In this Papers Podcast, Lottie Shipp discusses her JCPP Advances paper ‘The relationship between dissociation and panic symptoms in adolescence and the exploration of potential mediators’ (https://doi.org/10.1002/jcv2.12202). Lottie is the lead author of the paper.
There is an overview of the paper, methodology, key findings, and implications for practice.
Discussion points include:
- Definition of ‘dissociation’ and insight into the subtype ‘felt sense of anomaly dissociation’.
- The difference between ‘cognitive reappraisal strategies’ and ‘cognitive appraisal of dissociation’.
- How common panic disorders are and the impact of panic symptoms in young people.
- Implications of the study for researchers, clinicians, and practitioners.
- The importance of the relevance and interpretation of dissociative experiences.
In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are The Journal of Child Psychology and Psychiatry (JCPP); The Child and Adolescent Mental Health (CAMH) journal; and JCPP Advances.
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Lottie is a DPhil (PhD) student in the Department of Experimental Psychology at the University of Oxford. Her research focuses on developing an understanding of the cognitive and behavioural mechanisms that maintain anxiety disorders in adolescents. In particular, Lottie is interested in exploring the cognitive and behavioural mechanisms that contribute to the maintenance of Generalised Anxiety Disorder (GAD) in adolescents.
Transcript
[00:00:01.350] Mark Tebbs: Hello, and welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Mark Tebbs, and I’m a Freelance Consultant. Today, I’m really pleased to be talking with Lottie Shipp, who is a PhD student and who is the lead author of a paper entitled, “The Relationship Between Dissociation and Panic Symptoms in Adolescence and the Exploration of Potential Mediators.” This was recently published in the JCPP Advances journal. Lottie, thank you for joining me, I’m really looking forward to our conversation today.
[00:00:40.140] Lottie Shipp: It’s a pleasure, thank you for having me.
[00:00:42.129] Mark Tebbs: Good, good. So, could we just start with an introduction? Maybe if you could say who you are and the people that you worked with on the paper?
[00:00:50.469] Lottie Shipp: Yes, of course. I’m a first year PhD student at the University of Oxford. I’m supervised by Polly Waite and Eleanor Leigh, and my research focus is anxiety disorders in adolescence. So, my main interest is understanding some of the key factors that contribute to the maintenance of anxiety disorders, with the aim of then using that knowledge to inform the development of interventions that are very brief and effective.
But this current paper, which we’re discussing today, that explored dissociation and panic symptoms, and that was written following our undergraduate project. So, we worked with another student, Alisa Musatova, to decide on the research questions, and then to collect the data, and we were supervised by Polly Waite and Emma Černis.
So, Polly’s research is really focused on understanding anxiety in adolescence and developing effective interventions. And she’s done a lot of work on panic disorder, in particular, mainly because it usually has its onset in adolescence and it’s not really so common in younger children. And Emma’s research looks at dissociative experiences and their link with mental health difficulties, and she defined the concept of the felt sense of anomaly dissociative experiences, which were the focus of our paper.
[00:02:02.180] Mark Tebbs: Great stuff, thank you. So, let’s turn to that paper then. So, if you could just start by giving us a brief overview, and if you could just define some of those key terms that are used throughout the paper.
[00:02:13.040] Lottie Shipp: Yes, of course. So, overall, the paper was aiming to better understand this potential link between dissociative experiences and panic symptoms, and then some of the potential mediating factors in adolescents, which we used 13 to 18-year-olds. So, if we start with defining dissociation, ‘cause it can be a bit confusing, and there’s a lot of debate surrounding its definition. But, generally, we can think of it as a kind of feeling of being detached from yourself. It’s sometimes referred to also as “depersonalisation,” or “being detached from the world around you,” and that’s what we would normally term “derealisation.”
