Combined group and individual therapy for patients with avoidant personality disorder—A pilot study

ObjectiveAvoidant personality disorder (AvPD) is a common disorder within mental health services, associated with significant psychosocial impairment. The disorder has been neglected in research. There are currently no evidence-based treatments for AvPD, and there is a need for treatment studies focusing particularly on this form of personality pathology. The present study was a pilot study of combined group and individual therapy for patients with AvPD, based on mentalization-based and metacognitive interpersonal therapy. The aim was to investigate the feasibility of the treatment program and the course of symptoms and personality functioning during treatment and 1-year follow-up.MethodsThe study included 28 patients. Clinical evaluation at baseline comprised structured diagnostic interviews and patients' self-report of symptoms, psychosocial function, interpersonal problems, personality functioning, alexithymia, self-esteem, attachment style, therapeutic alliance, and client satisfaction. Patients' self-report were repeated at the end of treatment and 1-year follow-up.ResultsThe drop-out rate was 14%. Average treatment length among the 22 treatment completers was 17 months. Mean levels of therapeutic alliance and client satisfaction were satisfactory. Effect sizes were large for global symptom distress, depression, anxiety, and psychosocial adjustment, and in the moderate range for aspects of personality functioning. Yet, the results showed a wide range of outcomes among the patients.ConclusionsThis pilot study shows promising results for combined group- and individual therapy for AvPD patients with moderate to severe impairment. Larger scale studies should be conducted to increase empirically based knowledge to guide development of differentiated treatments adapted to patients' various levels of AvPD severity and profiles of personality dysfunction

A Psychometric Evaluation of the DSM-IV Criteria for Antisocial Personality Disorder:Dimensionality, Local Reliability, and Differential Item Functioning Across Gender

This study aims at evaluating the psychometric properties of the antisocial personality disorder (ASPD) criteria in a large sample of patients, most of whom had one or more personality disorders (PD). PD diagnoses were assessed by experienced clinicians using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Axis II PDs. Analyses were performed within an item response theory framework. Results of the analyses indicated that ASPD is a unidimensional construct that can be measured reliably at the upper range of the latent trait scale. Differential item functioning across gender was restricted to two criteria and had little impact on the latent ASPD trait level. Patients fulfilling both the adult ASPD criteria and the conduct disorder criteria had similar latent trait distributions as patients fulfilling only the adult ASPD criteria. Overall, the ASPD items fit the purpose of a diagnostic instrument well, that is, distinguishing patients with moderate from those with high antisocial personality scores

More is more:Evidence for the incremental value of the SCID-II/SCID-5-PD specific factors over and above a general personality disorder factor

Currently, 3 competing conceptualizations of personality dysfunction can be distinguished: the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM–5) categorical model delineating 10 distinct types of personality disorders (PDs); the alternative model for PDs (DSM–5 Section III), which assesses personality functioning and traits separately; and the International Classification of Diseases, 11th Version conceptualization, which provides 1 single code for the presence of a PD (which is based on problems in functioning) as well as codes that specify the level of the disorder (mild/moderate/severe), and prominent trait domains or patterns (5 domains and 1 pattern). The current study aims to assess the incremental value of the DSM–5 PDs over and above a global personality dysfunction factor, using expert ratings obtained with the Structured Clinical Interview for DSM–IV PDs and the Structured Clinical Interview for DSM–5 PDs interview in a large sample of clinical patients (N = 3,851). All estimated bifactor models provided adequate fit to the data. We found a surprisingly low explained common variance for the g-factor (<40%), indicating that ignoring the specific PD factors would lead to a substantial loss of information. The strongest specific PDs in terms of explained common variance were the avoidant, schizotypal, and schizoid PD factors and the conduct disorder criteria set if included. Correlations between our factors and external variables were relatively low, except for the Severity Indices of Personality Problems, which aims to measure personality functioning. Our findings suggest that specific PDs still have an important role to play in the assessment of personality pathology

A multi-center psychometric evaluation of the Severity Indices of Personality Problems 118 (SIPP-118):Do we really need all those facets?

