Toward a More Nuanced Perspective on Detachment: Differentiating Schizoid and Avoidant Personality Styles through Qualities of the Self-Representation

Avoidant personality disorder was introduced in DSM-III (American Psychiatric Association [APA], 1980), and debate persists regarding the utility of having two separate variants of the "detached personality." The present study addressed this issue through ratings of open-ended self-descriptions provided by community adults with high scores on schizoid versus avoidant personality traits (N = 229). The self-concept of individuals with avoidant personality style reflected a lack of positive self-regard and low self-efficacy/agency. Regarding schizoid personalities, neither positive nor negative self-regard, self-complexity, or self-efficacy/agency was found. Examination of specific variables yielded a relationship between avoidant personality styles, depression, and anxiety, consistent with literature noting simultaneous desire and fear of interpersonal relationships in avoidant patients (APA, 1980; Sheldon & West, 1990). Similarly, examination of individual variables yielded a negative association between schizoid personality styles and tolerance for contradictory aspects of the self, consistent with theoretical writings in this area (Kernberg, 1976; McWilliams, 2006). Results support the argument that these two personality styles represent distinct constructs. Findings support the utility of self-concept assessment to assist treatment planning and differential diagnosis. Treatment implications include using open-ended descriptions of patients' self-concepts to explore changes that may not be accessible via more structured forms of patient self-report.

Predicting non-improvement of symptoms in daily mental healthcare practice using routinely collected patient-level data: a machine learning approach

Objectives

Anxiety and mood disorders greatly affect the quality of life for individuals worldwide. A substantial proportion of patients do not sufficiently improve during evidence-based treatments in mental healthcare. It remains challenging to predict which patients will or will not benefit. Moreover, the limited research available on predictors of treatment outcomes comes from efficacy RCTs with strict selection criteria which may limit generalizability to a real-world context. The current study evaluates the performance of different machine learning (ML) models in predicting non-improvement in an observational sample of patients treated in routine specialized mental healthcare.

Methods

In the current longitudinal exploratory prediction study diagnosis-related, sociodemographic, clinical and routinely collected patient-reported quantitative outcome measures were acquired during treatment as usual of 755 patients with a primary anxiety, depressive, obsessive compulsive or trauma-related disorder in a specialized outpatient mental healthcare center. ML algorithms were trained to predict non-response (< 0.5 standard deviation improvement) in symptomatic distress 6 months after baseline. Different models were trained, including models with and without early change scores in psychopathology and well-being and models with a trimmed set of predictor variables. Performance of trained models was evaluated in a hold-out sample (30%) as a proxy for unseen data.

Results

ML models without early change scores performed poorly in predicting six-month non-response in the hold-out sample with Area Under the Curves (AUCs) < 0.63. Including early change scores slightly improved the models' performance (AUC range: 0.68-0.73). Computationally-intensive ML models did not significantly outperform logistic regression (AUC: 0.69). Reduced prediction models performed similar to the full prediction models in both the models without (AUC: 0.58-0.62 vs. 0.58-0.63) and models with early change scores (AUC: 0.69-0.73 vs. 0.68-0.71). Across different ML algorithms, early change scores in psychopathology and well-being consistently emerged as important predictors for non-improvement.

Conclusion

Accurately predicting treatment outcomes in a mental healthcare context remains challenging. While advanced ML algorithms offer flexibility, they showed limited additional value compared to traditional logistic regression in this study. The current study confirmed the importance of taking early change scores in both psychopathology and well-being into account for predicting longer-term outcomes in symptomatic distress.

Three Dimensional Approaches to Personality Disorders: a Review on Personality Functioning, Personality Structure, and Personality Organization

PURPOSE OF REVIEW

The concept of personality functioning (Alternative DSM-5 Model of Personality Disorders) has led to increased interest in dimensional personality disorder diagnosis. While differing markedly from the current categorical classification, it is closely related to the psychodynamic concepts of personality structure and personality organization. In this review, the three dimensional approaches, their underlying models, and common instruments are introduced, and empirical studies on similarities and differences between the concepts and the categorical classification are summarized. Additionally, a case example illustrates the clinical application.

