Minding mentalizing - convergent validity of the Mentalization Breakdown Interview.

Objectives: Mentalizing difficulties are central to borderline personality disorder (BPD), have severe consequences, and are an explicit focus in mentalization-based treatment. The significance of mentalizing capacity as a predictor or mediator of change is however still uncertain due to a scarcity of research. The Mentalization Breakdown Interview (MBI) was developed as a time saving tool for studying psychotherapy processes and outcome in borderline pathology. This study aimed to investigate the convergent validity of reflective functioning (RF) ratings based on the MBI (MBI-RF) by a comparison with the gold standard, i.e., RF assessments based on the Adult Attachment Interview (AAI-RF). A secondary aim was to investigate how MBI-RF relates to core symptoms of BPD, levels of functional impairment and symptom distress compared with AAI-RF. Method: Forty-five patients with BPD or significant BPD traits were included. MBI-RF and AAI-RF were rated using the Reflective Functioning Scale. Levels of MBI-RF and AAI-RF and the correlation between the measures were calculated, as well as their associations with the Difficulties in Emotion Regulation Scale, Levels of Personality Functioning-Brief Form 2.0, Work and Social Adjustment Scale, Patient Health Questionnaire, Depression, Generalized Anxiety Disorder-7, self-harm, suicide attempts, and PD diagnostics. Results: The correlation between MBI-RF and AAI-RF was 0.79 (p<0.01), indicating high convergent validity. There were few significant associations between MBI-RF and AAI-RF and clinical measures. Conclusions: The study provides support for the convergent validity of the MBI as a BPD-focused RF assessment method. The MBI has the potential as a time saving, reliable and valid method to be applied in treatment research on patients with borderline pathology. The results indicate that measures of MBI-RF and AAI-RF are different from clinical symptoms. Clinical trial registration: ClinicalTrials.gov ID NCT04157907.

Evaluating the Construct Validity of the Norwegian Version of the Level of Personality Functioning Scale - Brief Form 2.0 in a Large Clinical Sample.

The Level of Personality Functioning - Brief Form 2.0 (LPFS-BF 2.0) is a 12-item self-report questionnaire developed to gain a quick impression of the severity of personality pathology according to the DSM-5 Alternative Model for Personality Disorders (AMPD). The current study evaluated the construct validity and reliability of the Norwegian version of the LPFS-BF 2.0 in a large clinical sample (N = 1673). Dimensionality was examined using confirmatory factor analysis and bifactor analysis followed by an analysis of distinctiveness of the subscales using the proportional reduction in mean squared error (PRMSE), and the concurrent validity was examined using correlations with self-report questionnaires and clinical interviews assessing PDs according to section II of the DSM-5. Taking the findings of the dimensionality and concurrent validity results together, we found moderate to good support for the use of total scores for the Norwegian version of the LPFS-BF 2.0. We would advise against the use of subscale scores, since the subscales provided only a small amount of reliable unique variance.

Mental health disorders, functioning and health-related quality of life among extensively hospitalized patients due to severe self-harm - results from the Extreme Challenges project.

Background: Severe self-harm leading to extensive hospitalization generates extreme challenges for patients, families, and health services. Controversies regarding diagnoses and health care often follow. Most evidence-based treatments targeting self-harm are designed for borderline personality disorder (BPD). However, current knowledge about mental health status among individuals with severe self-harm is limited. Objectives: To investigate psychopathology among patients extensively hospitalized due to severe or frequent self-harming behaviors. Method: A cross sectional study (period 2019-2021) targeting psychiatric inpatients (>18 years) with frequent (>5) or long (>4 weeks) admissions last year due to self-harm. The target sample (N = 42, from 12 hospitals across all Norwegian health regions) was compared to individuals admitted to outpatient personality disorder (PD) treatment within specialist mental health services in the same period (N = 389). Clinicians performed interviews on self-harm and psychopathology, supplemented by self-report. Results: The target sample were young adults, mainly female, with considerable hospitalization and self-harming behaviors, both significantly more extensive than the comparison group. The majority in both groups reported self-harm onset <18 years. The target sample reported increasing severity of self-harm acts and suicidal intention over time. Both samples had high levels of childhood trauma, impaired personality functioning, and a majority fulfilled criteria for PD. In the target sample, comorbid depression, PTSD, anxiety disorders, and substance use occurred more frequently and in 50%, psychosis/dissociative disorder/autism spectrum disorder/ADHD was reported (outpatient comparison sample: 9%). 35% in the target sample screened over cut-off for possible intellectual disability. The target sample reported poor psychosocial functioning and health-related quality of life - greater impairment than the outpatient comparison sample. Conclusion: The study reveals that severe self-harm inpatients have complex psychopathology and highlights the importance of individualized and thorough assessment among patients with severe and/or repetitive self-harm.

