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Psychiatry Research

journal homepage: www.elsevier.com/locate/psychres

Letter to the Editor

Social cognition in adolescents with dissociative disorder

A R T I C L E I N F O

Keywords: Social cognition Dissociative disorder Adolescents

To the editor,

Dissociative disorder in adolescents is often known to be associated with stressful life events. Trauma tends to play an important role in the development of dissociative disorders as it leads to emotional turmoil which exhausts coping reserve or psychological force (Nakatani, 2000). Children and adolescents experiencing trauma in relationship to at- tachment figures, either overtly (e.g. abuse) or covertly (e.g. neglect) might make them vulnerable to dissociate.

Recent evidence suggests that adolescents with dissociative disorder have deficits in multiple domains of cognition (Ranjan et al, 2016; Dixit et al, 2019). Evidence suggests that individuals with dissociative experiences/symptoms have deficits in social cognition, particularly in the domains of “theory of mind” and “mentalization” (Dorahy, 2006; McKinnon et al, 2016), as well as in emotional processing (Dziobek et al, 2006, Novakova et al, 2015).

For a better understanding of social cognition in dissociative dis- order this study was undertaken, with the objective of studying social cognition in adolescents with Dissociative Disorder and compare with that of healthy controls.

The study sample consisted of 100 adolescents (dissociative dis- order: 50, healthy controls: 50) between the age of 10-16 years. Healthy controls were matched with the patient group for age, gender and years of education. The patients and controls were assessed on Social Cognition Rating Tools in Indian Setting (SOCRATIS),which is an Indianized computer-based tool to measure social cognition (Mehta et al, 2011). Domains of social cognition assessed were-Theory of Mind Test, Metaphor Irony and Faux Pas, Attributional Bias task (externalizing bias and personalizing bias) and Social Cue Recognition task. SPSS version-16.0 (Inc, 2007) was used to calculate student's in- dependent t-test (to compare scores of social cognitions between the study and the control groups.) All analyses were two-tailed and p values <0.01 were regarded as being significant.

The study participants were predominantly urban females (66%; n = 32) with the mean age of 13.3 ± 1.54 years for the study group and 13.57 ± 1.31 years for the control group, belonging to joint fa- milies with monthly family income between Rs 10,000-20,000 INR. Most of the subjects belonged to the Muslim community (62 %; n = 31) in the study group and (64 %; n = 32) in the control group studying in

9th -10th standard. There was no significant difference between the groups on any of the crucial sociodemographic variables.

In the study ‘cognitive theory of mind’ was assessed using the basic theory of mind (ToM) tasks, whereas ‘faux pas’ is used to assess higher order ToM. No significant difference between the two groups was found on cognitive ToM (t = 1.28, p > 0.01) although on faux pas there was a significant difference between the two groups (t = 3.04, p < 0.01). Significantly lower performance on faux pas of the study group with no significant deficit on cognitive ToM indicates that although the subjects suffering from dissociative disorder have no significant deficit in the ability to understand and comprehend the mental states of others at the cognitive level but have difficulty in understanding the affective com- ponent. The Baron Cohen model (Baron-Cohen, 2001) also suggests that cognitive ToM is a prerequisite for affective ToM. It is possible that the cognitive aspects of social cognition (ToM) are relatively intact among individuals with Dissociative Disorder, whereas there may be deficit in the empathic processing that is required in affective ToM.

The attribution bias was assessed in this study in terms of internal attribution and external attribution, which was further divided into personal and situational attributions. The study group subjects scored significantly higher than the control subjects on both the externalizing (t = 3.12, p < 0.01) and personalizing (t = 2.94, p < 0.01) bias (Table 1). They was found to be higher on self-serving bias i.e they tend to attribute positive events to themselves and negative events to the external factors. Among the external factors, they were found to attri- bute more to external persons than to external situations. Thus, ex- cessive attribution of negative events to the outside events, particularly to other individuals than to the situation may lead to a distorted per- ception of the social situation, causing negative feelings for others, in- terpersonal conflicts among persons with dissociative disorder.

On the test of social perception (Social Cue Recognition Test), the study group had significantly lower performance than the control group (t = 4.096, p < 0.01) indicating reduced capacity to integrate cues from face, prosody, gesture, and social context to correctly identify the emotions and intentions of people as well as experience difficulties in the domain of social reasoning. There was also presence of Hyper-ac- tivation towards sad or negative facial expressions and hypo-activation towards happy facial expressions. The effect size was calculated ac- cording to which Cohen's d ranged from 0.25 for ToM to 0.81 for social

https://doi.org/10.1016/j.psychres.2020.113095 Received 6 November 2019; Received in revised form 9 May 2020; Accepted 10 May 2020

Psychiatry Research 290 (2020) 113095

Available online 19 May 2020 0165-1781/ © 2020 Elsevier B.V. All rights reserved.

