Effectiveness of adolescent identity treatment (AIT) versus DBT-a for the treatment of adolescent borderline personality disorder

Borderline personality disorder (BPD) is among the most severe mental health problems with long-lasting deterioration of functioning. According to a Cochrane review, evidence for methods focused on treatment for adolescent BPD patients is very limited. Aims of the study were to demonstrate the noninferiority of adolescent identity treatment (AIT) compared with dialectical behavior therapy for adolescents (DBT-A), and that intensive early treatment of BPD leads to significant improvement of psychosocial and personality functioning in adolescent patients. In a nonrandomized controlled trial using a noninferiority approach, we compared 37 patients treated with DBT-A with 23 patients treated with AIT. Both treatments included 25 weekly individual psychotherapy sessions and five to eight family sessions. Patients were assessed at four timepoints: baseline, posttreatment, 1- and 2-year follow-up. Primary outcome was psychosocial functioning at 1-year follow-up. We performed both intention-to-treat analyses and per-protocol analyses (completers). Baseline characteristics of both groups were not significantly different except for age and self-injurious behavior. In all, six AIT patients (26%) and 10 DBT-A patients (27%) dropped out of treatment. Both DBT-A and AIT significantly improved adolescents' psychosocial functioning (AIT: d = 1.82; DBT-A: d = 1.73) and personality functioning. BPD criteria and depression were significantly reduced by both treatments. Overall, AIT was found to be not inferior to DBT-A and even more efficient in reducing BPD criteria. Both treatments are highly effective in improving psychosocial functioning and personality functioning in adolescent BPD patients. AIT is a promising approach and not inferior to DBT-A in respect to treatment efficiency. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Therapists' emotional state after sessions in which suicidality is addressed: need for improved management of suicidal tendencies in patients with borderline personality pathology

INTRODUCTION

Patient suicidality is a frequently experienced topic for psychotherapists. Especially adolescents with borderline personality pathology (BPP) often exhibit suicidal tendencies. Previous research which examined therapists' countertransference towards suicidal patients suggested that therapists are negatively affected and distressed by them. We hypothesize that this emotional response of the therapists is related to specific sessions in which suicidality came up as a topic. Accordingly, the objective of this study consists in examining therapists' emotional state on a session level of analysis.

METHODS

The sample consisted of N = 21 adolescents (age 13-19 years) with BPD or subthreshold BPD. Therapists' emotional states were measured in n = 418 sessions using the Session Evaluation Questionnaire. Principal component analysis was used to reduce dimensionality of the therapist response. The emotional states were compared depending on whether suicidality has been addressed in the session (SS) or not (NSS).

RESULTS

Two components could be identified. Firstly, therapists were more aroused, excited, afraid, angry and uncertain after SS than after NSS. Secondly, therapists were more aroused, excited, definite and pleased after SS than after NSS.

DISCUSSION

Suicidality does not always have to be a burden for therapists: Both a "distress" and an "eustress" component occur in this context from which the latter is supposed to help clinicians master a difficult situation. Since countertransference feelings are often not fully conscious, it is necessary to do research on therapists' emotional states after sessions in which suicidality is addressed. This is crucial to both prevent the therapeutic process from being endangered and preserve clinicians' mental health. Clinical implications and limitations are discussed.

Children of Mentally Ill Parents - A High Risk Population

The scientific and clinical interest in children with mentally ill parents increased in the last years. Those children belong to a high risk population so that prevention is urgently indicated. Due to genetic influences and partly to an impairment of the parent-child interaction because of the parent's illness there exists a higher risk for child abuse. They show a three to five time increased risk to develop mental problems which require treatment over the course of their lives. They show abnormalities in social, cognitive and emotional areas. Untreated mental disorders and associated behavioral problems in children often chronify and lead to permanent impairment of the emotional, social and also intellectual development. Early detection and treatment are indicated and of high relevance.

Silence in the psychotherapy of adolescents with borderline personality pathology

Silence in psychotherapy has been associated with different, sometimes opposing meanings. This study investigated silence during adolescent identity treatment in adolescent patients with borderline personality pathology. A more active therapeutic approach with less silence is advised in adolescent identity treatment. It was hypothesized that a session with more silence might be negatively perceived by adolescent patients. A total of 382 sessions that involved 21 female patients were analyzed. Silence was automatically detected from audio recordings. Diarization (segmenting an audio according to speaker identity) was performed. The patient's perception of the sessions was measured with the Session Evaluation Questionnaire. The amount of silence in the different speaker-switching patterns was not independent of one other. This finding supports the hypothesis of mutual attunement of patient and therapist concerning the amount of silence in a given session. Sessions with less silence were rated as being both smoother and better. The potential implications for clinical practice are discussed. The investigation of turn-taking and interpersonal temporal dynamics is relevant for psychotherapy research. The topic can be addressed efficiently using automated procedures. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Trajectories of alliance ruptures in the psychotherapy of adolescents with borderline personality pathology: timing, typology and significance

