Change in defense mechanisms during short-term dynamic and cognitive therapy in patients with cluster C personality disorders

Change in Defense Mechanisms During a Brief Cognitive Behavioral Therapy for Obsessive-Compulsive Disorder

ABSTRACT

Defense mechanisms (DMs) are strategies used by the individuals to protect the ego. Therefore, compulsive behaviors in obsessive-compulsive disorder (OCD) can be recognized as DMs. We analyzed how DMs changed in a brief cognitive behavioral therapy (CBT) for OCD. This was a quasi-experimental study with 92 OCD patients (aged 18-60 years). We used the Mini International Neuropsychiatric Interview to confirm OCD diagnosis, and we assessed the DMs with the Defense Style Questionnaire at three time points. Through a latent change score modeling, we found that the mature mechanism presented a constant change during the therapy. This mechanism increased in average 0.37 points at each measured moment of CBT, showing a linear trajectory. Neurotic and immature mechanisms showed no significant changes during therapy. The increased use of the mature mechanism can be an indicator of improvement in OCD treatment, showing that patients intensified their more adaptive responses to conflicts.

Maladaptive defense mechanisms moderate treatment outcome in 6 months versus 12 months dialectical-behavior therapy for borderline personality disorder

OBJECTIVE

We investigated whether defense mechanisms in patients with borderline personality disorder (BPD) predict treatment response of dialectical behavior therapy (DBT) and whether they moderate outcome in different treatment lengths.

METHOD

We analyzed a subsample of 60 outpatients with BPD, randomized into either 6 (n = 30) or 12 (n = 30) months of DBT. The average level of defensive adaptiveness, assessed with observer-rated overall defensive functioning (ODF) and "immature" (i.e., maladaptive) defenses were used as predictors and moderators of self-reported frequency of self-harm. We conducted a Generalized Linear Mixed Model (GLMM).

RESULTS

A lower ODF at treatment onset predicted smaller reductions in self-harm, irrespective of treatment length (IRR = 0.92, 95% CI = [0.86, 0.99], p = .020). Lower order "immature" ("major image distorting") defenses showed significantly smaller (IRR = 1.13, 95% CI = [1.06, 1.21], p < .001) and higher order "immature" ("minor image distorting") defenses showed significantly larger (IRR = .91, 95% CI = [.85, .97], p = .006) reductions in self harm in the 6-month but not in the 12-month treatment.

CONCLUSION

Even though the results have to be regarded as preliminary due to the small sample size, findings might indicate that patients with BPD and lower average defensive adaptiveness may benefit from individualized treatment plans including specific interventions targeting defense function.

Change in Defensive Functioning Following Group Psychodynamic-Interpersonal Psychotherapy in Women With Binge-Eating Disorder

We examined change in defensive functioning following group psychodynamic-interpersonal psychotherapy (GPIP) for binge-eating disorder (BED) compared to a waitlist control. We hypothesized that defensive functioning will improve to a greater extent at posttreatment for those in GPIP compared with those in a waitlist control condition. Participants were women with BED assigned to GPIP (n = 131) or a waitlist control (n = 44) condition in a quasi-experimental design. Those who received GPIP had significantly greater improvements in defensive functioning from pretreatment to six months posttreatment compared to the control group. GPIP may be effective for improving defensive functioning in individuals with BED. A randomized controlled trial is needed to confirm that GPIP is efficacious for addressing defensive functioning among women with BED.

Defense Mechanisms and Treatment Response in Depressed Inpatients

The study investigated the extent to which defensive functioning and defense mechanisms predict clinically meaningful symptomatic improvement within brief psychodynamic psychotherapy for recurrent and chronic depression in an inpatient setting. Treatment response was defined as a reduction in symptom severity of 46% or higher from the baseline score on the Montgomery-Asberg Depression Rating Scale (MADRS). A subsample of 41 patients (19 responders and 22 non-responders) from an RCT was included. For each case, two sessions (the second and the penultimate) of brief inpatient psychodynamic psychotherapy (a manualized 12-session therapy program developed in Lausanne) were transcribed and then coded using the Defense Mechanism Rating Scales (DMRS) and the Psychotic Defense Mechanism Rating Scales (P-DMRS), an additional scale developed to study psychotic defenses. Results showed that defensive functioning and mature and immature defense changed during psychotherapy and predicted treatment response. Patient's defenses observed throughout therapy also predicted treatment response at 12-month follow-up. The addition of psychotic defenses allows a better prediction of the treatment response. Overall, these results are in line with previous research and provide further validation of defensive functioning as a predictor of outcomes and a mechanism of change in psychotherapy.

