Auditory hallucinations in dissociative
identity disorder with and without adult
sexual abuse and schizophrenia
Martin J. Dorahy1, 2
Rachael Palmer1
Warwick Middleton1, 2
Lenaire Seager2
1Department
of Psychology
University of Canterbury
Christchurch, New Zealand
2The
Cannan Institute
Belmont Private Hospital
Brisbane, Australia
Orlando, 2015
Voices & dissociative disorders
Voice hearing in dissociative disorders has a long
history (e.g., Hart, 1926; Kluft, 1987; ; Middleton
& Butler, 1998; Prince, 1905; Ross, 2004; Ross et
al., 1995).
Recent empirical work has dispelled some
previously held beliefs; e.g.,
Voices internal for DID and external for
schizophrenia
• Eg., Honig et al. (1998): no difference in location
of voices in schizophrenia and dissociative
disorders
Both experienced voices inside and outside the head.
Even more nuanced than that
Location: Inside
Outside
Both
Sch
N=33
DID
N=29
Sig ()
59%
24%
18%
52%
3%
45%
NS
*
*
Dorahy et al., 2009
AH as psychological and dissociative
Dissociation strongly linked to AH (e.g., Anketell et
al., 2010; Brewin & Patel, 2010; Dorahy et al., 2009; Kilcommons et al.,
2008; Schäfer et al., 2008).
Growing movement towards viewing AH as
psychological and dissociative, rather than
biogenetic and psychotic (Longden et al., 2011;
Moskowtiz & Corsten, 2007).
Laddis & Dell (2012) caution that the dissociative
experiences in schizophrenia, may in fact be
dissociative-like, and not reflect dissociative
experiences in traumatised and dissociative
individuals
“We believe that the underlying mechanisms of the seemingly dissociative
phenomena in schizophrenia are different from the underlying mechanisms of
the dissociative phenomena in DID.”
Dorahy et al. 2009
N = 65
29 DID
18 schizophrenia with child maltreatment
16 schizophrenia without child maltreatment.
Later two groups had persistent AH
Schizophrenia voice experience looks somewhat
different from DID.
DID more likely to:
Start before 18
Hear constantly
Hear both internally and externally
Hear more than 2 voices
Hear both child and adult voices
Laddis & Dell, 2012
DID (40), schiz in remission (20), schiz active (20)
DID higher incidence of:
child voices
voices that converse or argue
Angry & persecutory voices
DID lower incidence of:
delusions
Current study
Further explored voice hearing in DID and
schizophrenia, and delusions
Two DID groups:
Abuse ended before 18
Sexual abuse after 18 (often/v.often) (growing
interest in ongoing abuse, Middleton, 2013)
To pick up potential differences in DID groupings
Sample
N
age
Sex
DID Abuse in DID sexual
childhood
abuse
adulthood
Schizophrenia
25
44.80
M=1
F=24
11
40.09
M=11
F=0
Age: F(2,54) = .88, p = .42
21
45.04
M=0
F=21
Measures
DES; DES-T
Interpretation of Voices Inventory (IVI; 26 items
Meta-physical beliefs about voices (e.g., They mean that I am close to God).
Positive beliefs (e.g., They help me keep control).
Loss of control (e.g., They control the way I think).
Formal Thought Disorder – SAPS (8 items e.g., derailment, illogicality)
Peter’s et al. Delusional Inventory (21 items); e.g., “Do you ever feel as if
some people are not what they seem to be?”
Psychotic Symptom Rating Scale (11 & 6 items)
Auditory Hallucinations (e.g., frequency, location)
Delusions (e.g, conviction)
Results:
Child abuse
All participants reported a history of child abuse/neglect
except 1 person with schizophrenia
DID Abuse DID sexual
in childhood abuse
(n=25)
adulthood
(n=21)
Total CTQ
91.00
94.71
Range: 28-140
(SD=17.98) (SD=16.32)
Adult Phy&Sex ab. 1.5*
3.39
Range: 1-4
(SD=.59)
(SD=1)
Schizophrenia
(n=11)
45.45*
(SD=12.15)
1.18 *
(SD=.31)
Pathological Dissociation
90
80
70
60
DID Child Abuse
DID Adult SA
Schizophrenia
50
40
30
*
20
10
0
DES-T (Path Diss)
Schizophrenia sig lower than 2 DID samples
Frequency of AH
• All participants reported AH except one
person with schizophrenia
DID Abuse DID sexual Schizophrenia
in childhood abuse
(n=11)
(n=25)
adulthood
(n=21)
Continuous voices 44%
57%
27%
3
Interpretation of Voices
Inventory
2.5
2
*
1.5
*
DID Child Abuse
DID Adult SA
Schizophrenia
1
0.5
0
Metaphys.
