Cord Benecke

Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised controlled trial

BACKGROUND Transference-focused psychotherapy is a manualised treatment for borderline personality disorder. AIMS To compare transference-focused psychotherapy with treatment by experienced community psychotherapists. METHOD In a randomised controlled trial (NCT00714311) 104 female out-patients were treated for 1 year with either transference-focused psychotherapy or by an experienced community psychotherapist. RESULTS Significantly fewer participants dropped out of the transference-focused psychotherapy group (38.5% v. 67.3%) and also significantly fewer attempted suicide (d = 0.8, P = 0.009). Transference-focused psychotherapy was significantly superior in the domains of borderline symptomatology (d = 1.6, P = 0.001), psychosocial functioning (d = 1.0, P = 0.002), personality organisation (d = 1.0, P = 0.001) and psychiatric in-patient admissions (d = 0.5, P = 0.001). Both groups improved significantly in the domains of depression and anxiety and the transference-focused psychotherapy group in general psychopathology, all without significant group differences (d = 0.3-0.5). Self-harming behaviour did not change in either group. CONCLUSIONS Transference-focused psychotherapy is more efficacious than treatment by experienced community psychotherapists in the domains of borderline symptomatology, psychosocial functioning, and personality organisation. Moreover, there is preliminary evidence for a superiority in the reduction of suicidality and need for psychiatric in-patient treatment.

Assessing the Level of Structural Integration Using Operationalized Psychodynamic Diagnosis (OPD): Implications for DSM–5

A key ingredient in the current proposal of the DSM–5 Work Group on Personality and Personality Disorders is the assessment of overall severity of impairment in personality functioning: the Levels of Personality Functioning Scale (LPFS). The aim of this article is to contribute a conceptual and empirical discussion of the LPFS from the perspective of the Operationalized Psychodynamic Diagnosis (OPD) system (OPD Task Force, 2008). First, we introduce the OPD Levels of Structural Integration Axis (OPD–LSIA), a measure of individual differences in severity of personality dysfunction that is rooted in psychodynamic theory. We show that the OPD–LSIA is reliable, valid, and highly associated with observer ratings of personality disorders. In the second part, we present results from an OPD expert consensus study exploring potential limitations of the current LPFS item set from the perspective of the OPD–LSIA. We conclude with highlighting implications for future revisions of the DSM–5 proposal.

Facial emotion recognition and its relationship to subjective and functional outcomes in remitted patients with bipolar I disorder

Hoertnagl CM, Muehlbacher M, Biedermann F, Yalcin N, Baumgartner S, Schwitzer G, Deisenhammer EA, Hausmann A, Kemmler G, Benecke C, Hofer A. Facial emotion recognition and its relationship to subjective and functional outcomes in remitted patients with bipolar I disorder. Bipolar Disord 2011: 13: 537–544.

THE STRUCTURE AND CORRELATES OF SELF- REPORTED DSM- 5 MALADAPTIVE PERSONALITY TRAITS: FINDINGS FROM TWO GERMAN- SPEAKING SAMPLES

The authors investigated the structure and correlates of DSM-5 maladaptive personality traits in two samples of 577 students and 212 inpatients using the German self-report form of the Personality Inventory for DSM-5. They found that (a) the factor structure of DSM-5 trait facets is largely in line with the proposed trait domains of Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism; (b) all DSM-5 trait domains except Psychoticism are highly related to the respective domains of the Five-Factor Model of personality; (c) the trait facets are positively associated with a self-report measure of general personality dysfunction; and (d) the DSM-5 trait facets show differential associations with a range of self-reported DSM-IV Axis I disorders. These findings give further support to the new DSM-5 trait model and suggest that it may generalize to other languages and cultures.

Assessing DSM–5 Level of Personality Functioning From Videotaped Clinical Interviews: A Pilot Study With Untrained and Clinically Inexperienced Students

Several authors have raised the concern that the DSM–5 Level of Personality Functioning Scale (LPFS) is relatively complex and theory laden, and thus might put high requirements on raters. We addressed this concern by having 22 untrained and clinically inexperienced students assess the personality functioning of 10 female psychotherapy inpatients from videotaped clinical interviews, using a multi-item version of the LPFS. Individual raters’ LPFS total scores showed acceptable interrater reliability, and were significantly associated with 2 distinct expert-rated measures of the severity of personality pathology. These findings suggest that, contrary to the previously mentioned concerns, successfully applying the LPFS to clinical cases might require neither extensive clinical experience nor training.

Facial affective relationship offers of patients with panic disorder.

Abstract The psychodynamic of patients with panic disorder is most often characterized by a domination of autonomy-dependency conflicts, including an ambivalent need for a positive relationship toward a significant object and an incapacity to express negative feelings because of fear of losing this relationship. Affective facial behavior can be considered as a tool for relationship regulation. The authors investigated facial affective indicators of this conflict in 20 women with panic disorder in their first psychotherapy session. A preponderance of facial smile and a lack of negative affective facial signals were expected. This was not confirmed for the total sample. A cluster analysis identified two subgroups of panic patients. One subgroup confirmed the assumption precisely. The other did as well but only insofar as the patients smiled more often than was seen in a mixed clinical control group that excluded panic disorders. In addition, the panic patients of this cluster showed much negative affect. The patients of the two panic clusters did not differ in panic and other symptoms but did so in their descriptions of their interpersonal behavior.

