Comprehensive Psychiatry 46 (2005) 181 – 185

www.elsevier.com/locate/comppsych

Dissociation and fantasy proneness in psychiatric patients:

a preliminary study
Harald Merckelbach*, Joost à Campo, Solange Hardy, Timo Giesbrecht
Department of Experimental Psychology, University of Maastricht, 6200 MD, Maastricht, The Netherlands
Faculty of Law, University of Maastricht, 6200 MD, Maastricht, The Netherlands
Psychiatric Hospital, Mondriaan Zorggroep, Heerlen, The Netherlands

Abstract
Nonclinical studies found that dissociative experiences are intimately linked to a trait known as fantasy proneness. We examined the links
among dissociative symptoms, fantasy proneness, and impulsivity in psychiatric outpatients. Our sample consisted of 22 patients with
schizophrenia, 20 patients with a diagnosis of borderline personality disorder, and 19 patients with a major depressive disorder. For the whole
sample, levels of dissociation were found to be related to fantasy proneness and impulsivity. There were group differences in dissociative
symptoms, with patients with borderline personality disorder reporting more such symptoms than patients with either schizophrenia or major
depressive disorder. The overlap between dissociation and fantasy proneness may have important ramifications for studies addressing
comorbid phenomena of dissociative symptoms.
D 2005 Published by Elsevier Inc.

1. Introduction tations of the higher order trait bopenness to experienceQ [4].

Research by Lynn and Rhue [5] showed that fantasy
Dissociative symptoms, such as derealization, deperson-
proneness is a benign trait and that most fantasizers are
alization, and amnesia, have attracted widespread attention
relatively well-adjusted people. As to its origins, the
in recent years. Clinical literature often emphasizes the close
moderately high heritability that the twin studies found for
connection between dissociative symptoms and childhood
openness to experience [6] and absorption [7] suggests that
trauma. Accordingly, trauma-oriented interpretations of
individual differences in fantasy proneness are, at least to
dissociative symptoms dominate this literature [1,2]. How-
some extent, mediated by genetic factors.
ever, apart from clinical studies on dissociative symptoms,
The first large-scale study that documented a substantial
recent work has focused on traitlike manifestations of
overlap between dissociative experiences and fantasy
dissociation and how they might relate to key personality
proneness was that by Silva and Kirsch [8], who reported
characteristics. One of the best replicable findings in this
for their undergraduate sample a correlation of 0.42 between
research line is that dissociation is intimately related to a
both constructs. Using a somewhat different approach,
trait known as fantasy proneness. Since the pioneering work
Rauschenberger and Lynn [9] and Waldo and Merritt [10]
of Wilson and Barber [3], fantasy proneness has come to be
recruited individuals high and low on fantasy proneness
used as a label for individuals who exhibit a deep, profound,
from their student samples and compared them with regard
and longstanding involvement in fantasy and imagery.
to dissociation levels. Both studies concluded that high-
Fantasy proneness is closely associated with the concept
fantasy–prone students reported significantly more disso-
of absorption, and both are often interpreted as manifes-
ciative symptoms than students scoring low or medium on
fantasy proneness. Thus, all these studies indicate that
dissociation and fantasy proneness define a common
* Corresponding author. Department of Experimental Psychology, domain. Relying on a nonclinical sample of older children
University of Maastricht, PO Box 616, 6200 MD, Maastricht, The
Netherlands.
and adolescents, Muris et al [11] reported a correlation of
E-mail address: [email protected] 0.65 between dissociation and fantasy proneness. This
(H. Merckelbach). shows that the overlap between both constructs is not
0010-440X/$ – see front matter D 2005 Published by Elsevier Inc.
doi:10.1016/j.comppsych.2004.08.001
182 H. Merckelbach et al. / Comprehensive Psychiatry 46 (2005) 181 –185

