Becoming Trustworthy in Treating Patients With Borderline Personality Disorder

No one doubts the importance of trust in psychotherapy, but few therapists think about the complexities of trusting relationships, and the trustworthiness that would justify trusting remains far from view. Fortunately, inasmuch as trusting and trustworthiness are inherently ethical concepts, contemporary philosophers have given trust the consideration it warrants. Integrating science and philosophy, the author reviews the broad scope and multifaceted nature of trust and trustworthiness, the social-cognitive development of trust, and the development of distrust in the context of borderline personality disorder. Without questioning therapists' character, the author makes the case for shifting the emphasis from the patient's distrust to the therapist's challenge to become trustworthy in the course of each treatment relationship and, more broadly, over the course of a professional career.

Contending With Polarization in the Expanding Scope of Psychotherapy

The author queried 32 colleagues about their sense of polarization in the field of psychotherapy, using as an example the contrast between generalists (like himself) and specialists. This query was inspired by the proliferation of brands of psychotherapy coupled with the dominance of cognitive-behavioral therapies. His key conclusions: (a) tensions in the field are associated with a multitude of polarities and individual differences; (b) it is folly to reduce polarization to any single polarity; and (c) given the field's huge diversity, we are all specialists. While the author advocates greater integration of theories and methods, he also argues for expansion by including ethical thought into the scientific zeitgeist. He proposes skill in being human as a broad aspiration for therapists and patients.

Predicting depression outcomes throughout inpatient treatment using the general and specific personality disorder factors

BACKGROUND

Clinical intuition suggests that personality disorders hinder the treatment of depression, but research findings are mixed. One reason for this might be the way in which current assessment measures conflate general aspects of personality disorders, such as overall severity, with specific aspects, such as stylistic tendencies. The goal of this study was to clarify the unique contributions of the general and specific aspects of personality disorders to depression outcomes.

METHODS

Patients admitted to the Menninger Clinic, Houston, between 2012 and 2015 (N = 2352) were followed over a 6-8-week course of multimodal inpatient treatment. Personality disorder symptoms were assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th edition Axis II Personality Screening Questionnaire at admission, and depression severity was assessed using the Patient Health Questionnaire-9 every fortnight. General and specific personality disorder factors estimated with a confirmatory bifactor model were used to predict latent growth curves of depression scores in a structural equation model.

RESULTS

The general factor predicted higher initial depression scores but not different rates of change. By contrast, the specific borderline factor predicted slower rates of decline in depression scores, while the specific antisocial factor predicted a U shaped pattern of change.

CONCLUSIONS

Personality disorder symptoms are best represented by a general factor that reflects overall personality disorder severity, and specific factors that reflect unique personality styles. The general factor predicts overall depression severity while specific factors predict poorer prognosis which may be masked in prior studies that do not separate the two.

Personality trait domains predict psychiatric symptom and functional outcomes

A review of high intensity, high dose mentalization-based inpatient psychiatric treatment indicated large effect-size reductions in symptoms of depression, anxiety, somatization, and improving emotion-regulation functioning (Allen et al., 2017). This study examined the impact of pathological personality traits has on baseline symptoms and functioning, as well as their impact on the longitudinal course in a large cohort of adult inpatient psychiatric sample (N = 804). The Personality Inventory for DSM-5 (PID-5; Krueger et al., 2012) was used to assess trait domains impact on longitudinal outcomes (anxiety, depression, somatic symptoms, and functional impairment) using hierarchical repeated measures modeling. Results indicate Negative Affectivity and Detachment were related to higher admission severity in all four outcome domains. Psychoticism was related to somatic symptoms, while Antagonism and Disinhibition were related to functional impairment. Paradoxically, when symptoms were plotted over 2-week intervals during hospitalization, patients with higher admission PID-5 trait scores exhibited greater improvement over time. The PID-5 appears to contribute to prediction of treatment outcome response above and beyond demographic and burden of illness. Importantly, the findings add to a growing body of literature indicating that impairments in personality traits do not preclude positive treatment response, particularly when treatments target pathological personality features. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Diagnostic accuracy of DSM-5 borderline personality disorder criteria: Toward an optimized criteria set

OBJECTIVE

The polythetic system used by the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) for diagnosing borderline personality disorders (BPD) is far from optimal; however, accumulated research and clinical data are strong enough to warrant ongoing utilization. This study examined diagnostic efficiency of the nine DSM-IV BPD criteria, then explored the feasibility of an optimized criteria set in classifying BPD.

METHODS

Adults (N=1,623) completed the Structured Clinical Interviews for DSM-IV Axis II Disorders resulting in a BPD group (n=352) and an inpatient psychiatric control group (PC) with no personality disorders (n=1,271). Receiver operator characteristics and diagnostic efficiency statistics were calculated to ascertain the relative diagnostic efficiency of each DSM-5 BPD criterion in classifying BPD cases.

RESULTS

Affective instability (Criterion 6) evidenced the strongest capacity to differentiate the groups (AUC = .84, SE = .01, p < .0001). Abandonment fears (Criterion 1), unstable relationships (Criterion 2), identity disturbance (Criterion 3), impulsivity (Criterion 4), and chronic emptiness (Criterion 7) yielded good-to-moderate discrimination (AUC range = .75-.79). A composite index of these six criteria yielded excellent accuracy (AUC = .98, SE = .002, p < .0001), sensitivity (SN=.99), and specificity (SP=.90).

CONCLUSIONS

The current findings add to evidence that affective instability is a useful gate criterion for screening, and the optimized criteria set evidences equivalent accuracy to the original 9 criteria, with a substantial reduction in estimated heterogeneity (from 256 combinations with the original set to 42 combinations with the optimized set).

