Cassel Personality Disorder Study. Methodology and treatment effects

Finding Psychodynamic Psychiatry's Lost Generation

This paper describes forces that have adversely affected the place of the psychodynamic perspective within psychiatric practice and training over the last generation. One effect of these forces has been to create a lost generation of psychiatrists with little knowledge or experience with psychodynamic treatment. The article addresses opportunities to reverse some of the detrimental effects of recent changes. The Residency Review Committee's introduction of a requirement that residents achieve a measurable level of competence in five schools of psychotherapy represents a major opportunity to influence psychiatric training and practice. The past and present work of the Committee on Psychotherapy by Psychiatrists (COPP) is summarized, including efforts to integrate and revise the five existing core competencies in psychotherapy into a "Y"-shaped model in a way that secures the future of psychodynamic therapy training in residencies. One existing unusual training opportunity with a central psychodynamic focus is described.

Specialist personality disorder services in England: a case for managed clinical networks?

Following the publication by the National Institute for Mental Health in England (NIMHE) of Personality Disorder: No Longer A Diagnosis of Exclusion (National Institute for Mental Health in England, 2003), it is perhaps surprising that so soon after there have been threats to the survival of some of the small number of existing specialist personality disorder services to which it refers. Indeed, one of the few in-patient units specialising in such disorders (Webb House in Crewe) closed in July 2004. Such closures or threats argue for closer collaboration in planning between the relevant secondary and tertiary services and also between the Department of Health, the NIMHE and local National Health Service commissioners. Not safeguarding existing tertiary specialist services, at a time of increasing awareness of the needs of patients with personality disorders, may be short-sighted.

Therapeutic community research: past, present and future

This paper gives an outline of four research areas examining therapeutic community practice: an international systematic review, health economics cost-offset work, a cross-institutional multi-level modelling outcome study and a proposed action research project to deliver continuous quality improvement in all British therapeutic communities. Results of the first two have been published and are summarised here; the third is under way and the fourth is seeking funding.

Four years comparative follow-up evaluation of community-based, step-down, and residential specialist psychodynamic programmes for personality disorders

Although the fulcrum of service provision for personality disorder (PD) has shifted from hospital-based to psychodynamically- and cognitively-oriented outpatient programmes, very few studies have attempted to compare specialist moderate intensity outpatient programmes with specialist high-intensity residential models, or to explore whether a period of inpatient treatment may be necessary to improve outcome and prognosis. In this article, we prospectively compare changes over a 4-year period in 3 groups of patients with personality disorders (N = 162) treated in a specialist community-based (CBP, N = 30), a step-down (RT-CBP, N = 87), and a specialist residential programme (RT, N = 45) in psychiatric distress, deliberate self-injury, and suicide attempt using multilevel modelling and multivariate logistic regression analyses. The results showed that percentages of early-dropout were significantly different (p = .0001) for the 3 programmes (CBP = 13.4%, RT-CBP = 10.2%, and RT = 41.4%). A significant interaction between treatment model and time was found for psychiatric distress (p = .001), with CBP and RT-CBP achieving more marked changes (g = 1.20 and g = 0.68, respectively) compared to RT (g = 0.30) at 48-month follow-up. CBP and RT-CBP were found to significantly reduce impulsive behaviour (deliberate self-injury and suicide attempt) compared to RT. Severity of presentation was not found to be a significant predictor of outcome. Long-term RT showed no advantage over long-term CBP, either as stand-alone or as step-down treatment. Replication may be needed to confirm generalizability of results, and a number of limitations in the study design may moderate the inferences that can be drawn from the results.

Mapping the road from childhood adversity to personality disorder: The role of unresolved states of mind

Childhood adversity has been found to be an important aetiological factor in the development of personality disorder (PD) in several studies. However, the role of disorganized attachment with unresolved mental states for traumatic experiences requires further investigation. This study explores the relationship between childhood adversities, unresolved states of mind, PD diagnosis and psychiatric distress. Two hundred forty-five adult participants, 124 from a clinical PD group and 121 non-psychiatric controls were assessed using the Structured Clinical Interview for DSM-IV, the Cassel Baseline Questionnaire, the Symptom Checklist-90-R and the Adult Attachment Interview, in order to ascertain presence of PD, childhood adversity, level of psychiatric distress and unresolved states of mind. Within the overall unresolved (U-overall) attachment category, a distinction was made between unresolved for abuse (U-abuse) and unresolved for loss (U-loss). The results indicated that childhood adversity was significantly associated with unresolved states of mind, as well as with overall PD diagnosis, paranoid PD, borderline PD, avoidant PD and psychiatric distress. Mediation analyses confirmed that U-overall and U-loss were significant mediators between childhood adversity and PD diagnoses, but surprisingly, U-abuse was not a significant mediator. The strength, limitations and clinical implications of the findings are discussed. Copyright © 2017 John Wiley & Sons, Ltd.

