Somatoform and Psychoform Dissociation Among Students

Benedetto Farina, 1,2 Eva Mazzotti, 3,4 Paolo Pasquini, 5 Ellert Nijenhuis, 6 and Massimo Di Giannantonio 7
1 2

Universita` Europea di Roma, School of Psychology, Rome, Italy Centro Clinico de Sanctis, Rome, Italy 3 Divisione di Oncologia e Dermatologia Oncologica, IDI-IRCCS, Rome, Italy 4 SPAD - Scuola di Psicoterapia dellAdolescenza e dellEta` Giovanile, Rome, Italy 5 Unita` di Epidemiologia, IDI-IRCCS, Rome, Italy 6 Top Referent Trauma Center GGZ Drenthe, Assen, Netherlands 7 Universita` DAnnunzio, Faculty of Psychology, Chieti, Italy
Recent evidence suggests a relationship between psychoform and somatoform dissociation both in clinical and non clinical samples. The aim of the study was to investigate the association between the two forms of dissociation among 947 university students who completed two self-administered questionnaires, the Somatoform Dissociation Questionnaire (SDQ-20) and the Dissociative Experience Scale (DES). The main result of the study was that the association between somatoform and psychoform dissociation was strong for individuals with moderate level of DES scores (O.R. 5 7.0), but much stronger for individuals with high level of DES scores (O.R. 5 18.9). & 2011 Wiley Periodicals, Inc. J Clin Psychol 67:665672, 2011. Keywords: DES-taxon; psychoform dissociation; questionnaires; somatoform dissociation

Dissociative disorders and somatoform disorders are classied by DSM-IV in two distinct categories (APA, 2000). However, it has been observed from the second half of the 19th century that dissociation can pertain to the mind and body (Janet, 1889, 1907; van der Kolk & van der Hart, 1989). In keeping with this, the dissociative disorders in ICD-10 (WHO, 1992) include dissociative disorders of movement and sensation. Dissociative symptoms that phenomenologically involve the body are called somatoform; dissociative symptoms that phenomenologically involve the mind are called psychoform (Nijenhuis, 2009). The labels psychoform dissociation and somatoform dissociation should not be taken to mean that only psychoform dissociation is of a mental nature. Both adjectives refer to manifestations of the existence of a dissociation of the personality as a whole dynamic biopsychosocial system into two or more insufciently integrated subsystem (Nijenhuis & Van der Hart, in press; van der Hart, Nijenhuis, & Steele, 2006). The complexity of this dissociation of the personality varies, and is associated with different degrees of psychoform and somatoform dissociative symptoms. Negative dissociative symptoms pertain to apparent losses such as losses of memory, motor control, skills, and somatosensory awareness. For example, negative psychoform dissociative symptoms include dissociative amnesia as well as dissociative loss of affect and will, and negative somatoform dissociative symptoms dissociative analgesia, anesthesia and loss of motor control, such as dissociative aphonia. Positive dissociative symptoms involve intrusions, and are common in dissociative disorders (Dell, 2006; Nijenhuis, 2009). These symptoms include, among others, dissociative ashbacks and full reexperiencing of traumatizing events, as well as intruding voices, thoughts, movements, and emotional or physical feelings, including pain. Consistent with the hypothesis that psychoform and somatoform dissociation are both manifestations of a division of personality, these two groups of symptoms were correlated
This article was reviewed and accepted under the editorship of Beverly E. Thorn.

Correspondence concerning this article should be addressed to: Eva Mazzotti, Divisione di Oncologia e Dermatologia Oncologica, Istituto Dermopatico dellImmacolata, IDI-IRCCS, Via dei Monti di Creta, 104, 00100 Rome, Italy; e-mail: eva.mazzotti@tiscali.it JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 67(7), 665--672 (2011) & 2011 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.20787

