Elfrida Hartveit Kvarstein

• Bremer, Kjetil; Pedersen, Geir; Ekberg, Daniel Gustav Andreas; Morken, Katharina Teresa Enehaug; Nissen-Lie, Helene Amundsen & Oftedal, Eileen [Show all 8 contributors for this article] (2026). Improvement of personality functioning in patients with personality disorders: a comparative study of mentalization-based treatment versus non-manualized treatments. Frontiers in Psychiatry. 17, p. 1–17. doi: 10.3389/fpsyt.2026.1831782. Full text in Research Archive
• Pedersen, Geir; Hummelen, Benjamin; Gulbrandsen, Sebastian; Leitemo, Kai; Oftedal, Eileen & Tenebroso, Alexandra [Show all 11 contributors for this article] (2026). Psychometric Evaluation of the Norwegian Difficulties in Emotion Regulation Scale in a Multi-Site Sample of Patients With Personality Disorders and Personality Problems. Journal of Clinical Psychology. ISSN 0021-9762. 82(9), p. 1388–1402. doi: 10.1002/jclp.70165. Full text in Research Archive Show summary

  Objective: The validity and psychometric qualities of the Difficulties in Emotion Regulation Scale (DERS) in populations with a broader range of personality disorders (PDs) are still unclear. The aim of the current study was to analyze the factor structure and validity of DERS and two of its short-forms (DERS-SF and DERS-18), their relation to PD features and personality functioning, gender differences, and the overlap between concepts of alexithymia and emotion regulation. Method: Data were extracted from a multi-site clinical sample of patients with PDs or personality related problems referred to specialist mental health services (n = 2093). Confirmatory factor analyses (CFA)—specifically first-order correlated and bifactor analysis, as well as analysis of measurement invariance—were applied. Linear associations and group differences were investigated by correlational analysis and independent samples t-tests. DERS and its shortforms were validated through associations with PD features (PD criteria), measures of personality functioning (LPFS-BF), and alexithymia (TAS-20). Results: CFA of the short forms revealed good model fit, while the full version of DERS showed poorer fit. None of the bifactor analyses supported a strong general factor. Gender differences were prominent, and substantial associations were found between DERS and PD criteria, LPFS-BF, and TAS-20. Conclusion: DERS and its short forms demonstrated acceptable reliability and validity in a sample of patients with PDs and personality related problems. Without support for a general factor, interpretation of the total scores of DERS should be conducted with care, especially if the subscales Awareness and Clarity are included. Given the advantages of the short forms, the selection of one version over another seems to be of limited consequence.

• Hove, Oddbjørn; Langjord, Tuva; Pedersen, Geir; Kildahl, Arvid Nikolai; Torgersen, Terje & Urnes, Øyvind [Show all 7 contributors for this article] (2026). Comorbid mental disorders in extensively hospitalized patients due to severe self-harm: the association with intellectual developmental disorders. Nordic Journal of Psychiatry. ISSN 0803-9488. doi: 10.1080/08039488.2026.2683511. Full text in Research Archive
• Ulvestad, Dag Anders; Ekberg, Daniel Gustav Andreas; Bakali, Jan-Vegard; Eikenæs, Ingeborg Helene Ulltveit-Moe; Fjermestad-Noll, Jane & Hjermann, Eirik [Show all 14 contributors for this article] (2026). Improvement of emotional dysregulation, aggression, and self-harm among people treated within outpatient personality disorder mental health services. A large longitudinal, observational, multi-centre study. Psychotherapy Research. ISSN 1050-3307. doi: 10.1080/10503307.2026.2650154. Full text in Research Archive
• Valstad, Mathias; Eftedal, Nikolai Haahjem; Yang, Tianfang; Kvarstein, Elfrida Hartveit; Reichborn-Kjennerud, Ted & Ystrom, Eivind [Show all 7 contributors for this article] (2026). The epidemiology of personality disorders in Norway: a nationwide patient registry study. Social Psychiatry and Psychiatric Epidemiology. ISSN 0933-7954. doi: 10.1007/s00127-026-03083-7. Full text in Research Archive
• Paap, Muirne C. S.; Lortz, Sebastian A  J; Hummelen, Benjamin; Fjermestad-Noll, Jane; Kvarstein, Elfrida Hartveit & Pedersen, Geir (2025). An Investigation of Longitudinal Measurement Invariance and Item Response Theory Analysis of the LPFS-BF 2.0 in a Large Clinical Norwegian Sample. Personality and Mental Health. ISSN 1932-8621. 19(3). doi: 10.1002/pmh.70032. Full text in Research Archive Show summary

  The LPFS-BF 2.0 (Level of Personality Functioning—Brief Form 2.0) is a brief self-report instrument that was developed in order to gain a quick first impression of personality dysfunction and was designed to align with the Level of Personality Scale as outlined in the DSM-5 Alternative Model for Personality Disorders (AMPD). In the current study, we used a factor analytic framework to evaluate the longitudinal measurement invariance of the Norwegian version of the LPFS-BF 2.0 in a sample of 1030 patients referred for personality disorder treatment with the R package lavaan. Additionally, we estimated item response theory (IRT) parameters for the 12 items, as well as local reliability, in order to facilitate comparisons with other studies. We found support for partial measurement invariance. Three items showed different thresholds across time points. However, these differences were minor and did not have a substantial impact on the estimated factor scores. The discrimination parameters were lower than could be expected for an instrument used in a clinical setting. Taking these findings together, we conclude that although the LPFS-BF 2.0 seems to measure the same latent trait across time, the items do not discriminate well between patients with high and low scores in a Norwegian population of adults seeking treatment for PD. Important next steps would be to estimate IRT parameters for comparable patient samples from other countries to assess the generalizability of our findings and to compare the LPFS-BF 2.0 scores to scores obtained through a clinical interview that aligns with the AMPD.

• Kvarstein, Elfrida Hartveit; Bremer, Kjetil; Baltzersen, Åse-Line; Ekberg, Daniel Gustav Andreas; Normann, Eivind & Ulvestad, Dag Anders [Show all 8 contributors for this article] (2025). Sustainability of Mentalization‐Based Treatment Programs for Poorly Functioning Patients With Borderline Personality Disorder. Can We Really Keep It Up? Personality and Mental Health. ISSN 1932-8621. 19(4). doi: 10.1002/pmh.70036. Full text in Research Archive Show summary

  Though positive effects of mentalization-based treatment (MBT) for patients with severe borderline personality disorder (BPD) are increasingly documented, less is known about the sustainability of specialized treatment standards and the maintenance of positive outcomes over time. This study aimed to investigate the organizational and clinical sustainability of an outpatient MBT program across two successive treatment periods. The study compares outpatients referred to MBT in a tertiary-level, specialist mental health service in 2009–2011 (Period I: n = 96) versus 2011–2015 (Period II: n = 89). Organizational quality was based on the MBT quality manual (2019). By structured clinical interviews and repeated self-reports, comparisons included baseline characteristics of eligible patients, clinical outcomes during treatment, therapeutic alliance, therapist countertransferences, and treatment adherence. The MBT team, organization, and systems for quality assurance held satisfactory standards and stability across the two time periods largely compatible with manual recommendations. Patient selection to MBT was in accordance with the targeted patient group, admitting poorly functioning young adults with BPD in both periods. Period II included patients with more severe BPD and self-harming behaviors. Clinical improvement rendered effect sizes in the large range irrespective of time period, and overall 70% remission rates of self-harming. Patient-reported alliance to therapists and therapist-reported countertransference responses were stable with satisfactory levels in both periods. Both periods had low rates of drop-out, though higher in Period II. Results support positive effects and sustainability of MBT for poorly functioning BPD patients treated in a tertiary outpatient MBT-unit within a supportive and stable organizational environment.

• Wichstrøm, Lars; Grønli, Hanne; Walstad, Jenny Sundbø; Raballo, Andrea; Kvarstein, Elfrida Hartveit & Steinsbekk, Silje (2025). Childhood predictors of cluster A personality disorder traits in adolescence: a seven-wave birth cohort study. European Child and Adolescent Psychiatry. ISSN 1018-8827. doi: 10.1007/s00787-025-02936-x. Full text in Research Archive
• Omvik, Siri; Kvamme, Arnheid; Assmus, Jørg; Kvarstein, Elfrida Hartveit; Pedersen, Geir & Zahl, Kjell-Einar (2025). Metacognitive Interpersonal Therapy in Group for Avoidant Personality Disorder—A Comparison With Best Available Practice. Clinical Psychology and Psychotherapy. ISSN 1063-3995. 32(5), p. 1–16. doi: 10.1002/cpp.70149. Full text in Research Archive Show summary

  Introduction Avoidant personality disorder (AvPD) is a prevalent condition characterized by low self‐esteem and social withdrawal. Nonetheless, targeted psychotherapy remains limited. This study aimed to examine short‐term metacognitive interpersonal therapy in group (MIT‐G) tailored for AvPD and to compare the outcomes of patients receiving this treatment with patients participating in outpatient group therapies within specialized mental health services for personality disorders (representing best available practice). Methods The study had a quasi‐experimental design and included 56 patients with AvPD who participated in MIT‐G. The comparison group was derived from the Norwegian Network for Personality Disorders ( N  = 154). Assessments for the MIT‐G group were conducted before and after treatment and at a 6‐month follow‐up. Outcome measures included personality functioning, alexithymia, symptoms of anxiety and depression, work/social functioning and group relationships. Results Significant, moderate improvements were found across all outcome measures in the MIT‐G group. Enhancement in personality functioning was greater, and group relationships, specifically regarding group cohesion and perceptions of positive work, were rated more satisfactory than in the comparison group. Conclusions The findings suggest that MIT‐G contributes to significant clinical improvements among patients with AvPD. The greater enhancement of personality functioning may link to better group relationships. Limitations include the nonrandomised design, unable to draw causal inferences.

