Health related quality of life and psychopathological distress in risk taking and self-harming adolescents with full-syndrome, subthreshold and without borderline personality disorder: rethinking the clinical cut-off?

Background: Diagnostic standards do not acknowledge developmental specifics and differences in the clinical presentation of adolescents with borderline personality disorder (BPD). BPD is associated with severe impairments in health related quality of life (HRQoL) and increased psychopathological distress. Previously no study addressed differences in HRQoL and psychopathology in adolescents with subthreshold and full-syndrome BPD as well as adolescents at-risk for the development but no current BPD. Methods: Drawing on data from a consecutive sample of N = 264 adolescents (12–17 years) presenting with risk-taking and self-harming behavior at a specialized outpatient clinic, we investigated differences in HRQoL (KIDSCREEN-52) and psychopathological distress (SCL-90-R) comparing adolescents with no BPD (less than 3 criteria fulfilled), to those with subthreshold (3–4 BPD criteria) and full-syndrome BPD (5 or more BPD criteria). Group differences were analyzed using one-way analysis of variance with Sidak corrected contrasts or Chi-Square test for categorical variables. Results: Adolescents with subthreshold and full-syndrome BPD presented one year later at our clinic and were more likely female. Adolescents with subthreshold and full-syndrome BPD showed greater Axis-I and Axis-II comorbidity compared to adolescents with no BPD, and reported greater risk-taking behaviour, self-injury and suicidality. Compared to those without BPD, adolescents with subthreshold and full-syndrome BPD reported significantly reduced HRQoL. Adolescents with sub-threshold BPD and those with full-syndrome BPD did not differ on any HRQoL dimension, with the exception of Self-Perception. Similar, groups with sub-threshold and full-syndrome BPD showed no significant differences on any dimension of self-reported psychopathological distress, with the exception of Hostility. Conclusions: Findings highlight that subthreshold BPD in adolescents is associated with impairments in HRQoL and psychopathological distress comparable to full-syndrome BPD. Findings raise awareness on the importance of early detection and question the diagnostic validity and clinical utility of existing cut-offs. Findings support a lower diagnostic cut-off for adolescent BPD, to identify those at-risk at an early stage

Frequency and predictors of individual treatment outcomes (response, remission, exacerbation, and relapse) in clinical adolescents with nonsuicidal self-injury.

BACKGROUND Nonsuicidal self-injury (NSSI) is prevalent in adolescent clinical samples. There is evidence that NSSI can be treated effectively but data on individual treatment outcomes is limited. The goal of this study was to examine response, remission, exacerbation, and relapse rates over one and two years, respectively, among a clinical sample of adolescents with NSSI. Furthermore, we aimed to identify clinically relevant predictors of NSSI trajectories. METHODS The sample consists of n = 203 adolescents (12-17 y., 94% female) from a specialized outpatient clinic for risk-taking and self-harming behavior with NSSI on at least five days in the six months before first assessment. Assessments were completed at baseline and one (FU1) and two (FU2) years later using structured clinical interviews and self-report questionnaires. RESULTS At FU1, 75% reported a reduction in NSSI frequency by at least 50% (treatment response); among those, one third (25% of the entire sample) achieved a remission (0 NSSI); an exacerbation (⩾50% more NSSI) was observed in 11% of patients. Of those in remission, 41% relapsed one year later. Predictors of non-response or non-remission were inpatient treatment and depressive symptoms. Adolescents with lower NSSI frequency at baseline had a higher risk of exacerbation. Due to limited sample size at FU2 no prediction model for relapse was established. CONCLUSIONS While most adolescents presenting with NSSI achieved significant improvement, more attention should be paid to the rather low rates of full remission. Prediction and early detection of individuals who deteriorate during or relapse after treatment is critical

