Treatment of adolescents with severe (borderline) personality disorder

1. Treatment of adolescents with severe (borderline) personality disorder Joost Hutsebaut & Dineke Feenstra September 2008, Basel

2. Case study Because of privacy reasons this information has been omitted.

3. Some results from an (unscientific) survey • Only 2% of psychiatrists regularly makes a diagnosis of PD before age 18 • Psychiatrists assume that they meet less than 15% of adolescents with personality disorders in their practice • 2 out of 3 psychiatrists do not know that the diagnosis can be made according to DSM-IV-TR • Among the last 20 admissions at our 3rd line centre, no PD was diagnosed before admission and in only 2 cases personality problems were mentioned. After intake 12 were diagnosed with a PD (SCID-II)

4. Personality disorders (PD’s) in adolescence:what do we know? • PD’s can be diagnosed in adolescence (DSM-IV TR, 2000). The classification can be made in a valid and reliable way. • About 15% of adolescents from a community sample suffers from a PD (CIC-study) • Without treatment these are the adults at risk for (among others) several axis I en II disorders, drug abuse, educational failure, unemployment, high costs in somatic and mental health services etc. • PD’s are best treated at an early stage.

5. Treatment of PD’s:what do we know? • PD’s are best treated by psychotherapy (+ pharmacotherapy). • Two evidence based models for treating PD’s in adults: Dialectical Behavior Therapy and Mentalization-based Treatment (other models: SFT, CAT, STEPPS) • No evidence based models for adolescents: few treatment manuals (Bleiberg, 2001; Miller et al., 2007; Freeman & Reinecke, 2007) • No APA guidelines for adolescents; adolescents are kept out of all multidisciplinary guidelines for treating PD’s

6. Guidelines for treating adolescents with (severe) PD’s? • Pathogenesis of PD’s in adolescence • How does adolescence explain the development and escalation of PD’s? • What adolescence-specific processes contribute to this? • Which guidelines can be derived from this? • How can these guidelines be made concrete in the diagnostics and treatment of PD’s in adolescence?

7. Adolescence in general • Changes accumulate: biological, cognitive, emotional, social • These changes imply developmental challenges • Restructuring relationships with parents and siblings • Taking care for health and appearance • Making sense of free time • Intimacy and sexuality • Peer contacts • These changes and challenges also affect the environment

8. Pathogenic processes in adolescence • These changes come too early • There is an accumulation of developmental challenges • It lacks of a safe harbor • Family interactions get rigidified • There is an interaction between developmental tasks and personality traits (in adolescents or parents)

9. Adolescence and PD’s • Adolescence does not explain the PD, but acts as a catalyst for the escalation of maladaptive personality traits into a (full blown) PD

10. General guidelines for treating PD’s in adolescence • Choose for one model that is directed at the pathogenesis of the PD • Involve the different systems in therapy: family, school, justice • Prepare your treatment carefully • Involve developmental tasks in treatment

11. Guideline 1: Choose for one model • A treatment program should be consistent, coherent and consequent • Is yours? • Two models • Dialectical Behavior Therapy (Miller, Rathus, Linehan, 2007) • Mentalization-based treatments (Bleiberg, 2001)

12. Application Guideline 1 • The whole treatment program is based on Mentalization-Based Treatment • This implies that all interventions in treatment are consistent with the aim of improving mentalization (in adolescents and parents) • F.ex. No therapy in the evening (hotel-idea) • All aspects (including diagnostics, psycho education, family therapy, pedagogics etc) are consistent with this model

13. Application guideline 1 • But how does adolescence impact upon the ability to mentalize? • How do developmental tasks affect the ability to mentalize? • How does the ability to mentalize affect the coping with developmental tasks? • In summary, how are the central constructs in your model affected by developmental issues?

14. Guideline 2: Involve different systems • Adolescents still live in an invalidating, non-mentalizing context in which their personality dysfunctioning is often strengthened • Adolescents have less possibilities to choose their environment • Change depends also on a change in the systems surrounding the adolescent • The more systems can be involved, the more generalized the change can be

15. Application guideline 2 • Parents/families are involved in different ways • Psycho-educational workshops • Treatment goals for the family • Family therapy aimed at improving mentalizing • Invited for regular evaluations of treatment • School is involved • Contact with school of origin • Staff members go to school and help to discuss a school plan • Peers are involved • 4 times/year peers are invited to learn more about the treatment (in general)

16. Guideline 3: Prepare the treatment carefully • Preparation phase before ‘actual’ treatment • Aims • Therapy-informing diagnostics • Psycho-education • Context regulation • Crisis management • Motivation enhancement • Ends in an admission case conference with different parties (adolescent, parents, treatment team, school, referring psychiatrist,…)

17. Application guideline 3: diagnostics Make a diagnostic formulation: • Understandable for the adolescent • Identifying the link between non-mentalizing interactions and symptoms • Identifying pitfalls and goals in treatment

18. Application guideline 3: diagnostics Start with a thorough assessment procedure allowing information to be collected in a model-specific way: • Developmental history • Multiple informants (patient, parents, siblings, teachers) • (Semi)-structured interview (SCID-II, AAI) • Personality questionnaires (SIPP, MMPI-A, …) • Projective material (Ror, TAT, Drawings)

19. Application guideline 3: diagnostics Diagnostic formulation: different steps • step 1: personality pathology • step 2: developmental history • step 3: developmental phase • step 4: interaction with the environment • step 5: identification of treatment goals and pitfalls • step 6: treatment selection

20. Application guideline 3: psycho-education • Psycho-education about • Borderline PD • MBT-A • How MBT can help to improve symptoms of BPD • Workshop ‘Basic mentalizing’ • 2*6 sessions • Psycho-education and exercises about mentalizing • F. ex. Discussion about thesis: Mentalizing well can be painful • F. ex. TAT drawings: can you understand why you wrote this story?

21. Guideline 4: involve developmental tasks • Treatment should also help to deal with developmental tasks • Create a safe harbor to deal with developmental tasks on other domains • Dose developmental tasks: one by one • Treatment should help parents to deal with parental tasks

22. Application guideline 4 • Dealing with developmental tasks is one of 5 basic goals in therapy • There is a weekly group session about developmental issues (on a mentalizing base) • There are workshops for parents about adolescence and developmental tasks for parents in adolescence

23. Contact • Email joost.hutsebaut@deviersprong.nl dineke.feenstra@deviersprong.nl • Website www.deviersprong.nl www.vispd.nl