- Email: [email protected]
Early intervention for personality disorder
Accepted Manuscript Title: Early Intervention for Personality Disorder Author: Andrew M. Chanen Katherine N. Thompson PII: DOI: Reference:
S2352-250X(18)30038-1 https://doi.org/doi:10.1016/j.copsyc.2018.02.012 COPSYC 619
To appear in: Received date: Revised date: Accepted date:
14-2-2018 19-2-2018 19-2-2018
Please cite this article as: P.A.M. Chanen, K.N. Thompson, Early Intervention for Personality Disorder, COPSYC (2018), https://doi.org/10.1016/j.copsyc.2018.02.012 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title: Early Intervention for Personality Disorder Authors: Professor Andrew M. Chanen
1,2,3
, MBBS, MPM, PhD, FRANZCP
[email protected] 1,2
ip t
Dr Katherine N Thompson , PhD [email protected]
Orygen, The National Centre of Excellence in Youth Mental Health,
us
1
cr
Affiliations:
Melbourne, Australia
Centre for Youth Mental Health, The University of Melbourne, Melbourne,
an
2
Australia
Orygen Youth Health, Melbourne, Australia
M
3
Corresponding Author:
Ac ce pt e
d
Professor Andrew Chanen
Orygen, the National Centre of Excellence in Youth Mental Health
Locked Bag 10
Parkville VIC 3052 Australia
Phone: +61 3 9342 2997
Regular Article: 1808 words Abstract: 119 words
1 Page 1 of 17
Abstract Specialized treatments for personality disorder are usually offered late in the course of the disorder, to a small number of help-seeking individuals with entrenched
ip t
disability. Intervention during the early stages of personality disorder might help to decrease the persistence and/or the severity of personality disorder and to prevent
cr
the cascading of secondary psychopathology and psychosocial disability. Research regarding the understanding of and appropriate treatment for early stage personality
us
disorder is growing. However, there is still a lack of clarity in the field about what
an
constitutes early intervention and how it might relate to early intervention for other mental disorders. Also, there is little research on how to design integrated early
Ac ce pt e
d
long-term effects of early intervention.
M
intervention services suitable for personality and other mental disorders or on the
Key words: early intervention, personality disorder, borderline personality disorder, staging model, psychiatry.
2 Page 2 of 17
Early Intervention for Personality Disorder While maladaptive personality traits are observable during childhood, the more severe forms of personality disorder become clinically apparent during the transition between childhood and adulthood [1]. Yet, diagnosis of personality disorder (PD) is
ip t
typically delayed, empirically supported treatments are largely inaccessible, and
cr
iatrogenic harm is still a common outcome [2]. Specialized treatments are usually
offered late in the course of the disorder, typically in the form of complex and lengthy
us
individual psychotherapy, and only to a select few help-seeking individuals who are able to manage the attendance, behavior or other requirements imposed by the
an
treatment setting. Evidence suggests that such treatments might be neither
M
necessary nor sufficient for the treatment of all individuals with PD and that they have little effect upon long-term psychosocial functioning [3]. Moreover, 'late
d
intervention', with its associated suboptimal outcomes, often serves to reinforce
Ac ce pt e
functional impairment, disability and therapeutic nihilism. These observations have led to the development of early intervention for PD. This article describes how this nascent field has capitalized upon knowledge about the development of personality across the normal-abnormal range, and also upon knowledge about the transition from childhood to adulthood and how this constitutes a developmentally sensitive period for the onset of the major mental disorders. It also takes stock of prototype early intervention programs internationally and outlines some key challenges for the future development of interventions and clinical trials for early stage PD.
An extended period of ‘onset’ for personality disorder 3 Page 3 of 17
Advances in understanding personality development [1] and the neurobiological substrates underpinning cognitive, emotional and social development in young people [4], along with secular trends toward delayed and less synchronized role transitions to adulthood [5] point to an extended period of development beginning
ip t
with puberty and ending with the achievement of adult role functioning in the mid- to late 20s [6]. The pace and extent of change makes this is a particularly sensitive
us
peak period for the onset for the major mental disorders [7].
cr
developmental period, borne out by the observation that this also coincides with the
‘Adaptive failure’ during this period has potentially wide ranging and severe personal
an
and social consequences, especially because it can foster vicious circles that will
M
further disrupt the complex developmental tasks associated with the achievement of adult role functioning. This has been clearly demonstrated for personality disorder.
d
Despite the waxing and waning course of personality disorder, which generally leads
Ac ce pt e
to attenuation of pathological traits over time, social and occupational functioning tends to remain poor and relatively stable over the long-term [8–10]. This underscores the need for timely and effective (early) intervention. The Global Alliance for Prevention and Early Intervention for BPD (GAP) has summarized the rationale for early intervention for personality disorder [11], highlighting its clinical onset, reliability and validity, prevalence and high burden in young people, along with the demonstrated effectiveness of the 'first wave' of evidence-based treatments for young people with BPD. Moreover, a growing body of evidence points to a specific focus on early intervention for BPD because it represents common or core features of severe personality pathology, rather than a distinct diagnostic category [12,13]. For these reasons the GAP has called for early intervention to be a routine part of clinical practice in child and youth mental health services.
4 Page 4 of 17
What is early intervention for PD? Although the DSM-5 [14] has continued the tradition of categorical, syndrome-based personality disorder diagnosis, it is widely acknowledged (including in Section III of the DSM-5) that the threshold for distinguishing patients with and without personality disorder is arbitrary and that there is no strict demarcation between ‘cases’ and ‘non-
ip t
cases’ [15,16] and therefore, no distinct point of ‘onset’. This is fundamental to the
cr
argument that early intervention for personality disorder requires inclusion of
‘subthreshold’ forms of the disorder [17] and is supported by recent evidence that
us
outpatient youth with subthreshold BPD (1-4 DSM-IV criteria) have more severe
an
mental illness and poorer social and occupational functioning than outpatient youth with no BPD features [18].
