New Research on Personality Disorders [1 ed.] 9781614703709, 9781604567267

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Copyright © 2008. Nova Science Publishers, Incorporated. All rights reserved. New Research on Personality Disorders, edited by Ida V. Halvorsen, and Sarah N. Olsen, Nova Science Publishers, Incorporated, 2008. ProQuest

Copyright © 2008. Nova Science Publishers, Incorporated. All rights reserved. New Research on Personality Disorders, edited by Ida V. Halvorsen, and Sarah N. Olsen, Nova Science Publishers, Incorporated, 2008. ProQuest

Copyright © 2008. Nova Science Publishers, Incorporated. All rights reserved.

NEW RESEARCH ON PERSONALITY DISORDERS

No part of this digital document may be reproduced, stored in a retrieval system or transmitted in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in New Research on Personality Disorders, by Ida Halvorsen, and Sarah N. Olsen, Nova Science Publishers, Incorporated, 2008. ProQuest rendering legal,edited medical orV.any other professional services.

Copyright © 2008. Nova Science Publishers, Incorporated. All rights reserved. New Research on Personality Disorders, edited by Ida V. Halvorsen, and Sarah N. Olsen, Nova Science Publishers, Incorporated, 2008. ProQuest

NEW RESEARCH ON PERSONALITY DISORDERS

IDA V. HALVORSEN AND SARAH N. OLSEN

Copyright © 2008. Nova Science Publishers, Incorporated. All rights reserved.

EDITORS

Nova Science Publishers, Inc. New York

New Research on Personality Disorders, edited by Ida V. Halvorsen, and Sarah N. Olsen, Nova Science Publishers, Incorporated, 2008. ProQuest

Copyright © 2008 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material.

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Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA New research on personality disorders / Ida V. Halvorsen and Sarah N. Olsen (editors). p. ; cm. Includes bibliographical references and index. ISBN H%RRN 1. Personality disorders. I. Halvorsen, Ida V. II. Olsen, Sarah N. [DNLM: 1. Personality Disorders--diagnosis. 2. Personality Disorders--therapy. 3. Psychotherapy--methods. 4. Risk Factors. WM 190 N532 2008] RC554.N49 2008 616.85'81--dc22 2008017567

Published by Nova Science Publishers, Inc., New York

New Research on Personality Disorders, edited by Ida V. Halvorsen, and Sarah N. Olsen, Nova Science Publishers, Incorporated, 2008. ProQuest

CONTENTS Preface Chapter 1

Chapter 2

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Chapter 3

Chapter 4

Chapter 5

Chapter 6

Chapter 7

vii Beneficial and Hindering Factors for Psychotherapy Utilization and Treatment Outcome in Personality Disorders Henriette Löffler-Stastka, Elisabeth Ponocny-Seliger, Margit Szerencsics, Matthias Bartenstein, Roland Grassl and Kurt Stastka Necessary Changes for the Assessment of Personality Disorders Steven K. Huprich Comorbidity of Personality Disorders and Posttraumatic Stress Disorder Sarah Reiland, Dean Lauterbach and Steven Huprich

1

63

85

A Self-Report Comparison of Five Semi-Structured Interviews Kimberly I. Saylor and Thomas A. Widiger

103

Personality Disorder Symptomatology: A Longitudinal Perspective Randy A. Sansone and Lori A. Sansone

121

Examining the Relationship Between Personality Trait and Disorder Scales: A Graphical Approach Stephanie N. Mullins-Sweatt Suicide Risk in Personality Disorders Maurizio Pompili, Marco Innamorati, David Lester, Claudia Comazzetto, Massimiliano Angelone, Ilaria Falcone and Roberto Tatarelli

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Contents

Chapter 8

Personality Traits in Drug Addictions José Luis Graña Gómez, Juan Jesús Muñoz García and Encarnación Navas Collado

Chapter 9

Diagnostic Efficiency of the Dutch-language Version of the Millon Clinical Multiaxial Inventory - III Gina Rossi and Hedwig Sloore

Chapter 10

Personality Disorders and Handedness Helmut Niederhofer

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Index

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193 213 217

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PREFACE This book provides leading research from around the globe on the topic of personality disorders which is formally referred to as a character disorder or a class of mental disorders characterized by rigid and on-going patterns of thought and action (cognitive modules). The underlying belief systems informing these patterns are referred to as fixed fantasies. The inflexibility and pervasiveness of these behavioral patterns often cause serious personal and social difficulties, as well as a general impairment of functioning. Chapter 1 - Background: Treatment response and therapy engagement is linked to the process of psychotherapy planning, but treatment response is difficult to be assessed with common, currently used diagnostic instruments. The aim is to investigate factors (patient’s affect experience and interpersonal functioning) in the initial psychotherapeutic interview, which are beneficial or hindering due to psychotherapy engagement, and how they could be properly assessed. Methods: In a first sample of 50 patients with borderline personality disorders self- and expert ratings concerning affect experience and affect regulation (State/Trait Anxiety Inventory, Questionnaire for aggressiveness vs. Hamilton-Anxiety-Scale, Affect experience and regulation Q-Sort-Test), and the Inventory for interpersonal problems vs. Quality of Object relations Scale were compared. Replication and add-on investigation in a second sample of 129 patients with personality disorders with the same instruments. Statistics: Canonical correlation and regression analyses. Results: Expert assessment of affect experience showed high predictive power for treatment utilization. Self-ratings do not reach the explanatory power of affect parameter due to psychotherapy engagement. With interpersonal functioning results is vice-versa. Conclusion: Findings point at the importance of expert assessment of intrapsychic parameters during the process of psychotherapy planning. The disability of patients with personality disorders to experience and regulate affects is discussed on the background of psychoanalytic theory (mechanism of projection, splitting, dissociation; the “false self”). Chapter 2 - The assessment and diagnosis of personality disorders (PDs) has changed considerably since the creation of the first Diagnostic and Statistical Manual of Mental Disorders. The earliest editions of this manual did not have a separate category of PD diagnoses per se; rather, descriptions of personality configurations with pathological manifestations were described. More prominent were psychoanalytically oriented, clinical descriptions of personality pathology that were described by clinicians. When DSM-III was published, a separate diagnostic axis for PDs was created. The newly-formed, multiaxial

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Ida V. Halvorsen and Sarah N. Olsen

diagnostic schema was designed to foster empirical research on PDs and the desire to have an “atheoretical” system of classifying thems. Now in existence for 28 years, the DSM Axis II schema has been criticized by many. Calls have been put forth to significantly change the assessment and diagnosis of PDs, yet the field is far from reaching a consensus on how to go about making these changes. In this chapter, the author will briefly review many of the problems that currently exist with how PDs are assessed and subsequently diagnosed. The author will suggest that the current system is in need of necessary changes so that: a) an agreed upon format of assessing and diagnosing PDs may be established, and b) science and practice may mutually inform each other. Chapter 3 - Posttraumatic stress disorder (PTSD) and personality disorders (PDs) often co-occur. Many studies have found higher rates of borderline, avoidant, paranoid, schizoid, and schizotypal PDs in persons diagnosed with PTSD. These higher rates have been found in studies of combat veterans and civilians, men and women, and clinical samples and nonclinical samples. The relationships with borderline and avoidant PD have been detected in both self-report measures and diagnostic interviews. Recent studies indicate that depressive PD (DPD) also often co-occurs with many of the same PDs that co-occur with PTSD, suggesting that there may be common features to DPD, related PDs, and PTSD that have empirical and clinical relevance. This chapter will review the literature on the associations among personality disorders and PTSD and suggest how future studies could shed light on these associations by focusing on the relationship between DPD and PTSD. Chapter 4 - There are currently five alternative semi-structured interviews for the assessment of the DSM-IV personality disorders. However, as yet, there have been only three published studies that have compared them empirically. The authors of the current study systematically coded each interview question contained in each of the five semi-structured interviews, indicating that the vast majority could be administered in a self-report format, thereby allowing for an empirical study of convergent validity via self-report inventories. Fifty-two psychiatric outpatients were given self-report questionnaires containing the respective questions from the five semi-structured interviews for the antisocial and borderline personality disorders, along with two additional self-report inventories. The results indicated substantial convergence among the five semi-structured interviews. However, some divergence was obtained for the assessment of individual diagnostic criteria, attributable to the relatively unique approach taken by a respective interview schedule for its assessment. Chapter 5 - In this chapter, the authors discuss personality disorder symptomatology from a longitudinal perspective. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, personality disorders are enduring and longstanding phenomena. This definition seems to conflict with clinical evidence that Axis II symptoms may dramatically recede below diagnostic thresholds within a relatively short time. The authors offer an explanation that addresses both the enduring nature of personality disorder symptomatology as well as the observed fluctuating nature of Axis II symptoms. In doing so, they broach their own theory about personality disorder functioning. In this dynamic theory, personality disorder symptoms are acknowledged as ever-present and enduring, but subject to wide fluctuations in amplitude in response to a variety of internal and external factors. The authors illustrate several of these factors and provide empirical evidence for their effect on Axis II functioning. The authors end the chapter by pointing out the challenges of diagnosis when the entity under scrutiny is in constant symptom flux.

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Preface

ix

Chapter 6 - O’Connor (2005) has proposed a unique and potentially innovative analytic approach to understanding the association between personality disorders and five-factor model (FFM) personality traits. His graphical analytic approach demonstrated how correlations of the same magnitude and direction could in fact have quite different substantive implications depending upon the shape of the relationship. More specifically, his analyses yielded three different shapes of significant relationships between respective scales of the most commonly used self-report measure of personality disorder, the Millon Clinical Multiaxial Inventory-III and the predominant measure of general personality functioning, the NEO Personality Inventory-Revised, Form R. The results of the current study replicated these relationships. However, this study also found that the anomalous findings reported by O’Connor with regard to the histrionic and narcissistic personality disorders reflected an anomaly with the MCMI-III assessment of these personality disorders rather than inconsistencies with FFM theory. The results for these personality scales appear instead to be consistent with problematic findings for the MCMI-III histrionic and narcissistic scales that have also been obtained in previous studies. When these analyses were conducted using one of the two most commonly used dimensional measures of personality disorder, the Schedule for Nonadaptive and Adaptive Personality, the anomalously shaped relationships no longer occurred. In sum, the graphical analyses do yield quite informative and useful information but in this instance the findings appear to concern a particular instrument rather than the FFM theoretical model. Chapter 7 - The aim of the chapter is to review significant literature published on peerreviewed research findings to study the link among personality disorders and suicidal behavior. Methods: The authors performed careful MedLine, Excerpta Medica, PsycINFO searches from 1980 to 2007. Search terms were “suicide”, “personality disorders” (including terms for single disorders), and “suicid*.” Results: The authors identified studies dealing with suicide and the following areas of interest: borderline personality disorder, narcissistic personality disorder, antisocial personality disorder, comorbidity (especially with affective disorder and substance abuse disorder) and risk factors for suicide in personality disorders. Conclusion: Despite the fact that comorbidity with DSM-IV Axis I disorders often impairs a correct judgment of suicidality in personality disorders, this overview showed that some personality disorders have a stronger link to suicide and that identifiable risk factors may be used for the development of preventive measures. Given the fact that personality disorders have high prevalence in the general population, evidence-based treatments, and prevention strategies for suicide among these individuals are major public health issues. Chapter 8 - The relation between drug addiction and personality has been extensively studied, but there have been few scientific attempts to reflect this interaction when developing effective interventions. The problem becomes even more complex when investigating the causality direction of the relation. Some investigators consider personality disorders to be a consequence of the addictive disorder, referring to induced disorders, whereas other authors state that personality disorders are what foments pathological consumption of psychotropic substances. Historically, one of the main research lines was to seek a toxicomania or addictive personality that would predispose an individual to drug consumption, so that specific personality traits would be the ethiopathogenic factors or underlying cause of drug addiction.

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The difficulties derived from establishing a prototypical addictive personality came to a halt with the appearance of another kind of studies that linked certain personality traits to drug addictions but from the perspective of dual pathology; that is, considering the reciprocal influence or comorbidity of both variables. These investigations analyzed both normal and pathological personality traits. The evolution of the studies that relate personality to drug addiction has also been accompanied by progress in the hypotheses about the link between these two variables. Starting with the traditional models of adaptation of Peele (1985) or the hypothesis of selfmedication of Khantzian (1985), other authors such as Verheuel (2001) postulate three possible paths/causes that favor a predisposition to a personality alteration along with the addiction to certain substances. These paths would be behavioral disinhibition, stress reduction, and sensitivity to reward. The most recent tendency is to consider that substance consumption can induce neurobiological alterations that derive in changes of personality traits or symptoms, generally related to disorders in which impulsivity plays a key role. This trait would be the most relevant factor to develop future explanations and more effective interventions to address drug addictions and personality disorders. Chapter 9 - Diagnostic efficiency statistics of the Millon Clinical Multiaxial Inventory were examined (n = 627) in Belgian clinical and forensic settings. Belgian base rates and the Dutch MCMI-III (MCMI-III-D) translation were used. MCMI-III-D generated Axis I and II diagnoses (using base rate 75 and base rate 85 as cutoff scores) were compared to cliniciandetermined diagnoses. Classical diagnostic validity measures pointed out that the MCMI-IIID is a useful screening instrument. Additionally, calculation of measures of incremental validity, chance-adjusted efficiency measures and cut score independent measures consistently showed out that all MCMI-III-D scales performed better than chance and discriminated in the right direction. Chapter 10 - 9 subjects diagnosed as Borderline were studied via parent questionnaire. More (5 of 9) patients were reported with a use of the left hand than is reported on the average in the general population, more in complex than simple and for external (touching food and objects) than internal tasks (scratching, rubbing eyes), which suggests a deficit in cerebral control of external, goal-oriented hand use. The authors' results support the former hypothesis of a right hemisphere dysfunction in patients with Borderline disorders.

New Research on Personality Disorders, edited by Ida V. Halvorsen, and Sarah N. Olsen, Nova Science Publishers, Incorporated, 2008. ProQuest

In: New Research on Personality Disorders Editors: Ida V. Halvorsen and Sarah N. Olsen

ISBN: 978-1-60456-726-7 © 2008 Nova Science Publishers, Inc.

Chapter 1

BENEFICIAL AND HINDERING FACTORS FOR PSYCHOTHERAPY UTILIZATION AND TREATMENT OUTCOME IN PERSONALITY DISORDERS Henriette Löffler-Stastka*1, Elisabeth Ponocny-Seliger1,2 , Margit Szerencsics1, Matthias Bartenstein1, Roland Grassl1,3 and Kurt Stastka3

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1

Department of Psychoanalysis and Psychotherapy, Medical University Vienna, Austria 2 EPS - Empirical Research and Statistical Consulting, Vienna, Austria 3 Otto-Wagner-Hospital, General Psychiatric Hospital of Vienna; Austria

ABSTRACT Background: Treatment response and therapy engagement is linked to the process of psychotherapy planning, but treatment response is difficult to be assessed with common, currently used diagnostic instruments. The aim is to investigate factors (patient’s affect experience and interpersonal functioning) in the initial psychotherapeutic interview, which are beneficial or hindering due to psychotherapy engagement, and how they could be properly assessed. Methods: In a first sample of 50 patients with borderline personality disorders selfand expert ratings concerning affect experience and affect regulation (State/Trait Anxiety Inventory, Questionnaire for aggressiveness vs. Hamilton-Anxiety-Scale, Affect experience and regulation Q-Sort-Test), and the Inventory for interpersonal problems vs. Quality of Object relations Scale were compared. Replication and add-on investigation in a second sample of 129 patients with personality disorders with the same instruments. Statistics: Canonical correlation and regression analyses. *

Address for correspondence: Dr. Henriette Löffler-Stastka Department of Psychoanalysis and Psychotherapy, Medical University of Vienna Währinger Gürtel 18-20, A-1090 Vienna, Austria Tel. 0043-1-40400-3070 or 3061 Fax. 0043-1-406 68 03 Email: [email protected]

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Results: Expert assessment of affect experience showed high predictive power for treatment utilization. Self-ratings do not reach the explanatory power of affect parameter due to psychotherapy engagement. With interpersonal functioning results is vice-versa. Conclusion: Findings point at the importance of expert assessment of intrapsychic parameters during the process of psychotherapy planning. The disability of patients with personality disorders to experience and regulate affects is discussed on the background of psychoanalytic theory (mechanism of projection, splitting, dissociation; the “false self”).

Treatment utilization is linked to the process of psychotherapy planning, but treatment response is difficult to be assessed with common, currently used diagnostic instruments. On the road to DSM-V it is often stated, that the clinical relevance of psychiatric classification will be improved by implementation of practical clinical aspects, as the course of disease, therapeutic response, or prognosis. Investigations of variables, which determine the response to treatment, are rare. It is also the question, how factors as for example therapeutic response could be assessed properly. Treatment response on the one hand is linked to psychotherapy utilization. In recent investigations beneficial and hindering factors concerning psychotherapy utilization could be found: Starting with an investigation of psychiatric inpatients with personality disorders (Löffler-Stastka & Meißel, 2004) our study showed, that within psychiatricpsychopharmacological treatment, difficulties concerning identity diffusion, self-concept, and aggression persisted and remained being attributed to external factors only in patients, who could not utilize further psychotherapeutic treatment after their hospitalisation. Additionally, treatment alliance was dominated by externalizing, paranoid-schizoid mechanisms, introspection could hardly be established in psychotherapy non-utilizers. Patients, who could utilize further psychotherapy in an outpatient setting presented a consolidated self-concept and increased internality, even at the beginning of the psychiatric inpatient treatment. These results emphasized the role of treating aggressive behavior together with identity disturbance and to support introspective thinking also within the psychiatric inpatient treatment of personality disorders. In a second sample (Löffler-Stastka et al., 2003) we found in patients with personality disorders, that high reactive readiness for aggression and thorough, narcissistically boosted conviction of self-efficacy had predictive value for non-utilization of psychotherapy. These factors were in correlation with severe interpersonal problems, whereas psychotherapyutilizers showed a strong subjective perception of interpersonal problems, and could reflect on their generalized negative self-concept of own capacities. Again these results pointed at the important role of acknowledging mechanisms of aggression, attachment, and mentalization in initial psychotherapy planning. Considering gender differences in a third, different sample of patients with borderline personality disorder, we found (Löffler-Stastka et al., 2006b), that women in gender-matched patient-therapist dyads gained insight into correlations between anxiety, aggression, and interpersonal problems to the extent that they experienced them as ego-syntonic problems, and as a concern of their own self-concept, and were therefore able to engage in psychotherapy. Men more often remained in regressive resistance and in narcissistically boosted conviction of self-efficacy, with simultaneous persistence of aggression and nonengagement in psychotherapy. The results underlined the importance of considering gender

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role stereotypes and suggest the significance of gender-sensitive attitudes, again in dealing with aggression and exploring object relation styles and reflective functioning. Further, we detected beneficial and hindering factors concerning treatment utilization in a sample of 140 psychotherapy seeking, psychiatric outpatient patients with personality disorders (Löffler-Stastka et al., 2005). Predictors concerning the non-utilization of psychotherapy on the personality dimension were a schizoid personality disorder in women, and a narcissistic personality disorder in men. Correlation analyses between predictors and quality of object relations or interpersonal problems were found in women, while in men correlations between the predictor and affect regulation were found. These results provided us material to draw consequences for psychotherapeutic intervention technique; we suggested that for men it is more important to interpret the dominating affect, while for women, understanding the pathological object relation pattern is useful for successful therapy planning. Even in a 6-years-follow up of 306 outpatients with personality disorders (Löffler-Stastka et al., 2007 and Löffler-Stastka, submitted) assessment of affect experience showed high prediction rates (multinominal logistic regression in the cross-validated data) for treatment rejecters. The more affect parameters were included in personality pathology measurements, the better treatment refusal could be predicted. In contrast, prediction rates for treatment engagers could be increased with the assessment of interpersonal problems. These findings pointed at the importance of assessment of intrapsychic and interpersonal parameters additionally to the descriptive assessment of personality traits and refer to the impact of nosological knowledge on treatment relevant diagnostics. Further, the question is raised now, how in clinical practice such factors could be observed, assessed and grasped, in order to and make patients aware of their problems concerning affect experience and their subjective experience of interpersonal problems, when therapy engagement should be facilitated. Coming to the question of assessment instruments, we compared the predictive power of the Shedler-Westen-Assessment Procedure-200 (Shedler & Westen, 1998) with the Structured Clinical Interview for DSM-IV (Wittchen et al., 1997) on psychotherapy engagement within a sample of 297 patients with personality disorders (Löffler-Stastka, submitted). Multinominal logistic regression showed small differences between the prediction rates. Both instruments showed clinically useful prediction rates especially for treatment rejecters. The SWAP-200 showed slightly higher prediction rates, which were increasable concerning treatment rejections by additional assessment of affect regulatory parameters. In contrast, prediction rates of the SCID were increasable with additional assessment of interpersonal problems. Although these findings represent the work of only one research group, it has to be stated, that similar findings can be found in the literature, which will be referred to in the following. In order to grasp and assess predictive and clinically meaningful – either beneficial or hindering – factors, as affect regulation and object relation style, at the beginning of psychotherapy planning, diagnostic procedures have to be reconsidered, which is presented in part 1 of this book chapter. In part 2 of this chapter we test and discuss, if these considerations are valid for treatment response, the course of treatment and treatment outcome in psychiatric and psychosomatic inpatients.

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PART 1: DIAGNOSTIC PROCEDURES RELEVANT FOR PSYCHOTHERAPY PLANNING Henriette Löffler-Stastka, Margit Szerencsics, and Elisabeth Ponocny-Seliger INTRODUCTION

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Diagnostic Procedures for Personality Disorders Personality Disorders are coded in the Diagnostic and Statistical Manual of Mental Disorder – Fourth Edition – Text revision (DSM-IV-TR) on axis II. The essential diagnostic feature of a Personality Disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual´s culture and is manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning, or impulse controll. DSM-IV-TR describes disturbance of affectivity to be one of the central problems and as general criteria for a Personality Disorder: for example emotional coldness, anhedonia, detachment or flattened affectivity in Schizoid Personality Disorder, inappropriate or constricted affect in Schizotypal Personality Disorder, irritability and aggressiveness in Antisocial Personality Disorder, affective instability due to a marked reactivity of mood or inappropiate, intense anger in Borderline Personality Disorder, excessive emotionality and attention seeking in Histrionic PD. Recent methodological research in the field of assessment of personality pathology shows that the DSM-IV-TR classification of personality disorders has not proven to be satisfying neither to researchers nor to clinicians. Axis II of DSM-IV-TR represents a hybrid of clinical and research observations (Westen & Shedler, 1999b). The diagnostic categories have their origins in clinical observation and theory, and the categories and criteria have been refined over the years through empirical research. The gradual, empirical based changes in axis II have clearly improved the personality disorder taxonomy. Incremental changes to categories and criteria using structured interviews may no longer be useful in attempting to refine axis II. The methods currently used to revise axis II have a number of limitations: Current personality disorder instruments have significant empirical and conceptual limitations. For example, clinicians typically assess personality by listening to patient’s narrative accounts of experiences, noting their behavior in the consulting room, and then making inferences about personality processes. In contrast, current instruments rely on direct Questions and expect patients to report on their own personalities. It is highly unlikely that most patients with personality disorders can do so adequately. Axis II committees have tended to exclude criteria that cannot be assessed by direct questions (Livesley, 1995). The questions included in current assessment instruments are derived from existing diagnostic criteria and therefore are of limited value for developing new and better criteria.

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Any alternative diagnostic category that better distinguished groups of patients currently classified into existing categories could not be discovered or implemented because its criteria would necessarily overlap with current criteria from other disorders, which may themselves be somewhat arbitrary. For example, concerning Axis I Comorbidity of Personality Disorders Zanarini et al. (1998b) found anxiety disorders to be almost as common among Borderline PD. Also a lifetime pattern of complex comorbidity (e.g. DSM-III-R criteria for both a disorder of affect and a disorder of impulse) was found to have strong positive predictive power for the Borderline PD – diagnosis as well as a high degree of sensitivity and specificity. Benjamin et al. (1989), Comtois et al. (1999) and Rogers et al. (1995) confirm the close relationship between anxiety disorders, aspects of depression and Borderline PD. The current diagnostic categories do not encompass the domains of functioning relevant to personality. Personality psychologists continue to debate the precise definition of personality, but most agree it refers to the interaction of enduring pattern of cognition, emotion, motivation and behavior expressed under particular circumstances (Mischel & Shoda, 1995). Elsewhere Westen (1995) has offered a slightly more differentiated model, arguing that case formulation should address three broad questions: What does the person wish for or fear, and to what extent are these wishes and fears conflicting or unconscious? What psychological resources - cognitive, affective, and behavioral- can the person draw upon to meet internal and external demands? How does the person perceive and experience self and others, and how able is he or she to sustain meaningful and pleasurable relationships? If the concept "personality" subsumes such domains of functioning, then current axis II criteria for many disorders do not provide even a minimal outline for describing a personality style (Westen & Shedler, 1999a, b). As already mentioned above, DSM-IV-TR describes disturbance of affectivity to be one of the central problems and as general criteria for a Personality Disorder. It is mentioned that this enduring pattern is inflexible and pervasive in a broad range of personal and social situations and leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. Therefore treatment of patients with Personality Disorders is often costly: frequent hospitalization is for example necessary because of suicide attempts; secondly often drugs are used to cope with affective or interpersonal distress, further problems with addiction can lead to financial disaster or even lead into criminality. Various behavioral problems could be mentioned. Therefore clinicians and research groups were interested in investigating effectiveness of psychotherapy and psychiatric treatment (Pfitzer et al., 1990; Eckert et al., 2000; Rosenbluth, 1987; Gabbard, 1986; Friedman, 1969; Adler, 1973; Tucker et al., 1987, 1992; Antikainen et al., 1995; Koenigsberg, 1984; Nurnberg et al., 1978; Bateman et al., 1999; Gordon et al., 1983; Lohmer, 1990; Trimborn, 1983; Viner, 1985; Hull et al., 1993; Keller et al., 1993). In most of these investigations diagnostic criteria is based on DSM-IV-TR, phenomenological description or structured interviews, which provides for example description of disturbance of affectivity in a rather vague way. These classifications say little about the patient’s characteristic ways of dealing with his or her feelings, how he or she experiences the feelings typically or regulates affective states under specific circumstances.