Self-rated risk as a predictor of suicide attempts among high-risk adolescents

Background: Predicting suicide attempts is a challenging task for clinicians and researchers, particularly among high-risk individuals (i.e. adolescents with lifetime suicide attempts). In this study, we examined whether adolescents were able to predict their own risk of attempting suicide in the future and whether borderline personality disorder (BPD) or depressive symptoms impacted the predictive value of self-ratings. Methods: Structured clinical assessments were conducted at baseline and after 12 months in a high-risk sample of treatment-seeking adolescents (n = 134; 12-17y.; 90% female) with at least one lifetime suicide attempt. Results: During the follow-up period, n = 51 participants (38%) attempted suicide at least once. Self-rated risk was a significant predictor for the recurrence of a suicide attempt, whereas BPD and depression were not. While there was no significant interaction between self-rated risk and BPD, a negative interaction emerged between self-rated risk and depression in the prediction of a suicide attempt. Greater depression severity diminished the predictive value of self-ratings. Limitations: Depression severity was measured using a questionnaire, not a clinical interview. The findings may not be applicable to less burdened samples. Conclusions: Asking high-risk adolescents to rate their own risk of attempting suicide appears to be an easy to apply method in improving the prediction of future suicide attempts in the clinical context

Self-injury: Treatment, Assessment, Recovery (STAR): online intervention for adolescent non-suicidal self-injury - study protocol for a randomized controlled trial

Background: Non-suicidal self-injury (NSSI) is a clinically significant behavior affecting approximately 18% of adolescents and young adults worldwide. The importance of NSSI is supported by its association with a broad spectrum of mental disorders. Despite its high relevance, evidence-based, specific, time-, and cost-effective treatment approaches are scarce. Cognitive behavioral therapy (CBT) seems effective in reducing the frequency of NSSI in adolescents and young adults. However, young people are often reluctant to seek professional help and effective interventions adressing NSSI are not sufficiently available across all regions of Germany. Research indicates that the majority of youth with risk behavior (including NSSI) prefer technology-based interventions. To date, effective interventions for adolescents and young adults with NSSI that are deliverd online are not available. Methods: The present project aims to develop and evaluate an online intervention for adolescents and young adults with NSSI based on the content of a recently evaluated face-to-face short-term program that includes elements of CBT and dialectical behavior therapy (DBT): “The Cutting Down Programme” (CDP). The efficacy of the new online CDP intervention will be tested in a randomized controlled trial (RCT) in which n = 700 youths engaging in repetitive NSSI will participate in either an online psychoeducation (n = 350) or online CDP (n = 350). Within a postline assessment four months after baseline (end of treatment; T1), and follow-up evaluations 12 and 18 months after baseline (follow-ups; T2 and T3), NSSI and comorbid symptoms as well as quality of life will be assessed. It is hypothesized that participants receiving online CDP report a greater reduction in the frequency of NSSI within the last three months at T2 (primary endpoint) compared to those receiving online psychoeducation. Exploratory analyses will focus on predictors of treatment outcome. Discussion: We report on the development and evaluation of an online intervention for adolescents and young adults engaging in NSSI based on the CDP. If supported by empirical evidence, an online-based intervention for NSSI might help to overcome the limited availability of adequate interventions for youth. Trial registration: German Clinical Trials Register, DRKS00014623. Registered on 22 May 2018

The Impact of Adverse Childhood Experiences on Therapy Outcome in Adolescents Engaging in Nonsuicidal Self-Injury

Objective: Nonsuicidal self-injury (NSSI) is a prevalent and clinically significant behavior. There is a substantial association between adverse childhood experiences (ACEs) and NSSI. However, there are no studies investigating the impact of ACEs on NSSI treatment (psychotherapy) outcome. The aim of this secondary analysis of a randomized controlled trial (RCT) on psychotherapy of NSSI was to investigate the relationship between ACEs and treatment outcome in adolescents engaging in NSSI. Method: A sample of 74 adolescent outpatients engaging in repetitive NSSI (incidents on ≥ 5 days within the last 6 months) was recruited for a RCT. ACEs were assessed by the Childhood Experience of Care and Abuse (CECA) interview before treatment onset. Based on the CECA, participants were divided in two groups: with a history of ACEs (n = 30) and without a history of ACEs (n = 44). Frequencies of NSSI, depression, and suicide attempts as well as quality of life were measured at three points in time: before treatment onset (baseline; T0), 4 (T1), and 10 months (T2) after treatment onset. Results: Both participants with and without ACEs were able to reduce the frequency of NSSI significantly [χ2(1) = 26.72; p < 0.001]. Surprisingly, participants with ACEs reached a significantly greater reduction in NSSI frequency within the past 6 months compared to participants without ACEs [χ2(1) = 5.08; p = 0.024]. There were also substantial and similar improvements regarding depressive symptoms, suicide attempts and quality of life in both groups. Conclusion: ACEs seem to positively predict treatment response in psychotherapy for adolescent NSSI. This is contrary to prior research suggesting ACE as an unfavorable prognostic factor in the treatment of mental disorders

