Elfrida H. Kvarstein

Large Variations of Global Functioning over Five Years in Treated Patients with Personality Traits and Disorders

The aim of this study was to examine the long-term course of global functioning in patients with personality disorders (PD) and investigate predictors of variation. The Global Assessment of Functioning (GAF) was repeated over five years in 352 patients with PDs of varying severity, all treated in psychotherapeutic day hospitals. Growth models were used for statistical analysis. Large variations in the long-term course of global functioning were evident in this clinical sample. At five-year follow-up, 46% reached a GAF-score above 60 with a mean GAF-score of 71. Their linear change-rate over the five years was estimated to be 4.4 GAF points per year. The average five-year GAF-score for the remaining subgroup (54%) was 50 and their linear yearly change-rate was 0.8 GAF points. Greater relief of symptom distress and interpersonal problems was typical of patients with functional improvement. The number of avoidant PD criteria was associated with slower functional change.

Health service costs and clinical gains of psychotherapy for personality disorders: a randomized controlled trial of day-hospital-based step-down treatment versus outpatient treatment at a specialist practice

BackgroundDay-hospital-based treatment programmes have been recommended for poorly functioning patients with personality disorders (PD). However, more research is needed to confirm the cost-effectiveness of such extensive programmes over other, presumably simpler, treatment formats.MethodsThis study compared health service costs and psychosocial functioning for PD patients randomly allocated to either a day-hospital-based treatment programme combining individual and group psychotherapy in a step-down format, or outpatient individual psychotherapy at a specialist practice. It included 107 PD patients, 46% of whom had borderline PD, and 40% of whom had avoidant PD. Costs included the two treatment conditions and additional primary and secondary in- and outpatient services. Psychosocial functioning was assessed using measures of global (observer-rated GAF) and occupational (self-report) functioning. Repeated assessments over three years were analysed using mixed models.ResultsThe costs of step-down treatment were higher than those of outpatient treatment, but these high costs were compensated by considerably lower costs of other health services. However, costs and clinical gains depended on the type of PD. For borderline PD patients, cost-effectiveness did not differ by treatment condition. Health service costs declined during the trial, and functioning improved to mild impairment levels (GAF > 60). For avoidant PD patients, considerable adjuvant health services expanded the outpatient format. Clinical improvements were nevertheless superior to the step-down condition.ConclusionOur results indicate that decisions on treatment format should differentiate between PD types. For borderline PD patients, the costs and gains of step-down and outpatient treatment conditions did not differ. For avoidant PD patients, the outpatient format was a better alternative, leaning, however, on costly additional health services in the early phase of treatment.Trial registrationClinical Trials NCT00378248

Step-down versus outpatient psychotherapeutic treatment for personality disorders: 6-year follow-up of the Ulleval personality project.

BackgroundAlthough psychotherapy is considered the treatment of choice for patients with personality disorders (PDs), there is no consensus about the optimal level of care for this group of patients. This study reports the results from the 6-year follow-up of the Ullevål Personality Project (UPP), a randomized clinical trial comparing outpatient individual psychotherapy with a long-term step-down treatment program that included a short-term day hospital treatment followed by combined group and individual psychotherapy.MethodsThe UPP included 113 patients with PDs. Outcome was evaluated after 8 months, 18 months, 3 years and 6 years and was based on a wide range of clinical measures, such as psychosocial functioning, interpersonal problems, symptom severity, and axis I and II diagnoses.ResultsAt the 6-year follow-up, there were no statistically significant differences in outcome between the treatment groups. Effect sizes ranged from medium to large for all outcome variables in both treatment arms. However, patients in the outpatient group had a marked decline in psychosocial functioning during the period between the 3- and 6-year follow-ups; while psychosocial functioning continued to improve in the step-down group during the same period. This difference between groups was statistically significant.ConclusionsThe findings suggest that both hospital-based long-term step-down treatment and long-term outpatient individual psychotherapy may improve symptoms and psychosocial functioning in poorly functioning PD patients. Social and interpersonal functioning continued to improve in the step-down group during the post-treatment phase, indicating that longer-term changes were stimulated during treatment.Trial registrationNCT00378248.

