Behavioral Medicine
ISSN: 0896-4289 (Print) 1940-4026 (Online) Journal homepage: http://www.tandfonline.com/loi/vbmd20
Role of Borderline Personality Disorder in the Treatment of Military Sexual Trauma-related Posttraumatic Stress Disorder with Cognitive Processing Therapy Nicholas Holder, Ryan Holliday, Anushka Pai & Alina Surís To cite this article: Nicholas Holder, Ryan Holliday, Anushka Pai & Alina Surís (2017) Role of Borderline Personality Disorder in the Treatment of Military Sexual Trauma-related Posttraumatic Stress Disorder with Cognitive Processing Therapy, Behavioral Medicine, 43:3, 184-190, DOI: 10.1080/08964289.2016.1276430 To link to this article: http://dx.doi.org/10.1080/08964289.2016.1276430
Published online: 02 Aug 2017.
Submit your article to this journal
Article views: 222
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=vbmd20 Download by: [Australian Catholic University]
Date: 10 September 2017, At: 00:03
BEHAVIORAL MEDICINE 2017, VOL. 43, NO. 3, 184–190 https://doi.org/10.1080/08964289.2016.1276430
Role of Borderline Personality Disorder in the Treatment of Military Sexual Trauma-related Posttraumatic Stress Disorder with Cognitive Processing Therapy Nicholas Holder, Ryan Holliday, Anushka Pai, and Alina Surıs
Downloaded by [Australian Catholic University] at 00:03 10 September 2017
Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center
Cognitive Processing Therapy (CPT) is an effective evidence-based treatment for many, but not all, veterans with posttraumatic stress disorder (PTSD). Understanding the factors that contribute to poorer response to CPT is important for providing the best care to veterans diagnosed with PTSD. Researchers investigating the effectiveness of CPT for individuals with comorbid personality symptoms have found that borderline personality disorder (BPD) characteristics do not negatively affect treatment outcome; however, participants in those studies were not diagnosed with BPD. The current pilot study investigated the effect of a BPD diagnosis on CPT dropout and outcomes. Data were compiled from a larger randomized clinical trial. Twenty-seven female veterans with military sexual trauma-related PTSD received CPT. Dropout was evaluated by treatment completion and number of sessions attended. Treatment outcome was assessed by the Clinician Administered PTSD Scale (CAPS) and the PTSD Checklist (PCL). No significant differences were observed between veterans with and without BPD comorbidity for number of treatment sessions attended, and there was not a significant relationship between comorbidity status and treatment completion. A hierarchical linear modeling approach was used with BPD entered as a level 2 predictor of outcome. In our sample, veterans with BPD had higher PTSD symptom severity on the CAPS at baseline compared to veterans without BPD comorbidity. CPT was effective in reducing PTSD symptoms; however, BPD diagnosis did not influence treatment response over time on the CAPS or PCL. Our results provide initial support for the use of CPT in female veterans with MST-related PTSD and comorbid BPD.
Introduction Posttraumatic stress disorder (PTSD) is a psychiatric disorder that may develop following a qualifying exposure to a traumatic event.1,2 PTSD is characterized by symptoms of avoidance, arousal, and intrusion, which are contextually and temporally tied to the trauma.1,2 Female veterans are particularly likely to be diagnosed with PTSD, with estimates of diagnostic prevalence ranging from 11% to 21%.3,4 Although female veterans can experience many traumatic events during and before their service,5 military sexual trauma (MST) is one of the most common potentially traumatic experiences endorsed by female veterans.6 Recent national surveys report that between 24% and 41% of female veterans experience MST during their service.7,8 A recent survey showed that 51% of female veterans who endorsed MST were also diagnosed with PTSD.9 In an effort to provide optimal care for veterans diagnosed with PTSD, the Veterans Health Administration has prioritized the dissemination of evidence-based treatments (EBTs) for PTSD.10,11 One EBT that has been disseminated extensively10 is Cognitive Processing Therapy (CPT), which was CONTACT Alina Surıs
[email protected]
This article is not subject to US copyright law.
KEYWORDS
posttraumatic stress disorder; borderline personality disorder; military sexual trauma; cognitive processing therapy; female veterans
originally designed to treat female sexual assault survivors.12 CPT has since been shown to be an effective treatment for veterans and active duty service members with combat-related PTSD13,14 as well as veterans with MSTrelated PTSD.15 In recent meta-analyses, CPT showed strong efficacy when compared to other treatments for PTSD.16,17 Despite its demonstrated efficacy, not all veterans diagnosed with PTSD are willing and/or able to complete CPT.18–21 Not all veterans who complete CPT experience clinically significant reduction in their PTSD symptoms following treatment.22 Additionally, many providers are resistant to providing CPT and other EBTs to veterans diagnosed with PTSD due to a variety of perceived barriers including comorbid diagnoses.23–25 One factor that may contribute to the discrepancy in treatment outcomes and provider utilization of CPT is a comorbid diagnosis of borderline personality disorder (BPD). An estimated 24.2% of the general population diagnosed with PTSD also meets criteria for BPD.26 Specific to veteran populations, there are no epidemiological studies documenting the rate of comorbid BPD in female veterans diagnosed with PTSD. However, Black and
4500 S. Lancaster Rd., Dallas, TX 75216, USA.
Downloaded by [Australian Catholic University] at 00:03 10 September 2017
BEHAVIORAL MEDICINE
colleagues27 estimated that 47% of veterans diagnosed with BPD also met criteria for PTSD. Historically, BPD has been viewed as a difficult diagnosis to treat and many providers have avoided treating patients with BPD.28 Consistent with this history, many providers continue to view BPD comorbidity as a barrier to utilization of traditional treatments for PTSD, including CPT.25 When investigating the role of BPD in PTSD treatment outcomes, researchers have used proxies of a formal BPD diagnosis (i.e., comorbid personality disorder diagnosis, BPD characteristics), with mixed results regarding psychological presentation and treatment. Although some studies have reported higher PTSD symptom severity in individuals with higher BPD characteristics29 or any comorbid personality disorder,19 others reported no differences with the same proxies.30,31 Additionally, although individuals with more BPD characteristics have been shown to terminate CPT earlier,29 no differences in the efficacy of CPT treatment have been reported due to BPD characteristics29 or any comorbid personality disorder.31 No research to date has examined this relationship in female veterans formally diagnosed with comorbid BPD and PTSD. The current pilot investigation examines the effects of comorbid BPD in a sample of female veterans diagnosed with MST-related PTSD who have been treated with CPT. Compared to veterans without comorbid BPD, we expect that veterans with comorbid BPD will have greater pretreatment PTSD symptom severity, will attend fewer sessions of CPT, and will drop out of treatment more frequently. Despite this, based on our review of the literature, we hypothesize that veterans with comorbid BPD will not significantly differ in CPT treatment outcome response when compared to veterans without comorbid BPD.
