Shame aversion and shame-proneness in Cluster C personality disorders.

The associations between shame and Cluster C personality disorders (PDs) were examined in 237 undergraduates, 35 of whom met at least subthreshold criteria for Cluster C PDs assessed using the Personality Disorder Interview–IV. Shame-proneness (the propensity to experience shame across many situations) was measured using the Test of Self-Conscious Affect–3, and shame aversion (the tendency to perceive shame as especially painful and undesirable) was measured using the Shame-Aversive Reactions Questionnaire. A go/no-go association task was used to assess the strength of implicit mental representations of the association between shame and pain, relative to that between shame and pleasure. Shame-proneness and shame aversion were associated with Cluster C PD symptoms over and above trait positive and negative affect. Further, shame-proneness was found to be associated with Cluster C PDs among individuals with high but not low levels of shame aversion. Finally, shame–pain associations were uniquely associated with dependent personality disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Reduced specificity of autobiographical memory in Cluster C personality disorders and the role of depression, worry, and experiential avoidance.

The study objective was to investigate whether, compared with nonclinical controls, participants with an avoidant, dependent, or obsessive–compulsive Cluster C personality disorder (PD) manifested reduced levels of memory specificity and whether the association of Cluster C PDs with memory specificity is mediated by repetitive negative thoughts and experiential avoidance. The Autobiographical Memory Test (R. J. McNally, N. B. Lasko, M. L. Macklin, & R. K. Pitman, 1995) was administered along with self-report measures (translated into Dutch) for repetitive, uncontrollable, and negative thinking in the form of worry (Penn State Worry Questionnaire; T. J. Meyer, M. L. Miller, R. L. Metzger, & T. D. Borkovec, 1990) and experiential avoidance (Acceptance and Action Questionnaire; S. C. Hayes et al., 2004) to 294 clinical participants diagnosed with Axis I disorders (assessed with the Structured Clinical Interview for DSM–IV Axis I Disorders [SCID-I]; M. B. First, R. L. Spitzer, M. Gibbon, & J. B. W. Williams, 1994) and Axis II disorders (assessed with the SCID-II; M. B. First, R. L. Spitzer, M. Gibbon, & J. B. W. Williams, 1997)—202 with avoidant, 49 with dependent, and 120 with obsessive–compulsive PD—and to 108 matched nonclinical controls. Participants with a Cluster C PD showed lower levels of memory specificity than did nonclinical controls. Depression and worry mediated the effect of Cluster C PDs on memory specificity. Besides depression severity, repetitive, uncontrollable, and negative thinking may constitute a general mechanism mediating the association of various Axis I and II disorders with memory specificity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comorbidity of personality disorders and depression: Implications for treatment.

Reviews naturalistic and controlled studies of the impact of comorbidity of personality disorders and depression on response to various forms of treatment. The findings support the common belief that personality disorders are associated with a poorer response to treatment for depression. In contrast, the limited data available suggest that the presence of depression may be a positive prognostic indicator for patients with borderline and antisocial personality disorder. There are insufficient data to draw conclusions regarding the influence of specific types of personality disorders on outcome with specific forms of treatment for depression. More specific assessment of personality disorders, particularly of possible underlying dimensions, is likely to be a more fruitful approach than the currently used categorical approach in identifying effective treatments for patients with personality disorders and depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Acceleration of changes in session impact during contrasting time-limited psychotherapies.

Following the suggestion that therapeutic change is accelerated in time-limited psychotherapy, this study investigated the across-session patterns of session impact in the treatments of 117 depressed clients who were randomly allocated to 8 or 16 sessions of cognitive-behavioral (CB) or psychodynamic-interpersonal (PI) therapy. After each session, all clients completed the Session Evaluation Questionnaire and 75 of the clients completed the Session Impacts Scale. Session ratings indicated that sessions were perceived increasingly positively on most impact dimensions (e.g., session depth and smoothness, relationship with the therapist, feelings of understanding and problem solving, postsession positive mood) as treatment progressed. Early in treatment, PI therapy sessions were less smooth (i.e., more tense and uncomfortable) and less focused on problem solving, but PI sessions changed more rapidly than CB sessions on these dimensions, so that later in treatment, sessions of both treatments were equivalently positive. In both treatments, the trend toward more positive sessions was more rapid (i.e., the across-session slope was steeper) in 8-session treatments than in 16 session treatments. Such accelerated changes in session impact may reflect the suggested acceleration … (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Role of perfectionism and personality disorder features in response to brief treatment for depression.

