Three studies of dissociative behavior and self-harm

Today, I address three articles that deal in different ways with dissociative behaviors. First, Carpenter, Hepp & Trull (2023) published “Pain Before, During, and After Nonsuicidal Self-Injury: Findings from a large web study” in Journal of Psychopathology and Clinical Science. Here’s the edited abstract and impact statement:

Competing models suggest that physical pain may play an important role in nonsuicidal self-injury (NSSI) via pain onset or pain offset, or that pain may be absent (analgesia). Few studies have tested these models in the same sample or examined factors that could explain differences in NSSI pain experience. We assessed 1,630 individuals with NSSI histories in an online survey. We descriptively examined pain during NSSI and tested preregistered hypotheses that NSSI frequency, NSSI severity, borderline personality disorder (BPD) features, emotional pain, and dissociation during NSSI are associated with experiencing less NSSI pain. Exploratorily, we also tested whether self-punishment motives were associated with less NSSI pain. Almost all participants reported recent and frequent NSSI. Participants were heterogenous in their report of NSSI pain. We found minimal support for analgesia (reported by only 4.3% of participants). More participants reported pain onset than offset, but offset was associated with reductions in emotional pain. Emotional pain was elevated prior to NSSI and decreased significantly during and after NSSI. We found that higher dissociation during NSSI was associated with less NSSI pain. Contrary to hypotheses, NSSI severity, emotional pain prior to NSSI, and self-punishment motives were associated with greater NSSI pain. NSSI frequency and BPD features were not associated with NSSI pain. BPD features interacted with dissociation and emotional pain prior to NSSI. Findings contrast with laboratory pain induction work, suggesting that, though people who self-harm may have heightened pain tolerance, they may seek to self-injure in a manner that results in pain. 

This large survey study of people who self-harm found that most report feeling physical pain and that people may seek to self-injure in a manner that results in pain. Self-reported dissociation during self-harm was associated with less pain. Reporting more physical pain was associated with more emotional pain, but experiencing a reduction in pain following self-harm, reported by approximately 39% of participants, was associated with reductions in emotional pain. 

I found this study intriguing because of its large sample size and the notion that physical pain with dissociation results in less pain, emotionally and physically. The next study looks at complex dissociative disorders. Schnupp, Sattel, Morawa, Kronester, Sack & Schäflein (2023) published “Autopilot Functionality and Self-Destructive Behavior in Patients with Complex Dissociative Disorders—A Qualitative Study” in Psychological Trauma: Theory, Research, Practice, and Policy. Here’s the edited abstract and impact statement:

Dissociative disorders are common in psychiatric patients and severely impact patients’ lives. They are, however, underdiagnosed, thus preventing patients from accessing timely and adequate therapy. Identifying how patients with dissociative disorders relate to themselves could improve diagnostics. However, this question has not been explored in detail. The aim of the study was to gain insights into how people with complex dissociative disorders relate to themselves. We conducted semistructured qualitative interviews with ten women diagnosed with complex dissociative disorders who had previously completed trauma-focused therapy. Data were analyzed through reflexive thematic analysis. Participants described their behavior toward themselves before the start of the therapy as “autopilot-functional” and “self-destructive.” The “autopilot functionality” was characterized by being outward-oriented and ignoring one’s own needs. Hence, participants only appeared to be functional. “Self-destructive behavior” was described as a spectrum of various destructive behaviors (e.g., eating disorders, self-harm, excessive exercise, and substance abuse) that participants perceived as a cohesive complex. The participants illustrated that both behaviors were driven by a lack of self-empathy and connected to suppression and poor perception of bodily stimuli. “Autopilot functionality” seems to be a hallmark in patients with complex dissociative disorders. With patients hiding their self-destructive behavior, health personnel may misjudge the severity of these patients’ mental illness. Neither “autopilot functionality” nor “self-destructive behavior” should be judged (neither negatively nor positively), but one should understand both as a coping mechanism for trauma-related disorders. 

Complex dissociative disorders are frequent and underdiagnosed, with patients suffering severely. In our qualitative study, we found a behavioral complex of self-destructiveness (which has already been well described) coexisting with a seemingly paradoxical behavioral complex of high functionality that we called “autopilot functionality” (reflecting quite well the yet underresearched concept of the apparently normal part of the theory of structural dissociation). As high functionality is often perceived as beneficial to the patient, this behavioral complex often remains unrecognized. Our insights could help clinicians improve diagnosis of dissociative disorders in high-functioning patients and lead to better therapy approaches. 

Unlike the first study, this one has only ten participants, all female. While the self-destructive behaviors are well known and common to other diagnoses, I find the idea of autopilot functionality fascinating. Finally, Chiu, Li, Hsieh, Chou, Au, Chen & Lin (2023) published “Linking Childhood Trauma and Dissociation to Psychotic Symptoms in Major Depressive Disorder, Bipolar Disorders, and Schizophrenia: A transdiagnostic examination using patient and clinician ratings” in Psychological Trauma: Theory, Research, Practice, and Policy. Here’s the edited abstract and impact statement:

Symptomatic overlap between dissociation and psychosis is well documented; however, the pathogenesis of these two phenomena might be distinct. Few studies have analyzed the relation of dissociative and psychotic symptoms transdiagnostically. The current study examines an emerging trauma-dissociation theoretical model that accounts for psychotic symptoms across affective disorders and schizophrenia (SCZ). Psychiatric inpatients with DSM-5 major depressive disorder (MDD), bipolar disorders (BD) currently in a major depressive episode, and SCZ, and healthy controls (HC) were recruited. Potentially traumatizing events in childhood, dissociative symptoms, and psychotic symptoms were assessed. In addition to participant’s self-report, dissociative and psychotic symptoms were rated by psychiatrists blind to the hypothesis. Path analysis was conducted. Dissociation was commonly experienced by clinical participants, particularly for those with MDD or BD. For the SCZ group, ratings of dissociation differed between patient and clinician; specifically, patient-reported dissociation scores, but not clinician-rated scores, were higher than that of the HC group. Importantly, the links between childhood trauma, dissociation, and psychotic symptoms were not homogenous across the diagnostic groups. Dissociation mediated the relationship between childhood trauma and psychotic symptoms in the MDD and BD groups, but not the SCZ group. Depending on the psychiatric condition, dissociation and psychosis have different clinical implications. Childhood trauma and dissociation provide an account for psychotic symptoms in patients diagnosed with MDD and BD, but not with SCZ. 

Dissociative and psychotic symptoms often appear in an acute phase of mental disorders. Their overlap creates confusion in clinical diagnosis, though growing evidence showed that psychotic disorders such as schizophrenia may have a distinct etiology from dissociative disorders. Our findings illustrated that psychotic symptoms in patients with a predominantly depressed mood could be attributable to dissociation and childhood trauma. By contrast, this relationship between psychotic symptoms, dissociation, and childhood trauma was not evident in schizophrenia. Assessing childhood relational trauma and dissociation helps make differential diagnosis of psychotic symptoms, particularly for those in a depressive episode. 

This study is important in illustrating that there are quite different impacts of childhood trauma and dissociation in clients with MDD, BD, and schizophrenia. It is especially interesting that dissociation does not mediate the relationship between childhood trauma and psychotic symptoms in schizophrenia.