Methods Participants and procedures Data from a previously conducted randomized clinical trial (RCT) investigating the efficacy of CPT compared to Present Centered Therapy (PCT) were utilized.15 Participants were recruited via clinician referrals and Institutional Review Board-approved advertisements and letters. Participants received monetary compensation for their participation. The RCT was approved by the local Institutional Review Board, and all participants voluntarily gave their written consent prior to beginning the study. Inclusion criteria for Surıs and colleagues15 were (1) veteran status with a current diagnosis of PTSD and an index trauma of MST; (2) trauma occurred more than 3 months prior to study entry; (3) for veterans with multiple traumatic experiences, MST was reported to be causing the most severe current distress; (4) the veteran
185
had more than one clear memory of the trauma; and (5) stable psychiatric medication for at least 6 or more weeks. Exclusion criteria were (1) active substance dependence within the last 3 months, (2) current psychosis, (3) current unstable bipolar disorder, (4) current cognitive impairment, (5) current EBT treatment for their PTSD, (6) involvement in a violent relationship, or (7) prominent suicidal or homicidal features. Of the 128 veterans randomized in the RCT, only data from participants randomized to receive CPT (n D 72) were considered for the current study.15 Of this sample, BPD diagnostic information was not available for 24 participants, and an additional 7 male participants were removed due to the focus on female veterans in the current report.32 Finally, due to low fidelity with delivery of CPT by two therapist, an additional 14 participants were removed from this sample because they did not receive an adequate trial of CPT.15 Consequently, statistical analyses were conducted on a sample of 27 female veterans with MST-related PTSD. This sample was divided into veterans with comorbid BPD (n D 7) and without comorbid BPD (n D 20). The presence of a BPD diagnosis was determined by electronic medical record chart review.32 The sociodemographic characteristics (i.e., age, education, race/ethnicity, and service era) for participants with and without BPD comorbidity can be found in Table 1. The study consisted of 17 sessions, including 5 assessment sessions and 12 intervention sessions. The baseline assessment included a demographic questionnaire to gather sociodemographic information (i.e., age, highest level of education, gender, race/ethnicity, and service era), administration of the Clinician Administered PTSD Scale (CAPS)33 to provide Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) PTSD diagnosis and clinician rated symptom severity, and the PTSD Checklist-Military Version (PCL-M)34 to assess self-reported PTSD symptom severity. After determining eligibility during baseline assessment, participants were randomized to receive either CPT or PCT. Randomized participants attended 12 individual therapy sessions that occurred either once or twice per week depending on participants’ schedules. Additional details regarding delivery of treatment and treatment fidelity are provided in Surıs and colleagues.15 “Treatment completion” was defined as a participant completing all 12 sessions of CPT. Follow-up sessions occurred at post-treatment (i.e., within 7 days of the final therapy session) as well as 2, 4, and 6 months after the final therapy session. Each follow-up session included both the CAPS and PCL.
186
N. HOLDER ET AL.
Table 1. Age, education, ethnicity, and service era based on BPD comorbidity. With BPD (n D 7) M
SD
M
SD
t
14.14 41.29 17.07
2.19 10.75 11.63
14.70 41.50 18.83
2.30 11.67 11.50
0.56 0.04 0.34
n
%
n
%
x2
Race/Ethnicity White, non-Hispanic Black, non-Hispanic White, Hispanic Native Hawaiian/Pacific Islander Other
3 2 1 0 1
42.9 28.6 14.3 0.0 14.3
6 11 1 1 1
30.0 55.0 5.0 5.0 5.0
Service Era Vietnam Post-Vietnam Gulf War Gulf War—OIF/OEF/OND OIF/OEF/OND Multiple Eras
1 1 0 3 2 0
14.3 14.3 0.0 42.9 28.6 0.0
2 3 6 1 6 2
10.0 15.0 30.0 5.0 30.0 10.0
Variable Years of education Age Time since traumaa
Downloaded by [Australian Catholic University] at 00:03 10 September 2017
Without BPD (n D 20)
2.57
7.91
p < 0.05. Date of trauma was not available for one participant. Abbreviations: BPD, Borderline Personality Disorder; OIF/OEF/OND, Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn. a
Measures The CAPS is a 30-item semistructured clinical interview, which is considered to be a “gold-standard” method of diagnosing PTSD in both clinical and research settings.33 In addition to establishing PTSD diagnosis, the CAPS assesses the frequency and intensity of DSM-IV-TR PTSD symptoms, with a total symptom severity score calculated by summing frequency and intensity scores for the 17 symptom criteria.1 The CAPS has good interrater reliability (k D 0.95–1.00) and appropriate concurrent validity with other measures of PTSD including the Mississippi Scale for Combat-related PTSD (r D 0.70, r D 0.81) and the PCL-M (r D 0.93).33,35–37 The PCL-M is commonly used in both research and clinical settings to assess self-report PTSD symptom severity.34 The PCL-M includes 17 items to assess a patient’s perceived intensity of all of the DSM-IV-TR PTSD symptoms, with a total score generated by summing the items. The PCL-M has good test-retest reliability (r D 0.96) and appropriate concurrent validity with other measures of PTSD including the Clinician Administered PTSD Scale (r D 0.93) and the Mississippi Scale for Combat PTSD (r D 0.93).35,38–40 Statistical analyses Veterans with and without BPD comorbidity were compared at baseline on sociodemographic factors (i.e., age, education, time elapsed since trauma, race/ethnicity, and service era) using independent samples t-tests for continuous variables and chi-square analyses for categorical variables. To determine the influence of BPD comorbidity on
treatment completion, veterans with and without BPD diagnosis were compared in terms of number of sessions attended using an independent samples t-test and treatment completion status using a chi-square analysis. Based on the longitudinal study design, a multilevel (or nested) data structure was analyzed to evaluate changes in PTSD symptoms over time using hierarchical linear modeling (HLM). HLM is advantageous when there is missing data and an unbalanced study design as it allows the number of observations to vary across groups more efficiently than a standard repeated measure analysis of variance.41,42 The first level of data (level-1) included the PTSD outcome measures (i.e., PCL-M, CAPS) that were collected at baseline (time D 0), post-treatment (time D 1), and each of the three follow-up visits (time D 2–4). The level-1 data were then nested within second level (level-2) groups (i.e., with and without BPD comorbidity). The final structure of our data included repeated measures (level-1) nested within groups (level-2). HLM 7.043 was utilized to calculate linear growth curves over time for each variable (PCL-M and CAPS), for each group (with and without BPD comorbidity) using a multilevel random coefficients regression framework.
Results Sociodemographic characteristics No significant differences were found for continuous sociodemographic characteristics (i.e., age, education, time elapsed since trauma) between veterans with and without BPD comorbidity (see Table 1). Additionally, no significant relationships were found between
BEHAVIORAL MEDICINE
Table 2. Participant scores on the PCL-M and CAPS over time by comorbidity group.
Downloaded by [Australian Catholic University] at 00:03 10 September 2017
With BPD
Without BPD
n/N
M(SD)
n/N
M(SD)
Baseline Post-treatment 2-month Follow-up 4-month Follow-up 6-month Follow-up
7/7 5/7 5/7 6/7 6/7
68.14(9.82) 50.60(15.36) 58.40(10.71) 61.83 (10.94) 48.67(12.71)
19/20 10/20 12/20 11/20 10/20
61.68(11.09) 41.40(13.09) 43.33(11.82) 42.36(15.29) 41.00(15.12)
CAPS
n/N
M(SD)
n/N
M(SD)
Baseline Post-treatment 2-month Follow-up 4-month Follow-up 6-month Follow-up
7/7 5/7 6/7 6/7 6/7
97.86(6.28) 67.00(29.33) 67.17(14.66) 67.17(21.29) 62.83(26.96)
20/20 11/20 12/20 11/20 10/20
78.70(14.94) 53.64(28.44) 53.42(23.22) 51.82(24.68) 44.60(26.14)
Abbreviations: BPD, Borderline Personality Disorder; PCL-M, PTSD ChecklistMilitary; CAPS, Clinician Administered PTSD Scale.
categorical variables (i.e., race/ethnicity, service era) and comorbidity group (see Table 1). Completion of CPT There were no significant differences between the number of sessions attended by veterans with comorbid BPD (M D 10.43, SD D 3.05) and veterans without comorbid BPD (M D 9.40, SD D 3.50), t(25) D 0.69, p D 0.497). In addition, there was not a significant relationship between BPD comorbidity and treatment completion (x2(1, N D 27) D 0.29; p D 0.590). Rates of completion were 71.43% for veterans with BPD and 60.00% for veterans without BPD. Hierarchical linear model of CPT response PCL-M Means and standard deviations for PCL-M scores at each administration of the PCL-M are provided in Table 2. Results of an unconditional PCL-M score model revealed a significant (b D ¡4.12, t(25) D ¡6.12[0.67], p < 0.001) Table 3. Longitudinal PCL-M outcomes during treatment and follow-up. Fixed effect Intercept Intercept Comorbidity group Slope Intercept Comorbidity group Random effect Intercept Slope Level one (r)
Coefficient
Standard error
t-ratio
p
57.14 7.02
2.41 3.77
23.67 1.86
< 0.001 0.075
¡4.56 1.10
0.99 1.10
¡4.59 1.01
< 0.001 0.325
Chi-square
p
27.30 12.78
< 0.001 > 0.500
Variance component 45.50 1.31 100.08
Table 4. Longitudinal CAPS outcomes during treatment and follow-up. Fixed effect
PCL-M
Abbreviation: PCL-M, PTSD Checklist-Military. Comorbidity group was a comparison of veterans with and without BPD comorbidity.
