Dine J. Feenstra

Prevalence and comorbidity of axis I and axis II disorders among treatment refractory adolescents admitted for specialized psychotherapy

Research shows that approximately half of the adolescents in a clinical setting suffer from a personality disorder (PD). This finding has not yet been replicated in Europe. To test whether this finding also applies to Europe, structured diagnostic interviews for both Axis I and Axis II disorders were used in 257 adolescents who were admitted to a highly specialized mental health setting in The Netherlands. In this study we found that 40.5% of the adolescents were diagnosed with at least one personality disorder. Most adolescents with a personality disorder (78.9%) also suffered from one or more Axis I disorders. These results are comparable to rates found in previous prevalence studies of personality disorders in both adolescents and adults. Our results provide further evidence to support the cross-national generalizability of the diagnosis of PD in adolescents.

Diagnosis of personality disorders in adolescents: A study among psychologists

BackgroundRecent guidelines concerning the treatment of personality disorders (PDs) recommend diagnosing PDs in adolescents. However, it remains unclear whether these guidelines influence the current opinions and practices of mental health care professionals.MethodsFive hundred sixty-six psychologists completed an online survey concerning PDs in adolescents, of whom 367 professionals reported working with adolescents. The survey contained demographical questions (age, gender, profession, work setting) and specific questions related to PD in adolescence.ResultsAlthough a majority of psychologists working with adolescents acknowledged the existence of PDs in adolescents (57.8%), only a small minority diagnoses PDs in adolescence (8.7%) and offers a treatment specifically aimed at targeting PD pathology (6.5%). Reasons for not diagnosing PDs in adolescence mainly concerned the belief that adolescent personality problems are transient (41.2%) and that the DSM-IV-TR does not allow diagnosing PDs in adolescence (25.9%).ConclusionsAlthough practice guidelines might have influenced clinicians’ opinions about PDs in adolescence, they have had little impact so far on routine clinical practice.

The burden of disease among adolescents with personality pathology: Quality of life and costs

In adults, personality disorders are associated with a low quality of life and high societal costs. To explore whether these findings also apply to adolescents, 131 adolescent patients were recruited from a mental health care institute in The Netherlands. Axis I and Axis II disorders were diagnosed using semi-structured interviews. The EuroQol EQ-5D was used to measure quality of life and costs were measured by the Trimbos and Institute for Medical Technology Assessment Questionnaire on Costs Associated with Psychiatric Illness. The mean EQ-5D index value was 0.55. The mean direct medical cost in the year prior to treatment was €14,032 per patient. The co-occurrence of Axis I and Axis II disorders was a significant predictor of a low quality of life. Direct medical costs were higher for the depressive personality disorder. This study shows that the burden of disease among adolescents with personality pathology is high. This high burden provides evidence to suggest that further research and development of (cost-)effective treatment strategies for this population may be worthwhile.

Severity Indices of Personality Problems (SIPP-118) in adolescents: reliability and validity

The Severity Indices of Personality Problems (SIPP-118; Verheul et al., 2008) is a self-report questionnaire focusing on core components of (mal)adaptive personality functioning. The SIPP-118 was developed and validated in an adult population. In adult populations, the 16 facets of the SIPP-118 fit into 5 higher order domains: self-control, identity integration, relational capacities, social concordance, and responsibility. In this study we present the 1st psychometric properties of the SIPP-118 in adolescents. We compared the SIPP-118 scores of a patient and a nonpatient sample of adolescents, and compared personality disordered and non-personality disordered adolescents. In addition, the relationship between scores on the SIPP-118 and other clinical instruments (Symptom Checklist-90-Revised; SCL-90-R; Derogatis, 1975; Dimensional Assessment of Personality Pathology-Basic Personality; DAPP-BQ; Livesley & Jackson, 2002) was investigated. The questionnaires were completed by 378 adolescent patients and 389 adolescents in the community. Facets appeared to be homogeneous, as alpha coefficients ranged from .62 to .89, indicating moderate to acceptable reliability. Also, more pathological SIPP-118 scores were found in the patient sample, and more specifically in the personality disordered sample, suggesting that the facet scores of the SIPP-118 can discriminate between various populations (divergent validity). Correlation with other clinical instruments was moderate to high (-.82 to .10). Taken together, the SIPP-118 seems to be a promising instrument measuring personality pathology in adolescents.

