Sigmund Karterud

An investigation of the prototype validity of the borderline DSM-IV construct

Objective:  To investigate the prototype validity of the borderline personality disorder (BPD) DSM‐IV construct.

The longitudinal pattern of suicidal behaviour in borderline personality disorder: a prospective follow-up study.

The aim was to study the longitudinal course of suicidal behaviour and ideation in patients with borderline personality disorder (BPD) compared with patients with other diagnoses. Ninety‐seven patients (41 BPD, 33 other personality disorders, 23 no personality disorder) consecutively admitted to a day unit were given a prospective personal interview follow‐up with evaluations at admission, discharge and at follow‐up after 2–5 years. Even when controlled for Axis I disorders, BPD patients showed significantly more often a lifetime history of suicide attempts. BPD patients with a history of suicide attempts were more suicidal at index admission, continued to be so over the follow‐up period and differed systematically in an unfavourable direction from other BPD patients on the major outcome measures. BPD patients without suicidal behaviour had an outcome nearly as good as non‐BPD patients, and only 41% of them retained the BPD diagnosis at follow‐up. Suicidal behaviour and ideation are highly prevalent in BPD. These suicidal expressions are of an enduring nature and seem as a diagnostic criterion to enhance the predictive capacity of the BPD diagnosis.

Personality disorders 2–5 years after treatment: a prospective follow‐up study

Ninety‐seven patients consecutively admitted to a day unit specializing in the treatment of personality disorders were included in a prospective follow‐up study. At follow‐up an average of 3 years after index admission, patients with borderline personality disorder (BPD) displayed a moderate symptom reduction and a fair global outcome. Patients with schizotypal personality disorder (STP) showed a similar reduction in symptoms but retained relatively poor global functioning. Individuals with cluster C personality disorders, in contrast, showed both a good global outcome and a marked symptom reduction. STP individuals were the least socially adjusted, employed and self‐supporting of all diagnostic subgroups. STP and BPD individuals had far more inpatient treatment in the follow‐up period than other groups. The overall suicide rate was low compared with most similar studies.

Is SCL-90R helpful for the clinician in assessing DSM-IV symptom disorders?

Objective:  To investigate associations between six of the Symptom Check‐List 90R (SCL‐90R) subscales and specific DSM‐IV symptom disorders in a sample of patients with high comorbidity of axis I and axis II disorders.

Day hospital therapeutic community treatment for patients with personality disorders. An empirical evaluation of the containment function.

Does a day hospital format represent an adequate level of treatment for decompensated patients with personality disorders? The study concerns 97 consecutive patients, 50 of whom belonged to cluster A and B personality disorders. The patients were referred partly from an acute admission ward and partly from outpatient departments. The mean treatment time was approximately 6 months. The dropout rate for schizotypal and borderline patients was 38%. No patient committed suicide. Two patients made suicidal attempts during treatment. The level of medication was moderate, and 58% of the patients were drug-free at discharge. Treatment results at discharge, measured by SCL-90 and Health Sickness Rating Scale, were very good for patients with axis I disorders only, good for cluster C personality disorders, modest for borderline patients, and very modest for schizotypal patients. In general, the results indicate that the containing capacity of a day hospital therapeutic community is substantial and that it may reduce the need for long-term inpatient treatment.

The symptom and function dimensions of the Global Assessment of Functioning (GAF) scale

OBJECTIVE The objective was to investigate the validity and clinical impact of the symptom and function dimensions of the Global Assessment of Functioning (GAF) in the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fourth Edition. Is there any need for revision with respect to the DSM, Fifth Edition? MATERIAL The sample comprised 2695 patients consecutively admitted to 14 different treatment units participating in the Norwegian Network of Personality-Focused Treatment Programs from 1998 to 2007. METHODS Convergent and discriminant validity of the symptom and function dimensions of GAF was analyzed by their associations with demographic variables, diagnostic status, and other self-reported variables assessing symptom distress, interpersonal problems, work and social impairment, and quality of life. RESULTS The validity of the separate GAF dimensions was confirmed by discriminant and concurrent associations to other relevant clinical measures. However, the traditional GAF measure based on the lower score of either symptom or function level was found to serve well as a global indicator of symptom distress and social dysfunction. A substantial difference between the symptom and function score of GAF was found in about 10% of the cases; and when differences were found, functional impairment was most often more severe. CONCLUSION This study confirms the validity of the 2 GAF dimensions. However, substantial differences between these dimensions are rarely occurring. We therefore recommend that the GAF scale be prolonged in the DSM, Fifth Edition, roughly in the same shape as in the DSM, Fourth Edition.

