1 s2.0 S0191886922004573 Main

Personality and Individual Differences 202 (2023) 111952
Contents lists available at ScienceDirect
Personality and Individual Differences

journal homepage: www.elsevier.com/locate/paid
Psychological trauma, mood and social isolation do not explain elevated

dissociation in functional neurological disorder (FND)
S.R. Blanco a, b, *, S. Mitra a, C.J. Howard a, A.L. Sumich a, c
a
Nottingham Trent University, 50 Shakespeare Street, Nottingham NG1 4FQ, UK
b
Psychology Division, Bishop Grosseteste University, Lincoln, United Kingdom
c
Auckland University of Technology, North Shore Campus Northcote, Auckland 1142, New Zealand
A R T I C L E I N F O A B S T R A C T
Keywords: Functional Neurological Disorder (FND) results in altered motor, sensory and cognitive function in the absence of
Dissociation evident organic disease. It often co-occurs alongside dissociative disorders and dissociation has been found to be
Functional Neurological Disorder high in patients across FND subtypes (particularly in those with Non-Epileptic Attack Disorder; NEADs). How
Psychological trauma
ever, the presence of dissociation in FND is varied and there are contradictory definitions and suggestions for
Anxiety
Depression
elevated levels. Here, three studies show that dissociation is a prominent, defining feature of people with FND
Social isolation compared to those who are healthy or have other, similar long-term health conditions, and that this heightened
dissociation is not explained by a history of trauma (study 1, N = 121), mood (study 2, N = 589) and is not
associated with social isolation/social exclusion (study 3, N = 542). As dissociation appeared to occur in FND in
the absence of the usual contributing factors, and as higher levels of dissociation were associated with increased
disability and illness impacts, understanding its role is of fundamental importance to developing our under
standing of FND. These findings have further applications, beyond the theoretical, in clinical settings and in
research; the implications for further research are discussed.
1. Introduction usually integrated higher-order cognitive processes i.e., sensory or

motor processing (Brown, 2004; Edwards et al., 2012; Van den Bergh
In Functional Neurological Disorder (FND), motor and sensory et al., 2017). Accumulating evidence implicates dissociation (Kozlow
symptoms (including seizures, movement disorders, loss or reduced ska, 2017), atypical sensory processing (Brown et al., 2007; Pick et al.,
sensory functions amongst others) occur in the absence of identifiable 2017) and altered processing of sensory-motor signals (Edwards et al.,
organic disorder or neurological disease (American Psychiatric Associ 2012; Van den Bergh et al., 2017) in the development and maintenance
ation, 2013). FND can be accompanied by severe pain and chronic of FND. Some subtypes of FND also show atypical emotional function
symptoms, which have considerable impact on patients' quality of life (Pick et al., 2019) or prominent alexithymia (the inability to identify
and psychosocial functioning, resulting in significant health and social one's own feelings; Demartini et al., 2016; Steffen et al., 2015), and it is
care costs (Carson et al., 2011). Biopsychosocial frameworks acknowl often considered that FND has a co-occurrence with mood disorders
edge a wide variety of predisposing, precipitating and perpetuating in (Brown and Reuber, 2016; Pick et al., 2016). However, little is under
fluences which can contribute toward FND, and the maintenance of stood about the potential underlying mechanisms for FND, nor the re
symptoms (McKee et al., 2018; Reuber, 2009) though the degrees to lationships between them, and current models fail to account for all
which they do and the influence of these on symptoms and illness out symptoms and varying degrees of severity; continued research in this
comes is widely disputed. Research is expanding, yet the mechanisms field is essential for advancing knowledge of the condition.
underlying FND remain little understood and whilst models are Dissociation has long been considered as underpinning FND (since
continuing to evolve there is no one favored theoretical framework. the work Janet, 1907) and remains upheld by the World Health Orga
Nonetheless, models have begun to diverge from simplistic trauma- nization's (World Health Organization, 2018) classification which de
centered models and advocate distortions in (and disruptions to) fines FND as “dissociative neurological symptom disorder”. On-the-
Abbreviations: FND, Functional Neurological Disorder.

* Corresponding author at: 50 Shakespeare Street, Nottingham NG1 4FQ, UK.
E-mail address: [email protected] (S.R. Blanco).
https://doi.org/10.1016/j.paid.2022.111952
Received 1 December 2021; Received in revised form 14 October 2022; Accepted 18 October 2022
Available online 5 November 2022
0191-8869/© 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
S.R. Blanco et al. Personality and Individual Differences 202 (2023) 111952
other-hand, DSM-5, has adopted “functional neurological symptom from distortions between top-down and bottom-up processing, impli
disorder”, categorised in somatic symptom disorders. Dissociation refers cating dissociation in the separation of (normally integrated) executive
to a pathological process of disconnection in which sensory awareness is control functions. This model is analogous to mechanisms proposed to
altered or there is a loss of typical integration of mental processes, underpin some symptoms of ADHD (Mattfeld et al., 2016) and certain
including sensorimotor functions, emotions, memories, awareness, positive symptoms in schizophrenia (Akbey et al., 2019; Sumich et al.,
movement, thoughts and affect (World Health Organisation, 1992). 2018, 2008). Whilst such diagnoses are subject to discussions of validity
Subtypes of dissociation may include detachment, an altered state of themselves in the absence of biomarkers (much like FND) and are highly
consciousness in which there is separation from the self (depersonalisa subjective, the models here might explain the role of dissociation as an
tion), or the world (derealisation) and compartmentalizing, an inability to autonomous symptom. However, the origins of dissociation remain
deliberately control actions or cognitive processes that would normally unclear and little is understood about the relationship between disso
be amenable to such control (Holmes et al., 2005). Biopsychosocial ciation via usual ACES (including mood, life events, trauma) or the role
frameworks acknowledge dissociation as a predisposing factor for FND of potential protective factors like social support. Further, an increased
(McKee et al., 2018), rather than a symptom or precipitating factor, understanding of the factors that contribute toward functional impair
which the current set of studies aims to explore. ments could allow for the progression and advancement of theoretical
The role of dissociation in FND is in part supported by the co- models and treatment options for FND.
occurrence of FND with other dissociative disorders (e.g., dissociative Through online cross-sectional research, the current three-study
identity, dissociative amnesia), which may reflect shared risk factors (e. project aims to establish whether dissociation is a prominent feature
g., traumatic life events, hypnotic susceptibility) and/or biological in FND (a finding which could distinguish it from other, similar long-
mechanisms (Brown et al., 2007). Moreover, in self-report scales, in term conditions) and to identify whether usual explanatory factors
dividuals with FND show higher psychological (Goldstein and Mellers, (mood, a history of trauma or social isolation) can adequately explain
2006; Perez et al., 2018; Reuber et al., 2003; Şar et al., 2004) and levels of dissociation in FND. More specifically, the association between
somatoform (Brown et al., 2013; Pick et al., 2017; Sar et al., 2009) implicated triggers for FND and the presence of dissociation is investi
dissociation, particularly in non-epileptic attack disorder (NEADs) sub gated, with four primary aims: i) to assess whether dissociation is a
types (Prueter et al., 2002) to a similar degree as in borderline person prominent feature in FND (Study 1,2,3); ii) to test relationships between
ality disorder and post-traumatic stress disorder (PTSD; see meta- a history of trauma and the presence of dissociation (Study 1); iii) to test
analysis by Lyssenko et al., 2018). Further evidence for dissociation in relationships between mood (anxiety, depression and stress) and the
FND comes from findings that normal muscle power or changes in the presence of dissociation (Study 2), and (iv) to test whether dissociation
frequency or character of tremors are observed when an individual with might be associated with social isolation, common in FND (Study 3). To
FND is distracted from the movement (Carson et al., 2015; Daum et al., address the first research aim, study 1 compared dissociation scores
2015). Hoover's tests are commonly used as positive diagnostic tools between those with FND and healthy controls and studies 2 and 3
with high specificity for FND (McWhirter et al., 2011), suggesting issues compared dissociation scores between those with FND, healthy controls
with distorted attention across the patient group. Recently, studies have and those with other long-term disorders. To address the second aim,
found that reduced interoceptive awareness is associated with increased study 1 measured levels of trauma and dissociation in those with FND
dissociation in NEADs (Yogarajah et al., 2019) and FND (Pick et al., and in comparison, to a healthy control group. To address the third aim,
2020), which could account for clinical observations of sensory distur study 2 measured the relationships between mood scores (anxiety,
bances and loss of sense of internal bodily changes. Thus, dissociation depression and stress) and explored the relationship between these to
appears to be a common feature across FNDs, though research has yet to dissociation in a cohort of those with FND and in comparison to both a
establish this or the potential causes of heightened dissociation in FND healthy control group and a long-term conditions group. To address the
(for example if this is a symptom of the illness or a result of other fourth aim, study 3 measured social isolation and explored the rela
mechanisms such as mood or trauma). tionship between this and dissociation in an FND group, a healthy
Interpretation of elevated dissociation in FNDs is varied, with several control group and a long-term conditions group.
contradictory suggestions (Nijenhuis and van der Hart, 2011). For
example, Myers et al. (2019) and Williams et al. (2020) interpret posi 1.1. Hypotheses
tive symptoms of dissociation as being formed through the conversion of
intrusive traumatic memories, comparable to the symptoms' presence in • Those with FND will show higher levels of dissociation that the two
psychological disorders, (e.g., PTSD; Myers et al., 2019). Many authors control groups (Healthy control and LTD) and those in the long-term
suggest that the presence of traumatic experiences mediates this rela conditions group will show higher dissociation levels than those in
tionship with dissociation, leading to increased susceptibility to the the healthy control group;
development of FND (Diez et al., 2020; Levita et al., 2020; Wieder and • Dissociation will correlate with dissociation in both the FND and
Terhune, 2019). However, the DSM-5 changed its criteria, removing the Healthy control group and this will result in positive correlations in
need for psychological precipitating events owing to limited and both groups between dissociation and trauma;
inconsistent evidence; many patients report physical (rather than psy • Scores for anxiety, depression and stress will positively correlate
chological) traumatic events at the onset of symptom development with dissociation scores in each of the three groups (FND, Healthy
(Pareés et al., 2014). For example, there are reports of infections and and LTD) and mood scores will be higher for those in the FND group
other physical injuries, in the absence of any known psychological than the healthy and LTD groups;
trauma, preceding the onset of FND, though physical traumas can elicit • Levels of social isolation will positively correlate with dissociation in
an emotional response too. Whilst the DSM-5 is considered to be a each of the three groups (FND, Healthy and LTD) and self-reported
diagnostic nosology, and the subjective nature of its various diagnostic social isolation scores will be higher for those with FND.
categories is widely accepted, other diagnostic manuals including the
ICD-11 (World Health Organization, 2018) have endorsed similar 2. Methods
changes owing to the expanding evidence base and the need to posi
tively differentiate FND from other disorders (Nicholson et al., 2020). 2.1. Ethics
Nevertheless, dissociation remains high within the patient group. Thus,
dissociation might be considered as an autonomous symptom in FND, Ethical approval for the following studies was provided by the Uni
and whether it is exacerbated by traumatic experiences remains unclear. versity's College Research Degrees Committee (CRDC). Standards and
In Edwards et al. (2012)’s prevailing model, FND is framed as arising practices of research were followed as outlined by the British
2
Table 1
Test statistics for FND and Control groups for anxiety, depression, life events, total self-reported dissociation (and each of the four subscales of dissociation; Study 1).
Variable M SD F 95 % CI p
FND Control FND Control
Anxiety 16.77 14.49 3.51 3.39 16.75 [0.0252, 0.1820] <0.001

