Staff Voices - Dissociation and Cognitive Processing Therapy for PTSD

Staff Voices - Dissociation and Cognitive Processing Therapy for PTSD

Dissociation is not unusual during psychological traumatization, and dissociative symptoms commonly occur with PTSD. Its manifestation both peri-trauma and during trauma recall is disturbing to both patients and therapists. Some trauma experts believe dissociation plays a unique role in management of trauma-related distress. A dissociative subtype of PTSD is being considered for DSM-V.

Questions therapists who treat PTSD often ask are, “Can evidence-supported PTSD treatments be used with patients who dissociate?” “Will dissociation affect PTSD treatment outcome?” “Should dissociation be treated separately and before treating the PTSD?” and “Can a standard course of PTSD treatment help PTSD-related dissociation?” A recently published paper in Depression and Anxiety provides some answers to these questions.

Dr. Patricia A Resick, the developer of Cognitive Processing Therapy (CPT), and several colleagues analyzed data from the CPT dismantling study specifically looking at different kinds and levels of dissociation to see how it affected treatment response. Because the dismantling study examined relative efficacy of CPT’s components compared to the full protocol, the current study could consider how dissociation affected three different PTSD treatment conditions: (1) cognitive therapy for PTSD: CPT-Cognitive only; (2) exposure therapy for PTSD: the CPT Written Account (WA); and (3) cognitive and exposure strategies combined: CPT full protocol.

In general, this study found that dissociation did not need to be treated separately or before PTSD treatment. PTSD and dissociation both improved among patients with high and low levels of dissociation in all three CPT conditions. However, high and low dissociators responded differently to the different treatments. Specifically, individuals with high levels of dissociation did better with the combination treatment that comprises the full CPT protocol (cognitive plus exposure work). Low dissociators showed quicker improvement with CPT-C.

What do these findings mean? The authors suggest that high dissociation at pre-treatment could be a reflection of how a person responded mentally at the time of the trauma. Because peri-traumatic dissociation may disrupt memory formation and is associated with trauma memory fragmentation, the combined exposure and cognitive strategies of the full CPT protocol may address the needs of high dissociators with PTSD in two ways. Writing the trauma narrative may help reconstruct the trauma memory in its entirety. Meanwhile, the Socratic work on meaning and the impact of trauma on beliefs – the cognitive therapy aspect of CPT – addresses distorted interpretations, such as misattribution of fault, that causes undue distress and interferes with recovery.

On the other hand, low dissociators likely have good recall of the trauma. The study’s authors suggest that for this group, recounting the trauma may be unnecessary and a “distraction,” and that this population may be more efficiently help with a PTSD treatment a model that focuses  primarily on trauma interpretations and consequent beliefs.

To read and understand more, the full citation of this article is:

Resick, P. A., Suvak, M. K., Johnides, B. D., Mitchell, K. S., & Iverson, K. M. (2012). The impact of dissociation on PTSD treatment with Cognitive Processing Therapy. Depression and Anxiety, doi: 10.1002/da.21938.