And some people say it feels a bit like being in a dream, or like you’re viewing yourself from an outsider’s perspective. But, overall, it’s a really broad umbrella term, that covers lots of different experiences that differ from person-to-person. And I think here it’s really important to note that feelings of dissociation are actually really common in the general population, and lots of us can probably relate to feeling a little bit spaced out or dissociated, maybe when we’re really tired or stressed.
And for most people, it’s a very normal and harmless sensation, but when it becomes more severe, that’s when it’s linked to a number of psychological disorders. So, you might often hear about dissociation with relation to PTSD, or psychosis, or anxiety disorders. And we specifically looked at a concept called felt sense of anomaly dissociation, which does sit under this bracket of dissociative experiences. And it’s defined as a feeling that something isn’t quite right, so a sense of strangeness within your mental content, your body, perception, your experience of yourself, or your surroundings, and it can feel like detachment, unfamiliarity, or a lack of control.
And it’s a construct that was developed by Emma with a bottom-up approach, so it was based on the lived experiences of people who reported dissociation. And so, it covers lots of those experiences that otherwise we might term as “depersonalisation,” and “derealisation.” But what makes it different is it isn’t constrained by that same kind of top-down description, so it’s a slightly different concept, which is why it’s measured separately.
And, in this study, we also looked at the relationship between felt sense of anomaly dissociation and panic in young people, and we looked at different emotion regulation strategies, cognitive appraisals of dissociation, and alexithymia. So, if we just quickly define what we’re talking about by “emotion regulation,” we looked at two different strategies. So, cognitive reappraisal, which is adaptive, it means you’re changing your interpretation of a situation in a way that makes it less distressing. And we also looked at expressive suppression, which is something that most people do, from time-to-time, but actually it becomes quite problematic if you use it all the time, and you’re always suppressing your emotions, and you don’t have any flexibility in that.
And because we were interested in this cognitive approach, we also looked at cognitive appraisals of dissociation, and there’s a really important distinction here to be made between this concept, and cognitive reappraisal. So cognitive reappraisal is an emotion regulation strategy, so that’s when you’re changing your interpretation to reduce the emotional impact of a situation. But cognitive appraisals dissociation is referring more to the content of that interpretation, so it’s the belief that someone holds about their dissociative experience, and that’s often quite negative, so thinking you might be losing your mind, or losing control.
[00:05:31.509] Mark Tebbs: Thank you, that’s really comprehensive. Just turning to the original research objectives, it’d be really interesting to know why you wanted to focus on panic and dissociation, were there any particular research questions you were trying to answer?
[00:05:47.150] Lottie Shipp: Yes, so we were really interested in it because we know that panic disorder is really quite common. So it’s estimated it affects about 3.5% of 17 to 19-year-olds, but those statistics are based on pre-pandemic levels, so it’s also possible they might have increased a bit. And it might sound like quite a small percentage, but panic symptoms are actually – exist on this kind of continuum. So they’re not only experienced by that 3.5% of young people who meet the criteria of panic disorder, but they’re actually also reported, at least one panic attack every year, by around two thirds of adolescents.
And we know that they’re really distressing, and they can have a really detrimental effect on young people’s ability to socialise, to go to school, to get public transport, and to develop independence with normal sorts of things that young people should be able to do. And because of it, it’s really important to be able to understand better how panic symptoms relate in young people.
But there isn’t very much existing research about the role of dissociation, in particular, but that’s quite surprising, because actually between a quarter and a half of young people who report panic attacks also experience dissociation. So, I think the main aim of our research was to really unpick that relationship and see whether the ways that adolescents regulate and understand their emotions and the way that they interpret feelings of dissociation, might influence that link between dissociation and panic.
[00:07:07.699] Mark Tebbs: Excellent. So, how did you go about the study? And were there any particular methodological challenges that you had to overcome?
