PLOS ONE

RESEARCH ARTICLE

A new perspective and assessment measure

for common dissociative experiences: ‘Felt
Sense of Anomaly’
Emma Černis ID1*, Esther Beierl2, Andrew Molodynski3, Anke Ehlers ID2,3‡,
Daniel Freeman1,3‡
1 Department of Psychiatry, University of Oxford, Oxford, United Kingdom, 2 Department of Experimental
Psychology, University of Oxford, Oxford, United Kingdom, 3 Oxford Health NHS Foundation Trust, Oxford,
United Kingdom
a1111111111
a1111111111 ‡ These authors are joint senior authors on this work.
a1111111111 * [Link]@[Link]
a1111111111
a1111111111
Abstract

OPEN ACCESS
Background
Citation: Černis E, Beierl E, Molodynski A, Ehlers A, Dissociative experiences occur across a range of mental health disorders. However, the
Freeman D (2021) A new perspective and term ‘dissociation’ has long been argued to lack conceptual clarity and may describe several
assessment measure for common dissociative distinct phenomena. We therefore aimed to conceptualise and empirically establish a dis-
experiences: ‘Felt Sense of Anomaly’. PLoS ONE
crete subset of dissociative experiences and develop a corresponding assessment
16(2): e0247037. [Link]
pone.0247037 measure.

Editor: Vedat Sar, Koc University School of

Medicine, TURKEY Methods
Received: June 29, 2020 First, a systematic review of existing measures was carried out to identify themes across
dissociative experiences. A theme of ‘Felt Sense of Anomaly’ (FSA) emerged. Second,
Accepted: January 31, 2021
assessment items were generated based on this construct and a measure developed using
Published: February 24, 2021
exploratory (EFA) and confirmatory (CFA) factor analyses of 8861 responses to an online
Peer Review History: PLOS recognizes the self-report survey. Finally, the resulting measure was validated via CFA with data from 1031
benefits of transparency in the peer review
patients with psychosis.
process; therefore, we enable the publication of
all of the content of peer review and author
responses alongside final, published articles. The Results
editorial history of this article is available here:
[Link]
‘Felt sense of anomaly’ (FSA) was identified as common to many dissociative experiences,
affecting several domains (e.g. body) and taking different forms (‘types’; e.g. unfamiliarity).
Copyright: © 2021 Černis et al. This is an open
access article distributed under the terms of the
Items for a novel measure were therefore systematically generated using a conceptual
Creative Commons Attribution License, which framework whereby each item represented a type-by-domain interaction (e.g. ‘my body
permits unrestricted use, distribution, and feels unfamiliar’). Factor analysis of online responses found that FSA-dissociation mani-
reproduction in any medium, provided the original
fested in seven ways: anomalous experiences of the self, body, and emotion, and altered
author and source are credited.
senses of familiarity, connection, agency, and reality (Χ2 (553) = 4989.435, p<0.001, CFI =
Data Availability Statement: Data cannot be
0.929, TLI = 0.924, RMSEA = 0.052, SRMR = 0.047). Additionally, a single-factor ‘global
shared publicly because of the terms and
conditions contained within the ethics permissions FSA’ scale was produced (Χ2 (9) = 312.350, p<0.001, CFI = 0.970, TLI = 0.950, RMSEA =
granted for this study from the Central Research 0.107, SRMR = 0.021). Model fit was adequate in the clinical (psychosis) group (Χ2 (553) =

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PLOS ONE A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’

Ethics Committee of the University of Oxford, the 1623.641, p<0.001, CFI = 0.927, TLI = 0.921, RMSEA = 0.043, SRMR = 0.043). The scale
NHS Research Ethics Committee, and Health had good convergent validity with a widely used dissociation scale (DES-II) (non-clinical: r =
Research Authority, and consented to by
participants. Surveys were confidential to enable
0.802), excellent internal reliability (non-clinical: Cronbach’s alpha = 0.98; clinical: Cron-
freedom of expression by participants, and bach’s alpha = 0.97), and excellent test-retest reliability (non-clinical: ICC = 0.92). Further,
participants consented into the study without being in non-clinical respondents scoring highly on a PTSD measure, CFA confirmed adequate
consulted as to the sharing of anonymised data.
model fit (Χ2 (553) = 4758.673, CFI = 0.913, TLI = 0.906, RMSEA = 0.052, SRMR = 0.054).
Therefore, only descriptive statistics, which qualify
as the minimal data set, are included in the paper.
Conclusions
Funding: This study was funded by a Wellcome
Trust Clinical Doctoral Fellowship awarded to EČ The Černis Felt Sense of Anomaly (ČEFSA) scale is a novel measure of a subset of disso-
(102176/B/13/Z [Link] AE is ciative experiences that share a core feature of FSA. It is psychometrically robust in both
funded by the Wellcome Trust (200796 https://
non-clinical and psychosis groups.
[Link]), the Oxford Health NIHR
Biomedical Research Centre (BRC-1215-20005)
and an NIHR Senior Fellowship. DF is funded by an
NIHR Research Professorship (RP-2014-05-003
[Link] The views expressed are Introduction
those of the authors and not necessarily those of
the NHS, the NIHR or the Department of Health.
The funders had no role in study design, data ‘Some have criticized the concept of dissociation itself, pointing out that it has become over-
collection and analysis, decision to publish, or inclusive and therefore meaningless [. . .] Between critics and specialists yawns an unbridged
preparation of the manuscript. chasm, so that the field has remained in disconnected state’ [1].
Competing interests: he authors have declared
that no competing interests exist. Since Janet’s influential work [2], which outlined dissociation as an altered state of conscious-
ness resulting from traumatic events, the array of phenomena encompassed within the term
dissociation has expanded to such an extent that–as the quotation above highlights–any unify-
ing concept has become obscured. This lack of clarity, combined with the often difficult to
describe nature of the phenomena, makes dissociation a challenging field of mental health
research. Because dissociation has become ‘a vague term used to describe a broad range of phe-
nomena’ [3], theorists, clinicians, and researchers may be using the same term to refer to
rather different phenomena, depending on which–often unstated–assumptions are being
made. This contributes to the continued under-recognition and misidentification of dissocia-
tion clinically [4], and impedes progress in research [5,6]. Therefore, this paper seeks to define
a circumscribed area within the broad concept of “dissociation”, delineate precisely which phe-
nomena fall within this category, and develop a corresponding measure to facilitate its study.
In response to the heterogeneity, several theorists have taken the approach of suggesting
that sub-categories of dissociative experience exist. Most notably, Holmes et al. [7] propose
that there are two distinct forms of dissociation: detachment and compartmentalisation. The
former describes experiences involving altered states of consciousness, such as depersonaliza-
tion, derealisation and other forms of separation from one’s internal or external environment.
The latter–compartmentalization–refers to deficits or loss of control in specific functions, such
as in dissociative amnesia, dissociative seizures, or functional neurological symptoms. Holmes
and colleagues [7] state that although both forms of dissociation may exist on a spectrum of
severity, they are nevertheless independent and need not co-occur. By referring to both forms
as ‘dissociation’, we may be conflating two separable phenomena.
In this study, we therefore propose to seek out phenomenological subcategories of dissocia-
tive experience de novo, using multiple sources of information, and without prior hypotheses
as to what distinctions may arise. This approach follows that taken by clinician-researchers
such as Clark and Ehlers [8,9], whose translational treatment-development work demonstrates
that before a theoretical basis for understanding a particular phenomenon can exist, it must
first be clearly understood at the phenomenological level.

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PLOS ONE A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’

At present, the majority of research uses the Dissociative Experiences Scale as a measure of
dissociation (DES; [10,11]). This is the longest-standing and most widely-used measure of dis-
sociative experiences, containing 28 items such as ‘Some people are told that they sometimes
do not recognize friends or family members’ and ‘Some people find that they sometimes are
able to ignore pain’. Whilst this measure has had significant impact in the field and greatly
facilitated discourse about dissociative experiences in clinic and research, the DES does have
limitations [7,12]. Most relevant here is the observation that the DES omits some experiences
(most notably emotional numbing) that would be required for a comprehensive measurement
of dissociation. Accordingly, it would be beneficial to research and clinical endeavours if any
new characterisations of dissociative sub-categories were accompanied by a comprehensive
measure of that construct.
Therefore, we describe here a novel definition of a category of dissociative experiences
using a patient-informed, data-driven approach, and then develop its corresponding measure.

