Establishing Levels of Personality Functioning Using the Structured Interview of Personality Organization (STIPO-R): a Latent Profile Analysis

Both the new ICD-11 and the latest Alternative DSM-5 Model for Personality Disorders focus on self and interpersonal functioning as the central feature of personality pathology, also acknowledging that personality disorders are organized along a dimensional continuum of severity. This revised understanding is in line with long-standing psychodynamic conceptualisations of personality pathology, in particular Kernberg's object relations model of personality organization. Despite existing evidence for the clinical utility of the derived Structured Interview of Personality Organization (STIPO-R), empirical support for the identification of clear cut-points between the different levels of personality functioning is missing. For this purpose, a total of 764 adult participants were recruited across two clinical (outpatient and inpatient) settings (n = 250) and two non-clinical (university students and general community) samples (n = 514). Results from the mixture modeling suggested the existence of five groups across the clinical and non-clinical samples that covered: healthy personality functioning, maladaptive personality rigidity, and mild, moderate, and severe levels of personality pathology. All five indicators of personality organization were found to be reliable predictors of personality pathology. Of the five STIPO-R indicators, Aggression and Moral Values had the most discriminative power for differentiating between the Mild, Moderate, and Severe personality disorder groups. Implications of these findings are discussed.

Evaluating Change in Transference, Interpersonal Functioning, and Trust Processes in the Treatment of Borderline Personality Disorder: A Single-Case Study Using Ecological Momentary Assessment

Transference-focused psychotherapy (TFP) is an empirically supported treatment for borderline personality disorder (BPD) that improves functioning via targeting representations of self affectively relating to others, particularly as evoked in the therapeutic relationship. If change in TFP operates as theorized, then shifts in patterns of "self affectively relating to others" should be observed in the transference prior to shifts in daily relationships. Using ecological momentary assessment (EMA), a patient with BPD rated daily interpersonal events for 2-week periods during 18 months of TFP; at 9 and 18 months these ratings included interactions with the therapist. Results suggest that positive perceptions of her therapist that ran counter to her negatively biased perception in other relationships preceded changes in her perceptions of others. EMA shifts corresponded to improvements in self-reported symptoms, interview-based personality functioning, and therapist assessments. Implications for assimilation of a trusting experience with the therapist as a mechanism of change in TFP are discussed.

Object Relations Theory Model of Personality Disorders

Contemporary models of the diagnosis and classification of personality disorders have diverged from the categorical diagnostic framework of the DSM system. One response to this movement can be found in the Alternative DSM-5 Model for Personality Disorders (AMPD), which uses dimensions of personality functioning, coupled with identification of dominant pathological traits, to define and classify personality disorders. By applying psychodynamic object relations theory to the AMPD, therapists can enrich the understanding and assessment of personality functioning and pathology as described in the AMPD.

General and Case-Specific Approval of Coercion in Psychiatry in the Public Opinion

BACKGROUND

Psychiatric patients are subjected to considerable stigmatization, in particular, because they are considered aggressive, uncontrollable, and dangerous. This stigmatization might influence the approval of coercive measures in psychiatry by the public and healthcare professionals and might have an influence on the clinical practice of coercive measures. We examined whether the general approval of coercive measures for psychiatric patients with dangerous behaviors differs from case-specific approval.

METHOD

We conducted a representative survey of the general population (n = 2207) in the canton of Basel-Stadt, Switzerland. In total, 1107 participants assessed a case vignette depicting a fictitious character with a mental illness and indicated whether they would accept coercive measures (involuntary hospitalization, involuntary medication, and seclusion) for the person in the vignette. It was explicitly stated that within the last month, the fictitious character displayed no dangerous behavior (Vignette ND) or dangerous behavior (Vignette D). Another 1100 participants were asked whether they would approve coercive measures (involuntary hospitalization, involuntary medication, and seclusion) for psychiatric patients with dangerous behavior in general (General D), i.e., without having received or referring to a specific case vignette.

FINDINGS

The logistic regression model containing all variables explained 45% of the variance in approval of any type of coercive measures. Assessment of case vignettes without dangerous behavior (Vignette ND) was associated with significantly reduced approval of coercive measures compared to assessment of a case vignette with dangerousness (Vignette D), while approval for coercive measures in a person with mental health disorder with dangerous behavior in general (General D) was significantly higher than for the case vignette with dangerousness.

CONCLUSIONS

The general approval of coercive measures for people with mental disorders seems to differ depending on if the respondents are asked to give a general assessment or to examine a specific and detailed clinical case vignette, indicating an increased role of stigmatization when asking about generalized assessments. This may contribute to diverging findings on the acceptance of coercive measures in the literature and should be considered when designing future studies.

Reflective functioning and its potential to moderate the efficacy of manualized psychodynamic therapies versus other treatments for borderline personality disorder

BACKGROUND

Impaired reflective functioning (RF) is common among patients with borderline personality disorder (BPD). Transference-focused psychotherapy (TFP) has been demonstrated to improve RF compared to other common BPD treatments. If RF reflects a treatment mechanism for TFP, differences in pretreatment RF may also serve as a prescriptive factor for TFP's effects.

