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A behavioral comparison of female adolescent inpatients with and without borderline personality disorder
A Behavioral Comparison of Female Adolescent Inpatients With and Without Borderline Personality Disorder Carol Jeanne Faulkner, W.L. Grapentine, and Greta Francis Patients with borderline personality disorder (BPD) are thought to have problematic hospitalizations. This study seeks to examine this phenomenon in adolescence by documenting the specific problem behaviors exhibited by patients, and the staff interventions in response to these behaviors in patients with and without BPD. Data were collected from the charts of 81 hospitalized adolescent girls regarding restraints, seclusions, incidents of self-abuse and aggression, incidents of signing the intent-to-leave form, nonroutine drug and/or alcohol screens, and discharges against medical advice. The two groups were compared using the analysis of variance (ANOVA) statistic for continuous variables and the chi-square statistic for the categorical variable. A follow-up multivariate ANOVA (MANOVA) was performed using the length of stay as a covariate. The BPD group displayed signifi-
cantly higher rates of certain behaviors per day, but not of others. The length of stay was significantly higher in the BPD group. Further analysis indicated that some of the behavioral differences between the two groups may be due to the effect of the difference in length of stay. The data also suggest that while most BPD patients behave similarly to other patients, there may be a subset of BPD patients who behave in an extreme manner while hospitalized. BPD patients may display more of certain problematic behaviors than non-BPD patients in the hospital. However, it is hypothesized that these differences in hospital behavior may be largely due to the different lengths of stay between the two groups or to an acting-out subgroup of BPD patients.
LINICAL EXPERIENCE suggests that patients with borderline personality disorder (BPD) are difficult to treat in any setting. These patients frequently exhibit intense interpersonal relationships, impulsivity, and suicidal threats and attempts--characteristics which often result in hospitalization in a psychiatric facility. Once hospitalized, patients with BPD are generally thought to have stormy inpatient stays, i-4 Theorists have associated certain behaviors such as self-injury, overdosing, and aggression with the inpatient stay of such patients. 5-7 However, a review of the literature reveals an absence of methodologically sound studies that empirically examine specific behaviors of inpatients with BPD. It therefore appears that patients with BPD have a reputation for problematic inpatient stays which has not yet been validated through research. Diagnosing serious personality disorders in the adolescent population is often thought to be difficult because of the common tumult in this stage of life. However, while the "borderline child ''8 does not appear to be synchronous with the adult BPD, there is support for the validity of the diagnosis in adolescence. 9-12 Block et al. 13 provided a review of the literature on both sides of the argument, and came to the conclusion that adolescents are not by nature "borderline" and that those who meet criteria for this disorder are clearly distinct from their normal peers. In addition, an examination of these disordered adolescents reveals that in terms of the early history, current behaviors, and coexist-
ing axis I disorders, they are indistinguishable from their adult BPD counterparts. 9 This study sought to examine the behavior of hospitalized adolescents with and without BPD. If patients with BPD do have difficult inpatient experiences, it is likely that they will show more of behaviors that reflect a problematic hospital stay. This study sought to examine this hypothesis by documenting quantifiable problem behaviors--and staff interventions in response to these behaviors--in a group of hospitalized adolescents with and without BPD.
C
Copyright© 1999by W.B, SaundersCompany
METHOD
Subjects The subjects were female adolescents hospitalized at a private university-affiliated psychiatric hospital for children in New England. Female adolescent patients consecutively admitted to this hospital between April 1989 and June 1990 were considered for participation in a study of BPD phenomenology in adolescence. 9 Only females were included because (1) there is a higher prevalence of BPD in the female population than in the male population, 3 (2) there are a significantly greater number of females than males on this adolescent inpatient psychiatric unit, and (3) the researchers wished to avoid confounding gender differences with group differences. Of the initial sample (N = 112), 30 subjects were excluded from this original study
From Brown University School of Medicine, E.P. Bradley Hospital, East Providence, RI. Address reprint requests to Carol Jeanne Faulkner, Ph.D., Bradley School, 2836 E Main Rd, Portsmouth, RI 02871. Copyright © 1999 by W.B. Saunders Company 0010-440X/99/4006-0011 $10. 00/0
Comprehensive Psychiatry, Vol. 40, No. 6 (November/December), 1999: pp 429-433
429
430 due to significant medical or CNS disorders, impaired cognition due to recent substance use or psychosis, an inability to speak English, an IQ score less than 70, incomplete data, a refusal to participate, or a Revised Diagnostic Interview for Borderlines (DIB-R) score of 6 or 7. An additional patient's chart could not be located by the medical records department at the time of chart review, and this subject was therefore excluded from the study. The remaining 81 patients were between 13.0 and 17.11 years old, had a full-scale IQ of 70 or greater, and spoke English. Five subjects were African-American, one was Asian, one was Latino, and the rest were Caucasian. These 81 patients served as the subjects for this chart-review study. After a complete description of the study to the subjects, written informed consent was obtained by the initial investigators. Approval for the chart review was later obtained from the hospital Institutional Review Board.