A systematic review of phenomenology

In the absence of a consensus regarding the symptoms and mechanisms of dissociation, we
first sought to identify a coherent set of experiences on the basis of the phenomenology studied
to date under the term. To achieve this, a systematic search of the literature for measures of
dissociation was undertaken (See Table 1 for search terms and Fig 1 for the PRISMA diagram;
the search and data extraction was performed by EČ). Measures were chosen since these must
necessarily specify which phenomena are most relevant or prototypical when assessing the
concept to be measured, and therefore should provide descriptions of notable, fundamental
examples of dissociative phenomenology. Specifically, papers were sought where a measure of
dissociation (or an incorporated concept, e.g. depersonalization) was subjected to factor analy-
sis. The aim was to inspect the factors produced by these analyses and search for common
themes among measures.
Table 2 summarises the 77 papers which factor analysed 26 measures of dissociation. The
DES received the most attention of any individual measure, with 28 factor analyses carried out
on the adult version of this scale. Of these, just over half found absorption (n = 19) and deper-
sonalization (n = 18) were a factor in dissociation; half incorporated some form of memory
difficulty or amnesia; and seven found a single factor structure. By contrast, non-DES mea-
sures (41 studies, 24 measures) were more mixed, and less likely to incorporate absorption (4
studies, 2 measures), or memory problems (11 studies, 9 measures). However, factors relating
to depersonalisation experiences were still relatively common (present in 20 studies of 13

Table 1. Summarising the search method and results of the systematic review of existing dissociation measure
studies.
Method
The search was run on 15th July 2019 in Ovid Medline using the search terms: dissociation; dissociative;
depersonali� ; dereali� ; “intrusi� + memor� ”; flashback� ; unreality; fugue; reliving; “conversion+disorder”. (Note that
the wildcard “dissociat� ” was not used as this returns many papers entitled “Dissociating. . . [X] and [Y]. . .” which
are not in the dissociation or wider clinical psychology literature).
The search was limited to English language, and to journal article or review formats. Due to the occurrence of the
word ‘dissociation’ used in other contexts (as above), search terms were limited to the title and abstract of the paper,
ensuring that a full-text search did not pick up irrelevant uses of the terms.
Results
Despite the conservative approach to search criteria, a large number of irrelevant results were produced. Therefore,
a total of 14474 papers were retrieved meeting the above criteria. Titles and abstracts were then searched by hand
using Mendeley Reference Manager (v.1.19.2) to identify relevant papers. This produced a smaller group of 138
papers discussing the measurement of dissociation (Fig 1).
[Link]

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PLOS ONE A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’

Fig 1. PRISMA 2009 flow diagram for the systematic review of dissociation measure studies.
[Link]

measures), and a similar proportion of factor analyses resulted in a single factor structure (12
studies of 6 measures). Across Table 2, excluding single factor results, approximately 70 unique
factors have been implicated in dissociation.
Table 2 illustrates the argument that experiences described as “dissociative” cover such a
wide range of domains and processes that these are now difficult to unify completely in an
understandable way. Although experiences of derealization, depersonalisation and amnesia
were described by a number of measures, Table 2 shows no unanimous inter-measure themes
of phenomenology.

Definition & framework development

In order to identify a common denominator for a proportion of people’s dissociative experi-
ences, the dissociation measures identified in the systematic review above were examined. This
inspection found that many items of these measures contain words which imply the presence
of a ‘felt sense of anomaly’, such as that described in the results of a recent qualitative study
[13]. This qualitative study aimed to improve understanding of the lived experience of dissoci-
ation by interviewing 12 people with psychosis diagnoses who reported co-morbid dissociative
experiences. The results of the study indicated that dissociation is commonly experienced as a
subjective ‘felt sense’ that something is ‘wrong’, ‘off’, ‘odd’, or somehow anomalous. These sen-
sations grouped into themes describing a type of anomaly, including ‘strange’, ‘unreal’ or

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PLOS ONE A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’

Table 2. Summarising the results of N = 77 studies which carried out factor analysis on measures of dissociation or closely-related concepts (e.g. depersonalisation).
Reference Factors Sample
characteristics
Dissociative Experiences Scale (Bernstein & Putnam, 1986):
Allen, Coyne & Detachment from one’s own actions Detachment from the self and the environment n = 266 female
Console (1997) inpatients
DES mean = 35.1
(SD = 23.2)
Amdur & Liberzon Depersonalization / Memory disturbance Absorption Distractibility n = 129 male
(1996) derealization patients
DES mean = 30.43
(SD = 17.94)
Armour, Absorption Amnesia Depersonalization / derealization n = 165 university
Contractor, students
Palmieri & Elhai DES mean not
(2014) stated
Brunner, Parzer, Dissociative amnesia Absorption / imaginative Depersonalisation / derealization n = 52 patients,
Schmitt & Resch involvement 1056 control
(2004) German DES mean = 2.81
version (SD = 1.67)
(BPD); 1.40
(SD = 1.06)
(schizophrenia);
1.72 (SD = 1.13)
(controls)
Carleton, Abram & Imaginative involvement Dissociative amnesia Attentional dissociation n = 841
Asmundson (2010) undergraduates,
DES items & 635 community
Tellegen Absorption women
Scale items DES mean not
stated
Darves-Bornoz, Depersonalisation / derealisation Amnestic fragmentation Absorption-imaginative involvement n = 140 victims of
Degiovanni & of identity rape
Gaillard (1999) DES mean = 24.1
French version (SD = 16.5)
Dunn, Ryan & Depersonalization / Moderate amnesiac dissociation Absorption-imaginative Severe amnesiac n = 493 male
Paolo (1994) derealization involvement dissociation substance use
patients
DES mean not
stated
Espirito Santo & Depersonalization- Absorption Distractibility Memory disturbances n = 570 mixed
Abreu (2009) Derealization patient & general
Portuguese version population
DES mean = 18.81
(SD = 13.82)
Fischer & Elnitsky Single factor n = 507
(1990) Including the undergraduates
Perceptual DES mean not
Alteration Scale stated
items
Holtgraves & Single factor n = 201 (study 1)
Stockdale (1997) & 195 (study 2)
undergraduates
DES mean not
stated
Korlin, Edman & Single factor n = 342 general
Nyback (2007) population; 181
patients
DES mean not
stated
(Continued )

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PLOS ONE A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’

Table 2. (Continued)

Reference Factors Sample

characteristics
Dissociative Experiences Scale (Bernstein & Putnam, 1986) cont’d:
Laroi, Billieux, Automatic pilot related dissociation Defensive dissociation n = 188 (study 1)
Defeldre, Ceschi & & 210 (study 2)
van der Linden university
(2013) French students
version DES mean not
stated
Lipsanen, Saarijarvi Single factor n = 924 general
& Lauerma (2003) population
Finnish version DES mean = 8.41
(SD not stated)
Mazzotti et al. Absorption Compartmentalization Detachment n = 780 patients;
(2016) 2303
undergraduates
and non-
psychiatry patients
DES mean = 14.63
(SD = 11.78)
(general
population); 20.02
(SD = 16.29)
(psychiatry
patients)
Olsen, Clapp, Parra Absorption Depersonalization n = 575 (study 1)
& Beck (2013) & 459 (study 2)
female
undergraduates
DES mean not
stated

