Assessment and treatment of severe personality disorders in adolescence

1
Assessment and treatment of severe personality
disorders in adolescence

• ISSPD Congress 2007
• The Hague, September 19
• Joost Hutsebaut, Kirsten Catthoor, and Dineke
  Feenstra

2
What do you know about personality disorders in
adolescence???Lets start with a little quiz
3
Thesis 1

• In DSM-IV-TR (2000), age is no criterion for the
  diagnosis of personality disorders.
• In other words, clinicians are allowed to give a
  diagnosis of PD to a minus 18-years old.

4
Multiple choice 1

• A. True in all cases
• B. True in all cases except for the diagnosis
  of antisocial PD
• C. Only true for the borderline PD
• D. Not true

5
Answer 1

• The correct answer is B.
• DSM-IV-TR p. 687
• There is no age criterion for the diagnosis of PD
  in DSM-IV-TR, except for the antisocial PD.

6
Thesis 2

• The prevalence of borderline PD in adults and
  adolescents is about the same.

7
Multiple choice 2

• A. Not true, the prevalence of borderline PD is
  higher in adults.
• B. Not true, the prevalence of borderline PD is
  higher in adolescents.
• C. True
• D. There is no information on this.

8
Answer 2

• The correct answer is C.
• There is empirical evidence that the prevalence
  of borderline PD is (more or less) the same in
  adults and adolescents in as well a community as
  a clinical sample.
• 14.4 of community adolescents can be diagnosed
  with a PD.

9
Thesis 3

• The diagnosis of BPD in adolescence predicts more
  axis 1 and axis 2 disorders in early adulthood.

10
Multiple choice 3

• A. True.
• B. Only true for axis 1, not for axis 2.
• C. Only true for axis 2, not for axis 1.
• D. Not true.

11
Answer 3

• The correct answer is A the diagnosis of PD in
  adolescence predicts as well axis 1 as axis 2
  disorders in early adulthood.
• Axis 1 disorders are a highly sensitive marker
  for the seriousness of the PD.

12
Thesis 4

• What is the most specific feature of a borderline
  PD in adolescence?

13
Multiple choice 4

• A. Impulsivity.
• B. Instability of affect.
• C. Identity confusion.
• D. Suicidal ideation and gestures.

14
Answer 4

• The correct answer is B.
• The most typical feature of borderline PD in
  adolescents is instability of affect, in adults
  it is impulsivity.

15
Thesis 5

• 4 to 20 of adult patients in an inpatient
  setting self mutilates. What is the percentage of
  self injurious behavior in adolescents in an
  inpatient treatment setting?

16
Multiple choice 5

• A. Less than adults, 5 to 10.
• B. The same as adults, 10 to 20.
• C. A little more than adults, 25-40.
• D. Much more than adults, 40-60.

17
Answer 5

• The correct answer is D.
• 90 of all self injurious behavior happens in
  adolescence.

18
Case Study

• (Because of privacy reasons this information has
  been omitted)

19
Psychotherapy in PD adolescents?

• Review of 25 empirically supported
  psychotherapies in adolescents (Weisz and Hawley,
  2002)
• 14 effective
• 7 adult models, 6 child models
• 1 adolescent model
• Review of 34 studies of CBT in adolescents
  (Holmbeck et al., 2003)
• 9 (26) involved developmental issues
• 1 studied a developmental factor as moderator of
  outcome
• PD in adolescence?
• No RCTs
• No age-specific treatment guidelines
• Few treatment manuals (Bleiberg, 2001), Miller et
  al (2007), Freeman and Reinecke (2007)

20
Psychotherapy in PD adolescents?

• Conclusion
• No evidence based adolescence-oriented
  psychotherapy models for PD
• Almost no well developed treatment manuals
• No age-specific practice guidelines (APA etc)
• Challenging!