Jeremy Safran and his research group suggest that rupture-repair processes are important for the therapeutic change in patients with personality disorders. In this exploratory study, we describe alliance ruptures and resolutions on a session-by-session basis in a clinical sample of adolescents with Borderline Personality Pathology (BPP). Three research questions are addressed: i) Is there a typical trajectory of alliance ruptures over treatment time? ii) Which rupture and resolution markers occur frequently? iii) Which rupture markers are most significant for the therapeutic alliance? Ten patients who presented with identity diffusion and at least three Borderline Personality Disorder criteria were studied and treated with Adolescent Identity Treatment. Alliance ruptures and resolutions were coded in 187 therapy sessions according to the Rupture Resolution Rating System. Mixed-effect models were used for statistical analyses. Findings supported an inverted U-shaped trajectory of alliance ruptures across treatment time. The inspection of individual trajectories displayed that alliance ruptures emerge non-linearly with particular significant alliance ruptures appearing in phases or single peak sessions. Withdrawal rupture markers emerged more often compared to confrontation markers. However, confrontation markers inflicted a higher impact or strain on the immediate collaboration between patient and therapist compared to withdrawal markers. Clinicians should expect alliance ruptures to occur frequently in the treatment of adolescents with BPP. The findings support the theory of a dynamic therapeutic alliance characterised by a continuous negotiation between patients and therapists.

A design for process-outcome psychotherapy research in adolescents with Borderline Personality Pathology

Underage patients with Borderline Personality Pathology (BPP) are in need of specialised psychotherapeutic treatment. A handful of these treatments, including Adolescent Identity Treatment (AIT) and Dialectical Behavior Therapy for Adolescents (DBT-A), have been adapted for adolescent patients. Psychotherapy research has shown that the outcome of different psychotherapeutic approaches can be very similar despite conceptual and practical differences between the theoretical models. Therefore, to understand what really works in psychotherapy, it is necessary to investigate the psychotherapeutic process and its effects on the patient. This paper presents a study design for process-outcome research, integrating (1) a classical outcome design, comparing AIT and DBT-A in a non-inferiority trial assessing changes in psychosocial functioning at 12 months after baseline as primary outcome; and (2) a process research design, addressing multiple BPP and psychotherapy relevant factors. These factors include well-studied generic variables such as the psychotherapeutic alliance, more recent approaches such as video-based identification of significant therapeutic events, as well as more experimental approaches such as psychophysiological markers measured during the therapeutic sessions. The use of repeated measures and the methodological pluralism which includes event and micro-process analyses has been recommended for psychotherapy research aiming at a better understanding of the interplay of factors at work to narrow the gap between research and practice in this field.

Assessment and Treatment of Identity Pathology During Adolescence

Personality disorders can be seen as patterns of maladaptive personality traits that have their onset during childhood or adolescence and that have an impact on the individual throughout the life span. Identity disturbance is seen as the central construct for detecting severe personality pathology—and, most notably, borderline personality disorder—in adults and adolescents. Therefore, in the revision of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the construct of “identity” has been integrated as a core diagnostic criterion for personality disorders.

One of the most central tasks of normal adolescent development is the consolidation of identity. Crises in the development of identity usually resolve into a normal and consolidated identity with flexible and adaptive functioning. By contrast, identity diffusion is viewed as a lack of integration of the concept of the self and significant others; it is also seen as the basis for subsequent personality pathology, including that of borderline personality disorder, which leads to a broad spectrum of maladaptive and dysfunctional behaviors.

To measure identity pathology and its improvement with treatment, we developed a self-report questionnaire entitled Assessment of Identity Development in Adolescence to establish a reliable, valid, and time-efficient inventory to represent a dimensional concept of healthy and impaired personality development. The reliability of this self-report questionnaire is excellent, and the total score differentiated significantly between controls and patients with personality disorders. Adolescent Identity Treatment is a treatment model that focuses on identity pathology as the core characteristic of personality disorders. This model integrates specific techniques for the treatment of adolescent personality pathology on the background of object-relation theories and modified elements of Transference-Focused Psychotherapy. Moreover, psychoeducation, behavior-oriented home plans, and family work support the therapeutic process of the adolescent.

Identity development in adolescents with mental problems

BACKGROUND

In the revision of the Diagnostic and Statistical Manual (DSM-5), "Identity" is an essential diagnostic criterion for personality disorders (self-related personality functioning) in the alternative approach to the diagnosis of personality disorders in Section III of DSM-5. Integrating a broad range of established identity concepts, AIDA (Assessment of Identity Development in Adolescence) is a new questionnaire to assess pathology-related identity development in healthy and disturbed adolescents aged 12 to 18 years. Aim of the present study is to investigate differences in identity development between adolescents with different psychiatric diagnoses.

METHODS

Participants were 86 adolescent psychiatric in- and outpatients aged 12 to 18 years. The test set includes the questionnaire AIDA and two semi-structured psychiatric interviews (SCID-II, K-DIPS). The patients were assigned to three diagnostic groups (personality disorders, internalizing disorders, externalizing disorders). Differences were analyzed by multivariate analysis of variance MANOVA.