Personality disorders: the impact of severity on societal costs.

Personality disorders (PDs) are associated with high levels of societal costs. However, previous research has found limited or no evidence of unique contributions of individual PD categories on the overall level of societal costs. Recent research supports the validity of PD as a dimensional construct, and PD severity may be a better predictor of societal costs than specific PD categories. The aim of this study was to explore if PD severity could predict the level of societal costs among treatment-seeking patients with PDs, while controlling for the impact of comorbid mental health and substance use disorders. Four different severity indicators were explored: the number of PDs, the total number of PD criteria, the number of BPD criteria, and the Level of Personality Functioning Scale (LPFS) from the alternative model in DSM-5. Participants (n = 798/794) were retrieved from the quality register of the Norwegian Network for Personality Disorders for the period 2017-2020. Societal costs were assessed using a structured interview covering the six-month period prior to assessment. Diagnoses and diagnostic criteria were determined using a semi-structured diagnostic interview (SCID-5-PD and M.I.N.I), and the LPFS was assessed by the LPFS-Brief Form 2.0 (LPFS-BF 2.0) questionnaire. Statistics included multiple regression analyses. None of the severity indicators were significant predictors of overall societal costs among treatment-seeking patients, and effect sizes were small.

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.

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

Objective: Avoidant 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. Methods: The 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. Results: The 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. Conclusions: This 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.

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.

Environmental Transformations Enhancing Dignity in an Acute Psychiatric Ward: Outcome of a User-Driven Service Design Project.

OBJECTIVES: The goal of the current project was to enhance the feeling of dignity for patients in the seclusion unit in an acute psychiatric ward through environmental design changes and to evaluate the effect of the refurbishment. BACKGROUND: Treating people with dignity is essential in all health-related work and important for our mental health. Hospital architecture and design signal values that can promote dignity. Patients who must spend time in seclusion are at their most vulnerable mental state and the often worn-down like environment can challenge the feeling of dignity. How environmental design can promote dignity in seclusion units have not been studied. METHODS: To reach suggestions for design changes enhancing dignity, we used service design that included a broad user group. The effect of design changes was evaluated by a questionnaire answered by the nursing staff during a 4-week period pre- and post refurbishment and included a control group. RESULTS: The design concepts agreed upon were a welcoming atmosphere, contact with nature, room for privacy, close contact with staff, and a designated smoking area inside the unit. The evaluation found that the environmental design changes significantly supported the patients in their situation and the staff in their work. CONCLUSION: We conclude that dignity design concepts are highly applicable also in an acute psychiatric setting and improve the situation of secluded mental health patients, which is much needed. Findings align with other environmental changes in psychiatric wards that improve the patients' well-being and reduce aggression.

The Norwegian network for personality disorders - development, contributions and challenges through 30 years.

BACKGROUND: Established in 1992, the Norwegian Network for Personality Disorders (The Network) is a clinical research collaboration of specialist mental health and addiction services in Norway. Its primary focus is to facilitate systematic and relevant clinical assessment for patients with personality disorder and evaluate progress in psychotherapeutic treatment. However, large-scale data registers for personality disorder are still unique. This article presents the circumstances that led to the establishment of the Network, and its development and challenges in many areas, and through various phases. METHODS: In the following, we will outline how this close interaction between researchers, clinicians, and well-adapted systems has facilitated cooperation and clinical research. We will highlight some key factors that have been decisive during the network's development, and not least for further adaptation and existence. RESULTS: Through 30 years, the Network has succeeded in establishing a large and sustainable clinical research collaboration with a persistent focus on personality disorder and psychotherapeutic treatment. The collaboration has resulted in a broad range of scientific contributions to the understanding of personality disorder, assessment and measurement methods, treatment alliance, clinical outcomes, service utilization, and costs. In addition, The Network has also resulted in a number of synergy effects that have benefited clinicians, patients, and researchers. CONCLUSIONS: The Norwegian Network for Personality Disorders has become an acknowledged institution in the field. Many aspects of its development, organization, maintenance, and solutions to challenges may be relevant to others who plan to establish, maintain, or further develop similar collaborations.

