Strengthening the status of psychotherapy for personality disorders: an integrated perspective on effects and costs

The Relevance of Internal Working Models of Self and Others for Equine-Assisted Psychodynamic Psychotherapy

Attachment characteristics play a key role in mental health and in understanding mental disorders. The aim of this study was to gain insight into the role the attachment characteristics can play in treatment effects in adult patients with intrapsychic and interpersonal problems who underwent Equine-assisted Short-term Psychodynamic Psychotherapy (ESTPP). In the first part of the study, we compared the effects of ESTPP to treatment-as-usual from a previous dataset regarding psychological dysfunction. For this, an explorative experimental non-randomized pre-treatment and 1-year post-treatment design was used. A mixed model revealed a significant decline in psychological dysfunction for both conditions, with no significant difference between the two. In the second part of the study, we examined the course of ESTPP effects over the period of 1 year when controlled for attachment styles and, subsequently, for internal working models of self and others. To this end, measurements were taken at baseline, 2 months waiting time, one-week intensive module, 6 months, and one year after the start of the treatment. Mixed models accounted for repeated measures showed significant improvements in psychological dysfunction, remoralization, and depression for ESTPP patients over time. The study implies that models of self and others may be used to predict the course of effects, which is relevant in determining what works for whom. In particularly, duration and intensity of therapy and a focus on the Model of Self seem relevant for shaping a more personalized treatment. ESTPP seems beneficial for patients with low pre-treatment attachment security.

Psychodynamic Based Equine-Assisted Psychotherapy in Adults with Intertwined Personality Problems and Traumatization: A Systematic Review

The growing field of equine-assisted psychotherapy (EAP), a subfield of animal-assisted psychotherapy (AAP), needs theoretically-based clinical studies. This systematic review examines the existing clinical studies in adult populations on psychodynamic psychotherapy combined with equine-assisted psychotherapy. An electronic database search was divided in two studies to identify publications on 1) EAP combined with psychodynamic psychotherapy and 2) EAP combined to personality problems and traumatization in order to compile studies by population, intervention, outcome and therapeutic assets. Study 1 revealed no relevant clinical studies on EAP with a psychodynamic background with an adult population. Study 2 revealed 12 publications to review predominantly addressing veterans with PTSD. The methodological limitations of most of the studies restrain the overall findings on outcome. However, overall positive effects for EAP, specifically on its experiential features and on finding interpersonal trust for patients, can be discerned. There is an apparent need for clinical studies meeting methodological standards on psychodynamic underpinned EAP methodologies in adults with intertwined personality problems and traumatization.

The shorter the better? A follow-up analysis of 10-session psychiatric treatment including the motive-oriented therapeutic relationship for borderline personality disorder

OBJECTIVE

There is little research on short-term treatments for borderline personality disorder (BPD). While the core changes may occur only in long-term treatments, short-term treatments may enable the study of early generic processes of engagement in therapy and thus inform about effective treatment components. It was shown that a 10-session version of a psychiatric treatment was effective in reducing borderline symptoms at the end of this treatment [Kramer, U., Kolly, S., Berthoud, L., Keller, S., Preisig, M., Caspar, F., … Despland, J.-N. (2014). Effects of motive-oriented therapeutic relationship in a ten-session general psychiatric treatment for borderline personality disorder: A randomized controlled trial. Psychotherapy and Psychosomatics, 83, 176-186.]. Also, it was demonstrated in a randomized design that adding the motive-oriented therapeutic relationship (MOTR), following an individualized case formulation based on Plan Analysis, further increased general outcome after session 10 and had a positive effect on the early changes in self-esteem and alliance.

METHOD

The present study focuses on the follow-up period after this initial treatment, examining treatment density and outcomes after 6 months and service utilization after 12 months. Outcome was measured using the OQ-45.

RESULTS

Results on a sub-sample of N = 40 patients with available OQ-45 data at follow-up (n = 21 for MOTR-treatment, n = 19 for comparison treatment) showed maintenance of gains over the follow-up period, which did not differ between both conditions. It appeared for this sample that MOTR treatments, while using the same number of sessions, lasted more weeks (i.e., lower treatment density, defined as the number of sessions per week), when compared to the treatments without MOTR. Density marginally predicted symptom reduction at follow-up. Patients in MOTR treatments had a greater likelihood of entering structured psychotherapy after the initial sessions than patients in the comparison group.

CONCLUSIONS

These results are overall consistent with earlier studies on short-term treatments for BPD and underline the importance of individualizing interventions, by using case formulations that rely on idiographic methods and integrative concepts.

