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Dissociation in Psychiatric Disorders: A Meta-Analysis
of Studies Using the Dissociative Experiences Scale
Lisa Lyssenko, Dipl.-Psych., Christian Schmahl, Dr.med., Laura Bockhacker, Dr.med., Ruben Vonderlin, M.Sc.,
Martin Bohus, Dr.med., Nikolaus Kleindienst, Dr.rer.hum.biol.

Objective: Dissociation is a complex, ubiquitous construct in
psychopathology. Symptoms of dissociation are present in a
variety of mental disorders and have been connected to
higher burden of illness and poorer treatment response, and
not only in disorders with high levels of dissociation. This
meta-analysis offers a systematic and evidence-based study
of the prevalence and distribution of dissociation, as assessed
by the Dissociative Experiences Scale, within different cat-
egories of mental disorders, and it updates an earlier meta-
analysis.

Method: More than 1,900 original publications were
screened, and 216 were included in the meta-analysis,
comprising 15,219 individuals in 19 diagnostic cate-
gories.

Results: The largest mean dissociation scores were found in
dissociative disorders (mean scores .35), followed by post-
traumatic stress disorder, borderline personality disorder, and
conversion disorder (mean scores .25). Somatic symptom
disorder, substance-related and addictive disorders, feeding
and eating disorders, schizophrenia, anxiety disorder, OCD,
and most affective disorders also showed mean dissociation
scores .15. Bipolar disorders yielded the lowest dissociation
scores (mean score, 14.8).

Conclusions: The findings underline the importance of
careful psychopathological assessment of dissociative symp-
toms in the entire range of mental disorders.

Am J Psychiatry 2018; 175:37–46; doi: 10.1176/appi.ajp.2017.17010025

Dissociation is a ubiquitous construct in modern psychopa-
thology. DSM-5 defines dissociation as “disruption of and/or
discontinuity in the normal integration of consciousness,
memory, identity, emotion, perception, body representation,
motor control, and behavior” (1). The corresponding phe-
nomena cover a range from relatively common experiences,
suchasbeingcompletelyabsorbedbyabookormovie,tosevere
states, such as not recognizing oneself in the mirror (2). More
common experiences have often been linked to mild forms of
absorption, that is, focusing on one aspect of experiences and
blocking others (3). More severe dissociative experiences are
reflected in the DSM-5 subtypes of dissociative disorders:
dissociative amnesia describes the inability to recall autobio-
graphical information; depersonalization/derealization disor-
derscompriseexperiencesoffeelingdisconnectedorestranged
from one’s body, thoughts,oremotionsand/or perceiving one’s
surroundings as foggy, surreal, or visually distorted (1).

Beyond the disorders primarily characterized by disso-
ciation, “transient, stress-related severe dissociative symp-
toms” serve as a criterion for borderline personality disorder
(1),andadissociativesubtypeofposttraumaticstressdisorder
(PTSD) was introduced in DSM-5 (4). Less noted but equally
important research has shown that dissociative features also

seem to play a role in the pathology of many other mental
disorders, such as schizophrenia (5), eating disorders (6),
panic disorders (7), affective disorders (8, 9), and obsessive-
compulsive disorder (OCD) (10).

Dissociative symptoms in mental disorders are of high
clinical relevance. They have been linked to maladaptive
functioning and symptom severity in some disorders, such as
executive functioning in borderline personality disorder (11),
neuropsychological performance in depression (9), number
of binge episodes in eating disorders (6), alexithymia in panic
disorders (12), and anxiety and depression in OCD (13). Apart
from a higher burden of illness, patients may also benefit less
from psychotherapeutic interventions. Several studies have
indicated that dissociative symptoms can serve as a predictor
for nonresponse in psychotherapeutic treatments of PTSD
(14–16), OCD (17–19), and panic disorders (20).

Transdiagnostically, the experience of dissociative symp-
toms has been linked to acute or chronic stress (21). Neuro-
biological findings suggest that dissociative phenomena are
likelytodisruptinformationprocessing,learning,andmemory
on various levels (22). Dissociation has been further linked
to physiological processes such as sleep (23) and fluid intake
(24), as well as to personality variables, such as fantasy

See related features: Editorial by Dr. Spiegel (p. 4) and Clinical Guidance (Table of Contents)

Am J Psychiatry 175:1, January 2018 ajp.psychiatryonline.org 37

ARTICLES

proneness and suggestibility (25). On a cognitive-emotional
level, dissociation may be a learned automatic response to re-
duce or avoid aversive emotional states (26, 27). As a secondary
process, the experience of dissociation can induce stress itself
because it not only disrupts neurocognitive functioning, but can
also be perceivedas losing control (28). Recurrent dissociation
may therefore reduce the individual’s confidence in reality
monitoring ability, perceivedcontrol,and sense of self (29, 30),
which in turn may result in a higher burden of disease.

