Early intervention for adolescents with borderline personality disorder: quasi-experimental comparison with treatment as usual

The (cost-)effectiveness of early intervention (MBT-early) versus standard protocolized treatment (CBT) for emerging borderline personality disorder in adolescents (the EARLY study): a study protocol for a randomized controlled trial

BACKGROUND

Although clinical guidelines prioritize the treatment of depression and anxiety in young persons, there is accumulating evidence that the presence of symptoms of borderline personality disorder (BPD) is associated with the limited effectiveness of these standard treatments. These findings stress the need for interventions addressing early-stage BPD in young people with presenting symptoms of anxiety and depressive disorders. The aim of this study is to investigate the (cost-)effectiveness of an early intervention programme for BPD (MBT-early) compared to first-choice psychological treatment for depression and anxiety according to Dutch treatment guidelines (CBT), in adolescents with either depression, anxiety, or both, in combination with early-stage BPD.

METHODS

This study is a multi-centre randomized controlled trial. A total of 132 adolescents, presenting with either depression, anxiety, or both and significant BPD features will be randomized to either MBT-early or CBT. The severity of BPD, symptoms of depression and anxiety, personality, social and academic functioning, and quality of life will be assessed at baseline, end of treatment, and at 12-, 18-, and 24-month follow-up, along with medical costs and costs of productivity losses for cost-effectiveness analyses.

DISCUSSION

This study will provide an empirical evaluation of the potential surplus value of early intervention in young people for whom treatment oriented at common mental disorders like anxiety and depression may be insufficient given their underlying personality problems.

TRIAL REGISTRATION

Netherlands Trial Register, NL9569. Registered on June 15, 2021.

Introducing brief admissions by self-referral in child and adolescent psychiatry: an observational cohort study in Sweden

BACKGROUND

Brief admission by self-referral, a novel crisis intervention designed to reduce suicide and self-harm in adults, was adopted for adolescents in paediatric psychiatry in Malmö, Sweden, in 2018. We aimed to investigate changes in utilisation of emergency psychiatric care.

METHODS

We did an observational longitudinal cohort study in The University Hospital in Malmö, Sweden, which provides the only psychiatric emergency unit with 24 h psychiatric facilities in Region Skåne. Eligible patients were those aged 13-17 years who were admitted to the psychiatric facility, who had at least one emergency visit or admission during the 6 months before admission, and had prominent features of instability and self-harm, corresponding to at least three of the nine criteria for borderline personality disorder as per the DSM-5 as assessed by a paediatric psychiatrist during the admission. Patients with intellectual disabilities, psychosis, or language barriers were excluded. Patients who signed a brief admissions contract between April 1, 2018, and April 30, 2021, were eligible for inclusion in the study. A brief admissions contract allows patients to admit themselves to psychiatric emergency care for a transitory time. The primary outcome measures were the number of emergency visits, emergency admissions, inpatient days, and episodes of coercive (involuntary) care, compared at individual level before and after signing the brief admissions contract until end of follow-up. The number of visits and days were modelled using random-effects Poisson regression models, and the relative changes in the expected numbers of days per time unit were reported as rate ratios (RRs).

FINDINGS

Of the 928 patients admitted to the psychiatric facility between April 1, 2018, and April 30, 2021, 60 were excluded, and a further 801 did not meet the inclusion criteria for age, previous emergency visits, or having at least three of the nine criteria of borderline personality disorder. 67 patients were eligible for inclusion, but four patients did not sign a contract. 63 patients were included in the study, including 60 females (95%) and three (5%) males, with a mean age of 14·8 years (SD 1·7). Ethnicity data were not collected. Patients were followed up for a median of 13·5 months (IQR 9·2 -19·6). After signing the contract, there was a decrease in the number of emergency visits (RR 0·22 [95% CI 0·15-0·32]; p<0·0001), emergency admissions (RR 0·26 [0·19-0·35]; p<0·0001), inpatient days (RR 0·29 [0·26-0·32]; p<0·0001), and inpatient days including brief admissions (RR 0·44 [95% CI 0·40-0·48]; p<0·0001). Episodes of coercive care did not change significantly (RR 0·99 [95% CI 0·40-2·43]; p=0·98). Psychiatric evaluation due to persistent suicidal ideations immediately after discharge was required for five patients.

INTERPRETATION

Our findings suggest that brief admissions can be successfully implemented in paediatric psychiatry and appear to be an effective crisis management method for adolescents, associated with reduced demand for emergency care. Future randomised controlled trials are warranted.

FUNDING

Region Skåne Health Care Authority.

Demystifying borderline personality disorder in primary care

Borderline personality disorder (BPD) is a common mental health diagnosis observed in the primary care population and is associated with a variety of psychological and physical symptoms. BPD is a challenging disorder to recognize due to the limitations of accurate diagnosis and identification in primary care settings. It is also difficult to treat due to its complexity (e.g., interpersonal difficulties and patterns of unsafe behaviors, perceived stigma) and healthcare professionals often feel overwhelmed when treating this population. The aim of this article is to describe the impact of BPD in primary care, review current state of knowledge, and provide practical, evidence-based treatment approaches for these patients within this setting. Due to the lack of evidence-based pharmacological treatments, emphasis is placed on describing the framework for treatment, identifying psychotherapeutic opportunities, and managing responses to difficult clinical scenarios. Furthermore, we discuss BPD treatment as it relates to populations of special interest, including individuals facing societal discrimination and adolescents. Through this review, we aim to highlight gaps in current knowledge around managing BPD in primary care and provide direction for future study.