M
The term early intervention is sometimes used imprecisely. In this context, early intervention refers to the stage of illness, not the chronological or developmental age
d
of the individual. The term encompasses two forms of intervention defined by the US
Ac ce pt e
Institutes of Medicine [19]. The first, indicated prevention, involves preventing the onset of new 'cases' of disorder by targeting individuals showing features of PD but who do not meet the threshold for a formal diagnosis of PD (i.e., sub-threshold disorder). The second, case identification and early treatment, entails formal diagnosis of and intervention for the full PD syndrome. Early intervention for personality disorder cannot be conducted separately from other clinical syndromes A crucial problem for early intervention is the disproportionate emphasis placed upon specific syndromes (e.g., bipolar disorder, unipolar depression, psychosis) as separate domains of risk [20]. Although, the presence of personality disorder features during childhood and adolescence is the strongest predictor of adult personality disorder [21–23], it is incorrect to assume that they have a specific, linear
5 Page 5 of 17
and direct relationship. Similar to other mental disorders, early clinical phenotypes for personality disorder are overlapping, non-specific, and non-linear [20,24]. Nelson and colleagues [25] have suggested that early intervention might benefit from viewing psychopathology as a system, rather than as a category. They suggest
ip t
identifying the dynamics of system change (e.g., sudden vs gradual onset) and ascertaining the factors that will most influence these systems (e.g., interpersonal
cr
dynamics, neurobiological changes) and the individual differences in system
us
structure and change. This will involve micro-level (momentary and day-to-day) and macro-level (month and year) assessments of relevant variables. For example, using
an
ecological momentary assessment to collect micro-level data, Andrewes and colleagues [26] found that initial self-injurious thoughts and changes in negative and
M
positive affect occurred a median of 35, 15, and 10 hours prior to non-suicidal selfinjury, respectively, suggesting a window of opportunity for intervention. At the
d
macro-level, Whalen and colleagues [27] found that positive maternal affective
Ac ce pt e
behavior and positive mother-daughter affective behaviors were prospectively associated with decreases in girls’ BPD severity scores over time. Mother-daughter negative affective escalation was associated with higher overall levels of BPD severity scores, whereas negative maternal affective behavior was not. Nonetheless, various childhood temperament and early onset mental state and behavioral problems (e.g., disruptive behavior disorders, substance use disorder, non-suicidal self-injury, anxiety, and depression) precede the clinical onset of personality disorder [28]. It has been suggested that these are often speciously defined as mental state pathology in children and later relabeled as personality pathology in adult life [21], perhaps due to lack of recognition that they are often underpinned by traits such as impulsivity, affective instability, or hyper-aggression
6 Page 6 of 17
[2]. This means that early intervention needs to be integrated with preventive strategies for the full range of mental disorders [20] and has led to the development of ‘clinical high at-risk mental state’ (CHARMS) criteria to identify help-seeking young people at
ip t
risk of developing a range of severe mental illnesses [24]. An added advantage of
cr
this strategy is that is more like to achieve sufficient statistical power to identify
predictors of case-level outcome (i.e., clinically relevant disorder vs no disorder) [24].
us
‘Clinical staging’ [29,30], analogous to disease staging in general medicine, offers a pragmatic, heuristic, and trans-diagnostic integrative framework to guide the
an
assessment of individual patients, emphasizing identification of risk factors for
M
persistence or deterioration of symptoms or problems, rather than just focusing on the initial onset of disorder. Clinical staging also guides the selection of interventions
d
that are proportionate to the phase and stage of disorder for that individual [20].
Ac ce pt e
Interventions are simpler and more benign during early stages of disorder, increasing in intensity (and potential adverse effects) with disorder progression. In later stage disorder, the risk of more severe adverse effects becomes more justified. Interventions might also be combined to address co-occurring psychopathology. For example, time-limited problem-solving, substance use reduction, or parenting skills might be appropriate for early stage PD, whereas intensive and long-term psychotherapy or targeted pharmacotherapy might be reserved for late-stage disorder. Early intervention internationally There has been a groundswell of activity in this area, with numerous programs now offering treatment to young people with BPD. At least five programs meeting the above definition of early intervention have been established in Australia [31], The
7 Page 7 of 17
Netherlands [32–34], and Germany [35]. However, only one program covers the extended developmental period into young adulthood [31]. Moreover, there are other programs in Norway [36] and the UK [37] that have primarily focused upon self-harm. The majority of the sample in each of these randomized controlled trials has had
ip t
BPD but the studies have not clearly articulated the phase or stage of their target
cr
population.
us
In the randomized controlled trial literature, treatments developed for BPD in young
an
people include, Cognitive Analytic Therapy (CAT) [38] within the Helping Young People Early (HYPE) Program [39], Emotion Regulation Training (ERT) [34,40],
M
Dialectical Behavior Treatment for Adolescents (DBT-A) [36], and MentalisationBased Therapy for Adolescents (MBT-A) [37]. These structured treatments have
d
been shown to outperform comparison treatments such as, treatment as usual
Ac ce pt e
(TAU), good clinical care (GCC) and enhanced usual care (EUC), except in the case of ERT. However, it is noteworthy that participants in these comparison treatments also showed meaningful clinical improvements in primary and secondary outcomes, such as BPD features, other psychopathology, suicidal ideation and self-harm. Critiques of the trial literature are available elsewhere [2,41]. Four key issues need to be addressed in future studies to facilitate implementation of early intervention for PD across mainstream health services [42]. First, stigma and discrimination are a barrier to early intervention [11]. Although such views are unfounded, many clinicians avoid the diagnosis in order to ‘protect’ their patients. Although discrimination is undeniable, delaying appropriate diagnosis for this reason risks colluding with this discrimination and causing treatment delay, which carries clinical risks of
8 Page 8 of 17
inappropriate and/or harmful intervention and worse outcomes. Second, no trial has studied adaptive functioning as a primary outcome, despite this being the domain of persistent impairment in PD. Third, no trial has included emerging adults with early stage disorder. Fourth, given that treatments such as GCC and EUC appear to be
ip t
effective, the degree of complexity of treatment and the specific importance of
cr
individual psychotherapy in treatment programs need to be clarified.