Categorical and dimensional approaches in the evaluation of the relationship between attachment and personality disorders: an empirical study

Although several studies have highlighted the relationship between attachment states of mind and personality disorders, their findings have not been consistent, possibly due to the application of the traditional taxonomic classification model of attachment. A more recently developed dimensional classification of attachment representations, including more specific aspects of trauma-related representations, may have advantages. In this study, we compare specific associations and predictive power of the categorical attachment and dimensional models applied to 230 Adult Attachment Interview transcripts obtained from personality disordered and nonpsychiatric subjects. We also investigate the role that current levels of psychiatric distress may have in the prediction of PD. The results showed that both models predict the presence of PD, with the dimensional approach doing better in discriminating overall diagnosis of PD. However, both models are less helpful in discriminating specific PD diagnostic subtypes. Current psychiatric distress was found to be the most consistent predictor of PD capturing a large share of the variance and obscuring the role played by attachment variables. The results suggest that attachment parameters correlate with the presence of PD alone and have no specific associations with particular PD subtypes when current psychiatric distress is taken into account.

Treatment of personality disorder

The evidence base for the effective treatment of personality disorders is insufficient. Most of the existing evidence on personality disorder is for the treatment of borderline personality disorder, but even this is limited by the small sample sizes and short follow-up in clinical trials, the wide range of core outcome measures used by studies, and poor control of coexisting psychopathology. Psychological or psychosocial intervention is recommended as the primary treatment for borderline personality disorder and pharmacotherapy is only advised as an adjunctive treatment. The amount of research about the underlying, abnormal, psychological or biological processes leading to the manifestation of a disordered personality is increasing, which could lead to more effective interventions. The synergistic or antagonistic interaction of psychotherapies and drugs for treating personality disorder should be studied in conjunction with their mechanisms of change throughout the development of each.

Developmental trauma disorder: an attachment-based perspective

Despite the evidence linking chronic early trauma with psychological distress, the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) has excluded developmental trauma disorder from its taxonomy. This article considers developmental trauma from an attachment-based perspective and raises some of the difficulties professionals may experience conceptualising the trauma-attachment relationship. It explores the impact of the decision to exclude the diagnosis from DSM-5 on professionals, those who have had traumatic early experiences and their carers. Finally, it presents formulation as an alternative proposition which may better suit those who present to mental health services with attachment- and trauma-linked difficulties.

Is the residential combined (psychotherapy plus medication) treatment of patients with severe personality disorder effective in terms of suicidality and impulsivity?

The aim of this study was to compare the effectiveness of combined treatment-medication plus psychodynamic psychotherapy-and psychodynamic psychotherapy alone on the outcome variables of suicidality and impulsivity in a population of adult inpatients with severe personality disorder (SPD). This is a naturalistic-empirical (observational) study under the conditions of clinical practice (an intensive specialized inpatient psychotherapeutic program [SIPP]). The sample consisted of 33 inpatients with SPD who were allocated to two subgroups (groups A and B). The patients in group A received psychodynamic psychotherapy and adjunctive pharmacotherapy, whereas the patients in group B received multimodal psychodynamic psychotherapy only. A statistically significant reduction in suicidality score was observed in the patients in group A, whereas a tendency for significant reduction in impulsivity score was observed in group B after the SIPP termination. Pharmacotherapy combined with multimodal psychodynamic psychotherapy, always within the SIPP, seems more effective in the case of suicidality rather than impulsivity.

Reflective function as a mediator between childhood adversity, personality disorder and symptom distress

A growing body of literature has indicated the central role of childhood adversity for the development in later life of personality disorder (PD) and psychiatric distress. In this investigation, we examine the role of reflective function (RF) as a mediator between childhood adversity, subsequent development of PD and psychiatric morbidity. We tested the hypothesis that adversity leads to decreased RF, which in turn is associated with PD, and both increase the likelihood of psychiatric distress. The study sample consisted of 234 individuals, drawn from a clinical PD group (n = 112) and one demographically matched non-psychiatric group (n = 122) using a shared battery of measures, which included the Structured Clinical Interview for DSM-IV, the Symptom Checklist-90-R and the Adult Attachment Interview, which was used to assess RF levels. The results indicated that childhood adversity predicted low level of RF, which in turn was associated with PD onset later in life. A combination of different early adverse experiences had a significantly greater impact on lowering RF scores than experiencing either neglect or abuse alone. Mediation analyses confirmed that RF was a significant mediator between adversity and PD diagnoses and between adversity and psychiatric distress.