Non-response to psychotherapy for borderline personality disorder: A systematic review

HIGHLIGHT

This is the first systematic review to investigate non-response to psychotherapy for borderline personality disorder.

BACKGROUND

Psychotherapy is the recommended treatment for borderline personality disorder. While systematic reviews have demonstrated the effectiveness of psychotherapy for borderline personality disorder, effect sizes remain small and influenced by bias. Furthermore, the proportion of people who do not respond to treatment is seldom reported or analysed.

OBJECTIVE

To obtain an informed estimate of the proportion of people who do not respond to psychotherapy for borderline personality disorder.

METHODS

Systematic searches of five databases, PubMed, Web of Science, Scopus, PsycINFO and the Cochrane Library, occurred in November 2020. Inclusion criteria: participants diagnosed with borderline personality disorder, treated with psychotherapy and data reporting either (a) the proportion of the sample that experienced 'reliable change' or (b) the percentage of sample that no longer met criteria for borderline personality disorder at conclusion of therapy. Exclusion criteria: studies published prior to 1980 or not in English. Of the 19,517 studies identified, 28 met inclusion criteria.

RESULTS

Twenty-eight studies were included in the review comprising a total of 2436 participants. Average treatment duration was 11 months using well-known evidence-based approaches. Approximately half did not respond to treatment; M = 48.80% (SD = 22.77).

LIMITATIONS

Data regarding within sample variability and non-response are seldom reported. Methods of reporting data on dosage and comorbidities were highly divergent which precluded the ability to conduct predictive analyses. Other limitations include lack of sensitivity analysis, and studies published in English only.

CONCLUSION

Results of this review suggest that a large proportion of people are not responding to psychotherapy for borderline personality disorder and that factors relating to non-response are both elusive and inconsistently reported. Novel, tailored or enhanced interventions are needed to improve outcomes for individuals not responding to current established treatments.

Effect of 3 Forms of Early Intervention for Young People With Borderline Personality Disorder: The MOBY Randomized Clinical Trial

Importance

Clinical trials have neither focused on early intervention for psychosocial impairment nor on the contribution of components of borderline personality disorder (BPD) treatment beyond individual psychotherapy.

Objective

To evaluate the effectiveness of 3 early interventions for BPD of differing complexity.

Design, Settings, and Participants

This single-blinded randomized clinical trial recruited young people between March 17, 2011, and September 30, 2015, into parallel groups. The study took place at 2 government-funded mental health services for young people in Melbourne, Australia. Inclusion criteria were age 15 to 25 years (inclusive), recent DSM-IV-TR BPD diagnosis, and never receiving evidence-based BPD treatment. A total of 139 participants were randomized (pool of 876; 70 declined, 667 excluded), balanced for sex, age, and depressive symptomatology. Data analysis completed May 2020.

Interventions

(1) The Helping Young People Early (HYPE) dedicated BPD service model for young people, combined with weekly cognitive analytic therapy (CAT); (2) HYPE combined with a weekly befriending psychotherapy control condition; and (3) a general youth mental health service (YMHS) model, combined with befriending. Therefore, the 3 treatment arms were HYPE + CAT, HYPE + befriending, and YMHS + befriending. Participants were randomly assigned both to 1 treatment arm (in a 1:1:1 ratio) and to a clinician.

Main Outcomes and Measures

Psychosocial functioning, measured with the Inventory of Interpersonal Problems Circumplex Version and the Social Adjustment Scale Self-report.

Results

One hundred twenty-eight participants (104 [81.3%] were female; mean [SD] age, 19.1 [2.8] years; HYPE + CAT: 40 [31.3%]; HYPE + befriending: 45 [35.2%]; YMHS + befriending: 43 [33.6%]) who provided postbaseline data were included in the intent-to-treat analysis. Regardless of group, from baseline to 12 months, there was a mean of 19.3% to 23.8% improvement in the primary outcomes and 40.7% to 52.7% for all secondary outcomes, except severity of substance use and client satisfaction. The latter remained high across all time points. Planned comparisons (YMHS + befriending vs HYPE; HYPE + CAT vs befriending) showed that neither the service model nor the psychotherapy intervention was associated with a superior rate of change in psychosocial functioning by the 12-month primary end point. The HYPE service model was superior to YMHS + befriending for treatment attendance (median [IQR], 22 [19] vs 3 [16] contacts; median duration, 200 [139.5] vs 94 [125] days) and treatment completion (44 of 92 [47.8%] vs 9 of 47 [19.2%]). HYPE + CAT was superior to befriending for treatment attendance (median [IQR], 12 [16.5] vs 3 [9.8] sessions) and treatment completion (24 of 46 [52.2%] vs 29 of 93 [31.2%]).

Conclusions and Relevance

In this randomized clinical trial of 3 interventions for young people with BPD, effective early intervention was not reliant on availability of specialist psychotherapy but did require youth-oriented clinical case management and psychiatric care. A dedicated early intervention BPD service model (HYPE), with or without individual psychotherapy, achieved greater treatment attendance and completion, making it more likely to meet service user, family, and community expectations of care.

Trial Registration

anzctr.org.au Identifier: ACTRN12610000100099.