Depression 16.02 13.26 3.56 3.29 24.77 [0.0492, 0.2269] <0.001
Life events 1.06 1.39 11.73 9.93 3.59 [0.0000, 0.0819] 0.064
Total dissociation 10.14 5.97 4.11 2.10 54.55 [0.1422, 0.3504] <0.001
Depersonalization/decentralisation 2.93 1.47 1.21 0.71 71.96 [0.1925, 0.4038] <0.001
Gaps 3.22 1.94 1.25 0.92 48.83 [0.1247, 0.3304] <0.001
Sensory dissociation 1.92 1.23 1.02 0.43 25.26 [0.0507, 0.2295] <0.001
Re-experiencing 2.06 1.32 1.15 0.47 23.49 [0.0452, 0.2202] <0.001
Psychological Society (BPS), especially guidelines pertaining to online 3. Study 1

mediated research (British Psychological Society, 2013).
3.1. Aim
2.2. Design
Study 1 aimed to assess whether dissociation is higher in those with
The current project comprises three online cross-sectional studies in FND, relative to healthy controls and if dissociation scores hold a rela
three volunteer (unpaid) cohorts. Participants with FND were recruited tionship with adverse life experiences.
through advertisements with charitable organisations and support
groups. Controls (healthy participants with no pre-existing mental or 3.2. Participants
physical health conditions) were recruited through existing online
platforms and snowballing. In studies 2 and 3, a long-term disability Participants (67.03 % UK residents) with FND (N = 121; 14 males,
group (LTD) formed an additional control. LTD had conditions charac 107 females) and healthy controls (N = 64, 10 males, 54 females) were
terized by similar physical impairments to those with FND, which had aged 18–72 years (entire group Mage = 37.23, SD = 12.09; FND par
lasted for >6 months. To recruit the LTD group, several support groups ticipants' Mage = 38.35, SD = 10.88; Controls Mage = 35.11, SD =
who supported people with conditions including Multiple Sclerosis, 13.94).
Elher-Danlos Syndrome, Epilepsy, Chronic Fatigue Syndrome and Fi
bromyalgia, advertised the study link. Much of the sample consisted of 3.3. Procedure
UK participants, the demographic variables for each cohort are provided
in the studies below. All participants were over the age of 18 and re Participants completed an online self-report survey with questions
ported being fluent in English language. Whilst additional demographic on demographics (i.e., health status, age, sex and country of residence),
information would have added to the strength of the data collected, and psychometrics (assessment of anxiety, depression, dissociation and
additional data regarding demographics (including SES, education and life events).
employment status) proved challenging to collect and analyse robustly
and thus are not described within the manuscript. Data were collected 3.4. Self-report scales
using an online survey collection platform (Qualtrics) and an anony
mous link was distributed to participants. Results were analysed using 3.4.1. Anxiety
IBM SPSS V.24. Anxiety was measured using a 10-item (5 negatively scored) subscale
from Jackson's Personality Inventory-Revised (JPI-R; Jackson, 1994).
2.3. Power & sample size Responses were scored on a true-false scale with scores ranging from 10
(low anxiety) to 20 (high anxiety), with high scores indicating higher
Given that the proportion of missing data is directly attributed to the anxiety. The scale was selected due to its short form, good reliability and
quality of statistical inferences, these three studies removed participants psychometric properties (Cronbach's Alpha = 0.87).
from the analysis if they had >10 % missing data (whilst not a
commonly applied rule Bennett (2001) states that statistical analysis is 3.4.2. Depression
more likely to be biased beyond this threshold). Given the equal Depression was assessed using a 10-item (3 negatively scored) sub
importance of sample size and quality of the data, a priori power anal scale from the Revised NEO Personality Inventory (NEO-PI-R; Costa and
ysis was conducted using using G*Power version 3.1.9.7 (Faul et al., McCrae, 2008). Responses were scored on a true-false scale with a total
2007), which generates minimum sample size requirements based on score range from 10 (low depression) to 20 (high depression). The scale
effect size, error probability, degrees of freedom, number of groups and has good psychometric properties and good reliability (Cronbach's =
covariates. Results indicated the required sample size to achieve 80 % 0.88).
power for detecting a medium effect, at a significance criterion of a =
0.05, was N = 225 for MANOVA global effects. G*Power suggested we 3.4.3. Dissociation
would need a minimum of 55 participants per group in an independent Dissociation was measured using the 20-item Dissociative Symptoms
samples t-test. Minimum recommended sample sizes were exceeded in Scale (DSS; Carlson et al., 2018). Examinations of misperceptions, cog
all studies (post data removal, based on missing values). Effect sizes nitions and behaviours were measured across four subscales, i) distor
were calculated by Eta Squared and interpreted based upon Cohen's tions in perceptions of the self/surroundings (decentralisation/
(1988) cut-off values and confidence intervals have been reported at 95 depersonalisation), ii) experiences of gaps in awareness/memory, iii)
%. sensory misperceptions and iv) trauma-related re-experiencing. The
mean of each of the subscales is summed to create an overall dissociation
score, where high scores equate to higher levels of dissociation. The
authors reported the reliability of the scale to be 0.82 (as measured by
Cronbach's alpha) with good properties when considered as a whole or
product of subscales and with high re-test reliability.
3
Table 2 samples were conducted, followed by independent comparisons of cor

Pearson's correlation coefficients for dissociation, anxiety, depression and life relation coefficients (using Fisher's z transformations where appro
events for the healthy control and FND group (Study 1). priate). Results revealed that the strength of the correlation between
Group Variable Dissociation Anxiety Depression Life events Dissociation and Life Events for those with FND (z = 0.07) and healthy
Dissociation
controls (z = 0.49) were significantly different,x2(2) = 2.67, p = .008,
Control Anxiety 0.130 with this correlation being greater in the Healthy control group. The
Depression 0.165 0.728** magnitude of the effect between Anxiety and Depression was significantly
Life events 0.457* − 0.058 − 0.115 greater for the FND group (z = 1.36) than the Healthy Group, z = 0.92;
FND Anxiety − 0.004
x2(2) = 2.78, p = .005.
Depression − 0.014 0.877**
Life events 0.072 − 0.079 0.125
4.1. Summary study 1
Note: significant indicated by * p < .05. ** p < .01.
The results of Study 1 show that dissociation in individuals with FND

