Is dissociation predicting the efficacy of psychological therapies for PTSD? Results from a randomized controlled trial comparing Dialectical Behavior Therapy for PTSD (DBT-PTSD) and Cognitive Processing Therapy (CPT)
Nikolaus Kleindienst, Regina Steil, Kathlen Priebe, Meike Müller‐Engelmann, Petra Lindauer, Annegret Krause-Utz, Franziska Friedmann, Christian Schmahl, Frank Enning, Martin Bohus
Abstract
BACKGROUND: Neuropsychological evidence suggests that dissociation might disturb emotional learning, which is a fundamental mechanism of psychotherapy. However, a recent meta-analysis on the impact of dissociation on treatment outcomes in psychotherapy trials for posttraumatic stress disorder (PTSD) reported inconsistent results and concluded that further high-quality clinical trials are needed to test whether dissociation affects the efficacy of psychotherapies. We had two main aims: First, to test whether the efficacy of two evidence-based psychotherapies for individuals with trauma-related PTSD is affected by the level of pretreatment dissociation. Second, we investigated whether a significant reduction in dissociation at an early stage of treatment is beneficial for subsequent efficacy. METHODS: The potential impact of dissociation on efficacy was studied in 193 women with PTSD related to childhood abuse who were randomized to dialectical behavior therapy for PTSD (DBT-PTSD) or cognitive processing therapy (CPT). Efficacy was operationalized as a change in the Clinician-Administered PTSD Scale (CAPS). Dissociation was assessed with the Dissociation Tension Scale (DSS). The analyses accounted for major confounders (in particular initial PTSD severity). RESULTS: Two main findings emerged from this study. First, baseline dissociation was a negative predictor for treatment efficacy. Second, a significant drop in dissociation at the initial stages of treatment was beneficial for subsequent efficacy. CONCLUSIONS: Dissociation likely reduces the efficacy of trauma-focused therapies. Accordingly, successful reduction of dissociation at an early stage of treatment assists the efficacy of trauma-focused psychotherapies.