Annemiek van Dijke

Psychotherapy for subclinical depression: meta-analysis

BACKGROUND There is controversy about whether psychotherapies are effective in the treatment of subclinical depression, defined by clinically relevant depressive symptoms in the absence of a major depressive disorder. AIMS To examine whether psychotherapies are effective in reducing depressive symptoms, reduce the risk of developing major depressive disorder and have comparable effects to psychological treatment of major depression. METHOD We conducted a meta-analysis of 18 studies comparing a psychological treatment of subclinical depression with a control group. RESULTS The target groups, therapies and characteristics of the included studies differed considerably from each other, and the quality of many studies was not optimal. Psychotherapies did have a small to moderate effect on depressive symptoms against care as usual at the post-test assessment (g = 0.35, 95% CI 0.23-0.47; NNT = 5, 95% CI 4-8) and significantly reduced the incidence of major depressive episodes at 6 months (RR = 0.61) and possibly at 12 months (RR = 0.74). The effects were significantly smaller than those of psychotherapy for major depressive disorder and could be accounted for by non-specific effects of treatment. CONCLUSIONS Psychotherapy may be effective in the treatment of subclinical depression and reduce the incidence of major depression, but more high-quality research is needed.

Fearful faces in schizophrenia - The relationship between patient characteristics and facial affect recognition

Although schizophrenia has often been associated with deficits in facial affect recognition, it is debated whether the recognition of specific emotions is affected and if these facial affect-processing deficits are related to symptomatology or other patient characteristics. The purpose of the present study was to explore whether particular patient characteristics are associated with the recognition of specific facial expressions in patients with schizophrenia. Sixty-four patients with a DSM-IV diagnosis of schizophrenia were assessed with a computerized test of degraded facial affect recognition. Linear regression analysis showed that, in particular, negative symptoms and male sex were associated with worse recognition of fearful faces. Furthermore, diagnosis of nonparanoid schizophrenia and later age of onset were associated with worse recognition of neutral faces. Findings are explained in the light of a neuroanatomical dysfunction accounting for both negative symptoms, such as reduced emotional expression and social-emotional dysfunction, for which men seem more vulnerable than women.

WHAT IS THE THRESHOLD FOR A CLINICALLY RELEVANT EFFECT? THE CASE OF MAJOR DEPRESSIVE DISORDERS

Randomized trials can show whether a treatment effect is statistically significant and can describe the size of the effect. There are, however, no validated methods available for establishing the clinical relevance of these outcomes. Recently, it was proposed that a standardized mean difference (SMD) of 0.50 be used as cutoff for clinical relevance in the treatment of depression.

Affect Dysregulation and Dissociation in Borderline Personality Disorder and Somatoform Disorder: Differentiating Inhibitory and Excitatory Experiencing States

Affect dysregulation and dissociation may be associated with borderline personality disorder (BPD) and somatoform disorder (SoD). In this study, both under-regulation and over-regulation of affect and positive and negative somatoform and psychoform dissociative experiences were assessed. BPD and SoD diagnoses were confirmed or ruled out in 472 psychiatric inpatients using clinical interviews and clinical multidisciplinary consensus. Affect dysregulation and dissociation were measured using self-reports. Under-regulation (but not over-regulation) of affect was moderately related to positive and negative psychoform and somatoform dissociative experiences. Although both BPD and SoD can involve dissociation, there is a wide range of intensity of both somatoform and psychoform dissociative phenomena in patients with these diagnoses. Compared with other groups, SoD patients more often reported low levels of dissociative experiences and reported fewer psychoform (with or without somatoform) dissociative experiences. Compared with the other groups, patients with both BPD and SoD reported more psychoform (with or without somatoform) dissociative experiences. Evidence was found for the existence of 3 qualitatively different forms of experiencing states. Over-regulation of affect and negative psychoform dissociation, commonly occurring in SoD, can be understood as inhibitory experiencing states. Under-regulation of affect and positive psychoform dissociation, commonly occurring in BPD, can be understood as excitatory experiencing states. The combination of inhibitory and excitatory experiencing states commonly occurred in comorbid BPD + SoD. Distinguishing inhibitory versus excitatory states of experiencing may help to clarify differences in dissociation and affect dysregulation between and within BPD and SoD patients.

AFFECT DYSREGULATION IN BORDERLINE PERSONALITY DISORDER AND SOMATOFORM DISORDER: DIFFERENTIATING UNDER- AND OVER-REGULATION

Although affect dysregulation is considered a core component of borderline personality disorder (BPD) and somatoform disorders (SoD), remarkably little research has focused on prevalence and nature of affect dysregulation in these disorders. BPD and SoD diagnoses were confirmed or ruled out in 472 psychiatric inpatients using clinical interviews. Three qualitatively different forms of affect dysregulation were identified: under-regulation, over-regulation of affect and combined under- and over-regulation of affect. BPD was associated with under-regulation of affect, and SoD was associated with over-regulation of affect. However, one in five patients with BPD also reported substantial over-regulation, and one in six patients with SoD reported clinically significant under-regulation, and the comorbid BPD and SoD group reported more frequently both over- and under-regulation than patients diagnosed with BPD or SoD alone or those with other psychiatric disorders.

