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Williams R, Fiorentino F, Lingiardi V, Moselli M, Sharp C, Tanzilli A. The assessment of pathways towards suicide in adolescent patients: A PDM-2-oriented approach. Psychol Psychother 2024. [PMID: 38742777 DOI: 10.1111/papt.12529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 03/28/2024] [Accepted: 05/02/2024] [Indexed: 05/16/2024]
Abstract
OBJECTIVES Increasing evidence has supported the mutual relationship between suicidal motivations and personality pathology, especially in adolescence. Distinctive aspects of personality functioning can explain the tendency to resort to suicidal ideation and behaviours, which, in turn, may play a specific role in exacerbating severe impairments in self-regulation mechanisms that underlie personality pathology. DESIGN This study illustrates, through two clinical cases, the clinical utility of using the Psychodynamic Diagnostic Manual - Second Edition (PDM-2) to better understand distinct pathways of suicidal processes. METHODS Two adolescents, named Luis and Gael, who attempted suicide multiple times were assessed using the Psychodiagnostic Chart Adolescent (PDC-A) of the PDM-2 to evaluate their mental functioning, emerging personality styles or syndromes, and symptom patterns. They were interviewed using the Motivational Interview for Suicidality in Adolescence (MIS-A) to identify the motivations underpinning their suicidal behaviour. RESULTS The results showed that Luis presented a narcissistic personality characterized by the need to deny his vulnerabilities through suicidal fantasies as a form of escape, while Gael presented a borderline personality characterized by the use of suicide attempts to express her inner and unspeakable pain. CONCLUSION The study seems to support the reciprocal interconnections between personality functioning and suicidal motivations that should be better identified to plan tailored and more effective interventions.
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Affiliation(s)
- Riccardo Williams
- Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome, Rome, Italy
| | - Flavia Fiorentino
- Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome, Rome, Italy
| | - Vittorio Lingiardi
- Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome, Rome, Italy
| | - Marta Moselli
- Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome, Rome, Italy
| | - Carla Sharp
- Department of Psychology, University of Houston, Houston, Texas, USA
| | - Annalisa Tanzilli
- Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome, Rome, Italy
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Tanzilli A, Fiorentino F, Liotti M, Lo Buglio G, Gualco I, Lingiardi V, Sharp C, Williams R. Patient personality and therapist responses in the psychotherapy of adolescents with depressive disorders: toward the Psychodynamic Diagnostic Manual - third edition. RESEARCH IN PSYCHOTHERAPY (MILANO) 2024; 27:752. [PMID: 38551500 PMCID: PMC11064774 DOI: 10.4081/ripppo.2024.752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 03/16/2024] [Indexed: 05/03/2024]
Abstract
Depressive disorders in adolescence pose unique challenges for assessment and treatment, particularly due to their high comorbidity with various personality disorders. Moreover, young depressed patients may elicit very intense and difficult-to-manage emotional responses in therapists (in this context, countertransference). This study aimed at empirically identifying specific personality disorders (or subtypes) among adolescents with depressive pathology and exploring distinct countertransference patterns emerging in their psychotherapy: 100 adolescents (58 with depressive disorders; 42 with other clinical conditions) were assessed by their respective clinicians (n=100) using the psychodiagnostic chart-adolescent of the Psychodynamic Diagnostic Manual (PDM) - second edition, and the therapist response questionnaire for adolescents. Results showed that depressed adolescent patients exhibited marked traits of four personality subtypes (i.e., depressive, anxious-avoidant, narcissistic, and borderline) characterized by different levels of mental functioning and personality organization. These subtypes were predictably related to specific clinicians' emotional responses, even when controlling for the intensity of depressive symptomatology. Patients with depressive or anxious-avoidant personality subtypes evoked more positive countertransference responses, whereas patients with narcissistic or borderline subtypes elicited strong and hard-to-face emotional responses in therapists. Consistent with the next edition of the PDM, the study emphasizes the importance of comprehensive psychodynamic assessment in the developmental age, which frames depressive disorders in the context of accurate emerging personality and mental functioning profiles. This approach, which also relies heavily on the clinician's subjective experience in therapy, provides crucial information on how to specifically tailor interventions that more effectively meet the needs of adolescents with these heterogeneous and complex clinical conditions.
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Affiliation(s)
- Annalisa Tanzilli
- Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome.
| | - Flavia Fiorentino
- Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome.
| | - Marianna Liotti
- Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome.
| | - Gabriele Lo Buglio
- Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome.
| | - Ivan Gualco
- Center for Individual and Couple Therapy, Genoa.
| | - Vittorio Lingiardi
- Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome.
| | - Carla Sharp
- Department of Psychology, University of Houston, TX.
| | - Riccardo Williams
- Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome.
