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.

Head-to-head comparison of the alternative model for personality disorders and Section II personality disorder model in terms of predicting patient outcomes 1 year later

The present study investigated the predictive validity of Criterion A and B of the Alternative Model for Personality Disorders (AMPD) compared to the DSM-5 Section II personality disorder (PD) model in predicting patient outcomes 1 year after initial assessment, in a hetero-method longitudinal design. A clinical sample of 84 participants were administered both traditional Section II and AMPD interviews by two independent interviewers. One year after assessment, disability (World Health Organization Disability Assessment Schedule 2.0) and symptom severity (Brief Symptom Inventory) were assessed. The Section II PD model did not predict disability (R² = .01) nor symptom severity (R² = .03). The AMPD model, on the other hand, predicted both disability (R² = .23) and symptom severity (R² = .29) 1-year postinitial assessment. Both Criterion A and B were significant predictors, but when jointly combined only Criterion A remained significantly predictive of both disability and symptom severity while Criterion B did not. Criterion A thus appears to capture core vulnerabilities of personality-disordered patients that are related to future functioning and symptom severity. Implications for clinical practice are discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Comparing the clinical utility of the alternative model for personality disorders to the Section II personality disorder model: A randomized controlled trial

The alternative model for personality disorders (AMPD) has been extensively studied over the past decade, but to date there is no direct comparison of the clinical utility of the AMPD model relative to the Section II personality disorder (PD) model in an ecologically valid design. The current study examined the clinical utility of an AMPD-informed assessment procedure and Section II PD assessment procedure as assessed by both patients and clinicians in a randomized controlled trial. A sample of 119 patients were randomly assigned to either an AMPD or a Section II PD assessment procedure. At the end of the assessment, patients filled out questionnaires pertaining to clinical utility, satisfaction, motivation for treatment, and general experience of the assessment. Clinicians who subsequently started treatment with these patients also completed two clinical utility questionnaires. There were no significant differences between the AMPD and Section II PD assessment procedure on patients' reported clinical utility, motivation for treatment, satisfaction, and general experience of the assessment nor were there significant differences between the models on clinician reported clinical utility. Explorative analyses revealed that, for patients, a positive relationship with the assessor was predictive of experienced utility. This study shows no superiority of the AMPD in terms of clinical utility but suggests that the alliance with the assessor is a particularly salient factor in clinical utility. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The development and psychometric evaluation of the Questionnaire Epistemic Trust (QET): A self-report assessment of epistemic trust

Epistemic trust (ET) refers to the predisposition to trust information as authentic, trustworthy and relevant to the self. Epistemic distrust - resulting from early adversity - may interfere with openness to social learning within the therapeutic encounter, reducing the ability to benefit from treatment. The self-report Questionnaire Epistemic Trust (QET) is a newly developed instrument that aims to assess ET. This study presents the first results on the psychometric properties of the QET in both a community and a clinical sample. Our findings indicate that the QET is composed of four meaningful subscales with good to excellent internal consistency. The QET shows relevant associations with related constructs like personality functioning, symptom distress and quality of life. QET scores clearly distinguish between a clinical and community sample and are associated with the quality of the therapeutic alliance. The QET provides a promising, brief and user-friendly instrument that could be used for a range of clinical and research purposes. Future studies with larger samples are needed to strengthen construct validity and to investigate the value of the QET to predict differential treatment responses or to study mechanisms of change.

Isn't criterion A rather than B the language of psychotherapy?: Comment on Sauer-Zavala et al. (2022)

Comments on the article by S. Sauer-Zavala et al. (see record 2022-23735-001), which presents BPD-Compass as a new intervention for borderline personality disorder (BPD). Sauer-Zavala et al. have written a stimulating article that challenges fixed beliefs about the treatment of personality disorders and offers the first attempt to design a treatment according to the heuristic framework of the alternative model of personality disorders. This article presents several elements of the direction our field is developing to but may have underrated the importance of Criterion A in designing good-quality generic PD treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The diagnosis that should speak its name: why it is ethically right to diagnose and treat personality disorder during adolescence

Although national guidelines explicitly state that personality disorder can be diagnosed and treated in young people aged 12 to 18 years (adolescents), most clinicians remain hesitant. This creates a gap between science and practice, which we argue is largely motivated by moral reasons and, therefore, is best challenged by ethical arguments. We provide seven arguments in support of the notion that it is ethically right to diagnose and treat personality disorder when it occurs in adolescents. Central to these arguments is the scientific evidence that features of personality disorder are among the best predictors of a complex cluster of psychopathology leading to impairments in many areas of current and future mental, social and vocational functioning. We argue that intervention during adolescence and young adulthood is not only humane, but also critical for efforts to avert the longstanding psychosocial and health problems that seem refractory to treatment in adults with personality disorder. Moreover, we argue that regular services are often inadequately equipped to meet the needs of young people with personality disorder and that the common 'stepped-care' approach should be replaced by a 'staged-care' approach. Finally, we argue that early detection and intervention might have anti-stigmatizing effects, similar to other areas of healthcare in which stigmatizing labels have changed meaning when the conditions to which they refer have become more amenable to treatment.

[A multi-centre ROM study of the Guideline-Informed Treatment for Personality Disorders]

BACKGROUND

The Guideline-Informed Treatment for Personality Disorders (GIT-PD) is widely used in the Netherlands and Belgium in the care of people with personality disorders. To date, no evidence existed for the possible efficacy of this treatment framework.  METHOD: In an observational cohort study in four institutions, based on Routine Outcome Monitoring-data, improvements in symptom burden (BSI/OQ-45) and personality functioning (SIPP-SF) in 470 patients were examined.  RESULTS: Significant improvements were observed in each of the settings for both symptom burden and personality functioning. Effect sizes for improvement in overall symptom burden ranged from d = 0.55 to 1.05.  CONCLUSION: Treatment outcomes for GIT-PD are in line with treatment outcomes also seen for specialized treatments for personality disorders in similar practice studies. Possible differences between settings could be related to the intensity, structure and coherence of the GIT-PD program in question. .