Attachment Style Mediates the Relationship between Trauma and Somatic Distress among Individuals with Serious Mental Illness

Objective: Individuals with mental illnesses severe enough to require psychiatric hospitalization often have significant trauma histories, have developed maladaptive attachment styles, and experience comorbid somatic distress. Gaining an understanding about the interaction of such factors may lead to prioritizing interventions that target factors that mediate the relationship between trauma and adverse somatic distress. Prior research has examined various mediation models, but results have been mixed and conducted only on outpatient samples.Method: Participants (47.7% female) in a large sample (N = 2702) with a mean age of 34.62 (SD = 14.7) were enrolled in a specialist inpatient program and completed self-report measures pertaining to demographics, attachment insecurity, lifetime trauma exposure, and somatic distress within 72 hours of admission. The dimensions of attachment insecurity (i.e., attachment anxiety and attachment avoidance) were tested as parallel mediators in the relationship between lifetime trauma exposure and somatic distress.Results: The mediation analyses revealed that attachment anxiety and avoidance partially mediated the relationship between lifetime trauma exposure and somatic distress.Conclusions: These results are the first to date to implicate both attachment anxiety and avoidance as mediators between trauma exposure and somatic distress in a high acuity sample. Although the results do not imply causality, they do call attention to social-cognitive factors related to somatic distress and highlight the importance of considering attachment styles as a possible contributor to comorbid physical symptoms in patients with trauma exposure.

Using the attachment network Q-sort for profiling one's attachment style with different attachment-figures

Attachment instruments vary substantially in practicability of administration, employment of categorical versus dimensional scoring, quality of scales, and applicability to different attachment figures. The Attachment Network Q-sort (ANQ) is a self-report, quasi-qualitative instrument that discriminates relationship-specific attachment styles for multiple attachment figures. The current study assesses the properties of the ANQ in psychotherapy patients and in non-patient respondents, using mother, father and romantic partner as possible attachment figures. Analyzing the ANQ-data with latent class analysis, we found four types or classes of participants: a group with an overall secure profile, a group only insecure for father, a group only insecure for mother, and a group insecure for mother as well as father but not for partner (if available). These profiles proved to have good concurrent, discriminant and construct validity. We conclude that the ANQ is potentially a useful alternative clinical self-report instrument to assess combinations of attachment styles for a range of attachment figures such as parents and a romantic partner.

Lifetime and prospective associations among personality trait domains and suicide-related behaviors in patients with severe mental illness

BACKGROUND

Despite extensive research and clinical efforts, the suicide rate in the United States continues to rise, driving the need for more research to identify latent factors that increase risk for suicide and to guide treatment decision-making.

METHODS

The current study examined a large cohort (N = 1,219) of high-risk psychiatric inpatients to explore associations between personality traits and suicide-related variables measured retrospectively (lifetime history prior to hospital admission) and prospectively (at discharge and 12-month follow-up).

RESULTS

Lifetime suicide-related behavior (SRB: combination of ideational severity, aborted, interrupted, actual attempts, and non-suicidal self-injury) was associated with age (younger), gender (female), and elevated scores on the Personality Inventory for DSM-5 (PID-5) negative affectivity, borderline trait composite score, and five-factor model traits of conscientiousness and neuroticism. Patients who manifested persistent suicidal ideation throughout a 6-8 week inpatient treatment (n = 162; 16.9%) tended to be younger, female, and to have elevated PID-5 borderline trait composite scores. Twelve-month post-discharge SRB was predicted by elevated PID-5 borderline trait composite scores.

LIMITATIONS

Personality traits accounted for a small amount of variance in the overall model, thus limiting prediction based on individual traits.

CONCLUSIONS

This large sample of high-risk inpatients with longitudinal outcomes provides a rare assessment of proximal personality traits in predicting lifetime SRB, persistent suicidal ideation observed during the course of a 6-8-week intensive inpatient treatment, and SRB outcomes within 12 months after discharge from hospitalization. Personality traits should be included in future attempts to create predictive algorithms that include relevant biological data (neuroimaging, genetic, microbiome).

Differentiating bipolar disorder from borderline personality disorder: Diagnostic accuracy of the difficulty in emotion regulation scale and personality inventory for DSM-5

BACKGROUND

Confusion abounds when differentiating the diagnoses of bipolar disorder (BD) from borderline personality disorder (BPD). This study explored the relative clinical utility of affective instability and self-report personality trait measures for accurate identification of BD and BPD.

METHODS

Receiver operator characteristics and diagnostic efficiency statistics were calculated to ascertain the relative diagnostic efficiency of self-report measures. Inpatients with research-confirmed diagnoses of BD (n = 341) or BPD (n = 381) completed the Difficulty in Emotion Regulation Scale (DERS) and Personality Inventory for DSM-5 (PID-5).

RESULTS

The total score for DERS evidenced relatively poor accuracy for differentiating the disorders (AUC = 0.72, SE = 0.02, p < .0001), while subscales of affective instability measures yielded fair discrimination (AUC range = 0.70-0.59). The PID-5 BPD algorithm (consisting of emotional lability, anxiousness, separation insecurity, hostility, depressivity, impulsivity, and risk taking) evidenced moderate-to-excellent accuracy (AUC = 0.83, SE = 0.04, p < .0001) with a good balance of specificity (SP = 0.79) and sensitivity (SN = 0.77).

CONCLUSION

Findings support the use of the PID-5 algorithm for differentiating BD from BPD. Furthermore, findings support the accuracy of the DSM-5 alternative model Criteria B trait constellation for differentiating these two disorders with overlapping features.

A naturalistic longitudinal study of extended inpatient treatment for adults with borderline personality disorder: An examination of treatment response, remission and deterioration

BACKGROUND

Experts express reluctance to hospitalize patients with borderline personality disorder (BPD) for more than a few days, arguing that extended inpatient care leads to deterioration and adverse events. To date, there is no empirical support for these assertions.