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Prusiński T. Personality disorder type only sometimes matters: An exploration of patient's personality disorder as a source of variance in early therapeutic alliance. Clin Psychol Psychother 2023. [PMID: 38149525 DOI: 10.1002/cpp.2943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/22/2023] [Accepted: 11/23/2023] [Indexed: 12/28/2023]
Abstract
OBJECTIVE The study aimed to analyse personality disorders among patients in the early phase of psychotherapy as a source of variance in the quality of the emerging alliance. METHODS The sample consisted of 131 individual psychotherapy patients with borderline (BPD), narcissistic (NPD), dependent (DPD) and obsessive-compulsive (OCPD) personality disorders and 131 psychotherapists. Different sources of alliance estimation were included. Therapeutic alliance was operationalized on several dimensions. The hypothesis was tested using an independent samples one-way analysis of variance. RESULTS The study revealed a significant effect of personality disorder type on early therapeutic alliance quality. BPD patients rated their early alliance the lowest compared to NPD, DPD and OCPD patients. This trend was dominant and replicated regardless of who rated the alliance and which dimension of alliance was estimated. CONCLUSIONS NPD, DPD and OCPD patients have better initial therapeutic alliances than BPD patients, and their alliances do not differ significantly. BPD patients build weaker alliances, and what poses a challenge for them is not only developing a strong and close bond but also conceptualizing goals and reaching agreement on tasks.
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Affiliation(s)
- Tomasz Prusiński
- Institute of Psychology, The Maria Grzegorzewska University, Warsaw, Poland
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Conversano C, Di Giuseppe M, Lingiardi V. Case report: Changes in defense mechanisms, personality functioning, and body mass index during psychotherapy with patients with anorexia nervosa. Front Psychol 2023; 14:1081467. [PMID: 36895755 PMCID: PMC9989464 DOI: 10.3389/fpsyg.2023.1081467] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/25/2023] [Indexed: 02/23/2023] Open
Abstract
Eating disorders (EDs) are difficult to treat in psychotherapy due to their pervasive symptomatology and frequent and rapid relapses. Restrictive anorexia nervosa (AN) is the most challenging ED, often associated with severe physical and mental conditions. Perceived as an ego-syntonic syndrome that somehow protects the patient from a number of developmental tasks, treating AN requires extensive multidisciplinary long-term intervention. As with other emotion regulation strategies, defense mechanisms mediate an individual's reaction to internal or external stressors, including those related to ED conditions. Improving defensive functioning adaptiveness predicts psychotherapy outcomes and is an essential component of the therapeutic process. In this study, we qualitatively described changes in the use of defense mechanisms, personality functioning (PF), and body mass index (BMI) in two patients with severe AN in treatment with intense dynamic psychotherapy. Changes in personality functioning and defense mechanisms were periodically assessed every 6 months using clinician report measures such as the Shedler-Westen Assessment Procedure-200 (SWAP-200) and the Defense Mechanisms Rating Scales Q-sort (DMRS-Q), respectively. BMI was also monitored throughout the treatment. A qualitative description of the patient's defensive profile and the quantitative score on all ranges of defense mechanisms were used for studying changes in patients' use of defenses during the treatment and relationships between defenses and outcome indexes. Personality and defensive functioning improved after 1 year of intense dynamic psychotherapy, independently from BMI improvement. All outcome indexes dramatically decreased before a scheduled interruption of the treatment, underling that an integrated therapeutic approach is essential for improving and eventually orienting toward complete ED symptoms remission. Long-term dynamic psychotherapy fosters self-awareness of psychological distress and enhances more mature ways of coping. Monitoring changes in personality and defense mechanisms helps in understanding patients' reactions to stressful life events and in developing specific therapeutic interventions.