Multinational evaluation of the measurement invariance of the Level of Personality Functioning Scale-brief form 2.0: Comparison of student and community samples across seven countries

The Diagnostic and Statistical Manual of Mental Disorders-fifth Edition's (DSM-5) Level of Personality Functioning Scale (LPFS) was introduced as a dimensional rating of impairments in self- and interpersonal functioning, and the LPFS-Brief Form (LPFS-BF) was the first published corresponding self-report. The updated LPFS-BF 2.0 has been translated into several languages and international research supports many of the instrument's psychometric properties; however, its measurement invariance has only been evaluated across a few countries. This study expands previous studies as an introductory step in a global evaluation of the LPFS-BF 2.0s measurement invariance. Archival data (N = 5,618, 57% female) from seven countries (Canada, Chile, Denmark, Germany, Italy, United Arab Emirates, United States of America) were used for this study. Participants were recruited from both community (n = 4,677) and student (n = 941) populations. After confirming adequate model fit separately in the community and student samples, we evaluated a series of increasingly stringent model comparisons to test three aspects of measurement invariance (configural, metric, scalar) and then examined latent mean differences across countries. Full scalar invariance was supported in the community sample and partial scalar invariance was supported in the student sample. Evaluation of latent mean differences revealed multiple significant differences. Overall, the LPFS-BF 2.0 appears to assess self- and interpersonal functioning impairment similarly across the included countries. Findings are discussed through the lenses of the cultures from which participants were recruited, as well as in the context of alternative explanations. Limitations, plans for future research, and implications for both research and clinical practice are offered. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Personality functioning and the pathogenic effect of childhood maltreatment in a high-risk sample

BACKGROUND

While the psychopathological sequalae of childhood maltreatment are widely acknowledged, less is known about the underlying pathways by which childhood maltreatment might lead to an increased risk for mental health problems. Recent studies indicated that impaired personality functioning might mediate this relationship. The aim of the present paper was to extend the current literature by investigating the mediating effect of impaired personality functioning between different types of childhood maltreatment and self-reported mental health problems in a high-risk sample.

METHODS

Overall, 173 young adults (mean age = of 26.61 years; SD = 3.27) with a history of residential child welfare and juvenile justice placements in Switzerland were included in the current study. The Childhood Trauma Questionnaire (CTQ-SF), Semi-structured Interview for Personality Functioning DSM-5 (STiP-5.1) and the self-report questionnaires of the Achenbach System of Empirically Based Assessment scales (ASEBA) were used. Mediation analyses were conducted through structural equation modeling.

RESULTS

Overall, 76.3% (N = 132) participants indicated at least one type of childhood maltreatment, with emotional neglect being most commonly reported (60.7%). A total of 30.6% (N = 53) participants self-reported mental health problems. Emotional abuse (r = 0.34; p < .001) and neglect (r = 0.28; p < .001) were found to be most strongly associated with mental health problems. In addition, impaired personality functioning was fond to be a significant mediator for overall childhood maltreatment (β = 0.089; p = 0.008) and emotional neglect (β = 0.077; p = 0.016). Finally, impaired self-functioning was found to be a significant mediator when both self-functioning and interpersonal functioning were included as potential mediators in the relationship between overall childhood maltreatment (β1 = 0.177, p1 = 0.007) and emotional neglect (β1 = 0.173, p1 = 0.003).

CONCLUSION

Emotional neglect may be particularly important in the context of childhood maltreatment, personality functioning, and mental health problems and, therefore, should not be overlooked next to the more "obvious" forms of childhood maltreatment. Combining interventions designed for personality functioning with trauma-informed practices in standard mental health services might counteract the psychopathological outcomes of maltreated children and adolescents.

Normative data for the LPFS-BF 2.0 derived from the Danish general population and relationship with psychosocial impairment

The Level of Personality Functioning Scale-Brief Form 2.0 is a frequently used self-report inventory that may be used to screen for self- and interpersonal dysfunction according to the DSM-5 Alternative Model for Personality Disorders (AMPD) and the ICD-11 Classification of Personality Disorders. Nevertheless, reliable norms and cut-off scores to aid interpretation and clinical decision making are still lacking. The LPFS-BF and relevant impairment measures were administered to a sociodemographically stratisfied sample of 2,002 adults from the general Danish population of whom 713 individuals eventually delivered data for inclusion in the present study. The unidimensionality of the LPFS-BF scores was established using Confirmatory Factor Analysis (CFA). Item-Response Theory (IRT) analysis indicated satisfactory item functioning for all 12 items and suggested normative observed score thresholds at different latent severity levels. Meaningful associations were found between the LPFS-BF norm-based cut-off scores, quality of life, and social and occupational functioning. This study presented the first normative data for LPFS-BF, which specifically applies to Denmark but likely also other socioeconomically comparable Nordic and Western societies. These results allow for interpretation of LPFS-BF scores and clinical decision-making. Future research should corroborate these findings and compare them to scores obtained in other general population samples.

The ICD-11 classification of personality disorders: a European perspective on challenges and opportunities

The 11th revision of the World Health Organization (WHO) International Classification of Diseases (ICD-11) includes a fundamentally new approach to Personality Disorders (PD). ICD-11 is expected to be implemented first in European countries before other WHO member states. The present paper provides an overview of this new ICD-11 model including PD severity classification, trait domain specifiers, and the additional borderline pattern specifier. We discuss the perceived challenges and opportunities of using the ICD-11 approach with particular focus on its continuity and discontinuity with familiar PD categories such as avoidant PD and narcissistic PD. The advent of the ICD-11 PD classification involves major changes for health care workers, researchers, administrators, and service providers as well as patients and families involved. The anticipated challenges and opportunities are put forward in terms of specific unanswered questions. It is our hope that these questions will stimulate further research and discussion among researchers and clinicians in the coming years.

[How evidence-based is the guideline-informed treatment for personality disorders (GIT-PD)?]

BACKGROUND

The guideline-informed treatment for personality disorders (GIT-PD) was developed as an alternative to the specific treatments for personality disorders. Even though this form of treatment is widely used in health care and has been included in the Health Care Standard for Personality Disorders, its scientific evidence remains unclear.

AIM

To review the indirect evidence for GIT-PD and compare it with the evidence for specific treatments.

METHOD

Literature review including reviews and meta-analyses in the field of personality disorders.

RESULTS

Although there is increasing evidence for specific treatments, the amount of studies remains limited and the quality of the evidence is rather low. There are indications that specific treatments are poorly implemented in clinical practice, which may detract from their efficacy. There is no clear evidence that specific treatments are on average no more effective than well-designed generic treatments that are similar to GIT-PD. There is considerable evidence for the role of the common factors on which GIT-PD is based.

CONCLUSION

There is indirect evidence for the efficacy of GIT-PD. Good care on a broad scale needs both specific and generic forms of treatment, whereby the most relevant question becomes how clients can be optimally allocated to both forms of treatment.