187
Intercept Intercept Comorbidity group Slope Intercept Comorbidity group Random effect Intercept Slope Level one (r)
Coefficient
Standard error
t-ratio
p
72.57 16.98
4.03 5.22
18.01 3.25
< 0.001 0.003
¡7.16 ¡0.41
1.89 2.68
¡3.79 ¡0.16
< 0.001 0.878
Chi-square
p
Variance component 60.13 11.61 206.00
22.69 19.39
0.122 0.249
Abbreviation: CAPS, Clinician Administered PTSD Scale. Comorbidity group was a comparison of veterans with and without BPD comorbidity.
reduction in self-reported PTSD symptoms over time (see Table 3). BPD comorbidity was not found to be a significant level-2 predictor of the intercept; however, there was a trend toward statistical significance (b D 7.02, t(24) D 1.86[3.77], p D 0.075) in the direction of veterans with comorbid BPD having more severe PCL-M scores at baseline than those without BPD comorbidity. BPD comorbidity was not a significant predictor of the slope, suggesting that there was not a significant difference in the pattern of change over time between veterans with and without BPD comorbidity (b D 1.10, t(24) D 1.01[1.10], p D 0.325). CAPS Means and standard deviations for CAPS scores at each time point are provided in Table 2. Similar to the PCL, results of an unconditional CAPS score model revealed a significant (b D ¡7.19, t(25) D ¡5.11[1.41], p < 0.001) reduction in PTSD symptoms over time (see Table 4). BPD comorbidity was found to be a significant level-2 predictor of the intercept, with veterans with comorbid BPD having more severe CAPS scores at baseline than those without BPD comorbidity (b D 16.98, t(24) D 2.33 [7.30], p D 0.029). BPD comorbidity was not a significant predictor of the slope; thus, there were no significant differences between veterans with and without BPD comorbidity in patterns of improvement in clinician-rated PTSD symptoms over time (b D ¡0.42, t(24) D ¡0.16 [2.68], p D 0.878).
Discussion Consistent with our hypothesis, our preliminary data suggest that female veterans with comorbid BPD endorsed higher clinician-reported PTSD symptom severity at baseline compared to veterans without BPD comorbidity. Overall, there was a significant reduction in PTSD symptoms over time for veterans with and without BPD comorbidity. Further, BPD status did not affect the
Downloaded by [Australian Catholic University] at 00:03 10 September 2017
188
N. HOLDER ET AL.
rate of improvement over time. Veterans with comorbid BPD did not show a significantly different treatment response compared to veterans without comorbid BPD. Contrary to our hypotheses, BPD comorbidity status did not affect treatment completion or number of sessions of completed. BPD is viewed clinically as a difficult diagnosis to treat and BPD comorbidity in veterans with PTSD is often perceived by providers as a barrier to the implementation of EBTs for PTSD.25,28 The present pilot study addressed multiple aspects of potential clinician concern regarding using CPT with veterans with comorbid BPD. Clinicians may perceive that veterans with comorbid BPD may be unlikely to complete treatment and will attend fewer sessions. Our preliminary findings that veterans with and without BPD attended a similar number of treatment sessions and complete treatment at a similar rate are inconsistent with our hypotheses, clinician perception, and previous research reporting that individuals with higher BPD traits attend fewer treatment sessions.29 Additionally, clinicians may perceive that individuals with BPD will endorse more severe PTSD symptoms and may not benefit from CPT. Consistent with our hypothesis, veterans with comorbid BPD and PTSD experienced higher clinician-rated PTSD symptom severity at baseline. Also consistent with our hypothesis, veterans with comorbid BPD did not significantly differ in their rate of improvement over time despite higher clinician-rated baseline symptom severity. Although clinician-rated PTSD symptom severity was significantly higher in veterans with comorbid BPD, selfreported PTSD symptom severity scores were not significantly higher in this group, but did trend toward a significant difference. The PCL-M and CAPS tend to correlate highly and produce similar results.36,38 However, selfreported and clinician-rated PTSD symptom severity are discordant in certain subpopulations of individuals diagnosed with PTSD (e.g., Intimate Partner Violence-related PTSD).44 Additional research is needed to determine why self-report and clinician rated baseline symptoms may be discrepant among veterans diagnosed with comorbid PTSD and BPD. Strengths of the current pilot study included the selection of participants from a real-world population of female veterans seeking treatment for MST-related PTSD. Although the veterans could not be randomized to the comparison groups in this study, no differences were observed between groups on any sociodemographic variables. An additional strength is that the study assessed PTSD symptom severity through multiple methods (i.e., clinician-report and self-report) using gold-standard assessment tools. Although the results of the current study are informative, this pilot study has several notable limitations. BPD
diagnosis was determined using documentation in veterans’ electronic medical records. Although this is common practice in research, a validated assessment tool would be preferable to identify presence and severity of BPD symptoms. It is important to note that clinicians’ naturalistic diagnoses of personality disorders have limited agreement with structured assessment.45 Therefore, the results of our study likely extend only to naturalistic diagnoses of BPD. The sample used for data analysis was small due to the unavailability of BPD diagnostic data, focus on female gender, and below average CPT treatment fidelity in the larger study. Missing data during follow-up measurements further reduced data available for analysis. As a result of our limited sample, it is possible that our analyses were underpowered to detect differences in treatment trajectory between veterans with and without BPD comorbidity. Considering the pilot nature of our study, it is important for our results to be replicated within a larger sample. Although statistical guidelines for sample size can be difficult to implement in applied clinical research, we suggest future research designs have balanced comparison groups with a level-2 sample size of 30 to ensure that bias in the statistical model is negligible.46,47 Additionally, some factors that may be associated with treatment outcome were not assessed (e.g., cumulative trauma). Veterans’ rationale for terminating CPT early was also not collected and it is unclear if they dropped out because of non-response to treatment or a more rapid than expected benefit, as measured in other CPT studies.21,48 In future studies, assessing treatment drop out in veterans with comorbid PTSD and BPD, reasons for drop out should be examined.
Conclusions Despite female veterans with comorbid MST-related PTSD and BPD experiencing higher clinician-rated PTSD symptom severity at baseline, there were no significant differences in treatment response over time to CPT due to BPD comorbidity. Further, comorbidity status did not influence veterans’ completion of CPT. Consistent with previous research, our preliminary results support the utilization of CPT for veterans with comorbid BPD and MST-related PTSD.
References [1] American Psychiatric Association. Diagnostic and statistical manual for mental disorders (4th ed.). Washington DC: Author; 2000. [2] North CS, Suris AM, Davis M, Smith RP. Toward validation of the diagnosis of posttraumatic stress disorder. Am J Psychiatry. 2009;166:34–41.