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Affiliation(s)
- Ciro Conversano
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy
| | | | - Vittorio Lingiardi
- Department of Dynamic and Clinical Psychology, and Health Studies, "Sapienza", University of Rome, Rome, Italy
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Tanzilli A, Boldrini T, Carone N, Gualco I, Lingiardi V, Williams R. Patient personality dimensions, relational patterns and therapeutic alliance in clinical practice: An empirical investigation. Clin Psychol Psychother 2023; 30:97-111. [PMID: 35981709 DOI: 10.1002/cpp.2779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 07/03/2022] [Accepted: 08/15/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Transference (meant in this context, as the patient relational patterns expressed towards the clinician) and therapeutic alliance play a crucial role in the treatment of personality pathology. To date, no empirical study examined the association between these two dimensions of the clinical relationship and patients' personality maladaptive traits in psychotherapy. METHODS A national sample of therapists (N = 100) of different theoretical orientations assessed dysfunctional personality features of a patient in their care using a comprehensive and empirically grounded dimensional diagnostic approach from the Shedler-Westen Assessment Procedure-200 (SWAP-200). Moreover, they filled in the Psychotherapy Relationship Questionnaire (PRQ) to identify interpersonal patterns expressed early in treatment by the patients and the Working Alliance Inventory (WAI-T) to evaluate quality of therapeutic alliance. RESULTS Overall, the most severe and maladaptive dimensions of patients' personality were associated with more negative clinician-patient dynamics and poorer levels of therapeutic alliance in statistically significant and clinically relevant ways. Notably, the hostile transference was predicted by both SWAP Hostility and Psychopathy, whereas the SWAP Narcissism was the strongest predictor of the special/entitled transference. The latter was also predicted by SWAP Emotional Dysregulation; conversely, the SWAP Dysphoria was the most robust predictor of anxious/preoccupied pattern. The SWAP Schizoid Orientation and Psychopathy predicted avoidant/dismissing attachment pattern; moreover, they were strongly and negatively related to the SWAP Psychological Health that was the best predictor of positive transference and alliance. CONCLUSIONS Findings support that therapists' careful understanding of patients' interpersonal ways during early treatment stages may meaningfully inform diagnostic and therapeutic processes.
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Affiliation(s)
- Annalisa Tanzilli
- Department of Dynamic and Clinical Psychology, and Health Studies, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Tommaso Boldrini
- Department of Developmental Psychology and Socialization, University of Padua, Padua, Italy
| | - Nicola Carone
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Ivan Gualco
- Center for Individual and Couple Therapy, Genoa, Italy
| | - Vittorio Lingiardi
- Department of Dynamic and Clinical Psychology, and Health Studies, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Riccardo Williams
- Department of Dynamic and Clinical Psychology, and Health Studies, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
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Tanzilli A, Trentini C, Grecucci A, Carone N, Ciacchella C, Lai C, Sabogal-Rueda MD, Lingiardi V. Therapist reactions to patient personality: A pilot study of clinicians’ emotional and neural responses using three clinical vignettes from in treatment series. Front Hum Neurosci 2022; 16:1037486. [DOI: 10.3389/fnhum.2022.1037486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 11/02/2022] [Indexed: 11/29/2022] Open
Abstract
IntroductionTherapists’ responses to patients play a crucial role in psychotherapy and are considered a key component of the patient–clinician relationship, which promotes successful treatment outcomes. To date, no empirical research has ever investigated therapist response patterns to patients with different personality disorders from a neuroscience perspective.MethodsIn the present study, psychodynamic therapists (N = 14) were asked to complete a battery of instruments (including the Therapist Response Questionnaire) after watching three videos showing clinical interactions between a therapist and three patients with narcissistic, histrionic/borderline, and depressive personality disorders, respectively. Subsequently, participants’ high-density electroencephalography (hdEEG) was recorded as they passively viewed pictures of the patients’ faces, which were selected from the still images of the previously shown videos. Supervised machine learning (ML) was used to evaluate whether: (1) therapists’ responses predicted which patient they observed during the EEG task and whether specific clinician reactions were involved in distinguishing between patients with different personality disorders (using pairwise comparisons); and (2) therapists’ event-related potentials (ERPs) predicted which patient they observed during the laboratory experiment and whether distinct ERP components allowed this forecast.ResultsThe results indicated that therapists showed distinct patterns of criticized/devalued and sexualized reactions to visual depictions of patients with different personality disorders, at statistically systematic and clinically meaningful levels. Moreover, therapists’ late positive potentials (LPPs) in the hippocampus were able to determine which patient they observed during the EEG task, with high accuracy.DiscussionThese results, albeit preliminary, shed light on the role played by therapists’ memory processes in psychotherapy. Clinical and neuroscience implications of the empirical investigation of therapist responses are discussed.
