Swart, Sanne Marijke, Smit, Johannes, Draijer, Petronella, Langeland, Willemien, APH - Mental Health, Psychiatry, Smit, Johannes Hendrikus, and Draijer, N.
The first objective of this thesis was to study the naturalistic two-year course of psychopathology of patients with (symptoms of) trauma-related disorders (TRDs), dissociative disorders (DDs) and personality disorders (PDs). Hereby, we focused on comorbidity between these disorders. The base of our thinking about the comorbidity between trauma-related psychopathology and disturbed personality functioning, was the theory behind the diagnostic model of Draijer (2003). This two-dimensional diagnostic square accounts for the influence of trauma and neglect on the development of trauma-related disorders as well as personality disorders. The diagnostic value of the model was quantified in our previous studies (e.g., Wildschut et al., 2019). In addition, the diagnostic square is assumed to give an indication of the treatability of (comorbid) psychopathology by combining the severity of psychopathology and the amount of comorbidity of disorders. It is hypothesized that patients located in the upper-right corner of the square representing the trauma-neglect model, thus at the high end of both dimensions, suffer from highly untreatable psychopathology, whereas patients located in the lower-left corner of the model, thus at the low end of the dimensions, have highly treatable psychopathology. This led us to the second aim of this thesis: testing if the trauma-neglect model of Draijer (2003) could indeed be quantified as a prognostic model. A total of 85 patients (56.7%) of the original 150 patients completed the follow-up assessment. During the two-year follow-up period, six patients (4.0%) died because of suicide. All patients who died were women, and all suffered from comorbid disorders: both TRD and/or DD and one or more PDs. This finding indicates a high mortality rate in patients with comorbid TRDs, DDs and PDs, and illustrates the severity of these disorders. Concerning the course of symptoms, we found that levels of general psychopathology, dissociative symptoms and personality psychopathology declined during the two-year follow-up period, but only among women. The percentage of patients who did not have a TRD or DD increased by 15.3% between baseline and follow-up. Furthermore, the percentage of patients without a PD increased by 35.3%. We tested the prognostic value of the trauma-neglect model by determining clinical relevant change (CRC) in symptomatology of patients with (comorbid) TRDs, DDs and PDs. The hypothesis was that the more severe the disorder(s), the less recovery in symptomatology is found. We found that severity of trauma diagnosis - the y-axis of the trauma-neglect model - predicted CRC in dissociative symptoms, but not in other symptomatology. Number of PDs, representing the x-axis of the trauma-neglect model, did not predict CRC in symptomatology. In addition, to evaluate the prognostic value of the trauma-neglect model, we tested if the improvement on general psychopathology was equal across the three clusters based on the psychiatric disease burden, and found that there was a significant difference. Opposite of what was hypothesized, patients with severe or moderate psychiatric disease burden showed improvement on general psychopathology, whereas mildly impaired patients did not.