Melitta Fischer-Kern

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.

Affective state of women following a prenatal diagnosis: predictors of a negative psychological outcome

The benefits of prenatal diagnostic procedures are well documented. However, the investigation of psychological consequences related to these procedures has remained a surprisingly neglected area of research. The main aim of the present study was to investigate the potential relationship between psychological outcome and associated (socio‐demographic, psychological and obstetric) variables in women attending a tertiary referral center for prenatal diagnosis and therapy for ultrasound scanning (due to the suspicion of a fetal malformation raised by the gynecologist in private practice), amniocentesis or chorionic villus sampling.

Mentalizing in female inpatients with major depressive disorder.

Abstract Depression is associated with profound impairments in social and interpersonal functioning. However, little research has addressed deficits in mentalizing capacity that may underlie these impairments. The aim of this study was, therefore, to investigate the capacity for mentalization in female inpatients with depression in comparison with healthy controls. We assessed 46 inpatients with major depressive disorder with regard to psychiatric diagnoses, severity of depression, cognitive impairment, and verbal intelligence. In addition, 20 healthy controls matched for sex, age, and education were included. Mentalization was scored on the Adult Attachment Interview using the Reflective Functioning Scale. The female inpatients with depression showed a significantly lower capacity for mentalization compared with the healthy controls. Mentalization deficits were not restricted to depression-specific topics. Moreover, deficits in mentalizing capacity were related to illness duration, number of admissions, and cognitive impairment. The results indicate severe impairment in the ability of the female inpatients with depression to identify and interpret mental states of the self and others. Correlations with illness duration and number of admissions suggest that a chronic course of depression results in further mentalizing impairments. The investigation of mentalization may be of particular importance for the development of targeted psychotherapeutic interventions for depression.

Internal Structure of the Reflective Functioning Scale.

The Reflective Functioning Scale (RFS) was developed to assess individual differences in the ability to mentalize attachment relationships. The RFS assesses mentalization from transcripts of the Adult Attachment Interview (AAI). A global score is given by trained coders on an 11-point scale ranging from antireflective to exceptionally reflective. Coding procedures rely on a distinction of demand and permit questions during the AAI. Demand questions directly probe for reflective functioning (RF), whereas permit questions do not. Coding focuses on detecting qualitative markers of RF and qualitative markers of absent RF, respectively. Despite its relevant empirical contributions in clinical research, several psychometric properties of the RFS are still unclear. In this article, we present data on the reliability and internal structure of the RFS based on a combined sample of 196 subjects. We were able to show that (a) the global score can be assessed with good interrater reliability, is relatively stable across time, and is significantly reduced in persons with mental disorders; (b) demand questions are based on a single latent factor; (c) demand questions do not differ in terms of difficulty; (d) all demand questions but 1 are incrementally predictive of the global score; (e) 5 permit questions contribute to the global score over and above demand questions; and (f) the number of qualitative markers of RF is also predictive of the global score. Our results have important conceptual and methodological implications for future studies using the RFS.

Attachment and Mentalization in Female Patients With Comorbid Narcissistic and Borderline Personality Disorder

We investigated attachment representations and the capacity for mentalization in a sample of adult female borderline patients with and without comorbid narcissistic personality disorder (NPD). Participants were 22 borderline patients diagnosed with comorbid NPD (NPD/BPD) and 129 BPD patients without NPD (BPD) from 2 randomized clinical trials. Attachment and mentalization were assessed on the Adult Attachment Interview (AAI; George, Kaplan, & Main, 1996). Results showed that as expected, compared with the BPD group, the NPD/BPD group was significantly more likely to be categorized as either dismissing or cannot classify on the AAI, whereas the BPD group was more likely to be classified as either preoccupied or unresolved for loss and abuse than was the NPD/BPD group. Both groups of patients scored low on mentalizing, and there were no significant differences between the groups, indicating that both NPD/BPD and BPD individuals showed deficits in this capacity. The clinical implications of the group differences in AAI classification are discussed with a focus on how understanding the attachment representations of NPD/BPD patients helps to illuminate their complex, contradictory mental states.

