Evaluating the Construct Validity of the Norwegian Version of the Level of Personality Functioning Scale - Brief Form 2.0 in a Large Clinical Sample.

The Level of Personality Functioning - Brief Form 2.0 (LPFS-BF 2.0) is a 12-item self-report questionnaire developed to gain a quick impression of the severity of personality pathology according to the DSM-5 Alternative Model for Personality Disorders (AMPD). The current study evaluated the construct validity and reliability of the Norwegian version of the LPFS-BF 2.0 in a large clinical sample (N = 1673). Dimensionality was examined using confirmatory factor analysis and bifactor analysis followed by an analysis of distinctiveness of the subscales using the proportional reduction in mean squared error (PRMSE), and the concurrent validity was examined using correlations with self-report questionnaires and clinical interviews assessing PDs according to section II of the DSM-5. Taking the findings of the dimensionality and concurrent validity results together, we found moderate to good support for the use of total scores for the Norwegian version of the LPFS-BF 2.0. We would advise against the use of subscale scores, since the subscales provided only a small amount of reliable unique variance.

Personality disorders: the impact of severity on societal costs.

Personality disorders (PDs) are associated with high levels of societal costs. However, previous research has found limited or no evidence of unique contributions of individual PD categories on the overall level of societal costs. Recent research supports the validity of PD as a dimensional construct, and PD severity may be a better predictor of societal costs than specific PD categories. The aim of this study was to explore if PD severity could predict the level of societal costs among treatment-seeking patients with PDs, while controlling for the impact of comorbid mental health and substance use disorders. Four different severity indicators were explored: the number of PDs, the total number of PD criteria, the number of BPD criteria, and the Level of Personality Functioning Scale (LPFS) from the alternative model in DSM-5. Participants (n = 798/794) were retrieved from the quality register of the Norwegian Network for Personality Disorders for the period 2017-2020. Societal costs were assessed using a structured interview covering the six-month period prior to assessment. Diagnoses and diagnostic criteria were determined using a semi-structured diagnostic interview (SCID-5-PD and M.I.N.I), and the LPFS was assessed by the LPFS-Brief Form 2.0 (LPFS-BF 2.0) questionnaire. Statistics included multiple regression analyses. None of the severity indicators were significant predictors of overall societal costs among treatment-seeking patients, and effect sizes were small.

Group-based comprehensive behavioral intervention for tics (CBIT) for adults with Tourette syndrome or chronic tic disorders: A pilot study.

Comprehensive behavioral intervention for tics (CBIT) administered individually is an effective treatment for tics. However, the effectiveness of CBIT administered in groups for adults with Tourette syndrome and chronic tic disorders has not been investigated yet. This pilot study examined the effectiveness of group-based CBIT with respect to reduction of tic severity and tic-related impairment, as well as improvement of tic-related quality of life. Data from 26 patients were included in the intention-to-treat analyses. The Yale Global Tic Severity Scale was used to assess total tic severity and tic-related impairment. The Gilles de la Tourette - Quality of Life Scale was used to assess tic-related quality of life. These measures were administered at three points in time: at pretreatment, posttreatment, and 1-year follow-up. The results showed a significant reduction of total tic severity from pretreatment to 1-year follow-up, with larges effect sizes. Tic-related impairment and tic-related quality of life also improved significantly, although the effect sizes were smaller. Motor tics showed a stronger reduction than vocal tics. Additional analysis revealed that all change was achieved during treatment and that this effect was maintained from posttreatment to 1-year follow-up. The results of this study indicate that group-based CBIT is a promising treatment for tics.

A systematic review of measurement uncertainty visualizations in the context of standardized assessments.

This systematic review summarized findings of 29 studies evaluating visual presentation formats appropriate for communicating measurement uncertainty associated with standardized clinical assessment instruments. Studies were identified through systematic searches of multiple databases (Medline, Embase, PsycInfo, ERIC, Scopus, and Web of Science). Strikingly, we found no studies which were conducted using samples of clinicians and included clinical decision-making scenarios. Included studies did however find that providing participants with information about measurement uncertainty may increase awareness of uncertainty and promote more optimal decision making. Formats which visualize the shape of the underlying probability distribution were found to promote more accurate probability estimation and appropriate interpretations of the underlying probability distribution shape. However, participants in the included studies did not seem to benefit from the additional information provided by such plots during decision-making tasks. Further explorations into how presentations of measurement uncertainty impact clinical decision making are needed to examine whether findings of the included studies generalize to clinician populations. This review provides an important overview of pitfalls associated with formats commonly used to communicate measurement uncertainty in clinical assessment instruments, and a potential starting point for further explorations into promising alternatives. Finally, our review offers specific recommendations on how remaining research questions might be addressed.

