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Gander M, Buchheim A, Sevecke K. Personality Disorders and Attachment Trauma in Adolescent Patients with Psychiatric Disorders. Res Child Adolesc Psychopathol 2024; 52:457-471. [PMID: 37889355 PMCID: PMC10896792 DOI: 10.1007/s10802-023-01141-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 10/28/2023]
Abstract
This study examined how personality disorders (PD) differ with respect to gender, attachment status and traumatic childhood experiences in adolescent psychiatric inpatients. In particular, we investigated attachment-related traumatic material underlying adolescent PD. Our sample consisted of 175 inpatient adolescents aged 14 to 18 years (77% female, Mage = 15.13, SD = 1.35; 23% male, Mage =14.85, SD = 1.41). Thirty-nine patients (22%) fulfilled the diagnostic criteria for a PD according to the SCID-II PD: 51% avoidant, 13% obsessive-compulsive, 13% antisocial, 19% borderline, 2% paranoid and 2% histrionic. In the total sample, eighty-three (47%) of our inpatients were classified with an unresolved attachment status using the Adult Attachment Projective Picture System (AAP). We did not find any significant gender differences for patients with and without a PD. Our results revealed a higher percentage of unresolved attachment status in patients with a PD. The in-depth analysis of the total sample showed that patients with a PD demonstrated more traumatic material in their attachment interviews indicating a greater severity of attachment trauma. Furthermore, patients with a PD reported higher scores on emotional and physical neglect. Intervention strategies targeting traumatic attachment-related themes might be useful to treat adolescents with PD.
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Affiliation(s)
- Manuela Gander
- Institute of Psychology, University of Innsbruck, Universitätsstrasse 5-7, Innsbruck, 6020, Austria.
- Department of Child and Adolescent Psychiatry, Tirol Kliniken, Milserstrasse 10, 6060 Hall in Tirol, Tirol, Austria.
| | - Anna Buchheim
- Institute of Psychology, University of Innsbruck, Universitätsstrasse 5-7, Innsbruck, 6020, Austria
| | - Kathrin Sevecke
- Department of Child and Adolescent Psychiatry, Tirol Kliniken, Milserstrasse 10, 6060 Hall in Tirol, Tirol, Austria
- Department of Child and Adolescent Psychiatry, Medical University of Innsbruck, Innsbruck, 6020, Austria
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2
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Lind M, Kiel L, Hansen SB, Jørgensen MS, Simonsen E. Narrative Identity within Mentalization-Based Group Therapy for Adolescents: A Feasibility Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050854. [PMID: 37238402 DOI: 10.3390/children10050854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/28/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023]
Abstract
Borderline personality disorder (BPD) is characterized by severe disturbances related to understanding oneself and other people and can be reliably detected and treated in adolescence. In this feasibility study, we aimed to focus on the features of, and changes in, narrative identity throughout the course of Mentalization-Based Treatment in Groups (MBT-G) for adolescents with BPD. Six female patients (M = 15.2, SD = 0.75) joined between 16 and 31 (M = 23.83) MBT g sessions. The narrated events within each session across sessions were coded for themes of agency and communion and the narrated reactions were coded for personality functioning. The patients and their parents also completed several self-report measures before and after therapy. Themes of diminished agency and communion were identified, with communion as the dominating theme. When comparing the patients' first five sessions with their last five sessions, there was an increase in themes related to agency and decreased in communion. The narrated reactions were dominated by themes related to thwarted self-functioning and primarily identity, although intimacy was also present. Patients improved in terms of self-reported functioning and internalizing and externalizing behavior before and after end of treatment. The importance of narration in BPD (group) therapy is discussed alongside clinical implications.
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Affiliation(s)
- Majse Lind
- Department of Communication and Psychology, Aalborg University, Nordkraft, Teglgårds Plads 1, 9000 Aalborg, Denmark
| | - Lennart Kiel
- Department of Psychology, Aarhus University, 8000 Aarhus, Denmark
| | - Sune Bo Hansen
- Department of Psychology, University of Copenhagen, 1353 Copenhagen, Denmark
| | - Mie Sedoc Jørgensen
- Psychiatric Research Unit, Mental Health Services of Region Zealand, Region Zealand, 4200 Slagelse, Denmark
| | - Erik Simonsen
- Psychiatry East, Mental Health Services of Region Zealand, 4000 Roskilde, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
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3
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Jørgensen MS, Storebø OJ, Poulsen S, Simonsen E. Burden and Treatment Satisfaction among Caregivers of Adolescents with Borderline Personality Disorder. FAMILY PROCESS 2021; 60:772-787. [PMID: 33010045 DOI: 10.1111/famp.12593] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Despite the fact that family involvement is encouraged in early interventions for borderline personality disorder (BPD), there is a limited knowledge on the experience of caring for adolescents with BPD. This is an exploratory retrospective study nested within a randomized controlled trial that compared mentalization-based treatment (MBT) in groups to treatment as usual for adolescents with BPD. Caregivers received six MBT-Parents sessions or standard care over one year. Three months after end of treatment (EOT), 75 caregivers (35 in MBT, 40 in TAU) filled out the Burden Assessment Scale, and 71 (34 in MBT, 37 in TAU) the Family Satisfaction Survey. The adolescents filled out the Borderline Personality Features Scale for Children at baseline and after twelve months at EOT. We tested whether caregiver demographics, adolescents' severity of BPD, treatment and adolescents' dropout from treatment predicted levels of caregiver burden and satisfaction with treatment. The caregivers reported high levels of burden on the BAS (M = 40.3, SD = 12.2). Our study suggests that higher BPD severity at EOT among the adolescents predicted caregiver burden (p = .03), whereas higher baseline BPD severity predicted satisfaction with treatment (p = .04) and that biological mothers could be more burdened than other types of caregivers but also might be more satisfied with treatment. Treatment and adolescents' dropout from treatment were not related to caregiver burden or satisfaction with treatment. To help inform future research and to devise appropriate interventions for caregivers and adolescents with BPD, it is important to identify possible predictors of caregiver burden. The results of this initial exploratory study indicate that caregivers (and particularly biological mothers) of adolescents with more severe levels of BPD could be particularly vulnerable toward feelings of burden and therefore are in need of support.
