Background
Methods
Study design
Phase 1: Literature search
Phase 2: Concept mapping
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The brainstorming session: initial criteria from the review were presented to the panel and subsequently the experts were asked to formulate additional criteria which they thought could distinguish between patients who are in need of highly specialized care and patients who are not in need of highly specialized care. The criteria from the literature review and the additional criteria provided by the experts were merged together and subsequently edited for redundancies. Criteria were solely selected by the working group if they related to the focus question and demonstrated a similar abstraction level. Moreover, all criteria had to be clearly defined and overlapping criteria were taken together.
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Sorting the criteria: the experts were asked to sort these criteria into piles on the basis of shared content or theme.
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Rating the relevance of the criteria: experts were asked to rate the perceived importance of the generated criteria on a 6-point scale (1 = not important, 6 = very important).
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Examine the variables in the cluster. Which variables do you think should be discarded, or are there other variables that should be included?
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Each cluster should have a name that adequately describes the contents. Can you indicate an appropriate name for this cluster?
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To operationalize the cluster, it is necessary to ask the patient questions. What questions can be asked? Or what questionnaire(s) could be administered to assess how a patient scores on the cluster in question?
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What value should the cluster have for referral to a specific therapy?
Phase 3: Validation study
Participants
Statistical analysis
Results
Phase 1: Literature search results
Author | Type PS | Type of article | Criteria | Positive effect on |
---|---|---|---|---|
Barnicot, K. et al. (2011) [23] | BPD | Systematic review | Schizoid personality disorder High level of impulsivity Less pre-treatment suicidal behavior Lack of motivation to change Less internal, more external motivation to change Experiencing higher stigmatization Experiential avoidance Higher trait anxiety Higher anger level | Dropout |
Barnow, S. et al. (2010) [26] | BPD | Review | Substance use disorders | Treatment outcome (suicidality/remission time) |
Chiesa, M. et al. (2011) [27] | PD | Observational study | Deliberate self-harm | DSM-IV- (comorbidity) |
Goodman, G. et al. (1998) [28] | BPD | Observational study | Initial depression and initial psychotic symptoms | Treatment outcome (SCID-P-comorbidity/ SCL-90R-symptom checklist) |
Gunderson, J. G. et al. (2006) [22] | BPD | Observational study | Meet several criteria for obsessive-compulsive personality disorder Number of borderline personality disorder criteria Number of personality disorder criteria Number of axis-I disorders Early history of abuse and neglect Low GAF score Lower quality relationships | Treatment outcome (DSM-IV-Number of criteria/ lower GAF score) |
McMurran, M. et al. (2010) [29] | PD | Systematic review | Lower age Lower level of educational attainment Lower-skilled occupation level Unemployed Convicted in court as an adolescent Parental divorce before the age of 10 Emotional neglect during childhood Less time alone Being in a relationship for less than six months Meet more than one PD diagnoses Meet more PD criteria Diagnosis of obsessive-compulsive PD, severe histrionic or antisocial PD and no specific PD Having a dependent PD Have a personality disorder in cluster A or B Higher level of narcism Higher level of impulsivity Fewer suicide attempts Higher trait anxiety Still be in the pre-consideration stage of change Less persistence Higher levels of avoidance Poor rational social problem-solving ability High level of carelessness in problem-solving High level of impulsivity in problem-solving More social competence Poor ego structure Less primitive defence Weaker adaptive defence style A greater denial of need for closeness Have conflicts regarding engagement and abandonment Fear of impulsive breakthrough of negative affect More externalizing defence Projective identification Lower level of general functioning Previous substance abuse Depressive self-image Less depressed No mood disorders Problems are focussed in one area | Dropout |
