Stephan Doering

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.

Videotape Preparation of Patients Before Hip Replacement Surgery Reduces Stress

Objective Elective surgery represents a considerable source of stress for the patient. Many attempts have been made to prepare patients before surgery with the aim of reducing stress and improving outcome. This study used a novel approach to fulfill this aim by showing a videotape of a patient undergoing total hip replacement surgery, covering the time period from hospital admission to discharge, that strictly keeps to the patient’s perspective. Methods Before elective total hip replacement surgery, 100 patients were randomly assigned to a control group or a preparation group; the latter group was shown the videotape on the evening before surgery. Anxiety and pain were evaluated daily for 5 days, beginning with the preoperative day, by means of the State-Trait Anxiety Inventory and a visual analog scale. Intraoperative heart rate and blood pressure, as well as postoperative intake of analgesics and sedatives, were recorded. Urinary levels of cortisol, epinephrine, and norepinephrine were determined in 12-hour samples collected at night for 5 nights, beginning with the preoperative night. Results Compared with the control group, the preparation group showed significantly less anxiety on the morning before surgery and the mornings of the first 2 postoperative days, and significantly fewer of them had an intraoperative systolic blood pressure increase of more than 15%. The pain ratings did not differ significantly between the two groups, but the prepared patients needed less analgesic medication after surgery. Prepared patients had significantly lower cortisol excretion during the preoperative night and the first 2 postoperative nights. Excretion of catecholamines did not differ significantly between groups. Conclusions We conclude that use of the videotape decreased anxiety and stress, measured in terms of urinary cortisol excretion and intraoperative systolic blood pressure increase, in patients undergoing hip replacement surgery and prepared them to cope better with postoperative pain.

Determinants of health-related quality of life in patients with coronary artery disease

Background Health-related quality of life (HRQL) is increasingly being assessed as an outcome parameter, especially in chronic diseases such as coronary artery disease (CAD), in which the goal of treatment is not only to prolong life but also to relieve symptoms and improve function. Design This study was carried out as a non-randomized prospective multicentre study. Methods Patients (N=432) with CAD were assessed at baseline, 1 and 3 months after treatment assignment [medication, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)]. HRQL was assessed using the MacNew Heart Disease Health-related Quality of Life Questionnaire (MacNew) and the Short Form 36 (SF-36). Depressive and anxiety symptoms were assessed using the Hospital Anxiety and Depression Scale. Routine clinical data including disease severity were collected. Results The short and intermediate-term results revealed HRQL differences between PCI and CABG in the month immediately after intervention despite the almost identical reduction in angina severity over the first month in both groups. PCI was associated with a relatively rapid increase in HRQL in the first month, with little further change by 3 months. In contrast, after CABG there was an initial deterioration in HRQL, which then improved significantly. The change in depression and anxiety score uniquely accounted for most of the change in the SF-36 (6%, 64%) and MacNew scales (4%, 69%), whereas treatment accounted for less than 1% in any HRQL scale score changes. Conclusions There appears to be evidence suggesting that HRQL changes after treatments in patients with CAD may be more strongly influenced by mood disturbance than by treatment methods. Eur J Cardiovasc Prev Rehabil 13:398–406

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.

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.

Reduced deactivation in reward circuitry and midline structures during emotion processing in borderline personality disorder

Abstract Objectives. Borderline personality disorder (BPD) is characterized by a pervasive affective dysregulation. While recent imaging studies demonstrated the neural correlates of abnormal emotion processing in BPD and recently one study reported alterations of the reward circuit in this patient group, the exact neural mechanisms underlying the impact of abnormal emotion on reward behavior remain unclear. Methods. We therefore conducted an fMRI study in healthy controls and BPD patients to investigate the modulation of the anticipation of reward by simultaneously presented emotional pictures. Results. BPD patients revealed a disturbed differentiation between reward and non-reward anticipation in the bilateral pregenual anterior cingulate cortex if a positive or negative emotional picture is presented simultaneously. In the ventral striatum and the bilateral ventral tegmental area, BPD patients and healthy controls are able to differentiate between reward and non-reward even under emotional stimulation, but BPD patients show a reduced deactivation in the above mentioned regions compared to healthy controls. Conclusions. Altered emotion processing in BPD patients is likely to affect the reward system. More basic deficits in reward circuitry and other midline regions’ level of resting state activity may contribute to this effect.