Improvement of personality functioning among people treated within personality disorder mental health services. A longitudinal, observational study.

Objective: Evidence-based personality disorder (PD) treatments are dominated by interventions targeting Borderline PD, although clinical populations characteristically include different PD features and severity. Personality functioning is a new concept intended to capture common features across PDs. This study aimed to investigate longitudinal improvement of personality functioning in a clinical sample assigned to PD treatment. Method: An observational, large, longitudinal study of patients in PD treatments on specialist mental health service levels (N = 1,051). DSM-5 PDs were systematically assessed on referral. Personality functioning was repeatedly assessed (LPFS-BF-2.0), supplemented by symptom distress (anxiety: PHQ-GAD-7, depression: PHQ-9), and social/occupational activity (WSAS, work/study activity). Statistics were linear mixed models. Results: Thirty per cent had personality difficulties below PD threshold. Among PDs, 31% had Borderline (BPD), 39% Avoidant (AvPD), 15% not otherwise specified, 15% other PDs, and 24% > one PD. More severe initial LPFS-BF was associated with younger age, presence of PD and increasing number of total PD criteria. Across PD conditions, LPFS-BF, PHQ-9 and GAD-7 improved significantly (overall effect size 0.9). Mean duration of PD treatment was 15 (SD 9) months. Drop-out rates were low (12%). LPFS-BF improvement-rates were higher for BPD. Younger age was moderately associated with slower PHQ-9 improvement. Work/study activity was initially poor, poorer levels associated with AvPD and younger age, and improvement was non-significant across PD conditions. AvPD was associated with slower WSAS improvement-rates. Conclusion: Personality functioning improved across PD conditions. The results highlight BPD improvements. The study points to challenges concerning AvPD treatment, poor occupational activity and age-related differences.

Visualizing Uncertainty to Promote Clinicians' Understanding of Measurement Error.

Measurement error is an inherent part of any test score. This uncertainty is generally communicated in ways that can be difficult to understand for clinical practitioners. In this empirical study, we evaluate the impact of several communication formats on the interpretation of measurement accuracy and its influence on the decision-making process in clinical practice. We provided 230 clinical practitioners with score reports in five formats: textual, error bar, violin plot, diamond plot, and quantile dot plot. We found that quantile dot plots significantly increased accuracy in the assessment of measurement uncertainty compared with other formats. However, a direct relation between visualization format and decision quality could not be found. Although traditional confidence intervals and error bars were favored by many participants due to their familiarity, responses revealed several misconceptions that make the suitability of these formats for communicating uncertainty questionable. Our results indicate that new visualization formats can successfully reduce errors in interpretation.

Avoidant and borderline personality disorder patients during the first Covid-19 wave in Norway - a survey-based comparison of therapy changes and patients' accommodations.

BACKGROUND: Patients with personality disorders (PDs) often have insecure attachment patterns and may be especially vulnerable to abrupt treatment changes. Patients with borderline PD (BPD) are often considered vulnerable to treatment interruption due to chronic fear of abandonment. Nonetheless, other PDs are poorly investigated. In the first Covid-19 wave in Norway, in-person treatment facilities and group treatments were strongly restricted from March 12th until May/June 2020. OBJECTIVES: To examine and compare changes in outpatient treatment for patients with avoidant (AvPD) and BPD during the first Covid-19 wave in Norway, and patients' reactions to these changes. METHODS: The study is based on a cross-sectional survey distributed to 1120 patients referred to 12 different PD treatment units on a specialist mental health service level within the Norwegian Network for Personality Disorders. The survey included questions on treatment situation, immediate reactions, and changes during the crisis. From 133 responders (response rate 12%), 40 patients reported BPD and 30 AvPD as diagnosis. RESULTS: All patients were followed up from their therapist after March 12th. Almost all patients in both groups expressed satisfaction under the new circumstances. Both groups experienced the same regularity as before, but more AvPD patients reported less than weekly consultations. AvPD patients reported more negative feelings about changes in therapy, and missed the therapy and group members more than the BPD group. CONCLUSION: After the lockdown, BPD patients received a closer follow-up than AvPD patients, and the latter reported more negative feelings related to change in their treatment situation.

