Jared A. DeFife

Emotion dysregulation and negative affect: association with psychiatric symptoms.

OBJECTIVE A growing body of research focuses on the development and correlates of emotion dysregulation, or deficits in the ability to regulate intense and shifting emotional states. Current models of psychopathology have incorporated the construct of emotion dysregulation, suggesting its unique and interactive contributions, along with childhood disruptive experiences and negative affect, in producing symptomatic distress. Some researchers have suggested that emotion dysregulation is simply a variant of high negative affect. The aim of this study was to assess the construct and incremental validity of self-reported emotion dysregulation over and above childhood trauma and negative affect in predicting a range of psychopathology. METHOD Five hundred thirty individuals aged 18 to 77 years (62% female) were recruited from the waiting areas of the general medical and obstetric/gynecologic clinics in an urban public hospital in Atlanta, Georgia. Participants completed a battery of self-report measures obtained by interview, including the Childhood Trauma Questionnaire, the Positive and Negative Affect Schedule, and the Emotion Dysregulation Scale. Regression analyses examined the unique and incremental associations of these self-report measurements of childhood traumatic experiences, negative affect, and emotion dysregulation with concurrent structured interview-based measurements of psychiatric distress and history of self-destructive behaviors. These measures included the Clinician-Administered PTSD Scale, the Alcohol Use Disorders Identification Test, the Short Drug Abuse Screening Test, the Beck Depression Inventory, and the Global Adaptive Functioning Scale from the Longitudinal Interval Follow-Up Evaluation. The presented data were collected between 2005 and 2009. RESULTS Regression models including age, gender, childhood trauma, negative affect, and emotion dysregulation were significantly (P ≤ .001) associated with each of the studys criterion variables, accounting for large portions of the variance in posttraumatic stress symptoms (R² = 0.21), alcohol and drug abuse (R² = 0.28 and 0.21, respectively), depression (R² = 0.55), adaptive functioning (R² = 0.14), and suicide history (omnibus χ² = 74.80, P < .001). Emotion dysregulation added statistically significant (P < .01) incremental validity to each regression model (β = 0.25, 0.34, 0.35, 0.34, and -0.18, and Wald = 24.43, respectively). CONCLUSIONS Results support the conceptualization of emotion dysregulation as a distinct and clinically meaningful construct associated with psychiatric distress that is not reducible to negative affect. Emotion dysregulation is a key component in a range of psychiatric symptoms and disorders and a core target for psychopharmacologic and psychosocial treatment interventions.

Identity disturbance in adolescence: Associations with borderline personality disorder

Although establishing a coherent identity is often viewed as a normative developmental task of adolescence, an important question is whether forms of identity disturbance seen in adult personality disorders can also be distinguished in adolescents. If so, such disturbances would constitute an essential target for research and clinical interventions. The goal of this study is to investigate the nature of identity disturbance in an adolescent clinical sample and to explore its links with personality pathology, particularly borderline personality disorder. A national random sample of 139 psychiatrists and clinical psychologists completed a battery of instruments on a randomly selected adolescent patient in their care, including measures of Axis II symptoms and the Identity Disturbance Questionnaire-Adolescent Version, an instrument designed for clinically experienced observers that assesses a wide range of manifestations of potential identity disturbance among adolescents. Factor analysis of the Identity Disturbance Questionnaire--Adolescent Version yielded four clinically and conceptually coherent factors that resembled dimensions previously identified in adults: lack of normative commitment, role absorption, painful incoherence, and lack of consistency. As in adults, identity disturbance in adolescents is a clinically meaningful, multidimensional construct exhibiting significant relationships with different forms of severe personality pathology, most notably borderline personality disorder. As such, identity disturbance can be a manifestation of psychopathology above and beyond the typical Sturm und Drang (storm and stress) of adolescence.

Psychotherapy appointment no-shows: rates and reasons.