METHOD

A total of 194 patients with BPD were randomized across two clinical trials to receive TFP (n = 83), dialectical behavior therapy (DBT; n = 31), supportive psychodynamic therapy (SPT; n = 28), or an enhanced treatment as usual (eTAU; n = 52). A mixed-effects model was used to examine whether baseline RF interacted with treatment condition to predict slopes of change in the Brief Symptom Inventory, the shared symptom outcome between trials. Moderation of changes in RF was also examined.

RESULTS

Treatment interacted with baseline RF to predict BSI slopes (p = .011). In TFP/SPT, RF did not predict outcomes, β = -0.00, p = .973, while higher RF was associated with relatively better outcomes in DBT/eTAU, β = -0.54, p < .001. Patients with poor RF (scores of 0/1) benefitted more from TFP/SPT, while patients with relatively ordinary RF (score of 4) had better outcomes in DBT/eTAU. Treatment effects on RF change were also moderated by baseline RF (p = .014), such that TFP improved RF most strongly among poor RF patients, SPT only among very poor RF patients, and DBT/eTAU not at all.

DISCUSSION

Low RF may reflect a deficit that may be targeted by TFP and other manualized psychodynamic treatments for BPD, which may be especially helpful among patients presenting with low RF. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Personality, self-esteem, familiarity, and mental health stigmatization: a cross-sectional vignette-based study

There has been little research exploring the relationship between personality traits, self-esteem, and stigmatizing attitudes toward those with mental disorders. Furthermore, the mechanisms through which the beholder’s personality influence mental illness stigma have not been tested. The aim of this study is to examine the relationship between Big Five personality traits, self-esteem, familiarity, being a healthcare professional, and stigmatization. Moreover, this study aims to explore the mediating effect of perceived dangerousness on the relationship between personality traits and desire for social distance. We conducted a vignette-based representative population survey (N = 2207) in the canton of Basel-Stadt, Switzerland. Multiple regression analyses were employed to examine the associations between personality traits, self-esteem, familiarity, and being a healthcare professional with the desire for social distance and perceived dangerousness. The mediation analyses were performed using the PROCESS macro by Hayes. Analyses showed associations between personality traits and stigmatization towards mental illness. Those who scored higher on openness to experience (β = − 0.13, p < 0.001), (β = − 0.14, p < 0.001), and those who scored higher on agreeableness (β = − 0.15, p < 0.001), (β = − 0.12, p < 0.001) showed a lower desire for social distance and lower perceived dangerousness, respectively. Neuroticism (β = − 0.06, p = 0.012) was inversely associated with perceived dangerousness. Additionally, high self-esteem was associated with increased stigmatization. Personal contact or familiarity with people having mental disorders was associated with decreased stigmatization. Contrarily, healthcare professionals showed higher perceived dangerousness (β = 0.04, p = 0.040). Finally, perceived dangerousness partially mediated the association between openness to experience (indirect effect = −  .57, 95% CI [− .71, − 0.43]) as well as agreeableness (indirect effect = − 0.57, 95% CI [− 0.74, − 0.39]) and desire for social distance. Although the explained variance in all analyses is < 10%, the current findings highlight the role of personality traits and self-esteem in areas of stigma. Therefore, future stigma research and anti-stigma campaigns should take individual differences into consideration. Moreover, the current study suggests that perceived dangerousness mediates the relationship between personality traits and desire for social distance. Further studies are needed to explore the underlying mechanisms of such relationship. Finally, our results once more underline the necessity of increasing familiarity with mentally ill people and of improving the attitude of healthcare professionals towards persons with mental disorders.

Approval of Coercion in Psychiatry in Public Perception and the Role of Stigmatization

Background: Coercion is routinely used in psychiatry. Its benefits and drawbacks are controversially debated. In addition, the majority of persons with mental health problems are exposed to stigmatization and are assumed to be dangerous. Stigmatization is associated with negative consequences for individuals with mental illness such as disapproval, social rejection, exclusion, and discrimination. Being subjected to coercive measures can increase the stigmatization of the affected persons, and stigmatization might lead to higher approval for coercion. Aims of the Study: This study aims to examine the approval for coercive measures in psychiatry by the general public, and to explore its relation with person- and situation-specific factors as well as with stigmatization. Method: We conducted a representative survey of the general population (N = 2,207) in the canton of Basel-Stadt, Switzerland. Participants were asked to read a vignette depicting psychopathological symptoms of a fictitious character and indicate whether they would accept coercive measures for the person in the vignette. Desire for social distance and perceived dangerousness were assessed as measures of stigmatization. Findings: The person in the case vignette exhibiting dangerous behavior, showing symptoms of a psychotic disorder, being perceived as dangerous, and treatment being understood as helpful increased approval of coercion in general, while familiarity of the respondents with mental illness decreased approval. Conclusions: The public attitude regarding the approval of coercion in psychiatry is highly differentiated and largely follows the current legal framework and medical treatment guidelines. Higher approval occurred in situations of self-harm or harm to others and when coercive measures were thought to have a beneficial effect for the affected persons. A considerable part of the approval for coercion is predicted by stigmatization. With the increasing severity of coercive measures, the influence of person- and situation-specific factors and of familiarity with mental illness decreased and generalizing and stigmatizing attitudes became stronger predictors for the approval of more severe measures.