The Incremental Utility of Criteria A and B of the DSM-5 Alternative Model for Personality Disorders for Predicting DSM-IV/DSM-5 Section II Personality Disorders.

The DSM-5 Alternative Model for Personality Disorders (AMPD) includes two main criteria: moderate or greater impairment in personality functioning (Criterion A) and the presence of one or more pathological personality traits (Criterion B). The aim of the study was to investigate the incremental utility of Criteria A and B for predicting DSM-5 Section II personality disorders (PD). The sample (N = 317) consisted of three well-defined groups: non-clinical participants (n = 35), psychiatric patients with PD (n = 193), and without PD (n = 83). All were assessed using the Structured Clinical Interview for the DSM-5 Alternative Model for Personality Disorders Module I (SCID-5-AMPD-I): Level of Personality Functioning Scale (LPFS), and the Personality Inventory for DSM-5 (PID-5). Logistic regression analyses showed that the SCID-5-AMPD-I could predict the presence of PDs in general, and the three specific PDs that were investigated (i.e., Antisocial, Borderline, and Avoidant PDs). The PID-5 domains enhanced prediction of the specific PDs, but not the presence of PDs in general, when entered in the second step. Our results support the AMPD model: Criterion A predicted the presence of DSM-5 Section II PDs in general, whereas measures of Criterion B incremented prediction of Antisocial, Borderline, and Avoidant PDs.

The Norwegian network for personality disorders - development, contributions and challenges through 30 years.

BACKGROUND: Established in 1992, the Norwegian Network for Personality Disorders (The Network) is a clinical research collaboration of specialist mental health and addiction services in Norway. Its primary focus is to facilitate systematic and relevant clinical assessment for patients with personality disorder and evaluate progress in psychotherapeutic treatment. However, large-scale data registers for personality disorder are still unique. This article presents the circumstances that led to the establishment of the Network, and its development and challenges in many areas, and through various phases. METHODS: In the following, we will outline how this close interaction between researchers, clinicians, and well-adapted systems has facilitated cooperation and clinical research. We will highlight some key factors that have been decisive during the network's development, and not least for further adaptation and existence. RESULTS: Through 30 years, the Network has succeeded in establishing a large and sustainable clinical research collaboration with a persistent focus on personality disorder and psychotherapeutic treatment. The collaboration has resulted in a broad range of scientific contributions to the understanding of personality disorder, assessment and measurement methods, treatment alliance, clinical outcomes, service utilization, and costs. In addition, The Network has also resulted in a number of synergy effects that have benefited clinicians, patients, and researchers. CONCLUSIONS: The Norwegian Network for Personality Disorders has become an acknowledged institution in the field. Many aspects of its development, organization, maintenance, and solutions to challenges may be relevant to others who plan to establish, maintain, or further develop similar collaborations.

Do Flexible Administration Procedures Promote Individualized Clinical Assessments? An Explorative Analysis of How Clinicians Utilize the Funnel Structure of the SCID-5-AMPD Module I: LPFS.

The current study examined clinicians' utilization of the SCID-5-AMPD-I funnel structure. Across 237 interviews, conducted as part of the NorAMP study, we found that clinicians administered on average 2-3 adjacent levels under each subdomain, effectively administering only about 50% of available items. Comparing administration patterns of interviews, no two interviews contained the exact same set of administered items. On average, when comparing individual interviews, only about half of the administered items in each interview were administered in both interviews. Cross-classified mixed effects models were estimated to examine the factors affecting item administration. Results indicated that the interplay between patient preliminary scores and item level had a substantial impact on item administration, suggesting clinicians tend to administer items corresponding to expected patient severity. Overall, our findings suggest clinicians utilize the SCID-5-AMPD-I funnel structure to conduct efficient and individually tailored assessments informed by relevant patient characteristics. Adopting similar non-fixed administration procedures for other interviews could potentially provide similar benefits compared to traditional fixed-form administration procedures. The current study can serve as a template for verifying and evaluating future adoptions of non-fixed administration procedures in other interviews.

