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.

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

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

Mentalization-based treatment or psychodynamic treatment programmes for patients with borderline personality disorder - the impact of clinical severity.

OBJECTIVES: Mentalization-based treatment (MBT), originally designed for patients with borderline personality disorder (BPD), may be particularly indicated for severe conditions. However, there is limited documentation of how increasing severity of personality disorder (PD) effect outcomes of highly specialized treatments. This study aimed to investigate associations between clinical severity and outcomes for patients in MBT as compared to a psychodynamic group-based treatment programme (PDT). DESIGN: A naturalistic, longitudinal, comparison study. METHODS: The sample included 345 patients with BPD (PDTn = 281, MBTn = 64). The number of diagnosed PDs, PD criteria, and symptom disorders were chosen as baseline indicators of clinical severity. Clinical outcomes (global functioning, symptom distress, interpersonal problems) were repeatedly assessed over three years. Therapists' fidelity to MBT was satisfactory. Linear mixed models were the applied statistics. RESULTS: In PDT, greater clinical severity was associated with poorer improvement rates. Clinical severity was not associated with significant differences in outcomes for patients in MBT. Differences in outcomes for patients in MBT and PDT increased significantly with higher severity of disorder. CONCLUSIONS: Supporting previous research, this study indicates that clinical benefits associated with MBT also apply for BPD patients with severe conditions. The results also suggest that increasing severity was a challenge in PDT. PRACTITIONER POINTS: MBT may be particularly beneficial for severely disordered BPD patients Differences between MBT and PDT were less pronounced in moderately disordered BPD patients.

Extreme challenges: psychiatric inpatients with severe self-harming behavior in Norway: a national screening investigation.

BACKGROUND: Extreme self-harming behavior is a major challenge for patients and health services. Nevertheless, this patient population is poorly described in research literature. AIMS: The aim of this study was to assess the volume of patients with extensive psychiatric hospitalization due to extreme self-harming behaviors, the extent of severe medical sequelae, and collaboration problems within health services. METHODS: In a national screening investigation, department managers in 83 adult psychiatric inpatient institutions across all health regions in Norway were invited to participate in a brief, prepared, telephone interview. RESULTS: Sixty-one interviews were completed. Extensive hospitalization (prolonged or multiple) due to extreme self-harm was reported for the last year in all health regions and in 427 individual cases. Mean number of cases did not differ by region. Psychiatric hospitalizations were more frequent in hospital units than mental health centers. In 109 of the cases, self-harming behavior had severe medical consequences, including five deaths. In 122 of the cases, substantial collaboration problems within the health services were reported (disagreements on diagnosis, treatment needs and resources). Extensive (long-term) hospitalization was particularly associated with the combination of severe medical sequelae and collaboration problems. CONCLUSION: This investigation confirms a noteworthy, nationwide, population of severely self-harming inpatients with extensive health service use, prevalent severe medical complications, and unsatisfactory collaboration within health services. These preliminary results are alarming, and indicate a need for more profound understanding of highly complex and severe cases.

Favourable outcome of long-term combined psychotherapy for patients with borderline personality disorder: Six-year follow-up of a randomized study.

OBJECTIVE: This study reports the six-year follow-up data of patients with borderline personality disorder (BPD) who participated in the Ullevål Personality Project (UPP), a randomized clinical study comparing outpatient individual psychotherapy (OIP) with a long-term combination programme (CP) comprising short-term day-hospital treatment followed by outpatient combined group and individual psychotherapy. METHODS: For 52 patients, outcomes were evaluated after 8 months, 18 months, 3 years, and 6 years based on a wide range of clinical measures, such as symptom severity, psychosocial functioning, personality functioning, and Axis-I and II diagnoses. RESULTS: At the six-year follow-up, patients in the CP condition reported significantly greater reduction of symptom distress and improvements in the personality functioning domains Identity Integration and Self-control compared with patients allocated to OIP. Patients in the CP also had a more favourable long-term course of psychosocial functioning. There were no differences between treatment conditions in outcomes of interpersonal functioning and self-esteem. CONCLUSIONS: Long-term psychotherapy in a combination programme seems favourable for BPD patients. In this study, patients who received combined treatment fared better on crucial parameters than patients who received individual therapy. Of particular importance are the positive effects on fundamental borderline problem areas like Identity Integration and Self-control.

The three factors of the psychoticism scale of SCL-90-R.