Ray & Faith (1995) Absorption / derealization Depersonalization Segment amnesia In situ amnesia n = 1190
undergraduates
DES mean = 67.97
(SE = 1.03)
(altered response
format)
Ray, June, Turaj & Fantasy / Segment Depersonalization In situ amnesia Different Denial n = 264 university
Lundy (1992) absorption amnesia selves students
Revised version DES mean not
stated
Ross, Ellason & Absorption / imaginative involvement Activities of dissociated Depersonalization / derealization n = 274 patients
Anderson (1995) states with DID
Full text not
available to
authors
Ross, Joshi & Currie Absorption / imaginative involvement Activities of dissociated Depersonalization / derealization n = 1055 general
(1991) states population
DES mean = 10.8
(SD = 10.1)
Ruiz, Poythress, Absorption Depersonalization Amnesia n = 1551 offenders
Lilienfeld & DES mean = 18.6
Douglas (2008) (SD = 13.6)
Sanders & Green Imaginative involvement Depersonalization / Amnesia n = 860
(1994) derealization undergraduates
Full text not
available to
authors
(Continued )

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PLOS ONE A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’

Table 2. (Continued)

Reference Factors Sample

characteristics
Schimmenti (2016a) Single factor n = 794 general
Italian version population
DES mean = 18.60
(SD = 13.85)
Schwartz & Amnestic dissociation Absorption & imaginative Depersonalisation / derealization Full text
Frischholz (1991) involvement unavailable to
authors
Dissociative Experiences Scale (Bernstein & Putnam, 1986) cont’d:
Simeon et al (1998) Absorption Amnesia Depersonalization / derealization n = 50 patients
with DPD; 20
controls
DES mean = 23.41
(SD = 13.63)
(DPD); 4.02
(SD = 2.91)
(controls)
Soffer-Dudek, Absorption / imaginative involvement Depersonalization / Amnesia n = 679
Lassri, Soffer- derealization undergraduates
Dudek & Shahar DES mean not
(2015) stated
Stockdale, Gridley, Absorption Depersonalization Amnesia n = 971
Balogh & undergraduates
Holtgraves (2002) DES mean not
stated
Wright & Loftus Single factor n = 75
(1999) undergraduates
Standard, verbal, & DES mean = 12.73
comparative (SD = 2.39)
versions
Zingrone & Single factor n = 308 university
Alvarado (2001) students
DES mean = 21.70
(SD = 12.87)
Adolescent Dissociative Experiences Scale (Armstrong, Putnam, Carlson, Libero & Smith 1997)
Armstrong et al. Amnesia Absorption Passive influence Depersonalization / n = 102 referred
(1997) derealization for psychological
evaluation
A-DES
mean = 4.85
(SD = 1.14)
(dissociative
disorders)
De Pasquale, Dissociative amnesia Absorption & imaginative Depersonalisation / Passive influence n = 633 students
Sciacca & Hichy involvement derealization A-DES
(2016) Italian mean = 2.02
version (SD = 1.47)
Farrington, Waller, Single factor n = 810 students
Smerden & Faupel A-DES
(2001) mean = 2.66
(SD = 1.81)
Kerig et al (2016) Depersonalization / derealization Amnesia Loss of conscious control n = 784 in juvenile
detention
A-DES
mean = 58.07
(SD = 48.69)
(Continued )

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PLOS ONE A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’

Table 2. (Continued)

Reference Factors Sample

characteristics
Muris, Merckelbach Single factor n = 331 students
& Peeters (2003) A-DES
mean = 1.27
(SD = 1.18)
Nilsson & Svedin Single factor n = 400 students;
(2006a) Swedish 20 outpatients
version A-DES
mean = 0.84
(SD = 1.05) (non-
clinical); 3.28
(SD = 1.89)
(clinical)
Schimmenti Single factor n = 1806 students
(2016b) Italian A-DES
version mean = 1.92
(SD = 1.43)
Yoshizumi, Depersonalization Disintegration of Amnesia n = 2272 students
Hamada, Kaida, conscious control A-DES
Gotow & Murase mean = 2.21
(2010) Japanese (SD = 1.69)
version
Peritraumatic Dissociative Experiences Questionnaire (Marmar, Weiss & Metzler, 1997)
Birmes et al. (2005) Single factor n = 48 (group 1);
French version 43 (group 2)
emergency
department
patients (critical
incident victims)
DES mean not
stated
Boelen, Keijsers & Single factor n = 168 grief
van den Hout processes research
(2012) programme
participants
DES mean not
stated
Brooks et al. (2009) Altered awareness Derealization n = 247 patients at
trauma hospitals
DES mean not
stated
Bui et al. (2011) Single factor n = 133 child
Child version emergency
department
patients
DES mean not
stated
Marshall, Orlando, Single factor n = 284 youth
Jaycox, Foy & exposed to
Belzberg (2002) community
Modified version violence
DES mean not
stated
(Continued )

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PLOS ONE A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’

Table 2. (Continued)

Reference Factors Sample

characteristics
Sijbrandij et al. Altered awareness Derealization n = 219 police
(2012) officers; 343
trauma-exposed
civilians
DES mean not
stated
Cambridge Depersonalisation Scale (Sierra & Berrios, 2000)
Aponte-Soto, Anomalous body experience Emotional and sensory numbing Alienation from Perceptual alterations n = 300 general
Velez-Pastrana, surroundings population
Martinez-Taboas & DES mean = 13.20
Gonzalez (2014) (SD = 14.19)
Blevins, Witte & Unreality and detachment Emotional and physical numbing n = 534
Weathers (2013) undergraduates
DES mean not
stated
Fagioli et al. (2015) Detachment from the Self Anomalous bodily experiences Numbing Temporal blunting n = 149 inpatients
Italian version & outpatients
DES mean not
stated
Sierra, Baker, Anomalous body experience Emotional numbing Anomalous subjective Alienation from n = 150
Medford & David recall surroundings depersonalisation
(2005) patients
DES mean = 24.1
(SD = 14.7)
Somatoform Dissociation Questionnaire (Nijenhuis, Spinhoven, van Dyck, van der Hart & Vanderlinden, 1996)
El-Hage, Darvez- Sensory neglect Subjective reactions to Vigilance modulation disturbance n = 140
Bornoz, Allilaire & perceptive distortions outpatients
Gaillard (2002) DES mean = 14.6
French version (SD = 12.9)
Mueller-Pfeiffer Single factor n = 225 psychiatry
et al. (2010) patients
German version DES mean = 4.5
(SD = 2.6) (non-
dissociative
group); 32.9
(SD = 15.8)
(dissociative
group)
Nijenhuis et al. Single factor n = 100
(1996) outpatients
DES mean not
stated
Nijenhuis, Single factor n = 31 outpatients
Spinhoven, van with dissociative
Dyck, van der Hart symptoms
& Vanderlinden DES mean not
(1998) stated
Multidimensional Inventory of Dissociation (Dell, 2006)
Dell (2013) Discovering dissociated actions Lapses of recent memory Gaps in remote memory n = 2569 clinical &
and skills non-clinical
DES mean not
stated
Dell (2006) Single factor n = 817 (multiple
groups)
DES mean not
stated
(Continued )

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PLOS ONE A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’

Table 2. (Continued)

Reference Factors Sample

characteristics
Somer & Dell Single factor n = 151
(2005) Hebrew undergraduate &
version general
population
DES mean not
stated
Curious Experiences Survey (Goldberg, 1999)
Cann & Harris Absorption Depersonalization Amnesia n = 194
(2003) undergraduates
DES mean not
stated
Goldberg (1999) Broad factor: Subscale: Subscale: Subscale: absorption Subscale: n = 755 general
Dissociation (31 dissociation (17 items) depersonalisation amnesia population
items) DES mean not
stated
Dissociation Questionnaire (Vanderlinden, Van Dyck, Vandereycken, Vertommen & Verkes, 1993)
Vanderlinden et al. Identity confusion Loss of control over behaviour, Amnesia Absorption n = 98 eating
(1993) thoughts & emotions disorder patients
DES mean not
stated
Nilsson & Svedin Identity confusion Loss of control Amnesia Absorption n = 74 outpatient
(2006b) Swedish adolescents; 400
version control
adolescents
DES mean not
stated
Perceptual Alterations Scale (Sanders, 1986)
Sanders (1986) Modification of Affect Modification of Control Modification of Cognition Full text not
available to the
authors
Fischer & Elnitsky Single factor n = 507
(1990) undergraduates
DES mean not
stated
Questionnaire of Experiences of Dissociation (Riley, 1988)
Ray & Faith (1995) Depersonalization Process amnesia Fantasy / daydream Dissociated body Trance n = 1190
behaviour undergraduates
DES mean = 67.97
(SE = 1.03)
(altered response
format)
Ray et al. (1992) Depersonalization Process amnesia Fantasy / daydream Dissociated body Trance n = 264
Revised version behaviour undergraduates
DES mean = 2.17
(SE = 0.03)
Scale of Bodily Connection (Price & Adams Thompson, 2007)
Price & Adams Body awareness Body dissociation n = 291
Thompson (2007) undergraduates
DES mean not
stated
Price, Adams Body awareness Body dissociation n = 3634 (various
Thompson & Chieh groups)
Cheng (2017) DES mean not
stated
(Continued )

