Treatment of adolescents with severe (borderline) personality disorder Joost Hutsebaut & Dineke Feenstra September 2008, Basel

Case study Because of privacy reasons this information has been omitted.

Some results from an (unscientific) survey  Only 2% of psychiatrists regularly makes a diagnosis of PD before age 18  Psychiatrists assume that they meet less than 15% of adolescents with personality disorders in their practice  2 out of 3 psychiatrists do not know that the diagnosis can be made according to DSM-IV-TR  Among the last 20 admissions at our 3rd line centre, no PD was diagnosed before admission and in only 2 cases personality problems were mentioned. After intake 12 were diagnosed with a PD (SCID-II)

Personality disorders (PD’s) in adolescence: what do we know?  PD’s can be diagnosed in adolescence (DSM-IV TR, 2000). The classification can be made in a valid and reliable way.  About 15% of adolescents from a community sample suffers from a PD (CIC-study)  Without treatment these are the adults at risk for (among others) several axis I en II disorders, drug abuse, educational failure, unemployment, high costs in somatic and mental health services etc.  PD’s are best treated at an early stage.

Treatment of PD’s: what do we know?  PD’s are best treated by psychotherapy (+ pharmacotherapy).  Two evidence based models for treating PD’s in adults: Dialectical Behavior Therapy and Mentalization-based Treatment (other models: SFT, CAT, STEPPS)  No evidence based models for adolescents: few treatment manuals (Bleiberg, 2001; Miller et al., 2007; Freeman & Reinecke, 2007)  No APA guidelines for adolescents; adolescents are kept out of all multidisciplinary guidelines for treating PD’s

Guidelines for treating adolescents with (severe) PD’s?  Pathogenesis of PD’s in adolescence –How does adolescence explain the development and escalation of PD’s? –What adolescence-specific processes contribute to this?  Which guidelines can be derived from this?  How can these guidelines be made concrete in the diagnostics and treatment of PD’s in adolescence?

Adolescence in general  Changes accumulate: biological, cognitive, emotional, social  These changes imply developmental challenges –Restructuring relationships with parents and siblings –Taking care for health and appearance –Making sense of free time –Intimacy and sexuality –Peer contacts  These changes and challenges also affect the environment

Pathogenic processes in adolescence  These changes come too early  There is an accumulation of developmental challenges  It lacks of a safe harbor  Family interactions get rigidified  There is an interaction between developmental tasks and personality traits (in adolescents or parents)

Adolescence and PD’s  Adolescence does not explain the PD, but acts as a catalyst for the escalation of maladaptive personality traits into a (full blown) PD

General guidelines for treating PD’s in adolescence 1.Choose for one model that is directed at the pathogenesis of the PD 2.Involve the different systems in therapy: family, school, justice 3.Prepare your treatment carefully 4.Involve developmental tasks in treatment

Guideline 1: Choose for one model  A treatment program should be consistent, coherent and consequent  Is yours?  Two models –Dialectical Behavior Therapy (Miller, Rathus, Linehan, 2007) –Mentalization-based treatments (Bleiberg, 2001)

Application Guideline 1  The whole treatment program is based on Mentalization-Based Treatment  This implies that all interventions in treatment are consistent with the aim of improving mentalization ( in adolescents and parents) –F.ex. No therapy in the evening (hotel-idea)  All aspects ( including diagnostics, psycho education, family therapy, pedagogics etc) are consistent with this model

Application guideline 1  But how does adolescence impact upon the ability to mentalize?  How do developmental tasks affect the ability to mentalize?  How does the ability to mentalize affect the coping with developmental tasks?  In summary, how are the central constructs in your model affected by developmental issues?

Guideline 2: Involve different systems  Adolescents still live in an invalidating, non- mentalizing context in which their personality dysfunctioning is often strengthened  Adolescents have less possibilities to choose their environment  Change depends also on a change in the systems surrounding the adolescent  The more systems can be involved, the more generalized the change can be

Application guideline 2  Parents/families are involved in different ways –Psycho-educational workshops –Treatment goals for the family –Family therapy aimed at improving mentalizing –Invited for regular evaluations of treatment  School is involved –Contact with school of origin –Staff members go to school and help to discuss a school plan  Peers are involved –4 times/year peers are invited to learn more about the treatment (in general)

Guideline 3: Prepare the treatment carefully  Preparation phase before ‘actual’ treatment  Aims –Therapy-informing diagnostics –Psycho-education –Context regulation –Crisis management –Motivation enhancement  Ends in an admission case conference with different parties (adolescent, parents, treatment team, school, referring psychiatrist,…)

Application guideline 3: diagnostics Make a diagnostic formulation:  Understandable for the adolescent  Identifying the link between non-mentalizing interactions and symptoms  Identifying pitfalls and goals in treatment

Application guideline 3: diagnostics Start with a thorough assessment procedure allowing information to be collected in a model-specific way:  Developmental history  Multiple informants (patient, parents, siblings, teachers)  (Semi)-structured interview (SCID-II, AAI)  Personality questionnaires (SIPP, MMPI-A, …)  Projective material (Ror, TAT, Drawings)

Application guideline 3: diagnostics Diagnostic formulation: different steps  step 1: personality pathology  step 2: developmental history  step 3: developmental phase  step 4: interaction with the environment  step 5: identification of treatment goals and pitfalls  step 6: treatment selection

Application guideline 3: psycho-education  Psycho-education about –Borderline PD –MBT-A –How MBT can help to improve symptoms of BPD  Workshop ‘Basic mentalizing’ –2*6 sessions –Psycho-education and exercises about mentalizing –F. ex. Discussion about thesis: Mentalizing well can be painful –F. ex. TAT drawings: can you understand why you wrote this story?

Guideline 4: involve developmental tasks  Treatment should also help to deal with developmental tasks –Create a safe harbor to deal with developmental tasks on other domains –Dose developmental tasks: one by one  Treatment should help parents to deal with parental tasks

Application guideline 4  Dealing with developmental tasks is one of 5 basic goals in therapy  There is a weekly group session about developmental issues (on a mentalizing base)  There are workshops for parents about adolescence and developmental tasks for parents in adolescence

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