Mentalization-Based Treatment in Adolescent Inpatients: A Naturalistic Multi-Informant Study of Outcomes

The present era of major cutbacks in intensive treatment programs throughout Europe stresses the importance of evaluating the outcomes of such programs for adolescents with severe personality pathology and comorbidity. Personality pathology has proven to be a valid concept in adolescents, with relatively high prevalence, that needs to be targeted by evidence-based interventions. The present study focused on the evaluation of outcomes of a 12-month mentalization-based treatment for adolescents (MBT-A) program in 118 inpatient adolescents with personality pathology symptoms, using a multi-informant multidomain design. The results showed that during treatment, adolescents improved on general psychiatric symptoms, personality pathology dimensions, and health-related and generic quality of life. Improvement was not only statistically significant, but also clinically important, especially for internalizing domains. Implications for clinical practice and research are discussed.

The Psychoanalytic-Interactional Method (PiM) for Adolescents with Borderline Personality Disorder

Background:

Studies have shown the practicality of diagnosing borderline personality disorder (BPD) in children from the age of 12 years (cf. ICD-11, DSM-5). Research in the psychodynamic therapy of adolescents with BPD has been rare to date, however, there do exist some studies on the efficacy and effectiveness of psychodynamic therapy in adults with borderline personality disorder.

Methods:

We adapted the psychoanalytic-interactional method (PiM), originally developed in the treatment of severely disturbed adults, to the conditions of adolescents diagnosed with borderline personality disorder or structural deficits. Randomized controlled trial in an inpatient setting (Salzer et al., 2013; Salzer et al., 2014) showed that PIM is efficacious for adolescents with BPD symptoms. We describe the approach to treatment in detail.

Results:

The results of the therapeutic study and the short case vignette show that PiM is a useful method in both inpatient and outpatient treatment and meets the specific requirements of adolescent treatment.

General psychiatric management for adolescents (GPM-A) with borderline personality disorder

While borderline personality disorder (BPD) has its onset in youth and is highly prevalent in young people, diagnosis and treatment are frequently delayed, leading to disruptions in development. The few treatments for this population are specialized, resource-intensive, and not widely implemented. Generalist treatments could broadly increase early intervention and access to care, at a less intensive level, when symptoms are milder and developmental arrests can be avoided. One generalist treatment for adults with BPD, General Psychiatric Management, has been adapted for adolescents (GPM-A). GPM-A can be flexibly implemented in different settings, and emphasizes psychoeducation, medicalization of the disorder, life-building activities, and conservative prescribing. This paper introduces GPM-A and proposes it serve as a primary intervention for adolescents with BPD.

Therapeutic interventions in Australian primary care, youth mental health settings for young people with borderline personality disorder or borderline traits

BACKGROUND

This study aimed to investigate what therapeutic interventions were being applied by clinicians working with young people with a diagnosis of Borderline Personality Disorder or borderline traits in Australian primary mental health care settings. Given the current lack of evidence-based guidelines for treatment with this client population, investigating what is being implemented is needed. The study also aimed to determine whether the interventions clinicians are using are effective in reducing distress and increasing functioning for these clients.

METHODS

Participant data came from the national minimum data set for headspace youth mental health centers across Australia. Young people's data were included in the study if the young person was diagnosed with Borderline Personality Disorder or borderline traits during their first episode of care (N = 701). Clinician data that indicated the type of intervention used at each client session and outcome measures routinely captured were analyzed to determine interventions used and outcomes achieved.

RESULTS

Results demonstrated that CBT was the most frequently used modality of intervention followed by supportive counselling and IPT, but that most clients received a variety of intervention types. There were no or only weak relationships between changes in outcomes and the amount of any type of intervention that was provided. No significant relationship was found with the amount of CBT a client received and changes in symptoms or functioning, despite being the most commonly employed modality.

CONCLUSIONS

The study highlights the need for evidence-based treatment guidelines for early intervention in young people with borderline personality disorder traits.

Investigating service features to sustain engagement in early intervention mental health services

AIM

To understand what service features would sustain patient engagement in early intervention mental health treatment.

METHODS

Mental health patients, family members of individuals with mental illness and mental health professionals completed a survey consisting of 18 choice tasks that involved 14 different service attributes. Preferences were ascertained using importance and utility scores. Latent class analysis revealed segments characterized by distinct preferences. Simulations were carried out to estimate utilization of hypothetical clinical services.

RESULTS

Overall, 333 patients and family members and 183 professionals (N = 516) participated. Respondents were distributed between a Professional segment (53%) and a Patient segment (47%) that differed in a number of their preferences including for appointment times, individual vs group sessions and mode of after-hours support. Members of both segments shared preferences for many of the service attributes including having crisis support available 24 h per day, having a choice of different treatment modalities, being offered help for substance use problems and having a focus on improving symptoms rather than functioning. Simulations predicted that 60% of the Patient segment thought patients would remain engaged with a Hospital service, while 69% of the Professional segment thought patients would be most likely to remain engaged with an E-Health service.

CONCLUSIONS

Patients, family members and professionals shared a number of preferences about what service characteristics will optimize patient engagement in early intervention services but diverged on others. Providing effective crisis support as well as a range of treatment options should be prioritized in the future design of early intervention services.

The Clinical Significance of Subthreshold Borderline Personality Disorder Features in Outpatient Youth

Studies among adult patients have found that subthreshold borderline personality disorder (BPD) features are associated with elevated psychosocial morbidity compared with patients with no BPD features. However, the clinical significance of subthreshold features of BPD has not been investigated among real-world patients during the clinical emergence of the disorder, which is usually between puberty and emerging adulthood. This study aimed to replicate and extend previous research by comparing outpatient youth aged 15-25 years with subthreshold BPD features with youth with no BPD features. The sample included 499 potential participants, of whom 111 had no DSM-IV BPD features at all, and 155 had between one and four features. Results indicated that the group with subthreshold BPD features had more severe mental illness and poorer social and occupational functioning. These findings suggest that subthreshold BPD features are clinically important and should be a focus of clinical intervention to reduce continuing disability and improve outcome.