Personality Disorders as a Possible Moderator of the Effects of Relational Interventions in Short-Term Psychoanalytic Psychotherapy with Depressed Adolescents.

A significant proportion of adolescents suffering from major depressive disorder (MDD) are likely to have a co-morbid personality disorder (PD). Short-term psychoanalytic psychotherapy (STPP) was found to be one treatment of choice for adolescents suffering from MDD. BACKGROUND: The first experimental study of transference work-in teenagers (FEST-IT) demonstrated the efficaciousness of transference work in STPP with adolescents suffering from MDD. The usefulness of STPP may be enhanced by exploring possible moderators. METHODS: Depressed adolescents (N = 69), aged 16-18 years, were diagnosed with the structured interview for DSM-IV PDs and randomized to 28 weeks of STPP with or without transference work. A mixed linear model was applied. The moderator effect was investigated by a three-way interaction including "time", "treatment group" and "number of PD criteria". RESULTS: A small but significant moderator effect was found for cluster B personality pathology. Patients with a higher number of cluster B PD criteria at baseline did better up to one-year post-treatment where therapists encouraged patients to explore the patient-therapist relationship in the here and now. CONCLUSION: When treated with psychoanalytic psychotherapy for MDD, adolescents with cluster B PD symptoms seem to profit more from transference work than adolescents without such pathology.

Is the alternative model for personality disorders able to capture avoidant personality disorder according to Section II of the DSM-5? A systematic review.

This review aims at examining the continuity between the categorical model for personality disorders (PDs) as defined by Section II of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the alternative model for personality disorders (AMPD) with respect to Section II avoidant personality disorder (AvPD). Because the Criterion A of the AMPD, that is, the Level of Personality Functioning Scale (LPFS), is a prerequisite for a PD diagnosis, only studies assessing the LPFS were included, whether or not the Criterion B, that is, pathological personality traits, were assessed as well. A total of 13 studies met the inclusion criteria, with 6 studies comprising community/undergraduate samples and 7 studies comprising clinical samples. Weighted correlation between global LPFS and AvPD was .39 (rw = .55 for community/undergraduate studies; rw =.17 for clinical studies). When AvPD-specific impairment was evaluated, that is, impairment of personality functioning characterizing AvPD in the AMPD, correlations were substantially larger. In studies using regression analyses, the Criterion B appeared to have incremental utility in predicting the presence of Section II AvPD. To capture Section II AvPD in a sufficient degree by the AMPD, it might be necessary to use an AvPD-specific impairment questionnaire. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Do Sleep Disturbances Improve Following Psychoanalytic Psychotherapy for Adolescent Depression?

Sleep disturbance is often a prominent symptom in adolescents diagnosed with major depressive disorder (MDD). Recent evidence indicates that short-term psychoanalytic psychotherapy (STPP) for depression may have an effect in reducing co-occurring sleep disturbance in youth. It is unknown if transference work (exploration of the patient-therapist relationship) has an additional effect in reducing sleep disturbance. Adolescents aged 16-18 years (n = 69, 84% female) who met diagnostic criteria for MDD based on the Mini International Neuropsychiatric Interview (M.I.N.I) were randomized to either STPP with transference work or without. Sleep problems were assessed at baseline, therapy session 20 (20 weeks), post-treatment (28 weeks), and one-year follow-up (80 weeks) with the Symptom Checklist-90-R. At baseline, 69% of the adolescents exhibited moderately to extreme sleep difficulties. Sleep disturbance was significantly correlated to depression depth at session 20 and at follow-up. Symptoms of insomnia significantly decreased from baseline to the end of treatment. Treatment gains were maintained until follow-up. No differences in recovery of sleep disturbance were found between the two treatment groups. The findings suggest that sleep disturbance improves following STPP for depression, with or without transference work. Future research should assess those with residual symptoms by different sleep measures.

