Johannes C. Ehrenthal

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.

Altered cardiovascular adaptability in depressed patients without heart disease.

Abstract Objectives. Despite its clinical importance and relevance for health care policy, the pathways between depression and stress regulation remain poorly understood. The objective of our study was to compare cardiovascular and autonomic responses to brief psychosocial stress in a group of severely depressed subjects without heart disease and a non-depressed control-group. Methods. We recorded cardiovascular and autonomic reactions to two different stress tasks including anger recall and mental arithmetic in a sample of 25 severely depressed and 25 non-depressed subjects. Aggregated data were compared with repeated-measures MANOVA. We used contrasts to evaluate different response patterns concerning cardiovascular and autonomic reactivity vs. recovery. Results. Depressed subjects showed overall reduced high-frequency heart rate variability and an altered cardiovascular adaptability concerning heart rate, blood pressure, cardiac output, and, on a trend level, peripheral resistance. With few exceptions, we found no differences between reactivity vs. recovery response patterns. Conclusions. Our results provide further evidence for altered cardiovascular reactivity and impaired cardiac autonomic functioning in depression. Further research is needed on psychophysiological response to either more disease-oriented or more personality-oriented stressors.

The Efficacy of Psychotherapy: Focus on Psychodynamic Psychotherapy as an Example

The growing number of individuals seeking treatment for mental disorders calls for intelligent and responsible decisions in health care politics. However, the current relative decrease in reimbursement of effective psychotherapy approaches occurring in the context of an increase in prescription of psychotropic medication lacks a scientific base. Using psychodynamic psychotherapy as an example, we review the literature on meta-analyses and recent outcome studies of effective treatment approaches. Psychodynamic psychotherapy is an effective treatment for a wide variety of mental disorders. Adding to the known effectiveness of other shorter treatments, the results indicate lasting change in many cases, especially for complex and difficult to treat patients, ultimately reducing health-care utilization. Research-informed health care decisions that take into account the solid evidence for the effectiveness of psychotherapy, including psychodynamic psychotherapy, have the potential to promote choice, increase mental health, and reduce societys burden of disease in the long run.

Attachment, Symptom Severity, and Depression in Medically Unexplained Musculoskeletal Pain and Osteoarthritis: A Cross-Sectional Study

Background Attachment insecurity relates to the onset and course of chronic pain via dysfunctional reactions to pain. However, few studies have investigated the proportion of insecure attachment styles in different pain conditions, and results regarding associations between attachment, pain severity, and disability in chronic pain are inconsistent. This study aims to clarify the relationships between insecure attachment and occurrence or severity of chronic pain with and without clearly defined organic cause. To detect potential differences in the importance of global and romantic attachment representations, we included both concepts in our study. Methods 85 patients with medically unexplained musculoskeletal pain (UMP) and 89 patients with joint pain from osteoarthritis (OA) completed self-report measures of global and romantic attachment, pain intensity, physical functioning, and depression. Results Patients reporting global insecure attachment representations were more likely to suffer from medically unexplained musculoskeletal pain (OR 3.4), compared to securely attached patients. Romantic attachment did not differ between pain conditions. Pain intensity was associated with romantic attachment anxiety, and this relationship was more pronounced in the OA group compared to the UMP group. Both global and romantic attachment anxiety predicted depression, accounting for 15% and 17% of the variance, respectively. Disability was independent from attachment patterns. Conclusions Our results indicate that global insecure attachment is associated with the experience of medically unexplained musculoskeletal pain, but not with osteoarthritis. In contrast, insecure attachment patterns seem to be linked to pain intensity and pain-related depression in unexplained musculoskeletal pain and in osteoarthritis. These findings suggest that relationship-informed focused treatment strategies may alleviate pain severity and psychological distress in chronic pain independent of underlying pathology.

Self-report and observer ratings of personality functioning: a study of the OPD system.

Recent considerations around DSM–5 criteria of personality disorders (PDs) demand new concepts of assessing levels of personality functioning. Of special interest are multiperspective approaches accounting for clinicians’ as well as patients’ points of view. The study investigates observer-rated and self-assessed levels of personality functioning measured by the level of structural integration as defined by the Operationalized Psychodynamic Diagnosis System (OPD). Both perspectives were positively related. The combination of both measures was most efficient in discriminating among 3 diagnostic groups of varying degrees of personality dysfunction. Future studies should take into account expert ratings as well as self-report data.

Quality and severity of depression in borderline personality disorder: A systematic review and meta-analysis.