Downloaded by [Australian Catholic University] at 00:03 10 September 2017
BEHAVIORAL MEDICINE
[3] Street AE, Gradus JL, Giasson HL, Vogt D, Resick PA. Gender differences among veterans deployed in support of the wars in Afghanistan and Iraq. J Gen Intern Med. 2013;28:556. [4] Seal KH, Bertenthal D, Miner CR, Sen S, Marmar CR. Bringing the war back home: Mental health disorders among 103 788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs Facilities. Arch Intern Med. 2007;167:476–82. [5] Zinzow HM, Grubaugh A, Monnier J, Suffoletta-Maierle S, Frueh BC. Trauma among female veterans: A critical review. Trauma, Violence, & Abuse. 2007;8:384–400. [6] Surıs A, Lind L. Military sexual trauma: A review of prevalence and associated health consequences in veterans. Trauma Violence Abuse. 2008;9:250–69. [7] Military Sexual Trauma Support Team. Military Sexual Trauma (MST) screening report fiscal year 2012. Washington, DC: U.S. Department of Veterans Affairs; 2013. [8] Barth SK, Kimerling RE, Pavao J, et al. Military sexual trauma among recent veterans: Correlates of sexual assault and sexual harassment. Am J Prev Med. 2016;50:77–86. [9] Kimerling R, Street AE, Pavao J, et al. Military-related sexual trauma among Veterans Health Administration patients returning from Afghanistan and Iraq. Am J Public Health. 2010;100:1409–12. [10] Karlin BE, Cross G. From the laboratory to the therapy room: National dissemination and implementation of evidence-based psychotherapies in the US Department of Veterans Affairs Health Care System. Am Psychol. 2014;69:19–33. [11] Karlin BE, Ruzek JI, Chard KM, et al. Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration. J Trauma Stress. 2010;23:663–73. [12] Resick PA, Schnicke MK. Cognitive processing therapy for sexual assault victims. J Consult Clin Psychol. 1992;60:748–56. [13] Resick PA, Wachen JS, Mintz J, et al. A randomized clinical trial of group cognitive processing therapy compared with group present-centered therapy for PTSD among active duty military personnel. J Consult Clin Psychol. 2015;83:1058–68. [14] Monson CM, Schnurr PP, Resick PA, Friedman MJ, Young-Xu Y, Stevens SP. Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. J Consult Clin Psychol. 2006;74:898–907. [15] Surıs A, Link-Malcolm J, Chard K, Ahn C, North C. A Randomized clinical trial of cognitive processing therapy for veterans with PTSD related to military sexual trauma. J Trauma Stress. 2013;26:28–37. [16] Watts BV, Schnurr PP, Mayo L, Young-Xu Y, Weeks WB, Friedman MJ. Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. J Clin Psychiatry. 2013;74:e541–e50. [17] Smid GE, Knipscheer JW, Kleber RJ. The efficacy of recommended treatments for veterans with PTSD: A metaregression analysis. Clin Psychol Rev. 2015;40:184–94. [18] Schottenbauer MA, Glass CR, Arnkoff DB, Tendick V, Gray SH. Nonresponse and dropout rates in outcome studies on PTSD: Review and methodological considerations. Psychiatry. 2008;71(2):134–68.
189
[19] Ehlers A, Grey N, Wild J, et al. Implementation of cognitive therapy for PTSD in routine clinical care: Effectiveness and moderators of outcome in a consecutive sample. Behav Res Ther. 2013;51:742–52. [20] Imel ZE, Laska K, Jakupcak M, Simpson TL. Meta-analysis of dropout in treatments for posttraumatic stress disorder. J Consult Clin Psychol. 2013;81:394–404. [21] Najavits LM. The problem of dropout from “gold standard” PTSD therapies. F1000Prime Rep. 2015;7; doi:10.12703/P7-43. [22] Steenkamp MM, Litz BT, Hoge CW, Marmar CR. Psychotherapy for military-related PTSD: A review of randomized clinical trials. JAMA. 2015;314:489–500. [23] Shiner B, Tang C, Trapp AC, Konrad R, Bar I, Watts BV. The provision of mental health treatment after screening: exploring the relationship between treatment setting and treatment intensity. Gen Hosp Psychiat. 2014;36:581–8. [24] Borah EV, Wright EC, Donahue DA, et al. Implementation outcomes of military provider training in cognitive processing therapy and prolonged exposure therapy for post-traumatic stress disorder. Mil Med. 2013;178:939– 44. [25] Osei-Bonsu PE, Bolton RE, Stirman SW, Eisen SV, Herz L, Pellowe ME. Mental health providers’ decision-making around the implementation of evidence-based treatment for PTSD. J Behav Health Ser R. in press. Online ahead of print. doi: 10.1007/s11414-015-9489-0. [26] Pagura J, Stein MB, Bolton JM, Cox BJ, Grant B, Sareen J. Comorbidity of borderline personality disorder and posttraumatic stress disorder in the US population. J Psychiatr Res. 2010;44:1190–8. [27] Black DW, Blum N, Letuchy E, Doebbeling CC, FormanHoffman VL, Doebbeling BN. Borderline personality disorder and traits in veterans: psychiatric comorbidity, healthcare utilization, and quality of life along a continuum of severity. CNS Spectr. 2006;11:680–9. [28] Gunderson JG. Borderline personality disorder: Ontogeny of a diagnosis. Am J Psychiatry. 2009;166:530–9. [29] Clarke SB, Rizvi SL, Resick PA. Borderline personality characteristics and treatment outcome in cognitivebehavioral treatments for PTSD in female rape victims. Beha Ther. 2008;39:72–8. [30] Feeny NC, Zoellner LA, Foa EB. Treatment outcome for chronic PTSD among female assault victims with borderline personality characteristics: A preliminary examination. J Pers Disord. 2002;16:30–40. [31] Walter KH, Bolte TA, Owens GP, Chard KM. The impact of personality disorders on treatment outcome for veterans in a posttraumatic stress disorder residential treatment program. Cognitive Ther Res. 2011;36:576–84. [32] Williams R, Holliday R, Clem M, Anderson E, Morris EE, Surıs A. Borderline personality disorder and military sexual trauma analysis of previous traumatization and current psychiatric presentation. J Interpers Violence. in press. Online ahead of print. doi:10.1177/ 0886260515596149. [33] Blake DD, Weathers FW, Nagy LM. The development of a clinician administered PTSD scale. J Trauma Stress. 1995;8:75–90.34. [34] Weathers FW, Litz BT, Herman D, Huska J, Keane T. The PTSD Checklist (PCL): Reliability, validity, and
190
[35]
[36]
[37]
[38]
Downloaded by [Australian Catholic University] at 00:03 10 September 2017
[39]
[40]
[41]
[42]
N. HOLDER ET AL.
diagnostic utility. Annual Meeting of the International Society of Traumatic Stress Studies. 1993. Keane TM, Caddell JM, Taylor KL. Mississippi Scale for Combat-Related Posttraumatic Stress Disorder: three studies in reliability and validity. J Consult Clin Psychol. 1988;56:85–90. Weathers FW, Keane TM, Davidson J. Clinician-administered PTSD scale: A review of the first ten years of research. Depress Anxiety. 2001;13:132–56. Hinton DE, Chhean D, Pich V. Assessment of posttraumatic stress disorder in Cambodian refugees using the ClinicianAdministered PTSD Scale: Psychometric properties and symptom severity. J Trauma Stress. 2006;19:405–9. Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD Checklist (PCL). Behav Res Ther. 1996;34:669–73. Keen SM, Kutter CJ, Niles BL, Krinsley KE. Psychometric properties of PTSD Checklist in sample of male veterans. J Rehabil Res Dev. 2008;45:465–74. Wilkins KC, Lang AJ, Norman SB. Synthesis of the psychometric properties of the PTSD checklist (PCL) military, civilian, and specific versions. Depress Anxiety. 2011;28:596–606. Edwards LJ. Modern statistical techniques for the analysis of longitudinal data in biomedical research. Pediatric Pulmonology. 2000;30:330–44. Krueger C, Tian L. A comparison of the general linear mixed model and repeated measures ANOVA using a
[43]
[44]
[45]
[46]
[47]
[48]
dataset with multiple missing data points. Biol Res Nurs. 2004;6:151–7. Raudenbush S, Bryk A, Cheong Y, Congdon R, du Toit M. HLM 6: Hierarchical linear and nonlinear modeling. [Computer Software] Lincolnwood, IL: Scientific Software Inc.; 2004. Cody MW, Jones JM, Woodward MJ, Simmons CA, Beck JG. Correspondence between self-report measures and clinician assessments of psychopathology in female intimate partner violence survivors. J Interpers Violence. in press. Online ahead of print doi:10.1177/ 0886260515589566. Samuel DB, Sanislow CA, Hopwood CJ, et al. Convergent and incremental predictive validity of clinician, selfreport, and structured interview diagnoses for personality disorders over five years. J Consult Clin Psychol. 2013;81:650–9. Hox JJ, Maas CJM. The accuracy of multilevel structural equation modeling with pseudobalanced groups and small samples. Struct Equ Modeling. 2001;8:157– 74. McNeish DM, Stapleton LM. The effect of small sample size on two-level model estimates: A review and illustration. Educ Psychol Rev. 2016;28:295–314. Gutner CA, Suvak MK, Sloan DM, Resick PA. Does Timing matter? Examining the impact of session timing on outcome. J Consult Clin Psychol. 2016;(84)12;1108–1115. doi:10.1037/ccp0000120.
