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

Contact

Email

joost.hutsebaut@deviersprong.nl

dineke.feenstra@deviersprong.nl

Website

www.deviersprong.nl

www.vispd.nl