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PLOS ONE A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’

Table 2. (Continued)

Reference Factors Sample

characteristics
Clinician- Bremner et al. (1998) Amnesia Depersonalisation Derealization n = 68 PTSD
Administered patients
Dissociative States DES mean not
Scale stated
Dissociative Carlson et al. Depersonalization / Gaps Sensory Misperceptions Cognitive- n = 1592 multiple
Symptoms Scale (2018) Derealization Behavioural groups
Reexperiencing DES mean not
stated
The Dissociative Černis, Cooper & Unreality Numb & Disconnected Memory Blanks Zoned Vivid Internal n = 691 general
Experiences Chan (2018) Out World population
Measure, Oxford DES mean not
stated
Self-Experience Heering et al. (2016) Disturbance of self- (Milder forms of) diminished self- n = 426 psychosis
Lifetime Frequency awareness affection or depersonalisation patients; 526
Scale healthy siblings;
297 healthy
controls
DES mean not
stated
Depersonalization Jacobs & Bovasso Inauthenticity Self-negation Self-objectification Derealization n = 368
scale including 12 (1992) undergraduates
items of Dixon’s DES mean not
(1963) scale stated
Scale Reference Factors Sample
characteristics
Wessex Kennedy et al. (2004) Stage 1 (hallucinations / pseudo- Stage 2 (including Somatic dissociation n = 80 psychology
Dissociation Scale hallucinations) cognitive blanking, services patients;
intrusions, numbing of 80 undergraduates
affect) DES mean = 20.7
(SD = 16.2)
clinical; 9.77
(SD = 7.68) non-
clinical
State Scale of Kruger & Mace (2002) Identity Conversion Amnesia Identity Hypermnesia n = 67 patients; 63
Dissociation confusion, alteration controls
derealization, DES mean not
depersonalization stated
Traumatic Laor et al. (2002) Perceptual Body-self distortions Irritability Guilt & anhedonia n = 303 children
Dissociation & distortions (202 displaced by
Grief Scale earthquake; 101
not directly
affected)
DES mean not
stated
Trait Dissociation Murray, Ehlers & Lability of Sense of split self Detachment Emotional Confusion Amnesia Memory lapses n = 27 inpatient &
Questionnaire Mayou (2002) mood & from others numbing & altered for 439 outpatient
impulsivity & the world time important accident &
senses life events emergency
department
patients
31.6% inpatients
& 28.3%
outpatients DES
mean not stated
(Continued )

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PLOS ONE A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’

Table 2. (Continued)

Reference Factors Sample

characteristics
Scale unknown: Noyes & Slymen (1979) Depersonalization Hyperalertness Mystical consciousness Full text not
‘Questionnaire available to
responses from 189 authors
victims of life-
threatening
accidents’
Steinberg Sar, Alioğlu & Cognitive-emotional self- Perceptual detachment Bodily self-detachment Detachment n = 1301
dissociation Akyuz (2017) detachment from reality undergraduates
questionnaires (5 DES mean not
measures) stated
(Steinberg &
Schnall, 2000)
Conversion Sarfraz & Ijaz (2014) Feeling of disability Body pain Seizures n = 107
Disorder Scale for outpatients &
Children controls
Full text not
available to
authors
Dissociation Stiglmayr et al. (2010) Single factor n = 294 psychiatry
Tension Scale patients
DES mean not
stated
Child Dissociative Wherry, Neil & Taylor (2009) Variability General externalising Pathological dissociation n = 232 children
Checklist (Putnam, problems with abuse
Helmers & Trickett, histories
1993) DES mean not
stated
Dissociative Yalin Sapmaz et al. (2017) Single factor n = 30 adolescent
Symptoms Severity patients; 83
Scale–Child form controls
A-DES
mean = 122.30
(SD = 52.61)
(clinical); 65.96
(SD = 53.52)
(controls)

NB: References can be found in S1.

[Link]

‘disconnected’ and could occur in relation to external or internal stimuli. This was defined as
‘a felt sense of anomaly’ (FSA).
Inspection of the above dissociation measures revealed that many items refer to experiences
as ‘different’, ‘altered’, or otherwise suggest that the respondent has noticed changes from what
they might have expected (e.g. ‘some people have the experience of looking in a mirror and
not recognizing themselves’; DES-II; [11]). As a result, we considered that there was adequate
basis in the measures found in the systematic review to consider FSA as a phenomenological
constant in many common dissociative experiences.
Whilst examining the measures in Table 2 for FSA, it became clear that there were further
‘types’ of FSA and a broader range of ways in which these could be experienced than those
found by Černis, Freeman and Ehlers [13]. We therefore developed a theoretical framework
for conceptualising a subset of ‘FSA-type’ dissociation where different ‘domains’ can be
affected by a ‘type’ of anomaly. The ‘domain’ affected by FSA may be that of physical sensation,
perception (of external or internal stimuli), mental content or processes (such as memory), or

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PLOS ONE A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’

in the experience of selfhood. The ‘type’ of anomaly may take the form of: unfamiliarity, unre-
ality, automaticity or lack of control (where this would be unexpected), or unanticipated sense
of detachment or absence.
This framework is summarised in an ‘FSA matrix’ (see Table 3), where each cell constitutes
an experience where a domain is affected by a type of anomaly. For example, one’s mind
[domain] could be experienced as detached [type]–as in reports of being unable to easily access
one’s memories; or one’s self [domain] may feel unfamiliar [type], such as in depersonalisa-
tion. In this way, the core experience of FSA unites these disparate experiences–all of which
have previously been described as dissociative. The matrix in the format ‘domain x type’
enables the identification of which experiences may be included in this subset of dissociative
experiences.
This conceptual framework was used to systematically generate items for a new measure;
the development of which, in turn, empirically tests the proposed framework. The key aim of
the empirical work reported in this paper is to develop a measure of FSA-type dissociation,
using possibly the largest ever sample size for the development of a measure of dissociation or
related constructs.

Part 1: Developing the measure

First, the experience statements systematically generated using the FSA matrix were used as an
item pool for generating a measure of FSA. Measure development took place within a non-
clinical (general population) group.

Table 3. The ‘FSA matrix’ used to systematically generate items for the development of a novel dissociation measure focusing on felt sense of anomaly, with one
example shown per cell.
Types of Anomaly
Unreal Unfamiliar Automatic Disconnected Absent
Domains Mind My thoughts don’t seem real. Some of the things in my I can’t access my I feel detached from my My mind goes completely
head don’t seem to be thoughts or memories own mind. empty.
mine. at will.
Affect My emotions don’t seem real I have emotions that My emotional reactions I feel disconnected from I can’t feel emotions.
don’t feel like they’re don’t fit with the my emotions.
mine. situation I am in.
Physiology My body (or parts of it) feels My body (or parts of it) My body (or parts of it) I feel disconnected from My body feels numb.
unreal or strange. feels like it doesn’t belong feels like it has a mind the sensations in my
to me. of its own. body.
Perception The things happening One or more of my My sense of sight, I feel as if I’m I don’t notice how much time
around me seem unreal to senses seem strange, touch, hearing (etc.) experiencing life from passes.
me–like a dream or a movie. distorted, or odd to me. don’t respond to me. very far away.
Identity I feel that I’m not a real I don’t recognize myself. I act like someone else I feel disconnected from I feel like I don’t exist.
person. without meaning to. who I really am.
Behaviour My actions feel fake or Things I’ve done many I feel like I’m on I feel disconnected from I freeze, unable to do
unreal. times before seem new or automatic pilot. my own actions. anything.
unfamiliar.
World The world around me seems Places that I know seem - I feel that I’m not part I am absorbed in my own
unreal. unfamiliar. of the world around me. world and do not notice what
is happening around me.
Others Other people seem unreal. People I know seem - I feel detached from the Other people stop existing
unfamiliar. people I am close to. when I can’t see them.
Unreal Unfamiliar Automatic Disconnected Absent

(NB: Two cells (Automatic x World; Automatic x Others) are blank, as it would not be considered anomalous if these did not respond to a person’s attempts at control.).

