Somatoform Dissociative Symptoms Have No Impact on the Outcome of Trauma-Focused Treatment for Severe PTSD

Harmen A Zoet,Ad De Jongh,Agnes Van Minnen

doi:10.3390/jcm10081553

Abstract

For patients with complex or other severe forms of PTSD, particularly in cases with dissociative symptoms, different treatment approaches have been suggested. However, the influence of somatoform dissociation on the effectiveness of trauma-focused treatment has hardly ever been studied. This study aims to test the hypotheses that (1) PTSD patients reporting a low level and those reporting a high level of somatoform dissociative symptoms would both benefit from an intensive trauma-focused treatment, and that (2) somatoform dissociative symptoms would alleviate. Participants were 220 patients with severe PTSD, enrolled in an intensive treatment program combining EMDR therapy and prolonged exposure therapy, without a preceding stabilization phase. Trauma history was diversified, and comorbidity was high. PTSD symptoms (CAPS-5 and PCL-5) and somatoform dissociative symptoms (SDQ-5 and SDQ-20) were assessed at pre-treatment, post-treatment and at six months after completion of treatment. The course of both PTSD and somatoform dissociative symptoms was compared for individuals reporting low and for those reporting high levels of somatoform dissociative symptoms. Large effect sizes were observed regarding PTSD symptoms reduction for patients with both low and high levels of somatoform dissociation. Somatoform dissociation did not impact improvement in terms of PTSD symptom reduction. The severity of somatoform dissociative symptoms decreased significantly in both groups. This decrease was greater for those with a positive screen for a dissociative disorder. These results add further support to the notion that the presence of strong somatoform dissociative symptoms in patients with PTSD does not necessarily call for a different treatment approach. Clinical implications are discussed.

Highlights

For patients with severe or complex forms of PTSD, such as those with dissociative symptoms, it has been suggested that a modified treatment approach, i.e., a phase-based approach, might be more appropriate than regular trauma-focused treatment [1,2]
Because only limited follow-up data were available at 6 months follow-up (n = 119), we explored the influence of somatoform dissociative symptoms on treatment outcome at 6 months follow-up in a separate analysis
Patients scoring above and below this cut-off score on the Somatoform Dissociation Questionnaire-20 (SDQ-20) at intake did not differ in age, t(217) = 1.60, p = 0.11, or gender, χ2 (1) = 0.93, p = 0.33, nor was there a difference in the proportion that experienced physical abuse, χ2 (1) = 1.47, p = 0.23, or armed violence, χ2 (1) = 0.58, p = 0.45

Summary

Introduction

For patients with severe or complex forms of PTSD, such as those with dissociative symptoms, it has been suggested that a modified treatment approach, i.e., a phase-based approach, might be more appropriate than regular trauma-focused treatment [1,2]. For example, start with a stabilization phase focused on skill training in emotion regulation, working on competences in social interactions, and grounding skills in order to decrease dissociative symptoms, before commencing the trauma-focused part of the treatment (see, e.g., [3]). In this view, dissociative symptoms are considered a distinct form of PTSD. Some studies found that direct trauma-focused therapy led to a decrease in dissociative symptoms, e.g., [8,9] Another view is, that dissociative symptoms are associated with PTSD, rather than being a distinct form of PTSD. It has been asserted that trauma-focused therapy should be considered as the first-choice treatment for PTSD patients with additional dissociative symptoms [5,10]

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Conclusion