PURPOSE: The Severity Indices of Personality Problems 118 (SIPP-118) is a self-report questionnaire that aims to measure core components of (mal)adaptive personality functioning that can change over time. In this study, we aimed to assess the facet strength of the 16 facets across three large clinical samples.METHODS: Data from Norwegian and Dutch psychiatric patients were analyzed in this international multi-center study (N1 = 2814, N2 = 4751, N3 = 2217). Bi-factor modeling was used to assess to what degree the SIPP items tap into an overall general factor. The incremental value (distinctiveness) of the facets was studied using proportional reduction in mean squared error (PRMSE) based statistics.RESULTS: The estimated model showed adequate fit. The explained common variance (ECV) attributable to the general factor equaled 50% for all three samples. All but two facets (stable self-image and frustration tolerance) showed sufficient levels of distinctiveness. The findings were observed to be comparable across the three samples.CONCLUSION: Our findings showed that the general factor was relatively weak, and the facets had a clear incremental value.</p

Building a strong European alliance for personality disorder research and intervention

People with personality disorders frequently face stigma, ignorance and pessimism regarding the treatability of their disorders. This is despite substantial progress that has been made in developing a number of effective evidence based psychotherapeutic treatments. However, expertise in how to systematically deliver these treatments in a sustainable way throughout Europe is largely lacking. To bridge the gap between evidence based treatments and their implementation in health services, the European Society for the Study of Personality Disorders is currently building a new alliance of experts to promote personality disorder scholarship, and to support the development of clinical expertise and systematic treatment implementation throughout Europe. The aim of this paper is to describe how the Society is currently using its interdisciplinary and international roster of experts to address the specific treatment and research needs of the European personality disorder field, particularly to countries in which expertise in the field is less developed

Avoidant and borderline personality disorder patients during the first Covid-19 wave in Norway – a survey-based comparison of therapy changes and patients’ accommodations

Background Patients with personality disorders (PDs) often have insecure attachment patterns and may be especially vulnerable to abrupt treatment changes. Patients with borderline PD (BPD) are often considered vulnerable to treatment interruption due to chronic fear of abandonment. Nonetheless, other PDs are poorly investigated. In the first Covid-19 wave in Norway, in-person treatment facilities and group treatments were strongly restricted from March 12th until May/June 2020. Objectives To examine and compare changes in outpatient treatment for patients with avoidant (AvPD) and BPD during the first Covid-19 wave in Norway, and patients’ reactions to these changes. Methods The study is based on a cross-sectional survey distributed to 1120 patients referred to 12 different PD treatment units on a specialist mental health service level within the Norwegian Network for Personality Disorders. The survey included questions on treatment situation, immediate reactions, and changes during the crisis. From 133 responders (response rate 12%), 40 patients reported BPD and 30 AvPD as diagnosis. Results All patients were followed up from their therapist after March 12th. Almost all patients in both groups expressed satisfaction under the new circumstances. Both groups experienced the same regularity as before, but more AvPD patients reported less than weekly consultations. AvPD patients reported more negative feelings about changes in therapy, and missed the therapy and group members more than the BPD group. Conclusion After the lockdown, BPD patients received a closer follow-up than AvPD patients, and the latter reported more negative feelings related to change in their treatment situation

Improvement of personality functioning among people treated within personality disorder mental health services. A longitudinal, observational study

Objective: Evidence-based personality disorder (PD) treatments are dominated by interventions targeting Borderline PD, although clinical populations characteristically include different PD features and severity. Personality functioning is a new concept intended to capture common features across PDs. This study aimed to investigate longitudinal improvement of personality functioning in a clinical sample assigned to PD treatment. Method: An observational, large, longitudinal study of patients in PD treatments on specialist mental health service levels (N = 1,051). DSM-5 PDs were systematically assessed on referral. Personality functioning was repeatedly assessed (LPFS-BF-2.0), supplemented by symptom distress (anxiety: PHQ-GAD-7, depression: PHQ-9), and social/occupational activity (WSAS, work/study activity). Statistics were linear mixed models. Results: Thirty per cent had personality difficulties below PD threshold. Among PDs, 31% had Borderline (BPD), 39% Avoidant (AvPD), 15% not otherwise specified, 15% other PDs, and 24% > one PD. More severe initial LPFS-BF was associated with younger age, presence of PD and increasing number of total PD criteria. Across PD conditions, LPFS-BF, PHQ-9 and GAD-7 improved significantly (overall effect size 0.9). Mean duration of PD treatment was 15 (SD 9) months. Drop-out rates were low (12%). LPFS-BF improvement-rates were higher for BPD. Younger age was moderately associated with slower PHQ-9 improvement. Work/study activity was initially poor, poorer levels associated with AvPD and younger age, and improvement was non-significant across PD conditions. AvPD was associated with slower WSAS improvement-rates. Conclusion: Personality functioning improved across PD conditions. The results highlight BPD improvements. The study points to challenges concerning AvPD treatment, poor occupational activity and age-related differences