Change in Defense Mechanisms and Depression in a Pilot Study of Antidepressive Medications Plus 20 Sessions of Psychotherapy for Recurrent Major Depression

Treatment studies of major depression commonly focus on symptoms, leaving aside change in putative psychological risk factors. This pilot study examines the relationship between changes in eight depressive defenses and depressive symptoms. Twelve adults with acute recurrent major depression were given antidepressive medications and randomized to 20 sessions of either cognitive behavioral therapy or dynamic psychotherapy and followed for 1 year. Defenses were assessed using the Defense Mechanism Rating Scales (DMRS) and Defense Style Questionnaire (DSQ) at intake, termination, and 1-year follow-up. Depression improved highly significantly on both the Hamilton Rating Scale for Depression and Beck Depression Inventory, respectively, eight (67%) and nine (75%) patients attained recovery by 1 year. Depressive defenses improved significantly by termination (mean ES = 0.97; 95% confidence interval, 0.30-2.16), but retrogressed somewhat by 1 year. A mean of 12.17% (SD = 10.60) depressive defenses remained; only five subjects (50%) attained normative levels. Although causal relationships were not established, depressive defenses are promising candidates for mediating treatment effects on outcome of major depression.

Disentangling within- and between-patient effects of defensive functioning on psychotherapy outcome using mixed models

Abstract There is a great need to identify predictors of treatment response, and the analysis of defense mechanisms is a promising approach. Defensive functioning may influence psychotherapy outcome in two ways: First, when it is generally higher or lower for some patients relative to others and second, as it shifts in individual patients over time. The present study examined both within- and between patient effects of defenses using hierarchical linear modeling. Forty-seven patients diagnosed with depression, anxiety, or adjustment disorders received 25 ± 3 sessions of integrative cognitive-behavioral therapy in a university outpatient clinic. The Defense Mechanism Rating Scale (DMRS) was used to assess defenses in the 1st, 8th, 16th, and 24th session and relate them to symptom severity of depression and anxiety. A higher number of adaptive defense mechanisms was associated with less severe depressive symptoms during treatment while a higher number of immature defenses was related to more severe depressive and anxiety symptoms. An increase in adaptive and a decrease in immature defenses over the course of treatment predicted symptom reduction of depression whereas a decrease in neurotic and immature defenses was associated with reductions in anxiety symptoms. Our results empirically support defensive functioning as a mechanism of change in psychotherapy.

Treating anxiety disorders by emotion-focused psychodynamic psychotherapy (EFPP)-An integrative, transdiagnostic approach

Anxiety disorders are characterized by high levels of anxiety and avoidance of anxiety-inducing situations and of negative emotions such as anger. Emotion-focused therapy (EFT) and psychodynamic psychotherapy (PP) have underscored the therapeutic significance of processing and transforming repressed or disowned conflicted or painful emotions. Although PP provides sophisticated means of processing intrapsychic and interpersonal conflict, EFT has empirically tested a set of techniques to access, deepen, symbolize, and transform emotions consistent with current conceptualizations of emotions and memory. Based on our clinical experience, we propose that an integrative emotion-focused and psychodynamic approach opens new avenues for treating anxiety disorders effectively, and we present a transdiagnostic manual for emotion-focused psychodynamic psychotherapy. The therapeutic approach takes into account both the activation, processing, and modification of emotion and the underlying intrapsychic and interpersonal conflicts. The short-term treatment is based on the three phases of initiating treatment, therapeutic work with anxiety, and termination. Emotional poignancy (or liveliness) is an important marker for emotional processing throughout treatment. Instead of exposure to avoided situations, we endorse enacting the internal process of generating anxiety in the session providing a sense of agency and access to warded-off emotions. Interpretation serves to tie together emotional experience and insight into the patterns and the nature of underlying intrapersonal and interpersonal conflict. Treatment modules are illustrated by brief vignettes from pilot treatments.

What is the effect on comorbid personality disorder of brief panic-focused psychotherapy in patients with panic disorder?

BACKGROUND

No studies of psychotherapies for panic disorder (PD) have examined effects on comorbid personality disorders (PersD), yet half such patients have a PersD.

METHODS

In a randomized trial for PD with and without agoraphobia comparing Cognitive-Behavioral Therapy (CBT) and Panic-Focused Psychodynamic Psychotherapy (PFPP), PersD was assessed pre-to-post treatment with the Structured Clinical Interview for the Diagnosis of Axis-II Disorders (SCID-II). For patients completing therapy (n = 118, 54 with PersD), covariance between panic and SCID-II criteria improvements was analyzed. SCID-II diagnostic remission and recovery were evaluated. Comparative efficacy of PFPP versus CBT for improving PersD was analyzed both for the average patient, and as a function of PersD severity.

RESULTS

37 and 17% of PersD patients experienced diagnostic PersD remission and recovery, respectively. Larger reductions in PersD were related to more panic improvement, with a modest effect size (r = 0.28). Although there was no difference between treatments in their ability to improve PersD for the average patient (d = 0.01), patients meeting more PersD criteria did better in PFPP compared to CBT (P = .007), with PFPP being significantly superior at 11 criteria and above (d = 0.66; 3 more criteria lost).

CONCLUSIONS

PersD presenting in the context of primary PD rarely resolves during psychotherapies focused on PD, and change in PersD only moderately tracks panic improvements, indicating non-overlap of the constructs. Patients receiving panic-focused psychotherapies may require additional treatment for their PersD. PFPP may be superior at improving severe PersD, but replication of this finding is required.

