Role of mindfulness in dissociative disorders among adolescents.

CONTEXT: Dissociation is understood as maladaptive coping and is common in children and adolescents. Treatment outcome studies show improvement in comorbid conditions suggesting the need to implement programs that target dissociative pathology. AIM: To study the effect of practicing mindfulness among adolescents diagnosed with dissociative disorders. SETTINGS AND
DESIGN: It was a hospital-based repeated measures design.
MATERIALS AND METHODS: 7 adolescents participated in a mindfulness-based therapeutic program for 6 weeks. STATISTICAL ANALYSIS: Scores were expressed as mean ± standard deviation. Friedman test was used to assess significance of the difference in scores at various assessment phases. Wilcoxon signed rank test was used for post hoc analysis.
RESULTS: Participants were mostly female adolescents from rural, Eastern India. There was a significant reduction in dissociative experiences and significant improvement in mindfulness.
CONCLUSIONS: Incorporating mindfulness in clinical practice may prove effective in reducing dissociation and promoting adaptive functioning.

INTRODUCTION

Dissociation is understood as a coping mechanism to deal with intense stressors accompanied by avoidant information processing style.[1] The prevalence rate of dissociative disorders in psychiatric settings is around 10% and is more common in adolescents.[2] Dissociative disorders in children and adolescents usually coexist with other childhood psychiatric conditions[3] and the available treatment modalities are effective in reducing only these comorbidities. Dissociative pathology remains untreated and impairment is still seen among the treated, in many areas of life.[456]

Being mindful is becoming aware and nonjudgmentally accepting towards the present moment experiences. This is contradictory to the state of experiential avoidance seen among patients with dissociative disorders. Mindfulness can help predict and control dissociation through building awareness of dissociative processes. Interventions based on mindfulness may thus, be useful in targeting dissociative pathology and promoting adaptive functioning.

MATERIALS AND METHODS

The study was conducted in Centre for Child and Adolescent Psychiatry, Central Institute of Psychiatry, Ranchi, India. Sample consisted of 7 adolescents fulfilling the International Classification of Diseases-10 Diagnostic Criteria for Research for dissociative/conversion disorder[7] with no comorbid psychiatric disorder (except, mild to moderate anxiety and depression), psychoactive substance use (except, nicotine and caffeine), severe medical, neurological, physical illness, or mental retardation/developmental disorder. None of the participants was exposed to any form of psychological intervention. The selection was done from inpatient and outpatient services of the institute through purposive sampling after obtaining informed consent from the guardians.

Sociodemographic details and clinical data on age, gender, habitat, symptoms were obtained followed by baseline assessment on Adolescent Dissociative Experience Scale (ADES)[8] and Child Acceptance and Mindfulness Measure (CAMM).[9] ADES is a 30 item self-report instrument that reliably measures pathological dissociation in adolescents. CAMM is a well-validated 25 item self-report inventory used for assessment of mindfulness skills in adolescents and children.

A therapeutic program comprising of weekly sessions of mindfulness practice spread over 6 weeks was adapted from the Mindfulness Based Stress Reduction (MBSR) program[10] and administered in an individualized format. The sessions focused on understanding the attitudinal factors in mindfulness by practicing formal mindfulness techniques of body scan, sitting meditation and yoga. Informal mindfulness practices such as mindful eating and mindful walking were also introduced to encourage the practice of mindfulness in everyday life. Homework assignments included practicing the techniques learnt in each session. Didactic instructions on using mindfulness in daily life and reflective discussions were done in each session. ADES and CAMM were again administered after 3 weeks and at the termination of the therapeutic program. Data analysis was done using Statistical Package for Social Sciences version 16.

RESULTS

The average age of adolescent participants was found to be 13 ± 2.5 years, majority of which were females (86%), hailing from rural background (57.1%). There were significant reductions in scores of dissociative experiences and significant improvement in scores of mindfulness from pre- to post-assessment [Table 1]. However, significant decrease in dissociative experience scores was observed only from mid- to post-assessment while significant increase in mindfulness scores was observed from pre- to mid-assessment.

Table 1

Comparison of change of scores on Adolescent Dissociative Experience Scale and Child Acceptance and Mindfulness Measure across time

DISCUSSION

Dissociative disorders are common among adolescents and young adults. More so in females from rural background and low socioeconomic status.[1112] In this study also, majority of the participants were female adolescents hailing from rural background of Eastern India. In a patriarchal society, like in India, men have a greater say and tend to dominate over women which leaves little opportunity for the latter to express their views. Dissociation may then, serve as means to express self. Furthermore, a higher level of economic stress experienced by people from low socioeconomic status may explain the development of dissociative symptoms as means of coping.

Participants in the study had symptoms characteristic of and significant enough to diagnose dissociative/conversion disorder. However, the dissociative experience mean scores were found to be subclinical. The use of defense mechanisms such as denial and repression which is commonly seen in dissociation[13] is reflected in under-reporting of symptoms on a self-report measure such as ADES.

Over the years, several new psychotherapies have been developed that are rooted in the concept of mindfulness. Mindfulness is defined as “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experiences, moment by moment.”[14] In practicing mindfulness, one becomes aware of the current internal and external experiences, observes them carefully, accepts them, and allows them to be let go of to attend to another present moment experience. Mindfulness-based interventions are found to be effective in a number of physical conditions such as fibromyalgia, mixed cancer diagnoses, coronary artery diseases, obesity[15] as well as in psychiatric conditions such as anxiety and depression.[16] However, there is dearth of researches on efficacy of MBSR or other mindfulness based interventions in dissociation among adolescents and children.[17] Avoiding emotions, thoughts, and aspects of personal experiences are common in many forms of psychopathology and such experiential avoidance is the core of dissociation. Intentionally attending with openness and nonjudgmental attitude leads to a shift in perspective and creates an attitude of acceptance toward uncontrollable events. This causes experiential avoidance to become less automatic.[18]

Consistent with the previous studies, this study also shows that practicing mindfulness is associated with an increase in mindfulness skills as evident by the significant increase in mindfulness scores over the course of the program. However, it is interesting to note that changes in mindfulness occurred during the first 3 weeks of the therapeutic program unlike the significant change in dissociative experiences which did not occur until week 3 suggesting that decrease in dissociation might have occurred only after participants had begun to experience improvement in mindfulness. The pattern of findings is generally consistent with the widely held view that mindfulness training should increase the ability to respond mindfully to the experiences of daily life, which in turn should lead to improvements in a variety of mental health outcomes.[19] In the present study, it may be concluded that inculcating mindfulness led to increased awareness, providing ways to intervene and presenting an alternative to dissociation.

To the best of our knowledge, this is the only study empirically assessing the role of mindfulness-based program among adolescents with dissociative disorders. Few of the previous researches are either case reports on adult cases,[5] or theoretical framework explaining the possible utility of mindfulness in dissociation,[19] or have studied the effectiveness of mindfulness-based programs in other disorders such as borderline personality disorder where dissociative symptoms may be observed.[20]

The study has limitations such as small sample size, lack of a control (comparison) group and no assessments made at follow-up. For future studies, use of randomized controlled trials on relatively larger sample sizes, and assessing long term effects of practicing mindfulness is encouraged.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.