Borderline personality disorder in adolescents: prevalence, diagnosis, and treatment strategies

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).

Caring for Young People Who Self-Harm: A Review of Perspectives from Families and Young People

Self-harm among young people remains largely stigmatised and misunderstood. Parents have been identified as key facilitators in the help-seeking process, yet they typically report feeling ill-equipped to support the young person in their care. The aim of this review was to examine the perspectives of both young people (aged 12⁻28) and parents and to develop the conceptual framework for a future qualitative study. A systematic search of MEDLINE and PsycINFO was performed to identify articles that focused on the experiences of family members and young people related to managing the discovery of self-harm. Fourteen articles were included for review. Four addressed the perspectives of young people and 10 reported on the impact of adolescent self-harm on parents. The impact of self-harm is substantial and there exists a discrepancy between the most common parental responses and the preferences of young people. In addition, parents are often reluctant to seek help for themselves due to feelings of shame and guilt. This highlights the need for accessible resources that seek to alleviate parents’ distress, influence the strategies implemented to manage the young person’s self-harm behaviour, reduce self-blame of family members, and increase the likelihood of parental help seeking.

Cognitive analytic therapy at 30

Cognitive analytic therapy (CAT) was formalised in 1984 by Anthony Ryle. It facilitated the clinical integration of psychodynamic therapy and personal construct/cognitive psychology. It is a brief, user-friendly relational therapy, applicable to the wide range of psychological problems typically seen in public mental health settings. It has recently been included in national guidelines for the treatment of personality disorder in the National Health Service. CAT provides a coherent model of development and psychopathology, which centrally views the self as both socially formed and embedded. Owing to its core relational grounding, CAT is being increasingly applied to team contexts/systems, enabling a ‘common language’ for team formulation/practice. It is also being successfully delivered as a group therapy. This article describes the development and unique features of the CAT model, analyses the current evidence base and identifies potential future directions for the model.

LEARNING OBJECTIVES

Examining changes in personality disorder and symptomology in an adolescent sample receiving intensive mentalization based treatment: a pilot study

OBJECTIVE

To examine changes in personality disorders and symptomology and the relation between personality disorder variables and treatment outcomes in an adolescent sample during partial residential mentalization based treatment.

METHODS

In a sample of 62 (out of 115) adolescents treated for personality disorders, assessment was done pre- and post-treatment using the Structured Clinical Interview for DSM personality disorders and the Symptom Check List 90.

RESULTS

Significant reductions in personality disorder traits (t = 8.36, p = .000) and symptoms (t = 5.95, p = .000) were found. During pre-treatment, 91.8% (n = 56) of the patients had one or more personality disorders, compared to 35.4% (n = 22) at post-treatment. Symptom reduction was not related to pre-treatment personality disorder variables.

CONCLUSION

During intensive psychotherapy, personality disorders and symptoms may diminish. Future studies should evaluate whether the outcomes obtained are the result of the treatment given or other factors.

Repeated self-harm in young people: a review

OBJECTIVES

This paper provides a review of the rates of self-harm and repeated self-harm among young people. It describes some of the risk factors associated with these behaviours and summarises some of the barriers to delivering optimal treatment.

CONCLUSIONS

The review concludes that there is an urgent need for the delivery of respectful and evidence-based practice to all young people who present with self-harm. In addition, improved monitoring of self-harm presentations to hospitals across Australia is required in order that robust data are collected and the impact of practice change can be reliably assessed.

Alliance rupture and repair processes and therapeutic change in youth with borderline personality disorder

OBJECTIVES

This study aimed to investigate alliance rupture and repair processes in psychotherapy for youth with borderline personality disorder. It sought to examine whether alliance processes differ between treatments, across the phases of therapy, and what associations these processes might have with therapeutic outcomes.

DESIGN

The study involves repeated measurement of both process and outcome measures. Hypotheses were addressed using within- and between-subjects analyses.

METHODS

Forty-four people, aged 15-24, with a diagnosis of BPD were randomized to receive either 16 sessions of Cognitive Analytic Therapy (CAT) or a supportive treatment known as Befriending. In addition to pre-post outcome assessments, alliance processes were rated using the observer-based Rupture Resolution Rating Scale.

RESULTS

Results indicated that CAT and Befriending did not differ in terms of number of ruptures, although CAT was associated with more stages of rupture resolution. Examination of alliance processes across time pointed to increasing ruptures, more frequent confrontation ruptures and increasing rupture resolution, suggesting increased volatility, directness and productivity in the therapeutic process across time. Contrary to hypotheses, there was no consistent link between alliance processes and outcome. However, two specific phases were significant. Early treatment ruptures were associated with poor outcome whereas greater late treatment resolution was associated with better outcomes.

CONCLUSIONS

This study suggests that alliance processes can differ across treatments and the phases of therapy in psychotherapy for youth with BPD. Alliance ruptures are more likely to be problematic early in therapy but later in therapy, they appear to be opportunities for therapeutic growth.

PRACTITIONER POINTS

Alliance ruptures are more likely than not to occur in any given session with a young person with Borderline Personality Disorder. Early in therapy, withdrawal type ruptures are more frequent, whereas late in therapy, confrontation ruptures are more frequent. Late in therapy, alliance ruptures should be viewed as opportunities for therapeutic change, rather than barriers to good outcomes.