AIMS

The current study examined the assumption of iatrogenic effects among BPD adults.

METHODS

Clinically significant and reliable change in symptoms, functional capacities, and adverse events were quantified for both inpatients with BPD (n = 245) and a well-matched inpatient reference (n = 220) sample. Latent growth curve (LGC) models were used to evaluate moderators of the trajectory of PHQ-9 depression scores over the course of hospitalization.

RESULTS

Large effect size improvements were observed in depression, anxiety, suicidal ideation and functional disability among patients with BPD (Cohen's d ≥ 1.0) and those in the reference sample (Cohen's d ≥ .80). Clinical deterioration and adverse events were rare (occurring in no more than 1.1% of BPD and reference patients on any outcome) with no difference across patient cohorts. BPD diagnosis failed to influence the trajectory of continuous depression severity. Rather, trait emotion dysregulation was associated with initial depression severity.

CONCLUSIONS

Twenty-five years ago it was assumed that adults with BPD could not benefit from psychiatric treatment. Today there are a number of effective evidence-based outpatient treatments for BPD, but beliefs about extended inpatient treatment have changed little. Current results indicate that extended inpatient treatment can result in significant and clinically meaningful symptomatic and functional improvement in BPD patients without iatrogenic effects.

A Novel Approach to Identifying a Neuroimaging Biomarker for Patients With Serious Mental Illness

Serious mental illness (SMI) is disabling, and current interventions are ineffective for many. This exploratory study sought to demonstrate the feasibility of applying topological data analysis (TDA) to resting-state functional connectivity data obtained from a heterogeneous sample of 235 adult inpatients to identify a biomarker of treatment response. TDA identified two groups based on connectivity between the prefrontal cortex and striatal regions: patients admitted with greater functional connectivity between these regions evidenced less improvement from admission to discharge than patients with lesser connectivity between them. TDA identified a potential biomarker of an attenuated treatment response among inpatients with SMI. Insofar as the observed pattern of resting-state functional connectivity collected early during treatment is replicable, this potential biomarker may indicate the need to modify standard of care for a small, albeit meaningful, percentage of patients.

Clinical utility of the DSM-5 alternative model for borderline personality disorder: Differential diagnostic accuracy of the BFI, SCID-II-PQ, and PID-5

BACKGROUND

With the publication of DSM 5 alternative model for personality disorders it is critical to assess the components of the model against evidence-based models such as the five factor model and the DSM-IV-TR categorical model. This study explored the relative clinical utility of these models in screening for borderline personality disorder (BPD).

METHODS

Receiver operator characteristics and diagnostic efficiency statistics were calculated for three personality measures to ascertain the relative diagnostic efficiency of each measure. A total of 1653 adult inpatients at a specialist psychiatric hospital completed SCID-II interviews. Sample 1 (n=653) completed the SCID-II interviews, SCID-II Questionnaire (SCID-II-PQ) and the Big Five Inventory (BFI), while Sample 2 (n=1,000) completed the SCID-II interviews, Personality Inventory for DSM5 (PID-5) and the BFI.

RESULTS

BFI measure evidenced moderate accuracy for two composites: High Neuroticism+ low agreeableness composite (AUC=0.72, SE=0.01, p<0.001) and High Neuroticism+ Low+Low Conscientiousness (AUC=0.73, SE=0.01, p<0.0001). The SCID-II-PQ evidenced moderate-to-excellent accuracy (AUC=0.86, SE=0.02, p<0.0001) with a good balance of specificity (SP=0.80) and sensitivity (SN=0.78). The PID-5 BPD algorithm (consisting of elevated emotional lability, anxiousness, separation insecurity, hostility, depressivity, impulsivity, and risk taking) evidenced moderate-to-excellent accuracy (AUC=0.87, SE=0.01, p<0.0001) with a good balance of specificity (SP=0.76) and sensitivity (SN=0.81).

CONCLUSIONS

Findings generally support the use of SCID-II-PQ and PID-5 BPD algorithm for screening purposes. Furthermore, findings support the accuracy of the DSM 5 alternative model Criteria B trait constellation for diagnosing BPD. Limitations of the study include the single inpatient setting and use of two discrete samples to assess PID-5 and SCID-II-PQ.

Kerosene lighting contributes to household air pollution in rural Uganda

The literature on the contribution of kerosene lighting to indoor air particulate concentrations is sparse. In rural Uganda, kitchens are almost universally located outside the main home, and kerosene is often used for lighting. In this study, we obtained longitudinal measures of particulate matter 2.5 microns or smaller in size (PM_2.5 ) from living rooms and kitchens of 88 households in rural Uganda. Linear mixed-effects models with a random intercept for household were used to test the hypotheses that primary reported lighting source and kitchen location (indoor vs outdoor) are associated with PM_2.5 levels. During initial testing, households reported using the following sources of lighting: open-wick kerosene (19.3%), hurricane kerosene (45.5%), battery-powered (33.0%), and solar (1.1%) lamps. During follow-up testing, these proportions changed to 29.5%, 35.2%, 18.2%, and 9.1%, respectively. Average ambient, living room, and kitchen PM_2.5 levels were 20.2, 35.2, and 270.0 μg/m³ . Living rooms using open-wick kerosene lamps had the highest PM_2.5 levels (55.3 μg/m³ ) compared to those using solar lighting (19.4 μg/m³ ; open wick vs solar, P=.01); 27.6% of homes using open-wick kerosene lamps met World Health Organization indoor air quality standards compared to 75.0% in homes using solar lighting.