Childhood traumatization by primary caretaker and affect dysregulation in patients with borderline personality disorder and somatoform disorder

Affect regulation is often compromised as a result of early life interpersonal traumatization and disruption in caregiving relationships like in situations where the caretaker is emotionally, sexually or physically abusing the child. Prior studies suggest a clear relationship between early childhood attachment-related psychological trauma and affect dysregulation. We evaluated the relationship of retrospectively recalled childhood traumatization by primary caretaker(s) (TPC) and affect dysregulation in 472 adult psychiatric patients diagnosed with borderline personality disorder (BPD), somatoform disorder (SoD), both BPD and SoD, or disorders other than BPD or SoD, using the Bermond-Vorst Alexithymia Questionnaire, the self-report version of the Structured Interview for Disorders of Extreme Stress, the Self-rating Inventory for Posttraumatic Stress Disorder (SRIP) and the Traumatic Experiences Checklist. Almost two-thirds of participants reported having experienced childhood TPC, ranging from approximately 50% of patients with SoD or other psychiatric disorders to more than 75% of patients with comorbid BPD+SoD. Underregulation of affect was associated with emotional TPC and TPC occurring in developmental epoch 0–6 years. Over-regulation of affect was associated with physical TPC. Childhood trauma by a primary caretaker is prevalent among psychiatric patients, particularly those with BPD, and differentially associated with underand over-regulation of affect depending on the type of traumatic exposure.

Dysfunctional affect regulation in borderline personality disorder and in somatoform disorder.

Background Although affect dysregulation is considered a core component of borderline personality disorder (BPD) and somatoform disorders (SoD), remarkably little research has focused on the prevalence and nature of affect dysregulation in these disorders. Also, despite apparent similarities, little is known about how dysfunctional under- and overregulation of affect and positive and negative somatoform and psychoform dissociative experiences inter-relate. Prior studies suggest a clear relationship between early childhood psychological trauma and affect dysregulation, especially when the caretaker is emotionally, sexually, or physically abusing the child, but how these relate to under- and overregulation while differentiating for developmental epochs is not clear. Although an elevated risk of childhood trauma exposure or complex posttraumatic stress disorder (CPTSD) symptoms has been reported in BPD and SoD, trauma histories, dysfunctional affect regulation, dissociation, PTSD, and CPTSD were never assessed in unison in BPD and/or SoD. Method BPD and/or SoD diagnoses were confirmed or ruled out in 472 psychiatric inpatients using clinical interviews. Dysfunctional under- and overregulation of affect and somatoform and psychoform dissociation, childhood trauma-by-primary-caretaker (TPC), PTSD, and CPTSD were all measured using self reports. Results No disorder-specific form of dysfunctional affect regulation was found. Although both BPD and SoD can involve affect dysregulation and dissociation, there is a wide range of intensity of dysfunctional regulation phenomena in patients with these diagnoses. Evidence was found for the existence of three qualitatively different forms of experiencing states: inhibitory experiencing states (overregulation of affect and negative psychoform dissociation) most commonly found in SoD, excitatory experiencing states (underregulation of affect and positive psychoform dissociation) most commonly found in BPD, and combination of inhibitory and excitatory experiencing states commonly occurring in comorbid BPD+SoD. Almost two-thirds of participants reported having experienced childhood TPC. Underregulation of affect was associated with emotional TPC and TPC occurring in developmental epoch, 0–6 years of age. Overregulation of affect was associated with physical TPC. Almost a quarter of all participants met the criteria for CPTSD. BPD+SoD patients had the most extensive childhood trauma histories and were most likely to meet CPTSD criteria, followed by BPD, psychiatric comparison (PC), and SoD. The BPD+SoD and BPD reported significantly higher levels of CPTSD than the SoD or PC groups but did not differ from each other except for greater severity of CPTSD somatic symptoms by the BPD+SoD group. Conclusion Three qualitatively different forms of dysfunctional regulation were identified: inhibitory, excitatory, and combined inhibitory and excitatory states. Distinguishing inhibitory versus excitatory states of experiencing may help to clarify differences in dissociation and affect dysregulation between and within BPD and SoD patients. Specific interventions addressing overregulation in BPD, or underregulation in SoD, should be added to disorder-specific evidence-based treatments. CPT is particularly prevalent in BPD and BPD+SoD and is differentially associated with under- and overregulation of affect depending on the type of traumatic exposure. CPTSD warrants further investigation as a potential independent syndrome or as a marker identifying a sub-group of affectively, or both affectively and somatically, dysregulated patients diagnosed with BPD who have childhood trauma histories.