Outpatient psychodynamic group psychotherapy - outcomes related to personality disorder, severity, age and gender

OBJECTIVES

Outpatient group psychotherapy is frequent within specialist services, recruits a mixed population, but effects are poorly documented. This study investigates long-term outcomes for patients with personality disorder (PD) treated in outpatient, psychodynamic groups within secondary mental health service.

METHODS

A naturalistic study (N = 103) with repeated assessments of process and clinical outcomes. Longitudinal statistics are linear mixed models.

RESULTS

The main PDs were avoidant, borderline and NOS PD, mean number of PDs 1.4(SD0.7), 60% females and mean initial age 38(SD10) years. Mean treatment duration was 1.5(SD 0.9) years. Therapist alliance and experienced group climate was satisfactory and stable. Improvements were significant (symptom distress, interpersonal problems, occupational functioning and additional mental health services), irrespective of general PD-severity, but not of PD-type, age or gender. The study demonstrates PD NOS benefits across all outcomes, occupational improvements for avoidant PD, despite prevailing symptoms, but generally poorer outcomes for males and age >38 years. For borderline PD, experienced conflict was stronger, treatment duration shorter and outcomes poor for early drop-outs (28%).

CONCLUSION

Psychodynamic group psychotherapy is a recommendable treatment for moderate PDs, which may address avoidant strategies, but may not meet clinical challenges of borderline PD. The outcome differences related to gender and age are noteworthy. Copyright © 2016 John Wiley & Sons, Ltd.

Bridging the gap: the assessment and treatment of adolescent personality disorder in routine clinical care

Despite a marked increase in research supporting the assessment, diagnosis and treatment of personality disorder (PD) in adolescence, clinicians continue to be reluctant to apply treatment guidelines and psychiatric nomenclature in routine clinical care. This gap arises from several beliefs: (1) psychiatric nomenclature does not allow the diagnosis of PD in adolescence; (2) certain features of PD are normative and not particularly symptomatic of personality disturbance; (3) the symptoms of PD are better explained by other psychiatric syndromes; (4) adolescents' personalities are still developing and therefore too unstable to warrant a PD diagnosis; and (5) because PD is long-lasting, treatment-resistant and unpopular to treat, it would be stigmatising to label an adolescent with borderline personality disorder (BPD). In this paper, the empirical evidence challenging each of these beliefs is evaluated in the hope of providing a balanced review of the validity of adolescent PD with a specific focus on BPD. The paper concludes with recommendations on how routine clinical care can integrate a PD focus.

Practitioner Review: Borderline personality disorder in adolescence--recent conceptualization, intervention, and implications for clinical practice

BACKGROUND

The past decade has seen an unprecedented increase in research activity on personality disorders (PDs) in adolescents. The increase in research activity, in addition to major nosological systems legitimizing the diagnosis of borderline personality disorder (BPD) in adolescents, highlights the need to communicate new research on adolescent personality problems to practitioners.

SCOPE

In this review, we provide up-to-date information on the phenomenology, prevalence, associated clinical problems, etiology, and intervention for BPD in adolescents. Our aim was to provide a clinically useful practitioner review and to dispel long-held myths about the validity, diagnostic utility, and treatability of PDs in adolescents.

FINDINGS AND CONCLUSION

Alongside providing up-to-date information on the phenomenology, prevalence, and etiology, we also report on associated clinical problems and interventions for adolescent BPD. It is only through early active assessment and identification of youngsters with these problems that a lifetime of personal suffering and health system burden can be reduced or altogether avoided. A variety of evidence-based approaches are now available to treat BPD and related clinical problems in young people. Future research should focus on establishing optimal precision in the diagnostic processes in different treatment settings.

A systematic review of mental health outcome measures for young people aged 12 to 25 years

BACKGROUND

Mental health outcome measures are used to monitor the quality and effectiveness of mental health services. There is also a growing expectation for implementation of routine measurement and measures being used by clinicians as a feedback monitoring system to improve client outcomes. The recent focus in Australia and elsewhere targeting mental health services to young people aged 12-25 years has meant that outcome measures relevant to this age range are now needed. This is a shift from the traditional divide of child and adolescent services versus adult services with a transitioning age at 18 years. This systematic review is the first to examine mental health outcome measures that are appropriate for the 12 to 25 year age range.

METHODS

MEDLINE and PsychINFO databases were systematically searched to identify studies using mental health outcome measures with young people aged 12 to 25 years. The search strategy complied with the relevant sections of the PRISMA statement.

RESULTS

A total of 184 published articles were identified, covering 29 different outcome measures. The measures were organised into domains that consisted of eight measures of cognition and emotion, nine functioning measures, six quality of life measures, and six multidimensional mental health measures. No measures were designed specifically for young people aged 12 to 25 years and only two had been used by clinicians as a feedback monitoring system. Five measures had been used across the whole 12 to 25 year age range, in a range of mental health settings and were deemed most appropriate for this age group.

CONCLUSIONS

With changes to mental health service systems that increasingly focus on early intervention in adolescence and young adulthood, there is a need for outcome measures designed specifically for those aged 12 to 25 years. In particular, multidimensional measures that are clinically meaningful need to be developed to ensure quality and effectiveness in youth mental health. Additionally, outcome measures can be clinically useful when designed to be used within routine feedback monitoring systems.