Incremental validity of the PID-5 in relation to the five factor model and traditional polythetic personality criteria of the DSM-5

BACKGROUND

This study assessed the incremental validity of the Personality Inventory for DSM-5 (PID-5) beyond the impact of demographic, burden of illness, five-factor model of personality, and DSM-5 personality disorder criteria with respect to associations with admission psychiatric symptoms and functional disability.

METHODS

Psychiatric inpatients (N = 927) were administered the Big Five Inventory, PID-5, and personality disorder criteria counts. Prior treatment utilization, as well as baseline depression, anxiety, emotion regulation, and functional disability were administered within two days of the personality measures. Hierarchical regression models were used to explore the association of personality functioning with symptom functioning, emotion regulation and disability.

RESULTS

Neuroticism was associated with all symptom measures, providing further support for its relevance in clinical populations. Personality trait domains (negative affect, detachment, and psychoticism) from the PID-5 demonstrated incremental validity in predicting baseline symptom and disability functioning over and above demographic, burden of illness, and psychiatric comorbidity and five-factor model (FFM) personality traits.

CONCLUSIONS

Dimensional measures of personality functioning were consistently associated with baseline symptom functioning, supporting the relevance of personality functioning as it relates to psychiatric symptoms. The PID-5 uniquely contributed to the prediction of baseline symptom functioning, thus providing incremental validity over gold-standard personality trait measures.

A controlled comparison trial of the Collaborative Assessment and Management of Suicidality (CAMS) in an inpatient setting: Outcomes at discharge and six-month follow-up

This controlled comparison trial evaluated a suicide-specific intervention, the Collaborative Assessment and Management of Suicidality (CAMS), in an extended-stay psychiatric inpatient setting. Multiple outcomes were examined for 104 patients, half of whom received individual therapy from therapists trained in CAMS. The comparison group was selected from a larger pool through Propensity Score Matching to ensure comparability on age, sex, treatment program, number of prior suicide attempts, and severity of suicidal ideation. Results showed that a) all patients improved significantly across a wide range of measures, including depression, suicidal ideation, functional disability, and well-being; b) these gains were durable over a 6-month post-discharge period; and c) patients treated by a CAMS-trained individual therapist improved significantly more from admission to discharge across all measures. Differences between CAMS and non-CAMS patients were no longer statistically significant at 6-month follow-up, although statistical power was compromised due to attrition. Although replication studies are needed, these findings suggest that interventions specifically tailored for suicidal patients may have advantages compared to usual, intensive inpatient treatment, perhaps by addressing psychological vulnerabilities specific to the population. The lack of significant differences at follow-up suggest that post-treatment contact may be needed to maintain advantages associated with this and similar interventions.

An Open Effectiveness Trial of a Multimodal Inpatient Treatment for Depression and Anxiety Among Adults With Serious Mental Illness

OBJECTIVE

This prospective open effectiveness trial examined symptom change trajectories and rates of remission from depression and anxiety in an intensive multimodal inpatient treatment for adults with serious mental illness (SMI). Patient baseline characteristics were examined as mediators/moderators of treatment response.

METHODS

Adult inpatients with SMI (N = 994) completed an average of 39 days of inpatient treatment. Latent growth curve (LGC) methods were used to model symptom trajectories, estimating expected remission based on individual patterns of change observed across the sample.

RESULTS

Absolute reductions in symptoms were substantial, with large effect size improvements for both depression (d = 1.21, 95% CI [1.13, 1.29]) and anxiety (d = 1.13, 95% CI [1.05, 1.21]). For those presenting with elevated depressive symptoms (Patient Health Questionnaire-Depression ≥ 5.0; 87.5% of the sample), 46.9% evidenced remission from admission to discharge. Among patients presenting with significant anxiety (Patient Health Questionnaire-Generalized Anxiety Disorder Screener ≥ 5.0; 84.5% of the sample), 50.0% evidenced remission from admission to discharge. Mediation analyses revealed that depression and anxiety severity decreased more rapidly with increasing age and initial levels of experiential avoidance.

CONCLUSIONS

Rates of remission of depression and anxiety were greater than anticipated in this large cohort of adult SMI inpatients and may be related to intensity and length of hospitalization.

Psychometric Reevaluation of the Columbia-Suicide Severity Rating Scale: Findings From a Prospective, Inpatient Cohort of Severely Mentally Ill Adults

OBJECTIVE

Accurate prediction of suicide remains elusive due to lack of predictive measures. Given the Columbia-Suicide Severity Rating Scale's (C-SSRS) emerging "gold-standard" status for risk assessment, studies are needed to assess its psychometric properties, particularly predictive validity. The current study adds to the limited literature by assessing the C-SSRS's internal consistency, factor structure, concurrent validity, and predictive validity.

METHODS

In this longitudinal study of 1,055 adults with DSM-IV diagnoses consecutively admitted to a specialized psychiatric hospital between July 1, 2012, and June 30, 2014, patients completed standardized assessments, including the C-SSRS, at admission and 2, 12, and 24 weeks postdischarge.

RESULTS

The C-SSRS evidenced excellent internal consistency (ordinal α = .95). Principal components analysis (PCA) revealed a 2-factor solution, accounting for 65.3% of the variance across items. The severity of ideation and behavioral items loaded onto the first factor, and the intensity of ideation items loaded onto the second factor. The total score, factors, and the most severe ideation single item were moderately correlated with other measures of suicidality (0.27 ≤ r ≤ 0.58; P < .0001). The summary score from the ideation/behavior factor was found to be modestly correlated with any suicide-related behavior within the 6 months following hospitalization. Receiver operator characteristics indicated that the C-SSRS performed adequately in correctly classifying any suicide-related behavior within 6 months of discharge from the hospital (AUC = 0.757, P < .001) with the total score and summary score from the ideation/behavior factor providing the best balance between sensitivity (0.694) and specificity (0.652-0.674).