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Henriette Löffler-Stastka, Elisabeth Ponocny-Seliger, Margit Szerencsics et al.

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Affect Regulation and Personality Disorders The clinical experience suggests that not only affect (i.e., presence of anxiety or negative affect states) but styles or strategies of affect regulation may be implicated in the initiation and/or maintenance of personality disorders. Researchers have increasingly begun to emphasize the role of affect regulation in personality, development, and psychopathology (Gross, 1998; Kobak et al., 1993; Kopp, 1989; Schore, 1994; Shields & Cicchetti, 1998; Westen, 1985, 1994, 1998; Westen et al., 1997). Affect regulation refers to cognitive and behavioral strategies people use to maximize pleasant, and minimize unpleasant emotions. These strategies may be explicit (coping mechanisms) or implicit (defences). For our purpose - to grasp, find and define beneficial or hindering factors, which are predictive for psychotherapy planning and utilization, and how they could be properly assessed - a model of affect regulation is being used that integrates research and theory from psychoanalytic, cognitive, behavioral, and evolutionary perspectives on personality (Westen & Shedler 1999a,b). It is proposed that feelings are mechanisms for the selection and retention of behavioral and mental responses. To the extent that particular behaviors, coping strategies, or defensive strategies become associated with regulation of aversive affective states and maximization of pleasurable ones, they will be encoded as "solutions" to affective problems. In this view, affect regulation strategies are a form of procedural knowledge and are activated under specific circumstances, such as the presence of particular affects. Affect regulation strategies can be adaptive or maladaptive. Some regulation strategies are affectspecific, whereas others can be used to regulate multiple affects of similar valence. These procedures are often activated to resolve discrepancies between perceived and desired states of self, significant others, and external circumstances. Emotions and other sensory feeling states are evolved mechanisms for channelling behavior in directions that foster adaptation. The avoidance of unpleasant states and pursuit of pleasant ones leads to goal-directed mental and behavioral processes, including defenses and compromise formations. Affects provide a flexible motivational mechanism in humans, as they become associated with representations of perceived, feared, wished-for, or otherwise valued states through the interaction of environmental events and highly specific naturallyselected biological proclivities. This reconzeptualization of motivation points towards a resolution of a contradiction in Freud’s models of affect and motivation between a theory of drive-reduction and a theory of affect regulation, and of the apparent contradiction between motivational models that emphasize either sexual desire or relational needs. The model also has implications for the theory of transference, since it suggests that the analytic situation evokes meaningful transferential processes. Current theories suggesting that for example Personality disorder symptoms are maladaptive attempts at affect regulation. Given that cognitive and behavioral mechanisms that are successful in regulating affect will be used again, personality-disordered behaviors that are even temporarily successful in alleviating negative mood states are likely to be activated under similar circumstances. The investigation of affect regulation refers to the detection of coping styles. Vollrath et al. (1995) showed that dispositional coping styles prospectively influence change in personality disorders. Therefore it might have an impact concerning psychotherapeutic interventions.

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As already stated above, definition of personality pathology should also refer to classification of relative level and quality of object relations.

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Object Relations and Personality Disorder The concept of object relations has played an increasingly important role in psychoanalytic and psychodynamic theorizing, as well as in clinical psychoanalysis and psychotherapy. A short summary of a few pertinent issues will provide a context for describing what is investigated. Ogden’s (1983) description of the theory approaches our concept of the theoretical underpinnings of the investigation we plan to do. He traced the contributions of Freud, Abraham, Melanie Klein, Fairbairn, Winnicott, and Bion to the conceptualization of internal object relations. The original model of all internal objects is Freud’s model of the normal development of the superego through the process of identification, as the ego assimilates aspects of the personality and functions of external objects. This newly established psychic agency acquires its own set of motivations and actions, including object relatedness. Ogden also drew on Freud’s extension of the role of splitting of the ego, beyond the formation of the superego, in the development of internal objects. For Ogden, another core concept is Fairbairn’s assertion that it are aspects of the relationship with the object, rather than aspects of the object, that become internalized. In addition, Ogden incorporated into his thesis Bion’s description of the potential for the defensive splitting of the mind into active suborganizations capable of engaging in specific forms of object relatedness. Ogden’s elaboration of these concepts indicates that splitting of the ego into new subdivisions is necessary for early interpersonal relationships to be internalized. Each suborganization – being a component of the ego - has a dynamic capacity to semiautonomously generate experience and leave its stamp on the quality of object relations. This psychoanalytically informed view of object relations stipulates that they are the product of intrapsychic suborganizations of the ego and not of external interpersonal relationships. However, the quality of object relations is manifested in the interpersonal situation (Horner, 1984). Despite the enduring quality of object relations, these intrapsychic structures are modifiable by experience during healthy development. By contrast, during pathological development these intrapsychic configurations become rigidified and fixated, a condition reflected in some aspects of feeling, thinking, and behaving. It is suggested that secure attachment – displayed in a mature quality of object relations - is the basis of the acquisition of metacognitive or mentalizing capacity. Horner (1984) cited that the concepts of internalization and of object relations are fundamental to the developmental psychology of psychoanalysis, especially in terms of technique. The investigation of object relation styles gives a benefit to understand the problems that patients with personality disorders have in intimate relationships and to inspire effective modes of intervention. Furthermore it can also be of broad use to clinicians in understanding the psychotherapeutic process showing up already in the initial interviews even before psychotherapy or also psychiatric treatment starts.

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Henriette Löffler-Stastka, Elisabeth Ponocny-Seliger, Margit Szerencsics et al.

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The Concept of Mentalization and Mentalized Affectivity The theory of mentalization and the theory of affect regulation are two intimately connected developmental theories. Both concern the relationship between the acquisitions of an understanding of the representational nature of minds on the one hand and affect regulation on the other. Mentalization is seen not just as a cognitive process, but developmentally connected with the “discovery” of affects through the primary-object relationships. Affect regulation, defined as the capacity to modulate affect states, is closely related to mentalization in that it plays a fundamental role in the unfolding of a sense of self and agency. Affect regulation is a prelude to mentalization; yet, once mentalization has occurred, the nature of affect regulation is transformed. One has to distinguish between affect regulation as a kind of adjustment of affect states (a basic form of affect regulation where the object is needed to modulate affects) and a more sophisticated variation of affect regulation, altered by mentalization, where affects are used to regulate the self. This distinction between first- and second-order representations of affect is consistent with data from psychology, neurophysiology and psychoanalytic theories. Mentalized affectivity has been defined as a sophisticated form of affect regulation that marks a mature capacity to discover the subjective meaning of one’s own affect states (Fonagy et al., 1995, 2004). In its essence, mentalized affectivity designates the human need to fathom and reinterpret one’s affects and is particularly exemplified through the internal expression of affects. Whereas the term “mentalization” denotes interest in one’s own mind in general, the term “affectivity” denotes interest in one’s own affects – that is, in a specific domain of one’s mind. Thus, for example Borderline personality disorders can be understood in terms of the absence or impairment of the capacity for emotion regulation, attention control, and mentalization, all of which are normally acquired in the context of early relationships with the caregivers (Bateman & Fonagy, 2000). The authors’ formulations have much in common with Sroufe’s systematization of the attachment relationship as the primary vehicle for the acquisition of emotional regulation (Fonagy et al., 2004). In conclusion, three components should be observed and assessed in the initial interview and during the process of treatment planning with patients with personality disorders: affect experience and affect regulation, quality of object relating and interpersonal functioning, and the metacognitive or mentalizing capacity, i.e. if the patient is able to reflect upon his or her mental state. Being able to observe and recognize these factors the treating clinician can grasp impairments or resources in the patient, which are relevant for building up a treatment alliance. Hindering factors or impairments can be worked through in order to get treatment started efficiently. These three components should be assessed in order to provide diagnostic procedures relevant for treatment, treatment planning, indication or prognostic considerations, and for estimating or predicting treatment response. But how could these components be properly assessed? In the following two studies affect experience and affect regulation, the quality of object relation and interpersonal functioning of patients with personality disorders, and their ability to reflect upon their mental states were tested by comparing self-assessment tools with expert ratings, in order to test the capacity of the patients with personality disorders to describe their affective states and interpersonal functioning, which is relevant for treatment planning and psychotherapy utilization.

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STUDY A (MARGIT SZERENCSICS AND HENRIETTE LÖFFLER-STASTKA) Empirical investigations and psychoanalytic literature confirm that patients with personality disorders functioning on the psycho-structural level of a Borderline Personality Organisation (BPO) have difficulties with perception and regulation of affects. Mentalization and personality development are influenced by adequate containment of affects during personality development, and therefore depends on the relationship to the primary caregiver (mother, parents), which is then internalized and observable in the quality of object relating of the patient. As stated above assessment of affect regulation and quality of object relating is relevant for treatment. The assessment of affect perception by means of self-assessment might be insufficient in personality disorders. This should be tested and demonstrated by comparing the outcomes of self-rating instruments with those of expert assessment. If the outcomes do not correspond, it would mean that the application of self-rating questionnaires in patients with personality disorders has to be challenged. Therefore expert ratings would be necessary then in order to grasp affect regulatory parameter, which are relevant for (psycho)therapy planning.

MATERIAL AND METHODS Description of the Sample

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The sample consisted of 25 (48%) women and 27 (52%) men. The youngest was 20 years old, the oldest 66. The mean age was 38 years (standard deviation 10.2).

Sociodemographic Data Unemployed (44. 2%), employed (34. 6%) and - because of mental health problems retired persons (21. 2%) were included in the sample. 5.8% of the participants were postgraduates, 26. 9% had a general qualification for university entrance (A-level), 23.1% had finished an apprenticeship, 42.3% had finished only compulsory school and 1.9% dropped out of school. The patients were living alone (44.2%), with their girlfriend (9.6%) or with their boyfriend (5.8%), with their parents (3.8%), father (1.9%), mother (7.7%), daughter (1.9%) or their son (1.9%), with their family (1.9%), with their divorced partner (1.9%), their children (3.8%), their spouse (3.8%). 3.8% were homeless, 1.9% were living in a women’s refuge home, and 1.9% in the Salvation Army. 57. 7% were single, 13.5% had a boyfriend, 5.8% a girlfriend, 13.5% were married, 7.7% divorced, and 1.9% widowed. 69.2% were childless, 15.4% of the participants had one child, 9.6% had two children, 3.8% of the patients had three children, and 1.9% had four children. Diagnoses Three experienced medical specialists for psychiatry and psychotherapy, who were responsible for the medical and psychiatric treatment of the patients, diagnosed the patients with DSM-IV (detailed table of diagnoses available on request). All of these consultants in

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the department showed on average professional experience of 15 years in psychiatric and psychoanalytic assessment. They also diagnosed the patients on a structural level according to the Structural Interview (Kernberg, 1984) in order to diagnose the psycho-structural Personality Organisation. In addition and to confirm the psycho-structural diagnoses of personality organisation all 52 Patient were rated with the SWAP-200 (Westen & Shedler, 1999a,b) by an independent rater (M.S.). The utility of the SWAP-200 procedure for assessing psycho-structural functioning had been proofed in a prior conducted validation study (Löffler-Stastka, 2007). Shedler-Westen Assessment Procedure-200 (SWAP-200): Personality Pathology Q-sort (Shedler& Westen, 1998) The SWAP-200 (Westen & Shedler, 1999a,b) is a 200-item Q-sort designed to assess personality and personality pathology. It considers character criteria, psychic functions, provides comparison with the DSM-IV personality categories (categorical diagnosis) (Westen & Shedler, 1999a) and offers a description of personality, which can be compared with other empirically evaluated prototypes (dimensional diagnosis) (Westen & Shedler, 1999b). Based on clinical experience and knowledge, it can be expected that these empirically evaluated prototypes reproduce the total mental assessment of a patient. By means of the prototypes a reliable assessment about intrapsychic and interpersonal functioning and an accurately described pictorial diagnostic investigation can be made. The clinician sorts these items into piles (from zero to seven) with a fixed distribution, depending on the degree to which the item describes the patient's enduring patterns of personality functioning. Items for the SWAP-200 were derived from a number of sources, including DSM-III-R and DSM-IV Axis II criteria; clinical literature on personality disorders; input from several hundred clinicians; research on personality disorders; research on normal personality traits and psychological health; and pilot interviews (Shedler & Westen, 1998). Development of the item set was an iterative process that took approximately seven years using standard psychometric methods, such as eliminating redundant items, items with minimal variance, etc. Providing a SWAP-200 diagnosis of a patient entails correlating the patient's Q-sort profile with empirically derived prototypes, either representing the current Axis II categories (Westen & Shedler, 1999a) or empirically-derived categories (Westen & Shedler, 1999b). The procedure yields a T-score profile similar to an MMPI profile, created by matching the patient's profile with a prototype, except that the profile is based on expert judgment rather than self-report. The instrument yields both dimensional and categorical diagnoses. Research thus far supports the validity and reliability of the instrument in predicting (a) clinician diagnoses, (b) objective indicators of personality dysfunction such as suicide attempts, (c) overall level of adaptation, assessed by measures such as the Global Assessment of Functioning Scale from the DSM-IV, and (c) various developmental and genetic history variables (Shedler & Westen, 1998; Westen & Shedler, 1999a). For example, in a recent study of a large sample of patients with personality disorders (PDs), 40% of patients in the upper 5th percentile in subclinical thought disorder (schizotypy) factor scores had a genetic history of psychosis, whereas none of the patients in the lower 5th percentile did (Westen & Shedler, 1999b). Similarly, analysis of links between etiological variables and the psychopathic-antisocial factor confirmed several predictions, including (a) a predicted negative correlation with anxiety disorders in biological relatives (predicting because of low autonomic arousal in people high in psychopathy), (b) a positive association with

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developmental history of physical abuse, and (c) a sex-linked association with alcohol and illicit drug abuse in biological relatives for males only. For our purpose, the SWAP items were translated independently by two different people: a native speaker with no knowledge of psychoanalytical terminology and a psychiatrist and psychoanalyst (H. L.-S.). Retranslation showed sufficient convergence (see also LöfflerStastka, 2004a). Inclusion criteria: Patients with Borderline Personality Organisation (Kernberg, 1984) were included in the sample, i.e. male and female patients with mental illness functioning on the level of a Borderline Personality Organisation; Minimum age: 20 years; Maximum age: 66 years. Exclusion criteria: against their free decision detained patients, solicitous patients, patients without agreement and without a Borderline Personality Organisation. The study had been proofed by the local ethic committee; the Agreement of the Vienna Ethic Committee is available on request.

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METHODOLOGICAL PROCEDURE The above mentioned 50 inpatients of a Viennese Psychiatric Department (Otto-WagnerHospital, Vienna, Austria) agreed (informed consent) to fill out five self-rating questionnaires. Each participant had the possibility to work on the self-rating questionnaires in a quiet room over a 24h- period. 52 patients were rated by an independent rater. Concerning the expert rating, the Spearman-correlation coefficient amounts to 0.8 and showed sufficient intra-rater-reliability. Two participants could not execute the questionnaires due to severe illness. We compared the following self-rating instruments - STAI: State/Trait Anxiety Inventory, FAF: Questionnaire for aggressivity and the IIP-C: Inventory of interpersonal problems – with the following expert-rating instruments -HAMA: Hamilton-AnxietyInventory, AREQ: Affect regulation and affect experience Q-sort-Assessment, and the QORS: The Quality of Object Relation Scale – as listed below: STAI - HAMA STAI - AREQ FAF - AREQ IIP-C – QORS

SELF-RATING INSTRUMENTS STAI: State/Trait Anxiety Inventory (Laux, et al., 1981) It is a clinical personality test. State-Anxiety describes a state of emotional strain (pressure), solicitude or internal agitation, which can be influenced by a concrete situation and can vary temporally.

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Trait-Anxiety is a relatively stable quality of a person. It characterises the tendency to describe a situation as threatening (anxiety). Trait-Anxiety influences the degree of State-Anxiety. High-anxious persons show more intense State-Anxiety than low-anxious persons. With modified instructions for state-anxiety the subject can be directed towards specific situations. The scales can be applied separately. Every scale consists of 20 items. The state-anxiety items range from not at all (1) to very much (4), the trait-anxiety-items range from hardly ever (1) to always (4).

Validity Middle and high correlations can be found with the construct related manifest Anxiety scale (.52 to .90). Scales of existential orientation have higher correlations with StateAnxiety-scales than with trait-anxiety. No correlations with intelligence as divergent validity construct have been made.

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Reliability Retest-reliabilities amount to .90 and to .77 for female (n=28) and male (n=27) students after a period of 63 days, and therefore show a sufficient level for trait-anxiety. The low retest-reliabilities for the state-scale confirm the theoretically explained expectancy, namely that state-anxiety is a temporally instable quality. Because of the cronbach alpha data (from .81 to .93) for trait-anxiety and (from .90 to .96) state-anxiety, the test shows a high internal consistency. Standardisation Standard values for men and women in three different age groups are available (15-29, 30-59, 60>). 1.278 women and 1.107 men were interviewed. T- Data, Stanine-Data and percentage rating were used for the standardisation of trait-anxiety. Standardisation calculations for state-anxiety were not performed because of its alterability. State-anxiety scales can be used for longitudinal research to measure changes in connection with medical-therapeutic interventions, or in scientific fields to analyse disposition oriented personality, as well as in the intercultural anxiety research (Berth & Balck, 2003, p. 174f).

FAF: Questionnaire for aggressivity (Hampel & Selg, 1975) The FAF gives information about the tendency towards aggressive behaviour. The inventory includes 77 items, which are also represented in the Freiburger Personality Inventory. The majority of the items are ego-statements, and possible answers are “yes” or “no”. The first item is a “warming-up”-item. Ten statements are assigned to the openness scale, which is a control scale that allows open responses. The other items are distributed to five aggression scales: spontaneous aggression, reactive aggression, excitement, self aggression, aggression inhibition. The first three scales are used for calculating the cumulative values (amount of aggression).

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Validity Many investigations from different development stages of the FAF are cited in the manual. There are significant differences between criminal offenders and control subjects. Some patient groups differ in the FAF. Socio-demographic characteristics deliver references for the validity. Men show higher values than women especially on the first two scales, and people of the lower classes had higher values than people of the middle class. Reliability The internal consistency of aggressiveness scales ranges between .65 and .79. The total scale for aggressiveness has a value of .85. The openness scale has an alpha of .61. Standardisation: It is based on the standardisation sample of the Freiburger Personality Inventory from 1970 (N=630). Age and sex specific T-, stanines and percentage ranges are alleged. For comparing the mean values and standard deviations of the standardisation sample, criminal offenders, psychotherapy patients and psychosomatic patients are calculated. The instrument can be used in scientific investigations for aggressive behaviour and also in clinical fields, for example in status and progress diagnostic of psychotherapy. It is also possible to use it in clinical and forensic science (compare Herpertz et al., 2003; Huber et al., 2001; Wolters, 1994, Berth & Balck, 2003, p. 50f).

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IIP-D/IIP-C: Inventory of interpersonal problems (Horowitz et al., 2000) This instrument is the German version of the Inventory of Interpersonal Problems of Horowitz et al. (1988), which is based on the personality theories of Sullivan (1953) and Leary (1957). Interpersonal relationships have a great influence on personality. This theory is supported by Leary’s empirical investigations. With his circumplex-model of interpersonal behaviour he showed that certain actions of a person provoke certain reactions in the other person. The dimensions “sympathy” (hostile vs. affectionate) and “dominance” (dominant vs. affectionately behaviour) are used for the description of interpersonal behaviour in that model. By dividing the two-dimensional semantic space into octants, specific behaviour patterns can be classified. It is expected that complementary as well as non-complementary behaviour appears in interpersonal relations. The inventory, which can be divided into two parts, includes 127 items relating to interpersonal behaviour patterns. In the first part, 78 items describe behaviour patterns having difficulties in interpersonal acquaintance. In the second part, 49 items refer to behaviour patterns appearing in abundance, which means “too often” or “very much”. The answer possibilities are based on a five-stage ranking system from “not at all” to “very much”. The subscales are 8 factor analytic scales according to the octants of the circumplex-model: autocratic/dominant, disputable/competitive, repellent/cool, introverted/social avoiding, self unconfident/submissive, usable/indulgent, caring/kind and expressive/intrusive. The scales in detail include 8 items. These 64 items form the short version IIP-C. The other 63 items are not assigned to any scale. Specific scale values and total values reflecting interpersonal problems in detail are calculated.

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Validity Studies (Horowitz et al., 1988; Davies-Osterkamp et al., 2003) have revealed that characteristic specific interpersonal problems are valid criteria for psychotherapy success. It was also discovered that interpersonal problems in close relationships are related to different styles of bonding. In comparison with other inventories, the constructive validity could be demonstrated. The internal consistency of the scales (alpha= .36-.64) is just satisfactory, the retest-reliability is satisfactory (.81-.90) (Davies-Osterkamp & Kriebel, 2003). Standardisation: A standardisation table (means and stanine-values) based on sex and age as a representing sample (3047 persons) is available. The primary use lies in the status and process diagnostics for psychotherapy (no specific form of psychotherapy) in clinic and science (Berth & Balck, 2003, p. 296f).

EXPERT-RATING INSTRUMENTS

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HAMA: Hamilton Anxiety Scale (CIPS, 1977) HAMA is an assessment instrument for the evaluation of the degree of severity concerning anxiety, independent from etiology and is applied on patients, who have already got a diagnosis from the group of the anxiety disorders (“neurotic anxiety disorder”, Hamilton, 1959). HAMA isn’t an instrument for diagnosing and isn’t able to distinguish between different anxiety disorders. The scale is appropriate for process description. HAMA is implemented for the verification of the effectiveness of anxiolytic antipsychotic drugs. The instrument is also used for other psychic disorders, which are accompanied by anxiety (e.g. substance-related disorders, addiction, somatoform disorders, depression). 14 Items of the HAMA are related to 7 psychic and 7 somatic anxiety symptoms, which are characterised by widespread terms (e.g. “anxious mood”) and a range of exemplary anxiety symptoms (e.g. “worries”, “expectancy of the worst”). The items have a 5-ary severity code, in which 0 means “inexistent”, 1 “little”, 2 “moderate”, 3 “strong” and 4 “very strong”. The items are specified by single symptoms, which help the investigator with the assessment of the phenomena. This assessment is based on an interview with the patient, in which the single symptom complexes are analysed. Except item number 14, this refers to behavioral symptoms observed during the interview. The item sentences are additively calculated to a total value (from 0 to 56 points), which shows the global amount of the anxiety severity code.

Objectivity Missing clues in the scaling and blurred bounded item contents give the investigator a rating of wide scope in his inquiry. The objectivity of the procedure and rating can be increased by a structured interview (guidelines) and a standardised training for the rater. Hamilton (1976) mentions a correlation coefficient of r=.89 for the interrater-reliability of the English version (after a z-transformation of the weighted means of the correlations by three experienced raters). Bruss et al. (1994) refer to a correlation coefficient of r = .74 to .96 for the correspondence of the raters after elaborate training.