The transdiagnostic evaluation of those mechanisms is im-
peded by the fact that neurobiological studies have been mostly
conducted in populations of patients who had experienced
various traumas, often chronically and/or early in life (e.g., 31).
Althoughthestatisticalassociationwasfoundtoberathersmallin
some studies (27), several studies have pointed to a strong asso-
ciation between trauma and dissociation (32–36). Thus, the ex-
perience of trauma does not seem to be a conditio sine qua non
for pathological dissociation. Studies covering a broader range of
mental disorders could shed light on common mechanisms and
enhance the development of transdiagnostic treatment modules
to deal with dissociative symptoms. The meta-analysis we present
hereaimstostimulatethislineofresearchbyprovidinganoverview
oftheoccurrenceofdissociativesymptomsacrossmentaldisorders.

By far, the most commonly
used psychometric instrument
for the assessment of dissocia-
tive experience is the Dissocia-
tive Experiences Scale (DES)
(2). The DES is a self-rating
instrument comprising 28 items
that build on the assumption
of a “dissociative continuum”
ranging from mild normative
to severe pathological disso-
ciation. Subjects are asked
to make slashes on 100-mm
lines to indicate where they fall
onacontinuum for questions
on experiences of amnesia,
absorption, depersonalization,
andderealization—forexample,
“Some people have the experi-
ence of driving a car and sud-
denly realizing that they don’t
remember what has happened
during all or part of the trip.
Mark the line to show what
percentageoftimethishappens
toyou”(2,p.733).Asthescoring
procedure of the continuous
scale was time consuming, a
revised version of the scale,
the Dissociative Experiences
Scale–II (DES-II) (37) uses an
11-point Likert scale ranging
from 0 to 100.

Studies on the psychometric properties of the scale have
shown high validity and reliability for both versions, both in
clinicalandnonclinicalpopulations(38–42).Thefirst,andsofar
the only, comprehensive meta-analysis on the DES, by van
IjzendoornandSchüngel(43),conductedin1996,showsamean
Cronbach’s alpha of 0.93 in 16 studies, a high predictive validity
concerning dissociative disorders and PTSD, as well as a high
convergent validity with alternative measures of dissociation
(mean Cohen’s d=1.82; N=5,916). While initial studies (e.g., 44)
found a three-factor structure with the factors amnesia, ab-
sorption, and depersonalization/derealization, the factorial
structure of the DES remains controversial (41, 42, 45, 46).

Considering the high number of original publications on
theDES(N.2,000),fewmeta-analyseshavebeenconducted.
One meta-analysis on schizophrenia showed a large effect
size comparing dissociation scores of patients (N=293) and
healthy subjects (N=474) (g=20.86, 95% CI=21.13, 20.60),
with trauma history being a potential mediator (5). Scalabrini
et al. (47) compared the dissociation scores in borderline
personality disorder with those in other mental disordersand
found significantly elevated dissociative symptoms in patients
withborderlinepersonalitydisordercomparedwithpatientswith
all other disorders (N=2,035; d=0.54, p,0.01) but lower levels of

FIGURE 1. PRISMA Flow Diagram for a Meta-Analysis of Dissociation in Psychiatric Disorders
Id

e
n

ti
fi

c
a

ti
o

n
E

li
g

ib
il

it
y

S
c

re
e

n
in

g
In

c
lu

d
e

d

Records identifi ed through
database searching (PubMed,

PsycINFO, Web of Science,
Academic Search Premier)

(N=3,492)

Excluded duplicates
(N=1,585)

Full-text articles assessed for
eligibility (N=1,247)

Articles eligible for review
(N=221)

Excluded because <4 articles
per diagnosis (N=5)

Records screened
(N=1,907)

Records excluded at title or
abstract screening (N=660)

Studies included
(N=216)

Full-text articles excluded (N=1,026)
– Healthy sample (N=296)

– No distinguishable diagnostic groups (N=149)

– No analysable DES score (N=142)

– Unpublished dissertations (N=109)

– No DES score (N=103)

– No DSM diagnosis (N=108)

– Other DES versions (N=27)

– Conference papers (N=23)

– Other reasons (N=69)