Former studies have repeatedly found the psychoticism (PSY) scale of Symptom Checklist-90-Revised to be a heterogeneous construct. The aim of this study was to confirm and further explore the nature of this heterogeneity within a large sample of patients with mainly personality disorders. Within a total sample of 3 794 patients, one-half was randomly selected for explorative factor analysis in order to assess the internal structure of the PSY scale and the other half to cross-validate the findings by a confirmatory factor analysis. The total sample was then used to assess associations between the components from the factor analyses and several clinical measures and diagnoses. A one-factor solution of the PSY scale yielded poor fit to the data, but a proposed structure of three latent constructs was confirmed by good model fit. The three subsets of the PSY scale, labelled metacognitive dysfunction, self-accusation and detachment, shared variance with different personality disorders and different aspects of psychopathology, e.g. previous psychotic episodes. The heterogeneous PSY scale of SCL-90-R can be divided into three meaningful clinical concepts, reflecting different aspects of psychosis-near experiences. The factors warrant confirmation in other populations. Copyright © 2014 John Wiley & Sons, Ltd.

Experiences in Close Relationships ­ Psychometric properties among patients with personality disorders.

Patients with personality disorders represent maladaptive attachment strategies, influencing the quality of their interpersonal relationships. Within these patient populations, it is important to have a measure, easily applied, to assess such strategies. A widely used instrument is Experiences in Close Relationships (ECR), assessing two constructs called avoidance and anxiety. Lately, two short forms of ECR have been proposed, called ECR-S and ECR-N12. The aim of this study is to investigate the psychometric properties of the Norwegian @version of ECR and its two short forms in a sample of patients with mainly personality disorders. An internal consistency and confirmatory factor analysis of ECR, ECR-S and ECR-N12 from 495 patients was conducted, as well as an exploratory factor analysis of ECR. The internal consistency of ECR was found questionable. Confirmatory factor analysis revealed a poor model fit based on ECR and ECR-S. The ECR-N12 revealed a mediocre fit, indicating a potential for improvement. Exploratory factor analysis indicated two different aspects of avoidance and three aspects of anxiety. This five-factor solution was called ECR-FF. Inferences from scores based on ECR should be derived with care. A revision of ECR and ECR-N12 is warranted, and further studies are needed to investigate the validity of ECR-FF.

Changing from a traditional psychodynamic treatment programme to mentalization-based treatment for patients with borderline personality disorder--does it make a difference?

OBJECTIVES: Few studies outside United Kingdom have documented effects of mentalization-based treatment (MBT) for patients with borderline personality disorder (BPD). This study aimed to investigate outcomes for BPD patients treated in an MBT programme in a Norwegian specialist treatment unit and compare benefits of the implemented MBT with the unit's former psychodynamic treatment programme. DESIGN: A naturalistic, longitudinal, comparison of treatment effects for BPD patients before and after transition to MBT. METHODS: The sample consisted of 345 BPD patients treated in the period 1993-2013. Before 2008, patients were admitted to a psychodynamic treatment programme (n = 281), after 2008 patients received MBT (n = 64). Symptom distress, interpersonal problems, and global functioning were assessed repeatedly throughout the treatment. Suicidal/self-harming acts, hospital admissions, medication, and occupational status were assessed at the start and end of treatment. Therapists' competence and adherence to MBT was rated and found satisfactory. The statistical method for longitudinal analyses was mixed models. RESULTS: BPD patients in MBT and in the former psychodynamic treatment programme had comparable baseline severity and impairments of functioning. BPD patients in MBT had a remarkably low drop-out rate (2%), significantly lower than the former treatment. Improvements of symptom distress, interpersonal, global and occupational functioning were significantly greater for MBT patients. Large reductions in suicidal/self-harming acts, hospital admissions, and use of medication were evident in the course of both treatments. CONCLUSIONS: The study confirms the effectiveness of MBT for BPD patients and indicates greater clinical benefits than in traditional psychodynamic treatment programmes. PRACTITIONER POINTS: MBT is an effective treatment for patients with BPD. MBT can successfully be implemented in therapeutic settings outside United Kingdom and may be more beneficial than psychodynamic treatment programmes for BPD patients.

Step-down versus outpatient psychotherapeutic treatment for personality disorders: 6-year follow-up of the Ullevål personality project.

