Ulleval Personality Project (UPP)
A randomised controlled study of intensive day treatment followed by long-term outpatient conjoint individual and group psychotherapy treatment, compared with eclectic individual therapy for poorly functioning patients with personality disorders. Synopsis | Theoretical frames | Treatment | Goals | Design | Hypotheses | Methods | Schedule | References | Publications | Presentations
Treatment of patients with personality disorders (PD)
A high prevalence of PD in the general population (approx. 12%), a high degree of subjective disorders, high suicidal risk, significant social costs such as disablement pension and extensive use of health services, as well as indirect social costs associated with failing parental functioning, and crime, indicate that the development of effective treatments of PD should be given high research priority. In particular, poorly functioning patients with severe PD (GAF below 50) represent a challenge for the treatment facilities due to the chronic and dysfunctional nature of the disorders, and a tendency of poor treatment alliance. The effect of the psychosocial treatment of patients with serious PD is still mainly being documented through naturalistic studies. So far, only one randomised study has examined the effect of treatment lasting longer than one year for serious PD (Bateman & Fonagy 1999, 2001). Still, The American Psychiatrist Association's (APA) treatment guidelines recommends for borderline PD (APA 2001) that these patients are given 1) long-term, individually adapted combined treatment in the form of "psychiatric management", including medication, crisis interventions, or psychosocial support measures, as well as 2) at least one year of psychotherapy. This is controversial, mainly due to the lack of controlled studies of long-term therapy for PD, and the need for such studies is also emphasised by the APA.
Severe PD in clinical practice is more than borderline PD. In clinical practice, e.g. the manner in which these patients present themselves for districts psychiatric centres (DPS), one encounters a wide range of personality pathology (Narud 2002). The most frequent PD in the Norwegian population, as well as in DPSs and day hospitals, is avoidant PD (Torgersen et al. 2001, Karterud et al. 2003). There are now indications that patients with severe avoidant PD may have a poorer prognosis than previously assumed (Gude & Vaglum 2002). However, we know very little about the treatment response of other types of PD than borderline PD. Thus, there is a need for treatment studies including a broader range of PDs.
Eating disorders. There is a frequent co-occurrence of PD and eating disorders, most pronounced for borderline PD and bulimia (Rosenvinge et al. 2000). In the treatment of representative samples of patients with severe PD, bulimia will therefore be a significant accompanying disorder. During the day treatment in the present project, such patients will be given a specific additional treatment ("group for eating disorders").
Self-destructive behaviour. Several types of PD, but borderline PD in particular, are associated with risk of self-destructive behaviour. This type of behaviour may vary from frequent self-mutilation (cutting, burnings, etc.) to serious attempts at suicide or completed suicide. Self-destructive impulsiveness is a central, but clinically challenging part of the symptom complex of borderline PD, and several treatment models have aimed at increasing the patients' ability to gain control over such impulses. It is hypothesized that an increased treatment focus on affect awareness, affect and impulse control will reduce the extent of self-destructive behaviour, especially of the impulsive kind.
Various types of day treatment have been widespread for this group of patients in Norway and in the western world at large. But even though studies of day treatment have shown promising results, it is still considered to be experimental treatment due to the lack of documentation by way of randomised controlled studies (Ogrodniczuk & Piper 2001). There are two randomised, controlled studies of day treatment for patients with PD (Piper et al. 1993, Bateman & Fonagy 1999). These studies showed good efficacy. There is a need for more controlled studies of day treatment in order to clarify the empirical evidence for such treatment. This is especially important in Norway, where this treatment continue to develope as a result of priorities in the National Plan for Mental Health Care.
Outpatient follow-up treatment
A combination of day treatment and outpatient psychotherapeutic follow-up treatment is presumably especially suitable for the most severely affected patients (Bateman & Fonagy 2001, Chiesa & Fonagy 2001). Through intensive but time-limited day treatment, focus is on attachment, symptom and functional improvement. The follow-up treatment aims at a more extensive integration and development of the personality to reduce vulnerability for new crises and/or symptoms. There is some agreement on the principles forming the basis for such a two-phase model (Karterud et al. 2001). Group psychotherapy is currently a widespread treatment method for patients with PD, as single treatment, as part of more extensive treatment programs in day centres, inpatient departments, or as outpatient follow-up treatment following a more intensive day- and inpatient treatment (Wilberg & Karterud 2001). However, at present there are no research-based guidelines indicating the optimal combination, frequency, and duration of treatment elements in an outpatient follow-up treatment program for patients with severe PD. In the present study, the experimental group will have long-term outpatient group psychotherapy combined with individual psychotherapy and regular consultations for pharmacotherapy as combination treatment, following short-term day treatment.
Diagnostic evaluation of personality disorders
The diagnostic evaluation of PD is commonly performed by structured interviews. SCID-II is one of the most frequently applied diagnostic interviews, but has not yet been validated with regard to long-term observations of patients in group situations where their interpersonal pathology is given the opportunity to unfold. UPP includes a study of the validity of SCID-II.