3.4.4. Life events
is higher than in people without FND. This is the case across all the
The Davidson Trauma Scale (DTS; Davidson et al., 2002) was used to
measured sub-facets of dissociation (derealization, gaps, sensory and re-
measure the impact of life events and presence of negative, traumatic
experiences). Although participants with FND scored higher for anxiety
experiences. This 17-item scale measures life events on a 5-point fre
and depression, they did not report significantly more adverse life-
quency and severity scale with scores ranging from 0 (no impact) to 68
events, suggesting that they do not experience more trauma than
(high impact). The scale assesses a range of life events and is robustly
those without FND. Unlike in the non-FND group, dissociation was not
tested across multiple populations with good reliability (Cronbach's
correlated with trauma in those with FND. Elevated dissociation scores
alpha = 0.86).
were also unrelated to mood scores in the FND group. Thus, current
results do not support an association between dissociation in FND and
3.5. Statistical analysis mood or psychological trauma. The comparison here was with a healthy
(non-FND) sample, so it is not clear from these results whether this
Preliminary analyses were performed to assess the assumptions of pattern of dissociation is unique to FND or a result of long-term chronic
normality, linearity, homogeneity of variance-covariance matrices and illness. Study 2 further investigated comparisons with other long-term
multicollinearity. No scale, or subscale was excluded because of data not health disorders (LTD).
being normally distributed (see Appendix A). MANOVA was used to
compare scores between the Groups (FND and Healthy) on anxiety, 5. Method Study 2
depression, dissociation and life events. Pearson's Correlations tested for
the relationship between dissociation, anxiety, depression and life 5.1. Aim
events. Fisher's Z-tests were computed to compare the magnitude of
these correlations between the FND and Healthy groups. This study aimed to explore dissociation levels between those with
FND, those with other long-term conditions and relatively healthy par
4. Results Study 1 ticipants to make direct illness comparisons. Study 2 aimed to explore
whether levels of dissociation differed between the three groups and if
Table 1 shows the descriptive statistics, F-values and significance for dissociation held a relationship with mood, impact of illness and/or
the groups for anxiety, depression, life-events and dissociation (total levels of disability.
dissociation and the four subscales). A statistically significant MAOVA
effect was obtained, Pillais' Trace = 0.35, F(4, 162) = 21.70, p < .001.
5.2. Participants
Significantly higher scores were seen in the FND group relative to
healthy controls for anxiety (F(1, 165) = 16.75, p < .001, η2 = 0.092,
Participants (N = 589; 79 males, 4 gender fluid; 18–79 years M =
moderate effect size) and depression (F(1, 165) = 24.77, p < .001, η2 =
37.04, SD = 12.42) were recruited. Twenty-one participants were
0.131, moderate effect size). There was no significant differences be
removed from the subsequent analysis due to missing data (>10 %) or
tween FND and controls life-events, F(1, 165) = 3.59, p = .064, η2 =
for being outliers (with scores exceeding the critical value obtained via
0.021, small effect. Compared to controls, FND showed higher mean and
examination of Manhalonobis distance scores, see Appendix A, and ex
greater standard deviation for dissociation and the difference in total
amination of individual responses appearing indicative of abnormal
dissociation scores was significant, F(1,17) = 54.55, p < .001, η2 =
responding from the populations which these cases were sampled from).
0.248, large effect,. Univariate analyses of the subscales of dissociated
The final cohort comprised, FND participants (N = 277; 24 males, Mage
showed effects of Group in all four subscales showed this effect was
= 39.22, SD = 11.93), controls (N = 202; 49 males, Mage = 32.73, SD =
present for all four subscales with FND scoring significantly higher in all
11.95) and a long-term disability control group (LTD; N = 89; 6 males,
subscales: Decentralisation/depersonalisation (F(1, 165) = 71.96, p <
Mag = 40.35, SD = 11.95).
.001, η2= 0.30); Gaps (F(1, 165) = 48.83, p < .001, η2= 0.228); sensory
experiences (F(1, 165) = 25.26, p < .001, η2= 0.13; and re-experiencing
(F(1, 165) = 23.49, p < .001, = 0.05, η2 = 0.13). 5.3. Self-report scales
Table 2 shows the Pearson's correlation coefficients for Anxiety,
Depression, Life Events and Dissociation, separated by Group. In the All participants provided demographic information and completed
healthy control group, there was a moderately strong, positive correla Dissociation and mood self-report measures. Those in FND and LTD
tion between dissociation and life-events, r = 0.616, p = .040, 95 % CI groups were asked to complete 3 additional scales in assessing impact of
[0.00, 0.08], but not between dissociation and anxiety (p = .650) nor health (Impact of Illness and a Disability scale).
between dissociation and depression (p = .204). In the FND group the
relationship between dissociation and life-events was not significant (p 5.4. Scales completed by all groups
= .450). No other significant correlations were found within the data.
To ascertain whether the magnitude of the correlations between the 5.4.1. Dissociation
psychometric measures differed significantly between the two groups Dissociation was measured using the 20-item Dissociative Symptoms
(FND and Healthy), two Fisher's z–Tests for multiple independent Scale (DSS; Carlson et al., 2018) as previously described in Study 1.
4
Table 3
Means, standard deviations, Cronbach's alpha and significant values of each of the tested variables for the three groups (Study 2).
Variables FND LTD Controls ∝ f Statistic 95 % CI p
M SD M SD M SD
Anxiety 29.30 9.21 27.75 9.26 21.49 9.29 0.80 45.70 [0.0977, 0.2065] <0.001
Depression 30.38 12.73 31.08 13.88 24.46 9.78 0.94 14.26 [0.0199, 0.0928] <0.001
Stress 32.02 10.12 32/84 10.12 25.78 8.20 0.85 24.92 [0.0458, 0.1364] <0.001
Dissociation (overall) 9.35 3.59 7.62 2.78 6.09 2.23 0.88 57.09 [0.1238, 0.2372] <0.001
Decentralisation/depersonalization 2.77 1.12 2.20 1.12 1.14 0.61 – 95.49 [0.2070, 0.3279] <0.001
Gaps 2.93 1.18 2.51 1.08 2.03 1.00 – 85.52 [0.1861, 0.3059] <0.001
Sensory experiences 1.84 0.90 1.38 0.56 1.25 0.46 – 37.63 [0.0766, 0.1788] <0.001
Re-experiencing 1.76 0.93 1.52 0.55 1.35 0.50 – 15.88 [0.0234, 0.0985] <0.001
Note: In rows, interactions have been detailed along with relevant significant values. ‘-’ has been used to represent where data was not available i.e. when testing was
not conducted as it was not applicable to the interaction or when this test was not conducted.
Table 4
Correlations between dissociation scales, impact of illness and levels of disability separated by Group (Study 2).
Group Variables Anxiety Depression Stress Impact of Levels of Dissociation Deper/ Gaps Sensory Re-
illness disability (total) Dereal exp.
FND Anxiety
Depression 0.689**
Stress 0.722** 0.724**
Impact of illness 0.379** 0.385** 0.278**
Levels of 0.300** 0.237** 0.252** 0.616**
disability
Dissociation 0.611** 0.604** 0.597** 0.449** 0.450**
(total)
Deper/dereal 0.516** 0.518** 0.511** 0.436** 0.439** 0.886**
Gaps 0.519** 0.530** 0.501** 0.440** 0.393** 0.898** 0.750**
Sensory 0.529** 0.478** 0.453** 0.339** 0.419** 0.857** 0.651** 0.691**
Re-exp. 0.567** 0.572** 0.613** 0.361** 0.301** 0.823** 0.621** 0.617** 0.695**
LTD Anxiety
Depression 0.683**
Stress 0.659** 0.882**
Impact of illness 0.455** 0.600** 0.547**
Levels of 0.455** 0.338** 0.285* 0.412**
disability
Dissociation 0.634** 0.600** 0.684** 0.456** 0.290**
(total)
Deper/dereal 0.594** 0.575** 0.666** 0.453** 0.363** 0.929**
Gaps 0.447** 0.555** 0.644** 0.453** 0.105 0.897** 0.761**
Sensory 0.573** 0.190 0.237* 0.138 0.282* 0.715** 0.572** 0.506**
Re-exp. 0.632** 0.674** 0.704** 0.423** 0.296** 0.825** 0.744** 628** 0.532**
Healthy Anxiety
Depression 0.617**
Stress 0.722** 0.718**
Impact of illness – – – –
Levels of – – – – –
disability
Dissociation 0.794** 0.658** 0.662** – –
(total)
deper/dereal 0.805** 0.615** 0.642** – – 0.852**
Gaps 0.681** 0.639** 0.594** – – 0.913** 0.585**
Sensory 0.434** 0.358** 0.360** – – 0.759** 0.557** 0.585**
Re-exp. 0.699** 0.542** 0.609** – – 0.868** 0.729** 0.706** 0.589**
**
Highlights that correlation is significant at the 0.01 level.
*
Indicates significance at the 0.05 level.
5.4.2. Mood 5.4.3. Additional scales completed by FND and LTD groups
The Depression, Anxiety and Stress scale (DASS-21; Lovibond and
Lovibond, 1995) is a 21-item scale (7-items each for depression, anxiety 5.4.3.1. Impact of illness. The impact of illness scale (Klimidis et al.,
and stress). Scores on each of the subscales ranged from 0 (none) to 3 2001) was also used to measure impact of illness for FND and LTD
(usually/always). The scale assesses dysphoric mood states including groups. The 9-item scale is measured on a 4-point Likert scale from
self-depreciation, lack of interest, hopelessness, arousal states and 0 (not at all) to (3) fully, giving potential scores of 0 (no impact) to 27
emotional liability to stressors across the subscales. Summed scores were (strong impact). The scale measures the degree that any illness interferes
generated and multiplied by two to match the authors’ recommenda with key roles and responsibilities associated with daily life, for example
tions. The scale has good psychometric properties (Cronbach's alpha = “To what extent has your capacity to carry out routine chores, been
0.80). reduced?”. This scale had good reliability measures (Cronbach's alpha =
0.93).
5.4.3.2. Disability scale. An adapted version of The Guy's Neurological
5
Table 5
Means, standard deviations, Cronbach's alpha and significant values of each of the tested variables for the three groups (Study 3).
Variables FND LTD Controls ∝ f Statistic 95 % CI p
M SD M SD M SD
Anhedonia 64.49 12.46 69.02 10.45 70.19 9.05 0.88 12.70 [0.0182, 0.0948] <0.001
Anxiety 10.32 5.57 9.40 4.77 7.37 5.54 0.93 13.13 [0.0193, 0.0969] <0.001
Depression 14.33 13.64 21.81 12.12 25.27 10.64 0.94 34.64 [0.0775, 0.1874] <0.001
Social isolation 5.70 2.08 6.39 1.94 6.75 1.99 0.83 11.68 [0.0157, 0.0896] <0.001
Social support 8.43 2.34 8.86 2.29 9.45 2.03 0.71 8.88 [0.0092, 0.0747] <0.001
Stress 7.98 5.83 6.10 4.71 3.73 4.23 0.93 30.26 [0.0662, 0.1721] <0.001
Dissociation 66.64 25.9 56.64 21.76 48.86 20.73 0.96 24.82 [0.0505, 0.1495] <0.001
(Total)
Disengagement 15.74 5.19 14.12 5.29 12.43 4.81 – 17.45 [0.0305, 0.1176] <0.001
Identity 7.52 4.52 6.88 3.63 6.89 3.98 – 1.27 [0.0000, 0.0236] 0.281
Emotional 11.41 6.20 10.36 5.93 8.28 4.95 – 12.88 [0.0186, 0.0957] <0.001
Memory 11.53 5.55 9.18 4.62 7.49 3.82 – 30.52 [0.0662, 0.1720] <0.001
Depersonalisation 9.96 5.60 7.73 3.68 6.65 3.54 – 23.89 [0.0479, 0.1456] <0.001
Derealisation 10.48 5.45 8.37 4.59 7.11 4.11 – 21.03 [0.0401, 0.1335] <0.001
Note: Cronbach's alpha scores under the ‘∝’ columns are bolded if deemed to be >0.7 and thus show good internal reliability. Significance is listed under ‘p’ column
with sign and significant effects are bolded. In rows, interactions have been detailed along with relevant significant values. ‘-’ has been used to represent where data
was not available i.e. when testing was not conducted as it was not applicable to the interaction or when this test was not conducted.
Table 6
Correlations between dissociation, anhedonia, anxiety, stress, depression, social isolation and social support in the FND, LTD and Healthy Groups (Study 3).
Group Variables Anhedonia Anxiety Stress Depression Social isolation Social support Dissociation
FND Anhedonia
Anxiety − 0.134
Stress − 0.125 0.809**
Depression − 0.329** 0.704** 0.724**
Social Isolation − 0.024 0.467** 0.437** 0.529**
Social Support 0.155* − 0.229** − 2.56* − 0.343** − 0.207**
Dissociation − 0.261** 0.617** 0.663** 0.687** 0.275** − 0.365**
LTD Anhedonia
Anxiety − 0.009
Stress 0.116 0.752**
Depression − 0.126 0.693** 0.592**
Social Isolation 0.013 0.301** 0.338** 0.352**
Social Support 0.127 − 0.245** − 0.175* − 0.386** − 0.293**
Dissociation − 0.102 0.514** 0.531** 0.586** 0.259** − 0.358**
Healthy Anhedonia
Anxiety − 0.054
Stress 0.015 0.733**
Depression 0.052 0.710** 0.615**
Social Isolation 0.008 0.470** 0.393** 0.512**
Social Support 0.106 − 0.272** − 0.245** − 0.396** − 0.278**
Dissociation 0.139 0.462** 0.679** 0.582** 0.329** − 0.277**
**
Highlights that correlation is significant at the 0.001 level.
Disability Scale (GNDS; Sharrack and Hughes, 1999) was used to mea 6. Results Study 2
sure levels of disability within the FND and other illness control group.
Whilst the scale was designed for MS, at the time of data collection for Table 3 shows the descriptive statistics, F/t values and significance
this study, there were no published scales to measure disability in FND. for the groups for mood and dissociation.
