Personality functioning and self-disorders in individuals at ultra-high risk for psychosis, with first-episode psychosis and with borderline personality disorder

BACKGROUND

Assessment of personality functioning in different stages of psychotic disorders could provide valuable information on psychopathology, course of illness and treatment planning, but empirical data are sparse.

AIMS

To investigate personality functioning and sense of self in individuals at ultra-high risk (UHR) for psychosis and with first-episode psychosis (FEP) in comparison with a clinical control group of individuals with borderline personality disorder (BPD) and healthy controls.

METHOD

In a cross-sectional design, we investigated personality functioning (Structured Interview of Personality Organization, STIPO; Level of Personality Functioning Scale, LPFS) and disturbances of the basic self (Examination of Anomalous Self-Experience, EASE) in 107 participants, comprising 24 individuals at UHR, 29 individuals with FEP, 27 individuals with BPD and 27 healthy controls.

RESULTS

The UHR, FEP and BPD groups had moderate to severe deficits in personality organisation (STIPO) compared with the healthy control group. Self-functioning with its subdomain (facet) 'self-direction' (LPFS) was significantly worse in participants with manifest psychosis (FEP) compared with those at-risk for psychosis (UHR). The FEP group showed significantly worse overall personality functioning than the UHR group and significantly higher levels of self-disturbance (EASE) than the BPD group, with the UHR group lying between these diagnostic groups. Hierarchical cluster analysis based on the seven STIPO domains yielded three clusters differing in level of personality functioning and self-disturbances.

CONCLUSIONS

Our data demonstrate that psychotic disorders are associated with impaired personality functioning and self-disturbances. Assessment of personality functioning can inform treatment planning for patients at different stages of psychotic disorder.

Capturing the Unconscious-The "Psychoanalytic Core Competency Q-Sort". An Innovative Tool Investigating Psychodynamic Therapeutic Skills

The Psychoanalytic Core Competency Q-Sort (PCC Q-Sort) is a newly developed empirical research tool that allows for the description and illustration of the ways psychodynamically-oriented psychotherapists work. It provides a simple, straightforward rating procedure utilizing a well-established q-sort method. The present pilot study describes the psychoanalytic core competency items and discusses the development procedure of the instrument as well as statistical analysis of ratings from psychoanalytic sessions, including inter-rater reliability as well as preliminary findings on possible construct validity. Additionally, a factor analysis was performed. Values were assessed by applying the PCC Q-Sort to 30 audio recordings of psychoanalytic sessions. The results of the present study indicate that the PCC Q-Sort is a reliable process research instrument that allows for a detailed investigation of psychotherapy processes in psychodynamic psychotherapies and change processes.

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.

Empathy in Psychoanalysis and Medical Education - what can we learn from each other?

BACKGROUND

Several research areas, including medical education (ME), focus on empathy as an important topic in interpersonal relationships. This focus is central to the use of communication skills related to empathy and even more crucial to provide information in a way that makes patients feel more involved in the treatment process. Psychoanalysis (PA) provides its initial concept of empathy based on affective aspects including findings from neuroscience and brain research. Enhancing cooperation between ME and PA can help to integrate both aspects of empathy into a longitudinal training program.

DISCUSSION

The condition of psychoanalytic empathy definitions is the understanding of unconscious processes. It is important to primarily attend especially the dominant affects towards the patient before interpreting his or her behaviour, since in explaining the emerging affects, the analyst has to empathize with the patient to understand the (unconscious) reasons for its behaviour. A strong consideration of nonverbal communication, clinical perceptions, intuitive interaction, contagion-like processes and their implementation and empowerment in medical and therapeutic curricula is one way of beneficially using interdisciplinary approaches to yield empathy in clinical interaction.

CONCLUSION

Established methods of PA, like training of containment, reflective functioning, affective holding and giving meaningful interpretations in accordance with countertransferential and transferential aspects may help to put a focus on the clinican-patient-interaction and the preservation of the physicians' (mental) health. In consequence of the discussion of various training methods that take the theoretical and practical concepts of empathy into account, we aim for an implementation of the named methods in the medical curricula.

