Transcript PowerPoint-presentatie

Assessment and treatment of
severe personality disorders in
adolescence
ISSPD Congress 2007
The Hague, September 19
Joost Hutsebaut, Kirsten Catthoor,
and Dineke Feenstra
What do you know about
personality disorders in
adolescence???
Let’s start with a little quiz…
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 18years old.
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
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.
Thesis 2
• The prevalence of borderline PD in adults
and adolescents is about the same.
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.
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.
Thesis 3
• The diagnosis of BPD in adolescence
predicts more axis 1 and axis 2 disorders
in early adulthood.
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.
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.
Thesis 4
• What is the most specific feature of a
borderline PD in adolescence?
Multiple choice 4
• A. Impulsivity.
• B. Instability of affect.
• C. Identity confusion.
• D. Suicidal ideation and gestures.
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.
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?
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%.
Answer 5
• The correct answer is D.
• 90% of all self injurious behavior happens
in adolescence.
Case Study
(Because of privacy reasons this information
has been omitted)
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)
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!
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
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
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
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?
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???
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
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
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
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; BraunScharm, 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)
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)
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)
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)
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)
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 is affective instability for adolescents
and impulsivity for adults the most useful criterion.
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%
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)
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.
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
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
Assessment
General 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
Assessment
Developmental history
• Indicators of high risk for the development
of personality disorders
Assessment
Intelligence
• Importance of intelligence testing
Case: Kaufman Adolescent and Adult Intelligence Test (KAIT)
Total
-
Crystallized
Definitions
Aud. Compreh.
Double mean.
110 (75)
12
11
12
Fluid
Rebus learning
Logical steps
Mystery codes
92 (30)
8
10
8
Assessment
Neuropsychological testing
• Gives additional information to validate the
diagnosis of a PD
• Indicates the impact of a PD
Assessment
Symptoms
Case: Brief Symptom Inventory (BSI)
Scale
Description
Score
Norm patients
Norm population
SOM
Somatization
0.429
Below average
Above average
O-C
Obsessive-Compulsive
1.667
Above average
High
I-S
Interpersonal Sensivity
1.25
Average
High
DEP
Depression
2.0
Above average
Very high
ANX
Anxiety
2.333
High
Very high
HOS
Hostility
2.8
Very high
Very high
PHOB
Phobic Anxiety
0.8
Average
High
PAR
Paranoid Ideation
2.4
High
Very high
PSY
Psychoticism
1.8
High
Very high
GSI
Global Severity Index
1.717
Above average
Very high
PST
Positive Symptom Total
34.0
Average
High
PSDI
Positive Symptom Distress Index
2.676
High
Very high
Assessment
Symptoms
Case: Child Behaviour Checklist (CBCL)
100
90
80
Biological
father
Stepmother
70
60
50
Intern.
Extern.
Total
Assessment
Axis 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
Assessment
Axis 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
Assessment
Specific borderline characteristics
• Suicide Risk Assessment
• Assessment of dissociation
Case: Diagnostic Interview for Borderlines (DIB-R), included in
Clinical Interview
Assessment
Structural characteristics
Case: Questionnaires
•
NEO-PI-R
Neuro
9
8
7
6
5
4
3
2
1
0
Conscient
Altrui
Extra
Open
Assessment
Structural characteristics
Case: Projective tests (Rorschach)
Assessment
Competence
Case: Competentie Belevingsschaal voor Adolescenten (CBSA),
derived from the Self-Perception Profile for Adolescents (SPPA)
Sv
Sa
Sp
Fv
Gh
Hv
Ge
Scale scores 17
18
6
19
8
15
15
Percentile
82
4
97
3
16
48
95
Assessment
Family
Case: Family Assessment Device (FAD)
Scale
Stepmother
Patient
Father
Problem solving
2,667
3,000
3,167
Communication
3,000
2,556
2,667
Role fulfillment
2,636
2,273
2,272
Affective respons
3,000
2,833
3,000
Affective involvement
2,714
2,429
3,429
Family culture
2,667
2,667
2,667
Global functioning
3,083
2,917
3,167
Assessment
Conclusions case
• Patient is diagnosed with a BPD on axis 2 and an associated PTSD,
conduct disorder and substance dependence on axis 1.
• Underlying we see a low-level borderline organization: identity is
fragmented, object representation are split, reality testing is fragile,
defenses are immature.