Patients who frequently miss or do not show for their scheduled psychotherapy appointments create administrative and clinical difficulties, and may not be receiving effective treatment. Prior research has predominately focused on either identifying demographic and administrative factors related to patient no-show rates or evaluating the effectiveness of administrative procedures for reducing no-shows. This paper attempts to identify rates of missed appointments in clinical practice and explore more specific clinical process factors related to patient no-shows. Psychotherapists (N = 24) and their patients (N = 542) in the outpatient department of a public safety-net hospital were surveyed to examine how frequently patients missed scheduled psychotherapy appointments and for what reasons. Findings indicate that the majority of missed appointments were accounted for by patients with occasional absences (approx. 1 per month), while only a small percentage of patients missed appointments with high frequency. Patients missed their psychotherapy appointments for a number of reasons, including clinical symptoms, practical matters, motivational concerns, and negative treatment reactions.

Patient ratings of psychodynamic psychotherapy session activities and their relation to outcome.

This study examines patient ratings of modality-specific technical interventions and their relation to therapeutic treatment change. The sample consisted of 55 individuals engaged in short-term psychodynamic psychotherapy at a university-based community outpatient treatment center. Results demonstrate that not only were patients capable of recognizing specific technical processes occurring within their psychotherapy, but also that those ratings were significantly related to measures of therapeutic outcome. Furthermore, patient ratings of session activities were found to be stable from early session rating to late in treatment. Findings support the conclusion that, as rated from the patient perspective, some degree of flexibility in and integration of modality-specific techniques is beneficial for outcome. Implications for future research and clinical practice are discussed.

The effects of borderline pathology on short-term psychodynamic psychotherapy for depression

Abstract This study examines the impact of borderline pathology (BP) on the effectiveness of short-term psychodynamic psychotherapy for depression in a naturalistic setting. Two groups were examined: 18 depressed patients with no Axis II diagnoses and 15 depressed patients with comorbid BP. Both groups demonstrated significant changes in depressive symptomatology. Likewise, many patients exhibited clinically significant reductions in depressive symptoms. Secondary analyses demonstrated significant changes for interpersonal functioning; no significant differences for therapeutic alliance were found between the two groups; and five therapist interventions were found to be more prevalent in the psychotherapy of the depressed patients with comorbid BP. The clinical utility and implications of these findings are discussed.

Clinical utility of the Defensive Functioning Scale in the assessment of depression.

The Defensive Functioning Scale (DFS) and Overall Defensive Functioning score (ODF) have been used as reliable and valid measures of defense structure when applied to clinical narratives. This study aims to replicate and extend positive clinical validity data for the ODF in the assessment of depression and examine the relationship between specific defense levels of the DFS and depressive symptoms. Sixty-nine outpatients who completed the Symptom Checklist 90—Revised and Personality Assessment Inventory were rated on the DFS by trained clinicians. Lower (more maladaptive) scores on the ODF were significantly related to the presence and severity of patient-reported depression symptoms. Furthermore, depression symptoms were significantly related to both the presence of low-level action defenses and an absence of higher-range defenses in the mental inhibitions—obsessional level. Findings from this study provide further support for the clinical application and relevance of the DFS system; support the theory of defensive processes falling into a hierarchy of adaptive functioning; and, because of a naturalistic setting, are highly generalizable to real-world practice.

Dimensional Assessment of Self- and Interpersonal Functioning in Adolescents: Implications for DSM-5's General Definition of Personality Disorder

Central to the proposed DSM-5 general definition of personality disorder (PD) are features of self- and interpersonal functioning. The Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G) is a coding system that assesses eight dimensions of self- and relational experience that can be applied to narrative data or used by clinically experienced observers to quantify observations of patients in ongoing psychotherapy. This study aims to evaluate the relationship of SCORS-G dimensions to personality pathology in adolescents and their incremental validity for predicting multiple domains of adaptive functioning. A total of 294 randomly sampled doctoral-level clinical psychologists and psychiatrists described an adolescent patient in their care based on all available data. Individual SCORS-G variables demonstrated medium-to-large effect size differences for PD versus non-PD identified adolescents (d = .49-1.05). A summary SCORS-Composite rating was significantly related to composite measurements of global adaptive functioning (r = .66), school functioning (r = .47), externalizing behavior (r = -.49), and prior psychiatric history (r = -.31). The SCORS-Composite significantly predicted variance in domains of adaptive functioning above and beyond age and DSM-IV PD diagnosis (ΔR(2)s = .07-.32). As applied to adolescents, the SCORS-G offers a framework for a clinically meaningful and empirically sound dimensional assessment of self- and other representations and interpersonal functioning capacities. Our findings support the inclusion of self- and interpersonal capacities in the DSM-5 general definition of personality disorder as an improvement to existing PD diagnosis for capturing varied domains of adaptive functioning and psychopathology.