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Reliability Internal consistency: the internal consistency of the German version is asserted by Beneke (1987) with r = .83 (Spearman-Brown) and r = .87 (Flanagan). Retest-reliability: for the English version very good to moderate stability coefficients are pointed out: rtt = .96 over 1 day and 1 week, rtt = .64 over 1 year (Bruss et al., 1994; Clark & Donovan, 1994). Validity Content validity/construct validity: The 14 symptom groups show a broad spectrum of anxiety symptoms. In comparison to the main symptoms “worry” and “excitement”, somatic symptoms and symptoms of the autonomic activation are overweighting. The factorial analysis of Hamilton shows three factors, which can be named after the highest levels as “emotional excitement” (psychic tension), “worries” (anxious mood) and “anxiety” (anxiety). Anxiety often does not correlate with the first both components (Becker, 1982; Hodapp, 1991; Laux & Glanzmann, 1996). The factorial analysis of Beneke (1987) shows beside the factor “psychic anxiety” two more somatic factors. These are the cardio-vascular/respiratory symptoms (2 symptom groups) and the gastro-intestinal/uro-genital/neurovegetativ symptoms (5 symptom groups). The data were evaluated in admission and are not specific to any diseases. Convergent Validity: Available results to validity show moderate to narrow correlations with similar construct values, for example correlations .49 ≤ r ≤ .81 by a global anxiety scale (Snaith et al., 1982), from .36 ≤ r ≤ .94 by an other anxiety scale (Wang et al., 1976) and from .31 ≤ r ≤.61 by the neuroticism-value of the Eysenck personality inventory (Bianchi & Fergusson, 1977). Maier et al. (1988) report correlations by the Covi Anxiety Scale (Covi et al., 1979): r = .56 in patients with panic attacks and r = .75 in patients with major depression. Discriminant validity: high correlations of the assessment test (.62 ≤ r ≤.73) by the HAMA refer to small discriminant validity in relation to depressivity (Clark & Donovan, 1994, Riskind et al., 1987). This is understandable due to the high level of overlapping symptom groups, which are brought up in both scales. Treatment sensitivity: The HAMA showed treatment sensitivity in many clinical studies. Standards, Cut-Off-Scores Neither for the English original version nor for the German Version standards based on a normative sample are existing. But there are comparative data of different samples from a lot of studies. For the English original scale scores above 13 are indices for clinical significant anxiety (Kobak et al. 1993). Rickels and Rynn (2001) report about cut-off-scores of >14 points in psychotherapeutic studies, and about >19 points in psychopharmacologic investigations (Weyer, 2005, p. 281ff).

Affect Regulation and Experience Q-sort (AREQ) (Westen et al., 1997) The AREQ (Westen et al., 1997) is a 98-item observer-based Q-sort designed to assess Affective Experience (including affect intensity, lability, and tendency to experience particular emotions) and Affect Regulation (including a range of conscious and unconscious procedures used to increase pleasant and decrease unpleasant emotions). Each of the 98 items is printed on a note card, and the observer sorts (rank orders) these cards into nine piles, from

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those that best describe the patient (pile 9) to those that do not describe the patient well (pile 1), using a fixed distribution. The Affective Experience dimension of the AREQ yields three factors, determined by factor analysis in previous research: Socialized Negative Affect, Positive Affect, and Intense Negative Affect. Socialized Negative Affect refers to the experience of affective states such as guilt, remorse, and regret, which reflect an internalization of social norms and moral standards. Positive Affect refers to the tendency to experience positive affective states. Intense Negative Affect refers to the tendency to experience strong negative emotions (e.g., "tends to feel unpleasant emotions intensely"; "tends to have panic attacks"). The Affect Regulation dimension includes three factors: Reality-focused Regulation, Externalizing Defenses, and Avoidant Defenses. Reality-focused Regulation is defined by the poles of active, goal-directed coping (e.g., "is able to anticipate problems and develop realistic plans for dealing with them") at one end, and impulsive, maladaptive coping and defensive strategies at the other (such as taking drugs, making suicide attempts, and dissociating when distressed). The Externalizing Defenses factor is defined by the poles of blaming others (e.g., " tends to blame other for own mistakes or misdeeds") and blaming the self (e.g., "tends to feel bad or unworthy instead of feeling appropriately angry at others"). Avoidant Defenses is defined by the poles of avoidance of unpleasant affect (e.g., "consciously and deliberately avoids thinking about distressing wishes, feelings, and experiences") vs. containing affective "leakage" (e.g., "tends to become needy, dependent, and clingy when distressed"; "tends to ruminate or dwell on concerns when distressed"). Internal consistency of the factors in previous research is acceptable to high (coefficient alpha ranging from .71-.92), as is interrater reliability assessed by interviews (r > .80). Factor scores predict multiple external criteria, including behavioral variables such as history of suicide attempts and psychiatric hospitalizations; ratings of patients' quality of relationships, work history, and Global Assessment of Functioning; diagnosis; and Q-sort descriptions made independently by interview and by the treating clinician. Again, for our purpose the AREQ items were translated independently by two different people: a native speaker with no knowledge of psychoanalytical terminology and a psychiatrist and psychoanalyst (H. L.-S.). Retranslation showed sufficient convergence (see also Löffler-Stastka, 2004b). Besides, a further description (esp. psychometric details) of the AREQ can be found in Löffler-Stastka (2004c).

The Quality of Object Relations Scale (QORS) (Azim et al., 1991) The quality of Objects Relations Scale (QORS) provides an assessment to quantify an individual’s relative level and quality of object relations, which can be used as a methodological and theoretical framework for personality classification. It has progressed through several forms during the past 15 years and consists of five organizational levels: mature, triangular, controlling, searching, and primitive. Criteria are arranged within each level under the following four headings: Behavioral manifestations, affect regulation, selfesteem regulation, and antecedent (etiological) factors. These four areas are defined in terms of patterns of relationships. Behavioral manifestations consist of description of an individual’s typical relationship pattern. Affect regulation is defined by the type of interpersonal relationships the subject unconsciously and consciously wishes for and engages

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in, both in fantasy and (ultimately) in action, to reduce anxiety, experience gratification, or both. Likewise, self-esteem regulation is considered as the wished for, fantasized, and behaviorally expressed interpersonal relationships that enhance self-esteem or reduce mortification. In assessing a person’s quality of object relations, more weight is given to behavioral manifestations because they are experience-near, observable, and usually manifested in the interviewer-interviewee interaction. The five suborganizations, designated in the scale, are related to Freud’s early theoretical formulations of psychosexual development levels and to the pregenital levels formulated by some of his disciples. Hence the primitive level has kinship to the schizoid phenomena described by Fairbairn and Guntrip and to the paranoid-schizoid position elaborated by Melanie Klein. Primitive defence mechanisms dominate the quality of object relations, and also the sense of reality testing and identity are dominated by for example projective identification. The searching level is related to Klein’s depressive position. The controlling level has aspects in common with Abraham’s formulation of the anal personality. The triangular and mature levels reflect Freud’s conception of the oedipal and genital psychosexual developmental levels. Quality of object relations is a dimensional construct. The five levels of the QORS are components of this dimension from high (mature) to low (primitive). The multitude of internalized early object relations leading to several suborganizations of the ego is manifested in this dimensional (rather than a DSM-IV categorical) approach to assessing the quality of object relations. Because of the enduring pervasive and lifelong effects of these internalized object relations on adult relationships, as many of the interviewee’s significant interpersonal relationships as possible have to be explored, including that with the interviewer. A further description (esp. psychometric details) of the QORS can be found in Löffler-Stastka (2004d).

STATISTICS AND RESULTS All expert-ratings were carried out by a rater (M.S.) after an intensive rater-training (H. L-S.). The internal stability of the rater was assured by inter- and intra-rater-reliability calculations (for both к ≥ 0.7, inter-rating with M.B.). The data of the 52 patients were coded by SPSS. In addition Microsoft-Excel-calculation matrix (provided by Peter Fonagy) and Microsoft Input-mask for AREQ, SWAP and QORS (provided by Löffler-Stastka) were used. Questionnaire manuals of the single inventories, like STAI, FAF, IIP-C, and HAMA, AREQ, QORS, described evaluation guidelines, and cited specific transcription codings. Univariate correlations where calculated between all scales of the self-rating and expertrating instruments and all significant (2-tailed) correlations are shown in Table 1. For sake of completeness all correlations with only a one-tailed significance also have been inserted and marked with “+”. Generally all correlations were considered significant at an error level of 5%. Inspecting Table 1 shows only very few substantial correlations between self-rating and external rating instruments, as expected. The corresponding scales are marked grey.

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QORS

AREQ

HAMA

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Table 1. STAI FAF State- Trait- Spont. React. Agita- Self Aggr. Autocratic Competitive anxiety anxiety Aggr. Aggr. tion Aggr. inhibition (PA) (BC) Som. Anx.

.260+

Psych. Anx. Sozialized negative affect Positive affect Intense negative affect Reality focussed response Avoidant defence Externalizing defence Mature Triangulating Controlling Searching Primitive QORS total score

IIP Cold Introverted Sub-assertive Exploitable Nurturant Expressive Overall (DE) (FG) (HI) (JK) (LM) (NO) score .329*

.342* .325* -.243 -.247

+

-.308

*

-.379

**

.243+

.269+

-.327* .264+

-.249+

-.323*

-.286* .284* .255+ -.309* -.298*

+

.337*

.247+

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Canonical Correlation Analyses Due to a probable inflation of the error type I two canonical correlations between the selfratings concerning STAI, IIP and FAF and the expert-ratings of the HAMA, AREQ and QORS were calculated. In the first canonical correlation model all scales of the QORS were used with scale ‘Mature’ being the anchor-scale; in the second model only the QORS-totalscore was used. Correlating the self-rating scales STAI, IIP and FAF with the external-rating instruments HAMA, AREQ and QORS (scales) and HAMA, AREQ and OQORS (total score) leads to no significant canonical correlations each (p > .434 and p > .351, respectively).

STUDY B (HENRIETTE LÖFFLER-STASTKA)

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Rationale Within refinement of the DSM system many personality researchers and clinicians suggest to include relationship disorders on axis II of the DSM system or to add assessment possibilities for grasping interpersonal functioning within the refinement of axis II (see for example Reiss & Emde, 2003). The question often raised is, if one could rely on self-rating instruments concerning interpersonal functioning additionally to the currently use Axis II of the DSM-IV-TR, or if certain expert ratings in form of an additional section on axis II should be added. As the correlation between self-rating and expert-rating of interpersonal functioning (IIP vs. QORS) was very poor in study A we compared the expert-rated quality of object relations and self-report of interpersonal problems in a replicational design in a second sample of n = 129 patients with personality disorders. Our aim was to compare an interview measure of quality of object relations to a selfreport-questionaire measuring recent interpersonal functioning. We had also found (Löffler-Stastka et al., 2005) – as it is suggested in the literature - that the patient’s conscious acknowledgment and awareness of disturbances in interpersonal relationships is a predictor for therapeutic alliance and therapy outcome. Piper et al. (1991) stated that quality of object relations was the best predictor for therapy outcome, and they furthermore discussed the advantages of pretherapy predictors for therapy outcome, such as the assessment of quality of object relations. The patient-rated Inventory of Interpersonal Problems provides assessment of interpersonal behaviour by efficiently assessing a comprehensive set of agentic and communal values. It is also useful to describe and estimate the importance of interpersonal problems and orientations for psychotherapy. We searched for correlations between quality of object relation and selfreport of conscious interpersonal problems.

Description of the Sample The total sample of n = 129 patients comprised 95 (74%) women and 34 (26%) men. The patients’ age distribution was skewed with respect to younger patients, with a median of 27

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years (Q1 = 21, Q3 = 36), and did not differ on average between female and male patients (z = 1.47, p =.142).

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Sociodemographic data Independent of their gender, 64% of the patients were single, 28% married or co-habiting, and 8% were divorced or were separated from their partners. Concerning education 30% had finished only compulsory school, 26% finished vocational school, 30% had an A-level and 14% finished university. Independent of the patients’ gender, 33% had a job, 9% had left work due to health problems for more than 2 weeks, 8% had retired, 16% were unemployed, 30% were still undergoing education and 4% were housewives or on maternity leave. Neither education nor job situation was gender related. Altogether, the sample displayed a population with low socio-economic status and high unemployment rate. Considering anamnestic data, the sample represented severely disturbed patients, mainly with long treatment careers. Concerning previous treatment history, 63% of the patients independent of their gender had undergone certain types of pre-treatment and 61% had had experience with psychotropic medication. In total, 39% of the patients came on their own initiative, 8% were advised by private persons, 27% were transferred by psychiatric/psychotherapeutic institutions, 6% were transferred by other medical institutions, 9% came from a psychiatrist, 4% from a psychotherapist, 1% from a general practitioner, 2% from an advice centre, 3% from school, and for 2% of the sample, this information was missing. In addition, therapy was used independently of previous treatments (p = .850). Diagnoses Altogether, the prevalent diagnoses on Axis I (DSM-IV) were substance-related disorders (3%), psychotic disorders (10%), mood disorders (36%), anxiety disorders and somatoform disorders (26%), eating disorders or sexual dysfunction (5%), disorders of adult personality and behaviour (4%) and disorders of psychological development (1%); for 17% a diagnosis was missing. Concerning Axis II diagnoses, 3% of the patients received only Cluster A diagnoses, 23% only Cluster B, and 13% only Cluster C. In 11% of the patients, Cluster A and B diagnoses were made, 8% of the patients fulfilled criteria for Cluster A and C diagnoses, and 16% for Clusters B and C. Of the sample, 11% received diagnoses of all three clusters and 15% of the patients showed character traits or several items of PD diagnoses, but did not fulfil criteria for certain specific PDs. Combining Axis I with Axis II did not show any significant systematic interaction in connection with the patients’ gender. Merely descriptively, it appeared that one third of the patients with anxiety disorders and somatoform disorders on Axis I did not receive any diagnoses on Axis II. The median GAF score was 50 (Q1 = 50, Q3 = 60) and did not differ between men and women.

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METHODS The Quality of object-relations scale (QORS; Azim et al., 1991) was used to quantify quality of object-relations. This expert rating questionnaire has been described already above. Rating was carried out after an initial psychotherapeutic interview by two independent raters. The median inter-rater correlation was k = .65 (minimum = .19, maximum = .77) for the QORS rating in this study. As the enduring quality of object relations is manifested in the interpersonal situation, the expert-rating was compared to the Inventory of Interpersonal Problems – IIP (Horowitz et al., 1988), which also has been described above in Study A.

STATISTICS & RESULTS

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Analogous to study A two models were used, namely a canonical correlation (model I) between the self-ratings concerning the scales of the IIP and the external-ratings of the QORS scales with scale Mature as an anchor scale was calculated. Further a linear regression model (model II) of the IIP scales on the QORS total score was adjusted to the data. Model I resulted in one significant root (R = .419, p = .008) with the IIP-scales IIP-DE (β = .888), IIP-BC (β = .831), and IIP-FG (β = .743) and the QORS-scales Triangulating (β = .549) and Primitive (β = .646) showing substantial loadings. Redundancy analysis showed that the external ratings explained only 6.7% of the variance of the self-rating scales and the latter only 6% of the external-rating scales. Model II between the IIP self-rating scales and the QORS total score was significant (R = .334, p < .001; 11% variance explained) with only IIP-BC being a significant predictor (β = .334).

CONCLUSION One of the main objectives was the proof of insufficient inquiry of affect disorders by the submission of self-rating questionnaires in patients with personality disorders. Each selfrating was compared with an appropriate expert-rating. It should be shown that in comparison to the expert-rating self-rating instruments give different results. Accordingly, the purpose of diagnosing affect experience disorders by using self-rating instruments in patients with personality disorders, especially in combination with a Borderline Personality Organisation should be discussed. Following studies support the supposition that patients with Borderline Personality Organisation (BPO) are impaired in their self-perception and self-concept, and are suffering from emotional instability and affect regulation disorders. One study about the metarepresentative functions in borderline personality disorder shows that these patients maintain their ability to identify internal states, whereas they are impaired in the integration of representations of self and others and in the differentiation between fantasy and reality (Semerari et al., 2005, p. 690-710). Pinto, Gragentine, Francis and Picariello (Pinto et al., 1996, p. 1338-43) describe in their study that patients with BPD (Borderline Personality

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disorders) are impaired in their self-concept, therefore suffer from pervasive emptiness and identity disturbance associated with BPD. The assumption that affect instability and dysregulation are the main criteria in the experience of patients with BPD is affirmed by Stein (1996, p. 32-40). In another investigation, patients suffering from BPD showed significantly lower levels of emotional awareness, less capacity to coordinate mixed valence feelings and lower accuracy at recognizing facial expressions of emotion, and gave more intense responses to negative emotions than the non-borderline controls (Levine et al., 1997, p. 240-6). Therefore it could be suggested that patients with Borderline-Personality Organisation (BPO) – and most of the patients with personality disorders seen in psychiatric care units are psycho-structurally functioning on this level or organisation - are not able to assess themselves in self-rating instruments. Results of the correlation analyses demonstrate that it is necessary to challenge the utilisation of self-rating instruments in patients with BPO. Eleven from fourteen possible correlations in study A do not show any correspondence between self- and expert- ratings. Self-rating questionnaires are measure instruments for self-assessment and self-perception. Depending on the questionnaire several psychic variables or behavioural tendencies can be measured and statistically described. A lot of medical doctors, psychiatrists and psychotherapists use self-rating questionnaires as an additional diagnostic instrument as well as for the description of the process of therapy planning in the initial interviews. Expert-rating instruments have been increasingly applied in psychiatric and clinical fields over the last years. An investigator with sufficient training and experience carries out the evaluation by using a standardised q-sort-assessment test or questionnaires. The assessment of a patient by an expert is getting more and more importance, especially in psychiatric departments, because patients with mental illnesses often have deficits and impairments in their self-concept, selfperception and self-investigation. Only top-quality and well-proven self-rating instruments and expert-rating instruments were used in this study. Till now, no other comparative studies using these instruments do exist. In spite of long lasting clinical appliance, the self-rating instruments, STAI, FAF and IIP-D could not achieve any satisfactory correlation results with the appropriate expert-rating instrument. The different results between both assessment instruments are probably caused by the sample of the patients itself. Patients with Borderline-Personality Organisation (BPO) do not have a steady self-and object- concept. They have to use primitive defence mechanisms in many life situations, because they were not able to replace them by mature defence mechanisms during their personality development. Projective identification and splitting processes affect their experience and perception of themselves and others. These facts make it impossible for patients with BPO to give reliable information about their emotional and mental experience in self-rating instruments. By denial, primitive idealisation, omnipotence and derogatory devaluation a world is created, which protects the Ego from unpleasant feelings, especially anxiety. Borderlinepatients need those defence mechanisms to create in some degree a tolerable life, and even sometimes to survive. Mechanisms of splitting lead to dissociative states, which scatter the emotional world and destroy the subjective validity of emotions. This kind of falsification impairs the affect- and ego-development.

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Reasons For understanding the psychopathology of patients with Borderline-Personality Organisation (BPO), it is necessary to go back to the roots of affects, to fathom egodevelopment and the associated psychodynamic process. The following assumptions are based on existing and already described psychoanalytic literature. The origin of affect experience and affect perception disorders caused by an inadequate “containment” during childhood shall be discussed. Insufficient maternal care, especially (childhood-) trauma and experience of inconsistencies has a negative influence on ego-development, and disturbs the ability of affect perception- and regulation. Due to the views of many psycho-analysts, psychotherapists, and the existing literature, it is supposed that affect perception disorders have its seeds in the childhood and are caused by traumatic experiences and inadequate “containment”. Patients with BPO acquired selfprotection-mechanisms and above mentioned primitive defence mechanisms in their early childhood, so that they do not have to experience their affects and needs. The experience and perception of their feelings and affects would have been associated with such a high level of frustration, which would have been incompatible with life. The attachment figure, the mother, often was not able to give the child sufficient support in the tolerance of difficult affects (for example high expressed emotions), though she could not help in the development of affects and ego. An insufficient mentalization of the self and incontingent mirroring processes let the self and its affective experience and perception shrivelling. The self- and object representations and appropriate affective components are split and often impress as dissociative experiences. The internal state of the patient appears disrupted, which can be observed during the interview. The mood or opinion of the patient can change from one moment to the other completely without any reason. If there is a dangerous situation, so that the patient could experience any unpleasant emotions, the patient will bring out an immense outburst of fury often in combination with projective identification. Primitive defence mechanisms like projective identification and splitting processes are mainly responsible for affect perception disorders. These incisive processes into ego-development already happen during childhood. The result is a disturbance of affective development, and an impairment of nomination and perception of emotion. Instead of a healthy steady ego with integrated good/bad self and object representations, the capacity to mature defence mechanisms and affect perception and regulation, a patient suffering from internal emptiness, ego-weakness and identity diffusion can be explored. The described processes are also responsible for the different results in the study, because many patients do not know what they are feeling, and can not specify it in selfrating questionnaires. Their ego-weakness and the predominance of primitive defence mechanisms disturb the patients in their self-perception, so that they do not have any knowledge about themselves. Descriptions about themselves and other persons, who are close to them, are often unsubstantial and meagre. In the interview it can be assessed that they are not able to perceive their feelings, and are not able to name or interpret their affects. One of the patients described his internal state as: “I don’t have any emotions. I don’t know, what I am feeling or perceiving!”, or as “I don’t need that rubbish (emotions)!” Lying and a certain kind of pseudo-stupidity (Bion, 1957) as a sign of ego-weakness appear especially in patients with malign narcissism functioning on a Borderline-Personality

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Organisation (BPO). Some of these patients show an intense curiosity towards the therapist and spy on him. The patient presents himself constantly arrogant and mistrustful towards the therapist. His disability to become involved in an interview, can give the therapist the impression of pseudo-stupidity in the patient (Kernberg, 2006, p59). The pathological behavioural patterns, as well as narcissistic transference resistance influences the ability to self-rating and filling out the questionnaires, which causes insufficient correspondence in the results of the correlation analyses. Riviere (1986) made the observation, that narcissistic resistances play an important role in negative therapeutic reactions. The imagination, to perceive gratefulness can not be born by the patient, because this would mean to accept help from others. The good, which the patient gets from the therapist, can not be tolerated. The reason for this inability is his own deep aggression for which he has unbearable feelings of guilt (Kernberg, 2006, p.71). Predominant envy and intense feelings of hate make it impossible for the patients to give reliable answers in self-rating assessment. Melanie Klein described the negative influence of hate, envy and greed in ego-development and the capacity to be grateful and happy. The phenomenon of primitive envy can be observed during the transference situation. Envy of the successful work of the therapist impairs the progress in the therapy, even in initial interviews or during the process of psychotherapy planning. The patient has envious and hostile parts of the self separated, which influence the therapy process. The analyst can not be introjected as a good object. The analysts and his job are damaged by the patients’ envy, and interpretations can not be accepted (Melanie Klein, 1957, p.279-367). Feelings of envy influence the treatment process. These destructive impulses also effect the fulfilment of the self-rating questionnaires. The self-assessment and rating of self-states can not be used, and should be challenged. As already mentioned the sample includes also patients with narcissistic character features, functioning on the level of a Borderline-Personality Organisation (BPO). As well as Melanie Klein, Kernberg also describes the pathology of narcissistic personality disorders, and their behavioural patterns. Apart from the pathological grandiose self, their self seems to be better integrated, but representations of important attachment persons are not integrated. They do not have any empathy for other people and in their relationships conscious and unconscious envy as a predominant feeling exists. Patients with narcissistic personality disorder devaluate other persons and symbolically destroy that, what they get from others. Their behaviour is exploitive and greedy. They are ambitious and unable to mature dependency. They can not get into friendships or behave loyal. Their pathological grandiose self shows egocentric behaviour and exaggerate self imagination and delusions of fantasies, which often contain exhibitionistic elements. They present themselves as superior and are ruthless. Peculiar is the discrepancy between great ambitions and insufficient capacity. The patients are excessively dependent from admiration, which they gain from others, but do not show any gratefulness. Their self experience and their emotional life is shallow, which impresses as a feeling of emptiness, boredom and hunger for stimulation (Kernberg, 2006, p.95). Feelings of grandiosity and the sense of entitlement, immoderate envy and devaluation as well as small amount of empathy and engagement are the main symptoms of a narcissistic personality. External behaviour can be mutable. However the typical contacts with the patient are characterized by superior attitude and self assurance as well as by charming and attractive cheerfulness, which is a mirror image of the pathological grandiose self. The atypical

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behaviour is marked by anxiety, strain and insecurity. The fear, that the narcissistic demands can not be fulfilled, stands in the foreground. In contrast to their usual self-esteem and superior attitude, a typical symptom of many patients is insecurity. In patients with better functions a conventional incompliance is predominant. Instead of the capacity to form deeper, meaningful relationships with important persons, a rigid adherence to conventional clichés stands in the centre. The absence of an integrated super-ego can imposingly be observed in patients with narcissistic personality disorder. The idealized level of the super-ego-precursors, the ego-ideal, is absorbed by the pathological grandiose self. This leads to a kind of false identity integration and facilitates a certain manifestation of ego-strength (tolerance of anxiety, impulse control and certain functions of sublimation). The patients seem to have a better efficiency than common patients with Borderline-PDs (Kernberg, 2006, p.96). These detailed explanations of Kernberg, lets one conclude that patients with BPO and narcissistic personality disorder are not able to assess themselves in an objective and realistic way. Their self- and internalized object-concept is interspersed with envy, feeling of grandiosity. Empathy and gratefulness do not seem to exist, and their mental world resembles an internal emptiness. A self-rating instrument can apparently not achieve reliable results. But it is possible to uncover such pathological behavioural patterns by expert-rating instruments like the AREQ or the QORS. Patients try to regulate their attention towards lifeless things, like drugs and alcohol, just not to be confronted with their psyche, because this would be related with anxiety. A selfrating questionnaire means to think about oneself and his/her psychic situation, and to give information about certain behaviour. The consideration about oneself provides troubles and unpleasant emotions for many patients, which leads to imprecise self-ratings. The patients do not read the sentences with concentration and are not willingly to reconsider the questions. A conscious or unconscious aim is to carry out the self-ratings as quick as possible and to mark any of the answer possibilities. These facts influence results of self-rating instruments. Nevertheless, few correlations were found in study A, which should be discussed as follows: •

•

Trait-anxiety scores assumedly correlate with the basic anxiety of borderlinepatients. They try to bring their anxiety under control by using primitive defence mechanisms, which do not work at any time, which can be coincidentally uncovered by self-rating questionnaires. Fury and anger are more tolerable for patients with a Borderline-Personality Organisation (BPO) than fear of annihilation, destruction or death, because this kind of energy can be discharged by projective identification, which can be expressed in self-rating questionnaires. Aggressive behaviour against themselves and others can be found in nearly every patient with BPO. As described by Kernberg (2006) libido and aggression are hierarchically higher-ranking drives, which integrate the appropriate affect states - eager and grievous. Affects are instinctive components of the human behaviour, which appear in early developmental phases. As a part of early object-relationships these affects are organised to drives. Eager-rewarding affects are integrated as libido, grievous-aversive negative affects as aggression. Physiological and physic experiences are the first activators for innate, constitutional and genetic contingently reactions called affects. Fury as the main affect of aggression and the drive-derivatives fate of fury explain the origin of hate, the predominant affects of

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•

severe personality disorders (Kernberg, 2006, p.26). Aggression is the main affect in the personality of patients with Borderline-Personality Organisation (BPO). It also stands for the activation of primitive defence mechanisms. These characteristics define results of self-rating questionnaires. “Autocratic/dominant” subscale-scores of the IIP show that some patients try to control their own world and that of their objects. Paranoid persecutory anxieties force patients with BPO to dominate a certain situation or a person, and to yield power. “Autocratic/dominant” statements activate the drive of destruction in some patients. That’s perhaps the reason why they tend to score them high.

