Inpatient Treatment of Early Sexually Abused Adults: Dissociation and Outcome

Abstract

This study was conducted within a naturalistic setting at the Department for Trauma Treatment at Modum Bad Psychiatric Center, Norway. Several follow-up studies have shown that adults with polysymptomatology related to child sexual abuse (CSA) may develop chronic symptoms and disorders that seriously impair their daily life. There are few studies on the course of illness in early traumatized adults following residential (first phase) trauma treatment. The present work provides knowledge of the course of chronic and mixed trauma-related symptoms in adult inpatients who reported CSA, and course of symptoms in patient subgroups with and without complex dissociative disorders, in addition to preliminary outcome data on patients with and without a co-morbid somatization disorder. The thesis consists of four papers on adult patients admitted to a three-month specialized inpatient treatment program at Modum Bad psychiatric hospital. The patients were assessed at pre-care evaluation, admission, discharge, and at one-year follow-up. Two different samples were studied. The first sample consisted of a consecutive series of 34 patients (Sample 1) and the second consisted of a consecutive series of 56 patients (Sample 2), who attended the treatment program during the period 2001-2003 and 2003-2007, respectively. All patients had mixed trauma-related disorders, such as post-traumatic stress disorders or dissociative disorders. The first paper reports preliminary outcome data on Sample 1. The key findings were that the patients improved during the treatment period in measures of post-traumatic and general psychiatric symptoms as well as interpersonal problems, and the gains were maintained at follow-up period. However, patients with co-morbid somatization disorders (n = 17) tended to have less favorable treatment response with regard to general psychiatric symptoms. The second paper reports treatment outcome data on Sample 2, and reports and compares symptom changes in patients with and without a complex dissociative disorder. The key findings were that the patients showed symptom reduction in dimensional measures of posttraumatic and general psychiatric symptoms, depression, and dissociative symptoms, as well as interpersonal problems during the treatment stay, and the gains were maintained at follow-up. Patients with complex dissociative disorders (n = 23) consistently had higher symptom scores (all measures) than the patients without this disorder (n = 33). Both patient groups showed parallel improvement from admission to follow-up, although those high in dissociation needed more time to show improvement and were still clinically worse at the end of treatment and at follow-up. The findings were matched by clinically significant changes. In paper 3 the impact of pathological dissociation and deterioration in interpersonal problems prior to admittance on outcome of general distress and interpersonal problems were examined. The study included 48 of the 56 patients of Sample 2. The key findings were that pathological dissociation alone predicted negative outcome during treatment, and the combination of pathological dissociation and a deterioration in interpersonal problems prior to admittance predicted negative outcome in the period following treatment. In paper 4 we examined whether it is clinically relevant to consider differences in type (psychoform, somatoform) and severity of baseline dissociative symptoms in early traumatized inpatients with poly-symptomatology related to childhood sexual abuse. The study included 55 of the 56 patients of Sample 2. The key finding was the patients high in both psychoform and somatoform dissociation had more complex symptoms compared to the other patients. Furthermore, these patients responded less well to the treatment compared to patients with the combination of high somatoform dissociation and low psychoform dissociation. The results highlight the clinical significance of using both baseline scores of psychoform dissociation and somatoform dissociation for identifying a subgroup of patients with severe complex symptoms and less well treatment response. The results support the importance of identifying patients with severe dissociative problems before start of treatment, to improve indications for treatment. Future research should investigate if building interpersonal skills in parallel with stabilization and specific address of pathological dissociation in the treatment of highly dissociative patients leads to better outcome, including long-term maintenance of gains after the end of treatment. Finally, future studies should include control groups in order to draw conclusions about the effectiveness of inpatient treatment for these patients.