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???Let’s 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 RCT’s • 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 isaffective 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)