restricted to adult samples only, but can also be found earlier Mean (SD) age of the patients was 41.3 (10.7) years, but
in the developmental pathway. patients with MDD (47.2 years; SD 10.0) were significantly
So far, only one clinical study looked at the link between older than patients with either BPD (38.2 years; SD 8.4) or
dissociation and fantasy proneness [12]. In that study, a schizophrenia (38.9 years; SD 11.5) (F2,58 = 4.77, P b .05).
large sample of male patients with substance abuse were
2.2. Measures
administered self-report measures of dissociation, fantasy
proneness, and childhood trauma. Replicating the results of Patients filled out the Dissociative Experiences Ques-
nonclinical studies, the authors found a moderate correlation tionnaire (DES) [18], the Creative Experiences Question-
between dissociation and fantasy proneness (r = 0.41). naire (CEQ) [19], and the Barratt Impulsiveness Scale (BIS-
Several authors noted a connection between fantasy 11) [20]. The DES is widely used for measuring dissociative
proneness, on the one hand, and reports of bizarre phenomena. Examples of such phenomena include distur-
symptoms [13] and overendorsement of trivial autobio- bances in memory (eg, not sure if remembered event
graphical events [14], on the other hand. This suggests that a happened or was a dream), perception (eg, hearing voices
positive response tendency is an intrinsic feature of fantasy inside one’s head), and awareness (eg, finding oneself in a
proneness, putting into question the accuracy of self-reports place but unaware how one got there). The DES contains 28
of fantasy-prone patients. To the extent that dissociation items that ask for the frequency of such disturbances. An
overlaps with fantasy proneness, a similar question can be illustrative item is: bSome people find that they sometimes
raised with regard to subjective reports of individuals sit staring off into space, thinking of nothing, and are not
scoring high on dissociation [15]. Another and theoretically aware of the passage of time. Mark the line to show what
more relevant issue has to do with the mechanism behind percentage of the time this happens to you.Q In the current
the tendency of fantasy-prone patients to overendorse study, patients used 100-mm visual analog scales (anchors,
implausible answer options. One possibility is that this 0 = not at all; 100 = very much) to indicate the percentage of
biased response tendency originates from impulsivity. To time they experienced dissociative phenomena. Scores were
the best of our knowledge, only a study by Steiger et al [16] averaged across items to obtain a mean DES score, with
examined whether impulsivity is linked to dissociation. In a higher DES scores indicating a higher frequency of
sample of bulimic patients, they found this to be the case. dissociative experiences. Waller et al [21] have pointed
As little is known about the link between dissociation out that mild dissociative experiences related to absorption
and fantasy proneness in psychiatric patients, the current and imaginative involvement are quite common in the
study made a first attempt to explore this issue in a sample normal population, whereas a subset of experiences tapping
of outpatients who suffered from severe psychopathology. pathological dissociation is rarely found among healthy
We also looked at the possible role of impulsivity in the link individuals. These pathological forms of dissociation are
between dissociation and fantasy proneness. To tap a broad represented with 8 items in the DES (ie, DES-T items).
range of psychopathology, we recruited patients with After the approach of Eisen and Carlson [22], we calculated
schizophrenia, borderline personality disorder (BPD), and a DES-T score by averaging across those 8 DES items that
major depressive disorder (MDD). are thought to tap pathological dissociation.
The CEQ is a 25-item yes/no measure of fantasy
proneness. Some CEQ items allude to the developmental
2. Method antecedents of fantasy proneness. Other items are related to
intense elaboration of and profound involvement in fantasy
2.1. Patients
and daydreaming. Still others pertain to the concomitants
Participants were 61 consecutive outpatients presenting and consequences of fantasizing. Items were derived from
at a follow-up treatment facility of a psychiatric clinic in the typology of this trait by Wilson and Barber [3]. Sample
Heerlen, the Netherlands. Before participating in the study, items are the following: bAs a child, I could very easily
all patients gave their written informed consent. Twenty-two identify with the main character of a story or movieQ; bWhen
patients (4 women) fulfilled the criteria of the Diagnostic I recall my childhood, I have very vivid and lively
and Statistical Manual of Mental Disorders, Fourth Edition memoriesQ; and bI can recall many occurrences before the
(DSM-IV) for chronic schizophrenia, 20 patients (12 age of three.Q Yes answers are summed to obtain a total score
women) had a DSM-IV diagnosis of BPD, and 19 (7 (range, 0-25), with higher scores indicating higher levels of
women) had a DSM-IV diagnosis of either single-episode or fantasy proneness. The CEQ possesses adequate reliability
recurrent MDD without psychotic features [17]. Clinical in terms of internal consistency and test-retest stability.
diagnoses had been made by a team of senior psychiatrists. Furthermore, the CEQ has predictive validity in the sense
All patients were clinically stabilized. Patients with neuro- that certain categories of individuals who are known to
logical abnormalities were excluded. All patients with exhibit fantasy-prone characteristics (eg, amateur actors)
schizophrenia were on maintenance neuroleptic medication, display higher scores on this scale than do control
whereas the large majority of patients with BPD and MDD individuals. Finally, the CEQ demonstrates concurrent
were treated with antidepressants and/or mood stabilizers. validity in that it correlates strongly with another index of
 H. Merckelbach et al. / Comprehensive Psychiatry 46 (2005) 181 –185 183