21
What are our objectives today?

• Proposal of practice guidelines for the
  assessment and treatment of severe PD in
  adolescents (mainly cluster B)
• Pragmatically how to design a concrete treatment
  trajectory
• Systematically from intake to follow-up
• Not restricted to one theoretical frame
• Based on
• Literature and evidence based results of
  research on PD in adults
• Available literature on (treatment of) PD in
  adolescence
• Literature on developmental psycho(patho)logy in
  adolescence
• Our clinical experiences with PD adolescents

22
Structure of the workshop

• Assessment of PD in adolescence
• Empirical research on PD in adolescence
• Assessment of PD in adolescence and indication
  for treatment setting
• Designing a flexible treatment trajectory
• Preparation phase
• Integrative, adolescence-specific, treatment,
  including psychotherapy, system therapy and
  pharmacotherapy
• Relapse prevention and follow-up

23
Structure of the workshop

• Assessment of PD in adolescence
• Empirical research on PD in adolescence
• Assessment of PD in adolescence and indication
  for treatment setting
• Designing a flexible treatment trajectory
• Preparation phase
• Integrative, adolescence-specific, treatment,
  including psychotherapy, system therapy and
  pharmacotherapy
• Relapse prevention and follow-up

24
Empirical research on PD in adolescence

• Is it allowed to give a diagnosis of PD to an
  adolescent?
• Is it wise to give a diagnosis of PD to an
  adolescent?
• How often do PD occur in adolescence?
• How do PD develop throughout adolescence?

25
Is it allowed to give a diagnosis of PD to an
adolescent?

• DSM-IV-TR (APA, 2000, p. 687)
• PD can be diagnosed in adolescents
• Clinicians should be careful
• Symptoms have to be present during 1 year
• Exception antisocial PD should not be diagnosed
  before the age of 18 yrs
• How well is this known in the field???

26
Is it wise to give a diagnosis of PD to an
adolescent?

• This is also an empirical issue
• Can PD be diagnosed in a reliable way in
  adolescence?
• Is it a valid diagnosis?
• Diagnosis refers to the same characteristics
• Diagnosis correlates with similar associated
  problems
• Diagnosis predicts similar problems in the future
• Diagnosis has some stability over time

27
Is it wise to give a diagnosis of PD to an
adolescent? 1. Reliability

• There are as many PD adolescents as PD adults in
  a clinical sample (Westen, Shedler et al., 2003
  Grilo, McGlashan et al., 1998) and in a community
  sample (Johnson, Cohen et al., 2000).
• Almost all specific PD occur in the same
  frequency
• Exception antisocial and avoidant PD
• These PD adolescents show a similar pattern of
  co-morbidity
• 2/3 between 2 and 9 PD diagnoses in a clinical
  sample
• 50 2 or more in a community sample

28
Is it wise to give a diagnosis of PD to an
adolescent? 2. Construct validity

• EFA on all PD symptoms gives evidence for 10
  empirically derived factors, similar to DSM IV PD
  categories (Durrett Westen, 2005)
• Q analysis based on clinical descriptions gives
  evidence for similar categories of PD in adults
  and adolescents (Westen, Shedler et al., 2003)
• EFA on personality symptoms (DIPSI, SIPP) has a
  similar structure in adolescents as in adults (De
  Clercq et al., 2006 Feenstra et al., 2007)
• ? Personality pathology in adolescence has a
  similar structure as personality pathology in
  adults

29
Is it wise to give a diagnosis of PD to an
adolescent? 3. Concurrent validity

• PD diagnosis in adolescence is associated with
• More suicidal ideation and acts (Westen et al.,
  2003 Braun-Scharm, 1996)
• More problems at school and less friends (Westen
  en al., 2003)
• More behavioral problems and problems at school
  (Johnson et al., 2005)
• Alcohol abuse, smoking and illegal drug abuse
  (Serman et al., 2002)
• More sexual partners and high risk sexual
  contacts (Lavan Johnson, 2002)
• More violent acts (assault, burglary, initiating
  fights, threatening)
• More MH service use, more medication use (Kasen
  et al., 2007)

30
Is it wise to give a diagnosis of PD to an
adolescent? 4. Predictive validity

• PD diagnosis in adolescence predicts
• Subsequent failure in school (Johnson et al.,
  2005)
• More negative affects, distress, problems in
  social support, living, mobility, finances and
  health in adulthood (Chen et al., 2006)
• More health problems, more problematic social
  contacts, less psychological wellbeing and more
  adversities in early adulthood (Chen et al.,
  2006)
• More conflicts with family members in early
  adulthood (Johnson et al., 2004)
• More depression in early adulthood (Daley et al.,
  1999)
• More interpersonal stress in early adulthood
  (Daley et al., 2006)
• More relational dysfunctioning in romantic
  relations (Daley et al., 2000)
• More anxiety, mood and substance abuse disorders
  in early adulthood (Johnson et al., 1999)
• More illegal dugs abuse and crisis intervention
  (Levy et al., 1999)

