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Nordic Journal of Psychiatry
ISSN: 0803-9488 (Print) 1502-4725 (Online) Journal homepage: https://www.tandfonline.com/loi/ipsc20
Psychoform and somatoform dissociation among
individuals with eating disorders
Doris Nilsson, Annika Lejonclou & Rolf Holmqvist
To cite this article: Doris Nilsson, Annika Lejonclou & Rolf Holmqvist (2019): Psychoform and somatoform dissociation among individuals with eating disorders, Nordic Journal of Psychiatry, DOI: 10.1080/08039488.2019.1664631
To link to this article: https://doi.org/10.1080/08039488.2019.1664631
© 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
Published online: 11 Sep 2019.
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ARTICLE
Psychoform and somatoform dissociation among individuals with
eating disorders
Doris Nilssona, Annika Lejonclouband Rolf Holmqvistc
a
Section for Clinical Psychology, Department for Behavioural Sciences and Learning, Link€oping University, Link€oping, Sweden;bLink€oping University Hospital , Region €Osterg€otland, Sweden;cDepartment of Psychology, Institution for Behavioral Sciences and Learning, Link€oping University, Link€oping, Sweden
ABSTRACT
Objective: This study analyzed the prevalence of psychoform and somatoform dissociation among individuals with the whole spectrum of eating disorder diagnoses and compared it with ratings from a non-clinical group. The relationship between dissociation and severity of eating disturbance was exam-ined as well as differences between the eating disorder diagnosis groups in extent of dissociation. The validity of a new structural dissociation interview suitable for eating disorder patients was analyzed. Method: Sixty individuals with eating disorder completed three self-report questionnaires: Dissociation Questionnaire Sweden, Somatoform Dissociation Questionnaire and Eating Disorder Examination Questionnaire. The ratings were compared with the scores in a female non-clinical group (N¼ 245). Twenty patients with eating disorder diagnoses were interviewed with the Interview for Dissociative Disorders and Trauma Related Symptoms. The validity of the interview was tested by comparing the ratings on the interview subscales with the scores on the Dissociation questionnaires and the Somatoform Dissociation Questionnaire.
Results: Participants with eating disorders reported a higher extent of both psychoform and somato-form dissociation compared with the non-clinical individuals. Analyses also showed a correlation between degree of dissociation and severity of eating disorder symptoms. No differences in dissoci-ation were found between the ED subgroups. Participants reporting more dissocidissoci-ation got higher rat-ings on the interview, indicating convergent validity.
Discussion: Eating disorders seem to be associated with presence and severity of dissociative symp-toms. The extent of dissociation needs to be assessed for these individuals as treatment may benefit from a focus on such symptoms in order to increase its effect.
ARTICLE HISTORY Received 21 May 2019 Revised 26 August 2019 Accepted 2 September 2019 KEYWORDS Dissociation; psychoform; somatoform; eating disorder; young adults
Introduction
Dissociation is defined as a disruption in the normal integra-tive functions of consciousness, memory, emotion, identity, perception, body representation, motor control and behavior. It includes experiences such as amnesia, identity disturbances, depersonalization and derealization [1]. Dissociation may be manifested in both mind and body, as psychoform and soma-toform dissociation. The concept of psychoform dissociation suggests that elements of the mind such as thoughts, sensa-tions and emosensa-tions are kept apart [2,3]. Psychoform dissoci-ation includes symptoms related to the mental functions such as memory, consciousness and identity [2,4]. Somatoform dis-sociation refers to dissociative symptoms that are manifested physically, and which are not possible to explain by medical causes and where the symptoms are thought to have devel-oped due to a failure to integrate a somatic aspect of an experience [3,5]. The somatoform dissociation includes a range of physical problems, like motor disturbances, analgesia and
anesthesia [5,6]. Several of these psychosomatic symptoms as well as conversion symptoms are found under somatic distur-bances in DSM-5 (1). Psychoform and somatoform dissociation are phenomena that affect the whole dynamic bio psycho-logical system [3,5,7,8].