Therapeutic assessment promotes treatment readiness but does not affect symptom change in patients with personality disorders: Findings from a randomized clinical trial

The field of clinical personality assessment is lacking in published empirical evidence regarding its treatment and clinical utility. This article reports on a randomized controlled clinical trial (N = 74) allocating patients awaiting treatment in a specialized clinic for personality disorders to either 4 sessions of (a) therapeutic assessment (TA) or (b) a structured goal-focused pretreatment intervention (GFPTI). In terms of short-term outcome, TA demonstrated superior ability to raise outcome expectancies and patient perceptions of progress toward treatment (Cohens d = 0.65 and 0.56, respectively) and yielded higher satisfaction (d = 0.68). Moreover, patients reported marginally stronger alliance to the TA clinicians than to GFPT clinicians (d = 0.46), even though therapists perceived the alliance as equally positive in both groups. No differences in symptomatic ratings were observed. Results are discussed with reference to treatment utility in this particular patient group.

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.

Feasibility of mentalization-based treatment for adolescents with borderline symptoms: a pilot study.

Mentalization-based treatment (MBT) is an evidence-based treatment for adults suffering from borderline personality disorder. Different adaptations of MBT for adolescents have been described, but almost none of these have been systematically evaluated so far. This article presents pilot data from a feasibility study of an adaptation of inpatient MBT for adolescents with borderline symptoms (MBT-A). Preliminary outcome results were examined in a pilot study including 11 female adolescents (aged 14-18 years) in a mental health care center in the Netherlands. Maximum treatment duration was 12 months and patients were assessed at start and at 12 months after start of treatment. Outcome measures included symptom severity (Brief Symptom Inventory), personality functioning (Severity Indices of Personality Problems), and quality of life (EuroQol). Results showed significant decreases in symptoms, and improvements in personality functioning and quality of life at 12 months after start of treatment. Effect sizes (d) ranged from .58 to 1.46, indicating medium to large effects. In total, 91% of the adolescents showed reliable change on the BSI, and 18% also moved to the functional range on the BSI. The results of this feasibility study are promising and encourage further research concerning the efficacy of MBT in adolescents with borderline symptoms, although some problems with implementation suggest that an outpatient variant of MBT for adolescents might be as effective while at the same time reducing potential iatrogenic effects of inpatient treatment for this age group.

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.

Day hospital Mentalization-based treatment versus intensive outpatient Mentalization-based treatment for patients with severe borderline personality disorder: protocol of a multicentre randomized clinical trial

BackgroundBorderline personality disorder (BPD) is associated with a high socioeconomic burden. Although a number of evidence-based treatments for BPD are currently available, they are not widely disseminated; furthermore, there is a need for more research concerning their efficacy and cost-effectiveness. Such knowledge promises to lead to more efficient use of resources, which will facilitate the effective dissemination of these costly treatments. This study focuses on the efficacy and cost-effectiveness of Mentalization-Based Treatment (MBT), a manualized treatment for patients with BPD. Studies to date have either investigated MBT in a day hospitalization setting (MBT-DH) or MBT offered in an intensive outpatient setting (MBT-IOP). No trial has compared the efficacy and cost-effectiveness of these MBT programmes. As both interventions differ considerably in terms of intensity of treatment, and thus potentially in terms of efficacy and cost-effectiveness, there is a need for comparative trials. This study therefore sets out to investigate the efficacy and cost-effectiveness of MBT-DH versus MBT-IOP in patients with BPD. A secondary aim is to investigate the association between baseline measures and outcome, which might improve treatment selection and thus optimize efficacy and cost-effectiveness.Methods/DesignA multicentre randomized controlled trial comparing MBT-DH versus MBT-IOP in severe BPD patients. Patients are screened for BPD using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, and are assessed before randomization, at the start of treatment and 6, 12, 18, 24, 30 and 36 months after the start of treatment. Patients who refuse to participate will be offered care as usual in the same treatment centre. The primary outcome measure is symptom severity as measured by the Brief Symptom Inventory. Secondary outcome measures include parasuicidal behaviour, depression, substance use, social, interpersonal, and personality functioning, attachment, mentalizing capacities, and quality of life. All analyses will be conducted based on the intention-to-treat principle. Cost-effectiveness will be calculated based on costs per quality-adjusted life-year.DiscussionThis multisite randomized trial will provide data to refine criteria for treatment selection for severe BPD patients and promises to optimize (cost-)effectiveness of the treatment of BPD patients.Trial registrationNTR2292. Registered 16 April 2010.

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.