[Link]

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PLOS ONE A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’

Methods
Study design. The study was a questionnaire development study using an online cross-
sectional self-report survey. A subsample of respondents also provided test-retest data for the
novel questionnaire by completing the new measure twice more (Week 1 and Week 2).
Ethical approval. The study received ethical approval from the Central University
Research Ethics Committee of the University of Oxford (ref: R57488/RE002).
Participants. Participants were recruited via social media, the majority via Facebook Ads.
The advertisements were titled “Mapping dissociation in mental health” and stated that ques-
tionnaires concerned “common thoughts and feelings”. The information sheet described dis-
sociation as “strange feelings and experiences such as ‘spacing out’, feeling ‘unreal’, or feeling
detached from the world around you”. Inclusion criteria were deliberately very broad: any adult
(age 18 years or over) normally resident in the UK. There were no exclusion criteria, and no
required level of current or past dissociation. Due to the online survey format, it was not possi-
ble to directly assess capacity to consent. However, this was assumed since the participant was
required to open the survey hyperlink, read the information sheet, and complete the consent
statements independently. Upon declining to consent, the survey was not shown and the end
page with resources for further support was instead displayed.
13186 responses were recorded by Qualtrics [14]. 144 (1.09%) did not consent to the study,
and 307 (2.33%) indicated consent but then left the survey without continuing onto the first
page of measures. After removing participants who did not meet the inclusion criteria, or had
high levels of missing data (greater than 20% in any of the measures required for analysis), the
final sample was 8861. The characteristics of the sample can be found in Table 4.
Procedures. Questionnaires were completed online using Qualtrics. Therefore, informed
consent and assessment were both carried out online. The questionnaire landing page con-
tained the participant information sheet and statements regarding informed consent, as per
the British Psychological Society guidelines for ethical internet-mediated research [15]. Partici-
pants were told that the aim of the study was to explore dissociation and common thoughts,
feelings, and experiences, and that they need not have experienced dissociation in order to
take part. After acknowledging the consent statements, participants were asked the demo-
graphic questions, and shown the item pool and measures described below (see Measures).

Table 4. Summarising the descriptive statistics for the three subsamples used for measure development.
Sample 1 (n = 2953) Sample 2 (n = 2954) Sample 3 (n = 2954)
Gender 287 (9.7%) male 317 (10.7%) male 280 (9.5%) male
2557 (86.6%) female 2544 (86.1%) female 2568 (86.9%) female
80 (2.7%) other 75 (2.5%) other 78 (2.6%) other
Ethnicity 2751 (93.1%) White 2751 (93.1%) White 2768 (93.7%) White
“Have you ever experienced mental health difficulties?” 2528 (85.6%) Yes 2497 (84.5%) Yes 2508 (84.9%) Yes
360 (12.2%) No 405 (13.7%) No 388 (13.1%) No
“If yes, are these still ongoing?” 1929 (65.3%) Yes 1900 (64.3%) Yes 1943 (65.8%) Yes
534 (18.1%) No 537 (18.2%) No 519 (17.6%) No
Range Mean (SD)
Age 18–88 40.04 (15.67) 18–84 40.02 (15.84) 18–85 40.38 (15.78)
Mean (SD) Mean (SD) Mean (SD)
Dissociative Experiences Scale (DES)� 2.37 (1.85) 2.41 (1.89) 2.40 (1.89)
�
PTSD Checklist (PCL-5) 30.07 (20.14) 29.29 (20.22) 27.00 (19.93)
�
t-tests for differences in mean scores between genders male and female found no significant statistical differences in any sample.

[Link]

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PLOS ONE A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’

The survey was accessible on desktop and mobile web browsers. Incomplete datasets were
retrieved automatically after a week of non-activity and added to the dataset.
Data collection began on May 24, 2018 and ended on July 23, 2018. Test-retest data were
collected between September 3 and 13, 2018.
Measures. Černis Felt Sense of Anomaly Scale (ČEFSA). First, an initial item pool of 98
items was systematically generated by EČ, DF and AE by completing the cells of the aforemen-
tioned FSA matrix (Table 3). For example, the cell at the juncture of affect [domain] and unreal
[type] would produce the item “my emotions don’t seem real”. Using this method, a minimum
of two items per cell were generated (with the exception of ‘world x automatic’ and ‘others x
automatic’ where it was considered that it would not be anomalous to experience the world or
others as not under one’s control). Generated items were required to clearly relate to both the
domain and the type of anomaly. Further, they were not to describe a reaction or behaviour
(as these may be idiosyncratic, and are not dissociative phenomena in their own right), nor
could items be written such that the item might have surface validity for another disorder (in
order to minimise misinterpretation by respondents). Items were validated against these crite-
ria via discussion between EČ, DF and AE.
Additionally, six items were generated that were ‘global’, in that they only described FSA
without reference to specific domain or type (e.g. ‘I feel odd’, ‘Things seem strange’; see S2).
These items were generated to develop a supplementary brief “Global FSA” scale (see Statisti-
cal analysis).
All 104 items were checked for readability by volunteers with lived experience of mental
health problems. In particular, volunteers checked that it was clear to a layperson what the
items were asking, and that the language used was easily accessible throughout.
Items were rated for the past two weeks on a Likert scale from “0 Never” to “4 Always”,
with the instruction ‘Please read the following items and rate how often you have experienced
these over the past TWO WEEKS’.
Dissociative Experiences Scale II (DES-II; [11]). The DES-II comprises 28 items each rated
from 0% to 100%. Items cover dissociative and amnestic experiences such as “Some people
sometimes find that they are approached by people that they do not know, who call them by
another name or insist that they have met them before.” Higher scores indicate greater dissoci-
ation. No time period is specified in the instructions.
Post-Traumatic Symptom Disorder Checklist (PCL-5; [16]). To assess PTSD symptoms over
the past month, the PCL-5 contains 20 items such as “feeling very upset when something
reminded you of the stressful experience”, rated on a five-point Likert scale from “0 not at all”
to “4 extremely”. Participants were asked to rate “the most upsetting event” they had experi-
enced, indicated via selecting from a list including “end of a relationship”, “natural death of a
significant other”, “severe accident”, and “other not listed”. Higher scores indicate greater
trauma symptomatology.
Statistical analysis. Analyses were conducted in R, version 3.5.1 [17] with packages psych
[18] and lavaan (version 0.6–3; [19]). For analysis, the sample was split into three equal sub-
samples of nearly 3000 people. This was to enable refinement of the item pool via two explor-
atory factor analyses with appropriately large samples, and then a test of the factor structure in
a third subsample via confirmatory factor analysis. Sample splitting was done by randomly
allocating cases to subsets using a function in R.
The global items were separated from items developed using the FSA matrix and analysed
separately. This was done for two reasons: first, because the construct underlying these items
was distinct (they represent general FSA, rather than an interaction between a type and
domain); and second, to fulfil the aim of providing a very brief, standalone tool with which to
measure the underlying common denominator of FSA.

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PLOS ONE A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’

Following measure development and confirmatory factor analysis, the psychometric prop-
erties of the final scale(s) were assessed. Validity was tested via convergent validity with an
existing dissociation measure (the DES-II) using Pearson correlation. Further, confirmatory
factor analyses were carried out to test the factor structure in participants scoring above and
below the clinical cut-off on the PTSD measure (PCL-5; [16]). Reliability was assessed via
internal consistency (Cronbach’s alpha) and one-week test-retest reliability (intra-class
correlation).