[00:07:15.349] Lottie Shipp: So, we conducted our study online, and we used social media advertising to recruit young people who were aged between 13 and 18, and we asked them to complete the same set questionnaires at two separate timepoints, with a one-month gap in the middle. So, these included the ČEFSA, which is the Černis Felt Sense of Anomaly scale, and that was our measure of dissociation. And we also had questionnaires about panic symptoms, interpretations of dissociative experiences, the use of emotion regulation strategies, and alexithymia as well. And we had actually a really great response, we had over 400 young people providing data at both timepoints.
I think one of our methodological challenges here was thinking about how we measure panic in the general population, without having a diagnosis of panic disorder as an inclusion criteria. But as I mentioned earlier, because panic symptoms are experienced on this continuum, and with around two thirds of young people reporting at least one panic attack in the past year, that means we could use the Panic Disorder Severity Scale for Adolescents. So, this is a measure that assesses panic symptoms and the level of distress and impairment that they’re associated with.
And we actually found that the mean panic score in our sample was about nine. So, to give you some context there, some previous research that uses the same measure, but in a clinical sample, has a mean of about 13. So, as we predicted, we did have lower levels, because we were looking at a community sample, but they were still high enough that we could get some meaningful results.
And I think one of our other methodological challenges was just making sure that our questionnaires could be understood by young people, because dissociation is quite an abstract and complicated thing to be talking about, and we wanted to make sure that they were really developmentally appropriate. So, to do that, we asked a young person to give us some feedback on the measures that we used before the study, and as a result of that, we made some very minor changes to the vocabulary, just to make sure that they were really clear and really understandable for adolescents.
[00:09:05.589] Mark Tebbs: Thank you. So turning to the results, what were the key findings?
[00:09:11.779] Lottie Shipp: So, our main finding was that higher levels of this felt sense of anomaly dissociation, at the first timepoint, were associated with higher levels of panic symptoms reported the following month. And that relationship was partially mediated by cognitive reappraisal, so more dissociation was then assess – associated with less use of cognitive reappraisal, and more severe panic symptoms.
And we also found that the way that the young people interpreted dissociation played a role in the relationship. So cognitive appraisals of dissociation was also a significant partial mediating factor. So, the adolescents who had higher dissociation and more negative interpretations, so, for example, seeing dissociation as a sign of losing control, they experienced more panic symptoms.
And when we actually conducted a more exploratory set of analyses, and we added baseline panic symptoms that were reported at the first point into the model to control for our initial levels of panic, we found that those mediators weren’t significant anymore. And we think that that’s because we had quite a short time gap between our assessment points, it was only a month, and the panic symptoms were very stable across those two timepoints. So, it does mean that our results can’t tell us much about the temporal relationship between those two factors, that’s really an area for some future research.
But the findings do fit really nicely into the, kind of, cognitive behavioural interpretation. So, when young people who experience dissociation generate a really negative or upsetting interpretation of that symptom. So, if they’re seeing dissociation as a sign of losing their mind, or not being in control of their body, and then, importantly, if they don’t reinterpret that experience in a way that makes it less distressing for them, that can lead to more anxiety and escalating panic symptoms, as well.
[00:10:52.820] Mark Tebbs: Thank you for that. So, was there any aspects of the results that surprised you?
[00:10:57.980] Lottie Shipp: I think we were a bit surprised that expressive suppression wasn’t a significant mediator, because we do know from existing research that people who have panic disorder, or high levels of panic symptoms, they have more of a tendency to, kind of, bottle up their feelings, so maybe as a way of, sort of, hiding panic symptoms from other people, or of controlling that anxiety.
And in adults, there’s been a link between expressive suppression and higher depersonalisation, or derealisation, and so, initially, we predicted that the same would be true in adolescents as well. But, actually, we found that expressive suppression that was reported at the first timepoint wasn’t significantly reported to panic symptoms – report – one month later.
And, actually, we think that that might be due to the tendency of people with higher levels of panic to be quite hypervigilant to their physiological symptoms. And we think that that hypervigilance, it’s possible it isn’t present in people who use expressive suppression, kind of, more habitually, because they’re actively trying to ignore those internal sensations instead.
