Evaluation der Dialektisch-Behavioralen Therapie der Posttraumatischen Belastungsstörung nach sexueller Gewalt in Kindheit und Jugend

Abstract

Posttraumatic stress disorder (PTSD) with co-occurring severe psychopathology, such as symptoms of borderline personality disorder (BPD), is a frequent sequel of childhood sexual abuse (CSA). Cognitive-behavioral therapy has been shown to be efficacious in treating adults with PTSD in general, but there is only limited data regarding patients with more complex symptomatology, such as suicidal ideation, self-injurious behavior, and dissociative symptoms. This dissertation focused on both the assessment and the treatment of patients with severe posttraumatic symptoms. The first aim was to elucidate whether traditional assessments of PTSD are well suited to assess the symptoms of patients with severe forms of PTSD. The second aim was to evaluate the efficacy of a newly developed treatment program, named DBT-PTSD. The third aim was to study the impact of DBT-PTSD on mental health care utilization and associated costs. To address these questions, two studies have been conducted involving female patients with PTSD related to CSA. Paper 1 presents data from an ambulatory assessment study. Patients (N = 28) were provided with electronic diaries for repeated real-time assessment of intrusions and flashbacks over the period of 1 week. Participants reported an average of 75 intrusions and 24 flashbacks during the week of assessment. These numbers are substantially higher than those reported in previous studies. Papers 2, 3, and 4 present data from primary and secondary analyses of a randomized controlled trial (RCT). Patients (N = 74) were randomized to either a 12-week residential DBT-PTSD program or a treatment-as-usual wait list. About half of the patients met the criteria for co-occurring BPD. Individuals with ongoing self-harm were not excluded. The results for primary and secondary outcomes are shown in Paper 2. Data revealed a significant reduction of posttraumatic symptoms with a large between-group effect size (Hedges’ g = 1.35) in the intention-to-treat population. Neither a diagnosis of BPD nor the severity of BPD symptoms was significantly related to treatment outcome. Paper 3 provides empirical results on the impact of the definition of the index trauma on PTSD severity scores and treatment outcome. When the index trauma included multiple traumas, PTSD severity scores were significantly higher, and improvements from preto post-treatment were significantly lower, compared to when the index trauma was defined as the worst single incident. Paper 4 presents data on psychiatric-psychotherapeutic treatment for the year before and after the DBT-PTSD. The mean total costs of utilization of mental health care were 18 000 € per patient during the year before and 7 233 € during the year after DBT-PTSD. The significant cost reduction was due to large reductions in inpatient treatment days (on average 57 days before and 14 days after DBT-PTSD). To sum up, the findings show clear evidence for the efficacy of the DBT-PTSD residential treatment program. Data further indicate that DBT-PTSD might contribute to reducing the mental health care costs. Also, the results suggest that the currently applied methods of assessing PTSD in patients with severe posttraumatic symptoms might miss aspects of clinically relevant symptomatology. Currently, DBT-PTSD is being evaluated under outpatient conditions in a multi-center RCT that compares it to the established treatment of Cognitive Processing Therapy. Inhaltsverzeichnis iii