38 ajp.psychiatryonline.org Am J Psychiatry 175:1, January 2018

DISSOCIATION IN PSYCHIATRIC DISORDERS

dissociation than in patients
withPTSD(d=20.50,p,0.01)
and dissociative disorders (d=
20.35, p,0.05). As noted,
theonlycomprehensivemeta-
analysis, by van Ijzendoorn
and Schüngel (43), was pub-
lished about 20 years ago and
included 85 individual studies
with about 6,000 patients.
As expected, the highest scores
for dissociation were found for
dissociative disorders (mean=
35.3), followed by PTSD
(mean=32.6), affective disor-
ders (mean=19.4), schizophre-
nia (mean=19.1), personality
disorders (mean=16.6), eating
disorders (mean=14.5), and
anxiety disorders (mean=10.2).
Comparison scores were cal-
culated for healthy samples
(mean=11.57) and students
(mean=14.27). The authors
conclude that “against the background of potential comor-
bidity and undiscovered dissociation, the means for normals
and nondissociative patients were remarkably similar” (43,
p. 372).

Since the meta-analysis by van Ijzendoorn and Schüngel
(43), dissociation has been studied in a range of mental
disorders that had not been included, such as OCD (10) and
substance abuse (48). Other research has shown that dis-
sociation plays a role in diseases like panic disorders (7, 31),
which showed surprisingly low mean dissociation scores
in that first analysis. The goal of our meta-analysis is thus to
provide an evidence base for the prevalence and distribution
of dissociation in adults suffering from mental disorders.

METHOD

Study Selection
We searched the following databases for primary stud-
ies through November 2016: PubMed, PsycINFO, Web
of Science, and Academic Search Premier. Our search
strategy aimed at articles using the DES or the German
version of the scale (FDS) (49, 50) in adults with mental
disorders. Although there are formal differences between
versions I and II of the DES (visual analogue scale versus
Likert-type scale, both ranging from 0 to 100), differences
in the results for the two versions have been shown to be
negligible (51). Therefore, we decided not to differentiate
between the versions of the scale. We developed the search
strategy for PsycINFO (“dissoc* exper* scale” OR “FDS”)
and adapted it for the other databases. We reviewed relevant
review articles and related systematic reviews to identify

studies that were missed in the database searches. If full text
was not retrievable from online databases or university li-
braries, we contacted the corresponding authors. There
were no language or publication date restrictions.

Two trained investigators independently screened titles
and abstracts for relevance. In the full-text screening, the
following inclusion criteria were imposed: 1) studying a
population with mental disorders diagnosed according to
ICD (52) or DSM; 2) reporting the sample size and the mean
score and standard deviation on the DES, or sufficient in-
formation to calculate them; and 3) specification of psy-
chometric properties fortranslationsofnon-English versions
of the DES. Data were extracted by two independent raters
using a standard form and systematically screened for full
agreement between raters. Every disagreement was resolved
by discussion within the review team. The protocol for this
meta-analysis is available in PROSPERO (the “International
prospective register of systematic reviews”) and can be
accessed at http://www.crd.york.ac.uk/prospero/display_
record.asp?ID=CRD42015020731.

Data Synthesis
Diagnostic group, mean and standard deviation of the dis-
sociation score, and number of participants were extracted
from the primary studies. For each diagnostic group, the
random-effects model described in DerSimonian and Laird
(53) was used to calculate a group-specific mean and the 95%
confidence interval. This approach allows for the integration
of data from intrinsically heterogeneous populations that
result, for example, from the use of different diagnostic
systems. To quantify heterogeneity of the dissociation scores

TABLE 1. Overview of the Results of a Meta-Analysis of Dissociation in Psychiatric Disordersa

Diagnostic Group k N
Mean

DES Score 95% CI I2 (%)