Measures The DIB-R 14 was administered to all patients by a child psychiatrist with demonstrated reliability in the use of the instrument. The DIB-R is the current version of the original DIB. 15,16 It is a semistructured interview designed to measure four areas of functioning considered necessary to the diagnosis of BPD--affect, cognition, impulsivity, and interpersonal relationships. A total score of 8 or greater is regarded as confirmation of a BPD diagnosis, and a score of 5 or less is considered nonindicative of BPD. Those with a score of 6 or 7 were excluded from the study to ensure unambiguous group membership. There is research support for the use of the original DIB and the DIB-R as a reliable and valid instrument for diagnosing BPD in adolescents. McManus et al/7 achieved interrater reliability K values between .72 and .85 and found a 75% convergence between BPD diagnoses using the DIB and the DSM. Atlas and Postelnek is found that their BPD group had significantly higher DIB-R scores than their non-BPD group. All subjects were also interviewed by the child psychiatrist according to DSM-III-R criteria for BPD. 19 According to the DSM-III-R, eight criteria are considered, with five of the eight required to be present to make the diagnosis of BPD. The 35-member BPD group consisted of patients who scored 8 or higher on the DIB-R and met five or more DSM-III-R criteria for BPD, while the 46-member non-BPD group were subjects who scored 5 or less on the DIB-R and met four or fewer DSM-III-R criteria. In the original study by Grapentine et al. 9 no significant differences were found between the two groups on the following variables: age, socioeconomic status, IQ score, or severity of illness (as measured by the Brief Psychiatric Rating Scale for Children2° and the Children's Global Assessment Scale21).
FAULKNER, GRAPENTINE, AND FRANCIS Appendix for specific definitions of variables that are not self-explanatory.) The length of stay was also tallied for each patient. Variables were chosen because they are quantifiable representations of problematic inpatient behaviors. Data were collected from milieu staff notes, physician orders, restraint and seclusion recording sheets, intent-to-leave forms, and discharge summary forms. A second coder, also unaware of group membership, reviewed a total of 18 charts at three points during the collection process. Interrater reliability was high, with the two coders reaching 91% agreement over all 18 charts. ("Agreement" was defined as both coders reaching the same decision regarding the presence or absence of the categorical variable and tallying within one count of each other on the continuous variables.) To provide a more stringent measure of reliability, the K statistic was used for the categorical variable (discharge against medical advice) and intraclass correlations were used for the continuous variables (restraints, seclusions, drug and/or alcohol screens, time-outs, signing the intent-to-leave form, and incidents of self-abuse and aggression). The K was acceptable, .77. All results of the intraclass correlations were also acceptable, with time-outs at .97, seclusions at .98, incidents of aggression at .93, nonroutine drug and/or alcohol screens at .99, incidents of self-abuse at .80, signing the intent-to-leave form at .89, and restraints at .99. RESULTS T h e p r i m a r y h y p o t h e s i s f o r this s t u d y w a s that patients with a diagnosis of BPD would exhibit b e h a v i o r s i n d i c a t i v e o f a p r o b l e m a t i c i n p a t i e n t stay m o r e f r e q u e n t l y t h a n w o u l d p a t i e n t s w i t h o u t this d i a g n o s i s . It w a s
also determined
e a r l y in t h e
a n a l y s i s that t h e l e n g t h o f s t a y w a s c o n s i d e r a b l y g r e a t e r , o n a v e r a g e , f o r t h o s e in t h e B P D g r o u p . The
mean
number
of days
( m e a n +__ S D )
was
5 4 . 1 7 _+ 5 2 . 8 9 f o r t h e B P D g r o u p a n d 3 1 . 3 0 ± 17.26 f o r t h e n o n - B P D
g r o u p ( F [ 1 , 79] = 7.57,
P < .01, ,q2 = .09). T h e r e f o r e , to e v a l u a t e t h e b e h a v i o r o f g r o u p m e m b e r s o n a c o m m o n m e t r i c , all b e h a v i o r a l v a r i a b l e s w e r e a n a l y z e d as t h e rate o f e a c h b e h a v i o r p e r day. A m u l t i v a r i a t e a n a l y s i s o f v a r i a n c e ( M A N O V A ) f o r all v a r i a b l e s s h o w e d that t h e t w o g r o u p s d i f f e r e d s i g n i f i c a n t l y f o r t h e rate o f p r o b l e m a t i c i n p a t i e n t b e h a v i o r (F[1, 79] = 2.74, P < .05). To e x a m i n e m o r e s p e c i f i c h y p o t h e s e s about particular behaviors, follow-up ANOVAs w e r e t h e n p e r f o r m e d o n all v a r i a b l e s ( T a b l e 1).