us
Conclusion Early intervention for personality disorder is now feasible and might help to decrease the persistence and/or the severity of a broad range of adverse psychopathological
an
outcomes and years lived with disability. Prototype early intervention programs have been developed internationally and have yielded promising early findings. Progress
M
in the field will depend upon improved knowledge of and precision about what constitutes early intervention and the successful integration of early intervention for
d
severe personality disorder into the global effort to intervene early for severe mental
Ac ce pt e
disorder. This latter challenge presents unique problems because of entrenched discrimination toward individuals with PD.
9 Page 9 of 17
References * of special interest ** of outstanding interest G. Newton-Howes, L.A. Clark, A. Chanen, Personality disorder across the life
ip t
[1*]
course, Lancet. 385 (2015) 727–734.
cr
Summarizes key findings regarding the development of personality across the normal-abnormal range.
an
Yet?, J. Clin. Psychol. 71 (2015) 778–791.
us
[2] A.M. Chanen, Borderline Personality Disorder in Young People: Are We There
[3] A.W. Bateman, J. Gunderson, R. Mulder, Treatment of personality disorder,
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Lancet. 385 (2015) 735–743.
[4] B.J. Casey, R.M. Jones, T.A. Hare, The Adolescent Brain, Ann. N. Y. Acad. Sci.
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1124 (2008) 111–126.
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[5*] J.J. Arnett, R. Žukauskienė , K. Sugimura, The new life stage of emerging adulthood at ages 18-29 years: implications for mental health, Lancet Psychiatry. 1 (2014) 569–576.
Outlines the basis for the extended developmental period from puberty to the third decade of life and its implications for the onset of and intervention for mental disorders.
[6] S.M. Sawyer, P.S. Azzopardi, D. Wickremarathne, G.C. Patton, The age of adolescence, The Lancet Child & Adolescent Health. (2018). doi:10.1016/s2352-4642(18)30022-1. [7] R.C. Kessler, P. Berglund, O. Demler, R. Jin, K.R. Merikangas, E.E. Walters, Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the
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National Comorbidity Survey Replication, Arch. Gen. Psychiatry. 62 (2005) 593– 602. [8] G. Winograd, P. Cohen, H. Chen, Adolescent borderline symptoms in the community: prognosis for functioning over 20 years, J. Child Psychol.
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Psychiatry. 49 (2008) 933–941.
Psychiatr. Clin. North Am. 31 (2008) 495–503, viii.
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[9] A.E. Skodol, Longitudinal course and outcome of personality disorders,
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[10] P. Cohen, T.N. Crawford, J.G. Johnson, S. Kasen, The children in the
community study of developmental course of personality disorder, J. Pers.
an
Disord. 19 (2005) 466–486.
[11**] A. Chanen, C. Sharp, P. Hoffman, Global Alliance for Prevention and Early
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Intervention for Borderline Personality Disorder, Prevention and early intervention for borderline personality disorder: a novel public health priority,
d
World Psychiatry. 16 (2017) 215–216.
Ac ce pt e
This international consensus position statement identifies personality pathology as a global public health priority and outlines key actions to progress the field. [12*] C. Sharp, A.G.C. Wright, J. Christopher Fowler, B. Christopher Frueh, J.G. Allen, J. Oldham, L.A. Clark, The structure of personality pathology: Both general (“g”) and specific (“s”) factors?, J. Abnorm. Psychol. 124 (2015) 387– 398.
Provides the rationale for focusing upon early intervention for BPD because BPD appears to represent a core severity factor of personality pathology. [13] L.A. Clark, H. Nuzum, E. Ro, Manifestations of personality impairment severity: comorbidity, course/prognosis, psychosocial dysfunction, and “borderline” personality features, Current Opinion in Psychology. 21 (2018) 117–121.
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[14] APA, Diagnostic and statistical manual of mental disorders (5th ed.), American Psychiatric Association, Washington, DC, 2013. [15] L.A. Clark, Assessment and diagnosis of personality disorder: perennial issues and an emerging reconceptualization, Annu. Rev. Psychol. 58 (2007) 227–257.
ip t
[16] S.C. Herpertz, S.K. Huprich, M. Bohus, A. Chanen, M. Goodman, L. Mehlum, P. Moran, G. Newton-Howes, L. Scott, C. Sharp, The Challenge of Transforming
cr
the Diagnostic System of Personality Disorders, J. Pers. Disord. 31 (2017) 577–
us
589.
[17] A.M. Chanen, L. McCutcheon, Prevention and early intervention for borderline
an
personality disorder: current status and recent evidence, Br. J. Psychiatry Suppl. 54 (2013) s24–9.
M
[18] K. Thompson, H.J. Jackson, M. Cavelti, J. Betts, L. McCutcheon, M. Jovev, A.M. Chanen, The clinical significance of subthreshold borderline personality disorder
d
features in outpatient youth, J. Pers. Disord. in press (2017).