How personality became treatable: The mutual constitution of clinical knowledge and mental health law

In recent years, personality disorders – psychiatric constructs understood as enduring dysfunctions of personality – have come into ever-greater focus for British policymakers, mental health professionals and service-users. Disputes have focussed largely on highly controversial attempts by the UK Department of Health to introduce mental health law and policy (now enshrined within the 2007 Mental Health Act of England and Wales). At the same time, clinical framings of personality disorder have dramatically shifted: once regarded as untreatable conditions, severe personality disorders are today thought of by many clinicians to be responsive to psychiatric and psychological intervention. In this article, I chart this transformation by means of a diachronic analysis of debates and institutional shifts pertaining to both attempts to change the law, and understandings of personality disorder. In so doing, I show how mental health policy and practice have mutually constituted one another, such that the aims of clinicians and policymakers have come to be closely aligned. I argue that it is precisely through these reciprocally constitutive processes that the profound reconfiguration of personality disorder from being an obdurate to a plastic condition has occurred; this demonstrates the significance of interactions between law and the health professions in shaping not only the State’s management of pathology, but also perceptions of its very nature.

Psychological therapies for people with borderline personality disorder

BACKGROUND

Psychotherapy is regarded as the first-line treatment for people with borderline personality disorder. In recent years, several disorder-specific interventions have been developed. This is an update of a review published in the Cochrane Database of Systematic Reviews in 2006.

OBJECTIVES

To assess the effects of psychological interventions for borderline personality disorder (BPD).

SEARCH METHODS

We searched the following databases: CENTRAL 2010(3), MEDLINE (1950 to October 2010), EMBASE (1980 to 2010, week 39), ASSIA (1987 to November 2010), BIOSIS (1985 to October 2010), CINAHL (1982 to October 2010), Dissertation Abstracts International (31 January 2011), National Criminal Justice Reference Service Abstracts (15 October 2010), PsycINFO (1872 to October Week 1 2010), Science Citation Index (1970 to 10 October 2010), Social Science Citation Index (1970 to 10 October 2010), Sociological Abstracts (1963 to October 2010), ZETOC (15 October 2010) and the metaRegister of Controlled Trials (15 October 2010). In addition, we searched Dissertation Abstracts International in January 2011 and ICTRP in August 2011.

SELECTION CRITERIA

Randomised studies with samples of patients with BPD comparing a specific psychotherapeutic intervention against a control intervention without any specific mode of action or against a comparative specific psychotherapeutic intervention. Outcomes included overall BPD severity, BPD symptoms (DSM-IV criteria), psychopathology associated with but not specific to BPD, attrition and adverse effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the risk of bias in the studies and extracted data.

MAIN RESULTS

Twenty-eight studies involving a total of 1804 participants with BPD were included. Interventions were classified as comprehensive psychotherapies if they included individual psychotherapy as a substantial part of the treatment programme, or as non-comprehensive if they did not.Among comprehensive psychotherapies, dialectical behaviour therapy (DBT), mentalisation-based treatment in a partial hospitalisation setting (MBT-PH), outpatient MBT (MBT-out), transference-focused therapy (TFP), cognitive behavioural therapy (CBT), dynamic deconstructive psychotherapy (DDP), interpersonal psychotherapy (IPT) and interpersonal therapy for BPD (IPT-BPD) were tested against a control condition. Direct comparisons of comprehensive psychotherapies included DBT versus client-centered therapy (CCT); schema-focused therapy (SFT) versus TFP; SFT versus SFT plus telephone availability of therapist in case of crisis (SFT+TA); cognitive therapy (CT) versus CCT, and CT versus IPT.Non-comprehensive psychotherapeutic interventions comprised DBT-group skills training only (DBT-ST), emotion regulation group therapy (ERG), schema-focused group therapy (SFT-G), systems training for emotional predictability and problem solving for borderline personality disorder (STEPPS), STEPPS plus individual therapy (STEPPS+IT), manual-assisted cognitive treatment (MACT) and psychoeducation (PE). The only direct comparison of an non-comprehensive psychotherapeutic intervention against another was MACT versus MACT plus therapeutic assessment (MACT+). Inpatient treatment was examined in one study where DBT for PTSD (DBT-PTSD) was compared with a waiting list control. No trials were identified for cognitive analytical therapy (CAT).Data were sparse for individual interventions, and allowed for meta-analytic pooling only for DBT compared with treatment as usual (TAU) for four outcomes. There were moderate to large statistically significant effects indicating a beneficial effect of DBT over TAU for anger (n = 46, two RCTs; standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.43 to -0.22; I(2) = 0%), parasuicidality (n = 110, three RCTs; SMD -0.54, 95% CI -0.92 to -0.16; I(2) = 0%) and mental health (n = 74, two RCTs; SMD 0.65, 95% CI 0.07 to 1.24 I(2) = 30%). There was no indication of statistical superiority of DBT over TAU in terms of keeping participants in treatment (n = 252, five RCTs; risk ratio 1.25, 95% CI 0.54 to 2.92).All remaining findings were based on single study estimates of effect. Statistically significant between-group differences for comparisons of psychotherapies against controls were observed for BPD core pathology and associated psychopathology for the following interventions: DBT, DBT-PTSD, MBT-PH, MBT-out, TFP and IPT-BPD. IPT was only indicated as being effective in the treatment of associated depression. No statistically significant effects were found for CBT and DDP interventions on either outcome, with the effect sizes moderate for DDP and small for CBT. For comparisons between different comprehensive psychotherapies, statistically significant superiority was demonstrated for DBT over CCT (core and associated pathology) and SFT over TFP (BPD severity and treatment retention). There were also encouraging results for each of the non-comprehensive psychotherapeutic interventions investigated in terms of both core and associated pathology.No data were available for adverse effects of any psychotherapy.