Results
Each of the three subsamples had a mean age of 40 years, scored within the general population
range [11] on the DES, and highly on the PCL-5 (see Table 4). In each sample, approximately
86% of respondents were female, 93% were White, and 85% reported lifetime mental health
difficulties (with a further two thirds of these reporting that such experiences are ongoing).
Items developed from the FSA matrix: The Černis Felt Sense of Anomaly scale. Explor-
atory Factor Analysis (EFA) with oblique rotation was carried out on the first two subsamples,
with items that loaded weakly to a factor (less than 0.3) or cross-loaded strongly across multi-
ple factors (loadings for different factors within 0.2 of each other) discarded after each EFA.
The first EFA (n = 2953) indicated that a seven-factor solution was the most appropriate using
parallel analysis and model comparison tests (Χ2 (4088): 20333.396, p<0.001, CFI = 0.922,
TLI = 0.909, RMSEA = 0.037, SRMR = 0.018). Factors were identified as ‘Anomalous Experi-
ence of the Self’, ‘Anomalous Experience of the Physical Body’, ‘Altered Sense of Familiarity’,
‘Anomalous Experience of Emotion’, ‘Altered Sense of Connection’, ‘Altered Sense of Agency’,
and ‘Altered Sense of Reality’. After the second EFA (n = 2954), only five items meeting the
aforementioned criteria were retained per factor. These were selected based on which combi-
nation of five items produced a theoretically well-rounded set of items (i.e. not all asking about
the same experience). This was achieved via consensus between EČ, DF and AE. The result
was a measure of 35 items, each of which load strongly to their factor (Χ2 (2138) = 10215.014,
p<0.001, CFI = 0.944, TLI = 0.931, RMSEA = 0.036, SRMR = 0.016). The final scale (the
Černis Felt Sense of Anomaly; ČEFSA scale) can be found in S 2.
On the third and final subsample, a Confirmatory Factor Analysis (CFA) (n = 2954) was car-
ried out to test the seven-factor structure of the 35-item measure. This showed a good model fit
for a second-order factor structure (Χ2 (553) = 4989.435, p<0.001, CFI = 0.929, TLI = 0.924,
RMSEA = 0.052, SRMR = 0.047), where the high loadings of each of the seven factors indicate
that they well-represent the higher-order construct of FSA-type dissociation (Fig 2).
The ČEFSA showed good psychometric properties (Table 5). There was good convergent
validity with the DES-II (r = 0.802, p<0.001), and excellent test-retest reliability over a week
(ICC = 0.92; 95% CI = 0.88–0.94; p<0.001). Internal consistency within the seven subscales
was excellent (Cronbach’s alphas of 0.86 to 0.92).
Further, CFAs were carried out after dividing cases in the sample with less than 20% miss-
ing data for ČEFSA items and the PCL-5 (Weathers et al., 2013) (N = 7021) into two groups:
those scoring above (N = 2836), and those below (N = 4135) the clinical cut off of 33 on the
PCL-5 (above group: mean = 50.38, SD = 11.07; below group: mean = 15.33, SD = 9.86). Both
demonstrated a good model fit, indicating that the factor structure of the ČEFSA is robust
even in a population with clinically significant trauma symptoms (high: Χ2 (553) = 4758.673,
p<0.001, CFI = 0.913, TLI = 0.906, RMSEA = 0.052, SRMR = 0.054; low: Χ2 (553) = 5487.204,
p<0.001, CFI = 0.919, TLI = 0.913, RMSEA = 0.046, SRMR = 0.050).
Global FSA items: The Global Felt Sense of Anomaly scale. The same methodology was
followed to separately develop and validate the Global FSA Scale: EFA with oblique rotation in

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PLOS ONE A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’

Fig 2. The second-order seven-factor structure of the Černis Felt Sense of Anomaly measure, with factor loadings
onto the latent variable (dissociation).
[Link]

the first and second subsamples indicated a single factor structure (1st EFA: Χ2 (9) = 275.050,
p<0.001, CFI = 0.975, TLI = 0.958, RMSEA = 0.100, SRMR = 0.019; 2nd EFA: Χ2 (9) = 301.402,
p<0.001, CFI = 0.969, TLI = 0.949, RMSEA = 0.105, SRMR = 0.021). Following the second
EFA, only five items were retained, following the same procedure as described for the main
scale, above. Additionally, one item was reworded for clarity, and therefore the CFA was carried
out in the test-retest subsample (n = 240), as these participants answered the newer version
of the item. The CFA indicated that the one-factor structure with 5 items was a good model fit
(Χ2 (9) = 312.350, p<0.001, CFI = 0.970, TLI = 0.950, RMSEA = 0.107, SRMR = 0.021).
The Global FSA Scale was also found to have good psychometric properties (Table 5).
Again, the scale demonstrated good convergent validity with the DES-II (r = 0.699, p<0.001),
good test-retest reliability (ICC = 0.84; 95% CI = 0.78–0.89; p<0.001), and excellent internal
consistency (Cronbach’s alpha = 0.95).
Relationship between measures. Correlations were carried out between the Global FSA
Scale and seven factors derived from the FSA matrix (Černis Felt Sense of Anomaly scale).
These indicated a high level of correlation (Table 6).
Additionally, the internal consistency was high when the items of the main seven-factor scale
and the Global FSA scale were analysed together (Cronbach’s alpha = 0.98). This indicates that
as well as being used independently as a 5-item ‘screener’ for FSA, the general items scale may
potentially act as an optional ‘eighth factor’ when assessing FSA-type dissociation in full.

Part 2: Validation in a clinical group

Next, the measure resulting from initial development in Part 1 was tested for psychometric fit
in a clinical group. Whilst dissociation has been demonstrated to have associations with a
broad range of mental health presentations [20], a group of patients with non-affective psycho-
sis diagnoses were recruited to validate the new scale in a clinical group. 1038 people with psy-
chosis diagnoses were surveyed as part of the Exploring Unusual Feelings study which aimed to
explore the relationship between dissociation, psychotic symptoms, and other psychological
factors. It is appropriate to study dissociation within the context of psychosis since dissociation
is thought to be transdiagnostic [21], and to occur at an elevated level in psychosis diagnoses

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Table 5. Summarising the psychometric properties of the Černis Felt Sense of Anomaly (ČEFSA) scale, and the 5
global felt sense of anomaly items which can act as a standalone brief measure.
Psychometric Statistic
Items developed from FSA matrix (35 items, 7 factors) (the Černis Felt Sense of Anomaly scale):
Test re-test reliability (n = 240) ICC statistic 0.92
Lower bound 0.88
Upper bound 0.94
Degrees of freedom 239; 239
K 2
P <0.001
F statistic 25
Internal consistency (n = 2954) Factor Cronbach’s alpha
Anomalous Experience of the Self 0.87
Anomalous Experience of the Body 0.91
Altered Sense of Familiarity 0.90
Anomalous Experience of Emotion 0.92
Altered Sense of Connection 0.91
Altered Sense of Agency 0.86
Altered Sense of Reality 0.89
Total (35 items) 0.97
Convergent validity (n = 2954) (vs. DES-II) Pearson’s r 0.802
Global Felt Sense Of Anomaly Scale (5 items, 1 factor):
Test re-test reliability (n = 240) ICC statistic 0.84
Lower bound 0.78
Upper bound 0.89
Degrees of freedom 239; 239
K 2
P <0.001
F statistic 12
Internal consistency (n = 240) Cronbach’s alpha 0.95
Convergent validity (n = 240) (vs. DES-II) Pearson’s r 0.699
[Link]

[22]. Further, as outlined in Definition & Framework Development, above, the concept of FSA
has been established as relevant to this patient group in a qualitative study with 12 people with
psychosis [13].