Several origins of dissociation have been suggested, such as exposure to potentially traumatizing events, problems in the attachment history and neurobiological factors [7,9–11]. Dissociation has been seen as a defense mechanism [2,4] and as a natural reaction of protection against overwhelming traumatic experiences [12]. Dissociation may occur on a con-tinuum that ranges from” normal” dissociation, like day-dreaming, to the most severe form of dissociation, Dissociative Identity Disorder [3,4]. Dissociative disturbances may be associated with psychiatric disorders including post-traumatic stress disorder, borderline personality disorder and eating disorders [8,9,13,14] .
During the two last decades there has been a growing interest in the possible relationship between dissociation and
CONTACT Doris Nilsson doris.nilsson@liu.se Section for Clinical Psychology, Department for Behavioural Sciences and Learning, Link€oping
University,Link€oping S-581 85, Sweden
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eating disturbances. In general, persons suffering from an eating disorder seem to have difficulties to distinguish between outer and inner experiences and between physical and emotional reactions [15,16]. Several studies have found that dissociative symptoms are more common in individuals with an eating disorder [17–19]. Some researchers argue that high levels of dissociation seem to be linked to more severe eating symptoms [16,20]. The majority of empirical studies of associations between eating disorders and dissociation have focused on bulimic behavior, where the association is well established [17,18,21]. There are, however, few studies that analyze extent of dissociation among patients with a restrict-ive anorexic diagnosis [20]. As an exception, Farrington et al. [20] found that individuals with restrictive anorexia showed relatively low levels of both psychoform and somatoform dissociation.
Persons with bulimia and anorexia of the binge/purge subtype, in contrast, have been found to score high on both forms of dissociation and particularly on somatoform dissoci-ation [16,19]. Several ways of interpreting the associations between bulimia and dissociative symptoms have been sug-gested [17,22]. Bulimic behavior may be seen as a way to produce a dissociative state creating a possibility to escape from unwanted experiences. Dissociation seems to fluctuate during the binge eating and purging cycle and may be inter-preted as episodically linked to the eating disorder rather than to the general psychopathology [17]. Some studies sug-gest that negative affects and dissociative experiences – for an example caused by an interpersonal situation – may act as triggers to the binge episodes [22]. The eating behavior provides the person with a concrete and bodily experience of reality. The dissociation and the binge eating would thus have a function for affect regulation [21,22]. These persons seem to have difficulties to distinguish between outer and inner experiences and between physical and emotional reac-tions. The purging process may be a way of getting back to reality from a dissociative state [15,16].
Somatoform dissociation has been found to be an import-ant problem in eating disorder patients [5,16,19,23]. The degree of somatic dissociation seems to be related to the degree of dissatisfaction about the individual’s own body. It may be based on a sensitivity about the body image and seems especially connected with bulimic behavior [24,25]. The relationship has been found so often that it has been suggested that this form of dissociation may distinguish indi-viduals using purging and other compensatory behaviors from those who do not. Somatic dissociation has been inter-preted as a defense strategy against emotional overload-ing [19].
Somatic dissociation may also be seen as linked to a his-tory of trauma and studies have found associations between bodily expressions of dissociation and posttraumatic stress disorder in persons with eating disorders [5,13]. High extent of dissociative symptoms as well as eating problems have been found among persons who have been traumatized from sexual abuse during childhood and/or in adulthood [17,26]. The dissociation seems to be correlated with the severity of the abuse [26] and seems to be more common in
patients with bulimic behavior [8,17]. Problems in the early attachment relationship and experiences of adverse child-hood circumstances have also have been found to increase the risk of psychopathology, including dissociation and eat-ing disorder, later in life [3,9,11]. However, some researchers argue that there is probably not a causal link between eating disturbance and dissociation. Instead both problems may be related to a general vulnerability [26,27]. In sum, the relations between dissociation and variants of eating disorders may be multi-facetted and there is an obvious need to further analyze these relations.