Client and Clinical Utility of the Assessment of Personality Disorders

ABSTRACT

Clinical utility and client utility are important desirable properties when developing and evaluating a new classification system for mental disorders. This study reports on four focus groups followed up by a Delphi study among clinicians working with clients with personality disorders (PD) and clients with PD themselves to harness both user groups' perspectives on the utility of PD diagnosis. Our findings show that the client and clinician views of the concept of utility were closely aligned and include aspects of transparency of communication and the ability of an assessment to enhance hope, curiosity, motivation, and insight into a client's personality patterns. Unique to clinicians' appraisal was the ability of an assessment to capture both vulnerabilities and resilience of clients and to give information about the prognosis in treatment. Unique to clients' appraisal was the ability of an assessment to be destigmatizing and collaborative. These findings may serve to expand our definition and measurement of clinical utility, in that collaborative and nonstigmatizing procedures likely promote client acceptability. To capture both aspects, we offer two preliminary questionnaires (i.e., item sets open to further empirical testing) based on the data derived from the Delphi procedure.

Changes in the classification of personality disorders: Comparing the DSM-5 Section II personality disorder model to the alternative model for personality disorders using structured clinical interviews

The current study examined the continuity of personality disorder (PD) diagnoses from Section II to Section III (alternative model for personality disorders [AMPD]) when using structured interviews. We investigated the continuity both in terms of stability of prevalence rates and in terms of convergent validity. A clinical sample of 189 participants were concurrently administered both Section II PD and AMPD interviews for diagnosing PD by 2 independent interviewers. Stability of prevalence between the models for specific PD diagnoses was generally supported. A higher prevalence of trait-specified PD in the AMPD model resulted in higher prevalence of PD in general when using the AMPD model compared with the Section II PD model. Correlations between matching criterion counts according to both models were generally high. Convergence between the Section II PD and AMPD model categorical diagnoses was adequate for the most frequently diagnosed and studied PDs (i.e., avoidant-, borderline-, and antisocial PD), but lower than previously found, likely due to the stringent test-retest design used in this study. Convergence between the models for narcissistic and obsessive-compulsive PD was low and could not be estimated for schizotypal PD. Future studies should investigate which of both models may prove to be most valid in terms of predicting current and future impairments. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Semi-structured interview for personality functioning DSM-5 (STiP-5.1): Psychometric evaluation of the Czech version

The DSM-5 Alternative Model for Personality Disorders introduced a dimensional perspective on personality disorders and their assessment by measuring personality functioning in the following domains: Identity, Self-Direction, Empathy, and Intimacy. This study provides a replication of the psychometric evaluation of the Semi-Structured Interview for Personality Functioning DSM-5 (STiP-5.1) within a mixed clinical sample and a community sample. The sample consisted of 188 adults: 86 participants from the general population and 102 people from a mixed clinical sample. All participants completed the STiP-5.1 and Level of Personality Functioning Scale-Brief Form (LPFS-BF 2.0). Results showed good internal consistency (McDonald's ω = 0.89-0.94) and promising convergent validity (correlations with LPFS-BF 2.0 above 0.6) of the STiP-5.1. Its scores differentiated participants within the community sample from those in the mixed clinical sample with large effect sizes (r_rb = 0.77-0.88). Moreover, the impairment in personality functioning was more pronounced in people with personality disorders than in other psychiatric disorders (medium effect size, r_rb = 0.46-0.57), supporting the notion of a continuum of personality functioning impairment. The STiP-5.1 therefore offers an instrument with satisfactory psychometric properties for the assessment of personality functioning both for research and clinical practice.

Resilient, undercontrolled, and overcontrolled personality types based upon DSM-5 maladaptive personality traits

We explored the clinical relevance of resilient, overcontrolled and undercontrolled personality types based upon DSM-5 maladaptive personality traits. We examined if these prototypes could be differentiated in terms of personality functioning, and internalizing and externalizing pathology. Self-report questionnaires and structured interviews were administered to 192 adult patients referred to a mental health care center specialized in assessment and treatment of personality disorders. Through cluster analysis we identified a resilient type with no elevation on maladaptive trait domains and showing better personality functioning and less pathology than the overcontrolled and undercontrolled types. Furthermore, the overcontrolled type had elevated Negative Affectivity and a higher prevalence of mood disorders, whereas the undercontrolled type had elevations on all maladaptive traits, with the exception of Disinhibition, and higher rates of narcissistic and borderline personality disorders. Given the differences in psychopathology between the types, identifying these types may inform treatment focus. Also, in line with a stepped care model, compared to overcontrollers, resilient types may need less intensive treatment and undercontrollers may need more intensive treatment.

Assessment of ICD-11 Personality Disorder Severity in Forensic Patients Using the Semi-structured Interview for Personality Functioning DSM-5 (STiP-5.1): Preliminary Findings

In forensic settings, several challenges may affect reliability of assessment of personality pathology, specifically when based upon self-report. This study investigates the Semi-Structured Interview for DSM-5 Personality Functioning (STiP-5.1) to assess level of severity of personality functioning in incarcerated patients. Thirty inpatients of three forensic psychiatric facilities completed the STiP 5.1 and additionally completed self-report questionnaires assessing symptom severity, personality functioning and traits. Staff members completed informant versions of personality functioning questionnaires. Previously assessed community (N = 18) and clinical samples (N = 80) were used as a reference. Interrater reliability and internal consistency of the STiP 5.1 were good. As expected, no associations were found between self-report and expert-ratings (STiP 5.1) of personality functioning. Remarkably, no associations were found between informant rated personality functioning and the STiP 5.1. This study confirms the discrepancies between self-report and expert-ratings in forensic settings and identifies the need to design and test assessment instruments within this context instead of generalizing findings obtained in regular mental health care samples. The STiP-5.1 may be a candidate for use in forensic samples, particularly to guide treatment planning and individual patient policy, although it remains unclear what specific information it offers above and beyond self-report and informant-report.