Replication in a larger sample (study B) also showed only correlations between the dominance-scales of the IIP (IIP-DE, IIP-BC) and primitive quality of object relation, where projective identification dominates the patients’ identity. Therefore this result of the canonical correlation analysis confirms study A and our discussion. Thus, these correlations aren’t reliable enough, and could also have shown up coincidentally. Results from expert-rating instruments are much more reliable because the assessment is carried out by an expert. Many interviews and behavioural observations are helpful methods for the exploration of the patient, which also enable to analyse specific problems. Transference and counter-transference reactions help the investigator to understand and interpret psychic states and reactions of the patient. The examination gives a picture of the patient and makes it possible to get a good expert-assessment by q-sort-tests. The expert-rating instruments AREQ, QORS and HAMA are in-use for a certain time and could get reliable outcomes. The expert-rating instrument, SWAP, was also used as a diagnostic instrument by giving a prototype description. These expert-rating instruments give reliable results as well as a very good description about the psychic structure, the defence mechanisms, and about the affect-perception and regulation of the patients. Expert-rating instruments support the investigator in his assessment about psychic functioning. In these studies the expert-rating instrument SWAP-200 (detailed methodological description can be found in part 2) was used, which gives information about categorical and dimensional psychiatric diagnosis. SWAP is a 200-item q-sort-test for the assessment of personality and personality pathologies. This instrument considers character criteria of the DSM-IV personality categories, and gives a personality description, which can be compared and correlated with other empirically evaluated prototypes. Based on clinical experience and knowledge, these empirically evaluated prototypes of the SWAP-200 reproduce the total assessment of the patient. By comparison and correlation of the patient’s rating with twelve prototypes it is possible to get a reliable assessment about the intrapsychic and interpersonal functioning of the patient. A descriptive and pictorial diagnostic examination can be carried out. Self-rating instruments are not able to give information about affect constellations, and do not consider the bias resulting from primitive defence mechanisms. The AREQ (as well described in the methods section) is a q-sort expert-rating instrument, and was used in the study for the assessment of the predominating affect experience and affect regulation mechanisms. The AREQ enables the investigator to evaluate coping strategies and defence mechanisms of the patient with the help of his description about affective experience, irksome events and narrations about interpersonal relations with important persons. Affects and mechanisms of affect processing play an important role for the understanding of personality. Psychoanalytic theories lead to important cognitions about

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processing of emotional important information, for example, that people often distort information about themselves and others, which is influenced by and reflect their wishes and anxieties. These mechanisms are not considered by self-rating instruments. This supports the utilisation of expert-rating instruments. The QORS is another expert-rating instrument (see methods section) and is used for the quantification of the quality of object-relation patterns and the object-relation level. The object-relation quality is defined as the internalized permanent tendency to establish certain relationship patterns, and is related to lifelong existing and present observable characteristics of relationship creation. The QORS gives a method for the assessment of object-relation patterns and is used for dimensional evaluation of character structures and personality classification. It allows meaningful, complex descriptions of human beings. Neither object-relation patterns nor their level or quality are analysed in self-rating instruments. These studies showed that outcomes of self-rating instruments do not correlate with that of expert-rating instruments. The utilization of the described expert-rating instruments means a clinically useful examination of the patient, an exact assessment and a therapy management adapted for each patient in its every different subjectivity.

PART 2: ASSESSMENT PROCEDURES RELEVANT FOR MEASURING THE COURSE OF THERAPY AND TREATMENT RESPONSE

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Henriette Löffler-Stastka ABSTRACT Background: In psychoanalytic treatments of severe personality disorders beneficial and impairing factors for the therapeutic progress were found. The aim is to investigate the impact of assessment of those moderators (affect experience, character traits, patient-therapistrelationship) on treatment response in daily routine practice, i.e. one sample of psychiatric inpatients and another sample of psychosomatic patients. Methods: Within psychiatric and psychosomatic in-patients hindering factors (e.g., negative affects, externalising defence, projection/projective identification, or dismissive interpersonal behaviour) and resilience factors (e.g. high psycho-structural functioning, mature quality of object relations, positive affect) were investigated with the same instruments described above (see Part 1) in a pre- post design (duration of treatment: 3 weeks in the first sample and 6 weeks in the second). Additionally treatment relationship was investigated with the Psychotherapy relationship questionnaire and the Counter-transference questionnaire. Results: Significant treatment response could hardly be measured with the procedures measuring patients’ variables, neither negative/positive outcome after 3 weeks, nor after 6 weeks. But on the therapist’s side (counter-transference) significant changes appeared constantly before patient’s treatment response.

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Conclusion: Assessment of the therapist’s counter-transference in daily routine practice is necessary to get information about treatment response in severely disturbed psychiatric patients.

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INTRODUCTION In part 2 of this chapter we test and discuss, if the assessment of affect regulation and quality of object relations, as well as the considerations presented in part 1, are valid for treatment response, the course of treatment and treatment outcome in psychiatric and psychosomatic inpatients. Affect regulation and quality of object relations displayed in the patient-therapistinteraction during psychoanalytic treatments has been evaluated and measured in the course of treatments in severely disturbed patients with personality disorders (Löffler-Stastka et al., 2006a). We also performed investigations of psychoanalytic treatments and micro-process evaluation focused on affect regulation and character traits, which was conducted in a naturalistic psychoanalytic treatment study with the aim to contrast outcome-moderators in prospering treatments vs. psychoanalytic treatments with poor outcome (Löffler-Stastka et al., 2008). A report on treatment of severely ill patients with personality disorders was presented with the focus on beneficial vs. impairing traits concerning the treatment course. The impact of investigation of treatment outcome moderators and mediators (affect experience, character traits, patient-therapist-relationship), which mainly concentrate on the topic of good enough understanding of mechanisms of projective identification, have been presented (LöfflerStastka et al., 2006a, Rössler-Schülein et al., 2006). Methodological questions concerning evaluation of psychoanalytic treatments and the impact on daily routine practice have been discussed. Questioning how to measure the course of treatment - what can we learn from evaluation of psychoanalytic treatments for the daily routine practice? or how to objectify the therapeutic process? – the Department of Psychoanalysis (Vienna Medical University) has put one focus on specializing in the long-term psychoanalytic treatment of persons who suffer from the severe consequences and complex disturbances of their pathological personal development. During years, in the course of many long-term psychoanalytic treatments we repeatedly observe and discuss character traits, including styles of thought, unconscious beliefs, and mechanisms of defence that are specific for the various personality disorders, which now are empirically investigated. There exist some qualitative psychoanalytic measurements, which are very sensitive to various changes. By contrasting so called good enough treatment outcome with unsatisfying ones, we focus on the clinical relevance of empirical data taken from a naturalistic sample (Löffler-Stastka et al., 2008) in order to get information about which character traits and variables are beneficial and which impair the therapeutic progress. Variables and character traits displaying resilience and beneficial factors due to the treatment progress are contrasted to hindering factors and impairment of treatment progress (Löffler-Stastka et al., 2006a). Assessment of resilience and therapy-impairing traits and the importance of evaluating such moderators for the therapeutic team and for treatment outcome in daily routine practice in a naturalistic setting lead further to the question of what is useful and clinically practicable to be investigated regularly during the course of treatment and

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further to the need of practicable assessment tools. Microprocess evaluation of psychoanalytic treatment sessions with the administered Q-sort instruments will be used to create a profile or set of variables, which can be defined as absolutely necessary to be observed in daily routine practice during treatments of severely disturbed psychiatric patients (see also Löffler-Stastka et al., 2008). The need of assessment and evaluation of psychoanalytic treatment including prospective and predictive outcome-oriented factors is formulated. The aim of the ongoing study is to evaluate the predictive power of an accompanying evaluation due to successful outcome vs. misleading aspects during the course of psychoanalytic treatments. We assess affect experience, affect regulation (AREQ - Westen et al.), character traits (SWAP-200 – Shedler & Westen), quality of object relations (QORS – Piper et al.) as well as patient-, therapist- and -interaction-variables (Psychotherapy Process Q-sort - PQS – E. Jones) in a sequence of five sessions every six months in the course of psychoanalytic treatment of patients with personality disorders. Differences in prospering psychoanalytic treatments should be contrasted to data of patients and therapists of psychoanalytic treatments with poor progress. Predictive constellations of patient- and therapist-variables pointing at good vs. poor outcome should be found. Discussion should be focused on evaluation accompanying the run of psychoanalytic treatment and the impact on treatment outcome. First preliminary results of a period of five years have been discussed (Löffler-Stastka et al., 2006a), detailed description is upcoming soon. A second study (Rössler-Schülein et al., 2006, 2007, Löffler-Stastka et al., 2008) a longitudinal study of psychoanalytic and psychotherapeutic process and outcome was conducted in a different sample and institution (Outpatient clinic of the Viennese Psychoanalytic Society). During four years, in the course of more than thirty long-term psychoanalytic treatments we repeatedly assessed character traits, and mechanisms of defence that are specific for the various personality disorders. The Shedler Westen Assessment procedure (SWAP-200) provided us an instrument that showed up to be very sensitive to various changes. In addition interpersonal problems and the amount of relevant symptoms were documented by two well known and validated self rating instruments, the IIP (Inventory of Interpersonal Problems) and the SCL 90-R (Symptom Check List of Derogatis). Contrasting a so called good enough treatment outcome with an unsatisfying one, we compared specific differences between the results of self rating and changes in the SWAP. Discussion focused on the clinical relevance of empirical data taken from a naturalistic sample, and on predictive factors, which impair the progress in psychoanalytic treatments of severe personality disorders. Affect regulatory mechanisms, as denial of needs for closeness, externalising defence, projection/projective identification, somatization, hypochondria, and affect experience, as fears of an impulsive breakthrough of negative affects, as well as dismissive interpersonal behaviour predicted dropout of therapy. For psychoanalytic technique we concluded, that it is necessary to perceive and interpret paranoid anxieties, negative affects, externalizing mechanisms, and work through these elements thoroughly in transference to gain good enough treatment outcome. Within an investigation concerning long-term psychoanalytically oriented inpatient treatment for traumatized patients with polytoxicomania (Schmid et al., 2006) we put the focus on beneficial vs. impairing traits concerning the treatment course, and questioned which character traits are beneficial or hindering for the therapeutic progress. In 150 traumatized patients we assessed character traits (SWAP-200, SCID I+II), traumata (IKPTBS),

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biographical data (Childhood Trauma Questionnaire) four times during the course of one year inpatient treatment. Variables and character traits displaying resilient and beneficial factors due to the treatment progress were contrasted to hindering factors. Concerning impairment of treatment progress traits being summarized as traits belonging to Cluster B personality disorders could be found. Results pointed at the importance of evaluation of such mediators for the therapeutic team and for treatment outcome in long-term inpatient psychotherapeutic treatments and gave support for prior results found in outpatient treatments. Forth, the impact of investigation of those moderators (affect experience, character traits, defence mechanisms), which mainly concentrate on the topic of good enough understanding of mechanisms of projective identification (see also Löffler-Stastka et al., 2008), were investigated in a sample of psychiatric patients (Grassl & Löffler-Stastka, 2006). Methodological questions concerning the topic, if there will ever be empirical data about Projective Identification, and a critical discussion of Melanie Klein’s’ concept, was focus of a trial of microprocess evaluation of psychiatric inpatient treatment. With respect to the complex interaction between patient and therapist, when involved in projective mechanisms, this study aimed at approximation to clinical reality and utility of the phenomenon of projective identification. A self-rating “Countertransference Questionnaire” (Zittel & Westen, 2005) for psychotherapists and the “PRQ-Psychotherapy Relationship Questionnaire” were used to create an observable and descriptive profile of patient-therapist relationship in an explorative interview. Discussion was focussed on methodological questions and the impact of microprocess investigation on evaluation of treatment interventions in daily routine practice and psychodynamic treatments of severely disturbed psychiatric patients (Grassl & Löffler-Stastka, 2006). As these results and investigations are the outcome of one research team further discussion is needed taking up comparative studies with the focus on what we can learn from microprocess-evaluation of psychoanalytic treatments for clinical daily psychiatric routine practice concerning the treatment of severely disturbed psychiatric patients. Therefore the background of recent psychiatric, psychotherapeutic and empirical psychoanalytic research had to be lightened.

TREATMENT OF PERSONALITY DISORDERS AND ITS RELEVANCE FOR THE PUBLIC HEALTH SERVICE As mentioned above one task and focus of the Department of Psychoanalysis and Psychotherapy of the Medical University of Vienna is the psychoanalytic treatment of outpatients with severe personality disorders, e.g. Borderline PD, Narcissistic PD, Schizoid PD, hypochondriac and psychosomatic disorders, perversions, etc. From a psychiatric view, patients with PDs suffer from dominating and enduring character-traits, which impair their ability of adequate perception of self and others, reflective thinking/functioning is impaired as well as the effortful control concerning impulse- and affect regulation are impaired, which altogether lead to dysfunctional interpersonal relationships and problems where social functioning is concerned. In practice, outpatient treatment of personality disorders has the character of a preventive task and therefore social value due to the following considerations: Nationwide, in the public

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population PDs show prevalence rates of 10-13.5 %. Patients with PDs utilize the psychiatric public health service to the same extent as patients with schizophrenia or bipolar disorders do (Pilkonis et al., 1999), whereas for the latter the severity of illness is much more commonly known and accepted. Taking for example patients with a Borderline Personality Disorder diagnosis according to DSM-IV, these patients are estimated to represent 20% of the inpatient psychiatric clientele, the diagnosis being made predominantly in women (approx. 75%). It is precisely this diagnosis of Borderline Personality Disorder which has in the meantime been referred to as a psychiatric “virus“ and partially incurs stigma. Although attempts have been made to attain a greater understanding of it through studies on comorbidity or risk factors, borderline patients repeatedly trigger the most violent team conflicts or complex countertransference in everyday clinic situations. Patients with Personality disorders often display long treatment careers, including treatment attempts which failed, long inpatient treatments and/or show high rehospitalization rates. Pre-treatment prior to the start of an outpatient psychoanalytic treatment often consists of psychopharmacological and psychosocial treatment attempts, whereas within the psychopharmacological treatment often a polypragmatic approach is used, which often might display the difficulties in handling and managing the patients. Not to forget the high frequency of consultation of emergency units or detoxification units after for instance suicide attempts. For an overview, Linehan & Heard (1999) reported en detail about the financial costs, which are caused for example by Borderline PDs in the public health service. Besides the financial cost factor , „emotional costs“ – the emotional involvement has to be taken into account, in that families/partners or friends of patients suffering from PDs get entangled through dysfunctional behaviour, acting out, dysfunctional object relation styles, etc. of the patients. In the literature it is discussed controversially, how to provide optimal help for patients with PDs in the public health system. Consistency is arrived, that psychological steps and interventions can reduce the financial costs, and that psychotherapeutic treatment should be investigated in more detailed naturalistic studies esp. concerning their long term efficacy.

PSYCHOANALYTIC PSYCHOTHERAPY Most of the therapeutic interest in the field of psychoanalytic psychotherapy and psychoanalytic treatment has been put on patients with borderline personality disorder (BPD) (Higgitt and Fonagy, 1992), which differs from almost all other types of PDs in frequent helpseeking behaviour and wish to change. This makes it more amenable to interventions. However, with a few notable exceptions, the literature is dominated either by descriptive papers or cohort studies. One of the first and most detailed naturalistic cohort studies of out-patient treatment for PD was the Menninger project (Wallerstein, 1986). The study began in 1954 as a prospective study and spanned a 25-year period looking at assessment, treatment, and outcome in patients referred to the Menninger Clinic. Forty-two patients were selected for intensive study. Many would now be classified as borderline and were referred because of failure of standard psychiatric treatment. Patients, their families, and their therapists were subjected to a battery of tests, and process notes and supervisory records were kept, charting the course of therapy. Not surprisingly, the mass of data has led to some disagreement about interpretation (see

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Kernberg, 1972; Wallerstein, 1986). Nevertheless, the data have been used to compare classical psychoanalysis with psychoanalytic psychotherapy in the treatment of BPD. Wallerstein classified 22 cases as having received psychoanalysis, 20 as in psychotherapy, but there was a clear spectrum from classical psychoanalysis, modified psychoanalysis, expressive-supportive psychotherapy, supportive-expressive psychotherapy to supportive psychotherapy. Full follow-up data were available for 27 patients. Good outcomes were obtained in 11 and a partial improvement in seven. Outcomes were generally better for patients with greater ego-strength. An important finding was the absence of a difference between psychoanalysis and supportive psychotherapy with this group of patients. Forty-six percent of psychoanalytic cases and 54% of psychotherapy cases did well, with good or moderately good outcomes. Improvements brought about by supportive therapy were just as stable, as enduring, as proof against subsequent environmental vicissitudes, and as free (or not free) from the requirement for supplemental post-treatment contact, support, or further therapeutic help as the changes in those patients treated via psychoanalysis. Nevertheless, there was a trend for patients with relatively good ego-strength and interpersonal relationships to do better with psychoanalytic or expressive therapy whilst those with low ego-strength responded best to supportive psychotherapy. An important aim of the study was to elucidate the controversy about the 'widening scope' of psychoanalysis (Stone, 1993) - the use of psychoanalytic techniques to treat much more severely disturbed patients than had previously been thought possible. Kernberg's (1972) contribution to the Menninger project suggested that a modified analytic approach including for example early interpretation of negative transference, and a focus on here-andnow interactions rather than reconstructions, enabled severe patients to be successfully treated. Wallerstein looked in detail at this group of 'heroic indication' patients and identified 11 such patients with paranoid features, major alcohol or drug addiction, or borderline pathology. It is important not to underestimate the importance of this study in the development of treatment of PD since other studies of treatment and long-term follow-up seemed to confirm the results that some patients did well whilst others did badly (McGlashan, 1986). Stevenson and Meares (1992) and Meares et al. (1999) were amongst the first to report on a different approach in which 48 borderline patients were treated with twice-weekly psychoanalytic psychotherapy that focused on a psychology of the self. Significant improvements were observed in the 30 patients who completed the therapy. Subjects made considerable gains compared to wait list controls in number of episodes of self-harm and violence, time away from work, number and length of hospital admissions, frequency of use of drugs, and self-report index of symptoms. Thirty percent of patients no longer fulfilled the criteria of BPD at the end of treatment. Improvement was maintained over 1 year. Further follow-up at 5 years has confirmed the enduring effect of treatment and demonstrated a substantial saving associated with health care costs (Stevenson and Meares, 1999). The therapy concentrated on the development of a therapeutic alliance. This factor may account for the low drop-out rate of 16% since other out-patient naturalistic studies of psychodynamic therapy, both prospective and retrospective, have shown high drop-out rates of 23-67%, particularly early in treatment (Skodol et al. 1983; Gunderson et al. 1989). Smith and colleagues (1995) have analyzed factors associated with such attrition, finding that younger patients and those with high initial hostility were most likely to withdraw, and the same group

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showed that the therapist's investment in the initial treatment contract and maintenance of an alliance were important factors in continuation of treatment. Other naturalistic studies have indicated the utility of psychoanalytically-based treatments for PD. Hoglend (1993) studied the outcome of manualized psychodynamic focal therapy which lasted an average of 27.5 sessions and Monsen et al. (1995) used a form of psychodynamic therapy that focused on object relations and self-psychology in a treatment that lasted for an average of 25 months. Both studies showed promising results for patients with Cluster B PD when applied to an out-patient population. Tucker et al. (1987) and Antikainen and colleagues (1995) studied treatment of severe borderline personality organization for an average of 8.4 months and 3 months respectively, again finding positive results, but none of these trials concentrated on specific factors, such as treatment mediating variables or trajectories for positive/negative treatment outcome, and so the possibility remains that the benefits are the result of time or other factors. The only randomized evaluation of psychoanalytic psychotherapy before our trial showed no difference between short-term dynamic psychotherapy and brief adaptational psychotherapy but both were superior to a waiting-list control (Winston et al., 1991). This study specifically excluded patients with borderline and narcissistic features although a later study including some Cluster B disorders produced similar results (Winston et al., 1994). Therefore we would argue that comparing treatments doesn’t lead to any significant contribution to this field of research, unless there are no investigations conducted, which concentrate on certain specific treatment-outcome mediating and treatment-outcome moderating variables. Studies of Transference-Focused Psychotherapy (TFP) are now becoming available and give promising results although the outcome of a randomized controlled trial comparing TFP, DBT, and supportive psychotherapy is not yet known. TFP relies on the techniques of clarification, confrontation, and transference interpretation within the evolving relationship between patient and therapist. The primary focus is on the dominant affect-laden themes that emerge in the therapeutic relationship in the here-and-now of the transference. At the beginning of treatment, a hierarchy of issues is established: the containment of suicidal and self-destructive behaviours, the various ways of destroying the treatment, and the identification and recapitulation of dominant object relational patterns as they are experienced and expressed in the here-and-now of the transference relationship. In a cohort study (Clarkin et al., 2001a) 23 female borderline patients were assessed at baseline and at the end of 12 months of treatment with diagnostic instruments, measures of suicidality, self-injurious behaviour, and measures of psychiatric and medical service utilization. Compared with the year prior to treatment, the number of patients who made suicide attempts significantly decreased, as did the medical risk and severity of medical condition following self-injurious behaviour. In addition, patients during the treatment year had significantly fewer hospitalizations as well as number and days of psychiatric hospitalization compared with the year before. The drop-out rate was 19%. When patients were compared with an untreated sample, significant differences on the same measures were reported in favour of the treated group. Other studies of dynamic therapy have used control groups and some have reported on day-hospital treatment. Karterud el al. (1992) studied prospectively 97 patients treated in a psychodynamically orientated day-hospital of whom 76% had an axis II DSM-III-R diagnosis. After a mean treatment time of 6 months, outcome on measures of global