Procedure The procedure used for this study was a hospital chart review. Data were collected from the patient charts in random order by an experimenter blind to the group membership of individual subjects. Data were collected on the following seven continuous dependent variables: number of seclusions, restraints, time-outs, nortroutine drug and/or alcohol screens, signings of intent-toleave forms, incidents of self-abuse, and incidents of aggression. An additional categorical variable, whether or not a patient was discharged against medical advice, was also collected. (See
B e f o r e r e p o r t i n g t h e r e s u l t s , it is i m p o r t a n t to note that the BPD
group
and non-BPD
group
showed significantly different degrees of variability on most of the variables. In other words, within the non-BPD
group,
individual group
members
re-
ceived similar scores on the variables, while within the BPD group, there was a subgroup that received extremely high scores on the variables. Although the BPD group variability could have been normal-
COMPARISON OF BPD AND NON-BPD ADOLESCENTS
431
Table 1. ANOVA Results (mean _+ SD) Variable Restraints time-outs Seclusions Self-abuse Aggression Drug/alcohol screens Signouts
BPD .0182 .1505 .0290 .0377 .0374 .0234 .0112
_+ .0350 _+ .3110 -+ .0913 _+ .0864 -+ .0623 _+ .0552 _+ .0426
Non-BPD .0011 .0411 .0037 .0127 .0085 .0048 .0052
F
_+ .0054 10.75t _+ .0890 5.15" -+ .0101 3.49 _+ .0444 2.88 -+ .0212 8.60t _+ .0188 4.57* _+ .0300 .56
NOTE. Mean values are the average of the number of events per day (e.g., .0182 is the number of restraints per day for each member of the BPD group averaged over the total number for members in the group). * P < .05. t P < .01.
ized to a variability closer to the non-BPD group in the analysis, this unique subgroup characteristic of the BPD group would have been lost. Therefore, the analysis proceeded as planned. It is also important to note in interpreting the results that the distribution as a whole was positively skewed for many of the variables. However, the analysis again proceeded as planned for the following reasons. First, the ANOVA statistic is relatively robust to violations of normality. Second, the sample sizes were adequate. Finally, the BPD group and non-BPD group were skewed in the same direction, indicating that the violation of the normality assumption did not affect the data from one group and not the other. The results were as follows. It was hypothesized that staff members would be more likely to restrain BPD patients and to separate them from other patients by using the time-out strategy or the seclusion room. The results showed that those with BPD were indeed restrained more often than other patients. However, while patients in the BPD group received significantly more time-outs than those in the non-BPD group, they were not secluded more often. Another hypothesis proposed that patients in the BPD group would self-abuse and aggress more often than those in the non-BPD group. While the results supported the aggression hypothesis, patients with BPD did not self-abuse more often than other patients. Further analyses were performed on both the restraint and aggression variables, examining specific types of restraints and targets of aggression. Because of the small number of restraints (seven chemical, six mechanical, and eight physical restraints in the entire sample), analyses of the specific types of restraint were not deemed
valid. In looking at the targets of aggression in the BPD group, it appears that the majority of aggressive acts (67%) were directed at objects rather than people. This is comparable to the ratio in the non-BPD group (73%). Data were also collected on the number of nonroutine drug and/or alcohol screens ordered on the patients. As expected, patients in the BPD group received more drug and/or alcohol screens than those in the non-BPD group. However, while another impulsive behavior, signing the intent-toleave form, was hypothesized to occur more often in the BPD group, the groups did not differ on this variable. Nor were those with BPD more likely to be discharged against medical advice. The chisquare statistic was used to analyze this variable and was not significant (×2[4, N = 80] = .612, P = .43). However, due to the small number of patients overall who were discharged against medical advice (two in the non-BPD group and three in the BPD group), any statements about the incidence in this population must be made with caution. To further investigate the possible effect of length of stay on rates of behavior, the MANOVA using the rate of behaviors per day was repeated covarying the length of stay. The results indicated that after covarying the length of stay, the two groups were no longer significantly different (F[1, 79] = 1.64, P = NS). While this study was not designed to investigate the relationship between behavior and the length of stay, these preliminary findings suggest that there may be a systematic relationship between the length of stay and the daily rate of behaviors. To explore this finding more specifically, correlations between the rates of behaviors and the length of stay were examined and are reported in Table 2. Significant relationships were found between the length of stay and restraints, episodes of aggression, and time-outs, indicating that the rates of these behaviors may be most influenced by an increased length of stay. DISCUSSION
This study adds to the knowledge about adolescent BPD as it manifests on an inpatient unit. Many theorists and researchers believe that patients with BPD regress behaviorally while hospitalized, and have assumed this to be true when writing about the disorder and conducting research. This study is the first to carefully scrutinize this assumption using
FAULKNER, GRAPENTINE, AND FRANCIS
432
Table 2. Pearson Correlations Between Daily Behavior Rates and Length of Stay for the Whole Sample (N = 81)
*P< tP<
Behavior
Length of Stay
Restraints 13me-outs Seclusions Self-abuse Aggression Drug/alcohol screens Signouts
.2712" .2768" .1236 .0420 .3164t .0999 -.0903
.05. .01.
