Step-down versus outpatient psychotherapeutic treatment for personality disorders: 6-year follow-up of the Ullevål personality project

Bjørnar T Antonsen, Ole Klungsøyr, Anne Kamps, Benjamin Hummelen, Merete S Johansen, Geir Pedersen, Oyvind Urnes, Elfrida H Kvarstein, Sigmund Karterud, Theresa Wilberg, Bjørnar T Antonsen, Ole Klungsøyr, Anne Kamps, Benjamin Hummelen, Merete S Johansen, Geir Pedersen, Oyvind Urnes, Elfrida H Kvarstein, Sigmund Karterud, Theresa Wilberg

Abstract

Background: Although psychotherapy is considered the treatment of choice for patients with personality disorders (PDs), there is no consensus about the optimal level of care for this group of patients. This study reports the results from the 6-year follow-up of the Ullevål Personality Project (UPP), a randomized clinical trial comparing outpatient individual psychotherapy with a long-term step-down treatment program that included a short-term day hospital treatment followed by combined group and individual psychotherapy.

Methods: The UPP included 113 patients with PDs. Outcome was evaluated after 8 months, 18 months, 3 years and 6 years and was based on a wide range of clinical measures, such as psychosocial functioning, interpersonal problems, symptom severity, and axis I and II diagnoses.

Results: At the 6-year follow-up, there were no statistically significant differences in outcome between the treatment groups. Effect sizes ranged from medium to large for all outcome variables in both treatment arms. However, patients in the outpatient group had a marked decline in psychosocial functioning during the period between the 3- and 6-year follow-ups; while psychosocial functioning continued to improve in the step-down group during the same period. This difference between groups was statistically significant.

Conclusions: The findings suggest that both hospital-based long-term step-down treatment and long-term outpatient individual psychotherapy may improve symptoms and psychosocial functioning in poorly functioning PD patients. Social and interpersonal functioning continued to improve in the step-down group during the post-treatment phase, indicating that longer-term changes were stimulated during treatment.

Trial registration: NCT00378248.

Figures

Figure 1
Figure 1
Patient dispensation in a randomized clinical trial comparing a step-down treatment program with outpatient treatment.
Figure 2
Figure 2
Course of primary outcome variables.