31
Is it wise to give a diagnosis of PD to an
adolescent? Differences

• Internal consistency of PD criteria of a given PD
  is generally lower in adolescence than in
  adulthood (except for BPD and dependent PD)
  (Becker et al., 2001)
• The overlap of criteria from different PDs is
  larger, suggesting a more diffuse range of
  psychopathology (Becker et al., 1999)
• There is evidence for more co-morbidity between
  different (A, B, C) clusters (Becker et al., 2000)

32
BPD in adolescence

• Frequency of BPD and BPD traits is similar in
  adolescent and adult clinical sample (Becker et
  al., 2002)
• Symptoms and phenomenology of BPD is similar for
  adolescent girls and adults (Bradley et al.,
  2005)
• Internal consistency of BPD criteria in
  adolescence is high (.76) (Becker et al., 1999)
• Q analysis gives evidence for similar subgroups
  of BPD girls as in adults (Bradley et al., 2005)

33
BPD in adolescents Types and associated axis 1
disorders

• Different types of BPD (Bradley et al., 2005)
• High functioning and internalizing
• Histrionic
• Depressive internalizing
• Angry and externalizing ? case study
• Associated axis 1 disorders (Becker, 2006)
• Suicidal gestures and emptiness (depressive
  disorders and alcohol abuse disorders)
• Affective instability, uncontrolled anger and
  identity disturbance (anxiety disorder and
  conduct disorder)
• Unstable relationships and fear of abandonment
  (anxiety disorder)
• Impulsivity and identity disturbance (conduct
  disorder and substance abuse disorder)

34
BPD in adolescence some differences

• Individual BPD criteria have a higher general
  positive predictive power than in adults (1
  symptom generally predicts better the overall
  disorder)
• Fear of abandonment is the best inclusion
  criterion in adolescence (if present, high
  predictive power for BPD)
• Uncontrolled anger is for adolescents the best
  exclusion criterion, for adults impulsivity (if
  absent, no BPD)
• Taken together is affective instability for
  adolescents and impulsivity for adults the most
  useful criterion.

35
Prevalence of PD in adolescence

• PD 14,4 (CIC study)
• Cluster A 5,9
• Paranoid 3,3
• Schizoid 1,1
• Schizotypal 1,7
• Cluster B 7,1
• Borderline 2,4
• Histrionic 2,5
• Narcissistic 3,1
• Cluster C 4,9
• Avoidant 2,0
• Dependent 2,2
• Obsessive-compulsive 1,1

36
Course of PD in adolescence

• CIC-study
• PD traits decrease with 28 between adolescence
  and early adulthood (Johnson et al., 2000)
• Stability is lowest between 14 and 16 yrs
  (Johnson et al., 2000)
• Clinical samples
• Modest stability for dimensional measures of
  personality pathology (Daley et al., 1999 Grilo
  et al., 2001)
• After two yrs 74 diagnosis PD (83 girls, 56
  boys) stability of specific PD is low (Chanen et
  al., 2004)
• Stability is high for schizoid and antisocial PD
  modest for borderline, histrionic and schizotypal
  PD and low for other Pds (Chanen et al., 2004)

37
Is it wise to give a diagnosis of PD to an
adolescent? General conclusions

• The diagnosis of PD can be made in a reliable way
  in adolescence
• About 10-15 of adolescents have a PD
• The diagnosis of PD in adolescence has excellent
  concurrent validity it is associated with many
  parameters of distress and dysfunctioning.
• The diagnosis of PD has modest predictive
  validity. It reliably predicts dysfunctioning in
  the future, but the diagnostic stability of
  specific PD categories is rather small.
  Diagnostic stability of the general PD diagnosis
  on the other hand is good.
• As in adults, co-morbidity is high, but probably
  broader (encompassing aspects of other PD
  clusters).
• BPD in adolescents has got excellent internal
  consistency, construct validity and concurrent
  validity.
• There is evidence that the weaker stability of
  BPD can be ascribed mainly to the instability of
  the affective and impulsive symptoms.

