State dissociation moderates response to dialectical behavior therapy for posttraumatic stress disorder in women with and without borderline personality disorder

Patients with posttraumatic stress disorder (PTSD) are prone to dissociation, which in theory should interfere with successful treatment. However, most empirical studies do not substantiate this assumption. The primary objective was to test whether state dissociation predicts the success of an adaptation of dialectical behavior therapy designed for the treatment of patients with PTSD after childhood sexual abuse (CSA) (DBT-PTSD). We further explored whether the operationalization of dissociation as state versus trait dissociation made a difference with respect to prediction of improvement. We present a hypothesis-driven <i>post hoc</i> analysis of a randomized controlled trial on the efficacy in patients with PTSD after CSA. Regression analyses relating pre–post improvements in the Clinician-Administered PTSD Scale (CAPS) and the Posttraumatic Diagnostic Scale (PDS) to dissociation were applied to the women who participated in the active treatment arm (DBT-PTSD). Multivariate models accounting for major confounders were used to relate improvements in both the CAPS and the PDS to (1) state dissociation as assessed after each treatment session and (2) trait dissociation as assessed at baseline. State dissociation during psychotherapy sessions predicted improvement after DBT-PTSD: patients with low state dissociation during treatment had a higher chance to show substantial improvement. This relation consistently emerged across subgroups of PTSD patients with and without borderline personality disorder. The operationalization of dissociation as state versus trait dissociation made a difference as improvement was not significantly predicted from trait dissociation. Dissociation during treatment sessions may reduce success with trauma-focused therapies such as DBT-PTSD. Accordingly, clinical studies aimed at improving ways to address dissociation are needed. The article investigates whether state dissociation during psychotherapeutic sessions moderates the success of an established treatment for PTSD. Patients were much more likely to substantially improve with respect to PTSD symptomatology if state dissociation during psychotherapeutic sessions was low. The article suggests that the relation between low dissociation and good response in highly symptomatic patients is stronger than previously thought. Future studies investigating the extent to which outcome might be improved when treating dissociation more vigorously than usually are necessary.

创伤后应激障碍（posttraumatic stress disorder, PTSD）患者易出现解离（dissociation）症状，理论上该症状会对治疗的成功实施造成阻碍。然而，绝大多数实证研究均未证实这一假设。本研究的首要目标为验证状态解离是否可预测针对童年性虐待（childhood sexual abuse, CSA）后创伤后应激障碍患者的改良版辩证行为疗法（DBT-PTSD）的治疗效果。本研究进一步探讨了将解离操作化为状态解离与特质解离这两种方式，在预测症状改善方面是否存在差异。本研究针对一项针对童年性虐待后创伤后应激障碍患者疗效的随机对照试验，开展了假说驱动的事后（post hoc）分析。研究针对参与主动治疗组（DBT-PTSD）的女性受试者，开展回归分析，将临床医师评定创伤后应激障碍量表（Clinician-Administered PTSD Scale, CAPS）与创伤后诊断量表（Posttraumatic Diagnostic Scale, PDS）的前后改善值与解离水平相关联。本研究采用控制主要混杂因素的多变量模型，将CAPS与PDS的症状改善情况分别与两项指标关联：（1）每次治疗结束后评估的状态解离水平；（2）基线评估的特质解离水平。心理治疗过程中的状态解离水平可预测DBT-PTSD的治疗改善效果：治疗期间状态解离水平较低的患者，出现显著症状改善的概率更高。该关联在伴或不伴边缘型人格障碍（borderline personality disorder, BPD）的创伤后应激障碍患者亚组中均稳定存在。将解离操作化为状态解离与特质解离的差异体现为：特质解离水平无法显著预测症状改善情况。治疗过程中出现的解离症状，可能会降低创伤聚焦疗法（如DBT-PTSD）的治疗成功率。因此，亟需开展旨在优化解离症状干预方案的临床研究。本研究旨在探讨心理治疗过程中的状态解离是否会调节现有创伤后应激障碍标准治疗方案的疗效。若受试者治疗期间的状态解离水平较低，则其创伤后应激障碍症状获得显著改善的概率显著更高。本研究表明，在高症状负荷患者群体中，低解离水平与良好治疗应答之间的关联强度较此前学界的认知更强。未来需开展进一步研究，以明确通过强化现有解离干预手段能否改善治疗结局。