Using data from the Treatment of Depression Collaborative Research Program (TDCRP), the authors compared the role of patients' perfectionism and features of personality disorder (PD) in the outcome of brief treatment for depression. Data were extracted as to patients' intake levels of symptoms; perfectionism; and PD features, measured as continuous variables, as well as their symptoms at termination; their contribution to the therapeutic alliance; and their satisfaction with social relations. Poorer therapeutic outcome was demonstrated for patients with elevated levels of perfectionism and odd-eccentric and depressive PD features. Patients' contribution to therapeutic alliance and satisfaction with social relations were predicted by perfectionism but not by PD features. Results highlight the central role played by patients' personality in the course of brief treatment for depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparative effects of cognitive-behavioral and brief psychodynamic psychotherapies for depressed family caregivers.

Clinically depressed family caregivers (N?=?66) of frail, elderly relatives were randomly assigned to 20 sessions of either cognitive-behavioral (CB) or brief psychodynamic (PD) individual psychotherapy. At posttreatment, 71% of the caregivers were no longer clinically depressed according to Research Diagnostic Criteria (RDC), with no differences found between the 2 outpatient treatments. The results suggested therapy specificity; there was an interaction between treatment modality and length of caregiving on symptom-oriented measures. Clients who had been caregivers for a shorter period showed improvement in the PD condition, whereas those who had been caregivers for at least 44 mo improved with CB therapy. These findings suggest that patient-specific variables should be considered when choosing treatment for clinically depressed family caregivers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship of early alliance ruptures and their resolution to process and outcome in three time-limited psychotherapies for personality disorders.

This study examined the relationship of early alliance ruptures and their resolution to process and outcome in a sample of 128 patients randomly assigned to 1 of 3 time-limited psychotherapies for personality disorders: cognitive–behavioral therapy, brief relational therapy, or short-term dynamic psychotherapy. Rupture intensity and resolution were assessed by patient- and therapist-report after each of the first 6 sessions. Results indicated that lower rupture intensity and higher rupture resolution were associated with better ratings of the alliance and session quality. Lower rupture intensity also predicted good outcome on measures of interpersonal functioning, while higher rupture resolution predicted better retention. Patients reported fewer ruptures than did therapists. In addition, fewer ruptures were reported in cognitive–behavioral therapy than in the other treatments. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical outcomes of an integrated treatment for depression and substance use disorders.

The authors compared longitudinal treatment outcomes for depressed substance-dependent veterans (N = 206) assigned to integrated cognitive–behavioral therapy plus standard pharmacotherapy (ICBT + P) or 12-step facilitation therapy plus standard pharmacotherapy (TSF + P). Drug and alcohol involvement and depressive symptomology were measured at intake and at 3-month intervals during treatment and up to 1 year posttreatment. Participants in both treatment conditions showed decreased depression and substance use from intake. ICBT + P participants maintained improvements in substance involvement over time, whereas TSF + P participants had more rapid increases in use in the months following treatment. Decreases in depressive symptoms were more pronounced for TSF + P than ICBT + P in the 6 months posttreatment. Within both treatment groups, higher attendance was associated with improved substance use and depression outcomes over time. Initial levels of depressive symptomology had a complex predictive relationship with long-term depression outcomes. Early treatment response predicted long-term substance use outcomes for a portion of the sample. Although both treatments were associated with improvements in substance use and depression, ICBT + P may lead to more stable substance use reductions compared with TSF + P. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship between activating affects, inhibitory affects, and self-compassion in patients with Cluster C personality disorders.

In the short-term dynamic psychotherapy model termed “Affect Phobia Treatment,” it is assumed that increase in patients' defense recognition, decrease in inhibitory affects (e.g., anxiety, shame, guilt), and increase in the experience of activating affects (e.g., sadness, anger, closeness) are related to enhanced self-compassion across therapeutic approaches. The present study aimed to test this assumption on the basis of data from a randomized controlled trial, which compared a 40-session short-term dynamic psychotherapy (N = 25) with 40-session cognitive treatment (N = 25) for outpatients with Cluster C personality disorders. Patients' defense recognition, inhibitory affects, activating affects, and self-compassion were rated with the Achievement of Therapeutic Objectives Scale (McCullough et al., 2003b) in Sessions 6 and 36. Results showed that increase in self-compassion from early to late in therapy significantly predicted pre- to post-decrease in psychiatric symptoms, interpersonal problems, and personality pathology. Decrease in levels of inhibitory affects and increase in levels of activating affects during therapy were significantly associated with higher self-compassion toward the end of treatment. Increased levels of defense recognition did not predict higher self-compassion when changes in inhibitory and activating affects were statistically controlled for. There were no significant interaction effects with type of treatment. These findings support self-compassion as an important goal of psychotherapy and indicate that increase in the experience of activating affects and decrease in inhibitory affects seem to be worthwhile therapeutic targets when working to enhance self-compassion in patients with Cluster C personality disorders. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Reasons for depression and the process and outcome of cognitive–behavioral psychotherapies.

