Manfred Cierpka

Operationalisierte Psychodynamische Diagnostik

Bei der „Operationalisierten psychodynamischen Diagnostik — OPD“ handelt es sich um ein in mehrjahriger Arbeit von insgesamt etwa 40 psychotherapeutischen Klinikern und Forschern erstelltes System der Diagnostik im Bereich der psychodynamischen und psychoanalytischen Psychotherapie. Die Arbeitsgruppe OPD fand sich zu Beginn der 90er Jahre zusammen, um Erganzungen zur inzwischen etablierten psychiatrischen Diagnostik zu entwickeln, die eher den Bedurfnissen psychotherapeutisch Tatiger entsprechen sollten. Hierzu wurden mehrere Untergruppen gebildet, die sich von Beginn an um Aspekte der Krankheitsverarbeitung, der Beziehungs- und Konfliktdiagnostik und der Einschatzung der strukturellen Merkmale der Personlichkeit sowie um die syndromale Ebene der kategorialen Diagnostik zentrierten. In einem mehrjahrigen Prozess erarbeiteten diese Gruppen Entwurfe fur die jeweiligen Teilbereiche. Zum Ende hin fand in der Gesamtgruppe die wechselseitige Kritik der Entwurfe statt. Vor der Veroffentlichung des Systems wurde dann eine Praktikabilitatsstudie durchgefuhrt, an der eine grose Zahl von Klinikern teilnahm. Diese fuhrte wieder zu einer Uberarbeitung der Einzelbereiche, die schlieslich in ihre jetzige Achsenform gebracht wurden. Der gesamte Diskussionsprozess war fur die Beteiligten auserst anregend und machte immer wieder deutlich, wie sehr der Einzelne oft unreflektierten diagnostischen Gewohnheiten anhangt und wieviel begriffliche Klarungen notwendig waren, im in exemplarisch diskutierten Einzelfallen zu einer Einigung zu kommen.

Changes in Prefrontal-Limbic Function in Major Depression after 15 Months of Long-Term Psychotherapy

Neuroimaging studies of depression have demonstrated treatment-specific changes involving the limbic system and regulatory regions in the prefrontal cortex. While these studies have examined the effect of short-term, interpersonal or cognitive-behavioural psychotherapy, the effect of long-term, psychodynamic intervention has never been assessed. Here, we investigated recurrently depressed (DSM-IV) unmedicated outpatients (N = 16) and control participants matched for sex, age, and education (N = 17) before and after 15 months of psychodynamic psychotherapy. Participants were scanned at two time points, during which presentations of attachment-related scenes with neutral descriptions alternated with descriptions containing personal core sentences previously extracted from an attachment interview. Outcome measure was the interaction of the signal difference between personal and neutral presentations with group and time, and its association with symptom improvement during therapy. Signal associated with processing personalized attachment material varied in patients from baseline to endpoint, but not in healthy controls. Patients showed a higher activation in the left anterior hippocampus/amygdala, subgenual cingulate, and medial prefrontal cortex before treatment and a reduction in these areas after 15 months. This reduction was associated with improvement in depressiveness specifically, and in the medial prefrontal cortex with symptom improvement more generally. This is the first study documenting neurobiological changes in circuits implicated in emotional reactivity and control after long-term psychodynamic psychotherapy.

The operationalized psychodynamic diagnostics system : Clinical relevance, reliability and validity

In this paper, we present a multiaxial system for psychodynamic diagnosis, which has attained wide usage in Germany in the last 10 years. First we will discuss the 4 operationalized psychodynamic diagnostics (OPD) axes: illness experience and treatment assumptions, relationships, mental conflicts, and structure, then clinical applications will be outlined. Focus psychodynamic formulations can be employed both with inpatients and with outpatients. Studies show good reliability in a research context and acceptable reliability for clinical purposes. Validity will be separately summarized as content, criterion, and construct validity. Validity studies indicate good validity for the individual axes. Numerous studies on the OPD indicate areas of possible improvement, for example for clinical purposes the OPD should be more practically formulated.

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.

Individualized and Clinically Derived Stimuli Activate Limbic Structures in Depression: An fMRI Study

Objectives In the search for neurobiological correlates of depression, a major finding is hyperactivity in limbic-paralimbic regions. However, results so far have been inconsistent, and the stimuli used are often unspecific to depression. This study explored hemodynamic responses of the brain in patients with depression while processing individualized and clinically derived stimuli. Methods Eighteen unmedicated patients with recurrent major depressive disorder and 17 never-depressed control subjects took part in standardized clinical interviews from which individualized formulations of core interpersonal dysfunction were derived. In the patient group such formulations reflected core themes relating to the onset and maintenance of depression. In controls, formulations reflected a major source of distress. This material was thereafter presented to subjects during functional magnetic resonance imaging (fMRI) assessment. Results Increased hemodynamic responses in the anterior cingulate cortex, medial frontal gyrus, fusiform gyrus and occipital lobe were observed in both patients and controls when viewing individualized stimuli. Relative to control subjects, patients with depression showed increased hemodynamic responses in limbic-paralimbic and subcortical regions (e.g. amygdala and basal ganglia) but no signal decrease in prefrontal regions. Conclusions This study provides the first evidence that individualized stimuli derived from standardized clinical interviewing can lead to hemodynamic responses in regions associated with self-referential and emotional processing in both groups and limbic-paralimbic and subcortical structures in individuals with depression. Although the regions with increased responses in patients have been previously reported, this study enhances the ecological value of fMRI findings by applying stimuli that are of personal relevance to each individuals depression.

