[Psychoanalysis and psychoanalytic oriented psychotherapy: differences and similarities]

The multi-level outcome study of psychoanalysis for chronically depressed patients with early trauma (MODE): rationale and design of an international multicenter randomized controlled trial

BACKGROUND

Whether and how psychotherapies change brain structure and function is unknown. Its study is of great importance for contemporary psychotherapy, as it may lead to discovery of neurobiological mechanisms that predict and mediate lasting changes in psychotherapy, particularly in severely mentally ill patients, such as those with chronic depression. Previous studies have shown that psychoanalytic psychotherapies produce robust and enduring improvements in not only symptom severity but also personality organization in patients who have chronic depression and early life trauma, especially if therapy is delivered at a high weekly frequency.

METHODS/DESIGN

Patients with chronic major depression and a history of early life trauma will be recruited, assessed, and treated across 3 international sites: Germany, Switzerland, and the United States. They will be randomized to one of two treatment arms: either (1) once weekly psychoanalytic psychotherapies, or (2) 3-4 times weekly psychoanalytic psychotherapies. They will have full clinical characterization as well as undergo MRI scanning at study baseline prior to randomization and again one year later. A group of matched healthy controls will undergo similar assessments and MRI scanning at the same time points to help discern whether study treatments induce brain changes toward or away from normal values. Primary study outcomes will include anatomical MRI, functional MRI, and Diffusion Tensor Imaging measures. Study hypotheses will be tested using the treatment-by-time interaction assessed in multiple general linear models with repeated measures analyses in an intent-to-treat analysis.

DISCUSSION

MODE may allow the identification of brain-based biomarkers that may be more sensitive than traditional behavioral and clinical measures in discriminating, predicting, and mediating treatment response. These findings could help to personalize care for patients who have chronic depression patients and early life trauma, and they will provide new therapeutic targets for both psychological and biological treatments for major depressive illness.

Affect regulation in psychoanalytic treatments of patients with a borderline personality disorder–psychoanalysis and psychodynamic psychotherapy–a comparison

BACKGROUND

A recent meta-analysis has confirmed that the effects of psychotherapy on patients with borderline personality disorders (BPD) are still insufficiently understood. Evidence of differences between different types of therapies has been questioned.

AIM

To study repetitive interaction patterns in patients with BPD undergoing either psychoanalysis or psychodynamic therapy.

METHODS

Psychoanalysis (PSA) or psychodynamic psychotherapy (PDT) was administered to 10 patients each, the two groups were matched. Therapy regimens were applied according to care as usual/manualized including quality control and supervision as usual. Randomization to one of the groups was done after baseline assessment. During classical PSA (n = 10) and PDT (n = 10), semiannually, recordings (audio or video) of five consecutive therapy sessions were taken over three years for an ex-post analysis. The patients' characteristics, such as affect parameters [Affect regulation and experience Q-sort (AREQ)], quality of object relations (quality of object relations scale) and personality traits [Shedler-Westen Assessment Procedure (SWAP-200)] were analyzed retrospectively by independent raters. Therapeutic action (psychotherapy process Q-sort) and affective (re)actions of the patients (AREQ) were then analyzed in relation to changes found in the patients' characteristics.

RESULTS

During the first year of therapy (PSA: n = 10; PDT: n = 9), the therapeutic method PSA was associated with significant improvements in the variable "SWAP Borderline", while in PDT change was not significantly different to baseline (PSA: P = 0.04; PDT: P = 0.33). Long-term results and follow up was available for seven participants in PSA and for five in PDT after three years; change in SWAP borderline for the whole sample was not significant at this time point when confronting to baseline (P = 0.545). However, differences between PSA and PDT were significant when analyzing the “mean change” in the SWAP Borderline variable after one year of therapy (P = 0.024): PSA led to slightly increased BPD symptoms, while PDT to a decrease; for the long run, variance of observed change was higher in PSA than in PDT (SD_PSA ± 9.29 vs SD_PDT ± 7.94). Our assumption that transference interpretations, closely followed by affective changes in the patient, could be useful modes of interaction was reproducible in our findings, especially when looking at the descriptive findings in the long-term data. The analysis of repetitive interaction structures demonstrated a very specific "time-lag" between therapeutic intervention and a corresponding increase in positive affect in successful therapy cases.

CONCLUSION

Exploring the change processes in the patients' characteristics and linking these changes to specific treatment strategies is of clinical importance when starting treatment and for its long-term progress.