Effectiveness of Short-Term Inpatient Psychotherapy Based on Transactional Analysis With Patients With Personality Disorders: A Matched Control Study Using Propensity Score

Controlled studies on the effectiveness of inpatient psychotherapy with patients with personality disorders (PD) are rare. This study aims to compare 3-month short-term inpatient psychotherapy based on transactional analysis (STIP-TA) with other psychotherapies (OP) up to 36-month follow-up. PD patients treated with STIP-TA were matched with OP patients using the propensity score. The primary outcome measure was general psychiatric symptomatology; secondary outcomes were psychosocial functioning and quality of life. In 67 pairs of patients, both STIP-TA and OP showed large symptomatic and functional improvements. However, STIP-TA patients showed more symptomatic improvement at all time points compared to OP patients. At 36 months, 68% of STIP-TA patients were symptomatically recovered compared to 48% of OP patients. STIP-TA outperformed OP in terms of improvements in general psychiatric symptomatology and quality of life. Superiority of STIP-TA was most pronounced at 12-month follow-up, but remained intact over the course of the 3-year follow-up.

Effectiveness of Psychotherapy in Personality Disorders Not Otherwise Specified: A Comparison of Different Treatment Modalities

OBJECTIVE

Although personality disorder not otherwise specified (PDNOS) is highly prevalent and associated with a high burden of disease, only a few treatment studies in this patient group exist. This study is the first to investigate the effectiveness of different modalities of psychotherapy in patients with PDNOS, i.e., short-term (up to 6 months) and long-term (more than 6 months) outpatient, day hospital, and inpatient psychotherapy.

METHOD

A total of 205 patients with PDNOS were assigned to one of six treatment modalities. Effectiveness was assessed over 60 months after baseline. The primary outcome measure was symptom severity, and the secondary outcome measures included psychosocial functioning and quality of life. The study design was quasi-experimental, and the multiple propensity score was used to control for initial differences between treatment groups.

RESULTS

All treatment modalities showed positive outcomes, especially in terms of improvements of symptom severity and social role functioning. At 12-month follow-up, after adjustment for initial differences between the treatment groups, short-term outpatient psychotherapy and short-term inpatient psychotherapy showed most improvement and generally outperformed the other modalities concerning symptom severity. At 60 months after baseline, effectiveness remained but observed differences between modalities mostly diminished.

CONCLUSION

Patients with PDNOS benefit from psychotherapy both at short-term and long-term follow-up. Short-term outpatient psychotherapy and short-term inpatient psychotherapy seem to be superior to the other treatment modalities at 12-month follow-up. At 60-month follow-up, treatments showed mostly comparable effectiveness.

KEY PRACTITIONER MESSAGES

The effectiveness of different modalities of psychotherapy in patients with PDNOS (i.e., short-term vs long-term; outpatient versus day hospital versus inpatient psychotherapy) has not yet been compared. Different modalities of psychotherapy are effective for patients with PDNOS, and positive effects remain after 5 years. In patients with PDNOS short-term (less than 6 months) outpatient psychotherapy and short-term inpatient psychotherapy seem to be superior to the four other treatment modalities at 12-month follow-up. At 60-month follow-up, treatments showed mostly comparable effectiveness.

Decision Making in Stepped Care: How Do Therapists Decide Whether to Prolong Treatment or Not?

Background: The efficiency of stepped care systems partly relies on systematic monitoring of patient outcomes and timely decisions to “step up” patients without any clear therapeutic gains to the next level of treatment. Qualitative evidence has suggested that this does not occur consistently, nor always congruently with clinical guidelines. Aims: To investigate factors that influence psychological therapists’ decisions to prolong or to conclude treatment in cases with little evidence of therapeutic gains. Method: Eighty-two clinicians in stepped care services completed questionnaires about the likelihood of “holding” non-improving patients in treatment, and factors associated with referrals and holding (FARAH-Q). The factor structure, internal consistency and test-retest reliability of the measures was examined prior to assessing correlations between FARAH-Q items and likelihood of holding. Results: A 4-factor solution indicated that clinicians’ decision making is influenced by a complex interplay between beliefs, attitudes, subjective norms and self-efficacy. Correlational analysis indicated that holding is more likely to happen if there are perceived barriers to refer the patient for further treatment, if the therapist likes the patient and has a good therapeutic alliance, and if the therapist feels confident that s/he has the ability to achieve a positive outcome by prolonging treatment. Conclusions: Decisions to prolong or conclude treatment are not only influenced by evidence and guidelines, but also subjective beliefs, norms and attitudes. Understanding this decision making process is relevant to clinicians and supervisors interested in enhancing the efficiency of stepped care.