Ac ce pt e
[19] P.B. Mrazek, R.J. Haggerty, Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research, National Academies, 1994. [20*] A.M. Chanen, M. Berk, K. Thompson, Integrating Early Intervention for Borderline Personality Disorder and Mood Disorders, Harv. Rev. Psychiatry. 24 (2016) 330–341.
This paper attempts to integrate early intervention for personality disorder with early intervention of other mental disorders and provides and offers a 'clinical staging' framework for this purpose. [21] A.M. Chanen, M. Kaess, Developmental Pathways to Borderline Personality Disorder, Curr. Psychiatry Rep. 14 (2012) 45–53. [22] P. Cohen, T.N. Crawford, J.G. Johnson, S. Kasen, The Children in the
12 Page 12 of 17
Community Study of Developmental Course of Personality Disorder, J. Pers. Disord. 19 (2005) 466–486. [23] T.N. Crawford, P. Cohen, J.G. Johnson, S. Kasen, M.B. First, K. Gordon, J.S. Brook, Self-reported personality disorder in the children in the community
ip t
sample: convergent and prospective validity in late adolescence and adulthood, J. Pers. Disord. 19 (2005) 30–52.
cr
[24] J.A. Hartmann, B. Nelson, R. Spooner, G. Paul Amminger, A. Chanen, C.G.
us
Davey, M. McHugh, A. Ratheesh, D. Treen, H.P. Yuen, P.D. McGorry, Broad clinical high-risk mental state (CHARMS): Methodology of a cohort study
an
validating criteria for pluripotent risk, Early Interv. Psychiatry. (2017). doi:10.1111/eip.12483.
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[25**] B. Nelson, P.D. McGorry, M. Wichers, J.T.W. Wigman, J.A. Hartmann, Moving From Static to Dynamic Models of the Onset of Mental Disorder: A
d
Review, JAMA Psychiatry. 74 (2017) 528–534.
Ac ce pt e
This paper canvasses key theoretical issues for progressing the field of prevention and early intervention.
[26] H.E. Andrewes, C. Hulbert, S.M. Cotton, J. Betts, A.M. Chanen, Ecological Momentary Assessment of Nonsuicidal Self-Injury in Youth With Borderline Personality Disorder, Personal. Disord. 8 (2017) 357–365. [27] D.J. Whalen, L.N. Scott, K.P. Jakubowski, D.L. McMakin, A.E. Hipwell, J.S. Silk, S.D. Stepp, Affective behavior during mother-daughter conflict and borderline personality disorder severity across adolescence, Personal. Disord. 5 (2014) 88–96. [28] A.M. Chanen, K. Thompson, Borderline Personality and Mood Disorders: Risk Factors, Precursors, and Early Signs in Childhood and Youth, in: Borderline
13 Page 13 of 17
Personality and Mood Disorders, 2014: pp. 155–174. [29] P. McGorry, Early clinical phenotypes and risk for serious mental disorders in young people: need for care precedes traditional diagnoses in mood and psychotic disorders, Can. J. Psychiatry. 58 (2013) 19–21.
ip t
[30**] P. McGorry, J. van Os, Redeeming diagnosis in psychiatry: timing versus specificity, Lancet. 381 (2013) 343–345.
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A seminal paper outlining clinical staging for prevention and early intervention.
us
[31] A.M. Chanen, L. McCutcheon, I.B. Kerr, HYPE: A Cognitive Analytic TherapyBased Prevention and Early Intervention Programme for Borderline Personality
an
Disorder, in: Handbook of Borderline Personality Disorder in Children and Adolescents, 2014: pp. 361–383.
M
[32] C. Hessels, M. van Aken, HYPE: Helping young people early, Kind &
0009-9.
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Adolescent Praktijk. (2014). http://link.springer.com/article/10.1007/s12454-014-
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[33] J. Hutsebaut, D. Feenstra, E. Keur, B. Schäfer, D. Bales, Tijdig herkennen en behandelen van borderlineproblematiek bij jongeren met MBT-early, Tijdschrift Voor Psychotherapie. 43 (2017) 330–344. [34] H.M. Schuppert, M.E. Timmerman, J. Bloo, T.G. van Gemert, H.M. Wiersema, R.B. Minderaa, P.M.G. Emmelkamp, M.H. Nauta, Emotion regulation training for adolescents with borderline personality disorder traits: a randomized controlled trial, J. Am. Acad. Child Adolesc. Psychiatry. 51 (2012) 1314–1323.e2. [35] M. Kaess, D. Ghinea, G. Fischer-Waldschmidt, F. Resch, [The Outpatient Clinic for Adolescent Risk-taking and Self-harm behaviors (AtR!Sk) - A Pioneering Approach of Outpatient Early Detection and Intervention of Borderline Personality Disorder], Prax. Kinderpsychol. Kinderpsychiatr. 66 (2017) 404–422.
14 Page 14 of 17
[36] L. Mehlum, A.J. Tørmoen, M. Ramberg, E. Haga, L.M. Diep, S. Laberg, B.S. Larsson, B.H. Stanley, A.L. Miller, A.M. Sund, B. Grøholt, Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial, J. Am. Acad. Child Adolesc. Psychiatry. 53 (2014) 1082–1091.
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[37] T.I. Rossouw, P. Fonagy, Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial, J. Am. Acad. Child Adolesc.
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Psychiatry. 51 (2012) 1304–1313.e3.
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[38] A.M. Chanen, H.J. Jackson, L.K. McCutcheon, M. Jovev, P. Dudgeon, H.P. Yuen, D. Germano, H. Nistico, E. McDougall, C. Weinstein, V. Clarkson, P.D.
an
McGorry, Early intervention for adolescents with borderline personality disorder
193 (2008) 477–484.
