Evaluation of Intensive Inpatient Treatment of Patients With Severe Personality Disorders

At the time of this study the C. F. Menninger Memorial Hospital in Topeka, Kansas, and Harding Hospital in Worthington, Ohio, the two study settings, had similar treatment programs. The inpatient approach was milieu oriented, with a strong emphasis on group treatment and individual psychotherapy. A continual effort was made to strike a therapeutic balance between exploratory goals and ego-building, rehabilitative goals.

Patients were seen in daily rounds by their hospital psychiatrists, and two-thirds of our sample received individual psychotherapy two or three times a week with a clinician other than the hospital psychiatrist. The vast majority of patients (96 percent) received psychopharmacologic treatment as well. Group approaches included group therapy, community meetings, patient and staff team meetings, and various specialized groups for psychoeducation, relapse prevention, and the like.

Patients admitted to the general psychiatry units at the Menninger and Harding hospitals who were age 18 or older and had an IQ over 70 were eligible to be contacted for informed consent for participation in this project. Although clinicians had the option of recommending that a patient not be contacted, this option was never exercised.

Of the 364 Menninger patients who entered the project and participated in the admission assessment, 325 also participated in the discharge and one-year follow-up assessments, a dropout rate of 10.7 percent. Of the 253 Harding patients who entered the project, 62 completed the follow-up, a dropout rate of 75.5 percent. The overall dropout rate was thus 37.3 percent, with 387 patients completing follow-up assessments. The greater loss of patients at the Harding site appeared to be related to managed care. Many patients were bitter about having to leave the hospital abruptly, and they refused to participate in the research interviews. Also, staff attrition resulted in the loss of key figures in the project.

The subjects we describe in this study are a subsample of the patients who entered the project and did not drop out at discharge or one-year follow-up and who had a DSM-III-R diagnosis of personality disorder. Overall, 216 such patients were studied between December 1986 and December 1993. The representativeness of the sample is unknown.

The largest group of patients, 99, had a DSM-III-R diagnosis of personality disorder not otherwise specified or mixed personality disorder, indicating that many of the patients with personality disorders did not fit neatly into DSM-III-R categories. Seventy-five received a diagnosis of borderline personality disorder, nine dependent, nine histrionic, seven narcissistic, five avoidant, five obsessive-compulsive, four schizotypal, two passive-aggressive, and one each antisocial, schizoid, paranoid, and masochistic-self-defeating. Three patients were given two personality disorder diagnoses: one borderline and narcissistic, one borderline and histrionic, and one borderline and not otherwise specified.

We excluded patients who had comorbid organic brain disorders and psychotic disorders. As one might expect, comorbidity with other conditions was common. Affective disorders— major depression, bipolar disorder, and dysthymia— were diagnosed for 179 (82.9 percent) of the patients with personality disorders.

Although the diagnoses were not made on the basis of research interviews, they were well-informed clinical diagnoses. They were based not only on a psychiatric history and evaluation but also on extensive psychological assessment, family history, and observation in intensive treatment over an extended period, which is especially useful in making axis II diagnoses.

The patients' mean±SD age was 37.9±10.9 years, with a range of 18 years to 79 years. Two-thirds of the sample (144, or 66.7 percent) were women. The mean±SD number of prior hospitalizations elsewhere was 2.6±4.5 (range, 0 to 35), indicating that the sample may have been "treatment resistant" in the sense that hospitalization elsewhere had not resulted in remission of symptoms.

Overall, 106 subjects (49.1 percent) were married or remarried, 70 (32.4 percent) had never married, 37 (17.1 percent) were divorced or separated, and three (1.4 percent) were widowed. Despite the severity of the psychopathology among patients in the sample, their educational achievements were impressive. Fifty patients (23.4 percent) had a baccalaureate degree, 38 (17.8 percent) had a master's degree, and 14 (6.5 percent) had a Ph.D. or M.D. degree.

Patients' length of stay varied widely. The mean±SD length of stay was 137.33±183.81 days, ranging from ten days to 1,014 days. Because the mean appeared to be inflated by several very long stays, the median, 58 days, is a better index of the typical patient's stay.

During the course of the study, patients' length of stay began to be influenced by managed care reviewers, who stipulated the number of days that would be reimbursed by insurance companies. Hence we included a measure of whether finances had a significant influence on discharge planning. Of the 215 patients for whom we had such data, the discharges of 103 patients (47.9 percent) were determined at least in part by finances, and the discharges of 112 patients (52.1 percent) were not.