Ryle, A. et al. (2000) [30] | BPD | Observational study | History of self-cutting Unemployed Alcohol abuse | Dropout |
Skodol, A. E. et al. (2002) [31] | BPD | Review | Childhood sexual abuse Incest Lower age at first psychiatric contact Symptom chronicity Affective instability Magical thinking Aggression in relationships Impulsivity Substance abuse More Schizotypical features More Antisocial features More Paranoid features Number of borderline personality disorder criteria A greater number of axis II disorders Comorbidity of axis I and II disorders | Treatment outcome (DSM-IV: diagnostic criteria of borderline) |
Thormählen B. et al. (2003) [32] | PD | Observational Study | Have a personality disorder in cluster A or B More distress Focus on 1 specific interpersonal problem Lower Age | Dropout |
Yen, S. et. Al (2002) [33] | BPD, Schizotypical, Avoidant, and Obsessive Compulsive PD | Observational study | Measured number of physical attacks on another person in the past (with and without a weapon) More exposure to various types of trauma More lifelong PTSD Lower age at first traumatic experience | Severity (DSM-IV: more severe: Schizotypal, BPD; other types) |
Yoshida, K. et al. (2006) [34] | BPD | Observational study | Overinvolvement in family relationships | Treatment outcome (lower GAF score) |
Phase 2: Concept mapping results
Demographic variables; concept mapping (N = 27) | |
Sex (N(%) male) | 15 (55%) |
Mean age | 48.85 (SD = 7.88) |
Mean years of professional experience | 20.37 (SD = 9.37) |
Occupational setting (N(%)) | |
Nursing department | 6 (22%) |
Daycare | 5 (19%) |
Ambulatory mental health care institute | 15 (56%) |
Ambulatory private practice | 1 (4%) |
Discipline(N (%)) | |
Psychiatrist | 18 (67%) |
Psychotherapist/Clinical psychologist | 6 (22%) |
GZ psychologist | 1 (4%) |
Researcher | 2 (7%) |
Results of the brainstorm process
Results of the sorting process
Results of the rating process
Results of the (final) expert meeting
Reliability
Phase 3: Validation study results
Pilot study
Validation study
highly specialized care (Patients: N = 110; Therapists: N = 29) | Specialized care (Patients: N = 268; Therapists: N = 59) | |
---|---|---|
Mean (sd)/percentage (%) | Mean (sd)/percentage (%) | |
Patients | ||
Age (years) | 35,0 (11,7) | 33,9 (10,6) |
Gender (%men) | 34% (35) | 28% (64) |
Therapists | ||
Age (years) | 42.4 (11.2) | 33,9 (10,4) |
Experience therapist (number of years) | 16.3 (8.7)** | 8.7 (7,1)** |
Talked to patient during intake (%Yes) | 94.9% | 100% |
Estimate | SE |
p-value | |
---|---|---|---|
Severe negative affect with disadaptive coping | 2.530693 | 0.616013 | 3.99e–05** |
Severe destructive behavior to oneself or others | 0.917365 | 0.234275 | 9.01e–05* |
Multiple comorbid disorders on axis I and/or axis II due to severe psychiatric problems | 1.737646 | 0.849724 | 0.04086 * |
Severe social and societal disfunction: GAF≤50 | 0.825936 | 0.380961 | 0.03016* |
Severe chronic traumatisation in childhood | 0.214238 | 0.807725 | 0.79083 |
Difficulties in developing a therapeutic relationship | -0.004092 | 0.265995 | 0.98773 |
Treatment in specialized care was not successful | 1.208202 | 0.387603 | 0.00183* |
Number of criteria positively scored | Sensitivity | Specificity |
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1. criteria or more | 0.88 | 0.31 |
2. criteria or more | 0.85 | 0.41 |
3. criteria or more | 0.83 | 0.52 |
4. criteria or more | 0.78 | 0.69 |
5. criteria or more | 0.70 | 0.85 |
6. criteria or more | 0.50 | 0.94 |
7. criteria | 0.18 | 0.98 |
Centre: | ||
Department: | ||
Name of professional/intaker | ||
Name of patient | ||
BSN number of patient | ||
Yes/No | Value or finding | |
1. Severe negative affect with disadaptive coping | Yes | |
No | ||
2. Severe destructive behavior to oneself or others | Yes | |
No | ||
3. Multiple comorbid disorders on axis I and/or axis II due to severe psychiatric problems | Yes | |
No | ||
4. Severe social and societal disfunction: GAF≤50 | Yes | |
No | ||
5. Severe chronic traumatisation in childhood | Yes | |
No | ||
6. Difficulties in developing a therapeutic relationship | Yes | |
No | ||
NAa
| ||
7. Treatment in specialized care was not successful | Yes | |
No | ||
NA | ||
Number of times positively scored (=YES) Score ≥4? | Yes -> Go to question 8 | |
No-> Not referred to highly specialized care based on this decision tool | ||
8. Possibility and motivation to conform to minimal treatment conditions for psychotherapy in intensive (day)care | Yes -> Referred to highly specialized care based on this decision tool | |
No-> Not referred to highly specialized care based on this decision tool | ||
NA-> Referred to highly specialized care based on this decision tool |