichiatria, Unità di Psichiatria Psicofarmacologia Clinica, S.P.D.C. Policlinico “Umberto I”, Sapienza Universitàdi RomaSummaryDissociative symptoms are a set of symptoms frequently encounteredin clinical practice, but they are often underestimated bymany clinicians, who in the routine assessment of the patient underrateor not diagnose, emphasizing instead the importance ofmore classic and obvious symptoms, such as those related to thesphere of mood, anxiety or psychosis. In this way, dissociativesymptoms often lose their descriptive complexity, although purelypsychopathological, of the very complex clinical status thatoften underlie dissociative symptoms and dissociative dynamics.For these reasons, this study assessed psychopathologicaldimensions of mood and anxiety disorders in a transnosographicway. The purpose of the study is to demonstrate that dissociativesymptoms, although placed in the diagnostic category of dissociativedisorders, have a common thread that correlates withthe main manifestations detected in routine clinical practice, andthat they may be susceptible to intervention by the physician,even in a nonspecific way on the main symptom, not dissociative,that is treated.Key wordsDissociative disorders • Dissociation • Anxiety • Depression • Bipolardisorder • Obsessive-compulsive disorder • StressThe diagnosis of dissociative disorders, as a group of categoricalindependent nosographic entities, was first includedin the Diagnostic and Statistical Manual of MentalDisorders (DSM)-III in 1980; before that, dissociativesymptomatology was included among psychopathologicalphenomena ascribed to hysteria 1 . The essentialcharacteristic of dissociative disorders, according to theDSM‐IV-TR, is the disconnection of functions (physiologicallyintegrated), of consciousness, memory and perceptionof identity 2 . The term dissociative was introduced byJames in 1890 as a translation of the French term désagrégationcoined by Pierre Janet in 1889; with this term,the French author individuated the failure of mental integrationof ‘experiences’ (perceptions, memories, thoughts,emotions) that are normally concatenated with each otherin the flow of consciousness 1 . Dissociation leads to fragmentationof the unitary sense of self in patients whoexperience it, cancelling the unity of chronological, biographicaland perceptual identity, which every individualnormally has 3 . In studies on hysteria (1893-1895), Freudelaborated a psychodynamic theory of dissociation (opposedto the psychopathological one of Janet, linked topassive ego deficits) based on active removal, in affectedsubjects, of traumatic material within a psychodynamicconflict. In both models, dissociation appears to be closelyrelated to the presence of a traumatic event 1 . Recentstudies have shown that the post-traumatic aetiologicalaspect of dissociative episodes identifies a part of dissociativesymptomatology (about 50%), but not the entiredissociative spectrum 4 . The dissociative spectrum (Fig. 1)is composed of a large continuum of dissociative symptomatologyalong a gradient of severity 1 .Such a spectrum even includes, according to some authors,somatoform disorders and can be divided into three groups:• non-clinical or subclinical dissociative experiences, suchas being so deeply assorbed in the contemplation of amovie or immersed in one’s own thoughts,that there is noawareness or realization of the surrounding environment(absorption);• transient dissociative phenomena in response to externalevents (trauma, induced states of trance);• clinically-relevant dissociative phenomena, either inassociation with other psychiatric disturbances (e.g.CorrespondenceFrancesco Macrì, Dipartimento di Neurologia e Psichiatria, Sapienza Università di Roma, Roma, Italia • E-mail: francesco.macri_md@libero.itJournal of Psychopathology 2013;19:105-108105

F. Macrì et al.Dissociative symptoms during other psychiatric disordersAbsorption Hypnotic Dissociative amnesia Dissociative identityand post-traumatic phenomena and dissociative fugue disorderTransient Depersonalization Somatizationdepersonalization disorder disorderPhysiologyHigher dissociative symptomatologyFigURe 1.Continuum of dissociative symptomatology and related dissociative disorders. Continuum della sintomatologia dissociativa e relatividisturbi dissociativi.PTSD), or as a defined nosographic category (depersonalizationdisorder, dissociative amnesia, dissociativefugue, dissociative identity disorder and dissociativedisorder not otherwise specified).According to some authors, the prevalence of dissociativedisorders in clinical practice is underestimated,which may be in part due to the lack of inclusion of diagnosticcriteria for dissociative disorders in the algorithmof the Structured Clinical Interview for the diagnosis ofAxis I disorders in the DSM-IV (SCID-I), as well as thelack of large population-based studies 3 ; at