reliable instruments, quantifiable data, and empirical analysis. The primary limitation of this study centers around the question of whether chart data were recorded accurately and completely and whether the groups were reported on differentially. Precautions were taken in the selection of variables to minimize this possibility. Seclusions, restraints, and drug and/or alcohol screens all require a doctor's order, are mandated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to be recorded in the chart in all situations, and require a witness to the documentation of these events. Documentation of the signing of the intent-to-leave form also is necessary, given the legal restraints on the amount of time that can elapse between signing the form and either discharge or obtaining a court order to commit a patient, and the fact that unit and hospital policy dictate that patients must be restricted to the unit once this form has been signed. It is unlikely that such events were not documented. Episodes of self-abuse and aggression are highly salient events and have a high likelihood of being noted in the charts, as well, particularly since they often lead to seclusion or restraint. Time-outs may have been missed on occasion, although many of the patients were on behavior plans that required careful monitoring of the number of time-outs. In a more general sense, each patient's behavior is reviewed at each shift change, and all staff members routinely receive supervision in documentation, further increasing the likelihood of any significant behaviors being noticed and recorded. While the risk of missing information is deemed minimal in this study, to eliminate the possibility of missing information, future research on the behavior of hospitalized patients with BPD should involve
careful monitoring of the documentation of data at the time they are entered into the charts. This being said, the implications of this study are threefold. First, the length of stay may contribute significantly to the behavioral differences found between BPD and non-BPD patients in this study. Patients with BPD were hospitalized for longer periods than non-BPD patients and, overall, showed higher rates of restraints, aggression, time-outs, and nonroutine drug and/or alcohol screens. However, it may be that any patient hospitalized for a long period would have shown more problematic behaviors than patients who had shorter stays. Preliminary analyses suggest that the rates of restraints, time-outs, and aggression may be most influenced by longer hospital stays. Second, the study calls into question the perception that BPD patients are more difficult than non-BPD patients on a day-to-day basis. While clinical folklore holds that patients with BPD have tumultuous inpatient stays, this perception is likely too simplistic. The results of this study indicate that while BPD patients showed higher rates of some behaviors, they were not more likely than other patients on any given day to be secluded, to self-abuse, or to sign intent-to-leave forms. The finding regarding self-abuse is particularly interesting, given that self-abuse is considered a hallmark of BPD. Third, while this study focused on BPD patients as a group, there may have been a subset of patients in the BPD group which exhibited a preponderance of the specific problematic behaviors. It appeared that a small group of seven BPD subjects accounted for a high proportion of the behaviors found in the BPD group. This group consisted of BPD patients who scored 2 SD above the group mean on one or more of the behavioral variables. For example, these seven patients (of the 35-member group) received 63% of the drug and/or alcohol screens, 55% of the seclusions, and 51% of the time-outs. Therefore, it seems possible that some of the differences between the BPD and non-BPD groups may thus be due simply to these particularly difficult BPD patients. It may be that there is a subgroup of BPD patients who have stormy hospitalizations and that these patients are responsible for the negative reputation of the BPD patient in the hospital. Future research should specifically address the issue of BPD subtypes and whether
COMPARISON OF BPD AND NON-BPD ADOLESCENTS
433
different subtypes of BPD patients have different inpatient experiences. T h e r e s u l t s o f this s t u d y c h a l l e n g e s o m e a s s u m p tions
about
BPD,
and
pose
hypotheses
to
be
e x a m i n e d in f u t u r e r e s e a r c h w i t h this p o p u l a t i o n . A P P E N D I X : DEFINITIONS Restraint: Controlling a patient who is believed to be a threat to self or others through physically holding, strapping to a bed, or giving a sedative medication. Time-out: Asking a patient who is behaving in an inappropriate or extreme manner to go to a quiet place away from others for a circumscribed period of time. Seclusion: Placing a patient who is believed to be escalating to a potentially unmanageable level in a small empty locked room with an observation window.
Self-abuse: Any behavior that a patient engages in with the intention of inflicting harm upon herself. Aggression: Any act of throwing, kicking, or hitting a person or an object. Nonroutine drug and~or alcohol screens: Any test of a patient's urine to detect the presence of drugs and/or alcohol that is in addition to routine screens. Signing out: Signing an intent-to-leave form, signifying a patient's desire to be discharged and necessitating finding a placement or involuntary commitment.
ACKNOWLEDGMENT The authors wish to acknowledge Ron Seifer, Ph.D., Lawrence Grebstein, Ph.D., Charles Collyer, Ph.D., Stephanie Riolo, M.D., Carla Picariello, and the reviewer for Comprehensive Psychiatry.
REFERENCES 1. Adler G. Hospital treatment of borderline patients. Am J Psychiatry 1973;130:32-36. 2. Friedman HJ. Some problems of inpatient management with borderline patients. Am J Psychiatry 1969;126:299-304. 3. Linehan MM. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, NY: Guilford, 1993. 4. Gunderson JG, Singer MT. Defining borderline patients: an overview. Am J Psychiatry 1975; 132:1-10. 5. Braden E. Supportive containment in the hospital care of treatment-resistant borderline adolescents. Psychiatry 1984;47: 315-322. 6. Brown L. The therapeutic milieu in the treatment of patients with borderline personality disorders. Bull Menninger Clin 1981 ;45:377-394. 7. Rosenbluth M. The inpatient treatment of the borderline personality disorder: a critical review and discussion of aftercare implications. Can J Psychiatry 1987;32:228-237. 8. Robson KS (ed). The Borderline Child: Approaches to Etiology, Diagnosis, and Treatment. New York, NY: McGrawHill, 1983. 9. Grapentine WL, Picariello CM, Nurcombe B, Seifer R, Scioli A. Borderline phenomenology in adolescence. Unpublished manuscript [1993]. 10. Masterson JR The borderline personality disorder in the adolescent: diagnosis and treatment. Adolesc Psychiatry 1988; 15:239-250. 11. Meijer M, Treffers PDA. Borderline and schizotypal disorders in children and adolescents. Br J Psychiatry 1991;158: 205-212.