ISSN: 0896-4289 (Print) 1940-4026 (Online) Journal homepage: http://www.tandfonline.com/loi/vbmd20
Role of Borderline Personality Disorder in the Treatment of Military Sexual Trauma-related Posttraumatic Stress Disorder with Cognitive Processing Therapy Nicholas Holder, Ryan Holliday, Anushka Pai & Alina Surís To cite this article: Nicholas Holder, Ryan Holliday, Anushka Pai & Alina Surís (2017) Role of Borderline Personality Disorder in the Treatment of Military Sexual Trauma-related Posttraumatic Stress Disorder with Cognitive Processing Therapy, Behavioral Medicine, 43:3, 184-190, DOI: 10.1080/08964289.2016.1276430 To link to this article: http://dx.doi.org/10.1080/08964289.2016.1276430
Published online: 02 Aug 2017.
Submit your article to this journal
Article views: 222
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=vbmd20 Download by: [Australian Catholic University]
Date: 10 September 2017, At: 00:03
BEHAVIORAL MEDICINE 2017, VOL. 43, NO. 3, 184–190 https://doi.org/10.1080/08964289.2016.1276430
Role of Borderline Personality Disorder in the Treatment of Military Sexual Trauma-related Posttraumatic Stress Disorder with Cognitive Processing Therapy Nicholas Holder, Ryan Holliday, Anushka Pai, and Alina Surıs
Downloaded by [Australian Catholic University] at 00:03 10 September 2017
Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center
Cognitive Processing Therapy (CPT) is an effective evidence-based treatment for many, but not all, veterans with posttraumatic stress disorder (PTSD). Understanding the factors that contribute to poorer response to CPT is important for providing the best care to veterans diagnosed with PTSD. Researchers investigating the effectiveness of CPT for individuals with comorbid personality symptoms have found that borderline personality disorder (BPD) characteristics do not negatively affect treatment outcome; however, participants in those studies were not diagnosed with BPD. The current pilot study investigated the effect of a BPD diagnosis on CPT dropout and outcomes. Data were compiled from a larger randomized clinical trial. Twenty-seven female veterans with military sexual trauma-related PTSD received CPT. Dropout was evaluated by treatment completion and number of sessions attended. Treatment outcome was assessed by the Clinician Administered PTSD Scale (CAPS) and the PTSD Checklist (PCL). No significant differences were observed between veterans with and without BPD comorbidity for number of treatment sessions attended, and there was not a significant relationship between comorbidity status and treatment completion. A hierarchical linear modeling approach was used with BPD entered as a level 2 predictor of outcome. In our sample, veterans with BPD had higher PTSD symptom severity on the CAPS at baseline compared to veterans without BPD comorbidity. CPT was effective in reducing PTSD symptoms; however, BPD diagnosis did not influence treatment response over time on the CAPS or PCL. Our results provide initial support for the use of CPT in female veterans with MST-related PTSD and comorbid BPD.
Introduction Posttraumatic stress disorder (PTSD) is a psychiatric disorder that may develop following a qualifying exposure to a traumatic event.1,2 PTSD is characterized by symptoms of avoidance, arousal, and intrusion, which are contextually and temporally tied to the trauma.1,2 Female veterans are particularly likely to be diagnosed with PTSD, with estimates of diagnostic prevalence ranging from 11% to 21%.3,4 Although female veterans can experience many traumatic events during and before their service,5 military sexual trauma (MST) is one of the most common potentially traumatic experiences endorsed by female veterans.6 Recent national surveys report that between 24% and 41% of female veterans experience MST during their service.7,8 A recent survey showed that 51% of female veterans who endorsed MST were also diagnosed with PTSD.9 In an effort to provide optimal care for veterans diagnosed with PTSD, the Veterans Health Administration has prioritized the dissemination of evidence-based treatments (EBTs) for PTSD.10,11 One EBT that has been disseminated extensively10 is Cognitive Processing Therapy (CPT), which was CONTACT Alina Surıs
[email protected]
This article is not subject to US copyright law.
KEYWORDS
posttraumatic stress disorder; borderline personality disorder; military sexual trauma; cognitive processing therapy; female veterans
originally designed to treat female sexual assault survivors.12 CPT has since been shown to be an effective treatment for veterans and active duty service members with combat-related PTSD13,14 as well as veterans with MSTrelated PTSD.15 In recent meta-analyses, CPT showed strong efficacy when compared to other treatments for PTSD.16,17 Despite its demonstrated efficacy, not all veterans diagnosed with PTSD are willing and/or able to complete CPT.18–21 Not all veterans who complete CPT experience clinically significant reduction in their PTSD symptoms following treatment.22 Additionally, many providers are resistant to providing CPT and other EBTs to veterans diagnosed with PTSD due to a variety of perceived barriers including comorbid diagnoses.23–25 One factor that may contribute to the discrepancy in treatment outcomes and provider utilization of CPT is a comorbid diagnosis of borderline personality disorder (BPD). An estimated 24.2% of the general population diagnosed with PTSD also meets criteria for BPD.26 Specific to veteran populations, there are no epidemiological studies documenting the rate of comorbid BPD in female veterans diagnosed with PTSD. However, Black and
4500 S. Lancaster Rd., Dallas, TX 75216, USA.
Downloaded by [Australian Catholic University] at 00:03 10 September 2017
BEHAVIORAL MEDICINE
colleagues27 estimated that 47% of veterans diagnosed with BPD also met criteria for PTSD. Historically, BPD has been viewed as a difficult diagnosis to treat and many providers have avoided treating patients with BPD.28 Consistent with this history, many providers continue to view BPD comorbidity as a barrier to utilization of traditional treatments for PTSD, including CPT.25 When investigating the role of BPD in PTSD treatment outcomes, researchers have used proxies of a formal BPD diagnosis (i.e., comorbid personality disorder diagnosis, BPD characteristics), with mixed results regarding psychological presentation and treatment. Although some studies have reported higher PTSD symptom severity in individuals with higher BPD characteristics29 or any comorbid personality disorder,19 others reported no differences with the same proxies.30,31 Additionally, although individuals with more BPD characteristics have been shown to terminate CPT earlier,29 no differences in the efficacy of CPT treatment have been reported due to BPD characteristics29 or any comorbid personality disorder.31 No research to date has examined this relationship in female veterans formally diagnosed with comorbid BPD and PTSD. The current pilot investigation examines the effects of comorbid BPD in a sample of female veterans diagnosed with MST-related PTSD who have been treated with CPT. Compared to veterans without comorbid BPD, we expect that veterans with comorbid BPD will have greater pretreatment PTSD symptom severity, will attend fewer sessions of CPT, and will drop out of treatment more frequently. Despite this, based on our review of the literature, we hypothesize that veterans with comorbid BPD will not significantly differ in CPT treatment outcome response when compared to veterans without comorbid BPD.