Beliefs
Positive Beliefs
Loss of Control
Formal thought disorder SAPS
4
3.5
3
2.5
DID Child Abuse
*
2
DID Adult SA
Schizophrenia
1.5
1
0.5
0
FTD
Schizophrenia sig lower than 2 DID samples
Peter’s et al. Delusional Inventory
0.8
0.7
0.6
0.5
DID Child Abuse
0.4
DID Adult SA
0.3
Schizophrenia
0.2
0.1
0
PDI
Initial summary
Both DID groups (higher on Diss) differed from schizo.
on:
More pathological dissociation
More continuous AH
More likely to hear solely inside
More formal thought disorder
More beliefs that voice mean they loss control
Generally the DID groups showed the same symptoms
frequency and were similar to the schizophrenia group
on:
Metaphysical beliefs about voices
Delusion
But do DDs differ when divided by dissociation and
not adult abuse history?
Dissociation as putative
mechanisms
Sample
Low Path Diss High Path
DID
Diss DID
N
age
Sex
25
25
44.84
45.44
M=1
M=1
F=24
F=24
Age: F(2,63) = .36, p = .69
Schizophrenia
16
42.56
M=14
F=2
Child and adult abuse
Total CTQ
Range: 28-140
Low DES-T
DID (n=25)
High DES- Schizophrenia
T DID
(n=16)
(n=25)
85*
(SD=17.78)
100*
51*
(SD=12.74) (SD=22.43)
Adult Phy&Sex ab. 2.06
Range: 1-4
(SD=1.1)
2.71
(SD=1.2)
1.16*
(SD=.30)
Pathological Dissociation
90
80
*
70
60
LowDES-T DID
High DES-T DID
Schizophrenia
50
40
*
30
*
20
10
0
DES-T (Path Diss)
All groups differ on pathol. dissociation
Interpretation of Voices Inventory
3.5
*
3
2.5
*
DID Child Abuse
2
DID Adult SA
1.5
Schizophrenia
1
0.5
0
Metaphys.
Beliefs
Positive Beliefs
Loss of Control
Formal thought disorder - SAPS
4
3.5
3
*
2.5
Low DES-T DID
2
High DES-T DID
Schizophrenia
1.5
1
0.5
0
FTD
Schizophrenia sig lower than hi path diss. DID
Peter’s et al. Delusional Inventory
0.8
0.7
0.6
0.5
Low DES-T DID
0.4
High DES-T DID
0.3
Schizophrenia
0.2
0.1
0
PDI
Discussion
With DID differentiated by dissociative symptom, High path
diss DID higher than 2 other groups on:
Metaphyscial and loss of control explanations for voices
More formal thought disorder than schizophrenia
Groups did not differ on:
positive beliefs about voices
General Delusions (other studies show differences in delusion,
Laddis & Dell, 2012)
Discussion - II
DID samples with child abuse only versus adult sexual abuse
look similar in thought disorder, hallucinatory and delusional
symptom experience,
Tend to be more severe than schizophrenia (except in
delusions)
However, when DID is differentiated on dissociative symptoms
severity, the more severe group generally have more ‘psychotic’
symptoms, and the less severe group are similar to
schizophrenia
Severity of pathological dissociative symptoms in DID is a
marker of more severe ‘psychotic’ symptom profile – all DID is
not equal and pathological dissociation may create difference.
Implications
‘Psychotic’ symptoms in DID should reduce in
therapy as dissociation is dealt with.
Assessing the severe of pathological symptoms
in DID is important
Is more severe ‘psychotic’ symptoms associated
with dissociative structure or specific symptoms?