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phenomena in various clinical samples (Nijenhuis, 2009; Ross, Heber, Norton, & Anderson, 1989; Saxe et al., 1994) and in general population samples (Maaranen, Tanskanen, Haatainen et al., 2005). Compared to subjects with lower psychoform and/or somatoform dissociation scores, subjects with high psychoform and somatoform dissociation scores showed differences in psychiatric, physical, psychological, social, and socio-economic variables (Maaranen et al., 2004). Following Janet (Janet, 1907; van der Kolk & van der Hart, 1989), several contemporary authors have hypothesized that dissociation of the personality relates to combination of subjective and objective factors. These include exposure to adverse events, particularly when these are socially hidden and involve signicant others (e.g., parents), lack of integrative capacity (e.g., due to psychobiological immaturity), lack of affect regulation by signicant others, and attachment disruptions, particularly in the form of disorganized attachment (Liotti, 2006; van der Hart et al., 2006). Van der Kolk and colleagues found that dissociation of consciousness, somatization and affective dysregulation are the major clinical features of prolonged trauma during childhood (van der Kolk et al., 1996; van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005). A relationship between exposure to potentially traumatizing events such as adverse early relational experiences and dissociative symptoms (both psychoform and somatoform) has been demonstrated (Chu & Dill, 1990; Liotti, 2006; Mulder, Beautrais, Joyce, & Fergusson, 1998; Nijenhuis, 2009; Ozturk & Sar, 2008; Pasquini, Liotti, Mazzotti, Fassone, & Picardi, 2002; Roelofs, Keijsers, Hoogduin, Naring, & Moene, 2002; Sar, Akyuz, Kundakci, Kiziltan, & Dogan, 2004; van der Hart et al., 2006). For example, the link between somatoform dissociation and reported potentially traumatizing events has also been documented in patients with chronic pelvic pain, and in general population and university student samples (Maaranen et al., 2004; Naring & Nijenhuis, 2005; Nijenhuis et al., 2003). Diseth (Diseth, 2006) demonstrated in a longitudinal prospective study that somatoform dissociation in adolescence and early adulthood was best predicted by a traumatizing longterm medical treatment in early childhood that included the parents, and that it was also a good predictor of psychoform dissociation. It can be speculated that involvement of the parents in this treatment was traumatizing in itself (e.g., painful daily insertion of anal dilatators), and also compromised secure attachment. In two prospective, longitudinal studies, a link between attachment disruptions in childhood and later dissociative symptoms has been documented (Dutra, Bureau, Holmes, Lyubchik, & Lyons-Ruth, 2009; Ogawa, Sroufe, Weineld, Carlson, & Egeland, 1997). Reinders et al. (Reinders et al., 2006) showed that two different types of dissociative parts of the personality in patients with dissociative identity disorder (APA, 1994) have very different sensorimotor, emotional, psychophysiological and neural reaction patterns to personalized trauma scripts. Neither high nor low fantasy prone healthy women were able to simulate these reactions (Reinders et al., 2006). These ndings indicate that complex dissociative disorders are not due to sociocognitive factors but relate to traumatization. The severity of psychoform dissociation is commonly evaluated with the Dissociative Experiences Scale (DES) (Bernstein & Putnam, 1986). However, there is concern that this selfreport questionnaire includes items that do not pertain to dissociation of the personality but involve different alterations of consciousness such as absorption and retracted consciousness (van der Hart, Nijenhuis, Steele, & Brown, 2004). Somatoform dissociation is measured with the Somatoform Dissociation Questionnaire (SDQ-20) (Nijenhuis, Spinhoven, Van Dyck, Van der Hart, & Vanderlinden, 1996). All items of this self-report questionnaire were designed to measure somatoform manifestations of the existence of a dissociation of the personality. Absorption and selective attention are phenomena that are common in the general population and in psychiatric patients, whereas dissociation of the personality characterizes patients with dissociative disorders. It can thus be hypothesized that low levels of psychoform dissociation and somatoform dissociation are less strongly correlated than high levels of psychoform dissociation and somatoform dissociation. The aims of the current study were (a) to estimate the prevalence of somatoform dissociation (SDQ-20) and psychoform dissociation/other alterations of consciousness (DES) in a large sample of Italian university students, and (b) to assess the association between these

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two different phenomenological kinds of dissociative symptoms at different levels of severity, thus testing the hypothesis that the strength of the association increases with increasing SDQ-20 and DES scores.