• Nevertheless, we also see some adaptive coping mechanisms and
a good self-reflexive capacity during the assessment.
• Because of her traumatically developed attachment, patient is
unable to experience any form of ‘ safe’ intimacy or nearness.
• When stress increases (e.g. in case of approaching separation)
patient loses the capacity to reflect and her adaptive coping
mechanisms. She then turns to maladaptive coping mechanisms,
like splitting, and aggressive and anti-social behavior to restore the
lost balance. This antisocial behavior has to be understood as a way
to protect her autonomy and her ‘self’ against unbearable feelings
provoked by intimacy and related fear for abandonment.
From assessment to indication:
levels of treatment setting
• Outpatient treatment
• Partial hospitalization
• Brief inpatient hospitalization
• Extended inpatient hospitalization
Indication for treatment setting:
Considerations about case study
• Based on APA guidelines: extended inpatient treatment
–
–
–
–
Persistent risk behavior
Severe symptoms interfering with family and school life
Risk of assaultive behavior towards others
Co-morbid substance abuse
• Based on extra adolescent considerations (Bleiberg,
2001): extended inpatient treatment
– Insufficient resources to provide a safe environment at home
– Need for more structure and support
• Based on clinical experience
– There is a serious pitfall that she cannot deal with the pressure
for attachment in an inpatient setting (psychological testing)
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
Designing a flexible treatment
trajectory
• Treatment should be seen as a continuous trajectory
– During different years (2-5 years)
– With changing intensity
• Stepped up and down:
– Preparation phase focused at psycho-education and
motivation, crisis management and context regulation
– A residential phase to decrease stress at home and start a
therapeutic process
– A day treatment phase to strengthen the achievements and
anchoring them in real life
– A follow-up of booster sessions to support the internalized
therapeutic process
• Involving psychotherapy, system therapy and
pharmacotherapy
Designing a flexible treatment
trajectory
Assessment
Preparation
phase
Psychoeducation
Commitment
Context regulation
Crisis management
Treatment
phase
Psychotherapy
System
therapy
Post treatment
phase
Pharmaco
therapy
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
Preparation phase:
goals
• Psycho education
• Context regulation
• Crisis management plan
Preparation phase:
methods for psycho-education
• Psycho-education is a necessary part of the
treatment of PD (APA guidelines)
• Explanation about the symptoms, the origin and
the course of the disorder, and the possibilities
of treatment.
• Giving hope. It is not about ‘learning to live with
the disorder’, but about ‘curing’.
• For patients and their family there’s often relief
that the problems have a name, so they can
start to understand them.
• Psycho-education helps to bring order in the
chaos
Preparation phase:
methods for psycho-education
• Practical tips:
– Try to use the language adolescents are
familiar with. Words like ‘psychiatric illness’
can be frightening.
– Mind the intelligence and cognitive skills of
the adolescent and the parents and adapt
your explanation to their limitations
– It might be necessary to dose the information
and plan different sessions
Preparation phase:
methods for psycho-education
• Examples of standardized sentences for
explaining the diagnosis:
– You came here because you have problems for quite
a while and treatment didn’t help you enough so far.
– We’ve had several sessions with you and your
parents and asked you to participate in some
psychological testing.
– We think it’s important to find out what is really going
on, in order to suggest a treatment designed for the
problems you have
Preparation phase:
methods for psycho-education
– Your problems can be understood as making part of a
(borderline) personality disorder.
– Easily speaking, it means that you have difficulties in
dealing with your self, with your feelings, thoughts
and behavior, and difficulties in contacts with other
people.
– A borderline PD consists of 9 characteristics, 5 is
enough for the diagnosis. This means that every
patient with a borderline PD is different from every
other patient.
– We now want to give you some information about the
characteristics. Do you agree with that?
Preparation phase:
methods for psycho-education
• Fear of abandonment:
– You are afraid that people will drop you.
– You are convinced that people don’t care for you and
that you’re worth nothing.
– You will do everything to avoid people leaving you, for
example sending text messages all the time, insisting
on your contacts on MSN
– People get irritated, feeling of being suffocated en
they will try to avoid your claim
– So what happens is just that scenario where you are
so afraight of
Preparation phase:
methods for psycho-education
• Affect instability:
– You feel like your affect is never stable, you can never
be happy for some longer time
– Sometimes you feel so depressed en sad that suicide
is all you can think of, and 1 minute later you are
euphoric en busy
– You are easily irritated and your parents have the
feeling they have to tread on eggs when you’re at
home
Preparation phase:
methods for psycho-education
• From the psychological testing we learned that
you have a splitted inner world, with anger and
emptiness as the only possible ways of
expressing your feelings.