12. Esman A. Borderline personality disorder in adolescents: current concepts. Adolesc Psychiatry 1989;16:319-336. 13. Block MJ, Westen D, Ludolph P, Wixom J, Jackson A. Distinguishing female borderline adolescents from normal and other disturbed female adolescents. Psychiatry 1991 ;54:89-103. 14. Zanarini MC, Gunderson JG. The Revised Diagnostic Interview for Borderlines: discriminating borderline personality disorder from other axis II disorders. J Pers Disord 1989;3: 10-18. 15. Kolb JE, Gunderson JG. Diagnosing borderline patients with a semistructured interview. Arch Gen Psychiatry 1980;37: 37-41. 16. Gunderson JG, Kolb JE, Austin V. The Diagnostic Interview for Borderline Patients. Am J Psychiatry 1981; 138:896903. 17. McManus M, Lerner H, Robbins D, Barbour C. Assessment of borderline symptomatology in hospitalized adolescents. J Am Acad Child Psychiatry 1984;23:685-694. 18. Atlas JA, Postelnek J. Applicability of the Revised Diagnostic Interview for Borderlines to hospitalized adolescents. Psychol Rep 1994;74:297-298. 19. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Ed. 3. Washington, DC: American Psychiatric Press, 1980. 20. Overall J, Pfefferbaum B. The Brief Psychiatric Rating Scale for Children. Psychopharmacol Bull 1982; 18: I0-16. 21. Schaffer D, Gould MS, Brasic J, Ambrosini P, Fisher P, Bird H, et al. A Children's Global Assessment Scale (C-GAS). Arch Gen Psychiatry 1983;40:1228-1231.
cantly higher rates of certain behaviors per day, but not of others. The length of stay was significantly higher in the BPD group. Further analysis indicated that some of the behavioral differences between the two groups may be due to the effect of the difference in length of stay. The data also suggest that while most BPD patients behave similarly to other patients, there may be a subset of BPD patients who behave in an extreme manner while hospitalized. BPD patients may display more of certain problematic behaviors than non-BPD patients in the hospital. However, it is hypothesized that these differences in hospital behavior may be largely due to the different lengths of stay between the two groups or to an acting-out subgroup of BPD patients.
LINICAL EXPERIENCE suggests that patients with borderline personality disorder (BPD) are difficult to treat in any setting. These patients frequently exhibit intense interpersonal relationships, impulsivity, and suicidal threats and attempts--characteristics which often result in hospitalization in a psychiatric facility. Once hospitalized, patients with BPD are generally thought to have stormy inpatient stays, i-4 Theorists have associated certain behaviors such as self-injury, overdosing, and aggression with the inpatient stay of such patients. 5-7 However, a review of the literature reveals an absence of methodologically sound studies that empirically examine specific behaviors of inpatients with BPD. It therefore appears that patients with BPD have a reputation for problematic inpatient stays which has not yet been validated through research. Diagnosing serious personality disorders in the adolescent population is often thought to be difficult because of the common tumult in this stage of life. However, while the "borderline child ''8 does not appear to be synchronous with the adult BPD, there is support for the validity of the diagnosis in adolescence. 9-12 Block et al. 13 provided a review of the literature on both sides of the argument, and came to the conclusion that adolescents are not by nature "borderline" and that those who meet criteria for this disorder are clearly distinct from their normal peers. In addition, an examination of these disordered adolescents reveals that in terms of the early history, current behaviors, and coexist-
ing axis I disorders, they are indistinguishable from their adult BPD counterparts. 9 This study sought to examine the behavior of hospitalized adolescents with and without BPD. If patients with BPD do have difficult inpatient experiences, it is likely that they will show more of behaviors that reflect a problematic hospital stay. This study sought to examine this hypothesis by documenting quantifiable problem behaviors--and staff interventions in response to these behaviors--in a group of hospitalized adolescents with and without BPD.