RECENT FINDINGS

Numerous studies demonstrate the broad empirical basis, validated assessment instruments and clinical usefulness of the dimensional concepts. Their advantages compared to the categorical approach, but also the respective differences, have been demonstrated empirically, in line with clinical observations. Evidence supports the three dimensional concepts, which share conceptual overlap, but also entail unique aspects of personality pathology, respectively.

Metacognitive improvement and symptom change in a 3-month treatment for borderline personality disorder

OBJECTIVES

Recognizing and reflecting on one's own and other people's mental states represent a major difficulty for patients with borderline personality disorder (BPD). Only recently have studies begun exploring whether these capacities increase with successful therapies and if such an improvement is linked with outcome. The present study investigated whether metacognition would improve and if its improvement was related with symptom change in BPD patients.

DESIGN

The transcripts from the first and the penultimate session of a ten-session version of good psychiatric management were analysed with the MAS-R scale in a N = 37 BPD sample. Patients, selected from a previously published RCT (Kramer et al., 2014), were assigned either to the good psychiatric management treatment or to the same treatment with the addition of the Motive-Oriented Therapeutic Relationship (Caspar, 2007), a form of therapeutic relationship based on an individualized case formulation. Symptoms were assessed with the OQ-45.

RESULTS

Findings partially support the hypotheses. First, improvement in capacities to understand others' mind, to take a critical distance from one's own rigid and maladaptive beliefs, and to use behavioural and attentional strategies to face adversities is found in both treatment groups. Controlling for marital status, only the ability to differentiate between reality and representations remains significant. Second, no link between metacognitive change and symptom change during treatment is found. However, a link is observed between the increase in metacognition and symptom reduction at 6-month follow-up.

CONCLUSIONS

Results invite to further investigate the role of metacognition in therapy change through different modalities and in longer-term treatments.

PRACTITIONER POINTS

The development of metacognitive processes and their links with symptom change were examined during a short-term treatment in 37 borderline patients Improvement was found in capacities to understand others' mind, to take a critical distance from own rigid and maladaptive beliefs, and to use behavioural and attentional strategies even in a short-term treatment Controlling for marital status, only the ability to take a critical distance from representations remained significant A link was observed between increase in metacognition and symptom reduction at 6-month follow-up Understanding and tailoring interventions to specific metacognitive difficulties could be associated with symptom change during treatment for BPD patients.

Does interpersonal dependency affect therapeutic outcome? A meta-analytic review

This study examined whether interpersonal dependency affects therapeutic outcome, using meta-analytic techniques to synthesize results from 31 studies (49 effect sizes; overall N = 3807). High levels of dependency were associated with more positive outcome in psychodynamic therapy (r = 0.11, p < 0.05), but not cognitive-behavioural therapy (r = -0.05, ns), and were associated with a less positive outcome in pharmacological treatment (r = -0.15, p < 0.001). Other predictors of outcome included patient diagnosis (high levels of dependency were linked with more positive outcome for patients with anxiety disorders but not those with depression), outcome measure (high levels of dependency were associated with significantly greater improvement in global functioning but not symptom reduction) and dependency measure (cognitive and cognitive-behavioural dependency scales yielded less positive results than other types of measures). These results contribute to a growing body of literature examining effects of personality on treatment process and outcome. © 2019 John Wiley & Sons, Ltd.

Alternative Model of Personality Disorders (DSM-5) Predicts Dropout in Inpatient Psychotherapy for Patients With Personality Disorder

Objective

Criterion A serves as the fundamental diagnostic criterion of the Alternative Model of Personality Disorders in section III of the Diagnostic and Statistical Manual 5. Consisting of a self- and an interpersonal dimension, it defines the construct of personality functioning as a general and dimensional factor of personality disorders. This study aimed to explore criterion A along with well-established treatment dropout predictors, e.g., sociodemographic factors, personality disorder diagnosis, symptom severity, and the therapeutic alliance.