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Affiliation(s)
- Mie Sedoc Jørgensen
- Child and Adolescent Psychiatry, Region Zealand, Roskilde, Denmark
- Psychiatric Research Unit, Region Zealand, Slagelse, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ole Jakob Storebø
- Child and Adolescent Psychiatry, Region Zealand, Roskilde, Denmark
- Psychiatric Research Unit, Region Zealand, Slagelse, Denmark
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Stig Poulsen
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Erik Simonsen
- Psychiatric Research Unit, Region Zealand, Slagelse, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Simonsen E, Vestergaard M, Storeb OJ, Bo S, J Rgensen MS. Prediction of Treatment Outcome of Adolescents With Borderline Personality Disorder: A 2-Year Follow-Up Study. J Pers Disord 2021; 35:111-130. [PMID: 33999658 DOI: 10.1521/pedi_2021_35_524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This study examined prediction of various clinical outcomes in adolescents with borderline personality disorder (BPD) features. Of the 112 adolescents who participated at baseline, 97 were seen at 2-year follow-up, of which 49 (50.5%) had clinically improved, defined as a decrease in BPD pathology of minimum 12 points on the Borderline Personality Features Scale for Children (BPFS-C). Eighty-one adolescents fulfilled the diagnostic criteria for BPD and scored above clinical cutoff on the BPFS-C at baseline, of which 26 (32%) had remitted at follow-up by self-report on the BPFS-C. Results showed that adolescents with comorbid oppositional defiant disorder at baseline were less likely to have clinically improved or remitted at follow-up. Participants with increased self-reported depression and less exposure to physical abuse at baseline had increased odds of remission. Our findings suggest that more internalizing and less externalizing symptoms increase the odds of positive treatment outcome in adolescents with BPD.
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Affiliation(s)
- Erik Simonsen
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Martin Vestergaard
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark.,Department of Child and Adolescent Psychiatry, Psychiatry Region Zealand, Roskilde, Denmark
| | - Ole Jakob Storeb
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark.,Department of Child and Adolescent Psychiatry, Psychiatry Region Zealand, Roskilde, Denmark.,Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Sune Bo
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark.,Department of Child and Adolescent Psychiatry, Psychiatry Region Zealand, Roskilde, Denmark
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Mentalization-based treatment in groups for adolescents with Borderline Personality Disorder: 3- and 12-month follow-up of a randomized controlled trial. Eur Child Adolesc Psychiatry 2021; 30:699-710. [PMID: 32388627 DOI: 10.1007/s00787-020-01551-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 04/28/2020] [Indexed: 10/24/2022]
Abstract
Mentalization-based treatment in groups (MBT-G) has never been tested in adolescents with Borderline Personality Disorder (BPD) in a randomized controlled trial. The current study aimed to test the long-term effectiveness of MBT-G in an adolescent sample with BPD or BPD features (≥ 4 DSM-5 BPD criteria). Hundred and eleven patients with BPD (n = 106) or BPD features (n = 5) were randomized to either (1) a 1-year modified MBT-G program comprising three MBT introductory sessions, five individual case formulation sessions, 37 weekly MBT group sessions, and six MBT-Parent sessions, or (2) treatment as usual (TAU), defined as at least 12 individual monthly treatment sessions with follow-up assessments at 3 and 12 months post treatment. The primary outcome was the score on the Borderline Personality Features Scale for Children (BPFS-C), and secondary outcomes included clinician-rated BPD symptoms and global level of functioning as well as self-reported self-harm, depression, externalizing and internalizing symptoms, and caregiver reports. There were no statistically significant differences between MBT-G and TAU on the primary outcome measure or any of the secondary outcomes. Both groups showed improvement on the majority of clinical and social outcomes at both follow-up points, although remission rates were modest with just 35% in MBT-G and 39% in TAU 2 years after inclusion into the study. MBT-G was not superior to TAU in improving borderline features in adolescents. Although improvement was observed equally in both interventions over time, the patients continued to exhibit prominent BPD features, general psychopathology and decreased functioning in the follow-up period, which points to a need for more research and better understanding of effective components in early intervention programs. The ClinicalTrials.gov identifier is NCT02068326.
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Jørgensen MS, Bo S, Vestergaard M, Storebø OJ, Sharp C, Simonsen E. Predictors of dropout among adolescents with borderline personality disorder attending mentalization-based group treatment. Psychother Res 2021; 31:950-961. [PMID: 33428543 DOI: 10.1080/10503307.2020.1871525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Background: Premature termination from treatment or dropout is prevalent among patients with borderline personality disorder (BPD). To our knowledge, no studies have examined which factors predisposes dropout from therapy among adolescents with BPD. The current study examined sociodemographic, clinical and psychological predictors of dropout among adolescents who attended a one-year treatment program with mentalization-based group treatment (MBT-G).Methods: Participants were 89 female adolescent patients aged 14-18 years who attended MBT-G in a Danish child and adolescent psychiatric service and 56 matched controls who received non-manualized individual sessions (treatment as usual). Forty (45%) dropped out and 49 (55%) completed treatment in MBT-G. Pretreatment predictors included (1) sociodemographic variables such as age, schooling, relationship status and after-school job, (2) clinical measures of self-reported adolescent borderline personality features, depression, self-harm, internalizing and externalizing symptoms, and (3) psychological measures on self-reported reflective functioning (i.e., mentalizing) and attachment to peers and parents.Results: Binary logistic regression analyses revealed that lower reflective functioning was the only significant predictor of dropout in MBT-G. No sociodemographic or clinical variables predicted dropout. No significant predictors of dropout were identified among participants who received treatment as usual.Conclusions: Adolescents with BPD who report low reflective functioning are at increased risk of dropping out of MBT-G treatment but not treatment as usual. These findings highlight that clinicians need to consider level of reflective functioning among adolescents with BPD in MBT or in group therapy and adapt psychotherapy to the needs of the patient in order to reduce dropout.
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Affiliation(s)
| | - Sune Bo
- Psychiatric Research Unit, Region Zealand, Denmark.,Child and Adolescent Psychiatric Department, Region Zealand, Denmark
| | - Martin Vestergaard
- Psychiatric Research Unit, Region Zealand, Denmark.,Child and Adolescent Psychiatric Department, Region Zealand, Denmark
| | - Ole Jakob Storebø
- Psychiatric Research Unit, Region Zealand, Denmark.,Child and Adolescent Psychiatric Department, Region Zealand, Denmark.,Department of Psychology, University of Southern Denmark, Denmark
| | - Carla Sharp
- Department of Psychology, University of Houston, Houston, TX, USA
| | - Erik Simonsen
- Psychiatric Research Unit, Region Zealand, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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7
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Andersen CF, Poulsen S, Fog-Petersen C, Jørgensen MS, Simonsen E. Dropout from mentalization-based group treatment for adolescents with borderline personality features: A qualitative study. Psychother Res 2020; 31:619-631. [PMID: 32878583 DOI: 10.1080/10503307.2020.1813914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Objective: Premature termination, or dropout, is a major concern in psychotherapy in general and an issue of particular importance in treatments for borderline personality disorder (BPD). Yet few studies investigating dropout from therapy in adolescent BPD populations exist. This study investigates reasons for dropping out from group-based mentalization-based treatment (MBT-G) for BPD or borderline features in an adolescent population.Method: Ten semi-structured interviews were performed with female adolescents who had dropped out from group-based MBT for BPD. The data were analyzed qualitatively using Systematic Text Condensation.Results: The results point to the existence of a subgroup of adolescent BPD patients who do not perceive the treatment sufficiently helpful or worthwhile, who experienced treatment as emotionally demanding, time-consuming and connected with unpleasant experiences. Positive reasons for early termination were reported in the form of experienced improvement in condition. Dropping out became understood as a process of weighing perceived benefits against perceived costs of staying in treatment. This understanding of dropout as a process implies the existence of a window of time where intervention to prevent dropout is possible, presupposing the detection of at-risk patients.