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Di Giuseppe M, Orrù G, Gemignani A, Ciacchini R, Miniati M, Conversano C. Mindfulness and Defense Mechanisms as Explicit and Implicit Emotion Regulation Strategies against Psychological Distress during Massive Catastrophic Events. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191912690. [PMID: 36231993 PMCID: PMC9566362 DOI: 10.3390/ijerph191912690] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/14/2022] [Accepted: 09/20/2022] [Indexed: 05/31/2023]
Abstract
Emotion regulation is an important aspect of psychological functioning that influences subjective experience and moderates emotional responses throughout the lifetime. Adaptive responses to stressful life events depend on the positive interaction between explicit and implicit emotion regulation strategies, such as mindfulness and defense mechanisms. This study demonstrates how these emotion regulation strategies predict psychological health during the early phase of the COVID-19 pandemic. A convenience sample of 6385 subjects, recruited via snowball sampling on various social media platforms, responded to an online survey assessing psychological reaction to social restrictions imposed to limit the spread of COVID-19 in Italy. Psychological distress, post-traumatic stress symptoms, mindfulness, and defense mechanisms were assessed using SCL-90, IES-R, MAAS, and DMRS-30-SR, respectively. Higher mindfulness was significantly associated with higher overall defensive maturity and a greater use of high-adaptive defenses (p < 0.0001). Both mindfulness and defense mechanisms acted as good predictors of psychological health (R2 = 0.541) and posttraumatic symptoms (R2 = 0.332), confirming the role of emotion regulation in protecting against maladaptive responses to stressful situations.
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Affiliation(s)
- Mariagrazia Di Giuseppe
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, 56126 Pisa, Italy
- Department of History, Culture and Society, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Graziella Orrù
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, 56126 Pisa, Italy
| | - Angelo Gemignani
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, 56126 Pisa, Italy
| | - Rebecca Ciacchini
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, 56126 Pisa, Italy
| | - Mario Miniati
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, 56126 Pisa, Italy
| | - Ciro Conversano
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, 56126 Pisa, Italy
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Brøsholen P, Ulberg R, Dahl HSJ, Thorén A. Therapists’ Emotional Responses in Individual Therapy with Depressed Adolescents: An Evaluation of the Data Structure of the Feeling-Word Checklist—28. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159496. [PMID: 35954850 PMCID: PMC9368093 DOI: 10.3390/ijerph19159496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/18/2022] [Accepted: 07/28/2022] [Indexed: 02/06/2023]
Abstract
Countertransference (CT) responses during therapy sessions can be understood as the therapist’s emotional reactions towards the patient. Within adolescents’ psychotherapy, little is known about the effects of the therapists’ feelings on treatment outcome. The Feeling-Word Checklist—28 (FWC-28) is a self-report questionnaire designed to evaluate the therapist’s in-session feelings during therapy with younger patients. The aim of the study was to evaluate the psychometric properties of the clinician-rated FWC-28 and explore the associations between the CT-subscales and therapeutic alliance. Data were collected from a randomized controlled trial in which 11 therapists specialized in child and adolescent psychotherapy treated 16- to 18-year-old patients (n = 62) with major depressive disorder in outpatient clinics. The patients received psychodynamic psychotherapy treatment over 28 sessions. Therapists rated their emotional responses towards their patients on FWC-28 after sessions 3, 12, 20, and 28. Principal component analysis (PCA) with oblique rotation was performed to find clinically meaningful subscales of the FWC-28. PCA revealed four clinically meaningful components termed as follows: inadequate, confident, motherly, and disengaged. The psychometric properties of the FWC and the reliability of the CT subscales measured with Cronbach’s alpha were acceptable. The therapist-reported alliance showed significant and clinically meaningful correlations with all CT-subscales. Our findings indicate that the checklist is adequate for clinical practice and countertransference research in adolescents’ psychotherapy.
