Societal costs of personality disorders among treatment-seeking patients in Norway: the relative contribution of specific DSM-5 categories.

Personality disorders (PDs) are associated with high levels of societal costs, regardless of whether a single PD or a broad range of PDs have been studied. However, research on the relative contribution of specific PD-types on societal costs is limited. The aim of this study was to explore the possible contributions of the individual DSM-5 categories of PDs on the level of societal costs and its components (health service costs and productivity loss), while controlling for the impact of comorbid mental health and substance use disorders on these outcomes. Participants (n = 798) were retrieved from the quality register of the Norwegian Network for Personality Disorders-a collaboration of PD-treatment units within specialist mental health services. The patients were referred to treatment in the time-period 2017-2020. Costs were assessed using a structured interview covering the 6-month period prior to assessment. Diagnoses were determined by semi-structured diagnostic interviews (SCID-5-PD and M.I.N.I.). Statistics included multiple regression analyses. The main result was that no specific PD had a unique contribution to the high level of societal costs generally found among treatment-seeking patients with PDs. Borderline PD (BPD) was the only PD with significantly higher health service costs than the other PDs, while BPD, avoidant PD, and unspecified PD were independently associated with enhanced productivity loss. The differential cost-effects of specific PDs on the cost components were small. Several comorbid mental health and substance use disorders were significant contributors to costs, irrespective of PD status. The results underscore the importance of developing and implementing effective treatments for a broader range of PDs, to reduce the high levels of societal costs associated with all PDs.

Countertransference in the treatment of patients with personality disorders: A longitudinal study.

OBJECTIVE: This study examines how therapist emotional response/countertransference (CT) develops during treatment for patients with personality disorders (PDs) and how pre-treatment patient factors (severity of personality pathology, PD category, level of symptom distress) predict CT responses. Secondly, we explored associations between patient clinical outcome and CT. METHOD: A longitudinal, observational study including 1956 patients with personality pathology treated at psychotherapy units within specialist mental health services. Therapists' emotional response was repeatedly assessed by the Feeling Word Checklist-Brief Version (FWC-BV) with three subscales-Inadequate, Confident, and Idealized. RESULTS: Levels of Inadequate CT were lowest and stable over time while Confident and Idealized increased over time. Greater severity of personality pathology and borderline PD predicted higher initial Inadequate, lower initial Confident and decreasing Inadequate over time. Antisocial PD predicted decreasing Confident. Number of PD criteria had higher impact on therapist CT than level of symptom distress. Clinical improvement was associated with decreasing Inadequate. CONCLUSION: Therapists reported predominantly Confident CT when working with PD patients. More severe personality pathology, and borderline PD, specifically, predicted more negative CT initially, but the negative CT decreased over time. Patients who did not improve were associated with increasing Inadequate.

Societal costs of personality disorders: A cross-sectional multicenter study of treatment-seeking patients in mental health services in Norway.

OBJECTIVE: There is a relatively small body of research on the cost-of-illness of personality disorders (PDs). Most studies only include borderline PD. The aim of this study was to investigate mean societal costs, including its components, (direct) health service costs and (indirect) productivity loss, among treatment-seeking patients with the broad range of all PDs according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). METHODS: Cross-sectional data from 911 patients diagnosed with at least 1 PD were retrieved from the quality register of the Norwegian Network for Personality Disorders-a collaboration of PD treatment units within specialist mental health services. The patients were referred in the time period 2017-2020. Estimation of costs was based on a bottom-up approach, using information from a structured interview covering the 6-month period before assessment, whereas unit costs were retrieved from public reports, public records, or public agencies. The human capital approach was used to calculate productivity loss. Diagnoses were determined by semi-structured diagnostic interviews (Structured Clinical Interview for DSM-5-PD [SCID-5-PD]). RESULTS: The mean societal costs were €20.260 during the 6-month period before specialized treatment. The largest cost component was productivity loss (65%), whereas health service costs constituted 35%. The main contributors to societal costs from the underlying health service cost components were inpatient treatment (20.5%) and individual outpatient treatment (10.5%). CONCLUSION: Societal costs were substantial among treatment-seeking patients with the broad range of DSM-5 PDs, comparable to the societal costs of schizophrenia, and significantly higher than the societal costs of both depression and anxiety disorders. The cost estimates converged with recent, register-based cost-of-illness studies of different PDs but exceeded previous findings from other bottom-up studies. Furthermore, the results underscore the importance of implementing effective and specialized treatment for patients with a broad range of PDs, not only to alleviate individual suffering but also to reduce the level of societal costs. The emphasis on productivity loss as a main contributor to the overall societal costs is substantiated, hence underlining the relevance of interventions focusing on improving occupational functioning.