CONCLUSIONS

This study is the first to assess the factor structure of the C-SSRS in a large, high-risk sample. The measure has solid psychometric properties and merits use as a suicide risk assessment measure.

Should the century-old practice of psychotherapy defer to science and ignore its foundations in two millennia of ethical thought?

While agreeing with the mainstream view that psychotherapeutic practice must be grounded in science, including research on the effectiveness of psychotherapy, the author advocates giving more weight to the venerable philosophical literature on ethics that bears directly on what patients bring to therapists: problems in living. These problems have been the domain of ethics since Socrates, who--like psychotherapists--promoted reflective dialogue. This article reviews some contemporary thought regarding the importance of reflection and the limits that patients and therapists face in promoting it. Relying on attachment theory and the process of mentalizing, the author identifies a convergence of science and ethics in the therapeutic aspiration to cultivate epistemic trust and illustrates this convergence with a case example.

Treatment of Depression in Voluntary Versus Mandated Physicians

Few if any publications discuss the effectiveness of voluntary versus mandated treatment for impaired physicians. This retrospective case-control study compared the recovery rates of physicians whose treatment was mandated or coerced by either licensure boards or employers (mandated physicians) with the rates for physicians admitted voluntarily (voluntary physicians) to the Menninger Clinic's Professionals in Crisis program from 2009 through 2012. Beck Depression Inventory (BDI)-II scores served as the primary outcome measure. At the time of admission, voluntary physicians were more depressed, but the improvement rates in the voluntary and mandated groups did not differ significantly. In addition, the two groups differed neither in rates of return to the healthy range of BDI-II scores, nor in whether BDI-II scores had decreased by at least two standard deviations by the time of discharge. These findings suggest that state physician health programs can continue to mandate physicians into treatment despite concerns that mandatory treatment may be less efficacious than voluntary treatment.

Impact of a Suicide-Specific Intervention within Inpatient Psychiatric Care: The Collaborative Assessment and Management of Suicidality

A growing body of literature indicates that suicidal patients differ from other psychiatric patients with respect to specific psychological vulnerabilities and that suicide-specific interventions may offer benefits beyond conventional care. This naturalistic controlled-comparison trial (n = 52) examined outcomes of intensive psychiatric hospital treatment (mean length of stay 58.8 days), comparing suicidal patients who received individual therapy from clinicians utilizing the Collaborative Assessment and Management of Suicidality (CAMS) to patients whose individual therapists did not utilize CAMS. Propensity score matching was used to control for potential confounds, including age, sex, treatment unit, and severity of depression and suicidality. Results showed that both groups improved significantly over the course of hospitalization; however, the group receiving CAMS showed significantly greater improvement on measures specific to suicidal ideation and suicidal cognition. Results are discussed in terms of the potential advantages of treating suicide risk with a suicide-specific intervention to make inpatient psychiatric treatment more effective in reducing risk for future suicidal crises.

Early identification of treatment non-response utilizing the Patient Health Questionnaire (PHQ-9)

BACKGROUND

Treatment non-response among high-risk, psychiatric patients exposes those suffering to suicidal risk as well as persistent social and occupational difficulties. Strategies for identification of treatment non-response are limited.

AIMS

Diagnostic efficiency of a self-report, cross-cutting symptom measure was assessed as a marker of treatment non-response.

METHOD

835 inpatients at a specialist psychiatric hospital completed the Patient Health Questionnaire - Depression (PHQ-9) at admission and every two weeks during hospitalization.

RESULTS

For patients admitted with severe depression (PHQ-9 ≥ 20), results indicated good accuracy of 2-week PHQ-9 change score in identifying treatment non-response (AUC = 0.80, SE = 0.04, p < .0001; sensitivity = 85%; specificity = 73%; OR = 14.91).

CONCLUSIONS

The search for predictors of non-response to psychiatric treatment has a long and generally unfulfilled history. The PHQ-9 change score holds promise as a cost-effective test with comparable diagnostic characteristics to other medical tests.

Improvement in health-related quality of life among adults with serious mental illness receiving inpatient treatment: a prospective cohort study

OBJECTIVE

This study examined changes in health-related quality of life in adult inpatients with serious mental illness engaged in a 6- to 8-week intensive treatment program.

METHOD

Admission and discharge assessment with the MOS 36-item Short-Form Health Survey was completed (June 2010-June 2012) for 410 adults aged 18-68 years. Paired t tests and effect size estimates were calculated for the overall sample, and reliable change index scores and clinical significance were calculated to estimate individual-level response and recovery rates. Hierarchical stepwise regression analyses were conducted to explore patient pretreatment characteristics, including total number of DSM-IV-TR diagnoses, that influence treatment response.

RESULTS

Large effect size improvements were demonstrated for the Mental Component Summary score (Cohen d = 1.5), including subjective ratings of vitality (Cohen d = 1.1), social functioning (Cohen d = 1.3), role-emotional functioning (Cohen d = 1.3), and mental health (Cohen d = 1.3). Equivocal findings for change in physical health were demonstrated, with the majority of patients demonstrating no significant change in function (t409 = 0.14, P = .89) but approximately equal numbers of patients demonstrating improvement and deterioration. The pretreatment characteristic of a tendency to be interpersonally distant, cold, and disengaged was predictive of a poorer outcome on Mental Component Summary treatment response (P < .001).

CONCLUSIONS

In light of a heavy burden of illness and high psychiatric comorbidity of this sample, treatment response was generally positive for improvement in mental health functioning. This study adds to a growing body of evidence indicating robust treatment response even for those with serious mental illness when treatment is intensive and multimodal.