• This means that your emotions are not easily
accessible, and it is very difficult for you to
differentiate what you really feel and experience.
You don’t have tools to make your inner feelings
more comprehensible for yourself.
Preparation phase:
methods for psycho-education
• You are very frightened, and you can only
control that feeling by showing aggression.
• It is very difficult for you to make a difference
between experiences in reality, and what you
feel inside. F.e. when your therapist sets limits,
when you are thinking of the humiliations of your
stepfather, you will not always be able to make a
distinction between these 2 situations. You will
confuse your inner and outer world.
Preparation phase:
methods for psycho-education
• Because you are impulsive, as well in changing
schools, living with your parents, using drugs
and alcohol, as having sex with boys, there is a
chance that you will be impulsive in terminating
the treatment also.
• It will be important to focus on that when it’s
difficult for you to fully cooperate.
Preparation phase:
methods for psycho-education
• You find it very difficult when people want to
make close contact with you. You do not trust
intimate relationships. You prefer to break
contact yourself, to avoid that people will leave
you.
• Therefore it will be extremely important to keep
that pattern in mind in the relationship with your
therapists.
Preparation phase:
goals
• Psycho-education
• Context regulation
• Crisis management plan
Preparation phase:
methods for context regulation
• What should be arranged for the treatment
to be able to start?
– Financially
– Juridical
– Mobility (transport to treatment setting)
– Structured daily activity (in case of outpatient)
– Safe weekend destination (in case of
inpatient)
Preparation phase:
methods for context regulation
• How can continuity before, during and
after treatment be improved?
–
–
–
–
Contact with referring psychiatrist/psychologist
Contact with school
Home visit by social worker
Social network, neighborhood etc
• Use a clear therapeutic frame
– What rules about drugs and alcohol?
– Give an information sheet with basis rules,
expectancies, treatment methods
Preparation phase:
goals
• Psycho-education
• Context regulation
• Crisis management plan
Preparation phase:
methods for crisis management
• Severe PD lead almost by definition to crises during treatment.
• Crises give agitation and can interfere with countertransference,
leading to splitting in a team.
• Designing a plan for crisis management gives control and
predictability
• The goal is to stabilize the crisis so the treatment process is not
jeopardized
• Make clear agreements with patient and parents in advance,
specifically about the availability of therapists
• Give clear roles to staff members in dealing with the crisis: medical
care, psychological care, decision about transfer to other setting
• Agree with patient and parents on a plan for crisis management
during the weekend or evening. Put it on paper.
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
Designing a flexible treatment
trajectory
Assessment
Preparation
phase
Psychoeducation
Commitment
Context regulation
Crisis management
Treatment
phase
Psychotherapy
System
therapy
Post treatment
phase
Pharmaco
therapy
Designing an integrative,
adolescence-specific treatment
• Psychotherapy is treatment of first choice
– Dialectical Behavior Therapy
– Mentalization Based Treatment
– (Schema Focused Therapy)
• Pharmacotherapy should be considered
as an ‘enabler’ of psychotherapy
• System therapy is a necessary
complement of psychotherapy in
adolescence
Some general remarks about
psychotherapy for severe PD
• Two evidence based models for treating
BPD in adults (Cochrane review, 2006)
– Dialectical Behavior Therapy (Linehan, 1991)
– Mentalization Based Treatment (Bateman &
Fonagy, 1999, 2004, 2006)
Dialectical Behavior Therapy
• Based on cognitive-behavioural therapy
• Hierarchy of interventions:
– Interventions aimed at reducing self-mutilating behaviour
– Interventions aimed at behaviour that interferes with the
therapeutic process
– Interventions aimed at improving quality of life
• Out-patient individual therapy, once a week, in
combination with group therapy
• Empirical evidence for effectiveness of DBT (Koons, 2001;
Linehan 1991, 1999, 2002; Turner, 2000; van den Bosch, 2002)
• Adaptations made for adolescents!