The GNDS has demonstrated good reliability, re-test reliability and There was a significant effect of Group on anxiety (F(2, 510) = 45.70,
validity over the phone and through self-administration, Cronbach's = p < .001, η2 = 0.15, large effect), depression (F(2, 510) = 14.26, p <
0.96 (Rossier and Wade, 2002). The adapted scale had a total of 9-items .001, η2= 0.05, large effect size), and stress (F(2, 512) = 24.92, p < .001,
measuring cognitive, visual, bladder, bowel, sexual, speech and motor η2 = 0.09, moderate effect size). Post-hoc comparisons (using Turkey
impairments with high scores indicating high levels of disability. This HSD) indicated higher scores in FND than controls for anxiety (p =
scale showed good psychometric properties when used online in the .006), depression (p = .001) and stress (p = .001). The LTD group also
current sample (Cronbach's alpha = 0.90). showed significantly higher scores than controls for anxiety (p = .001),
depression (p = .001) and stress (p = .001). There were no significant
5.4.3.3. Statistical analysis. Following preliminary analysis to ensure differences between the FND and LTD groups for anxiety (p = .323),
data assumptions were met, Multivariate analysis (MANOVA) were depression (p = .887) and stress (p = .778).
carried out to compare scores between the FND, LTD and Healthy con There was an effect of Group on dissociation, F(2, 516) = 57.09, p <
trol groups for anxiety, depression, stress and dissociation. Further an .001; η2 = 0.18. Post-hoc comparisons (using Turkey HSD) indicated
alyses of variance explored illness effects (impact of illness and levels of higher dissociation in FND than LTD and control (p = .001) groups. The
disability) and Pearson's correlations were used to investigate relation LTD group had higher dissociation than controls (p = .001) Univariate
ships with dissociation. Fisher's Z-tests were computed to explore the analyses of subscales showed effects of Group in all subscales Decen
magnitude of these correlations between the FND, LTD and Healthy tralisation/depersonalisation (F(2, 516) = 95.49, p < .001, η2 = 0.27,
groups. large effect); Gaps (F(2, 518) = 85.52, p < .001, η2= 0.25); sensory
6
experiences (F(2, 518) = 37.63, p < .001, η2= 0.13, moderate effect 7. Methods Study 3
size); and re-experiencing (F(2,5 18) = 15.88, p < .001, η2= 0.06, small
effect). In all cases, post-hoc comparisons indicated higher scores in FND 7.1. Aim
than LTD (Decentralisation/depersonalisation p < .001; Gaps p = .008;
Sensory p < .001; Re-experiencing p = .034). FND also scored higher Social isolation/exclusion is often experienced by those with long-
than Healthy controls, in all cases (Decentralisation p < .001; Gaps p < term chronic illnesses (Cacioppo and Hawkley, 2003; Dalenberg and
.001; Sensory p < .001; Re-experiencing p < .001). Carlson, 2012). However, it is unclear whether this relates to Dissocia
tion in FND. Studies 1 and 2 did not show a relationship with adverse
6.1. Effects of illness life-events or mood and dissociation in FND, however given such high
levels of dissociation in the patient group this could represent a
Higher scores were seen in the FND group (M M = 26.51, SD = 4.98) detachment of emotion for the participants rendering self-report of
relative to the LTD group (M = 25.12, SD = 5.18) for impact of illness F emotions difficult. The current study thus explored the relationship
(1, 357) = 4.96, p = .027, η2 = 0.026, small effect. Higher scores were between dissociation and social isolation during COVID-19 restrictions
also seen in the FND Group (M = 22.30, SD = 5.01) than the LTD group between three groups: FND, LTD and healthy controls. In addition,
(M = 19.14, SD = 5.50) for levels of disability, F(1, 342) = 23.48, p < dissociation was explored with reference to Anhedonia, as this
.001, η2 = 0.08, moderate effect size. emotional detachment could account for an inability to self-identify and
Table 4 shows the Pearson's correlation coefficients for impact of therefore report mood scores in the FND cohort. The study used different
illness, levels of disability and dissociation for each group. Correlations scales to those previously tested to ensure that results were not reliant
with mood were not significant, replicating the findings of study 1. upon specific psychometric measures.
There was a strong, positive correlation between disability levels and
impact of illness in the FND group, r = 0.616, n = 349, p < .001, 95 % CI 7.2. Participants
[0.55, 0.68]. There were moderately strong, positive correlations be
tween dissociation and impact of illness, r = 0.449, N = 349, p < .001, Participants (N = 542; 158 males, 382 females, 2 gender fluid) took
95 % CI [0.36, 0.53] and dissociation and levels of disability, r = 0.450, part in an online questionnaire. Eighty-two participants were removed
n = 349, p < .001, 95 % CI [0.37, 0.53]. Subscales for dissociation were from the subsequent analysis as they had >10 % data missing or were
correlated with impact of illness and levels of disability. deemed to be outliers in preliminary analysis (11 cases had a score
To ascertain the magnitude of the correlations for impact of illness exceeding the critical value obtained via Manhalonobis distances and
measures between the FND and LTD Groups, three Fisher's z-tests for after examination of individual cases by response pattern these cases
independent samples were conducted. Results revealed that the strength were removed, see Appendix A for additional clarity). The final sample
of the correlation between impact of illness and levels of disability for comprised FND participants (N = 163; Mage = 43.41, SD = 12.79),
those with FND (z = 0.67) and LTD (z = 0.41) were significantly healthy controls (N = 202; Mage = 35.11, SD = 14.17) with no long-term
different, x2(2) = 2.27, p = .023. The correlations between dissociation or physical health conditions and a long-term disability control group
and impact of illness (p = .943) and dissociation and levels of disability (LTD; N = 129; Mage = 37.51, SD = 12.52) were recruited using the
(p = .132) did not significantly differ between the two groups. same methods as study 2.
6.2. Summary study 2 7.3. Self-report scales
Whilst those with FND scored higher on mood measures (anxiety, 7.3.1. Anhedonia
depression and stress) than healthy controls (mimicking the results from Anhedonia was measured using the 17-item Dimensional Anhedonia
Study 1), they did not score significantly higher on these measures when Rating Scale (DARS; Rizvi et al., 2015). Responses across four subscales,
compared to the LTD group. This suggests that high anxiety, depression on a 5-point rating system, were averaged to create a total anhedonia
and stress may not be specific to those with FND, rather it could result score. The scale considers assessment of anhedonia across areas such as
from living with a long-term chronic illness and associated changes in interest, motivation, effort and pleasure and showed good reliability
quality of life, self or economic status and/or shared underpinning (Cronbach's alpha = 0.88).
biological mechanisms of long-term ill health, such as inflammation.
The FND group did however report significantly higher impact of illness 7.3.2. Anxiety & stress
and greater levels of disability than the LTD group. Elevated levels of Anxiety and Stress were measured using subscales from The
dissociation were found for the FND group relative to both the healthy Depression Anxiety Stress Scale (DASS-21; Lovibond and Lovibond,
and LTD groups. This suggests that dissociation may be a prominent 1995), described in Study 2.
feature of FND that distinguishes the condition from other long-term
illnesses, especially as dissociation is also associated with the impact 7.3.3. Depression
of illness and increased disability in the FND group. However, social and Depression was assessed using The Beck's Depression Inventory (BDI-
environmental factors (e.g., social isolation) are also known to increase II) which contains 21 items on a 4-point scale from 0 (symptom absent)
dissociation in interaction with biological drivers (Nijenhuis and van der to 3 (severe symptoms). Affective, cognitive, somatic and vegetative
Hart, 2011). Moreover, living with a long-term condition or disability symptoms are assessed, reflecting the DSM-IV criteria for major
can increase risk for social isolation/exclusion (Guilcher et al., 2021; depression (Steer et al., 2000). Scoring was computed as per the scales
O'Grady et al., 2004), impacting self-concept and/or social support recommendations with scores ranging from 0 to 63 and high scores
(Dalenberg and Carlson, 2012). Therefore, in study 3 we assessed the indicating greater symptom severity. In non-clinical populations, scores
relationship between social isolation and dissociation between FND, above 20 indicate depression. The internal consistency was very good
LTD and healthy groups. (Cronbach's alpha = 0.94).
7.3.4. Dissociation
Briere et al. (2005)’s Multiscale Dissociation Inventory (MDI) was
used to assess dissociation across 6 subscales; Disengagement, Identity,
Emotional, Memory, Depersonalisation and Derealisation. The 30-item
scale also generates a total dissociation score. The scale asks people to
7
consider how often they find themselves in particular circumstances or the three groups, F (2, 457) = 24.82, p < .001, η2 = 0.098, moderate
feeling dissociative tendencies e.g., “Feeling like you don't belong in effect. Significantly higher mean scores were seen in the FND group than
your body”. The scale showed good psychometric properties and good the LTD group (p = .001) and the healthy control group (p < .001). The
internal consistency (Cronbach's alpha = 0.96). mean score of the LTD group was also significantly higher than the mean
score for the healthy control group (p = .011), however the greatest
7.3.5. Social isolation difference was between the FND and Control groups (Meandif = 17.78, p
The Social Isolation Scale (Cotten et al., 2017) was used to measure < .001).
the extent of participant's social isolation during COVID-19 restrictions. Further analysis showed this effect was present for most of the 6
The 3-item scale rates items on a 5-item scale with high responses subscales of dissociation: the FND group scored significantly higher than
indicative of high levels of social support. The scale showed good psy the LTD group for Disengagement (p = .019), Memory (p < .001),
chometric properties (Cronbach's alpha = 0.83). Depersonalisation (p < .001) and Derealisation (p = .001). The FND
group also scored significantly higher than healthy controls for Disen
7.3.6. Social support gagement (p < .001), Emotional (p < .001), Memory (p < .001),
Using the OSLO Social Support Scale-3 (Meltzer, 2003), participants Depersonalisation (p < .001) and Derealisation (p = .001). The LTD
answered multiple-choice structured items on a 3-item scale. The sum of group showed significantly higher scores than healthy controls for
the scores ranges from 3 to 14 with high values indicative of strong Disengagement (p = .014), Emotional (p < .001), Memory (p = .007),
levels of social support, the median score of 10 indicates moderate social Depersonalisation (p = .009). The subscale Identity did not show any
support. The scale showed good psychometric properties and good statistically significant differences between the groups; there were no
reliability (Cronbach's alpha = 0.71). other noteworthy significant interactions.
7.4. Procedure
8.2. Social isolation and social support
Data for this study was collected between April – June 2020 at a time
when large sections of the population were forced to limit social inter There was a significant effect for Group for social isolation, F (2,457)
action and travel due to the COVID-19 pandemic. This provided an = 11.68, p < .001, η2= 0.05 and social support, F(2,457) = 8.88, p <
opportunity to study social isolation and its relationship with dissocia .001, η2= 0.04. Post-hoc tests showed lower scores for social isolation in
tion in FND, using a unique social situation in which people, regardless the FND group compared to the Healthy group (p < .001) and lower
of health status, experienced similar restrictions to social movement. scores in the FND group compared to the LTD group (p = .009). LTD and
After providing informed consent, participants provided demographic healthy group (p = .297) showed no significant difference in social
information and answered a battery of psychological self-report mea isolation scores. Significantly lower scores were reported by the FND
sures before being debriefed. group in social support compared to the healthy control group (p <
.001). There were no significant differences in social support between
7.5. Statistical analysis the FND and LTD group (p = .226) or between the LTD and healthy
group (p = .06).
Preliminary analyses (see Power & Sample Size) were performed to
ensure no violation of the assumptions of normality, homogeneity of