Many studies have found associations between dissoci-ation and extent of bulimic eating disorders. The specific aim of this study was to analyze the prevalence of psychoform as well as somatoform dissociation in all the different sub-groups of eating disorder patients. A second aim was to ana-lyze differences between the eating disorder diagnosis subgroups, also those with restrictive anorexia, concerning psychoform and somatoform dissociation. A third aim was to study the relationship between extent of dissociation and severity of eating disturbance since this relationship has not been clearly described in previous research.
In addition to these aims, a preliminary assessment was made of the usefulness and the validity of the Interview for dissociative disorders and trauma-related symptoms (IDDTS) [8].
Materials and methods Participants
The clinical group consisted of 60 females aged 14 to 30 years (M age ¼ 20.0, median ¼ 20.0, SD ¼ 3.26) who met ICD-10 [28] criteria for eating disorder diagnoses. The partici-pants were recruited from a Child and Adolescent Psychiatric outpatient unit specializing in eating disorders and were diagnosed by experienced clinicians, physicians and thera-pists. Several professionals participated in the specialized evaluation team. The team diagnosed eating disorder syn-dromes but no other psychiatric diagnoses. When diagnos-ing, a number of evaluation instruments were used, e.g. the Structured Eating Disorder Interview– SEDI, Eating Disorders Examination Questionnaire (EDEQ), Clinical Impairment Assessment (CIA), Psychiatric Status Rating scale for anorexia/ bulimia (PSR).
The group included patients with anorexia nervosa (n¼ 20), atypical anorexia nervosa (n ¼ 12), bulimia nervosa (n¼ 5), atypical bulimia nervosa (n ¼ 4), overeating associated with other psychological disturbances (n¼ 1), other eating dis-orders (n¼ 1) and eating disorders, unspecified (n ¼ 17),
In order to simplify analyses, three diagnosis groups were formed as follows:
Eating disorder, anorectic (including anorexia nervosa and atypical anorexia nervosa), n¼ 32, aged 15 to 30 years (M age¼ 19.8, median ¼ 19.0, SD ¼ 3.4)
Eating disorder, bulimic (including bulimia nervosa and atypical bulimia nervosa) n¼ 9 aged 17 to 29 years (M age ¼ 21.4, median ¼ 20.0, SD ¼ 3.6
Eating disorder, Unspecified (including overeating associ-ated with other psychological disturbances and other eating disorders) n¼ 19, aged 14 to 23 years (M age ¼ 19.6, median¼ 20.0, SD ¼ 2.78)
In the non-clinical group data was gathered from 245 young women aged 15 to 19 years (M age¼ 16.7, median ¼ 17, SD¼ 1.04). The sample was recruited from secondary schools and high schools representing different socioeco-nomic areas in two cities in the south of Sweden.
Measures
Eating disorder diagnoses were assessed according to the Classification of Mental and Behavioral Disorders, [28] by expe-rienced clinicians.
The Dissociation Questionnaire (DIS-Q) [29] is a self-report questionnaire with 63 items designed to measure dissoci-ation. The instrument gives a total scale score and scores on four subscales intended to assess different aspects of dis-sociative experiences: 1) identity confusion/fragmentation, 2) loss of control 3) amnesia and 4) absorption. The items have five answer alternatives from 1¼ “not at all” to 5¼ “extremely”. The subscale scores are obtained by summing up the total scores and dividing the number of items in each subscale. Reliability and validity are satisfactory [29]. The Swedish translation of the scale (DIS-Q-Sweden) has been used in several studies and has been found to have good psychometric properties such as reliability, internal consist-ency and stability over time [12,30]. The cutoff between clin-ical and non-clinclin-ical groups has been set to 2.5 [12,29].