[The German Version of the Level of Personality Functioning Scale-Brief Form 2.0 (LPFS-BF): Latent Structure, Convergent Validity and Norm Values in the General Population]

The Alternative DSM-5 Model of Personality Disorders describes the level of personality functioning, defined by impairments in self functioning (self pathology) and problems in interpersonal functioning (interpersonal pathology), as the core feature of all personality disorders. A brief self-report measure to assess the level of personality functioning, the Level of Personality Functioning Scale-Brief Form 2.0 (LPFS-BF) comprising 12 items, was developed by a Dutch work group. The present study aimed at a first and comprehensive psychometric evaluation of the German version of the LPFS-BF in a large and representative general population sample (n=2470) as well as a non-clinical sample (n=849), particularly focusing on the factor structure, convergent validity and norm values. Confirmatory factor analyses revealed that the theoretically assumed and for the original version empirically confirmed two-factor solution was replicated in both samples with acceptable fit. Reliability of the total scale as well as both subscales (defined by the internal consistency) was high in both samples (McDonalds ω ≥0.83). Satisfactory convergent validity was indicated by high correlations of the German version of the LPFS-BF with other measures assessing personality dysfunction (r ≥0.72). The association with current psychological distress was similarly high. In the general population sample, the mean norm value (T₅₀) of the total scale was 15 and T₇₀ was 33. Although psychometric evaluations of the German LPFS-BF in patients with mental disorders, particularly those with personality disorders, have not yet been performed, this measure can be recommended as it provides a quick and user-friendly impression of the severity of personality functioning in the domains of self and interpersonal pathology.

Assessing Criterion A in adolescents using the Semistructured Interview for Personality Functioning DSM-5

Accumulating evidence supports the reliability and validity of the diagnosis of personality disorders (PDs) in adolescents, but whether the current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), criteria are optimal to capture and help detect emerging PDs in this age-group remains controversial. The Level of Personality Functioning Scale (LPFS), included in the alternative model for personality disorders, may provide a more developmentally sensitive way to identify impaired personality features in young people. This study investigates the feasibility of the LPFS in adolescents by examining the psychometric properties of the Semistructured Interview for Personality Functioning DSM-5 in a clinical sample of referred adolescents (N = 84) and in a community sample (N = 12). Additionally, referred adolescents completed self-report questionnaires pertaining to symptom severity, personality functioning, and personality traits. In general, good interrater reliability and internal consistency were observed, and the associations with external variables largely followed theoretical prediction. Interestingly, and in contrast to data on adults, we found no significant associations between the LPFS scores on the one hand and traditional DSM-5 PD diagnoses in the clinical sample on the other (except for borderline PD criteria). In discussing these findings, we argue that the assessment of personality functioning may be better suited for detecting personality pathology in adolescence than the traditional Section II criteria. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Scripting the DSM-5 Alternative Model for Personality Disorders assessment procedure: A clinically feasible multi-informant multi-method approach

Published case studies on the DSM-5 (section III) Alternative Model for Personality Disorders (AMPD) generally utilized unstandardized assessment procedures or mono-method approaches. We present a case from clinical practice to illustrate a standardized, clinically feasible procedure for assessing personality pathology according to the full AMPD model, using a multi-method approach. We aim to present a procedure that can guide and inspire clinicians that are going to work with dimensional models as presented in DSM-5 and ICD-11. Specifically, we show how questionnaire and interview data from multiple sources (i.e. patient and family) can be combined. The clinical case also illustrates how Criterion A (i.e. functioning) and B (i.e. traits) are interrelated, suggesting that the joint assessment of both Criterion A and B is necessary for a comprehensive and clinically relevant case formulation. It also highlights how multi-method information can enhance diagnostic formulations. Finally, we show how the AMPD model can serve treatment planning and provide suggestions for how patient feedback might be delivered. © 2020 John Wiley & Sons, Ltd.

Euthanasia and assisted suicide in patients with personality disorders: a review of current practice and challenges

BACKGROUND

Over the last two decades an increasing number of countries have legalized euthanasia and physician-assisted suicide (EAS) leading to considerable debate over the inherent ethical dilemmas. Increasing numbers of people with personality disorders, faced with unbearable suffering, have requested and received assistance in terminating their lives. EAS in people with personality disorders has, however, received very sparse attention from clinicians and researchers. In this paper, we examine the literature on the practice and prevalence of EAS in people with personality disorders to date and discuss the associated challenges for research and practice.

METHODS

Narrative review of the literature combined with the authors' collective experience and knowledge of personality disorders.

RESULTS

In six of the eight countries where EAS is currently legal, mental disorders are accepted as disorders for which EAS may be granted. In four of these countries, EAS in minors with mental disorders is also accepted. Our literature search resulted in 9 papers on the subject of EAS in people with personality disorders. These studies suggest that most clinicians who grant EAS have indeed perceived their patients' suffering as chronic, unbearable and untreatable without prospect of improvement. The majority of patients with personality disorders had tried some form of psychotherapy, but very few had received any of the relevant evidence-based treatments. The decision to grant EAS based on a perception of the patient's illness as being untreatable with no prospect of improvement, could, thus, in many cases fail to meet the due care criteria listed in EAS laws. People with personality disorders more often wish for death for extended periods of time than people without these disorders. However, there is ample empirical data to show that suicidal tendencies and behaviour can be treated and that they fluctuate rapidly over time.

CONCLUSIONS

In light of our findings, we believe that the current legislation and practice of EAS for people with personality disorders is based on an inadequate understanding of underlying psychopathology and a lack of awareness about the contemporary treatment literature. Moreover, we assert that this practice neglects the individual's potential for having a life worth living.

Improving access to and effectiveness of mental health care for personality disorders: the guideline-informed treatment for personality disorders (GIT-PD) initiative in the Netherlands

Evidence-based treatment for patients suffering from personality disorders (PDs) is only available to a limited extend in the Netherlands. Consequently, most patients receive non-manualized, unspecialized care. This manuscript describes the background, rationale and design of the Guideline-Informed Treatment for Personality Disorders (GIT-PD) initiative. GIT-PD aims to provide a simple, principle-driven, 'common-factors' framework for the treatment of PDs. The GIT-PD framework integrates scientific knowledge, professional expertise and patient experience to design a good-enough practice, based on common factors. It offers a basic framework including general principles, a structured clinical pathway, a basic professional stance, interventions focused on common factors, and team and organizational strategies, based on common features of evidence-based treatments and generic competences of professionals. The GIT-PD initiative has had a large impact on the organization of treatment for PDs in the Netherlands. For countries with an interest in improving their health care system for PDs, it could serve as a template that requires only limited resources.

Designing a range of mentalizing interventions for young people using a clinical staging approach to borderline pathology

Borderline personality disorder (BPD) can have a long-lasting impact on social and professional functioning, even when core symptoms of BPD are in remission. Adolescence may be a critical developmental period to change the potential long-term functional outcome of BPD. This paper presents a range of mentalizing interventions to alter the course and outcome of BPD, based upon a model of clinical staging. Mentalizing interventions have in common a focus on strengthening self-regulatory and interpersonal capacities, aiming to improve adaptive social learning. This paper argues that these interventions should be dosed and organized according to the stage of progression of BPD, which is illustrated by discussing different specific formats for mentalization-based interventions, including an early-intervention program for BPD and a standard program for full BPD.

