Clinical and service implications of a cognitive analytic therapy model of psychosis

Cognitive analytic therapy (CAT) is an integrative, interpersonal model of therapy predicated on a radically social concept of self, developed over recent years in the UK by Anthony Ryle. A CAT-based model of psychotic disorder has been developed much more recently based on encouraging early experience in this area. The model describes and accounts for many psychotic experiences and symptoms in terms of distorted, amplified or muddled enactments of normal or ‘neurotic’ reciprocal role procedures (RRPs) and of damage at a meta-procedural level to the structures of the self. Reciprocal role procedures are understood in CAT to represent the outcome of the process of internalization of early, sign-mediated, interpersonal experience and to constitute the basis for all mental activity, normal or otherwise. Enactments of maladaptive RRPs generated by early interpersonal stress are seen in this model to constitute a form of ‘internal expressed emotion’. Joint description of these RRPs and their enactments (both internally and externally) and their subsequent revision is central to the practice of CAT during which they are mapped out through written and diagrammatic reformulations. This model may usefully complement and extend existing approaches, notably recent CBT-based interventions, particularly with ‘difficult’ patients, and generate meaningful and helpful understandings of these disorders for both patients and their treating teams. We suggest that use of a coherent and robust model such as CAT could have important clinical and service implications in terms of developing and researching models of these disorders as well as for the training of multidisciplinary teams in their effective treatment

Personality disorder among youth with first episode psychotic mania: An important target for specific treatment?

Personality disorder is a common co-occurrence ('comorbidity') among patients with bipolar disorder and appears to affect outcome negatively. However, there is little knowledge about the impact of this comorbidity in the early phases of bipolar disorder. We examined the prevalence and effect of personality disorder co-occurrence on outcome in a cohort of youth with first episode mania with psychotic features. Seventy-one first episode mania patients, aged 15-29, were assessed at baseline, 6, 12, and 18 months as part of a randomized controlled trial of olanzapine and chlorpromazine as add-on to lithium in first episode mania with psychotic features. The current study involved secondary analysis of trial data. A co-occurring clinical personality disorder diagnosis was present in 16.9% of patients. Antisocial and narcissistic personality disorders were the most common diagnoses. Patients with co-occurring personality disorder had higher rates of readmission to hospital, lower rates of symptomatic recovery and poorer functional levels at 6 months, but these differences disappeared after 12 and 18 months. In the early phase of bipolar disorder, patients with personality disorder comorbidity display delayed symptomatic and functional recovery and increased likelihood to need hospital readmissions. These observations suggest that routine assessment for personality disorder and specific interventions are important in order to improve short-term treatment efficacy in this subgroup

Outcomes for 18 to 25-year-olds with borderline personality disorder in a dedicated young adult only DBT programme compared to a general adult DBT programme for all ages 18

Aim Targeting young adults with borderline personality disorder (BPD) for treatment may carry significant social and clinical benefits. We aimed to evaluate a community‐based Dialectical Behaviour Therapy (DBT) programme delivered exclusively to young adults with BPD. Methods We describe a naturally occurring non‐equivalent, quasi‐experimental comparison of outcomes for young adults (18‐25 years) with BPD following 1 year of treatment in either a young adult only DBT programme or a general adult DBT programme (18+ years). Twenty‐four young adults enrolled in a community‐based young adult DBT programme open only to 18‐ to 25‐year‐olds with BPD. Another 13 young adults, also 18‐25 years, enrolled in a general adult DBT programme open to all ages above 18 years. Both treatment conditions offered all modes of standard DBT for 1 year. Participants completed a battery of self‐report measures on mental health symptoms at baseline and again at treatment completion after 1 year. Discharge rates at 2 years post‐treatment completion were also recorded. Results Better outcomes were found on borderline symptom severity and general psychopathology among completers of young adult DBT, with a large effect size for treatment condition as well as greater clinically significant change. Discharge rates from mental health services 24 months later were also higher for completers of young adult DBT. Conclusions There may be advantages in delivering DBT to young adults in an age‐specific programme, possibly due to group cohesion. Methodological limitations apply, such as small sample size and non‐randomization. Further controlled research is needed

The College News, 1918-05-23, Vol. 04, No. 27

Bryn Mawr College student newspaper. Merged with The Haverford News in 1968 to form the Bi-college News (with various titles from 1968 on). Published weekly (except holidays) during the academic year

The addition of fluoxetine to cognitive behavioural therapy for youth depression (YoDA-C): study protocol for a randomised control trial.

