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PurposeAssessment of psychotherapeutic competence is increasingly regarded as important in the delivery of psychological services and training programmes. This article reviews tools designed to assess clinical competence in psychodynamic, interpersonal, and relational models of therapy.MethodsPsycINFO, CINAHL, and Web of Science online databases were reviewed using terms relating to competence, psychotherapy, and measurement. Titles and abstracts of all articles were screened, and full texts of remaining articles were read. Reference lists of included articles were also screened. Papers that described a measure of psychotherapeutic competence in a psychodynamic, interpersonal, or relational model, and reported at least one assessment of the reliability and/or validity of the measure, were included. The quality of the studies was evaluated, and the quality of individual measures was summarized.ResultsFourteen studies met the inclusion criteria, examining 13 competence measures for 12 specific models of therapy. Competence measures were not found for several NICE‐recommended models of therapy. Some measures demonstrated strengths in certain areas of reliability and validity; however, there were a number of quality issues in development and psychometric properties that suggest none of the measures are currently proven for widespread use.ConclusionsFurther research is required to refine currently existing measures and develop new measures for key NICE‐recommended models of therapy.Practitioner pointsAssessment and improvement of therapist competence is key to provision of high‐quality psychotherapeutic interventions.This review shows there are few measures of competence in relational therapy models and several NICE‐recommended models do not have corresponding competence measures.Measures that do exist are mixed in terms of their validity and reliability and should therefore be used with caution.

This paper describes a condensed version of psychodynamic interpersonal therapy (PIT), Psychodynamic Interpersonal-Empathy (PI-E), which consists of the first level of competencies of the PIT model. The intention is to use basic psychodynamic principles and skills to enhance delivery of manualised, cognitive therapy based treatments. The intervention is designed to improve two common factors of therapy: the bond between client and therapist, and the ability of the therapist to create positive expectations through an explanation and understanding of the person’s problems. Both of these so-called common factors are consistently associated with clinical outcomes. Training has been developed specifically for low-intensity therapists who are employed in the Improving Access to Psychological Treatment programme. Training focuses upon 5 basic components of PI: negotiation; picking up cues;using statements rather than questions; focusing on feelings and understanding hypotheses. When used skilfully together, these simple components, offer a powerful way of empathizing with and deepening the collaborative work with the client. They all help the therapist to focus upon how the client is feeling ‘here and now’ in the session. Training in the model has the potential to improve outcomes and reduce drop-out rates by enabling therapists to manage problem scenarios in an empathic way.

We developed a brief (5.5 min), continuous voice-hearing task (VHT) to address the limitations of existing paradigms used to study auditory verbal hallucinations in the laboratory. Correlational analysis of VHT data obtained from ordinary participants indicated that false alarm responses on the task were reliable and had convergent and divergent validity. Advantages of the VHT over other similar tasks include its sound psychometric properties, brevity, flexibility, control over confounding factors, suitability for multi-task study, and potential for broader application.

Using the Internet to obtain health information (“online health research”, OHR) is commonplace. This paper provides a systematic narrative review of evidence concerning the relationship between OHR and health anxiety. We conclude that health anxiety is associated with more frequent self-reported OHR, heightened distress after OHR, and increased doctor visits post-OHR. Evidence suggests that OHR often has a reassurance seeking function and can relieve anxiety, but that it can also cause alarm and become a distressing, compulsive behaviour. We present a novel model that integrates these perspectives and existing research within a single explanatory framework that distinguishes between problematic OHR and compulsive OHR and describes the role of positive and negative metacognitions in their respective development.

Delusional disorder (DD) is still considered a diagnosis of exclusion for a difficult-to-treat condition characterised by the presence of delusional beliefs in the absence of other psychiatric symptoms. Attempts to contextualise psychological processes recognised since the earliest observations of this disorder have had very limited impact on improving some fixed beliefs. In the Cambridge Early Intervention in Psychosis Service we have observed a particular phenomenon, often categorised as a delusional idea in the context of DD, which manifests through highly repetitive belief expression that fails to respond to pharmacological and psychological treatments. Key aspects of this phenomenon are similar to those observed in dissociative (functional neurological) presentations. Drawing on the Integrative Cognitive Model of functional neurological disorders, we developed a successful psychological intervention that places less emphasis on challenging delusional content and focuses more on dismantling dissociation and underlying affective factors associated with the activation of the fixed belief. Our initial findings reinforce the need to continue developing a multi-level phenomenological approach to define a variety of symptoms traditionally grouped under the concept of “delusion.”

The current study aimed to explore the phenomenon of disease-related ‘query escalation’ in high/low health anxious Internet users ( N = 40). During a 15-minute health-related Internet search, participants rated their anxiety and the perceived seriousness of information on each page. Post-search interviews determined the reasons for, and effects of, escalating queries to consider serious diseases. Both groups were found to be significantly more anxious after escalating queries. The high group was significantly more likely to escalate queries. Evaluating personal relevance of material was the main reason for escalations and moderated anxiety post-escalation. We conclude that searching for online disease information can increase anxiety, particularly for people worried about their health.

