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.

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.

Standard set of patient-reported outcomes for personality disorder.

PURPOSE: The purpose of the article is to present standard set of outcomes for people with personality disorder (PD), in order to facilitate patient outcome measurement worldwide. METHODS: The International Consortium for Health Outcomes Measurement (ICHOM) gathered a multidisciplinary international working group, consisting of 16 experts, including clinicians, nurses, psychologists, methodologists and patient representatives, to develop a standard set of outcome measures for people with PD. The Delphi method was used to reach consensus on the scope of the set, outcome domains, outcome measures, case-mix variables and time points for measuring outcomes in service users. For each phase, a project team prepared materials based on systematic literature reviews and consultations with experts. RESULTS: The working group decided to include PD, as defined by International Classification of Diseases 11th revision (ICD-11). Eleven core outcomes and three optional outcomes across four health domains (mental health, behaviour, functioning and recovery) were defined as those relevant for people with PD. Validated measures for the selected outcomes were selected, some covering more than one outcome. Case-mix variables were aligned to other ICHOM mental health standard sets and consisted of demographic factors and those related to the treatment that people received. The group recommended that most outcomes are measured at baseline and annually. CONCLUSION: The international minimum standard set of outcomes has the potential to improve clinical decision making through systematic measurement and comparability. This will be key in improving the standard of health care for people with PD across the world.

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.

Moving forward: closing the gap between research and practice for young people with BPD.

The study of personality disorders has come a long way, and this is characterized by the optimism prevalent within the community dedicated to its study. Outside this community - delays in intervention, ostracism, and ignorance remain common place. With a significant burden of disease and high costs at individual, social, and societal levels there is an urgent need to translate research into practice. Proposed solutions include educating the workforce to improve attitudes and developing more sustainable treatment alternatives. This paper brings forward a user perspective on the need to close the gap between what we know from research and what is done in policy and clinical practice.