AUTHORS' CONCLUSIONS

There are indications of beneficial effects for both comprehensive psychotherapies as well as non-comprehensive psychotherapeutic interventions for BPD core pathology and associated general psychopathology. DBT has been studied most intensely, followed by MBT, TFP, SFT and STEPPS. However, none of the treatments has a very robust evidence base, and there are some concerns regarding the quality of individual studies. Overall, the findings support a substantial role for psychotherapy in the treatment of people with BPD but clearly indicate a need for replicatory studies.

Predictors of dropout among personality disorders in a specialist outpatients psychosocial treatment: a preliminary study

AIM

The aim of this study was to identify factors that may affect treatment retention in a 1-year psychosocial program for adult personality disorders.

METHODS

The sample consists of patients admitted to the Adult Personality Disorder Outpatient Programme of the Bologna Community Mental Health Centre in the period 2003-2008. At the beginning of the program, patients were evaluated through a comprehensive assessment including sociodemographic form, diagnostic interviews and self-report questionnaires. Patients who dropped out from treatment were retrospectively compared with patients who completed the program.

RESULTS

Out of 39 patients enrolled in the program, 20 (51.3%) dropped out and 19 (48.7%) completed the treatment. Out of 20 patients who dropped out, 14 terminated the treatment within the first 2 months. The dropout group and the group which remained showed significant differences in diagnosis (borderline personality disorder [BPD]), demographic data (age, time from first contact with psychiatric services), clinical variable (impulsiveness) and subjective experience (motivation, treatment expectation, therapeutic relation perception and barriers to access). BPD and subjective evaluation were found to be predictors of premature termination in the sample. In detail, BPD patients who experienced a less satisfactory therapeutic relationship and reported many external problems were more likely to drop out of the program.

CONCLUSION

Important factors contributing to dropout were identified, with potential implication for clinical practice. Further efforts need to be made to find ways to retain BPD patients who find the first subjective experience of the service more problematic.

Controversies surrounding classification of personality disorder

Nowadays, it is apparent that personality disorder is a common condition. Some of the concepts of personality disorder that are currently in use are flawed and need to be revised. The aim of this article is to discuss the controversy created by the uncertainties in the current classification system and to suggest ways forward. In particular, the clinician needs to be aware of the importance of assessing personality abnormality in terms of a severity dimension, and of the ways in which such an abnormality can impact on treatments for other conditions. These changes in the notion of personality disorder are needed as, for the first time, a good evidence base is being established for potential treatments and these will be maximized if we have a classification fit for therapeutic purpose.

The struggle to establish a research culture in the psychotherapy hospital: reflections from the Cassel Hospital experience

The institutional impact and defensive reactions to the results of a longitudinal controlled outcome trial carried out within a psychotherapy hospital specializing in the treatment of personality disorder are described and discussed. The authors argue that integration of research findings with clinical practice, the development of a research culture, and building bridges with other disciplines such as psychology and neuroscience will enhance the prospect of long-term survival of psychoanalytically oriented institutions.

Psychiatric morbidity and treatment pathway outcomes of patients presenting to specialist NHS psychodynamic psychotherapy services: results from a multi-centre study

OBJECTIVE

Little is known about socio-demographic, diagnostic, and clinical characteristics of patients referred for assessment to psychodynamic psychotherapy services. The aim of this study was to remedy this by prospectively collecting comprehensive and systematic demographic and clinical information on a large number of patients referred to NHS psychodynamic psychotherapy services.

DESIGN

Fourteen psychotherapy services operating within a National Health Service joined the study and contributed data for 1,136 patients referred from primary and secondary care clinics.