How therapists in cognitive behavioral and psychodynamic therapy reflect upon the use of metaphors in therapy: a qualitative study.

BACKGROUND: Research suggests that metaphors are integral to psychotherapeutic practice. We wanted to explore how 10 therapists reflect upon the use of metaphors in therapy, and how they react to some metaphors expressed by patients treated for of major depressive disorder (MDD). METHODS: Five therapists practicing psychodynamic therapy (PDT) and five practicing cognitive behavioral therapy (CBT) were interviewed with a semi-structured qualitative interview. Transcripts were analyzed using a thematic analysis approach. RESULTS: Our analysis resulted in two main themes: the therapeutic use of metaphors, and conflicting feelings towards metaphors used by depressed patients. Most therapists said that they do not actively listen for metaphors in therapy and many said that they seldom use metaphors deliberately. While PDT-therapists appeared more attentive to patient-generated metaphors, CBT-therapists seemed more focused on therapist-generated metaphors. Most therapists did not try to alter the patient-generated metaphors they evaluated as unhelpful or harmful. Some therapists expressed strong negative feelings towards some of the metaphors used by patients. PDT-therapists were the most critical towards the metaphor of tools and the metaphor of depression as an opponent. CBT-therapists were the most critical towards the metaphor of surface-and-depth. CONCLUSIONS: These results remind us of the complexity of using metaphors in therapy, and can hopefully be an inspiration for therapists to reflect upon their own use of metaphors. Open therapeutic dialogue on the metaphor of tools, surface-depth and depression as an opponent may be necessary to avoid patient-therapist-conflicts. TRIAL REGISTRATION: Clinical Trial gov. Identifier: NCT03022071 . Date of registration: 16/01/2017.

Digging down or scratching the surface: how patients use metaphors to describe their experiences of psychotherapy.

BACKGROUND: In the present study, we wanted to explore which metaphors patients suffering from major depressive disorder (MDD) use to explain their experience of being in therapy and their improvement from depression. METHODS: Patients with MDD (N = 22) received either psychodynamic therapy (PDT) or cognitive behavioral therapy (CBT). They were interviewed with semi-structured qualitative interviews after ending therapy. The transcripts were analyzed using a method based on metaphor-led discourse analysis. RESULTS: Metaphors were organized into three different categories concerning the process of therapy, the therapeutic relationship and of improvement from depression. Most frequent were the metaphorical concepts of surface and depth, being open and closed, chemistry, tools, improvement as a journey from darkness to light and depression as a disease or opponent. CONCLUSIONS: Patient metaphors concerning the therapeutic experience may provide clinicians and researchers valuable information about the process of therapy. Metaphors offer an opportunity for patients to communicate nuances about their therapeutic experience that are difficult to express in literal language. However, if not sufficiently explored and understood, metaphors may be misinterpreted and become a barrier for therapeutic change. TRIAL REGISTRATION: Clinical Trial gov. Identifier: NCT03022071 . Date of registration: 16/01/2017.

Mechanisms of change and heterogeneous treatment effects in psychodynamic and cognitive behavioural therapy for patients with depressive disorder: a randomized controlled trial.