Attachment insecurity and obsessive-compulsive personality disorder among inpatients with serious mental illness

BACKGROUND

Obsessive-compulsive personality disorder (OCPD) is characterized by traits such as extreme rigidity, perfectionism, and controlling behavior, all of which have a negative impact on interpersonal functioning. Attachment theory provides a useful framework to elucidate the interpersonal dysfunction characteristic of OCPD; yet, there is a dearth of attachment research on OCPD in the context of severe mental illness.

METHODS

Attachment security and personality disorders were assessed in adult inpatients with severe mental illness. Propensity Score Matching (PSM) was used to match OCPD and control subjects on age, gender, number of psychiatric disorders, and number of criteria endorsed for borderline personality disorder.

RESULTS

Consistent with hypotheses, the OCPD group (n=61) showed greater attachment avoidance than controls (n=61), and the avoidance was manifested in a predominance of the most insecure attachment style, fearful attachment. Correlations between attachment anxiety/avoidance with specific OCPD diagnostic criteria revealed that attachment avoidance was correlated with four of eight OCPD criteria across the full sample. Within the subset of OCPD patients, attachment avoidance was significantly correlated with OCPD criterion 3 (is excessively devoted to work and productivity to the exclusion of leisure activities and friendships).

LIMITATIONS

The use of self-report measure of attachment and the high burden of illness in the SMI population may not generalize to interview based assessment or outpatients, respectively.

CONCLUSIONS

Findings attest to the severity of impairment in interpersonal functioning and attachment avoidance, in particular, is characteristic of OCPD patients. These results suggest that viable treatment targets include interpersonal functioning along with more classical features of OCPD such as perfectionism and obsessiveness in task performance.

Comparison of Attachments in Real-World and Virtual-World Relationships

OBJECTIVE

The burgeoning of online social networks raises questions about the quality and value of these interpersonal relationships. The present study employed an established measure of attachment security to compare the nature of individuals' attachments in virtual-world relationships with those in real-world relationships and also examined the relative strength of attachments in the two types of relationships.

METHOD

Participants were 125 volunteers recruited online who had established relationships in Second Life, a popular virtual world. Participants consented and completed all measures anonymously online.

RESULTS

The findings indicate that equally strong attachments are formed in virtual- and real-world relationships; there is modest correspondence in the quality of attachment in the two types of relationship; the strength of attachments in the virtual world is influenced by capacity to immerse oneself in fantasy; duration of the relationship is correlated with strength of attachment in both worlds; and emotional well-being relates to strength of attachment in real-world relationships and lower attachment anxiety in virtual-world relationships.

CONCLUSIONS

The value of attachment relationships in virtual worlds calls for further investigation. Moreover, consistent with the growing employment of telemedicine, the potential for clinical interventions in virtual worlds merits consideration.

Erratum to: intensive inpatient treatment improves emotion-regulation capacities among adults with severe mental illness

[This corrects the article DOI: 10.1186/2051-6673-1-19.].

Presence and Persistence of Sleep-Related Symptoms and Suicidal Ideation in Psychiatric Inpatients

Background: Although sleep is an important risk factor for suicidal behavior, research has yet to examine the association between sleep problems and suicidality across the course of inpatient treatment. This study examined the relationship among sleep-related symptoms and suicidal ideation across inpatient treatment. Aims: To examine whether poor sleep at admission longitudinally predicts less improvement in suicidal ideation over the course of treatment. Further, to examine whether suicidal ideation is reduced in patients whose sleep does not improve. Method: The study utilized the Beck Depression Inventory (BDI)-II, which contains items measuring depressive symptoms, sleep-related symptoms, and suicidal ideation. The study sample consisted of 1,529 adult psychiatric inpatients. Patients were assessed at admission, biweekly, and at treatment termination. Results: Admission fatigue, loss of energy, and change in sleep pattern were associated with higher levels of suicidal ideation at admission and discharge. Fatigue at admission predicted suicidal ideation at termination independent of admission depression and suicidal ideation. Individuals whose sleep did not improve over the course of treatment had significantly higher suicidal ideation scores at termination relative to those whose sleep symptoms improved, after controlling for sleep, depression, and suicidal ideation scores at admission. Conclusion: These findings suggest that persistence of sleep-related symptoms warrants clinical attention in the treatment of suicidal patients.

Construct validity and factor structure of the difficulties in Emotion Regulation Scale among adults with severe mental illness

BACKGROUND

The Difficulties in Emotion Regulation Scale (DERS: Gratz and Roemer, 2004) is a measure of emotion-regulation capacities with good construct validity, test-retest reliability and internal consistency. Factor analytic studies have produced mixed results, with the majority of studies supporting the original 6-factor model while several studies advance alternative 5-factor models, each of which raises questions about the psychometric validity of the Lack of Emotional Awareness factor. A limitation of prior psychometric studies on the DERS is the reliance on healthy subjects with minimal impairment in emotion regulation. The current study assesses the construct validity and latent factor structure of the DERS in a large sample of adult psychiatric inpatients with serious mental illness (SMI).

METHODS

Inpatients with SMI (N = 592) completed the DERS, Acceptance and Action Questionnaire (AAQ-2), Patient Health Questionnaire (PHQ-SADS), and research diagnostic interviews (SCID I/II) at admission.

RESULTS

DERS total scores were correlated with AAQ-2 (r = .70), PHQ-Depression (r = .45), PHQ-Anxiety (r = .44) and moderately correlated with PHQ-Somatization (r = .28). Confirmatory factor analysis indicated that five and six-factor model produced equivalent fit indices. All factors demonstrated positive correlations with the exception of difficulty engaging in goal-directed behavior and lack of emotional awareness.

CONCLUSIONS

The DERS is a strong measure with excellent internal consistency and good construct validity. Caution is warranted in discarding the six-factor model given the equivalence with the five-factor model, particularly in light of the body of clinical research evidence utilizing the full scale.