Dyadic facial affective indicators of severity of symptomatic burden in patients with panic disorder

Background: Based on the results of research on facial affective behaviour in different psychological disorders, as well as on available findings on the specific behaviour of patients with panic disorder in interaction with their therapists, hypotheses about dyadic facial affective behaviour and its correlation with symptomatic burden of female panic patients are formulated. Sampling and Methods: The facial affective behaviour of 20 patients with panic disorder and their therapists, coded with the Emotional Facial Action Coding System, in the first treatment session is analyzed regarding interactive enmeshment, and for a subgroup of 15 dyads these data are correlated with those on symptomatic burden before treatment. Results: A high degree of interactive enmeshment between patient and therapist correlates positively with the severity of symptomatic burden. All dyadic enmeshment indicators show highly significant positive correlations with body-related symptoms, but not with more general variables like global severity index of the SCL-90R or general anxiety (State Trait Anxiety Inventory). Conclusions: These results are discussed against the background of specific psychodynamics of panic patients and show that, on the one hand, therapists practise an interactive abstinence, but on the other hand, they tend to be pulled into a specific interactive enmeshment by patients with greater symptomatic burden. Limitations of the study arise from the small sample and the lack of a comparison group, therefore the question if the results are disorder specific or more general cannot be answered.

Change in Identity Diffusion and Psychopathology in a Specialized Inpatient Treatment for Borderline Personality Disorder

OBJECTIVES Patients with borderline personality disorder (BPD) show various psychopathological symptoms and suffer especially from disturbance in their identity. The purpose of the study was to investigate changes-particularly in affective BPD symptoms and identity diffusion-during a structured, disorder-specific inpatient treatment (DST) that combined a psychodynamic transference-focused psychotherapy approach with modules of dialectical behavioural skills training. METHOD In a prospective, two-group comparison trial, 44 patients with BPD were assessed with questionnaires addressing identity diffusion and state, as well as trait affective psychopathology, before and after 12 weeks of inpatient treatment. Thirty-two patients received DST, whereas 12 patients were given inpatient treatment-as-usual (TAU). The patients were allocated in a non-random procedure for two groups, in order of admission and availability of treatment options in the DST unit. RESULTS In the pre-post-comparison, the DST group showed a significant decrease in identity diffusion (p < 0.001) and improvements in instability of the image of self and others (p < 0.008), as well as in pathological (trait and state) symptoms. However, there was no significant improvement in the TAU group. CONCLUSIONS After a 12-week inpatient treatment, the findings indicate significant improvements in the DST group in typical affective borderline symptomatology and in the personality structure feature of identity diffusion. This highlights the significance of a short-term specific inpatient therapy for BPD. KEY PRACTITIONER MESSAGE A structured, disorder-specific inpatient treatment of patients diagnosed with borderline personality disorder (BPD) combined a psychodynamic transference-focused psychotherapy treatment approach (focusing on pathological features in personality organization, particularly on non-integrated images of self and others) with modules of dialectical behavioural skills training. This treatment is associated with a decrease in identity diffusion of these patients after 12 weeks of treatment. The treatment is also related to a significant decrease in borderline typical psychopathological symptoms such as depressive symptoms, as well as an improvement in state anger. The outcomes of this structured, disorder-specific inpatient treatment of severely ill BPD patients indicated the relevance of intensive short-term inpatient psychotherapy in terms of psychopathological improvements as well as initial changes in structural personality organization.

Normierung der deutschsprachigen 16-Item-Version des Inventars der Persönlichkeitsorganisation (IPO-16)

UNLABELLED Standardization of the German 16-item short version of the Inventory of Personality Organization (IPO-16). OBJECTIVES The 16-item short version of the Inventory of Personality Organization (IPO-16) is a self-report measure assessing the severity of personality dysfunction. This study provides representative norms and determines the smallest real difference value for the IPO-16. METHODS Standardization of the IPO-16 was based on a representative survey among the German general population (N = 2502). Retest reliability and the smallest real difference were assessed in a separate longitudinal online survey, whereby participants completed the IPO-16 three times at time intervals of 2 months (N = 495). RESULTS The average IPO-16-mean score in the general population was 1.87. The influence of age and sex was small, albeit statistically significant.We therefore developed sex- and age-specific norms. The average retest reliability across 2 months was .85, and the smallest real difference was 0.66. CONCLUSIONS The IPO-16 is a well-validated, and now standardized, screening instrument for the assessment of severity of personality dysfunction. It can be recommended for use in research and practice.

Facial recognition in primary focal dystonia

The basal ganglia seem to be involved in emotional processing. Primary dystonia is a movement disorder considered to result from basal ganglia dysfunction, and the aim of the present study was to investigate emotion recognition in patients with primary focal dystonia. Thirty‐two patients with primary cranial (n = 12) and cervical (n = 20) dystonia were compared to 32 healthy controls matched for age, sex, and educational level on the facially expressed emotion labeling (FEEL) test, a computer‐based tool measuring a persons ability to recognize facially expressed emotions. Patients with cognitive impairment or depression were excluded. None of the patients received medication with a possible cognitive side effect profile and only those with mild to moderate dystonia were included. Patients with primary dystonia showed isolated deficits in the recognition of disgust (P = 0.007), while no differences between patients and controls were found with regard to the other emotions (fear, happiness, surprise, sadness, and anger). The findings of the present study add further evidence to the conception that dystonia is not only a motor but a complex basal ganglia disorder including selective emotion recognition disturbances.