38
How to conceive personality disorders?

• PD is a chronic condition of structural
  vulnerability, that develops from early childhood
  through adolescence into adulthood and that
  expresses itself in interaction with a changing
  environment in a fluctuating pattern of
  maladaption.
• Chronic condition, but fluctuating expression
• Expression depends on context
• Expression might depend on developmental factors
• Different developmental pathways, starting from
  childhood

39
Structure of the workshop

• Assessment of PD in adolescence
• Empirical research on PD in adolescence
• Assessment of PD in adolescence and indication
  for treatment setting
• Designing a flexible treatment trajectory
• Preparation phase
• Integrative, adolescence-specific, treatment,
  including psychotherapy, system therapy and
  pharmacotherapy
• Relapse prevention and follow-up

40
AssessmentGeneral remarks

• Use of multiple informants (parents, teachers,
  children)
• Attitude of the clinician
• Assessment should be evidence based
• Aim not only diagnostic assessment, but also to
  increase the motivation of the patient

41
AssessmentDevelopmental history

• Indicators of high risk for the development of
  personality disorders

42
AssessmentIntelligence

• Importance of intelligence testing
• Case Kaufman Adolescent and Adult Intelligence
  Test (KAIT)

43
AssessmentNeuropsychological testing

• Gives additional information to validate the
  diagnosis of a PD
• Indicates the impact of a PD

44
AssessmentSymptoms

• Case Brief Symptom Inventory (BSI)

45
AssessmentSymptoms

• Case Child Behaviour Checklist (CBCL)

46
AssessmentAxis I

• Case Anxiety Disorders Interview Schedule for
  DSM-IV, Child Version (Adis-C), Complemented with
  modules from the Structured Clinical Interview
  for DSM-IV axis I disorders (SCID-I)
• Diagnosis axis I
• Posttraumatic stress disorder
• Substance dependence
• Conduct disorder

47
AssessmentAxis II

• Case Structured Clinical Interview for DSM-IV
  axis II Personality Disorders (SCID-II)
• Diagnosis axis II Borderline Personality
  Disorder
• Frantic efforts to avoid real or imagined
  abandonment
• A pattern of unstable and intense interpersonal
  relationships characterized by alternating
  between extremes of idealization and devaluation
• Identity disturbance
• Impulsivity
• Recurrent suicidal behavior, gestures or threats,
  or self-mutilating behavior
• Affective instability
• Chronic feelings of emptiness
• Inappropriate, intense anger or difficulty
  controlling anger
• Transient, stress-related paranoid ideation or
  severe dissociative symptoms

48
AssessmentSpecific borderline characteristics

• Suicide Risk Assessment
• Assessment of dissociation
• Case Diagnostic Interview for Borderlines
  (DIB-R), included in Clinical Interview

49
AssessmentStructural characteristics

• Case Questionnaires
• NEO-PI-R

50
AssessmentStructural characteristics

• Case Projective tests (Rorschach, plate IV)

51
AssessmentCompetence

• Case Competentie Belevingsschaal voor
  Adolescenten (CBSA), derived from the
  Self-Perception Profile for Adolescents (SPPA)

52
AssessmentFamily

• Case Family Assessment Device (FAD)

53
AssessmentConclusions case

• Patient is diagnosed with a BPD on axis 2 and an
  associated PTSD, conduct disorder and substance
  dependence on axis 1.
• Underlying we see a low-level borderline
  organization identity is fragmented, object
  representation are split, reality testing is
  fragile, defenses are immature.
• Nevertheless, we also see some adaptive coping
  mechanisms and a good self-reflexive capacity
  during the assessment.
• Because of her traumatically developed
  attachment, patient is unable to experience any
  form of safe intimacy or nearness.
• When stress increases (e.g. in case of
  approaching separation) patient loses the
  capacity to reflect and her adaptive coping
  mechanisms. She then turns to maladaptive coping
  mechanisms, like splitting, and aggressive and
  anti-social behavior to restore the lost balance.
  This antisocial behavior has to be understood as
  a way to protect her autonomy and her self
  against unbearable feelings provoked by intimacy
  and related fear for abandonment.