Methods

The sample consisted of 132 patients diagnosed with personality disorder in a psychotherapeutic inpatient treatment. Cox proportional hazard regression models and a lasso model were applied.

Results

28% of the sample prematurely discontinued treatment. The risk for dropout was 2.3 times higher for patients with high impairments in self-functioning as assessed with criterion A. Moreover, a positive therapist-rated therapeutic alliance was associated with a lower dropout risk.

Conclusion

The study suggests criterion A is a useful clinical indicator by identifying patients with personality disorder with a higher risk for dropout. An individualized therapeutic approach for such patients might be required.

Mental Representation in The Thought of Sidney Blatt: Developmental Processes

Mental representation was a central construct in Sidney Blatt's contributions to psychology and psychoanalysis. This brief review demonstrates that Blatt's understanding of representation was always informed by basic psychoanalytic concepts like the centrality of early caregiver-infant relationships and of unconscious mental processes. Although Blatt's earlier writings were informed by psychoanalytic ego psychology and Piagetian cognitive developmental psychology, they focused nonetheless on how an individual uses bodily and relational experiences to construct an object world; they also consistently presented object representations as having significant unconscious dimensions. From the mid-1980s onward, Blatt's contributions, in dialogue with his many students, moved in an even more experiential/relational direction and manifested the influence of attachment theory, parent-infant interaction research, and intersubjectivity theory. They also incorporated contemporary cognitive psychology, with its emphasis on implicit or procedural, rather than explicit, dimensions as a means of accounting for aspects of object representations that are not in conscious awareness. Throughout his career, however, Blatt regarded mental representation as the construct that mediates between the child's earliest bodily and relational experiences and the mature adult's symbolic, most emotionally profound capacities.

Changes in Self-Representations Following Psychoanalytic Psychotherapy for Young Adults: A Comparative Typology

Changes in dynamic psychological structures are often a treatment goal in psychotherapy. The present study aimed at creating a typology of self-representations among young women and men in psychoanalytic psychotherapy, to study longitudinal changes in self-representations, and to compare self-representations in the clinical sample with those of a nonclinical group. Twenty-five women and sixteen men were interviewed according to Blatt's Object Relations Inventory pretreatment, at termination, and at a 1.5-year follow-up. In the comparison group, eleven women and nine men were interviewed at baseline, 1.5 years, and three years later. Typologies of the 123 self-descriptions in the clinical group and 60 in the nonclinical group were constructed by means of ideal-type analysis for men and women separately. Clusters of self-representations could be depicted on a two-dimensional matrix with the axes Relatedness-Self-definition and Integration-Nonintegration. In most cases, the self-descriptions changed over time in terms of belonging to different ideal-type clusters. In the clinical group, there was a movement toward increased integration in self-representations, but above all toward a better balance between relatedness and self-definition. The changes continued after termination, paralleled by reduced symptoms, improved functioning, and higher developmental levels of representations. No corresponding tendency could be observed in the nonclinical group.

Psychopathological Functioning Levels (PFLs) and their possible relevance in psychiatric treatments: a qualitative research project

BACKGROUND

Symptoms description is often not enough to provide clinicians with guidelines for treatments and patients' clinical history does not represent an exhaustive source of data. Psychopathological dysfunctions are known to relate to the core disturbances that underlie different forms of psychopathology so the identification of such dysfunctions could be helpful for treatments. Some tools are available although highly complex and lengthy. This study aimed to provide clinicians with an easy-to-administer instrument able to capture different levels of impairment in psychopathological functioning, namely the Psychopathological Functioning Levels - Rating Scale (PFL-RS).