The Somatoform Dissociation Questionnaire (SDQ- 20) [31] is a 20-item self-administered instrument measuring somato-form manifestations of dissociation. The answer alternatives concerning different physical complaints range from 1¼ “not true at all for me” to 5¼ “extremely true”. Each question is followed by a supplementary question asking whether the physical symptom is possible to explain by medical causes or not. The total score is obtained by summarizing the answers of the 20 items. The instrument has shown good reliability and validity [31]. The Swedish translation of the scale [32] has been used in two studies in Sweden and was found to have satisfactory psychometric properties [33,34]. The cutoff between clinical and non-clinical groups has been set to 1.5 [34,35]
Eating Disorder Examination Questionnaire, version 6.0 (EDE-Q) was administered to assess the extent of eating dis-order. The EDE-Q v.6.0 is a self-report questionnaire [36] derived from the Eating disorder examination [37] that uses a 7-point Likert type scale assessing the frequencies of eating problems over the past 28 days from no days ¼ 0 to every-day ¼ 6. This 36-item instrument examines the attitudinal, emotional and behavioral symptoms of disordered eating and assesses the symptoms of purging and binge eating over the same period. The symptoms of purging include
vomiting, laxative use, use of diuretics and hard exercising. The EDE-Q consists of four subscales: restraint, eating con-cern, shape concern and weight concern as well as a global score which is the average of the four subscales. The instru-ment has good psychometric properties [38] concerning internal consistency [39] and temporal stability [40]. Convergent validity with the EDE interview supports the use of the instrument as a screening tool for eating disorder psy-chopathology [41]. Normative data for EDE-Q have been published in e.g. in England [42] in the USA [43] and in Sweden [44]. In a recent Norwegian study cutoff was sug-gested at 2.5, based on data across different levels of BMI and age and different diagnostic groups [45]. This cutoff is used in the present study.
Interview for dissociative disorders and trauma-related symptoms
In order to more thoroughly assess dissociative symptoms among for instance eating disorder patients, the Interview for Dissociative Disorders and Trauma-related Symptoms (IDDTS) [8] has been created. The IDDTS is a semi-structured interview for examining and determining dissociative symp-toms and disorders. For persons with eating disorders the IDDTS interview has several advantages compared to the commonly used interview for assessing dissociation, SCID-D [46]. The IDDTS contains several questions about eating con-cerns and somatoform dissociative symptoms and questions around complex comorbidity and trauma-related symptoms [8]. The IDDTS is based on the structural dissociation theory [3]. This is an integrative theory that takes into account psy-chological as well as somatoform symptoms. According to this theory, dissociation occurs through a structural separ-ation of the self as different parts within the same insuffi-ciently integrated personality.
The interview, which consists of several sections, starts with evaluating physical complaints and somatoform dis-sociative symptoms. The main part of the interview contains questions about psychiatric symptoms that may be con-nected with traumatization such as substance abuse, eating problems, self-destructive behavior, sleeping and mood prob-lems, anxiety and panic symptoms. The interview ends with examining psychoform dissociative symptoms. The frequency and severity of the symptoms are evaluated by the inter-viewer. Based on the content and manner of presentation of the examples the clinician decides to what extent dissocia-tive or other trauma-related symptoms may be present. Instructions concerning criteria for the examples are included in the text for the interviewer. The interview was formed through many years of clinical and research-related experien-ces [8] but its validity has not yet been assessed. This is the first time IDDTS is used in Sweden.
Procedure
For inclusion in the clinical group, ninety-eight potential par-ticipants were asked to take part in the study. Thirty-eight persons decided not to participate before completing the
questionnaires. The attrition was due to the patients’ not feeling well enough to participate or that they had left treat-ment or in some cases that they did not submit their answers or declined to participate. The self-report question-naires were administered by trained and experienced thera-pists at the eating disorder outpatient clinic after information about the study and a request for participation had been given to the participants. Information was posted to the parents and caretakers of individuals below 18 years. The patients were assured of the confidentiality of their answers and then gave informed consent and completed the ques-tionnaires in the waiting room while visiting the clinic. Some participants needed help from their therapists to understand the questions and some asked to take the questionnaires home for completion. It was considered more important to receive responses than to keep to a uniform procedure. The participants had reached different stages in their treatment process. Some were new at the clinic while others were at the end of their treatment.