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Affiliation(s)
| | - Stig Poulsen
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Cecilie Fog-Petersen
- Psychiatric Research Unit, Region Zealand, Slagelse, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Psychiatry West, Region Zealand, Slagelse, Denmark
| | | | - Erik Simonsen
- Psychiatric Research Unit, Region Zealand, Slagelse, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Bo S, Vilmar JW, Jensen SL, Jørgensen MS, Kongerslev M, Lind M, Fonagy P. What works for adolescents with borderline personality disorder: towards a developmentally informed understanding and structured treatment model. Curr Opin Psychol 2020; 37:7-12. [PMID: 32652486 DOI: 10.1016/j.copsyc.2020.06.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/12/2020] [Accepted: 06/14/2020] [Indexed: 10/24/2022]
Abstract
The efficacy of treatment of borderline personality disorder in adolescents is an underresearched area. Although increasing research in borderline personality disorder in adolescents has emerged over the last decade there is a paucity of knowledge about how treatment is adequately designed for this group of patients. As a consequence, it is currently difficult to provide evidence-based guidelines and firm recommendations for how to design and implement borderline treatment in adolescence. In this selective review we summarize the most important research findings concerning treatment for adolescents with borderline personality disorder, including a recent mentalisation-based group treatment program. We highlight pivotal developmental obstacles for psychotherapy in adolescence and integrate these into a framework for the understanding and designing of effective treatment of borderline in adolescence.
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Affiliation(s)
- Sune Bo
- Psychiatric Research Unit, Region Zealand, Denmark; Child and Adolescents Psychiatry, Region Zealand, Denmark.
| | | | | | | | - Mickey Kongerslev
- Psychiatric Research Unit, Region Zealand, Denmark; Department of Psychology, University of Southern Denmark, Denmark
| | - Majse Lind
- Department of Psychology, University of Florida, United States; Department of Psychology and Behavioural Sciences, Aarhus University, Denmark
| | - Peter Fonagy
- Anna Freud National Centre for Children and Families, England, United Kingdom
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9
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The identification of a risk profile for young people with borderline personality pathology: a review of recent literature. Curr Opin Psychol 2020; 37:13-20. [PMID: 32653538 DOI: 10.1016/j.copsyc.2020.06.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/25/2020] [Accepted: 06/07/2020] [Indexed: 12/28/2022]
Abstract
The shift towards early intervention in borderline personality disorder (BPD) has introduced a clinical staging approach in the treatment for young persons with BPD. Complementary to staging is profiling: the identification of psychological, social and biological risk variables that may predict prognosis. The aim of this paper is to provide a risk profile for BPD by systematically reviewing literature on potential risk markers for poor prognosis for BPD. An extensive literature search revealed evidence for seven categories of risk factors: adverse childhood experiences, BPD symptom profile, associated mental disorders, personality impairments and traits, current interpersonal context, biological disposition and socio-demographics. Including these markers within the current staging approach, to compose individual risk profiles for poor BPD prognosis, may assist in personalizing treatment for young people with BPD and in refining research protocols for treatment outcome studies.
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10
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Storebø OJ, Stoffers-Winterling JM, Völlm BA, Kongerslev MT, Mattivi JT, Jørgensen MS, Faltinsen E, Todorovac A, Sales CP, Callesen HE, Lieb K, Simonsen E. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev 2020; 5:CD012955. [PMID: 32368793 PMCID: PMC7199382 DOI: 10.1002/14651858.cd012955.pub2] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Over the decades, a variety of psychological interventions for borderline personality disorder (BPD) have been developed. This review updates and replaces an earlier review (Stoffers-Winterling 2012). OBJECTIVES To assess the beneficial and harmful effects of psychological therapies for people with BPD. SEARCH METHODS In March 2019, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication. SELECTION CRITERIA Randomised controlled trials comparing different psychotherapeutic interventions with treatment-as-usual (TAU; which included various kinds of psychotherapy), waiting list, no treatment or active treatments in samples of all ages, in any setting, with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects. DATA COLLECTION AND ANALYSIS At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis. MAIN RESULTS We included 75 randomised controlled trials (4507 participants), predominantly involving females with mean ages ranging from 14.8 to 45.7 years. More than 16 different kinds of psychotherapy were included, mostly dialectical behaviour therapy (DBT) and mentalisation-based treatment (MBT). The comparator interventions included treatment-as-usual (TAU), waiting list, and other active treatments. Treatment duration ranged from one to 36 months. Psychotherapy versus TAU Psychotherapy reduced BPD symptom severity, compared to TAU; standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -0.70 to -0.33; 22 trials, 1244 participants; moderate-quality evidence. This corresponds to a mean difference (MD) of -3.6 (95% CI -4.4 to -2.08) on the Zanarini Rating Scale for BPD (range 0 to 36), a clinically relevant reduction in BPD symptom severity (minimal clinical relevant difference (MIREDIF) on this scale is -3.0 points). Psychotherapy may be more effective at reducing self-harm compared to TAU (SMD -0.32, 95% CI -0.49 to -0.14; 13 trials, 616 participants; low-quality evidence), corresponding to a MD of -0.82 (95% CI -1.25 to 0.35) on the Deliberate Self-Harm Inventory Scale (range 0 to 34). The MIREDIF of -1.25 points was not reached. Suicide-related outcomes improved compared to TAU (SMD -0.34, 95% CI -0.57 to -0.11; 13 trials, 666 participants; low-quality evidence), corresponding to a MD of -0.11 (95% CI -0.19 to -0.034) on the Suicidal Attempt Self Injury Interview. The MIREDIF of -0.17 points was not reached. Compared to TAU, psychotherapy may result in an improvement in psychosocial functioning (SMD -0.45, 95% CI -0.68 to -0.22; 22 trials, 1314 participants; low-quality evidence), corresponding to a MD of -2.8 (95% CI -4.25 to -1.38), on the Global Assessment of Functioning