BACKGROUND: Although psychotherapy is considered the treatment of choice for patients with personality disorders (PDs), there is no consensus about the optimal level of care for this group of patients. This study reports the results from the 6-year follow-up of the Ullevål Personality Project (UPP), a randomized clinical trial comparing outpatient individual psychotherapy with a long-term step-down treatment program that included a short-term day hospital treatment followed by combined group and individual psychotherapy. METHODS: The UPP included 113 patients with PDs. Outcome was evaluated after 8 months, 18 months, 3 years and 6 years and was based on a wide range of clinical measures, such as psychosocial functioning, interpersonal problems, symptom severity, and axis I and II diagnoses. RESULTS: At the 6-year follow-up, there were no statistically significant differences in outcome between the treatment groups. Effect sizes ranged from medium to large for all outcome variables in both treatment arms. However, patients in the outpatient group had a marked decline in psychosocial functioning during the period between the 3- and 6-year follow-ups; while psychosocial functioning continued to improve in the step-down group during the same period. This difference between groups was statistically significant. CONCLUSIONS: The findings suggest that both hospital-based long-term step-down treatment and long-term outpatient individual psychotherapy may improve symptoms and psychosocial functioning in poorly functioning PD patients. Social and interpersonal functioning continued to improve in the step-down group during the post-treatment phase, indicating that longer-term changes were stimulated during treatment. TRIAL REGISTRATION: NCT00378248.

The MBT Adherence and Competence Scale (MBT-ACS): development, structure and reliability.

The properties of the 17-item Mentalization-Based Treatment Adherence and Competence Scale (MBT-ACS) were investigated in a reliability study in which 18 psychotherapy sessions, comprising two sessions by nine different therapists, were rated by seven different raters. The overall reliabilities for adherence and competence for seven raters were high, .84 and .88 respectively. The level of reliability declined by number of raters but was still acceptable for two raters (.60 and .68). The reliabilities for the various items differed. The MBT-ACS was found to be an appropriate rating measure for treatment fidelity and useful for the purposes of quality control and supervision. The reliability may be enhanced by redefining some items and reducing their numbers.

Is treatment in a day hospital step-down program superior to outpatient individual psychotherapy for patients with personality disorders? 36 months follow-up of a randomized clinical trial comparing different treatment modalities.

Despite increasing interest in the development of effective treatments for patients with PDs, there is still no consensus about the optimal treatment setting for this group of patients. This study reports the 36 months follow-up of the Ullevål Personality Project (UPP) (n=113), a randomized clinical trial comparing two treatment modalities for patients with PDs: an intensive long-term step-down treatment program, consisting of short-term day hospital treatment followed by combined group and individual psychotherapy organized in a hospital setting, with "ordinary" outpatient individual psychotherapy in private practice for patients with moderate to severe PDs. Patients in both treatment groups showed improvements in several clinical measures after 36 months. However, contrary to our expectations, patients in the outpatient treatment setting improved significantly more. Possible explanations for this surprising finding are discussed. The study cannot exclude the possibility that treatment aspects other than differences in modalities could explain some of the differential effectiveness (e.g. differences between therapists).

Psychotherapy for personality disorders: 18 months' follow-up of the ullevål personality project.

The Ullevål Personality Project is a randomized controlled trial (N = 114) initiated as a response to the limited evidence justifying provision of day hospital treatment for patients with personality disorders (PDs). A step-down model (CP) consisting of initial short-term day hospital treatment followed by conjoint group and individual outpatient treatment was compared with outpatient individual psychotherapy (OIP). The patients were evaluated at baseline, 8 months, and 18 months on a wide range of clinical measures assessing symptoms, interpersonal problems, psychosocial functioning, and personality pathology. This study indicates that eclectic psychotherapy provided by private practitioners has at least as good an effect upon personality-disordered patients as a more comprehensive day hospital and outpatient follow-up treatment. However, this study has to be supplemented with a cost-benefit analysis before any consideration of implications for health care planning.

[Self-harm and personality disorders]. / Selvskading og personlighetsforstyrrelser.

BACKGROUND: Clinical experience and recent research convey that patients with personality disorders who harm themselves with a suicidal intention should be treated differently than those who do so without a suicidal intention. The purpose of this article is to give an overview of non-suicidal self-harm in these patients. MATERIAL AND METHOD: The article is based on a non-systematic literature search in PsycINFO, Medline, Clinical Evidence and Cochrane and own clinical experience. RESULTS: Self-harm in patients with personality disorders is associated with borderline personality traits. Up to 70 % of patients with borderline personality disorders have reported non-suicidal self-harm. Non-suicidal self-harm is one of the risk factors for suicide. Borderline personality disorder develops due to interaction between genetic vulnerability and a traumatic and unsafe upbringing. The patients are often influenced by intense negative emotions and have reduced ability to regulate and handle these in interpersonal situations. Self-harm can give short-term alleviation of the inner pain associated with emotion dysregulation. Dialectical behavior therapy and mentalization-based therapy is shown to reduce the prevalence of self-harm in patients with borderline personality disorder. Acute referral to in-patient treatment should only be used in crises that cannot be handled in out-patient treatment. The regular general practitioner can function as a stable attachment figure and contribute to self-regulation. INTERPRETATION: Non-suicidal self-harm in patients with personality disorders should be given more attention.