How to measure quality of life for cost-effectiveness analyses of personality disorders: a systematic review

A systematic review was undertaken to assess the construct validity and responsiveness of four generic health-related quality of life (HRQL) measures in personality disorders (PDs). Ten databases were searched and reference lists scrutinized to identify relevant studies. Relevant data were extracted accordingly. A narrative synthesis was performed of the evidence on construct validity, including known groups validity (detecting differences in HRQL scores between two different groups), convergent validity (strength of association between generic HRQL), and other measures (e.g., symptom) and responsiveness (differences in generic HRQL measure scores in responders/nonresponders or correlation with changes in other measures). Ten studies were identified: six of the EQ-5D, two involving the SF-36, and another two the SF-12, but none with the SF-6D. Evidence indicated that the EQ-5D, SF-36, and SF-12 were probably valid measures with PDs. Four studies demonstrated that the EQ-5D Index was able to detect changes in patients. The authors conclude that generic HRQL measures appear appropriate for use with people with PDs in terms of psychometric performance. However, qualitative concerns remain as to whether they fully reflect the impact of the condition.

Moving beyond specialized therapies for borderline personality disorder: the importance of integrated domain-focused treatment

This article argues the recent emphasis on specializing treatments for borderline personality disorder needs to be replaced by a more integrated and evidence-based approach that combines effective methods from all therapies. This proposition is based on evidence that specialized treatments for borderline personality disorder do not differ significantly from each and that they are not more effective than good structured care designed to meet the needs of patients with the disorder. It is also argued that current therapies are limited because they do not recognize or accommodate the extensive heterogeneity of borderline personality disorder and its complex etiology. These factors make a one-approach-fits-all strategy inappropriate for treatment. An integrated approach is proposed as an alternative to the specialized therapies that makes use of all effective interventions regardless of their conceptual origins and delivers them in a coordinated way. A two-component framework is proposed for organizing integrated treatment: 1. a system for conceptualizing borderline personality disorder based on current empirical knowledge about the structure, etiology, and stability of borderline pathology that serves as a guide when selecting and delivering interventions; and 2. a model of therapeutic change based on the general literature on psychotherapy outcome and specific studies of PD treatments. This framework proposes that integrated treatment be organized around principles of therapeutic change common to all effective therapies supplemented with more specific treatment methods taken from the different therapies as needed to tailor treatment to individual patients and treat specific problems and psychopathology.

Psychotherapy for personality disorders

Personality disorders are widely prevalent among those seeking mental health services, resulting in substantial distress and a heavy burden on public assistance and health resources. We conducted a qualitative review of randomized controlled trials (RCTs) of psychosocial interventions for personality disorders. Articles were identified through searches of electronic databases and classified based on the focus of the psychological intervention. Data regarding treatment, participants and outcomes were identified. We identified 33 RCTs that evaluated the efficacy of various psychosocial treatments. Of these studies, 19 focused on treatment of borderline personality disorder, and suggested that there are several efficacious treatments and one well-established treatment for this disorder. In contrast, only five RCTs examined the efficacy of treatments for Cluster C personality disorders, and no RCTs tested the efficacy of treatments for Cluster A personality disorders. Although other personality disorders, especially Cluster A, place heavy demands on public assistance, and in spite of recommendations that psychosocial interventions should be the first line of treatment for these disorders, our review underscored the dearth of treatment research for many of these personality disorders. We highlight some obstacles to such research and suggest directions for future research.

Promising psychotherapies for personality disorders

OBJECTIVE

To provide a narrative review of recent research on the psychotherapeutic treatment of patients with personality disorders (PDs).

METHOD

We conducted PubMed and PsycINFO searches of recently published articles that reported on the treatment outcomes of psychotherapies for PDs. Our focus was on studies that used randomized controlled trial (RCT) methodology. The search period was from January 2006 to June 2009.

RESULTS

The effectiveness of various psychotherapy treatment packages for PDs is well supported by favourable results from RCTs. Beneficial effects of psychotherapy included reduced symptomatology, improved social and interpersonal functioning, reduced frequency of maladaptive behaviours, and decreased hospitalization. Equivalent effects among the interventions we compared were common. Many of the treatments studied required only limited training by therapists. Most studies were focused on treating patients with borderline personality disorder (BPD). Some findings were suggestive of psychotherapy being cost-effective; however, few studies actually included formal cost analyses. Only one study included follow-up of treated patients beyond 1-year posttreatment.

CONCLUSIONS

There is strong support for the use of psychotherapy to treat patients with PDs. However, most of the evidence is limited to BPD. The findings of recent studies hold promise for training and practice. Future research should attend to identification of appropriate patient-treatment matches, elucidation of active treatment ingredients, and illumination of factors that are common among treatments that account for their equivalent effects.