Anhedonia predicts suicidal ideation in a large psychiatric inpatient sample

This study examined the relationship among symptoms of anhedonia and suicidal ideation at baseline, at termination, and over time in 1529 adult psychiatric inpatients. Anhedonia was associated with suicidality cross-sectionally at baseline and at termination. In addition, change in anhedonia from baseline to termination predicted change in suicidality from baseline to termination, as well as level of suicidality at termination; moreover, anhedonia remained a robust predictor of suicidal ideation independent of cognitive/affective symptoms of depression. Symptom-level analyses also revealed that, even after accounting for the physical aspect of anhedonia (e.g., loss of energy), loss of interest and loss of pleasure were independently associated with higher levels of suicidal ideation at baseline, over time, and at discharge. Loss of interest was most highly predictive of suicidal ideation, providing support for recent differential conceptualizations of anhedonia. Taken together, these findings indicate that the manner in which anhedonia is conceptualized is important in predicting suicidal ideation, and that anhedonia symptoms warrant particular clinical attention in the treatment of suicidal patients.

Radiation dose to workers due to the inhalation of dust during granite fabrication

There has been very little research conducted to determine internal radiation doses resulting from worker exposure to ionising radiation in granite fabrication shops. To address this issue, we estimated the effective radiation dose of granite workers in US fabrication shops who were exposed to the maximum respirable dust and silica concentrations allowed under current US regulations, and also to concentrations reported in the literature. Radiation doses were calculated using standard methods developed by the International Commission on Radiological Protection. The calculated internal doses were very low, and below both US occupational standards (50 mSv yr(-1)) and limits applicable to the general public (1 mSv yr(-1)). Workers exposed to respirable granite dust concentrations at the US Occupational Safety and Health Administration (OSHA) respirable dust permissible exposure limit (PEL) of 5 mg m(-3) over a full year had an estimated radiation dose of 0.062 mSv yr(-1). Workers exposed to respirable granite dust concentrations at the OSHA silica PEL and at the American Conference of Governmental Industrial Hygienists Threshold Limit Value for a full year had expected radiation doses of 0.007 mSv yr(-1) and 0.002 mSv yr(-1), respectively. Using data from studies of respirable granite dust and silica concentrations measured in granite fabrication shops, we calculated median expected radiation doses that ranged from <0.001 to 0.101 mSv yr(-1).

Intensive inpatient treatment improves emotion-regulation capacities among adults with severe mental illness

BACKGROUND

Impaired capacity for emotion regulation is associated with a broad spectrum of psychiatric disturbances; however, little is known about treatment response in emotion regulation functioning among patients with severe mental illness. This study examined treatment response and the role that experiential avoidance plays in mediating the relationship between attachment anxiety/avoidance and change in emotion regulation.

METHODS

Difficulties in emotion regulation were assessed at admission and at discharge, and rates of improvement and deterioration in emotion regulation were calculated. Attachment anxiety and avoidance were assessed in conjunction with experiential avoidance at baseline in a large cohort (N = 493) of adults admitted to a specialized adult psychiatric hospital.

RESULTS

Inpatient treatment was associated with clinically significant improvement in emotion-regulation capacities for 49 percent of patients completing at least four weeks of treatment. Fifty-six percent of patients attained a status of recovery. Greater attachment avoidance and anxiety were related to positive change in emotion regulation at discharge. Experiential avoidance fully mediated the relationship between insecure attachment and change in emotion-regulation capacities.

CONCLUSIONS

Contrary to expectation, greater attachment insecurity (anxiety and avoidance) as well as greater experiential avoidance predicted improvement in emotion regulation. These counterintuitive findings add to a growing evidence base indicating that severity of psychopathology is associated with greater improvement in hospitalized patients. Results of the mediation analysis suggest that targeting experiential avoidance may be an effective augmentation in the treatment of impaired emotion regulation functioning.

Interpersonal Change Following Intensive Inpatient Treatment

OBJECTIVE

Persons admitted for inpatient psychiatric care often present with interpersonal difficulties that disrupt adaptive social relations and complicate the provision of treatment. Whereas domains of psychosocial functioning in this population demonstrate clear growth in response to intervention, the impact of treatment on more complex patterns of interpersonal behavior has been largely overlooked within the existing literature. Interpersonal profiles characteristic of psychiatric inpatients were identified in the current study to determine rates of transition to adaptive functioning following hospitalization.

METHODS

Personality disturbance was assessed in 513 psychiatric inpatients using the Inventory of Interpersonal Problems. Scores were analyzed within a series of latent profile models to isolate unique interpersonal profiles at admission and at discharge. Longitudinal modeling was then employed to determine rates of transition from dysfunctional to adaptive profiles. Relationships with background characteristics, clinical presentation, and treatment response were explored.

RESULTS

Normative, Submissive, and Hostile/Withdrawn profiles emerged at both admission and discharge. Patients in the Normative profile demonstrated relatively moderate symptoms. Submissive and Hostile/Withdrawn profiles were related to known risk factors and elevated psychopathology. Approximately half of the patients who had been identified as Submissive or Hostile/Withdrawn transitioned to the Normative profile by discharge. Transition status evidenced modest associations with background characteristics and clinical presentation. Treatment engagement and reduction of clinical symptoms were strongly associated with adaptive transition.

CONCLUSION

Maladaptive interpersonal profiles characteristic of psychiatric inpatients demonstrated categorical change following inpatient hospitalization. Enhanced therapeutic engagement and overall reductions in psychiatric symptoms appear to increase potential for interpersonal change.