Methods
Our sample consisted of 1,290 undergraduate students enrolled at Chieti University, School of Psychology. Of the whole, 1,020 (79%) anonymously completed and returned the two questionnaires. To restrict the age range, we excluded 25 subjects (2,5%) older than 28 years (aged between 29 and 56 years). Participants (N 5 995) were aged between 18 and 28 years (mean age 5 20.6, standard deviation, SD 5 1.5; median 5 20). Eighty-three percent were females (N 5 827). Less than 2% (N 5 14) were married. No differences were observed between included and excluded subjects regarding gender, DES and SDQ-20 scores.

Assessment Instruments
The 20-item Somatoform Dissociation Questionnaire (Nijenhuis et al., 1996) is a selfadministered instrument that evaluates the severity of somatoform dissociation. The SDQ-20 assesses positive symptoms as site-specic pain (sometimes I have pain while urinating) and negative symptoms as blindness, impairment of auditory perception, motor inhibitions, kinesthetic anesthesia and analgesia (sometimes my body, or a part of it, is insensitive to pain). Items are answered on a ve-point scale, ranging from 1 5 this applies to me not at all to 5 5 this applies to me extremely. Items are summed to provide a total score (range 20100). Subjects were asked to respond with reference to a time frame of the preceding 12 months. In this study the internal consistency of the scale was high (a 5 0.80). The Dissociative Experiences Scale (Bernstein & Putnam, 1986) is a 28-item selfadministered inventory to measure the frequency of dissociative experiences. To answer DES questions, subjects circle the percentage of time (given in 10% increments ranging from 0 to 100) that they have the experience described. A subset of eight items of the DES, the so-called DES-Taxon (DES-T) (Waller, Putnam, & Carlson, 1996), is thought to be especially sensitive to identify pathological dissociation. The DES-T total score can be obtained by averaging across DES items 3, 5, 7, 8, 12, 13, 22, and 27. In this study we used the Italian version of the DES (Mazzotti & Cirrincione, 2001). Subjects were asked to respond with reference to a time frame of the preceding 12 months. In this study, the internal consistency of the scale was high (DES, a 5 0.92; DES-T, a 5 0.76). Information about gender, age and marital status were also collected. The study procedure was in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki).

Data Analysis
All statistical analyses were performed using STATA, version 9.0 (StataCorp, College Station, Tex), with statistical signicance set at po0.05. Cases of high somatoform dissociation were operationally dened as subjects scoring Z35 for SDQ-20 (Sar, Tutkun, Alyanak, Bakim, & Baral, 2000). According to previous research (Maaranen, Tanskanen, Haatainen et al., 2005; Waller, Ohanian, Meyer, Everill, & Rouse, 2001; Waller & Ross, 1997) a cutoff Z20 in DES-T has been choose to discriminate subjects with dissociative disorders. For the purposes of the analysis, the DES-T score was divided into four categories according to its quartile scores. The rst category (DES-T scores o2.5) was used as reference, the second (2.55.0) was labeled mild DES-T scores, the third (5.112.5) was denominated moderate DES-T scores, and the fourth (412.5) was denominated high DES-T scores. Cronbachs alpha was used to assess internal consistency of the scales. Owing to nonnormality of the SDQ-20 and DES data, Spearman rank correlations and Mann-Whitney U-test were calculated. Crude and adjusted Odds Ratios (O.R.) with 95% condence intervals

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(CI) were calculated to study the association between selected variables and the propensity to high somatoform dissociation (SDQ-20Z35). To test if the effect of the psychoform dissociation (DES-T) on the high somatoform dissociation would increase systematically with the level of exposure we included DES-T categories as an ordinal variables in the logistic regression and tested for trend (Wald test). The scores for 48 questionnaires, involving 48 participants, were excluded because of missing values. Analyses were conducted on a sample of 947 students.

