Marco Chiesa

Reflective function as a mediator between childhood adversity, personality disorder and symptom distress†

A growing body of literature has indicated the central role of childhood adversity for the development in later life of personality disorder (PD) and psychiatric distress. In this investigation, we examine the role of reflective function (RF) as a mediator between childhood adversity, subsequent development of PD and psychiatric morbidity. We tested the hypothesis that adversity leads to decreased RF, which in turn is associated with PD, and both increase the likelihood of psychiatric distress. The study sample consisted of 234 individuals, drawn from a clinical PD group (n = 112) and one demographically matched non-psychiatric group (n = 122) using a shared battery of measures, which included the Structured Clinical Interview for DSM-IV, the Symptom Checklist-90-R and the Adult Attachment Interview, which was used to assess RF levels. The results indicated that childhood adversity predicted low level of RF, which in turn was associated with PD onset later in life. A combination of different early adverse experiences had a significantly greater impact on lowering RF scores than experiencing either neglect or abuse alone. Mediation analyses confirmed that RF was a significant mediator between adversity and PD diagnoses and between adversity and psychiatric distress.

Prediction of Medium-Term Outcome in Cluster B Personality Disorder following Residential and Outpatient Psychosocial Treatment

Background: There is a paucity of research concerning the identification of individual characteristics predictive of outcome in the treatment of personality disorders (PDs). Methods: In this study, we carried out a predictor analysis of a sample of 73 hospitalized patients with a primary diagnosis of cluster B PD admitted to two different psychosocial programs for PD: (a) long-term inpatient treatment, and (b) a step-down program. Results: Younger age, higher Global Assessment Scale intake scores, longer length of treatment, absence of self-mutilation and avoidant PDs were a significant predictor of outcome at 24-month follow-up. Self-harming patients allocated to the step-down program had higher rates of improvement compared with patients allocated to the long-term inpatient model. Conclusions: The findings may carry potential clinical implications concerning patient selection and treatment delivery for inpatient and outpatient psychosocial programs for cluster B PD. Limitations include a relatively low sample size for a regression analysis, and a larger sample of cluster B patients may be needed to ensure greater reliability of results.

Patients' characteristics, outcome and cost-benefit of hospital-based treatment for patients with personality disorder: A comparison of three different programmes

In this study we aimed (a) to ascertain whether a relationship exists between different treatment programmes and settings for personality disorder and patient characteristics; (b) to give an indication of treatment effects in three personality disordered populations admitted to different treatment contexts; and (c) to compare costs in relation to outcomes. We collected and compared three samples from one in-patient site (Cassel in England) and two day hospitals (Halliwick in England and Ulleval in Norway) on a number of demographic, diagnostic and other key clinical variables. Outcome in the areas of symptom severity (Symptom Checklist-90-R) and social adaptation (Social Adjustment Scale) was evaluated by comparing admission with discharge scores. Treatment costs for each sample were also estimated and compared. Significant differences were found on most baseline variables across the three sites. In general with regard to severity of psychopathology, the Halliwick sample was the most disturbed, Ulleval the least, with Cassel somewhat in between. No significant differences in improvement were found among the three sites, but treatment costs were considerably higher at Cassel than in the two day centres. The differences found in the three samples bear no clear relationship to context of treatment. These results suggest that referral of personality disorder for in-patient or day hospital treatment is less influenced by severity of problem than had previously been supposed and may depend more on availability of treatment facility.

When less is more: An exploration of psychoanalytically oriented hospital-based treatment for severe personality disorder.

This paper discusses the main findings of a prospective study based at the Cassel Hospital, a centre dedicated to the psychoanalytically informed residential treatment of severe personality disorders. The results‐showing that significantly greater improvements on a number of outcome indicators were found in patients exposed to the psychoanalytically informed treatment programmes compared to a general psychiatric approach based on management and pharmacotherapy alone‐underscores the importance and the centrality of the psychoanalytic input in the treatment of severe personality disorders. However, the results of the study also suggested that some features of long‐term hospital treatment might carry the risk of iatrogenic and anti‐therapeutic effects for a sub‐group of patients with severe borderline core pathology. The authors present the clinical and psychodynamic implications of the study results based on an understanding of the internal and interpersonal mode of functioning of borderline patients.

Community-based psychodynamic treatment program for severe personality disorders: clinical description and naturalistic evaluation

Long-term inpatient treatment for personality disorders has become infrequent in the last two decades, and the gap left in service provision has been filled by psychodynamically and cognitively oriented partial hospitalization and outpatient, community-based approaches. It is still uncertain how these low-cost, lower-intensity models have fared relative to residential models that treat patients with severe personality disorders with the containment and control offered by the inpatient setting. In this article, we describe key features of a community-based psychodynamic program developed at the Cassel Hospital in the United Kingdom and present preliminary findings of a 2-year prospective naturalistic outcome study that monitored psychiatric morbidity (Brief Symptom Inventory General Severity Index [BSI-GSI]) and clinical outcome (self-mutilation, suicide attempts, and hospital admissions) in 68 patients with personality disorders who were consecutively admitted to the program. Improvements shown by the community-based sample on all variables were compared with the results in a comparable sample of inpatients treated in a long-term psychosocial treatment program in the same institution. The naturalistic comparison of the two non-randomized treatment models revealed that the community-based sample improved to a significantly greater degree on all three clinical outcome dimensions and had significantly lower early dropout rates than those who received the long-term residential treatment. The findings indicate that, at least in terms of impulsive behavior and treatment adherence, the community-based program appears to offer a viable adequate alternative to long-term inpatient admission.