METHOD

Patients were assessed using questionnaires and self-rated measures, which included the clinician-based version of the diagnostic form of the Millon clinical multi-axial inventory-III-revised edition (MCMI-III-R), the brief symptom inventory (BSI), the inventory of interpersonal problems (IIP), and the clinical outcome in routine evaluation (CORE). The pathway from assessment through to treatment and variables associated with treatment uptake and exclusion are described and examined.

RESULTS

Most patients were in the moderate to severe range of psychiatric severity at the time of presentation. Ninety-five percent met clinically based criteria for a psychiatric disorder (mostly anxiety and mood disorders) and/or personality disorder. Although the majority of patients were found suitable for treatment (N=935, 82%), analysis of uptake showed relatively high rates of treatment rejection by patients and treatment drop-out. Partial outcome data at 6-month follow-up after intake into treatment revealed significant change but modest effect size (d=0.35).

CONCLUSION

Systematic collection of baseline and outcome data would provide a national database of the performance of psychotherapy services that would be invaluable in facilitating comparative studies.

Substance use disorders among personality disordered patients admitted for day hospital treatment. Implications for service developments

Personality disorders (PD) and substance use disorders (SUD) are highly comorbid conditions. However, their treatment services are often separated. The aims of this study was to investigate how extensive this separation was prior to a Norwegian health reform (2004) that promoted integration, and to discuss clinical challenges for an integrated treatment of PD and SUD. All patients with a diagnosis of PD (n=1783) admitted to 10 day hospital treatment programs (1993-2003) were examined. Diagnoses were assessed by Mini International Neuropsychiatric Interview and Structured Clinical Interview for DSM-IV interviews. Socio-demographic data, psychosocial functioning (Global Assessment of Functioning Scale), symptom distress (Symptom Check List-90-Revised), interpersonal problems (Circumplex of Interpersonal Problems) and treatment course were recorded. The majority of patients were females (72%) and the prevalence of SUD was low (14%). SUD occurred among all PD categories. Patients with borderline PD were over-represented and patients with cluster C disorders were under-represented in the SUD sample. The SUD sample contained more men and it was associated with more previous violence against self and others. The reported violence was partly explained by gender (males) and diagnoses (borderline and SUD). PD patients with SUD also displayed more aggression during treatment and dropped out more frequently. The findings demonstrate that the female dominated specialized psychiatric treatment services for PD to a large extent had excluded PD patients who also had SUD. The reasons are probably related to the surplus problems that characterized the SUD sample and gender issues. Implications for the development of the PD and SUD services with respect to an integrated treatment for these comorbid conditions are discussed.

QEEG guided neurofeedback therapy in personality disorders: 13 case studies

According to DSM-IV, personality disorder constitutes a class only when personality traits are inflexible and maladaptive and cause either significant functional impairment or subjective distress. Classical treatment of choice for personality disorders has been psychotherapy and/or psychopharmacotherapy. Our study is to determine if subjects with antisocial personality disorders will benefit from quantitative EEG (qEEG) guided neurofeedback treatment. Thirteen subjects (9 male, 4 female) ranged in age from 19 to 48 years. All the subjects were free of medications and illicit drugs. We excluded subjects with other mental disorders by clinical assessment. Psychotherapy or psychopharmacotherapy or any other treatment model was not introduced to any of the subjects during or after neurofeedback treatment. For the subject who did not respond to neurofeedback, training was applied with 38 sessions of LORETA neurofeedback training without success. Evaluation measures included qEEG analysis with Nx Link data base, MMPI, T.O.V.A tests and SA-45 questionaries at baseline, and at the end of neurofeedback treatment. Lexicor qEEG signals were sampled at 128 Hz with 30 minutes-neurofeedback sessions completed between 80-120 sessions depending on the case, by Biolex neurofeedback system. At baseline and after every 20 sessions, patients were recorded with webcam during the interview. Twelve out of 13 subjects who received 80-120 sessions of neurofeedback training showed significant improvement based on SA-45 questionaries, MMPI, T.O.V.A. and qEEG/Nx Link data base (Neurometric analysis) results, and interviewing by parent/family members. Neurofeedback can change the view of psychiatrists and psychologists in the future regarding the treatment of personality disorders. This study provides the first evidence for positive effects of neurofeedback treatment in antisocial personality disorders. Further study with controls is warranted.

Prediction of medium-term outcome in cluster B personality disorder following residential and outpatient psychosocial treatment

BACKGROUND

There is a paucity of research concerning the identification of individual characteristics predictive of outcome in the treatment of personality disorders (PDs).

METHODS

In this study, we carried out a predictor analysis of a sample of 73 hospitalized patients with a primary diagnosis of cluster B PD admitted to two different psychosocial programs for PD: (a) long-term inpatient treatment, and (b) a step-down program.

