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Of Emergent Personality Disorder Among Adolescents: the Effect Developing a ‘Profile’ of Emergent Personality Disorder Among Adolescents: The Effect on Treatment Outcomes in the IMPACT Adolescent Depression Study Katarzyna Mullan D.Clin.Psy Thesis (Volume 1), 2017 University College London Doctorate in Clinical Psychology Declaration Form I confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. Signature: Name: Katarzyna Mullan Date: 5th October 2017 OVERVIEW PART I is a systematic review of existing research investigating the relationship between peer victimisation in childhood and subsequent emergence of personality disorder (PD) in adolescence or adulthood. The quality of current evidence and key outcomes are considered, while potential mechanisms that could account for a peer victimisation-PD relationship are explored by drawing on theoretical models of PD development. PART II comprises of an empirical study involving secondary analysis of data from the IMPACT Trial (Goodyer et al, 2016). The study focuses on the development of an emergent Personality Disorder ‘profile’ among adolescents with a diagnosis of major depression, and subsequently exploring whether this profile predicts depression treatment outcomes for young people in terms of depression severity, rates of recovery and withdrawal from treatment. PART III is a critical appraisal of the research process overall. The experience of conducting the research is reflected upon, including how the project developed in the context of the author’s professional, intellectual and personal interests. Strengths and limitations of the research are considered as well as ideas for how it could be expanded in future. 3 ACKNOWLEDGEMENTS I wish to thank Professor Peter Fonagy for his unfailing support and encouragement, not only throughout the process of writing the thesis but through the entire course of my clinical training. For reading the numerous drafts, advising on statistics and for providing advice with a seemingly limitless stock of patience and mental endurance, I am very grateful. This research project would not have been possible without the support and collaboration of the IMPACT research team, who not only facilitated access to data and provided crucial advice but also inspired my interest in the project in the first place. Long before the thesis came into existence, I gained indispensable experience working directly on the trial with this group of inspirational and knowledgeable investigators, research assistants and clinicians. For this I am incredibly thankful. Of course, the greatest acknowledgement is due for the young people, their families and all the dedicated CAMHS clinicians involved in the IMPACT trial who ultimately made the research possible. The work presented in this thesis is the result of a long professional, as well as personal, journey. I wish to thank my husband Steve for everything he has done to support me in this endeavour, including frequently having to fill the role of both parents to our son while I spent endless weekends trying to master SPSS. More generally, I am hugely grateful to my family and friends who, in many ways, have helped to keep me on track particularly over the past year. Finally, I wish to thank Will Mandy, Tony Roth and staff at UCL for their tremendous support and flexibility over the past few years, as I gradually found my way towards becoming a clinical psychologist. 4 TABLE OF CONTENTS OVERVIEW 3 ACKNOWLEDGEMENTS 4 TABLE OF CONTENTS 5 TABLES AND FIGURES 9 PART I: LITERATURE REVIEW 10 ABSTRACT 11 1.0 INTRODUCTION 13 1.1 The Significance of Peer Victimisation: Developmental Sequelae and Outcomes for Victims and Perpetrators 13 1.2 Pathways to Personality Disorder 15 1.2.i Epidemiological Considerations 16 1.2.ii Theoretical and Ontogenetic Considerations 17 1.3 Current Study: Summary of Aims 22 2.0 METHOD 22 2.1 Literature Search Strategy 22 2.2 Key Search Terms 23 2.3 Search Limits 25 2.4 Obtaining the Literature 25 2.5 Inclusion and Exclusion Criteria 26 2.6 Statistical Comparisons 27 3.0 RESULTS 29 3.1 An Overview of Study Attributes 29 3.1.i Sample Characteristics and Variety of Participants 29 3.1.ii Bullying/Victimisation and its Subtypes 30 5 3.1.iii Personality Pathology and its Subtypes 31 3.2 Methodological Considerations 32 3.2.i Design 32 3.2.ii Data Gathering: Source of Informants 36 3.2.iii Measurement of Predictor and Outcome Variables 37 3.2.iv Statistical Control for Covariance 40 3.3 Key Outcomes 41 3.3.i Findings from Prospective Studies 41 3.3.ii Findings from Cross-Sectional Studies 44 4.0 DISCUSSION 47 4.1 Addressing Key Questions: Quality and Adequacy of Current Evidence 47 4.2 Theoretical Considerations: How Might Peer Victimisation lead to Personality Disorder? 