Psychotherapy is an ethical endeavor: Balancing science and humanism in clinical practice

The author proposes that psychotherapy is best grounded in scienceinformed humanism and, more specifically, that psychotherapists at least implicitly promote ethical, moral--and indeed, virtuous--behavior. In doing so, therapists are challenged continually to engage in making evaluative moral judgments without being judgmental. He contends that psychotherapists, and psychologists especially, are overly reliant on science and might benefit from being more explicit in their ethical endeavors by being better informed about the illuminating philosophical literature on ethics. He highlights the concept of mentalizing, that is, attentiveness to mental states in self and others, such as needs, feelings, and thoughts. He proposes that mentalizing in the context of attachment relationships is common to all psychotherapies, and that this common process is best understood conjointly from the perspectives of developmental psychology and ethics. The author defends the thesis that employing psychotherapy to promote ethical, moral, and virtuous functioning can be justified on scientific grounds insofar as this functioning is conducive to health.

Sociability and attachment as distinct domains of the interpersonal relationships factor of the BASIS-24

The Behavior and Symptom Identification Scale (BASIS-24) was administered to 1972 patients in a private psychiatric hospital specializing in intensive treatment of several weeks' duration. The study was designed to investigate the factor structure in a large inpatient population with a high burden of psychiatric illness. While largely replicating previous factor analyses, the study unexpectedly yielded two factors from the items comprising the interpersonal relationships factor, which were interpreted as assessing sociability and attachment. These two new factors showed differential relationships with other measures of interpersonal functioning (Inventory of Interpersonal Problems) and attachment (Relationship Questionnaire), and both factors were sensitive to improvement over the course of intensive inpatient treatment. These results suggest that different treatment interventions might be employed to target these two separable domains of potentially problematic interpersonal functioning.

Exposure to interpersonal trauma, attachment insecurity, and depression severity

BACKGROUND

Exposure to traumatic events is a nonspecific risk factor for psychiatric symptoms including depression. The trauma-depression link finds support in numerous studies; however, explanatory mechanisms linking past trauma to current depressive symptoms are poorly understood. This study examines the role that attachment insecurity plays in mediating the relationship between prior exposure to trauma and current expression of depression severity.

METHODS

Past trauma and attachment anxiety and avoidance were assessed at baseline in a large cohort (N=705) of adults admitted to a specialized adult psychiatric hospital with typical lengths of stay ranging from 6 to 8 weeks. Depression severity was assessed at day 14 of treatment using the Beck Depression Inventory-II.

RESULTS

Interpersonal trauma (e.g., assaults, abuse) was correlated with depression severity, whereas exposure to impersonal trauma (e.g., natural disasters, accidents) was not. Adult attachment partially mediated the relationship between past interpersonal trauma and depression severity at day 14 among psychiatric inpatients.

LIMITATIONS

Measure of trauma exposure did not systematically differentiate the age of exposure or relationship to the perpetrator. Individuals scoring high on the self-report attachment measure may be prone to over-report interpersonal traumas.

CONCLUSIONS

Treatment of depression in traumatized patients should include an assessment of attachment insecurity and may be fruitful target for intervention.

Modeling trajectory of depressive symptoms among psychiatric inpatients: a latent growth curve approach

OBJECTIVE

Changes in the parameters of inpatient psychiatric care have inspired a sizable literature exploring correlates of prolonged intervention as well as symptom change over varying lengths of hospitalization. However, existing data offer limited insight regarding the nature of symptom change over time. Objectives of this longitudinal research were to (1) model the trajectory of depressive symptoms within an inpatient psychiatric sample, (2) identify characteristics associated with unique patterns of change, and (3) evaluate the magnitude of expected gains using objective clinical benchmarks.

METHOD

Participants included 1,084 psychiatric inpatients treated between April 2008 and December 2010. Latent growth curve modeling was used to determine the trajectory of Beck Depression Inventory II depressive symptoms in response to treatment. Age, gender, trauma history, prior hospitalization, and DSM-IV diagnoses were examined as potential moderators of recovery.

RESULTS

Results indicate a nonlinear model of recovery, with symptom reductions greatest following admission and slowing gradually over time. Female gender, probable trauma exposure, prior psychiatric hospitalization, and primary depressive diagnosis were associated with more severe trajectories. Diagnosis of alcohol/substance use, by contrast, was associated with more moderate trajectories. Objective benchmarks occurred relatively consistently across patient groups, with clinically significant change occurring between 2-4 weeks after admission.

CONCLUSIONS

The nonlinear trajectory of recovery observed in these data provides insight regarding the dynamics of inpatient recovery. Across all patient groups, symptom reduction was most dramatic in the initial week of hospitalization. However, notable improvement continued for several weeks after admission. Results suggest that timelines for adequate inpatient care are largely contingent on program-specific goals.

Predicted indoor radon concentrations from a Monte Carlo simulation of 1,000,000 granite countertop purchases

Previous research examining radon exposure from granite countertops relied on using a limited number of exposure scenarios. We expanded upon this analysis and determined the probability that installing a granite countertop in a residential home would lead to a meaningful radon exposure by performing a Monte Carlo simulation to obtain a distribution of potential indoor radon concentrations attributable to granite. The Monte Carlo analysis included estimates of the probability that a particular type of granite would be purchased, the radon flux associated with that type, the size of the countertop purchased, the volume of the home where it would be installed and the air exchange rate of that home. One million countertop purchases were simulated and 99.99% of the resulting radon concentrations were lower than the average outdoor radon concentrations in the US (14.8 Bq m(-3); 0.4  pCi l(-1)). The median predicted indoor concentration from granite countertops was 0.06 Bq m(-3) (1.59 × 10(-3) pCi l(-1)), which is over 2000 times lower than the US Environmental Protection Agency's action level for indoor radon (148 Bq m(-3); 4 pCi l(-1)). The results show that there is a low probability of a granite countertop causing elevated levels of radon in a home.