Among these sixty eating disorder patients, ten patients with the highest sum-scale scores on Dis-Q-Sweden and ten participants with the lowest sum-scale scores were inter-viewed with the Interview for Dissociative Disorders and Trauma Related Symptoms (IDDTS) without the interviewer knowing the Dis-Q-Sweden scores. Information was given to the participants and a request about participation. They were assured of the confidentiality of their answers.
Statistical analyses
Statistical analyses were made with parametric tests (t-tests, analyses of variance and Pearson correlations) and with non-parametric tests (Kruskal–Wallis and Spearman correlations) when group sizes were less than 30. Effect sizes, using Cohen’s d, were assessed when differences between means were significant.
Ethical considerations
The study was approved by the Human Research Ethics Committee, Faculty of Health Sciences, Link€oping University (Dnr. 02-196). Informed consent was given by all participants.
Results
InTable 1 mean differences between the clinical groups and control group on Dis-Q and SDQ-20 are presented.
Cronbach’s alpha for the whole DIS-Q scale was a ¼ 0.96. For Identity confusion, it was a¼ 0.96, for Loss of control a ¼ 0.88, for Amnesia a ¼ 0.85, and for Absorption a ¼ 0.67. For SDQ-20, Cronbach’s alpha was a ¼ 0.83. There were large differences between the clinical and non-clinical groups on all subscales on DIS-Q-Sweden and on SDQ-20 as shown in
Table 1. In the clinical group, the mean score 2.56 on DIS-Q-Sweden was just above the cutoff limit for clinical dissoci-ation 2.5 [12,29]. The mean for the non-clinical group was below the cutoff.
The difference was somewhat smaller on SDQ-20. The mean score for both the clinical and the non-clinical group was under the cutoff for clinical significance which is 1.5.
In Table 2, the mean scores and standard deviations for the clinical group on EDE-Q are presented.
The results inTable 2 show that the mean total score on EDE-Q was above the cutoff (2.5). Cronbach’s alpha for EDE-Q wasa ¼ 0.91.
InTable 3, correlations between DIS-Q-Sweden and EDE-Q are presented.
There were moderate to strong correlations between sev-eral of the subscales of EDE-Q and DIS-Q-Sweden. The sub-scale Eating concern had particularly strong associations with the DIS-Q-Sweden scales. The correlations with SDQ-20 were significant but somewhat weaker.
Differences between diagnosis groups
The differences in psychoform and somatoform dissociation between the eating disorder diagnosis groups were tested with the Kruskal–Wallis test. The results are presented in
Table 4.
There were no differences between the diagnosis groups on either psychoform or somatoform dissociation.
Interview for dissociative disorders and trauma-related symptoms
In Table 5, the mean scores on the subscales in IDDTS
are presented.
Table 1. Mean differences between the clinical group (n ¼ 60) and the control group (n ¼ 245) on DIS-Q –Sweden and SDQ-20.
Control group Mean (std) Clinical group Mean (std) Mean difference p-value Cohen’s d DIS-Q Total 1.91 (0.52) 2.56 (0.69) 0.65 <.001 1.08 Identity confusion 1.66 (0.62) 2.73 (0.91) 1.07 <.001 1.39 Loss of control 2.13 (0.65) 2.74 (0.86) 0.61 <.001 .81 Amnesia 1.71 (0.55) 1.96 (0.67) 0.24 .004 .39 Absorption 2.13 (0.69) 2.81 (0.80) 0.69 <.001 .92 SDQ-20 1.21 (0.26) 1.50 (0.46) 0.29 <.001 .81 control group n ¼ 242.
Table 2. Means scores and standard deviations for EDE-Q (n ¼ 60).
Mean (std) Median EDE-Q total 3.66 (1.53) 3.98 Restraint 3.26 (1.87) 3.30 Eating concern 2.93 (1.43) 3.20 Shape concern 4.46 (1.61) 5.13 Weight concern 3.56 (1.81) 3.90 4 D. NILSSON ET AL.
The results in Table 5 show that depersonalization, iden-tity problems and somatoform problems were most common in the interview.