Dissociative identity disorder 29 1,313 48.7 46.4, 50.9 77.9
Dissociative disordersb 70 3,073 38.9 36.1, 41.6 95.3
Posttraumatic stress disorder 33 2,106 28.6 25.6, 31.5 96.9
Borderline personality disorder 27 1,705 27.9 25.3, 30.6 89.2
Conversion disorder 20 857 25.6 21.5, 29.7 93.4
Depersonalization/derealizationdisorder 16 759 25.1 22.7, 27.4 80.2
Anorexia nervosa 6 253 24.1 16.3, 31.9 92.9
Bulimia nervosa 8 353 22.0 16.9, 27.0 90.5
Gambling disorder 4 187 19.9 7.9, 31.8 98.5
Alcohol use disorder 12 1,467 19.7 16.5, 23.0 97.5
Somatic symptom disorder 4 132 18.8 16.4, 21.2 16.1
Feeding and eating disordersb 24 1,401 18.6 16.0, 21.2 91.6
Schizophrenia 17 594 17.8 15.6, 20.2 80.5
Other substance-related disorders 14 1,107 17.7 14.7, 20.7 91.9
Panic disorder 11 319 15.6 10.8, 20.4 94.9
Obsessive-compulsive disorder 14 858 15.3 13.2, 17.4 80.3
Depressive disordersb 12 833 15.3 11.2, 19.4 98.1
Anxiety disordersb 19 615 15.2 12.4, 18.0 93.1
Bipolar and related disordersb 7 208 14.8 8.8, 20.8 97.3
Total 216 15,219

a Articles that reported on more than one diagnostic group were included in every category the authors reported
dissociation scores on. Diagnostic groups are sorted in descending order of Dissociative Experiences Scale (DES) mean
score. k=number of included studies; N=number of patients included in diagnostic group; I2= heterogeneity statistic.

b DSM-5 main category.

Am J Psychiatry 175:1, January 2018 ajp.psychiatryonline.org 39

LYSSENKO ET AL.

between studies, we used I2 (54)—an index, based on chi-
square statistics and degrees of freedom, that was recom-
mended for Cochrane Reviews (55). Because only descriptive
data on dissociation scores were included in the analysis,
the risk of bias in the primary studies was assumed to be
unlikely and therefore was not assessed. Data synthesis
was conducted with R, version 3.2.4 (56), using the metafor
package (57).

RESULTS

The search in the electronic databases yielded 1,907 different
articles (Figure 1). After exclusion of 660 articles during title
or abstract screening, 1,247 articles were retrieved for full-
text screening, of which 1,026 were subsequently excluded;
reasons for exclusion are listed in Figure 1. Across all di-
agnostic groups, weincluded 216 articles with a total of 15,219
individuals.

To calculate meta-analytic statistics, the original studies
were grouped according to the DSM diagnosis described in
the articles. For some diagnoses, this procedure revealed
specific subcategories of DSM chapters (e.g., gambling dis-
orders). For some categories, only articles reporting on
broader categories or entire DSM chapters (e.g., bipolar
disorders) werefound. To avoid the confounding influence of
diagnostic specification, we included articles reporting on
subcategories in both the relevant subcategory as well as the
corresponding broader category. Articles that reported on
more than one diagnostic group were included in every
category the authors reported dissociation scores on. In cases
ofco-occurringdisorders,weincludedtheindividualsinboth
categories. We included all subcategories in which at least
four studies reported data, regardless of whether this sub-
category of disorders is still included in DSM-5. In the final

step, we excluded five studies because there were not enough
studies for each diagnosis: one study each on kleptomania
(58) and pathological Internet use (59) and three studies on
mixed personality disorders (60).

Diagnostic categories, number of individual studies, and
number of individual patients as well as statistics are listed in
Table 1. A graphical illustration of the results is presented in
Figure2.Forestplotsofeachdiagnostic categoryareincluded
in the datasupplement that accompanies theonline edition of
this article.

The highest dissociation scores were found for dissocia-
tive identity disorders, with a mean score of 48.7 (95%
CI=46.4, 50.9), based on 29 publications with 1,313 patients
(Figure 3; the full reference list of included studies can be
found in the online data supplement).

Scores for posttraumatic stress disorder were the second
highest, with a mean score of 28.6 (95% CI=25.6, 31.5), based
on 33 publications with 2,106 patients (Figure 4).

Scores for borderline personality disorder were third
largest, with a mean score of 27.9 (95% CI=25.3, 30.6), based
on 27 publications and 1,705 individual patients (Figure 5).
Scores for other mental disorders were distributed among (in
descending order) conversion disorder (mean=25.6), somatic
symptoms disorder (mean=18.8), substance-related and ad-
dictive disorders (gambling disorder, mean=19.9; alcohol
use disorder, mean=19.7; other substance-related disorders,
mean=17.7), feeding and eating disorders (mean=18.6),
schizophrenia (mean=17.8), OCD (mean=15.3), depressive
disorders (mean=15.3), anxiety disorders (mean=15.2), and
bipolar and related disorders (mean=14.8).

Only three categories yielded enough studies to analyze
dissociation subfactors: borderline personality disorder,
dissociative disorders, and schizophrenia. Patients suffering
from borderline personality disorder and schizophrenia

FIGURE 2. Mean Dissociative Experiences Scale Score for Each Diagnostic Group in a Meta-Analysis of Dissociation in
Psychiatric Disordersa

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a Error bars indicate 95% confidence interval.

