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| Ahead of print
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| Efficacy of dialectical behavior therapy-A in adolescents with dissociative disorder in India: An open-label trial |
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Sneha Das1, Nishant Goyal2, Neha Sayeed3
1 Assistant Professor, Indian Naval Hospital Ship Asvini, Centre of Excellence, Colaba, India
2 Associate Professor of Psychiatry, Central Institute of Psychiatry, Mumbai, India
3 Associate Professor, Department of Clinical Psychology, Central Institute of Psychiatry, Ranchi, Mumbai, India
Click here for correspondence address and email
| Date of Submission | 12-Apr-2022 |
| Date of Acceptance | 24-Jun-2022 |
| Date of Web Publication | 27-Sep-2022 |
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Introduction: Dialectical behavior therapy-A (DBT-A) is a comprehensive, evidence-based treatment for children and adolescents. To date, there is no empirically validated research for adolescents diagnosed with dissociative disorder (DD) which implies the efficacy of DBT-A.
Methods: This was a hospital-based, prospective, open-label trial based on purposive sampling. It was conducted on 40 adolescents diagnosed with DD. They were divided into study group (N = 20) and treatment-as-usual (TAU; N = 20). The TAU group did not receive any psychotherapy apart from medications, but in the study group, they received pharmacotherapy along with DBT-A module (20 sessions). Multidimensional Inventory of Dissociation and Cognitive Emotion Regulation Questionnaire were used as outcome measures before and after the intervention and compared between the two groups.
Results: Findings suggested improvement in the spectrum of dissociative symptoms and cognitive emotion regulations (maladaptive) in sample over 8 weeks at the postassessment phase. However, the outcome measures did not reflect significant improvement in the case of adaptive emotion regulation skills at the post-tests. Further, analyses suggested a mild-to-moderate effect size in terms of therapeutic efficacy in the study group compared to TAU.
Conclusion: DBT-A intervention module is an effective addition to the management of adolescents diagnosed with DD.
Keywords: Children and adolescents, dialectical behavior therapy, dissociative disorder, emotion regulations
How to cite this URL:
Das S, Goyal N, Sayeed N. Efficacy of dialectical behavior therapy-A in adolescents with dissociative disorder in India: An open-label trial. Arch Ment Health [Epub ahead of print] [cited 2023 Mar 24]. Available from: https://www.amhonline.org/preprintarticle.asp?id=357203 |
| Introduction | |  |
Dissociative disorders (DDs) manifest as a disruption of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements. Physical disorders do not explain the symptoms and evidence for underlying psychological factors is required to make a diagnosis of DD.[1] According to screening studies, the lifetime prevalence rate is around 10% in both clinical populations and community settings. Clinical findings related to the association between childhood adverse experiences and DD have also been reported in epidemiological studies.[2] Dissociation primarily occurs due to stress reactions, which worsen symptoms and cause problems in day-to-day functioning. The severity of dissociation in children and adolescents is linked to accumulated exposure to various types of trauma.[3]
Treatment of DD emphasizes a stage-based intervention approach, consisting of behavioral and safety issues along with trauma management.[4] An open-label pilot study indicated the effectiveness of adjunctive dialectical behavior therapy (DBT) skills in improving dissociative symptoms along with associated psychopathology in adolescents.[5]
Although DBT for adolescents has been examined in several studies, the research is still in its infancy. Studies have shown significant reductions in inpatient hospitalizations, attrition, and behavioral incidents. The effectiveness of DBT in suicidal ideation, parasuicide, borderline personality disorder, depression, anxiety, general psychiatric symptoms, and global severity have also been found in research, but improvements in these areas were either not compared with adolescents receiving treatment-as-usual (TAU)[6] or significant in both DBT and TAU groups.[7] Additional research findings using a less rigorous methodology demonstrated the effectiveness of DBT in the management of dissociative symptoms, eating disorders, trichotillomania, externalizing behaviors, impulsivity, hopelessness, emotion dysregulation, general psychopathology, and medication usage, along with significant improvements in interpersonal strength, coping, general functioning, and psychosocial adjustment.[8] It increases the therapeutic outcome and prevents relapse with better coping skills. DBT appears to be a promising intervention for adolescents presenting with a broad array of emotion dysregulation but the number of studies is limited. Randomized controlled trials (RCTs) are sorely needed to provide more definitive evidence for the efficacy of DBT-A. Henceforth, the application of DBT-A in DD is a major challenge among researchers. The current study aimed to examine the efficacy of DBT-A in improving the spectrum of dissociative symptoms and emotion dysregulation in adolescents diagnosed with DD.