Large variation of severity and longitudinal change of symptom distress among patients with personality disorders

Main objectives were to investigate (1) the longitudinal course of symptom distress among patients with personality disorders (PD) and (2) how different Axis-I and Axis-II pathology and treatment factors predict or moderate long-term outcome. All patients (n = 751) were admitted to short-term day hospital treatment, and 47% continued in group psychotherapy (mean duration 2.3 years). Symptom distress was assessed repeatedly over 5 years (Symptom Check List 90-R). Mixed models were chosen for statistical analyses. A main finding was the large variation in severity and longitudinal course of symptom distress. Five-year trends ranged from full symptom remission (31%) to pervasive, severe distress (36%). Co-occurring Axis-I disorders did not explain longitudinal variability of symptom distress. However, the presence and increasing severity of Axis-II pathology was strongly associated with more severe baseline symptom distress. Poor long-term outcomes were associated with the combination of avoidant PD and long treatment durations (>2.5 years), and borderline PD and short treatment durations (<0.4 years). Contrastingly, considerable symptom relief was associated with borderline PD and long treatment duration. In conclusion, the severity and longitudinal course of symptom distress among PD patients is closely associated with their personality structures and not sufficiently explained by Axis-I comorbidity.

Favourable outcome of long-term combined psychotherapy for patients with borderline personality disorder: Six-year follow-up of a randomized study

Abstract Objective: This study reports the six-year follow-up data of patients with borderline personality disorder (BPD) who participated in the Ullevål Personality Project (UPP), a randomized clinical study comparing outpatient individual psychotherapy (OIP) with a long-term combination programme (CP) comprising short-term day-hospital treatment followed by outpatient combined group and individual psychotherapy. Methods: For 52 patients, outcomes were evaluated after 8 months, 18 months, 3 years, and 6 years based on a wide range of clinical measures, such as symptom severity, psychosocial functioning, personality functioning, and Axis-I and II diagnoses. Results: At the six-year follow-up, patients in the CP condition reported significantly greater reduction of symptom distress and improvements in the personality functioning domains Identity Integration and Self-control compared with patients allocated to OIP. Patients in the CP also had a more favourable long-term course of psychosocial functioning. There were no differences between treatment conditions in outcomes of interpersonal functioning and self-esteem. Conclusions: Long-term psychotherapy in a combination programme seems favourable for BPD patients. In this study, patients who received combined treatment fared better on crucial parameters than patients who received individual therapy. Of particular importance are the positive effects on fundamental borderline problem areas like Identity Integration and Self-control.

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

OBJECTIVES Outpatient group psychotherapy is frequent within specialist services, recruits a mixed population, but effects are poorly documented. This study investigates long-term outcomes for patients with personality disorder (PD) treated in outpatient, psychodynamic groups within secondary mental health service. METHODS A naturalistic study (N = 103) with repeated assessments of process and clinical outcomes. Longitudinal statistics are linear mixed models. RESULTS The main PDs were avoidant, borderline and NOS PD, mean number of PDs 1.4(SD0.7), 60% females and mean initial age 38(SD10) years. Mean treatment duration was 1.5(SD 0.9) years. Therapist alliance and experienced group climate was satisfactory and stable. Improvements were significant (symptom distress, interpersonal problems, occupational functioning and additional mental health services), irrespective of general PD-severity, but not of PD-type, age or gender. The study demonstrates PD NOS benefits across all outcomes, occupational improvements for avoidant PD, despite prevailing symptoms, but generally poorer outcomes for males and age >38 years. For borderline PD, experienced conflict was stronger, treatment duration shorter and outcomes poor for early drop-outs (28%). CONCLUSION Psychodynamic group psychotherapy is a recommendable treatment for moderate PDs, which may address avoidant strategies, but may not meet clinical challenges of borderline PD. The outcome differences related to gender and age are noteworthy. Copyright

The three factors of the psychoticism scale of SCL-90-R.