ESCAP Expert Article: borderline personality disorder in adolescence: an expert research review with implications for clinical practice

Borderline personality disorder (BPD) has onset in adolescence, but is typically first diagnosed in young adulthood. This paper provides a narrative review of the current evidence on diagnosis, comorbidity, phenomenology and treatment of BPD in adolescence. Instruments available for diagnosis are reviewed and their strengths and limitations discussed. Having confirmed the robustness of the diagnosis and the potential for its reliable clinical assessment, we then explore current understandings of the mechanisms of the disorder and focus on neurobiological underpinnings and research on psychological mechanisms. Findings are accumulating to suggest that adolescent BPD has an underpinning biology that is similar in some ways to adult BPD but differs in some critical features. Evidence for interventions focuses on psychological therapies. Several encouraging research studies suggest that early effective treatment is possible. Treatment development has just begun, and while adolescent-specific interventions are still in the process of evolution, most existing therapies represent adaptations of adult models to this developmental phase. There is also a significant opportunity for prevention, albeit there are few data to date to support such initiatives. This review emphasizes that there can be no justification for failing to make an early diagnosis of this enduring and pervasive problem.

Comparing three forms of early intervention for youth with borderline personality disorder (the MOBY study): study protocol for a randomised controlled trial

Background

Borderline personality disorder is a severe mental disorder that usually has its onset in youth, but its diagnosis and treatment are often delayed. Psychosocial ‘early intervention’ is effective in improving symptoms and behaviours, but no trial has studied adaptive functioning as a primary outcome, even though this remains the major persistent impairment in this patient group. Also, the degree of complexity of treatment and requirements for implementation in mainstream health services are unclear.

The primary aim of this trial is to evaluate the effectiveness of three forms of early intervention for borderline personality disorder in terms of adaptive functioning. Each treatment is defined by combining either a specialised or a general service delivery model with either an individual psychotherapy or a control psychotherapy condition.

Methods/design

The study is a parallel-group, single-blind, randomised controlled trial, which has randomised permuted blocking, stratified by depression score, sex and age. The treatments are: (1) the specialised Helping Young People Early service model plus up to 16 sessions of individual cognitive analytic therapy; (2) the Helping Young People Early service plus up to 16 sessions of a control psychotherapy condition known as ‘befriending’; (3) a general youth mental health care model plus up to 16 sessions of befriending. Participants will comprise 135 help-seeking youth aged 15–25 years with borderline personality disorder. After baseline assessment, staff blind to the study design and treatment group allocation will conduct assessments at 3, 6, 12 and 18 months. At the 12-month primary endpoint, the primary outcome is adaptive functioning (measures of social adjustment and interpersonal problems); secondary outcomes include measures of client satisfaction, borderline personality disorder features, depression and substance use.

Discussion

The results of this trial will help to clarify the comparative effectiveness of a specialised early intervention service model over and above general youth mental health care, along with the contribution of individual cognitive analytic therapy over and above specialised general clinical care in early intervention for borderline personality disorder. Consequently, the findings will also inform the level of training and competency required for effective delivery of early intervention services.

Trial registration

Registered with the Australian New Zealand Clinical Trial Registry ACTRN12610000100099 on 1 February 2010.

Borderline Personality Disorder in Young People: Are We There Yet?

Although borderline personality disorder (BPD) usually has its onset in young people, its diagnosis and treatment is often delayed. The past 2 decades have seen a rapid increase in evidence establishing that BPD can be diagnosed before 18 years of age and that BPD in young people is both continuous with BPD in adults and more notable for its similarities than for any differences. This knowledge has led to the first wave of controlled treatment trials, which have established that early intervention through appropriate BPD diagnosis and treatment leads to clinically meaningful improvements for patients. However, there is still much work to do in terms of treatment development and innovation and overcoming challenges to successful translation of evidence into practice. To advance early intervention for BPD, access to evidence-based treatments needs to improve, the variety of available treatments (including novel pharmacotherapies) needs to increase, treatments need to be matched to individual development and to the phase and stage of disorder, and workforce development strategies need to update knowledge, culture, and practice in relation to BPD in young people.

The 'Self' and Borderline Personality Disorder: Conceptual and Clinical Considerations

Some concept of self has been used by many, although not all, researchers and clinicians as an 'organising construct' for borderline personality disorder (BPD). There is considerable variation in this usage and how clearly researchers have defined the self. Given this diversity, and that 'self' is often used interchangeably with parallel concepts (e.g., psyche, brain-mind, 'person') or with features of self (e.g., self-awareness, identity), unqualified use of the term is problematic. This is further complicated by the heterogeneity and 'comorbidity' of BPD and the limitations of syndromally based psychiatric nosology. Still, BPD remains in current classification systems and can be reliably diagnosed. A considerable body of research on self and BPD has accrued, including a recent profusion and confluence of neuroscientific and sociopsychological findings. These have generated supporting evidence for a supra-ordinate, functionally constituted entity of the self ranging over multiple, interacting levels from an unconscious, 'core' self, through to a reflective, phenotypic, 'idiographic' and relational self constituted by interpersonal and sociocultural experience. Important insights have been generated regarding emotional and social-cognitive dysregulation, disorder of self-awareness, relationality, identity, and coherence and continuity of the self. Many of these are shared by various trauma-related, dissociative disorders. A construct of the self could be useful as an explanatory principle in BPD, which could be construed as a 'self-state' (and relational) disorder, as opposed to a less severe disorder of aspects of the self (e.g., mood or memory). We offer a tentative description of 'Self' in this context, noting that any such construct will require a clear definition and to be evaluable.

Youth services: meeting the mental health needs of adolescents

Objectives

Youth mental health services are poised for a paradigm shift. Recent epidemiological evidence confirms the seriousness of adolescence as a risk period for mental ill-health - 50% of all adult mental disorders begin before the age of 16% and 75% before the age of 25. Here, we identify issues with transition of care between CAMHS-AMHS service, and effectiveness of early intervention services.