C
Copyright© 1999by W.B, SaundersCompany
METHOD
Subjects The subjects were female adolescents hospitalized at a private university-affiliated psychiatric hospital for children in New England. Female adolescent patients consecutively admitted to this hospital between April 1989 and June 1990 were considered for participation in a study of BPD phenomenology in adolescence. 9 Only females were included because (1) there is a higher prevalence of BPD in the female population than in the male population, 3 (2) there are a significantly greater number of females than males on this adolescent inpatient psychiatric unit, and (3) the researchers wished to avoid confounding gender differences with group differences. Of the initial sample (N = 112), 30 subjects were excluded from this original study
From Brown University School of Medicine, E.P. Bradley Hospital, East Providence, RI. Address reprint requests to Carol Jeanne Faulkner, Ph.D., Bradley School, 2836 E Main Rd, Portsmouth, RI 02871. Copyright © 1999 by W.B. Saunders Company 0010-440X/99/4006-0011 $10. 00/0
Comprehensive Psychiatry, Vol. 40, No. 6 (November/December), 1999: pp 429-433
429
430 due to significant medical or CNS disorders, impaired cognition due to recent substance use or psychosis, an inability to speak English, an IQ score less than 70, incomplete data, a refusal to participate, or a Revised Diagnostic Interview for Borderlines (DIB-R) score of 6 or 7. An additional patient's chart could not be located by the medical records department at the time of chart review, and this subject was therefore excluded from the study. The remaining 81 patients were between 13.0 and 17.11 years old, had a full-scale IQ of 70 or greater, and spoke English. Five subjects were African-American, one was Asian, one was Latino, and the rest were Caucasian. These 81 patients served as the subjects for this chart-review study. After a complete description of the study to the subjects, written informed consent was obtained by the initial investigators. Approval for the chart review was later obtained from the hospital Institutional Review Board.
Measures The DIB-R 14 was administered to all patients by a child psychiatrist with demonstrated reliability in the use of the instrument. The DIB-R is the current version of the original DIB. 15,16 It is a semistructured interview designed to measure four areas of functioning considered necessary to the diagnosis of BPD--affect, cognition, impulsivity, and interpersonal relationships. A total score of 8 or greater is regarded as confirmation of a BPD diagnosis, and a score of 5 or less is considered nonindicative of BPD. Those with a score of 6 or 7 were excluded from the study to ensure unambiguous group membership. There is research support for the use of the original DIB and the DIB-R as a reliable and valid instrument for diagnosing BPD in adolescents. McManus et al/7 achieved interrater reliability K values between .72 and .85 and found a 75% convergence between BPD diagnoses using the DIB and the DSM. Atlas and Postelnek is found that their BPD group had significantly higher DIB-R scores than their non-BPD group. All subjects were also interviewed by the child psychiatrist according to DSM-III-R criteria for BPD. 19 According to the DSM-III-R, eight criteria are considered, with five of the eight required to be present to make the diagnosis of BPD. The 35-member BPD group consisted of patients who scored 8 or higher on the DIB-R and met five or more DSM-III-R criteria for BPD, while the 46-member non-BPD group were subjects who scored 5 or less on the DIB-R and met four or fewer DSM-III-R criteria. In the original study by Grapentine et al. 9 no significant differences were found between the two groups on the following variables: age, socioeconomic status, IQ score, or severity of illness (as measured by the Brief Psychiatric Rating Scale for Children2° and the Children's Global Assessment Scale21).
FAULKNER, GRAPENTINE, AND FRANCIS Appendix for specific definitions of variables that are not self-explanatory.) The length of stay was also tallied for each patient. Variables were chosen because they are quantifiable representations of problematic inpatient behaviors. Data were collected from milieu staff notes, physician orders, restraint and seclusion recording sheets, intent-to-leave forms, and discharge summary forms. A second coder, also unaware of group membership, reviewed a total of 18 charts at three points during the collection process. Interrater reliability was high, with the two coders reaching 91% agreement over all 18 charts. ("Agreement" was defined as both coders reaching the same decision regarding the presence or absence of the categorical variable and tallying within one count of each other on the continuous variables.) To provide a more stringent measure of reliability, the K statistic was used for the categorical variable (discharge against medical advice) and intraclass correlations were used for the continuous variables (restraints, seclusions, drug and/or alcohol screens, time-outs, signing the intent-to-leave form, and incidents of self-abuse and aggression). The K was acceptable, .77. All results of the intraclass correlations were also acceptable, with time-outs at .97, seclusions at .98, incidents of aggression at .93, nonroutine drug and/or alcohol screens at .99, incidents of self-abuse at .80, signing the intent-to-leave form at .89, and restraints at .99. RESULTS T h e p r i m a r y h y p o t h e s i s f o r this s t u d y w a s that patients with a diagnosis of BPD would exhibit b e h a v i o r s i n d i c a t i v e o f a p r o b l e m a t i c i n p a t i e n t stay m o r e f r e q u e n t l y t h a n w o u l d p a t i e n t s w i t h o u t this d i a g n o s i s . It w a s
also determined
e a r l y in t h e
a n a l y s i s that t h e l e n g t h o f s t a y w a s c o n s i d e r a b l y g r e a t e r , o n a v e r a g e , f o r t h o s e in t h e B P D g r o u p . The
mean
number
of days
( m e a n +__ S D )
was
5 4 . 1 7 _+ 5 2 . 8 9 f o r t h e B P D g r o u p a n d 3 1 . 3 0 ± 17.26 f o r t h e n o n - B P D
g r o u p ( F [ 1 , 79] = 7.57,
P < .01, ,q2 = .09). T h e r e f o r e , to e v a l u a t e t h e b e h a v i o r o f g r o u p m e m b e r s o n a c o m m o n m e t r i c , all b e h a v i o r a l v a r i a b l e s w e r e a n a l y z e d as t h e rate o f e a c h b e h a v i o r p e r day. A m u l t i v a r i a t e a n a l y s i s o f v a r i a n c e ( M A N O V A ) f o r all v a r i a b l e s s h o w e d that t h e t w o g r o u p s d i f f e r e d s i g n i f i c a n t l y f o r t h e rate o f p r o b l e m a t i c i n p a t i e n t b e h a v i o r (F[1, 79] = 2.74, P < .05). To e x a m i n e m o r e s p e c i f i c h y p o t h e s e s about particular behaviors, follow-up ANOVAs w e r e t h e n p e r f o r m e d o n all v a r i a b l e s ( T a b l e 1).
