Ulrike Dinger

Does alliance predict symptoms throughout treatment, or is it the other way around?

OBJECTIVE Scholars increasingly recognize that therapeutic alliance and symptomatic change are associated with one another. A common assumption is that alliance predicts symptomatic change. However, the issue is far from settled. One challenge in determining the causality is the establishment of temporal precedence showing that alliance, as opposed to previous symptomatic change, drives subsequent symptomatic reduction. METHOD To make further advances in untangling this chicken-and-egg question, we employed autoregressive cross-lagged modeling over 4 time points in a sample of 149 depressive patients receiving supportive-expressive psychotherapy or clinical management combined with pharmacotherapy or clinical management combined with placebo. RESULTS Using this methodology, we found that both alliance and symptoms across treatment made significant and unique contributions in predicting subsequent symptomatic levels throughout treatment. Additionally, alliance, but not symptoms, predicted subsequent alliance levels. No differences were found between treatments. CONCLUSIONS Our findings imply that alliance temporally precedes symptomatic levels throughout treatment.

A meta-analytic review of psychodynamic therapies for anxiety disorders

Recent randomized controlled trials (RCTs) suggest that psychodynamic therapy (PDT) may be useful in the treatment of anxiety disorders. This paper presents the most comprehensive meta-analysis to date examining the controlled effects of PDT for anxiety disorders. 14 RCTs totaling 1073 patients were included. PDT was found to be significantly more effective than control conditions (g=0.64). PDT did not differ significantly from alternative treatments at post-treatment (g=0.02), follow-up (FU) up to a year (g=-0.11), and FU past a year (g=-0.26). Medium-to-high levels of heterogeneity were detected, indicating significant differences between studies. Nevertheless, our findings remained unchanged when heterogeneity outliers were removed (termination g=-0.06/short FU g=-0.01/long FU g=-0.10). Power analyses indicated that large or medium effect size differences between PDT and other active treatments could be detected even with high heterogeneity. Exploratory moderator analyses found few significant predictors of effect (e.g., relative risk of dropout). No differences were found examining remission rates or relative risk of dropout. Overall, PDT was shown to be as efficacious as other active treatments that have been studied for anxiety disorders.

INFLUENCES OF PATIENTS’ AND THERAPISTS’ INTERPERSONAL PROBLEMS AND THERAPEUTIC ALLIANCE ON OUTCOME IN PSYCHOTHERAPY

Abstract The aim of this study was to investigate the importance of therapists’ and patients’ interpersonal problems as well as the impact of the therapeutic alliance on symptomatic outcome in psychotherapy. Of interest were direct effects of interpersonal problems, represented through the dimensions of affiliation and control, as well as possible interaction effects between patient and therapist variables on outcome. Further hypotheses referred to therapist differences in the predictive impact of the therapeutic alliance for outcome. Outcome ratings of 1,513 psychotherapy inpatients treated by 31 psychodynamically oriented individual psychotherapists were studied. Therapists’ and patients’ interpersonal dispositions were assessed with the Inventory of Interpersonal Problems, and patients answered standardized outcome measures before and after therapy and retrospectively evaluated the therapeutic alliance at discharge. The results indicate that dominant patients profited better from their therapy and that therapists’ interpersonal disposition did not have a direct influence on outcome. The influence of the therapeutic alliance on outcome varied among the therapists. The general positive effect of therapeutic alliance on outcome was stronger for less affiliative therapists. Limitations of the study and implications of the results are discussed.

The associations among improvement and alliance expectations, alliance during treatment, and treatment outcome for major depressive disorder

Abstract Objective: To examine the associations between treatment/outcome expectations, alliance before and during treatment, and the impact of alliance on symptomatic improvement. Methods: One hundred and fifty-three depressed patients randomized to dynamic supportive-expressive psychotherapy (SET), antidepressant medication (ADM) or placebo (PBO) + clinical management completed ratings of treatment expectations, therapeutic alliance (CALPAS, WAI-S), and depressive symptoms (HAM-D). Results: Pretreatment expectations of the therapeutic alliance were significantly related to alliance later in therapy but did not differ across treatments and did not predict outcome. Alliance development over time differed between treatments; it increased more in SET than in PBO. After controlling for prior symptom improvement, early alliance predicted subsequent depression change. Conclusions: Expectations of alliance and of treatment outcome/improvement, measured prior to treatment onset, predicted subsequent alliance.