Scale (range 0 to 100). The MIREDIF of -4.0 points was not reached. Our additional Trial Sequential Analysis on all primary outcomes reaching significance found that the required information size was reached in all cases. A subgroup analysis comparing the different types of psychotherapy compared to TAU showed no clear evidence of a difference for BPD severity and psychosocial functioning. Psychotherapy may reduce depressive symptoms compared to TAU but the evidence is very uncertain (SMD -0.39, 95% CI -0.61 to -0.17; 22 trials, 1568 participants; very low-quality evidence), corresponding to a MD of -2.45 points on the Hamilton Depression Scale (range 0 to 50). The MIREDIF of -3.0 points was not reached. BPD-specific psychotherapy did not reduce attrition compared with TAU. Adverse effects were unclear due to too few data. Psychotherapy versus waiting list or no treatment Greater improvements in BPD symptom severity (SMD -0.49, 95% CI -0.93 to -0.05; 3 trials, 161 participants), psychosocial functioning (SMD -0.56, 95% CI -1.01 to -0.11; 5 trials, 219 participants), and depression (SMD -1.28, 95% CI -2.21 to -0.34, 6 trials, 239 participants) were observed in participants receiving psychotherapy versus waiting list or no treatment (all low-quality evidence). No evidence of a difference was found for self-harm and suicide-related outcomes. Individual treatment approaches DBT and MBT have the highest numbers of primary trials, with DBT as subject of one-third of all included trials, followed by MBT with seven RCTs. Compared to TAU, DBT was more effective at reducing BPD severity (SMD -0.60, 95% CI -1.05 to -0.14; 3 trials, 149 participants), self-harm (SMD -0.28, 95% CI -0.48 to -0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD -0.36, 95% CI -0.69 to -0.03; 6 trials, 225 participants). MBT appears to be more effective than TAU at reducing self-harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD -0.58, 95% CI -1.22 to 0.05, 4 trials, 333 participants). All findings are based on low-quality evidence. For secondary outcomes see review text. AUTHORS' CONCLUSIONS Our assessments showed beneficial effects on all primary outcomes in favour of BPD-tailored psychotherapy compared with TAU. However, only the outcome of BPD severity reached the MIREDIF-defined cut-off for a clinically meaningful improvement. Subgroup analyses found no evidence of a difference in effect estimates between the different types of therapies (compared to TAU) . The pooled analysis of psychotherapy versus waiting list or no treatment found significant improvement on BPD severity, psychosocial functioning and depression at end of treatment, but these findings were based on low-quality evidence, and the true magnitude of these effects is uncertain. No clear evidence of difference was found for self-harm and suicide-related outcomes. However, compared to TAU, we observed effects in favour of DBT for BPD severity, self-harm and psychosocial functioning and, for MBT, on self-harm and suicidality at end of treatment, but these were all based on low-quality evidence. Therefore, we are unsure whether these effects would alter with the addition of more data.
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Affiliation(s)
- Ole Jakob Storebø
- Child and Adolescent Psychiatric Department, Region Zealand, Roskilde, Denmark
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Department of Psychology, Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | | | - Birgit A Völlm
- Department of Forensic Psychiatry, Center for Neurology, University Rostock, Rostock, Germany
| | - Mickey T Kongerslev
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Department of Psychology, Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | - Jessica T Mattivi
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Mie S Jørgensen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | - Erlend Faltinsen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | - Adnan Todorovac
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | - Christian P Sales
- Duncan MacMillan House, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
- Institute of Mental Health, Department of Psychiatry & Applied Psychology, Nottingham, UK
| | | | - Klaus Lieb
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Erik Simonsen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
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11
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Beck E, Bo S, Jørgensen MS, Gondan M, Poulsen S, Storebø OJ, Fjellerad Andersen C, Folmo E, Sharp C, Pedersen J, Simonsen E. Mentalization-based treatment in groups for adolescents with borderline personality disorder: a randomized controlled trial. J Child Psychol Psychiatry 2020; 61:594-604. [PMID: 31702058 DOI: 10.1111/jcpp.13152] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/02/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Borderline personality disorder (BPD) typically onsets in adolescence and predicts later functional disability in adulthood. Highly structured evidence-based psychotherapeutic programs, including mentalization-based treatment (MBT), are first choice treatment. The efficacy of MBT for BPD has mainly been tested with adults, and no RCT has examined the effectiveness of MBT in groups (MBT-G) for adolescent BPD. METHOD A total of 112 adolescents (111 females) with BPD (106) or BPD symptoms ≥4 DSM-5 criteria (5) referred to child and adolescent psychiatric outpatient clinics were randomized to a 1-year MBT-G, consisting of three introductory, psychoeducative sessions, 37 weekly group sessions, five individual case formulation sessions, and six group sessions for caregivers, or treatment as usual (TAU) with at least 12 monthly individual sessions. The primary outcome was the score on the borderline personality features scale for children (BPFS-C); secondary outcomes included self-harm, depression, externalizing and internalizing symptoms (all self-report), caregiver reports, social functioning, and borderline symptoms rated by blinded clinicians. Outcome assessments were made at baseline, after 10, 20, and 30 weeks, and at end of treatment (EOT). The ClinicalTrials.gov identifier is NCT02068326. RESULTS At EOT, the primary outcome was 71.3 (SD = 15.0) in the MBT-G group and 71.3 (SD = 15.2) in the TAU group (adjusted mean difference 0.4 BPFS-C units in favor of MBT-G, 95% confidence interval -6.3 to 7.1, p = .91). No significant group differences were found in the secondary outcomes. 29% in both groups remitted. 29% of the MBT group completed less than half of the sessions compared with 7% of the control group. CONCLUSIONS There is no indication for superiority of either therapy method. The low remission rate points to the importance of continued research into early intervention. Specifically, retention problems need to be addressed.