Methods Participants and procedures Data from a previously conducted randomized clinical trial (RCT) investigating the efficacy of CPT compared to Present Centered Therapy (PCT) were utilized.15 Participants were recruited via clinician referrals and Institutional Review Board-approved advertisements and letters. Participants received monetary compensation for their participation. The RCT was approved by the local Institutional Review Board, and all participants voluntarily gave their written consent prior to beginning the study. Inclusion criteria for Surıs and colleagues15 were (1) veteran status with a current diagnosis of PTSD and an index trauma of MST; (2) trauma occurred more than 3 months prior to study entry; (3) for veterans with multiple traumatic experiences, MST was reported to be causing the most severe current distress; (4) the veteran
185
had more than one clear memory of the trauma; and (5) stable psychiatric medication for at least 6 or more weeks. Exclusion criteria were (1) active substance dependence within the last 3 months, (2) current psychosis, (3) current unstable bipolar disorder, (4) current cognitive impairment, (5) current EBT treatment for their PTSD, (6) involvement in a violent relationship, or (7) prominent suicidal or homicidal features. Of the 128 veterans randomized in the RCT, only data from participants randomized to receive CPT (n D 72) were considered for the current study.15 Of this sample, BPD diagnostic information was not available for 24 participants, and an additional 7 male participants were removed due to the focus on female veterans in the current report.32 Finally, due to low fidelity with delivery of CPT by two therapist, an additional 14 participants were removed from this sample because they did not receive an adequate trial of CPT.15 Consequently, statistical analyses were conducted on a sample of 27 female veterans with MST-related PTSD. This sample was divided into veterans with comorbid BPD (n D 7) and without comorbid BPD (n D 20). The presence of a BPD diagnosis was determined by electronic medical record chart review.32 The sociodemographic characteristics (i.e., age, education, race/ethnicity, and service era) for participants with and without BPD comorbidity can be found in Table 1. The study consisted of 17 sessions, including 5 assessment sessions and 12 intervention sessions. The baseline assessment included a demographic questionnaire to gather sociodemographic information (i.e., age, highest level of education, gender, race/ethnicity, and service era), administration of the Clinician Administered PTSD Scale (CAPS)33 to provide Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) PTSD diagnosis and clinician rated symptom severity, and the PTSD Checklist-Military Version (PCL-M)34 to assess self-reported PTSD symptom severity. After determining eligibility during baseline assessment, participants were randomized to receive either CPT or PCT. Randomized participants attended 12 individual therapy sessions that occurred either once or twice per week depending on participants’ schedules. Additional details regarding delivery of treatment and treatment fidelity are provided in Surıs and colleagues.15 “Treatment completion” was defined as a participant completing all 12 sessions of CPT. Follow-up sessions occurred at post-treatment (i.e., within 7 days of the final therapy session) as well as 2, 4, and 6 months after the final therapy session. Each follow-up session included both the CAPS and PCL.
186
N. HOLDER ET AL.
Table 1. Age, education, ethnicity, and service era based on BPD comorbidity. With BPD (n D 7) M
SD
M
SD
t
14.14 41.29 17.07
2.19 10.75 11.63
14.70 41.50 18.83
2.30 11.67 11.50
0.56 0.04 0.34
n
%
n
%
x2
Race/Ethnicity White, non-Hispanic Black, non-Hispanic White, Hispanic Native Hawaiian/Pacific Islander Other
3 2 1 0 1
42.9 28.6 14.3 0.0 14.3
6 11 1 1 1
30.0 55.0 5.0 5.0 5.0
Service Era Vietnam Post-Vietnam Gulf War Gulf War—OIF/OEF/OND OIF/OEF/OND Multiple Eras
1 1 0 3 2 0
14.3 14.3 0.0 42.9 28.6 0.0
2 3 6 1 6 2
10.0 15.0 30.0 5.0 30.0 10.0
Variable Years of education Age Time since traumaa
Downloaded by [Australian Catholic University] at 00:03 10 September 2017
Without BPD (n D 20)
2.57
7.91
p < 0.05. Date of trauma was not available for one participant. Abbreviations: BPD, Borderline Personality Disorder; OIF/OEF/OND, Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn. a
Measures The CAPS is a 30-item semistructured clinical interview, which is considered to be a “gold-standard” method of diagnosing PTSD in both clinical and research settings.33 In addition to establishing PTSD diagnosis, the CAPS assesses the frequency and intensity of DSM-IV-TR PTSD symptoms, with a total symptom severity score calculated by summing frequency and intensity scores for the 17 symptom criteria.1 The CAPS has good interrater reliability (k D 0.95–1.00) and appropriate concurrent validity with other measures of PTSD including the Mississippi Scale for Combat-related PTSD (r D 0.70, r D 0.81) and the PCL-M (r D 0.93).33,35–37 The PCL-M is commonly used in both research and clinical settings to assess self-report PTSD symptom severity.34 The PCL-M includes 17 items to assess a patient’s perceived intensity of all of the DSM-IV-TR PTSD symptoms, with a total score generated by summing the items. The PCL-M has good test-retest reliability (r D 0.96) and appropriate concurrent validity with other measures of PTSD including the Clinician Administered PTSD Scale (r D 0.93) and the Mississippi Scale for Combat PTSD (r D 0.93).35,38–40 Statistical analyses Veterans with and without BPD comorbidity were compared at baseline on sociodemographic factors (i.e., age, education, time elapsed since trauma, race/ethnicity, and service era) using independent samples t-tests for continuous variables and chi-square analyses for categorical variables. To determine the influence of BPD comorbidity on
treatment completion, veterans with and without BPD diagnosis were compared in terms of number of sessions attended using an independent samples t-test and treatment completion status using a chi-square analysis. Based on the longitudinal study design, a multilevel (or nested) data structure was analyzed to evaluate changes in PTSD symptoms over time using hierarchical linear modeling (HLM). HLM is advantageous when there is missing data and an unbalanced study design as it allows the number of observations to vary across groups more efficiently than a standard repeated measure analysis of variance.41,42 The first level of data (level-1) included the PTSD outcome measures (i.e., PCL-M, CAPS) that were collected at baseline (time D 0), post-treatment (time D 1), and each of the three follow-up visits (time D 2–4). The level-1 data were then nested within second level (level-2) groups (i.e., with and without BPD comorbidity). The final structure of our data included repeated measures (level-1) nested within groups (level-2). HLM 7.043 was utilized to calculate linear growth curves over time for each variable (PCL-M and CAPS), for each group (with and without BPD comorbidity) using a multilevel random coefficients regression framework.
Results Sociodemographic characteristics No significant differences were found for continuous sociodemographic characteristics (i.e., age, education, time elapsed since trauma) between veterans with and without BPD comorbidity (see Table 1). Additionally, no significant relationships were found between
BEHAVIORAL MEDICINE
Table 2. Participant scores on the PCL-M and CAPS over time by comorbidity group.
Downloaded by [Australian Catholic University] at 00:03 10 September 2017
With BPD
Without BPD
n/N
M(SD)
n/N
M(SD)
Baseline Post-treatment 2-month Follow-up 4-month Follow-up 6-month Follow-up
7/7 5/7 5/7 6/7 6/7
68.14(9.82) 50.60(15.36) 58.40(10.71) 61.83 (10.94) 48.67(12.71)
19/20 10/20 12/20 11/20 10/20
61.68(11.09) 41.40(13.09) 43.33(11.82) 42.36(15.29) 41.00(15.12)
CAPS
n/N
M(SD)
n/N
M(SD)
Baseline Post-treatment 2-month Follow-up 4-month Follow-up 6-month Follow-up
7/7 5/7 6/7 6/7 6/7
97.86(6.28) 67.00(29.33) 67.17(14.66) 67.17(21.29) 62.83(26.96)
20/20 11/20 12/20 11/20 10/20
78.70(14.94) 53.64(28.44) 53.42(23.22) 51.82(24.68) 44.60(26.14)
Abbreviations: BPD, Borderline Personality Disorder; PCL-M, PTSD ChecklistMilitary; CAPS, Clinician Administered PTSD Scale.
categorical variables (i.e., race/ethnicity, service era) and comorbidity group (see Table 1). Completion of CPT There were no significant differences between the number of sessions attended by veterans with comorbid BPD (M D 10.43, SD D 3.05) and veterans without comorbid BPD (M D 9.40, SD D 3.50), t(25) D 0.69, p D 0.497). In addition, there was not a significant relationship between BPD comorbidity and treatment completion (x2(1, N D 27) D 0.29; p D 0.590). Rates of completion were 71.43% for veterans with BPD and 60.00% for veterans without BPD. Hierarchical linear model of CPT response PCL-M Means and standard deviations for PCL-M scores at each administration of the PCL-M are provided in Table 2. Results of an unconditional PCL-M score model revealed a significant (b D ¡4.12, t(25) D ¡6.12[0.67], p < 0.001) Table 3. Longitudinal PCL-M outcomes during treatment and follow-up. Fixed effect Intercept Intercept Comorbidity group Slope Intercept Comorbidity group Random effect Intercept Slope Level one (r)
Coefficient
Standard error
t-ratio
p
57.14 7.02
2.41 3.77
23.67 1.86
< 0.001 0.075
¡4.56 1.10
0.99 1.10
¡4.59 1.01
< 0.001 0.325
Chi-square
p
27.30 12.78
< 0.001 > 0.500
Variance component 45.50 1.31 100.08
Table 4. Longitudinal CAPS outcomes during treatment and follow-up. Fixed effect
PCL-M
Abbreviation: PCL-M, PTSD Checklist-Military. Comorbidity group was a comparison of veterans with and without BPD comorbidity.