Transference and countertransference: A review

Originally a psychodynamic concept, the therapeutic relationship (also therapeutic alliance, helping alliance or simply alliance) has become a pan-theoretical model for the professional relationship between a therapist and his or her client (Kivlighan, 1995). With the development of this concept in the latter half of the 20th century, psychotherapeutic theory and practice saw a paradigm shift away from strict adherence to technique with little room for responsive, individual behavior from the therapist and toward the "authentic" human relationship at the core of therapy. This meant that more consideration was given to the idea of mutual influence from patient and therapist to the success of therapy (Safran & Muran, 2006). This article aims to provide a comprehensive overview of the complex and shifting research on the therapeutic relationship to promote a greater understanding of the concept.

Dimensions of Activity in Countertransference and Therapist Reactions: Therapist Reactions During Sessions with Depressed Patients

OBJECTIVES

This paper presents the interaction structure between the therapist's countertransference and the patient's affect based on identified dimensions of how therapists feel and react during sessions with depressed patients.

METHODS

639 sessions were audio-recorded and rated by trained raters. These recordings were obtained from the Munich Psychotherapy Study and analyzed with the PQS, the AREQ, and the TRQ/CTQ.

RESULTS

Seven components with good to excellent internal consistency (Cronbach α = .745-.902) were found and labeled Hostile Feelings, Positive, Disengaged, Overwhelmed and Encroaching Feelings concerning countertransference and therapists' emotional reaction, while the therapist's behavior was scored on separate dimensions. The middle and final sessions reveal significant correlations between a patient's positive affect experience and positive countertransference.

CONCLUSIONS

The confirmed pattern implies not only that a positive affect is related to a positive countertransference reaction, but also that a positive countertransference entails a positive affect. The fact that this pattern could be accounted for only during the middle and the last sessions indicate that the working alliance is not fully established at the beginning of the treatment.

Psychosomatic patients in integrated care: Which treatment mediators do we have to focus on?

The field of psychosomatics has gained increasing significance; it has been struggling to establish its position as either an independent discipline or a subdomain of specific areas such as internal medicine or psychiatry. However, the rise of psychosomatic syndromes and disease patterns as well as an increase of specific integrated psychosomatic wards is a clear indication for the growing importance of interdisciplinary approaches to psychosomatic disorders. The study presents data from an 8-week inpatient treatment at a psychosomatic facility and investigates whether patients improved in their subjective symptom experience. A complex treatment approach, ranging from pharmacological treatment and group and individual psychotherapy to physiotherapy and ergotherapy was integrated into this intervention. In essence, containment of intrapsychic aggression derivatives played a central role in the treatment of psychosomatic symptoms. A significant factor contributing to a successful treatment is the doctor-patient relationship. All these factors were investigated in the present study.

Circadian patterns of plasma cortisol, 17-hydroxyprogesterone, and testosterone in congenital adrenal hyperplasia

In 11 children aged between 2 and 17 years with (nonsalt-losing) congenital adrenal hyperplasia (21-hydroxylase deficiency) blood was drawn at 90-minute intervals during a 24-hour period and levels of 17-hydroxyprogesterone, testosterone, and cortisol were measured. Levels of 17-ketosteroids and pregnanetriol were measured too in 24-hour urine samples. These measurements were taken under different regimens of treatment and after interruption of treatment. Cortisol level rose and fell rapidly after administered corticosteroid, and reached unphysiologically high levels. Testosterone levels showed pronounced variations but stayed in the normal range for most of the time even in untreated patients; thus testosterone provides a poor control parameter. Levels of 17-hydroxyprogesterone showed extreme fluctuations and very high peak levels in untreated patients; standard treatment with two or three daily doses of corticosteroids did not prevent a pronounced rise in its level after midnight. After the first morning dose of hydrocortisone a very steep fall was observed. The 24-hour pregnanetriol excretion correlated well with the corresponding total integrated 17-hydroxyprogesterone area. It is concluded that single 17-hydroxyprogesterone values are unlikely to give adequate information about the quality of treatment.

[Endocrinological aspects of ketotic hypoglycemia and adrenal calcification (author's transl)]

Case report on a 2 6/12 years old girl with bilateral adrenal calcifications and ketotic hypoglycemia. Adrenal function tests showed a normal response of the adrenal cortex but signs of adrenal medullary insufficiency. Urinary adrenaline in samples before and after insulin did not increase significantly and plasma adrenaline was undetectable during hypoglycemia. We suggest, that the absence of adrenaline, caused by perinatal adrenal hemorrhagia, is one of the possible pathogenetic keys of ketotic hypoglycemia and examinations on this disease should always include the search for adrenal calcifications.