• Aghdami, Aryan; Pedersen, Geir; Kvarstein, Elfrida Hartveit & Schnell, Tatjana (2025). Meaning in life among Norwegian outpatients with personality disorders: a cross-sectional study. BMC Psychiatry. 25(1). doi: 10.1186/s12888-025-07366-2. Full text in Research Archive Show summary

  Background Meaning in life (MIL) is associated with positive health outcomes, but is generally low among people suffering from borderline personality disorder (PD). Research has shown that MIL has a buffering effect on depression, as well as borderline traits such as suicidality and self-harm. However, to date, no studies have examined Meaning in Life (MIL) in relation to other prevalent personality disorders such as avoidant PD, nor have they investigated how PD severity influences MIL or whether MIL buffers the impact of PDs on psychosocial functioning. Methods Norwegian outpatients (N = 1708) were assessed for PDs in specialized clinics, and measured for meaning in life, symptoms of depression, anxiety and impairment of psychosocial functioning. The data underwent correlational analyses, then grouped into sub-threshold PD, borderline PD, avoidant PD and dual PD (satisfying criteria for both) and tested for mean differences in MIL. Mean differences in MIL were explored across different levels of psychosocial functioning impairment. Finally, a moderation analysis tested whether MIL would buffer the effect that symptoms of depression had on impairment of psychosocial functioning. Results As expected, correlational analyses showed a negative relationship between MIL and symptoms of ill mental health. A community sample demonstrated the highest MIL, followed by the sub-threshold PDs, the single PDs (either borderline or avoidant), and the Dual PDs with the lowest MIL. Impairment in psychosocial functioning showed significant differences between each level of impairment (low, moderate, severe), with varying results between the PD-groups across these levels. The moderation analysis only showed a buffering effect for the sub-threshold PDs, and not for any other group who received a diagnosis of PD. Conclusion Having a PD is associated with a severe detriment to the level of MIL. There is no apparent difference in mean MIL between the two most prevalent types of PDs in healthcare (borderline and avoidant PDs). However, the current findings indicate that severity results in different levels of MIL, thus lending support to the dimensional perspective of personality disorder.

• Sayar, Hanna; Wilberg, Theresa; Eikenæs, Ingeborg Helene Ulltveit-Moe; Ekberg, Daniel Gustav Andreas; Leitemo, Kai & Morken, Katharina Teresa Enehaug [Show all 11 contributors for this article] (2025). Improvement of alexithymia in patients treated in mental health services for personality disorders: a longitudinal, observational study. Frontiers in Psychiatry. 16, p. 1–14. doi: 10.3389/fpsyt.2025.1558654. Full text in Research Archive Show summary

  Background The majority of mental health services include patients with personality disorder (PD) and comorbid conditions. Alexithymia, a psychological construct referring to difficulties in identifying and describing internal mental states, may represent a challenge to the psychotherapeutic treatment of patients with PD. This study aimed to investigate the prevalence of alexithymia among patients in specialized PD mental health services, differences according to PD severity and PD type, and the longitudinal course of alexithymia during treatment. Methods The study included 1,019 patients treated in specialized PD treatment units, with 70% of them with personality difficulties above the PD diagnostic threshold [borderline PD, 31%; avoidant PD, 39%; PD not otherwise specified (PD-NOS), 15%; other PDs, 15%; and more than one PD, 24%]. Alexithymia was measured repeatedly throughout treatment using the Toronto Alexithymia Scale (TAS-20) self-report questionnaire. Supplementary outcomes included global psychosocial function and health-related life quality. Linear mixed models were applied for data analysis. Results Alexithymia was highly prevalent in the sample: 53% of subjects reported high levels and 20% moderate levels. The TAS-20 subscale Difficulty Identifying Feelings was more strongly associated with borderline PD, while the subscale Difficulty Describing Feelings was more closely linked to avoidant PD. For all TAS subscales, poorer abilities were associated with more severe PD, higher levels of anxiety and depression, and poorer psychosocial functioning and life quality. Both alexithymia and measures of psychological functioning improved significantly during treatment with moderate effect sizes regardless of initial PD status. In total, 19% of the patients reported full remission of alexithymia. Conclusion Alexithymia is a common problem among patients with PDs and is associated with mental health difficulties and psychosocial dysfunction, with rates varying across PD type and severity. The study demonstrates moderate improvement of alexithymia during treatment in specialized PD mental health services. Further research should evaluate the effectiveness of different treatments and interventions in reducing alexithymia among PD patients.

• Kildahl, Arvid Nikolai; Langjord, Tuva; Pedersen, Geir; Hove, Oddbjørn; Urnes, Øyvind & Torgersen, Terje [Show all 8 contributors for this article] (2025). Screening for autism in psychiatric inpatients with severe self-harm–results from the Extreme Challenges research project. Nordic Journal of Psychiatry. ISSN 0803-9488. 79(4), p. 303–313. doi: 10.1080/08039488.2025.2497820. Full text in Research Archive Show summary

  Purpose: Living with undiagnosed autism may have negative consequences for mental health, includingincreased risk of self-harm and suicidal behaviours. Autism is currently underdiagnosed in adult females.While severe self-harm is associated with complex psychopathologies, it is often assumed to signify thepresence of borderline personality disorder, and underlying autism may not be recognised. The purposeof the current study was to explore the prevalence of diagnosed autism, as well as the prevalence ofbeing screen positive for autism and its clinical correlates, in a clinical sample of inpatients with severeself-harm.Materials and methods: In a national multisite project comprising 12 hospitals, 42 patients (40 female,2 male; age >18) with frequent (≥ 5) or long (≥ 4 weeks) inpatient admissions due to self-harm duringthe last year were recruited for a cross-sectional study. The Ritvo Autism and Asperger DiagnosticScale-Revised (RAADS-R) was used to screen for autism.Results: Four participants, all female, were diagnosed with autism. When applying different cut-offcriteria for the RAADS-R, even the strictest cut-off resulted in a considerably higher proportion of thesample being screen positive for autism. Participants with higher scores on the RAADS-R reported moreanxiety, depressive, and trauma-related symptoms, as well as poorer functioning across measures ofpersonality, close relationships, emotion regulation and alexithymia.Conclusions: These findings highlight the importance of actively screening for and assessing autism inpatients with severe self-harm. Undiagnosed autism may involve a risk that unhelpful interactions withthe mental health care system exacerbate these patients’ difficulties over time

• Sveen, Carl-Aksel; Pedersen, Geir; Wilberg, Theresa & Kvarstein, Elfrida Hartveit (2025). The societal costs of avoidant personality disorder. Personality and Mental Health. ISSN 1932-8621. 19(1). doi: 10.1002/pmh.1644. Full text in Research Archive Show summary

  The study aims to estimate the societal costs of avoidant personality disorder (AvPD). Cross-sectional data on AvPD patients during 2017–2020 were retrieved from the quality register of the Norwegian Network for Personality Disorders. Cost estimations were based on a bottom-up approach, using a structured interview covering the 6-month period prior to initial assessment. Unit costs were retrieved from public records. The human capital approach was used to calculate productivity losses. Diagnoses were determined according to DSM-5 by semi-structured diagnostic interviews (SCID-5-PD). Mean societal costs were €19,378 for the total group (N = 410). The subgroup with a single diagnosis (n = 270) incurred €18,818, whereas the subgroup with at least one comorbid PD (n = 140) incurred €20,458. The difference between the two subgroups was not statistically significant. The largest cost component was productivity loss (69%), whereas health service costs constituted 31%. The main contributors to societal costs from the health service cost components were inpatient treatment (18%) and individual outpatient treatment (11%). In conclusion, societal costs for AvPD patients were high, on the same level as borderline PD, schizotypal PD, and schizophrenia, and higher than anxiety disorders, depression, and rheumatoid arthritis. In the future, development of effective AvPD treatment programs enhancing personality functioning and workforce participation is important in order reduce the cost of illness.

• Wichstrøm, Lars; Wilberg, Theresa; Kvarstein, Elfrida Hartveit & Steinsbekk, Silje (2024). Childhood predictors of avoidant personality disorder traits in adolescence: a seven-wave birth cohort study. Journal of Child Psychology and Psychiatry. ISSN 0021-9630. 66(3). doi: 10.1111/jcpp.14064. Full text in Research Archive Show summary

  Background: Although it is widely assumed that avoidant personality disorder (AvPD) originates in childhood, there is little prospective research to substantiate this claim. We therefore aimed to determine whether presumed childhood risk factors predict AvPD traits at 16 years. Methods: A population-based sample (n = 1,077; 50.9% female) from the 2003 and 2004 birth cohorts in Trondheim, Norway was examined biennially from 4 to 16 years. The number of AvPD traits at the age of 16 was assessed with the structured clinical interview for DSM-5 personality disorders and regressed on the intercept and growth in child risk and protective factors until the age of 14. Results: The prevalence of AvPD at the age of 16 was 3.2% (95% CI: 2.2–4.1). Higher levels and an increased number of social anxiety symptoms over time, as well as increased negative affectivity/neuroticism, predicted a higher number of AvPD traits. When the levels and changes in these factors were adjusted for, less and decreasing extraversion forecasted more AvPD traits, as did declining self-worth, higher levels of parental AvPD traits, and increased onlooking behavior. Conclusions: Neuroticism, low extraversion, social anxiety symptoms, passive onlooking behavior, and low self-worth predicted a higher number of AvPD traits in adolescence, as did more AvPD traits in parents. Efforts to enhance self-worth, reduce social anxiety, and promote peer interaction among onlooking children may reduce the development of AvPD traits in adolescence.

• Eikeseth, Fillip Ferreira; Pedersen, Geir; Hummelen, Benjamin; Sütterlin, Stefan; Stubhaug, Audun & Kvarstein, Elfrida Hartveit [Show all 7 contributors for this article] (2024). Pain prevalence rates and the mediating role of negative affect in adults referred to personality disorder treatment: A cross-sectional study. Journal of Pain. ISSN 1526-5900. 26. doi: 10.1016/j.jpain.2024.104724. Full text in Research Archive Show summary

  Personality disorders (PDs) are prevalent among individuals with chronic pain, but less is known about the prevalence of pain in the PD population. This study therefore sought to explore the prevalence of current or everyday pain among individuals referred to outpatient PD treatment, and further explore the mediating role of negative affect in the relationship between PD severity and current pain. Data was retrieved from the Norwegian Network for PDs’ quality register which included 4361 participants. Pain was operationalized using the EQ-5D-3L “pain or discomfort” item and four SCL-90-R pain-related items (“pain bothersomeness”). Rates of self-reported pain were explored both pre and post treatment to determine the persistency of the pain-related symptoms. The role of negative affect in the relationship between PD severity and pain was investigated by linear regression analysis. A substantial burden of pain-related symptoms was demonstrated, as 71 % and 80 % reported moderate to extreme pain or discomfort and pain bothersomeness, respectively. Muscle soreness was the most common pain (59 %) followed by headache (48 %), low back pain (46 %), and heart or chest pain (34 %). Moderate to extreme pain or discomfort was persistent for 77 % of the participants who provided end of treatment data (mean treatment duration was 82 weeks). Negative affect mediated the relationship between PD severity and pain. To our knowledge, this is the first large-scale study on everyday pain in patients with PDs. The findings reveal that moderate to extreme pain is prevalent among persons with PDs and that this co-occurrence is driven by negative affect.