A borderline focused Reflective Functioning measure - Interrater reliability of the Mentalization Breakdown Interview.

OBJECTIVE: Mentalizing difficulties can be considered the core psychopathology of borderline personality disorder (BPD). Typical failures of mentalizing are targets in therapy for BPD. They are related to severe distress, relational problems, self-destructive behaviors, violence, or substance misuse. A major obstacle in BPD treatment research is the lack of suitable and easily administrated methods to assess mentalizing ability during treatment. The Mentalization Breakdown Interview (MBI) is a new method for capturing episodic mentalizing difficulties occurring in close relationships. Interviews are videotaped and scored in accordance with the Reflective Functioning Scale (MBI-RF). In this way the patients' ability to retrospectively reflect over such episodes are evaluated. This study investigates the interrater reliability of MBI-RF. METHODS: The study includes videotapes of MBIs from 32 patients with BPD in an outpatient clinic specialized on mentalization-based treatment (MBT). The MBIs were performed by MBT therapists. Three certified raters scored MBI-RF. RESULTS: The interrater reliability was good for MBI-RF. CONCLUSIONS: The MBI is promising as a BPD-focused method for the assessment of Reflective Functioning.

Pedagogical stance in mentalization-based treatment.

BACKGROUND: A common aspect of evidence-based treatments for people with borderline personality disorder (BPD) is pedagogical interventions and formats. In mentalization-based treatment (MBT) the introductory course has a clear pedagogical format, but a pedagogical stance is not otherwise defined. METHODS: Treatment integrity was quantitatively assessed in a sample of 346 individual MBT sessions. Nine group sessions and 24 individual MBT sessions were qualitatively subjected to interpretative phenomenological analysis (IPA). RESULTS: The dominating intervention type was MBT Item 16-therapist checking own understanding (31% of the interventions). IPA unveiled the following: (1) a pervasive, but hidden/implicit psychopedagogical agenda, (2) psychopedagogical content seemed precious for the patients, and (3) four tentative strategies for pedagogical interventions in MBT (a) independent reasoning; (b) epistemic trust; (c) mental flexibility; and (d) application of verified insights, knowledge, or strategies. CONCLUSION: Development and clarification of the pedagogical stance in MBT could further improve the quality of therapists' interventions.

Psychometric evaluation of the Norwegian Toronto Alexithymia Scale (TAS-20) in a multisite clinical sample of patients with personality disorders and personality problems.

OBJECTIVE: Psychometric properties of 20-item Toronto Alexithymia Scale (TAS-20) have been widely analyzed, but the validity and psychometric qualities of the TAS-20 in populations with personality disorders are still poorly understood. The aim of the current study was to analyze the factor structure and validity of TAS-20. METHOD: Data were extracted from a multisite clinical sample of patients with personality disorders or personality-related problems referred to specialist mental health services in Norway. RESULTS: With one exception, TAS-20 revealed acceptable psychometric properties. Variations of TAS-20 are associated with other clinical measures of distress and severity. Anxiety disorders, borderline, and avoidant personality disorders were all highly related to levels of TAS-20. The TAS-20 also revealed unique variance not accounted for by subjective distress, symptom disorders, or dysfunctional personality traits. CONCLUSION: The TAS-20 is a relevant instrument for use in assessment of personality disorders, but one subscale should be improved.

Vulnerability of personality disorder during the Covid-19 crises - a multicenter survey of treatment experiences among patients referred to treatment.

