1. EXPERIENCES AND OUTCOMES OF PSYCHOTHERAPY IN PERSONALITY DISORDER: THE ROLE OF POST TRAUMATIC STRESS DISORDER
Kirsten Barnicot,1 Mike Crawford,1 Stefan Priebe,2 Rana Rashed,3,Monica Doran3 , Tim Mold,4 Amanda Wildgoose,5 Vivia Cowdrill.6 1Centre for Mental Health, Imperial College London, 2 Social & Community Psychiatry, Queen Mary University of London, 3 West London Mental Health Trust 4 East London NHS Foundation Trust, 5 South London and Maudsley NHS Foundation Trust, 6 Southern Health NHS Foundation Trust.
1) BACKGROUND - WHY DO SOME BENEFIT MORE THAN OTHERS FROM PSYCHOTHERAPY FOR PERSONALITY DISORDER?
FIGURE 1 Effect of PTSD on remission from self-harm after DBT
FIGURE 2 Effect of PTSD on self-harm frequency during DBT
Based on extensive RCT evidence, we know that dialectical behaviour therapy (DBT) and mentalization based therapy (MBT) are effective approaches for personality disorder
But not everyone benefits equally. Some patients have poorer outcomes than others, despite receiving the same evidence-based treatment approach – WHY?
At least half of patients with BPD also have comorbid PTSD (Harned et al. 2010, Zanarini et al. 2004), often related to childhood sexual abuse, physical abuse or rape.
Having comorbid PTSD is associated with double the rate of self-harm, a higher rate of suicide attempts, more frequent hospitalisation, poorer quality of life, lower likelihood of BPD recovery and greater emotional dysregulation (Harned et al. 2010, Pagura et al. 2010).
But does it make it more difficult to benefit from treatment for personality disorder?
Preliminary evidence we have obtained from a DBT service in East London suggests this is the case.
Adjusted OR = 0.24
(95% CI )
P = 0.03
Adjusted IRR = 2.86,
p < 0.01
72% self-harm free
50% self-harm free
By the end of treatment, 72% of those without PTSD had stopped self-harming, whereas only 50% of those with comorbid PTSD had stopped. The adjusted rate of self-harm during treatment was 2.86 times higher in patients with PTSD than in those without PTSD. BPD severity was also elevated throughout in those with PTSD. [Barnicot & Priebe 2013].
a) Do patients with untreated comorbid PTSD experience poorer outcomes and a higher likelihood of dropping out from psychological treatment for personality disorder?
b) If there is a negative effect of untreated comorbid PTSD, is it mediated by emotional numbing, shame, hopelessness or dissociation?
Design: Observational longitudinal study.
Patients beginning a month programme of MBT or DBT treatment will be approached and asked to take part in the study. Teams in CNWL, ELFT, WLMHT, Southern Health and SLaM are participating.
Inclusion criterion: A diagnosis of personality disorder.
Exclusion criteria: Incapacity to consent; Learning or English language difficulties of sufficient severity to interfere with completion of study measures.
Personality disorder and PTSD diagnoses will be established at baseline using the SCID-I and SCID-II semi-structured interviews.
Patients’ BPD severity, self-harm, emotional numbing, dissociation, shame and hopelessness will be assessed at baseline and at month 3, month 6, month 9 and month 12 of treatment.
Outcomes will be compared between those with comorbid PTSD and those without PTSD.
Structural equation modelling will be used to determine whether any negative effect of untreated PTSD is mediated by emotional numbing, dissociation, shame or hopelessness.
3) RESEARCH METHODS
2) RESEARCH QUESTIONS