دلایل ختم زودرس رفتاردرمانی دیالکتیکی برای بیماران مبتلا به اختلال شخصیت مرزی

Although one of the main aims of dialectical behavior therapy (DBT) for borderline personality disorder (BPD) is to increase the retention rates, premature termination rates for DBT inpatient programs were found to be over 30%. The aim of the study was to identify the reasons for, and to analyze, patient characteristics that are associated with premature termination. We studied 541 inpatients with BPD, who were consecutively admitted for an open-door 3-month DBT inpatient treatment in Berlin, Germany. All participants completed several self-rating measures and participated in clinical interviews. Fourteen percent, who did not complete the full 84 days of assigned treatment, were expelled, mainly due to treatment-disturbing behaviors, or substance abuse or possession. Nearly 19% dropped out of treatment, mostly due to lack of motivation, arguments with others, and poor tolerance of emotional distress. Using non-parametric conditional inference trees, expulsion was associated with anorexia nervosa and alcohol abuse, whereas more than 9 suicide attempts, antisocial personality disorders, and more than 86 weeks in a psychiatric hospital were risk factors for dropout. We discussed measures and interventions that might lead to an adaptation of DBT inpatient programs. Future research should examine the symptom course and utilization of health-care services of non-completers.

Results Sample description Table 1 shows the socio-demographic data and clinical characteristics. The analysis included N = 541 BPD patients, of whom n = 489 were women (90.4%). All participants were Caucasian. Treatment was terminated before day 84 by 176 patients (32.5%). The treatment length for those who terminated treatment prematurely was, on average, 40 days (SD = 21.35). One-hundred participants dropped out and 76 were expelled. Table 1. Clinical and socio-demographic characteristics at pre-treatment. Completers (n = 365) Expelled (n = 76) Dropouts (n = 100) n % n % n % χ2 df p Gender Female 331 90.7 71 93.4 87 87.0 2.16 2 .339 Male 34 9.3 5 6.6 13 13.0 Marital status 5.18 6 .521 Single 229 62.7 45 59.2 65 65.0 Cohabitated 47 12.9 12 15.8 15 15.0 Married 49 13.4 9 11.8 6 6.0 Divorced/separated 40 11.0 10 13.2 14 14.0 School education 7.19 6 .303 Secondary modern school 21 5.8 4 5.3 9 9.0 Junior high school 98 26.8 19 25.0 35 25.0 University-entrance-level school-leaving qualification 184 50.4 42 55.3 38 38.0 High school and students of a university 62 17.0 11 14.5 18 18.0 Employment status 6.32 8 .201 Employed 146 39.3 23 30.3 38 38 Seeking work 97 26.1 21 27.6 30 30 Vocational training 17 4.6 3 3.9 4 4 Student 41 11.0 6 7.9 10 10 Early retired 25 6.7 8 105 9 9 Housewife/housemen 46 12.37 11 14.5 14 14 Co-occurring current mental disorders Mood disorders 137 37.5 21 27.6 35 35.0 5.00 2 .082 Substance use disorders 156 42.8 39 51.3 54 54.0 3.58 2 .167 Anxiety disorders 170 46.6 36 47.4 42 42.0 2.71 2 .258 Eating disorders 107 29.3 30 39.5 35 35.0 0.47 2 .791 Antisocial personality disorder 10 2.7 3 3.9 6 6.0 2.51 2 .285 M SD M SD M SD t/F df p Inpatient days after admission – – 42.55 21.60 37.35 21.11 1.60 174 .111 Weeks in psychiatric hospitals 28.19 31.64 26.86 27.56 32.05 30.04 0.69 2;538 .500 Number of suicide attempts 3.07 4.44 2.88 4.08 4.39 8.33 2.68 2;538 .069 Number of self-injurious behaviors in the last week before admission 2.32 2.45 2.32 1.88 2.50 2.42 1.29 2;538 .795 Number of BPD criteria 5.48 1.40 5.43 1.44 5.45 1.40 0.67 2;538 .511 BSL-95 score 4.34 1.41 4.02 1.67 4.12 1.60 1.97 2;538 .140 BDI score 1.60 0.46 1.52 0.54 1.53 0.51 1.38 2;538 .254 FDS score 25.00 13.42 27.23 17.43 23.66 16.34 1.30 2;538 .274 Note. BSL-95 = Borderline-Symptom-List-95; BDI = Beck Depression Inventory; FDS = Fragebogen zu dissoziativen Symptomen (Dissociative Symptom Questionnaire); BPD = borderline personality