Efficacy of high-intensity versus low-intensity psychoanalytically oriented long-term treatments and determinants of outcome: individual participant data Meta-analysis of Long-term Analytic treatment Studies (MeLAS)

INTRODUCTION

Long-term psychodynamic/psychoanalytic psychotherapy (LTPP) is a prevalent treatment option for complex mental disorders. Yet, little is known about the role of treatment intensity in LTPP. We present a study protocol for a systematic review and individual participant data (IPD) meta-analysis aggregating and analysing individual data from randomised and quasi-experimental trials by meta-analysis. The purpose is to (1) determine the treatment effectiveness of LTPP with low versus high intensity (up to 2 weekly sessions vs three or more), (2) compare their joint effectiveness to shorter therapies and treatments as usual, (3) identify predictors and moderators of treatment outcomes and (4) determine reciprocal relationships between different outcome domains (symptomatic and structural/personality change) over the courses of LTPP.

METHODS AND ANALYSIS

We include studies from (randomised controlled trial, RCT) and quasi-experimental trials, where at least one condition was LTPP of high or low frequency. Long-term treatment is defined as ≥1 year or ≥50 sessions. To be eligible studies must include a standardised outcome measure of symptoms (global or disorder specific) with at least one proof of reliability. The primary outcome is symptom reduction (global or specific), secondary outcome criteria are reliable change, remission, functional capacities, personality, personality functioning and interpersonal pathology. Relevant studies will mainly be identified by searching relevant databases: PubMed, PsycINFO (via EBSCO), Web of Science (via Elsevier), Chochrane's Central Register of Controlled Trials (via Wiley). Risk of bias will be evaluated in line with the Cochrane assessments tools for quasi-experimental trials and RCTs, respectively.

ETHICS AND DISSEMINATION

Aggregation of data from primary trials collected based on ethics votes. Dissemination into clinical practice via open access publications of findings.

PROSPERO REGISTRATION NUMBER

CRD42022304982; Pre-results.

Personality functioning in anxiety disorders

BACKGROUND

The Alternative DSM-5 Model for Personality Disorders as well as the upcoming IDC-11 have established a new focus on diagnosing personality disorders (PD): personality functioning. An impairment of self and interpersonal functioning in these models represents a general diagnostic criterion for a personality disorder. Little is known so far about the impairment of personality functioning in patients with other mental disorders than PD. This study aims to assess personality functioning in patients with anxiety disorders.

METHODS

Ninety-seven patients with the diagnosis of generalized anxiety disorder, panic disorder, or phobia, and 16 healthy control persons were diagnosed using the Structured Clinical Interview for DSM-IV (SCID-I and -II) and were assessed by means of the Structured Interview for Personality Organization (STIPO) to determine the level of personality functioning.

RESULTS

While all three patient groups showed significant impairment in personality functioning compared to the control group, no significant differences were observed between the different patient groups. In all three groups of anxiety disorders patients with comorbid PD showed significantly worse personality functioning than patients without. Patients without comorbid PD also yielded a significant impairment in their personality functioning when compared to the control group.

CONCLUSIONS

Anxiety disorders are associated with a significant impairment in personality functioning, which is significantly increased by comorbid PD. There are no differences in terms of personality functioning between patients with different anxiety disorders.

[Psychoanalysis and psychoanalytic oriented psychotherapy: differences and similarities]

Psychoanalysis as well as Psychoanalytic Psychotherapy derived from Psychoanalysis are efficient methods offered by the Austrian health care system in the treatment for anxiety, depression, personality disorders, neurotic and somatoform disorders. In both methods similar basic treatment techniques are applied. Therefore differentiation between both treatment options often is made pragmatically by the frequency of sessions or the use of the couch and seems to be vague in the light of empirical studies. This overview focuses a potential differentiation-the objective and subjective dimensions of the indication process. Concerning the latter it is to investigate, if reflective functioning and ego-integration can be enhanced in the patient during the interaction process between patient and psychoanalyst. Empirical data underline the necessity to investigate to which extent externalizing defence processes are used and to integrate such factors into the decision and indication process. Differing treatment aims display another possibility to differentiate psychoanalysis and psychoanalytic psychotherapy. Psychoanalytic psychotherapy aims for example more at circumscribed problem-foci, the capability for self-reflexion is one of the most prominent treatment effects in psychoanalysis that results in on-going symptom reduction and resilience. The most prominent differentiation lies in the utilization of technical neutrality. Within Psychoanalytic Psychotherapy neutrality has sometimes to be suspended in order to stop severe acting out. Empirical evidence is given concerning the differentiation between psychoanalysis and psychoanalytic psychotherapy, that treatment efficacy is not correlated with the duration of the treatment, but with the frequency of sessions. Results give support to the assumption that the dosage of specific and appropriate psychoanalytic techniques facilitates sustained therapeutic change.

[Predictors of dropout during psychoanalytic treatments of patients with personality disorders]

OBJECTIVES

Are there predictive factors which impair the progress in psychoanalytic treatments of patients with severe personality disorders?

METHODS

In 38 psychoanalytic treatments, severity of symptoms (SCL-90-R), interpersonal problems (IIP), character traits and psychostructural functioning (SWAP-200) were investigated half-yearly. Predictors for drop-out were identified using stepwise binary logistic regression models and repeated ANOVA models. The statistical stability was controlled using a jackknife algorithm.

RESULTS

For the first year denial of needs for closeness, conflicts around engagement and abandonment, as well as fears of an impulsive breakthrough of negative affects predicted dropout of therapy. During the second year externalizing defence, projection/projective identification, somatisation, hypochondria and dismissive interpersonal behaviour predicted break-ups.

CONCLUSIONS

For psychoanalytic technique, it is necessary to perceive and catch paranoid anxieties, negative affects, externalizing mechanisms and projective identification from the very beginning as well as to interpret and work through these elements in transference thoroughly in order to prevent treatment dropout.

[Indication of psychoanalytic treatment for personality disorders]

AIM

The study investigates how a psychoanalytic institution reaches its aims by identifying different factors like diagnosis, sociodemographic characteristics of the patient, motivation of the psychoanalyst, and their impact on the indication-process.

MATERIAL AND METHODS

38 patients diagnosed as having severe personality disorders and treated in a psychoanalytic outpatient clinic were compared with 49 patients who were referred for psychoanalytic treatment to a private practice.

RESULTS

Although the groups were similar regarding the severity of their problems, more comorbidity and a more stable professional life were found in the group referred to private practice. Patients who tend to distort their social life in order to maintain a fragile psychic balance are more likely to get institutional treatment. The psychoanalytic team-conference and discussion of unconscious object-relationship pattern had great impact on the process of giving correct indications.

CONCLUSION

The indication for psychoanalytic treatment does not correlate with personality disorder diagnosis or with the motivation of the therapist. Nevertheless, more differentiated, in clinical routine practicable instruments measuring reflective functioning, or the quality of object relationship have to be developed in order to give an adequate indication for psychoanalytic treatment.