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Affiliation(s)
- Emma Beck
- Psychiatric Research Unit, Region Zealand, Denmark.,Child and Adolescent Psychiatric Department, Region Zealand, Denmark.,Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Sune Bo
- Psychiatric Research Unit, Region Zealand, Denmark.,Child and Adolescent Psychiatric Department, Region Zealand, Denmark
| | - Mie Sedoc Jørgensen
- Psychiatric Research Unit, Region Zealand, Denmark.,Child and Adolescent Psychiatric Department, Region Zealand, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Matthias Gondan
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Stig Poulsen
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Ole Jakob Storebø
- Psychiatric Research Unit, Region Zealand, Denmark.,Child and Adolescent Psychiatric Department, Region Zealand, Denmark.,Department of Psychology, University of Southern Denmark, Odense, Denmark
| | | | - Espen Folmo
- Norwegian National Advisory Unit on Personality Psychiatry, Oslo University Hospital, Oslo, Norway
| | - Carla Sharp
- Department of Psychology, University of Houston, Houston, TX, USA.,Center for Development Support, University of the Free State, Bloemfontein, South Africa
| | - Jesper Pedersen
- Child and Adolescent Psychiatric Department, Region Zealand, Denmark
| | - Erik Simonsen
- Psychiatric Research Unit, Region Zealand, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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12
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Vogt KS, Norman P. Is mentalization-based therapy effective in treating the symptoms of borderline personality disorder? A systematic review. Psychol Psychother 2019; 92:441-464. [PMID: 30099834 PMCID: PMC6900007 DOI: 10.1111/papt.12194] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Indexed: 12/25/2022]
Abstract
OBJECTIVE This review sought to systematically review evidence on the efficacy of mentalization-based therapy (MBT) for the treatment of borderline personality disorder (BPD), in particular, in decreasing psychiatric symptoms associated with BPD and its comorbid disorders. METHOD Fourteen papers were included in the review which examined the effectiveness of MBT in the context of BPD; these included 11 original studies and three follow-up papers. RESULTS Mentalization-based therapy was found to achieve either superior or equal reductions in psychiatric symptoms when compared with other treatments (supportive group therapy, treatment as usual/standard psychiatric care, structured clinical management, and specialized clinical management). DISCUSSION Mentalization-based therapy can achieve significant reductions in BPD symptom severity and the severity of comorbid disorders as well as increase quality of life. However, caution is required, as the need for better quality research such as randomized controlled trials is pressing. Research is also needed on the proposed mediators of MBT. PRACTITIONER POINTS Mentalization-based therapy (MBT) is increasingly being considered as a treatment for people with borderline personality disorder (BPD), and a systematic review was required to investigate its effectiveness. MBT was found to be equally as effective or superior to well-established comparison treatments of BPD, however, the majority of studies was of unsatisfying quality. Little is known about the mechanisms of MBT. Further, better quality trials are needed to investigate its efficacy in treating BPD.
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Affiliation(s)
- Katharina Sophie Vogt
- Sheffield Institute of Translational Neuroscience (SiTran)The University of SheffieldUK
- Department of PsychologyThe University of SheffieldUK
| | - Paul Norman
- Department of PsychologyThe University of SheffieldUK
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13
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Griffiths H, Duffy F, Duffy L, Brown S, Hockaday H, Eliasson E, Graham J, Smith J, Thomson A, Schwannauer M. Efficacy of Mentalization-based group therapy for adolescents: the results of a pilot randomised controlled trial. BMC Psychiatry 2019; 19:167. [PMID: 31170947 PMCID: PMC6554935 DOI: 10.1186/s12888-019-2158-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 05/23/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Mentalization Based Therapy (MBT) has yielded promising outcomes for reducing self-harm, although to date only one study has reported MBT's effectiveness for adolescents (Rossouw and Fonagy, J Am Acad Child Adolesc Psychiatry 51:1304-1313, 2012) wherein the treatment protocol consisted of an intensive programme of individual and family therapy. We sought to investigate an adaptation of the adult MBT introductory manual in a group format for adolescents. METHODS The present study is a randomised controlled single blind feasibility trial that aims to (1) adapt the original explicit MBT introductory group manual for an adolescent population (MBT-Ai) and to (2) assess the feasibility of a trial of MBT-Ai through examination of consent rates, attendance, attrition and self-harm. Repeated measures ANOVAs were conducted to examine change over time in independent and dependent variables between groups, and multi level models (MLM) were conducted to examine key predictors in relation to change over time with self-report self-harm and emergency department presentation for harm as the primary outcome variables. RESULTS Fifty-three young people consented to participate and were randomised to MBT-Ai + TAU or TAU alone. Five participants withdrew from the trial. Trial procedures seemed appropriate and safe, with acceptable group attendance. Self-reported self-harm and emergency department presentation for self-harm significantly decreased over time in both groups, though there were no between group differences. Social anxiety, emotion regulation, and borderline traits also significantly decreased over time in both groups. Mentalization emerged as a significant predictor of change over time in self reported self harm and hospital presentation for self-harm. CONCLUSIONS It was feasible to carry out an RCT of MBT-Ai for adolescents already attending NHS CAMHS who have recently self-harmed. Our data gave signals that suggested a relatively brief group-based MBT-Ai intervention may be a promising intervention with potential for service implementation. Future research should consider the appropriate format, dosage and intensity of MBT for the adolescent population. TRIAL REGISTRATION NCT02771691 ; Trial Registration Date: 25/04/2016.