• Øvstebø, Randi Breivik; Pedersen, Geir; Wilberg, Theresa; Røssberg, Jan Ivar; Dahl, Hanne-Sofie Johnsen & Kvarstein, Elfrida Hartveit (2024). Countertransference, alliance, and outcome in the treatment of patients with personality disorder: a longitudinal naturalistic study. Frontiers in Psychiatry. 15. doi: 10.3389/fpsyt.2024.1490056. Full text in Research Archive Show summary

  Objective: Relational dynamics, including countertransference responses and the therapeutic alliance, are crucial in the treatment of patients with personality disorders (PD). However, few studies on PD treatment focus on the dyadic process of therapy. The present study aims to investigate associations between therapist emotional response/countertransference (CT) and patients’ experience of treatment alliance, and CT developments in therapies with treatment completion as outcome. Method: A longitudinal, observational study of patients (N = 365) treated at PD treatment units within specialist mental health services. CT was assessed repeatedly during therapy by the Feeling Word Checklist – Brief Version with three subscales—Inadequate, Confident, and Idealized. Early alliance was assessed after 6 months of treatment (Working Alliance Inventory, WAI). Treatment completion was defined as completing treatment according to schedule versus not completing treatment. Statistical analyses included Linear Mixed Models. Results: In the early phase of therapy, lower WAI predicted lower levels of Confident, Idealized, and higher Inadequate CT. The relation between early WAI and CT levels during treatment remained stable. The development of CT during treatment differed according to treatment completion with significant trends of increasing Inadequate CT and decreasing Idealized CT in not completed treatments. WAI and treatment completion had strong and independent effects. Further moderator analysis did not yield additional information. Conclusion: The study demonstrates significant associations between negative CTs and lower patient-rated WAI in the early phase of therapy, and a development of increasingly more negative CTs during therapy in treatments which were not completed according to schedule. The results indicate high clinical relevance of monitoring therapeutic relationships in PD treatments. Further research on the emotional and relational quality of psychotherapeutic relationships in PD treatments is needed.

• Ulvestad, Dag Anders; Johansen, Merete Selsbakk; Kvarstein, Elfrida Hartveit; Pedersen, Geir & Wilberg, Theresa (2024). Minding mentalizing - convergent validity of the Mentalization Breakdown Interview. Frontiers in Psychiatry. 15. doi: 10.3389/fpsyt.2024.1380532. Full text in Research Archive Show summary

  Objectives: Mentalizing difficulties are central to borderline personality disorder (BPD), have severe consequences, and are an explicit focus in mentalization-based treatment. The significance of mentalizing capacity as a predictor or mediator of change is however still uncertain due to a scarcity of research. The Mentalization Breakdown Interview (MBI) was developed as a time saving tool for studying psychotherapy processes and outcome in borderline pathology. This study aimed to investigate the convergent validity of reflective functioning (RF) ratings based on the MBI (MBI-RF) by a comparison with the gold standard, i.e., RF assessments based on the Adult Attachment Interview (AAI-RF). A secondary aim was to investigate how MBI-RF relates to core symptoms of BPD, levels of functional impairment and symptom distress compared with AAI-RF. Method: Forty-five patients with BPD or significant BPD traits were included. MBI-RF and AAI-RF were rated using the Reflective Functioning Scale. Levels of MBI-RF and AAI-RF and the correlation between the measures were calculated, as well as their associations with the Difficulties in Emotion Regulation Scale, Levels of Personality Functioning-Brief Form 2.0, Work and Social Adjustment Scale, Patient Health Questionnaire, Depression, Generalized Anxiety Disorder-7, self-harm, suicide attempts, and PD diagnostics. Results: The correlation between MBI-RF and AAI-RF was 0.79 (p<0.01), indicating high convergent validity. There were few significant associations between MBI-RF and AAI-RF and clinical measures. Conclusions: The study provides support for the convergent validity of the MBI as a BPD-focused RF assessment method. The MBI has the potential as a time saving, reliable and valid method to be applied in treatment research on patients with borderline pathology. The results indicate that measures of MBI-RF and AAI-RF are different from clinical symptoms. Clinical trial registration: ClinicalTrials.gov ID NCT04157907.

• Bakali, Jan Vegard; Solbakken, Ole Andre; Hoffart, Asle; Brækhus, Hege; Kvarstein, Elfrida Hartveit & Johnson, Sverre Urnes (2024). Affect integration, metacognitions, and early maladaptive schemas as predictors of outcome in cognitive and metacognitive therapies for social anxiety disorder. Psychotherapy Research. ISSN 1050-3307. 35(7), p. 1149–1161. doi: 10.1080/10503307.2024.2443499. Full text in Research Archive Show summary

  Objective Few reliable patient characteristics have emerged as significant predictors of outcomes for Social Anxiety Disorder (SAD). This study aimed to explore whether affect integration, metacognitions, and maladaptive schemas could serve as predictors of therapeutic outcomes for patients with SAD. Relationships between these psychological constructs and baseline SAD symptomatology were also examined. Methods Eighty-eight patients across three sites participated in Cognitive Behavioral Therapy (CBT) or Metacognitive Therapy (MCT) for SAD in inpatient or outpatient clinics. Measures of predictors and SAD symptomatology were repeatedly assessed. Statistical analyses included longitudinal, multilevel modeling. Results Difficulties with affect integration, metacognitions and early maladaptive schemas clearly related to higher levels of SAD symptoms at baseline but were not generally predictive of changes in SAD symptoms during therapy. However, examining sub-domains revealed that difficulties with the integration of jealousy and tenderness, and the maladaptive schema of defectiveness/shame, predicted poorer outcomes. In contrast, initial difficulties with the integration of sadness, a greater lack of cognitive confidence, and the maladaptive schema of dependence/incompetence were associated with greater symptom improvement. Conclusion Identifying issues of affect integration and core self-other beliefs prior to therapy may enhance patient selection and allow for a more individualized treatment.

• Langjord, Tuva; Pedersen, Geir Arild Feigum; Bovim, Tone Helene; Bremer, Kjetil; Christensen, Tore Buer & Hove, Oddbjørn [Show all 20 contributors for this article] (2024). Evaluation of health services and treatment alliance among extensively hospitalized patients due to severe self-harm – results from the Extreme Challenges project. Nordic Journal of Psychiatry. ISSN 0803-9488. 78(7), p. 591–602. doi: 10.1080/08039488.2024.2376162. Full text in Research Archive Show summary

  Background - Extensive psychiatric hospitalization due to repeated severe self-harm (SH), is a poorly researched area, but a challenge within health services (HS). Recent studies have demonstrated high levels of involuntary treatment among patients with severe personality disorder (PD) and complex comorbidity. Keeping focus on extensively hospitalized SH patients, this study aimed to investigate patients’ and clinicians’ evaluation of HS and treatment alliance. Method - A cross-sectional study with an inpatient sample (age >18 years) with frequent (>5) or long (>4 weeks) psychiatric hospital admissions last year due to SH or SA recruited from 12 hospitals across health regions (N = 42). Evaluation included patient and clinician report. Results - A minority of the patients (14%) were satisfied with HS before the current admission, 45% (patients) and 20% (clinicians) found the current admission helpful, and 46% (patients) and 14% (clinicians) worried about discharge. Treatment complaints were received in 38% of the cases. Outpatient mental HS were available after discharge for 68% and a majority of clinicians indicated satisfactory contact across HS. More intensive or specialized formats were unusual (structured outpatient treatment 35%, day treatment 21%, ambulatory services 32%, planned inpatient services 31%). Mutual problem understanding, aims, and confidence in therapists during the hospital stay were limited (patient-rated satisfactory mutual problem understanding: 39%, aims of stay: 50%, confidence: 50%). Patient and therapist alliance-ratings were in concordance for the majority. Conclusion - The study highlights poor HS satisfaction, poor patient–therapist coherence, limited treatment alliance and limited follow-up in structured treatments addressing SH or intermediary supportive ambulatory/day/inpatient services.

• Sveen, Carl-Aksel; Pedersen, Geir Arild Feigum; Hummelen, Benjamin & Kvarstein, Elfrida Hartveit (2023). Personality disorders: the impact of severity on societal costs. European Archives of Psychiatry and Clinical Neuroscience. ISSN 0940-1334. doi: 10.1007/s00406-023-01715-6. Full text in Research Archive Show summary

  Personality disorders (PDs) are associated with high levels of societal costs. However, previous research has found limited or no evidence of unique contributions of individual PD categories on the overall level of societal costs. Recent research supports the validity of PD as a dimensional construct, and PD severity may be a better predictor of societal costs than specific PD categories. The aim of this study was to explore if PD severity could predict the level of societal costs among treatment-seeking patients with PDs, while controlling for the impact of comorbid mental health and substance use disorders. Four different severity indicators were explored: the number of PDs, the total number of PD criteria, the number of BPD criteria, and the Level of Personality Functioning Scale (LPFS) from the alternative model in DSM-5. Participants ( n  = 798/794) were retrieved from the quality register of the Norwegian Network for Personality Disorders for the period 2017–2020. Societal costs were assessed using a structured interview covering the six-month period prior to assessment. Diagnoses and diagnostic criteria were determined using a semi-structured diagnostic interview (SCID-5-PD and M.I.N.I), and the LPFS was assessed by the LPFS-Brief Form 2.0 (LPFS-BF 2.0) questionnaire. Statistics included multiple regression analyses. None of the severity indicators were significant predictors of overall societal costs among treatment-seeking patients, and effect sizes were small.

• Sveen, Carl-Aksel; Pedersen, Geir Arild Feigum; Ulvestad, Dag Anders; Zahl, Kjell-Einar; Wilberg, Theresa & Kvarstein, Elfrida Hartveit (2023). Societal costs of personality disorders among treatment-seeking patients in Norway: the relative contribution of specific DSM-5 categories. European Archives of Psychiatry and Clinical Neuroscience. ISSN 0940-1334. doi: 10.1007/s00406-023-01655-1. Full text in Research Archive Show summary

  Personality disorders (PDs) are associated with high levels of societal costs, regardless of whether a single PD or a broad range of PDs have been studied. However, research on the relative contribution of specific PD-types on societal costs is limited. The aim of this study was to explore the possible contributions of the individual DSM-5 categories of PDs on the level of societal costs and its components (health service costs and productivity loss), while controlling for the impact of comorbid mental health and substance use disorders on these outcomes. Participants ( n  = 798) were retrieved from the quality register of the Norwegian Network for Personality Disorders—a collaboration of PD-treatment units within specialist mental health services. The patients were referred to treatment in the time-period 2017–2020. Costs were assessed using a structured interview covering the 6-month period prior to assessment. Diagnoses were determined by semi-structured diagnostic interviews (SCID-5-PD and M.I.N.I.). Statistics included multiple regression analyses. The main result was that no specific PD had a unique contribution to the high level of societal costs generally found among treatment-seeking patients with PDs. Borderline PD (BPD) was the only PD with significantly higher health service costs than the other PDs, while BPD, avoidant PD, and unspecified PD were independently associated with enhanced productivity loss. The differential cost-effects of specific PDs on the cost components were small. Several comorbid mental health and substance use disorders were significant contributors to costs, irrespective of PD status. The results underscore the importance of developing and implementing effective treatments for a broader range of PDs, to reduce the high levels of societal costs associated with all PDs.