Psychogenic Nonepileptic Seizures (PNES) superficially resemble epileptic seizures but are thoughtto have a psychological rather than epileptic basis. Patients with PNES vary widely in terms ofbackground, personality profiles, comorbidities, response to treatment and outcomes. Previousaccounts interpreting these seizures as the activation of dissociated material, a physical manifestationof emotional distress, hard-wired reflex responses, or learned behaviours cannot explain key featuresof the phenomenon. Drawing on a brief review of the literature on etiology, correlates andphenomenology of PNES, this paper integrates existing approaches and data within a novelexplanatory framework that applies to all PNES patients with subjectively involuntary seizures.Following the Integrative Cognitive Model of medically unexplained symptoms, we suggest that thecentral feature of all PNES is the automatic activation of a mental representation of seizures (the“seizure scaffold”) in the context of a high level inhibitory processing dysfunction. This often arisesin response to elevated autonomic arousal, and may disrupt the individual‟s awareness of distressingmaterial, but can become divorced from abnormal autonomic and emotional activity. This modelaccounts both for existing findings and the heterogeneity of patients with PNES, whilst leading to anumber of novel hypotheses against which it can be evaluated.

Psychogenic non-epileptic seizures (PNES) are common in neurological settings and often associated with considerable distress and disability. The psychological mechanisms underlying PNES are poorly understood and there is a lack of well-established, evidence-based treatments. This paper advances our understanding of PNES by providing a comprehensive systematic review of the evidence pertaining to the main theoretical models of this phenomenon. Methodological quality appraisal and effect size calculation were conducted on one hundred forty empirical studies on the following aspects of PNES: life adversity, dissociation, anxiety, suggestibility, attentional dysfunction, family/relationship problems, insecure attachment, defence mechanisms, somatization/conversion, coping, emotion regulation, alexithymia, emotional processing, symptom modelling, learning and expectancy. Although most of the studies were only of low to moderate quality, some findings are sufficiently consistent to warrant tentative conclusions: (i) physical symptom reporting is elevated in patients with PNES; (ii) trait dissociation and exposure to traumatic events are common but not inevitable correlates of PNES; (iii) there is a mismatch between subjective reports of anxiety and physical arousal during PNES; and (iv) inconsistent findings in this area are likely to be attributable to the heterogeneity of patients with PNES. Empirical, theoretical and clinical implications are discussed.

Operant conditioning has been shown to influence perceptual decision making in the auditory and visual modalities but the effects of conditioning on touch perception are unknown. If conditioning can be used to reduce the tendency to misinterpret somatic noise as signal (tactile false alarms), there may be the potential to use similar procedures in the treatment of excessive physical symptom reporting in clinical settings. We explored this possibility in 4 experiments investigating whether the false alarm (FA) rate in a somatic signal detection task (SSDT) could be altered with operant conditioning, and whether the resultant learning would transfer to other sensory decisions. In Experiments 1a and 2a, nonclinical participants were rewarded for hits and punished for misses on the SSDT, with a view to increasing their FA rate. In Experiments 1b and 2b, participants were rewarded for correct rejections and punished for FAs, with a view to decreasing their FA rate. Control participants received no treatment in Experiments 1a and 1b and underwent sham training in Experiments 2a and 2b. As predicted, operant conditioning increased (Experiments 1a, 2a) and decreased (Experiments 1b, 2b) FAs on the SSDT. Training effects did not transfer to an unrelated somatosensory task and there was only weak evidence for transfer to an auditory task in Experiment 2a. Auditory and tactile FAs correlated positively in the baseline phase. The results indicate that the tactile FA rate is trainable, but that the conditioning effect does not transfer across sensory decisions with this brief training paradigm. (PsycINFO Database Record

It is well known that the efficacy of treatment effects, including those of placebos, is heavily dependent on positive expectations regarding treatment outcomes. For example, positive expectations about pain treatments are essential for pain reduction. Such positive expectations not only depend on the properties of the treatment itself, but also on the context in which the treatment is presented. However, it is not clear how the preceding threat of pain will bias positive expectancy effects. One hypothesis is that threatening contexts trigger fearful and catastrophic thinking, reducing the pain-relieving effects of positive expectancy. In this study, we investigated the disruptive influence of threatening contexts on positive expectancy effects while 41 healthy volunteers experienced laser-induced heat pain. A threatening context was induced using pain-threatening cues that preceded the induction of positive expectancies via subsequent pain-safety cues. We also utilised electroencephalography (EEG) to investigate potential neural mechanisms underlying these effects. Lastly, we used the Fear of Pain Questionnaire to address whether the disruptive effect of negative contexts on cued pain relief was related to the degree of fear of pain. As predicted, participants responded less to pain-safety cues (i.e., experienced more pain) when these were preceded by pain-threatening cues. In this threatening context, an enhancement of the N2 component of the laser-evoked potential was detected, which was more pronounced in fearful individuals. This effect was localised to the midcingulate cortex, an area thought to integrate negative affect with pain experience to enable adaptive behaviour in aversive situations. These results suggest that threatening contexts disrupt the effect of pain relief cues via an aversive priming mechanism that enhances neural responses in the early stages of sensory processing.

Background: Mucopolysaccharidosis type IH (MPS-IH) [Hurlers Syndrome] is a developmental genetic disorder characterised by severe physical symptoms and cognitive decline. This study aimed to investigate the behavioural phenotype of MPS-IH treated by haematopoietic cell transplantation, focusing on social functioning and sleep. Parental stress was also measured.\ud \ud Methods: Participants were 22 children with MPS-IH (mean age 9 years 1 month), of whom 10 were male (45%). Parents completed the Social Responsiveness Scale (SRS), Child Behaviour Checklist (CBCL), Children’s Sleep Habit Questionnaire and Parent Stress Index, Short Form (PSI-SF).\ud \ud Results: Twenty-three per cent of children with MPS-IH scored in the severe range of the SRS, suggesting significant difficulties in social functioning. Children with MPS-IH were more than 30 times more likely to receive scores in the severe range than typically developing children. Thirty-six per cent scored in the mild-to-moderate range, suggesting milder, but marked, difficulties in social interaction. Although children with MPS-IH did not show significantly higher rates of internalising, externalising or total behaviour problems than the normative sample, they received scores that were significantly higher on social, thought and attention problems and rule-breaking behaviour, and all the competence areas of the CBCL. Parents of children with MPS-IH did not score significantly higher on parental stress than parents in a normative sample.\ud \ud Conclusions: Parents of children with MPS-IH rate their children as having problems with social functioning and various areas of competence more frequently than previously thought, with implications for clinical support.

