Alec L. Miller

Fact or fiction: diagnosing borderline personality disorder in adolescents.

Borderline Personality Disorder (BPD) has long been considered a mental health problem that results in considerable costs in terms of human suffering and psychiatric expenses among adult patients. Although the diagnosis of BPD for adolescents is frequently used in clinical settings, the field of mental health has questioned whether one should diagnose BPD among adolescents. This paper reviews the recent empirical literature (identified through PsycINFO 1980 to present) to evaluate prevalence, reliability, and validity of a BPD diagnosis in adolescents. It is concluded that the features BPD diagnoses in adolescents are comparable to those in adults. Furthermore, there appears to be a legitimate subgroup of adolescents for whom the diagnosis remains stable over time as well as a less severe subgroup that moves in and out of the diagnosis. While caution is warranted, formal assessment of BPD in adolescents may yield more accurate and effective treatment for adolescents experiencing BPD symptomatology. More longitudinal research is necessary to further explicate the issues of diagnosing BPD in adolescents.

Dialectical behavior therapy adapted for suicidal adolescents

We report a quasi-experimental investigation of an adaptation of Dialectical Behavior Therapy (DBT) with a group of suicidal adolescents with borderline personality features. The DBT group (n = 29) received 12 weeks of twice weekly therapy consisting of individual therapy and a multifamily skills training group. The treatment as usual (TAU) group (n = 82) received 12 weeks of twice weekly supportive-psychodynamic individual therapy plus weekly family therapy. Despite more severe pre-treatment symptomatology in the DBT group, at post-treatment this group had significantly fewer psychiatric hospitalizations during treatment, and a significantly higher rate of treatment completion than the TAU group. There were no significant differences in the number of suicide attempts made during treatment. Examining pre-post change within the DBT group, there were significant reductions in suicidal ideation, general psychiatric symptoms, and symptoms of borderline personality. DBT appears to be a promising treatment for suicidal adolescents with borderline personality characteristics.

Analysis of behavioral skills utilized by suicidal adolescents receiving dialectical behavior therapy

Researchers are currently applying dialectical behavior therapy (DBT), originally developed for adult chronically parasuicidal women diagnosed with borderline personality disorder (BPD), to a suicidal adolescent population diagnosed with BPD or borderline features. The four characteristic problem areas often found among these multiproblem patients are (a) confusion about self, (b) impulsivity, (c) emotional instability, and (d) interpersonal problems. DBT employs four corresponding behavioral skills modules aimed at increasing adaptive behaviors while simultaneously reducing maladaptive behaviors. The four skill modules include mindfulness skills, distress tolerance skills, emotion-regulation skills, and interpersonal effectiveness skills. The present study examines adolescent self-report of the helpfulness and overall effectiveness of these skills by using pre- and posttreatment evaluations. Consistent with prior research of DBT with adolescents, this study found significant reductions in BPD symptoms in all four problem areas. The four most highly rated skills included distress tolerance and mindfulness skills. Relationships found between the helpfulness of specific skills and improvement in particular problem areas are described. Lastly, implications for future research of DBT skill comprehension and application among adolescents are discussed.

Psychiatric and social barriers to HIV medication adherence in a triply diagnosed methadone population.

Although antiretrovirals can prolong life, medication adherence also poses a constant challenge for HIV-infected individuals because the success of antiretroviral regimens demands nearly perfect adherence to medications. This paper describes the psychiatric and social barriers to adherence in a convenience sample of HIV-positive clients in methadone treatment in the Bronx, New York. The study sample was part of a national study of HIV treatment adherence and health care utilization among triply diagnosed populations, the HIV/AIDS Treatment Adherence Health Outcomes and Cost Study. The triply diagnosed study sample is defined here as HIV-infected individuals who screened into the study with at least one psychiatric diagnosis in addition to opioid dependence on agonist therapy (methadone treatment) and at least one substance use diagnosis. Interviewers utilized modified versions of the Structured Clinical Interview for DSM-IV Disorders (SCID-I), the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II), and the Addiction Severity Index (ASI-Lite), among a battery of Cost Study instruments. Results showed that within this sample, borderline personality disorder was significantly associated with nonadherence to HIV medications. A related finding showed a significant relationship between serious social/family problems and nonadherence. These findings build on previous research on the impact of psychiatric illness on HIV medication adherence and suggest that psychiatric assessment and treatment options be linked to adherence interventions.

Youth suicidal behavior: assessment and intervention.

In this article, the authors review the research on risk assessment of suicidal adolescents and describe the small body of randomized-clinical-treatment trials for this population. Research has yielded a fairly consistent set of direct and indirect risk factors for suicidal behavior in adolescents. The authors describe a variety of measures commonly used to assess these risk factors. Treatment studies targeting suicide are sparse for all ages. In the adult literature, evidence suggests clozapine, depot flupenthixol, lithium, and dialectical behavior therapy (DBT) are significantly more effective in decreasing suicidal behavior than placebo or Treatment as Usual. For adolescents, it is difficult to draw conclusions about treatment efficacy. In general, control conditions are just as effective at reducing suicidal behavior as experimental conditions. While some novel interventions for suicidal adolescents are described, there is a desperate need for more research to be conducted in order to advance this burgeoning field.