A description of an audit cycle of early dropouts from an inpatient psychotherapy unit

This paper describes the results and implications of an 8-year audit cycle concerning premature termination of treatment in a population with severe personality disorder treated within a specialist residential setting. The results of the first audit showed (a) a high early dropout rate, (b) a significant difference in early dropout rates between the two clinical programmes (one-stage and step-down) offered by the unit, and (c) a higher attrition of non-borderline personality disorders compared to borderline type disorder. Qualitative analysis of interviews with early dropout patients helped to identify deficiencies in practice, which may have contributed to dropout. Discussion of results amongst the team led to corrective measures that allowed reduction of early dropout in the one-stage programme over the subsequent years. The implications of the results are discussed.

From the efficacy to the effectiveness model in psychotherapy research: The app multi-centre project

Summary In this paper we discuss the differences that exists between the efficacy and the effectiveness models in psychotherapy research. We argue that randomised-controlled trials have several shortcomings and that they may not be the most appropriate method for evaluating psychoanalytic psychotherapy. Well-designed field studies may provide an informative, relevant and complementary approach to the evaluation of the effectiveness of psychotherapy as delivered in routine clinical practice. An example of a multi-centre effectiveness study is presented.

Psychiatric morbidity and treatment pathway outcomes of patients presenting to specialist NHS psychodynamic psychotherapy services : Results from a multi-centre study

OBJECTIVE Little is known about socio-demographic, diagnostic, and clinical characteristics of patients referred for assessment to psychodynamic psychotherapy services. The aim of this study was to remedy this by prospectively collecting comprehensive and systematic demographic and clinical information on a large number of patients referred to NHS psychodynamic psychotherapy services. DESIGN Fourteen psychotherapy services operating within a National Health Service joined the study and contributed data for 1,136 patients referred from primary and secondary care clinics. METHOD Patients were assessed using questionnaires and self-rated measures, which included the clinician-based version of the diagnostic form of the Millon clinical multi-axial inventory-III-revised edition (MCMI-III-R), the brief symptom inventory (BSI), the inventory of interpersonal problems (IIP), and the clinical outcome in routine evaluation (CORE). The pathway from assessment through to treatment and variables associated with treatment uptake and exclusion are described and examined. RESULTS Most patients were in the moderate to severe range of psychiatric severity at the time of presentation. Ninety-five percent met clinically based criteria for a psychiatric disorder (mostly anxiety and mood disorders) and/or personality disorder. Although the majority of patients were found suitable for treatment (N=935, 82%), analysis of uptake showed relatively high rates of treatment rejection by patients and treatment drop-out. Partial outcome data at 6-month follow-up after intake into treatment revealed significant change but modest effect size (d=0.35). CONCLUSION Systematic collection of baseline and outcome data would provide a national database of the performance of psychotherapy services that would be invaluable in facilitating comparative studies.

Hospital adjustment in personality disorder patients admitted to a therapeutic community milieu

This study investigated aspects of adjustment to the therapeutic community milieu in a group of personality disorder patients. Eighty-one patients consecutively admitted to the Cassel Hospital for medium/long-term residential treatment between April 1994 and October 1997 comprised the sample. The adjustment to the milieu was rated on the Hospital Adjustment Scale, while outcome was evaluated at 6-monthly intervals using a battery of self-rated and rater-based instruments. The aims of the study were: (a) to identify demographic and pre-admission clinical variables that would predict adjustment to the therapeutic regime; (b) to study the relationship between hospital adjustment and external social adjustment; and (c) to investigate the hypothesis that hospital adjustment and internally and externally directed aggression do not predict clinical outcome. The results showed that pre-admission level of global functioning and a previous history of substance misuse are the most significant predictors of hospital adjustment. No significant association between hospital adjustment and external social adjustment was found. Neither hospital adjustment not level of aggressiveness predicted outcome at 12 months. The implications of these results for therapeutic community treatment of personality disorder are discussed.

The struggle to establish a research culture in the psychotherapy hospital: reflections from the Cassel Hospital experience.

The institutional impact and defensive reactions to the results of a longitudinal controlled outcome trial carried out within a psychotherapy hospital specializing in the treatment of personality disorder are described and discussed. The authors argue that integration of research findings with clinical practice, the development of a research culture, and building bridges with other disciplines such as psychology and neuroscience will enhance the prospect of long-term survival of psychoanalytically oriented institutions.