40 ajp.psychiatryonline.org Am J Psychiatry 175:1, January 2018

DISSOCIATION IN PSYCHIATRIC DISORDERS

had the highest scores for absorption, and patients with dis-
sociativedisordershadthehighestscoresfordepersonalization/
derealization (see Table S1 in the online data supplement for
details).

Heterogeneity, as assessed by I2, was .70% in all anal-
yses, except for somatic symptom disorders (I2=16.1%); the
highest heterogeneity was observed in gambling disorders
(I2=98.5%) (see Table 1).

DISCUSSION

This is the second meta-analysis of dissociation scores in a
broad variety of psychiatric disorders. While the first meta-
analysis was published more than 20 years ago (43) and
comprised85individualstudies,ourmeta-analysis reportson
216 individual studies with more than 15,000 individuals with
mental disorders. The largest dissociation scores were found
for dissociative disorders, followed by PTSD, borderline
personality disorder, and conversion disorder, and the lower
range of scores included substance-related and addictive
disorders, feeding and eating disorders, schizophrenia,
anxiety disorder, OCD, and affective disorders.

Our data confirm some but not all of the results reported in
the earlier meta-analysis. Confirming results were found
regarding dissociative disorders showing the highest overall

dissociation scores. In their analysis, van Ijzendoorn and
Schüngel (43) reported mean dissociation scores of 45.6
for multiple personality disorder (now called dissociative
identity disorder), 41.1 for unspecified dissociative disorders,
and 35.3 for the category of dissociative disorder not other-
wise specified. In our study we differentiated between dis-
sociative identity disorder and depersonalization/derealization
disorder, as listed in DSM-5 (1). Although the existence of
dissociativeidentitydisorderhasbeendiscussedcontroversially
(e.g., 61), our result of a mean dissociation score of 48.7 in a
total of 1,313 individuals with this diagnosis indicates very
high levels of dissociative experience in this diagnostic group.
Interestingly, depersonalization/derealization disorder yielded
numerically lower DES scores than PTSD and border-
line personality disorder. This may be due to the fact that
depersonalization/derealization disorder does not cover the
entire spectrum of dissociative symptoms, therefore leading
to lower overall dissociation scores.

Dissociation scores in PTSD and schizophrenia in our
analysis were close to those reported by van Ijzendoorn and
Schüngel (43), although their study included only one study
onschizophrenia(comparedwith17here)andfourstudieson
PTSD (compared with 33 here). Scores in PTSD were the
second highest in our analysis, reflecting the importance of
dissociation in relation to PTSD (62), for which a dissociative

FIGURE 3. Forest Plot of Dissociative Experiences Scale Scores in Dissociative Identity Disordera

0.00 20.00 40.00 60.00 80.00

Mean

First Author and Year

Berger 1994 (13)

Boon 1993 (18)

Carlson 1993 (28)

Choe 1995 (34)

Dell 2002 (40)

Dorahy 2005 (45)

Draijer 1993 (46)

Ellason 2003 (49)

Frischholz 1990 (70)

Gleaves 1995a (75)

Latz 1995 (99)

Lauer 1993 (100)

Martínez−Taboas 1995 (109)

Nijenhuis 1997 (127)

Nijenhuis 1999 (128)

Pokrajac 1994 (140)

Putnam 1996 (148)

Rodewald 2006 (153)

Ross 1988 (158)

Ross 1989 (157)

Ross 1995 (156)

Sar 1996 (166)

Sar 2007b (165)

Scroppo 1998 (173)

Shearer 1994 (177)

Tutkun 1995 (202)

Wassink 1996 (207)

Welburn 2003 (209)

Yargic 1998 (211)

Random-effects model

DES Score (95% CI)

26.80 (13.80, 39.80)

49.40 (45.49, 53.31)

42.80 (40.31, 45.29)

59.54 (54.09, 64.99)

46.15 (39.01, 53.29)

55.10 (44.29, 65.91)

56.80 (50.93, 62.67)

47.80 (41.87, 53.73)

55.00 (48.45, 61.55)

59.85 (51.83, 67.87)

59.50 (51.12, 67.88)

46.60 (36.59, 56.61)

60.30 (53.64, 66.96)

38.60 (32.27, 44.93)

54.20 (48.02, 60.38)

54.21 (44.00, 64.42)

44.60 (42.04, 47.16)

45.37 (41.73, 49.01)

37.20 (27.07, 47.33)

38.30 (29.14, 47.46)

44.60 (42.33, 46.87)

49.10 (43.40, 54.80)

51.10 (44.39, 57.81)

45.97 (38.16, 53.78)

48.50 (34.23, 62.77)

47.20 (39.29, 55.11)

48.86 (41.92, 55.80)

44.52 (36.23, 52.81)

46.10 (38.26, 53.94)

48.66 (46.38, 50.93)

a Reference numbers refer to the list of analyzed studies included in the online data supplement. DES=Dissociative Experiences Scale.