• Øvstebø, Randi Breivik; Pedersen, Geir Arild Feigum; Wilberg, Theresa; Røssberg, Jan Ivar; Dahl, Hanne-Sofie Johnsen & Kvarstein, Elfrida Hartveit (2023). Countertransference in the treatment of patients with personality disorders: A longitudinal study. Psychotherapy Research. ISSN 1050-3307. doi: 10.1080/10503307.2023.2279645. Full text in Research Archive Show summary

  Objective This study examines how therapist emotional response/countertransference (CT) develops during treatment for patients with personality disorders (PDs) and how pre-treatment patient factors (severity of personality pathology, PD category, level of symptom distress) predict CT responses. Secondly, we explored associations between patient clinical outcome and CT. Method A longitudinal, observational study including 1956 patients with personality pathology treated at psychotherapy units within specialist mental health services. Therapists’ emotional response was repeatedly assessed by the Feeling Word Checklist—Brief Version (FWC-BV) with three subscales—Inadequate, Confident, and Idealized. Results Levels of Inadequate CT were lowest and stable over time while Confident and Idealized increased over time. Greater severity of personality pathology and borderline PD predicted higher initial Inadequate, lower initial Confident and decreasing Inadequate over time. Antisocial PD predicted decreasing Confident. Number of PD criteria had higher impact on therapist CT than level of symptom distress. Clinical improvement was associated with decreasing Inadequate. Conclusion Therapists reported predominantly Confident CT when working with PD patients. More severe personality pathology, and borderline PD, specifically, predicted more negative CT initially, but the negative CT decreased over time. Patients who did not improve were associated with increasing Inadequate.

• Sveen, Carl-Aksel; Pedersen, Geir Arild Feigum; Ulvestad, Dag Anders; Zahl, Kjell-Einar; Wilberg, Theresa & Kvarstein, Elfrida Hartveit (2023). Societal costs of personality disorders: A cross-sectional multicenter study of treatment-seeking patients in mental health services in Norway. Journal of Clinical Psychology. ISSN 0021-9762. 79(8), p. 1752–1769. doi: 10.1002/jclp.23504. Full text in Research Archive Show summary

  Abstract Objective There is a relatively small body of research on the cost‐of‐illness of personality disorders (PDs). Most studies only include borderline PD. The aim of this study was to investigate mean societal costs, including its components, (direct) health service costs and (indirect) productivity loss, among treatment‐seeking patients with the broad range of all PDs according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM‐5). Methods Cross‐sectional data from 911 patients diagnosed with at least 1 PD were retrieved from the quality register of the Norwegian Network for Personality Disorders—a collaboration of PD treatment units within specialist mental health services. The patients were referred in the time period 2017–2020. Estimation of costs was based on a bottom‐up approach, using information from a structured interview covering the 6‐month period before assessment, whereas unit costs were retrieved from public reports, public records, or public agencies. The human capital approach was used to calculate productivity loss. Diagnoses were determined by semi‐structured diagnostic interviews (Structured Clinical Interview for DSM‐5‐PD [SCID‐5‐PD]). Results The mean societal costs were €20.260 during the 6‐month period before specialized treatment. The largest cost component was productivity loss (65%), whereas health service costs constituted 35%. The main contributors to societal costs from the underlying health service cost components were inpatient treatment (20.5%) and individual outpatient treatment (10.5%). Conclusion Societal costs were substantial among treatment‐seeking patients with the broad range of DSM‐5 PDs, comparable to the societal costs of schizophrenia, and significantly higher than the societal costs of both depression and anxiety disorders. The cost estimates converged with recent, register‐based cost‐of‐illness studies of different PDs but exceeded previous findings from other bottom‐up studies. Furthermore, the results underscore the importance of implementing effective and specialized treatment for patients with a broad range of PDs, not only to alleviate individual suffering but also to reduce the level of societal costs. The emphasis on productivity loss as a main contributor to the overall societal costs is substantiated, hence underlining the relevance of interventions focusing on improving occupational functioning.

• Wilberg, Theresa; Pedersen, Geir Arild Feigum; Bremer, Kjetil; Johansen, Merete Selsbakk & Kvarstein, Elfrida Hartveit (2023). Combined group and individual therapy for patients with avoidant personality disorder—A pilot study. Frontiers in Psychiatry. 14. doi: 10.3389/fpsyt.2023.1181686. Full text in Research Archive Show summary

  Objective Avoidant personality disorder (AvPD) is a common disorder within mental health services, associated with significant psychosocial impairment. The disorder has been neglected in research. There are currently no evidence-based treatments for AvPD, and there is a need for treatment studies focusing particularly on this form of personality pathology. The present study was a pilot study of combined group and individual therapy for patients with AvPD, based on mentalization-based and metacognitive interpersonal therapy. The aim was to investigate the feasibility of the treatment program and the course of symptoms and personality functioning during treatment and 1-year follow-up. Methods The study included 28 patients. Clinical evaluation at baseline comprised structured diagnostic interviews and patients' self-report of symptoms, psychosocial function, interpersonal problems, personality functioning, alexithymia, self-esteem, attachment style, therapeutic alliance, and client satisfaction. Patients' self-report were repeated at the end of treatment and 1-year follow-up. Results The drop-out rate was 14%. Average treatment length among the 22 treatment completers was 17 months. Mean levels of therapeutic alliance and client satisfaction were satisfactory. Effect sizes were large for global symptom distress, depression, anxiety, and psychosocial adjustment, and in the moderate range for aspects of personality functioning. Yet, the results showed a wide range of outcomes among the patients. Conclusions This pilot study shows promising results for combined group- and individual therapy for AvPD patients with moderate to severe impairment. Larger scale studies should be conducted to increase empirically based knowledge to guide development of differentiated treatments adapted to patients' various levels of AvPD severity and profiles of personality dysfunction.

• Kvarstein, Elfrida Hartveit; Frøyhaug, Mathias; Skjeklesæther-Pettersen, Mona; Carlsen, Sara; Ekberg, Andreas & Fjermestad-Noll, Jane [Show all 16 contributors for this article] (2023). Improvement of personality functioning among people treated within personality disorder mental health services. A longitudinal, observational study. Frontiers in Psychiatry. 14. doi: 10.3389/fpsyt.2023.1163347. Full text in Research Archive Show summary

  Objective: Evidence-based personality disorder (PD) treatments are dominated by interventions targeting Borderline PD, although clinical populations characteristically include different PD features and severity. Personality functioning is a new concept intended to capture common features across PDs. This study aimed to investigate longitudinal improvement of personality functioning in a clinical sample assigned to PD treatment. Method: An observational, large, longitudinal study of patients in PD treatments on specialist mental health service levels (N = 1,051). DSM-5 PDs were systematically assessed on referral. Personality functioning was repeatedly assessed (LPFS-BF-2.0), supplemented by symptom distress (anxiety: PHQ-GAD-7, depression: PHQ-9), and social/occupational activity (WSAS, work/study activity). Statistics were linear mixed models. Results: Thirty per cent had personality difficulties below PD threshold. Among PDs, 31% had Borderline (BPD), 39% Avoidant (AvPD), 15% not otherwise specified, 15% other PDs, and 24% > one PD. More severe initial LPFS-BF was associated with younger age, presence of PD and increasing number of total PD criteria. Across PD conditions, LPFS-BF, PHQ-9 and GAD-7 improved significantly (overall effect size 0.9). Mean duration of PD treatment was 15 (SD 9) months. Drop-out rates were low (12%). LPFS-BF improvement-rates were higher for BPD. Younger age was moderately associated with slower PHQ-9 improvement. Work/study activity was initially poor, poorer levels associated with AvPD and younger age, and improvement was non-significant across PD conditions. AvPD was associated with slower WSAS improvement-rates. Conclusion: Personality functioning improved across PD conditions. The results highlight BPD improvements. The study points to challenges concerning AvPD treatment, poor occupational activity and age-related differences.

• Langjord, Tuva; Pedersen, Geir Arild Feigum; Bovim, Tone Helene; Christensen, Tore Buer; Eikenæs, Ingeborg Helene Ulltveit-Moe & Hove, Oddbjørn [Show all 21 contributors for this article] (2023). Mental health disorders, functioning and health-related quality of life among extensively hospitalized patients due to severe self-harm – results from the Extreme Challenges project. Frontiers in Psychiatry. 14. doi: 10.3389/fpsyt.2023.1258025. Full text in Research Archive Show summary

  Background: Severe self-harm leading to extensive hospitalization generates extreme challenges for patients, families, and health services. Controversies regarding diagnoses and health care often follow. Most evidence-based treatments targeting self-harm are designed for borderline personality disorder (BPD). However, current knowledge about mental health status among individuals with severe self-harm is limited. Objectives: To investigate psychopathology among patients extensively hospitalized due to severe or frequent self-harming behaviors. Method: A cross sectional study (period 2019–2021) targeting psychiatric inpatients (>18 years) with frequent (>5) or long (>4 weeks) admissions last year due to self-harm. The target sample (N = 42, from 12 hospitals across all Norwegian health regions) was compared to individuals admitted to outpatient personality disorder (PD) treatment within specialist mental health services in the same period (N = 389). Clinicians performed interviews on self-harm and psychopathology, supplemented by self-report. Results: The target sample were young adults, mainly female, with considerable hospitalization and self-harming behaviors, both significantly more extensive than the comparison group. The majority in both groups reported self-harm onset <18 years. The target sample reported increasing severity of self-harm acts and suicidal intention over time. Both samples had high levels of childhood trauma, impaired personality functioning, and a majority fulfilled criteria for PD. In the target sample, comorbid depression, PTSD, anxiety disorders, and substance use occurred more frequently and in 50%, psychosis/dissociative disorder/autism spectrum disorder/ADHD was reported (outpatient comparison sample: 9%). 35% in the target sample screened over cut-off for possible intellectual disability. The target sample reported poor psychosocial functioning and health-related quality of life – greater impairment than the outpatient comparison sample. Conclusion: The study reveals that severe self-harm inpatients have complex psychopathology and highlights the importance of individualized and thorough assessment among patients with severe and/or repetitive self-harm.