M
using cognitive analytic therapy: randomised controlled trial, Br. J. Psychiatry.
[39] A.M. Chanen, L.K. McCutcheon, D. Germano, H. Nistico, H.J. Jackson, P.D.
d
McGorry, The HYPE Clinic: an early intervention service for borderline
Ac ce pt e
personality disorder, J. Psychiatr. Pract. 15 (2009) 163–172. [40] H.M. Schuppert, J. Giesen-Bloo, T.G. van Gemert, H.M. Wiersema, R.B. Minderaa, P.M.G. Emmelkamp, M.H. Nauta, Effectiveness of an emotion regulation group training for adolescents--a randomized controlled pilot study, Clin. Psychol. Psychother. 16 (2009) 467–478. [41] A.M. Chanen, K. Thompson, Preventive Strategies for Borderline Personality Disorder in Adolescents, Current Treatment Options in Psychiatry. 1 (2014) 358–368. [42] A. Chanen, H. Jackson, S.M. Cotton, J. Gleeson, C.G. Davey, J. Betts, S. Reid, K. Thompson, L. McCutcheon, Comparing three forms of early intervention for youth with borderline personality disorder (the MOBY study): study protocol for a
15 Page 15 of 17
Ac ce pt e
d
M
an
us
cr
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randomised controlled trial, Trials. 16 (2015) 476.
16 Page 16 of 17
Conflict of interest
Ac ce pt e
d
M
an
us
cr
ip t
None
17 Page 17 of 17
S2352-250X(18)30038-1 https://doi.org/doi:10.1016/j.copsyc.2018.02.012 COPSYC 619
To appear in: Received date: Revised date: Accepted date:
14-2-2018 19-2-2018 19-2-2018
Please cite this article as: P.A.M. Chanen, K.N. Thompson, Early Intervention for Personality Disorder, COPSYC (2018), https://doi.org/10.1016/j.copsyc.2018.02.012 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title: Early Intervention for Personality Disorder Authors: Professor Andrew M. Chanen
1,2,3
, MBBS, MPM, PhD, FRANZCP
[email protected] 1,2
ip t
Dr Katherine N Thompson , PhD [email protected]
Orygen, The National Centre of Excellence in Youth Mental Health,
us
1
cr
Affiliations:
Melbourne, Australia
Centre for Youth Mental Health, The University of Melbourne, Melbourne,
an
2
Australia
Orygen Youth Health, Melbourne, Australia
M
3
Corresponding Author:
Ac ce pt e
d
Professor Andrew Chanen
Orygen, the National Centre of Excellence in Youth Mental Health
Locked Bag 10
Parkville VIC 3052 Australia
Phone: +61 3 9342 2997
Regular Article: 1808 words Abstract: 119 words
1 Page 1 of 17
Abstract Specialized treatments for personality disorder are usually offered late in the course of the disorder, to a small number of help-seeking individuals with entrenched
ip t
disability. Intervention during the early stages of personality disorder might help to decrease the persistence and/or the severity of personality disorder and to prevent
cr
the cascading of secondary psychopathology and psychosocial disability. Research regarding the understanding of and appropriate treatment for early stage personality
us
disorder is growing. However, there is still a lack of clarity in the field about what
an
constitutes early intervention and how it might relate to early intervention for other mental disorders. Also, there is little research on how to design integrated early
Ac ce pt e
d
long-term effects of early intervention.
M
intervention services suitable for personality and other mental disorders or on the
Key words: early intervention, personality disorder, borderline personality disorder, staging model, psychiatry.
2 Page 2 of 17
Early Intervention for Personality Disorder While maladaptive personality traits are observable during childhood, the more severe forms of personality disorder become clinically apparent during the transition between childhood and adulthood [1]. Yet, diagnosis of personality disorder (PD) is
ip t
typically delayed, empirically supported treatments are largely inaccessible, and
cr
iatrogenic harm is still a common outcome [2]. Specialized treatments are usually
offered late in the course of the disorder, typically in the form of complex and lengthy
us
individual psychotherapy, and only to a select few help-seeking individuals who are able to manage the attendance, behavior or other requirements imposed by the
an
treatment setting. Evidence suggests that such treatments might be neither
M
necessary nor sufficient for the treatment of all individuals with PD and that they have little effect upon long-term psychosocial functioning [3]. Moreover, 'late
d
intervention', with its associated suboptimal outcomes, often serves to reinforce
Ac ce pt e
functional impairment, disability and therapeutic nihilism. These observations have led to the development of early intervention for PD. This article describes how this nascent field has capitalized upon knowledge about the development of personality across the normal-abnormal range, and also upon knowledge about the transition from childhood to adulthood and how this constitutes a developmentally sensitive period for the onset of the major mental disorders. It also takes stock of prototype early intervention programs internationally and outlines some key challenges for the future development of interventions and clinical trials for early stage PD.