present, theprevalence of dissociative disorders in the general populationis estimated to be from 5.6% to 10% 1 .At the same time, there is some evidence regarding theassociation of dissociative symptoms with some psychopathologicaldimensions, (in particular with obsessions 5 ,depression and anxiety 6 , psychotic symptoms 7 8 and withthe severity of a psychiatric disorders 5 ). Moreover, it hasbeen observed that patients affected with dissociativedisorders have levels of psychopathology (assessed withSCL90-R) that are significantly greater than those in psychiatricpatients who are non-dissociators 10 . Consideringthis, the aim of the present study was to investigate therelation between dissociative symptomatology, psychopathologicaldimensions (assessed with SCL90-R) andclinical severity in an out-patient population.Materials and methodsOver an 18-month period, a total of 83 patients (of 213contacted) were recruited among those presenting to theout-patient psychopharmacological clinic at PoliclinicoUmberto I, during the first visit. Inclusion criteria included:diagnosis of anxiety, mood and somatoform disorder andadaptation; score > 17 on at least one of the Hamiltonscales (A or D). Exclusion criteria were: psychotic disorder,illiteracy, unable to understand questionnaires, presenceof a neurodegenerative disease, concomitant diagnosis ofepilepsy or on-going problem with addiction.The study protocol included the administration of aquestionnaire for personal data, authorization to keepsensitive data, evaluation scales completed by a clinician(Clinical Global Impression [CGI], Hamilton AnxietyRating Scale [HAM-A], Hamilton Depression RatingScale [HAM-D]); self-evaluation questionnaires relativeto general psychiatric symptoms (Symptom Checklist-90-Revised-SCL90-R) and dissociative symptomatology(Dissociative Experiences Scale [DES]).The CGI evaluates general clinical severity of the patientusing a scale from 0 to 7 (0 = Not assessed 1 = Normal,not at all ill, 2 = Borderline mentally ill, 3 = Mildlyill, 4 = Moderately ill, 5 = Markedly ill, 6 = Severely ill,7 = Among the most extremely ill patients); the two Hamiltonscales evaluate anxiety symptoms (score ≥18 consideredpathological) and depression (score ≥ 25 = severedepression; 18-24 = moderate depression; 8-17 = slightdepression; ≤ 7 absence of depression).The SCL 90-R assesses 9 psychopathological dimensions(somatization, obsession-compulsion, interpersonal sensitivity,depression, anxiety, anger-hostility, phobic anxiety,paranoid ideation, psychoticism), and on the basis of thetotal score considering 90 items, the Global Severity Index(GSI) can be calculated; a value greater than 0.566 is con-106

Psychopatological severity index and dissociative symptomatology in a group of non-psychotic outpatientssidered indicative of clinically-relevant psychopathology.Using the DES, dissociative symptomatology was evaluateddimensionally and transnosographically. The DES isa self-rating scale that measures the level and type of dissociativeexperience present (the period of evaluation islifelong, in general) without considering the diagnosis; itis quick to compile and is composed of 30 questions thatconsider a score from 0 to 100 in intervals of 10; overallmean global scores higher than 20 are indicative for thepresence of a dissociative disturbance 9 . Through a diagnosticinterview, for each patient, a diagnosis was formulatedbased on the criteria in the DSM IV-TR 2 .The SPSS 13 programme was used for statistical analysis,and the distribution of variance was analyzed usingthe Kolmogorov-Smirnov test. Based on the results of thequantitative distribution of variables (e.g. CGI and age didnot have a normal distribution), non-parametric statisticalanalyses were carried out. Correlations between quantitativevariables were evaluated with Spearman’s rho test.A p < 0.05 was considered statistically significant.ResultsThe sample population was recruited over a period of18 months. A total of 83 patients were included, with amean age of 46.75 (± 15.33) years (range 17-82); therewere 51 females and 32 males. The presence of disordersaccording to DSM-IV TR criteria, are shown in Table 1.Mood and anxiety disorders were present in similar proportions(42.17% and 38.55%, respectively).From a descriptive analysis of the psychometric parametersevaluated (Table II), the sample cohort had intermediatelevels of dissociation from normal (DES 17) and moderateglobal clinical levels of disease (mean CGI = 4); thelevel of psychopathology as revealed by the self-administeredSCL90-R (GSI) test was clinically significant(GSI > 0.566).The psychopathological dimension of the SCL90-R mostfrequently seen was depression, obsessive-compulsive,anxiety, somatization, paranoid ideation and interpersonalsensitivity. The indices of psychopathological severityfrom the GSI and CGI were significantly correlatedwith the severity