• Paap, Muirne C. S.; Pedersen, Geir Arild Feigum; Kvarstein, Elfrida Hartveit & Hummelen, Benjamin (2023). Evaluating the Construct Validity of the Norwegian Version of the Level of Personality Functioning Scale–Brief Form 2.0 in a Large Clinical Sample. Journal of Personality Assessment. ISSN 0022-3891. doi: 10.1080/00223891.2023.2182694. Full text in Research Archive Show summary

  The Level of Personality Functioning – Brief Form 2.0 (LPFS-BF 2.0) is a 12-item self-report questionnaire developed to gain a quick impression of the severity of personality pathology according to the DSM-5 Alternative Model for Personality Disorders (AMPD). The current study evaluated the construct validity and reliability of the Norwegian version of the LPFS-BF 2.0 in a large clinical sample (N = 1673). Dimensionality was examined using confirmatory factor analysis and bifactor analysis followed by an analysis of distinctiveness of the subscales using the proportional reduction in mean squared error (PRMSE), and the concurrent validity was examined using correlations with self-report questionnaires and clinical interviews assessing PDs according to section II of the DSM-5. Taking the findings of the dimensionality and concurrent validity results together, we found moderate to good support for the use of total scores for the Norwegian version of the LPFS-BF 2.0. We would advise against the use of subscale scores, since the subscales provided only a small amount of reliable unique variance.

• Pedersen, Geir Arild Feigum; Wilberg, Theresa; Hummelen, Benjamin & Kvarstein, Elfrida Hartveit (2022). The Norwegian network for personality disorders–development, contributions and challenges through 30 years. Nordic Journal of Psychiatry. ISSN 0803-9488. doi: 10.1080/08039488.2022.2147995. Full text in Research Archive Show summary

  Background Established in 1992, the Norwegian Network for Personality Disorders (The Network) is a clinical research collaboration of specialist mental health and addiction services in Norway. Its primary focus is to facilitate systematic and relevant clinical assessment for patients with personality disorder and evaluate progress in psychotherapeutic treatment. However, large-scale data registers for personality disorder are still unique. This article presents the circumstances that led to the establishment of the Network, and its development and challenges in many areas, and through various phases. Methods In the following, we will outline how this close interaction between researchers, clinicians, and well-adapted systems has facilitated cooperation and clinical research. We will highlight some key factors that have been decisive during the network’s development, and not least for further adaptation and existence. Results Through 30 years, the Network has succeeded in establishing a large and sustainable clinical research collaboration with a persistent focus on personality disorder and psychotherapeutic treatment. The collaboration has resulted in a broad range of scientific contributions to the understanding of personality disorder, assessment and measurement methods, treatment alliance, clinical outcomes, service utilization, and costs. In addition, The Network has also resulted in a number of synergy effects that have benefited clinicians, patients, and researchers. Conclusions The Norwegian Network for Personality Disorders has become an acknowledged institution in the field. Many aspects of its development, organization, maintenance, and solutions to challenges may be relevant to others who plan to establish, maintain, or further develop similar collaborations.

• Ulvestad, Dag Anders; Johansen, Merete Selsbakk; Kvarstein, Elfrida Hartveit; Pedersen, Geir Arild Feigum & Wilberg, Theresa (2022). A borderline focused Reflective Functioning measure–Interrater reliability of the Mentalization Breakdown Interview. Nordic Journal of Psychiatry. ISSN 0803-9488. doi: 10.1080/08039488.2022.2123040. Full text in Research Archive Show summary

  Objective Mentalizing difficulties can be considered the core psychopathology of borderline personality disorder (BPD). Typical failures of mentalizing are targets in therapy for BPD. They are related to severe distress, relational problems, self-destructive behaviors, violence, or substance misuse. A major obstacle in BPD treatment research is the lack of suitable and easily administrated methods to assess mentalizing ability during treatment. The Mentalization Breakdown Interview (MBI) is a new method for capturing episodic mentalizing difficulties occurring in close relationships. Interviews are videotaped and scored in accordance with the Reflective Functioning Scale (MBI-RF). In this way the patients’ ability to retrospectively reflect over such episodes are evaluated. This study investigates the interrater reliability of MBI-RF. Methods The study includes videotapes of MBIs from 32 patients with BPD in an outpatient clinic specialized on mentalization-based treatment (MBT). The MBIs were performed by MBT therapists. Three certified raters scored MBI-RF. Results The interrater reliability was good for MBI-RF. Conclusions The MBI is promising as a BPD-focused method for the assessment of Reflective Functioning.

• Folmo, Espen Jan; Langjord, Tuva; Myhrvold, Nini; Stänicke, Erik; Lind, Majse & Kvarstein, Elfrida Hartveit (2022). Pedagogical stance in mentalization-based treatment. Journal of Clinical Psychology. ISSN 0021-9762. p. 1–21. doi: 10.1002/jclp.23335. Full text in Research Archive Show summary

  Background A common aspect of evidence-based treatments for people with borderline personality disorder (BPD) is pedagogical interventions and formats. In mentalization-based treatment (MBT) the introductory course has a clear pedagogical format, but a pedagogical stance is not otherwise defined. Methods Treatment integrity was quantitatively assessed in a sample of 346 individual MBT sessions. Nine group sessions and 24 individual MBT sessions were qualitatively subjected to interpretative phenomenological analysis (IPA). Results The dominating intervention type was MBT Item 16—therapist checking own understanding (31% of the interventions). IPA unveiled the following: (1) a pervasive, but hidden/implicit psychopedagogical agenda, (2) psychopedagogical content seemed precious for the patients, and (3) four tentative strategies for pedagogical interventions in MBT (a) independent reasoning; (b) epistemic trust; (c) mental flexibility; and (d) application of verified insights, knowledge, or strategies. Conclusion Development and clarification of the pedagogical stance in MBT could further improve the quality of therapists' interventions.

• Færden, Ann; Rosenqvist, Christine; Håkansson, Mats; Strøm-Gundersen, Eline; Stav, Åshild & Svartsund, Jan [Show all 14 contributors for this article] (2022). Environmental Transformations Enhancing Dignity in an Acute Psychiatric Ward: Outcome of a User-Driven Service Design Project. Health Environments Research & Design Journal. ISSN 1937-5867. 16(2), p. 55–72. doi: 10.1177/19375867221136558. Full text in Research Archive
• Zahl, Kjell-Einar; Pedersen, Geir Arild Feigum; Eikenæs, Ingeborg Helene Ulltveit-Moe; Stänicke, Line Indrevoll; Wilberg, Theresa & Baltzersen, Åse-Line [Show all 11 contributors for this article] (2022). Avoidant and borderline personality disorder patients during the first Covid-19 wave in Norway – a survey-based comparison of therapy changes and patients’ accommodations. Nordic Journal of Psychiatry. ISSN 0803-9488. doi: 10.1080/08039488.2022.2110614. Full text in Research Archive Show summary

  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.

• Stänicke, Line Indrevoll; Arnevik, Espen Ajo; Pettersen, Mona Skjeklesæther; Baltzersen, Åse-Line; Zahl, Kjell-Einar & Eikenæs, Ingeborg Helene Ulltveit-Moe [Show all 9 contributors for this article] (2022). The importance of feeling remembered during the Covid-19 crisis–A qualitative study of experiences among patients with personality disorders. Nordic Psychology. ISSN 1901-2276. doi: 10.1080/19012276.2022.2062038. Full text in Research Archive
• Ditlefsen, Ingrid Tande; Nissen-Lie, Helene Amundsen; Andenæs, Agnes; Normann-Eide, Eivind; Johansen, Merete Selsbak & Kvarstein, Elfrida Hartveit (2021). “Yes, There Is Actually Hope!”—A Qualitative Investigation of How Patients Experience Mentalization-Based Psychoeducation Tailored for Borderline Personality Disorder. Journal of psychotherapy integration. ISSN 1053-0479. 31(3), p. 257–276. doi: 10.1037/int0000243. Full text in Research Archive Show summary

  Common factors, such as the working alliance, positive expectations, and psychoeducation have been robustly related to outcome in studies of psychotherapy. As a multicomponent treatment for borderline personality disorder (BPD), Mentalization-based treatment (MBT) includes introductory group-based psychoeducation on core features of personality functioning, BPD, the treatment program and disorder-related personal management. Generally, few studies have investigated patients’ views on how psychoeducation works. This study aimed to explore their experience of the group-based psychoeducation. Twelve patients who had attended the introductory group-based psychoeducation in MBT participated. Qualitative interviews were analyzed using Interpretative Phenomenological Analysis. MBT psychoeducation was found helpful in itself and in the further treatment process. Identified experiences related to the group (feeling less ashamed, learning from others, feeling different from others), acquisition of “tools” for better personal management (the psychoeducational content; putting new knowledge into practice), preparation for longer term therapy (therapy became more trustworthy, easier to understand, felt more effective), and demanding aspects (problems with attendance or concentration). This qualitative study is the first to present patients’ own experiences of psychoeducation as part of MBT and suggests that psychoeducation is a powerful and facilitating intervention. Careful patient selection may further optimize its potential. (PsycInfo Database Record (c) 2020 APA, all rights reserved)

• Pedersen, Geir Feigum; Kvarstein, Elfrida Hartveit; Wilberg, Theresa; Folmo, Espen; Burlingame, Gary M. & Lorentzen, Steinar (2021). The Group Questionnaire (GQ)—Psychometric Properties Among Outpatients With Personality Disorders. Group Dynamics. ISSN 1089-2699. doi: 10.1037/gdn0000176. Full text in Research Archive Show summary

  Objective: Relational and emotional vulnerability represent essential problems among patients with personality disorder (PD). Group psychotherapy is a central component of evidence-based PD treatments. Generally, patient and therapist interrelationships predict improvement in therapy. However, although treatment of patients with PD is a more complex process, group processes are poorly elaborated in PD research. Documentation of the psychometric quality of group process measures in PD samples is an important precursor of such research. The Group Questionnaire—GQ is based on concepts of group cohesion and climate, empathy, and alliance and aims to capture the quality of member–member, member–group, and member–leader relationships in group therapy. A three latent factor structure (positive bond, positive work, and negative relationship) has generally been supported. This study aimed to perform a psychometric analysis of GQ administered in a clinical population of patients with PD. Method: The study included 369 patients with PDs attending group psychotherapy in 14 outpatient treatment units on a specialist mental health service level within the Norwegian Network of Personality Disorders in the period 2017–2020. Psychometric analyses included three latent factors and eight subfacets. Results: The three latent factors, positive bond, positive work, and negative relationship, were replicated. Psychometric integrity of the tripartite relationship structure—member–member, member–group, and member–leader, with eight subfacets, was supported. Conclusion: The GQ with three latent factors and eight subfacets can be recommended for future research and clinical practice in patient populations with PD.