The relationship between the conscious experience of physical symptoms and indicators of objective physiological dysfunction is highly variable and depends on characteristics of the person, the context and their interaction. This relationship often breaks down entirely in the case of "medically unexplained" or functional somatic symptoms, violating the basic assumption in medicine that physical symptoms have physiological causes. In this paper, we describe the prevailing theoretical approach to this problem and review the evidence pertaining to it. We then use the framework of predictive coding to propose a new and more comprehensive model of the body-symptom relationship that integrates existing concepts within a unifying framework that addresses many of the shortcomings of current theory. We describe the conditions under which a close correspondence between the experience of symptoms and objective physiology might be expected, and when they are likely to diverge. We conclude by exploring some theoretical and clinical implications of this new account. publisher: Elsevier articletitle: Symptoms and the body: Taking the inferential leap journaltitle: Neuroscience & Biobehavioral Reviews articlelink: http://dx.doi.org/10.1016/j.neubiorev.2017.01.015 content_type: article copyright: © 2017 Elsevier Ltd. All rights reserved. ispartof: Neuroscience and Biobehavioral Reviews vol:74 issue:Pt A pages:185-203 ispartof: location:United States status: published

Non-clinical participants viewed pictures of either neutral or stressful interpersonal scenes before completing a voice-detection task. Exposure to stress did not influence voice detection, but scores on a measure of depersonalisation were positively correlated with voices.

Psychological therapy is generally considered the treatment of choice for psychogenic nonepileptic seizures (PNES), but there is a paucity of research on patients' attitudes towards psychological referral. We conducted semistructured interviews with twelve patients with PNES awaiting psychological treatment in order to understand their perceived treatment needs. Data were analyzed inductively according to the principles of thematic analysis. The results indicated that our patients had clear ideas about their treatment needs and a desire to recover by 'returning to normality'. Many participants felt 'caught in limbo' following their PNES diagnosis, however, because of uncertainties about their condition and a lack of support from professionals. This linked with participants feeling unsure whether psychological treatment would meet their needs; there was also apprehension for some participants about the potential negative consequences of therapy. The clinical implications of these findings are discussed, and recommendations for future research are made.

Psychogenic Nonepileptic Seizures (PNES) are one of the commonest differential diagnoses of epilepsy. This paper provides a narrative review of what has been learnt in the last 25 years regarding the visible manifestations, physiological features, subjective experiences and interactional aspects of PNES. We then explore how current insights into PNES semiology and phenomenology map onto the Integrative Cognitive Model (ICM), a new account of these phenomena that unifies previous approaches within a single explanatory framework. We discuss to what extent recent psychological and neurophysiological research is consistent with the ICM and indicate how the more detailed analysis of physiological data, connectivity analyses of EEG and functional or structural MRI data may provide greater insights into the biopsychosocial underpinnings of a disabling and under-researched disorder.

We have previously found that attention to internal somatic sensations (interoceptive attention) during a heart beat perception task increases the misperception of external touch on a somatic signal detection task (SSDT), during which healthy participants erroneously report feeling near-threshold vibrations presented to their fingertip in the absence of a stimulus. However, it has been suggested that mindful interoceptive attention should result in more accurate somatic perception, due to its non-evaluative and controlled nature. To investigate this possibility, 62 participants completed the SSDT before and after a period of brief body-scan mindfulness meditation training, or a control intervention (listening to a recorded story). The meditation intervention reduced tactile misperception and increased sensitivity during the SSDT. This finding suggests that the perceptual effects of interoceptive attention depend on its particular nature, and raises the possibility that body-scan meditation could reduce the misperception of physical symptoms in individuals with medically unexplained symptoms.

Conversion disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) describes neurological symptoms, including weakness, numbness and events resembling epilepsy or syncope, which can be positively identified as not being due to recognised neurological disease. This review combines perspectives from psychiatry, psychology and neurology to identify and discuss key problems with the current diagnostic DSM-IV criteria for conversion disorder and to make the following proposals for DSM-5: (a) abandoning the label "conversion disorder" and replacing it with an alternative term that is both theoretically neutral and potentially more acceptable to patients and practitioners; (b) relegating the requirements for "association of psychological factors" and the "exclusion of feigning" to the accompanying text; (c) adding a criterion requiring clinical findings of internal inconsistency or incongruity with recognised neurological or medical disease and altering the current 'disease exclusion' criteria to one in which the symptom must not be 'better explained' by a disease if present, (d) adding a 'cognitive symptoms' subtype. We also discuss whether conversion symptoms are better classified with other somatic symptom disorders or with dissociative disorders and how we might address the potential heterogeneity of conversion symptoms in classification.

The current study aimed to obtain health anxious students’ perspectives on their reasons for using the Internet to obtain health information, and the nature and effects of such usage. Data were gathered using semi-structured interviews with 20 postgraduate and undergraduate students identified as highly health anxious, and were examined using thematic analysis. Results suggested that themes were organized by different stages of the search process. Reasons for searching included curiosity, anxiety/worry about undiagnosed symptoms, and remedy-seeking. Both positive (e.g. reassurance) and negative (e.g. uncertainty) outcomes were reported. Findings from the current study suggest that the Internet constitutes an important resource for obtaining health information by health anxious individuals, with the potential to both reduce and exacerbate health anxiety.