Dialectical Behavior Therapy Compared With Enhanced Usual Care for Adolescents With Repeated Suicidal and Self-Harming Behavior: Outcomes Over a One-Year Follow-Up.

OBJECTIVE We conducted a 1-year prospective follow-up study of posttreatment clinical outcomes in adolescents with recent and repetitive self-harm who had been randomly allocated to receive 19 weeks of either dialectical behavior therapy adapted for adolescents (DBT-A) or enhanced usual care (EUC) at community child and adolescent psychiatric outpatient clinics. METHOD Assessments of self-harm, suicidal ideation, depression, hopelessness, borderline symptoms, and global level of functioning were made at the end of the 19-week treatment period and at follow-up 1 year later. Altogether 75 of the 77 (97%) adolescents participated at both time points. Frequencies of hospitalizations, emergency department visits and other use of mental health care during the 1-year follow-up period were recorded. Change analyses were performed using mixed effects linear spline regression and mixed effect Poisson regression with robust variance. RESULTS Over the 52-week follow-up period, DBT-A remained superior to EUC in reducing the frequency of self-harm. For other outcomes such as suicidal ideation, hopelessness, and depressive or borderline symptoms and for the global level of functioning, inter-group differences apparent at the 19-week assessment were no longer observed, mainly due to participants in the EUC group having significantly improved on these dimensions over the follow-up year, whereas DBT-A participants remained unchanged. CONCLUSION A stronger long-term reduction in self-harm and a more rapid recovery in suicidal ideation, depression, and borderline symptoms suggest that DBT-A may be a favorable treatment alternative for adolescents with repetitive self-harming behavior. CLINICAL TRIAL REGISTRATION INFORMATION Treatment for Adolescents With Deliberate Self Harm; http://clinicaltrials.gov/; NCT00675129.

DBT for adolescents: Dialectical dilemmas and secondary treatment targets

The primary aim of this paper is to describe the central dialectical dilemmas the authors have observed in treating suicidal adolescents and their families using Dialectical Behavior Therapy (DBT). These dilemmas supplement those described by Linehan in standard DBT with adults. The adolescent/family dialectical dilemmas are excessive leniency vs. authoritarian control, normalizing pathological behaviors vs. pathologizing normative behaviors, and forcing autonomy vs. fostering dependence. We also discuss the corresponding treatment targets we have identified; these are aimed at achieving a synthesis between the polarities inherent in each dialectical dilemma.

MACI personality scale profiles of depressed adolescent suicide attempters: A pilot study

Employing the Millon Adolescent Clinical Inventory (MACI), we examined differences in the maladaptive personality style profiles of clinically referred, depressed adolescents presenting with (n = 26) and without (n = 23) a history of previous suicide attempts. Relative to the comparison group, adolescent attempters experienced more severe overall levels of personality dysfunction. At the trait level, attempters obtained higher scores on the forceful and borderline tendency scales and lower scores on the submissive and conforming scales of the MACI, reflecting negative mood regulation deficits (e.g., anger control problems) and persistently high levels of aggressive impulsivity. These preliminary findings suggest that MACI personality scales may be useful in discriminating adolescents with and without previous suicidal behavior, especially among depressed outpatient samples.

HIV/AIDS Cost Study: Construct Validity and Factor Structure of the PTSD Checklist in Dually Diagnosed HIV-Seropositive Adults

Abstract Published findings are mixed regarding the underlying factor structure of the PTSD Checklist (PCL). Studies have found two-, three-, and four-factor solutions, which are only partially consistent with DSM-IV-defined PTSD symptom clusters (reexperiencing, avoidance, and hyperarousal). The current study examined the reliability, validity, and factor structure of the PCL in a sample of dually diagnosed (substance use disorder and other psychiatric disorder) participants living with HIV/AIDS. Results supported the robust psychometric properties of the PCL, with high reliability and validity. Using confirmatory factor analysis, two models, a second-order (two-factor) and a first-order (four-factor) solution were supported. The utility of the PCL and implications for the dimensionality of PTSD in this population are discussed

Feasibility of Dialectical Behavior Therapy with Suicidal and Self-Harming Adolescents with Multi-Problems: Training, Adherence, and Retention

We evaluated the feasibility of DBT training, adherence, and retention preparing for a randomized controlled trial of Dialectical Behavior Therapy (DBT) adapted for Norwegian adolescents engaging in self-harming behavior and diagnosed with features of borderline personality disorder. Therapists were intensively trained and evaluated for adherence. Adherence scores, treatment retention, and present and previous self-harm were assessed. Twenty-seven patients were included (mean age 15.7 years), all of them with recent self-harming behaviors and at least 3 features of Borderline Personality Disorder. Therapists were adherent and 21 (78%) patients completed the whole treatment. Three subjects reported self-harm at the end of treatment, and urges to self-harm decreased. At follow up, 7 of 10 subjects reported no self-harm. DBT was found to be well accepted and feasible. Randomized controlled trials are required to test the effectiveness of DBT for adolescents.