Procedure The procedure used for this study was a hospital chart review. Data were collected from the patient charts in random order by an experimenter blind to the group membership of individual subjects. Data were collected on the following seven continuous dependent variables: number of seclusions, restraints, time-outs, nortroutine drug and/or alcohol screens, signings of intent-toleave forms, incidents of self-abuse, and incidents of aggression. An additional categorical variable, whether or not a patient was discharged against medical advice, was also collected. (See
B e f o r e r e p o r t i n g t h e r e s u l t s , it is i m p o r t a n t to note that the BPD
group
and non-BPD
group
showed significantly different degrees of variability on most of the variables. In other words, within the non-BPD
group,
individual group
members
re-
ceived similar scores on the variables, while within the BPD group, there was a subgroup that received extremely high scores on the variables. Although the BPD group variability could have been normal-
COMPARISON OF BPD AND NON-BPD ADOLESCENTS
431
Table 1. ANOVA Results (mean _+ SD) Variable Restraints time-outs Seclusions Self-abuse Aggression Drug/alcohol screens Signouts
BPD .0182 .1505 .0290 .0377 .0374 .0234 .0112
_+ .0350 _+ .3110 -+ .0913 _+ .0864 -+ .0623 _+ .0552 _+ .0426
Non-BPD .0011 .0411 .0037 .0127 .0085 .0048 .0052
F
_+ .0054 10.75t _+ .0890 5.15" -+ .0101 3.49 _+ .0444 2.88 -+ .0212 8.60t _+ .0188 4.57* _+ .0300 .56
NOTE. Mean values are the average of the number of events per day (e.g., .0182 is the number of restraints per day for each member of the BPD group averaged over the total number for members in the group). * P < .05. t P < .01.
ized to a variability closer to the non-BPD group in the analysis, this unique subgroup characteristic of the BPD group would have been lost. Therefore, the analysis proceeded as planned. It is also important to note in interpreting the results that the distribution as a whole was positively skewed for many of the variables. However, the analysis again proceeded as planned for the following reasons. First, the ANOVA statistic is relatively robust to violations of normality. Second, the sample sizes were adequate. Finally, the BPD group and non-BPD group were skewed in the same direction, indicating that the violation of the normality assumption did not affect the data from one group and not the other. The results were as follows. It was hypothesized that staff members would be more likely to restrain BPD patients and to separate them from other patients by using the time-out strategy or the seclusion room. The results showed that those with BPD were indeed restrained more often than other patients. However, while patients in the BPD group received significantly more time-outs than those in the non-BPD group, they were not secluded more often. Another hypothesis proposed that patients in the BPD group would self-abuse and aggress more often than those in the non-BPD group. While the results supported the aggression hypothesis, patients with BPD did not self-abuse more often than other patients. Further analyses were performed on both the restraint and aggression variables, examining specific types of restraints and targets of aggression. Because of the small number of restraints (seven chemical, six mechanical, and eight physical restraints in the entire sample), analyses of the specific types of restraint were not deemed
valid. In looking at the targets of aggression in the BPD group, it appears that the majority of aggressive acts (67%) were directed at objects rather than people. This is comparable to the ratio in the non-BPD group (73%). Data were also collected on the number of nonroutine drug and/or alcohol screens ordered on the patients. As expected, patients in the BPD group received more drug and/or alcohol screens than those in the non-BPD group. However, while another impulsive behavior, signing the intent-toleave form, was hypothesized to occur more often in the BPD group, the groups did not differ on this variable. Nor were those with BPD more likely to be discharged against medical advice. The chisquare statistic was used to analyze this variable and was not significant (×2[4, N = 80] = .612, P = .43). However, due to the small number of patients overall who were discharged against medical advice (two in the non-BPD group and three in the BPD group), any statements about the incidence in this population must be made with caution. To further investigate the possible effect of length of stay on rates of behavior, the MANOVA using the rate of behaviors per day was repeated covarying the length of stay. The results indicated that after covarying the length of stay, the two groups were no longer significantly different (F[1, 79] = 1.64, P = NS). While this study was not designed to investigate the relationship between behavior and the length of stay, these preliminary findings suggest that there may be a systematic relationship between the length of stay and the daily rate of behaviors. To explore this finding more specifically, correlations between the rates of behaviors and the length of stay were examined and are reported in Table 2. Significant relationships were found between the length of stay and restraints, episodes of aggression, and time-outs, indicating that the rates of these behaviors may be most influenced by an increased length of stay. DISCUSSION
This study adds to the knowledge about adolescent BPD as it manifests on an inpatient unit. Many theorists and researchers believe that patients with BPD regress behaviorally while hospitalized, and have assumed this to be true when writing about the disorder and conducting research. This study is the first to carefully scrutinize this assumption using
FAULKNER, GRAPENTINE, AND FRANCIS
432
Table 2. Pearson Correlations Between Daily Behavior Rates and Length of Stay for the Whole Sample (N = 81)
*P< tP<
Behavior
Length of Stay
Restraints 13me-outs Seclusions Self-abuse Aggression Drug/alcohol screens Signouts
.2712" .2768" .1236 .0420 .3164t .0999 -.0903
.05. .01.