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cue recognition test. The present study indicates that adolescents suffering from dis-

sociative disorder performed significantly poorer than the control subjects in detecting social cues, mental state attributions (faux pas) and were higher on self-serving and personalizing attributional biases. These significant deficits in various domains of social cognition would significantly hinder in dealing with stressful life events as well as impair functioning in day to day interaction. Thus, it becomes important to have a pre-therapy assessment of social cognition in dissociative dis- order and integrate the management of deficits in social cognition into the therapeutic program of these individuals for enhancing the efficacy of intervention.

With the use of techniques over a period of time the social cognition abilities may be amenable to change. A skill-oriented approach to social cognitive disability has been used in the treatment of patients with schizophrenia (Kurtz and Mueser, 2008) and could be relevant for pa- tients with dissociative disorder but needs to be adapted to their range and depth of impairment. Furthermore, educating patients and families would be help increase understanding and prevent stigma.

CRediT authorship contribution statement

Ayushi Dixit: Investigation, Formal analysis, Writing - original draft. Sujita Kumar Kar: Formal analysis, Writing - review & editing. Shweta Singh: Conceptualization, Methodology, Writing - review & editing. Vivek Agarwal: Supervision, Resources. Amit Arya: Supervision, Resources.

Declaration of Competing Interest

None.

Ayushi Dixit, Sujita Kumar Kar, Shweta Singh⁎, Vivek Agarwal, Amit Arya,

Department of Psychiatry, King George's Medical University, Lucknow, U.P., India

E-mail address: [email protected] (S. Singh).

References

Baron-Cohen, S., 2001. Theory of mind in normal development and autism. Prisme 34, 74–183.

Dixit, A., Singh, S., Kar, S.K., Arya, A., Agarwal, V., 2019. Neuro-Cognition in adolescents with dissociative disorder: A study from a Tertiary Care Center of North India. Indian J. Psychol. Med. 41, 246. https://doi.org/10.4103/IJPSYM.IJPSYM_127_18.

Dorahy, M.J., 2006. The dissociative processing style:a cognitive organization activated by perceived or actual threat in clinical dissociators. J. Trauma Dissociation Off. J. Int. Soc. Study Dissociation ISSD 7, 29–53.

Dziobek, I., Fleck, S., Kalbe, E., Rogers, K., Hassenstab, J., Brand, M., Kessler, J., Woike, J.K., Wolf, O.T., Convit, A., 2006. Introducing MASC: a movie for the assessment of social cognition. J. Autism Dev. Disord. 36, 623–636. https://doi.org/10.1007/ s10803-006-0107-0.

Kurtz, M.M., Mueser, K.T., 2008. A meta-analysis of controlled research on social skills training for schizophrenia. J. Consult. Clin. Psychol. 76, 491.

McKinnon, M.C., Boyd, J.E., Frewen, P.A., Lanius, U.F., Jetly, R., Richardson, J.D., Lanius, R.A., 2016. A review of the relation between dissociation, memory, executive func- tioning and social cognition in military members and civilians with neuropsychiatric conditions. Neuropsychologia 90, 210–234. https://doi.org/10.1016/j. neuropsychologia.2016.07.017.

Mehta, U.M., Thirthalli, J., Kumar, C.N., Mahadevaiah, M., Rao, K., Subbakrishna, D.K., Gangadhar, B.N., Keshavan, M.S., 2011. Validation of Social Cognition Rating Tools in Indian Setting (SOCRATIS): A new test-battery to assess social cognition. Asian J. Psychiatry 4, 203–209.

Nakatani, Y., 2000. Dissociative disorders: from Janet to DSM-IV. Seishin Shinkeigaku Zasshi 102, 1–12.

Novakova, B., Howlett, S., Baker, R., Reuber, M., 2015. Emotion processing and psy- chogenic non-epileptic seizures: a cross-sectional comparison of patients and healthy controls. Seizure 29, 4–10.

Ranjan, R., Mehta, M., Sagar, R., Sarkar, S., 2016. Relationship of cognitive function and adjustment difficulties among children and adolescents with dissociative disorder. J. Neurosci. Rural Pract. 7, 238.

Table 1 Comparison of Study and Control Groups on SOCRATIS.

Study group (n = 50) Mean( ± SD) Control group(n = 50) Mean( ± SD) t VALUE (df = 98) p value Effect size d

ToM -0.20(0.37) -0.10(0.41) 1.28 0.20 o.25 Faux Pas 0.79(0.15) 0.87(0.11) 3.04 0.003 0.60 EB 8.86(4.15) 6.21(4.35) 3.12 0.002 0.62 PB 0.89(0.12) 0.81(0.15) 2.94 0.004 0.58 Social Cue Recognition 0.92(0.11) 0.99(0.05) 4.096 <0.001 0.81

SD = Standard Deviation, ToM = Theory of Mind, EB = Externalizing Bias, PB = Personalizing Bias

⁎ Corresponding author: Department of Psychiatry, King George's Medical University, Lucknow, U.P., India.

Letter to the Editor Psychiatry Research 290 (2020) 113095

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