As soon as possible after admission, eligible patients were contacted by a research assistant. After the subjects had been given a complete description of the study, written informed consent was obtained as directed by the internal review board. The research assistant then scheduled the first research interview with one of the project interviewers within one week after admission. The interviewers were practicing clinicians but did not work on the unit of the patient to be interviewed.

Data on admission were collected in semistructured face-to-face interviews lasting one to one and a half hours. Discharge data were collected in face-to-face interviews within two weeks before discharge when possible; otherwise, discharge interviews were conducted by telephone within two weeks after discharge. Follow-up interviews were conducted by telephone one year after discharge, with a window of one month.

All interviews were derived from Bellak's interview for the ego function scales (15), with specific questions added from the Brief Psychiatric Rating Scale, the Global Assessment Scale, and the risk scales described below.

All interviews were rated by two clinician-raters, trained to reliability, who were not the patients' treating clinicians. If rating discrepancies on a particular scale exceeded a predetermined amount, the raters met and reconciled differences by consensus. Otherwise, the ratings were averaged. This procedure helped to reduce measurement error below the level of expected change.

Bellak's ego function scales. We used selected scales from Bellak's ego function scales to assess structural change (15). These scales have been used widely in outcome and efficacy research, and many studies attest to their validity and reliability. They are 7-point scales with detailed definitions and descriptions of anchor points. Midpoints between scale points, such as 3.5 or 4.5, were also used in ratings. We selected scales for the following ego functions on the basis of their relevance to our patient population and to the treatment goals: reality testing; judgment; regulation and control of drives, impulses, and affects; object relations; thought processes; autonomous functioning; mastery-competence; and superego.

Reliability estimates (Spearman-Brown corrected intraclass correlations) were calculated for 30 patients balanced on assessment point and length of stay. Reliability estimates for the three pairs of raters were as follows: reality testing, .88, .81, and .94; judgment, .89, .89, and .88; regulation and control, .81, .81, and .91; object relations, .83, .47, and .68; thought processes, .84, .86, and .89; autonomous functioning, .82, .86, and .87; mastery-competence, .81, .85, and .83; and superego, .65, .81, and .74.

Brief Psychiatric Rating Scale (BPRS). The Brief Psychiatric Rating Scale (16) is widely used to assess common psychiatric symptoms in outcome research. Symptoms are rated on a 7-point scale, ranging from 0, indicating not present, to 6, indicating extremely severe, on the basis of questions in the interview together with observations of the patient's behavior during the interview.

Because of problems in achieving reliability using the original scale-point descriptions, we developed a set of behavioral-example anchors as scale-point definitions (17). Although we were able to achieve adequate reliability for the 18-symptom version of the BPRS, the scale distributions for many of the symptoms at admission were positively skewed to the right as a result of a preponderance of 0 or other low scores, indicating low levels of pathology; thus they would have been unlikely to show significant change with treatment. Thus the five scales with a sufficient level of pathology at admission (that is, a skewness coefficient of less than 1) were kept for statistical analysis— somatic concern, anxiety, depression, guilt, and hostility. Reliabilities, computed as described above, were as follows: somatic concern, .96, .97, and .97; anxiety, .96, .93, and .96; depression, .96, .96, and .95; guilt, .87, .90, and .98; and hostility, .88, .92, and .85.

Global Assessment Scale (GAS).The Global Assessment Scale is a 100-point scale that is divided into ten 10-point clinical bands to assess overall level of functioning (18). It has been widely employed in outcome and other research, and many studies attest to its validity and reliability when raters have been trained. Reliability estimates were .68, .89, and .83.

Risk scales.Four risk scales were developed by the third author for hospital outcome research. They are 5-point scales ranging from 1, very high, to 5, not at all. Only the scales for substance abuse and suicide risk showed sufficient pathology at admission (skewness less than 1) to potentially show change. Reliability estimates were .83, .85, and .85 for substance abuse and .79, .62, and .63 for suicide risk.

For testing the significance of the change from admission through discharge and then one-year follow-up, a multivariate profile analysis of variance (SPSS repeated-measures multiple analysis of variance) was conducted for the set of scores within each measure. Post hoc univariate analyses were conducted for each of the scales in the set.

The change from admission to discharge and the change from discharge to one-year follow-up were then tested using Roy-Bargmann step-down tests (19) to determine whether the change from admission to discharge was significant, and then whether the change from discharge to follow-up was significant when admission-to-discharge change was controlled for. This procedure avoids the inflated significance that often occurs when the changes from admission to discharge, from discharge to follow-up, and from admission to follow-up are tested separately.