Psychometrische Evaluation der deutschen Version des Semistrukturierten Interviews zur Erfassung der DSM-5 Persönlichkeitsfunktionen (STiP-5.1)

Theoretischer Hintergrund Das alternative Modell für Persönlichkeitsstörungen des DSM-5 führt erstmals ein evidenzbasiertes, dimensionales Konzept für die Diagnostik von Störungen der Persönlichkeit ein. Kriterium A, operationalisiert mit der Level of Personality Functioning Scale, differenziert das Ausmaß von Beeinträchtigungen im Funktionsniveau der Persönlichkeit. Mit dem Semi-Structured Interview for Personality Functioning DSM-5 (STiP-5.1) liegt bereits ein valides, reliables und ökonomisches Interview zur Erfassung von Kriterium A vor. Bisher existiert jedoch keine validierte Form des Interviews in deutscher Sprache. Ziel der vorliegenden Studie ist die psychometrische Evaluation der deutschsprachigen Version des STiP-5.1.

Methodik Die Validität und Reliabilität des STiP-5.1 wurde in einer Stichprobe von gesunden Erwachsenen (n=55) und stationär behandelten Patienten mit der Diagnose einer psychischen Störung (n=55) untersucht. Die Konstruktvalidität wurde über Korrelationen mit Fragebögen zu strukturellen Beeinträchtigungen (IPO-16, OPD-SFK) und maladaptiven Persönlichkeitseigenschaften (SKID-II-PF) überprüft. Die Interrater-Reliabilität wurde in einer Teilstichprobe von Gesunden und Patienten (n=50) untersucht.

Ergebnisse Bezüglich der Validität wurden hohe Korrelationen (r=0,68–0,78) zwischen STiP-5.1-Ratings und konvergenten Selbstberichtfragebögen festgestellt. In der Teilstichprobe zeigte sich eine sehr gute Interrater-Reliabilität (ICC=0,93). Die Dauer der Interviews betrug durchschnittlich 38 Min.

Schlussfolgerungen Mit der deutschen Version des STiP-5.1 liegt ein valides, reliables und ökonomisches Interviewverfahren zur dimensionalen Erfassung von Beeinträchtigungen im Funktionsniveau der Persönlichkeit für Forschung und klinische Praxis vor.

Managing borderline personality disorder from a life course perspective: Clinical staging and health management

Personality disorders change phenomenologically throughout the life course, in interaction with biological, psychological, and social events. In this article, we present a life course perspective on borderline personality disorder (BPD), based on clinical staging (conditional stimulus [CS]) and health management (HM). CS is presented as an alternative to the traditional categorical classification, providing improved opportunities to assess the severity of borderline impairment throughout the life course. It is primarily proposed as a heuristic strategy to guide design and selection of appropriate treatment according to the stage of disease progression. In addition, we introduce the concept of HM in the field of BPD, to organize continuous and coordinated health care management for patients with (emerging) BPD. HM redirects the exclusive focus on curative treatment of late-stage disorders to the broad spectrum of preventive, curative, and care interventions necessary to respond to the various needs in the different stages of BPD throughout the life course. Combining clinical staging and HM could provide a more effective and efficient framework for organizing mental health care for BPD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Level of Personality Functioning Scale-Brief Form 2.0: Update of a brief instrument for assessing level of personality functioning

Section III of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) introduced the alternative model of personality disorders that includes assessing levels of personality functioning. Here, we describe the development, preliminary psychometric evaluation and sensitivity to change of a revised brief self-report questionnaire, the Level of Personality Functioning Scale-Brief Form 2.0 (LPFS-BF 2.0). Patients (N = 201) referred to a specialized centre for the assessment and treatment of personality disorders completed the LPFS-BF 2.0, the Brief Symptom Inventory and the Severity Indices of Personality Problems Short Form and were administered the Structured Clinical Interview for DSM-IV Axis I and Axis II Disorders. Internal structure and aspects of construct validity were examined. A subsample of 39 patients also completed the questionnaires after 3 months of inpatient treatment. Confirmatory factor analyses demonstrated better fit for a two-factor solution (interpretable as self-functioning and interpersonal functioning) than for a unidimensional model, though acceptable model fit was evident only after two post hoc modifications. The LPFS-BF 2.0 demonstrated satisfactory internal consistency and promising construct validity. Sensitivity to change after 3 months of treatment was high. The LPFS-BF 2.0 constitutes a short, user-friendly instrument that provides a quick impression of the severity of personality pathology. © 2018 John Wiley & Sons, Ltd.

A Mentalization-Informed Staging Approach to Clinical High Risk for Psychosis

The practice of diagnosis is fundamentally designed to orient treatment. In the case of early diagnosis for schizophrenia spectrum disorders (SSP) risk, the empirical base for such a practice is still young, and many clinical questions arise in the everyday clinical application of risk algorithms and ensuing therapeutic options. One of the key questions that we will focus on is the following: in cases of SSP where symptoms are successfully treated, why does residual social functioning impairment remain the most serious obstacle to remission and reinsertion in society? We will present the evidence suggesting that the roots of residual social functioning impairment may, in many cases, come from thwarted or arrested development in the specialization of social cognition during adolescence and early adulthood. We will review the evidence suggesting that both during the premorbid phase and clinical high-risk phase, attenuated psychotic symptoms may impede the maturation of key social cognitive processes, particularly the suite of reflective thinking processes coming under the term of mentalization. From this evidence base, we will adapt the staging model of SSP progression in function of our mentalization-informed model, tailored to provide a coherent framework of care addressing the key clinical needs at every stage of psychosis progression.

[Time for cluster C personality disorders: state of the art]

BACKGROUND

Compared to cluster B personality disorders, the assessment and treatment of people with obsessive-compulsive, dependent, and avoidant personality disorders (cluster C) is given little attention in the field of research and clinical practice.

AIM

Presenting the current state of affairs in regard to cluster C personality disorders.

METHOD

A systematic literature search was conducted using the main data bases.

RESULTS

Cluster C personality disorders are present in approximately 3-9% of the general population. In about half of the cases of mood, anxiety, and eating disorders, there is co-morbid cluster C pathology. This has a major influence on the progression of symptoms, treatment effectiveness and potential relapse. There are barely any well conducted randomized studies on the treatment of cluster-C in existence. Open cohort studies, however, show strong, lasting treatment effects.