Am J Psychiatry 175:1, January 2018 ajp.psychiatryonline.org 41

LYSSENKO ET AL.

subtype was introduced in DSM-5. Although dissociative
symptoms are less pronounced in schizophrenia (mean
score, 17.8), they have been studied intensively in this disorder
because of similarities in the description of dissociative phe-
nomena and psychotic symptoms (63). Empirical studies have
yielded varying correlations between schizophrenia and
different aspects of dissociation, with depersonalization/
derealization showing the strongest relation (5). Several
authors have emphasized the relevance of depersonalization
as a mediator between childhood trauma and hallucinatory
experiences, thus acting as a risk factor for schizophrenia (e.g.,
64). It is hypothesized that depersonalization may facilitate a
person’s attribution of their own thoughts to external sources
(65), and a trauma-dissociation subgroup within schizophrenia
has been proposed (66).

Our data differ from the earlier meta-analysis (43) with
respect to eating disorders, anxiety disorders, and affective
disorders. While eating disorders and anxiety disorders show
considerably higher mean dissociation scores in our analysis
than in the earlier one (18.6 compared with 14.5 for eating
disorders; 15.2 compared with 10.2 for anxiety disorders), we

found lower scores for affective disorders (15.3 for depressive
disorders and 14.8 for bipolar disorders compared with 19.4
for affective disorders in the earlier analysis). Recent re-
search points to differential relations between dissociation
and symptoms of these disorders. In anorexia nervosa, where
thehighestmeandissociationscoreswerefound(meanscore,
24.1), symptoms of depersonalization in the form of body
schema distortions have been investigated (67). In bulimia
nervosa, dissociative qualities of amnesia, timelessness, and
involuntariness seem to play a role in bingeing behavior
and severity (6, 68). In anxiety disorders, experiences of
depersonalization/derealization have often been described
in relationship with panic attacks, although the sequence
of incidence is not clear: dissociation might trigger panic
attacks—for example, via the fear of losing control—but
concomitantsymptomsofpanicattacks,suchashyperarousal
or hyperarousal, might also produce dissociation (29). In
depressive disorders, the research on mechanisms of disso-
ciation is impeded by a strong overlap between depressive
symptoms such as emotional numbing, feelings of de-
tachment, and restricted emotional responsiveness (69), as

FIGURE 4. Forest Plot of Dissociative Experiences Scale Scores in Posttraumatic Stress Disordera

0.00 20.00 40.00 60.00 80.00

Mean

First Author and Year

Abramowitz 2010 (1)

Akyüz 2007 (4)

Amdur 1996 (6)

Aydin 2012 (8)

Bokhan 2012 (16)

Bolu 2014 (17)

Branscomb 1991 (22)

Bremner 1992 (23)

Callegari 2007 (26)

Chard 2005 (33)

Crowson 1998 (37)

Dasse 2015 (39)

El-Hage 2003 (48)

Espirito-Santo 2008 (51)

Evren 2011 (60)

Favaro 2000 (64)

Favaro 2006 (65)

Frewen 2014 (69)

Frueh 1994 (71)

Geraerts 2007 (73)

Karatzias 2010 (92)

Landre 2012 (96)

Matlack 2010 (110)

Mickleborough 2011 (118)

Najavits 2012 (124)

Nardo 2013 (125)

Nejad 2007 (126)

Öezdemir 2015 (132)

Prasko 2016a (141)

Putnam 1996 (148)

Tapia 2007 (199)

Tapia 2012 (198)

Zucker 2006 (214)

Random-effects model

DES Score (95% CI)

47.30 (40.80, 53.80)

18.70 (14.37, 23.03)

30.43 (27.33, 33.53)

27.93 (17.71, 38.15)

19.20 (18.67, 19.73)

50.24 (43.80, 56.68)

41.11 (36.07, 46.15)

27.00 (22.15, 31.85)

28.75 (23.36, 34.14)

