Transcript Dia 1 - de Viersprong

TRAP:
A long term outcome and process study of a
residential treatment for treatment refractory
adolescents with personality disorders
Dineke Feenstra & Joost Hutsebaut
September 2009, Ghent
PTC De Viersprong
 PTC De Viersprong is a third line mental health
setting. It offers specialized assessment and
treatment programs (outpatient, day hospital and
inpatient) for adolescents and adults with
personality disorders
 De Viersprong has its own research department, the
VISPD: Viersprong Institute for Studies on
Personality Disorders
Research group
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
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Joost Hutsebaut
Dineke Feenstra
Annelies Laurenssen
Jan van Busschbach
Roel Verheul
Els Havermans
Background:
Outcome research in adolescents
 Progress in child- and adolescent psychotherapy
outcome research:
– Psychotherapy is an effective treatment for children and
adolescents (mood-, anxiety-, eating-, and conduct
disorders) (Kazdin & Weisz, 2004).
– Improvement in methodological qualities of research (more
controlled studies, treatment protocols etc.) (Kazdin,
2002).
Background:
Outcome research in adolescents
 Limitations in child- and adolescent psychotherapy
outcome research:
– Uncovered area: personality disorders (PD) in adolescents
– Lack of developmental sensitivity: treatment models as
well as outcome instruments are little developmentally
sensitive
• Review of 25 empirically supported psychotherapies in adolescents
(Weisz & Hawley, 2002)
– 14 effective treatments
– 7 adult models, 6 child models, 1 adolescent model (MST)
Background:
Treatment of PD in adolescents
 Adolescents are left out of multidisciplinary
guidelines for the treatment of PD’s
 No evidence based models for the treatment of
adolescent PD
 Few handbooks: Kernberg, 2000 (psychodynamic
approach); Bleiberg, 2001 (relational approach
rooted in attachment theory); Miller et al., 2007
(DBT); Freeman & Reinecke, 2007
Background:
Outcome studies adolescents with PD
 Chanen et al., 2008:
– RCT Cognitive Analytic Therapy (CAT) versus manualised
good clinical care
 Rathus & Miller, 2002:
– Quasi experimental investigation of an adaptation of
Dialectical Behavior Therapy (DBT)
TRAP-study:
Rationale
 Rationale:
– First: little is known about severe personality disorders in
adolescents
– Second: little is known about intensive inpatient treatment
(for personality disturbed adolescents)
– Third: we know little about developmental sensitive
outcomes of psychotherapy for adolescents
TRAP-study:
Objectives
 Objective 1: treatment outcome
 Objective 2: prediction of treatment outcome
 Objective 3: relation between relational changes and
relapse
TRAP-study:
Design
 Naturalistic study
 Include 130 adolescents with personality pathology
who are admitted to the inpatient unit of the youth
department of De Viersprong (duration of treatment
is 1 year)
 Measurements at start of treatment, 6, 12 and 24
months after the start of treatment
TRAP-study:
Instruments
Instrument
General questionnaire
Anxiety Disorders Interview Schedule for DSM-IV (Adis-C)
Structured Clinical Interview for DSM IV axis II Personality
Diusorders (SCID-II)
Brief Symptom Inventory (BSI)
Severity Indices of Personality Problems (SIPP-118)
Autnomy and attachtment quest. (AHV)
Depressive experiences quest. For Adolescents (DEQ-A)
Competence quest. for adolesc. (CBSA)
Life events
Quality of relationships Inventory (QRI)
Family Assessment Device (FAD-N)
Outcome quest.
IQ (KAIT)
Stigma
Therapeutic alliance
Group cohesion
Intake/ Start
of treatment
6 months after start
of treatment
12 months after start
of treatment
24 months after start
of treatment
TRAP-study:
Sample charachteristics
 Sample characteristics (baseline):
–
–
–
–
N
Gender
Mean age
Mean IQ
= 133
= 113 female (85%); 20 male (15%)
= 16.55 (range 14-19)
= 104 (range 78-137)
TRAP-study:
Sample characteristics
 Sample characteristics (baseline):
– Axis I: 100 adolescents (75.19%) had at least 1 Axis I
disorder
Axis I disorder
N
%
Dysthymic disorder
36
27.07
Social phobia
34
25.56
Major depressive disorder
16
12.03
PTSD
14
10.53
100
75.19
Any Axis I disorder
* Other axis I disorders were diagnosed in less than 10% of the adolescents.
TRAP-study:
Sample characteristics
 Sample characteristics (baseline):
– Axis II: 63 adolescents (47.37%) had at least 1 Axis II
personality disorder
Axis II disorder
N
%
Borderline PD
33
24.81
Avoidant PD
22
16.54
Depressive PD
5
15.15
Obsessive-compulsive PD
4
3.01
PD not otherwise specified
7
5.26
63
47.37
Any PD
TRAP-study:
Drop out
 Dropping out of the treatment:
N
%
Drop out
44
33
No drop out
89
67
133
100
Total
TRAP-study:
Results symptom level (BSI)
 Brief symptom inventory (BSI)
General symptomatology
2
1,8
1,6
1,4
1,2
1
0,8
0,6
0,4
0,2
0
BSI-score (PD)
BSI-score (no PD)
BSI-score (mean
patiënt)
BSI-score (mean
normal)
Start of treatment
12 months after start of
treatment
TRAP-study:
Results personality functioning (SIPP)
SIPP domain self-control
SIPP domain social concordance
7
7
6
6
No PD
No PD
5
PD
5
PD
4
4
3
3
Start of treatment
Start of treatm ent
12 months after start of treatment
SIPP domain identity integration
12 m onths after start of treatm ent
SIPP domain relational capacities
7
7
6
6
No PD
5
PD
4
No PD
5
PD
4
3
3
Start of treatment
12 months after start of treatment
Start of treatm ent
SIPP domain responsibility
7
6
No PD
5
PD
4
3
Start of treatment
12 months after start of treatment
12 m onths after start of treatm ent
TRAP-study:
Results other outcome measures (self report)
School
Drug use
50
80
40
%
70
Start of treatment
60
30
20
12 months after start of
treatment
10
Start of treatment
50
% 40
12 months after start of
treatment
30
0
Not going
to school
Less than
Missing
half of the school only
time
now and
then
20
Always
10
0
No drugs
Monthly
Self-harm
Weekly
Daily
Contacts with police
60
100
50
80
Start of treatment
40
Start of treatment
60
% 30
12 months after start of
treatment
20
10
%
12 months after start of
treatment
40
20
0
No selfharm
Monthly
Weekly
Daily
0
No contact
1
>1
TRAP-study:
Strengths & limitations
 Strengths:
– Use of developmentally sensitive (and positive) outcome
instruments
– Several measuring points
– Including severely personality disturbed adolescents
– Use of semi structured interviews to assess both Axis I and Axis
II disorders
 Limitations:
– No control group
– High level of drop-out
– Underrepresentation of boys
– No treatment manual
TRAP-study
 Conclusion:
– A group of severely disturbed adolescents underwent an
intensive inpatient treatment program. A large group of
these adolescents dropped out of treatment. The
adolescents that stayed in treatment showed improvement
in symptom level, personality functioning and
developmental tasks (f.e. school).
– This is a first step (pilot study) in investigating the
uncovered area of adolescents with severe personality
disorders. Further research is needed, investigating
manualized treatment programs with methodologically
stronger research designs.
Contact
 Website:
– www.deviersprong.nl
– www.vispd.nl
 Email:
– [email protected]
– [email protected]