Utilization of psychotherapy in patients with personality disorder: The impact of gender, character traits, affect regulation, and quality of object-relations

OBJECTIVES The aim of the study was to generate hypotheses for examining gender differences in variables with predictive value for the utilization of psychotherapy in patients with personality disorders (PDs). DESIGN Personality traits, affect experience and regulation, the quality of object relations and interpersonal problems within the process of psychotherapy planning were assessed in 140 psychiatric outpatients. METHODS Besides the structured clinical interviews for DSM-IV I+II, variables were assessed with the Shedler-Westen assessment procedure (SWAP-200), the affect regulation and experience Q sort (AREQ), the quality of object-relations scale (QORS), and the Inventory of Interpersonal Problems (IIP). Correlation and group difference statistics, regression and canonical correlation analysis were performed. RESULTS Predictors concerning the utilization or non-utilization of psychotherapy were a schizoid PD rating a self-report of subassertive behaviour related to interpersonal problems in women, and a narcissistic PD rating in men. Canonical correlations between predictors and quality of object relations or interpersonal problems were found in women, while in men there was merely a tendency for predictor and affect regulation to be related. CONCLUSION The results suggest that for men it is more important to interpret the dominating affect, while for women, understanding the pathological object relation pattern is useful for successful therapy planning.

Validation of the SWAP-200 for diagnosing psychostructural organization in personality disorders

Background: The aim of the study was to investigate the validity of the prototype-matching, empirically based 200-item Shedler-Westen Assessment Procedure (SWAP-200) and its clinical utility for describing underlying dimensions of psychostructural organization and functioning. Sampling and Methods: Patients (n = 306) from two psychoanalytic out-patient departments were included. Replicatory and exploratory factor analysis, correlation and discriminant validity statistics, and canonical correlation analysis were performed. Results: Replicatory factor analysis failed to reproduce the identical original factorial structure. Standard factor analysis revealed an eight-factor solution displaying a dimensional description of psychostructural personality organization (high functioning – neurotic/inhibited – borderline/emotionally dysregulated – psychotic/dissocial). Discriminant validity exists across the sample owing to high/poor psychological functioning. Canonical correlation analysis does not support the replacement of the Structured Clinical Interview for DSM-IV, but provides relevant implications for refining DSM-IV axis II. Conclusions: Support is given for the SWAP instrument in describing dimensional higher-order personality organization and psychostructural functioning.

Personality organization in borderline patients with a history of suicide attempts

Suicide attempts (SA) are common in patients with Borderline Personality Disorder (BPD). Recent studies focus on aspects of personality associated with risk for SA such as deficits in affect regulation including impulse control and aggression. The current study examines associations of dysfunctional personality organization, psychiatric comorbidities as well as non-suicidal self-injury (NSSI) with SA in a sample of 68 BPD outpatients. Patients with a history of SA yielded higher scores in personality domains of aggression, especially self-directed aggression. Further, a history of SA was associated with a worse general level of personality organization and a higher prevalence rate of NSSI and substance abuse disorder. The results demonstrate that SA in BPD patients might be regarded as a manifestation of impaired personality functioning rather than mere state variables and symptoms. Moreover, these findings might have implications for indication, treatment, and prognosis of Borderline Personality Disorder.

Transference-focused psychotherapy for borderline personality disorder: change in reflective function

Borderline personality disorder is associated with deficits in personality functioning and mentalisation. In a randomised controlled trial 104 people with borderline personality disorder received either transference-focused psychotherapy (TFP) or treatment by experienced community therapists. Among other outcome variables, mentalisation was assessed by means of the Reflective Functioning Scale (RF Scale). Findings revealed only significant improvements in reflective function in the TFP group within 1 year of treatment. The between-group effect was of medium size (d = 0.45). Improvements in reflective function were significantly correlated with improvements in personality organisation.

The Relationship between Personality Organization and Psychiatric Classification in Chronic Pain Patients

Background: The present study investigated the relationship between psychiatric classification and personality organization (PO) in a secondary/tertiary clinical sample of chronic pain patients (CPPs). Sampling andMethods: Forty-three patients were administered the Structured Clinical Interview for DSM-IV (SCID I+II) and the Structured Interview of Personality Organization (STIPO). The prevalence of axis I and axis II disorders was correlated with the STIPO level of PO. The STIPO dimensional ratings of patients without personality disorder (PD) were compared to those of patients diagnosed with one or more PDs. Results: Axis I comorbidity was high (93%), and 63% of the patients met the criteria for at least one axis II diagnosis. Twenty-five patients (58%) were diagnosed as borderline PO, with high-level impairments in the dimensions ‘coping/rigidity’, ‘primitive defenses’ and ‘identity’. Higher axis I and axis II comorbidity corresponded with greater severity of PO impairment. No difference was found between the dimensional ratings of patients without PD and those of patients with one or more PDs. Conclusions: The assessment of PO is a crucial issue for diagnosis and treatment planning in CPPs, since it represents a measure of structural impairment that is to a considerable extent independent of axis I and II diagnoses. Moreover, the STIPO dimensional rating focuses on the most salient dysfunctions at a given time.