The impact of avoidant personality disorder on psychosocial impairment is substantial.

Few studies have compared the psychosocial problems associated with different types of personality disorders (PDs). The aim of this study was to investigate the functional impairment and symptomatic distress associated with six PD diagnoses coded in DSM-IV: paranoid, borderline, avoidant, dependent, obsessive-compulsive PD and PD not otherwise specified, as well as a condition of non-psychotic symptom disorders with no PD. The study included 1023 patients from eight day treatment units specialized in the treatment of PDs. Eighty-one per cent had one or more PD diagnoses. At admission to day treatment, the patients were evaluated with respect to global functioning, symptomatic and interpersonal distress, education, quality of life, social support, legal problems and previous psychotic episodes and psychiatric hospitalizations. There were few differences in global functioning or symptomatic and interpersonal distress between patients with a single PD diagnosis. Avoidant PD and borderline PD was the diagnoses that contributed most to dysfunction in most variables when taking into account the presences of several co-occurrent PD diagnoses and axis I disorders. The psychosocial problems associated with avoidant and borderline PD were partly domain specific. The study indicates that avoidant PD is associated with severe dysfunction and subjective distress, at a level comparable to that of borderline PD. Avoidant PD deserves more attention, both with respect to the specific psychopathology and dynamics underlying the disorder and the development of treatment approaches.

Nineteen-month stability of Revised NEO Personality Inventory domain and facet scores in patients with personality disorders.

We lack knowledge of the temporal stability of major personality dimensions in patients with personality disorders (PDs). The Revised NEO Personality Inventory (NEO-PI-R) is a self-report instrument that operationalizes the Five-Factor Model of personality. This study investigated the relative stability, mean level stability, and individual level stability of the NEO-PI-R scores in patients with PDs (n = 393) and patients with symptom disorders only (n = 131). The NEO-PI-R was administered at admission to short-term day treatment and after an average of 19 months. The results showed a moderate to high degree of stability of NEO-PI-R scale scores with no substantial difference in stability between patients with and without PD. Changes in NEO-PI-R scores were associated with changes in symptom distress. Neuroticism was the least stable domain. The study indicates that the Five-Factor Model of personality dimensions and traits are fairly stable in patients with PDs. The lower stability of Neuroticism may partly be explained by its inherent state aspects.

Psychotherapy for personality disorders: short-term day hospital psychotherapy versus outpatient individual therapy - a randomized controlled study.

This article describes the results of an eight-month follow-up investigation from a randomized controlled trial of day hospital psychotherapy (DHP) compared with outpatient individual psychotherapy (OIP) for patients with personality disorders (N=114). The patients were randomly assigned to either 18 weeks of day hospital treatment followed by long-term conjoint group and individual therapy (DHP), or outpatient individual psychotherapy (OIP). The main outcome measures were attrition rate, suicide attempts, suicidal thoughts, self-injury, psychosocial functioning, symptom distress, and interpersonal and personality problems. The study showed a low dropout rate and a moderate improvement on a broad range of clinical measures for both treatments. However, there was no indication of the superiority of one treatment over the other. Neither was there any indication that day hospital treatment was better for the most poorly functioning patients. Further studies will follow this group of patients for the next few years, the results of which may have implications for resource allocation and the organization of mental health services for patients with personality disorders.

Short-term day treatment programmes for patients with personality disorders. What is the optimal composition?

Research evidence indicates that approximately 10 h a week is a sufficient intensity for short-term day treatment programmes for patients with personality disorders. In this article, we discuss which therapeutic components should be included in such a programme. Relevant research and clinical literature are reviewed. The fit between the therapeutic components and the programme as a whole is discussed according to: 1) scientific evidence of the effectiveness of the therapeutic components, 2) a sound theoretical rationale, 3) evidence of user satisfaction among patients, 4) clinical experiences of staff, 5) comprehensiveness and consistency, and 6) available therapeutic skills and resources. We advocate an 11-h treatment programme comprising small group psychotherapy, art group therapy, large group psychotherapy, cognitive group therapy, problem-solving group therapy and optional adjuncts (cognitive behavioural group therapy) for patients with additional anxiety and eating disorders.