187
Intercept Intercept Comorbidity group Slope Intercept Comorbidity group Random effect Intercept Slope Level one (r)
Coefficient
Standard error
t-ratio
p
72.57 16.98
4.03 5.22
18.01 3.25
< 0.001 0.003
¡7.16 ¡0.41
1.89 2.68
¡3.79 ¡0.16
< 0.001 0.878
Chi-square
p
Variance component 60.13 11.61 206.00
22.69 19.39
0.122 0.249
Abbreviation: CAPS, Clinician Administered PTSD Scale. Comorbidity group was a comparison of veterans with and without BPD comorbidity.
reduction in self-reported PTSD symptoms over time (see Table 3). BPD comorbidity was not found to be a significant level-2 predictor of the intercept; however, there was a trend toward statistical significance (b D 7.02, t(24) D 1.86[3.77], p D 0.075) in the direction of veterans with comorbid BPD having more severe PCL-M scores at baseline than those without BPD comorbidity. BPD comorbidity was not a significant predictor of the slope, suggesting that there was not a significant difference in the pattern of change over time between veterans with and without BPD comorbidity (b D 1.10, t(24) D 1.01[1.10], p D 0.325). CAPS Means and standard deviations for CAPS scores at each time point are provided in Table 2. Similar to the PCL, results of an unconditional CAPS score model revealed a significant (b D ¡7.19, t(25) D ¡5.11[1.41], p < 0.001) reduction in PTSD symptoms over time (see Table 4). BPD comorbidity was found to be a significant level-2 predictor of the intercept, with veterans with comorbid BPD having more severe CAPS scores at baseline than those without BPD comorbidity (b D 16.98, t(24) D 2.33 [7.30], p D 0.029). BPD comorbidity was not a significant predictor of the slope; thus, there were no significant differences between veterans with and without BPD comorbidity in patterns of improvement in clinician-rated PTSD symptoms over time (b D ¡0.42, t(24) D ¡0.16 [2.68], p D 0.878).
Discussion Consistent with our hypothesis, our preliminary data suggest that female veterans with comorbid BPD endorsed higher clinician-reported PTSD symptom severity at baseline compared to veterans without BPD comorbidity. Overall, there was a significant reduction in PTSD symptoms over time for veterans with and without BPD comorbidity. Further, BPD status did not affect the
Downloaded by [Australian Catholic University] at 00:03 10 September 2017
188
N. HOLDER ET AL.
rate of improvement over time. Veterans with comorbid BPD did not show a significantly different treatment response compared to veterans without comorbid BPD. Contrary to our hypotheses, BPD comorbidity status did not affect treatment completion or number of sessions of completed. BPD is viewed clinically as a difficult diagnosis to treat and BPD comorbidity in veterans with PTSD is often perceived by providers as a barrier to the implementation of EBTs for PTSD.25,28 The present pilot study addressed multiple aspects of potential clinician concern regarding using CPT with veterans with comorbid BPD. Clinicians may perceive that veterans with comorbid BPD may be unlikely to complete treatment and will attend fewer sessions. Our preliminary findings that veterans with and without BPD attended a similar number of treatment sessions and complete treatment at a similar rate are inconsistent with our hypotheses, clinician perception, and previous research reporting that individuals with higher BPD traits attend fewer treatment sessions.29 Additionally, clinicians may perceive that individuals with BPD will endorse more severe PTSD symptoms and may not benefit from CPT. Consistent with our hypothesis, veterans with comorbid BPD and PTSD experienced higher clinician-rated PTSD symptom severity at baseline. Also consistent with our hypothesis, veterans with comorbid BPD did not significantly differ in their rate of improvement over time despite higher clinician-rated baseline symptom severity. Although clinician-rated PTSD symptom severity was significantly higher in veterans with comorbid BPD, selfreported PTSD symptom severity scores were not significantly higher in this group, but did trend toward a significant difference. The PCL-M and CAPS tend to correlate highly and produce similar results.36,38 However, selfreported and clinician-rated PTSD symptom severity are discordant in certain subpopulations of individuals diagnosed with PTSD (e.g., Intimate Partner Violence-related PTSD).44 Additional research is needed to determine why self-report and clinician rated baseline symptoms may be discrepant among veterans diagnosed with comorbid PTSD and BPD. Strengths of the current pilot study included the selection of participants from a real-world population of female veterans seeking treatment for MST-related PTSD. Although the veterans could not be randomized to the comparison groups in this study, no differences were observed between groups on any sociodemographic variables. An additional strength is that the study assessed PTSD symptom severity through multiple methods (i.e., clinician-report and self-report) using gold-standard assessment tools. Although the results of the current study are informative, this pilot study has several notable limitations. BPD
diagnosis was determined using documentation in veterans’ electronic medical records. Although this is common practice in research, a validated assessment tool would be preferable to identify presence and severity of BPD symptoms. It is important to note that clinicians’ naturalistic diagnoses of personality disorders have limited agreement with structured assessment.45 Therefore, the results of our study likely extend only to naturalistic diagnoses of BPD. The sample used for data analysis was small due to the unavailability of BPD diagnostic data, focus on female gender, and below average CPT treatment fidelity in the larger study. Missing data during follow-up measurements further reduced data available for analysis. As a result of our limited sample, it is possible that our analyses were underpowered to detect differences in treatment trajectory between veterans with and without BPD comorbidity. Considering the pilot nature of our study, it is important for our results to be replicated within a larger sample. Although statistical guidelines for sample size can be difficult to implement in applied clinical research, we suggest future research designs have balanced comparison groups with a level-2 sample size of 30 to ensure that bias in the statistical model is negligible.46,47 Additionally, some factors that may be associated with treatment outcome were not assessed (e.g., cumulative trauma). Veterans’ rationale for terminating CPT early was also not collected and it is unclear if they dropped out because of non-response to treatment or a more rapid than expected benefit, as measured in other CPT studies.21,48 In future studies, assessing treatment drop out in veterans with comorbid PTSD and BPD, reasons for drop out should be examined.
Conclusions Despite female veterans with comorbid MST-related PTSD and BPD experiencing higher clinician-rated PTSD symptom severity at baseline, there were no significant differences in treatment response over time to CPT due to BPD comorbidity. Further, comorbidity status did not influence veterans’ completion of CPT. Consistent with previous research, our preliminary results support the utilization of CPT for veterans with comorbid BPD and MST-related PTSD.
References [1] American Psychiatric Association. Diagnostic and statistical manual for mental disorders (4th ed.). Washington DC: Author; 2000. [2] North CS, Suris AM, Davis M, Smith RP. Toward validation of the diagnosis of posttraumatic stress disorder. Am J Psychiatry. 2009;166:34–41.