Adult attachment and emotion dysregulation in borderline personality and somatoform disorders

BackgroundBorderline personality disorder (BPD) and somatoform disorders (SoD) involve significant problems in relationships and emotion regulation, but the similarities and differences between these disorders in these areas is not well understood.MethodIn 472 psychotherapy inpatients BPD and/or SoD diagnoses were confirmed or ruled out using clinical interviews and standardized measures. Emotional under- and over-regulation and indices of adult attachment working models and fears were assessed with validated self-report measures. Bivariate and multivariate analyses were conducted to examine relationships among the study variables and differences based on diagnostic status.ResultsUnder-regulation of emotion was moderately related to fear of abandonment but weakly related to fear of closeness. Over-regulation of emotion was moderately related to fear of closeness but not to fear of abandonment. BPD was associated with under-regulation of emotion and fear of abandonment, and, when comorbid with SoD, with fear of closeness. SoD was associated with inhibition or denial of fears of abandonment or closeness, and over-regulation of emotion.ConclusionsStudy results suggest that insecure attachment may play a role in both BPD and SoD, but in different ways, with hyperactivating emotion dysregulation prominent in BPD and deactivating emotion dysregulation evident in SoD. Also, combined hyper- and de-activating strategy components that may reflect a pattern of disorganized attachment were found, particularly in patients with comorbid BPD and SoD.

Affect dysregulation, psychoform dissociation, and adult relational fears mediate the relationship between childhood trauma and complex posttraumatic stress disorder independent of the symptoms of borderline personality disorder

ABSTRACT Objective: Complex posttraumatic stress disorder (CPTSD) as defined by the Disorders of Extreme Stress Not Otherwise Specified (DESNOS) formulation is associated with childhood relational trauma and involves relational impairment, affect dysregulation, and identity alterations. However, the distinct contributions of relational impairment (operationalized in the form fears of closeness or abandonment), affect dysregulation (operationalized in the form of overregulation and under-regulation of affect), and identity alterations (operationalized in the form of positive or negative psychoform or somatoform dissociation) to the relationship between childhood trauma and CPTSD/DESNOS have not been systematically tested. Method and Results: In a clinical sample of adults diagnosed with severe and chronic psychiatric and personality disorders (n = 472; M = 34.7 years, SD = 10.1), structural equation modelling with bootstrap 95% confidence intervals demonstrated that the association between childhood trauma and CPTSD/DESNOS symptoms in adulthood was partially mediated by under-regulation of affect, negative psychoform dissociation, and adult relational fears of closeness and of abandonment. These results also were independent of the effects of borderline personality disorder (BPD) symptoms. Conclusions: Some, but not all, hypothesized components of the DESNOS formulation of CPTSD statistically mediate the relationship between childhood trauma and adult CPTSD/DESNOS. These relationships appear specific to CPTSD/DESNOS and not to the effects of another potential sequelae of childhood trauma BPD. Replication with prospective longitudinal studies is needed.

Deficits in Degraded Facial Affect Labeling in Schizophrenia and Borderline Personality Disorder

Although deficits in facial affect processing have been reported in schizophrenia as well as in borderline personality disorder (BPD), these disorders have not yet been directly compared on facial affect labeling. Using degraded stimuli portraying neutral, angry, fearful and angry facial expressions, we hypothesized more errors in labeling negative facial expressions in patients with schizophrenia compared to healthy controls. Patients with BPD were expected to have difficulty in labeling neutral expressions and to display a bias towards a negative attribution when wrongly labeling neutral faces. Patients with schizophrenia (N = 57) and patients with BPD (N = 30) were compared to patients with somatoform disorder (SoD, a psychiatric control group; N = 25) and healthy control participants (N = 41) on facial affect labeling accuracy and type of misattributions. Patients with schizophrenia showed deficits in labeling angry and fearful expressions compared to the healthy control group and patients with BPD showed deficits in labeling neutral expressions compared to the healthy control group. Schizophrenia and BPD patients did not differ significantly from each other when labeling any of the facial expressions. Compared to SoD patients, schizophrenia patients showed deficits on fearful expressions, but BPD did not significantly differ from SoD patients on any of the facial expressions. With respect to the type of misattributions, BPD patients mistook neutral expressions more often for fearful expressions compared to schizophrenia patients and healthy controls, and less often for happy compared to schizophrenia patients. These findings suggest that although schizophrenia and BPD patients demonstrate different as well as similar facial affect labeling deficits, BPD may be associated with a tendency to detect negative affect in neutral expressions.