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Affiliation(s)
- Pernille Brøsholen
- Institute of Clinical Medicine, University of Oslo, P.O. Box 1039, Blindern, 0315 Oslo, Norway;
- Correspondence:
| | - Randi Ulberg
- Institute of Clinical Medicine, University of Oslo, P.O. Box 1039, Blindern, 0315 Oslo, Norway;
- Research Unit, Division of Mental Health and Addiction, Vestfold Hospital Trust, P.O. Box 2169, 3125 Tønsberg, Norway;
- Department of Psychiatry, Diakonhjemmet Hospital, P.O. Box 85, Vinderen, 0319 Oslo, Norway
| | - Hanne-Sofie Johnsen Dahl
- Research Unit, Division of Mental Health and Addiction, Vestfold Hospital Trust, P.O. Box 2169, 3125 Tønsberg, Norway;
- Department of Psychiatry, Diakonhjemmet Hospital, P.O. Box 85, Vinderen, 0319 Oslo, Norway
- Department of Psychology, Faculty of Social Sciences, University of Oslo, P.O. Box 1094, Blindern, 0317 Oslo, Norway
| | - Agneta Thorén
- The Erica Foundation, Odengatan 9, P.O. Box 114 24, 911424 Stockholm, Sweden;
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Personality Disorders in Childhood: Validity of the Coolidge Personality and Neuropsychological Inventory for Children (CPNI). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19074050. [PMID: 35409734 PMCID: PMC8998288 DOI: 10.3390/ijerph19074050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/24/2022] [Accepted: 03/26/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND A growing body of evidence has shown that maladaptive traits and emerging patterns of personality can be traced to an early stage of development and may be assessed in childhood. The goal of present study was to provide preliminary data on the validity of the Coolidge Personality and Neuropsychological Inventory for Children (CPNI), an instrument designed to assess personality pathologies and other clinical conditions in childhood. METHOD A sample of 146 clinicians completed the CPNI, as well as the Child Behavior Checklist (CBCL) to evaluate the behavioral problems and social competencies, regarding a child (aged 6-11 years) who had been in their care between 2 and 12 months. The clinicians also filled out a clinical questionnaire to provide information on the children, their families, and psychotherapies. RESULTS There were significant and clinically consistent associations between the CPNI and CBCL. They confirmed the good concurrent (convergent and discriminant) validity of the CPNI. CONCLUSIONS The findings seem to support the validity of the CPNI as diagnostic instrument, taking children's PDs and behavioral problems into account. Despite some limitations, the CPNI represents a helpful measure to evaluate the children's personality configurations according to the DSM model. It may be employed along with other tools based on other diagnostic frameworks within the context of a multi-method and multi-informant assessment to provide an accurate and comprehensive formulation of children's overall functioning.
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Houshangi H, Khanipour H, Farahani MN. Therapist attitudes and countertransference as predictors of professional quality of life and burnout among psychotherapists. COUNSELLING & PSYCHOTHERAPY RESEARCH 2022. [DOI: 10.1002/capr.12523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Homa Houshangi
- Department of Psychology Kharazmi University Tehran Iran
| | - Hamid Khanipour
- Department of Psychology, Institute for Educational, Psychological and Social Research Kharazmi University Tehran Iran
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Fortunato A, Tanzilli A, Lingiardi V, Speranza AM. Psychodiagnostic Chart-Child (PDC-C): a valid and clinically sensitive diagnostic tool for patient-tailored intervention planning. RESEARCH IN PSYCHOTHERAPY (MILANO) 2022; 25. [PMID: 35373960 PMCID: PMC9153754 DOI: 10.4081/ripppo.2022.591] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 02/03/2022] [Indexed: 11/22/2022]
Abstract
The reliable clinical-diagnostic evaluation of child patients is crucial. The present research sought to examine the validity of the Psychodiagnostic Chart-Child (PDC-C) in assessing children’s mental functioning and personality organization, according to the framework of the Psychodynamic Diagnostic Manual, Second Edition (PDM-2). A sample of 209 clinicians assessed 209 children (aged 4-11 years) who had been in their care between 2-12 months, using the PDC-C. Each clinician also completed a clinical questionnaire to provide demographic information, the Child Behavior Checklist to evaluate children’s behavioral problems and social competences, and the Childhood Personality Assessment Q-Sort measure to assess children’s emerging personality patterns. The findings suggest that the PDC-C is a valid diagnostic tool that considers children’s full range of functioning. Moreover, the measure has good sensitivity and appears clinically useful in differentiating between certain clinical populations according to psychological characteristics. The PDC-C could promote more accurate assessment during childhood and inform the development of individualized therapies. One of the advantages of the tool is its ability to capture individual variations in child functioning (illuminating strengths and psychological vulnerabilities), even within children in the same diagnostic group. Of note, additional research is needed to establish the utility of PDC-C ratings in predicting clinically relevant constructs and to monitor the processes and outcomes of interventions.
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Affiliation(s)
- Alexandro Fortunato
- Department of Dynamic and Clinical Psychology, and Health Studies, La Sapienza University of Rome.
| | - Annalisa Tanzilli
- Department of Dynamic and Clinical Psychology, and Health Studies, La Sapienza University of Rome.
| | - Vittorio Lingiardi
- Department of Dynamic and Clinical Psychology, and Health Studies, La Sapienza University of Rome.
| | - Anna Maria Speranza
- Department of Dynamic and Clinical Psychology, and Health Studies, La Sapienza University of Rome.