variance-covariance matrices and multicollinearity. Outliers were 8.3. Relationships to dissociation
removed from the data, but no other serious violations were noted.
MANOVA's were used to compare the mean scores of the FND, LTD and Table 6 shows the Pearson's Correlation Coefficients for Anhedonia,
Healthy control groups for anhedonia, anxiety, stress, depression, so Anxiety, Depression, Stress, Dissociation, Social Support and Social
cialization and social support. Pearson's correlations tested the rela Isolation separated by Group. In those with FND, Dissociation showed
tionship between these variables in each group and Fisher's z-tests were statistically significant, weak, negative correlations with Anhedonia (p
computed to compare the magnitude of these correlations. = .001, 95 % CI [− 0.405, − 0.117]) and Social Support (p < .001, 95 %
CI [− 0.50, − 0.23]). There were strong positive correlations in the FND
8. Results Study 3 group with Dissociation for Anxiety (p < .001, 95 % CI [0.52, 0.71]),
Stress, (p < .001, 95 % CI [0.58, 0.75]) and Depression (p < .001, 95 %
Table 6 shows the descriptive statistics, inferential statistics and CI [0.61, 0.77]). A weak, positive correlation was found between
significance for the groups for anhedonia, anxiety, depression, dissoci Dissociation and Social Isolation (p < .001, 95 % CI [0.13, 0.41]). A
ation, social isolation and social support. similar pattern of results is seen in both the LTD and Healthy groups with
There was a significant effect of Group for Anhedonia (F(2, 457) = Dissociation showing strong positive correlations with Anxiety (p <
12.70, p < .001, η2= 0.05, small effect), Anxiety (F(2, 457) = 13.13, p < .001), Stress (p < .001), and Depression (p < .001). Both groups showed
.001, η2=0.05, small effect), Depression (F (2, 457) = 34.64, p < .001, a weak negative correlation between Dissociation and Social Support (p
η2=0.13, moderate effect) and Stress (F(2, 457) = 30.53, p < .001, < .001) and a weak positive correlation between Dissociation and Social
η2=0.12, moderate effect). Compared to healthy controls, the FND Isolation (p < .001). Correlations between Anhedonia and Dissociation
group showed significantly lower scores for anhedonia (p < .001), in the LTD and Healthy groups were not significant.
anxiety (p < .001) and depression (p < .001). The FND group has To ascertain whether the magnitude of the correlations between the
significantly higher stress scores than healthy controls (p < .001). In psychometric measures differed significantly between the three groups
comparison to the LTD group, the FND group showed significantly lower (FND, LTD and Healthy), 6 Fisher's z-Tests for multiple independent
scores for anhedonia (p = .001) and depression (p < .001). The FND samples were conducted, followed by independent comparisons of cor
group showed significantly higher scores than the LTD group for stress relation coefficients (using Fisher's z transformations where appro
(p < .001). There were no significant differences between the FND and priate). Results revealed that the strength of the correlation between
LTD group for anxiety (p = .308). Dissociation and Anhedonia was significantly different between the FND
(z = − 0.27), LTD (z = − 0.10) and Healthy (z = 0.14) Groups [x2(3) =
8.1. Dissociation 15.04, p = .001]. The magnitude of difference was not significant for
Dissociation and the following: Anxiety (p = .112), Depression (p = .195),
There was also a significant difference in dissociation scores between Stress (p = .095), Social Anxiety (p = .760) or Social Support (p = .590).
8
8.4. Summary Study 3 have a relationship with adverse life-experiences. Future research
should explore the extent to which adverse life events increases sus
When we compare FND to others (with or without long-term con ceptibility to developing FND across symptom subtypes.
ditions) who are being subjected to the kinds of social isolation that Study 2 investigated whether dissociation in FND is associated with
often accompanies FND, we still find elevated dissociation in people being chronically ill (and concomitant life changes) or a product of
with FND. This suggests that elevated dissociation in FND is likely not mood. Our findings suggest dissociation in FND is higher than both
attributable to the social isolation the patients endure as a result of their healthy controls and those with other long-term health conditions whose
chronic illness. It is worth noting that the FND group reported less symptoms mimic FND. Thus, high dissociation scores appear to be a key
anhedonia than the other two groups, which might indicate a prior feature in FND, and more prominent than in conditions with similar
habituation with the isolation conditions that affected the other groups symptoms. Given the high variability of dissociation in the FND group, it
more strongly. is possible that dissociation may be particularly associated with certain
subtypes, such as NEADS (Goldstein and Mellers, 2006); NEADs is also
9. General discussion associated with raised dissociation compared to those with epilepsy
(Myers et al., 2019). Identification of such FND subtypes, characterized
The present three-study, cross-sectional project aimed to establish by dissociation, might have implications for tailoring treatment for FND.
the relationship between dissociation and FND and explore several Dissociation was associated with higher disability scores and could
factors implicated in the development of dissociation, that could influ reflect generally higher disability and impairment to quality of life than
ence this relationship. Specifically, we measured i) comparisons in those with other organic disorders (Carson et al., 2011).
dissociation between healthy controls and those with other chronic ill In the current data there was no association between dissociation and
nesses (all studies); ii) relationships between adverse life-events and social isolation in FND. Moreover, even during global social isolation
dissociation (study 1); iii) relationships between social isolation and (Study 3 was conducted during the COVID-19 pandemic), FND partici
dissociation (study 3); and iv) the relationship with dissociation and pants maintained higher dissociation than both control groups. This is
mood (stress, anxiety and depression; all studies). particularly interesting as it could be argued that those with FND may be
The findings from all 3 studies support elevated dissociation in FND more accustomed to social isolation and restrictions to their movement,
relative to both controls and those with other long-term illness, on most as a result of the unpredictability of symptoms and reduced quality of
subscales (Derealisation, Memory/gaps, Emotional, Disengagement and life. This might explain why those with FND also reported lower
Depersonalization) but not on those focusing on identity. However, the depression, than in studies 1 and 2 and compared to healthy and LTD
findings do not support a relationship between dissociation and trauma, controls, despite reporting less social support. Those with FND and long-
dissociation and mood or dissociation and social isolation in FND. This term other conditions reported higher anxiety, although this might
suggests that elevated dissociation may be particularly prominent in reflect a lack of access to medical or support care for their conditions
FND and greater than in other similar chronic illnesses; thus, corrobo during “lockdown”. Given these findings, we would recommend that
rating previous assertions that dissociative tendencies are a significant future research continues to explore the importance of dissociation in
difficulty for those diagnosed with FND (Brown et al., 2007; Pick et al., FND. Further, given the lack of evidence here to support that elevated
2017). For example, those with FND are also known to have greater dissociation is a product of usual triggering factors (mood, adverse life-
susceptibility to dissociation induction in laboratory studies (Perez experiences and social isolation) it should be considered if dissociation
et al., 2018) and are susceptible to both detachment and compartmen in FND is a symptom of the illness which may distinguish it from other
talization phenomena (Brown et al., 2007; Holmes et al., 2005). Such similar conditions and what, if any, biopsychosocial mechanisms trigger
findings help to identify main areas of dysfunction in FND, with impli such elevated levels.
cations for focusing interventions and future research. Understanding This series of studies is not without its limitations, namely the use of
dissociation in FND could be valuable in refining treatment options and self-report measurements of psychological constructs collected remotely
increasing focus on overcoming dissociation, in combination with with individuals self-identifying their health status. At the time of data
grounding and body or emotion focused techniques, such as eye collection, methods of online screening of FND were limited and thus
movement desensitization and reprocessing (EMDR; Cope, 2020) and participants with FND were asked to confirm that they had i) been given
mindfulness-based therapies (Baslet et al., 2020). Whilst the effective the diagnosis of FND from a neurologist and ii) had experienced symp
ness of EMDR and mindfulness-based theories are not without contro toms for >6 months. Those with other Long-term conditions (control
versy (see Herbert et al., 2000) further studies should investigate their group) were asked to provide similar information as well as naming
effectiveness at reducing dissociation in FND and potential effectiveness health conditions. The presence of comorbid physical and mental health
at reduction of symptoms as a result. diagnosis, and the use of medications, may influence the findings in the
Whilst the typical relationship between dissociation and adverse life FND group. However, symptom pure groups are unlikely in this condi
experiences was seen in the control group, it was absent in the FND tion and given that the studies here repeatedly demonstrate high
group (study 1). Thus, current findings do not support a link between dissociation, this influence seems unlikely. Future studies should how
adverse life events and dissociation in FND. Nevertheless, some studies ever also aim to explore if dissociation subtypes and levels, influence
have found relationships between dissociation and adverse life-events or symptoms in FND and illness outcomes. However, despite these limita
trauma in FND (Brown et al., 2007; Nicholson et al., 2016) and adverse tions and across different and large samples of patients with FND this
early life-events have been found to be higher in those with FND when pattern of elevated dissociation remains and warrants further explora
compared to healthy controls (see Ludwig et al., 2018 for review).The tion and incorporation into theoretical models and the provision of
discrepancy between previous findings and our own could reflect treatment.
differing methodologies and sample acquisition; we recruited partici
pants through advertisements on FND support groups whereas prior 9.1. Conclusion
literature more heavily relies upon patients in either neurological or
psychiatric clinics or meta-analyses. Alternatively, disruption to the The current study repeatedly demonstrates raised dissociation in
typical dissociation-ACEs relationship in FND might reflect a reluctance FND, relative to healthy individuals and those with other long-term
to report adverse life-events due to a sensitivity/awareness of stigma. chronic health conditions. Understanding mechanisms underpinning
However, this alternative explanation is somewhat speculative and will dissociation in FND would have implications for development of etio
need to be more specifically explored in further studies. Thus, based on logical models and may be key to the disorder in general. Based on the
the current results, we argue that high dissociation scores in FND do not present findings, dissociation in FND does not appear to be associated
9
with adverse life events or mood (stress, anxiety and depression) or tests indicated eleven cases with a distance score exceeding this crit
psychosocial adversity (social isolation). Dissociation was however ical value. After examination of the individual cases by response pattern
associated with increased levels of disability and anhedonia in those and parameter estimates, these cases were deemed to be abnormal from
with FND, but not in those with other long-term conditions. Future the populations which they were drawn from. Thus, given this and their
studies should look toward identifying any biological correlates of sufficiently large influence on the regression parameters, these eleven
dissociation in FND. cases were excluded from the subsequent analyses.
CRediT authorship contribution statement A.2. Normality
Stephanie-Roxanne Blanco: Conceptualisation, Methodology, A.2.1. Study 1