RESULTS

In line with our hypotheses, patients with personality disorders showed the highest scores in all AIDA scales with T>70. Patients with externalizing disorders showed scores in an average range compared to population norms, while patients with internalizing disorders lay in between with scores around T=60. The AIDA total score was highly significant between the groups with a remarkable effect size of f= 0.44.

CONCLUSION

Impairment of identity development differs between adolescent patients with different forms of mental disorders. The AIDA questionnaire is able to discriminate between these groups. This may help to improve assessment and treatment of adolescents with severe psychiatric problems.

The role of identity in the DSM-5 classification of personality disorders

In the revised Diagnostic and Statistical Manual DSM-5 the definition of personality disorder diagnoses has not been changed from that in the DSM-IV-TR. However, an alternative model for diagnosing personality disorders where the construct "identity" has been integrated as a central diagnostic criterion for personality disorders has been placed in section III of the manual. The alternative model's hybrid nature leads to the simultaneous use of diagnoses and the newly developed "Level of Personality Functioning-Scale" (a dimensional tool to define the severity of the disorder). Pathological personality traits are assessed in five broad domains which are divided into 25 trait facets. With this dimensional approach, the new classification system gives, both clinicians and researchers, the opportunity to describe the patient in much more detail than previously possible. The relevance of identity problems in assessing and understanding personality pathology is illustrated using the new classification system applied in two case examples of adolescents with a severe personality disorder.

Assessment of identity development and identity diffusion in adolescence - Theoretical basis and psychometric properties of the self-report questionnaire AIDA

BACKGROUND

In the continuing revision of Diagnostic and Statistical Manual (DSM-V) "identity" is integrated as a central diagnostic criterion for personality disorders (self-related personality functioning). According to Kernberg, identity diffusion is one of the core elements of borderline personality organization. As there is no elaborated self-rating inventory to assess identity development in healthy and disturbed adolescents, we developed the AIDA (Assessment of Identity Development in Adolescence) questionnaire to assess this complex dimension, varying from "Identity Integration" to "Identity Diffusion", in a broad and substructured way and evaluated its psychometric properties in a mixed school and clinical sample.

METHODS

Test construction was deductive, referring to psychodynamic as well as social-cognitive theories, and led to a special item pool, with consideration for clarity and ease of comprehension. Participants were 305 students aged 12-18 attending a public school and 52 adolescent psychiatric inpatients and outpatients with diagnoses of personality disorders (N = 20) or other mental disorders (N = 32). Convergent validity was evaluated by covariations with personality development (JTCI 12-18 R scales), criterion validity by differences in identity development (AIDA scales) between patients and controls.

RESULTS

AIDA showed excellent total score (Diffusion: α = .94), scale (Discontinuity: α = .86; Incoherence: α = .92) and subscale (α = .73-.86) reliabilities. High levels of Discontinuity and Incoherence were associated with low levels in Self Directedness, an indicator of maladaptive personality functioning. Both AIDA scales were significantly different between PD-patients and controls with remarkable effect sizes (d) of 2.17 and 1.94 standard deviations.

CONCLUSION

AIDA is a reliable and valid instrument to assess normal and disturbed identity in adolescents. Studies for further validation and for obtaining population norms are in progress and may provide insight in the relevant aspects of identity development in differentiating specific psychopathology and therapeutic focus and outcome.

[Brief report of working group OPD-CA (children and adolescents) Axis IV: structural standard]

Apart from the structural differentiation of the body and its functions, the enlargement of the child's repertoire of possibilities to make experiences and to act is a manifestation of the development of the child's psychic structure which, advancing in years, may be considered as a treasure of all the experiences one has made with oneself, with the world and with the others. Structure will develop along with the interactional experiences with the world around us and becomes manifest in one's behaviour which may be witnessed and observed. The description of the psychic structure comprises three dimensions (perception of the self and of the objects, control, communication and bonding) which will be described by certain capabilities and will be assessed with the help of an anchoring example typical for each age which serves the purpose of clinical illustration. The adaptational achievement may then be assessed on the basis of a structural standard independent of age and may be ranged on a structural level. It appears that the exemplary description of different scopes of tasks typically to be performed at certain ages which serves as a basis for the assessment of the adaptational competence during childhood and adolescence seems to be a good policy. The purpose of our studies is the development of a valid instrument which is easy to handle in practice and which has a high interrater-reliability.

[The inpatient routine as a therapeutic community: multiprofessional treatment concept within the scope of a child psychiatric day care clinic]

The article will describe a multiprofessional (nurses, social workers, teachers, psychologists, physicians) treatment in a child psychiatric daycare-clinic. In that context the importance of relationship as an equivalence to the "primary motherliness" for early-disturbed children will be stressed. Further the article will focus on the relevance of continuous "post-education" and the broadening of the children's cognitive range by way of this object relation. Also, the article will inform about the uncovering psychotherapy with the children and their parents and about the importance of informations both from the therapists to the team as the other way round. Based on case studies it will be demonstrated how the multiprofessional team functioning as a "whole object" becomes instrumental for patients to work through affective relationships and mechanisms of defence.