A cost-utility analysis of psychoanalysis versus psychoanalytic psychotherapy

Objectives: Despite the considerable and growing body of research about the clinical effectiveness of long-term psychoanalytic treatment, relatively little attention has been paid to economic evaluations, particularly with reference to the broader range of societal effects. In this cost-utility study, we examined the incremental cost-effectiveness ratio (ICER) of psychoanalysis versus psychoanalytic psychotherapy.

Methods: Incremental costs and effects were estimated by means of cross-sectional measurements in a cohort design (psychoanalysis, n = 78; psychoanalytic psychotherapy, n = 104). Quality-adjusted life-years (QALYs) were estimated for each treatment strategy using the SF-6D. Total costs were calculated from a societal perspective (treatment costs plus other societal costs) and discounted at 4 percent.

Results: Psychoanalysis was more costly than psychoanalytic psychotherapy, but also more effective from a health-related quality of life perspective. The ICER—that is, the extra costs to gain one additional QALY by delivering psychoanalysis instead of psychoanalytic psychotherapy—was estimated at €52,384 per QALY gained.

Conclusions: Our findings show that the cost-utility ratio of psychoanalysis relative to psychoanalytic psychotherapy is within an acceptable range. More research is needed to find out whether cost-utility ratios vary with different types of patients. We also encourage cost-utility analyses comparing psychoanalytic treatment to other forms of (long-term) treatment.

Three-year follow-up of syndromal antisocial behavior in adults: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVE

To present nationally representative findings on total antisocial personality disorder (ASPD) symptoms, major violations of others' rights (MVOR), and violent symptoms over a 3-year follow-up in Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions among adults diagnosed at Wave 1 with ASPD versus syndromal adult antisocial behavior without conduct disorder before age 15 years (AABS, not a codable DSM-IV disorder).

METHOD

Face-to-face interviews were conducted with 34,653 respondents aged 18 years and older. Antisocial syndromes and comorbid lifetime substance use, mood, and 6 additional personality disorders were diagnosed at Wave 1 using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version (AUDADIS-IV). The Wave 2 AUDADIS-IV assessed antisocial symptoms over follow-up, lifetime attention-deficit/hyperactivity disorder (ADHD) and posttraumatic stress disorder, and borderline, narcissistic, and schizotypal personality disorders. Wave 1 was conducted in 2001-2002 and Wave 2 in 2004-2005 by the National Institute on Alcohol Abuse and Alcoholism.

RESULTS

In unadjusted analyses, respondents with ASPD reported significantly more total, MVOR, and violent symptoms over follow-up than did respondents with AABS. Adjustment for baseline sociodemographics and psychiatric comorbidity attenuated these associations; after further adjustment for parallel antisocial symptom counts from age 15 years to Wave 1, associations with antisocial syndromes disappeared. Independent Wave 1 predictors of persistent antisociality over follow-up included male sex, not being married or cohabiting, low income, high school or less education, lifetime drug use disorders, additional personality disorders, and ADHD.

CONCLUSIONS

The distinction between ASPD and AABS holds limited value in predicting short-term course of antisocial symptomatology among adults. However, the prediction of persistent antisociality by psychiatric comorbidity argues for comprehensive diagnostic assessments, treatment of all identified disorders, and investigation of whether treatment of comorbidity might hasten remission of antisociality.

Psychotherapy of personality disorders and concomitant substance dependence

PURPOSE OF REVIEW

Psychotherapy of patients with personality disorder and concomitant substance dependence requires an integrative approach. Although a number of studies have evaluated psychotherapy for one of these disorders, only few studies have described the effectiveness of treatment programs in comorbid patients. These limited findings provide a basis for the further development of treatments for personality disorder and concomitant substance dependence. This review gives an overview of the current state of research in this field.

RECENT FINDINGS

Although a large number of evaluation studies tested the effectiveness of several therapies for alcohol dependence, far fewer evaluated nonalcohol substance dependence. There are very few evaluations of the efficacy of psychotherapy for other forms of drug dependence. Only dialectical behavior therapy and dual-focus schema therapy have been tested for the treatment of personality disorder and substance dependence.

SUMMARY

To date, two randomized controlled trials in 59 female-only patients with borderline personality disorder and substance abuse provided the best evidence-based data for the effectiveness of dialectical behavior therapy. For dual-focus schema therapy, a single randomized controlled trial indicated a curative effect in a small group of patients with personality disorder and substance dependence. Although the results of these studies are encouraging, further clinical trials need to be conducted in larger populations including male participants.