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symptoms and overall mental health was best for anxious-avoidant PD with only modest gains for BPD. Dick and Woof (1986), using a similar programme, found that after 12 weeks of treatment a small sub-group of patients diagnosed retrospectively as BPD increased their use of services possibly indicating that longer-term treatment was necessary for this group. A feminist, psychodynamically-informed programme with a socio-political dimension was effective in reducing symptoms and health service usage in 31 personality disordered patients treated in day and semi-residential facilities. Gains were sustained over a 2-year follow-up (Krawitz, 1997). Use of a socio-political dimension may be highly pertinent given the breadth of social adaptational difficulties of most patients. In a prospective study using a design of treatment-versus-control (delayed treatment), Piper et al. (1993) found significant treatment effects of 18 weeks day-hospital treatment for 79 patients with both affective disorder and longstanding PD. Interpersonal functioning, symptoms, self-esteem, life satisfaction, and defensive functioning all improved after 4 months treatment when compared with the control group and gains were maintained at 8month follow-up. Our initial task in setting up the study (Löffler-Stastka et al., 2006a, 2008) was to review the literature, to consider the evidence for effective interventions. From the evidence discussed above we concluded that treatments shown to be effective with PD had certain common features. They tended (a) to be well-structured, (b) to devote considerable effort to the enhancing of compliance, (c) to be clearly focused, whether that focus was a problem behaviour such as self-harm or an aspect of interpersonal relationship patterns, (d) to be theoretically highly coherent to both therapist and patient, sometimes deliberately omitting information incompatible with the theory, (e) to be relatively long term, (f) to encourage a powerful attachment relationship between therapist and patient, enabling the therapist to adopt a relatively active rather than a passive stance, and (g) to be well-integrated with other services available to the patient. The study was designed so that it can be dismantled at a later date to determine the therapeutic components and to identify any effective ingredients. At present the former study has given results, which parameters are important for therapy utilization, but include elements that we consider to be the effective components of the psychoanalytic treatment. While some of these features may be those of a successful research study rather than those of a successful therapy, we concluded that these variables resulting of the therapy utilization study are probably as important in the success of treatment as the theoretically-driven interventions. With these general features in mind, we set about developing a study to test the effectiveness of the interventions. From the outset it is clear that this is to be 'effectiveness research' rather than 'efficacy' research. Concerning therapy research and outcome, treatment of personality disorder (PD) continues to be governed by clinical opinion rather than being based on evidence. Although psychotherapy has long since considered PD as its domain and attempted to help individuals modify socially and personally-damaging behaviours (Bateman & Holmes, 1995), this clinical zeal has not been matched by enthusiasm for research. It was our concern about the gap between passion for psychoanalytic therapy as a treatment for PD on the one hand and absence of 'hard data' on the other that stimulated us to design a psychoanalytically-oriented treatment based on 'best clinical evidence' and to subject it to scientific scrutiny. If we assume that PD is akin to other mental disorders that have a longtime course then scientific requirements include: studying robustly-defined populations, carefully defining treatment and assessing its specificity, ensuring treatment is superior to no

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treatment since personality disorders show gradual improvement over time (McGlashan, 1986; Paris et al., 1987; Stone, 1993), demonstrating that treatment impacts on personality rather than merely causing a change in mood, incorporating an adequate follow-up, and addressing cost-effectiveness relative to other alternative interventions. In brief, studies should show that personality change is both measurable and clinically meaningful. Research into PD singularly fails to meet these requirements. Despite these problems, a number of reviews of treatment of PD have been published, all of which conclude that further studies are necessary to examine specific forms of psychotherapy for specific types of PDs (Perry, 1999; Bateman and Fonagy, 2000). In a recent meta-analysis (Leichsenring and Leibing, 2003) psychodynamic therapy yielded a large overall effect size of 1.46 with effect sizes of 1.08 for self-report measures and 1.79 for observer-rated measures. In addition, the effect sizes for psychodynamic therapy indicated long-term rather than short-term change in PD. Meanwhile investigations concentrating on treatment outcome showed variables and traits functioning as mediators and trajectories for positive therapeutic results (e.g., Piper et al., 2003; Hull et al., 1993). Affect experience and affect regulation is hypothized to have predictive power concerning treatment outcome, as e.g. Clarkin (2006) mentioned the predominance of positive over negative affect experience to be predictive concerning a positive treatment outcome. Treatment literature, especially literature concerning treatment interventions and psychoanalytic technique (Clarkin et al., 2001b; Limentani, 1977) suggest addressing the dominating affect in order to gain positive therapeutic results. Skodol & Perry (1993) suggested to include a Defense Mechanisms Axis in DSM-IV and showed the clinical relevance of rating defense mechanisms. Thus, in most of the efficacy studies diagnostic criteria are based on DSM-IV, phenomenological description or structured interviews, which provide for example description of treatment/outcome mediating variables, such as affect parameters (Piper et al., 2003) in a rather vague way. As already stated in part1 of this book chapter, currently used classifications (e.g., DSM-IV-TR) say little about the patient’s characteristic way of dealing with his or her feelings, how he or she typically experiences feelings or regulates affective states under specific circumstances or in social situations, relationships and interpersonal functioning. But, to concentrate on affect parameters provides also compatibility to the DSM system, as the DSM-IV-TR describes disturbance of affectivity to be one of the central problems and a general criterion for a Personality Disorder. DSM-IV-TR also states that the essential diagnostic feature of a PD is an enduring pattern of inner experience and behaviour that is manifested in affectivity and interpersonal functioning, that is inflexible and pervasive in a broad range of personal and social situations and leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning (American Psychiatric Association, 1994). Therefore definition of personality pathology should refer to classification of affectivity/affect regulation under particular circumstances (e.g., in interpersonal relationships) and thus include investigation of the quality of object relations. The enduring quality of object relations is manifested in the interpersonal situation (Horner, 1984). The investigation of object relation styles gives a benefit to understand the problems that patients with personality disorders have in intimate relationships, is of broad use to clinicians and inspires effective modes of intervention (e.g., Clarkin, et al., 2001b). Investigations of the quality of object relations are also stated to have predictive power concerning therapy outcome (Piper et al., 1991). Shedler and Westen developed an instrument, which provides a diagnostic procedure,

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which includes parameters such as affect experience. Besides, mechanisms of the patient’s relating to other people can be described with the Shedler-Westen-Assessment Procedure (SWAP-200). As we could show the SWAP-200 provides the possibility for evaluating psychostructural functioning (Löffler-Stastka et al., 2007) because of the inclusion of affect parameters and object relation styles. Besides, it is comparable to the DSM concerning the trait variables and item listing. Now it should be tested, if the inclusion of affect and object relating parameters into the coding of personality disorders has predictive value for treatment outcome, which had been done for psychoanalysis proper and psychoanalytic psychotherapy (Löffler-Stastka et al., 2008).

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THE STUDY OF THE PSYCHOANALYTIC PROCESS It is well established that psychoanalysis provides knowledge to understand the development maintenance of personality disorders. The clinical experience suggests that not only affect but strategies of affect regulation may be implicated in the initiation and/or maintenance of personality disorders. Researchers have increasingly begun to emphasize the role of affect regulation in personality, development, and psychopathology. Affect regulation refers to cognitive and behavioral strategies people use to maximize pleasant, and minimize unpleasant emotions. These strategies may be explicit (coping mechanisms) or implicit (defenses). It is proposed that feelings are mechanisms for the selection and retention of behavioral and mental responses. To the extent that particular behaviors, coping strategies, or defensive strategies become associated with regulation of aversive affective states and maximization of pleasurable ones, they will be encoded as "solutions" to affective problems. In this view, affect regulation strategies are a form of procedural knowledge and are activated under specific circumstances, such as the presence of particular affects. Affect regulation strategies can be adaptive or maladaptive. Some regulation strategies are affect-specific, whereas others can be used to regulate multiple affects of similar valence. These procedures are often activated to resolve discrepancies between perceived and desired states of self, significant others, and external circumstances. Emotions and other sensory feeling states are evolved mechanisms for channelling behavior in directions that foster adaptation. The avoidance of unpleasant states and pursuit of pleasant ones leads to goaldirected mental and behavioral processes, including defenses and compromise formations. Affects provide a flexible motivational mechanism in humans, as they become associated with representations of perceived, feared, wished-for, or otherwise valued states through the interaction of environmental events and highly specific naturally-selected biological proclivities. This reconceptualization of motivation points towards a resolution of a contradiction in Freud’s models of affect and motivation between a theory of drive-reduction and a theory of affect regulation, and of the apparent contradiction between motivational models that emphasize either sexual desire or relational needs. The model also has implications for the theory of transference, since it suggests that the analytic situation evokes meaningful transferential processes. Current theories suggesting that for example Personality disorder symptoms are maladaptive attempts at affect regulation. Given that cognitive and behavioral mechanisms that are successful in regulating affect will be used again, personalitydisordered behaviors that are even temporarily successful in alleviating negative mood states

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are likely to be activated under similar circumstances. The investigation of affect regulation refers to the detection of coping styles. Vollrath et al. (1995) showed that dispositional coping styles prospectively influence change in personality disorders. Therefore it might have an impact concerning psychotherapeutic interventions. Observing affect parameters should not be left alone, as affects are activated under specific circumstances, i.e. in (transference-) object-relationship. The concept of object relations has played an increasingly important role in psychoanalytic and psychodynamic theorizing, as well as in clinical psychoanalysis and psychotherapy. A short summary of a few pertinent issues will provide a context for describing what is investigated: Ogden’s (1983) description of the theory approaches our concept of the theoretical underpinnings of the investigation we plan to do. He traced the contributions of Freud, Abraham, Melanie Klein, Fairbairn, Winnicott, and Bion to the conceptualization of internal object relations. The original model of all internal objects is Freud’s model of the normal development of the superego through the process of identification, as the ego assimilates aspects of the personality and functions of external objects. This newly established psychic agency acquires its own set of motivations and actions, including object relatedness. Ogden also drew on Freud’s extension of the role of splitting of the ego, beyond the formation of the superego, in the development of internal objects. For Ogden, another core concept is Fairbairn’s assertion that it are aspects of the relationship with the object, rather than aspects of the object, that become internalized. In addition, Ogden incorporated into his thesis Bion’s description of the potential for the defensive splitting of the mind into active suborganizations capable of engaging in specific forms of object relatedness. Ogden’s elaboration of these concepts indicates that splitting of the ego into new subdivisions is necessary for early interpersonal relationships to be internalized. Each suborganization – being a component of the ego - has a dynamic capacity to semiautonomously generate experience and leave its stamp on the quality of object relations. This psychoanalytically informed view of object relations stipulates that they are the product of intrapsychic suborganizations of the ego and not of external interpersonal relationships. However, the quality of object relations is manifested in the interpersonal situation (Horner, 1984). Despite the enduring quality of object relations, these intrapsychic structures are modifiable by experience during healthy development. By contrast, during pathological development these intrapsychic configurations become rigidified and fixated, a condition reflected in some aspects of feeling, thinking, and behaving. It is suggested that secure attachment is the basis of the acquisition of metacognitive or mentalizing capacity. Horner (1984) cited that the concepts of internalization and of object relations are fundamental to the developmental psychology of psychoanalysis, especially in terms of technique. The investigation of object relation styles gives a benefit to understand the problems that patients with personality disorders have in intimate relationships and to inspire effective modes of intervention. Furthermore it can also be of broad use to clinicians in understanding the psychotherapeutic process. Piper W, et al. (1991) stated that quality of object relations was the best predictor for therapy outcome and furthermore discussed the advantages of pretherapy predictors of therapy outcome, such as the assessment of quality of object relations. Nevertheless, in current international treatment and outcome studies it remains unclear, which specific ingredients of the therapeutic process are leading to prospering treatments or impair the optimal treatment process. Especially concerning the therapeutic technique, detailed empirical data is lacking (see e.g. Leuzinger-Bohleber, 2001), or results are reported

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Henriette Löffler-Stastka, Elisabeth Ponocny-Seliger, Margit Szerencsics et al.

in too general ways, as already stated above (e.g. the Menninger Research Project). One aspect, which is discussed with much emphasis, is the hypothesis, that understanding of affective themes, which are difficult to bear or stand, is the most important vehicle for change. Additionally, it is discussed, if and to what extent the interplay between patient and analyst is mediating the course of therapy towards an effective and successful treatment. Further, it is to specify, which and to what extent affective themes have be worked through in order to gain satisfying progress in therapy. To come to this point of qualitative data analysis, a precise investigation has to be conducted, also because multivariate statistical procedures only show global trends (see also, e.g. Bachrach, 1997). An exactly documented report about the course of treatment gives the opportunity to test theoretically grounded assumptions. The best form of evaluation is the qualitative analysis of the psychoanalytic process in form of a naturalistic study design, as e.g. recommended by Perry et al. (1999) in a meta-analytic study on fifteen psychotherapy outcome studies with patients with personality disorders. On the basic of observation of psychoanalytic treatments we detected ingredients, which are effective concerning successful treatment outcome. J. Kantrowitz (1997) describes in some studies, that the central element for successful analytical work is the transference-countertransference-process, not only the personal traits of the patient and the personal traits of the analyst, but the specific interplay between the both. Investigations of patient-therapist-dyads lead to the assumption, that in the course of time the influence of the patient’s and therapist’s similarities or differences has more impact on therapy outcome, than certain specific traits or diagnostic features of the patients. The dynamic aspect of the patient-therapist interaction, the resonance or dissonance and the therapist’s ability to come across with “blind spots”, are estimated to be essential for therapy outcome. Therefore Kantrowitz suggested investigating the “Two-person process” to widen the understanding of outcome mediating variables, such as affect parameters or transference/object relationship patterns. The Anna Freud Centre Study 4 (AFC4) (Fonagy et al., in preparation) compared psychoanalytic treatment with different frequencies (5 times a week vs. One time a week) of juvenile patients with borderline and narcissistic personality disorders and came to the result, that transference-processes of successful treatments were characterized by dominance of anxiety/guilt feelings of being rejected, idealization and projected aggression, while failed treatments were dominated by shame, humiliation, existential anxieties and the feeling of being „left out“ or feelings of boredom on the analyst’s side. Recently conducted investigations with therapy utilizers vs. non-utilizers led to a profile of traits and variables, which were predictive for therapy utilization (see Löffler-Stastka et al., 2005, 2006b). In the next step it was now to evaluate, if these variables are important in order to predict therapy outcome and develop a list of “do’s and don’ts” concerning the psychoanalytic technique, what to focus on and to which extent (see Löffler-Stastka et al., 2008). The further question should now be stressed, if the variables, as affect parameter, defence mechanisms, quality of object relation and patient-therapist-relationship, are valid predictors for treatment response, the course of treatment and treatment outcome in psychiatric and psychosomatic inpatients.

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STUDY A (MATTHIAS BARTENSTEIN AND HENRIETTE LÖFFLER-STASTKA)  This study investigated the outcome of psychiatric routine treatment and changes in affect experience, affect regulation, and quality of object relations, as well as their correlations to the patient-therapist-relationship and to the therapist’s countertransference. At the beginning and at the end of an on average 19 days lasting psychiatric inpatient treatment affect parameter and object relation styles were assessed with expert-rating and self-rating measurements. The aim was to test, if those outcome-mediating variables found in psychoanalytic treatments also predict change in psychiatric inpatients, and in what way or to which extent psychoanalytic theory and technique is applicable for the treatment of severely disturbed psychiatric patients in an acute admission ward.

MATERIAL AND METHODS

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Description of the Sample In total 11 inpatients, 5 men (45%) and 6 (55%) women, from a psychiatric department of the Viennese Otto Wagner hospital agreed to participate in the study. Age ranged from 20 to 51 years, the mean age was 36 years with a standard deviation of 10.5. Concerning employment and education, 72% of the patients had a job, 9% were students, 9% were unemployed, and 9 % were homemakers. Nine% had dropped out of school, 27% had finished compulsory school, 26% had finished an apprenticeship, 18 % had a general qualification for university entrance, and 9% had a PhD. DSM-IV-TR diagnoses, evaluated by the treating clinicians produced the following results, and displayed a broad spectrum of diagnoses and a typical clientele and of a psychiatric ward for acute admission and crisis intervention: On Axis I 64% of the patients received a diagnosis of a depressive episode, 27% chronic alcoholism, 9% bipolar affective disorder II, current episode mild or moderate depression, 9% adjustment disorder, 9% acute polymorph-psychotic disorder with symptoms of schizophrenia, 9% dementia in Alzheimer’s disease, atypical or mixed type, and 9% an Eating disorder, unspecified. Diagnoses on axis II were in 9% a dissocial personality disorder and in 9% a borderline personality disorder.

DESCRIPTION OF THE TREATMENT Patients stayed at the hospital for a mean time of 19 days (minimum 13d, maximum 39d, SD 8d). During their hospitalisation, participants attended a standard treatment program consisting of daily morning group-therapy, occupational therapy 5x/week, physical therapy 4x/week, group psychotherapy 2x/week, and music therapy 1x/week. Supportive conversational therapies were prescribed irregularly, crisis intervention given on demand. All interventions were conducted by specialists for psychiatry and psychotherapy, the consultants of the psychiatric department, as well as psychologists and psychotherapists. These experts

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had clinical experience in conducting social-psychiatric and psychotherapeutic treatment, as well as in prescribing medication for 15 years on average. Patients also received psychopharmacological treatment, 91% received antidepressive drugs, 91% tranquilizers and 36% received antipsychotic drugs additionally.

ASSESSMENT PROCEDURE After obtaining informed consent, patients were asked to fill out a copy of the SCL90-R and IIP self-rating instruments. After completing the questionnaires they had an interview with an independent rater (M. B.) who investigated assessed the patients using the SWAP-200 and AREQ Q-sort tests and the QORS. The same procedure was repeated at the end of treatment. Psychotherapy Relationship Questionnaires were filled out by the same rater observing patient-therapist interactions at admission interviews, conversational therapy and daily morning group. Countertransference Questionnaires were filled out by the therapists.

MEASUREMENTS

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Symptom-check-list SCL-90-R (Derogatis et al., 1974): Symptoms and subjective illness-constraint was measured with the Symptom-check-list SCL-90-R (German version: Franke 1995), which provides a psychopathological symptom description via 90 items and ends up with nine syndrome-scales (ranging from somatization to psychoticism). IIP-D/IIP-C: Inventory of interpersonal problems (Horowitz et al., 1994), detailed description is presented in part 1. Affect Regulation and Experience Q-sort (AREQ) (Westen et al., 1997) and the Quality of Object Relations Scale (QORS) (Azim et al., 1991), both instruments also have been described in part 1 of this book chapter.

The Psychotherapy Relationship Questionnaire (PRQ; Bradley et al., 2005) The PRQ is a 90-item clinician-report questionnaire designed to provide a normed, psychometrically valid instrument for assessing transference relationship patterns in psychotherapy. It provides five dimensions to describe these patterns: angry/entitled, anxious/ preoccupied, secure/engaged, avoidant/ counterdependent and sexualized. Factors were obtained by scree plot, percentage of variance accounted for (45% for 5 factors) and parallel analysis. To create factor-based (unit weighted) scores, items loading 0.50 or more for factor 1 and 0.40 or more for factors 2–5 were included to maximize reliability. Intercorrelations among the five factors ranged from 70.12 to 0.54, with a median of 0.14. To demonstrate the connection between transference, as measured with the PRQ, and personality pathology, Bradley et al. correlated each of the 5 factors with the three clusters of DSM-IV Axis II disorders (A odd/eccentric, B dramatic/erratic and C anxious/fearful) in a sample of 181

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patients (15.5% met criteria for a cluster A disorder, 28.2% for cluster B and 38.7% for cluster C). Partial correlation yielded a strong association of cluster B disorders with the angry/entitled (r = .49) and sexualized (r = .41) factors and cluster C disorders with anxious/preoccupied (r = .51) transference patterns (p < .001) (Bradley et al, 2005). The secure/engaged dimension is of particular interest. Westen et al. argue that this factor not only describes an attachment style but is also an indicator for the quality of the “working alliance”, which strongly predicts treatment outcome in psychotherapy (Horvath & Symonds, 1991).

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The Countertransference Questionnaire (Zittel and Westen, 2005) The CTQ is a 79-item clinician-report questionnaire designed to provide a normed, psychometrically valid instrument for assessing countertransference patterns in psychotherapy. Scree plot, percentage of variance accounted for, and parallel analysis were used to select the number of factors to rotate. To create factor based scores for use in this and subsequent studies, items loading ≥ .50 for factors 1 and 2, ≥ .40 for factor 3, and ≥ .375 for factors 4–8 were included to maximize reliability (coefficient alpha). Intercorrelations among the eight factors ranged from –.16 to .58, with a median of .30. An 8-factor model was subsequently chosen, accounting for 69% of variance, the factors being as follows: 1) overwhelmed/disorganized, 2) helpless/inadequate, 3) positive, 4) special/overinvolved, 5) sexualized, 6) disengaged, 7) parental/protective, and 8) criticized/mistreated. To illustrate the close association of countertransference reactions to personality pathology, Bentan et al. correlated the 8 factors of the CTQ with the three clusters of DSM-IV Axis II disorders (A odd/eccentric, B dramatic/erratic and C anxious/fearful) in a sample of 181 patients. Partial correlation showed: cluster A (odd/ eccentric) disorders to have a significant association with the criticized/mistreated factor (partial r = .17, p < .05); cluster B (dramatic/erratic) disorders to be associated with the overwhelmed/ disorganized (partial r = .43, p < .001), helpless/inadequate (partial r = .16, p < .05), disengaged (partial r = .24, p < .001), and sexualized factors (partial r = .24, p < .001), as well as having a negative correlation with positive countertransference (partial r = -.22, p < .01); cluster C (anxious) disorders to be associated with the parental/protective factor (partial r = .24, p < .001). In a second analysis, borderline personality disorder displayed association with the special/overinvolved factor partial r = .23, df = 170, p = .002). Narcissistic personality disorder, on the other hand, significantly correlates with the disengaged factor (partial r = .30, df = 170, p < .001), in contrast to other cluster B disorders (Betan 2005).

STATISTICS Pre-post comparisons were done by means of paired sample t-tests and Pearson correlations were used to inter-relate the pre-post difference score with the CTQ- and PRQscores. All data were analyzed using SPSS 15.0 at a level of significance of 5%; p-values 20%): borderline personality disorder, anxiety, dysthymia, alcohol dependence and major depression. The majority of the subjects (n = 520, mean age 36.72, SD = 12.16; 253 males and 267 females) were clinical patients: 420 inpatients and 100 outpatients. Sixty-nine percent of the patients were seen in a therapeutic and diagnostic context and 31 % purely diagnostically. Contact hours (during clinical or counseling sessions) varied from 4 to 160 hours (mean = 11.29). The remainder of the subjects (n = 107, mean age 37.94, SD = 10.23; 84 males, 23 females) came from forensic settings. All were assessed post-trial. They were mainly evaluated in a diagnostic context (58.9%) and 41.1% were seen diagnostically and therapeutically. Contact hours between the clinician and the subject varied between 4 and 208 hours (mean = 11.73). The current sample (n = 627) is not independent from and includes the subjects used in the Belgian BR sample (n = 524; Rossi, 2004; Rossi & Sloore, 2005).

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Gina Rossi and Hedwig Sloore

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Instruments The MCMI-III was translated into Dutch (Sloore & Derksen, 1997; Sloore et al., 1994). Detailed information on the Belgian BR sample can be found in Rossi and Sloore (2005). Rossi, Van den Brande, Tobac, Sloore, and Hauben (2003) investigated the validity of the MCMI-III personality disorder scales using a Belgian sample. Correlations of MCMI-III-D scales with the MMPI-2 clinical scales reflected logical and expected relationships, supporting the content validity. With the exception of the compulsive scale, all personality disorder scales revealed good concurrent validity. Rossi, Van der Ark and Sloore (2007) demonstrated that the factor structure of the MCMI-III is cross-culturally invariant. The four identified factors (General Maladjustment, Aggression/Social Deviance, Paranoid/Delusional Thinking, and Emotional Instability/Detachment) were also invariant across scale composition (linear dependent vs. independent scales), factor analytic method (principal factor vs. principal component solutions), and sample characteristics (gender ‘male/female’ and setting ‘clinical/forensic’). Moreover, the range of Cronbach alpha values of the MCMIIII-D (.67-.94) was comparable to the range of values of the original American MCMI-III (.66-.95). The diagnostic decision taking of the clinicians was standardized by using a rigorous and systematic rating system. For both Axis I and Axis II disorders, descriptions were provided in a booklet. These descriptions included the Diagnostic and Statistical Manual of mental disorders criteria (DSM-IV & DSM-IV-TR; American Psychiatric Association [APA], 1994, 2000), scale descriptions from the MCMI-III manuals (Millon, 1994; Millon et al., 1997; Millon et al., 2006), and prototypal personality descriptions as defined by Millon on basis of his theory (Millon & Davis, 1996). In a first part of the rating system the clinicians rated the presence of personality disorders. Clinicians first evaluated the general DSM-IV (APA, 1994; p.633) diagnostic criteria for a personality disorder. If these general criteria were met, the degree to which a particular individual matched a prototypal description of the specific DSMIV personality disorders was evaluated. This system closely adheres to other recent clinical approaches that try to quantify personality pathology by a score that indicates the degree to which the symptoms for each personality disorder are present (Trull & Durett, 2005)1. In the revised MCMI-III manual, the DSM/MCMI correspondence is explained and prototypal descriptions are provided, based on functional and structural domains of personality: expressive acts, interpersonal conduct, cognitive style, self-image, object representations, regulatory mechanisms, morphologic organization and mood/temperament (cf. Millon et al.; 1997, pp.27-28). In the rating system, the clinician evaluated the degree to which an individual matched the prototypal description on a scale from 1 to 9 (1 = trait, 3 = style, 5 = disorder, 7 = marked disorder, 9 = extreme disorder). The scale anchor points were clearly defined. A rating ≥ 5 for example indicates a DSM-IV diagnosis (APA, 1994, 2000), because the ‘disorder’ level (rating 5) requires that the personality pattern is sufficiently problematic to justify a clinical diagnosis and that DSM-IV criteria are fulfilled. In the same way, the presence of clinical symptoms was evaluated in the second part of the clinical ratings. The degree to which the clinical symptom was present was evaluated on a scale from 1 to 9 (1 = slight, 3 = mild, 5 = syndrome, 7 = marked syndrome, 9 = extreme syndrome). A rating ≥ 5 1

Some well-known examples are Oldham and Skodol’s (2000) prototype matching approach and Westen and Shedler’s (2000) assessment procedure model.