reliable instruments, quantifiable data, and empirical analysis. The primary limitation of this study centers around the question of whether chart data were recorded accurately and completely and whether the groups were reported on differentially. Precautions were taken in the selection of variables to minimize this possibility. Seclusions, restraints, and drug and/or alcohol screens all require a doctor's order, are mandated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to be recorded in the chart in all situations, and require a witness to the documentation of these events. Documentation of the signing of the intent-to-leave form also is necessary, given the legal restraints on the amount of time that can elapse between signing the form and either discharge or obtaining a court order to commit a patient, and the fact that unit and hospital policy dictate that patients must be restricted to the unit once this form has been signed. It is unlikely that such events were not documented. Episodes of self-abuse and aggression are highly salient events and have a high likelihood of being noted in the charts, as well, particularly since they often lead to seclusion or restraint. Time-outs may have been missed on occasion, although many of the patients were on behavior plans that required careful monitoring of the number of time-outs. In a more general sense, each patient's behavior is reviewed at each shift change, and all staff members routinely receive supervision in documentation, further increasing the likelihood of any significant behaviors being noticed and recorded. While the risk of missing information is deemed minimal in this study, to eliminate the possibility of missing information, future research on the behavior of hospitalized patients with BPD should involve
careful monitoring of the documentation of data at the time they are entered into the charts. This being said, the implications of this study are threefold. First, the length of stay may contribute significantly to the behavioral differences found between BPD and non-BPD patients in this study. Patients with BPD were hospitalized for longer periods than non-BPD patients and, overall, showed higher rates of restraints, aggression, time-outs, and nonroutine drug and/or alcohol screens. However, it may be that any patient hospitalized for a long period would have shown more problematic behaviors than patients who had shorter stays. Preliminary analyses suggest that the rates of restraints, time-outs, and aggression may be most influenced by longer hospital stays. Second, the study calls into question the perception that BPD patients are more difficult than non-BPD patients on a day-to-day basis. While clinical folklore holds that patients with BPD have tumultuous inpatient stays, this perception is likely too simplistic. The results of this study indicate that while BPD patients showed higher rates of some behaviors, they were not more likely than other patients on any given day to be secluded, to self-abuse, or to sign intent-to-leave forms. The finding regarding self-abuse is particularly interesting, given that self-abuse is considered a hallmark of BPD. Third, while this study focused on BPD patients as a group, there may have been a subset of patients in the BPD group which exhibited a preponderance of the specific problematic behaviors. It appeared that a small group of seven BPD subjects accounted for a high proportion of the behaviors found in the BPD group. This group consisted of BPD patients who scored 2 SD above the group mean on one or more of the behavioral variables. For example, these seven patients (of the 35-member group) received 63% of the drug and/or alcohol screens, 55% of the seclusions, and 51% of the time-outs. Therefore, it seems possible that some of the differences between the BPD and non-BPD groups may thus be due simply to these particularly difficult BPD patients. It may be that there is a subgroup of BPD patients who have stormy hospitalizations and that these patients are responsible for the negative reputation of the BPD patient in the hospital. Future research should specifically address the issue of BPD subtypes and whether
COMPARISON OF BPD AND NON-BPD ADOLESCENTS
433
different subtypes of BPD patients have different inpatient experiences. T h e r e s u l t s o f this s t u d y c h a l l e n g e s o m e a s s u m p tions
about
BPD,
and
pose
hypotheses
to
be
e x a m i n e d in f u t u r e r e s e a r c h w i t h this p o p u l a t i o n . A P P E N D I X : DEFINITIONS Restraint: Controlling a patient who is believed to be a threat to self or others through physically holding, strapping to a bed, or giving a sedative medication. Time-out: Asking a patient who is behaving in an inappropriate or extreme manner to go to a quiet place away from others for a circumscribed period of time. Seclusion: Placing a patient who is believed to be escalating to a potentially unmanageable level in a small empty locked room with an observation window.
Self-abuse: Any behavior that a patient engages in with the intention of inflicting harm upon herself. Aggression: Any act of throwing, kicking, or hitting a person or an object. Nonroutine drug and~or alcohol screens: Any test of a patient's urine to detect the presence of drugs and/or alcohol that is in addition to routine screens. Signing out: Signing an intent-to-leave form, signifying a patient's desire to be discharged and necessitating finding a placement or involuntary commitment.
ACKNOWLEDGMENT The authors wish to acknowledge Ron Seifer, Ph.D., Lawrence Grebstein, Ph.D., Charles Collyer, Ph.D., Stephanie Riolo, M.D., Carla Picariello, and the reviewer for Comprehensive Psychiatry.
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