An extended period of ‘onset’ for personality disorder 3 Page 3 of 17
Advances in understanding personality development [1] and the neurobiological substrates underpinning cognitive, emotional and social development in young people [4], along with secular trends toward delayed and less synchronized role transitions to adulthood [5] point to an extended period of development beginning
ip t
with puberty and ending with the achievement of adult role functioning in the mid- to late 20s [6]. The pace and extent of change makes this is a particularly sensitive
us
peak period for the onset for the major mental disorders [7].
cr
developmental period, borne out by the observation that this also coincides with the
‘Adaptive failure’ during this period has potentially wide ranging and severe personal
an
and social consequences, especially because it can foster vicious circles that will
M
further disrupt the complex developmental tasks associated with the achievement of adult role functioning. This has been clearly demonstrated for personality disorder.
d
Despite the waxing and waning course of personality disorder, which generally leads
Ac ce pt e
to attenuation of pathological traits over time, social and occupational functioning tends to remain poor and relatively stable over the long-term [8–10]. This underscores the need for timely and effective (early) intervention. The Global Alliance for Prevention and Early Intervention for BPD (GAP) has summarized the rationale for early intervention for personality disorder [11], highlighting its clinical onset, reliability and validity, prevalence and high burden in young people, along with the demonstrated effectiveness of the 'first wave' of evidence-based treatments for young people with BPD. Moreover, a growing body of evidence points to a specific focus on early intervention for BPD because it represents common or core features of severe personality pathology, rather than a distinct diagnostic category [12,13]. For these reasons the GAP has called for early intervention to be a routine part of clinical practice in child and youth mental health services.
4 Page 4 of 17
What is early intervention for PD? Although the DSM-5 [14] has continued the tradition of categorical, syndrome-based personality disorder diagnosis, it is widely acknowledged (including in Section III of the DSM-5) that the threshold for distinguishing patients with and without personality disorder is arbitrary and that there is no strict demarcation between ‘cases’ and ‘non-
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cases’ [15,16] and therefore, no distinct point of ‘onset’. This is fundamental to the
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argument that early intervention for personality disorder requires inclusion of
‘subthreshold’ forms of the disorder [17] and is supported by recent evidence that
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outpatient youth with subthreshold BPD (1-4 DSM-IV criteria) have more severe
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mental illness and poorer social and occupational functioning than outpatient youth with no BPD features [18].
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The term early intervention is sometimes used imprecisely. In this context, early intervention refers to the stage of illness, not the chronological or developmental age
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of the individual. The term encompasses two forms of intervention defined by the US
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Institutes of Medicine [19]. The first, indicated prevention, involves preventing the onset of new 'cases' of disorder by targeting individuals showing features of PD but who do not meet the threshold for a formal diagnosis of PD (i.e., sub-threshold disorder). The second, case identification and early treatment, entails formal diagnosis of and intervention for the full PD syndrome. Early intervention for personality disorder cannot be conducted separately from other clinical syndromes A crucial problem for early intervention is the disproportionate emphasis placed upon specific syndromes (e.g., bipolar disorder, unipolar depression, psychosis) as separate domains of risk [20]. Although, the presence of personality disorder features during childhood and adolescence is the strongest predictor of adult personality disorder [21–23], it is incorrect to assume that they have a specific, linear
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and direct relationship. Similar to other mental disorders, early clinical phenotypes for personality disorder are overlapping, non-specific, and non-linear [20,24]. Nelson and colleagues [25] have suggested that early intervention might benefit from viewing psychopathology as a system, rather than as a category. They suggest
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identifying the dynamics of system change (e.g., sudden vs gradual onset) and ascertaining the factors that will most influence these systems (e.g., interpersonal
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dynamics, neurobiological changes) and the individual differences in system
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structure and change. This will involve micro-level (momentary and day-to-day) and macro-level (month and year) assessments of relevant variables. For example, using
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ecological momentary assessment to collect micro-level data, Andrewes and colleagues [26] found that initial self-injurious thoughts and changes in negative and
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positive affect occurred a median of 35, 15, and 10 hours prior to non-suicidal selfinjury, respectively, suggesting a window of opportunity for intervention. At the
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macro-level, Whalen and colleagues [27] found that positive maternal affective
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behavior and positive mother-daughter affective behaviors were prospectively associated with decreases in girls’ BPD severity scores over time. Mother-daughter negative affective escalation was associated with higher overall levels of BPD severity scores, whereas negative maternal affective behavior was not. Nonetheless, various childhood temperament and early onset mental state and behavioral problems (e.g., disruptive behavior disorders, substance use disorder, non-suicidal self-injury, anxiety, and depression) precede the clinical onset of personality disorder [28]. It has been suggested that these are often speciously defined as mental state pathology in children and later relabeled as personality pathology in adult life [21], perhaps due to lack of recognition that they are often underpinned by traits such as impulsivity, affective instability, or hyper-aggression
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[2]. This means that early intervention needs to be integrated with preventive strategies for the full range of mental disorders [20] and has led to the development of ‘clinical high at-risk mental state’ (CHARMS) criteria to identify help-seeking young people at
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risk of developing a range of severe mental illnesses [24]. An added advantage of
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this strategy is that is more like to achieve sufficient statistical power to identify
predictors of case-level outcome (i.e., clinically relevant disorder vs no disorder) [24].
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‘Clinical staging’ [29,30], analogous to disease staging in general medicine, offers a pragmatic, heuristic, and trans-diagnostic integrative framework to guide the
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assessment of individual patients, emphasizing identification of risk factors for
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persistence or deterioration of symptoms or problems, rather than just focusing on the initial onset of disorder. Clinical staging also guides the selection of interventions
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that are proportionate to the phase and stage of disorder for that individual [20].
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Interventions are simpler and more benign during early stages of disorder, increasing in intensity (and potential adverse effects) with disorder progression. In later stage disorder, the risk of more severe adverse effects becomes more justified. Interventions might also be combined to address co-occurring psychopathology. For example, time-limited problem-solving, substance use reduction, or parenting skills might be appropriate for early stage PD, whereas intensive and long-term psychotherapy or targeted pharmacotherapy might be reserved for late-stage disorder. Early intervention internationally There has been a groundswell of activity in this area, with numerous programs now offering treatment to young people with BPD. At least five programs meeting the above definition of early intervention have been established in Australia [31], The
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Netherlands [32–34], and Germany [35]. However, only one program covers the extended developmental period into young adulthood [31]. Moreover, there are other programs in Norway [36] and the UK [37] that have primarily focused upon self-harm. The majority of the sample in each of these randomized controlled trials has had
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BPD but the studies have not clearly articulated the phase or stage of their target
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population.