Results
As expected, the SDQ-20 and DES scores were not normally distributed (z Shapiro-Wilk test 5 11.9 and 10.1, respectively; po0.001). The median SDQ-20 score was 23 (range 2078; mean 5 24.6; SD 5 5.5). The median DES score was 13.6 (range 080; mean 5 16.7; SD 5 12.0). The median DES-T score was 5.0 (range 076; mean 5 8.9; SD 5 10.4). No signicant differences were observed for males and females regarding their SDQ-20, DES and DES-T scores. The correlations between SDQ-20 and DES, and SDQ-20 and DES-T scores were both 0.40 (p-valueo0.001). Prevalence of high somatoform dissociation (SDQ-20Z35) was 4.7%, it was 2.6% in males and 5.1% in females (p 5 0.171). Prevalence of psychoform dissociation (DES-TZ20) was 12.9%, it was 19.1% in males and 11.7% in females (p 5 0.011). High somatoform dissociation and psychoform dissociation were strongly associated (age and gender adjusted O.R. 5 10.2; 95% C.I. 5 5.319.3). In order to explore this association, we rst examined the differences of SDQ-20 median scores among the DES-T categories and found a signicant difference (po0.001, data not shown). Next, we studied the association between somatoform dissociation and the DES-T categories. As shown in Table 1, we observed an increasing propensity to high somatoform dissociation for higher levels of DES-T scores (test for trend, po0.001). This association was rather strong (O.R. 5 7.0; 95% CI 5 1.631.6) at the level of moderate DES-T scores, and much stronger in high DES-T scores (O.R. 5 18.9; 95% CI 5 4.481.5).

Discussion
The DES median score (13.6) in the present sample of university students was consistent with those reported in other studies including student samples (Armando et al., 2008; Mazzotti & Cirrincione, 2001; Putnam et al., 1996). The general relationship between DES and SDQ-20 scores was comparable with that reported by Maaranen et al. (2005). The prevalence of pathological psychoform dissociation (DES-TZ20) in our study was 12.9% and that of high somatoform dissociation (SDQ-20Z35) 4.7%. We also found that pathological dissociators were signicantly more frequent among male students compared to female students. The prevalence of pathological psychoform dissociation in the general

Table 1
Association Between Somatoform Dissociation (SDQ-20, No-Cases; cases) and DES-T Categories
SDQ-20 No-cases DES-T reference mild moderate high N (%) 230 265 216 192 (25.5) (29.4) (23.9) (21.3) Cases N (%) 2 2 13 27 (4.6) (4.6) (29.6) (61.4) OR 1.00 0.87 6.92 16.17 95% CI 0.126.21 1.5431.03 3.8068.88 OR 1.00 0.88 7.03 18.93 95% CI 0.126.30 1.5631.63 4.4081.48 p^ o0.001

Gender and age-adjusted odds ratio. ^Test for trend (Wald test).