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Di Giuseppe M, Perry JC, Prout TA, Conversano C. Editorial: Recent Empirical Research and Methodologies in Defense Mechanisms: Defenses as Fundamental Contributors to Adaptation. Front Psychol 2021; 12:802602. [PMID: 34925197 PMCID: PMC8678405 DOI: 10.3389/fpsyg.2021.802602] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mariagrazia Di Giuseppe
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy
| | - John Christopher Perry
- McGill University and the Institute of Community and Family Psychiatry, Jewish General Hospital, Montreal, QC, Canada
| | - Tracy A Prout
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, United States
| | - Ciro Conversano
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy
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Di Giuseppe M, Prout TA, Ammar L, Kui T, Conversano C. Assessing children's defense mechanisms with the Defense Mechanisms Rating Scales Q-sort for Children. RESEARCH IN PSYCHOTHERAPY (MILANO) 2021; 24:590. [PMID: 35047431 PMCID: PMC8715263 DOI: 10.4081/ripppo.2021.590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/17/2021] [Indexed: 11/23/2022]
Abstract
Defense mechanisms are unconscious and automatic psychological processes that serve to protect the individual from painful emotions and thoughts. There is ample evidence from the adult psychotherapy and mental health literature suggesting the salience of defenses in the maintenance and amelioration of psychological distress. Although several tools for the assessment of children's defenses exist, most rely on projective and self-report tools, and none are based on the empirically derived hierarchy of defenses. This paper outlines the development of the defense mechanisms rating scale Q-sort for children (DMRS-Q-C), a 60-item, observer-rated tool for coding the use of defenses in child psychotherapy sessions. Modifications to the Defense Mechanisms Rating Scale Q-Sort for adults to create a developmentally relevant measure and the process by which expert child psychotherapists collaborated to develop the DMRS-Q-C are discussed. A clinical vignette describing the child's defensive functioning as assessed by the innovative DMRS-Q-C method is also reported. Finally, we provide an overview of forthcoming research evaluating the validity of the DMRS-Q-C.
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Affiliation(s)
- Mariagrazia Di Giuseppe
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy
| | - Tracy A. Prout
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, USA
| | - Lauren Ammar
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, USA
| | - Thomas Kui
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, USA
| | - Ciro Conversano
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy
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Di Giuseppe M, Perry JC. The Hierarchy of Defense Mechanisms: Assessing Defensive Functioning With the Defense Mechanisms Rating Scales Q-Sort. Front Psychol 2021; 12:718440. [PMID: 34721167 PMCID: PMC8555762 DOI: 10.3389/fpsyg.2021.718440] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/24/2021] [Indexed: 11/13/2022] Open
Abstract
The psychodynamic concept of defense mechanisms is nowadays considered by professionals with various theoretical orientations of great importance in the understanding of human development and psychological functioning. More than half century of empirical research has demonstrated the impact of defensive functioning in psychological well-being, personality organization and treatment process-outcome. Despite the availability of a large number of measures for their evaluation, only a few instruments assess the whole hierarchy of defenses, based on the Defense Mechanisms Rating Scales (DMRS), which arguably offers an observer-rated gold standard of assessment. The present article illustrates the theoretical and methodological background of the DMRS-Q, the Q-sort version of the DMRS for clinical use. Starting from the definition and function of the 30 defense mechanisms included in the hierarchy, we extracted 150 items that captured a full range of defensive manifestations according to the DMRS theory. The DMRS-Q set is described in this paper with reference to the DMRS manual. Directions are also provided for using the DMRS-Q online software for the free and unlimited coding of defense mechanisms. After each coding, the DMRS-Q software provides a report including qualitative and quantitative scores reflecting the individual’s defensive functioning. Qualitative scores are displayed as the Defensive Profile Narratives (DPN), while quantitative scores are reported as Overall Defensive Functioning (ODF), defensive categories, defense levels, and individual defense mechanisms. Syntax for the scoring is displayed in the results and a clinical vignette of a psychotherapy session coded with the DMRS-Q is provided. The DMRS-Q is an easy-to-use, free, computerized measure that can help clinicians in monitoring changes in defense mechanisms, addressing therapeutic intervention, fostering symptoms decreasing and therapeutic alliance. Moreover, the DMRS-Q might be a valid tool for teaching the hierarchy of defense mechanisms and increase the observer-rated assessment of this construct in several research fields.