Dissociation has been cited as a possible psychologic mechanism underpinning functional neurologic disorders (FND) since the 19th century. Since that time, changes in psychiatric classification have created confusion about what the term dissociation actually means. The available evidence suggests that it now refers to at least two qualitatively distinct types of phenomena: detachment (an altered state of consciousness characterized by a sense of separation from the self or world) and compartmentalization (a reversible loss of voluntary control over apparently intact processes and functions), as well as their underlying mechanisms. This chapter considers some of the problems with conflating these phenomena under a single heading as well as the relationship between detachment, compartmentalization, and FND. It is argued that FNDs are fundamentally compartmentalization disorders, but that detachment is often part of the clinical picture and may contribute to the development and maintenance of functional symptoms in many cases. By this view, understanding compartmentalization requires an appreciation of the mechanisms involved in controlling and accessing mental processes and contents. Two possible mechanisms in this regard are described and the evidence for these is considered, followed by a discussion of clinical and empiric implications.

When asked to judge the presence or absence of near-threshold tactile stimuli, participants often report touch experiences when no tactile stimulation has been delivered ('false alarms'). The simultaneous presentation of a light flash during the stimulation period can increase the frequency of touch reports, both when touch is and is not present. Using fMRI, we investigated the BOLD response during both light-present and light-absent false alarms, testing predictions concerning two possible neural mechanisms underlying these illusory touch experiences: activation of a tactile representation in primary somatosensory cortex (SI) and/or activation of a tactile representation in late processing areas outside of sensory-specific cortex, such as medial prefrontal cortex (MPC). Our behavioural results showed that participants made false alarms in light-present and light-absent trials, both of which activated regions of the medial parietal and medial prefrontal cortex including precuneus, posterior cingulate and paracingulate cortex, suggesting the same underlying mechanism. However, only a non-significant increase in SI activity was measured in response to false alarm vs. correct rejection trials. We argue that our results provide evidence for the role of top-down regions in somatic misperception, consistent with findings from studies in humans and non-human primates.

The diagnostic criteria and related features of conversion disorder are under revision for DSM-5, including the requirement that psychological factors accompany the symptoms or deficits in question (Criterion B) and whether conversion disorder should be re-labeled as a dissociative, rather than a somatoform, condition. We examined the cross-cultural evidence on the prevalence, characteristics, and associated features of pseudoneurological symptoms more generally, and conversion disorder in particular, in order to inform the ongoing re-evaluation of the conversion disorder category. We also examined the relationship between these constructs and dissociative symptoms and disorders across cultural groups. Searches were conducted of the mental health literature, particularly since 1994, regarding culture, race, or ethnicity factors related to conversion disorder. Many proposed DSM-5 revisions were supported, such as the elimination of Criterion B. We also found cross-cultural variability in predominant symptoms, disorder prevalence, and relationship with cultural syndromes. Additional information that may contribute to DSM-5 includes the elevated rates across cultures of traumatic exposure and psychiatric comorbidity in conversion disorder. Cross-culturally, conversion disorder is associated strongly with both dissociative and somatoform presentations, revealing no clear basis on which to locate the disorder in DSM-5. Careful consideration should be given to the possible alternatives.

This review by three established clinicians/researchers and two 'rising stars' in the field of psychogenic nonepileptic seizures (PNES) describes recent progress in this area and highlights priorities for future research. Empirically testable models of PNES are emerging but many questions about the aetiology of PNES remain unanswered at present. Video-EEG has made it possible for doctors to make secured diagnoses of PNES in more cases. However, unacceptable diagnostic delays and misdiagnoses are still common. Non-specific EEG changes are often misinterpreted as evidence of epilepsy. A better understanding of the symptomatology of PNES may allow earlier and more accurate diagnoses using self-report questionnaires. The communication of the diagnosis and the engagement of patient in psychological treatment can be difficult. A recent pilot RCT has demonstrated the effectiveness of a psychological treatment in reducing seizures in the short term, but longer-term effectiveness is yet to be demonstrated.

I have often argued that the construct of dissociation lacks clarity and that the term dissociation is widely used without consideration for its varied meanings and implications. I agree that more ...

Research suggests that attention has a significant effect on somatic perception in both healthy people and those who suffer from somatic disturbance. The current study investigates the effects of attending to the body on somatic awareness and a particular type of somatic disturbance: erroneous reports of touch sensation, as measured by the Somatic Signal Detection Task (SSDT). During the SSDT, participants are required to detect near-threshold tactile stimulation at their fingertip. Previous research has found that healthy participants erroneously report touch sensations in the absence of a stimulus on this task and that such false alarms are increased when a simultaneous light flash is presented next to their fingertip. Thirty-seven participants completed the SSDT under two conditions: non-informative vision of the hand and no vision of the hand. False alarms were significantly higher in light trials in the non-informative vision condition compared to light trials in the no-vision condition. However, hit rates, sensitivity (d') and response criterion (c) were not affected by non-informative vision of the hand. Using the SSDT, we found that viewing the body increased somatic interference, possibly due to raised awareness of internal bodily sensations. This work provides evidence that viewing the body can have a detrimental effect on simple detection of near-threshold tactile stimulation.