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implies that the symptoms are sufficiently problematic to justify a clinical diagnosis. Descriptions for the different anchor points are provided in the MCMI-III revised manual (Millon et al., 1997, p. 90-91). These descriptions were integrated in the rating booklet for clinicians. Several precautions were taken to guarantee reliable diagnoses and avoid some methodological problems encountered with the American validation studies. All clinicians were experienced in making clinical evaluations (i.e. all licensed psychologists with at least two years of diagnostic experience). In order to be allowed to make a DSM-IV diagnosis (APA, 1994, 2000), several inclusion criteria had to be fulfilled: the clinician had to have seen the patient for at least 4 (therapeutic or counseling) contact hours (test-taking not included); diagnosing was preferably done at the end of the diagnostic process, so that a complete understanding of the patient’s personality was possible; clinicians made diagnostic ratings before the MCMI-III-D was being completed by the patient; MCMI-III-D test results were only scored and returned to clinicians after diagnostic decisions had been taken and rating forms were completed; and a ‘Longitudinal Expert evaluation that uses All Data (LEAD)’ was applied (Spitzer, 1983). The calculation of inter-rater reliability for the total sample was not feasible under the research design. Under ideal conditions (i.e., two experienced clinicians that had enough clinical contact with the patient, that have all data necessary to make an expert evaluation, that have time to complete the clinical evaluation as described in the MCMI-III revised manual and worked out in our standardized rating system) there would be no methodological limitations. However, in real world conditions mostly only one single clinician has access to and the possibility of gaining enough data to make such rigorous clinical evaluations. Therefore a small pilot study was carried out on a sub-sample of 28 patients. A fifth-year undergraduate psychology student, independently (i.e. blind to the clinical ratings made by the psychologist working at the psychiatric unit) made DSM-IV (APA, 1994) diagnoses2. These diagnoses were compared to the clinical rating made by the psychologist, by using the ‘disorder’ and ‘syndrome’ anchor points of the rating system as cutoff scores. The student and the psychologist agreed on 39 diagnoses. There were no disagreements, with the exception of one additional diagnosis of personality disorder not otherwise specified, assigned by the student. These results support the reliability of the used rating system, although a major limitation is that the comparison between the two raters was limited to the diagnostic level (i.e. disorder and syndrome anchor points).

Procedure The MCMI-III-D was administered by experienced psychologists during a psychodiagnostic evaluation. MCMI-III profiles were scored by the researchers with the Microtest Q Assessment System (Pearson Assessments, 2004). Profiles were considered valid if the total number of omitted or invalid responses (e.g., both a ‘yes’ response and a ‘no’ response to a single item) was less than 12, if the validity index was less than 2, and if the raw score on scale X (disclosure) was within the range 34-178 (Millon et al., 2006).

2

This was done during a clinical practice training (which is part of a master of science program).

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To guarantee the quality of this diagnostic study, the STARD (Standards for Reporting of Diagnostic Accuracy) statement was used (Bossuyt et al., 2003): the chapter was clearly identified as a study of diagnostic accuracy, the sample and patient selection was rigorously described, the test (MCMI-III-D) and the reference standard (clinician-determined diagnosis) was identified and the way of test administration and process to make clinician-determined diagnoses (rating system) was indicated and explained, all diagnostic efficiency measures were reported and the clinical applicability of the study findings was discussed.

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DATA ANALYSIS Clinicians only provided ratings if their confidence in the correctness and reliability was high. By examining mean scale scores on the MCMI-III-D, the study evaluated if the MCMIIII-D profiles of the group for which a clinical rating was available (current sample) were not significantly different from the MCMI-III profiles of the group for which no clinical rating was available. The current sample was also compared with the Belgian BR sample to ensure that the addition of profiles did not bias the results in terms of differences in MCMI-III-D profiles. Cohen’s d was used as a measure of effect size. The following heuristic rules (Cohen, 1988, pp. 20-26) were used to interpret the effect size: d = .20 indicates a small effect, d = .50 indicates a medium effect and d = .80 indicates a large effect. Diagnostic efficiency statistics were calculated on the basis of 627 subjects for whom a clinical rating and valid MCMI-III profile was available. One way to examine the diagnostic validity of a test is to calculate classical diagnostic validity statistics: sensitivity (sens), specificity (spec), positive predictive power (PPP), negative predictive power (NPP) and the overall correct classification (OCC; also called overall diagnostic power) (e.g. Gibertini, Brandenburg, & Retzlaff, 1986; Hsu, 2002). PPP and NPP are affected by the prevalence (or so called “walk-in” probability, i.e. Gibeau & Choca, 2005, p. 273) of a given trait or disorder, so prevalence rates have to be reported. In addition, some supplementary diagnostic efficiency statistics (including chanceadjusted statistics, measures of incremental validity and odds measures) were calculated (Hsu, 2000; Streiner, 2003). Classical diagnostic measures are affected by the diagnostic cutoff score on the scale or chosen anchor point. On the contrary, Cohen’s effect size d, is not affected by anchor points (or prevalence rates) and provides information about the relative abilities of a test to discriminate between disordered and non-disordered persons. The incremental validity of a test (incremental PPP and NPP) was evaluated: positive values indicate that positive or negative test-based findings are more informative for diagnostic decisions (diagnosis or no diagnosis) than the prevalence rate of a disorder. Chance-adjusted diagnostic efficiency measures (see Table 1: QPPP, QNPP, Ck, Kk and Phi) also indicate better-than-chance performance if values are above zero. All mentioned measures can be calculated by the use of 2 x 2 tables with cliniciandetermined diagnoses (or sample attributes) as columns and test results (or test attributes) as rows (see Streiner, 2003). Column based indexes are conditional on the sample. Besides sensitivity and specificity, the likelihood ratio (LR+ and LR-) is a column based index. PPP and NPP are row-based indexes. Furthermore it is possible to derive some indexes based on the table as a whole, like the proportion of correct decisions (OCC), statistics correcting for

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chance (e.g. Ck), and the odds ratio (or relative odds). Besides the relative odds, pre- and posttest odds can be calculated. Finally, the concordance index can be used as common metric to measure and compare diagnostic validity of scales, since this measure is independent from cutoff scores (i.e. can be calculated for the all range of BR scores) and prevalence rates (Hsu, 2002; McFall & Treat, 1999). If C exceeds 0.50, predictions are better than random guessing (Agresti, 2002). Table 1 gives an overview and definition (Hsu, 2002; Streiner, 2003) of all measures that were calculated. The below mentioned statistics were calculated for two possible cutoff scores: i.

The MCMI-III-D trait/symptom cutoff score (i.e. MCMI-III-D scale score ≥ BR 75) was compared to the clinician-determined presence of the trait/symptom (i.e. clinical rating ≥ 1); ii. The MCMI-III-D disorder/syndrome cutoff score (i.e. MCMI-III-D scale score ≥ BR 85) was compared to the clinician determined presence of the disorder/syndrome (clinical rating ≥ 5).

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Table 1. Diagnostic Efficiency Statistics: Measures and Definitions Measure (abbreviation) Sensitivity (Sens)

the probability that the test is positive given the disorder is present

Specificity (Spec)

the probability that the test is negative given the disorder is absent

Positive Predictive Power (PPP) Negative Predictive Power (NPP) Overall correct classification (OCC) Cohen’s effect size d (Cd) Prevalence (Prev) Incremental PPP (IPPP) Incremental NPP (INPP) Quality PPP (QPPP)

the probability that the disorder is present given the test is positive

Quality NPP (QNPP) Cohen’s kappa (Ck) Kraemer’s kappa (Kk) Phi Odds ratio (OR)

Definition

the probability that the disorder is absent given the test is negative the proportion correctly classified the distance (in pooled standard deviation units) between the scale means of disordered and nondisordered patients proportion that have a particular disorder incremental validity of a positive test score incremental validity of a negative test score chance corrected PPP (rescaled IPPP by dividing by the maximum possible range) chance corrected NPP (rescaled INPP by dividing by the maximum possible range) combined chance-adjusted diagnostic validities of both positive and negative test diagnoses weighted kappa (the importance of sensitivity versus specificity determines the given weight) Pearson correlation for dichotomous data (point biserial correlation) relative odds

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Gina Rossi and Hedwig Sloore Table 1. (Continued)

Measure (abbreviation) Likelihood ratio+ (LR+) Likelihood ratio- (LR-) Positive pretest odds (PRO+) Positive posttest odds (POO+) Negative pretest odds (PRO-) Negative posttest odds (POO-) Concordance index (C)

Definition the odds that a positive test result has come from a person who has the attribute the odds that a negative test result has come from a person who does not have the attribute prevalence / (1 – prevalence) PRO+ x LR+ (1 – prevalence) / prevalence PRO- x LRthe probability that a randomly selected person from the disordered population will have a higher scale score than a randomly selected person from the non-disordered population

RESULTS3 AND CONCLUSION Descriptive Statistics and Differences in Mean Scale Scores Table 2. Mean BR Scores and Standard Deviations for the Three Samples and Cohen’s d Effect Sizes Copyright © 2008. Nova Science Publishers, Incorporated. All rights reserved.

MCMI-III Scale

1-schizoid 2A-avoidant 2B-depressive 3-dependent 4-histrionic 5-narcissistic 6A-antisocial 6B-aggressive 7-compulsive 8Anegativistic 8Bmasochistic S-schizotypal 3

Valid MCMI-III and clinical rating (n = 627) BR SD 62.99 28.41 58.89 31.68 58.90 30.21 62.89 30.75 70.40 34.04 71.46 27.07 65.94 29.40 63.11 27.87 72.40 28.63 66.76 29.34

Valid MCMI-III No clinical rating available (n = 719) BR Cd SD 57.05 29.67 .20 53.23 31.72 .18 54.36 31.36 .15 56.14 30.92 .22 78.84 32.02 .26 76.39 25.25 .19 71.05 27.43 .18 64.99 27.14 .07 73.62 27.51 .04 61.72 30.50 .17

Belgian BR sample (n = 524) BR 62.40 57.76 57.11 62.13 70.79 70.99 62.56 59.57 74.05 64.84

SD 28.87 31.73 30.87 31.50 34.48 26.36 30.11 28.74 28.90 30.41

Cd .02 .04 .06 .02 .01 .02 .11 .13 .06 .06

55.57

28.76

49.97

30.47

.19

53.48

29.40

.07

57.57

30.78

53.75

31.36

.12

55.04

31.49

.08

An example of the calculation of all diagnostic efficiency statistics (by the use of contingency tables) can be found in Appendix A.

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Diagnostic Efficiency of the Dutch-language Version of the MCMI-III MCMI-III Scale

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C-borderline P-paranoid A anxiety H-somatoform N-bipolar: manic D-dysthymia B-alcohol dependence T-drug dependence R-posttraumatic stress SS-thought disorder CC-major depression PP-delusional disorder

Valid MCMI-III and clinical rating (n = 627) BR SD 61.52 25.56 63.81 30.92 71.72 33.89 60.71 37.17 71.96 28.42

Valid MCMI-III No clinical rating available (n = 719) BR Cd SD 57.45 26.00 .16 60.34 31.53 .11 62.73 35.53 .26 51.11 38.40 .25 70.71 29.16 .04

BR 59.91 61.15 70.33 60.00 69.23

SD 26.38 31.95 34.79 37.70 29.17

Cd .06 .09 .04 .02 .10

68.65 67.64

35.43 29.28

60.65 69.83

36.21 27.00

.22 .08

67.20 65.03

36.68 29.76

.04 .09

63.30

31.63

70.45

30.87

.23

59.69

31.63

.11

66.31

33.67

58.48

35.25

.23

64.77

34.47

.05

68.98

33.93

59.56

35.34

.27

67.50

34.46

.04

70.62

38.71

58.98

40.46

.29

70.70

39.25

.00

63.05

35.72

61.24

36.33

.05

60.61

36.22

.07

Belgian BR sample (n = 524)

When no clinical rating was available, subjects seemed to have lower mean scores on the schizoid, dependent, anxiety, somatoform, dysthymia, post-traumatic stress, thought disorder and major depression scale and higher mean scores on the histrionic and drug dependence scale of the MCMI-III-D (Table 2; cf. small effect sizes: .20 ≤ Cd < .50). However, clinicians did not have a tendency to only make ratings when confronted with more serious pathology: there were no medium or large effect sizes. Mean scale scores of the current sample were comparable to the mean scale scores of the Belgian BR sample (Table 2; all effect sizes were < .20).

Classical Diagnostic Efficiency Statistics and Cohen’s d Effect Size at Trait or Symptom Level Table 3 shows the classical diagnostic efficiency statistics, the prevalence rates, and Cohen’s d effect size at trait or symptom level. Sensitivity levels of all scales were higher than prevalence rates. With the exception of the masochistic and borderline scales, specificity levels were lower than sensitivity levels. NPP values ranged from .59 to .98. PPP levels were uniformly lower than NPP levels. OCC levels ranged from .41 to .67. For most scales (14) large or medium effect sizes were found and for the remainder of the scales (10) small effect sizes were found.

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Table 3. Classical Diagnostic Validity Statistics, Prevalence Rates and Cohen’s d Effect Sizes for the MCMI-III Scales (BR > 74 and Clinical Rating ≥ 1) (n = 627) Scale 1-schizoid 2A-avoidant 2B-depressive 3-dependent 4-histrionic 5-narcissistic 6A-antisocial 6B-aggressive 7-compulsive 8A-negativistic 8B-masochistic S-schizotypal C-borderline P-paranoid A anxiety H-somatoform N-bipolar: manic D-dysthymia B-alcohol dependence T-drug dependence R-post-traumatic stress SS-thought disorder CC-major depression PP-delusional disorder Mean

Sens .745 .683 .582 .683 .615 .729 .794 .680 .733 .722 .609 .634 .642 .672 .769 .696 .714 .705 .810

Spec .555 .635 .573 .566 .475 .493 .492 .512 .493 .454 .645 .549 .654 .472 .521 .529 .361 .471 .502

PPP .119 .320 .164 .309 .212 .250 .223 .055 .164 .146 .120 .090 .398 .121 .718 .398 .147 .499 .452

NPP .964 .888 .905 .863 .843 .887 .929 .975 .932 .926 .954 .955 .837 .930 .586 .795 .891 .681 .839

OCC .569 .644 .574 .592 .501 .537 .539 .518 .522 .485 .643 .555 .651 .491 .673 .581 .408 .571 .606

Cd .611 .715 .432 .649 .259 .592 .738 .359 .552 .264 .539 .332 .699 .378 .641 .528 .237 .487 .793

Prev .075 .201 .126 .222 .187 .188 .155 .040 .120 .115 .073 .065 .263 .097 .614 .309 .134 .427 .337

.807 .750

.585 .509

.302 .321

.932 .868

.625 .566

1.001 .531

.182 .236

.659 .732 .611

.431 .515 .400

.241 .573 .154

.822 .684 .852

.480 .617 .432

.242 .656 .128

.215 .470 .152

.699

.516

.271

.864

.558

.515

.209

One can conclude that the classical diagnostic validity statistics indicated that the MCMIIII-D was more sensitive (mean sens value .70, range .61 - .81) than specific (mean spec value .52, range .36 - .56). In other words, the probability that the test is positive given the trait or symptom is present, was higher than the probability that the test is negative given the trait or symptom is absent. Furthermore, for all scales, the probability that the trait/symptom is absent given the test is negative (mean NPP value .86) was higher than the probability that the trait/symptom is present given the test is positive (mean PPP value .27). This implies that positive test results remain highly hypothetical. However, since negative test results corresponded to a high probability that the trait/symptom was absent and sensitivity values were high, the MCMI-III scales can certainly be used to screen the possible presence of traits and symptoms.

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Classical Diagnostic Efficiency Statistics and Cohen’s d Effect Size at Disorder or Syndrome Level Table 4 shows the diagnostic efficiency statistics, the prevalence rates, and Cohen’s d effect size at personality disorder or clinical syndrome level (i.e. clinical diagnosis warranted).

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Table 4. Classical Diagnostic Validity Statistics, Prevalence Rates and Cohen’s d Effect Sizes for the MCMI-III Scales (BR > 84 and Clinical Rating ≥ 5) (n = 627) Scale 1-schizoid 2A-avoidant 2B-depressive 3-dependent 4-histrionic 5-narcissistic 6A-antisocial 6B-aggressive 7-compulsive 8A-negativistic 8B-masochistic S-schizotypal C-borderline P-paranoid A anxiety H-somatoform N-bipolar: manic D-dysthymia B-alcohol dependence T-drug dependence R-post-traumatic stress SS-thought disorder CC-major depression PP-delusional disorder Mean

Sens .613 .516 .377 .533 .523 .618 .710 .600 .617 .547 .118 .226 .376 .581 .701 .555 .692 .667 .714

Spec .678 .752 .774 .690 .562 .599 .651 .758 .591 .587 .897 .836 .887 .659 .569 .611 .488 .594 .710

PPP .090 .261 .171 .261 .160 .203 .201 .057 .109 .109 .062 .067 .472 .112 .509 .233 .082 .364 .415

NPP .971 .902 .909 .878 .881 .904 .948 .987 .950 .934 .947 .954 .841 .955 .749 .866 .960 .836 .896

OCC .675 .718 .730 .663 .557 .601 .657 .754 .593 .584 .855 .805 .778 .654 .620 .601 .501 .612 .711

Cd .562 .680 .577 .706 .294 .608 .766 .305 .422 .230 .543 .472 .827 .367 .585 .463 .472 .621 .952

Prev .049 .145 .110 .171 .137 .142 .110 .024 .075 .085 .054 .049 .212 .069 .389 .175 .062 .258 .223

.795 .697

.724 .593

.275 .221

.964 .922

.732 .608

1.161 .780

.116 .142

.627 .735 .609

.502 .554 .561

.116 .408 .099

.928 .833 .948

.514 .608 .565

.445 .681 .289

.094 .295 .073

.573

.660

.211

.911

.654

.575

.136

Sensitivity levels of all scales were higher than prevalence rates. For the following scales sensitivity levels were higher than specificity levels: the narcissistic, antisocial, compulsive, anxiety, bipolar, dysthymia, alcohol dependence, drug dependence, post-traumatic stress, thought disorder, major depression and delusional disorder scales. NPP values ranged from .75 to .99. PPP (mean .91) levels were uniformly lower than NPP (mean .21) levels. The probability that the personality disorder/clinical syndrome is absent given the test is negative was higher than the probability that the trait/symptom is present given the test is positive.

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OCC levels ranged from .50 to .86. For most scales (14) large or medium effect sizes were found. The effect sizes demonstrate the ability of the test to discriminate between disordered and non-disordered persons. In comparison to the benchmark of BR 75 the sensitivity of the scales was more limited (mean .57). At the BR 85 benchmark the MCMI-III scales are most useful to rule out the possible presence of disorders and syndromes: negative test results corresponded to a high probability that the disorder/syndrome was absent.

Additional Diagnostic Efficiency Statistics Trait/ Disorder and Symptom/Syndrome Level Calculation of measures of incremental validity (IPPP, INPP), chance-adjusted efficiency (QPPP, QNPP, Ck, Kk, Phi) and cut score independent measures (C) consistently showed that the MCMI-III-D scales perform better than chance and discriminate in the right direction. All IPPP, INPP, QPPP, QNPP, Ck, Kk and Phi were positive values and all C values were above .50. Detailed statistics for each scale can be found in Table 5 and 6.

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Table 5. Additional Diagnostic Validity Statistics for the MCMI-III Scales (BR >74 and Clinical Rating ≥ 1 (n = 627) Scale 1-schizoid 2A-avoidant 2B-depressive 3-dependent 4-histrionic 5-narcissistic 6A-antisocial 6B-aggressive 7-compulsive 8A-negativistic 8B-masochistic S-schizotypal C-borderline P-paranoid A anxiety H-somatoform N-bipolar: manic D-dysthymia B-alcohol dependence T-drug dependence R-post-traumatic stress SS-thought disorder CC-major depression PP-delusional disorder Mean

IPPP .044 .119 .038 .088 .025 .062 .068 .015 .045 .032 .046 .024 .135 .023 .104 .089 .013 .071 .116 .120 .085 .026 .102 .002 .062

INPP .039 .089 .031 .084 .030 .075 .084 .015 .051 .041 .028 .021 .100 .028 .200 .105 .025 .109 .176 .113 .104 .037 .154 .004 .073

QPPP .048 .149 .044 .113 .031 .076 .080 .015 .051 .036 .050 .026 .184 .026 .271 .129 .016 .124 .175 .146 .111 .033 .193 .003 .089

QNPP .521 .444 .245 .380 .160 .399 .540 .365 .427 .360 .376 .319 .379 .284 .326 .338 .186 .255 .523 .624 .442 .172 .328 .023 .351

Ck .088 .223 .074 .174 .052 .128 .140 .030 .091 .065 .088 .048 .247 .047 .296 .186 .029 .167 .262 .237 .177 .055 .243 .005 .131

Kk .279 .308 .183 .269 .131 .259 .300 .218 .255 .226 .239 .207 .300 .193 .307 .259 .141 .217 .343 .352 .289 .139 .281 .022 .238

Phi .158 .257 .104 .207 .070 .174 .208 .075 .147 .113 .137 .091 .264 .086 .297 .208 .054 .178 .302 .302 .221 .075 .252 .008 .166

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C .670 .707 .610 .671 .567 .669 .712 .627 .646 .590 .638 .607 .700 .636 .684 .664 .584 .645 .746 .792 .668 .571 .684 .561 .652

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Table 6. Additional Diagnostic Validity Statistics for the MCMI-III Scales (BR > 84 and Clinical Rating ≥ 5) (n = 627) Scale 1-schizoid 2A-avoidant 2B-depressive 3-dependent 4-histrionic 5-narcissistic 6A-antisocial 6B-aggressive 7-compulsive 8A-negativistic 8B-masochistic S-schizotypal C-borderline P-paranoid A anxiety H-somatoform N-bipolar: manic D-dysthymia B-alcohol dependence T-drug dependence R-post-traumatic stress SS-thought disorder CC-major depression PP-delusional disorder Mean

IPPP .041 .116 .061 .091 .022 .061 .091 .033 .034 .024 .007 .017 .260 .043 .120 .057 .020 .105 .192 .158 .079 .022 .113 .026 .075

INPP .021 .047 .020 .048 .018 .046 .058 .011 .025 .018 .001 .003 .053 .024 .138 .041 .022 .095 .120 .080 .064 .022 .128 .021 .047

QPPP .043 .136 .069 .110 .026 .071 .102 .034 .037 .027 .008 .018 .329 .046 .196 .070 .021 .142 .247 .179 .092 .024 .161 .028 .092

QNPP .408 .322 .177 .284 .134 .327 .525 .466 .335 .214 .016 .070 .249 .349 .355 .235 .355 .367 .536 .690 .450 .238 .435 .287 .326

Ck .077 .191 .099 .158 .043 .117 .171 .064 .066 .048 .010 .029 .284 .082 .253 .107 .040 .205 .338 .285 .152 .043 .235 .050 .131

Kk .249 .255 .153 .227 .113 .230 .307 .258 .218 .160 .015 .065 .268 .227 .295 .187 .218 .277 .384 .381 .282 .171 .311 .195 .227

Phi .133 .209 .110 .176 .059 .153 .232 .126 .111 .076 .011 .036 .286 .127 .264 .128 .087 .228 .364 .352 .203 .075 .265 .089 .163

C .675 .698 .649 .686 .574 .668 .720 .624 .614 .579 .650 .652 .742 .642 .662 .637 .650 .678 .796 .827 .721 .615 .687 .624 .670

Table 7 and 8 show the odds measures. The relative odds, LR+ and LR- are always larger than 1. With the exception of the major depression scale, positive posttest odds are always larger than pretest odds. For all scales, negative posttest odds are larger than pretest odds. Table 7. Odds measures for the MCMI-III Scales (BR > 74 and Clinical Rating ≥ 1) (n = 627) Scale 1-schizoid 2A-avoidant 2B-depressive 3-dependent 4-histrionic 5-narcissistic 6A-antisocial 6B-aggressive 7-compulsive

OR 3.640 3.736 1.870 2.811 1.445 2.615 3.736 2.226 2.671

LR+ 1.674 1.869 1.364 1.573 1.171 1.438 1.564 1.392 1.446

LR2.174 1.999 1.372 1.787 1.234 1.818 2.388 1.599 1.848

PRO+ .081 .251 .144 .285 .229 .232 .183 .042 .136

POO+ .136 .470 .197 .448 .269 .333 .286 .058 .196

PRO12.340 3.976 6.937 3.511 4.359 4.314 5.464 24.080 7.360

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POO26.833 7.950 9.515 6.273 5.378 7.844 13.050 38.500 13.600

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Scale 8A-negativistic 8B-masochistic S-schizotypal C-borderline P-paranoid A anxiety H-somatoform N-bipolar: manic D-dysthymia B-alcohol dependence T-drug dependence R-post-traumatic stress SS-thought disorder CC-major depression PP-delusional disorder Mean

OR 2.162 2.832 2.114 3.391 1.831 3.613 2.569 1.412 2.128 4.316 5.890 3.115 1.465 2.904 1.047 2.731

LR+ 1.323 1.717 1.408 1.855 1.272 1.604 1.477 1.118 1.333 1.629 1.944 1.529 1.558 1.510 1.018 1.491

LR1.635 1.649 1.502 1.828 1.439 2.252 1.739 1.263 1.597 2.650 3.030 2.038 1.265 1.923 1.028 1.794

PRO+ .130 .079 .070 .357 .108 1.591 .448 .155 .747 .507 .222 .309 .274 .889 .179 .319

POO+ .172 .136 .098 .663 .137 2.552 .662 .173 .995 .826 .432 .472 .318 1.342 .182 .481

PRO7.708 12.630 14.293 2.800 9.279 0.629 2.232 6.464 1.340 1.972 4.500 3.236 3.644 1.125 5.600 6.215

POO12.600 20.833 21.467 5.119 13.350 1.416 3.881 8.167 2.139 5.225 13.636 6.595 4.609 2.165 5.757 10.663

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Table 8. Odds Measures for the MCMI-III Scales (BR > 84 and Clinical Rating ≥ 5) (n = 627) Scale 1-schizoid 2A-avoidant 2B-depressive 3-dependent 4-histrionic 5-narcissistic 6A-antisocial 6B-aggressive 7-compulsive 8A-negativistic 8B-masochistic S-schizotypal C-borderline P-paranoid A anxiety H-somatoform N-bipolar: manic D-dysthymia B-alcohol dependence T-drug dependence R-post-traumatic stress SS-thought disorder

OR 3.332 3.237 2.073 2.542 1.408 2.411 4.561 4.703 2.332 1.718 1.163 1.482 4.712 2.687 3.095 1.957 2.145 2.921 6.135 10.134 3.345 1.694

LR+ 1.903 2.081 1.669 1.721 1.194 1.539 2.032 2.481 1.510 1.325 1.144 1.373 3.316 1.706 1.627 1.426 1.352 1.640 2.467 2.877 1.711 1.259

LR1.752 1.555 1.242 1.477 1.179 1.567 2.244 1.895 1.544 1.297 1.017 1.079 1.421 1.575 1.903 1.372 1.586 1.781 2.487 3.523 1.954 1.346

PRO+ .052 .170 .124 .206 .159 .165 .124 .025 .081 .092 .057 .052 .269 .074 .637 .213 .066 .348 .287 .132 .165 .104

POO+ .098 .353 .206 .354 .190 .255 .251 .061 .122 .122 .066 .071 .893 .126 1.036 .303 .090 .571 .709 .379 .283 .131

PRO19.408 5.890 8.087 4.860 6.291 6.045 8.087 40.800 12.340 10.830 17.441 19.226 3.714 13.581 1.570 4.700 15.077 2.870 3.479 7.589 6.045 9.627

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POO34.003 9.159 10.047 7.180 7.415 9.471 18.150 77.333 19.056 14.042 17.733 20.750 5.277 21.389 2.986 6.449 23.917 5.111 8.650 26.733 11.815 12.955

Diagnostic Efficiency of the Dutch-language Version of the MCMI-III Scale CC-major depression PP-delusional disorder Mean

OR 3.452 1.989 3.135

LR+ 1.649 1.387 1.766

LR2.093 1.434 1.680

PRO+ .419 .079 .171

POO+ .690 .110 .311

PRO2.389 12.630 10.107

207 POO5.000 18.111 16.364

The additional diagnostic validity statistics clearly indicate that the MCMI-III-D can give valuable information in the process of screening for possible clinical diagnoses.