References

    1. Ogrodniczuk JS. New directions in treatment research for personality disorders: effectiveness of different levels of care. Psychother Psychosom. 2011;80(2):65–69. doi: 10.1159/000322239.
    1. Verheul R, Herbrink M. The efficacy of various modalities of psychotherapy for personality disorders: a systematic review of the evidence and clinical recommendations. Int Rev Psychiatry. 2007;19:25–38. doi: 10.1080/09540260601095399.
    1. Livesley J. Integrated therapy for complex cases of personality disorder. J Clin Psychol. 2008;64:207–221. doi: 10.1002/jclp.20453.
    1. Gunderson JG, Gratz KL, Neuhaus EC, Smith GW. In: Textbook of Personality Disorders. 1. Oldham JM, Skodol AE, Bender DS, editor. Washington DC, USA: American Psychiatric Publishing, Inc; 2005. Levels of Care in Treatment; pp. 239–255.
    1. Stoffers JM, Vollm BA, Rucker G, Timmer A, Huband N, Lieb K. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev. 2012;8:CD005652.
    1. Ogrodniczuk JS, Piper WE. Day treatment for personality disorders: a review of research findings. Harv Rev Psychiatry. 2001;9:105–117. doi: 10.1080/10673220127889.
    1. Bartak A, Andrea H, Spreeuwenberg MD, Thunnissen M, Ziegler UM, Dekker J, Bouvy F, Hamers EF, Meerman AM, Busschbach JJ, Verheul R, Stijnen T, Emmelkamp PM. Patients with cluster a personality disorders in psychotherapy: an effectiveness study. Psychother Psychosom. 2011;80:88–99. doi: 10.1159/000320587.
    1. Bartak A, Andrea H, Spreeuwenberg MD, Ziegler UM, Dekker J, Rossum BV, Hamers EF, Scholte W, Aerts J, Busschbach JJ, Verheul R, Stijnen T, Emmelkamp PM. Effectiveness of outpatient, day hospital, and inpatient psychotherapeutic treatment for patients with cluster B personality disorders. Psychother Psychosom. 2011;80:28–38. doi: 10.1159/000321999.
    1. Bartak A, Spreeuwenberg MD, Andrea H, Holleman L, Rijnierse P, Rossum BV, Hamers EF, Meerman AM, Aerts J, Busschbach JJ, Verheul R, Stijnen T, Emmelkamp PM. Effectiveness of different modalities of psychotherapeutic treatment for patients with cluster C personality disorders: results of a large prospective multicentre study. Psychother Psychosom. 2010;79:20–30. doi: 10.1159/000254902.
    1. Chiesa M, Bateman A, Wilberg T, Friis S. Patients’ characteristics, outcome and cost-benefit of hospital-based treatment for patients with personality disorder: a comparison of three different programmes. Psychol Psychother. 2002;75(Pt 4):381–392.
    1. Karterud S, Wilberg T. From general day hospital treatment to specialized treatment programmes. Int Rev Psychiatry. 2007;19:39–49. doi: 10.1080/09540260601080821.
    1. Livesley WJ. Research trends and directions in the study of personality disorder. Psychiatr Clin North Am. 2008;31:545–559. doi: 10.1016/j.psc.2008.03.014. ix.
    1. Bateman A, Fonagy P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry. 1999;156:1563–1569.
    1. Bateman A, Fonagy P. Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up. Am J Psychiatry. 2001;158:36–42. doi: 10.1176/appi.ajp.158.1.36.
    1. Bateman A, Fonagy P. 8-year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual. Am J Psychiatry. 2008;165:631–638. doi: 10.1176/appi.ajp.2007.07040636.
    1. Chiesa M, Fonagy P. Prediction of medium-term outcome in cluster B personality disorder following residential and outpatient psychosocial treatment. Psychother Psychosom. 2007;76:347–353. doi: 10.1159/000107562.
    1. Chiesa M, Fonagy P, Holmes J. Six-year follow-up of three treatment programs to personality disorder. J Pers Disord. 2006;20:493–509. doi: 10.1521/pedi.2006.20.5.493.
    1. Chiesa M, Fonagy P, Holmes J, Drahorad C. Residential versus community treatment of personality disorders: a comparative study of three treatment programs. Am J Psychiatry. 2004;161:1463–1470. doi: 10.1176/appi.ajp.161.8.1463.
    1. Bateman A, Fonagy P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry. 2009;166:1355–1364. doi: 10.1176/appi.ajp.2009.09040539.
    1. Giesen-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Dirksen C, van Asselt T, Kremers I, Nadort M, Arntz A. Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Arch Gen Psychiatry. 2006;63:649–658. doi: 10.1001/archpsyc.63.6.649.
    1. Davidson KM, Tyrer P, Norrie J, Palmer SJ, Tyrer H. Cognitive therapy v. usual treatment for borderline personality disorder: prospective 6-year follow-up. Br J Psychiatry. 2010;197:456–462. doi: 10.1192/bjp.bp.109.074286.
    1. Kvarstein EH, Karterud S. Large variations of global functioning over five years in treated patients with personality traits and disorders. J Pers Disord. 2012;26:141–161. doi: 10.1521/pedi.2012.26.2.141.
    1. Skodol AE, Gunderson JG, Shea MT, McGlashan TH, Morey LC, Sanislow CA, Bender DS, Grilo CM, Zanarini MC, Yen S, Pagano ME, Stout RL. The Collaborative Longitudinal Personality Disorders Study (CLPS): overview and implications. J Pers Disord. 2005;19:487–504. doi: 10.1521/pedi.2005.19.5.487.