Congenital adrenal hyperplasia: simultaneous determination of plasma aldosterone and 17-hydroxyprogesterone

Plasma levels of aldosterne and 17-hydroxyprogesterone were determined in 5 just diagnosed cases of congenital adrenal hyperplasia due to 21-hydroxylase deficiency without salt-loss before onset of therapy, and in 14 children suffering from the same disorder, under glucocorticoid therapy before and after withdrawal of therapy for one week as well as before and after ACTH-stimulation. Furthermore, urinary pregnanetriol, pregnanetriolone, 17-ketosteroids and 17-ketogenic steroids were determined with and without therapy. Serum concentrations of 17-hydroxyprogesterone in patients before onset of therapy were at least 40 times above the normal range (normal range: 0.39 ± 0.23 ng/ml determined in 19 children of age 1–12 years), aldosterone was also elevated (range 16.5–84.4 ng/100 ml, normal aldosterone being 7.3 ± 4.7 ng/ml). In contrast, well controlled patients (judged on urinary pregnanetriol-excretion) had normal aldosterone (one exception) and 17-hydroxyprogesterone levels below 5 ng/ml. Both steroids were well stimulated by ACTH. In 3 poorly controlled cases elevated pregnanetriol and 17-hydroxyprogesterone values up to 130.9 ng/ml were found. Withdrawal of therapy resulted in pronounced rise of aldosterone and 17-hydroxyprogesterone. Exogenous ACTH had no detectable effect in 7 cases leading to further stimulation in the other children. We found an excellent correlation between plasma 17-hydroxyprogesterone and urinary pregnanetriol (r = 0.84, P < 0.003, n = 14). Fairly good correlation also exists between aldosterone and 17-hydroxyprogesterone values (r = 0.65, P < 0.01, n = 14) in patients before the onset and after withdrawal of therapy.

The data confirm the value of 17-hydroxyprogesterone determinations for diagnosis and management of congenital adrenal hyperplasia on the one hand, and the compensatory elevated aldosterone production in the non-salt-losing form of the disorder on the other.

Determination of plasma aldosterone in children by thin layer chromatography and radioimmunoassay

An accurate and relatively simple radioimmunoassay for the determination of aldosterone concentration in peripheral plasma has been developed, 0.5-2.0 ml plasma with added [1,2-3H]aldosterone is extracted with dichloromethane. Purification of the extract is achieved by thin later chromatography in the system benzene-acetone 1:1. Recovery of [1,2-3H] aldosterone is 58 +/- 6 (SD)%. Bound and free fractions are separated by dextran-coated charcoal. The intra-assay reproducibility is 8.8% and the inter-assay reproducibility varies from 11.4-16.1%. The sensitivity of the assay for a 5 ml plasma sample can be put at 0.2 ng/100 ml. Normal values determined in 52 healthy children of different age groups are presented. Furthermore the aldosterone stimulating effect of low sodium diet (17 children), severe and prolonged vomiting (19 children) and synthetic ACTH (10 children) has been studied by our modified method.

[The clinical value of the cortisol secretion rate determination in paediatric endocrinology (author's transl)]

The cortisol secretion rate was determined in 18 children according to a modified and simplified method. In 7 cases the determination was repeated after stimulation with synthetic ACTH. 12 of these children suffered from diseases which may affect glucocorticoidsteroid production and the remaining 6 children served as normal controls. In some cases the plasma 11-hydrocorticoid level and urinary excretion of 17-ketogenic steroids were additionally determined. Differences in adrenal function were noted in 2 patients with congenital adrenal hyperplasia (one of the salt-losing type, the other nonsalt-losing type) and 5 patients with adrenal insufficiency. A normal cortisol secretion rate was found in 3 children with diverse disturbances of carbohydrate metabolism, as well as in a child with subtotal adrenalectomy. The clinical value of the determination of the cortisol secretion rate is discussed and was found to be a more reliable indicator of glucocorticoid activity than other parameters.