Recent studies have reported that in normal healthy individuals, the perception of illusory sensations in one modality can be induced by the presentation of a stimulus in another modality. These illusory sensations may arise from the activation of a tactile representation in memory induced by the non-target stimulus, in a process mirroring that thought to be responsible for many forms of medically unexplained symptoms. The reliability of illusory-touch reports was investigated here in two experiments with a novel perceptual paradigm designed to simulate the occurrence of somatoform symptoms in the laboratory. A concurrent light significantly increased the number of tactile stimuli reported, and resulted in a higher number of illusory-touch reports, while the modality of the trial start cue did not affect subsequent responses. In addition, a strong relationship was found between the rates of illusory sensations that participants produced in successive sessions, indicating that the tendency to report illusory sensations is a robust phenomenon.

Contains fulltext : 81193.pdf (Publisher’s version ) (Closed access) BACKGROUND: The syndrome of fixed dystonia includes both CRPS-dystonia and psychogenic dystonia. The underlying mechanisms are unclear, but a high prevalence of neuropsychiatric illness has previously been reported. METHODS: Clinical and neuropsychiatric follow-up study by telephone and self-administered instruments (HADS, SDQ-20, DES II, EQ-5D), on 41 patients with fixed dystonia after a mean of 7.6 (+/-3.6) years. RESULTS: We obtained information on clinical outcome in 35 (85.4%) patients and neuropsychiatric questionnaire data in 22 (53.7%). Eighty-three percent were women. Thirty-one percent had worsened, 46% were the same and 23% had improved, of whom 6% had major remissions. At follow-up, mean duration of illness was 11.8 (+/-4.9) years and mean age 43.2 (+/-14.8) years. Except for 1 patient who was re-diagnosed with corticobasal degeneration, the diagnosis remained unchanged in others. Forty-one percent had scores indicating anxiety and 18% indicating depression; 18% scored within the range of dissociative/somatoform disorders on DES II and 19% on SDQ-20. The mean EQ-5D index and VAS scores were 0.34 and 56.1%. Comparison between the 3 outcome groups revealed significant difference only in the EQ-5D (p=0.003). Only baseline CRPS predicted a worse outcome (chi(2)=0.006). CONCLUSIONS: Our findings revealed that the prognosis of this syndrome is poor, with improvement in less than 25% of patients, major remission in only 6% and continued worsening in a third. A high rate of neuropsychiatric findings was noted and new neuropsychiatric features had occurred in some. Average health status was poor. Of the baseline parameters, only CRPS predicted poorer outcome.

Non-epileptic attack disorder (NEAD) poses a significant clinical problem but is poorly understood. Attachment theory provides a framework for understanding the development and maintenance of NEAD and the contribution of childhood abuse and neglect to these processes. A cross-sectional design was used to study attachment style and early traumatic experiences in individuals with NEAD (N=17) compared to those with epilepsy (N=26). A significant difference in predominant attachment style between the two groups was found, with fearful attachment occurring more frequently in the NEAD group. Abuse and neglect were also significantly more common in the NEAD patients. Both early traumatic experiences and fearful attachment added significantly to the predictive power of a logistic regression equation after controlling for anxiety and dysthymia. The findings suggest a link between disturbed attachment and NEAD and have clinical implications for therapeutic intervention with this group.

OBJECTIVE: High suggestibility is widely regarded as an important feature of patients with medically unexplained symptoms (MUS), particularly those with multiple MUS [i.e. somatization disorder (SD)], although there are few empirical data attesting to this assumption. A study was therefore conducted to compare levels of non-hypnotic suggestibility in patients with SD and medical controls. METHOD: A modified version of the Barber Suggestibility Scale was administered to 19 patients with SD and 17 controls with an established organic dystonia. RESULTS: Patients with SD were no more suggestible than control patients. Dystonia controls were more likely to deliberately comply with suggestions than the SD patients. CONCLUSION: Contrary to popular belief, high suggestibility is not necessarily a feature of SD.

OBJECTIVE: This study aimed to develop an experimental paradigm, using healthy controls, to measure change in tactile sensitivity and response bias for subsequent testing of patients with medically unexplained symptoms (MUS). METHODS: Participants judged whether or not they detected a weak tactile pulse (presented in 50% of trials). Performance in two conditions (tactile pulses presented with or without a concomitant light) was compared using signal detection analysis to assess whether a task-irrelevant light can invoke the sensation of touch, even in its absence. RESULTS: The results showed that the presence of a concurrent light significantly improved participants' detection of the tactile stimulus by 13.7% [t(18)=4.24, P

Pseudoneurological symptoms (i.e., conversion disorder), historically subsumed within the "hysteria" concept alongside phenomena such as psychogenic amnesia and multiple personality disorder, have been classified as somatoform disorders since DSM-III. Since then, there have been repeated calls to reclassify conversion disorder with the dissociative disorders, as in ICD-10. The authors review issues such as the high correlations between pseudoneurological and dissociative symptoms, the high rates of trauma reported for both groups, and the position that these phenomena share underlying processes. Although reintegrating pseudoneurological symptoms with the dissociative disorders is not without complications, there is a strong case for such a reclassification.

Theory suggests that as activation of pain concepts in memory increases, so too does subsequent pain perception. Previously, researchers have found that activating pain concepts in memory increases pain perception of subsequent painful stimuli, relative to neutral information. However, they have not attempted to quantify the nature of the association between information studied and ensuing pain perception. We subliminally presented words that had either a low or high degree of association to the word ‘pain,’ although this was only partially successful and some words were consciously perceived. Participants then received randomized laser heat stimuli, delivered at 1 of 3 intensity levels (low, moderate, high), and we measured the effect of this on behavioral and electrophysiological measures of pain. Participants (N = 27) rated moderate- and high-intensity laser stimuli as more painful after viewing high relative to low associates of pain; these effects remained present when we controlled for measures of mood, anxiety, and physical symptom reporting. Similar effects were observed physiologically, with higher stimulus negativity preceding after high relative to low associates and greater amplitudes for the N2 component of the laser-evoked potential after presentation of high associates in the moderate and high laser intensity conditions. These data support activation-based models of the effects of memory on pain perception. Perspective Consistent with current theories of memory and pain, we found that high, relative to low activation of pain concepts in memory increased psychological and physiological responses to laser-induced pain. The effect remained regardless of whether participants showed conscious awareness of activation. Theoretical and clinical implications are discussed.