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Affiliation(s)
- Helen Griffiths
- School of Health in Social Science, The University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG UK
- NHS Lothian Child and Adolescent Mental Health Services, Royal Edinburgh Hospital, Tipperlinn Road, Edinburgh, EH10 5HF UK
| | - Fiona Duffy
- School of Health in Social Science, The University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG UK
- NHS Lothian Child and Adolescent Mental Health Services, Royal Edinburgh Hospital, Tipperlinn Road, Edinburgh, EH10 5HF UK
| | - Louise Duffy
- NHS Lothian Child and Adolescent Mental Health Services, Royal Edinburgh Hospital, Tipperlinn Road, Edinburgh, EH10 5HF UK
| | - Sarah Brown
- School of Health in Social Science, The University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG UK
- NHS Lothian Child and Adolescent Mental Health Services, Royal Edinburgh Hospital, Tipperlinn Road, Edinburgh, EH10 5HF UK
| | - Harriet Hockaday
- School of Health in Social Science, The University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG UK
- NHS Lothian Child and Adolescent Mental Health Services, Royal Edinburgh Hospital, Tipperlinn Road, Edinburgh, EH10 5HF UK
| | - Emma Eliasson
- School of Health in Social Science, The University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG UK
- NHS Lothian Child and Adolescent Mental Health Services, Royal Edinburgh Hospital, Tipperlinn Road, Edinburgh, EH10 5HF UK
| | - Jessica Graham
- NHS Lothian Child and Adolescent Mental Health Services, Royal Edinburgh Hospital, Tipperlinn Road, Edinburgh, EH10 5HF UK
| | - Julie Smith
- School of Health in Social Science, The University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG UK
- NHS Lothian Child and Adolescent Mental Health Services, Royal Edinburgh Hospital, Tipperlinn Road, Edinburgh, EH10 5HF UK
| | - Alice Thomson
- School of Health in Social Science, The University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG UK
- NHS Lothian Child and Adolescent Mental Health Services, Royal Edinburgh Hospital, Tipperlinn Road, Edinburgh, EH10 5HF UK
| | - Matthias Schwannauer
- School of Health in Social Science, The University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG UK
- NHS Lothian Child and Adolescent Mental Health Services, Royal Edinburgh Hospital, Tipperlinn Road, Edinburgh, EH10 5HF UK
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14
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Temes CM, Zanarini MC. Recent developments in psychosocial interventions for borderline personality disorder. F1000Res 2019; 8. [PMID: 31069059 PMCID: PMC6489987 DOI: 10.12688/f1000research.18561.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2019] [Indexed: 11/20/2022] Open
Abstract
Borderline personality disorder (BPD) is a serious psychiatric disorder that affects multiple symptomatic domains and is associated with an increased risk of suicidality. Several empirically supported treatments for BPD have been developed in recent years for adults with BPD. More recent work has focused on tailoring or applying (or both) these existing treatments to specific patient populations, including patients with certain types of comorbidity (for example, BPD and post-traumatic stress disorder or antisocial personality disorder) and younger patients. Other work has involved developing treatments and models of treatment delivery that address concerns related to access of care. Relatedly, new adjunctive and technology-assisted interventions have been developed, adding to the growing repertoire of treatment options for these patients. Advances in the last several years address specific treatment needs and offer cost-efficient options for this diverse patient population.
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Affiliation(s)
- Christina M Temes
- McLean Hospital, Belmont, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Mary C Zanarini
- McLean Hospital, Belmont, MA, USA.,Harvard Medical School, Boston, MA, USA
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15
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Moseley RL, Gregory NJ, Smith P, Allison C, Baron-Cohen S. A 'choice', an 'addiction', a way 'out of the lost': exploring self-injury in autistic people without intellectual disability. Mol Autism 2019; 10:18. [PMID: 31007885 PMCID: PMC6458651 DOI: 10.1186/s13229-019-0267-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 03/17/2019] [Indexed: 12/19/2022] Open
Abstract
Background Non-suicidal self-injury (NSSI) describes a phenomenon where individuals inflict deliberate pain and tissue damage to their bodies. Self-injurious behaviour is especially prevalent across the autism spectrum, but little is understood about the features and functions of self-injury for autistic individuals without intellectual disability, or about the risk factors that might be valuable for clinical usage in this group. Methods One hundred and three autistic adults who responded to an online advertisement were classified as current, historic or non-self-harmers in accordance with responses to the Non-Suicidal Self-Injury Assessment Tool (NSSI-AT). Multinomial regression aimed to predict categorisation of participants in accordance with scores on tests of autistic traits, alexithymia, depression, anxiety, mentalising and sensory sensitivity. Linear regression examined relationships between these predictors and the range, frequency, lifetime occurrence and functional purposes of NSSI. Qualitative analysis explored the therapeutic interventions that participants had found helpful, and what they wished people understood about self-injury. Results Current, historic and non-self-harming participants did not differ in age, age at diagnosis, male-to-female ratio, level of employment or education (the majority qualified to at least degree level). The most common function of NSSI was the regulation of low-energy affective states (depression, dissociation), followed by the regulation of high-energy states such as anger and anxiety. Alexithymia significantly predicted the categorisation of participants as current, historic or non-self-harmers, and predicted use of NSSI for regulating high-energy states and communicating distress to others. Depression, anxiety and sensory-sensitivity also differentiated participant groups, and sensory differences also predicted the range of bodily areas targeted, lifetime incidence and frequency of NSSI. Sensory differences, difficulty expressing and identifying emotions also emerged as problematic in the qualitative analysis, where participants expressed the need for compassion, patience, non-judgement and the need to recognise diversity between self-harmers, with some participants perceiving NSSI as a practical, non-problematic coping strategy. Conclusions Alexithymia, depression, anxiety and sensory differences may place some autistic individuals at especial risk of self-injury. Investigating the involvement of these variables and their utility for identification and treatment is of high importance, and the voices of participants offer guidance to practitioners confronted with NSSI in their autistic clients. Electronic supplementary material The online version of this article (10.1186/s13229-019-0267-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- R L Moseley
- 1Social, Cognitive, Clinical and Affective Neuroscience group, Department of Psychology, Bournemouth University, Talbot Campus, Fern Barrow, Poole, Dorset UK
| | - N J Gregory
- 1Social, Cognitive, Clinical and Affective Neuroscience group, Department of Psychology, Bournemouth University, Talbot Campus, Fern Barrow, Poole, Dorset UK
| | - P Smith
- 2Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - C Allison
- 2Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - S Baron-Cohen
- 2Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
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16
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Juul S, Lunn S, Poulsen S, Sørensen P, Salimi M, Jakobsen JC, Bateman A, Simonsen S. Short-term versus long-term mentalization-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder: a protocol for a randomized clinical trial. Trials 2019; 20:196. [PMID: 30953536 PMCID: PMC6451226 DOI: 10.1186/s13063-019-3306-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 03/19/2019] [Indexed: 11/23/2022] Open
Abstract
Background Psychotherapy for borderline personality disorder is often lengthy and resource-intensive. However, the current length of outpatient treatments is arbitrary and based on trials that never tested if the treatment intensity could be reduced. As a result, there is insufficient evidence to inform the decision between short-term and long-term psychotherapy for borderline personality disorder. Mentalization-based therapy is one treatment option for borderline personality disorder and consists traditionally of an 18-month treatment program. Methods/design This trial is an investigator-initiated single-center randomized clinical superiority trial of short-term (20 weeks) compared to long-term (14 months) mentalization-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder. Participants will be recruited from the Outpatient Clinic for Personality Disorders at Stolpegaard Psychotherapy Centre, Mental Health Services, Capital Region of Denmark. Participants will be included if they meet a minimum of four DSM-V criteria for borderline personality disorder. Participants will be assessed before randomization, and at 8, 16, and 24 months after randomization. The primary outcome is severity of borderline symptomatology assessed with the Zanarini Rating Scale for borderline personality disorder. Secondary outcomes include self-harm incidents, functional impairment (Work and Social Adjustment Scale, Global Assessment of Functioning) and quality of life (Short-Form Health Survey 36). Severity of psychiatric symptoms (Symptom Checklist 90-R) will be included as an exploratory outcome. Measures of personality functioning, attachment, borderline symptoms, group alliance, and mentalization skills will be included to explore potential predictors and mechanisms of change. Discussion This trial will provide evidence of the beneficial and harmful effects of short-term compared to long-term mentalization-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder. Trial registration ClinicalTrials.gov, NCT03677037. Registered on September 19, 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3306-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sophie Juul
- Stolpegaard Psychotherapy Centre, Mental Health Services, Gentofte, Capital Region of Denmark, Denmark. .,Department of Psychology, University of Copenhagen, Copenhagen, Denmark.
