Brown, R. J.

Terhune, Devin B.

Wieder, Lillian

English

King's Research Portal

                       King’s Research Portal  Document VersionPeer reviewed versionLink to publication record in King's Research PortalCitation for published version (APA):Wieder, L., Brown, R. J., & Terhune, D. B. (Accepted/In press). Revisiting the role of verbal suggestion indissociative psychopathology. Acta Psychiatrica Scandinavica .Citing this paperPlease note that where the full-text provided on King's Research Portal is the Author Accepted Manuscript or Post-Print version this maydiffer from the final Published version. If citing, it is advised that you check and use the publisher's definitive version for pagination,volume/issue, and date of publication details. And where the final published version is provided on the Research Portal, if citing you areagain advised to check the publisher's website for any subsequent corrections.General rightsCopyright and moral rights for the publications made accessible in the Research Portal are retained by the authors and/or other copyrightowners and it is a condition of accessing publications that users recognize and abide by the legal requirements associated with these rights.•Users may download and print one copy of any publication from the Research Portal for the purpose of private study or research.•You may not further distribute the material or use it for any profit-making activity or commercial gain•You may freely distribute the URL identifying the publication in the Research PortalTake down policyIf you believe that this document breaches copyright please contact librarypure@kcl.ac.uk providing details, and we will remove access tothe work immediately and investigate your claim.Download date: 08. Oct. 2023Suggestibility and psychopathology 1   Revisiting the role of verbal suggestion in dissociative psychopathology   Lillian Wiedera, Richard J. Brownb,c, & Devin B. Terhunea  a Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King’s College London  b School of Health Sciences, University of Manchester, Manchester, UK c Psychotherapy Services, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Sciences Centre, UK   ORCID: Wieder: 0000-0003-0725-7856, lillian.wieder@kcl.ac.uk Brown: 0000-0003-3961-2023, richard.j.brown@manchester.ac.uk Terhune: 0000-0002-6792-4975, devin.terhune@kcl.ac.uk  Correspondence address: Devin B. Terhune Department of Psychology Institute of Psychiatry, Psychology & Neuroscience, King’s College London 16 De Crespigny Park London SE5 8AB E-mail: devin.terhune@kcl.ac.uk  For the purposes of open access, the author has applied a Creative Commons Attribution (CC BY) licence to any Accepted Author Manuscript version arising from this submission  Data availability statement N/A (non-empirical)  Funding statement This work was supported by a grant from the Gyllenbergs Foundation to DBT.  Conflict of interest disclosure All authors report having no conflicts of interest to disclose.  Funding statement This work was supported by a grant from the Gyllenbergs Foundation to DBT.  Ethical approval statement N/A (non-empirical)  Patient consent statement N/A (non-empirical)  Other source permission N/A (non-empirical)  Clinical trial registration N/A (non-empirical)  Metrics: Word count: 837 References: 9 Figure: 1 Tables: 0 Suggestibility and psychopathology 2   Dissociative symptoms, which are characterised by a disruption between normally integrated cognitive-perceptual systems, and suggestion effects, such as changes in awareness, perception and behaviour in response to verbal suggestions, are historically intertwined and long believed to share a family resemblance.1 This association continues to figure prominently in contemporary debates regarding the aetiology of dissociative psychopathology2,3 with prominent theories diverging regarding aberrant suggestibility in the dissociative disorders. The sociocognitive model proposes that greater responsiveness to suggestion (suggestibility) among dissociative disorder patients facilitates false memories of trauma through an admixture of processes including iatrogenesis and responsiveness to sociocultural cues (Figure 1a).3 By contrast, the trauma model maintains that dissociation functions as a coping response to traumatic stress that progresses to psychopathology in certain individuals independently of suggestion (Figure 1b).2 Proponents of the sociocognitive model have recently conceded that suggestibility is not strongly related to dissociation,3 intimating a potential emerging consensus. Irrespective of the merits of these models, here we correct the record on responsiveness to suggestion in dissociative psychopathology.    Figure 1. Schematic depiction of competing conceptual models of the interrelations between dissociative psychopathology, trauma, and direct verbal suggestibility. All paths depict positive associations. * The form of suggestibility is not specified in the sociocognitive model.  Proponents of both models mischaracterise the available empirical evidence. Suggestibility is a heterogeneous phenomenon but within historical and contemporary contexts denotes an individual’s capacity to respond to direct verbal suggestions (e.g., “you will be completely unable to move your arm” [suggested motor paralysis])1. In contrast with claims that dissociative disorder patients are not suggestible,2,3 recent meta-analytic evidence demonstrates that they reliably display greater responsiveness than controls to direct verbal suggestions following a hypnotic induction, even though elevated suggestibility is not a signature of general psychopathology.1 These effects are moderate-to-large in Dissociative psychopathologySuggestibility*False memory  and symptom  misreportingDissociative psychopathologyTrauma exposurec. Diathesis-stress model d. Dissociative sequelae modela. Sociocognitive model b. Trauma modelDissociative psychopathologyTrauma exposureDirect verbal suggestibilityDirect verbal suggestibilityDissociative psychopathologyTrauma  exposureSuggestibility and psychopathology 3 magnitude and observed in four of the five psychiatric conditions with the most severe dissociative symptomatology (dissociative identity