Patients with chronic medically unexplained symptoms (MUS) are frequently encountered in medical practice. Despite the distress, disability and resource utilization associated with MUS, these conditions remain poorly understood. This contribution describes a novel account of MUS that combines existing models in this area within a common explanatory framework based on cognitive psychological principles. According to the model, some MUS can be understood as distortions in bodily consciousness or control produced by the over-activation of symptom representations in memory. The primary goal of treatment is to minimize the repetitive re-allocation of attention onto symptoms that maintain this process.

The goals of this study were to determine 1) the occurrence of various dissociative phenomena in patients with somatization disorder, 2) the occurrence of six different types of childhood interpersonal trauma in these patients, and 3) the nature of these patients' early family environment.Twenty-two patients with somatization disorder and 19 medical comparison subjects completed the Structured Clinical Interview for DSM-IV Dissociative Disorders, the Childhood Trauma Interview, and the Family Functioning Scale.The somatization disorder patients reported significantly higher level of dissociative amnesia than the comparison subjects. The two groups reported similar levels of depersonalization, derealization, identity confusion, and identity alteration. Somatization disorder patients reported significantly greater childhood emotional abuse and more severe forms of physical abuse, relative to the comparison subjects, with chronic emotional abuse being the best predictor of unexplained symptoms. Childhood sexual abuse, separation/loss, and witnessing violence were equally common in the two groups. The somatization disorder group reported significantly more family conflict and less family cohesion.Only some types of dissociation are more severe in patients with somatization disorder, relative to medical comparison subjects. Many patients with somatization disorder are raised in an emotionally cold, distant, and unsupportive family environment characterized by chronic emotional and physical abuse. Sexual abuse is not a necessary prerequisite for the disorder.

Theories of medically unexplained illness based on the concepts of dissociation, conversion, and somatization are summarized. Evidence cited in support of these theories is described and the conceptual strengths and shortcomings of each approach are considered. It is argued that each of these approaches adds to the understanding of unexplained illness but that none is able to provide a comprehensive explanation of the phenomenon. An integrative conceptual model of unexplained illness based on cognitive psychological principles is then presented. This model attempts to combine existing theoretical approaches within a single explanatory framework, extending previous theory by explaining how compelling symptoms can exist in the absence of organic pathology. The clinical and empirical implications of the model are then considered.

In contrast to previous research on directed forgetting, the present studies adopted a recent modification of the process dissociation procedure (Jacoby, 1991; Richardson-Klavehn & Gardiner, 1995) to accommodate the cross-contamination of memory test performance by implicit and explicit memorial factors. In Experiment 1, 120 subjects were compared in global directed forgetting, item-by-item directed forgetting, and control conditions on estimates of voluntary conscious memory, involuntary conscious memory, and involuntary unconscious memory performance. In Experiment 2, 80 subjects were compared in specific directed forgetting and control conditions on estimates of voluntary conscious memory, involuntary conscious memory, and involuntary unconscious memory performance. Subjects showed significant decrements in voluntary and involuntary conscious memory performance following instructions for directed forgetting in all conditions. None of the directed forgetting conditions showed a decrement in involuntary unconscious memory performance. Results suggest that, regardless of instruction type, directed forgetting prevents the conscious expression of memorial information (both voluntary and involuntary) while leaving unconscious memory intact.

Research suggests that inhibiting the effect of irrelevant stimuli on subsequent thought and action (cognitive inhibition) may be an important component of suggestibility. Two small correlation studies were conducted to address the relationship between different aspects of suggestibility and individual differences in cognitive inhibition, operationalized as the degree of negative priming generated by to-be-ignored stimuli in a semantic categorization task. The first study found significant positive correlations between negative priming, hypnotic suggestibility, and creative imagination; a significant negative correlation was obtained between negative priming and interrogative suggestibility, demonstrating the discriminant validity of the study results. The second study replicated the correlation between negative priming and hypnotic suggestibility, using a different suggestibility measurement procedure that assessed subjective experience and hypnotic involuntariness as well as objective responses to suggestions. These studies support the notion that the ability to engage in cognitive inhibition may be an important component of hypnotic responsivity and maybe of other forms of suggestibility.

Health-related Internet use has grown rapidly, yet little research has considered how health anxious individuals use the Internet for this purpose. Our aim was to examine the relationships between health anxiety and the extent of, reasons for, and consequences of health-related Internet usage in university students (n = 255). Responses on a purpose-made Internet use questionnaire were correlated with health anxiety scores; multiple regression analyses controlling for depression and anxiety were also conducted. Health anxiety positively correlated with (all ps < .01): frequency of health-related searching (r(s) = .163), proportion of health-related information sought (r(s) = .200), time spent online for health purposes (r(s) = .166), and number of searches for both illness (r(s) = .453) and wellness (r(s) = .208) information. Health anxiety further positively correlated with advantages perceived in health-related Internet use (r(s) = .183), heightened tension (r(s) = .364) and relief (r(s) = .174) post-search, and perceived doctor disadvantages (r(s) = .306), yet a greater likelihood to visit a doctor post-search (r(s) = .217). Health anxiety also correlated with six measures of possible addiction to using the Internet for health purposes (r(s) range = .171 to .366, all ps < .01). Some (including several potentially dysfunctional) aspects of health-related Internet use correlate with health anxiety. Research evaluating the possible role of Internet use in the development and maintenance of health anxiety is warranted.