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In the randomized controlled trial literature, treatments developed for BPD in young
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people include, Cognitive Analytic Therapy (CAT) [38] within the Helping Young People Early (HYPE) Program [39], Emotion Regulation Training (ERT) [34,40],
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Dialectical Behavior Treatment for Adolescents (DBT-A) [36], and MentalisationBased Therapy for Adolescents (MBT-A) [37]. These structured treatments have
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been shown to outperform comparison treatments such as, treatment as usual
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(TAU), good clinical care (GCC) and enhanced usual care (EUC), except in the case of ERT. However, it is noteworthy that participants in these comparison treatments also showed meaningful clinical improvements in primary and secondary outcomes, such as BPD features, other psychopathology, suicidal ideation and self-harm. Critiques of the trial literature are available elsewhere [2,41]. Four key issues need to be addressed in future studies to facilitate implementation of early intervention for PD across mainstream health services [42]. First, stigma and discrimination are a barrier to early intervention [11]. Although such views are unfounded, many clinicians avoid the diagnosis in order to ‘protect’ their patients. Although discrimination is undeniable, delaying appropriate diagnosis for this reason risks colluding with this discrimination and causing treatment delay, which carries clinical risks of
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inappropriate and/or harmful intervention and worse outcomes. Second, no trial has studied adaptive functioning as a primary outcome, despite this being the domain of persistent impairment in PD. Third, no trial has included emerging adults with early stage disorder. Fourth, given that treatments such as GCC and EUC appear to be
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effective, the degree of complexity of treatment and the specific importance of
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individual psychotherapy in treatment programs need to be clarified.
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Conclusion Early intervention for personality disorder is now feasible and might help to decrease the persistence and/or the severity of a broad range of adverse psychopathological
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outcomes and years lived with disability. Prototype early intervention programs have been developed internationally and have yielded promising early findings. Progress
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in the field will depend upon improved knowledge of and precision about what constitutes early intervention and the successful integration of early intervention for
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severe personality disorder into the global effort to intervene early for severe mental
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disorder. This latter challenge presents unique problems because of entrenched discrimination toward individuals with PD.
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References * of special interest ** of outstanding interest G. Newton-Howes, L.A. Clark, A. Chanen, Personality disorder across the life
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Yet?, J. Clin. Psychol. 71 (2015) 778–791.
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[2] A.M. Chanen, Borderline Personality Disorder in Young People: Are We There
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[4] B.J. Casey, R.M. Jones, T.A. Hare, The Adolescent Brain, Ann. N. Y. Acad. Sci.
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[5*] J.J. Arnett, R. Žukauskienė , K. Sugimura, The new life stage of emerging adulthood at ages 18-29 years: implications for mental health, Lancet Psychiatry. 1 (2014) 569–576.
Outlines the basis for the extended developmental period from puberty to the third decade of life and its implications for the onset of and intervention for mental disorders.
[6] S.M. Sawyer, P.S. Azzopardi, D. Wickremarathne, G.C. Patton, The age of adolescence, The Lancet Child & Adolescent Health. (2018). doi:10.1016/s2352-4642(18)30022-1. [7] R.C. Kessler, P. Berglund, O. Demler, R. Jin, K.R. Merikangas, E.E. Walters, Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the
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National Comorbidity Survey Replication, Arch. Gen. Psychiatry. 62 (2005) 593– 602. [8] G. Winograd, P. Cohen, H. Chen, Adolescent borderline symptoms in the community: prognosis for functioning over 20 years, J. Child Psychol.
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[11**] A. Chanen, C. Sharp, P. Hoffman, Global Alliance for Prevention and Early
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Intervention for Borderline Personality Disorder, Prevention and early intervention for borderline personality disorder: a novel public health priority,
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World Psychiatry. 16 (2017) 215–216.
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This international consensus position statement identifies personality pathology as a global public health priority and outlines key actions to progress the field. [12*] C. Sharp, A.G.C. Wright, J. Christopher Fowler, B. Christopher Frueh, J.G. Allen, J. Oldham, L.A. Clark, The structure of personality pathology: Both general (“g”) and specific (“s”) factors?, J. Abnorm. Psychol. 124 (2015) 387– 398.
Provides the rationale for focusing upon early intervention for BPD because BPD appears to represent a core severity factor of personality pathology. [13] L.A. Clark, H. Nuzum, E. Ro, Manifestations of personality impairment severity: comorbidity, course/prognosis, psychosocial dysfunction, and “borderline” personality features, Current Opinion in Psychology. 21 (2018) 117–121.
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[14] APA, Diagnostic and statistical manual of mental disorders (5th ed.), American Psychiatric Association, Washington, DC, 2013. [15] L.A. Clark, Assessment and diagnosis of personality disorder: perennial issues and an emerging reconceptualization, Annu. Rev. Psychol. 58 (2007) 227–257.
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[17] A.M. Chanen, L. McCutcheon, Prevention and early intervention for borderline
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[18] K. Thompson, H.J. Jackson, M. Cavelti, J. Betts, L. McCutcheon, M. Jovev, A.M. Chanen, The clinical significance of subthreshold borderline personality disorder
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features in outpatient youth, J. Pers. Disord. in press (2017).