BACKGROUND: Major depressive disorder (MDD) is a prevalent psychiatric condition associated with significant disability, mortality and economic burden. Cognitive behavioral therapy (CBT) and psychodynamic psychotherapy (PDT) are found to be equally effective for patients with depression. However, many patients do not respond sufficiently to either treatment. To offer individualized treatment, we need to know if some patients benefit more from one of the two therapies. At present little is known about what patient characteristics (moderators) may be associated with differential outcomes of CBT and PDT, and through what therapeutic processes and mechanisms (mediators) improvements occur in each therapy mode. Presently only theoretical assumptions, sparsely supported by research findings, describe what potentially moderates and mediates the treatment effects of CBT and PDT. The overall aim of this study is to examine theoretically derived putative moderators and mediators in CBT and PDT and strengthen the evidence base about for whom and how these treatments works in a representative sample of patients with MDD. METHODS: One hundred patients with a diagnosis of MDD will be randomized to either CBT or PDT. Patients will be treated over 28 weeks with either CBT (one weekly session over 16 weeks and three monthly booster sessions) or PDT (one weekly session over 28 weeks). The patients will be evaluated at baseline, during the course of therapy, at the end of therapy, and at follow-up investigations 1 and 3 years post treatment. A large range of patient and observer rated questionnaires (specific preselected putative moderators and mediators) are included. DISCUSSION: The clinical outcome of this study may better guide clinicians when deciding what kind of treatment any individual patient should be offered. Moreover, the study aims to further our knowledge of what mechanisms lead to symptom improvement and increased psychosocial functioning. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03022071.

Countertransference feelings and personality disorders: a psychometric evaluation of a brief version of the Feeling Word Checklist (FWC-BV).

BACKGROUND: The Feeling Word Checklist (FWC) is a self-report questionnaire designed to assess therapists' countertransference (CT) feelings. The primary aim of the study was to evaluate the psychometric properties of a brief, 12-item version of the Feeling Word Checklist (FWC-BV). The second aim was to validate the factor structure by examining the associations between the FWC-BV factors, patients' personality pathology and therapeutic alliance (TA). METHODS: Therapists at 13 different outpatient units within the Norwegian Network of Personality Disorders participated, and the study includes therapies for a large sample of patients (N = 2425) with personality pathology. Over a period of 2.5 years, therapists completed the FWC-BV for each patient in therapy every 6 months. Statistical methods included exploratory (EFA) and confirmatory (CFA) factor analysis. Internal consistency was estimated using Mc Donald's coefficient Omega (ωt). The Structured Clinical Interview for DSM-IV - Axis II (SCID II) and Mini International Neuropsychiatric Interview (MINI) were used as diagnostic instruments, and patient-rated TA was assessed using the Working Alliance Inventory (WAI-SR). RESULTS: Factor analyses revealed three clinically meaningful factors: Inadequate, Idealised and Confident. These factors had acceptable psychometric properties. Most notably, a number of borderline PD criteria correlated positively with the factors Inadequate and Idealised, and negatively with the factor Confident. All the factors correlated significantly with at least one of the WAI-SR subscales. CONCLUSIONS: The FWC-BV measures three clinically meaningful aspects of therapists' CT feelings. This brief version of the FWC seems satisfactory for use in further research and in clinical contexts.

Revised manual for the Global Assessment of Functioning scale.

Global Assessment of Functioning (GAF) is a single measure of overall psychosocial impairment caused by mental factors, constituting Axis V of the Diagnostic and Statistical manual of Mental disorders, third and fourth versions. Despite its widespread use, several challenges and shortcomings have been discussed the last three decades. The current article describes some of the more serious challenges of the GAF manual, and presents a revised version more in accordance with the nature of this clinical construct. Some crucial aspects of the understanding of GAF and general guidelines for scoring are also discussed.

The Work and Social Adjustment Scale: Psychometric properties and validity among males and females, and outpatients with and without personality disorders.

The Work and Social Adjustment Scale (WSAS) is an outcome measure assessing degree of functional impairment. Its psychometric properties, validity and sensitivity to change have been supported in several studies. However, no explicit psychometric or validity study of WSAS has been performed on data from a large sample of psychiatric outpatients, with and without personality disorders. The aim of this study was therefore to provide additional knowledge of the properties of WSAS in such a sample. The material comprised data from 1371 patients, from 15 different units participating in the Norwegian Network of Personality-Focused Treatment Programs. Psychometric properties of the scale, such as measurement invariance among males and females, longitudinal invariance, as well as associations with other clinical measures and sensitivity to change were analysed. The results confirm that WSAS constitutes a reliable, unidimensional and gender invariant measure, sensitive to change and to severity of mental distress. Although highly associated with levels of depression, WSAS measures a clinically important aspect of impairment. Copyright © 2017 John Wiley & Sons, Ltd.