This study examined the relationships between clients' reasons for depression and the process and outcome of a cognitive therapy (CT) and a behavioral activation (BA) treatment for major depression. Reason giving was conceptualized as the tendency to offer multiple explanations for a problem. Different reasons for depression were also thought to match or mismatch the theoretical model underlying each treatment. Reasons for depression were assessed pretreatment with a previously developed questionnaire. Process variables including homework compliance and perceived treatment helpfulness were measured early in treatment. Results demonstrated that perceived helpfulness of the treatment was associated with positive outcomes in BA. Reason giving was associated with worse outcomes in BA. Specific reasons also predicted differential outcome in the 2 treatments. Clients who endorsed existential reasons for depression had better outcomes in CT and worse outcomes in BA. Relationship-oriented reasons were consistently associated with negative process and outcome in CT. Results are discussed in terms of the function of reason giving and the role of specific explanations for depression in treatment process and outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A shaky future for personality disorders.

The major accomplishment of the fourth edition of the American Psychiatric Association's diagnostic manual was not in the development of surprising new content but rather in the careful, cautious, and systematic method with which it was constructed. The authors of the forthcoming fifth edition may have reversed the priorities, instead emphasizing radical changes without first conducting careful, systematic, thorough, or objective reviews of the scientific literature. Of particular concern are the proposals to cut half of the diagnoses from the manual, to abandon diagnostic criterion sets, and to include a dimensional model that lacks empirical support, fails to be integrated with normal personality functioning, and will lack official recognition. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Evaluating the outcomes of psychotherapies: The Personality Health Index.

This paper introduces two related measures that can be used to evaluate, describe, and track changes in personality functioning. Both are derived from the Shedler-Westen Assessment Procedure (SWAP-200). The first measure is the Personality Health Index (PHI) that offers an assessment of personality functioning that may be applied to the study of outcome in any treatment purporting to affect overall psychological health, such as long-term psychodynamic therapy and psychoanalysis. Preliminary studies suggest robust construct validity for the PHI. The second measure, RADIO, uses the item content of the SWAP-200 to categorize personality functioning into five domains: Reality testing and thought process, Affect regulation and tolerance, Defensive organization, Identity integration, and Object relations. Referred to by the acronym RADIO, this measure provides a picture of personality health across major dimensions of personality functioning. Applying these measures to the well-studied case of “Mrs. C” illustrates their potential clinical, educational and research utility. Both the PHI, a global measure, and the RADIO, a more specific measure, demonstrate changes in her functioning from early to late periods in her psychoanalysis. The paper elaborates the wider application of the PHI and RADIO in clinical and research contexts. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Treatment of major depressive disorder in older adult outpatients with brief psychotherapies.

Examined (a) whether older adults in a current major depressive episode would improve systematically when treated with short-term psychotherapies and (b) if they would respond differentially to treatment approaches emphasizing the importance of either cognitive, behavioral, or relational/insight factors in the therapy process. 30 elderly outpatients (aged 59–80 yrs) were assigned to 1 of the 3 individual treatment conditions for 16 sessions over a 12-wk period. Evaluation (Hamilton Rating Scale for Depression, Beck Depression Inventory, and Self-Rating Depression Scale) occurred before and after therapy and at 4 times during a 1-yr follow-up. Comparable improvement in depressive symptoms was seen from pre- to posttest for Ss in all 3 treatment conditions. However, improvement during the 1-yr follow-up was maintained more effectively by Ss treated with behavioral or cognitive therapy than with relational/insight therapy. Results indicate that brief psychotherapies can be effective in the treatment of elderly depressives and that structured therapies may be more beneficial than nonstructured relationally oriented therapy during a treatment-free follow-up period. (35 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Distinctions without a difference: Direct comparisons of psychotherapies for alcohol use disorders.

To estimate the relative efficacy of alcohol use disorder treatments, the authors meta-analyzed studies that directly compared 2 bona fide psychological treatments. The authors accommodated problems with the inclusion of multiple treatment comparisons by randomly assigning a positive/negative sign to the effect size derived from each comparison and then estimating the extent to which effect sizes were heterogeneous. The authors' primary hypothesis was that the variability in effect sizes of bona fide psychological treatments for alcohol use disorders that were directly compared would be zero. For both alcohol measures and measures of abstinence, analyses indicate that effects were homogenously distributed about zero (I2 = 10.61, 0.00, respectively), indicating that different treatment comparisons yielded a common effect size that was not significantly different from zero. Analyses also indicate that allegiance accounted for a significant portion of variability in differences between treatments. Implications for the treatment of alcohol use disorders as well as research on the mechanisms responsible for the benefit of treatment are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Conceptions of personality disorders and dimensions of personality.