• Kvarstein, Elfrida Hartveit; Zahl, Kjell_Einar; Stänicke, Line Indrevoll; Pettersen, MS; Baltzersen, Åse-Line & Johansen, Merete Selsbakk [Show all 11 contributors for this article] (2021). Vulnerability of personality disorder during COVID-19 crises: a multicenter survey of mental and social distress among patients referred to treatment. Nordic Journal of Psychiatry. ISSN 0803-9488. doi: 10.1080/08039488.2021.1942980. Full text in Research Archive Show summary

  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.

• Kvarstein, Elfrida Hartveit; Antonsen, Bjørnar Torske; Klungsøyr, Ole; Pedersen, Geir Arild Feigum & Wilberg, Theresa (2021). A Longitudinal, Observational Study Investigating Predictors of Change in a Clinical Sample. Personality Disorders: Theory, Research, and Treatment. ISSN 1949-2715. doi: 10.1037/per0000471. Full text in Research Archive
• Pedersen, Geir Arild Feigum; Normann, Eivind; Eikenæs, Ingeborg Helene Ulltveit-Moe; Kvarstein, Elfrida Hartveit & Wilberg, Theresa (2021). Psychometric evaluation of the Norwegian Toronto Alexithymia Scale (TAS-20) in a multi-site clinical sample of patients with personality disorders and personality problems. Journal of Clinical Psychology. ISSN 0021-9762. doi: 10.1002/jclp.23270. Full text in Research Archive Show summary

  Objective Psychometric properties of 20-item Toronto Alexithymia Scale (TAS-20) have been widely analyzed, but the validity and psychometric qualities of the TAS-20 in populations with personality disorders are still poorly understood. The aim of the current study was to analyze the factor structure and validity of TAS-20. Method Data were extracted from a multisite clinical sample of patients with personality disorders or personality-related problems referred to specialist mental health services in Norway. Results With one exception, TAS-20 revealed acceptable psychometric properties. Variations of TAS-20 are associated with other clinical measures of distress and severity. Anxiety disorders, borderline, and avoidant personality disorders were all highly related to levels of TAS-20. The TAS-20 also revealed unique variance not accounted for by subjective distress, symptom disorders, or dysfunctional personality traits. Conclusion The TAS-20 is a relevant instrument for use in assessment of personality disorders, but one subscale should be improved.

• Kvarstein, Elfrida Hartveit; Zahl, Kjell_Einar; Stänicke, Line Indrevoll; Pettersen, Mona Skjeklesæther; Baltzersen, Åse-Line & Johansen, Merete Selsbakk [Show all 11 contributors for this article] (2021). Vulnerability of personality disorder during the Covid-19 crises – a multicenter survey of treatment experiences among patients referred to treatment. Nordic Journal of Psychiatry. ISSN 0803-9488. 76(1), p. 52–63. doi: 10.1080/08039488.2021.1934110. Full text in Research Archive Show summary

  <p>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 implementa- tion of treatment modifications was required for patients typically characterized by insecure attach- ment and vulnerability to separation. <p>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. <p>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. <p>Results: The response-rate was 12% (N¼133). 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 tele- phone 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. <p>Conclusion: The survey confirms a radical modification from comprehensive group-based PD pro- grams 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 con- cern about treatment progress.

• Kvarstein, Elfrida H; Folmo, Espen; Antonsen, Bjørnar Torske; Normann, Eivind; Pedersen, Geir & Wilberg, Theresa (2020). Social Cognition Capacities as Predictors of Outcome in Mentalization-Based Treatment (MBT). Frontiers in Psychiatry. 11, p. 1–12. doi: 10.3389/fpsyt.2020.00691. Full text in Research Archive Show summary

  Background: Mentalization-based treatment (MBT) is an evidence-based treatment for borderline personality disorder (BPD). Differences in treatment outcomes related to specific capacity of social cognition need further attention. This study aimed to investigate social cognition as a predictor of outcome. Method: The study included 31 BPD patients who completed a test of social cognition (Movie for the Assessment of Social Cognition, MASC) before outpatient MBT. The MASC-scores indicated a person’s theory of mind (ToM) and different error-types. During treatment repeated self-reports of alliance and clinical outcomes (symptoms, interpersonal problems, social functioning) were applied. Longitudinal analyses were based on Linear Mixed Models (n = 24). Results: The most frequent error-type was excessive ToM (hypermentalizing). Higher levels of excessive ToM were associated with greater improvement of alliance over time and good clinical outcomes. Insufficient ToM errors and low levels of accurate cognitive ToM responses were both associated with poorer improvement over time. The subgroup with frequent insufficient ToM errors had a larger total number of ToM errors. Insufficient ToM errors were associated with more childhood trauma, comorbid avoidant PD traits and/or PTSD, extensive prior treatment, and/or treatment irregularity. Conclusion: This study demonstrates considerable variation of social cognitive capacity among BPD patients and good outcomes for patients with mainly ToM errors of hypermentalizing. It also indicates that poorly responding patients may represent a cohort with more complex problems of social cognition and insufficient mentalizing.

• Simonsen, Sebastian; Eikenæs, Ingeborg Helene Ulltveit-Moe; Bach, Bo; Kvarstein, Elfrida H; Gondan, Matthias & Møller, Stine Bjerrum [Show all 7 contributors for this article] (2020). Level of alexithymia as a measure of personality dysfunction in avoidant personality disorder. Nordic Journal of Psychiatry. ISSN 0803-9488. doi: 10.1080/08039488.2020.1841290. Full text in Research Archive
• Kvarstein, Elfrida Hartveit; Folmo, Espen Jan; Antonsen, Bjørnar Torske; Norman-Eide, Eivind; Pedersen, Geir Arild Feigum & Wilberg, Theresa (2020). Social Cognition Capacities as Predictors of Outcome in Mentalization-Based Treatment (MBT). Frontiers in Psychiatry. doi: 10.3389/fpsyt.2020.00691. Full text in Research Archive
• Folmo, Espen; Stänicke, Erik; Johansen, Merete Selsbakk; Pedersen, Geir Feigum & Kvarstein, Elfrida H (2020). Development of therapeutic alliance in mentalization-based treatment—Goals, Bonds, and Tasks in a specialized treatment for borderline personality disorder. Psychotherapy Research. ISSN 1050-3307. p. 1–15. doi: 10.1080/10503307.2020.1831097. Full text in Research Archive Show summary

  Objective: Mentalization-based treatment (MBT) is an evidence-based long-term treatment for borderline personality disorder (BPD). Alliance is central for effective psychotherapies. Few studies have addressed aspects of working alliance in BPD evidence-based treatments. This study aimed to investigate alliance development in MBT therapies with different clinical outcomes. Method: The sample included 155 patients in an MBT programme. Clinical outcomes were based on Global Assessment of Functioning (GAF). The sample was divided in two subgroups according to GAF levels at the end of treatment (cut-off = 60). Working alliance was assessed by patient report (Working Alliance Inventory, subscales, Goals, Bonds and Tasks) and assessed repeatedly over 36 months. The method for statistical analyses was linear mixed models. Results: Initial levels of Goals, Bonds, and Tasks did not differ by subgroup, but change over time differed significantly by subgroup. In the good outcome subgroup, ratings of Goals, Bonds, and especially Tasks increased significantly over time. In the poor outcome subgroup, paranoid PD was associated with poorer alliance development over time. Conclusions: Good outcome therapies were characterized by a process where the working alliance grew over time. Results encourage an explicit focus on tasks in therapy particularly for patients with high levels of mistrust.

• Normann, Eivind; Antonsen, Bjørnar Torske; Kvarstein, Elfrida H; Pedersen, Geir Feigum; Vaskinn, Anja & Wilberg, Theresa (2019). Are impairments in theory of mind specific to borderline personality disorder? Journal of Personality Disorders. ISSN 0885-579X. 34(6), p. 827–841. doi: 10.1521/pedi_2019_33_417. Full text in Research Archive Show summary

  Impaired theory of mind (ToM) is an assumed feature of borderline personality disorder (BPD). Yet, no studies have compared ToM abilities in patients with BPD, other personality disorders, and healthy controls, or investigated the relationship between ToM and severity of psychopathology and interpersonal problems. In this study, ToM was investigated by the Movie for the Assessment of Social Cognition. No differences were found between the three groups in overall ToM abilities. The BPD group was, however, characterized by more excessive ToM (interpreted as hypermentalization). Yet, when differentiating between BPD and further severity indicators, excessive ToM was not specifically associated with a BPD diagnosis per se. Finally, there was a moderate association between hypermentalization and interpersonal problems in the BPD group. This study suggests that BPD patients tend to hypermentalize when they misinterpret social information, and that this tendency is related to the severity of their psychopathology.

• Folmo, Espen Jan; Karterud, Sigmund; Kongerslev, Mickey; Kvarstein, Elfrida H & Stänicke, Erik (2019). Battles of the Comfort Zone: Modelling Therapeutic Strategy, Alliance, and Epistemic Trust—A Qualitative Study of Mentalization-Based Therapy for Borderline Personality Disorder. Journal of Contemporary Psychotherapy. ISSN 0022-0116. p. 1–11. doi: 10.1007/s10879-018-09414-3. Full text in Research Archive
• Kvarstein, Elfrida H; Pedersen, Geir Feigum; Folmo, Espen; Urnes, Øyvind; Hummelen, Benjamin & Wilberg, Theresa [Show all 8 contributors for this article] (2019). Mentalization-based treatment or psychodynamic treatment programs for patients with borderline personality disorder – the impact of clinical severity. Psychology and Psychotherapy: Theory, Research and Practice. ISSN 1476-0835. 92(1), p. 91–111. doi: 10.1111/papt.12179. Full text in Research Archive Show summary

  Objectives: Mentalization‐based treatment (MBT), originally designed for patients with borderline personality disorder (BPD), may be particularly indicated for severe conditions. However, there is limited documentation of how increasing severity of personality disorder (PD) effect outcomes of highly specialized treatments. This study aimed to investigate associations between clinical severity and outcomes for patients in MBT as compared to a psychodynamic group‐based treatment programme (PDT). Methods: The sample included 345 patients with BPD (PDTn = 281, MBTn = 64). The number of diagnosed PDs, PD criteria, and symptom disorders were chosen as baseline indicators of clinical severity. Clinical outcomes (global functioning, symptom distress, interpersonal problems) were repeatedly assessed over three years. Therapists’ fidelity to MBT was satisfactory. Linear mixed models were the applied statistics. Results: In PDT, greater clinical severity was associated with poorer improvement rates. Clinical severity was not associated with significant differences in outcomes for patients in MBT. Differences in outcomes for patients in MBT and PDT increased significantly with higher severity of disorder. Conclusions: Supporting previous research, this study indicates that clinical benefits associated with MBT also apply for BPD patients with severe conditions. The results also suggest that increasing severity was a challenge in PDT.