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.

Faustlos: Evaluation eines Curriculums zur Förderung sozial-emotionaler Kompetenzen und zur Gewaltprävention in der Grundschule

Zusammenfassung. Kinder mit guten Fahigkeiten in der Konfliktlosung greifen in heftigen Auseinandersetzungen mit groserer Wahrscheinlichkeit nicht zur Gewalt, weil sie ihr Selbstwertgefuhl nicht auf Kosten von anderen stabilisieren mussen. Das Fordern von sozial-emotionalen Kompetenzen bei Kindern zur Starkung ihrer Konfliktfahigkeit hat sich deshalb als ein elementarer Bestandteil in der Gewaltpravention herausgestellt. Im deutschsprachigen Raum liegt mit “Faustlos“ ein differenziert ausgearbeitetes und evaluiertes Curriculum zur Pravention aggressiven Verhaltens fur die Grundschule vor. Die in einer Drei-Jahres-Studie im Kontrollgruppen-Design erzielten Evaluationsergebnisse in insgesamt 44 Schulklassen im Heidelberg/Mannheimer Raum zeigen, dass mit “Faustlos“ vor allem auf der emotionalen Ebene positive Entwicklungen von Kindern angestosen werden konnen. So wurden durch die “Faustlos“-Lektionen die Angstlichkeit und die Internalisierungstendenz der unterrichteten Grundschulkinder deutlich reduziert. Di...

Psychosocial care by general practitioners--where are the problems? Results of a demonstration project on quality management in psychosocial primary care.

Objective: Since 1987, psychosocial services have been a part of the primary care setting in Germany. In the framework of an eight-center national demonstration program, problems in the diagnosis and therapy of psychosocial problems and psychosomatic disorders were assessed. Methods to improve quality were also implemented. Method: General practitioners (n = 191) from six regions participated in the study. One thousand three hundred and forty-one treatment episodes of patients with predominantly psychosocial symptoms were documented. Differences between psychosocial strain, treatment, and outcome were determined by analyses of variance. Results: Anxiety (62%), depression (51%), and marital/family conflicts (44%) were the most frequent symptoms. Psychosocial treatment was offered more often to those patients who had the highest level of anxiety and depression. Patients with pain and without a psychological attribution to their illnesses were offered less psychosocial treatment and suffered worse results. Partners and family members were rarely integrated into therapy. The procedures employed to improve outcome were quality circles, family-oriented case conferences, consultation services, and collaborative groups. Conclusions: These initial results are promising. A process of internal quality management has been initiated. Some of the physicians still resist documenting the data. Patients with somatic symptoms without psychological attribution may need special psychosocial interventions to improve their outcomes.

Complications during pregnancy, peri- and postnatal period in a sample of women with a history of child abuse

Background. As a proposed risk factor for infant and child development, maternal history of abuse has been a frequent target of investigation. However, there have been no controlled studies about the impact of maternal history of abuse on the medical course of pregnancy, the peri- and postnatal period. Method. All women with a newborn child were contacted by mail and presented with the Childhood Trauma Questionnaire (CTQ). The index group (n = 58) was formed by women who scored above the cutoff for moderate or severe abuse and compared to a control group (n = 60) with regard to pre,- peri-, and postnatal complications as documented in the patient charts. Results. The results show that women with a history of abuse have significantly more prenatal medical complications and infant medical complications in the post- but not perinatal period. Conclusions. Maternal history of abuse significantly impacts the medical course of delivery and the puerperium. Given the prevalence of abusive experiences, this finding is highly relevant from a preventive point of view.

On the Connection Between Affective Evaluation of Recollected Relationship Experiences and the Severity of the Psychic Impairment

This study, carried out at three different university centers contributes to validating the valence dimension of the CCRT-method. Working on the state of the CCRT-research on affective evaluation of relationship narratives, the connection between the valence dimension of the responses from others (RO), responses of the self (RS) and the severity of the psychic disorder has been analysed with the help of two different samples (n = 266 resp. n = 32) taken from female patients. Both, therapists as well as patients themselves, evaluated the severity of the impairment similarly. The more the patients were impaired, the more negatively they describes both their own reactions and those of their interaction partners as shown in the relationship episodes.