More is more: Evidence for the incremental value of the SCID-II/SCID-5-PD specific factors over and above a general personality disorder factor.

Currently, 3 competing conceptualizations of personality dysfunction can be distinguished: the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) categorical model delineating 10 distinct types of personality disorders (PDs); the alternative model for PDs (DSM-5 Section III), which assesses personality functioning and traits separately; and the International Classification of Diseases, 11th Version conceptualization, which provides 1 single code for the presence of a PD (which is based on problems in functioning) as well as codes that specify the level of the disorder (mild/moderate/severe), and prominent trait domains or patterns (5 domains and 1 pattern). The current study aims to assess the incremental value of the DSM-5 PDs over and above a global personality dysfunction factor, using expert ratings obtained with the Structured Clinical Interview for DSM-IV PDs and the Structured Clinical Interview for DSM-5 PDs interview in a large sample of clinical patients (N = 3,851). All estimated bifactor models provided adequate fit to the data. We found a surprisingly low explained common variance for the g-factor (<40%), indicating that ignoring the specific PD factors would lead to a substantial loss of information. The strongest specific PDs in terms of explained common variance were the avoidant, schizotypal, and schizoid PD factors and the conduct disorder criteria set if included. Correlations between our factors and external variables were relatively low, except for the Severity Indices of Personality Problems, which aims to measure personality functioning. Our findings suggest that specific PDs still have an important role to play in the assessment of personality pathology. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Vulnerability of personality disorder during the Covid-19 crises - a multicenter survey of treatment experiences among patients referred to treatment.

BACKGROUND: The societal shutdown due to the Covid-19 pandemic involved mental health services for personality disorder (PD) and was introduced from 12 March 2020 in Norway. Rapid implementation of treatment modifications was required for patients typically characterized by insecure attachment and vulnerability to separation. AIM: To investigate immediate reactions to the shutdown of services; alternative treatment received; and differences related to age in a clinical sample of patients with PD. DESIGN: A survey performed from June to October 2020 (after the first Covid-19 wave) among 1120 patients from 12 units offering comprehensive group-based PD programs. RESULTS: The response-rate was 12% (N = 133). Negative feelings of anxiety, sadness, and helplessness were noteworthy immediate reactions, but the dominating attitude was accommodation. Younger patients (<26 years) reported more skepticism and less relief. Modified treatment was mainly telephone therapy. Digital therapy was less available, but was more frequent among younger patients. A minority received digital group therapy. Most patients rated the frequency and quality of modified treatments as satisfactory in the given situation, but also worried about own treatment progress, lack of group therapy, and 47% missed seeing the therapist when having telephone consultations. CONCLUSION: The survey confirms a radical modification from comprehensive group-based PD programs to telephone consultations, low availability of digital consultations and group treatments. Taking a short-term, first wave perspective, the survey indicates a noteworthy capacity among poorly functioning patients for accommodating to a clearly challenging situation, as well as considerable concern about treatment progress.

Norwegian Clinicians' Experiences of Learnability and Usability of SCID-II, SCID-5-PD and SCID-5-AMPD-I Interviews: A Sequential Multi-Group Qualitative Approach.

The DSM-5 presents two competing diagnostic frameworks for personality disorders: the standard categorical model and the Alternative Model of Personality Disorders (AMPD). The AMPD was initially criticized for being too complex and theory laden for clinical implementation. Though inter-rater reliability studies have contested initial claims of the model's complexity, little attention has been paid to how clinicians experience the usability and learnability of either model. We interviewed twenty Norwegian clinicians about their experiences with either the SCID-II/5-PD (n = 9), SCID-5-AMPD-I (n = 8), or both (n = 3). Separate thematic analyses were conducted for SCID-II/5-PD and SCID-5-AMPD-I groups, and group themes were compared. We identified four themes for each group, relating to required skills, training, challenges and information gained through the interview. We found that training and clinical experience were considered to be important for both interviews. Moreover, the SCID-5-AMPD-I was considered to rely more explicitly on theory specific to the development and content of the AMPD model in general and the LPFS specifically We also identified shared and unique challenges and shortcomings of each interview. We comment on how our findings relate to the debate surrounding the AMPD, and recommend development of clear training guidelines for both interviews.