RESULTS

Younger age, higher Global Assessment Scale intake scores, longer length of treatment, absence of self-mutilation and avoidant PDs were a significant predictor of outcome at 24-month follow-up. Self-harming patients allocated to the step-down program had higher rates of improvement compared with patients allocated to the long-term inpatient model.

CONCLUSIONS

The findings may carry potential clinical implications concerning patient selection and treatment delivery for inpatient and outpatient psychosocial programs for cluster B PD. Limitations include a relatively low sample size for a regression analysis, and a larger sample of cluster B patients may be needed to ensure greater reliability of results.

Differences in clinical characteristics between patients assessed for NHS specialist psychotherapy and primary care counselling

OBJECTIVES

Although several studies have described patient populations in primary care counselling settings and NHS (National Health Service) specialist psychotherapy settings, there is a paucity of studies specifically comparing differences in clinical characteristics between the two groups of patients. The aim of this study is to ascertain if specialist psychotherapy referrals represent a more challenging client group than primary care counselling patients.

DESIGN

We compare the socio-demographic features and severity of presentation in the symptomatic, interpersonal problems and global adjustment dimensions of a sample of patients (N=384) assessed by a primary care counselling service located in North London and a sample of patients (N=853) assessed in eight NHS psychotherapy centres located within urban settings in England.

METHODS

Both the groups completed the Brief Symptom Inventory, the Inventory of Interpersonal Problems and Clinical Outcomes in Routine Evaluation Outcome Measure.

RESULTS

Patients referred for specialist psychotherapy services were more dysfunctional than those referred for primary care counselling. The linear function constructed to discriminate the groups showed that a combination of more psychotic symptoms, social inhibitions and higher risk of self-harm effectively identified those referred to psychotherapy services, while patients exhibiting greater levels of somatic and anxiety symptoms and non-assertiveness were more likely to be seen in primary care settings. However, similarities between the two samples were also marked, as shown by the overlap in the distribution of clinical outcomes in routine evaluation clinical scores in the two samples.

CONCLUSIONS

The findings are discussed in terms of their implications for policy and service delivery of these two types of psychological therapy services.

The efficacy of various modalities of psychotherapy for personality disorders: a systematic review of the evidence and clinical recommendations

The aim of this paper is to review the level of empirical evidence for four different formats and settings that are available for psychotherapy delivery, i.e., group psychotherapy, out-patient individual psychotherapy, day hospital psychotherapy, and in-patient psychotherapy. The focus is on studies which include a wide range of DSM-IV-TR Axis II personality disorders. The results show that various psychotherapeutic treatments have proven to be efficacious with respect to reducing symptomatology and personality pathology, and improving social functioning in patients with Cluster A, B, C, or not-otherwise-specified personality disorders. This is especially true for cognitive-behaviorally or psychodynamically oriented out-patient individual psychotherapies. However, some evidence indicates that this also applies to (1) long-term, psychodynamically oriented group psychotherapy, (2) short-term, psychodynamically oriented psychotherapy in a day hospital setting, and (3) various duration variants of psychodynamically oriented, in-patient psychotherapy programmes. The available evidence mostly applies to borderline, dependent, avoidant and not-otherwise-specified personality disorder, and perhaps also paranoid, obsessive-compulsive, and schizotypal personality disorder. It is unknown whether these conclusions also apply to schizoid, antisocial, narcissistic, and histrionic personality disorder.

Advances in psychotherapy of personality disorders: a research update

This article reviews psychotherapy studies published between 2003 and 2006 directed at psychotherapy for personality disorders (PDs). Over the past 3 years, there has been a substantial increase in these studies compared with previous decades. Psychodynamic therapy, cognitive-behavioral therapy, and variants of these approaches have been evaluated and shown to have positive results. Borderline personality disorder continues to garner the most attention and has been shown to respond favorably to several types of therapeutic interventions on a range of outcomes. Avoidant personality disorder and obsessive-compulsive personality disorder also respond positively to psychotherapy. Although growing attention to the treatment of PDs is encouraging, further research is indicated. A summary of recent empirical findings and their implications for clinical practice are discussed.

A view from Riggs--treatment resistance and patient authority: I. A psychodynamic perspective on treatment resistance

Treatment resistance has emerged as a significant issue in our era emphasizing biological treatments for psychiatric disorders. This article suggests that, particularly when Axis II disorders are part of the clinical presentation, a subset of treatment refractory patients responds to a psychodynamic treatment approach that includes careful attention to the meaning of treatment resistance, and to the importance of relationships and of patient authority in recovery. The importance of engaging the negative transference and countertransference in treatment is also emphasized. A case example is offered to illustrate the article's thesis.