disorder [DID], otherwise specified dissociative disorder [OSDD], posttraumatic stress disorder, and functional neurological disorder [FND]), with the most pronounced effects in DID and OSDD.5 Although FND is not listed as a dissociative disorder in the DSM, the ICD recognises the historical association between the two and views FND as a dissociative neurological symptom disorder4. These data stand in stark contrast to the apparent consensus reached by proponents of the sociocognitive and trauma models.2,3 Of note, elevated responsiveness to verbal suggestions is not present in depersonalisation-derealisation disorder5, which aligns with a hypothesised link between suggestion and dissociative compartmentalisation, rather than dissociative detachment phenomena6. Disregard of this research is partly due to the heterogeneous nature of suggestibility but also the tendency to incorrectly generalize from one form of suggestibility to another. For example, multiple studies have assessed suggestibility in the dissociative disorders with interrogative suggestibility measures that are widely used in forensic contexts.3 However, these scales are primarily measures of compliance and do not generalize to direct verbal suggestibility,1 which has greater relevance to clinical applications of suggestion. Interrogative suggestibility has never been theoretically linked to dissociation and we would not expect elevated compliance among dissociative disorder patients. The same holds for studies in which participants simulate dissociative symptoms;2,3 this methodology can inform our understanding of beliefs regarding dissociation, but it does not have any bearing on direct verbal suggestibility in the dissociative disorders.1  A second reason for the neglect of the evidence regarding suggestibility in the dissociative disorders is the tendency to view suggestion through the narrow lens of iatrogenesis and false memories. Researchers and clinicians frequently conflate suggestibility with proneness to false memories3 even though they are distinct phenomena. This equivalence arises from the inference that elevated suggestibility in the dissociative disorders would signify that suggestion causes dissociative symptoms.2,3 However, this conclusion does not follow from meta-analytic (correlational) evidence for elevated direct verbal suggestibility in this population.1 At present, there is no evidence for a causal role of suggestion or suggestibility in the emergence of dissociative symptoms. Narrowly interpreting suggestion in this manner has stunted the field in harnessing these data to inform our understanding of pathological dissociation. Recognizing elevated responsiveness to direct verbal suggestions as a feature of dissociative psychopathology has the potential to open up novel avenues for research and treatment.1,7 Accumulating evidence aligns with the proposal that elevated suggestibility confers predisposition to dissociative psychopathology in response to traumatic stress (Figure 1c).1,8 Further research is required to more precisely interrogate this diathesis effect and its neurocognitive substrates as well as the alternate hypotheses that elevated suggestibility is a sequela of dissociative psychopathology9 (Figure 1d) or that it confers risk for dissociative psychopathology in the absence of trauma. Elevated responsiveness to suggestion may help to explain involuntary dissociative responses including those triggered by environmental stimuli. Symptom suggestibility is widely used to aid the diagnosis of FND1 and data highlighting its utility in the discrimination of dissociative disorders and schizophrenia could be harnessed to complement diagnosis protocols.5 Suggestibility also seems to augment the efficacy of suggestion-based treatments1 however, Suggestibility and psychopathology 4 incorporating suggestion into therapeutic interventions may be contraindicated in the dissociative disorders precisely because of elevated response to suggestions in this group. Moving beyond misrepresentations of suggestibility will allow us to leverage accumulating knowledge of the link between dissociation and responsiveness to suggestion with the potential to substantially advance our understanding of dissociative psychopathology.  References 1. Wieder L, Brown RJ, Thompson T, Terhune DB. Hypnotic suggestibility in dissociative and related disorders: A meta-analysis. Neurosci Biobehav Rev in press; 139: 104751. 2. Dalenberg CJ, Brand BL, Gleaves DH, et al. Evaluation of the evidence for the trauma and fantasy models of dissociation. Psychol Bull 2012; 138(3): 550-88. 3. Lynn SJ, Maxwell R, Merckelbach H, Lilienfeld SO, Kloet DVH, Miskovic V. Dissociation and its disorders: Competing models, future directions, and a way forward. Clin Psychol Rev 2019; 73: 101755. 4. World Health Organization. International classification of diseases for mortality and morbidity statistics (11th Revision): https://icd.who.int/browse11/l-m/en; 2018. 5. Millman LSM, Hunter ECM, David AS, Orgs G, Terhune DB. Assessing responsiveness to direct verbal suggestions in depersonalization-derealization disorder. Psychiatry Res in press. 6. Brown RJ. Different types of "dissociation" have different psychological mechanisms. J Trauma Dissociation 2006; 7(4): 7-28. 7. Poole NA, Wuerz A, Agrawal N. Abreaction for conversion disorder: Systematic review with meta-analysis. Br J Psychiatry 2010; 197(2): 91-5. 8. Butler LD, Duran RE, Jasiukaitis P, Koopman C, Spiegel D. Hypnotizability and traumatic experience: A diathesis-stress model of dissociative symptomatology. Am J Psychiatry 1996; 153(7 Suppl): 42-63. Suggestibility and psychopathology 5 9. Soffer-Dudek S, Somer E. Maladaptive daydreaming is a dissociative disorder: Supporting evidence and theory. In: Dorahy MJ, Gold SN, O’Neil JA, eds. Dissociation and the dissociative disorders: Past, present, future (2nd ed) 2022: 547-59.  

Revisiting the role of verbal suggestion in dissociative psychopathology

https://kclpure.kcl.ac.uk/portal/files/224360857/sugg_psy_100723.pdf

Revisiting the role of verbal suggestion in dissociative psychopathology

Abstract

Similar works

Full text

Available Versions

King's Research Portal