of dissociative symptomology (DES).Each psychopathological dimension investigated usingthe SCL90-R test showed a significant correlation withthe dissociative symptomology score (p < 0.001). TheHamilton scales did not show any significant correlationwith the severity of dissociation.ConclusionsThe aim of the present study was to investigate corre-TabLe I.Stratification of the sample according to diagnosticarea. Stratificazione del campione in funzione delle areediagnostiche DSM IV-TR.Diagnostic area N %Anxiety disorders 32 38.55Mood disorders (monopolar) 18 21.69Mood disorders (bipolar) 17 20.48Adaptive disorders 11 13.25Somatoform disorders 5 6.03lations between severity of psychopathological manifestationsand dissociative symptomology. Our resultsshowed that the intensity of dissociative symptoms appearedto be directly proportional to the severity of thepsychopathological dimensions considering both theGSI and CGI. In addition, the severity of dissociationseems to be correlated with severity of each psychopathologicaldimension assessed with the SCL90-R. Previousstudies have shown a relationship between somepsychopathological dimensions and dissociative symptomologyin patients grouped by the type of disorder 5-8 .It has also been demonstrated that in patients with dissociativedisorders the psychopathological dimension ofthe SCL90-R was significantly higher compared to psychiatricpatients that were not affected by dissociativedisorders 10 . The data from our patient cohort allowedfor the individuation, in a transnosographic manner, of aclose relation between psychopathological severity andthe level of dissociation. From a clinical standpoint, inour opinion, these results should prompt considerationsregarding the relevance of dissociative symptomologyduring a psychiatric visit as a tool for future integratedand personalized approaches to treatment. Consideringpsychological disturbances in a hodological context, oras the manifestations of functional disconnection betweendifferent brain areas, as suggested by Ffytche 11 ,the results of our study are suggestive of the possibilitythat the dissociative symptomology represents a quantitativemanifestation of alterations in cerebral circuits;at the same time, the psychopathological dimensionswould qualitatively identify areas that are disconnected.Such a hodological vision of psychopathology, lastly,brings us back to the definition of dissociative disordersas a manifestation of désagrégation of brain functionoriginally described by Janet. Further studies on largerpatient series, using neuroimaging techniques, instrumentsto assess neurophysiopathological function andmental tests, are needed to evaluate the reliability of ourresults and their interpretation.107

F. Macrì et al.TabLe II.Descriptive statistics and correlations. Statistica descrittiva e correlazioni.Descriptive StatisticsStatistical correlationParameter Mean SD Correlation coefficientSpearman’s rho testSig(2 code)DES 13.800 14.900 1.000 –Ham-A 18.870 4.420 - 0.075 0.533Ham-D 16.980 4.670 0.117 0.326CGI 4.000 0.563 0.233 0.049GSI 1.286 0.687 0.757 0.000Somatization 1.302 0.787 0.497 0.000Obsessive/compulsivity 1.575 0.949 0.677 0.000Interpersonal sensitivity 1.172 0.871 0.716 0.000Depression 1.703 0.878 0.603 0.000Anxiety 1.514 0.809 0.540 0.000Anger/hostility 0.873 0.802 0.655 0.000Phobic anxiety 0.775 0.920 0.396 0.000Paranoid ideation 1.196 0.964 0.616 0.000Psychoticism 0.892 0.761 0.725 0.000References1Dell PF, O’Neil JA, editors. Dissociation and the dissociativedisorders: DSM-V and beyond. New York: Routledge 2009.2American Psychiatric Association. DSM-IV-TR. Manuale Diagnosticoe Statistico dei disturbi mentali. Milano: Masson 2001.3Steinberg M, Schnall M. La dissociazione. Cinque sintomifondamentali. Milano: Raffaello Cortina Editore 2006.4Isaac M, Chand PK. Dissociative and conversion disorders:defining boundaries. Curr Opin Psychiatry 2006;19:61-6.5Belli H, Ural C, Vardar MK, et al. Dissociative symptoms anddissociative disorder comorbidity in patients with obsessivecompulsivedisorder. Compr Psychiatry 2012;53:975-80.6Moscariello MM, Ratti F, Quartini A, et al. [Dissociativesymptoms in patients with mood and anxiety disorders]. RivPsichiatr 2010;45:234-43.7Perona-Garcelán S, Cuevas-Yust C, García-Montes JM, etal. Relationship between self-focused attention and dissociationin patients with and without auditory hallucinations.J Nerv Ment Dis 2008;196:190-7.8Modestin J, Hermann S, Endrass J. Schizoidia in schizophreniaspectrum and personality disorders: role of dissociation.Psychiatry Res 2007;153:111-8.9Conti, L. Repertorio delle scale di valutazione in psichiatria.Firenze: SEE Editrice 2002.10Steinberg M, Barry DT, Sholomskas D, et al. SCL-90 symptompatterns: indicators of dissociative disorders. Bull MenningerClin 2005.;69:237-49.11Ffytche DH. The hodology of hallucinations. Cortex2008;44:1067-83.108