Die Ambulanz für Risikoverhalten und Selbstschädigung (AtR!Sk) – ein Pionierkonzept der ambulanten Früherkennung und Frühintervention von Borderline-Persönlichkeitsstörungen

Riskantes und selbstschädigendes Verhalten ist ein häufiges Problem im Alltag von Jugendlichen und stellt das Gesundheitssystem mehr und mehr vor neue Herausforderungen. Solche riskanten und selbstschädigenden Verhaltensweisen sind besonders typisch bei Jugendlichen mit einer Borderline-Persönlichkeitsstörung (BPS). Nach Jahrzehnten der Kontroverse gilt die Diagnose der adoleszenten BPS inzwischen als valide und reliabel. Sie ist mit einem großen Leidensdruck, erhöhter Mortalität und einer massiven psychosozialen Beeinträchtigung der betroffenen Jugendlichen verbunden. Lange Wartezeiten für ambulante Therapien und hohe Kosten bei unnötig langen stationären Aufenthalten kennzeichnen leider das aktuelle Bild in der medizinischen Versorgungslandschaft bei Kinder- und Jugendlichen mit BPS in Deutschland. Modelle, die gezielt auf Früherkennung und Frühintervention der Borderline-Symptomatik ausgerichtet sind und bereits bei Patienten mit Risikokonstellationen ansetzen, können als Alternativkonzepte dienen. Die Spezialambulanz AtR!Sk der Klinik für Kinder- und Jugendpsychiatrie der Universitätsklinik Heidelberg sichert eine niederschwellige, schnelle und auf die Problematik der Jugendlichen „zugeschnittene“ Behandlung durch eine umfassende und akkurate Diagnostik und leistet seit 2013 Pionierarbeit auf dem Gebiet der evidenzbasierten Früherkennung und Frühintervention der BPS im Jugendalter.The Outpatient Clinic for Adolescent Risk-taking and Self-harm behaviors (AtR!Sk) – A Pioneering Approach of Outpatient Early Detection and Intervention of Borderline Personality Disorder. Self-harm and risk-taking behaviors are frequently occurring problems in adolescents’ everyday life and commonly challenge the present child and adolescent health-care system. Those behaviors are typical features of borderline-personality disorder (BPD), a severe mental disorder that is associated with immense psychological strain, increased risk of mortality and poor psychosocial functioning. Despite controversy in the past, recent evidence shows that BPD is a valid and reliable diagnosis in adolescence. Consequently, specified and effective intervention programs for this age group are necessary. Instead, present health-care services for children and adolescents in Germany are usually characterized by long waiting periods for specialized outpatient treatments and unnecessary expanses of unnecessary long inpatient stays. Alternatively, and in order to prevent serious long-term consequences, new concepts – integrated in an ambulatory setting and close to patients’ daily routines – should focus on early detection and treatment of adolescents at-risk presenting with borderline personality features. The specialist outpatient clinic AtR!Sk at the University Hospital Heidelberg ensures a low-threshold initial contact service, comprehensive and accurate diagnosis of BPD features, and rapidly “tailored” therapy for young people presenting with any types of risk-taking and self-harm behavior. AtR!Sk – as a pioneering approach in south Germany – provides evidence-based early detection and intervention for adolescent BPD

Age dependent effects of early intervention in borderline personality disorder in adolescents.