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To Conclude: Some Important Issues Some scales deserve special consideration. Since the MCMI-III is a self-report instrument, one cannot expect it to be a good predictor of psychotic symptoms. People with psychotic symptoms are often not able to respond to questionnaires in a valid way. Consequently, it is not unexpected that all classical diagnostic statistics calculated for the scales SS-thought disorder and PP-delusional disorder were lower than the mean statistics at the BR 75 benchmark. At the BR 85 benchmark results were less straightforward: sensitivity and NPP values for scale SS and PP were higher than the mean values. Anyway, the incremental validity of positive test scores (IPPP) was very limited and confirmed the problems identified by previous research (Gibeau & Choca, 2005). On the contrary, the substance abuse scales (B and T), have shown to have high diagnostic power (Craig, 1997; Gibeau and Choca, 2005) and also in the current study these scales performed well (high sensitivity values, high PPP, medium to large effect sizes, etc.). In contrast to previous versions of the MCMI (see Craig, Kuncel, & Olson, 1994; FalsStewart, 1995), the MCMI-III(-D) is able to detect substance abuse. Research (Craig, 2005) suggests alternative interpretations for the Histrionic, Narcissistic and Compulsive scales of the MCMI-III. Elevated scores on the histrionic and compulsive scale are often obtained by healthy functioning persons and elevated scores in clinical groups tend to be associated with less pathology. This suggests that these scales are measuring styles rather than disorders. Elevated scores on the narcissistic scales appear in both healthy functioning and clinical groups, and are associated with either a healthy confident personality style or with traits of the narcissistic personality disorder. In the current study the narcissistic and compulsive scale performed reasonably well at the trait level with e.g. good sensitivity levels, medium effect sizes, etc. The histrionic scale had lower sensitivity and the effect size was small. The scale score does not seem to correspond with trait descriptions of this personality style, or at least with how clinicians interpret the presence of an histrionic style. Differences between clinician’s descriptions of histrionic styles and self-report on basis of item content of the MCMI-III scale should be further investigated. Finally, an important difference between the MCMI-III-D and the original American MCMI-III should be noted. In both American validation studies mean specificity values were higher than mean sensitivity values. The opposite is true for the MCMI-III-D: mean sensitivity values were higher than mean specificity values. Nevertheless, this is logical: priority was given by Rossi (2004) to avoid false negatives, whereas Millon et al. (1997) considered a high positive predictive ratio (PPP divided by prevalence rate) or avoiding false positives to be the most important. For the development of the BR’s of the MCMI-III-D (see

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Rossi & Sloore, 2005) receiver operating characteristic curves were calculated that represent the ratio of sensitivity and specificity. The incentive was to keep the level of both values (sensitivity and specificity) above .70. If this was not possible, priority was given to sensitivity, in order to avoid false negatives. The way receiver operating characteristics were applied by Rossi (2004) directly implied higher sensitivity levels.

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REFERENCES American Psychiatric Association (1994). Diagnostic and statistic manual of mental disorders (4th Ed.). Washington DC: American Psychiatric Association. American Psychiatric Association (2000). Diagnostic and statistic manual of mental disorders (4th Ed.). Text revision. Washington DC: Author. Balderassini, R. J., Finkelstein, S., & Arana, G. W. (1983). The predictive power of diagnostic tests and the effect of prevalence of illness. Archives of General Psychiatry, 40, 569-573. Bossuyt, P. M., Reitsma, J. B., Bruns, D. E., Gatsonis, C. A., Glasziou, P. P., Irwig, L. M., Moher, D., Rennie, D., De Vet, H. C. W., & Lijmer, J. G. (2003). The STARD statement for reporting studies of diagnostic accuracy: Explanation and elaboration. Clinical Chemistry, 49, 7-18. Choca, J. P. (2003). Interpretative guide to the Millon Clinical Multiaxial Inventory (3rd ed.). Washington, DC: American Psychological Association. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum. Craig, R. J. (1997). Sensitivity of the MCMI-III scales T (Drugs) and B (Alcohol) in detecting substance abuse. Substance Use and Misuse, 32, 1385-1393. Craig, R. J. (2005). Alternative interpretations for the histrionic, narcissistic, and compulsive personality disorder scales of the MCMI-III. In Craig, R. (Ed.) New directions in interpreting the Millon Clinical Multiaxial Inventory (MCMI): Essays on current issues (pp. 71 - 93). Hoboken, NJ: Wiley. Craig, R. J., Kuncel, R., & Olson, R. (1994). Ability of drug abusers to avoid detection of substance abuse on the MCMI-II. Journal of Social Behavior and Personality, 9, 95-106. Fals-Stewart, W. (1995). The effect of defensive responding by substance-abusing patients on the Millon Clinical Multiaxial Inventory. Journal of Personality Assessment, 64, 540551. Daubert, S. D., & Metzler, A. E. (2000). The detection of fake bad and fake good responding on the Millon Clinical Multiaxial Inventory. Psychological Assessment, 12, 418-424. Davis, R. D., Wenger, A., & Guzman, A. (1997). Validation of the MCMI-III. In T. Millon (Ed.), The Millon inventories: Clinical and personality assessment (pp. 327-362). New York: Guilford Press. Gibeau, P., & Choca, J. (2005). The diagnostic efficiency of the MCMI-III in the detection of Axis I disorders. In Craig, R. (Ed.) New directions in interpreting the Millon Clinical Multiaxial Inventory (MCMI): Essays on current issues (pp. 272 -283). Hoboken, NJ: Wiley.

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209

Gibertini, M., Brandenburg, N. A., & Retzlaff, P. D. (1986). The operating characteristics of the Millon Clinical Multiaxial Inventory. Journal of Personality Assessment, 50, 554567. Hsu, L. M. (2002). Diagnostic validity statistics and the MCMI-III. Psychological Assessment, 14, 410-422. McFall, R. M., & Treat, T. A. (1999). Quantifying the information value of clinical assessments with signal detection theory. Annual Review of Psychology, 50, 215-241. Mertens, J., Baert, H., & Clara, R. (Eds.). (1991). Welzijnsgids: gezondheidszorg, welzijnszorg: noden en behoeften, organisaties en voorzieningen, aanpak en methodiek, beleid. Sociale kaart van Vlaanderen. [Welfare guide: Health care, public welfare: needs and necessities, organizations and services, approach and methodology, policy. Social card of Flanders]. Deurne, Belgium: Kluwer. Millon, T. (1994). MCMI-III manual. Minneapolis, MN: National Computer Systems. Millon, T., & Davis, R. D. (1996). Disorders of personality. DSM-IV and beyond (2nd Ed.). New York: John Wiley and Sons, Inc. Millon, T., Davis, R., & Millon, C. (1997). MCMI-III Manual (2nd Ed.). Minneapolis, MN: National Computer Systems. Millon, T., Millon, C., Davis, R., & Grossman, S. (2006). MCMI-III Manual (3rd Ed.). Minneapolis, MN: Pearson Assessments. Oldham, J. M. & Skodol, A. E. (2000). Charting the future of Axis II. Journal of Personality Disorders, 14, 17-29. Pearson Assessments (2004). Microtest Q 5.08A [Computer software]. Bloomington, MN: NCS Pearson. Retzlaff, P. D. (1996). MCMI-III diagnostic validity: Bad test or bad validity study? Journal of Personality Assessment, 66, 431-437. Rogers, R., Salekin, R. T., & Sewell, K. W. (1999). Validation of the Millon Clinical Multiaxial Inventory for Axis II disorders: Does it meet the Daubert standard? Law and Human Behavior, 23, 425-443. Rossi, G. (2004). Interpersoonlijk uit balans: Empirische validatie van de MCMI-III en de theorie van Millon met betrekking tot de afhankelijke, narcistische, theatrale en antisociale persoonlijkheid [Interpersonally imbalanced: Empirical validation of the MCMI-III and the theory of Millon considering the dependent, narcissistic, histrionic and antisocial personality]. Unpublished doctoral dissertation. Brussel, Belgium: Vrije Universiteit Brussel. Rossi, G., Hauben, C., Van den Brande, I., & Sloore, H. (2003). Empirical evaluation of the MCMI-III personality disorder scales. Psychological Reports, 92, 627-642. Rossi, G., & Sloore, H. (2005). International uses of the MCMI: Does interpretation change? In Craig, R. (Ed.), New directions in interpreting the Millon Clinical Multiaxial Inventory (MCMI): Essays on current issues (pp. 144-161). Hoboken, NJ: Wiley. Rossi, G., Van den Brande, I., Tobac, A., Sloore, H., & Hauben, C. (2003). Convergent validity of the MCMI-III personality disorder scales and the MMPI-2 scales. Journal of Personality Disorders, 17, 330-340. Rossi, G., van der Ark, L. A., Sloore, H. (2007). Factor analysis of the Dutch language version of the MCMI-III. Journal of Personality Assessment, 88, 144-157.

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Ryder, A. G., & Wetzler, S. (2005). In Craig, R. (Ed.), New directions in interpreting the Millon Clinical Multiaxial Inventory (MCMI): Essays on current issues (pp. 248 -271). Hoboken, NJ: Wiley. Sloore, H. V., & Derksen, J. L. L. (1997). Issues and procedures in MCMI translations. In T. Millon (Ed.), The Millon Inventories: Clinical and personality assessment (pp. 287-302). New York: The Guilford Press. Sloore, H., Derksen, J., & De Mey, H. (1994). MCMI-III. Nijmegen, The Netherlands: Pen Test Publishers. Streiner, D. L. (2003). Diagnosing tests: Using and misusing diagnostic and screening tests. Journal of Personality Assessment, 81, 209-219. Trull, T. J., & Durrett, C. A. (2005). Categorical and dimensional models of personality disorders. Westen, D. & Shedler, J. (2000). A prototype matching approach to diagnosing personality disorders: toward DSM-V. Journal of Personality Disorders, 14, 109-126.

APPENDIX A Table 9. Contingency Table for the Schizoid Personality Disorder (Clinical Rating ≥ 5) and the Schizoid Scale (BR > 85) MCMI-III scale 1 test result

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Present (BR ≥ 85) Absent (BR < 85) Column total

Has a schizoid personality disorder (rating ≥ 5) yes 19 (A) 12 (C) 31 (A+C)

No 192 (B) 404 (D) 596 (B+D)

Row total 211 (A+B) 416 (C+D) 627 (N = A+B+C+D)

Sens = A / (A + C) = 19 / (19 + 12) = .613 Spec = D / (B + D) = 404 / (192 + 404) = .678 PPP = A / (A + B) = 19 / (19 + 192) = .090 NPP = D / (C + D) = 404 / (12 + 404) = .971 OCC = (A + D) / N = (19 + 404) / 627 = .675 Cd = (μdisorder - μno disorder) / σpooled where μdisorder is the mean scale score of the disorder group, μno disorder is the mean scale score of the no-disorder group and σpooled is the pooled standard deviation of the two groups = (77.871 – 62.220) / 27.859 = .562 Prev = (A + C) / N = 31 / 627 = .049 IPPP = [A / (A+B)] – [(A + C) / N] = (19 / 211) – (31 / 627) = .041 INPP = [D / (C + D)] - [(B + D) / N] = (404 / 416) – (596 / 627) = .021 QPPP = (PPP – prev) / (1 – prev) = (0.090 – 0.049) / (1 – 0.049) = .043

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QNPP = [NPP – (1-prev)] / prev = (0.971 – 0.951) / 0.049 = .408 Ck = (No – Ne) / (N – Ne) where No is the observed number of correct agreements and Ne4 the number of agreements expected by chance = (423 - 406) / (627 - 406) = .077 Kk = (AD – BC) / [(A + B)(B + D)Ck + (C + D)(A + C)(1 – Ck)] = (7676 – 2304) / [(211 x 596 x .077) + (416 x 31 x .923)] = 5372 / (9683.212 + 11903.008) = .249 Phi = (AD – BC) / [(A + C)(B + D)(A + B)(C + D)]1/2 = 5372 / 40270.95 = .133 OR = AD / BC = 7676 / 2304 = 3.332 LR+ = sens / (1 – spec) = .613 / .322 = 1.904 LR- = spec / (1 – sens) = .678 / .387 = 1.752 PRO+ = prev / (1 – prev) = .049 / .951 = .052 POO+ = PRO+ x LR+ = .098 PRO- = (1 – prev) / prev = .951 / .049 = 19.408 POO- = PRO- x LR- = 19.408 x 1.752 = 34.003 C = area under the receiver operating curve, which is a plot of sensitivity as a function of 1 minus the specificity for all possible cut-offs = .675

4

[(A + B)(A + C) + (C + D)(B + D)] / N = (6541 + 247936) / 627 = 406

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In: New Research on Personality Disorders Editors: Ida V. Halvorsen and Sarah N. Olsen

ISBN: 978-1-60456-726-7 © 2008 Nova Science Publishers, Inc.

Chapter 10

PERSONALITY DISORDERS AND HANDEDNESS Helmut Niederhofer* Department of Pediatrics General Hospital of Bolzano, Via L.-Boehler 5, 39100 Bolzano, Italy

SUMMARY

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Nine subjects diagnosed as Borderline were studied via parent questionnaire. More (5 of 9) patients were reported with a use of the left hand than is reported on the average in the general population, more in complex than simple and for external (touching food and objects) than internal tasks (scratching, rubbing eyes), which suggests a deficit in cerebral control of external, goal-oriented hand use. Our results support the former hypothesis of a right hemisphere dysfunction in patients with Borderline disorders.

Key words: handedness – Borderline disorders.

Muller (1992) hypothesizied a neuronal basis for borderline splitting. There are only few studies reporting neuropsychological impairment in patients with impulsive personality disorders (Stein & Hollander, 1993). Also left-hemispheric dysfunction has been reported to be increased in patients with severe psychiatric disorders (Driessen, Herrmann, Stahl, Zwaan; Meier, Hill, Osterheider, Petersen, 2000), as well as for patients with borderline disorders (Kawabata & Hatta, 1985). Giotakos (2001) showed, that even clinical observations of handedness are significantly associated with various psychiatric disorders like autism, attention deficit hyperactivity syndrome (ADHD), depressions, psychoses, tics, OCD, and personality disorders. Consequently, the aim of the present investigation (preliminary results published by Niederhofer, 2004) was to check the expression of right- versus left-hand * Correspondence addresse: Helmut Niederhofer, Department of Pediatrics, General Hospital of Bolzano, Via L.-Boehler 5, 39100 Bolzano Email: [email protected]

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Helmut Niederhofer

preference in patients diagnosed as borderline according to DSM-IV criteria, using clinical observations and the Youth self report (YSR). Hand preference and extent of laterality were studied in relation to two distinct categories of functional hand use: internally directed hand functions and externally directed hand functions. A questionnaire, answered during an interview, was used to identify the handedness. Borderline disorders have been diagnosed clinically according to the DSM-IV criteria. Additional medical disorders as well as an IQ lower than 70 were defined as exclusion criteria. 9 subjects returned the questionnaire and were therefore included in the study. The sample ranged in age from 17 to 25 years (M = 21.3, SD = 2.7) and included 5 men (M = 22.4, SD = 2.2) and 4 women (M = 20.9, SD = 2.1). Questionnaire data regarding eight functional hand tasks were analyzed in this study. Internally directed tasks, i.e. touching one self, were rubbing eyes and scratching self. Externally directed tasks, i.e. touching other objects, were three simple tasks, only touching (touching food, touching objects, and holding a bottle or cup to drink) and three complex ones, i.e. sequences of movements (using fingers to eat, use of a spoon or fork, and manipulating objects). Respondent`s right hand use was categorized on three levels: Does This Often, Does This Infrequently, and. Does This Seldom. The two levels at which any use was present (Always or Often) were combined into a singleuse category (1+2. Right hand used almost always/often; 3. About equal use (left and right); 4+5. Right Hand Use Seldomly or Never = Left hand used almost always/often). The percentage of ambidexter/left-handed persons has been calculated. Hand use was examined for the eight tasks. Thus, a single number represents a placement on the hand preference scale. The average index was obtained for each subject by averaging the preference ratings. Functional hand use in these subjects was markedly restricted. Only “touch objects” was performed "often" by a majority of these subjects (Table 1). The average hand preference index (anchors 1, left used almost always, and 5, right used almost always) was 3.7, a fact, which deviates from an expected index of greater than 4.0 for a normal largely right-handed population (Coren & Porac, 1977). Table 1. Level of Right Hand Use in Internal and External Tasks (N=9) Task

Never Does This % of Subjects

Internally directed tasks Rub eyes 11.2 Scratch self 22.3 Externally directed tasks Simple tasks Touch objects 11.2 Touch food 44.4 Hold bottle/cup 55.5 Complex tasks Finger feed 55.5 Manipulate objects 44.4 Use spoon/fork 77.8

Does Infrequently % of Subjects

Does Often % of Subjects

44.4 33.3

44.4 44.4

33.3 33.3 11.2

55.5 33.3 33.3

11.2 22.3 11.2

33.3 33.3 11.2

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Personality Disorders and Handedness

215

Earlier, it was hypothesized that a deficit in a discrete cerebral network normally serving externally directed (goal oriented) limb movements in people may be responsible for this clinical abnormality (Bishop, 1990). It is not surprising that externally directed hand functions might be the most vulnerable and rely most heavily on network integrity. The normal neural control of scratching has a strong reflex basis, although modified by higher centers) (DennyBrown, 1966). It has been shown that externally directed hand functions are worse affected than internally directed functions. Also, the fact that the reflex basis of scratching is strictly unilateral (Denny-Brown, 1966) may account for the relatively high incidence of equal rightand left-hand use. Reach and prehension by the dominant hand are largely directly managed by the contralateral motor center in the brain (Lawrence & Kuypers, 1968). In accordance with the gradual manifestation of right-handedness in childhood occurring in 90% of normally developing individuals, such control is usually primarily inferred by the left hemisphere. In humans, irrespective of handedness, the left hemisphere is dominant and controls a variety of aspects of praxis involving purposeful skilled movements of the limbs on both sides (Leiguarda & Marschen, 2000). Left-right structural brain differences linked to handedness have been described in normal individuals, and hemispheric neurotransmitter asymmetries associated with specialized speech and motor function (Toga & Thompson, 2003) have been proposed. Some bilateral brain diseases are known to progress asymmetrically, for example, Alzheimer's disease or cerebral palsy, in which the left hemisphere is affected earlier and more severely (Ykochi et al., 1990). The present findings of less functional hand use in a number of skill areas is consistent with previous reports of decline in neuromotor skills over time in behavioral disorders (Kawabata & Hatta., 1985). The fact that patients diagnosed as borderline show a reported left-hand preference for functional tasks overall (internally and externally directed) corresponds well to the results in previous studies (Kawabata & Hatta., 1985. The left-hand preference reported in our small sample is not only much greater than the 8 to 10% usually cited of normal individuals (Coren & Porac., 1977) and mental retardation (Silva & Satz., 1979). Actually the study sample is enlarged and results will include not only patients with borderline personality disorders, but also patients with various other personality disorder and focus on differences with respect to handedness with the aim to distinguish peronality disorders by having more insight in neurological bases.

REFERENCES Bishop, D. (1990). Handedness and developmental disorder. London, MacKeith Press. Denny-Brown, D. (1966). The cerebral control of movement.. Springfield, IL, Charles C. Thomas. Coren, S. & Porac (1977). C Fifty centuries of right-handedness: the historical record. Science, 198, 631-632. Driessen, M., Herrmann, J., Stahl, K., Zwaan, M., Meier, S., Hill, A., Osterheider, M., & Petersen, D. (2000). Magnetic resonance imaging volumes of the hippocampus and the amygdala in women with borderline personality disorder and early traumatization. Arch Gen Psychiatry, 57(12), 1115-22.

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Giotakos (2001). O Narrow and broad definition of mixed-handedness in male psychiatric patients. Percept Mot Skills, 93(3), 631-8. Kawabata, Y. & Hatta, T. (1985). Behavior disorders and laterality of cerebral function. Int J Neurosci, 27, 235-239. Lawrence, D. & Kuypers, H. (1968). The functional organization of the motor system in the monkey II. The effects of lesions in the descending brain-stem pathways. Brain, 91, 1536. Leiguarda, R. & Marsden, C.D. (2000). Limb apraxias--higher-order disorders of sensorimotor integration. Brain, 123, 860-87. Muller, R.J. (1992). Is there a neural basis for borderline splitting? Compr Psychiatry, 33(2), 92-104. Niederhofer, H. (2004). Left-Handedness in a sample of nine patients with Borderline Personality Disorder. Perceptual and Motor Skills, 99, 849-852. Silva, D. & Satz, P. (1979). Pathological left-handedness: Evaluation of a model. Brain Lang, 7, 8-16. Stein, D.J., Hollander, E., Cohen, L., Frenkel, M., Saoud, J.B., Decaria, C., Aronowitz, B., Levin, A., Liebowitz, M.R., & Cohen, L. (1993). Neuropsychiatric impairment in impulsive personality disorders. Psychiatry Res, 48(3), 257-66 Toga, A.W. & Thompson, P.M. (2003). Mapping brain asymmetry. Nat Rev Neurosci, 4, 3748. Yokochi, K., Shimabukoro, S. & Kodama, M. (1990) Dominant use of the left hand by athetotic cerebral palsied children. Brain Dev, 12, 807-808.