In Table 6, correlations (Spearman’s rho) between ratings on DIS-Q-Sweden and IDDTS are presented.
The IDDTS scales were generally strongly correlated with DIS-Q-Sweden and particularly with SDQ-20. Strong correla-tions were found between identity confusion and amnesia and most of the IDDTS subscales. The correlations for SDQ-20 were strong for many of the IDDTS scales and particularly for somatoform symptoms.
In a final analysis, differences on the IDDTS subscales between the group with highest scores on the DIS-Q-Sweden sum scale and the group with lowest scores on this scale were compared with Mann–Whitney’s U-test. The scores on DIS-Q- Sweden in these two groups were significantly
different (1.57 vs. 2.99, t(18)¼70.85, p<.001). In Table 7, the scores in the two groups and significance of the differences are shown.
The results in Table 7 show that participants with high and low scores on DIS-Q-Sweden differed significantly in their answers on the interview on all dimensions except dis-sociating during the interview. The strongest differences were found for depersonalization, somatoform symptoms, amnesia, and identity problems.
Discussion
This study investigated the presence and extent of both psy-choform and somatoform dissociation in individuals suffering from eating disorder compared with a non-clinical group. The results showed that the persons with eating disorder
Table 3. Correlations between DIS-Q-Sweden and EDE-Q (n ¼ 60).
Restraint Eating concern Shape concern Weight concern EDE-Q total Identity confusion 0.59 0.66 0.58 0.50 0.63 Loss of control 0.37 0.61 0.43 0.35 0.47 Amnesia 0.48 0.54 0.50 0.42 0.53 Absorption 0.39 0.46 0.44 0.38 0.46 DIS-Q total 0.54 0.67 0.57 0.48 0.62 SDQ-20 0.37 0.36 0.39 0.38 0.41 p < .05 p < .01 p < .001.
Table 4. Tests of differences (Kruskal-Wallis) on DIS-Q-Sweden and SDQ-20 between the eating disorder diagnoses. Dissociation scale
Anorexia (n ¼ 32) Mean (std)
Bulimia (n ¼ 9) Mean (std)
Eating disorder Unspecified (n ¼ 19)
Mean (std) p DIS-Q total 2.48 (0.68) 2.57 (0.64) 2.69 (0.73) .279 Identity confusion 2.67 (0.92) 2.56 (0.80) 2.91 (0.94) .819 Loss of control 2.58 (0.73) 3.15 (1.20) 2.80 (0.85) .138 Amnesia 1.90 (0.67) 1.71 (0.55) 2.16 (0.68) .382 Absorption 2.75 (0.86) 2.85 (0.61) 2.90 (0.80) .202 SDQ-20 1.51 (0.38) 1.39 (0.31) 1.53 (0.60) .725
Table 5. Ratings on the subscales in IDDTS (n ¼ 20).
Interview subscales Mean Median Standard deviation Somatoform symptoms 1.55 1.00 1.47
Amnesia 1.00 0.50 1.21
Depersonalization 2.15 2.00 1.14 Derealization 1.10 1.00 1.07 Identity problems 1.65 1.50 1.31 Indication of dissociated parts of the personality 0.45 0.00 0.89 Pseudo hallucinations 0.65 0.00 0.93 Schneider’s symptom 0.90 1.00 1.02 Dissociation during the interview 0.50 0.00 0.76
Table 6. Correlations (Spearman’s rho) between DIS-Q-Sweden and SDQ and subscales in IDDTS (n ¼ 20).