BACKGROUND: The societal shutdown due to the Covid-19 pandemic involved mental health services for personality disorder (PD) and was introduced from 12 March 2020 in Norway. Rapid implementation of treatment modifications was required for patients typically characterized by insecure attachment and vulnerability to separation. AIM: To investigate immediate reactions to the shutdown of services; alternative treatment received; and differences related to age in a clinical sample of patients with PD. DESIGN: A survey performed from June to October 2020 (after the first Covid-19 wave) among 1120 patients from 12 units offering comprehensive group-based PD programs. RESULTS: The response-rate was 12% (N = 133). Negative feelings of anxiety, sadness, and helplessness were noteworthy immediate reactions, but the dominating attitude was accommodation. Younger patients (<26 years) reported more skepticism and less relief. Modified treatment was mainly telephone therapy. Digital therapy was less available, but was more frequent among younger patients. A minority received digital group therapy. Most patients rated the frequency and quality of modified treatments as satisfactory in the given situation, but also worried about own treatment progress, lack of group therapy, and 47% missed seeing the therapist when having telephone consultations. CONCLUSION: The survey confirms a radical modification from comprehensive group-based PD programs to telephone consultations, low availability of digital consultations and group treatments. Taking a short-term, first wave perspective, the survey indicates a noteworthy capacity among poorly functioning patients for accommodating to a clearly challenging situation, as well as considerable concern about treatment progress.

Vulnerability of personality disorder during COVID-19 crises: a multicenter survey of mental and social distress among patients referred to treatment.

BACKGROUND: Relational and emotional problems, dysregulation, self-harming or substance abuse often characterize personality disorders (PD). In Norway, COVID-19 restrictions led to an abrupt shutdown of services from 12 March 2020 also including specialized PD treatments. AIMS: The objective of this study was to investigate social and mental distress among patients with PDs during the first COVID-19 wave. DESIGN: A survey was distributed after the first COVID-19 wave (June-October 2020) among 1120 patients from 12 PD treatment units. RESULTS: The response rate was 12% (N = 133). The survey reflected impairment of occupational activity (53% <50% activity last 6 months), life quality (EQ-5D-VAS: 56, SD 19), and personality functioning (LPFS-BF ≥12: 81%, 35% avoidant PD, 44% borderline PD) and high levels of depression and anxiety (PHQ-9 ≥ 10: 84%, GAD-7 ≥ 10: 68%), 49% with health-related anxiety. Problem increase was reported for anxiety (28%), depression (24%), aggression (23%), substance use (14%), and 70% of parents had more child-care difficulties. Self-destructive behaviors (26%) did not increase. The majority (78%) reported increased or unchanged social isolation and loneliness. Occupational activity declined with negative effects on part-time jobs/rehabilitation. Therapist contact was mainly telephone-based (63% ≥ weekly contact). More severe personality problems, current depressive symptoms, and self-harming before 12 March were associated with more frequent consultations. CONCLUSION: The survey confirms severe, enhanced levels of mental distress among patients receiving telephone-based consultations as the main alternative to specialized PD treatment during the COVID-19 shutdown. The most vulnerable patients received more frequent consultations and self-destructive actions did not increase.

Avoidant personality disorder and social functioning: A longitudinal, observational study investigating predictors of change in a clinical sample.

Avoidant personality disorder (AvPD) is an understudied, severe disorder. This study includes a clinical sample of AvPD patients (N = 460) treated within specialist mental health services. Social functioning was repeatedly assessed by self-report: Work and Social Adjustment Scale. Personality functioning (self-report), pretreatment occupational activity, civil status/family situation (self-report), and comorbidity; personality and symptom disorders were assessed at baseline. More extensive baseline impairment of social functioning was significantly associated with poorer personality functioning, occupational inactivity, and a larger number of comorbid PD traits and symptom disorders. Poorer personality functioning and greater comorbidity did not impede improvement. More persisting impairment of functioning was associated with living alone. The study confirms major impairments of social functioning in AvPD, strongly related to personality dysfunction. A slow improvement of social functioning was demonstrated. With the exception of the civil status, living alone, improvement was not impeded by baseline severity aspects. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Level of alexithymia as a measure of personality dysfunction in avoidant personality disorder.