19.48 (15.54, 23.42)

54.16 (48.94, 59.38)

29.80 (23.57, 36.03)

23.03 (19.41, 26.65)

35.00 (31.26, 38.74)

26.34 (22.30, 30.38)

19.10 (11.18, 27.02)

20.00 (13.42, 26.58)

33.17 (30.27, 36.07)

40.10 (33.45, 46.75)

34.50 (30.62, 38.38)

29.80 (26.33, 33.27)

26.80 (20.67, 32.93)

23.87 (21.16, 26.58)

9.30 (5.50, 13.10)

19.44 (15.14, 23.74)

14.60 (10.20, 19.00)

26.01 (23.89, 28.13)

44.40 (40.14, 48.66)

21.56 (15.45, 27.67)

31.50 (28.17, 34.83)

36.87 (28.81, 44.93)

22.80 (14.55, 31.05)

15.10 (13.86, 16.34)

28.57 (25.61, 31.54)

a Reference numbers refer to the list of analyzed studies included in the online data supplement. DES=Dissociative Experiences Scale.

42 ajp.psychiatryonline.org Am J Psychiatry 175:1, January 2018

DISSOCIATION IN PSYCHIATRIC DISORDERS

well as by shared covariates, such as sleep quality and dis-
tortions in autobiographic memory (23, 70).

Our analysis is the first to report systematically retrieved
mean dissociation scores for borderline personality disorder,
somatic symptom disorder, conversion disorder, substance-
related and addictive disorders, and OCD. Borderline per-
sonality disorder showed dissociation scores similar to those
of PTSD in 27 studies (mean score, 27.9). Furthermore, our
study confirmed the significance of dissociative symptoms in
borderline personality disorder, which has been acknowl-
edged by adding dissociative experiences as part of one of the
nine criteria for borderline personality disorder in DSM-IV
(71). Although classified as a personality disorder, borderline
personality disorder is closely associated with traumatic
stress. Rates of adverse childhood experiences have been
consistently demonstrated to be higher than 50% (72). In-
dependent of trauma experience and comorbid diagnoses,
almost all patients with borderline personality disorder re-
port identity confusion, unexplained mood changes, and
depersonalization (73).

“Somatic symptom and related disorders” is a new cate-
gory in DSM-5 (1) and comprises a broad spectrum of
disorders, including somatic symptom disorder (formerly
known as somatoform disorders), illness anxiety disorders,
conversion disorder (functional neurological symptom dis-
order), and factitious disorder. Notably, conversion disorder

is part of the dissociative spectrum in ICD-10 (52), and
dissociation scores were in a range similar to those of other
dissociative and trauma-related disorders in our meta-
analysis.

The high mean dissociation scores for addictive disorders—
19.9 for gambling disorder, 19.7 for alcohol use disorder, and
17.7 for other substance-related disorders—may be partly
related to comorbidities with PTSD, borderline personal-
ity disorder, and dissociative disorders (74–76). General
findings regarding the link between dissociation and sub-
stance abuse have been inconsistent but suggest lower
scores in samples without comorbid disorders (77–79). The
mean dissociation score of 15.3 for OCD falls within the
lower range of dissociative symptoms. Nevertheless, dis-
sociation has gained increasing attention in this area of
research. On a symptomatic level, dissociative amnesia has
been related to checking compulsion (80). This effect does
not seem to be linked to poorer memory or reality moni-
toring performance but rather to a reduced confidence in
these abilities (81).

Recent population-based studies show mean dissociation
scores in the general population of 8 in a Finnish sample
(N=2,001)(82)and10inaPortuguesesample(N=224)(83).In
their meta-analysis, van Ijzendoorn and Schüngel (43) report
a mean score of 11.6 for healthy subjects. Those numbers
appear to be considerably lower than all mean dissociation

FIGURE 5. Forest Plot of Dissociative Experiences Scale Scores in Borderline Personality Disordera

0.00 20.00 40.00 60.00 80.00

Mean

First Author and Year

Barnow 2011 (10)

Berger 1994 (13)

Brodsky 1995 (24)

Frewen 2014 (69)

Grambal 2016 (77)

Kanter 2001 (91)

Kleindienst 2011 (93)

Korzekwa 2009 (94)

Krause-Utz 2014 (95)

Lauer 1993 (100)

Löffler-Stastka 2009 (106)

Macchi 1998 (107)

Mazzotti 2016 (111)

Pokrajac 1994 (140)

Putnam 1996 (148)

Ross 2007 (155)

Russ 1996 (160)