disorder. Table options For the total sample, the mean age lay at 29 years (SD = 8.237). Approximately 25.5% lived in a partnership. At admission, 35.7% met the criteria for mood disorders, 46.0% for anxiety disorders, 31.8% for eating disorders, and 46% for substance abuse disorders. On average, each patient had 2 (SD = 1.39) current mental disorders. Participants met more than 5 BPD criteria (SD = 1.41). They reported self-injuries more than twice in the week before admission (SD = 2.42) and had attempted suicide approximately three times in their lifetime (SD = 5.85). The mean pre-treatment BSL score appeared to be higher compared to the level of borderline-specific symptoms of BPD samples reported in previous studies (Bohus et al., 2007 and Kröger et al., 2013), whereas the mean BDI score and the mean FDS score were comparable to those of other inpatient samples (Bohus et al., 2004, Kröger et al., 2006 and Kröger et al., 2013). No differences were found, in terms of socio-demographic data and clinical characteristics, between the subgroups. Reasons for premature termination Table 2 displays the reasons for premature termination. About one third of the participants who did not complete the treatment were expelled due to treatment-disturbing behaviors (17%) or due to substance abuse or possession (15%). Another third dropped out due to a lack of motivation (13%), arguments with others (11%), and no willingness to tolerate emotional distress (10%). Other reasons amounted to less than 10%. One individual (0.6%) died due to an overdose during a treatment break and six attempted suicide during the inpatient stay (3.4%). Table 2. Reasons for premature termination of treatment (N = 176). n % Expulsion (1) Treatment-disturbing behaviors 30 17.0 (2) Alcohol and substance abuse twice or possession 26 14.8 (3) Offenses, threats and use of violence 7 4.0 (4) Suicide attempt 6 3.4 (5) Two cases of missing pre-arranged weight-gain 4 2.3 (6) Start of a sexual relationship with another inpatient 3 1.7 Dropout (1) Lack of motivation 23 13.1 (2) Repeated arguments with others 19 10.8 (3) No willingness to tolerate emotional distress 18 10.2 (4) Critical life events or other severe changes in the social network 16 9.1 (5) Feeling stable, but discharged against medical advice 11 7.4 (6) Unknown reasons 7 4.0 (7) Withdrawal due to substance dependence 5 2.8 (8) Death because of an overdose 1 0.6 Table options Characteristics associated with premature termination Fig. 1 and Fig. 2 illustrate the risk of dropout in the Surv CTree. Analyses for expulsion revealed a significant effect for anorexia nervosa (AN). The algorithm implemented a binary split between participants with and without AN, indicating a higher risk of expulsion for those with AN, in particular, during the second half of the inpatient stay. In addition, those with alcohol abuse also showed a higher risk for expulsion; however, this risk continued over a period of time. Full-size image (27 K) Fig. 1. The risk of expulsion in a non-parametric conditional inference tree. (The percentage of expelled individuals in each subgroup is shown over the time of the inpatient stay within 84 days.) Figure options Full-size image (35 K) Fig. 2. The risk of dropout in a non-parametric conditional inference tree. Figure options The analysis for dropout revealed a significant effect for suicide attempts, indicating a higher risk for those participants who reported more than nine suicide attempts. Those who reported less than nine suicide attempts, but met the criteria of ASPD, were also at a particularly higher risk for dropout. The risk appeared to be continuous over a period of time for both characteristics. Moreover, participants who reported more than 86 weeks in a psychiatric hospital also showed a significantly higher risk for dropout. This risk turned out to be higher during the first half of the inpatient stay.