Corrigendum: Approval of Coercion in Psychiatry in Public Perception and the Role of Stigmatization

[This corrects the article DOI: 10.3389/fpsyt.2021.819573.].

Levels of Personality Organization

Level of personality organization refers to a system of classification of personality pathology based in object relations theory. Within this framework, personality disorders are characterized according to severity of pathology, ranging from mild to extreme, based on assessment of the individual’s identity, quality of object relations, defensive functioning, management of aggression, moral functioning, and reality testing. The object relations theory model of personality and personality disorders prioritizes personality functioning, while focusing on the mental representations of self and others that organize subjective experience and observable behavior. Assessment of the level of personality organization guides clinical intervention, including determinations of level of care, treatment goals, and clinical foci. The object relations theory model of classification both overlaps significantly with and can also be distinguished from the Alternative Model of Personality Functioning of DSM-5.

An Object Relations Model Perspective on the Alternative Model for Personality Disorders (DSM-5)

The Alternative Model of DSM-5 combines dimensional ratings of self-functioning, interpersonal functioning, and traits with categorical classification. The object relations model has a long tradition pre-dating the Alternative Model and, in part, has been incorporated into the Alternative Model. The object relations model provides a theoretical background (generally missing in the Alternative Model) that enhances the clinical assessment of personality pathology and its relationship to treatment planning.

Structural Magnetic Resonance Imaging Correlates of Aggression in Psychosis: A Systematic Review and Effect Size Analysis

Background: Aggression in psychoses is of high clinical importance, and volumetric MRI techniques have been used to explore its structural brain correlates. Methods: We conducted a systematic review searching EMBASE, ScienceDirect, and PsycINFO through September 2017 using thesauri representing aggression, psychosis, and brain imaging. We calculated effect sizes for each study and mean Hedge's g for whole brain (WB) volume. Methodological quality was established using the PRISMA checklist (PROSPERO: CRD42014014461). Results: Our sample consisted of 12 studies with 470 patients and 155 healthy controls (HC). After subtracting subjects due to cohort overlaps, 314 patients and 96 HC remained. Qualitative analyses showed lower volumes of WB, prefrontal regions, temporal lobe, hippocampus, thalamus and cerebellum, and higher volumes of lateral ventricles, amygdala, and putamen in violent vs. non-violent people with schizophrenia. In quantitative analyses, violent persons with schizophrenia exhibited a significantly lower WB volume than HC (p = 0.004), and also lower than non-violent persons with schizophrenia (p = 0.007). Conclusions: We reviewed evidence for differences in brain volume correlates of aggression in persons with schizophrenia. Our results point toward a reduced whole brain volume in violent as opposed to non-violent persons with schizophrenia. However, considerable sample overlap in the literature, lack of reporting of potential confounding variables, and missing research on affective psychoses limit our explanatory power. To permit stronger conclusions, further studies evaluating structural correlates of aggression in psychotic disorders are needed.

Stigmatization of psychiatric symptoms and psychiatric service use: a vignette-based representative population survey

Background There is evidence for two different types and/or sources of mental illness stigma, namely the display of psychiatric symptoms and the use of psychiatric service institutions. However, no current study has compared the two. Furthermore, gaps exist in our knowledge of both types of stigma. Little is known about the perceived stigma of specific psychiatric service treatment environments, for instance forensic settings. In addition, systematic research on stigma attached to symptoms of personality disorders in the general population is scarce, and for borderline personality disorder, nonexistent. Methods We conducted a representative survey of the general population (N = 2207) in the canton of Basel-Stadt, Switzerland. Participants were asked to read a vignette depicting either the psychiatric symptoms of a fictitious character or a psychiatric service institution to which the character had been admitted, and indicate desired social distance (an indicator for stigma). Type of symptoms, type of psychiatric service, dangerousness, and gender were systematically varied between vignettes. Findings Desired social distance was significantly lower in relation to psychiatric service use than to psychiatric symptoms. Overall, symptoms of alcohol dependency, behavior endangering others, and the fictitious character's being male tend to increase stigmatization. Interestingly, the character's being hospitalized in a psychiatric unit at a general hospital and also respondent familiarity with psychiatric services tend to decrease stigmatization. Interpretation Familiarity of the general population with psychiatric patients should be increased. Furthermore, treatment in psychiatric units located within general hospitals should be promoted, as such treatment is associated with decreased stigma.