Uitnodiging P e r Voor het bijwonen van de s o openbare verdediging van n a het proefschrift l i t y d i “Personality disorders in s o r adolescents: d e prevalence, burden, r s i assessment, and treatment” n a d o van Dineke Feenstra l e s c e n Woensdag 17 oktober 2012 t s om 11.30u : p r e v in de Andries Querido Zaal van a le het Erasmus Medisch Centrum n c (faculteitsgebouw), e , b Dr. Molewaterplein 50 u r te Rotterdam. d e n , a Receptie na afloop ter plaatse. s s e s s m Paranimfen e n Marieke Braat t , a [email protected] n d t r Ellen Koopmans e a t [email protected] m e n t Personality disorders in adolescents: prevalence, burden, assessment, and treatment D in e k e F e e n Dineke Feenstra s t r a Feenstra_Omslag.indd 1 07-08-12 15:24 Personality disorders in adolescents: prevalence, burden, assessment, and treatment Dineke Feenstra Personality disorders in adolescents: prevalence, burden, assessment, and treatment Persoonlijkheidsstoornissen bij adolescenten: prevalentie, ziektelast, diagnostiek en behandeling Proefschrift ter verkrijging van de graad van doctor aan de Erasmus Universiteit Rotterdam op gezag van de rector magnificus Prof. dr. H.G. Schmidt en volgens besluit van het College voor Promoties. De openbare verdediging zal plaatsvinden op woensdag 17 oktober 2012 om 11.30 uur door Dine Jerta Feenstra geboren te Geldrop © Dineke Feenstra, 2012 ISBN: 978-90-5335-573-2 Printed by Ridderprint, Ridderkerk Personality disorders in adolescents: prevalence, burden, assessment, and treatment Persoonlijkheidsstoornissen bij adolescenten: prevalentie, ziektelast, diagnostiek en behandeling Proefschrift ter verkrijging van de graad van doctor aan de Erasmus Universiteit Rotterdam op gezag van de rector magnificus Prof. dr. H.G. Schmidt en volgens besluit van het College voor Promoties. De openbare verdediging zal plaatsvinden op woensdag 17 oktober 2012 om 11.30 uur door Dine Jerta Feenstra geboren te Geldrop © Dineke Feenstra, 2012 ISBN: 978-90-5335-573-2 Printed by Ridderprint, Ridderkerk Promotores Contents Prof. dr. J.J. van Busschbach Prof. dr. R. Verheul Chapter 1 General introduction 7 Copromotor Chapter 2 Personality disorders in adolescents 15 Dr. J. Hutsebaut Chapter 3 Prevalence and comorbidity of Axis I and Axis II 33 Beoordelingscommissie Disorders among treatment refractory adolescents Prof. dr. F. Verheij admitted for specialized psychotherapy Prof. dr. P. Luyten Prof. dr. J.E. Hovens Chapter 4 The burden of disease among adolescents with 47 personality pathology: quality of life and costs Chapter 5 Severity Indices of Personality Problems (SIPP-118) 65 in adolescents: reliability and validity Chapter 6 Predictors of treatment outcome of Inpatient 89 Psychotherapy for Adolescents (IPA) with personality pathology Chapter 7 Long-term outcome of Inpatient Psychotherapy for 109 Adolescents (IPA) with personality pathology Chapter 8 General discussion 131 Summary 139 Samenvatting 145 Dankwoord 153 Curriculum Vitae 159 PhD portfolio 163 Promotores Contents Prof. dr. J.J. van Busschbach Prof. dr. R. Verheul Chapter 1 General introduction 7 Copromotor Chapter 2 Personality disorders in adolescents 15 Dr. J. Hutsebaut Chapter 3 Prevalence and comorbidity of Axis I and Axis II 33 Beoordelingscommissie Disorders among treatment refractory adolescents Prof. dr. F. Verheij admitted for specialized psychotherapy Prof. dr. P. Luyten Prof. dr. J.E. Hovens Chapter 4 The burden of disease among adolescents with 47 personality pathology: quality of life and costs Chapter 5 Severity Indices of Personality Problems (SIPP-118) 65 in adolescents: reliability and validity Chapter 6 Predictors of treatment outcome of Inpatient 89 Psychotherapy for Adolescents (IPA) with personality pathology Chapter 7 Long-term outcome of Inpatient Psychotherapy for 109 Adolescents (IPA) with personality pathology Chapter 8 General discussion 131 Summary 139 Samenvatting 145 Dankwoord 153 Curriculum Vitae 159 PhD portfolio 163 Chapter 1 General introduction Chapter 1 General introduction In adults, personality disorders are among the most common mental disorders in the general population (Torgersen, Kringlen, & Cramer, 2001) and patient samples (Zimmerman, Rothschild, & Chelminski, 2005). Prevalence rates vary from 13.4% in the general population, to 56.5% in treated addicted patients, and 60.4% in psychiatric outpatients (Verheul & van den Brink, 