| | - Susanne Lunn
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Stig Poulsen
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Per Sørensen
- Stolpegaard Psychotherapy Centre, Mental Health Services, Gentofte, Capital Region of Denmark, Denmark
| | - Mehrak Salimi
- Stolpegaard Psychotherapy Centre, Mental Health Services, Gentofte, Capital Region of Denmark, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Center for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Sebastian Simonsen
- Stolpegaard Psychotherapy Centre, Mental Health Services, Gentofte, Capital Region of Denmark, Denmark
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17
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Burke AS, Shapero BG, Pelletier-Baldelli A, Deng WY, Nyer MB, Leathem L, Namey L, Landa C, Cather C, Holt DJ. Rationale, Methods, Feasibility, and Preliminary Outcomes of a Transdiagnostic Prevention Program for At-Risk College Students. Front Psychiatry 2019; 10:1030. [PMID: 32158406 PMCID: PMC7051934 DOI: 10.3389/fpsyt.2019.01030] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 12/30/2019] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Early adulthood represents one period of increased risk for the emergence of a serious mental illness. The college campus provides a unique opportunity to assess and monitor individuals in this at-risk age group. However, there are no validated early detection programs that are widely implemented on college campuses. In an effort to address this gap, we designed and tested an early detection and prevention program tailored to college students. A transdiagnostic approach was employed because of evidence for shared risk factors across major mental illnesses. DESIGN Single arm, prospective study evaluating outcomes following a 4-week intervention. METHOD Three in-person mental health screenings were conducted on the campus of one university. Undergraduate students with at least mildly elevated, self-reported levels of depressive or subclinical psychotic symptoms, who were not receiving treatment for these symptoms, were invited to participate in a 4-session workshop focused on increasing self- and other- awareness and emotion regulation using established mindfulness, self-compassion, and mentalization principles and experiential exercises. Symptoms, resilience-promoting capacities, and aspects of social functioning were assessed pre- and post- intervention. RESULTS 416 students were screened and a total of 63 students participated in the workshop. 91% attended at least 3 of the 4 sessions. The majority of participants found the workshop interesting and useful and would recommend it to a friend. Significant pre-to-post reductions in symptoms (depression, anxiety, and subclinical psychotic symptoms, ps < 0.004) and improvements in resilience-promoting capacities (self-compassion and self-efficacy, ps < 0.006) and indices of social functioning (social motivation, activity, and a measure of comfort with the physical presence of others, ps < 0.04) were observed. Moreover, the significant increases in resilience-promoting capacities correlated with the reductions in affective symptoms (ps < 0.03). CONCLUSIONS These findings suggest that an on-campus mental health screening and early intervention program is feasible, acceptable, and may be associated with improvements in resilience-related capacities and symptom reductions in young adults with non-impairing, subclinical symptoms of psychopathology. Follow-up work will determine whether this program can improve both shorter and longer-term mental health and functional outcomes in this at-risk population.
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Affiliation(s)
- Anne S Burke
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Benjamin G Shapero
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | | | - Wisteria Y Deng
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Maren B Nyer
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Logan Leathem
- Department of Psychology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Leah Namey
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Carrie Landa
- Behavioral Medicine, Boston University, Boston, MA, United States
| | - Corinne Cather
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Daphne J Holt
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
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18
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Guilé JM, Boissel L, Alaux-Cantin S, de La Rivière SG. Borderline personality disorder in adolescents: prevalence, diagnosis, and treatment strategies. Adolesc Health Med Ther 2018; 9:199-210. [PMID: 30538595 PMCID: PMC6257363 DOI: 10.2147/ahmt.s156565] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Using the same Diagnostic and Statistical Manual of Mental Disorders, fifth version (DSM-V) criteria as in adults, borderline personality disorder (BPD) in adolescents is defined as a 1-year pattern of immature personality development with disturbances in at least five of the following domains: efforts to avoid abandonment, unstable interpersonal relationships, identity disturbance, impulsivity, suicidal and self-mutilating behaviors, affective instability, chronic feelings of emptiness, inappropriate intense anger, and stress-related paranoid ideation. BPD can be reliably diagnosed in adolescents as young as 11 years. The available epidemiological studies suggest that the prevalence of BPD in the general population of adolescents is around 3%. The clinical prevalence of BPD ranges from 11% in adolescents consulting at an outpatient clinic to 78% in suicidal adolescents attending an emergency department. The diagnostic procedure is based on a clinical assessment with respect to developmental milestones and the interpersonal context. The key diagnostic criterion is the 1-year duration of symptoms. Standardized, clinician-rated instruments are available for guiding this assessment (eg, the Diagnostic Interview for Borderlines-Revised and the Childhood Interview for DSM-IV-TR BPD). The assessment should include an evaluation of the suicidal risk. Differential diagnosis is a particular challenge, given the high frequency of mixed presentations and comorbidities. With respect to clinical and epidemiological studies, externalizing disorders in childhood constitute a risk factor for developing BPD in early adolescence, whereas adolescent depressive disorders are predictive of BPD in adulthood. The treatment of adolescents with BPD requires commitment from the parents, a cohesive medical team, and a coherent treatment schedule. With regard to evidence-based medicine, psychopharmacological treatment is not recommended and, if ultimately required, should be limited to second-generation antipsychotics. Supportive psychotherapy is the most commonly available first-line treatment. Randomized controlled trials have provided evidence in favor of the use of specific, manualized psychotherapies (dialectic-behavioral therapy, cognitive analytic therapy, and mentalization-based therapy).