BACKGROUND AND OBJECTIVES: Avoidant Personality Disorder (AvPD) is considered a mild to moderate personality disorder. However, few studies have focused on the heterogeneity of AvPD in terms of symptoms and severity. In the current study we set out to replicate and extend earlier findings showing that there is variation among patients with AvPD in terms of alexithymia and, further, that this variation is especially associated with specific facets of personality functioning and is not explained by measures of depression, symptom severity, or co-occurring personality disorder traits. METHOD: We used intake data from a sample of AvPD patients (n = 56) who had been treated in similar outpatient services. Alexithymia was measured using the Toronto Alexithymia Scale (TAS-20). Patients filled out questionnaires that were analysed using linear regression models. RESULTS AND CONCLUSIONS: Using well-established cut-off points for low, intermediate and high levels of alexithymia we found an almost equal distribution of alexithymia groups in our sample. Alexithymia was associated with higher personality dysfunction on twelve out of sixteen facets of personality functioning. For eight of these personality facets the alexithymia total score explained significant variance even after controlling for self-reported depression, symptom severity and clinician ratings of personality disorder. Results suggest that AvPD is heterogeneous and that alexithymia may be important as an indicator of severity of specific personality dysfunction.

Social Cognition Capacities as Predictors of Outcome in Mentalization-Based Treatment (MBT).

BACKGROUND: Mentalization-based treatment (MBT) is an evidence-based treatment for borderline personality disorder (BPD). Differences in treatment outcomes related to specific capacity of social cognition need further attention. This study aimed to investigate social cognition as a predictor of outcome. METHOD: The study included 31 BPD patients who completed a test of social cognition (Movie for the Assessment of Social Cognition, MASC) before outpatient MBT. The MASC-scores indicated a person's theory of mind (ToM) and different error-types. During treatment repeated self-reports of alliance and clinical outcomes (symptoms, interpersonal problems, social functioning) were applied. Longitudinal analyses were based on Linear Mixed Models (n = 24). RESULTS: The most frequent error-type was excessive ToM (hypermentalizing). Higher levels of excessive ToM were associated with greater improvement of alliance over time and good clinical outcomes. Insufficient ToM errors and low levels of accurate cognitive ToM responses were both associated with poorer improvement over time. The subgroup with frequent insufficient ToM errors had a larger total number of ToM errors. Insufficient ToM errors were associated with more childhood trauma, comorbid avoidant PD traits and/or PTSD, extensive prior treatment, and/or treatment irregularity. CONCLUSION: This study demonstrates considerable variation of social cognitive capacity among BPD patients and good outcomes for patients with mainly ToM errors of hypermentalizing. It also indicates that poorly responding patients may represent a cohort with more complex problems of social cognition and insufficient mentalizing.

Are Impairments in Theory of Mind Specific to Borderline Personality Disorder?

Impaired theory of mind (ToM) is an assumed feature of borderline personality disorder (BPD). Yet, no studies have compared ToM abilities in patients with BPD, other personality disorders, and healthy controls, or investigated the relationship between ToM and severity of psychopathology and interpersonal problems. In this study, ToM was investigated by the Movie for the Assessment of Social Cognition. No differences were found between the three groups in overall ToM abilities. The BPD group was, however, characterized by more excessive ToM (interpreted as hypermentalization). Yet, when differentiating between BPD and further severity indicators, excessive ToM was not specifically associated with a BPD diagnosis per se. Finally, there was a moderate association between hypermentalization and interpersonal problems in the BPD group. This study suggests that BPD patients tend to hypermentalize when they misinterpret social information, and that this tendency is related to the severity of their psychopathology.

Evaluation of Diagnostic Thresholds for Criterion A in the Alternative DSM-5 Model for Personality Disorders.

The Level of Personality Functioning Scale (LPFS) of the Alternative DSM-5 Model for Personality Disorders (AMPD) was formulated to assess the presence and severity of personality disorders (PDs). Moderate impairment (Level 2) in personality functioning, as measured by the LPFS, was incorporated into the AMPD as a diagnostic threshold for PD in Criterion A of the general criteria, as well as for the "any two areas present" rule for assigning a specific PD diagnosis. This study represents the first evaluation of the diagnostic decision rules for Criterion A, in a clinical sample (N = 282). The results indicate that an overall diagnostic threshold for PDs should be used with caution because it may not identify all DSM-IV PDs. The "any two areas present" rule proved to be a reasonable alternative, although this finding should be interpreted with caution because the LPFS does not measure the disorder-specific A criteria.