To study the nature of personality and psychopathology in nonepileptic attack disorder (NEAD) and epilepsy, we prospectively assessed 45 consecutive attendees to a specialist assessment unit for epilepsy. Patients with NEAD were more likely to report clinically significant symptoms of anxiety, worry, disordered eating, and somatoform disorder. An ICD-10 diagnosis of anxiety or phobic disorder was significantly more common in NEAD patients. Together DSM-IV personality Clusters A and C were more common in epilepsy than NEAD. Hierarchical logistic regression with diagnosis as the target variable found anxiety, eating, and worry but not somatoform symptoms were reliably associated with NEAD. Together the Present State Examination (PSE) eating, PSE worrying/tension, PSE expansive mood, past psychiatric history, and gender variables allowed for correct classification of more than 88% of all cases. Personality and psychopathology variables seem to be valid clinical predictors of epilepsy and NEAD, and should be examined in epidemiological studies.

The suggestibility-enhancing effects of hypnosis are widely accepted, although poorly understood. In the present study, an attempt was made to address the effect of absorption and reduced critical thought on suggestibility change occurring in the hypnotic context. Study participants were presented with a waking suggestibility assessment followed by an induction consisting of instructions for progressive relaxation and a manipulation designed to establish an hypnotic context and an expectation for increased suggestibility. They were then presented with either further relaxation instructions, instructions to become absorbed or instructions to reduce critical thought, followed by a second suggestibility assessment. Groups were compared on objective and subjective suggestibility score change, controlling for suggestibility on the first test. Results indicate that the addition of instructions for absorption or reduced critical thought to relaxation procedures created a significantly larger suggestibility increase than instructions for relaxation alone. Moreover, instructions for relaxation alone were insufficient to produce an increase in suggestibility, despite the presence of an hypnotic context and positive expectations. These findings cast doubt on the notion that only non-state factors are responsible for suggestibility increases observed in the hypnotic context, and raise the possibility that absorption and reduced critical thought are important components of hypnosis. Copyright © 2001 British Society of Experimental and Clinical Hypnosis

The latest edition of the International Classification of Diseases (ICD-10)1 defines dissociation as “ . . . a partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of body movements” (p 151). Thus defined, the concept of dissociation captures a heterogeneous group of psychiatric conditions previously subsumed within the broader construct of hysteria. The dissociative (conversion) disorders category in ICD-10 comprises subcategories of dissociative amnesia, dissociative fugue, trance and possession disorders, dissociative anaesthesia and sensory loss, dissociative motor disorders and dissociative convulsions, and waste basket categories included to capture uncommon, impure, or less severe instances of dissociation. Other symptoms previously viewed as hysterical are placed within the somatoform disorders category of ICD-10, on the grounds that their primary characteristic is an apparent disturbance of bodily rather than cerebral function. By contrast, DSM-IV2 classifies convulsions, motor dysfunction, and sensory loss as somatoform disorders, despite adopting an otherwise similar definition of dissociation and categorisation of dissociative complaints. In the context of this editorial we embrace the more inclusive scheme offered by ICD-10. The basis for their inclusion within current psychiatric nosology is the assumption that dissociative disorders are primarily psychological in nature.1 Nevertheless, the concept of dissociation has important implications for practice and research within the neurological sphere also. Dissociative psychopathology was witnessed almost exclusively within the neurological setting until the late 19th and early 20th centuries, and many such patients present to neurologists even now. What is striking about dissociative symptoms is their apparent similarity to those found in many common neurological conditions, and it is often extremely difficult to distinguish between the two; the case of dissociative convulsions provides an instructive example. Recent estimates suggest that between 9% and 50% of patients referred to specialist …

The authors describe a study investigating the relationship between posthypnotic amnesia (PHA) and directed forgetting (DF) and their impact on implicit and explicit memory. This study adopted a recent modification of the process dissociation procedure to accommodate the cross-contamination of memory test performance by implicit and explicit memorial factors. Forty high and 40 low hypnotically susceptible participants were compared in PHA, DF, and control conditions on estimates of voluntary conscious (VCM), involuntary conscious (ICM), and involuntary unconscious memory (IUM) performance. Both groups showed significant decrements in VCM and ICM following instructions for DF, whereas only high susceptibles showed this decrement in the PHA condition; neither DF nor PHA affected IUM. Moreover, there was no relationship between forgetting in PHA and DF. Although both PHA and DF seem to prevent the conscious (i.e., explicit) expression of memorial information while leaving implicit memory intact, the...