CONCLUSION

Given the frequent occurrence of cluster C personality disorders, the burden of disease, associated societal costs and the prognostic implications in case of a co-morbid cluster C personality disorder, early detection and treatment of these disorders is warranted.

Implementation of evidence-based treatments for borderline personality disorder: The impact of organizational changes on treatment outcome of mentalization-based treatment

The quality of implementation of evidence-based treatment programs for borderline personality disorder (BPD) in routine clinical care is a neglected issue. The first aim of this mixed-method naturalistic study was to explore the impact of organizational changes on treatment effectiveness of a day-hospital programme of mentalization-based treatment. Consecutively referred BPD patients were divided into a pre-reorganization cohort (PRE-REORG) and a cohort during reorganization (REORG). Psychiatric symptoms (Brief Symptom Inventory) and personality functioning (Severity Indices of Personality Problems-118) before treatment and at 18- and 36-month follow-up were compared using multilevel modelling. Effect sizes in the PRE-REORG cohort were approximately twice as large at 18 months (PRE-REORG: range 0.81-1.22; REORG: range 0.03-0.71) and three times as large at 36 months (PRE-REORG: range 0.81-1.80; REORG: range 0.27-0.81). The quantitative results of this study suggest that even when mentalization-based treatment is successfully implemented and the structure of the programme remains intact, major organizational changes may have a considerable impact on its effectiveness. Second, we aimed to explore the impact of the reorganization on adherence at organizational, team and therapist level. The qualitative results of this study indicate that the organizational changes were negatively related to adherence to the treatment model at organizational, team and therapist level, which in turn was associated with a decrease in treatment effectiveness. The implications of these findings for the implementation of effective treatments for BPD in routine clinical practice are discussed. Copyright © 2017 John Wiley & Sons, Ltd.

Barriers and facilitators to the implementation of mentalization-based treatment (MBT) for borderline personality disorder

There are several evidence-based treatments for borderline personality disorder, but very little is known about the success or failure of implementation in daily practice. This study aims to investigate the success or failure of newly started mentalization-based treatment programs, and to explore the barriers and facilitators. The implementation trajectories of seven different mentalization-based treatment programs in six mental health clinics in the Netherlands were included in a multiple case study combining a qualitative and quantitative design. Semi-structured interview data were collected from several stakeholders of each program. Narrative reconstructions of each interview were assessed by 12 independent experts. Results showed that several programs struggled to implement their program successfully, leading to discontinuation in three programs. According to the experts, particularly elements at the organizational level (i.e. organizational support) and team level (i.e. leadership) contributed to implementation outcome. These findings have important implications for the translation of guidelines and research findings in daily practice. Copyright © 2017 John Wiley & Sons, Ltd.

[Clinical staging and early intervention for borderline personality disorder]

Within the accumulating evidence for a life span perspective on borderline personality disorder (BPD), the key factor is a developmental perspective.<br/> AIM: To demonstrate that the lessons learnt from early intervention in somatic medicine and psychosis should be used to improve the diagnosis and treatment of BPD.<br/> METHOD: We describe the rationale for early detection and intervention and present a staging model which can serve as a guideline for the development and selection of interventions for BPD.<br/> RESULTS: There is increasing evidence that BPD first manifests itself in adolescence and that BPD symptoms can already be distinguished from normative adolescent development. BPD tends to develop gradually and to have a progressive, social and professional impact. Inadequate treatment can lead to iatrogenic damage, whereas adequate treatment shows promising results in adolescents with emerging BPD. These findings may underpin an early intervention paradigm for BPD.<br/> CONCLUSION: Early intervention and clinical staging can improve the assessment and treatment of severe forms of psychopathology, such as BPD. This has implications for research, mental health care policy and society.

[Interacting with patients with a personality disorder: 10 tips]

Personality disorders have a high prevalence. The behaviour of patients with a personality disorder may make it difficult for doctors to maintain a professional attitude, which may lead to a breakdown in the therapeutic relationship. In order to prevent an imbalance in the therapeutic relationship, we describe in this paper 10 tips for interacting appropriately with patients with a personality disorder in general medical practice. We divide these into three domains. In the first domain we deal with the organisation of care, which should ideally be safe and predictable because unpredictability and unreliability can easily upset these patients. In the second domain recommendations on the attitude of the doctor are given: it should ideally be investigative and inviting but also involve boundaries. In the third domain we advise doctors to monitor the quality of the therapeutic relationship and to restore it if necessary.

Assessing DSM-5-oriented level of personality functioning: Development and psychometric evaluation of the Semi-Structured Interview for Personality Functioning DSM-5 (STiP-5.1)

The alternative model for personality disorders (AMPD) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) features a Level of Personality Functioning Scale, measuring intrinsic personality processes that include identity, self-direction, empathy, and intimacy. This study describes the development and psychometric evaluation of a semistructured interview schedule for the multi-item assessment of the level of personality functioning, the Semi-Structured Interview for Personality Functioning DSM-5 (STiP-5.1). Eighty patients and 18 community subjects completed the STiP-5.1. Patients additionally completed the Brief Symptom Inventory, the Severity Indices of Personality Problems, and the Structured Clinical Interview for DSM-IV Axis I and Axis II Personality Disorders. Good interrater reliability was observed in subsamples of patients (n = 40) and nonpatients (n = 18). Associations between the interview scores and conceptually relevant external measures consistently supported the construct validity of the instrument. The STiP-5.1 thus offers a brief, relatively user-friendly instrument with generally favorable psychometric properties for the assessment of level of personality functioning of the DSM-5 AMPD. (PsycINFO Database Record

Developmentally sensitive markers of personality functioning in adolescents: Age-specific and age-neutral expressions

Criterion D of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) refers to a possible onset of personality disorders (PDs) in adolescence and in Section II the development/course in adolescence is described by some typical characteristics for several PDs. Yet, age-specific expressions of PDs are lacking in Section III. We urgently need a developmentally sensitive assessment instrument that differentiates developmental and contextual changes on the one hand from expressions of personality pathology on the other hand. Therefore we investigated which items of the Severity Indices for Personality Problems-118 (SIPP-118) were developmentally sensitive throughout adolescence and adulthood and which could be considered more age-specific markers requiring other content or thresholds over age groups. Applying item response theory (IRT) we detected differential item functioning (DIF) in 36% of the items in matched samples of 639 adolescents versus 639 adults. The DIF across age groups mainly reflected a different degree of symptom expressions for the same underlying level of functioning. The threshold for exhibiting symptoms given a certain degree of personality dysfunction was lower in adolescence for areas of personality functioning related to the Self and Interpersonal domains. Some items also measured a latent construct of personality functioning differently across adolescents and adults. This suggests that several facets of the SIPP-118 do not solely measure aspects of personality pathology in adolescents, but likely include more developmental issues. (PsycINFO Database Record