Software, Formal Analysis, Investigation, Data Curation, Writing – The normality of variables in study 1 (Anxiety, Depression, Life
Original Draft, Visualisation Preparation Suvo Mitra: Conceptualisa Events and Dissociation) was assessed. The Shapiro-Wilk test indicated
tion, Writing – Review and Editing, Supervision Christina J Howard: that the scores were not normally distributed for Anxiety [W(184) =
Writing – Review and Editing, Supervision Alex L Sumich: Writing – 0.879, p ≤0.001], Depression [W(179) = 0.888, p ≤0.001], Life Events
Review and Editing, Supervision, Project Administration. [W(173) = 0.923, p ≤0.001] or Dissociation [W(185) = 0.905, p
≤0.001]. However, given the large sample size (>30) this violation was
Data availability not considered to be problematic. Skewness and kurtosis values were
between − 2 to +2 for each of the scales and subscales suggesting that
The data that support the findings of this study are available on data were normally distributed (Table 1).
request from the corresponding author. The data are not publicly
available due to privacy or ethical restrictions. A.2.2. Study 2
Normality of variables in study 2 (Anxiety, Depression, Dissociation,
Acknowledgements Impact of Illness, Levels of Disability and Stress) were assessed. Again
the Shapiro-Wilk test indicated a violation of the assumption of
We would like to thank FND Action, FND Dimensions and FND Hope normality for all variables; Anxiety [W(513) = 0.942, p ≤0.001],
UK for their assistance with advertising this study to their members, and Depression [W(513) = 0.902, p ≤0.001], Dissociation [W(513) = 0.907,
for all participants for their involvement in these studies. p ≤0.001], Impact of Illness [W(359) = 0.982, p ≤0.001], Levels of
Disability [W(344) = 0.990, p ≤0.001] and Stress [W(513) = 0.967, p
Funding ≤0.001]. However, again given the large sample size and the robustness
of MANOVA, this violation was not considered to be problematic.
This sutdy did not recieve a grant but the project was supported by Skewness and Kurtosis values were between − 2 to +2 for each of the
Nottingham Trent University through indirect funding and conducted scales and subscales (Table 3).
over the course of a number of years as part of the lead authors studies
(as an undergraduate, masters and PhD student). A.2.3. Study 3
Normality of variables was assessed in study 3 for all variables. Again
Appendix A the Shapiro-Wilk test indicated a violation for the assumption of
normality for all variables with p < .001; Anhedonia [W(460) = 0.952, p
≤0.001], Anxiety [W(460) = 0.969, p ≤0.001], Depression [W(459) =
A.1. Statistical assumption tests 0.966, p ≤0.001], Dissociation [W(459) = 0.880, p ≤0.001], Social
Isolation [W(458) = 0.906, p ≤0.001], Social Support [W(460) = 0.975,
A.1.1. Multivariate outliers p ≤0.001] and Stress [W(460) = 0.905, p ≤0.001]. Skewness and Kur
To screen for multivariate outliers amongst the variables in each of tosis remained between − 2 to +2 for all variables (Table 5).
the three studies, Mahalonobis distance scores were generated from
multiple regression analyses. Mahalanobis distance follows a Chi-square A.3. Homogeneity of variance-covariance matrices
(x2) distribution, in which the degrees of freedom are equivalent to the
number of independent variables in the model (Tabachnick et al., 2007). To protect against inflating Type 1 error MANOVAs with follow up
In study 1, there were 4 degrees of freedom, which equated to a critical ANOVAs and post-hoc comparisons were applied. Pearson correlations
Chi-Square value of 18.47 (at a = 0.001). The test revealed three cases performed between the dependent variables, showed correlations to be
with a distance score exceeding this critical value and examination of mostly within the moderate range (i.e., 0.20–0.60; Meyers et al., 2016).
the cases revealed that individual response patterns across variables was As can be seen in Table 2 (study 1) Table 4 (study 2) and Table 6 (study
not sufficiently abnormal to indicate illegitimate respondents nor did 3) a meaningful pattern of correlations was observed amongst most of
they seem unrepresentative of the population from which they were the dependent variables validating the appropriateness of the us of
drawn. Further examination of the parameter estimates excluded from MANOVA in these studies. Additionally, Box's M value for study 2 of
the model confirmed this indicating that no cases had a large influence 98.605 (p = .007), Box's M value for study 3 of 133.411 (p = .009) was
on the regression parameters and as such these three cases were interpreted as being non-significant. Thus, the covariance matrices be
retrained. tween the groups were assumed to be equal for the purposes of the
In study 2, there were 6 degrees of freedom, which equated to a MANOVA in studies 1 and 2. Study 1's Box's M value of 17.89 (p = .003)
critical Chi-Square value of 22.46 (at a = 0.001). Mahalonbis distance presumably as a result of the larger gap between sample sizes and
tests indicated five cases with a distance score exceeding this critical smaller sample of this study. For Study 1, Pillai's trace statistics were
value. After examination of the cases by individual response pattern used and reported to compensate for this potential violation of the
across the variables and parameter estimates, which were excluded from assumption, as reported in the results section.
the model, these cases indicated that responses were sufficiently Prior to conducting follow-up ANOVAs, the homogeneity of variance
abnormal and had a large influence on the regression parameters. Thus, assumption was tested for all subscales of Dissociation in each study.
these five cases were considered outliers and excluded from the analysis. Based on a series of Levene's F tests, the homogeneity of variance
In study 3, there were 7 degrees of freedom, which equated to a assumption was considered satisfied (p < .05). However, there were two
critical Chi-Square value of 24.32 (at a = 0.001). Mahalonbis-distance instances where this was not the case; in Study 3 Levene's F test
10
suggested that the variances associated with the dissociation subscales neurology outpatients. J. Neurol. Neurosurg. Psychiatry, 86(3), 295–301. https://doi.
org/10.1136/jnnp-2014-308234
Identity and Depersonalisation were not homogeneous. An examination
Cohen, S. (1988). Perceived stress in a probability sample of the United States. In
of the standard deviations revealed that none of the largest standard S. Spacapan, & S. Oskamp (Eds.), The social psychology of health (pp. 31–67). Sage
deviations (Table 5) revealed that none of the largest standard de Publications Inc.
viations were more than four times the size of the smallest, suggesting Cope, S. R. (2020). EMDR as an adjunctive psychological therapy for patients with
functional neurological disorder: Illustrative case examples. Journal of EMDR Practice
that the ANOVA would be robust enough to handle this (Howell, 2012). and Research, 14(2), 76–89. https://doi.org/10.1891/emdr-d-20-00008
Costa, P. T., & McCrae, R. R. (2008). The Revised NEO Personality Inventory (NEO-PI-R).
The SAGE Handbook of Personality Theory and Assessment: Volume 2 — Personality
A.4. Multicollinearity Measurement and Testing, 179–198. https://doi.org/10.4135/9781849200479.n9
Cotten, S. R., Anderson, W. A., & McCullough, B. M. (2017). Social Isolation Scale..
Tolerance and VIF were used to assess multicollinearity in each of the https://doi.org/10.1037/t62081-000
Dalenberg, C., & Carlson, E. B. (2012). Dissociation in posttraumatic stress disorder part
three studies and Durbin-Watson statistics were examined to assess for II: how theoretical models fit the empirical evidence and recommendations for
the assumption of independent errors which explores serial correlations modifying the diagnostic criteria for PTSD. Psychol. Trauma Theory Res. Pract. Policy,
and tests whether adjacent residuals were correlated. Tolerances were 4(6), 551–559. https://doi.org/10.1037/a0027900
Daum, C., Gheorghita, F., Spatola, M., Stojanova, V., Medlin, F., Vingerhoets, F.,
deemed accepted of a value >0.1, VIF values <10 and Durbin-Watson Berney, A., Gholam-Rezaee, M., Maccaferri, G. E., Hubschmid, M., & Aybek, S.
values between 0 and 4 (with values closest to 2 indicating uncorre (2015). Interobserver agreement and validity of bedside 'positive signs' for functional
lated nature of residuals). In study 1, tests to see if the data met the weakness, sensory and gait disorders in conversion disorder: a pilot study. J. Neurol.
Neurosurg. Psychiatry, 86(4), 425–430. https://doi.org/10.1136/jnnp-2013-307381
assumption of collinearity (using Dissociation as the outcome variable) Davidson, J. R. T., Tharwani, H. M., & Connor, K. M. (2002). Davidson trauma scale
indicated that multicollinearity was not a concern [Anxiety, Tolerance = (DTS): normative scores in the general population and effect sizes in placebo-
0.280, VIF =3.58; Depression, Tolerance = 0.280, VIF = 3.57; Life Events, controlled SSRI trials. Depression and Anxiety, 15(2), 75–78. https://doi.org/
10.1002/da.10021
Tolerance = 0.990, VIF = 1.01]. Study 1 data also met the assumption of
Demartini, B., Ricciardi, L., Crucianelli, L., Fotopoulou, A., & Edwards, M. J. (2016).
independent errors [Durbin-Watson value = 1.53]. In study 2, tests Sense of body ownership in patients affected by functional motor symptoms
indicated that multicollinearity was not a concern [Anxiety, Tolerance = (conversion disorder). Conscious. Cogn., 39, 70–76. https://doi.org/10.1016/j.
0.431, VIF = 2.32; Depression, Tolerance = 0.346, VIF = 2.89; Stress, concog.2015.11.005
Diez, I., Larson, A. G., Nakhate, V., Dunn, E. C., Fricchione, G. L., Nicholson, T. R.,
Tolerance = 0.359, VIF = 2.79; Impact of Illness, Tolerance = 0.547, VIF Sepulcre, J., & Perez, D. L. (2020). Early-life trauma endophenotypes and brain
= 1.83; Levels of Disability, Tolerance = 0.60, VIF = 1.67]. Data from circuit–gene expression relationships in functional neurological (conversion)
Study 2 also met the assumptions of independent errors [Durbin-Watson disorder. Mol. Psychiatry, 1–12.
Edwards, M. J., Adams, R. A., Brown, H., Parees, I., & Friston, K. J. (2012). A bayesian
value = 1.88]. Tests also indicated that multicollinearity was not a account of ‘hysteria’. Brain, 135(11), 3495–3512. https://doi.org/10.1093/brain/
concern for study 3 data [Anhedonia, Tolerance = 0.928, VIF = 1.07; aws129
Anxiety, Tolerance = 0.338, VIF = 2.96; Depression, Tolerance = 0.363, Faul, F., Erdfelder, E., Lang, A.-G., & Buchner, A. (2007). G*Power 3: a flexible statistical
power analysis program for the social, behavioral, and biomedical sciences. Behav.
VIF = 2.75; Social Isolation, Tolerance = 0.708, VIF = 1.41; Social Sup Res. Methods, 39, 175–191. https://doi.org/10.3758/BF03193146
port, Tolerance = 0.817, VIF = 1.23; Stress, Tolerance = 0.356, VIF = Goldstein, L. H., & Mellers, J. D. C. (2006). Ictal symptoms of anxiety, avoidance
2.81]. Study 3 data also met the assumption of independent errors behaviour, and dissociation in patients with dissociative seizures. J. Neurol.
Neurosurg. Psychiatry, 77(5), 616–621. https://doi.org/10.1136/jnnp.2005.066878
[Durbin-Watson value = 1.95]. Guilcher, S. J. T., Catharine Craven, B., Bassett-Gunter, R. L., Cimino, S. R., & Hitzig, S. L.
(2021). An examination of objective social disconnectedness and perceived social
References isolation among persons with spinal cord injury/dysfunction: A descriptive cross-
sectional study. Disab. Rehabil., 43(1), 69–75. https://doi.org/10.1080/
09638288.2019.1616328
Akbey, Z. Y., Yildiz, M., & Gündüz, N. (2019). Is there any association between childhood
Herbert, J. D., Lilienfeld, S. O., Lohr, J. M., Montgomery, R. W. T., O'Donohue, W.,
traumatic experiences, dissociation and psychotic symptoms in schziophrenic
Rosen, G. M., & Tolin, D. F. (2000). Science and pseudoscience in the development of
Patients? Psychiatry Investig., 16(5), 346.
eye movement desensitization and reprocessing: Implications for clinical
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
psychology. Clinical Psychology Review, 20(8), 945–971.
disorders (DSM-5®). American Psychiatric Pub..
Holmes, E. A., Brown, R. J., Mansell, W., Fearon, R. P., Hunter, E. C., Frasquilho, F., &