It has been suggested that an everyday preference for holistic and emotional thought is related to the ability to enter hypnosis, although research addressing the idea has often yielded inconsistent results. This study correlated hypnotic susceptibility, as measured by the Harvard Group Scale (Shor and Orne, 1962), with three measures of a holistic/emotional thinking style: the experiential sub-scale of the Rational Versus Experiential Inventory (RVEI) (Epstein et al., 1995), the right hemisphere sub-scale of the Human Information Processing Survey (HIPS) (Taggart and Torrance, 1984) and the elaborative processing sub-scale of the Inventory of Learning Processes (ILP) (Schmeck et al., 1977). A social desirability measure was also included. Only the experiential scale of the RVEI and the social desirability scale showed significant positive correlations with susceptibility; a multiple regression analysis showed the RVEI scale to be the best predictor of susceptibility. The implications of these results for the analytic-holistic hypothesis in hypnosis are discussed. Copyright © 1998 British Society of Experimental and Clinical Hypnosis

Evidence for a shift from analytical to holistic processing during hypnosis is presented as a basis for a new conceptualization of hypnosis in terms of Epstein's integrative theory of personality, Cognitive-Experiential Self-Theory (CEST; e.g., Epstein, 1973, 1990, 1994). Support for this view comes from parallels between the hypnotic state and the experiential system as embodied in CEST and from converging lines of enquiry from cognitive psychology. It is concluded that there is significant heuristic value in such a conceptualization, which can form a framework within which to organize data and generate research, and can serve as an interface between cognitive psychology, the psychology of individual differences and hypnosis theory. Copyright © 1997 British Society of Experimental and Clinical Hypnosis

Objectives Psychogenic nonepileptic seizures (PNESs) are poorly understood and difficult to treat. Research and theory suggest that problems with recognizing, acknowledging, and regulating emotional states (i.e., emotional dysregulation) may contribute to the development and maintenance of PNESs. However, there is a lack of well-controlled studies using dedicated measures of emotional regulation with patients with PNESs. The current study sought to address this gap. Methods Forty-three patients with PNESs and 24 with epilepsy completed a postal survey comprising measures of emotional dysregulation (Difficulties in Emotion Regulation Scale), alexithymia (Toronto Alexithymia Scale), attachment (Relationship Scales Questionnaire), and psychopathology (Generalized Anxiety Disorder-7; Patient Health Questionnaire-9; Somatoform Dissociation Questionnaire-20). Cluster analysis was used to identify possible subgroups of patients with PNESs characterized by distinct patterns of emotional dysregulation. Results Two clusters of patients with PNESs were identified. The first (n = 11) was characterized by higher levels of psychopathology, somatization, alexithymia, and difficulties with most aspects of emotional regulation (including identifying, accepting, and describing feelings, accessing adaptive regulatory strategies, performing goal-directed behaviors, and controlling feelings and actions) compared with the group with epilepsy. The second (n = 32) was characterized by relatively high somatization and depression scores but comparatively normal levels of alexithymia and emotional regulation. Conclusions The findings suggest that patients with PNESs can be divided into at least two meaningful subgroups characterized by distinct psychological profiles, only one of which is characterized by significant problems with emotional dysregulation. Further research is needed to determine whether the relatively normal emotional dysregulation and high somatization scores of some patients with PNESs are due to emotional avoidance or more basic problems with perceptual and behavioral control.

The neurobiological basis of psychogenic movement disorders remains poorly understood and the management of these conditions difficult. Functional neuroimaging studies have provided some insight into the pathophysiology of disorders implicating particularly the prefrontal cortex, but there are no studies on psychogenic dystonia, and comparisons with findings in organic counterparts are rare. To understand the pathophysiology of these disorders better, we compared the similarities and differences in functional neuroimaging of patients with psychogenic dystonia and genetically determined dystonia, and tested hypotheses on the role of the prefrontal cortex in functional neurological disorders. Patients with psychogenic (n = 6) or organic (n = 5, DYT1 gene mutation positive) dystonia of the right leg, and matched healthy control subjects (n = 6) underwent positron emission tomography of regional cerebral blood flow. Participants were studied during rest, during fixed posturing of the right leg and during paced ankle movements. Continuous surface electromyography and footplate manometry monitored task performance. Averaging regional cerebral blood flow across all tasks, the organic dystonia group showed abnormal increases in the primary motor cortex and thalamus compared with controls, with decreases in the cerebellum. In contrast, the psychogenic dystonia group showed the opposite pattern, with abnormally increased blood flow in the cerebellum and basal ganglia, with decreases in the primary motor cortex. Comparing organic dystonia with psychogenic dystonia revealed significantly greater regional blood flow in the primary motor cortex, whereas psychogenic dystonia was associated with significantly greater blood flow in the cerebellum and basal ganglia (all P < 0.05, family-wise whole-brain corrected). Group × task interactions were also examined. During movement, compared with rest, there was abnormal activation in the right dorsolateral prefrontal cortex that was common to both organic and psychogenic dystonia groups (compared with control subjects, P < 0.05, family-wise small-volume correction). These data show a cortical-subcortical differentiation between organic and psychogenic dystonia in terms of regional blood flow, both at rest and during active motor tasks. The pathological prefrontal cortical activation was confirmed in, but was not specific to, psychogenic dystonia. This suggests that psychogenic and organic dystonia have different cortical and subcortical pathophysiology, while a derangement in mechanisms of motor attention may be a feature of both conditions.

To assess the relationship between the behavioural triad of hyper-religiosity, hypergraphia and hyposexuality in epilepsy, and volumes of the mesial temporal structures.Magnetic resonance images were obtained from 33 patients with refractory epilepsy and mesial temporal structure volumes assessed. Amygdala and hippocampal volumes were then compared in high and low scorers on the religiosity, writing, and sexuality sub-scales of the Neurobehavioural Inventory.Patients with high ratings on the religiosity scale had significantly smaller right hippocampi. Religiosity scores rated by both patient and carer showed a significant negative correlation with right hippocampal volumes in this group. There were no other differences in amygdala or hippocampal volumes between these groups, or between high and low scorers on the writing and sexuality sub-scales.These findings suggest that right hippocampal volumes are negatively correlated with religiosity in patients with refractory epilepsy.