Development and Preliminary Psychometric Evaluation of a Brief Self-Report Questionnaire for the Assessment of the DSM-5 level of Personality Functioning Scale: The LPFS Brief Form (LPFS-BF)

The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) alternative model for personality disorders (PDs) introduced a new paradigm for the assessment of PDs that includes levels of personality functioning indexing the severity of personality pathology irrespective of diagnosis. In this study, we describe the development and preliminary psychometric evaluation of a newly developed brief self-report questionnaire to assess levels of personality functioning, the Level of Personality Functioning Scale-Brief Form (LPFS-BF; Bender, Morey, & Skodol, 2011). Patients (N = 240) referred to a specialized setting for the assessment and treatment of PDs completed the LPFS-BF, the Brief Symptom Inventory (BSI; Derogatis, 1975), the Severity Indices of Personality Problems (SIPP-118; Verheul et al., 2008), and were administered the Structured Clinical Interview for DSM-IV Axis I Personality Disorders (SCID-I; APA, 1994; First, Spitzer, Gibbon, & Williams, 1997) and the SCID Axis II Personality Disorders (SCID-II; First, Spitzer, Gibbon, Williams, & Benjamin, 1996). When constrained to a 2-factor oblique solution, the LPFS-BF yielded a structure that corresponded well to an interpretation of Self- and Interpersonal Functioning scales. The instrument demonstrated fair to satisfactory internal consistency and promising construct validity. The LPFS-BF constitutes a short, user-friendly instrument that provides a quick impression of the severity of personality pathology, specifically oriented to the DSM-5 model. Clearly, more research is needed to test its validity and clinical utility.

Psychiatric Stigma in Treatment-Seeking Adults with Personality Problems: Evidence from a Sample of 214 Patients

Stigmatization is a major burden in adult psychiatric patients with Axis-I diagnoses, as shown consistently in most studies. Significantly fewer studies on the emergence of psychiatric stigma in adult patients with personality disorders (PDs) exist, although the resulting evidence is conclusive. Some authors consider patients with PDs at risk for severe stigmatization because of intense difficulties during interpersonal contact, even in a psychotherapeutic relationship. The aim of this study was primarily the assessment of pre-existing stigma in patients referred for intensive treatment for PDs. The study enrolled 214 patients admitted to the adult department of a highly specialized mental health care institute offering psychotherapy for patients with severe and complex personality pathology. All patients underwent a standard assessment with self-report questionnaires and a semi-structured interview to measure Axis II PDs. The stigma consciousness questionnaire and the perceived devaluation-discrimination questionnaire, both validated instruments, were used to measure perceived and actual experiences of stigma. Independent sample t-tests were used to investigate differences in the mean total stigma scores for patients both with and without a PD. One-way ANOVAs were performed to assess the differences between having a borderline PD, another PD, or no PD diagnosis. Multiple regression main effect analyses were conducted in order to explore the impact of the different PD diagnosis on the level of stigma. The mean scores across all patient groups were consistent with rather low stigma. No differences were found for patients with or without a PD diagnosis. Level of stigma in general was not associated with an accumulating number of PDs. Given the remarkable results, we would strongly recommend further investigations in the field to better understand the phenomenon of stigma in all its aspects.

Adolescents with personality disorders suffer from severe psychiatric stigma: evidence from a sample of 131 patients

BACKGROUND

The aim of the study is to assess the severity of psychiatric stigma in a sample of personality disordered adolescents in order to evaluate whether differences in stigma can be found in adolescents with different types and severity of personality disorders (PDs). Not only adults but children and adolescents with mental health problems suffer from psychiatric stigma. In contrast to the abundance of research in adult psychiatric samples, stigma in children and adolescents has hardly been investigated. Personality disordered adolescents with fragile identities and self-esteem might be especially prone to feeling stigmatized, an experience which might further shape their identity throughout this critical developmental phase.

MATERIALS AND METHODS

One hundred thirty-one adolescent patients underwent a standard assessment with Axis I and Axis II diagnostic interviews and two stigma instruments, Stigma Consciousness Questionnaire (SCQ) and Perceived Devaluation-Discrimination Questionnaire (PDDQ). Independent sample t-tests were used to investigate differences in the mean SCQ and PDDQ total scores for patients with and without a PD. Multiple regression main effect analyses were conducted to explore the impact of the different PDs on level of stigma, as well as comorbid Axis I disorders. Age and sex were also entered in the regression models.

RESULTS AND CONCLUSIONS

Adolescents with severe mental health problems experience a burden of stigma. Personality disordered patients experience more stigma than adolescents with other severe psychiatric Axis I disorders. Borderline PD is the strongest predictor of experiences of stigma. More severely personality disordered adolescents tend to experience the highest level of stigma.

Associative stigma in family members of psychotic patients in Flanders: An exploratory study

AIM: To assess presence and severity of associative stigma in family members of psychotic patients and factors for higher associative stigma.

METHODS: Standardized semi-structured interview of 150 family members of psychotic patients receiving full time treatment. This study on associative stigma in family members of psychotic patients was part of a larger research program on the burden of the family, using “Interview for the Burden of the Family” and the chapters stigma, treatment and attribution from the “Family interview Schedule”. The respondents were relatives, one per patient, either partner or parent. The patients had been diagnosed with schizophrenia or schizo-affective disorder. All contacts with patients and relatives were in Dutch. Relatives were deemed suitable to participate in this research if they saw the patient at least once a week. Recruitment took place in a standardized way: after obtaining the patient’s consent, the relatives were approached to participate. The results were analyzed using SPSS Version 18.0.

RESULTS: The prevalence of associative stigma in this sample is 86%. Feelings of depression in the majority of family members are prominent. Twenty-one point three percent experienced guilt more or less frequent, while shame was less pronounced. Also, 18.6% of all respondents indicated that they tried to hide the illness of their family member for others regularly or more. Three six point seven percent really kept secret about it in certain circumstances and 29.3% made efforts to explain what the situation or psychiatric condition of their family member really is like. Factors with marked significance towards higher associative stigma are a worsened relationship between the patient and the family member, conduct problems to family members, the patients’ residence in a residential care setting, and hereditary attributional factors like genetic hereditability and character. The level of associative stigma has significantly been predicted by the burden of aggressive disruptions to family housemates of the psychotic patient.