Depression in borderline personality disorder (BPD) is hypothesized to be distinct in quality and severity. This paper provides a systematic review of depression quality, and a meta-analysis of depression severity in BPD patients compared to those with depressive disorders (DeDs) only. Based on a systematic literature search, 26 studies were identified for systematic review and 35 studies (3425 participants) were included for meta-analysis. The review focused on different forms of depressive symptoms, affective impairment, self-evaluation, and negative interpersonal experiences. The meta-analysis examined age, gender, presence of comorbid DeDs in BPD patients, and type of depression scale as moderators of effect sizes. Findings indicate that depression quality in BPD is characterized by higher anger/hostility and self-criticism. There was no significant difference in depression severity between BPD and DeD groups, and a high level of heterogeneity. Moderator analyses revealed lower depression severity in BPD patients without comorbid DeDs, but higher severity in BPD patients with comorbid DeDs compared to depressed controls. Our results suggest high variability in depression severity across BPD patients, point toward the consideration of comorbid DeDs, and lend partial support to a BPD-specific depression quality. We discuss difficulties in research on depression in BPD, and offer directions for future studies.

Day-Clinic and Inpatient Psychotherapy for Depression (DIP-D): A Randomized Controlled Pilot Study in Routine Clinical Care

by randomization with the RANDI-2 software [8] . Afterwards, patients were admitted to either the day-clinic or inpatient setting and treated for 8 weeks with multimodal psychotherapy. Four weeks after discharge, patients received a follow-up assessment, which served as primary outcome assessment point. All patients gave written informed consent, the study protocol was approved by the local ethics committee and the study was registered at the German Clinical Trials Register (DRKS00000550). The therapy unit combines inpatient and day-clinic treatment, therapeutic staff is the same for both treatment arms. Both groups received equal amounts of psychotherapeutic interventions. These included psychodynamic individual psychotherapy, psychodynamic-interactional group psychotherapy, non-verbal therapies, and social competence trainings. Psychopharmacological antidepressant treatment followed the German national treatment guidelines for depression [9] . In order to be representative for routine clinical practice, no further specifications with regard to psychopharmacological medications were made for the study. Inpatients were free to leave the unit outside of night hours and therapy sessions and spent 6 weekends at home. Day-clinic patients attended therapy on 5 weekdays from 8 a.m. to 4 p.m. There were no group differences for socio-demographic variables, antidepressant medication, DSM-IV diagnoses, or depression severity. Two patients dropped out before admission to dayclinic. During therapy, 3 patients terminated prematurely (2 inpatient, 1 day-clinic), 1 patient was discharged due to illegal drug consumption during day-clinic therapy, and another patient (dayclinic) was excluded due to a first manic episode. Two inpatients dropped out of the study in order to continue treatment in the day-clinic setting. In total, 9 patients dropped out following randomization, leaving 35 completers (18 inpatient, 17 day-clinic). Dropouts were invited to the follow-up assessment, only 3 refused further assessments (2 inpatient, 1 day-clinic). There were no significant differences for socio-demographic variables or diagnoses between completers and dropouts, but depression severity showed a non-significant trend towards lower initial severity for dropouts (HDRS completers, mean 19.5 (SD 5.42); HDRS dropouts, mean 15.8 (SD 6.06); t (42) = –1.78, p = 0.08). At admission, 22 patients (50%) were taking antidepressant medication. Within the completer sample, 11 patients (31.4%) had a change in antidepressant medication during treatment. Antidepressants were reduced or terminated for 6 patients (17.2%) and increased or started for 4 patients (11.4%). One patient had a change of drug class. At termination, 51.4% of completer patients were taking antidepressant medication. There were no differences between groups for change during therapy or medication at termination. Change of medication was not related to initial depression severity and beginning or increasing medication was not significantly related to symptom reduction. Change of symptoms was examined with multilevel models for completers as well as the intent-to-treat sample ( table 1 ). DepresDepending on the severity of depression, patients may be treated at different levels of care with psychotherapy and/or antidepressant medication [1] . Randomized controlled studies comparing different levels of care for severely impaired patients are still lacking. This is of special relevance with regard to a growing interest in multimodal psychotherapeutic day-clinic settings which have been increasing since the 1960s [2] due to the high costs of inpatient care [3] and specific advantages of the setting. Compared to inpatient therapy, the daily transition between therapy and the home environment can be more demanding [4] , but the greater proximity to daily stressors may facilitate a successful transfer of therapeutic gains to everyday life. Both treatments are intensive forms of time-limited multimodal psychotherapy. The psychotherapeutic hospital setting in Germany is indicated for patients with a history of treatment failures in outpatient therapy. Typically, patients are admitted in the context of an exacerbation that poses a threat to their long-term social and economic functioning. While several previous studies compared the efficacy of different levels of care for psychotherapy of personality disorders [5] , sufficient data is lacking for the comparison of day-clinic and inpatient psychotherapy for depression. The current pilot study evaluates the feasibility of randomization in a routine hospital setting and compares preliminary efficacy for day-clinic and inpatient psychotherapy for depression. A total of 1,412 new incoming patients were screened at the hospital outpatient center. A total of 144 patients met inclusion criteria. Of these, 65 agreed to a detailed patient briefing, after which 44 patients agreed to participate. Of these, 97.7% had a major depressive episode, 1 patient was primarily diagnosed with dysthymia. Comorbid diagnoses included anxiety (45.5%), somatoform (13.6%), obsessive-compulsive (6.8%), and personality disorder (33.3%). Participants had a mean age of 35.1 years (range 18–55), 50% were female. Patients received structured diagnostic interviews (SCID) [6] , depressive symptoms were measured by two independent observers with the Hamilton Depression Rating Scale (HDRS) [7] . Their interrater reliability was r = 0.96. Initial assessment was followed Received: September 6, 2013 Accepted after revision: November 18, 2013 Published online: April 17, 2014

