Louise McCutcheon

Early intervention for adolescents with borderline personality disorder using cognitive analytic therapy: randomised controlled trial

BACKGROUND No accepted intervention exists for borderline personality disorder presenting in adolescence. AIMS To compare the effectiveness of up to 24 sessions of cognitive analytic therapy (CAT) or manualised good clinical care (GCC) in addition to a comprehensive service model of care. METHOD In a randomised controlled trial, CAT and GCC were compared in out-patients aged 15-18 years who fulfilled two to nine of the DSM-IV criteria for borderline personality disorder. We predicted that, compared with the GCC group, the CAT group would show greater reductions in psychopathology and parasuicidal behaviour and greater improvement in global functioning over 24 months. RESULTS Eighty-six patients were randomised and 78 (CAT n=41; GCC n=37) provided follow-up data. There was no significant difference between the outcomes of the treatment groups at 24 months on the pre-chosen measures but there was some evidence that patients allocated to CAT improved more rapidly. No adverse effect was shown with either treatment. CONCLUSIONS Both CAT and GCC are effective in reducing externalising psychopathology in teenagers with sub-syndromal or full-syndrome borderline [corrected] personality disorder. Larger studies are required to determine the specific value of CAT in this population.

Borderline Personality Disorder in Young People and the Prospects for Prevention and Early Intervention

Borderline personality disorder (BPD) is associated with substantial psychosocial impairment, morbidity, mortality and high health resource utilization. These data make a compelling case for developing prevention and early intervention strategies for BPD. This review examines the BPD diagnosis in young people, along with prospective risk factors for and precursors to the development of BPD. It then considers the prospects for and potential risks and benefits associated with prevention and early intervention for BPD. It concludes that the BPD diagnosis in young people has similar reliability, validity and prevalence to BPD in adults and that BPD in young people almost certainly has serious and pervasive negative repercussions over subsequent decades. Current data are inadequate to inform specific universal or selective prevention programs for BPD. However, they do support including BPD prevention as an outcome when evaluating universal and/or selective interventions for a variety of mental health problems and adverse psychosocial outcomes. The data are stronger for developing indicated preventive interventions but the strongest data support early intervention for the emerging BPD phenotype. Early intervention programs will need to be realistic in their aims, require change in clinician attitudes and service systems and must be mindful of the risk of iatrogenic harm.

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

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

The HYPE Clinic: An Early Intervention Service for Borderline Personality Disorder

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

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

Objective: The aim of the present study was to compare the effectiveness of specialized team-based early intervention for borderline personality disorder (BPD) with treatment as usual. Method: In a quasi-experimental design, 32 outpatients who received historical treatment as usual (H-TAU) were compared with 78 participants from a recently published randomized controlled trial of cognitive analytic therapy (CAT; n = 41) versus manualized good clinical care (GCC; n = 37), conducted in a specialized early intervention service for BPD (the Helping Young People Early (HYPE) programme). All participants were 15–18-year-old outpatients who fulfilled 2–9 DSM-IV BPD criteria. It was predicted that, compared with H-TAU, HYPE + GCC and HYPE + CAT would show greater reductions in psychopathology and parasuicidal behaviour and greater improvement in global functioning over 24months. Results: At 24month follow up: (i) HYPE + CAT had lower standardized levels of, and a significantly faster standardized rate of improvement in, internalizing and externalizing psychopathology, compared with H-TAU; and (ii) HYPE + GCC had lower standardized levels of internalizing psychopathology and a faster rate of improvement in global functioning than H-TAU. HYPE + CAT yielded the greatest median improvement on the four continuous outcome measures over 24months. No adverse effects were shown with any of the treatments. Conclusions: Specialized early intervention for subsyndromal or full-syndrome BPD is more effective than TAU, with HYPE + CAT being the most effective intervention. Reform of existing services using the HYPE model might yield substantial improvements in patient outcomes.

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

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

HYPE: A Cognitive Analytic Therapy-Based Prevention and Early Intervention Programme for Borderline Personality Disorder

Borderline personality disorder (BPD) is a leading candidate for developing empirically based prevention and early intervention programmes because it is common in clinical practice, it is among the most distressing and functionally disabling of all mental disorders, it is often associated with help-seeking, and it has been shown to respond to treatment, even in those with established disorder. Moreover, BPD can be reliably diagnosed in its early stages and it demarcates a group with high levels of current and future distress, morbidity and mortality, making intervention a clinically justified and humane response. Data also suggest considerable flexibility and malleability of BPD traits in youth, making this a key developmental period during which to intervene.

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

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

Evaluation of a psychoeducational group intervention for family and friends of youth with borderline personality disorder

BackgroundDespite high levels of burden and distress among families with a member who has borderline personality disorder (BPD), only two BPD specific family psychoeducation groups have been empirically evaluated. Neither of these is designed specifically for the family and friends of young people who are presenting early in the course of BPD. This study aimed to evaluate Making Sense of Borderline Personality Disorder (MS-BPD), a three-session, developmentally tailored, manualised psychoeducational group for the family and friends of youth with BPD features.MethodsThe study employed a pre- and post-intervention, repeated measures design. Twenty-three participants completed self-report measures assessing for family burden, psychological distress, and knowledge about personality disorder. Demographic data were collected for the group participants and for their associated young person with BPD. Paired-samples t-tests were conducted to evaluate the effect of the MS-BPD intervention on participants’ burden, distress and personality disorder knowledge.ResultsAt the completion of session three (day 15), group participants reported significantly decreased subjective burden and increased personality disorder knowledge. Objective burden and distress remained unchanged.ConclusionsFamily and friends of young people with BPD features experienced subjective, but not objective, benefit from attending a brief group-based psychoeducation intervention. Longer follow-up is likely to be required to detect behavioural change. The current findings support proceeding to a randomised controlled trial of MS-BPD.

A psychoeducational group intervention for family and friends of youth with borderline personality disorder features: protocol for a randomised controlled trial

BackgroundCaring for a person with borderline personality disorder is associated with poor outcomes including elevated psychological distress and burden. This study will compare the effectiveness of two brief psychoeducational programs for carers of youth presenting for early intervention for borderline personality disorder features. The protocol for this study is presented here.MethodsThe study is a single-centre parallel group, randomised controlled trial. As a family unit, relatives, partners and friends (‘carers’) are randomly allocated to one of two treatment arms to receive either an online borderline personality disorder psychoeducation program, or both the online psychoeducation group and a face-to-face group program, Making Sense of Borderline Personality Disorder. Carers are assessed at baseline and follow-up (4 weeks after the intervention). It is expected that participants who received the combined group and online programs will have better outcomes than those who received the online program alone. The primary outcome is carer burden, assessed using the negative appraisal subscales of the Experience of Caregiving Inventory. Secondary outcomes include positive experiences of caregiving, coping, self-rated personality disorder knowledge, psychological distress, expressed emotion and quality of life.DiscussionThis will be the first published evaluation of a psychoeducational intervention for carers of youth with borderline personality disorder features using a randomised controlled trial design. The results have the potential to inform clinicians and carers about the effectiveness of brief interventions designed to support families and friends of young people with borderline personality disorder, and what medium those interventions should utilise.Trial registrationProspectively registered with the Australian New Zealand Clinical Trial Registry ACTRN12616000304437 on 08 March 2016.