The impact of extended longitudinal observation on the assessment of personality disorders.

Multiple sources of information are necessary for a valid assessment of personality disorders (PDs). This study investigates the impact of longitudinal observation. The sample comprised 1217 patients from 15 different treatment units. PDs were assessed at admission to treatment using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) and additional clinical information (best estimate diagnosis). After approximately 18 weeks of treatment, the SCID-II protocols were re-examined at clinical conferences and the diagnostic status reassessed on the basis of longitudinal observations in multiple group situations (longitudinal, expert, all data principle). Using this procedure, 78% of the patients' diagnostic criteria sets were changed, and 32% of patients' diagnostic statuses were changed. Many (32%) patients who were evaluated initially as not having a PD received a PD diagnosis after re-examination. The information provided by customary clinical assessment has important limitations, and longitudinal observation provides additional information that may change the diagnostic status in approximately one-third of PD cases.

Self-esteem in patients with borderline and avoidant personality disorders.

This study compared self-esteem in patients with avoidant personality disorder (APD) and borderline personality disorder (BPD). Patients diagnosed with one or more personality disorders answered the questionnaire Index of Self Esteem as part of a comprehensive evaluation within the setting of a treatment trial. Our hypotheses were that (1) both patients with APD and patients with BPD would report low levels of self-esteem, (2) patients with APD would report lower self-esteem than patients with BPD. We further expected that (3) patients with higher levels of depression would report lower levels of self-esteem, but that (4) both borderline and avoidant personality pathology would contribute to explained variance in self-esteem beyond what would be accounted for by depression. All of our hypotheses were supported. The results from our study showed a significant difference in self-esteem level between the two personality disorders, patients with APD reporting lower self-esteem than patients with BPD. Subjects with both disorders were measured to have self-esteem levels within the range that presumes clinical problems. Self-esteem represents an important quality of subjective experience of the self, and the study of self-esteem in PDs can offer new and important knowledge of PDs as self-pathology.

Comparing Personality Diagnostic questionnaire-4+ with Longitudinal, Expert, All Data (LEAD) standard diagnoses in a sample with a high prevalence of axis I and axis II disorders.

A comparison between the Personality Diagnostic Questionnaire-4+ (PDQ-4+) and Longitudinal, Expert, All Data (LEAD) standard diagnoses was made in a sample of 100 patients with a high prevalence of both axis I and axis II disorders. The internal consistency was considered acceptable (alpha >.70) for 3 of 12 PDQ-4+ scales. Diagnostic agreement between the assessment methods was poor for specific personality disorders (PDs). The PDQ-4+ gave many false-positive diagnoses. Changing the diagnostic thresholds only marginally increased the agreement between methods or the diagnostic efficiency of the PDQ-4+. Multiple regression analyses showed that the discrepancies between the methods were strongly associated with the current level of perceived symptoms (SCL-90-R).

One-year follow-up of day treatment for poorly functioning patients with personality disorders.

OBJECTIVE: The study evaluated the effectiveness of day treatment for poorly functioning patients with personality disorders who participated in day treatment consisting of analytically oriented and cognitive-behavioral therapy groups as part of a comprehensive group therapy program. METHODS: At admission, discharge, and one year after discharge, patients completed the Global Severity Index (GSI) of the Symptom Check List 90-R and the circumplex version of the Inventory of Interpersonal Problems (IIP-C) and were assessed using the Global Assessment of Functioning (GAF) scale. At one-year follow-up, patients also completed a questionnaire covering social adaptation and clinical information and participated in a telephone interview with a clinician. The clinician used the completed instruments and results of the interview to assign patients follow-up GAF scores. RESULTS: Follow-up data were available for 96 patients who completed the study, or 53 percent of the patients who were admitted to the study. Improvements in GAF, GSI, and IIP-C scores during day treatment were maintained at follow-up. Seventy-four percent of the treatment completers improved clinically from program admission to follow-up, as indicated by change in GAF scores, and 64 percent of the treatment completers continued in the outpatient group program. For the 26 percent of patients whose change in GAF score did not indicate clinical improvement, lack of improvement was most strongly predicted by the expression of suicidal thoughts during treatment. No patients committed suicide. CONCLUSIONS: The day treatment program appears to be effective in improving the symptoms and functioning of poorly functioning patients with personality disorders and in encouraging patients to continue in longer-term outpatient therapy.