54
From assessment to indication levels of
treatment setting

• Outpatient treatment
• Partial hospitalization
• Brief inpatient hospitalization
• Extended inpatient hospitalization

55
Indication for treatment setting Considerations
about case study

• Based on APA guidelines extended inpatient
  treatment
• Persistent risk behavior
• Severe symptoms interfering with family and
  school life
• Risk of assaultive behavior towards others
• Co-morbid substance abuse
• Based on extra adolescent considerations
  (Bleiberg, 2001) extended inpatient treatment
• Insufficient resources to provide a safe
  environment at home
• Need for more structure and support
• Based on clinical experience
• There is a serious pitfall that she cannot deal
  with the pressure for attachment in an inpatient
  setting (psychological testing)

56
Structure of the workshop

• Assessment of PD in adolescence
• Empirical research on PD in adolescence
• Assessment of PD in adolescence and indication
  for treatment setting
• Designing a flexible treatment trajectory
• Preparation phase
• Integrative, adolescence-specific, treatment,
  including psychotherapy, system therapy and
  pharmacotherapy
• Relapse prevention and follow-up

57
Designing a flexible treatment trajectory

• Treatment should be seen as a continuous
  trajectory
• During different years (2-5 years)
• With changing intensity
• Stepped up and down
• Preparation phase focused at psycho-education and
  motivation, crisis management and context
  regulation
• A residential phase to decrease stress at home
  and start a therapeutic process
• A day treatment phase to strengthen the
  achievements and anchoring them in real life
• A follow-up of booster sessions to support the
  internalized therapeutic process
• Involving psychotherapy, system therapy and
  pharmacotherapy

58
Designing a flexible treatment trajectory
59
Structure of the workshop

• Assessment of PD in adolescence
• Empirical research on PD in adolescence
• Assessment of PD in adolescence and indication
  for treatment setting
• Designing a flexible treatment trajectory
• Preparation phase
• Integrative, adolescence-specific, treatment,
  including psychotherapy, system therapy and
  pharmacotherapy
• Relapse prevention and follow-up

60
Preparation phase goals

• Psycho education
• Context regulation
• Crisis management plan

61
Preparation phase methods for psycho-education

• Psycho-education is a necessary part of the
  treatment of PD (APA guidelines)
• Explanation about the symptoms, the origin and
  the course of the disorder, and the possibilities
  of treatment.
• Giving hope. It is not about learning to live
  with the disorder, but about curing.
• For patients and their family theres often
  relief that the problems have a name, so they
  can start to understand them.
• Psycho-education helps to bring order in the chaos

62
Preparation phase methods for psycho-education

• Practical tips
• Try to use the language adolescents are familiar
  with. Words like psychiatric illness can be
  frightening.
• Mind the intelligence and cognitive skills of the
  adolescent and the parents and adapt your
  explanation to their limitations
• It might be necessary to dose the information and
  plan different sessions

63
Preparation phase methods for psycho-education

• Examples of standardized sentences for explaining
  the diagnosis
• You came here because you have problems for quite
  a while and treatment didnt help you enough so
  far.
• Weve had several sessions with you and your
  parents and asked you to participate in some
  psychological testing.
• We think its important to find out what is
  really going on, in order to suggest a treatment
  designed for the problems you have

64
Preparation phase methods for psycho-education

• Your problems can be understood as making part of
  a (borderline) personality disorder.
• Easily speaking, it means that you have
  difficulties in dealing with your self, with your
  feelings, thoughts and behavior, and difficulties
  in contacts with other people.
• A borderline PD consists of 9 characteristics, 5
  is enough for the diagnosis. This means that
  every patient with a borderline PD is different
  from every other patient.
• We now want to give you some information about
  the characteristics. Do you agree with that?

65
Preparation phase methods for psycho-education

• Fear of abandonment
• You are afraid that people will drop you.
• You are convinced that people dont care for you
  and that youre worth nothing.
• You will do everything to avoid people leaving
  you, for example sending text messages all the
  time, insisting on your contacts on MSN
• People get irritated, feeling of being suffocated
  en they will try to avoid your claim
• So what happens is just that scenario where you
  are so afraight of

66
Preparation phase methods for psycho-education

• Affect instability
• You feel like your affect is never stable, you
  can never be happy for some longer time
• Sometimes you feel so depressed en sad that
  suicide is all you can think of, and 1 minute
  later you are euphoric en busy
• You are easily irritated and your parents have
  the feeling they have to tread on eggs when
  youre at home

67
Preparation phase methods for psycho-education

• From the psychological testing we learned that
  you have a splitted inner world, with anger and
  emptiness as the only possible ways of expressing
  your feelings.
• This means that your emotions are not easily
  accessible, and it is very difficult for you to
  differentiate what you really feel and
  experience. You dont have tools to make your
  inner feelings more comprehensible for yourself.