    1. Zanarini MC, Frankenburg FR, Hennen J, Reich DB, Silk KR. The McLean Study of Adult Development (MSAD): overview and implications of the first six years of prospective follow-up. J Pers Disord. 2005;19:505–523. doi: 10.1521/pedi.2005.19.5.505.
    1. Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice G. The 10-year course of psychosocial functioning among patients with borderline personality disorder and axis II comparison subjects. Acta Psychiatr Scand. 2010;122:103–109. doi: 10.1111/j.1600-0447.2010.01543.x.
    1. Arnevik E, Wilberg T, Urnes O, Johansen M, Monsen JT, Karterud S. Psychotherapy for personality disorders: short-term day hospital psychotherapy versus outpatient individual therapy - a randomized controlled study. Eur Psychiatry. 2009;24:71–78. doi: 10.1016/j.eurpsy.2008.09.004.
    1. Arnevik E, Wilberg T, Urnes O, Johansen M, Monsen JT, Karterud S. Psychotherapy for personality disorders: 18 months’ follow-up of the ulleval personality project. J Pers Disord. 2010;24:188–203. doi: 10.1521/pedi.2010.24.2.188.
    1. Gullestad FS, Wilberg T, Klungsoyr O, Johansen MS, Urnes O, Karterud S. Is treatment in a day hospital step-down program superior to outpatient individual psychotherapy for patients with personality disorders? 3- years follow-up of a randomized clinical trial comparing different treatment modalities. Psychother Res. 2012;22:426–441. doi: 10.1080/10503307.2012.662608.
    1. Mundt JC, Marks IM, Shear MK, Greist JM, Marks IM, Shear MK, Greist JM. The work and social adjustment scale: a simple measure of impairment in functioning. Br J Psychiatry. 2002;180:461–464. doi: 10.1192/bjp.180.5.461.
    1. Pedersen G, Hagtvet KA, Karterud S. Generalizability studies of the global assessment of functioning-split version. Compr Psychiatry. 2007;48:88–94. doi: 10.1016/j.comppsych.2006.03.008.
    1. Perdersen G. Norwegian revised version of inventory of interpersonal problems- circumplex (IIP-C) Tidsskr Nor Laegeforen. 2002;39:25–34.
    1. Alden LE, Wiggins JS, Pincus AL. Construction of circumplex scales for the inventory of interpersonal problems. J Pers Assess. 1990;55:521–536. doi: 10.1207/s15327752jpa5503&4_10.
    1. Derogatis LR. Misuse of the symptom checklist 90. Arch Gen Psychiatry. 1983;40:1152–1153.
    1. Groth-Marnat G. The handbook of psychological assessment. 2. New York: John Wiley & Sons; 1990.
    1. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, Dunbar GC. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59(Suppl 20):22–33. quiz 34–57.
    1. First MB, Gibbon M, Spitzer RL, William JBW, Benjamin LS. The Structural Clinical Interview for DSM- IV Axis II Personality Disorder (SCID-II.) Washington DC, USA: American Psychiatric Press; 1997.
    1. Bateman A, Fonagy P. Mentalization based treatment for borderline personality disorder. World Psychiatry. 2010;9:11–15.
    1. Chiesa M, Fonagy P, Gordon J. Community-based psychodynamic treatment of severe personality disorder: clinical description and naturalistic evaluation. J Psychiatr Pract. 2009;15:12–24. doi: 10.1097/01.pra.0000344915.61706.d4.
    1. Chiesa M, Hanton R, Fonagy P. Clinical Associations of deliberate self-injury and its impact on the outcome of community-based and long term inpatient treatment for personality disorder. Psychother Psychosom. 2011;80:100–109. doi: 10.1159/000320975.
    1. Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry. 2007;164:922–928. doi: 10.1176/appi.ajp.164.6.922.
    1. Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, Korslund KE, Tutek DA, Reynolds SK, Lindenboim N. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63:757–766. doi: 10.1001/archpsyc.63.7.757.
    1. McMain SF, Links PS, Gnam WH, Guimond T, Cardish RJ, Korman L, Streiner DL. A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. Am J Psychiatry. 2009;166:1365–1374. doi: 10.1176/appi.ajp.2009.09010039.
    1. Vinnars B, Barber JP, Noren K, Gallop R, Weinryb RM. Manualized supportive-expressive psychotherapy versus nonmanualized community-delivered psychodynamic therapy for patients with personality disorders: bridging efficacy and effectiveness. Am J Psychiatry. 2005;162:1933–1940. doi: 10.1176/appi.ajp.162.10.1933.
    1. Kvarstein EH, Arnevik E, Halsteinli V, Rø FG, Karterud S, Wilberg T. Health service costs and clinical gains of psychotherapy for personality disorders: a randomized controlled trial of day-hospital-based step-down treatment versus outpatient treatment at a specialist practice. BMC Psychiatry. 2013;13:315. doi: 10.1186/1471-244X-13-315.
    1. Hummelen B, Wilberg T, Karterud S. Interviews of female patients with borderline personality disorder who dropped out of group psychotherapy. Int J Group Psychother. 2007;57:67–91. doi: 10.1521/ijgp.2007.57.1.67.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe