The prognosis of patients with complex trauma-related and neglect-related disorders such as personality disorders (PDs), dissociative disorders (DDs) and (complex) posttraumatic stress disorder (PTSD) or a mixture of those, is unclear. Optimal treatment is debated, and these patients often have a long course of treatment for their mental health problems.1–3 Considering previous studies on the course and prognosis of improvement of (symptoms of) trauma-related disorders (TRDs: e.g. [complex] PTSD), DDs and PDs, results are far from clear and hard to compare, due to methodological issues such as different follow-up periods and variation in the exclusion of patients with comorbidities. The present study focused on the prognosis of patients with complex psychopathology (and comorbidity) that were included at baseline in the Friesland cohort study.4 The Friesland cohort study was set up to examine the phenomenology and course of (comorbidity between) TRDs, DDs and PDs and associations between these disorders and reports of (early childhood) trauma and emotional neglect in a treatment setting.5

Previously, we evaluated the two-dimensional trauma-neglect model of Draijer6 (see Fig. 1), as a diagnostic model which relates the influence of trauma and neglect to the development of TRDs, DDs, and PDs.7 The first dimension concerns the severity of the trauma endured, situated at the y-axis (hereafter trauma-axis) of the model. This dimension was assumed to be related to primarily the severity of TRDs and DDs.5 The second dimension represents the severity of emotional neglect, situated on the x-axis (hereafter neglect-axis) of the model, which was presumed to be related to the severity of personality pathology. We found that reported trauma severity was associated with severity of TRDs and DDs, supporting the trauma-axis of the model.8 Findings indicated that TRDs and DDs may be considered as a continuum with PTSD at the ‘mild’ end and more complex trauma-related diagnoses such as DDs at the severe end of the continuum. Furthermore, we also found support for the neglect-axis, indicating a link between lack of parental warmth and problematic personality functioning.7

Fig. 1.

The two-dimensional trauma-neglect modela. a Reprinted from 5. Wildschut et al., 2014.

More recently, we conducted a follow-up study of the 150 patients on the course of (symptoms of) TRDs, DDs and PDs, focusing on change in disorders after two years.9 We found that 33 % of patients had improved on their trauma-related diagnosis. Furthermore, 62 % of patients had improved on the neglect-axis, meaning they had fewer PDs at follow-up, compared to baseline. In addition, we found a significant decline in dissociative symptoms and symptoms of general psychopathology. When we analyzed the course of (symptoms of) TRDs, DDs and PDs for women and men separately, findings indicated that the improvement in reported symptoms of dissociative and general psychopathology was only significant in women.9

In addition to the role of trauma and neglect in the development of TRDs, DDs and PDs, respectively, variation in clinical response is also expected in Draijer's two-dimensional trauma-neglect model.6 The model assumes that psychopathology in the upper right corner of the square will show less and slower clinical improvement (i.e. harder to treat), compared to psychopathology in the lower left corner of the model,4 but so far this hypothesis about variation in clinical response has not been tested. The present study, with its 2-year follow up period, will provide more insight into the course and prognosis of improvement of (symptoms of) trauma-related disorders (TRDs: e.g. [complex] PTSD), DDs and PDs in a treatment setting. The primary aim of the current study was to determine clinically relevant change in symptomatology of patients with (comorbid) TRDs, DDs and PDs after 2-year follow-up. Can we use the trauma- and the neglect-axis to predict which patients may have a chance to recover or who will show clinically relevant symptomatic change? We expected that patients at the more severe end of the trauma-axis improve less on symptoms of dissociation, anxiety, depression and general psychopathology than patients with less severe TRDs. For the neglect-axis, we expected that patients with a higher number of PDs improve less than patients with a lower number of PDs. More knowledge on (predictors of) the treatment course of psychopathology in patients reporting trauma and emotional neglect is highly relevant for clinical practice and for the development of (more) integrative treatment for patients suffering from TRDs, DDs and PDs.

At follow-up, 65 patients out of the 150 patients were either not traceable or refused to participate in the follow-up assessment, leaving 85 patients (57 %) who completed the follow-up assessment (hereafter respondents), of which 61 (72 %) were women. Of these 65 non-respondents, 50 patients refused to participate at follow-up for reasons such as somatic illness, hospitalization, personal circumstances (for example death of a relative), or did not want to be confronted with their histories. Despite multiple attempts, another nine patients could not be contacted, mostly due to change of address or phone number. One patient had emigrated. Furthermore, and strikingly, six patients died by suicide during the follow-up period. Just like at baseline no differences in demographics and in clinical profiles of respondents and non-respondents were found . For more details, we refer to our previous study⁹.

First, we calculated RCI's, leading to a RCI of 19.2 for the DES, meaning that if a patient's score on the DES declined by 19.2 points, there was a CRC in dissociative symptoms. Similarly, RCI's for the other symptoms were 10.6 for the IDS, 18.1 for the BAI and 0.52 for the SCL-90-R. Notice that the magnitude of the RCI depends on the scale, which explains the differences in magnitudes between the questionnaires. Next, to determine which patients had recovered, improved, deteriorated, or remained stable at two-year follow-up, we calculated the change scores. Descriptive statistics of these change scores are shown in Table 1. Based on the RCI, we found that across all symptoms, many patients remained stable. The highest recovery and improvement rates were found in general psychopathology (the SCL-90-R score) and in symptoms of depression (see Table 2), with respectively 36 % and 41 % of patients improved or recovered.

Univariate logistic regression analysis using CRC as a dichotomous outcome variable showed that the severity of trauma diagnosis was a significant predictor of CRC in dissociative symptoms (Odds ratio = 1.87; X2(1) = 5.39; p = .020), but not of CRC in other symptoms, such as depression and anxiety (see Table 3). Results from the multivariable logistic regression analyses with both axes as possible predictors were comparable to those of the separate univariable logistic regression analyses, indicating that the two axes were independent of each other considering prognostic value (see Table 3).

In this study, we evaluated the prognostic value of the trauma-neglect model in a naturalistic follow-up study and determined CRC in symptomatology of patients with complex psychopathology, including (comorbid) TRDs, DDs and PDs. Our results indicated that 14 % to 41 % of patients show clinically relevant improvement or recovery across different dimensions of symptomatology over a follow-up period of two years. When studying the predictive value of the two dimensions of the trauma-neglect model, we found that severity of trauma-related diagnosis had a statistically significant effect on the CRC in dissociative symptoms, i.e. the more severe the trauma-related diagnosis, the more improvement in dissociative symptoms, but not in other symptomatology. Regression analysis indicated a univariable effect of severity of trauma-related disorder on dissociative symptomatology, and this effect remained in the multivariable regression analysis. This finding indicates that the two axes of the trauma-neglect model are independent of each other, or in other words, the effect of severity of trauma-related disorders on dissociation is independent of personality pathology. Numbers of PDs did not predict amount of improvement on symptomatology, whereas we expected to find that a higher number of PDs implicated less improvement on symptomatology.

We could speculate on explanations for the puzzling findings of our research, which contradicted our expectations and the clinical intuition that severe psychopathology is harder to treat than mild psychopathology. It might be that the patients with mild psychopathology improved less simply because their scores at baseline were lower, so they had less room for symptom reduction. There could also be a methodological clarification in the phenomenon of ‘regression to the mean’, meaning that unusual large or unusual small measurement values are followed by values closer to the mean²⁸. This phenomenon implies that patients with the highest scores at baseline are more likely to score lower at a re-test, independent of any real improvement on the measured psychopathology, and vice versa: patients with the lowest scores at baseline are more likely to score higher at a re-test. Another methodological explanation might be a lack of variation between ‘mild’ and ‘severe’ patients, making it less likely to find (clinically relevant) differences between patients. The fact that we included patients from specialist treatment departments and did not use any exclusion criteria, resulted in a more severely impaired cohort of patients compared to other studies, which mostly exclude patients with, for example, suicidality, hospitalization, or comorbid disorders.29,30

However, it might be worthwhile to explore an alternative explanation of the findings. It might be that specialized treatment programs may have special benefit for more severely impaired patients, while they might be more difficult to treat at the same time. This speculation is supported by findings of Brand et al.31 indicating that patients with higher levels of dissociation showed faster and greater improvement in emotion regulation, PTSD symptoms and dissociative symptoms than patients with low levels of dissociation at 2-year follow-up after a web-based psychoeducational intervention. Brand and colleagues suggest that treatment with a focus on psychoeducation and stabilization, by providing self-regulation skills, results in meaningful changes in the most severe patients with DDs. Information on the effectiveness of specific therapies or treatment interventions was unavailable in our study. Also, most patients in our cohort received multiple therapies during the follow-up period. Therefore, we do not know if specialized treatment programs may have had special benefit for more severely impaired patients. What we do know, is that the amount of received treatment and days of hospitalization did not predict two-year course of symptoms in our study.9

Strengths of our study are the use of structured interviews to assess TRDs, DDs and PDs, and the naturalistic design, which increases the generalizability of our findings to daily clinical practice. In addition, not excluding patients due to suicidality, comorbidity, or hospitalization, also increases the generalizability and utility of this study outcomes for clinicians. A possible limitation is the use of diagnostic instruments conform DSM-IV-R, due to the start of this follow-up study before the arrival of DSM-5. Furthermore, the psychologists who conducted the follow-up assessment were not blind to diagnostic status at baseline. Since blinding was not possible, it should be recognized that knowledge of diagnostic status could have influenced the assessment of ‘outcome’ at follow up. Our relatively short follow-up period could also be a limitation and may have been too short to find higher rates of symptomatic improvement, considering the cohort of patients with complex psychopathology. Previous research showed that patients with (comorbid) TRDs, DDs and PDs may need a longer time to recover¹־³, indicating recovery can take up to ten years. Finally, a possible limitation is the way we operationalized the trauma and neglect axis. Although every operationalization has its own limitations, it might be that using another operationalization of severity of trauma such as the sum of reported childhood and adult traumatic events or a childhood trauma index score, would have provided other results.

We would recommend that in future cohort studies patients with (simple) PTSD without comorbidities are included, to gain enough variation in severity and allow a better prognostic differentiation between mildly, moderately, and severely impaired groups of patients. We would also recommend future research to include a broad range of patients with (comorbid) TRDs, DDs and PDs to gain insight in different patterns of recovery, and to invest in longitudinal studies on these patients with a complex clinical profile. This could contribute to the development of more integrative treatment for these patients, which is highly relevant for clinical practice.

To summarize, our main conclusions are that we found little support for the prognostic value of the trauma-neglect model, and that, contrary to our expectation, the severity of symptoms did not predict course in a negative way.

The research protocol of the baseline study was approved by The Institutional Review Board of Mental Health Institutions (Instellingen Geestelijke Gezondheidszorg – METiGG; registration no. 11.121). For the follow-up study, ethical approval was given by the Medical Ethics Committee of the Regional Toetsingscommissie Patiëntgebonden Onderzoek (RTPO), with registration number NL47054.099.14. Written informed consent was obtained if patients agreed to participate.