Sar 2003 (163)

Semiz 2005 (176)

Semiz 2008 (175)

Shearer 1994 (177)

Simeon 2003c (187)

Turner 1998 (201)

Vuchelen 1996 (203)

Zanarini 2000 (213)

Zweig-Frank 1994a (215)

Zweig-Frank 1994b (216)

Random-effects model

DES Score (95% CI)

21.04 (16.49, 25.59)

24.40 (13.37, 35.43)

19.58 (15.44, 23.72)

30.22 (28.29, 32.15)

19.06 (15.95, 22.17)

40.17 (32.45, 47.89)

25.80 (21.46, 30.14)

26.90 (18.39, 35.41)

32.25 (25.33, 39.17)

17.70 (9.65, 25.75)

19.10 (14.48, 23.72)

30.59 (25.15, 36.03)

29.60 (26.61, 32.59)

39.31 (32.11, 46.51)

21.60 (14.85, 28.35)

22.70 (19.06, 26.34)

32.87 (25.87, 39.87)

44.41 (35.56, 53.26)

41.96 (35.59, 48.33)

41.33 (37.77, 44.89)

25.02 (19.75, 30.29)

25.80 (18.63, 32.97)

30.85 (25.05, 36.65)

30.65 (24.61, 36.69)

21.80 (19.66, 23.94)

22.36 (18.07, 26.65)

24.80 (21.43, 28.17)

27.95 (25.32, 30.57)

a Reference numbers refer to the list of analyzed studies included in the online data supplement. DES=Dissociative Experiences Scale.

Am J Psychiatry 175:1, January 2018 ajp.psychiatryonline.org 43

LYSSENKO ET AL.

scores calculated for mental disorders in our analysis. Van
Ijzendoorn and Schüngel’s conclusion that “the means for
normals and nondissociative patients were remarkably
similar” (43, p. 372) does not seem to be supported by our
results. The variety of mental disorders ranging between
15 and 25 in dissociation scores clearly speaks for dissociative
experience as an unspecific and ubiquitous psychopatho-
logical phenomenon. From a clinical perspective, this finding
underlines the importance of careful evaluation of disso-
ciativesymptoms,andnotonlyinpatientswithdissociativeor
trauma-related disorders.

Our study has several limitations. Although the overall
number of included studies was quite large, the number of
studies and subjects per diagnostic category varied sub-
stantially. We only included categories with at least four
individual studies, but categories varied between four and
66 studies andbetween187and 2,860 subjects. Aswehad no a
priori hypothesis to explain heterogeneity, we did not carry
out subgroup analysis. Heterogeneity may be rooted in dif-
ferent factors, including heterogeneity of the diagnostic
entity, diagnostic shifts over time, and differences between
individual studies, for example, with respect to diagnostic
procedures, gender distribution, and the countries of origin.
Most likely, comorbidity and trauma experiences also in-
fluence dissociation scores and should be systematically
considered in future studies. Finally, we note that the DES is
a self-rating instrument and that certain dissociative fea-
tures may be over- or underrepresented in comparison to
observer-based ratings (84).

In summary, our meta-analysis confirms the prevalence of
dissociative symptoms not only in dissociative disorders,
posttraumatic stress disorder, and borderline personality
disorder, but in nearly all mental disorders. Research on the
distinct diagnostic categories suggests a variety of mecha-
nisms linking dissociative experiences to a higher burden of
illness and detrimental effects on treatment. An evaluation
of dissociation should therefore be part of every careful
psychopathological assessment, and future studies should
engage a transdiagnostic perspective to enhance the devel-
opment of treatment modules to deal with dissociative
symptoms.

AUTHOR AND ARTICLE INFORMATION

From the Institute for Psychiatric and Psychosomatic Psychotherapy,
Central Institute of Mental Health, Mannheim, Germany; the Depart-
ment of Psychosomatic Medicine and Psychotherapy, Medical Faculty
Mannheim, Heidelberg University, Mannheim, Germany; the Depart-
ment of Psychiatry, Schulich School of Medicine and Dentistry, Western
University, London, Ontario; and the Department of Health, Antwerp
University, Antwerp, Belgium.

The first two authors contributed equally.

Address correspondence to Ms. Lyssenko ([email protected]).

Dr. Schmahl has received advisory panel payments from Boehringer
Ingelheim. The other authors report no financial relationships with
commercial interests.

Received Jan. 6, 2017; revisions received April 22, June 1, and June 19,
2017; accepted June 26, 2017; published online September 26, 2017.

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