The quality of the DSM-IV obsessive-compulsive personality disorder construct as a prototype category.

The study evaluated the quality of the DSM-IV obsessive-compulsive personality disorder (OCPD) construct as a prototype category. A sample of 2237 patients from the Norwegian Network of Psychotherapeutic Day Hospitals was examined by a variety of psychometric analyses. A high number of OCPD patients (77%) had co-occurrent PDs, but only the co-occurrence with paranoid was significantly higher than expected. Exploratory factor analysis of the PD criteria indicated that OCPD consists of 2 dimensions. The first dimension, perfectionism, was constituted by OCPD criteria only and was significantly related to obsessive-compulsive disorder. The second dimension, aggressiveness, included 2 OCPD criteria, reluctance to delegate and stubbornness, but was also defined by criteria from paranoid, antisocial, and borderline PD. Confirmatory factor analysis of the OCPD criteria indicated a poor fit of both a unitary model and a 3-dimensional model. Overall, the OCPD criteria had poor psychometric properties. Although it seems that the quality of the DSM-IV OCPD as a prototype construct is insufficient, it may be improved by deleting the criteria hoarding behavior and miserliness. Alternative criteria could be related to problems in close relationships involving the need for predictability. Such revisions may add a third dimension to the 2 dimensions of perfectionism and aggressiveness.

Self-esteem in patients with borderline and avoidant personality disorders

This study compared self-esteem in patients with avoidant personality disorder (APD) and borderline personality disorder (BPD). Patients diagnosed with one or more personality disorders answered the questionnaire Index of Self Esteem as part of a comprehensive evaluation within the setting of a treatment trial. Our hypotheses were that (1) both patients with APD and patients with BPD would report low levels of self-esteem, (2) patients with APD would report lower self-esteem than patients with BPD. We further expected that (3) patients with higher levels of depression would report lower levels of self-esteem, but that (4) both borderline and avoidant personality pathology would contribute to explained variance in self-esteem beyond what would be accounted for by depression. All of our hypotheses were supported. The results from our study showed a significant difference in self-esteem level between the two personality disorders, patients with APD reporting lower self-esteem than patients with BPD. Subjects with both disorders were measured to have self-esteem levels within the range that presumes clinical problems. Self-esteem represents an important quality of subjective experience of the self, and the study of self-esteem in PDs can offer new and important knowledge of PDs as self-pathology.

Psychotherapy for personality disorders: Short-term day hospital psychotherapy versus outpatient individual therapy – a randomized controlled study

This article describes the results of an eight-month follow-up investigation from a randomized controlled trial of day hospital psychotherapy (DHP) compared with outpatient individual psychotherapy (OIP) for patients with personality disorders (N=114). The patients were randomly assigned to either 18 weeks of day hospital treatment followed by long-term conjoint group and individual therapy (DHP), or outpatient individual psychotherapy (OIP). The main outcome measures were attrition rate, suicide attempts, suicidal thoughts, self-injury, psychosocial functioning, symptom distress, and interpersonal and personality problems. The study showed a low dropout rate and a moderate improvement on a broad range of clinical measures for both treatments. However, there was no indication of the superiority of one treatment over the other. Neither was there any indication that day hospital treatment was better for the most poorly functioning patients. Further studies will follow this group of patients for the next few years, the results of which may have implications for resource allocation and the organization of mental health services for patients with personality disorders.

Outpatient group psychotherapy: A valuable continuation treatment for patients with borderline personality disorder treated in a day hospital?: A 3-year follow-up study

Our objective was to investigate, in a naturalistic, prospective study, the follow-up status of patients with borderline personality disorder (BPD) treated with a combination of day treatment and subsequent outpatient group psychotherapy (G-group, n=12) and compare their status with that of patients with BPD treated in the same day hospital but without subsequent outpatient group therapy (Non-G-group, n=31). At follow-up an average of 34 months after discharge from the day hospital, the G-group patients had a moderate impairment in global health (HSRS), a low level of symptoms (GSI), a low rate of rehospitalization and suicide attempts, and a high rate of remission from substance use disorders. Compared with the Non-G-group, the G-group patients had a significantly higher HSRS and a significantly lower GSI at follow-up. In multivariate analyses controlling for background and treatment variables, number of months in work last year before admission and outpatient group therapy predicted a better HSRS at fol...