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Affiliation(s)
- Mariagrazia Di Giuseppe
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy
| | - J Christopher Perry
- McGill University Department of Psychiatry at the Institute of Community and Family Psychiatry, Jewish General Hospital, Montreal, QC, Canada
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Fredum HG, Rost F, Ulberg R, Midgley N, Thorén A, Aker JFD, Johansen HF, Sandvand L, Tosterud L, Dahl HSJ. Psychotherapy Dropout: Using the Adolescent Psychotherapy Q-Set to Explore the Early In-Session Process of Short-Term Psychodynamic Psychotherapy. Front Psychol 2021; 12:708401. [PMID: 34744869 PMCID: PMC8568886 DOI: 10.3389/fpsyg.2021.708401] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 09/20/2021] [Indexed: 11/13/2022] Open
Abstract
Research suggests that short-term psychodynamic psychotherapy (STPP) is an effective treatment for depression in adolescence, yet treatment dropout is a major concern and what leads to dropout is poorly understood. Whilst studies have begun to explore the role of patient and therapist variables, there is a dearth of research on the actual therapy process and investigation of the interaction between patient and therapist. This study aims to address this paucity through the utilisation of the Adolescent Psychotherapy Q-set (APQ) to examine the early treatment period. The sample includes 69 adolescents aged 16-18 years with major depressive disorder receiving STPP as part of the First Experimental Study of Transference Work-in Teenagers (FEST-IT) trial. Of these, 21 were identified as dropouts and were compared to completers on pre-treatment patient characteristics, symptomatology, functioning, and working alliance. APQ ratings available for an early session from 16 of these drop out cases were analysed to explore the patient-therapist interaction structure. Results from the Q-factor analysis revealed three distinct interaction structures that explained 54.3% of the total variance. The first described a process of mutual trust and collaboration, the second was characterised by patient resistance and emotional detachment, the third by a mismatch and incongruence between therapist and adolescent. Comparison between the three revealed interesting differences which taken together provide further evidence that the reasons why adolescents drop out of therapy vary and are multidimensional in nature.
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Affiliation(s)
| | - Felicitas Rost
- Portman Clinic, The Tavistock and Portman NHS Foundation Trust, London, United Kingdom
| | - Randi Ulberg
- Division of Mental Health and Addiction, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Vestfold Hospital Trust, Division of Mental Health, Research Unit, Tønsberg, Norway
- Department of Psychiatry, Diakonhjemmet Hospital, Oslo, Norway
| | - Nick Midgley
- Anna Freud National Centre for Children and Families, The Kantor Centre of Excellence, London, United Kingdom
| | | | | | | | - Lena Sandvand
- Department of Psychology, University of Oslo, Oslo, Norway
| | - Lina Tosterud
- Department of Psychology, University of Oslo, Oslo, Norway
| | - Hanne-Sofie Johnsen Dahl
- Department of Psychology, University of Oslo, Oslo, Norway
- Vestfold Hospital Trust, Division of Mental Health, Research Unit, Tønsberg, Norway
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Tanzilli A, Giovanardi G, Patriarca E, Lingiardi V, Williams R. From a Symptom-Based to a Person-Centered Approach in Treating Depressive Disorders in Adolescence: A Clinical Case Formulation Using the Psychodynamic Diagnostic Manual (PDM-2)'s Framework. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:10127. [PMID: 34639429 PMCID: PMC8508312 DOI: 10.3390/ijerph181910127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Depressive disorders in adolescence are among the most challenging clinical syndromes to diagnostically identify and treat in psychotherapy. The Psychodynamic Diagnostic Manual, Second Edition (PDM-2) proposes an integration between nomothetic knowledge and an idiographic understanding of adolescent patients suffering from depression to promote a person-centered approach. This single-case study was aimed at describing and discussing the clinical value of an accurate diagnostic assessment within the PDM-2 framework. METHOD Albert, a 16-year-old adolescent with a DSM-5 diagnosis of major depressive disorder, was assessed using instruments from various perspectives: the Structured Clinical Interview for DSM-5; the Psychodynamic Chart-Adolescent of the PDM-2, and other clinician-report instruments; and the Shedler-Westen Assessment Procedure for Adolescents and Defense Mechanisms Rating Scale Q-sort, coded by external observers. RESULTS Albert's assessment revealed impairments in various mental capacities, especially in regulating self-esteem. He presented a borderline personality organization at a high level and an emerging narcissistic personality syndrome. CONCLUSIONS The case discussion showed the importance of providing clinically meaningful assessments to plan for effective treatments in youth populations. Especially, it is necessary to understand the adolescent's unique characteristics in terms of mental and personality functioning and consider the developmental trajectories and adaptation processes that characterize this specific developmental period.
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Affiliation(s)
- Annalisa Tanzilli
- Department of Dynamic and Clinical Psychology, and Health Studies, Faculty of Medicine and Psychology, “Sapienza” University of Rome, Via degli Apuli 1, 00185 Rome, Italy; (G.G.); (E.P.); (V.L.); (R.W.)