Baslet, G., Ehlert, A., Oser, M., & Dworetzky, B. A. (2020). Mindfulness-based therapy for
Oakley, D. A. (2005). Are there two qualitatively distinct forms of dissociation? A
psychogenic nonepileptic seizures. Epilepsy Behav., 103, Article 106534.
review and some clinical implications. Clin. Psychol. Rev., 25(1), 1–23. https://doi.
Bennett, D. A. (2001). How can I deal with missing data in my study? Aust. N. Z, 25(5),
org/10.1016/j.cpr.2004.08.006
464–469.
Howell, D. C. (2012). Statistical Methods for Psychology. Cengage Learning.
Briere, J., Weathers, F. W., & Runtz, M. (2005). Is dissociation a multidimensional
Jackson, D. N. (1994). Jackson personality inventory-revised. Sigma Assessment Systems,
construct? Data from the multiscale dissociation inventory. Journal of Traumatic
Research Psychologists Press Division.. https://doi.org/10.4135/9781412952644.
Stress: Official Publication of the International Society for Traumatic Stress Studies, 18
n232
(3), 221–231.
Janet, P. (1907). The major symptoms of hysteria: Fifteen lectures given in the medical school
British Psychological Society. (2013). Ethics guidelines for internet-mediated research. The
of. Harvard University. Macmillan.
British Psychological Society.
Klimidis, S., Minas, I. H., & Yamamoto, K. (2001). Impact of illness scale: reliability,
Brown, R. J. (2004). Psychological mechanisms of medically unexplained symptoms: an
validity, and cross-cultural utility. Compr. Psychiatry, 42(5), 416–423. https://doi.
integrative conceptual model. Psychol. Bull., 130(5), 793–812.
org/10.1053/comp.2001.26266
Brown, R. J., & Reuber, M. (2016). Psychological and psychiatric aspects of psychogenic
Kozlowska, K. (2017). A stress-system model for functional neurological symptoms.
non-epileptic seizures (PNES): a systematic review. Clin. Psychol. Rev., 45, 157–182.
J. Neurol. Sci., 383, 151–152. https://doi.org/10.1016/j.jns.2017.10.044
https://doi.org/10.1016/j.cpr.2016.01.003
Levita, L., Mayberry, E., Mehmood, A., & Reuber, M. (2020). Evaluation of LiNES: A new
Brown, R. J., Cardeña, E., Nijenhuis, E., Sar, V., Hart, O., & v. de.. (2007). Should
measure of trauma, negative affect, and relationship insecurity over the life span in
conversion disorder be reclassified as a dissociative disorder in DSM-V?
persons with FND. J. Neuropsychiatry Clin. Neurosci., 32(1), 43–49. https://doi.org/
Psychosomatics, 48(5), 369–378. https://doi.org/10.1176/appi.psy.48.5.369
10.1176/appi.neuropsych.19050121
Brown, R. J., Bouska, J. F., Frow, A., Kirkby, A., Baker, G. A., Kemp, S., Burness, C., &
Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states:
Reuber, M. (2013). Emotional dysregulation, alexithymia, and attachment in
comparison of the depression anxiety stress scales (DASS) with the beck depression
psychogenic nonepileptic seizures. Epilepsy Behav., 29(1), 178–183.
and anxiety inventories. Behav. Res. Ther., 33(3), 335–343. https://doi.org/10.1016/
Cacioppo, J. T., & Hawkley, L. C. (2003). Social isolation and health, with an emphasis
0005-7967(94)00075-u
on underlying mechanisms. Perspect. Biol. Med., 46(3x), S39–S52. https://doi.org/
Ludwig, L., Pasman, J., Nicholson, T., Aybek, S., David, A., & Tuck, S. (2018). Stressful
10.1353/pbm.2003.0063
life events and maltreatment in conversion (functional neurological) disorder:
Carlson, E. B., Waelde, L. C., Palmieri, P. A., Macia, K. S., Smith, S. R., & McDade-
Systematic review and meta-analysis of case-control studies. Lancet Psychiatry, 5(4),
Montez, E. (2018). Development and validation of the dissociative symptoms scale.
307–320. https://doi.org/10.1016/s2215-0366(18)30051-8
Assessment, 25(1), 84–98. https://doi.org/10.1177/1073191116645904
Lyssenko, L., Schmahl, C., Bockhacker, L., Vonderlin, R., Bohus, M., & Kleindienst, N.
Carson, A., Stone, J., Hibberd, C., Murray, G., Duncan, R., & Coleman, R. (2011).
(2018). Dissociation in psychiatric disorders: a meta-analysis of studies using the
Disability, distress and unemployment in neurology outpatients with symptoms
dissociative experiences scale. Am. J. Psychiatry, 175(1), 37–46. https://doi.org/
'unexplained by organic disease'. J. Neurol. Neurosurg. Psychiatry, 82(7), 810–813.
10.1176/appi.ajp.2017.17010025
https://doi.org/10.1136/jnnp.2010.220640
Mattfeld, A. T., Whitfield-Gabrieli, S., Biederman, J., Spencer, T., Brown, A., Fried, R., &
Carson, A. J., Stone, J., Hansen, C. H., Duncan, R., Cavanagh, J., Matthews, K.,
Gabrieli, J. D. (2016). Dissociation of working memory impairments and attention-
Murray, G., & Sharpe, M. (2015). Somatic symptom count scores do not identify
patients with symptoms unexplained by disease: a prospective cohort study of
11
deficit/hyperactivity disorder in the brain. NeuroImage: Clinical, 10, 274–282. Prueter, C., Schultz-Venrath, U., & Rimpau, W. (2002). Dissociative and associated
https://doi.org/10.1016/j.nicl.2015.12.003 psychopathological symptoms in patients with epilepsy, pseudoseizures, and both
McKee, K., Glass, S., Adams, C., Stephen, C. D., King, F., Parlman, K.Kontos, N., … seizure forms. Epilepsia, 43(2), 188–192.
(2018). The inpatient assessment and management of motor functional neurological Reuber, M. (2009). The etiology of psychogenic non-epileptic seizures: toward a
disorders: an interdisciplinary perspective. Psychosomatics, 59(4), 358–368. https:// biopsychosocial model. Neurol. Clin., 27(4), 909–924.
doi.org/10.1016/j.psym.2017.12.006 Reuber, M., House, A. O., Pukrop, R., Bauer, J., & Elger, C. E. (2003). Somatization,
McWhirter, L., Stone, J., Sandercock, P., & Whiteley, W. (2011). Hoover's sign for the dissociation and general psychopathology in patients with psychogenic non-epileptic
diagnosis of functional weakness: a prospective unblinded cohort study in patients seizures. Epilepsy Res., 57(2–3), 159–167.
with suspected stroke. J. Psychosomatic Res., 71(6), 384–386. https://doi.org/ Rizvi, S. J., Quilty, L. C., Sproule, B. A., Cyriac, A., Bagby, R. M., & Kennedy, S. H. (2015).
10.1016/j.jpsychores.2011.09.003 Development and validation of the dimensional anhedonia rating scale (DARS) in a
Meltzer, H. (2003). Oslo Social Support Scale-3 [Database record]. Retrieved from community sample and individuals with major depression. Psychiatry Res., 229(1–2),
PsycTESTS. https://doi.org/10.1037/t75682-000 109–119.
Meyers, L. S., Gamst, G., & Guarino, A. J. (2016). Applied multivariate research: Design and Rossier, P., & Wade, D. T. (2002). The Guy's neurological disability scale in patients with
interpretation. Sage publications. multiple sclerosis: a clinical evaluation of its reliability and validity. Clin. Rehabil., 16
Myers, L., Trobliger, R., Bortnik, K., Zeng, R., Saal, E., & Lancman, M. (2019). (1), 75–95.
Psychological trauma, somatization, dissociation, and psychiatric comorbidities in Şar, V., Akyüz, G., Kundakçı, T., Kızıltan, E., & Doğan, O. (2004). Childhood trauma,
patients with psychogenic nonepileptic seizures compared with those in patients dissociation, and psychiatric comorbidity in patients with conversion disorder. Am.
with intractable partial epilepsy. Epilepsy & Behavior, 92, 108–113. https://doi.org/ J. Psychiatry, 161(12), 2271–2276.
10.1016/j.yebeh.2018.12.027. Nicholson, T. R., Aybek, S., Craig, T., Harris, T., Sar, V., Islam, S., & Öztürk, E. (2009). Childhood emotional abuse and dissociation in
Wojcik, W., David, A. S., & Kanaan, R. A. (2016). Life events and escape in patients with conversion symptoms. Psychiatry Clin. Neurosci., 63(5), 670–677.
conversion disorder. Psychological medicine, 46(12), 2617-2626. doi:10.1017/ Sharrack, B., & Hughes, R. A. (1999). The guy's neurological disability scale (GNDS): a
s0033291716000714. new disability measure for multiple sclerosis. Mult. Scler. J., 5(4), 223–233.
Nicholson, T., Carson, A., Edwards, M., Goldstein, L., Hallett, M., Mildon, B., et al. Steer, R. A., Rissmiller, D. J., & Beck, A. T. (2000). Use of the beck depression inventory-
(2020). Outcome measures for functional neurological disorder: a review of the II with depressed geriatric inpatients. Behav. Res. Ther., 38(3), 311–318.
theoretical complexities. J. Neuropsychiatry Clin. Neurosci., 32(1), 33–42. https://doi. Steffen, A., Fiess, J., Schmidt, R., & Rockstroh, B. (2015). “That pulled the rug out from
org/10.1176/appi.neuropsych.19060128 under my feet!”–adverse experiences and altered emotion processing in patients with
Nicholson, T. R., Aybek, S., Craig, T., Harris, T., Wojcik, W., David, A. S., & Kanaan, R. A. functional neurological symptoms compared to healthy comparison subjects. BMC
(2016). Life events and escape in conversion disorder. Psychol. Med., 46(12), Psychiatry, 15(1), 1–9.
2617–2626. Sumich, A., Kumari, V., Gordon, E., Tunstall, N., & Brammer, M. (2008). Event-related
Nijenhuis, E. R., & van der Hart, O. (2011). Dissociation in trauma: a new definition and potential correlates of paranormal ideation and unusual experiences. Cortex, 44(10),
comparison with previous formulations. J. Trauma Dissociation, 12(4), 416–445. 1342–1352.
https://doi.org/10.1080/15299732.2011.570592 Sumich, A., Anderson, J. D., Howard, C. J., Heym, N., Castro, A., Baker, J., &
O'grady, A., Pleasence, P., Balmer, N. J., Buck, A., & Genn, H. (2004). Disability, social Belmonte, M. K. (2018). Reduction in lower-alpha power during ganzfeld flicker
exclusion and the consequential experience of justiciable problems. Disability Soc., 19 stimulation is associated with the production of imagery and trait positive
()), 259–272. schizotypy. Neuropsychologia, 121, 79–87.
Pareés, I., Kojovic, M., Pires, C., Rubio-Agusti, I., Saifee, T. A., Sadnicka, A., Tabachnick, B. G., Fidell, L. S., & Ullman, J. B. (2007), 5. Using Multivariate Statistics.
Kassavetis, P., Macerollo, A., Bhatia, K. P., Carson, A., Stone, J., & Edwards, M. J. Boston: Pearson.
(2014). Physical precipitating factors in functional movement disorders. J. Neurol. Van den Bergh, O., Witthöft, M., Petersen, S., & Brown, R. J. (2017). Symptoms and the
Sci., 338(1–2), 174–177. https://doi.org/10.1016/j.jns.2013.12.046 body: taking the inferential leap. Neurosci. Biobehav. Rev., 74, 185–203.
Perez, D. L., Matin, N., Williams, B., Tanev, K., Makris, N., LaFrance, W. C., Jr., & Wieder, L., & Terhune, D. B. (2019). Trauma and anxious attachment influence the
Dickerson, B. C. (2018). Cortical thickness alterations linked to somatoform and relationship between suggestibility and dissociation: a moderated-moderation
psychological dissociation in functional neurological disorders: Cortical thickness analysis. Cogn. Neuropsychiatry, 24(3), 191–207.
alterations. Hum. Brain Mapp., 39(1), 428–439. https://doi.org/10.1002/hbm.23853 Williams, I. A., Reuber, M., & Levita, L. (2020). Interoception and stress in patients with
Pick, S., Mellers, J. D., & Goldstein, L. H. (2016). Emotion and dissociative seizures: a functional neurological symptom disorder. Cogn. Neuropsychiatry, 1–20.
phenomenological analysis of patients' perspectives. Epilepsy & Behav., 56, 5–14. World Health Organisation. (1992). The ICD-10 classification of mental and behavioural
Pick, S., Mellers, J. D. C., & Goldstein, L. H. (2017). Dissociation in patients with disorders: Clinical descriptions and diagnostic guidelines..
dissociative seizures: relationships with trauma and seizure symptoms. Psychol. Med., World Health Organization. (2018). International statistical classification of diseases and
47(7), 1215–1229. related health problems (11th ed.). https://icd.who.int/en.
Pick, S., Goldstein, L. H., Perez, D. L., & Nicholson, T. R. (2019). Emotional processing in Yogarajah, M., Koreki, A., Agrawal, N., Cope, S., Eilon, T., Van Praag, C. G., Garfkinel, S.,
functional neurological disorder: a review, biopsychosocial model and research Critchley, H., Mula, M., & Edwards, M. (2019). 17 State and trait interoception is
agenda. J. Neurol. Neurosurg. Psychiatry, 90(6), 704–711. disrupted in functional seizures.
Pick, S., Rojas-Aguiluz, M., Butler, M., Mulrenan, H., Nicholson, T. R., & Goldstein, L. H.
(2020). Dissociation and interoception in functional neurological disorder. Cog.
Neuropsychiatry, 25(4), 294–311.
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Personality and Individual Differences 202 (2023) 111952