1999). Furthermore, among adults seeking specialized treatment, personality disorders are associated with low quality of life (Soeteman, Verheul, & Busschbach, 2008) and high societal costs (Soeteman, Hakkaart-van Roijen, Verheul, & Busschbach, 2008). Since the inclusion of personality disorders in the DSM-III in 1980, much research has been conducted investigating the effectiveness of treatments for these patients. Based on this literature, psychotherapy is generally considered the treatment of choice for adult patients with personality disorders (Landelijke Stuurgroep Richtlijnontwikkeling in de GGZ, 2008). Much less is known about personality disorders in adolescents. To the best of our knowledge, the study of Grilo and colleagues (1998) is the only published prevalence study among adolescent patients. Most research on personality disorders in adolescents is derived from the Children in the Community study (CIC; see for example Chen, Cohen, Kasen, & Johnson, 2006; Johnson et al., 2000; Johnson, Chen, & Cohen, 2004; Kasen et al., 2007), which was carried out in the general population. Valuable information to yield arguments in favor of reimbursing treatments for this particular patient group, like the burden of disease or costs, is virtually non-existing. Furthermore, there are almost no outcome studies available in this particular group of patients. This thesis aims to address these above mentioned issues, thereby filling in the existing gap. Personality disorders Personality disorders are defined as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” (DSM-IV-TR; American Psychiatric Association, 2000). The current general diagnostic criteria for personality disorders are presented in Table 1.1. Personality disorders can be classified in three clusters. The odd or eccentric cluster A includes schizoid, schizotypal, and paranoid personality disorder. The dramatic, emotional, or erratic cluster B includes narcissistic, histrionic, borderline, and antisocial personality disorder. General introduction In adults, personality disorders are among the most common mental disorders in the general population (Torgersen, Kringlen, & Cramer, 2001) and patient samples (Zimmerman, Rothschild, & Chelminski, 2005). Prevalence rates vary from 13.4% in the general population, to 56.5% in treated addicted patients, and 60.4% in psychiatric outpatients (Verheul & van den Brink, 1999). Furthermore, among adults seeking specialized treatment, personality disorders are associated with low quality of life (Soeteman, Verheul, & Busschbach, 2008) and high societal costs (Soeteman, Hakkaart-van Roijen, Verheul, & Busschbach, 2008). Since the inclusion of personality disorders in the DSM-III in 1980, much research has been conducted investigating the effectiveness of treatments for these patients. Based on this literature, psychotherapy is generally considered the treatment of choice for adult patients with personality disorders (Landelijke Stuurgroep Richtlijnontwikkeling in de GGZ, 2008). Much less is known about personality disorders in adolescents. To the best of our knowledge, the study of Grilo and colleagues (1998) is the only published prevalence study among adolescent patients. Most research on personality disorders in adolescents is derived from the Children in the Community study (CIC; see for example Chen, Cohen, Kasen, & Johnson, 2006; Johnson et al., 2000; Johnson, Chen, & Cohen, 2004; Kasen et al., 2007), which was carried out in the general population. Valuable information to yield arguments in favor of reimbursing treatments for this particular patient group, like the burden of disease or costs, is virtually non-existing. Furthermore, there are almost no outcome studies available in this particular group of patients. This thesis aims to address these above mentioned issues, thereby filling in the existing gap. Personality disorders Personality disorders are defined as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” (DSM-IV-TR; American Psychiatric Association, 2000). The current general diagnostic criteria for personality disorders are presented in Table 1.1. Personality disorders can be classified in three clusters. The odd or eccentric cluster A includes schizoid, schizotypal, and paranoid personality disorder. The dramatic, emotional, or erratic cluster B includes narcissistic, histrionic, borderline, and antisocial personality disorder. 9