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population was estimated to range between 0.8 and 3.4% (Maaranen et al., 2004; Maaranen, Tanskanen, Honkalampi et al., 2005; Spitzer et al., 2006; Waller & Ross, 1997), and no-gender differences have been found (Spitzer et al., 2006). Whereas the prevalence of pathological psychoform dissociation in the present study was much higher than in studies of the general population, the prevalence of high somatoform dissociation was lower. Using the same cut-off point (SDQ-20430), Maaranen and colleagues (Maaranen et al., 2004) documented a prevalence of 9.4% and we found a prevalence of 12.3%. As noted by Spitzer et al. (Spitzer et al., 2006), this variability in prevalence rates can in part reect differences in sampled populations as well as methodological differences (i.e., different cut-off points, subjects were not assigned taxonomic class by the statistical method recommended by Waller and Ross (Waller & Ross, 1997)). The high prevalence of pathological psychoform dissociation in our sample is hard to explain. One possibility is that motivation underlying the career choice of mental health professionals may include a desire to resolve personal psychological distress as reported in previous studies (Nikcevic, Kramolisova-Advani, & Spada, 2007). Still, the nding of a higher degree of psychoform dissociation among males in this study is remarkable but hard to interpret given that females constituted 83% of the sample. Future work will have to clarify if higher psychoform dissociation among male students was a chance nding or a common phenomenon in Italian students. The severity of somatoform dissociation was not different for males and females, and was within the expected range given the prevalence of dissociative disorders in the general population (Van der Hart & Nijenhuis, 2008). Consistent with our hypothesis, the association between somatoform and psychoform dissociation was strong (O.R. 5 7.0) and that its strength increases with high DES-T scores (O.R. 5 18.9). This new nding invites in-depth studies of the differences and relations between dissociative symptoms understood as manifestations of a division of personality and phenomena that indicate lowering and retraction of consciousness. There is an urgent need for a self-report questionnaire that specically assesses the psychoform dissociative symptoms, but that does not include items measuring lowering and retraction of consciousness. Consistent with Nijenhuis and Van der Hart (Nijenhuis & Van der Hart, in press), we hypothesize that manifestations of a division of personality are sensitive and specic for DSMIV dissociative disorders, as well as somatoform dissociative disorders, whereas lowering and retraction of consciousness is sensitive but not specic for these disorders. A debate is still open on how high dissociation should be viewed, as the extreme end of a continuum of dissociative symptoms or as a separate taxon that represents a deviation from normal development (Ogawa et al., 1997). In this regard, Putnam and colleagues (Putnam et al., 1996) found a subgroup of high dissociators among patients with signicant elevation of dissociative scores. They contended that dissociation is a discontinuous process and that a typological model, rather than a continuum model, may more accurately describe the phenomenology of pathological dissociation. In consonance with Putnam and colleagues (1996), we consider that a deviation from normal development could cause a separate taxon where the individuals integrative capacity is pathologically and structurally compromised and where psychoform and somatoform dissociation are more strongly associated. However, with Van der Hart, Nijenhuis, and Steele (2006), we contend that there is dimensionality within this taxon. Van der Hart et al. (2006) proposed that there is a dimension of complexity of dissociation of the personality. In simple dissociative disorders, the division of personality is simple. The division is more complex in more complex dissociative disorders, and more dissociative parts of the personality than in simple dissociative disorders are more elaborate and more evolved. If it would be shown that normality does not involve a (minor) division of personality, the concept of normal dissociation is better discarded. Our results are compatible with models suggesting that lack of integrative capacity in combination with other factors such as exposure to highly adverse, potentially traumatizing events, including severe attachment disruptions, and lack of interpersonal affect regulation, is a common pathogenetic feature that mediates somatoform and psychoform dissociative symptoms (Mulder et al., 1998; Nijenhuis & Van der Hart, in press; Nijenhuis, van Dyck, van der Hart, & Spinhoven, 1998; Ozturk & Sar, 2008). In this light, and given the strong association between psychoform and somatoform dissociation, conversion disorders in DSM-IV

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(APA, 2000) are better conceptualized and classied as dissociative disorders in that conversion, in fact, involves somatoform dissociation. The reclassication is consonant with ICD-10 dissociative disorders of movement and sensation (WHO, 1992). Recognition of conversion as somatoform dissociation may help clinicians mind more that psychoform dissociative symptoms may also be present, that the patients personality as a whole system is dissociated into two or more subsystems, and that treatment may need to address this division of personality (Brown, Cardena, Nijenhuis, Sar, & van der Hart, 2007; Van der Hart & Nijenhuis, 2008). The study has several limitations. Our study population was that of university students of the School of Psychology in a small central Italian town (54.000 inhabitants) and may be not representative of national or regional population of students. This limitation may have affected our prevalence estimates, but much less our O.R. estimates. Although we used standardized validated questionnaires to measure somatoform and psychoform dissociation, limitations inherent in subjects self-report assessment and choice of cut-off points should be considered. Women were overrepresented, and a clinical diagnosis of dissociative or somatoform disorders was not available. Finally, we were unable to include a trauma history assessment in the current study. Future work will have to explore the inuence of factors such as personality, cognitive styles, and exposure adverse events, including attachment disruptions and emotional neglect.

Conclusion
The present study documents a strong association between somatoform and psychoform dissociation, as well as an increasing strength of this association at higher levels of these symptoms in a sample of university students. These ndings are consistent with the 19th century observation that both somatoform dissociation and psychoform dissociation are manifestations of a lack of integration at different levels of the hierarchical organization of the mind (Farina, Ceccarelli, & Di Giannantonio, 2005). Increasing evidence suggests that this lack constitutes the essence of a spectrum of trauma-related disorders (Nijenhuis, 2009; van der Hart et al., 2006). Acknowledgments Conict of interest: The authors have no conict of interest, nancial or otherwise, related to this work.

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