| Methods | | |
The current trial was approved by the Institute Ethics Committee, Central Institute of Psychiatry, Ranchi. It was a hospital-based, prospective, open-label trial, conducted at Erna Hoch Center for Child and Adolescent Psychiatry (CCAP), Central Institute of Psychiatry, Ranchi. A purposive sampling technique was followed. Inclusion criteria included the criteria for F44 Dissociative (Conversion) disorder according to the International Classification of Diseases-10 (ICD-10)-Diagnostic Criteria for Research (DCR), between the age of 13 and 17 years, of both male and female, with a Grade III intellectual capacity average (50th percentile) and above. Informed consent and assent were taken from both the participants and caregivers. Participants having a history of comorbid psychiatric diagnosis, organic psychiatric diagnosis, substance use disorder (F10-F19, ICD 10, and DCR), chronic or other significant general medical or neurological conditions, and physical/sensory disability were excluded from the study. Participants who received any psychotherapy earlier were not excluded from the study. Initially, 57 participants were selected, but 17 participants were eliminated based on the inclusion and exclusion criteria, below-average intellectual functioning, and dropouts during the treatment period. Selected participants were sequentially and randomly allocated to either the study group (N = 20) or TAU group (N = 20) using a single random number sequence (no stratification). The numbers were written in a series of sealed envelopes. The envelope for each participant was opened immediately before the commencement of the first treatment session by the clinician. Before that, both clinicians and participants were blinded about the treatment program. Henceforth, a double-blinding method was followed for dividing participants into two groups.
Measures
A sociodemographic data sheet was prepared specifically for the present study, consisting of sociodemographic and clinical variables (age, gender, education, domicile, history of physical/psychiatric illness, family history, duration of illness, and diagnosis). Mini-International Neuropsychiatric Interview for Children and Adolescents[9] and Standard Progressive Matrices[10] were administered as screening tools to rule out psychiatric comorbidity and below-average intellectual functioning. Only those adolescents between the ages of 13 and 17 years with no other psychiatric comorbidity and with average intelligence were included. The following questionnaires/inventories were used as outcome measures in this current study:
Multidimensional inventory of dissociation
It is a self-report measure and is considered a diagnostic tool for dissociation. Respondents indicate how much each experience happens to them on a 0–10 scale (“never” to “always.”) It consists of 218 items which are categorized under major domains of general dissociative symptoms, dissociative amnesia, and partially dissociative intrusions. Scoring was calculated by the Multidimensional Inventory of Dissociation (MID) software (version 4.0).[11]
Cognitive emotion regulation questionnaire
It is a multidimensional, self-report questionnaire measuring cognitive coping strategies after experiencing a negative or traumatic event in adults and adolescents aged 12 years and more. Participants responded on a five-point scale (1-never; 2-sometimes; 3-regularly; 4-often; and 5-always). It consists of 36 items and is broadly divided into adaptive emotion regulation (ER) (self-blame, rumination, catastrophizing, and other blame) and maladaptive ER (acceptance, positive refocusing, refocus on planning, positive reappraisal, and putting into perspective).[12]
Intervention module (dialectical behavior therapy skills manual for adolescents)
DBT-A is a comprehensive intervention program for children and adolescents. It has five modules – mindfulness, distress tolerance, walking the middle pathway, ERs, and interpersonal effectiveness. “Walking the middle pathway” is a new addition to DBT for adolescents. It focuses on parent management training including behavior modifications.[13] In the present study, DBT-A training was provided for 20 sessions (8 weeks). During the first 4 weeks, three sessions per week and in the past 4 weeks, two sessions per week were planned for the participants in the study group.
Procedure
[Figure 1] indicates procedure of the current Study.
Statistical analysis
The Statistical Package for the Social Sciences (SPSS) version 25 SPSS 25.0v, (IBM, Chicago, IL) was used for statistical analysis. Descriptive statistics were done to compare the two groups on sociodemographic and clinical variables. For comparing categorical data, the Chi-square test was used. To compare the overall effects of treatment over time for the two groups, a set of multivariate repeated measures of ANOVA was employed with treatment as the between-group factor and time as the within-subject factor. The effect size was calculated with partial eta squared to quantify the strength of the treatment procedure in bringing about changes in various psychopathological variables. The power of the test was seen to predict the ability of this test to detect the effect. The level of significance was considered <0.05.
| Results | | |
Sociodemographic and clinical variables of participants and their scores on various subscales of dissociation and ER over 8 weeks DBT-A intervention program are described in [Table 1].
With regard to the sociodemographic variables, the majority of participants in the study group were females (54.2%), aged 15 years, hailing from rural India, and diagnosed with mixed DD (62.9%). Significant differences were seen with respect to diagnosis, and domicile at the 0.01 level of significance [Table 1].