METHODS

The Psychopathological Functioning Level - Research and Training Committee (PFL-RTC) has been established in Turin since 2002 including psychiatrists and clinical psychologists with extensive clinical and research experience. Our research was grounded on the Qualitative Research Criteria (QRC) 1-7 and conducted with subsequent steps in order to identify those core psychopathological dysfunctions to be rated by this tool.

RESULTS

From 2002 until 2014, 316 outpatients were administered the clinical interview on at least two different occasions. Diagnoses were mixed and included: Schizophrenic and Psychotic Disorders, Depressive Disorders, Anxiety Disorders, Obsessive-Compulsive Disorder, Post- Traumatic Stress Disorder, Somatic Symptoms Disorders, Eating Disorders and Personality Disorders. Focus groups were conducted to identify those psychopathological dysfunctions which needed to be rated, according to two Phenomenological Selection Criteria (PhSC) and four Etiopathogenetic Selection Criteria (EtSC). As a result, five dysfunctional areas emerged: Identity (ID); Comprehension (CO); Negative Emotions (NE); Action-Regulation (AR); Social Skills (SS). After checking such dimensions for consistency with the existing instruments, 7 levels of severity were identified for each area. Finally, a provisional Italian schedule of Psychopathological Functioning Levels - Rating Scale (PFL-RS) was obtained and checked for semantic comprehension and then administered gathering preliminary data.

CONCLUSIONS

Psychopathological dysfunctions underlying mental disorders have been recognized in the present study with the PFL-RS. This instrument seems promising to inform in a specific way treatments strategies and goals, specifically concerning psychotherapy. Notwithstanding, further research is needed in order to confirm validity, sensitivity and reliability of this instrument.

Shape of the self-concept clarity change during group psychotherapy predicts the outcome: an empirical validation of the theoretical model of the self-concept change

BACKGROUND

Self-Concept Clarity (SCC) describes the extent to which the schemas of the self are internally integrated, well defined, and temporally stable. This article presents a theoretical model that describes how different shapes of SCC change (especially stable increase and "V" shape) observed in the course of psychotherapy are related to the therapy outcome. Linking the concept of Jean Piaget and the dynamic systems theory, the study postulates that a stable SCC increase is needed for the participants with a rather healthy personality structure, while SCC change characterized by a "V" shape or fluctuations is optimal for more disturbed patients.

METHOD

Correlational study in a naturalistic setting with repeated measurements (M = 5.8) was conducted on the sample of 85 patients diagnosed with neurosis and personality disorders receiving intensive eclectic group psychotherapy under routine inpatient conditions. Participants filled in the Self-Concept Clarity Scale (SCCS), Symptoms' Questionnaire KS-II, and Neurotic Personality Questionnaire KON-2006 at the beginning and at the end of the course of psychotherapy. The SCCS was also administered every 2 weeks during psychotherapy.

RESULTS

As hypothesized, among the relatively healthiest group of patients the stable SCC increase was related to positive treatment outcome, while more disturbed patients benefited from the fluctuations and "V" shape of SCC change.

CONCLUSIONS

The findings support the idea that for different personality dispositions either a monotonic increase or transient destabilization of SCC is a sign of a good treatment prognosis.

A psychoanalytically informed hospitalization-based treatment of personality disorders

This study presents a model of psychic change in personality disorders focusing on three dimensions: felt safety, mentalization and self-object relations. Based upon this model a hospitalization-based therapy program was created. Four scales to measure these three dimensions on the Object Relation Interview are discussed: the Felt Safety Scale, the Reflective Functioning Scale and the Bion Grid Scale and the Differentiation-Relatedness Scale. A naturalistic symptom outcome study of the program showed a large effect on both symptoms and personality functioning. Furthermore, trajectory based on pre-treatment patient characteristics (i.e., anaclitic versus introjective personality styles). Importantly, we also found a relation between symptomatic and personality change and change in felt safety and object relations. At 5-year follow-up, patients showed sustained improvement in symptomatic distress and further improvement in terms of personality and interpersonal functioning.