DBT in adolescence
Adaptations (Miller et al., 2007)
• Parents participate in the skill groups (multifamily skill
training group)
• Shorter treatment
• Simpler hand-outs
• Simpler diary
• Including family therapy (as-needed base)
• Including extra skills that are relevant for parents or
siblings
• Telephone consultations for parents
• A new module: walking the middle path, introducing
three new dialectical dilemma’s
Mentalization Based Treatment
• Psychodynamic oriented treatment
program
• Attachment theory
• Primary aim: to enhance mentalization
• Outpatient treatment program (18 months)
• Empirical evidence for effectiveness of
MBT (Bateman, 1999)
Some general remarks about
pharmacotherapy for severe PD
• Psychotherapy is treatment of first choice
• Pharmacotherapy as “enabler”, to make
psychotherapy “more possible”
• No evidence based treatment methods
• Guidelines for adults, warnings for children
and adolescents
• Controversies, for instance about SSRi’s
Some general remarks about
pharmacotherapy for severe PD
• Be aware of the differences in
pharmacokinetics in children and
adolescents:
– Percentage of body fat
– Lipophile binding
– Speed of metabolism
– Plasma proteins
– Demolition
Some general remarks about
pharmacotherapy for severe PD
• Symptom-targeted pharmacotherapy in
patients with PD is confusing.
• Is the symptom (f.e. negative affect) part
of the personality disorder, or is it part of
an axis-1 disorder (f.e. major depressive
disorder)
• Cochrane review: no exclusion of axis 1
disorders, except for psychotic disorders
Some general remarks about
pharmacotherapy for severe PD
• APA-guidelines (2001):
– 3 algorithms:
• Affective dysregulation
• Impulsive behavior
• Cognitive-perceptual symptoms
• No clinical trials
• More practice based than evidence based
Pharmacotherapy:
some case study interventions
• Because of the seriousness of the symptoms of
our patient we choose a combinations of
different products:
– Escitalopram 10 mg for heavy mood changes
– Quetiapine 300 mg for cognitive-perceptual
symptoms, psychotic-like fears and impulsivity
– Topiramate 50 mg for dissociation, the images of
sexual abuse and humiliations of step father
– Diazepam 5 mg for the side effects after alcohol stop.
Some general remarks about
system therapy for severe PD
• Is a necessary part of the treatment of a PD
adolescent, on practice based arguments
• Youngsters can only change and grow within the
context of their family. When there is no
continuity between the therapy and the milieu at
home, changes will not last long.
• Several different models have proven their
solidity, but there is no evidence based
background.
• New research can support the guideline of
always working with the family of the adolescent.
Some general remarks about
system therapy for severe PD
• I-BAFT: integrative borderline adolescent
family therapy
• Multidimensional family therapy, based on
attachment theory
• Integrative family therapy with genograms
and core qualities
How to design a flexible and effective
treatment integrating those components?
• Therapeutic relationship including limit setting
• How does developmental phase affect therapy
for severe PD’s?
• What are goals and methods in different phases
of the therapeutic process?
Therapeutic relation
• Install a therapeutic alliance based on
cooperation
• Be transparent (about interventions,
treatment goals etc)
• Avoid an expert or moralizing position.
• Balance between acceptance/validation
and change/empathic confrontation
Therapeutic relation:
limit setting
• It is probably impossible to avoid setting limits
(and it is probably damaging)
• There are three principles to keep in mind:
– Adolescents should be given a proper (and growing)
responsibility
– Limits should not be administered in an automatic,
procedural way, but with the mind of the adolescent in
mind
– Therapists should be transparent about the ‘why’ of
limit setting
• Be aware of extremes: authoritarian control
versus excessive leniency (Miller et al., 2007)
How does developmental phase
affect therapy for severe PD’s?
• Methods and interventions
– Cognitive, emotional, social and identity
development determine how to do therapy
• Attune to cognitive level, …
• Content/issues
– Developmental tasks determine what therapy
is about (treatment goals)
• Sexual identity, separation from parents, …
Developmental guidelines for
choosing methods and interventions
• Based on cognitive development
– Be concrete (especially with adolescents
under 15 yrs)
– Visualize
– Be careful with metaphors
– Don’t lean too much on hypothetical thinking
– Support critical thinking
– Practice meta-thinking
Developmental guidelines for
choosing methods and interventions
• Based on emotional development
– Be aware that affective instability is the core
of BPD in adolescents
– Start by identifying ‘simple’ emotions before
proceeding to complex mental states
– Give words to identify emotions
– Learn to discriminate between intensities and
sorts of emotions
– Reinforce proper expression of emotions
Developmental guidelines for
choosing methods and interventions
• Based on social development
– Let the adolescent ‘save face’
– Be aware of the enhanced vulnerability in
groups
– Be aware that the attachment to peers might
be as important (or even more) than the
attachment to therapists
– Invest in installing a positive, accepting group
norm
Developmental guidelines for
choosing methods and interventions
• Based on identity development
– Support autonomy
• What do you want to change?