Finding Psychodynamic Psychiatry's Lost Generation

This paper describes forces that have adversely affected the place of the psychodynamic perspective within psychiatric practice and training over the last generation. One effect of these forces has been to create a lost generation of psychiatrists with little knowledge or experience with psychodynamic treatment. The article addresses opportunities to reverse some of the detrimental effects of recent changes. The Residency Review Committee's introduction of a requirement that residents achieve a measurable level of competence in five schools of psychotherapy represents a major opportunity to influence psychiatric training and practice. The past and present work of the Committee on Psychotherapy by Psychiatrists (COPP) is summarized, including efforts to integrate and revise the five existing core competencies in psychotherapy into a "Y"-shaped model in a way that secures the future of psychodynamic therapy training in residencies. One existing unusual training opportunity with a central psychodynamic focus is described.

The costs and effectiveness of two psychosocial treatment programmes for personality disorder: a controlled study

This paper examines the costs and cost-effectiveness of psychosocial treatment for personality disorder in a controlled study. Using well-validated cost and outcome measures three groups are compared: the One-Stage group (n=32) received 12 months of inpatient treatment; the Step-Down group (n=29) received 6 months of inpatient treatment followed by 12 months of outpatient therapy; and the control group of 47 people used routinely available services. Both specialist programmes were more effective than routine psychiatric services but more costly. Using an extended dominance approach the incremental cost-effectiveness ratio showed that achieving one extra person with clinically relevant outcomes required an investment in the Step-Down programme of around 3400 pound sterling over 18 months. Small sample sizes and non-random allocation to programmes are limitations of this study but the costs and effectiveness findings consistently point to advantages for the shorter residential programme followed by community-based psychotherapeutic support.

Psychodynamic psychotherapies: Evidence-based practice and clinical wisdom

This article is based on an exhaustive review of the psychotherapy outcomes literature, undertaken originally at the instigation of the UK Department of Health by Roth and Fonagy (Department of Health, 1995). We have recently updated this review (Fonagy, Target, Cottrell, Phillips, & Kurtz, 2002; Roth & Fonagy, 2004) and extended it to identify all studies of psychoanalytic psychotherapy. The usual methods for identifying studies were employed (Fonagy, Target, et al., 2002; Roth & Fonagy, in press). The key questions that should be asked of this literature given the current state of research in this area (also see Westen, Morrison, & Thompson-Brenner, 2004) are: Are there any disorders for which short-term psychodynamic psychotherapy (STPP) can be considered evidence-based, Are there any disorders for which STPP is uniquely effective as either the only evidence-based treatment or as a treatment that is more effective than alternatives, and Is there any evidence base for long-term psychodynamic psychotherapy (LTPP) either in terms of achieving effects not normally associated with short-term treatment or addressing problems that have not been addressed by STPP? In this context, short-term therapy is conceived of as a treatment of around 20 sessions delivered usually once weekly.

Borderline personality disorder: attitudinal change following training

OBJECTIVE

To assess the effect of a two-day training workshop on clinician attitudes to working with people with borderline personality disorder (BPD). The main goal of the workshop was to achieve positive change in the attitude of clinicians treating people with BPD in a public setting. The hypothesis underlying the intervention was that informing clinicians about current concepts of the diagnosis, aetiology, prognosis and treatment of BPD, combined with detailed discussion of the principles of treatment in the public setting, would result in positive attitude change.

METHOD

Changes in attitudes (optimism, enthusiasm, confidence and willingness to work with people with BPD) and self-perceptions of knowledge and skills among staff working with BPD patients were assessed for 418 participants from public mental health and substance abuse services who attended the workshops over an 18-month period. A survey questionnaire was administered pre- and post-workshop and at 6 month follow-up (time 1, time 2, time 3, respectively). One-way repeated measures analysis of variance (anova) were carried out to compare scores on attitudes and perceptions of knowledge and skills at time 1, time 2 and time 3.

RESULTS

The results from repeated measures anova show that there was a statistically significant effect for time for all six items. Analyses of within-subject contrasts indicated that, for all six variables, the time 2 and the time 3 scores were statistically significantly different from time 1 scores (p < 0.01). These findings confirm that there were statistically significant changes at the post-workshop assessment, which were either maintained or showed a non-significant decrease at 6-month follow-up.

CONCLUSIONS

The brief training workshop described was effective in achieving positive attitude change in clinicians working with patients with BPD. This research shows that it is possible through brief training to assist clinician positivity and to effect clinician attitude change. Implications of this research could include the influencing of future training of clinicians in public mental health and substance abuse fields.

A culture of enquiry: research evidence and the therapeutic community

This paper presents data from a systematic review and meta-analysis of 29 published studies of therapeutic community effectiveness using controls, including 8 randomised control trials. Meta-regressions suggest that the two types of therapeutic community, democratic and concept-based, and the age of the study, are the key sources of heterogeneity in the collection of studies analysed. Otherwise, heterogeneity is low and the meta-analysis confirms the effectiveness of therapeutic community treatment with overall summary log odds ratio for the 29 studies of 0.512 (95% ci -0.598 to -0.426).