The effects of sertraline on psychopathic traits

We examined whether antidepressants alter expression of psychopathic personality traits in patients with major depressive disorder (MDD). Data were collected from a double-blind, placebo-controlled 8-week trial evaluating the efficacy of sertraline (50–200 mg/day) combined with either tri-iodothyronine (T3) or matching placebo in adult outpatients with major depressive disorder. Administration of sertraline was open-label; T3/placebo was double-blind. At the baseline and week 8 visits, patients completed the short form of the Psychopathic Personality Inventory (PPI), a well-validated self-report measure assessing two major factors of psychopathy: Fearless Dominance (PPI-1) and Self-Centered Impulsivity (PPI-2). Change in PPI scores were assessed using paired t-tests for all participants who completed a baseline and postrandomization PPI. Ninety patients (84 completers and six who terminated the trial early) were eligible for the analysis. Both PPI factors changed significantly from baseline to endpoint, but in opposing directions. The mean score on PPI-1 increased significantly during treatment; this change was weakly correlated with change in depression scores. In contrast, the mean score on PPI-2 decreased significantly, but these changes were not correlated with changes in depression scores. Independent of their effects on depression, antidepressants increase adaptive traits traditionally observed in psychopathic individuals, such as social charm and interpersonal and physical boldness. Antidepressants reduce other, more maladaptive, traits associated with psychopathy, including dysregulated impulsivity and externalization.

Attachment, Social Cognition, and Posttraumatic Stress Symptoms in a Traumatized, Urban Population: Evidence for the Mediating Role of Object Relations

Research has linked multiple risk and resiliency factors to developing posttraumatic stress disorder (PTSD). One potentially important construct for understanding connections between trauma and PTSD is attachment. Although relationships between attachment and risk for PTSD have been described theoretically, limited research has addressed these relationships empirically. Furthermore, aspects of object relations overlap with attachment and PTSD, but have not been adequately incorporated in empirical research. One proposed pathway between attachment and PTSD involves the mediating role of object relations, particularly views of self and others. Present data were from a larger study investigating environmental and genetic risk factors for PTSD in an impoverished, primarily African American sample seeking care at a public urban hospital. Correlations indicated that adult attachment (with the exception of dismissing) and object relations relate to childhood traumas, (|r|s = .19-.29), adult traumas (|r|s = .14-.20), and self-reported PTSD symptoms (|r|s = .20-.36). Analyses also found support for mediational roles of object relations in relationships between attachment and PTSD symptoms (Model R(2) range = .136-.160). These data have theoretical, clinical, and research implications for understanding how particular aspects of attachment, specifically its effects on object relations, may protect against or predispose one to develop PTSD.

Process Measures for Psychodynamic Psychotherapy

Research focusing on psychodynamic psychotherapy has grown considerably in the past three decades [1]. Recently, there has been growing interest in studying the process of psychotherapy. The present chapter provides a brief review of some measures that are useful for research into psychodynamic psychotherapy. We review ten measures designed to assess the process occurring in psychotherapy. For each measure, we provide a general description of the measure’s purpose, scales, and methods, and provide some examples of how the measure has been used by researchers in the past. This chapter is not intended to be comprehensive. Instead, we provide a sample of several different types of measures and measurement methods, all of which are likely to be of interest to investigators who wish to empirically study psychodynamic psychotherapy.