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[19] P.B. Mrazek, R.J. Haggerty, Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research, National Academies, 1994. [20*] A.M. Chanen, M. Berk, K. Thompson, Integrating Early Intervention for Borderline Personality Disorder and Mood Disorders, Harv. Rev. Psychiatry. 24 (2016) 330–341.
This paper attempts to integrate early intervention for personality disorder with early intervention of other mental disorders and provides and offers a 'clinical staging' framework for this purpose. [21] A.M. Chanen, M. Kaess, Developmental Pathways to Borderline Personality Disorder, Curr. Psychiatry Rep. 14 (2012) 45–53. [22] P. Cohen, T.N. Crawford, J.G. Johnson, S. Kasen, The Children in the
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Community Study of Developmental Course of Personality Disorder, J. Pers. Disord. 19 (2005) 466–486. [23] T.N. Crawford, P. Cohen, J.G. Johnson, S. Kasen, M.B. First, K. Gordon, J.S. Brook, Self-reported personality disorder in the children in the community
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[24] J.A. Hartmann, B. Nelson, R. Spooner, G. Paul Amminger, A. Chanen, C.G.
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Davey, M. McHugh, A. Ratheesh, D. Treen, H.P. Yuen, P.D. McGorry, Broad clinical high-risk mental state (CHARMS): Methodology of a cohort study
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validating criteria for pluripotent risk, Early Interv. Psychiatry. (2017). doi:10.1111/eip.12483.
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[25**] B. Nelson, P.D. McGorry, M. Wichers, J.T.W. Wigman, J.A. Hartmann, Moving From Static to Dynamic Models of the Onset of Mental Disorder: A
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Review, JAMA Psychiatry. 74 (2017) 528–534.
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This paper canvasses key theoretical issues for progressing the field of prevention and early intervention.
[26] H.E. Andrewes, C. Hulbert, S.M. Cotton, J. Betts, A.M. Chanen, Ecological Momentary Assessment of Nonsuicidal Self-Injury in Youth With Borderline Personality Disorder, Personal. Disord. 8 (2017) 357–365. [27] D.J. Whalen, L.N. Scott, K.P. Jakubowski, D.L. McMakin, A.E. Hipwell, J.S. Silk, S.D. Stepp, Affective behavior during mother-daughter conflict and borderline personality disorder severity across adolescence, Personal. Disord. 5 (2014) 88–96. [28] A.M. Chanen, K. Thompson, Borderline Personality and Mood Disorders: Risk Factors, Precursors, and Early Signs in Childhood and Youth, in: Borderline
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Personality and Mood Disorders, 2014: pp. 155–174. [29] P. McGorry, Early clinical phenotypes and risk for serious mental disorders in young people: need for care precedes traditional diagnoses in mood and psychotic disorders, Can. J. Psychiatry. 58 (2013) 19–21.
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[30**] P. McGorry, J. van Os, Redeeming diagnosis in psychiatry: timing versus specificity, Lancet. 381 (2013) 343–345.
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A seminal paper outlining clinical staging for prevention and early intervention.
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[31] A.M. Chanen, L. McCutcheon, I.B. Kerr, HYPE: A Cognitive Analytic TherapyBased Prevention and Early Intervention Programme for Borderline Personality
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Disorder, in: Handbook of Borderline Personality Disorder in Children and Adolescents, 2014: pp. 361–383.
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[32] C. Hessels, M. van Aken, HYPE: Helping young people early, Kind &
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[33] J. Hutsebaut, D. Feenstra, E. Keur, B. Schäfer, D. Bales, Tijdig herkennen en behandelen van borderlineproblematiek bij jongeren met MBT-early, Tijdschrift Voor Psychotherapie. 43 (2017) 330–344. [34] H.M. Schuppert, M.E. Timmerman, J. Bloo, T.G. van Gemert, H.M. Wiersema, R.B. Minderaa, P.M.G. Emmelkamp, M.H. Nauta, Emotion regulation training for adolescents with borderline personality disorder traits: a randomized controlled trial, J. Am. Acad. Child Adolesc. Psychiatry. 51 (2012) 1314–1323.e2. [35] M. Kaess, D. Ghinea, G. Fischer-Waldschmidt, F. Resch, [The Outpatient Clinic for Adolescent Risk-taking and Self-harm behaviors (AtR!Sk) - A Pioneering Approach of Outpatient Early Detection and Intervention of Borderline Personality Disorder], Prax. Kinderpsychol. Kinderpsychiatr. 66 (2017) 404–422.
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[36] L. Mehlum, A.J. Tørmoen, M. Ramberg, E. Haga, L.M. Diep, S. Laberg, B.S. Larsson, B.H. Stanley, A.L. Miller, A.M. Sund, B. Grøholt, Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial, J. Am. Acad. Child Adolesc. Psychiatry. 53 (2014) 1082–1091.
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McGorry, The HYPE Clinic: an early intervention service for borderline
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personality disorder, J. Psychiatr. Pract. 15 (2009) 163–172. [40] H.M. Schuppert, J. Giesen-Bloo, T.G. van Gemert, H.M. Wiersema, R.B. Minderaa, P.M.G. Emmelkamp, M.H. Nauta, Effectiveness of an emotion regulation group training for adolescents--a randomized controlled pilot study, Clin. Psychol. Psychother. 16 (2009) 467–478. [41] A.M. Chanen, K. Thompson, Preventive Strategies for Borderline Personality Disorder in Adolescents, Current Treatment Options in Psychiatry. 1 (2014) 358–368. [42] A. Chanen, H. Jackson, S.M. Cotton, J. Gleeson, C.G. Davey, J. Betts, S. Reid, K. Thompson, L. McCutcheon, Comparing three forms of early intervention for youth with borderline personality disorder (the MOBY study): study protocol for a
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Conflict of interest
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None
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