The aim of the Youth Depression Alleviation-Combined Treatment (YoDA-C) study is to determine whether antidepressant medication should be started as a first-line treatment for youth depression delivered concurrently with psychotherapy. Doubts about the use of medication have been raised by meta-analyses in which the efficacy and safety of antidepressants in young people have been questioned, and subsequent treatment guidelines for youth depression have provided only qualified support

Standard set of patient-reported outcomes for personality disorder

Purpose The purpose of the article is to present standard set of outcomes for people with personality disorder (PD), in order to facilitate patient outcome measurement worldwide. Methods The International Consortium for Health Outcomes Measurement (ICHOM) gathered a multidisciplinary international working group, consisting of 16 experts, including clinicians, nurses, psychologists, methodologists and patient representatives, to develop a standard set of outcome measures for people with PD. The Delphi method was used to reach consensus on the scope of the set, outcome domains, outcome measures, case-mix variables and time points for measuring outcomes in service users. For each phase, a project team prepared materials based on systematic literature reviews and consultations with experts. Results The working group decided to include PD, as defined by International Classification of Diseases 11th revision (ICD-11). Eleven core outcomes and three optional outcomes across four health domains (mental health, behaviour, functioning and recovery) were defined as those relevant for people with PD. Validated measures for the selected outcomes were selected, some covering more than one outcome. Case-mix variables were aligned to other ICHOM mental health standard sets and consisted of demographic factors and those related to the treatment that people received. The group recommended that most outcomes are measured at baseline and annually. Conclusion The international minimum standard set of outcomes has the potential to improve clinical decision making through systematic measurement and comparability. This will be key in improving the standard of health care for people with PD across the world

The prevalence, age distribution and comorbidity of personality disorders in Australian women

OBJECTIVE: We aimed to describe the prevalence and age distribution of personality disorders and their comorbidity with other psychiatric disorders in an age-stratified sample of Australian women aged ⩾25 years. METHODS: Individual personality disorders (paranoid, schizoid, schizotypal, histrionic, narcissistic, borderline, antisocial, avoidant, dependent, obsessive-compulsive), lifetime mood, anxiety, eating and substance misuse disorders were diagnosed utilising validated semi-structured clinical interviews (Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Non-patient Edition and Structured Clinical Interview for DSM-IV Axis II Personality Disorders). The prevalence of personality disorders and Clusters were determined from the study population ( n = 768), and standardised to the Australian population using the 2011 Australian Bureau of Statistics census data. Prevalence by age and the association with mood, anxiety, eating and substance misuse disorders was also examined. RESULTS: The overall prevalence of personality disorders in women was 21.8% (95% confidence interval [CI]: 18.7, 24.9). Cluster C personality disorders (17.5%, 95% CI: 16.0, 18.9) were more common than Cluster A (5.3%, 95% CI: 3.5, 7.0) and Cluster B personality disorders (3.2%, 95% CI: 1.8, 4.6). Of the individual personality disorders, obsessive-compulsive (10.3%, 95% CI: 8.0, 12.6), avoidant (9.3%, 95% CI: 7.1, 11.5), paranoid (3.9%, 95% CI: 3.1, 4.7) and borderline (2.7%, 95% CI: 1.4, 4.0) were among the most prevalent. The prevalence of other personality disorders was low (⩽1.7%). Being younger (25-34 years) was predictive of having any personality disorder (odds ratio: 2.36, 95% CI: 1.18, 4.74), as was being middle-aged (odds ratio: 2.41, 95% CI: 1.23, 4.72). Among the strongest predictors of having any personality disorder was having a lifetime history of psychiatric disorders (odds ratio: 4.29, 95% CI: 2.90, 6.33). Mood and anxiety disorders were the most common comorbid lifetime psychiatric disorders. CONCLUSIONS: Approximately one in five women was identified with a personality disorder, emphasising that personality disorders are relatively common in the population. A more thorough understanding of the distribution of personality disorders and psychiatric comorbidity in the general population is crucial to assist allocation of health care resources to individuals living with these disorders