Personality Factors and Suicide Risk in a Representative Sample of the German General Population

Objective Previous research has shown an association between certain personality characteristics and suicidality. Methodological differences including small sample sizes and missing adjustment for possible confounding factors could explain the varying results. The aim of this study was to assess the impact of the Big Five personality dimensions on suicidality in a representative population based sample of adults. Method Interviews were conducted in a representative German population-based sample (n=2555) in 2011. Personality characteristics were assessed using the Big Five Inventory-10 (BFI-10) and suicide risk was assessed with the Suicidal Behaviors Questionnaire-Revised (SBQ-R). Multivariate logistic regression models were calculated adjusting for depression, anxiety, and various sociodemographic variables. Results Neuroticism and openness were significantly associated with suicide risk, while extraversion and conscientiousness were found to be protective. Significant sex differences were observed. For males, extraversion and conscientiousness were protective factors. Neuroticism and openness were found to be associated with suicide risk only in females. These associations remained significant after adjusting for covariates. Conclusion The results highlight the role of personality dimensions as risk factors for suicide-related behaviors. Different personality dimensions are significantly associated with suicide-related behaviors even when adjusting for other known risk factors of suicidality.

The role of identity in the DSM-5 classification of personality disorders

In the revised Diagnostic and Statistical Manual DSM-5 the definition of personality disorder diagnoses has not been changed from that in the DSM-IV-TR. However, an alternative model for diagnosing personality disorders where the construct “identity” has been integrated as a central diagnostic criterion for personality disorders has been placed in section III of the manual. The alternative model’s hybrid nature leads to the simultaneous use of diagnoses and the newly developed “Level of Personality Functioning-Scale” (a dimensional tool to define the severity of the disorder). Pathological personality traits are assessed in five broad domains which are divided into 25 trait facets. With this dimensional approach, the new classification system gives, both clinicians and researchers, the opportunity to describe the patient in much more detail than previously possible. The relevance of identity problems in assessing and understanding personality pathology is illustrated using the new classification system applied in two case examples of adolescents with a severe personality disorder.

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.

Is progression of periodontitis relevantly influenced by systemic antibiotics? A clinical randomized trial

AIM We investigated the long-term impact of adjunctive systemic antibiotics on periodontal disease progression. Periodontal therapy is frequently supplemented by systemic antibiotics, although its impact on the course of disease is still unclear. MATERIAL & METHODS This prospective, randomized, double-blind, placebo-controlled multi-centre trial comprising patients suffering from moderate to severe periodontitis evaluated the impact of rational adjunctive use of systemic amoxicillin 500 mg plus metronidazole 400 mg (3x/day, 7 days) on attachment loss. The primary outcome was the percentage of sites showing further attachment loss (PSAL) ≥1.3 mm after the 27.5 months observation period. Standardized therapy comprised mechanical debridement in conjunction with antibiotics or placebo administration, and maintenance therapy at 3 months intervals. RESULTS From 506 participating patients, 406 were included in the intention to treat analysis. Median PSAL observed in placebo group was 7.8% compared to 5.3% in antibiotics group (Q25 4.7%/Q75 14.1%; Q25 3.1%/Q75 9.9%; p < 0.001 respectively). CONCLUSIONS Both treatments were effective in preventing disease progression. Compared to placebo, the prescription of empiric adjunctive systemic antibiotics showed a small absolute, although statistically significant, additional reduction in further attachment loss. Therapists should consider the patients overall risk for periodontal disease when deciding for or against adjunctive antibiotics prescription.