[00:11:52.691] Mark Tebbs: And so, I’m just thinking about the potential implications of the study, so maybe starting with looking at the, kind of, research field.
[00:12:02.150] Lottie Shipp: So, I think this study provides nice evidence for a link between dissociation and panic symptoms in adolescents, and the role of some of those potential mediators. But, as I mentioned, we really weren’t able to explore the temporal relationships, and I think that’s an area that’d be really great to be researched more in the future. And our findings are a really nice insight into panic symptoms in the general population of adolescents. But what we don’t know, necessarily, is if those relationships would be the same in people who have a diagnosis of panic disorder. And it might be the case that their experiences of, for example, felt sense of anomaly dissociation, that might be different or, potentially, they could use different emotion regulation strategies.
So, we looked at two different strategies in our study, but it’s possible that in a clinical sample, there could be more dependency on processes like catastrophising or ruminating, or those pathways to panic might look a little bit different. So that’s also something I think that’d be really interesting to explore in the future.
But, overall, I think this study really sets the scene for the ways that we understand panic in young people, and looking at the ways that they might interpret those feelings of dissociation and regulate their emotions as potential maintaining factors. It really highlights how important a cognitive interpretation of an internal experience is in panic and young people, which is a really valuable finding when we’re thinking about the factors that keep panic symptoms going, and how we might think about then breaking those cycles in treatment for panic disorder.
[00:13:29.529] Mark Tebbs: Excellent, and thinking about that from a, kind of, Practitioner, or an intervention perspective, what are the, kind of, implications of the study?
[00:13:37.279] Lottie Shipp: So, because we used a community population, we’d obviously need to do a little bit more further research before we would generalise our findings to a clinical sample. But I think, hopefully, what our findings show Practitioners is that where dissociative experiences are reported by young people, and when they’re persistently misinterpreted in this negative or catastrophic way, that could potentially be one of the factors that contributes to the maintenance of panic symptoms.
And I think just being aware of this is really valuable, and it might be worth thinking about the ways that young people are taught about dissociation, so, kind of, normalising that feeling, and, hopefully, reducing some of those negative interpretations. And it would be really great to see any further research that explores this more in the future with a more clinical sample.
[00:14:20.720] Mark Tebbs: And have you got any, kind of, further research in the pipeline? Is there anything that you would like to share with us around your ongoing work?
[00:14:28.649] Lottie Shipp: So, not by myself personally, but there is more work being done on the ČEFSA, which is this felt sense of anomaly measure that we use in the study by Emma Černis. And she’s very recently published a paper with a shortfall with the measure and which has been validated for use in adolescents who are 13 and older, and that would be a really valuable tool for future research into this field in dissociative experiences in young people going forwards.
But in terms of my research for my PhD, I’m interested in further exploring cognitive behavioural interpretations of anxiety in adolescents. Moving slightly away from panic disorder, I’m currently looking at generalised anxiety disorder and some of the mechanisms that maintain it. So, things like cognitive avoidance, positive beliefs about worry, and intolerance of uncertainty, as well.
[00:15:17.380] Mark Tebbs: Thank you. We’re coming to the end of the podcast, is there a, kind of, final take home message for our listeners?
[00:15:23.339] Lottie Shipp: Yeah, I think the main thing to take away is definitely the relevance of dissociative experiences. I don’t think they’re often discussed with relation to panic, maybe as much as they should be, given how common and distressing they are, and particularly for those young people who have either panic disorder or elevated levels of panic symptoms. And I think we’ve really highlighted the dissociative experiences and, importantly, the way they’re interpreted and the way that you manage your emotions, that those factors do play a role in panic symptoms in young people. And, again, I think it would really interesting to see where that research goes in the future.
[00:15:57.079] Mark Tebbs: Thank you so much, Lottie, it’s been a really interesting podcast. For more details on Lottie Shipp, please visit the ACAMH website, www.acamh.org, and Twitter @ACAMH. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rating or review, and do share with friends and colleagues.