CONCLUSION: Family members of psychotic patients in Flanders experience higher associative stigma compared to previous international research. Disruptive behavior by the patient towards in-housing family members is the most accurate predictor of higher associative stigma.

Long-term outcome of inpatient psychotherapy for adolescents (IPA) with personality pathology

Little is known about the effectiveness of treatment programs for adolescents with personality disorders (PDs). This descriptive study investigated long-term outcomes of inpatient psychotherapy for adolescents (IPA). In addition, predictors of long-term treatment effects were investigated. Seventy adolescents who completed their treatment were followed during and after their stay in IPA. Semistructured interviews were used to assess Axis I and Axis II disorders. Patients completed questionnaires to measure symptom severity and personality styles and functioning. Patients showed improvements (d ranging from .18 to .80). After leaving IPA, a small relapse rate was shown. Higher levels of dependency or more Cluster C PD traits significantly predicted positive long-term treatment outcome. Although IPA might be effective for a particular group of adolescents, mean long-term treatment effects were at best modest. Given the high costs of IPA, developing adjustments to IPA and their guidelines is warranted to ensure cost-effectiveness.

Preliminary study of associative stigma among trainee psychiatrists in Flanders, Belgium

AIM: To study the degree of stigmatization among trainee psychiatrists, individual characteristics potentially leading to higher associative stigma, and coping mechanisms.

METHODS: Two hundred and seven trainee psychiatrists in Flanders (Belgium), all member of the Flemish Association of Trainee Psychiatrists, were approached to participate in the survey. A non-demanding questionnaire that was specifically designed for the purpose of the study was sent by mail. The questionnaire consisted of three parts, each emphasizing a different aspect of associative stigma: devaluing and humiliating interactions, the focus on stigma during medical training, and identification with negative stereotypes in the media. Answers were scored on a Likert scale ranging from 0 to 3. The results were analyzed using SPSS Version 18.0.

RESULTS: The response rate of the study was 75.1%. The internal consistency of the questionnaire was good, with a Cronbach’s α of 0.71. Seventy-five percent of all trainee psychiatrists confirmed hearing denigrating or humiliating remarks about the psychiatric profession more than once. Additionally, more than half of them had had remarks about the incompetence of psychiatrists directed at them. Only 1.3% remembered having stigma as a topic during their psychiatric training. Trainees who had been in training for a longer period of time had experienced a significantly higher level of stigmatization than trainees with fewer years of experience (mean total stigma scores of 16.93 ± SD 7.8 vs 14.45 ± SD 6.1, t = -2.179 and P < 0.05). In addition, senior trainees effectively kept quiet about their profession significantly more often than their junior colleagues (mean item score 0.44 ± SD 0.82 vs 0.13 ± SD 0.48, t = 2.874, P < 0.01). Comparable results were found in trainees working in adult psychiatry as were found in those working in child or youth psychiatry (mean item score 0.38 ± SD 0.77 vs 0.15 ± SD 0.53, t = -2.153, P < 0.05). Biologically oriented trainees were more inclined to give preventive explanations about their profession, which can be seen as a coping mechanism used to deal with this stigma (mean item score 2.05 ± SD 1.05 vs 1.34 ± SD 1.1, t = -3.403, P < 0.01).

CONCLUSION: Associative stigma in trainee psychiatrists is underestimated. More attention should be paid to this potentially harmful phenomenon in training.

Predictors of treatment outcome of Inpatient Psychotherapy for Adolescents with personality pathology

Little is known about the effectiveness of treatment programmes for personality disordered adolescents. This study investigates the treatment outcome of Inpatient Psychotherapy for Adolescents (IPA), i.e. an intensive programme for treatment refractory adolescents with personality pathology. In addition, this study examines predictors of treatment outcome. One hundred and nine adolescents admitted for treatment of their personality problems were followed up during their stay in IPA. Axis I and Axis II disorders were measured using semi-structured interviews, and the adolescents completed several questionnaires to measure symptom severity (global indices of distress), personality styles and functioning, and quality of life at both start and 12 months after start of treatment. Patients showed improvement in level of symptom severity, personality functioning and quality of life (d ranging from 0.49 to 0.97). As for level of symptom severity, 29% of the adolescents moved into a normative range of symptom severity. Higher levels of self-criticism significantly predicted poorer outcome in terms of symptom severity. Type of personality disorder did not predict treatment outcome. IPA is a potentially effective treatment programme for (a subgroup of) treatment refractory adolescents with personality pathology.

Identity: empirical contribution. Changes in the identity integration of adolescents in treatment for personality disorders

A renewed interest in identity as one of the core markers of personality disorders has been introduced by the DSM-5 Level of Personality Functioning Scale. However, little is known about the utility of the construct of identity in children and adolescents. This study aimed to broaden the knowledge of identity integration as a core component of personality functioning in adolescents. The authors investigated levels of identity integration, as measured by the Severity Indices of Personality Problems (SIPP-118; Verheul et al., 2008), in adolescents in both normal (n = 406) and clinical populations (n = 285). Furthermore, changes in levels of identity integration during treatment were investigated in a clinical subsample (n = 76). Levels of identity integration were not associated with age. They were, however, associated with the absence or presence of personality pathology. Most adolescents receiving inpatient psychotherapy gradually changed toward more healthy levels of identity integration; a significant number, however, remained at maladaptive levels of identity functioning after intensive psychotherapy.

[The prevalence, burden, structure and treatment of personality disorders in adolescents]

BACKGROUND

Clinicians seem hesitant about diagnosing personality disorders in adolescents. Furthermore, little is known about the assessment and treatment of adolescents with personality disorders.

AIM

To investigate the prevalence, burden, structure, and treatability of personality disorders in adolescents. method 257 adolescents, referred to De Viersprong (the Dutch national centre for personality disorders), were tested on different variables. 133 of them were admitted to the inpatient psychotherapy unit for adolescents and were followed for a period of one year after treatment.

RESULTS

Personality disorders were frequently present in the referred adolescents. The burden of disease was high. The structure of the core components underlying personality pathology in adolescents was similar to the structure found in adults. Adolescents with a cluster C personality disorder profited most from the inpatient treatment.

CONCLUSION

There appear to be more similarities than differences between personality disorders in adolescents and adults. It seems important to assess personality pathology in referred adolescents so that the most suitable treatment can be provided.