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17
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Tanzilli A, Gualco I. Clinician Emotional Responses and Therapeutic Alliance When Treating Adolescent Patients With Narcissistic Personality Disorder Subtypes: A Clinically Meaningful Empirical Investigation. J Pers Disord 2020; 34:42-62. [PMID: 32186983 DOI: 10.1521/pedi.2020.34.supp.42] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This study examined clinician emotional responses and therapeutic alliance in psychotherapy with adolescent patients with specific subtypes of narcissistic personality disorder (NPD). A national sample of therapists (N = 58) completed the Therapist Response Questionnaire for Adolescents to identify patterns of clinician response, the Working Alliance Inventory to evaluate the quality of alliance, and the Shedler-Westen Assessment Procedure-II for Adolescents to assess the personality pathology of a patient in their care. The results showed that the grandiose narcissistic subtype was positively related to angry/criticized and disengaged/hopeless therapist responses and negatively related to warm/attuned response. The fragile subtype was positively related to overinvolved/worried therapist response. The high-functioning/exhibitionistic subtype was negatively related to angry/criticized response. Lower quality of therapeutic alliance was positively associated with the grandiose subtype. Moreover, the empirically founded prototypes of therapist responses to adolescent patients with NPD subtypes strongly resemble theoretical-clinical accounts. The clinical implications are addressed.
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Affiliation(s)
- Annalisa Tanzilli
- Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Ivan Gualco
- Center for Individual and Couple Therapy, Genoa, Italy
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Boldrini T, Tanzilli A, Di Cicilia G, Gualco I, Lingiardi V, Salcuni S, Tata MC, Vicari S, Pontillo M. Personality Traits and Disorders in Adolescents at Clinical High Risk for Psychosis: Toward a Clinically Meaningful Diagnosis. Front Psychiatry 2020; 11:562835. [PMID: 33363479 PMCID: PMC7753018 DOI: 10.3389/fpsyt.2020.562835] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 10/20/2020] [Indexed: 11/28/2022] Open
Abstract
Aims: Recent meta-analytic data show that approximately 40% of individuals at clinical high risk for psychosis (CHR) receive at least one personality disorder (PD) diagnosis. Personality pathology could significantly influence CHR patients' prognosis and response to treatment. We aimed at exploring the PD traits of CHR adolescents, in order to outline a prototypic description of their most frequently observed personality characteristics. Methods: One hundred and twenty-three psychiatrists and psychologists used a Q-sort procedure [i.e., the Shedler-Westen Assessment Procedure-200 for Adolescents (SWAP-200-A)] to assess personality traits and disorders in 58 (30 male; mean age = 16 years, range = 13-19 years) CHR adolescents and two gender- and age-matched samples, respectively, with (n = 60) and without PDs (n = 59). Results: Differences between the CHR, PD, and clinical groups showed that CHR adolescents had pervasive and more clinically relevant schizoid, schizotypal, borderline, and avoidant traits, as well as poorer adaptive functioning. Moreover, by collecting the highest mean SWAP-200-A items, we empirically outlined a prototypic description of CHR youths, comprised of avoidance of social relationships; suspiciousness; obsessional thoughts; lack of psychological insight; dysphoric and overwhelming feelings of anxiety and depression; odd and anomalous reasoning processes or perceptual experiences; symptoms of depersonalization and derealization; and negative symptoms of avolition, abulia, blunted affects, and impaired role functioning. Conclusions: The results suggest that avoidant interpersonal strategies, impaired mentalization, and difficulties in emotional regulation could become important targets for psychosocial interventions with CHR adolescent populations.
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Affiliation(s)
- Tommaso Boldrini
- Department of Developmental Psychology and Socialization, University of Padua, Padua, Italy
| | - Annalisa Tanzilli
- Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Di Cicilia
- Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy
| | - Ivan Gualco
- Center for Individual and Couple Therapy, Genoa, Italy
| | - Vittorio Lingiardi
- Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy
| | - Silvia Salcuni
- Department of Developmental Psychology and Socialization, University of Padua, Padua, Italy
| | - Maria Cristina Tata
- Child and Adolescence Neuropsychiatry Unit, Department of Neuroscience, Children Hospital Bambino Gesú, IRCCS, Rome, Italy
| | - Stefano Vicari
- Child and Adolescence Neuropsychiatry Unit, Department of Neuroscience, Children Hospital Bambino Gesú, IRCCS, Rome, Italy.,Department of Life Sciences and Public Health, Catholic University, Rome, Italy
| | - Maria Pontillo
- Child and Adolescence Neuropsychiatry Unit, Department of Neuroscience, Children Hospital Bambino Gesú, IRCCS, Rome, Italy
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