68
Preparation phase methods for psycho-education

• You are very frightened, and you can only control
  that feeling by showing aggression.
• It is very difficult for you to make a difference
  between experiences in reality, and what you feel
  inside. F.e. when your therapist sets limits,
  when you are thinking of the humiliations of your
  stepfather, you will not always be able to make a
  distinction between these 2 situations. You will
  confuse your inner and outer world.

69
Preparation phase methods for psycho-education

• Because you are impulsive, as well in changing
  schools, living with your parents, using drugs
  and alcohol, as having sex with boys, there is a
  chance that you will be impulsive in terminating
  the treatment also.
• It will be important to focus on that when its
  difficult for you to fully cooperate.

70
Preparation phase methods for psycho-education

• You find it very difficult when people want to
  make close contact with you. You do not trust
  intimate relationships. You prefer to break
  contact yourself, to avoid that people will leave
  you.
• Therefore it will be extremely important to keep
  that pattern in mind in the relationship with
  your therapists.

71
Preparation phase goals

• Psycho-education
• Context regulation
• Crisis management plan

72
Preparation phase methods for context regulation

• What should be arranged for the treatment to be
  able to start?
• Financially
• Juridical
• Mobility (transport to treatment setting)
• Structured daily activity (in case of outpatient)
  
• Safe weekend destination (in case of inpatient)

73
Preparation phase methods for context regulation

• How can continuity before, during and after
  treatment be improved?
• Contact with referring psychiatrist/psychologist
• Contact with school
• Home visit by social worker
• Social network, neighborhood etc
• Use a clear therapeutic frame
• What rules about drugs and alcohol?
• Give an information sheet with basis rules,
  expectancies, treatment methods

74
Preparation phase goals

• Psycho-education
• Context regulation
• Crisis management plan

75
Preparation phase methods for crisis management

• Severe PD lead almost by definition to crises
  during treatment.
• Crises give agitation and can interfere with
  countertransference, leading to splitting in a
  team.
• Designing a plan for crisis management gives
  control and predictability
• The goal is to stabilize the crisis so the
  treatment process is not jeopardized
• Make clear agreements with patient and parents in
  advance, specifically about the availability of
  therapists
• Give clear roles to staff members in dealing with
  the crisis medical care, psychological care,
  decision about transfer to other setting
• Agree with patient and parents on a plan for
  crisis management during the weekend or evening.
  Put it on paper.

76
Structure of the workshop

• Assessment of PD in adolescence
• Empirical research on PD in adolescence
• Assessment of PD in adolescence and indication
  for treatment setting
• Designing a flexible treatment trajectory
• Preparation phase
• Integrative, adolescence-specific, treatment,
  including psychotherapy, system therapy and
  pharmacotherapy
• Relapse prevention and follow-up

77
Designing a flexible treatment trajectory
78
Designing an integrative, adolescence-specific
treatment

• Psychotherapy is treatment of first choice
• Dialectical Behavior Therapy
• Mentalization Based Treatment
• (Schema Focused Therapy)
• Pharmacotherapy should be considered as an
  enabler of psychotherapy
• System therapy is a necessary complement of
  psychotherapy in adolescence

79
Some general remarks about psychotherapy for
severe PD

• Two evidence based models for treating BPD in
  adults (Cochrane review, 2006)
• Dialectical Behavior Therapy (Linehan, 1991)
• Mentalization Based Treatment (Bateman Fonagy,
  1999, 2004, 2006)

80
Dialectical Behavior Therapy

• Based on cognitive-behavioural therapy
• Hierarchy of interventions
• Interventions aimed at reducing self-mutilating
  behaviour
• Interventions aimed at behaviour that interferes
  with the therapeutic process
• Interventions aimed at improving quality of life
• Out-patient individual therapy, once a week, in
  combination with group therapy
• Empirical evidence for effectiveness of DBT
  (Koons, 2001 Linehan 1991, 1999, 2002 Turner,
  2000 van den Bosch, 2002)
• Adaptations made for adolescents!