Table 6. Summarising the correlation statistics (r) between the Global FSA scale and the factor scores and Černis
Felt Sense of Anomaly (ČEFSA) scale total and factor scores.
Factor r statistic
ČEFSA total score 0.856
Anomalous Experience of the Self 0.797
Anomalous Experience of the Body 0.761
Altered Sense of Familiarity 0.767
Anomalous Experience of Emotion 0.674
Altered Sense of Connection 0.848
Altered Sense of Agency 0.682
Altered Sense of Reality 0.801

NB: All p values <0.001.

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Methods
Study design. The design was a cross-sectional self-report questionnaire study.
Ethical approval. The study received ethical approval from the NHS Health Research
Authority, London (City & East) Research Ethics Committee (ref: 19/LO/1394).
Procedure & participants. This study was supported by the National Institute of Health
Research (NIHR) Clinical Research Network (CRN). Participants were recruited by CRN
research assistants and clinical studies officers embedded in clinical teams and Research and
Development departments across 36 NHS trusts. Research workers from these teams
approached patients meeting the inclusion criteria, assessed capacity to consent, gained
informed consent, and supported participants to complete the assessment pack. Inclusion cri-
teria were broad: any person (age 16 years or over), currently under the care of an NHS mental
health service, with a diagnosis of non-affective psychosis, who was willing and able to give
informed consent to participate. Exclusion criteria were: insufficient English language to com-
plete the questionnaires with support, and an affective psychosis diagnosis (i.e. psychotic
depression, bipolar disorder).
Recruitment took place between 18th October 2019 and 19th March 2020. Datasets from
1038 participants were returned. For this analysis, only cases without high levels of missing
data in the ČEFSA measure (less than or equal to 20% missing) were retained for analysis. This
resulted in a participant group of 1031 patients for the ČEFSA validation, and 1028 for the
Global FSA measure validation analysis.
In the ČEFSA validation group (n = 1031), the majority of participants were White
(66.83%), male (69.74%), under the care of mental health services as an outpatient (74.30%)
and had a diagnosis of Schizophrenia (64.60%). The mean age of the sample was 41.54
(SD = 12.32) years. See Table 7 for full demographic details.

Table 7. Showing the demographic data for the clinical participant group (n = 1031).
Demographic n (% of group)
Gender Female: 303 (29.39%)719 (69.74%)5 (0.48%)
Male:
Other:
Ethnicity White (any): 689 (66.83%)
Black (any): 176 (17.07%)
Asian (any): 98 (9.51%)
Mixed / Multiple: 44 (4.27%)
Other: 18 (1.75%)
Diagnosis Schizophrenia 666 (64.60%)
Schizoaffective 153 (14.84%)
Delusional Disorder 14 (1.36%)
Psychotic Disorder NOS� 69 (6.69%)
First Episode Psychosis 105 (10.18%)
Other psychosis disorder 24 (2.33%)
Care team type Inpatient 265 (25.70%)
Outpatient 766 (74.30%)
Early intervention 124 (12.03%)
Demographic Range Mean (Standard Deviation)
Age 18–74 41.54 (12.32)
Measure Range Mean (Standard Deviation)
Černis Felt Sense of Anomaly scale�� 0–140 39.54 (30.48)
�
including Unspecified Non-Organic Psychosis.
�� �
t-tests for differences in mean scores between genders male and female found no significant statistical differences.

[Link]

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PLOS ONE A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’

The Global FSA scale validation group (n = 1028) did not differ significantly from the
ČEFSA validation group in terms of any demographics presented in Table 7. Their mean score
on the Global FSA scale was 7.85 (SD = 5.61; range = 0–20).
Measures. Participants completed the Černis Felt Sense of Anomaly (ČEFSA) and the
Global FSA scales as developed in Part 1, above.
Statistical analysis. Analyses were conducted in R, version 3.6.3 [17] with packages psych
(version [Link]; [18]) and lavaan (version 0.6–5; [19]).
The measure model fit was assessed using Confirmatory Factor Analysis (CFA) with MLR
robust maximum likelihood estimator in the clinical group (n = 1015). Due to restrictions
within the study design, it was not possible to collect data for assessing convergent validity
against another dissociation measure, nor test-retest reliability. Internal reliability was ana-
lysed using Cronbach’s alpha.

Results
Černis Felt Sense of Anomaly (ČEFSA) scale. Confirming that factor analysis was appro-
priate, Bartlett’s test of Sphericity was significant (χ2 = 4269.89, df = 595, p<0.001) and the
Kaiser-Meyer-Olkin test of sampling adequacy was high (KMO = 0.98).
Confirmatory Factor Analysis (CFA) indicated an adequate fit for an 8-factor second-order
model (Χ2 (553) = 1623.641, p<0.001, CFI = 0.927, TLI = 0.921, RMSEA = 0.043,
SRMR = 0.043), with factor loadings as shown in Table 8. In this group, the ČEFSA had good
internal consistency (whole scale Cronbach’s alpha = 0.97).
Global FSA scale. Confirming that factor analysis was appropriate, Bartlett’s test of Sphe-
ricity was significant (χ2 = 684.543, df = 10, p<0.001) and the Kaiser-Meyer-Olkin test of sam-
pling adequacy was adequate (KMO = 0.89).
CFA indicated an adequate fit for a 1-factor model (Χ2 (5) = 12.127, p = 0.033, CFI = 0.996,
TLI = 0.991, RMSEA = 0.037, SRMR = 0.011). In this group, the global FSA scale had good
internal consistency (whole scale Cronbach’s alpha = 0.92).

Discussion
The aim of this paper is to demarcate a substantial subset of dissociative experiences using a
data-driven approach. Since there continues to be controversy regarding the mechanisms of
dissociation [6], we have taken the ‘bottom-up’ approach of focusing on the phenomenological
level to achieve this. By so doing, we have demonstrated that a seemingly disparate set of

Table 8. Summarising the factor loadings and internal consistencies of the Černis Felt Sense of Anomaly scale.
Factor: Factor loading onto the latent construct of Internal consistency: Cronbach’s
dissociation alpha
Anomalous Experience of the 0.96 0.83
Self
Anomalous Experience of the 0.89 0.85
Body
Altered Sense of Familiarity 0.92 0.84
Anomalous Experience of 0.78 0.89
Emotion
Altered Sense of Connection 0.98 0.87
Altered Sense of Agency 0.96 0.84
Altered Sense of Reality 0.92 0.85
Whole scale (35 items): 0.97
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common dissociative experiences can be unified by the phenomenological common denomi-