Skin picking disorder. / Hudplukkingslidelse.

Skin picking disorder is an under-recognised mental disorder that typically starts during adolescence and leads to considerable emotional distress and/or reduced functioning in important areas of life. Repeated picking at the skin happens despite efforts to stop. Feelings of lack of control and shame are prominent, and anxiety disorders and depression are common comorbidities. SSRIs and n-acetylcysteine may be beneficial, but cognitive behavioural therapy is probably more effective.

Vulnerability of personality disorder during COVID-19 crises: a multicenter survey of mental and social distress among patients referred to treatment.

BACKGROUND: Relational and emotional problems, dysregulation, self-harming or substance abuse often characterize personality disorders (PD). In Norway, COVID-19 restrictions led to an abrupt shutdown of services from 12 March 2020 also including specialized PD treatments. AIMS: The objective of this study was to investigate social and mental distress among patients with PDs during the first COVID-19 wave. DESIGN: A survey was distributed after the first COVID-19 wave (June-October 2020) among 1120 patients from 12 PD treatment units. RESULTS: The response rate was 12% (N = 133). The survey reflected impairment of occupational activity (53% <50% activity last 6 months), life quality (EQ-5D-VAS: 56, SD 19), and personality functioning (LPFS-BF ≥12: 81%, 35% avoidant PD, 44% borderline PD) and high levels of depression and anxiety (PHQ-9 ≥ 10: 84%, GAD-7 ≥ 10: 68%), 49% with health-related anxiety. Problem increase was reported for anxiety (28%), depression (24%), aggression (23%), substance use (14%), and 70% of parents had more child-care difficulties. Self-destructive behaviors (26%) did not increase. The majority (78%) reported increased or unchanged social isolation and loneliness. Occupational activity declined with negative effects on part-time jobs/rehabilitation. Therapist contact was mainly telephone-based (63% ≥ weekly contact). More severe personality problems, current depressive symptoms, and self-harming before 12 March were associated with more frequent consultations. CONCLUSION: The survey confirms severe, enhanced levels of mental distress among patients receiving telephone-based consultations as the main alternative to specialized PD treatment during the COVID-19 shutdown. The most vulnerable patients received more frequent consultations and self-destructive actions did not increase.

The first experimental study of transference work-in teenagers (FEST-IT): a multicentre, observer- and patient-blind, randomised controlled component study.

BACKGROUND: Little is known about the influence on outcome of exploration of the patient-therapist relationship (that is, transference work) in psychoanalytic psychotherapy. We hypothesized that depressed adolescents would have better long-term effects from psychoanalytic psychotherapy with than without transference work. METHODS: Depressed adolescent (16 to 18 years) were recruited in health authority funded out-patient clinics in Oslo and Vestfold County, Norway. They were randomized to 28 weeks of treatment with psychoanalytic psychotherapy with or without transference work. Change was assessed using linear-mixed models. The primary outcome measure was the Psychodynamic Functioning Scale (pre- post-, and 1-year post-treatment). Level of depression was measured at the same time points and during therapy (week 12, and 20). RESULTS: 69 adolescents were treated with (N = 39) or without (N = 31) transference work. The mean number of sessions was 18.6 (SD = 8,6) in the transference work group and 18.0 (SD = 10.9) in the non-transference work group. Both groups showed large and significant improvement on Psychodynamic Functioning Scale during the whole study period. The difference between the two groups was not significant during the treatment period (95% CI -.79 to 1.2, p = .674, F = .18), or from post-treatment to one-year follow-up (95% CI -.13 to .96; p = .134; F = 2.3). For the secondary outcome measures the transference work group had significantly better outcomes from 12 weeks in treatment to one-year follow-up (Beck Depression Inventory, 95% CI - 1.7 to -.14, p = .022; Montgomery and Åsberg Depression Rating Scale, 95% CI - 1.6 to -.23, p = .009). CONCLUSION: The findings suggest that exploration of the adolescents' relations to the therapist amplify the effects of short-term psychoanalytic psychotherapy on their depressive symptoms for adolescents with a Major Depressive Disorder. TRIAL REGISTRATION: ClinicalTrials.gov . Id: NCT01531101 . Registered 8 February 2012.