Contents lists available at ScienceDirect

Personality and Individual Differences

Psychological trauma, mood and social isolation do not explain elevated

1. Introduction usually integrated higher-order cognitive processes i.e., sensory or

Abbreviations: FND, Functional Neurological Disorder.

FND Control FND Control

Anxiety 16.77 14.49 3.51 3.39 16.75 [0.0252, 0.1820] <0.001

Psychological Society (BPS), especially guidelines pertaining to online 3. Study 1

Table 2 samples were conducted, followed by independent comparisons of cor

The results of Study 1 show that dissociation in individuals with FND

5.4.3.2. Disability scale. An adapted version of The Guy's Neurological

6.2. Summary study 2 7.3. Self-report scales

CRediT authorship contribution statement A.2. Normality

Stephanie-Roxanne Blanco: Conceptualisation, Methodology, A.2.1. Study 1

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Personality and Individual Differences 202 (2023) 111952

Contents lists available at ScienceDirect

Personality and Individual Differences

Psychological trauma, mood and social isolation do not explain elevated

1. Introduction usually integrated higher-order cognitive processes i.e., sensory or

Abbreviations: FND, Functional Neurological Disorder.

FND Control FND Control

Anxiety 16.77 14.49 3.51 3.39 16.75 [0.0252, 0.1820] <0.001

Psychological Society (BPS), especially guidelines pertaining to online 3. Study 1

Table 2 samples were conducted, followed by independent comparisons of cor­

The results of Study 1 show that dissociation in individuals with FND

5.4.3.2. Disability scale. An adapted version of The Guy's Neurological

6.2. Summary study 2 7.3. Self-report scales

CRediT authorship contribution statement A.2. Normality

Stephanie-Roxanne Blanco: Conceptualisation, Methodology, A.2.1. Study 1

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Table 2 samples were conducted, followed by independent comparisons of cor