DIS-Q SDQ
Interview subscales Identity confusion Loss of control Amnesia Absorption Total DIS-Q
Somatoform symptoms 0.82 0.66 0.84 0.63 0.75 0.86 Amnesia 0.78 0.55 0.82 0.58 0.66 0.77 Depersonalization 0.82 0.74 0.80 0.66 0.76 0.78 Derealization 0.57 0.44 0.65 0.55 0.58 0.74 Identity problems 0.75 0.66 0.69 0.59 0.72 0.72 Indications of dissociated parts 0.54 0.41 0.56 0.36 0.41 0.54 Pseudo hallucinations 0.64 0.55 0.71 0.51 0.55 0.70 Schneider’s symptom 0.63 0.56 0.82 0.38 0.51 0.69 Dissociation during the interview 0.39 0.17 0.41 0.16 0.21 0.33 p <.05 p <.01 p < .001.
reported substantially and significantly more psychoform and somatoform dissociation symptoms than the non-clinical group. The mean score for the clinical group was over the cutoff limit for psychoform dissociation. The results confirm previous studies that have found associations between dis-sociation symptoms like absorption, identity confusion and loss of control and eating disorder symptoms [14,15,19,21].
The associations between binge eating and vomiting on one hand and dissociation on the other may vary. For some individuals binge eating and vomiting can be perceived as an opportunity to escape from negative feelings [20,22]. Such behavior may also be experienced as a loss of control that may evoke additional negative affects like shame which in turn leads to dissociation. For other individuals, dissociation may precede the bulimic symptoms and vomiting may be a means to come out of the dissoci-ation [14,17].
Persons with eating disorders seem to be unsure in their own identity and often tend to withdraw in interpersonal relations [11,15,18,20,21]. In a longitudinal Finish study, asso-ciations between social phobia, depression, eating disorder, and a reluctance to seek help for the eating disorder were found [47].
The absorption may be a way to deal with difficult affects and to withdraw into oneself. Problems may be experienced through bodily symptoms using the body as a representation of mental states [21]. Abbate-Daga et al. [48] found a high percentage of psychosomatic symptoms and conversion symptoms in different eating disorder groups.
The ratings on SDQ-20 in our study showed that the eat-ing disorder group scored significantly higher on somato-form dissociation compared to the non-clinical group which is consistent with previous research [13,16,19,22,23,25].
The level of somatoform dissociation was not, however, as high as in other studies and was below the clinical cutoff. One reason could be the low proportion of patients with bulimia. Persons with this diagnosis have been found to score high on somatoform dissociation in previous studies [16,19,23–25]. This study also included restrictive diagnoses in the clinical group which may have influenced the results. Another reason could be that some of the participants were at the end of their treatment. Successful treatment may have decreased the dissatisfaction with the individual’s body and the tendency to dissociate.
Individuals with eating problems often describe a dis-turbed sense of body self containing feelings of shame and
disgust towards their own body [15,21–25]. It is known that dissociation sometimes is a way to deal with bodily feelings related to previous trauma [5,13,22,23,25,49]. As patients with eating disorders often have been exposed to traumatic experiences, the high rate of dissociation might be caused by such experiences.
The perceived severity of eating disorder was associated with the degree of dissociation. The correlation between dif-ficulties of eating problems and somatoform dissociation was significant but slightly weaker than for psychoform dissociation.
We found no differences between the eating disorder subgroups concerning dissociation. The results could be due to inadequate power to detect differences between the eat-ing disorder diagnoses. Recent studies, however, have found similar results, implying that the eating disorder sub-diagno-ses may not differ with regard to predisposing factors or comorbidity [13,25,50,51].
To get a deeper understanding of the symptoms of dis-sociation a newly developed interview, the Interview for Dissociative Disorders and Trauma Related Symptoms (IDDTS) was used. This is the first time this interview instrument is used in research. The purpose of IDDTS is to identify both somatoform and psychoform dissociation. We chose to use the sub-scales relevant for persons with eating dis-order problems.
The ratings on the interview correlated significantly with the ratings on DIS-Q-Sweden as well as with the ratings on SDQ-20, suggesting adequate convergent validity with these established measures.
The clinical value of the interview is that it may give a more clear understanding of the patient’s personal experien-ces of the dissociations symptoms. Several individuals described a relief from this opportunity to talk about dis-sociative experiences. In the interviews a number of serious dissociative symptoms were described such as somatic prob-lems and trauma-related symptoms. During the interviews some participants described experiences indicative of deper-sonalization as linked to strongly affective and stressful eat-ing situations or associated to interpersonal relationships. These symptoms often seem to emerge in a bodily way. Sometimes the depersonalization was described as a positive way of escaping and sometimes as an unpleasant experience outside the individual’s control. Difficulties with fragmenta-tion and identity confusion were also described as very stressful experiences.