Gender differences in automatic thoughts and cortisol and alpha-amylase responses to acute psychosocial stress in patients with obsessive-compulsive personality disorder

INTRODUCTION

Obsessive-compulsive personality disorder (OCPD) has a pervasive pattern of preoccupation with orderliness, perfection, and mental and interpersonal control at the expense of flexibility, openness, and efficiency. The aims of the present study were to explore the relationship between OCPD and psychological stress and psychological tests.

METHODS

We evaluated 63 OCPD patients and 107 healthy controls (HCs). We collected saliva samples from patients and controls before and after a social stress procedure, the Trier Social Stress Test (TSST), to measure the concentrations of salivary alpha-amylase (sAA) and salivary cortisol. The Childhood Trauma Questionnaire (CTQ), Profile of Mood State (POMS), State-Trait Anxiety Inventory (STAI), Beck Depression Inventory (BDI), Social Adaptation Self-Evaluation Scale (SASS), and Depression and Anxiety Cognition Scale (DACS) were administered to patients and HCs.

RESULTS

Following TSST exposure, the salivary amylase and cortisol levels were significantly decreased in male patients compared with controls. Additionally, OCPD patients had higher CTQ, POMS, STAI, and BDI scores than HCs and exhibited significantly higher anxiety and depressive states. OCPD patients scored higher on future denial and threat prediction as per the DACS tool. According to a stepwise regression analysis, STAI, POMS, and salivary cortisol responses were independent predictors of OCPD.

CONCLUSIONS

Our results suggested that attenuated sympathetic and parasympathetic reactivity in male OCPD patients occurs along with attenuated salivary amylase and cortisol responses to the TSST. In addition, there was a significant difference between OCPD patients and HCs in child trauma, mood, anxiety, and cognition. The finding support the modeling role of cortisol (20min) on the relationships between STAI trait and depression among OCPD.

Changes in Defense Mechanism Functioning During Group Therapy for Binge-Eating Disorder

OBJECTIVE

This study examined change in defensive mechanism functioning during group psychodynamic interpersonal psychotherapy (GPIP) for women with binge-eating disorder (BED).

PROCEDURE

Women with BED (N = 85) received 16 weeks of GPIP. Five group therapy sessions (sessions 1, 3, 8, 12, and 16) from each of the 12 groups were video recorded and transcribed. Participants were rated on an observer-based measure of defensive functioning, the Defense Mechanism Rating Scale (DMRS). Symptom outcomes were assessed pre- and posttreatment.

RESULTS

Overall defensive functioning (ODF) scores improved significantly during group treatment, with specific defense level improvements in high adaptive, major image distorting, and action defenses. The linear increase in ODF mediated a decrease in binge-eating episodes and depressive symptoms. Reverse mediation was also noted. A cubic growth curve best modeled ODF data such that ODF improved in the early stage, followed by a slower rate of improvement in the middle stage, and a further increase in rate of improvement at the end of treatment.

DISCUSSION

Change in defense mechanism functioning may be an important aspect of group psychotherapy that is related to improved symptoms for women with BED who receive GPIP. The cubic trend that represented nonlinear growth in ODF is consistent with psychodynamic theory and a stage model of psychotherapy.

Health service costs and clinical gains of psychotherapy for personality disorders: a randomized controlled trial of day-hospital-based step-down treatment versus outpatient treatment at a specialist practice

BACKGROUND

Day-hospital-based treatment programmes have been recommended for poorly functioning patients with personality disorders (PD). However, more research is needed to confirm the cost-effectiveness of such extensive programmes over other, presumably simpler, treatment formats.

METHODS

This study compared health service costs and psychosocial functioning for PD patients randomly allocated to either a day-hospital-based treatment programme combining individual and group psychotherapy in a step-down format, or outpatient individual psychotherapy at a specialist practice. It included 107 PD patients, 46% of whom had borderline PD, and 40% of whom had avoidant PD. Costs included the two treatment conditions and additional primary and secondary in- and outpatient services. Psychosocial functioning was assessed using measures of global (observer-rated GAF) and occupational (self-report) functioning. Repeated assessments over three years were analysed using mixed models.

RESULTS

The costs of step-down treatment were higher than those of outpatient treatment, but these high costs were compensated by considerably lower costs of other health services. However, costs and clinical gains depended on the type of PD. For borderline PD patients, cost-effectiveness did not differ by treatment condition. Health service costs declined during the trial, and functioning improved to mild impairment levels (GAF > 60). For avoidant PD patients, considerable adjuvant health services expanded the outpatient format. Clinical improvements were nevertheless superior to the step-down condition.

CONCLUSION

Our results indicate that decisions on treatment format should differentiate between PD types. For borderline PD patients, the costs and gains of step-down and outpatient treatment conditions did not differ. For avoidant PD patients, the outpatient format was a better alternative, leaning, however, on costly additional health services in the early phase of treatment.

TRIAL REGISTRATION

Clinical Trials NCT00378248.