Effectiveness of nursing interventions in people with personality disorders

BACKGROUND

Nurses usually provide care for people with personality disorders on a day-to-day basis. Consequently, it is important to establish how effective nursing interventions are for those with personality disorders, both in terms of general management and more specific therapeutic approaches. These are also issues of current political and professional debate. The crucial question, however, for planners, providers and commissioners of services is, What research evidence is there about effectiveness? There is also a need to determine what further research is necessary to evaluate programmes for managing or modifying behaviours.

AIM

The aim of this paper is to report on a systematic review of the literature on the effectiveness of nursing interventions in people with personality disorders, whether delivered by nurses alone or in combination with other health care professionals.

METHOD

The review was conducted according to the United Kingdom National Health Service Centre for Reviews and Dissemination guidelines. Literature was identified from electronic database searching, footnote chasing, hand searching of journals and contact with authors of studies. Narrative synthesis was undertaken in relation to study design, participants, and type of intervention.

FINDINGS

Eighteen separate studies were included in the review: four randomized controlled trials, four non-randomized controlled trials, seven before-and-after studies and three case studies.

CONCLUSIONS

There is a weak evidence-base for what constitutes effective nursing intervention with people with personality disorders. There is stronger evidence from mixed disciplines intervention studies than from nursing only intervention studies. Studies of interventions based on psychological approaches show greater improvements in outcomes than nursing management studies.

Psychosocial treatment for severe personality disorder. 36-month follow-up

BACKGROUND

In a previous report a step-down psychosocial programme for severe personality disorders was found to be more effective at expected termination of treatment than a longer in-patient treatment with no planned after-care.

AIMS

To evaluate the clinical effectiveness of these two psychosocial specialist programmes over a 3-year follow-up period.

METHOD

Two samples allocated to the in-patient treatment and to the step-down programme were compared prospectively on symptom severity, social adjustment, global assessment of mental health and other clinical indicators at 6, 12, 24 and 36 months after intake.

RESULTS

Improvements were significantly greater in the step-down programme for social adjustment and global assessment of mental health. Patients in the programme were found to self-mutilate, attempt suicide and be readmitted significantly less at 24- and 36-month follow-up than patients in the in-patient group.

CONCLUSIONS

Improvements associated with specialist residential treatment continued 2 years after discharge. A step-down model has significant advantages over a purely in-patient model.

The value of therapeutic communities in the treatment of personality disorder: a suitable place for treatment?

In the United Kingdom, a government program investigating the links between offending and personality disorder has stimulated renewed interest in the treatment of personality disorders. One psychosocial treatment option for patients with personality disorders is the therapeutic community (TC). In 2000, the authors conducted a small qualitative study with a sample of psychiatrists which suggested that TCs were not well understood and that the status of evidence on efficacy might be partly responsible for low referral numbers. This article reviews the evidence for the efficacy and cost-effectiveness of TCs as a treatment for personality disorders and considers which types of disorders are amenable to TC treatment. We conclude that there is a strong case for more rigorous evaluation and that some of the difficulties anticipated in applying randomized clinical trial (RCT) methodology to the study of TCs could be overcome.

Abusive help-- helping abuse: the psychodynamic impact of severe personality disorder on caring institutions

Personality-disordered patients have invariably suffered abuse at the hands of carers when young, and they tend to repeat an abusive relationship when they encounter care in later life. The provision of care in psychiatric, forensic, penal and other institutions may degenerate into a form of unconscious abuse perpetrated against those in care. This is almost always unrecognized and the experience of carers is often to mismanage their own frustrated inability to understand what is happening to them, their charges and the institution.

Early termination of treatment in personality disorder treated in a psychotherapy hospital. Quantitative and qualitative study

BACKGROUND

Factors underlying premature discontinuation of psychosocial in-patient treatment are still unclear.

AIMS

Investigation of early discontinuation of specialised in-patient psychosocial treatment in a sample of people with personality disorder.

METHOD

Out of 134 consecutive admissions to the Cassel Hospital, 42 early drop-outs and 92 patients who remained were compared on demographic and clinical variables. Early drop-outs were invited for in-depth interviews, to explore their hospital experiences.

RESULTS

The early drop-out group and the group which remained showed significant differences in occupational status, borderline personality disorder (BPD) and the treatment programme to which they were allocated. All three independent variables predicted early discontinuation of treatment. The qualitative analysis of interview transcripts identified significant problems in institutional dimensions.

CONCLUSIONS

Important subjects and process variables contributing to early drop-out in people with personality disorder were identified, with potential implications for clinical practice.