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Affiliation(s)
- Jean Marc Guilé
- Child and Adolescent Psychiatry Services, Amiens-Picardie University Medical Centre, Amiens, France,
- Psychiatry Residency Program, University of Picardie-Jules Verne, Amiens, France,
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada,
| | - Laure Boissel
- Child and Adolescent Psychiatry Services, Amiens-Picardie University Medical Centre, Amiens, France,
- Psychiatry Residency Program, University of Picardie-Jules Verne, Amiens, France,
| | - Stéphanie Alaux-Cantin
- Child and Adolescent Psychiatry Services, Amiens-Picardie University Medical Centre, Amiens, France,
- Psychiatry Residency Program, University of Picardie-Jules Verne, Amiens, France,
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19
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Abstract
Assessment and Therapy of Adolescent Identity Diffusion Identity diffusion, one of the main diagnosis criteria for borderline personality disorder (BPD), is characterized by a lack of coherent sense of self and of significant others, paired with a painful sense of incoherence. The revision of the age limit for the diagnosis of personality disorders in DSM-5 has opened the doors to research on diagnosis and treatment of BPD in adolescence. This paper offers a summary of past and present work on the diagnosis and therapy of identity disturbance in adolescent patients.
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20
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Rytilä-Manninen M, Haravuori H, Fröjd S, Marttunen M, Lindberg N. Mediators between adverse childhood experiences and suicidality. CHILD ABUSE & NEGLECT 2018; 77:99-109. [PMID: 29324274 DOI: 10.1016/j.chiabu.2017.12.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 11/29/2017] [Accepted: 12/04/2017] [Indexed: 05/26/2023]
Abstract
We investigated whether psychiatric symptomatology, impulsivity, family and social dysfunction, and alcohol use mediate the relationship between adverse childhood experiences (ACEs) and suicidality. The study population comprised 206 adolescent psychiatric inpatients and 203 age- and gender-matched adolescents from the community. ACEs and suicidality were assessed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime version, the Life Events Checklist, and a structured background data collection sheet. Psychiatric symptomatology was measured using the Symptom Checklist -90. Impulsivity, social dysfunction, and family dysfunction were measured using the Offer Self-Image Questionnaire, and alcohol use was assessed with the Alcohol Use Disorders Identification Test. A simple mediation test and multiple mediation analyses were conducted. A positive direct effect of ACEs on suicidality was observed. Also seen was a positive indirect effect of ACEs on suicidality through psychiatric symptomatology, impulsivity, and family and social dysfunctions. Alcohol misuse did not, however, mediate the relationship between ACEs and suicidality. According to the multiple mediation analyses, psychiatric symptomatology was the most significant mediator, followed by impulsivity. Psychiatric symptoms, impulsivity, and family and social dysfunctions are factors that should be taken into consideration when assessing suicidality in adolescents.
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Affiliation(s)
- Minna Rytilä-Manninen
- Adolescent Psychiatry, Helsinki University and Helsinki University Hospital, Helsinki, Finland.
| | - Henna Haravuori
- Adolescent Psychiatry, Helsinki University and Helsinki University Hospital, Helsinki, Finland; National Institute for Health and Welfare, Department of Health, Mental Health Units, Helsinki, Finland
| | - Sari Fröjd
- University of Tampere, School of Health Sciences, Tampere, Finland
| | - Mauri Marttunen
- Adolescent Psychiatry, Helsinki University and Helsinki University Hospital, Helsinki, Finland; National Institute for Health and Welfare, Department of Health, Mental Health Units, Helsinki, Finland
| | - Nina Lindberg
- Forensic Psychiatry, Helsinki University and Helsinki University Hospital, Helsinki, Finland
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21
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Übertragungsfokussierte Psychotherapie von Borderline-Jugendlichen im tagesklinischen Setting. Prax Kinderpsychol Kinderpsychiatr 2017; 66:445-463. [DOI: 10.13109/prkk.2017.66.6.445] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Mentalisierungsbasierte Therapie bei Adoleszenten mit Borderline-Persönlichkeitsstörung – Konzept und Wirksamkeit. Prax Kinderpsychol Kinderpsychiatr 2017; 66:423-434. [DOI: 10.13109/prkk.2017.66.6.423] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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23
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Beck E, Sharp C, Poulsen S, Bo S, Pedersen J, Simonsen E. The mediating role of mentalizing capacity between parents and peer attachment and adolescent borderline personality disorder. Borderline Personal Disord Emot Dysregul 2017; 4:23. [PMID: 29204276 PMCID: PMC5701352 DOI: 10.1186/s40479-017-0074-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/08/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Insecure attachment is a precursor and correlate of borderline personality disorder. According to the mentalization-based theory of borderline personality disorder, the presence of insecure attachment derails the development of the capacity to mentalize, potentially resulting in borderline pathology. While one prior study found support for this notion in adolescents, it neglected a focus on peer attachment. Separation from primary caregivers and formation of stronger bonds to peers are key developmental achievements during adolescence and peer attachment warrants attention as a separate concept. FINDINGS In a cross-sectional study, female outpatients (Mage 15.78=, SD = 1.04) who fulfilled DSM-5 criteria for BPD (N = 106) or met at least 4 BPD criteria (N = 4) completed self-reports on attachment to parents and peers, mentalizing capacity (reflective function) and borderline personality features. Our findings suggest that in a simple mediational model, mentalizing capacity mediated the relation between attachment to peers and borderline features. In the case of attachment to parents, the mediational model was not significant. CONCLUSIONS The current study is the first to evaluate this mediational model with parent and peer attachment as separate concepts and the first to do so in a sample of adolescents who meet full or sub-threshold criteria for borderline personality disorder. Findings incrementally support that mentalizing capacity and attachment insecurity, also in relation to peers, are important concepts in theoretical approaches to the development of borderline personality disorder in adolescence. Clinical implications are discussed.
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Affiliation(s)
- Emma Beck
- Psychiatric Research Unit, Region Zealand, Fælledvej 6, 4200 Slagelse, Denmark.,Child and Adolescent Psychiatric Department, Region Zealand, Smedegade 16, 4000 Roskilde, DK Denmark.,Department of Psychology, University of Copenhagen, 2A Øster Farimagsgade, -1353 Copenhagen K, DK Denmark
| | - Carla Sharp
- Department of Psychology, University of Houston, Houston, TX 77204 USA
| | - Stig Poulsen
- Department of Psychology, University of Copenhagen, 2A Øster Farimagsgade, -1353 Copenhagen K, DK Denmark
| | - Sune Bo
- Psychiatric Research Unit, Region Zealand, Fælledvej 6, 4200 Slagelse, Denmark.,Child and Adolescent Psychiatric Department, Region Zealand, Smedegade 16, 4000 Roskilde, DK Denmark
| | - Jesper Pedersen
- Child and Adolescent Psychiatric Department, Region Zealand, Smedegade 16, 4000 Roskilde, DK Denmark
| | - Erik Simonsen
- Psychiatric Research Unit, Region Zealand, Fælledvej 6, 4200 Slagelse, Denmark.,Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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