nator of ‘a felt sense of anomaly’ (FSA).
The development of the ČEFSA (Černis Felt Sense of Anomaly) scale constitutes the first
empirical test of the theoretical framework of the subset of ‘FSA-type’ dissociation outlined
here. This framework posits that a set of common dissociative experiences take the form of a
felt sense of anomaly, which may be of a particular ‘type’ (e.g. unfamiliarity, unreality) and
may occur in a particular ‘domain’ of experience (e.g. physical body, external world). The sec-
ond-order seven-factor solution of the ČEFSA closely follows the structure of the FSA matrix
developed from this framework. Four factors of the ČEFSA (Altered Sense of Familiarity, of
Connection, of Agency, and of Reality) reflect nearly all ‘type’ columns of the matrix. The
remaining three factors of the ČEFSA (Anomalous Experience of the Self, of the Body, and of
Emotion) reflect three of the eight ‘domain’ rows of the matrix–one might hypothesise that
these are particularly important domains in the context of FSA-type dissociation.
Importantly, this scale may also be a valuable tool for the assessment of FSA-type dissocia-
tion. The ČEFSA is a novel measure of dissociative experiences which share a core feature of
FSA, and is psychometrically robust, easy to read, and appropriate for both non-clinical
respondents (including those reporting trauma symptoms) and clinical respondents with diag-
noses of psychosis. The correlation between the ČEFSA and DES was high, likely because of
the number of items within the DES that concern FSA. However, the ČEFSA has the additional
benefit of being developed through a systematic delineation of the concept of FSA. Conse-
quently, it reflects an underlying theoretical framework, and reflects this construct compre-
hensively. As a result, the ČEFSA includes less severe, or more difficult to articulate
experiences that may not have received adequate attention previously such as ‘I feel like I don’t
have a personality’ and ‘I can’t feel emotions’ in the Anomalous Experience of the Self and
Anomalous Experience of Emotion factors.
Of course, it remains to be seen whether ‘FSA-type’ dissociative experiences represent a sep-
arable construct or type of dissociation with a shared aetiology. Whilst we envisage FSA-type
dissociation as a set of experiences at the milder end of a dissociation spectrum (albeit causing
considerable distress; [13]), it currently stands only as a working hypothesis, and requires thor-
ough investigation. Specifically, further exploration of this construct and the factor structure
of the corresponding measure within other clinical groups would be a logical and necessary
next step for the development of the ideas proposed here, particularly as dissociation is consid-
ered transdiagnostic [21] and FSA-dissociation has recently been demonstrated to relate to a
broad range of subclinical mental health presentations, including depression and anxiety as
well as psychotic and post-traumatic symptoms [20].
Despite being a working hypothesis, we hope that the construct of FSA-type dissociation
will prove useful in clinic and research because of its emphasis on the core lived experience of
FSA. It is a strength of the present study that the proposed theoretical framework is consistent
with first-person reports, and that the measure items were approved by experts by experience.
Centring the framework on this core experience distils the surface-level complexity of such
presentations into a broad but nevertheless descriptive heuristic which may aid recognition of
such symptoms when they arise. It also enables clarity about which experiences are included in
this subtype (for example, by using the FSA matrix), which is perhaps less straightforward with
definitions which are built upon proposed mechanisms.
It is important to note that the construct of FSA-type dissociation proposed here does not
preclude existing suggestions of dissociative subtypes. For example, domains relating to the
self, the body and internal experiences also describe ‘depersonalisation’, and domains relating
to the external world and other people describe ‘derealisation’. There is also feasible overlap
between Holmes et al.’s [7] detachment and the ‘disconnected’ (and possibly ‘unreal’ and

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PLOS ONE A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’

Fig 3. The ‘FSA matrix’ with previous conceptualisations overlaid. (NB: Detachment and compartmentalisation
refer to constructs outlined by Holmes et al. [7]).
[Link]

‘unfamiliar’) ‘type’ of FSA, and between compartmentalisation and the ‘automatic’ (and possi-
bly ‘absent’) types (Fig 3). Accordingly, it would be of interest to explore this suggestion further
using the ČEFSA and the recently published Detachment and Compartmentalization Inven-
tory (DCI; [23]).
There are, of course, limitations to the proposed theoretical framework. One major criti-
cism may be the omission of traditional ‘dissociative amnesia’ experiences from the FSA
matrix. This symptom is considered a cardinal feature of dissociation, comprising a diagnostic
entity in its own right [24], and forming a factor in many established dissociation measures
(Table 2), including the DES [11]. Whilst detachment or unfamiliarity of memory falls within
the framework of FSA-type dissociation, the relationship of FSA to frank dissociative amnesia
(such that another ‘part’ of the personality retains a memory that is entirely inaccessible by
another ‘part’) is unclear. Further exploration is required to determine whether such experi-
ences may be described by the conjunction of ‘absent’ and ‘mind’ in the FSA-matrix, or
whether a ‘felt sense of anomaly’ simply does not occur with dissociative amnesia in the same
way as other items included in the ČEFSA scale. Indeed, an inherent feature of FSA is the sub-
jective experience of (and plausibly, appraisal of) anomaly–however, many compartmentalisa-
tion symptoms are defined by a subjective absence or inaccessibility of experience until after
the event has passed [7]. The ČEFSA scale therefore does not capture processes where the per-
son completely loses awareness of their current surroundings or responds to content in mem-
ory as if it represented the present, and further research is required to determine the
compatibility of the concept of FSA with these processes. However, we emphasise that FSA-
type dissociation does not preclude the possibility of dissociative amnesia, and that the ČEFSA
scale includes experiences where memory is experienced with a subjective sense of strangeness,
including detachment and unfamiliarity.

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PLOS ONE A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’

A key limitation of the measure development is the sampling method in Part 1. Recruitment
via Facebook ads attracted a sample which does not accurately reflect the general population,
since it relies upon people who engage with social media and are willing to partake in online
questionnaires. In particular, there is a large skew towards female gender and White ethnicity in
the sample demographics, as well as a high level of self-reported mental health difficulties. This
is further reflected in the relatively high group mean scores on the PTSD measure and high
number of people exceeding the clinical cut-off score of 33, which suggests that this sample–
although drawn from the general population–contains higher levels of post-traumatic stress
than expected. People who have dissociative symptoms may also be overrepresented, likely
resulting from self-selection bias due to the title of the study. Further, the quality of the data is
unclear, as there is some evidence that up to eleven percent of Facebook profiles may be dupli-
cates [25]. It is also a limitation of the study that test-retest data could not be collected in Part 2.

Conclusions
This study defines a discrete set of common dissociative experiences unified by a phenomeno-
logical common denominator (‘Felt Sense of Anomaly’; FSA), and demonstrates that the pro-
posed framework underlying these experiences finds support in non-clinical (general
population) and psychosis groups. The measure developed here is intended to support clini-
cians and researchers to detect this type of experience, which we hope will facilitate progress in
the challenging field of dissociation more broadly.

Supporting information
S1 File.
(DOCX)

Acknowledgments
The authors would like to thank the R&D and NIHR CRN staff within the following NHS
trusts for participating in the ‘Exploring Unusual Feelings’ study: Avon and Wiltshire Mental
Health Partnership NHS Trust; Black Country Healthcare NHS Foundation Trust; Barnet,
Enfield & Haringey Mental Health NHS Trust; Birmingham and Solihull Mental Health NHS
Foundation Trust; Berkshire Healthcare NHS Foundation Trust; Birmingham Women’s and
Children’s NHS Foundation Trust; Camden and Islington NHS Foundation Trust; Central
and North West London NHS Foundation Trust; Coventry and Warwickshire Partnership
NHS Trust; Cambridge and Peterborough NHS Foundation Trust; Cornwall Partnership NHS
Foundation Trust; Cheshire and Wirral Partnership NHS Foundation Trust; Cumbria, North-
umberland, Tyne and Wear NHS Foundation Trust; Dorset Healthcare University NHS Foun-
dation Trust; Dudley and Walsall Mental Health Partnership NHS Trust; Devon Partnership
NHS Trust; East London NHS Foundation Trust; Gloucestershire Health and Care NHS Foun-
dation Trust; Hertfordshire Partnership University NHS Foundation Trust; Humber Teaching
NHS Foundation Trust; Kent and Medway NHS and Social Care Partnership Trust; Leicester-
shire Partnership NHS Trust; Midlands Partnership NHS Foundation Trust; Mersey Care
NHS Foundation Trust; North East London Foundation Trust; North Staffordshire Combined
Healthcare NHS Trust; Oxford Health NHS Foundation Trust; Pennine Care NHS Foundation
Trust; Surrey and Borders Partnership NHS Foundation Trust; Sheffield Health & Social Care
NHS Foundation Trust; Solent NHS Trust; Somerset Partnership NHS Foundation Trust;
Southern Health NHS Foundation Trust; Tees, Esk and Wear Valleys NHS Foundation Trust;
Worcestershire Health and Care NHS Trust; and West London NHS Trust.

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PLOS ONE A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’

Author Contributions
Conceptualization: Emma Černis, Anke Ehlers, Daniel Freeman.
Data curation: Emma Černis, Esther Beierl.
Formal analysis: Emma Černis, Esther Beierl.
Funding acquisition: Emma Černis.
Investigation: Emma Černis.
Methodology: Emma Černis, Anke Ehlers, Daniel Freeman.
Project administration: Emma Černis, Andrew Molodynski.
Resources: Andrew Molodynski.
Software: Esther Beierl.
Supervision: Anke Ehlers, Daniel Freeman.
Visualization: Emma Černis.
Writing – original draft: Emma Černis.
Writing – review & editing: Emma Černis, Esther Beierl, Andrew Molodynski, Anke Ehlers,
Daniel Freeman.

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