81
DBT in adolescenceAdaptations (Miller et al.,
2007)

• Parents participate in the skill groups
  (multifamily skill training group)
• Shorter treatment
• Simpler hand-outs
• Simpler diary
• Including family therapy (as-needed base)
• Including extra skills that are relevant for
  parents or siblings
• Telephone consultations for parents
• A new module walking the middle path,
  introducing three new dialectical dilemmas

82
Mentalization Based Treatment

• Psychodynamic oriented treatment program
• Attachment theory
• Primary aim to enhance mentalization
• Outpatient treatment program (18 months)
• Empirical evidence for effectiveness of MBT
  (Bateman, 1999)

83
Some general remarks about pharmacotherapy for
severe PD

• Psychotherapy is treatment of first choice
• Pharmacotherapy as enabler, to make
  psychotherapy more possible
• No evidence based treatment methods
• Guidelines for adults, warnings for children and
  adolescents
• Controversies, for instance about SSRis

84
Some general remarks about pharmacotherapy for
severe PD

• Be aware of the differences in pharmacokinetics
  in children and adolescents
• Percentage of body fat
• Lipophile binding
• Speed of metabolism
• Plasma proteins
• Demolition

85
Some general remarks about pharmacotherapy for
severe PD

• Symptom-targeted pharmacotherapy in patients with
  PD is confusing.
• Is the symptom (f.e. negative affect) part of the
  personality disorder, or is it part of an axis-1
  disorder (f.e. major depressive disorder)
• Cochrane review no exclusion of axis 1
  disorders, except for psychotic disorders

86
Some general remarks about pharmacotherapy for
severe PD

• APA-guidelines (2001)
• 3 algorithms
• Affective dysregulation
• Impulsive behavior
• Cognitive-perceptual symptoms
• No clinical trials
• More practice based than evidence based

87
Pharmacotherapy some case study interventions

• Because of the seriousness of the symptoms of our
  patient we choose a combinations of different
  products
• Escitalopram 10 mg for heavy mood changes
• Quetiapine 300 mg for cognitive-perceptual
  symptoms, psychotic-like fears and impulsivity
• Topiramate 50 mg for dissociation, the images of
  sexual abuse and humiliations of step father
• Diazepam 5 mg for the side effects after alcohol
  stop.

88
Some general remarks about system therapy for
severe PD

• Is a necessary part of the treatment of a PD
  adolescent, on practice based arguments
• Youngsters can only change and grow within the
  context of their family. When there is no
  continuity between the therapy and the milieu at
  home, changes will not last long.
• Several different models have proven their
  solidity, but there is no evidence based
  background.
• New research can support the guideline of always
  working with the family of the adolescent.

89
Some general remarks about system therapy for
severe PD

• I-BAFT integrative borderline adolescent family
  therapy
• Multidimensional family therapy, based on
  attachment theory
• Integrative family therapy with genograms and
  core qualities

90
How to design a flexible and effective treatment
integrating those components?

• Therapeutic relationship including limit setting
• How does developmental phase affect therapy for
  severe PDs?
• What are goals and methods in different phases of
  the therapeutic process?

91
Therapeutic relation

• Install a therapeutic alliance based on
  cooperation
• Be transparent (about interventions, treatment
  goals etc)
• Avoid an expert or moralizing position.
• Balance between acceptance/validation and
  change/empathic confrontation

92
Therapeutic relation limit setting

• It is probably impossible to avoid setting limits
  (and it is probably damaging)
• There are three principles to keep in mind
• Adolescents should be given a proper (and
  growing) responsibility
• Limits should not be administered in an
  automatic, procedural way, but with the mind of
  the adolescent in mind
• Therapists should be transparent about the why
  of limit setting
• Be aware of extremes authoritarian control
  versus excessive leniency (Miller et al., 2007)

93
How does developmental phase affect therapy for
severe PDs?

• Methods and interventions
• Cognitive, emotional, social and identity
  development determine how to do therapy
• Attune to cognitive level,
• Content/issues
• Developmental tasks determine what therapy is
  about (treatment goals)
• Sexual identity, separation from parents,

94
Developmental guidelines for choosing methods and
interventions

• Based on cognitive development
• Be concrete (especially with adolescents under 15
  yrs)
• Visualize
• Be careful with metaphors
• Dont lean too much on hypothetical thinking
• Support critical thinking
• Practice meta-thinking

95
Developmental guidelines for choosing methods and
interventions

• Based on emotional development
• Be aware that affective instability is the core
  of BPD in adolescents
• Start by identifying simple emotions before
  proceeding to complex mental states
• Give words to identify emotions
• Learn to discriminate between intensities and
  sorts of emotions
• Reinforce proper expression of emotions

96
Developmental guidelines for choosing methods and
interventions

• Based on social development
• Let the adolescent save face
• Be aware of the enhanced vulnerability in groups
• Be aware that the attachment to peers might be as
  important (or even more) than the attachment to
  therapists
• Invest in installing a positive, accepting group
  norm