Former studies have repeatedly found the psychoticism (PSY) scale of Symptom Checklist-90-Revised to be a heterogeneous construct. The aim of this study was to confirm and further explore the nature of this heterogeneity within a large sample of patients with mainly personality disorders. Within a total sample of 3 794 patients, one-half was randomly selected for explorative factor analysis in order to assess the internal structure of the PSY scale and the other half to cross-validate the findings by a confirmatory factor analysis. The total sample was then used to assess associations between the components from the factor analyses and several clinical measures and diagnoses. A one-factor solution of the PSY scale yielded poor fit to the data, but a proposed structure of three latent constructs was confirmed by good model fit. The three subsets of the PSY scale, labelled metacognitive dysfunction, self-accusation and detachment, shared variance with different personality disorders and different aspects of psychopathology, e.g. previous psychotic episodes. The heterogeneous PSY scale of SCL-90-R can be divided into three meaningful clinical concepts, reflecting different aspects of psychosis-near experiences. The factors warrant confirmation in other populations. Copyright

The Work and Social Adjustment Scale: Psychometric properties and validity among males and females, and outpatients with and without personality disorders

The Work and Social Adjustment Scale (WSAS) is an outcome measure assessing degree of functional impairment. Its psychometric properties, validity and sensitivity to change have been supported in several studies. However, no explicit psychometric or validity study of WSAS has been performed on data from a large sample of psychiatric outpatients, with and without personality disorders. The aim of this study was therefore to provide additional knowledge of the properties of WSAS in such a sample. The material comprised data from 1371 patients, from 15 different units participating in the Norwegian Network of Personality-Focused Treatment Programs. Psychometric properties of the scale, such as measurement invariance among males and females, longitudinal invariance, as well as associations with other clinical measures and sensitivity to change were analysed. The results confirm that WSAS constitutes a reliable, unidimensional and gender invariant measure, sensitive to change and to severity of mental distress. Although highly associated with levels of depression, WSAS measures a clinically important aspect of impairment. Copyright

Mentalization-based treatment or psychodynamic treatment programmes for patients with borderline personality disorder - the impact of clinical severity

Objectives Mentalization‐based treatment (MBT), originally designed for patients with borderline personality disorder (BPD), may be particularly indicated for severe conditions. However, there is limited documentation of how increasing severity of personality disorder (PD) effect outcomes of highly specialized treatments. This study aimed to investigate associations between clinical severity and outcomes for patients in MBT as compared to a psychodynamic group‐based treatment programme (PDT). Design A naturalistic, longitudinal, comparison study. Methods The sample included 345 patients with BPD (PDT n = 281, MBT n = 64). The number of diagnosed PDs, PD criteria, and symptom disorders were chosen as baseline indicators of clinical severity. Clinical outcomes (global functioning, symptom distress, interpersonal problems) were repeatedly assessed over three years. Therapists’ fidelity to MBT was satisfactory. Linear mixed models were the applied statistics. Results In PDT, greater clinical severity was associated with poorer improvement rates. Clinical severity was not associated with significant differences in outcomes for patients in MBT. Differences in outcomes for patients in MBT and PDT increased significantly with higher severity of disorder. Conclusions Supporting previous research, this study indicates that clinical benefits associated with MBT also apply for BPD patients with severe conditions. The results also suggest that increasing severity was a challenge in PDT. Practitioner points MBT may be particularly beneficial for severely disordered BPD patients Differences between MBT and PDT were less pronounced in moderately disordered BPD patients.

The relationship between reflective functioning and affect consciousness in patients with avoidant and borderline personality disorders.

Avoidant personality disorder (APD) and borderline personality disorder (BPD) are the most frequent personality disorders (PDs) in clinical practice. Although BPD research dominates the field, both PDs are clearly associated with severe functional impairments and substantial treatment challenges. Few have investigated the relationship between core personality vulnerabilities across PDs. However, such research has high clinical relevance, could expand our understanding of the distinct nature of the disorders, and thus have important therapeutic implications. Central PD vulnerabilities have been conceptualized in two, possibly overlapping, constructs: mentalization and affect consciousness (AC). The interrelationship between mentalizing and AC and PD specific differences are, as yet, not well established. The present study investigated the relationship between mentalizing capacity and AC among 73 treatment-seeking patients with APD and/or BPD, 81% females. Mentalization was measured by assessment of reflective functioning (RF) from transcripts of the Adult Attachment Interview (AAI). AC was measured by using the Affect Consciousness Interview (ACI). In this mixed PD sample, the RF and AC scores indicated poor functioning and correlations between RF and AC were low to moderately positive. In the PD-specific subgroups, correlations between RF and AC were positive (moderate to high) in the APD group (n = 26), but insignificant in the BPD group (n = 33). In conclusion, the positive relationship between RF and AC may not be generalized to all types of psychopathology. Our results indicate a strong relationship between impaired AC and poor mentalizing capacities among APD patients in particular.