1. Auditory hallucinations in dissociative identity disorder with and without adult sexual abuse and schizophrenia Martin J. Dorahy 1, 2 Rachael Palmer 1 Warwick Middleton 1, 2 Lenaire Seager 2 1 Department of Psychology University of Canterbury Christchurch, New Zealand 2 The Cannan Institute Belmont Private Hospital Brisbane, Australia Orlando, 2015

2. 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.,

3. 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 Sch N=33 DID N=29 Sig (  ) Location: Inside Outside Both 59% 24% 18% 52% 3% 45% NS * Dorahy et al., 2009

4. 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.”

5. 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

6. 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

7. 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

8. Sample Age: F(2,54) =.88, p =.42 DID Abuse in childhood DID sexual abuse adulthood Schizophrenia N252111 age44.8045.0440.09 SexM=1 F=24 M=0 F=21 M=11 F=0

9. 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)

10. Results: Child abuse All participants reported a history of child abuse/neglect except 1 person with schizophrenia DID Abuse in childhood (n=25) DID sexual abuse adulthood (n=21) Schizophrenia (n=11) Total CTQ Range: 28-140 91.00 (SD=17.98) 94.71 (SD=16.32) 45.45* (SD=12.15) Adult Phy&Sex ab. Range: 1-4 1.5* (SD=.59) 3.39 (SD=1) 1.18 * (SD=.31)

11. Pathological Dissociation Schizophrenia sig lower than 2 DID samples

12. Frequency of AH DID Abuse in childhood (n=25) DID sexual abuse adulthood (n=21) Schizophrenia (n=11) Continuous voices44%57%27% All participants reported AH except one person with schizophrenia

13. Interpretation of Voices Inventory *

14. Formal thought disorder - SAPS Schizophrenia sig lower than 2 DID samples

15. Peter’s et al. Delusional Inventory

16. 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?

17. Dissociation as putative mechanisms Sample Age: F(2,63) =.36, p =.69 Low Path Diss DID High Path Diss DID Schizophrenia N25 16 age44.8445.4442.56 SexM=1 F=24 M=1 F=24 M=14 F=2

18. Child and adult abuse Low DES-T DID (n=25) High DES- T DID (n=25) Schizophrenia (n=16) Total CTQ Range: 28-140 85* (SD=17.78) 100* (SD=12.74) 51* (SD=22.43) Adult Phy&Sex ab. Range: 1-4 2.06 (SD=1.1) 2.71 (SD=1.2) 1.16* (SD=.30)

19. Pathological Dissociation All groups differ on pathol. dissociation

20. Interpretation of Voices Inventory *

21. Formal thought disorder - SAPS Schizophrenia sig lower than hi path diss. DID

22. Peter’s et al. Delusional Inventory

23. 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)

24. 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.

25. 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?