97
Developmental guidelines for choosing methods and
interventions

• Based on identity development
• Support autonomy
• What do you want to change?
• How do you want to use this session?
• Offer opportunities to separate
• Support critical thinking
• Give privacy
• Tolerate experimenting behavior

98
Developmental guidelines for determining
treatment goals

• Based on developmental tasks (12-15 yrs)
• Dealing with physical changes
• Constructing own frame of reference (norms,
  values)
• Connect with peers
• Based on developmental tasks (15-20 yrs)
• Becoming more independent from feedback of peers
  and adults
• Developing a stronger self-esteem
• Developing social and professional skills
• Re-constructing a relationship with parents

99
Goals and methods in different phases of the
therapeutic process

• Start phase
• Middle phase
• End phase

100
Start phaseGoals

• Install a secure, predictable environment
• Enhance motivation / commitment
• Agree upon prior treatment goals
• Start by improving a sense of competence in the
  adolescent and his/her family
• Medication

101
Start phase some methodological issues

• About motivation
• Roll with resistance
• Do not convince from an expert position
• Let the adolescent motivate himself by eliciting
  self-motivating expressions
• Use authentic and focused reinforcements to
  highlight advances
• How was it for you to experience you succeeded in
  managing stress in this way?

102
Start phasesome methodological issues

• About improving competence
• Start by thinking about or even teaching skills
  to cope with stress
• Assist caregivers in achieving skills to remain
  in control even when facing internal and
  interpersonal turmoil
• Psycho-education
• Skill group

103
Start phase some case study interventions

• We predicted upcoming relational patterns
• If you tell me you always tend to break up
  friendships after some months, this might be
  happening here too.
• We looked for agreement on prior symptoms
• She was frightened by her cutting and burning,
  being afraid she would lose control
• About trauma I understand this is something
  extremely important for you, which we will have
  to work on further in treatment, but at this
  moment I notice that talking about it gives you a
  lot of tension and often leads to cutting
  yourself.

104
Start phase some case study interventions

• We looked for alternatives to cope with stress
• We made a concrete minute-to-minute crisis plan
• There was a joined consult with the therapist and
  psychiatrist about medication
• The family was taught some basic skills to
  prevent discussions from escalating

105
Middle phaseGoals

• Help the adolescent to relate symptoms to mental
  states that occur in the context of relations
• Help the adolescent to face developmental tasks,
  including developing a new relationship with
  parents

106
Middle phasesome methodological issues

• About developing a reflective stance
• Identify and validate actual or recent mental
  states
• Differentiate and contextualize
• Internalize and help to take responsibility
• Digest and help to tolerate ambivalence
• Integrate in alternative behavior and mental
  states

107
Middle phase some case study interventions

• Tania often started therapy announcing how crap
  she felt
• What do you mean by crap? How sad, angry,
  anxious?
• Can you remember when you noticed some change in
  how you felt? Attitude it might be worth to
  explore in detail how you came to feel this way
• Can you understand why this (trigger) made you
  feel this way?
• How is it to understand yourself in this way?

108
Middle phase some case study interventions

• After three months, acting out dramatically
  increased (drinking, crossing limits)
• She wanted to stop treatment because it got
  boring
• Can you help me to understand how it got this
  far? Where did you notice a change in motivation?
  
• This enhanced reflective stance made her aware of
  her fear for intimacy of group members
• I cannot tolerate it anymore. I dont want to
  experience a goodbye of group members anymore
• She experienced extremely aggressive thoughts
  including group members, which made her angry
• With this broadening perspective, she was invited
  to rethink her decision to stop.
• We accepted her decision.

109
End phaseGoals

• Anticipate on reintegration
• Prepare for loss associated with leaving
• Relapse prevention

110
End phasesome methodological issues

• About relapse prevention
• Identify traps
• Identify future life stressors
• Identify successful coping and new competencies
• Make a written therapy summary with your patient

111
Follow-up

• Stepped down care gradually less intensive
  treatment and more intensive reintegration in
  school, work etc
• Booster sessions

112
Contact

• Email joost.hutsebaut_at_deviersprong.nl
• kirsten.catthoor_at_deviersprong.nl
• dineke.feenstra_at_deviersprong.nl
• Website www.deviersprong.nl
• www.vispd.nl