Interpersonal problems as predictors of alliance, symptomatic improvement and premature termination in treatment of depression

BACKGROUND Previous studies reported inconsistent findings regarding the association of interpersonal problems with therapy outcome. The current study investigates if interpersonal problems predict process and outcome of three different treatments for depression. METHODS The data originate from a randomized clinical trial comparing supportive-expressive psychotherapy, antidepressant medication and pill-placebo for treatment of depression. Interpersonal problems were used as predictors of alliance, symptomatic improvement and premature termination of treatment. RESULTS Interpersonal problems related to communion predicted better alliances, but slower symptomatic improvement. Low agency predicted slower symptomatic improvement in supportive-expressive psychotherapy, but not in the medication or placebo condition. Lower interpersonal distress was associated with an increased likelihood to terminate treatment prematurely. LIMITATIONS The sample size did not allow the detection of small effects within the treatment groups. CONCLUSIONS Interpersonal problems are influential for the treatment of depression, but parts of their effects depend on the type of treatment.

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.

Are there subtypes of panic disorder? An interpersonal perspective.

OBJECTIVE Panic disorder (PD) is associated with significant personal, social, and economic costs. However, little is known about specific interpersonal dysfunctions that characterize the PD population. The current study systematically examined these interpersonal dysfunctions. METHOD The present analyses included 194 patients with PD out of a sample of 201 who were randomized to cognitive-behavioral therapy, panic-focused psychodynamic psychotherapy, or applied relaxation training. Interpersonal dysfunction was measured with the Inventory of Interpersonal Problems-Circumplex (Horowitz, Alden, Wiggins, & Pincus, 2000). RESULTS Individuals with PD reported greater levels of interpersonal distress than that of a normative cohort (especially when PD was accompanied by agoraphobia), but lower than that of a cohort of patients with major depression. There was no single interpersonal profile that characterized PD patients. Symptom-based clusters (with vs. without agoraphobia) could not be discriminated on core or central interpersonal problems. Rather, as revealed by cluster analysis based on the pathoplasticity framework, there were 2 empirically derived interpersonal clusters among PD patients that were not accounted for by symptom severity and were opposite in nature: domineering-intrusive and nonassertive. The empirically derived interpersonal clusters appear to be of clinical utility in predicting alliance development throughout treatment: Although the domineering-intrusive cluster did not show any changes in the alliance throughout treatment, the nonassertive cluster showed a process of significant strengthening of the alliance. CONCLUSIONS Empirically derived interpersonal clusters in PD provide clinically useful and nonredundant information about individuals with PD.

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

Interpersonal problems, dependency, and self-criticism in major depressive disorder.

OBJECTIVES The goal of the present research was the examination of overlap between 2 research traditions on interpersonal personality traits in major depression. We hypothesized that Blatts (2004) dimensions of depressive experiences around the dimensions of relatedness (i.e., dependency) and self-definition (i.e., self-criticism) are associated with specific interpersonal problems according to the interpersonal circumplex model (Leary, 1957). In addition, we examined correlations of interpersonal characteristics with depression severity. METHOD Analyses were conducted on 283 patients with major depressive disorder combined from 2 samples. Of the patients, 151 participated in a randomized controlled trial in the United States, and 132 patients were recruited in an inpatient unit in Germany. Patients completed measures of symptomatic distress, interpersonal problems, and depressive experiences. RESULTS Dependency was associated with more interpersonal problems related to low dominance and high affiliation, while self-criticism was associated with more interpersonal problems related to low affiliation. These associations were independent of depression severity. Self-criticism showed high overlap with cognitive symptoms of depression. CONCLUSION The findings support the interpersonal nature of Blatts dimensions of depressive experiences. Self-criticism is associated with being too distant or cold toward others as well as greater depression severity, but is not related to the dimension of dominance.