• How do you want to use this session?
– Offer opportunities to separate
• Support critical thinking
• Give privacy
• Tolerate experimenting behavior
Developmental guidelines for
determining treatment goals
• Based on developmental tasks (12-15 yrs)
– Dealing with physical changes
– Constructing own frame of reference (norms, values)
– Connect with peers
• Based on developmental tasks (15-20 yrs)
– Becoming more independent from feedback of peers
and adults
– Developing a stronger self-esteem
– Developing social and professional skills
– Re-constructing a relationship with parents
Goals and methods in different
phases of the therapeutic process
• Start phase
• Middle phase
• End phase
Start phase:
Goals
•
•
•
•
Install a secure, predictable environment
Enhance motivation / commitment
Agree upon prior treatment goals
Start by improving a sense of competence
in the adolescent and his/her family
• Medication
Start phase:
some methodological issues
• About motivation
– ‘Roll with resistance’
– Do not convince from an expert position
– Let the adolescent motivate himself by
eliciting self-motivating expressions
– Use authentic and focused reinforcements to
highlight advances
• How was it for you to experience you succeeded in
managing stress in this way?
Start phase:
some methodological issues
• About improving competence
– Start by thinking about or even teaching skills
to cope with stress
– Assist caregivers in achieving skills to remain
in control even when facing internal and
interpersonal turmoil
• Psycho-education
• Skill group
Start phase:
some case study interventions
• We predicted upcoming relational patterns
– If you tell me you always tend to break up friendships
after some months, this might be happening here too.
• We looked for agreement on prior symptoms
– She was frightened by her cutting and burning, being
afraid she would lose control
– About trauma: I understand this is something
extremely important for you, which we will have to
work on further in treatment, but at this moment I
notice that talking about it gives you a lot of tension
and often leads to cutting yourself.
Start phase:
some case study interventions
• We looked for alternatives to cope with
stress
• We made a concrete ‘minute-to-minute’
crisis plan
• There was a joined consult with the
therapist and psychiatrist about medication
• The family was taught some basic skills to
prevent discussions from escalating
Middle phase:
Goals
• Help the adolescent to relate symptoms to
mental states that occur in the context of
relations
• Help the adolescent to face developmental
tasks, including developing a new
relationship with parents
Middle phase:
some methodological issues
• About developing a reflective stance
– Identify and validate actual or recent mental
states
– Differentiate and contextualize
– Internalize and help to take responsibility
– Digest and help to tolerate ambivalence
– Integrate in alternative behavior and mental
states
Middle phase:
some case study interventions
• Tania often started therapy announcing how
‘crap’ she felt
– What do you mean by ‘crap’? How sad, angry,
anxious?
– Can you remember when you noticed some change
in how you felt? Attitude: it might be worth to explore in detail
how you came to feel this way
– Can you understand why this (trigger) made you feel
this way?
– How is it to understand yourself in this way?
Middle phase:
some case study interventions
• After three months, acting out dramatically
increased (drinking, crossing limits)
• She wanted to stop treatment because it got
‘boring’
– Can you help me to understand how it got this far? Where
did you notice a change in motivation?
– This enhanced reflective stance made her aware of her fear
for intimacy of group members
• I cannot tolerate it anymore. I don’t want to experience a
goodbye of group members anymore
• She experienced extremely aggressive thoughts
including group members, which made her angry
– With this broadening perspective, she was invited to rethink
her decision to stop.
– We accepted her decision.
End phase:
Goals
• Anticipate on reintegration
• Prepare for loss associated with leaving
• Relapse prevention
End phase:
some methodological issues
• About relapse prevention
– Identify ‘traps’
– Identify future life stressors
– Identify successful coping and new
competencies
– Make a written therapy summary with your
patient
Follow-up
• Stepped down care: gradually less
intensive treatment and more intensive
reintegration in school, work etc
• Booster sessions
Contact
Email:
[email protected]
[email protected]
[email protected]
Website: www.deviersprong.nl
www.vispd.nl