In cognitive distraction and general dissociative symptoms, a greater level of improvement has been found in the abovementioned domains in the study group, compared to TAU, over 8 weeks at a 0.001 level of significance [Table 2]. | Table 2: Multidimensional inventory of dissociation, cognitive distraction, and general dissociative symptoms (subdomains) over time (n=40)
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In dissociative amnesia (subdomains) as compared to TAU, a greater level of significant improvement has been found in the study group, over 8 weeks at a 0.001 level of significance [Table 3].
In partially dissociative intrusions (subdomains) as compared to TAU, a greater level of significant improvement has been found in the study group, over 8 weeks at a 0.001 level of significance [Table 4]. | Table 4: Scores of partially dissociative intrusion (subdomains) over time (n=40)
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Maladaptive ER showed a greater level of significant improvement over time in the study group at a 0.001 level of significance, compared to TAU. Adaptive ER has not been improved significantly at posttest [Table 5]. | Table 5: Emotional regulation over groups within various time points in sample population (n=40)
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[Table 6] demonstrated the effect size of significant variables. Mild effect size has been found in the following domains – “thought insertion” (intruding thoughts feel like they have “come from out of nowhere” and may feel like they do not really “belong” to the person), “intrusive actions” (it tends to feel as if they were done by someone or something else inside the person), at 0.05 level of significance, and “puzzlement” (the person is recurrently puzzled by his or her inexplicable feelings, reactions, behavior, and so on) at 0.01 level of significance. Improvement has been observed in both adaptive (mild effect size) and maladaptive (moderate effect size) ER. | Table 6: Comparison of various subdomains of multidimensional inventory of dissociation and cognitive emotion regulation questionnaire between study and treatment-as-usual group over time (n=40)
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| Discussion | | |
The present open-label study highlighted the efficacy of DBT-A in DD. To date, there is no published Indian study in DD, using DBT-A as a treatment module. Findings showed that participation in DBT-A training proved efficacious for the improvement of dissociative symptoms and building ER skills. DBT has been adopted in several research across different psychiatric conditions. Some of these adaptations show limited but promising evidence, suggesting the effectiveness of the treatment.[14],[15] In the present study, the majority of the participants were females, hailing from the rural background of India [Table 1]. Findings were corroborated with previous research which suggested that DD is common among adolescents and young adults, especially females from the rural background and low socioeconomic status. A higher level of economic stress is evident in the lower socioeconomic status which may explain the manifestation of dissociative symptoms.[16],[17]
There was a significant improvement in various domains and subdomains of MID (cognitive distraction, general dissociative symptoms, dissociative amnesia, and partially dissociative intrusions) in both groups over time (8 weeks), compared to TAU. Improvement was reflected more in the study group than TAU, suggesting better improvement in symptom reductions and adaptive self-growth [Table 2],[Table 3], [Table 4]. Incorporating mindfulness in clinical practice may prove therapeutic effectiveness in reducing dissociation and promoting adaptive functioning.[18]
Analysis of the cognitive ER questionnaire scale indicated an overall improvement in ER skills. However, significant treatment efficacy is reflected, especially in maladaptive ER at postassessment. Furthermore, the findings suggested that an 8-week treatment program was efficacious to reduce maladaptive style of ER. To improve adaptive ER or cognitive coping, participants might need a longer period of treatment [Table 5]. Emotional and behavioral dysregulations in adolescents make DBT a relevant treatment modality across diagnoses and behavioral problems.[19] In addition, the analysis of effect size suggested a mild-to-moderate level of effect size in dissociative psychopathology (“puzzlement”, “thought insertion,” and “intrusive actions”) and ER (adaptive and maladaptive), reflecting statistically significant therapeutic improvement (efficacy) in the study group compared to TAU [Table 6]. The present study highlighted various utilities of the DBT-A training program in DD. However, the current trial has some limitations. One major limitation of this study was the limited sample size and data were collected from only one psychiatric hospital. Henceforth, it is difficult to generalize. Second, follow-up data were not analyzed, due to which, the maintenance effect of intervention could not be reflected in this study. Third, the treatment efficacy for other major comorbid psychopathologies such as the severity of anxiety, depression, and impulsivity was not assessed in this study. Finally, the use of a self-report questionnaire may lead to variations in outcomes due to response bias. The present study encompasses various strengths. First, this is the first published study, especially on the Indian sample, where the entire DBT-A module was used to manage adolescents' DD. Second, the use of a structured diagnostic tool (MID) aids in gaining a holistic understanding of dissociative psychopathology. Third, the effect size was mild to moderate in terms of treatment efficacy. Fourth, the methodological and statistical strength of this study reflects through a stringent statistical criterion (0.001 level of significance). Future research shall include correlations between the spectrum of dissociative psychopathology and other related comorbidities. Therefore, there is a need to conduct more RCTs in this arena across clinical settings and various demographic groups which may contribute to novel findings in the literature.
| Conclusion | | |
DBT-A is a promising intervention module for children and adolescents in the management of DD. Early identification of symptoms helps in both symptom reduction and early modification of behavioral and emotional problems in children and adolescents.