• Karterud, Sigmund & Kvarstein, Elfrida H (2019). Misleading about MBT in Oslo. BMC Psychiatry. 19(1). doi: 10.1186/s12888-019-2193-5. Full text in Research Archive
• Christensen, Tore Buer; Hummelen, Benjamin; Paap, Muirne C. S.; Eikenæs, Ingeborg Helene; Selvik, Sara Germans & Kvarstein, Elfrida H [Show all 10 contributors for this article] (2019). Evaluation of Diagnostic Thresholds for Criterion A in the Alternative DSM-5 Model for Personality Disorders. Journal of Personality Disorders. ISSN 0885-579X. 34, p. 40–61. doi: 10.1521/pedi_2019_33_455. Full text in Research Archive Show summary

  The Level of Personality Functioning Scale (LPFS) of the Alternative DSM-5 Model for Personality Disorders (AMPD) was formulated to assess the presence and severity of personality disorders (PDs). Moderate impairment (Level 2) in personality functioning, as measured by the LPFS, was incorporated into the AMPD as a diagnostic threshold for PD in Criterion A of the general criteria, as well as for the “any two areas present” rule for assigning a specific PD diagnosis. This study represents the first evaluation of the diagnostic decision rules for Criterion A, in a clinical sample (N = 282). The results indicate that an overall diagnostic threshold for PDs should be used with caution because it may not identify all DSM-IV PDs. The “any two areas present” rule proved to be a reasonable alternative, although this finding should be interpreted with caution because the LPFS does not measure the disorder-specific A criteria.

• Pedersen, Geir Feigum; Urnes, Øyvind; Hummelen, Benjamin; Wilberg, Theresa & Kvarstein, Elfrida H (2018). Revised manual for the Global Assessment of Functioning scale. European psychiatry. ISSN 0924-9338. 51, p. 16–19. doi: 10.1016/j.eurpsy.2017.12.028. Full text in Research Archive
• Johansen, Merete Selsbakk; Karterud, Sigmund; Normann, Eivind; Rø, Frida Gullestad; Kvarstein, Elfrida H & Wilberg, Theresa (2018). The relationship between reflective functioning and affect consciousness in patients with avoidant and borderline personality disorders. Psychoanalytic psychology. ISSN 0736-9735. 35(4), p. 382–393. doi: 10.1037/pap0000169. Full text in Research Archive
• Holth, Fredrik; Walby, Fredrik A; Røstbakken, Thea; Lunde, Ingeborg; Ringen, Petter Andreas & Ramleth, Ruth-Kari [Show all 11 contributors for this article] (2018). Extreme challenges: psychiatric inpatients with severe self-harming behavior in Norway: a national screening investigation. Nordic Journal of Psychiatry. ISSN 0803-9488. 72(8), p. 605–612. doi: 10.1080/08039488.2018.1511751. Full text in Research Archive
• Christensen, Tore Buer; Paap, Muirne C. S.; Arnesen, Marianne; Koritzinsky, Karoline H.; Nysæter, Tor Erik & Eikenæs, Ingeborg Helene [Show all 14 contributors for this article] (2018). Interrater reliability of the structured clinical interview for the DSM-5 alternative model of personality disorders module i: Level of personality functioning scale. Journal of Personality Assessment. ISSN 0022-3891. 100(6), p. 630–641. doi: 10.1080/00223891.2018.1483377. Full text in Research Archive Show summary

  The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) presents an alternative model for personality disorders in which severity of personality pathology is evaluated by the Level of Personality Functioning Scale (LPFS). The Structured Interview for the DSM–5 Alternative Model for Personality Disorders, Module I (SCID–5–AMPD I) is a new tool for LPFS assessment, but its interrater reliability (IRR) has not yet been tested. Here we examined the reliability of the Norwegian translation of the SCID–5–AMPD I, applying two different designs: IRR assessment based on ratings of 17 video-recorded SCID–5–AMPD I interviews by five raters; and test–retest IRR based on interviews of 33 patients administered by two different raters within a short interval. For the video-based investigation, intraclass correlation coefficient (ICC) values ranged from .77 to .94 for subdomains, .89 to .95 for domains, and .96 for total LPFS. For the test–retest investigation, ICC ranged from .24 to .72 for subdomains, .59 to .90 for domains, and .75 for total LPFS. The test–retest study revealed questionable reliability estimates for some subdomains. However, overall the level of personality functioning was measured with a sufficient degree of IRR when assessed by the SCID–5–AMPD I.

• Folmo, Espen Jan; Karterud, Sigmund; Bremer, Kjetil; Wahlter, Kristoffer Lygren; Kvarstein, Elfrida H & Pedersen, Geir Feigum (2017). The design of the MBT-G adherence and quality scale. Scandinavian Journal of Psychology. ISSN 0036-5564. 58(4), p. 341–349. doi: 10.1111/sjop.12375. Full text in Research Archive
• Pedersen, Geir Feigum; Kvarstein, Elfrida H & Wilberg, Theresa (2017). The Work and Social Adjustment Scale: Psychometric properties and validity among males and females, and outpatients with and without personality disorders. Personality and Mental Health. ISSN 1932-8621. 11(4), p. 215–228. doi: 10.1002/pmh.1382. Full text in Research Archive
• Antonsen, Bjørnar Torske; Kvarstein, Elfrida H; Urnes, Øyvind; Hummelen, Benjamin; Karterud, Sigmund & Wilberg, Theresa (2017). Favourable outcome of long-term combined psychotherapy for patients with borderline personality disorder: Six-year follow-up of a randomized study. Psychotherapy Research. ISSN 1050-3307. 27(1), p. 51–63. doi: 10.1080/10503307.2015.1072283. Full text in Research Archive Show summary

  Objective: This study reports the six-year follow-up data of patients with borderline personality disorder (BPD) who participated in the Ullevål Personality Project (UPP), a randomized clinical study comparing outpatient individual psychotherapy (OIP) with a long-term combination programme (CP) comprising short-term day-hospital treatment followed by outpatient combined group and individual psychotherapy. Methods: For 52 patients, outcomes were evaluated after 8 months, 18 months, 3 years, and 6 years based on a wide range of clinical measures, such as symptom severity, psychosocial functioning, personality functioning, and Axis-I and II diagnoses. Results: At the six-year follow-up, patients in the CP condition reported significantly greater reduction of symptom distress and improvements in the personality functioning domains Identity Integration and Self-control compared with patients allocated to OIP. Patients in the CP also had a more favourable long-term course of psychosocial functioning. There were no differences between treatment conditions in outcomes of interpersonal functioning and self-esteem. Conclusions: Long-term psychotherapy in a combination programme seems favourable for BPD patients. In this study, patients who received combined treatment fared better on crucial parameters than patients who received individual therapy. Of particular importance are the positive effects on fundamental borderline problem areas like Identity Integration and Self-control.

• Kvarstein, Elfrida H; Nordviste, Ola; Dragland, Lone Irene & Wilberg, Theresa (2016). Outpatient psychodynamic group psychotherapy – outcomes related to personality disorder, severity, age and gender. Personality and Mental Health. ISSN 1932-8621. 11(1), p. 37–50. doi: 10.1002/pmh.1352. Full text in Research Archive
• Antonsen, Bjørnar Torske; Johansen, Merete Selsbakk; Rø, Frida Gullestad; Kvarstein, Elfrida H & Wilberg, Theresa (2016). Is reflective functioning associated with clinical symptoms and long-term course in patients with personality disorders? Comprehensive Psychiatry. ISSN 0010-440X. 64, p. 46–58. doi: 10.1016/j.comppsych.2015.05.016. Full text in Research Archive Show summary

  Objective Mentalization is the capacity to understand behavior as the expression of various mental states and is assumed to be important in a range of psychopathologies, especially personality disorders (PDs). The first aim of the present study was to investigate the relationship between mentalization capacity, operationalized as reflective functioning (RF), and clinical manifestations before entering study treatment. The second aim was to investigate the relationship between baseline RF and long-term clinical outcome both independent of treatment (predictor analyses) and dependent on treatment (moderator analyses). Methods Seventy-nine patients from a randomized clinical trial (Ullevål Personality Project) who had borderline and/or avoidant PD were randomly assigned to either a step-down treatment program, comprising short-term day-hospital treatment followed by outpatient combined group and individual psychotherapy, or to outpatient individual psychotherapy. Patients were evaluated on variables including symptomatic distress, psychosocial functioning, personality functioning, and self-esteem at baseline, 8 and 18 months, and 3 and 6 years. Results RF was significantly associated with a wide range of variables at baseline. In longitudinal analyses RF was not found to be a predictor of long-term clinical outcome. However, when considering treatment type, there were significant moderator effects of RF. Patients with low RF had better outcomes in outpatient individual therapy compared to the step-down program. In contrast, patients in the medium RF group achieved better results in the step-down program. Conclusion These findings indicate that RF is associated with core aspects of personality pathology and capture clinically relevant phenomena in adult patients with PDs. Moreover, patients with different capacities for mentalization may need different kinds of therapeutic approaches.