BACKGROUND Psychological treatments for young people with sub-threshold or full-syndrome borderline personality disorder (BPD) are found to be effective. However, little is known about the age at which adolescents benefit from early intervention. This study investigated whether age affects the effectiveness of early intervention for BPD. METHODS N = 626 participants (M age = 15 years, 82.7% female) were consecutively recruited from a specialized outpatient service for early intervention in BPD in adolescents aged 12- to 17-years old. DSM-IV BPD criteria were assessed at baseline, one-year (n = 339) and two-year (n = 279) follow-up. RESULTS Older adolescents presented with more BPD criteria (χ2(1) = 58.23, p < 0.001) and showed a steeper decline of BPD criteria over the 2-year follow-up period compared with younger adolescents (χ2(2) = 13.53, p = 0.001). In an attempt to disentangle effects of early intervention from the natural course of BPD, a parametrized regression model was used. An exponential decrease (b = 0.10, p < 0.001) in BPD criteria was found when starting therapy over the 2-year follow-up. This deviation from the natural course was impacted by age at therapy commencement (b = 0.06, p < 0.001), although significant across all ages: older adolescents showed a clear decrease in BPD criteria, and young adolescents a smaller decrease. CONCLUSIONS Early intervention appears effective across adolescence, but manifests differently: preventing the normative increase of BPD pathology expected in younger adolescents, and significantly decreasing BPD pathology in older adolescents. The question as to whether developmentally adapted therapeutic interventions could lead to an even increased benefit for younger adolescents, should be explored in future studies

Heterogeneity of borderline personality disorder symptoms in help-seeking adolescents

Background: The heterogeneous presentation of borderline personality disorder (BPD) represents a clinical challenge. There is an ongoing scientific debate whether the heterogeneity can best be understood in terms of qualitative (categorical) or quantitative (dimensional) differences between individuals. The present study examined the latent structure of BPD in adolescents. Methods: Five-hundred and six outpatients aged 12 to 17 years with risk-taking and/or self-harming behavior were assessed at baseline and one-year follow-up. Latent class analysis (corresponding with the categorical approach), factor analysis (corresponding with the dimensional approach), and factor mixture models (allowing for both categorical and dimensional aspects) were applied to the DSM-IV BPD criteria. Results: The best fitting model distinguished between a majority class with high probabilities for all BPD criteria ("borderline group") and a minority class with high probabilities for the impulsivity and anger criteria only ("impulsive group"). Sex significantly affected latent class membership, and both a latent factor and age explained within-class variability. The borderline group primarily consisted of females, frequently reported adverse childhood experiences, scored high on the emotion dysregulation and inhibitedness personality traits, and was associated with internalizing psychopathology. In contrast, the impulsive group primarily consisted of males, scored high on the dissocial behavior personality trait, and was associated with externalizing psychopathology. After one year, the two groups showed similar clinical improvement. Conclusions: The study provides evidence for two distinct subgroups of adolescents with BPD features that resemble the subtypes of the ICD-10 emotionally unstable personality disorder. More research is needed to further investigate the diagnostic stability of the two groups over time and potential differential treatment indications

Effectiveness of a brief psychotherapeutic intervention compared with treatment as usual for adolescent nonsuicidal self-injury: a single-centre, randomised controlled trial

Although nonsuicidal self-injury (NSSI) is a clinically significant behavior, evidence-based, specific, time-, and cost-effective treatment approaches are lacking. The aim of this study was to compare the efficacies of a brief cognitive-behavioral psychotherapy manual, the Cutting Down Programme (CDP), and treatment as usual (TAU) in the treatment of adolescent NSSI. We conducted a single-centre randomised controlled trial (RCT). Eligible participants were aged 12-17 years engaging in repetitive NSSI (at least 5 times within the past 6 months). We randomly allocated 74 participants to CDP (n = 37) or TAU (n = 37; in a 1:1 ratio). Outcome measures were administered before treatment (T0), directly after CDP or 4 months after baseline evaluation in the TAU group (T1), and another 6 months later (T2; primary endpoint). Primary outcome was a 50% reduction in NSSI frequency within the past 6 months at 10-month follow-up (T2). Regarding the primary outcome, there were no significant differences between the CDP (n = 26; 70.3%) and TAU group [n = 27; 73.0%; χ2(1) = 0.07; p = 0.797]; NSSI frequency within the past 6 months was significantly reduced at T2 [χ2(1) = 12.45; p < 0.001] with no between-group difference [χ2(1) = 0.14; p = 0.704]. However, we found a significant group x point of measurement interaction [χ2(2) = 7.78; p = 0.021] regarding NSSI within the last month indicating at T1. CDP was equally effective and achieved faster recovery compared to a significantly more intensive TAU in treating adolescent NSSI. The CDP could provide a brief and pragmatic first treatment within a stepped-care model for NSSI in routine clinical care.Clinical Trial Registration The trial was prospectively registered in the German Registry of Clinical Trials ( https://www.drks.de ; DRKS00003605) and is now complete