49 4.2.i Peer Victimisation Constitutes an Invalidating Environment and ‘High Risk’ Interpersonal Transactions 50 4.2.ii Peer Victimisation Inhibits Mentalisation and Reflective Function 53 4.2.iii Peer Victimisation Experiences Interact with Interpersonal Hypersensitivity and Increase Likelihood of Disorganised Interpersonal Strategies 55 4.2.iv Peer Victimisation is a Negative Socialising Context 55 4.2.v A Question of Directionality 57 4.3 Limitations 59 4.4 Implications and Future Recommendations 60 REFERENCES 62 PART II: EMPIRICAL PAPER 67 ABSTRACT 68 6 1.0 INTRODUCTION 70 1.1 Conceptualisation of Personality Disorder and its Core Components 71 1.2 Emerging Personality Pathology in Adolescence: The Validity and Importance of Assessment 74 1.3 Personality Disorders and Major Depression: Implications for Treatment and Outcomes 75 1.4 Improving Mood with Psychoanalytic and Cognitive Therapies (IMPACT Trial): Background and Considerations of Personality Pathology 79 2.0 METHOD 81 2.1 IMPACT Study 81 2.1.i Study Design and Participants 81 2.1.ii Procedures 82 2.1.iii Outcomes and Analyses 86 2.2 Current Study 87 2.2.i Ethical Considerations 87 2.2.ii Procedures 88 2.2.iii Design and Statistical Analyses 90 2.2.iv Power Analysis 92 3.0 RESULTS 93 3.1 Descriptive Statistics 93 3.2 Exploratory Factor Analysis (EFA): Identifying and Developing an Emergent PD Profile 93 3.3 Does the Emergent PD Profile Predict Depression Treatment Outcomes in Terms of Depression Severity? 96 3.4 Are High Scores on the Emergent PD Profile Associated with Depression Treatment Drop-Out? 98 7 3.5 Are High Scores on the Emergent PD Profile Associated with Lower Rates of Recovery from Depression Post-Treatment? 98 3.6 Does the Emergent PD Profile Impact Depression Outcomes Differently Depending on Severity of Depression at the Outset? 99 3.7 Does the Emergent PD Profile Impact Depression Outcomes Differently Depending on Treatment Modality? 100 4.0 DISCUSSION 101 4.1 Summary of Hypotheses and Key Findings 101 4.2 Methodological Strengths and Limitations 103 4.3 Why Might Different Treatments for Depression be Effective Regardless of the Personality Pathology Features Young People Present With? 106 4.4 Recovery from Depression: Possible Mechanisms to Explain the Persistence of Symptomatology Following Treatment 108 5.0 CONCLUSION 111 TABLES 113 REFERENCES 130 PART III: CRITICAL APPRAISAL 135 REFERENCES 148 APPENDICES 149 APPENDIX A Database Search Strategy (PsychInfo Example) 150 APPENDIX B Overview of Study Characteristics (Table 2) 152 APPENDIX C Summary of Measures, Key Findings and Bias Considerations (Table 3) 156 APPENDIX 1 DSM-5 Matrix Illustrating PD Domains and Their Facets 166 APPENDIX 2 Glossary of Measures Used in the IMPACT Study 168 APPENDIX 3 SPSS Output: Scree plot (Exploratory Factor Analysis) 177 8 TABLES AND FIGURES PART I: LITERATURE REVIEW Table 1 Key Search Terms 23 Table 2 Overview of Study Characteristics 152 Table 3 Summary of Measures, Key Findings and Bias Considerations 156 Figure 1.0 Systematic Literature Search Flowchart 28 PART II: EMPIRICAL PAPER Table 1 Core Components of Personality Disorder 113 Table 2 Initial Screening of Data: Valid and Missing Values, and Central Tendency across 46 Items Based on Complete Sample 117 Table 3 Selected Items for Analysis 120 Table 4 Demographic Data and Treatment Allocation 123 Table 5 Rotated Factor Loadings (Four Factors) 125 Table 5a Rotated Factor Loadings (Two Factors) 126 Table 6 Sum MFQ Scores at Baseline and Follow-Up 127 Table 7 Linear Model of Predictors of Depression Treatment Outcome (as indicated by follow-up MFQ scores/depression severity) (Two-Factor PD Profile) 127 Table 8 Summary of Multiple Regression Analyses for Predictors of Depression Outcome (as indicated by follow-up MFQ scores): Baseline MFQ Groups 128 Table 9 Linear Model of Predictors of Depression Treatment Outcome (as indicated by follow-up MFQ scores/depression severity) – Treatment Modality and Interaction Effects 129 Figure 1.0 Schedule of Assessments in the IMPACT Study 84 Figure 2.0 IMPACT Study Profile (Consort Diagram) 87 9 PART I: LITERATURE REVIEW Peer Victimisation in Childhood and the Emergence of Personality Disorder in Adolescence and Adulthood: A Systematic Literature Review 10 ABSTRACT AIMS: A review of existing research investigating associations between peer victimisation in childhood and subsequent emergence of personality disorder (PD) in adolescence or adulthood. The quality of current evidence and key outcomes are considered, while potential mechanisms that could account for a peer victimisation-PD relationship are explored by drawing on theoretical models of PD development. Implications for anti-bullying policy and clinical intervention are considered. METHOD: 15 studies were identified for review following a systematic literature search across major electronic journal databases in September 2015. Studies were evaluated narratively with reference to design, sample and setting characteristics, measurement of peer victimisation and PD, statistical analyses and risks of bias. Key findings were identified for each and an overall interpretation of results is presented. A discussion of the limitations of the current body of evidence is presented, along with future implications for research and clinical practice.
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