Methods

We provide a selective review providing evidence of adolescence as a risk period, discuss CAMHS-AMHS service transition problems, and discuss avenues for change to implement the early intervention model across youth mental health.

Results

Traditional service structures,with paediatric -adult split at 16–18 years increasingly appear not fit for purpose. A radical redesign of youth mental health services is not only necessary, it is also feasible and achievable, as illustrated by a pilot Birmingham youth service – Youthspace.

Conclusions

Pilot youth mental projects currently underway can help radically redesign the existing child and adolescent services. This will in turn lead to an improvement in the young people's experience of engagement with the services so that they too have a positive future.

Borderline personality disorder in adolescence

Borderline personality disorder (BPD) is a common and severe mental disorder that is associated with severe functional impairment and a high suicide rate. BPD is usually associated with other psychiatric and personality disorders, high burden on families and carers, continuing resource utilization, and high treatment costs. BPD has been a controversial diagnosis in adolescents, but this is no longer justified. Recent evidence demonstrates that BPD is as reliable and valid among adolescents as it is in adults and that adolescents with BPD can benefit from early intervention. Consequently, adolescent BPD is now recognized in psychiatric classification systems and in national treatment guidelines. This review aims to inform practitioners in the field of adolescent health about the nature of BPD in adolescence and the benefits of early detection and intervention. BPD diagnosis and treatment should be considered part of routine practice in adolescent mental health to improve these individuals' well-being and long-term prognosis.

Cognitive analytic therapy: a review of the outcome evidence base for treatment

PURPOSE

This study reviews the quality of the extant outcome evidence for cognitive analytic therapy (CAT) to inform clinical practice and to stimulate a future CAT research strategy.

METHOD

An electronic search identified CAT efficacy and effectiveness studies and these were subject to systematic review. The methodological quality of studies meeting inclusion criteria were appraised using two validated research study quality checklists and studies were fitted to an established model of psychotherapy evaluation.

RESULTS

Twenty-five outcome studies met the inclusion criteria, including five randomized controlled trials. The CAT evidence base is predominated by small-scale practice-based studies, in typically complex and severe clinical populations - 44% were focal to the treatment of personality disorder. Although the quality of extant CAT evidence is generally sound (52% of studies were high quality), the depth and breadth of the evidence base is currently limited. Where comparisons with other modalities are available, CAT appears largely equivocal.

CONCLUSIONS

Cognitive analytic therapy is a popular and promising intervention for complex presentations. However, the evidence base currently lacks wider credibility due to having largely bypassed the rigours of the controlled phase of the hourglass model of psychotherapy evaluation. There is a particular need for further CAT outcome research with common mental health problems.

PRACTITIONER POINTS

CAT can be an effective intervention across a range of mental health difficulties. Consider a 24-session CAT contract for those patients presenting with complex and severe difficulties. Practice research networks could make a significant contribution to the CAT evidence base.

Does the concept of borderline personality features have clinical utility in childhood?

PURPOSE OF REVIEW

Phenotypic features of borderline personality disorder may first emerge during childhood, alongside symptoms of common externalizing and internalizing disorders. Children with these borderline personality features (BPF) are, therefore, likely to come into contact with clinical services prior to adolescence. This raises the question of whether BPF may be clinically informative with respect to the formulation and treatment of childhood psychopathology.

RECENT FINDINGS

BPF in late childhood appear to be highly heritable, while also predicted by environmental risk factors that overlap with those related to both externalizing and internalizing disorders. These risk factors include hostile parenting, maternal insensitivity to infant attachment cues, and early peer victimization, thereby implicating both family and peer processes that play out across early development. Children with BPF appear to be further characterized by social-cognitive factors including social perspective coordination deficits, a shame-prone self-concept, and hypermentalizing, which may represent potential therapeutic targets.

SUMMARY

Clinical research into the implications of BPF for the treatment of childhood psychopathology is a current priority. It is proposed that the research designs that have contributed to recent evidence for the clinical utility of childhood psychopathic traits may likewise aid in understanding the potential clinical utility of BPF in children.

Prevention and early intervention for borderline personality disorder: current status and recent evidence

Borderline personality disorder (BPD) is a leading candidate for developing empirically based prevention and early intervention programmes because it is common in clinical practice, it is among the most functionally disabling of all mental disorders, it is often associated with help-seeking, and it has been shown to respond to intervention, even in those with established disorder. Moreover, it can be reliably diagnosed in its early stages and it demarcates a group with high levels of current and future morbidity and mortality. Data also suggest considerable flexibility and malleability of BPD traits in youth, making this a key developmental period during which to intervene. Novel indicated prevention and early intervention programmes have shown that BPD in young people responds to intervention. Further work is required to develop appropriate universal and selective preventive interventions.

Borderline personality disorder and mental healthcare service use among adolescents

Borderline personality disorder (BPD) is believed to be frequent among adolescents. While several prospective studies have assessed the use of mental health services among adults who suffer from BPD, few studies have provided adolescent data. This paper presents findings from the first assessment point of the European Research Network on Borderline Personality Disorder (EURNET BPD) study. In this study, we describe lifetime treatment utilization for 85 adolescents with BPD (Mean age: 16.3 years old). In line with adult findings, adolescents with BPD reported greater mental healthcare service use (outpatient: 98%; inpatient: 79%) compared to controls. Phenothiazine, a sedative neuroleptic, was the most frequently prescribed treatment. 47% of patients had received psychotherapy; in one our of three cases this was psychodynamic therapy. Patients who had received psychotherapy did not differ on any psychopathological variables from those who did not receive psychotherapy; however, psychotherapy was more frequent among females.