Influence of psychological attachment patterns on periodontal disease – a pilot study with 310 compliant patients

OBJECTIVES Psychosocial variables have received increased attention in periodontology. Attachment theory adds to known risk factors by linking early interactional experiences with adult tendencies of stress-regulation, health behaviour, symptom reporting, and healthcare utilization. The study investigates associations between attachment patterns and periodontal parameters. METHODS Within the context of a longitudinal study on periodontal diseases, 310 patients with aggressive (AgP) and chronic periodontitis (CP) filled out questionnaires on psychological attachment patterns. The influence of attachment style on health behaviour, treatment attendance and utilization, and periodontal variables was tested. RESULTS We found associations between psychological attachment anxiety on smoking and higher number of session use, independent of disease severity, which was more pronounced for women. Patients with higher attachment avoidance attended periodontal treatment later when diagnosed with CP and earlier with AgP. For men, we found differential associations for attachment avoidance and anxiety and number of teeth at beginning of treatment. CONCLUSION Psychological attachment patterns are a promising target for understanding periodontal disease in addition to known psychosocial risk factors.

Aktuelle Entwicklungen der psychodynamischen Psychotherapieforschung

ZusammenfassungDie Frage nach der Wirksamkeit psychodynamischer Behandlungsverfahren hat in berufspolitischen und wissenschaftlichen Debatten der letzten Jahre einen hohen Stellenwert eingenommen. In diese Zeit fällt eine Vielzahl weiterer Studienergebnisse mit neuen Effektivitätsnachweisen. Ziel des vorliegenden Beitrags ist es, einen überblick über aktuelle Ergebnisse der psychodynamischen Psychotherapieforschung zu geben, mit einem Schwerpunkt auf Metaanalysen und randomisierten Vergleichsstudien. Die Ergebnisse zeigen, dass es für eine große Anzahl von Störungsbildern mittlerweile Effektivitätsnachweise auf einer robusten Datengrundlage gibt. Die methodische Qualität der aktuellen Studien ist gut; auch der Vergleich mit anderen Therapieverfahren braucht nicht gescheut zu werden. Gleichzeitig sind weitere Studien notwendig, sowohl in Bezug auf Störungsbilder als auch Praxisstudien zur Abbildung der Wirksamkeit in der Breite der Anwendung im Alltag.AbstractThe effectiveness of psychodynamic psychotherapy has been a “hot topic” in scientific and healthcare related debates in recent years. During this time a significant amount of new evidence supporting the effectiveness of psychodynamic psychotherapy has been published. The paper provides an overview on current psychodynamic psychotherapy research, with a focus on meta-analytic findings and randomized effectiveness trials. The results in the literature show robust evidence for the effectiveness of psychodynamic therapies for a wide range of psychiatric disorders. The methodological quality of current studies is good and comparative trials with other forms of psychotherapy yield mostly equivalent results. However, further studies are needed with regard to different mental disorders as well as effectiveness studies in everyday practice.

[Development of a 12-item version of the OPD-Structure Questionnaire (OPD-SQS)].

OBJECTIVES Screening for personality dysfunction is relevant to treatment planning in psychotherapy, psychosomatic medicine and psychiatry. This makes short versions of field-tested approaches such as the OPD Structure Questionnaire (OPD-SQ) necessary. METHODS With the aim of developing a screening version, the original sample of the OPD-SQ was divided into two subsamples. After developing a preliminary 12-item version in one subsample, we used confirmatory factor-analysis in the second subsample as well as an independent sample to test the factor structure. RESULTS The analyses confirmed a structure of three correlating factors with adequate fit indices. Other findings relating to the validity of the long version were replicated as well. In addition, data from an independent sample of psychotherapy inpatients confirmed the factor structure and provided further evidence for its validity. CONCLUSIONS The OPD-SQS is a viable screening instrument for supporting clinical decision making in stepped-care approaches in psychotherapy, psychosomatic medicine and psychiatry.