• Johansen, Merete Selsbakk; Normann, Eivind; Normann-Eide, Tone; Klungsøyr, Ole; Kvarstein, Elfrida Hartveit & Wilberg, Theresa (2016). Relationship Between Affect Consciousness and Personality Functioning in Patients With Personality Disorders: A Prospective Study. Journal of Personality Disorders. ISSN 0885-579X. 30(5), p. 633–652. doi: 10.1521/pedi_2015_29_220. Full text in Research Archive
• Kvarstein, Elfrida Hartveit; Pedersen, Geir Feigum; Urnes, Øyvind; Hummelen, Benjamin; Wilberg, Theresa & Karterud, Sigmund (2015). Changing from a traditional psychodynamic treatment programme to mentalization-based treatment for patients with borderline personality disorder - Does it make a difference? Psychology and Psychotherapy: Theory, Research and Practice. ISSN 1476-0835. 88(1), p. 71–86. doi: 10.1111/papt.12036. Full text in Research Archive
• Pedersen, Geir Feigum; Urnes, Øyvind; Kvarstein, Elfrida H & Karterud, Sigmund (2014). The three factors of the psychoticism scale of SCL-90-R. Personality and Mental Health. ISSN 1932-8621. 10(3), p. 244–255. doi: 10.1002/pmh.1278. Full text in Research Archive Show summary

  Former studies have repeatedly found the psychoticism (PSY) scale of Symptom Checklist-90-Revised to be a heterogeneous construct. The aim of this study was to confirm and further explore the nature of this heterogeneity within a large sample of patients with mainly personality disorders. Within a total sample of 3 794 patients, one-half was randomly selected for explorative factor analysis in order to assess the internal structure of the PSY scale and the other half to cross-validate the findings by a confirmatory factor analysis. The total sample was then used to assess associations between the components from the factor analyses and several clinical measures and diagnoses. A one-factor solution of the PSY scale yielded poor fit to the data, but a proposed structure of three latent constructs was confirmed by good model fit. The three subsets of the PSY scale, labelled metacognitive dysfunction, self-accusation and detachment, shared variance with different personality disorders and different aspects of psychopathology, e.g. previous psychotic episodes. The heterogeneous PSY scale of SCL-90-R can be divided into three meaningful clinical concepts, reflecting different aspects of psychosis-near experiences.

• Antonsen, Bjørnar Torske; Klungsøyr, Ole; Kamps, Anne; Hummelen, Benjamin; Johansen, Merete Selsbakk & Pedersen, Geir Feigum [Show all 10 contributors for this article] (2014). Step-down versus outpatient psychotherapeutic treatment for personality disorders: 6-year follow-up of the Ullevål personality project. BMC Psychiatry. 14(119). doi: 10.1186/1471-244X-14-119. Full text in Research Archive Show summary

  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 .

• Wilberg, Theresa; Kvarstein, Elfrida Hartveit & Røvik, Jan Ole (2014). Pasienter med personlighetsforstyrrelse i avtalepraksis. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 134(23/24), p. 2267–2271. doi: 10.4045/tidsskr.13.1581. Full text in Research Archive
• Kvarstein, Elfrida Hartveit & Karterud, Sigmund (2013). Large variation of severity and longitudinal change of symptom distress among patients with personality disorders. Personality and Mental Health. ISSN 1932-8621. 7(4), p. 265–276. doi: 10.1002/pmh.1226. Full text in Research Archive
• Kvarstein, Elfrida Hartveit; Arnevik, Espen Kristian; Halsteinli, Vidar; Rø, Frida Gullestad; Karterud, Sigmund & Wilberg, Theresa (2013). 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. 13(315). doi: 10.1186/1471-244X-13-315. Full text in Research Archive Show summary

  Background: Day-hospital-based treatment programmes have been recommended for poorly functioning patients with personality disorders (PD). However, more research is needed to confirm the cost-effectiveness of such extensive programmes over other, presumably simpler, treatment formats. Methods: This study compared health service costs and psychosocial functioning for PD patients randomly allocated to either a day-hospital-based treatment programme combining individual and group psychotherapy in a step-down format, or outpatient individual psychotherapy at a specialist practice. It included 107 PD patients, 46% of whom had borderline PD, and 40% of whom had avoidant PD. Costs included the two treatment conditions and additional primary and secondary in- and outpatient services. Psychosocial functioning was assessed using measures of global (observer-rated GAF) and occupational (self-report) functioning. Repeated assessments over three years were analysed using mixed models. Results: The costs of step-down treatment were higher than those of outpatient treatment, but these high costs were compensated by considerably lower costs of other health services. However, costs and clinical gains depended on the type of PD. For borderline PD patients, cost-effectiveness did not differ by treatment condition. Health service costs declined during the trial, and functioning improved to mild impairment levels (GAF > 60). For avoidant PD patients, considerable adjuvant health services expanded the outpatient format. Clinical improvements were nevertheless superior to the step-down condition. Conclusion: Our results indicate that decisions on treatment format should differentiate between PD types. For borderline PD patients, the costs and gains of step-down and outpatient treatment conditions did not differ. For avoidant PD patients, the outpatient format was a better alternative, leaning, however, on costly additional health services in the early phase of treatment.

• Kvarstein, Elfrida Hartveit & Karterud, Sigmund (2012). Large variations of global functioning over five years in treated patients with personality traits and disorders. Journal of Personality Disorders. ISSN 0885-579X. 26(2), p. 141–161. doi: 10.1521/pedi.2012.26.2.141. Full text in Research Archive

View all works in NVA

• Kvarstein, Elfrida Hartveit (2025). Forstyrrelser i personligheten. In Gonzalez, Marianne Thorsen (Eds.), Psykiske lidelser - faglig forståelse og terapeutisk tilnærming. Sykepleiefaglige og flerfaglige perspektiver.. Gyldendal Norsk Forlag A/S. ISSN 9788205590106. p. 139–152. Full text in Research Archive
• Morken, Katharina Teresa Enehaug; Øvrebø, Morten; Bergwitz, Astrid Tonstad; Ekberg, Daniel Gustav Andreas; Gikling, Elisabeth Lied & Kvarstein, Elfrida Hartveit [Show all 10 contributors for this article] (2024). Mentalization based treatment for Antisocial personality disorder - preliminary findings and an update from a feasibility study. Full text in Research Archive
• Aghdami, Aryan; Schnell, Tatjana; Pedersen, Geir Arild Feigum; Kvarstein, Elfrida Hartveit & Sørensen, Kristine Dahl (2023). A cross-sectional study of meaning in life among patients with personality disorders in Norway. Full text in Research Archive
• Morken, Katharina Teresa Enehaug & Kvarstein, Elfrida Hartveit (2021). Kapittel 18 - Mentaliseringsbasert terapi. In Binder, Per-Einar; Lorås, Lennart & Thuen, Frode (Ed.), Håndbok i individualterapi. Fagbokforlaget. ISSN 9788245036817. Full text in Research Archive
• Bekkevold-Jernberg, Ina; Pedersen, Geir Arild Feigum; Kvarstein, Elfrida Hartveit & Mehlum, Lars (2021). Avoidant Personality Disorder and Deliberate Self-Harm. Full text in Research Archive Show summary

  Objectives: Deliberate self-harm (DSH) is frequent among patients with Borderline personality disorder (BPD), whereas the prevalence of this behaviour and its associations with psychosocial distress and impairment among patients with other PDs is less known. The purpose of this study was to determine the prevalence of DSH among 959 outpatients with Avoidant PD (AvPD), and to examine the association between DSH and psychological distress, impairment in work and social functioning, and the number of fulfilled BPD-criteria within this group of patients. Methods: Data on all patients with AvPD (but no comorbid BPD) were retrieved from 20 outpatient treatment units on a specialist mental health service level within the Norwegian Network for Personality Disorders. Logistic Regression was used to explore associations between selected variables and last year history of DSH. Results: Almost 1 in 4 patients (24%) with AvPD had a last year history of DSH and DSH was strongly associated with high levels of psychosocial distress (OR 2.04; p=<.010), depression (OR 4.19; p=<.010), anxiety (OR 2.16; p=<.010), work impairment (OR 2.07; p=<.050) and number of fulfilled BPD criteria (OR 1.52; p=<.010). Conclusion: DSH is highly prevalent among clients with AvPD in outpatient treatment settings and strongly associated with depression and psychosocial and work impairment. DSH was also significantly linked to clinical features captured by diagnostic criteria for BPD. The latter may imply that treatment interventions originally developed for patients with BPD could also be an effective treatment for self-harming patients with AvPD.

• Kvarstein, Elfrida H; Langjord, Tuva; Pedersen, Geir; Eikenæs, Ingeborg Helene Ulltveit-Moe; Urnes, Øyvind & Walby, Fredrik (2020). Ekstrem selvskading ; Nasjonal kartlegging av pasienter med omfattende behandling i døgninstitusjon grunnet høy selvmordsfare. Full text in Research Archive
• Kvarstein, Elfrida H; Walby, Fredrik A & Holst, Andrea (2019). "Extreme challenges" - Nasjonal kartlegging av pasienter med svært alvorlig selvskading og omfattende behandling i døgninstitusjon. Full text in Research Archive
• Ekeberg, Øivind; Kvarstein, Elfrida H; Urnes, Øyvind; Eikenæs, Ingeborg Ulltveit-Moe & Hem, Erlend (2019). Pasienter med emosjonelt ustabil personlighetsforstyrrelse trenger tilpasset akuttbehandling. 139(15). doi: 10.4045/tidsskr.19.0492. Full text in Research Archive
• Ekeberg, Øivind; Kvarstein, Elfrida H; Urnes, Øyvind; Eikenæs, Ingeborg Ulltveit-Moe & Hem, Erlend (2019). Suicidale pasienter med personlighetsforstyrrelse. 139(15), p. 1445–1447. doi: 10.4045/tidsskr.19.0493. Full text in Research Archive
• Sveen, Carl-Aksel & Kvarstein, Elfrida Hartveit (2026). The societal costs of personality disorders: Cost estimates and variations associated with diagnostic categories and severity. Universitetet i Oslo. ISSN 9788234808739. Full text in Research Archive Show summary

  This thesis, within clinical psychology and health economics, examines the societal costs of personality disorders (PDs) in Norway. The aims were to estimate the societal costs associated with the full range of DSM-5 PDs, provide the first explicit estimate for avoidant PD, and investigate whether specific PD categories or dimensional measures of personality pathology severity were associated with variations in societal costs. It is based on cross-sectional data (2017–2020) from the Norwegian Network for Personality Disorders, a multicenter treatment and research collaboration within specialist mental health services. Resource use, including healthcare utilization and productivity losses before assessment, was estimated using a societal cost-of-illness approach. Regression analyses examined the independent contributions of PD diagnoses and dimensional measures of personality pathology while controlling for common comorbid mental disorders. PDs were associated with substantial societal costs, comparable to those reported for schizophrenia and higher than those for anxiety and depressive disorders. Productivity losses accounted for about two-thirds of total costs, largely reflecting that up to 80% of patients were outside the workforce. Costs associated with avoidant PD were similar to those observed across DSM-5 PDs. Neither specific PD categories nor dimensional measures of severity were independently associated with overall societal costs, suggesting that the economic burden is largely related to impaired functioning shared across treatment-seeking patients rather than to diagnostic subtype or differences in severity. Beyond economic consequences, PDs are associated with profound psychological distress, impaired functioning, and reduced quality of life. The findings highlight the need for effective treatment across the full spectrum of PDs and interventions that improve occupational functioning, thereby alleviating patients' suffering while reducing societal costs.

View all works in NVA