Borderline and avoidant personality disorders and the five-factor model of personality: a comparison between DSM-IV diagnoses and NEO-PI-R.

A self-report measure of the Five-Factor Model (FFM) of personality, NEO-PI-R, was administered to a sample of patients with borderline (BPD, N = 29) or avoidant PD (AVPD, N = 34), admitted to a day treatment program, to investigate the NEO-PI-R profiles of the disorders, and the ability of NEO-PI-R to discriminate between the two disorders. The diagnoses were assessed according to the LEAD standard. AVPD was associated with high levels of Neuroticism and Agreeableness, and low levels of Extraversion and Conscientiousness. BPD was associated with high levels of Neuroticism and low levels of Agreeableness, Extraversion, and Conscientiousness. Eighty-eight percent of the AVPD group had high scores on Neuroticism and low scores on Extraversion, whereas 65% of the BPD group were high on Neuroticism and low on Agreeableness. The Extraversion and Agreeableness scales of NEO-PI-R discriminated between patients with BPD and those with AVPD. Patients with BPD scored significantly higher on the Angry Hostility and Impulsiveness subscales of Neuroticism and significantly lower on three Extraversion subscales, three Agreeableness subscales, and one Conscientiousness subscale. At the DSM-IV criterion level, there were more significant relationships between the subscales of NEO-PI-R and the AVPD criteria than with the BPD criteria. The findings suggest that the FFM has good discriminating ability regarding BPD and AVPD. However, there may be a closer conceptual relationship between the FFM and AVPD than between the FFM and BPD.

Outcomes of poorly functioning patients with personality disorders in a day treatment program.

OBJECTIVE: Rates of completion, complications, and outcome were examined in a sample of poorly functioning patients who participated in a group-oriented day treatment program for patients with personality disorders. METHODS: The study was a naturalistic prospective study of 183 patients admitted to a day treatment program in Oslo, Norway. The program consists of a combination of group analytically oriented groups and cognitive-behavioral groups. The Global Severity Index (GSI) of the Symptom Check List, the circumplex version of the Inventory of Interpersonal Problems (IIP-C), and the Global Assessment of Functioning (GAF) were administered at admission and discharge. RESULTS: A total of 138 [corrected] patients (77 percent) completed the day treatment program. Few patients experienced treatment complications. Effect sizes for GAF, GSI, and IIP-C scores for treatment completers were in the medium-to-high range, indicating a fair level of improvement. Patients' rating of benefit was positive. CONCLUSIONS: The results are promising as a first step toward development of a cost-efficient comprehensive long-term treatment program for patients with severe personality disorders.

Patterns of short-term course in patients treated in a day unit for personality disorders.

The objectives of the study were (1) to explore differences in the course for patients treated in a day unit specializing in personality disorders (PDs), and (2) to determine characteristics of patients with different courses and predictors of various courses. K-mean cluster analysis was applied to partition a sample of 128 patients, 101 with various PDs and 27 with axis I disorders only, into four groups representing different courses. The course was defined on the basis of global functioning (Health Sickness Rating Scale [HSRS]) at admission, discharge, and 3-years follow-up evaluation. The four courses were labeled good, fair, late improvement, and poor, demonstrating great variation in the short-term course among patients with PDs. Predictors were studied by means of polychotomous logistic regression using the patients with a fair course as the reference group. The dichotomy no PD/cluster C versus cluster A/B predicted a good versus a fair course. A poor work status the last year before admission and irregular discharge predicted a poor or late improvement course versus a fair course, also when controlling for PD clusters. None of the included variables discriminated between patients with a poor versus late improvement course.