Table 7. Ratings on IDDTS in the groups with the highest (n ¼ 10) and the group with the lowest (n ¼ 10) ratings on DIS-Q-Sweden and the significance of the difference between these groups (Mann–Whitney).
Interview subscales Low rating Mean (std) High ratings Mean (std) Mean Difference p-value Cohen’s d Somatoform symptoms 0.60 (0.97) 2.50 (1.27) 1.90 .005 1.70 Amnesia 0.20 (0.42) 1.80 (1.23) 1.60 .004 1.95 Depersonalization 1.30 (.82) 3.00 (.67) 1.80 .001 2.40 Derealization 0.50 (0.71) 1.70 (1.06) 1.30 .015 1.48 Identity problems 0.80 (1.03) 2.50 (.97) 1.80 .003 1.80 Indication of dissociated parts 0 (0) .90 (1.10) 0.50 .063 0.91 Pseudo hallucinations 0.10 (0.32) 1.20 (1.03) 0.70 .019 1.04 Schneider’s symptom 0.30 (0.48) 1.50 (1.08) 0.90 .023 1.15 Dissociation during
the interview 0.30 (0.67) .70 (.82) 0.40 .247 0.54 6 D. NILSSON ET AL.
Research has shown that dissociative symptoms often are not noticed or may be mistaken as neuropsychiatric symp-toms or other somatic or psychiatric sympsymp-toms [4,8,11] .This study shows that it is important to inform clinicians about the dissociative type of psychopathology and develop instru-ments for assessment to reduce such inaccuracies.
Limitations
A problem with studies based on self-report questionnaires is that answers may be inaccurate because they are subject to memory failure and to the respondent’s current mood. The problem of common-method variance, implying that persons tend to give similar answers to all questions about mental health and well-being, must also be considered. Some of the participants, when interviewed, indicated that they had more problems than they had rated on the questionnaires.
Eating disorders are often co-morbid with mood disorders. It is possible that the dissociative symptoms were associated with mood problems. The present study could have benefit-ted from a comparison with a clinical group with mood disorders.
Another major limitation is that the clinical group com-prised only 60 patients, and thus the diagnostic subgroups were small. The sample in the clinical group may therefore not have been representative of an outpatient eating dis-order group, considering especially the low number of per-sons with bulimia. The individuals in the clinical group were on the average some years older than the non-clinical group, a fact that may be considered to make the comparisons less appropriate. So for future research it is a recommendation to make a case control study with matched groups concerning age and gender.
Conclusions
Our findings indicate that both psychoform and somatoform dissociation need to be measured in the assessment of indi-viduals with eating disorders. Both screening instruments and the structural interview may be used when there is a need to better understand the symptoms. Since the dissocia-tive symptoms seem to be associated with the severity of the eating disorder a focus on such problems may lead to better treatment and may potentially reduce the eating dis-turbance. An important task is to find interventions that in addition to focusing on the eating disturbance problems also target dissociative problems.
Disclosure statement
There is no conflict of interest in the present study for any of the authors
Funding
This study was supported by The Department of Research and Development, Region €Osterg€otland and by Gyllenstiernska Krapperup stiftelsen.
Notes on contributors
Doris Nilssonis Assistant professor in Clinical psychology at Link€opings
University and has done quite a lot of research concerning Children and adolescents with dissociation and has been working clinically with children and adolecensts for many years.
Annika Lejonclou is Licensed Psychotherapist and have been working with adolescents with eating disorder for many years.
Rolf Holmqvist is Professor of Clinical psychology at Link€oping
University and has been doing a lot of research in Clinical psychology and work in clinical practice.
ORCID
Rolf Holmqvist http://orcid.org/0000-0003-2093-2510 References
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