Differing conceptions of personality disorders inherent in the Minnesota Multiphasic Personality Inventory Personality Disorder Scales and the Personality Adjective Checklist were evaluated within the context of the circumplex model of interpersonal behavior and the 5-factor model of personality in a sample of 581 university students. Conceptions of personality disorders were strongly and clearly related to dimensions of normal personality traits. Although the circumplex model illuminated conceptions of some of the disorders, the full 5-factor model was required to capture and clarify the entire range of personality disorders. Implications of these findings are discussed with reference to (a) personality disorders and personality traits and (b) suggestions for assessment of personality disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comorbidity of personality disorders and unipolar major depression: a review

The association of major depressive disorders with personality disorders is relevant in terms of clinical, therapeutic and prognostic aspects. However, the prevalence of this association remains unclear. This may be due to methodological considerations. Nonetheless, it could be estimated from this review that 20% to 50% of inpatients and 50% to 85% of out-patients with a current major depressive disorder have an associated personality disorder. Cluster B personality disorders, in particular borderline (10-30%), histrionic (2-20%) and antisocial (0-10%), seem to be overrepresented, even if the narcissistic one is rare (less than 5%). The main characteristic of Cluster C personality disorders is the great variability of results across studies, except for the obsessive compulsive personality disorder, whose prevalence is consistent and rather high (0-20%). Cluster A personality disorders are an heterogeneous group, since the prevalence of schizotypal personality disorder is rather high (0-20%), the prevalence of paranoid personality disorder is low (less than 5%) and the prevalence of schizoid personality disorder is quite variable from one study to another. The prevalence of personality disorders among patients with a lifetime major depression has been insufficiently studied, although it may concern half of these patients. The prevalence of current of lifetime major depression among patients with a personality disorder has not been sufficiently studied and results are very scattered. Also, the coexistence of personality disorder and major depression is frequent, and this review emphasizes the heterogeneity of the personality styles associated with major depression. Finally, an optimization of methods and the adjunction of a dimensional point of view to the categorical approach may help to study the comorbidity of major depression and personality disorders and its consequences.     

Evaluating an alliance-focused treatment for personality disorders.

This paper presents a study with the aim of evaluating the relative efficacy of an alliance-focused treatment, brief relational therapy, in comparison to a short-term dynamic therapy and a cognitive-behavioral therapy on a sample of highly comorbid personality disordered patients. Results indicated that the three treatments were equally effective on standard statistical analyses of change, including those conducted on repeated measures and residual gain scores. Some significant differences were indicated regarding clinically significant change and reliable change, favoring the brief relational and cognitive-behavioral models. There was also a significant difference regarding dropout rates, favoring brief relational therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Modeling relapse in unipolar depression: The effects of dysfunctional cognitions and personality disorders.

Survival analytic models were used to determine the effects of Axis II pathology and dysfunctional cognitions on depressive relapse in a sample of 50 depressed inpatients followed 33 to 84 months (M?=?49.9) postdischarge. In analyses based on follow-up interview measures, expected remission duration among patients without personality disorders was approximately 7.4 times longer than among patients with Axis II comorbidity. Attributional style also accounted for unique variance in the relapse model, with adaptive positive event attributions inversely related to relapse probability. Neither dysfunctional attitudes nor negative event attributions were significantly related to relapse. Dimensional Axis II Cluster B and C pathology ratings were associated with decreased survival time, whereas Cluster A pathology was associated with increased survival. Among measures obtained during index hospitalization, only the dimensional rating of Axis II pathology was significantly predictive, with a cumulative 8% decrease in expected survival for each Axis II criterion item met. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evidence-based assessment of personality disorders.

The purpose of this article is to provide a foundation for the development of evidence-based guidelines for the assessment of personality disorders, focusing in particular on integrated assessment strategies. The general strategy recommended herein is to first administer a self-report inventory to alert oneself to the potential presence of particular maladaptive personality traits followed by a semistructured interview to verify their presence. This strategy is guided by the existing research that suggests particular strengths of self-report inventories and semistructured interviews relative to unstructured clinical interviews. However, the authors also consider research that suggests that further improvements to the existing instruments can be made. The authors emphasize, in particular, a consideration of age of onset, distortions in self-perception and presentation, gender bias, culture and ethnicity, and personality change. (PsycINFO Database Record (c) 2010 APA, all rights reserved)