Acknowledgment
The authors would like to extend their gratitude to the Erna Hoch CCAP, Central Institute of Psychiatry, Ranchi. The researchers would also express their sincere thanks to the adolescents who had participated in the study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostics Guidelines. Geneva: World Health Organization; 2002. p. 151-61.  |
| 2. | Sar V. Epidemiology of dissociative disorders: An overview. Epidemiol Res Int 2011;2011. |
| 3. | Goffinet SJ, Beine A. Prevalence of dissociative symptoms in adolescent psychiatric inpatients. Eur J Trauma Dissociation 2018;2:39-45. |
| 4. | Foote B, Van Orden K. Adapting dialectical behavior therapy for the treatment of dissociative identity disorder. Am J Psychother 2016;70:343-64. |
| 5. | Das S, Goyal N, Sayeed N. Efficacy of adjunctive dialectical behavior therapy skills in childhood and adolescent dissociative disorders: An open-label pilot study. J Indian Assoc Child Adolesc Mental Health 2020;16. |
| 6. | Rathus JH, Miller AL. Dialectical behavior therapy adapted for suicidal adolescents. Suicide Life Threat Behav 2002;32:146-57. |
| 7. | Katz LY, Cox BJ, Gunasekara S, Miller AL. Feasibility of dialectical behavior therapy for suicidal adolescent inpatients. J Am Acad Child Adolesc Psychiatry 2004;43:276-82. |
| 8. | MacPherson HA, Cheavens JS, Fristad MA. Dialectical behavior therapy for adolescents: Theory, treatment adaptations, and empirical outcomes. Clin Child Fam Psychol Rev 2013;16:59-80. |
| 9. | Sheehan DV, Sheehan KH, Shytle RD, Janavs J, Bannon Y, Rogers JE, et al. Reliability and validity of the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID). J Clin Psychiatry 2010;71:313-26. |
| 10. | Raven J. Research Supplement No. 1: The 1979 British Standardisation of the Standard Progressive Matrices and Mill Hill Vocabulary Scales, Together with Comparative Data from Earlier Studies in the UK, US, Canada, Germany and Ireland. In: Manual for Raven's Progressive Matrices and Vocabulary Scales. Oxford Psychologists Press Oxford; 1981. |
| 11. | Dell PF. The multidimensional inventory of dissociation (MID): A comprehensive measure of pathological dissociation. J Trauma Dissociation 2006;7:77-106. |
| 12. | Garnefski N, Kraaij V, Spinhoven P. Manual for the Use of the Cognitive Emotion Regulation Questionnaire. Leiderdorp, The Netherlands: DATEC; 2002. |
| 13. | Rathus JU, Miller AL. DBT Skills Manual for Adolescents. New York: The Guildford Press; 2015. |
| 14. | Sadock BJ, Sadock VA. Kaplan & Sadock's Concise Textbook of Clinical Psychiatry. Lippincott Williams & Wilkins; 2008. |
| 15. | Chaturvedi SK, Desai G, Shaligram D. Dissociative disorders in a psychiatric institute in India – A selected review and patterns over a decade. Int J Soc Psychiatry 2010;56:533-9. |
| 16. | Chattopadhyay P, Ghosh S, Nayak A, Das P, Bandyopadhyay A. Sociodemographic profile of normal EEG-dissociative disorder (convulsion) patients. J Indian Med Assoc 2009;107:549-550, 559. |
| 17. | Coskun M, Bozkurt H, Ayaydin H, Karakoc S, Suleyman F, Ucok A, et al. Clinical and sociodemographic features of adolescents hospitalized in the psychiatric inpatient unit of a university hospital. Turk J Child Adolesc Ment Health 2012;19:17-24. |
| 18. | Sharma T, Sinha VK, Sayeed N. Role of mindfulness in dissociative disorders among adolescents. Indian J Psychiatry 2016;58:326-8. [ PUBMED] [Full text] |
| 19. | Miller AL, Rathus JH, DuBose AP, Dexter-Mazza ET, Goldklang AR. Dialectical behavior therapy in practice. In: Linda A, Koerner D, Koerner K, editors. Dialectical Behavior Therapy for Adolescents. 2007. p. 245-363. |
Correspondence Address:
Sneha Das,
Assistant professor, Department of Clinical Psychology, Indian Naval Hospital Ship, Centre of Excellence, Mumbai
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/amh.amh_57_22
[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6] |
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