European guidelines for personality disorders: past, present and future

Personality disorders (PD) are common and burdensome mental disorders. The treatment of individuals with PD represents one of the more challenging areas in the field of mental health and health care providers need evidence-based recommendations to best support patients with PDs. Clinical guidelines serve this purpose and are formulated by expert consensus and/or systematic reviews of the current evidence. In this review, European guidelines for the treatment of PDs are summarized and evaluated. To date, eight countries in Europe have developed and published guidelines that differ in quality with regard to recency and completeness, transparency of methods, combination of expert knowledge with empirical data, and patient/service user involvement. Five of the guidelines are about Borderline personality disorder (BPD), one is about antisocial personality disorder and three concern PD in general. After evaluating the methodological quality of the nine European guidelines from eight countries, results in the domains of diagnosis, psychotherapy and pharmacological treatment of PD are discussed. Our comparison of guidelines reveals important contradictions between recommendations in relation to diagnosis, length and setting of treatment, as well as the use of pharmacological treatment. All the guidelines recommend psychotherapy as the treatment of first choice. Future guidelines should rigorously follow internationally accepted methodology and should more systematically include the views of patients and users

Contours of a causal feedback mechanism between adaptive personality and psychosocial function in patients with personality disorders: a secondary analysis from a randomized clinical trial

Background Patients with personality disorders commonly exhibit impairment in psychosocial function that persists over time even with diagnostic remission. Further causal knowledge may help to identify and assess factors with a potential to alleviate this impairment. Psychosocial function is associated with personality functioning which describes personality disorder severity in DSM-5 (section III) and which can reportedly be improved by therapy. Methods The reciprocal association between personality functioning and psychosocial function was assessed, in 113 patients with different personality disorders, in a secondary longitudinal analysis of data from a randomized clinical trial, over six years. Personality functioning was represented by three domains of the Severity Indices of Personality Problems: Relational Capacity, Identity Integration, and Self-control. Psychosocial function was measured by Global Assessment of Functioning. The marginal structural model was used for estimation of causal effects of the three personality functioning domains on psychosocial function, and vice versa. The attractiveness of this model lies in the ability to assess an effect of a time – varying exposure on an outcome, while adjusting for time – varying confounding. Results Strong causal effects were found. A hypothetical intervention to increase Relational Capacity by one standard deviation, both at one and two time-points prior to assessment of psychosocial function, would increase psychosocial function by 3.5 standard deviations (95% CI: 2.0, 4.96). Significant effects of Identity Integration and Self-control on psychosocial function, and from psychosocial function on all three domains of personality functioning, although weaker, were also found. Conclusion This study indicates that persistent impairment in psychosocial function can be addressed through a causal pathway of personality functioning, with interventions of at least 18 months duration

Health service costs and clinical gains of psychotherapy for personality disorders: a randomized controlled trial of day-hospital-based step-down treatment versus outpatient treatment at a specialist practice

Background Day-hospital-based treatment programmes have been recommended for poorly functioning patients with personality disorders (PD). However, more research is needed to confirm the cost-effectiveness of such extensive programmes over other, presumably simpler, treatment formats. Methods This study compared health service costs and psychosocial functioning for PD patients randomly allocated to either a day-hospital-based treatment programme combining individual and group psychotherapy in a step-down format, or outpatient individual psychotherapy at a specialist practice. It included 107 PD patients, 46% of whom had borderline PD, and 40% of whom had avoidant PD. Costs included the two treatment conditions and additional primary and secondary in- and outpatient services. Psychosocial functioning was assessed using measures of global (observer-rated GAF) and occupational (self-report) functioning. Repeated assessments over three years were analysed using mixed models. Results The costs of step-down treatment were higher than those of outpatient treatment, but these high costs were compensated by considerably lower costs of other health services. However, costs and clinical gains depended on the type of PD. For borderline PD patients, cost-effectiveness did not differ by treatment condition. Health service costs declined during the trial, and functioning improved to mild impairment levels (GAF > 60). For avoidant PD patients, considerable adjuvant health services expanded the outpatient format. Clinical improvements were nevertheless superior to the step-down condition. Conclusion Our results indicate that decisions on treatment format should differentiate between PD types. For borderline PD patients, the costs and gains of step-down and outpatient treatment conditions did not differ. For avoidant PD patients, the outpatient format was a better alternative, leaning, however, on costly additional health services in the early phase of treatment. Trial registration Clinical Trials NCT0037824