Cognitive analytic therapy for personality disorder: randomised controlled trial

BACKGROUND

Cognitive analytic therapy (CAT) is a theoretically coherent approach developed to address common processes underlying personality disorders, but is supported by limited empirical evidence.

AIMS

To investigate the effectiveness of time-limited CAT for participants with personality disorder.

METHOD

A service-based randomised controlled trial (trial registration: ISRCTN79596618) comparing 24 sessions of CAT (n = 38) and treatment as usual (TAU) (n = 40) over 10 months for individuals with personality disorder. Primary outcomes were measures of psychological symptoms and interpersonal difficulties.

RESULTS

Participants receiving CAT showed reduced symptoms and experienced substantial benefits compared with TAU controls, who showed signs of deterioration during the treatment period.

CONCLUSIONS

Cognitive analytic therapy is more effective than TAU in improving outcomes associated with personality disorder. More elaborate and controlled evaluations of CAT are needed in the future.

Treating co-occurring first-episode psychosis and borderline personality: a pilot randomized controlled trial

AIM

First-episode psychosis and borderline personality disorder are severe mental disorders that have their onset in youth. Their co-occurrence is clinically well recognized, is associated with significant risks and is complex to treat. Yet, there is no published specific intervention for this problem. This study reports a pilot randomized controlled trial comparing combined specialist first-episode treatment plus specialist early intervention for borderline personality, entitled Helping Young People Early, with specialist first-episode treatment alone. We aimed to evaluate the safety and feasibility of adding early intervention for borderline personality.

METHODS

The study investigated the safety of specialist first-episode treatment plus specialist early intervention for borderline personality in relation to deterioration in psychosis, aggression, self-harm and suicidality, and feasibility in relation to the completion of therapy phases. Sixteen patients meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR) criteria for first-episode psychosis and borderline personality (four or more DSM-IV criteria) were randomized either to specialist first-episode treatment alone or specialist first-episode treatment plus specialist early intervention for borderline personality and were followed up at the end of treatment and 6 months later.

RESULTS

The results showed that it was feasible to recruit and assess a high risk and complex group of patients who were agreeable to study participation. Specialist first-episode treatment plus specialist early intervention for borderline personality was an acceptable and safe treatment.

CONCLUSION

A larger-scale randomized controlled trial of early intervention for borderline personality for young first-episode psychosis patients with co-occurring full or subsyndromal borderline personality is warranted.

Cognitive analytic therapy for borderline personality disorder: therapist competence and therapeutic effectiveness in routine practice

This study sought to examine the competency of cognitive analytic therapy (CAT) delivered under routine care conditions and to identify the effectiveness of CAT for patients with borderline personality disorder (BPD). Ten cognitive analytic therapists in six National Health Service Trust sites treated 19 patients with BPD using the standard CAT BPD contract of 24 sessions plus four follow-ups. The methodology was small N repeated measures deign, with patients interviewed at the third follow-up session using the Change Interview. Results indicate a high treatment and follow-up compliance rate (89.47%). Significant reductions in psychological distress, risk and dissociation over the time course of the CAT occurred, with a significant increase in personality integration. Most sessions (92.85%) were delivered in a competent manner. Reductions to psychological distress occurred early in treatment and were sustained, whereas increases in personality integration typically occurred later on in treatment. Patients tended to attribute change to the therapy received. Benchmarking against extant CAT BPD evidence notes a moderate effect size across routine care and trial contexts. The results are discussed in terms of identified methodological shortcomings, clinical implications and the contribution made by the CAT model to the treatment of BPD.

Why do adolescents return to an acute psychiatric unit?

OBJECTIVE

The aim of this paper is to determine potentially modifiable factors associated with the high proportion of patients who are readmitted to adolescent psychiatric units.

METHOD

The case notes of 112 adolescents admitted over 1 year to an acute adolescent psychiatry unit were reviewed. Socio-demographic and clinical variables were compared between those who were readmitted over a 12-month period post discharge and those who were not.

RESULTS

The readmission rate over a 12-month period was 31%. Males were significantly more likely to be readmitted. No other statistically significant predictors of readmission were identified. There was a trend towards readmission for those with bipolar disorder and a trend away from readmission for those with adjustment disorders. A history of sexual abuse and cluster B personality traits were significantly related to a history of previous admission, but not with subsequent readmission.

CONCLUSIONS

Readmission is influenced by a number of factors, which may not be easily identified by a chart review. Prospective studies which follow-up adolescents for several years after discharge are needed.

The HYPE Clinic: an early intervention service for borderline personality disorder

Borderline personality disorder (BPD) emerges during adolescence and young adulthood and has profound effects throughout this vulnerable developmental phase and beyond. Hitherto, clinical interventions for BPD have focused on individuals with established and/or chronic forms of the disorder. However, over the past 15 years, a body of evidence has developed supporting the reliability, validity, and clinical importance of the diagnosis of BPD in adolescence, underscoring the need for prevention and early intervention for BPD. This paper describes the work of the Helping Young People Early (HYPE) Clinic in Melbourne, Australia. HYPE is a novel indicated prevention and early intervention service for BPD in youth (15 to 25 y of age). It uses an integrated, team-based intervention model comprising time-limited cognitive analytic therapy as developed by Ryle, case management, and general psychiatric care. The HYPE intervention is supported by effectiveness data.