Table 1 on the one hand, and BIS-11, on the other hand, re-
Pearson correlations between dissociation measures (DES and DES-T), mained nonsignificant. A regression analyses indicated that
fantasy proneness (CEQ), and impulsivity (BIS-11) for the whole sample
(N = 61)
together, fantasy proneness and impulsivity explained 35%
of the variance in DES scores (R = 0.59, R 2 = 0.35).
DES DES-T CEQ
Table 2 shows the mean scores of the 3 patient groups on
DES-T 0.91*
the DES, DES-T, CEQ, and BIS-11. A series of 1-way
CEQ 0.55* 0.48*
BIS-11 0.32* 0.23 0.25 analyses of variance made it clear that there were significant
group differences with regard to DES (F2,58 = 3.93, P b .05)
* P b .05, 2-tailed.
and CEQ (F2,58 = 4.32, P b .05), but that group differences
fantasy proneness, namely the Inventory of Childhood in DES-T and BIS-11 fell short of significance (both F’s
Memories and Imaginings. There is no direct overlap in b1.78, both P’s N .18). As for the group differences in DES
item content between CEQ and DES [19,23]. scores, post hoc least significant difference (LSD) compar-
The BIS-11 is a 30-item self-report scale designed to isons indicated that patients with BPD had significantly
measure impulsivity. The scale is widely used in psychiatric higher dissociation levels than patients with either schizo-
research on impulsivity [24]. It contains items such as bI buy phrenia or MDD, but that dissociation scores of patients
things on impulse,Q bI am a careful thinker,Q and bI say with schizophrenia and MDD did not differ at the P b .05
things without thinking.Q Items are scored on a 4-point scale level. A similar pattern was found for CEQ, that is, patients
(anchors, 1 = rarely; 4 = always), and scores are then with BPD displayed higher scores on the fantasy proneness
summed to obtain a total impulsivity score, with higher scale (CEQ) than patients with either schizophrenia or
scores indicating higher levels of impulsivity. MDD, whereas the latter 2 groups did not differ in this
respect. When CEQ was entered as a covariate in an analysis
2.3. Procedure
of variance performed on DES scores, group differences in
After they had given their informed consent, patients dissociative symptoms disappeared (F2,57 = 1.07, P = .35).
were tested individually in a quiet room at the psychiatric
clinic. A research assistant was present for providing
4. Discussion
clarification when patients had questions. Patients were
instructed to complete the scale in their own pace and they The key finding of this initial study is that the overlap
were told that the data thus obtained would be treated between dissociation and fantasy proneness is not restricted
confidentially. to healthy samples or samples with mild psychopathology
[8-12], but it also occurs in individuals with severe
psychopathology. Clearly, our data do not indicate whether
3. Results
this overlap can be found in patients with a dissociative
Cronbach a’s for DES, DES-T, CEQ, and BIS-11 were disorder, which is an issue that requires further study. How-
.93, .79, .82, and .78, respectively, indicating that internal ever, they do indicate that common dissociative phenomena
consistency of our measures was satisfactory. There were no (as measured by the DES) as well as pathological
significant sex differences with regard to any of the manifestations of dissociation (as measured by the DES-T)
measures (all t 59’s b 1.0). Neither were there significant overlap with fantasy proneness. Given the tendency of high-
correlations between age and any of our measures (all fantasy–prone people to overendorse bizarre items [13], the
r’s b 0.21, all P’s N .09, 2-tailed). implications of this overlap might be far-reaching. More
Table 1 shows the Pearson product moment correlations precisely, our findings suggest that studies relying on self-
among DES, DES-T, CEQ, and BIS-11 for the full sample. reports to address comorbid phenomena of dissociation (eg,
As can be seen, both indices of dissociation (ie, DES and visual distortions [25,26]) would be well advised to consider
DES-T) were significantly related to fantasy proneness the role of fantasy proneness into account.
(CEQ), with correlations coming close to those that have As was the case in previous studies [27], we found that
been reported for nonclinical samples [8,11,23]. As well, patients with BPD are characterized by significantly higher
DES was significantly related to the impulsivity measure group mean levels of dissociation than are patients with
(BIS-11). However, correlations between DES-T and CEQ, schizophrenia or depression. In clinical literature, such group

Table 2
Mean (SD) scores on dissociation measures (DES and DES-T), fantasy proneness (CEQ), and impulsivity (BIS-11) of patients with schizophrenia, BPD, and
MDD
Measures Patients with schizophrenia (n = 22) Patients with BPD (n = 20) Patients with MDD (n = 19) F P
DES 21.5 (16.5) 31.0 (15.9) 17.8 (12.8) 3.9 .03
DES-T 17.8 (18.1) 21.1 (16.8) 11.3 (14.1) 1.8 .18
CEQ 8.4 (4.4) 11.8 (5.1) 7.6 (4.7) 4.3 .02
BIS-11 66.5 (11.6) 67.2 (10.2) 63.2 (7.9) 0.9 .43
184 H. Merckelbach et al. / Comprehensive Psychiatry 46 (2005) 181 –185

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