Downloaded by [Australian Catholic University] at 00:03 10 September 2017
BEHAVIORAL MEDICINE
[3] Street AE, Gradus JL, Giasson HL, Vogt D, Resick PA. Gender differences among veterans deployed in support of the wars in Afghanistan and Iraq. J Gen Intern Med. 2013;28:556. [4] Seal KH, Bertenthal D, Miner CR, Sen S, Marmar CR. Bringing the war back home: Mental health disorders among 103 788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs Facilities. Arch Intern Med. 2007;167:476–82. [5] Zinzow HM, Grubaugh A, Monnier J, Suffoletta-Maierle S, Frueh BC. Trauma among female veterans: A critical review. Trauma, Violence, & Abuse. 2007;8:384–400. [6] Surıs A, Lind L. Military sexual trauma: A review of prevalence and associated health consequences in veterans. Trauma Violence Abuse. 2008;9:250–69. [7] Military Sexual Trauma Support Team. Military Sexual Trauma (MST) screening report fiscal year 2012. Washington, DC: U.S. Department of Veterans Affairs; 2013. [8] Barth SK, Kimerling RE, Pavao J, et al. Military sexual trauma among recent veterans: Correlates of sexual assault and sexual harassment. Am J Prev Med. 2016;50:77–86. [9] Kimerling R, Street AE, Pavao J, et al. Military-related sexual trauma among Veterans Health Administration patients returning from Afghanistan and Iraq. Am J Public Health. 2010;100:1409–12. [10] Karlin BE, Cross G. From the laboratory to the therapy room: National dissemination and implementation of evidence-based psychotherapies in the US Department of Veterans Affairs Health Care System. Am Psychol. 2014;69:19–33. [11] Karlin BE, Ruzek JI, Chard KM, et al. Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration. J Trauma Stress. 2010;23:663–73. [12] Resick PA, Schnicke MK. Cognitive processing therapy for sexual assault victims. J Consult Clin Psychol. 1992;60:748–56. [13] Resick PA, Wachen JS, Mintz J, et al. A randomized clinical trial of group cognitive processing therapy compared with group present-centered therapy for PTSD among active duty military personnel. J Consult Clin Psychol. 2015;83:1058–68. [14] Monson CM, Schnurr PP, Resick PA, Friedman MJ, Young-Xu Y, Stevens SP. Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. J Consult Clin Psychol. 2006;74:898–907. [15] Surıs A, Link-Malcolm J, Chard K, Ahn C, North C. A Randomized clinical trial of cognitive processing therapy for veterans with PTSD related to military sexual trauma. J Trauma Stress. 2013;26:28–37. [16] Watts BV, Schnurr PP, Mayo L, Young-Xu Y, Weeks WB, Friedman MJ. Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. J Clin Psychiatry. 2013;74:e541–e50. [17] Smid GE, Knipscheer JW, Kleber RJ. The efficacy of recommended treatments for veterans with PTSD: A metaregression analysis. Clin Psychol Rev. 2015;40:184–94. [18] Schottenbauer MA, Glass CR, Arnkoff DB, Tendick V, Gray SH. Nonresponse and dropout rates in outcome studies on PTSD: Review and methodological considerations. Psychiatry. 2008;71(2):134–68.
189
[19] Ehlers A, Grey N, Wild J, et al. Implementation of cognitive therapy for PTSD in routine clinical care: Effectiveness and moderators of outcome in a consecutive sample. Behav Res Ther. 2013;51:742–52. [20] Imel ZE, Laska K, Jakupcak M, Simpson TL. Meta-analysis of dropout in treatments for posttraumatic stress disorder. J Consult Clin Psychol. 2013;81:394–404. [21] Najavits LM. The problem of dropout from “gold standard” PTSD therapies. F1000Prime Rep. 2015;7; doi:10.12703/P7-43. [22] Steenkamp MM, Litz BT, Hoge CW, Marmar CR. Psychotherapy for military-related PTSD: A review of randomized clinical trials. JAMA. 2015;314:489–500. [23] Shiner B, Tang C, Trapp AC, Konrad R, Bar I, Watts BV. The provision of mental health treatment after screening: exploring the relationship between treatment setting and treatment intensity. Gen Hosp Psychiat. 2014;36:581–8. [24] Borah EV, Wright EC, Donahue DA, et al. Implementation outcomes of military provider training in cognitive processing therapy and prolonged exposure therapy for post-traumatic stress disorder. Mil Med. 2013;178:939– 44. [25] Osei-Bonsu PE, Bolton RE, Stirman SW, Eisen SV, Herz L, Pellowe ME. Mental health providers’ decision-making around the implementation of evidence-based treatment for PTSD. J Behav Health Ser R. in press. Online ahead of print. doi: 10.1007/s11414-015-9489-0. [26] Pagura J, Stein MB, Bolton JM, Cox BJ, Grant B, Sareen J. Comorbidity of borderline personality disorder and posttraumatic stress disorder in the US population. J Psychiatr Res. 2010;44:1190–8. [27] Black DW, Blum N, Letuchy E, Doebbeling CC, FormanHoffman VL, Doebbeling BN. Borderline personality disorder and traits in veterans: psychiatric comorbidity, healthcare utilization, and quality of life along a continuum of severity. CNS Spectr. 2006;11:680–9. [28] Gunderson JG. Borderline personality disorder: Ontogeny of a diagnosis. Am J Psychiatry. 2009;166:530–9. [29] Clarke SB, Rizvi SL, Resick PA. Borderline personality characteristics and treatment outcome in cognitivebehavioral treatments for PTSD in female rape victims. Beha Ther. 2008;39:72–8. [30] Feeny NC, Zoellner LA, Foa EB. Treatment outcome for chronic PTSD among female assault victims with borderline personality characteristics: A preliminary examination. J Pers Disord. 2002;16:30–40. [31] Walter KH, Bolte TA, Owens GP, Chard KM. The impact of personality disorders on treatment outcome for veterans in a posttraumatic stress disorder residential treatment program. Cognitive Ther Res. 2011;36:576–84. [32] Williams R, Holliday R, Clem M, Anderson E, Morris EE, Surıs A. Borderline personality disorder and military sexual trauma analysis of previous traumatization and current psychiatric presentation. J Interpers Violence. in press. Online ahead of print. doi:10.1177/ 0886260515596149. [33] Blake DD, Weathers FW, Nagy LM. The development of a clinician administered PTSD scale. J Trauma Stress. 1995;8:75–90.34. [34] Weathers FW, Litz BT, Herman D, Huska J, Keane T. The PTSD Checklist (PCL): Reliability, validity, and
190
[35]
[36]
[37]
[38]
Downloaded by [Australian Catholic University] at 00:03 10 September 2017
[39]
[40]
[41]
[42]
N. HOLDER ET AL.
diagnostic utility. Annual Meeting of the International Society of Traumatic Stress Studies. 1993. Keane TM, Caddell JM, Taylor KL. Mississippi Scale for Combat-Related Posttraumatic Stress Disorder: three studies in reliability and validity. J Consult Clin Psychol. 1988;56:85–90. Weathers FW, Keane TM, Davidson J. Clinician-administered PTSD scale: A review of the first ten years of research. Depress Anxiety. 2001;13:132–56. Hinton DE, Chhean D, Pich V. Assessment of posttraumatic stress disorder in Cambodian refugees using the ClinicianAdministered PTSD Scale: Psychometric properties and symptom severity. J Trauma Stress. 2006;19:405–9. Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD Checklist (PCL). Behav Res Ther. 1996;34:669–73. Keen SM, Kutter CJ, Niles BL, Krinsley KE. Psychometric properties of PTSD Checklist in sample of male veterans. J Rehabil Res Dev. 2008;45:465–74. Wilkins KC, Lang AJ, Norman SB. Synthesis of the psychometric properties of the PTSD checklist (PCL) military, civilian, and specific versions. Depress Anxiety. 2011;28:596–606. Edwards LJ. Modern statistical techniques for the analysis of longitudinal data in biomedical research. Pediatric Pulmonology. 2000;30:330–44. Krueger C, Tian L. A comparison of the general linear mixed model and repeated measures ANOVA using a
[43]
[44]
[45]
[46]
[47]
[48]
dataset with multiple missing data points. Biol Res Nurs. 2004;6:151–7. Raudenbush S, Bryk A, Cheong Y, Congdon R, du Toit M. HLM 6: Hierarchical linear and nonlinear modeling. [Computer Software] Lincolnwood, IL: Scientific Software Inc.; 2004. Cody MW, Jones JM, Woodward MJ, Simmons CA, Beck JG. Correspondence between self-report measures and clinician assessments of psychopathology in female intimate partner violence survivors. J Interpers Violence. in press. Online ahead of print doi:10.1177/ 0886260515589566. Samuel DB, Sanislow CA, Hopwood CJ, et al. Convergent and incremental predictive validity of clinician, selfreport, and structured interview diagnoses for personality disorders over five years. J Consult Clin Psychol. 2013;81:650–9. Hox JJ, Maas CJM. The accuracy of multilevel structural equation modeling with pseudobalanced groups and small samples. Struct Equ Modeling. 2001;8:157– 74. McNeish DM, Stapleton LM. The effect of small sample size on two-level model estimates: A review and illustration. Educ Psychol Rev. 2016;28:295–314. Gutner CA, Suvak MK, Sloan DM, Resick PA. Does Timing matter? Examining the impact of session timing on outcome. J Consult Clin Psychol. 2016;(84)12;1108–1115. doi:10.1037/ccp0000120.