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INDEX

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A abstinence, 174, 184 access, 162, 197 accounting, 41, 71, 75 accuracy, 22, 92, 194, 198, 208 acquisitions, 8 activation, 15, 26, 46 adaptation, x, 6, 10, 36, 72, 171, 183 adaptive functioning, 147 addiction, x, 5, 14, 171, 172, 173, 175, 176, 185, 188, 189, 190 adjustment, 8, 39, 157 administration, 105, 107, 114, 115, 139, 178, 198 adolescence, 129, 155, 175 adolescents, 58, 75, 153, 164, 165, 166, 168, 169 adult, 17, 20, 54, 76, 90, 100, 167, 179 adulthood, 95, 129, 155 adults, 59, 75, 81, 95, 123 affect intensity, 15 affective disorder, ix, 34, 39, 152, 153, 154, 158, 159, 161, 163, 164 affective experience, 23, 26, 57, 60, 73 affective states, 5, 6, 8, 16, 35, 36, 51 African American, 86, 87 afternoon, 105 age, 9, 11, 12, 14, 19, 39, 44, 47, 48, 51, 60, 74, 91, 107, 115, 139, 152, 155, 157, 158, 159, 174, 175, 190, 195, 214 agent, 163 aggression, 2, 12, 24, 25, 38, 46, 48, 56, 57, 58, 59, 74, 140, 159, 160, 162, 169, 170 aggression scales, 12 aggressive behavior, 2, 128, 162, 165, 169, 174 aggressiveness, vii, 1, 4, 13, 71, 110, 116, 179 agoraphobia, 156 agreeableness, 139, 140, 144, 175 aid, 71

AIDS, 179 alcohol, 11, 25, 32, 91, 125, 126, 128, 129, 153, 158, 159, 168, 173, 174, 175, 177, 178, 180, 182, 183, 189, 195, 201, 202, 203, 204, 205, 206 alcohol abuse, 158 alcohol consumption, 174, 175, 181 alcohol dependence, 195, 201, 202, 203, 204, 205, 206 alcohol use, 153, 168 alcoholics, 128, 173, 177, 182, 186, 187, 188, 189, 190, 191 alcoholism, 39, 128, 133, 158, 174, 187, 188, 189, 191 alternative, viii, 5, 35, 72, 81, 103, 107, 139, 148, 207 alternatives, 65, 74, 163 American Psychiatric Association (APA), 35, 52, 58, 63, 65, 66, 68, 71, 76, 83, 85, 90, 93, 96, 97, 98, 104, 105, 110, 115, 118, 121, 122, 125, 130, 177, 186, 196, 197, 208 American Psychological Association, 77, 132, 149, 208 amphetamines, 184 amplitude, viii, 121, 125 amygdala, 215 analgesic, 128 analysts, 23, 24 anger, 4, 25, 116, 147, 156, 162, 185 annihilation, 25 anomalous, ix, 135, 138, 139, 140, 146, 147, 148 anorexia nervosa, 128 antagonists, 188 anticonvulsants, 129 antidepressants, 45, 129, 162 antipsychotic drugs, 14, 40, 46, 162 antisocial behavior, 73, 153, 174 antisocial personality, ix, 81, 107, 109, 110, 112, 116, 151, 153, 154, 156, 158, 160, 161, 167, 175, 176, 177, 178, 180, 181, 209

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218

Index

antisocial personality disorder (antisocial PD), ix, 42, 71, 81, 90, 107, 109, 110, 112, 116, 152, 153, 154, 156, 160, 161, 167, 175, 176, 177, 178, 180 anxiety, vii, 1, 2, 5, 6, 10, 11, 12, 14, 15, 17, 18, 20, 22, 25, 38, 45, 48, 53, 54, 55, 58, 59, 60, 73, 74, 78, 88, 90, 91, 92, 100, 101, 107, 126, 156, 173, 178, 179, 184, 195, 201, 202, 203, 204, 205, 206 anxiety disorder, 5, 10, 14, 20, 45, 53, 73, 78, 88, 90, 101, 126, 156 anxiolytic, 14 anxious mood, 14, 15 appendix, 92 arousal, 10 arterial hypertension, 45 assessment, vii, viii, ix, 2, 3, 4, 9, 10, 14, 15, 16, 19, 22, 24, 26, 27, 28, 29, 31, 37, 45, 52, 54, 55, 56, 60, 63, 65, 67, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 82, 83, 85, 92, 99, 103, 104, 105, 106, 107, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 122, 124, 130, 135, 138, 139, 147, 148, 149, 152, 161, 173, 174, 178, 189, 196, 208, 210 assessment procedures, 69, 72 assessment techniques, 70 assessment tools, 29, 65, 67, 70 assignment, 65 assumptions, 23, 38 attachment, 2, 7, 8, 23, 24, 34, 37, 41, 48, 54, 127 attention, 4, 8, 25, 59, 65, 73, 75, 93, 96, 190, 213 attention deficit hyperactivity syndrome (ADHD), 213 attitudes, 3 atypical, 24, 39, 129, 162, 163, 170 audio, 115 Austria, 1, 11 authority, 179 autism, 213 autonomic, 10, 15 autopsy, 152, 155, 164, 166 availability, 72 averaging, 93, 214 avoidance, 6, 16, 36, 93, 96, 160, 174, 175, 178, 179, 194 avoidance behavior, 94 awareness, 19, 22, 46

B base rate, x, 94, 193, 194 battery, 31, 117 beating, 46 behavior, 4, 5, 6, 36, 44, 48, 71, 74, 79, 92, 106, 107, 113, 116, 122, 127, 132, 148, 152, 153, 155, 157,

158, 159, 160, 161, 168, 169, 172, 174, 183, 185, 188, 189, 191 behavior therapy, 161, 169 behavioral change, 53 behavioral difficulties, 68 behavioral dimension, 162 behavioral disorders, 185, 215 behavioral manifestations, 17 behavioral medicine, 132 behavioral problems, 5 behavioral sciences, 208 Belgium, 193, 195, 209 belief systems, vii beliefs, 28, 71 benefits, 33, 137 benzodiazepine, 181 benzodiazepines, 178, 180, 183 bias, 26, 80, 96, 138, 146, 148, 149, 176, 198 bilateral, 215 biological, 6, 10, 36, 55, 66, 74, 125, 127, 128, 129, 162, 164, 176, 184 biophysical, 75 bipolar, 31, 39, 81, 107, 163, 164, 201, 202, 203, 204, 205, 206 bipolar disorder, 31, 107, 163, 164 blame, 16, 147 blaming, 16 blind spot, 38 bonding, 14 borderline, vii, viii, ix, 1, 2, 21, 22, 25, 31, 32, 33, 38, 39, 41, 42, 45, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 79, 81, 82, 83, 85, 86, 88, 90, 91, 92, 93, 94, 95, 96, 98, 99, 101, 103, 105, 107, 108, 112, 114, 115, 116, 117, 118, 119, 123, 124, 126, 127, 131, 132, 133, 137, 151, 153, 154, 155, 157, 158, 159, 160, 161, 162, 165, 166, 167, 168, 169, 170, 177, 180, 181, 183, 185, 189, 195, 201, 202, 203, 204, 205, 206, 213, 215, 216 borderline personality disorder (borderline PD, BPD), vii, viii, ix, 1, 2, 4, 5, 21, 22, 30, 31, 32, 34, 39, 41, 52, 53, 56, 57, 59, 60, 61, 82, 89, 90, 98, 101, 103, 107, 112, 115, 117, 118, 123, 124, 125, 126, 127, 128, 129, 131, 132, 133, 137, 151, 153, 154, 155, 156, 157, 158, 159, 160, 161, 162, 163, 165, 166, 167, 168, 169, 170, 177, 180, 185, 189, 195, 215, 216 boredom, 24, 38 Boston, 151 brain, 188, 215, 216 brain asymmetry, 216 bronchial asthma, 45 Brussels, 193 burn, 45, 94

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Index

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C cannabis, 173, 178, 179, 180, 188 capacity, 7, 8, 22, 23, 24, 25, 37, 52, 70, 73, 130 car accidents, 116 caregivers, 8 Caucasian, 139 causality, ix, 171, 176, 184 central nervous system, 173 cerebral function, 216 cerebral palsy, 215 chemical, 191 childhood, 23, 87, 88, 90, 91, 99, 153, 215 childhood sexual abuse, 87, 88, 90, 91, 99 children, 9, 59, 75, 167, 187, 216 Chinese, 165 chronic fatigue syndrome, 127 civilian, 85 classes, 13 classification, 2, 4, 7, 16, 27, 35, 60, 72, 73, 77, 80, 82, 83, 95, 161, 175, 198, 199 clients, 187, 189, 194 clinical, vii, viii, x, 2, 3, 4, 6, 7, 10, 11, 13, 15, 22, 26, 28, 29, 30, 34, 35, 36, 37, 40, 46, 53, 54, 55, 58, 59, 60, 61, 63, 64, 65, 67, 69, 71, 73, 74, 75, 77, 78, 79, 83, 85, 97, 99, 103, 106, 108, 119, 121, 122, 123, 125, 127, 128, 130, 131, 136, 139, 146, 147, 152, 154, 158, 159, 160, 162, 163, 167, 169, 173, 184, 185, 189, 191, 193, 194, 195, 196, 197, 198, 199, 200, 201, 203, 207, 209, 213, 215 clinical approach, 196 clinical assessment, 209 clinical diagnosis, 196, 203 clinical disorders, 79, 195 clinical judgment, 106 clinical presentation, 58, 73, 123 clinical psychology, 74 clinical symptoms, 128, 196 clinical syndrome, 122, 185, 203 clinicians, vii, 4, 5, 7, 10, 19, 35, 37, 39, 63, 64, 65, 70, 71, 72, 92, 97, 104, 119, 130, 161, 164, 194, 196, 197, 201, 207 close relationships, 14 clozapine, 162, 163, 170 cluster analysis, 97, 175 clusters, 20, 40, 41, 66, 94, 160, 161, 164 cocaine, 173, 175, 177, 178, 180, 181, 184, 186, 188, 189 cocaine abuse, 186 cocaine use, 177 coding, 36, 106, 114 cognition, 4, 5, 122

219

cognitive, vii, 5, 6, 8, 36, 45, 56, 58, 70, 71, 74, 75, 80, 128, 131, 155, 161, 162, 196 cognitive behavior therapy, 56 cognitive function, 155 cognitive impairment, 45 cognitive process, 8 cognitive style, 75, 196 cognitive-behavioral therapies, 128 cohort, 31, 33, 128, 165 colitis, 45 collectivism, 60 college students, 87, 137, 138, 139 combat, viii, 85, 86, 89, 90, 91, 95, 96, 97, 99, 100, 101 combined effect, 96 communication, 46, 64, 73 community, 80, 83, 95, 99, 100, 101, 109, 123, 153, 164, 165 community-based, 95, 100, 165 comorbidity, ix, x, 5, 31, 61, 65, 67, 73, 78, 79, 80, 83, 86, 90, 91, 93, 94, 95, 96, 101, 132, 152, 154, 157, 159, 160, 161, 164, 165, 166, 168, 169, 171, 172, 175, 176, 177, 178, 182, 183, 184, 185, 186, 189 compatibility, 35 complementary, 13 compliance, 34 complications, 158 components, 8, 15, 17, 23, 25, 34, 43, 51, 73, 75, 94 composition, 196 compulsive personality disorder, 79, 99, 128, 132, 153, 160, 177, 208 concentration, 25 conception, 17 conceptualization, 7, 37, 73, 125, 130, 137, 138, 172 concordance, 78, 81, 194, 199 concrete, 11 conduct disorder, 153 confidence, 70, 154, 156, 163, 198 confidence interval, 70, 154, 156, 163 configuration, 81 confinement, 117 conflict, viii, 121 confrontation, 33 conscientiousness, 139 consciousness, 58 consensus, viii, 63, 68, 104 consent, 109, 195 constraints, 42, 48 construct validity, 15, 98, 100 consultants, 9, 39, 46 consulting, 4 consumers, 174, 175, 176, 177, 178, 179, 181, 182

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220

Index

consumption, ix, x, 171, 172, 173, 174, 175, 177, 179, 181, 183, 184, 185 contingency, 161, 200 control, x, 8, 12, 13, 25, 26, 30, 33, 34, 56, 90, 95, 122, 152, 158, 159, 163, 164, 165, 166, 168, 169, 174, 179, 184, 185, 186, 190, 213, 215 control group, 33, 34, 90, 159, 179 convergence, viii, 11, 16, 75, 103, 107, 109, 112, 113, 114, 115, 116, 117, 118 conviction, 2 cooking, 46 coordination, 46 coping strategies, 6, 26, 36, 71, 99 correlation, vii, 1, 2, 10, 11, 14, 19, 21, 22, 24, 26, 41, 42, 43, 44, 69, 75, 110, 116, 136, 137, 140, 146, 147, 199 correlation analysis, 26 correlation coefficient, 11, 14, 140, 146 correlations, ix, 2, 3, 12, 14, 15, 17, 19, 22, 25, 26, 39, 42, 51, 66, 69, 76, 88, 110, 112, 126, 127, 135, 137, 139, 147 cost-effective, 35 costs, 31, 58 counseling, 46, 194, 195, 197 credibility, 104 credit, 139 criminal behavior, 156 criminality, 5 criticism, 93, 94, 98, 173, 174 cross-cultural, 195, 196 cues, 161 culture, 4, 67, 122 curiosity, 24 current limit, 70

D data analysis, 38 data collection, 139 data set, 147, 156 death, 25, 152, 154, 160, 162 deaths, 166 decisions, 115, 197, 198 defense, 35, 42, 43, 59, 76, 81, 83, 118 defense mechanisms, 35, 59, 81, 118 defenses, 6, 36, 71, 72, 75, 81, 83 defensive strategies, 6, 16, 36 defensiveness, 138 deficit, x, 213, 215 deficits, 22, 74 definition, viii, 5, 7, 35, 88, 121, 123, 199, 216 delusional, 196 delusions, 24

demand, 39, 46 dementia, 39 demographic, 13, 97, 139, 154 demographic characteristics, 13, 154 demographic data, 139 denial, 22, 29 Department of Defense, 121 dependent personality disorder, 77, 160, 177 depressed, 84, 93, 98, 101, 104, 157, 160, 162, 167 depression, 5, 14, 39, 45, 53, 58, 59, 60, 89, 90, 93, 95, 97, 98, 107, 126, 131, 155, 156, 157, 158, 160, 163, 173, 174, 182, 185 depressive PD (DPD), viii, 85, 86, 93 depressive symptoms, 182 derivatives, 25 desensitization, 128 desire, viii, 6, 36, 63 destruction, 25, 26 detachment, 4, 178 detection, 6, 37, 96, 132, 194, 208 detoxification, 31, 181, 187 devaluation, 22, 24 developmental disorder, 122, 215 developmental psychology, 7, 37 developmental theories, 8 deviant behaviour, 165 deviation, 69, 137, 140, 143, 145, 146 diagnostic criteria, viii, 4, 5, 35, 65, 68, 88, 90, 93, 103, 104, 105, 110, 114, 115, 116, 117, 118, 123, 125, 136, 154, 155, 161, 177, 185, 196 dichotomy, 79 diet, 46 differential diagnosis, 66, 119 differentiation, 21, 73 dimensionality, 99 disability, vii, 2, 24, 104 disaster, 5, 100 discipline, 142 disclosure, 197 discomfort, 127 disinhibition, x, 73, 128, 133, 171, 183 disposition, 12 dissociation, vii, 2, 97, 131 distress, 5, 35, 45, 56, 75, 161 distribution, 10, 16, 19, 69, 136, 137, 148 divergence, viii, 103 doctors, 22, 46 dominance, 13, 26, 38 dopamine, 67, 74 dose-response relationship, 95 dream, 106 drinking, 188 drug abuse, 11, 158, 175, 187, 191, 208

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Index drug abusers, 187, 191, 208 drug addict, ix, x, 32, 171, 172, 173, 174, 175, 176, 178, 179, 181, 182, 184, 187, 189, 190, 191 drug addiction, ix, x, 32, 171, 172, 173, 174, 176, 182, 184, 189 drug consumption, ix, 171, 172, 173, 176, 177, 179, 182, 183, 185 drug dependence, 158, 190, 201, 202, 203, 204, 205, 206 drug reactions, 162 drug use, 176 drugs, 5, 16, 25, 32, 40, 46, 125, 128, 129, 156, 161, 162, 163, 164, 172, 173, 175, 176, 177, 179, 184, 185 DSM (Diagnostic and Statistical Manual of Mental Disorders), vii, viii, ix, 2, 3, 4, 5, 9, 10, 17, 19, 20, 26, 31, 33, 35, 39, 40, 41, 45, 63, 64, 65, 66, 67, 68, 70, 71, 72, 73, 76, 77, 78, 79, 80, 81, 82, 83, 85, 89, 90, 92, 93, 94, 96, 98, 99, 100, 101, 103, 104, 105, 106, 108, 109, 110, 111, 112, 113, 114, 115, 118, 119, 121, 122, 123, 124, 125, 130, 136, 139, 140, 146, 148, 149, 152, 154, 155, 157, 158, 160, 161, 164, 166, 177, 180, 187, 188, 189, 191, 196, 197, 209, 210, 214 DSM-II, vii, 5, 10, 33, 63, 65, 68, 76, 78, 80, 82, 85, 89, 90, 93, 99, 100, 101, 104, 105, 113, 114, 119, 149, 154, 158, 164, 166, 187, 188, 191 DSM-III, vii, 5, 10, 33, 63, 65, 68, 76, 78, 80, 82, 85, 89, 90, 93, 99, 100, 101, 104, 105, 113, 114, 119, 149, 154, 158, 164, 166, 187, 188, 191 DSM-IV, viii, ix, 3, 4, 5, 9, 10, 17, 19, 20, 26, 31, 35, 39, 40, 41, 45, 66, 67, 71, 73, 76, 80, 81, 86, 92, 93, 94, 96, 98, 99, 103, 104, 106, 108, 109, 110, 111, 112, 113, 114, 115, 118, 119, 122, 123, 124, 139, 140, 146, 148, 149, 152, 154, 157, 160, 177, 180, 189, 196, 197, 209, 214 duration, 27, 45, 125, 127, 159 dysphoria, 93, 94 dysregulation, 22, 59 dysthymia, 93, 98, 100, 125, 126, 156, 195, 201, 202, 203, 204, 205, 206 dysthymic disorder, 99, 125

E eating, 20, 132 eating disorder(s), 20, 39, 132 economic status, 20, 176 education, 20, 39, 46, 121 ego, 2, 7, 12, 17, 22, 23, 24, 25, 32, 37, 51, 55, 162, 179 elaboration, 7, 37, 208 email, 103

emotion, 5, 8, 22, 23, 54, 56, 59, 161 emotion regulation, 8, 54, 56, 161 emotional abuse, 96 emotional stimuli, 132 emotionality, 4, 73 emotions, 6, 15, 16, 22, 23, 25, 36, 131, 177 empathy, 24, 161 employment, 39, 157 energy, 25 engagement, vii, 1, 2, 3, 24 enthusiasm, 34 environment, 80, 127, 161, 174, 175 environmental, 6, 32, 36, 45, 73, 79, 82, 127, 152, 174, 176, 183, 185, 189 environmental factors, 152, 176, 189 environmental influences, 73 epidemiological, 176 epidemiology, 164, 177 estimating, 8 etiology, 14, 152 etiopathogenic factors, 172 European, 76, 81, 82, 148, 149, 191, 193 evidence, viii, ix, 34, 73, 76, 80, 82, 91, 93, 95, 96, 121, 122, 123, 125, 130, 136, 152, 158, 164, 166, 172, 178 evolution, x, 83, 171 evolutionary, 6 exclusion, 214 exercise, 105 experimental condition, 127 expert, vii, 1, 2, 8, 9, 10, 11, 17, 19, 21, 22, 25, 26, 27, 39, 42, 45, 197 expertise, 72 experts, 39, 46, 169 exposure, 94, 95, 97, 99, 100, 161 external environment, 125 external influences, 122, 130 externalizing disorders, 76, 78 extraversion, 94, 139, 140, 143, 145, 146, 148, 179, 182 extroversion, 175 eye, 128 eye movement, 128 eyes, x, 64, 213, 214

F facial expression, 22 factor analysis, 16, 66, 99 failure, 31, 75, 110, 115, 147 false negative, 92, 194, 207 false positive, 92, 138, 180, 207 family, 9, 44, 46, 78, 158, 160, 161, 175, 183

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family history, 158, 161 family therapy, 46 fatigue, 117 fear, 5, 25, 105, 147 fears, 5, 29 feelings, 5, 6, 16, 22, 23, 24, 35, 36, 38, 42, 43, 46, 48, 52, 161, 179, 185 females, 139, 181, 195 femininity, 182 feminist, 34 fibromyalgia, 127 Filipino, 67 financial problems, 45 Finland, 153 five-factor model (FFM), ix, 66, 67, 69, 71, 77, 81, 100, 135, 136, 137, 138, 139, 140, 143, 146, 147, 148, 149, 178, 187 fixation, 172 flatness, 140, 144, 145 flexibility, 72 fluctuations, viii, 121, 125 fluoxetine, 162 focusing, viii, 71, 85 food, x, 213, 214 forensic, x, 13, 104, 193, 195, 196 forensic settings, x, 193, 195 forgetting, 132 Freud, 6, 7, 17, 36, 37, 38, 73, 74 frustration, 23, 156, 178

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G GABA, 74 gastric ulcer, 45 gastrointestinal, 45 gender, 2, 20, 47, 48, 57, 67, 76, 138, 146, 148, 149, 189, 196 gender differences, 2 gender role, 3 gender-sensitive, 3 general practitioner, 20 generalized anxiety disorder, 58, 156 genetic, 10, 25, 73, 74, 75, 78, 79, 80, 152, 183, 185 genetics, 79, 80 gestures, 155, 158 global trends, 38 goal-directed, 6, 16, 36 graph, 140, 143, 146 greed, 24 grief, 58 group processes, 45, 46 group therapy, 58, 161 grouping, 183

groups, 5, 12, 13, 15, 46, 88, 90, 91, 105, 106, 146, 157, 159, 160, 162, 174, 179, 180, 207, 210 growth, 55 guessing, 194, 199 guidance, 195 guidelines, 14, 17, 162 guilt, 16, 24, 38, 179 guilt feelings, 38 gymnastics, 46

H haloperidol, 162 handedness, 213, 214, 215, 216 hardness, 43 harm, 32, 34, 71, 97, 116, 127, 128, 153, 160, 166, 167, 174 Harvard, 76, 91, 98, 100, 151, 189, 191 hate, 24, 25 headache, 45 health, 20, 31, 32, 34, 45, 97, 122, 131, 160, 166 health care, 32, 131, 160, 166 health care costs, 32 health problems, 20, 97 hegemony, 165 hemisphere, 215 heritability, 67, 78 heroin, 158, 168, 173, 175, 177, 178, 179, 180, 181, 182, 183, 186, 188, 190 heroin addicts, 173, 178, 179, 181, 182, 186, 188, 190 heterogeneity, 154, 195 heterogeneous, 152, 156 heuristic, 198 high scores, 43, 51, 136, 137, 146, 175 higher education, 158 high-risk, 160, 164 hip, 34 hippocampus, 215 histrionic personality disorder, 137, 138, 140, 143, 146, 147, 177, 178 HIV, 132, 179 homogeneity, 47 hopelessness, 157, 159, 165 hospital, 32, 33, 34, 39, 42, 45, 54, 55, 58, 60, 155, 156, 159, 166, 176 hospital stays, 159, 176 hospitalization, 5, 33, 53, 56, 125, 138, 159, 161, 162, 167 hospitalizations, 16, 33, 128, 159, 160 hospitalized, 58, 159 hospitals, 195 hostility, 32, 141, 159, 160, 165, 178

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Index human, 8, 25, 27, 66, 67, 80 human nature, 66 humans, 6, 36, 215 humiliation, 38 hybrid, 4 hyperactivity, 213 hyperarousal, 94 hypersensitivity, 127 hypertension, 45 hypochondriasis, 95, 173 hypothesis, x, 38, 44, 66, 80, 115, 127, 139, 162, 171, 185, 188, 190, 213

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I ICD, 161, 166 idealization, 38 identification, 7, 17, 22, 23, 25, 26, 27, 28, 29, 30, 33, 37, 44, 47, 51, 52, 54, 66, 73, 179 identity, 2, 17, 22, 23, 25, 26, 97, 112, 116 identity diffusion, 2, 23 idiosyncratic, 146 Illinois, 187 illusion, 80 imagination, 24 imaging, 75, 215 impairments, 8, 22, 122 implementation, 2 impulsive, 16, 29, 115, 161, 162, 164, 165, 169, 180, 182, 185, 213, 216 impulsiveness, 159, 177 impulsivity, x, 74, 95, 110, 115, 124, 127, 128, 132, 140, 157, 158, 159, 160, 161, 162, 170, 172, 173, 177, 184, 185 in situ, 104 incidence, 153, 154, 174, 215 inclusion, 36, 93, 107, 115, 148, 154, 155, 197 independence, 174 indication, 8, 32 indicators, 10, 186 indices, 15, 71, 140 infection, 179 inferences, 4 inflation, 19 informed consent, 11, 40, 109, 139 inheritance, 175 inhibition, 12, 18, 74 inhibitory, 131 initiation, 6, 36 injury, 97, 98, 116, 165 inmates, 165 insecurity, 25 insight, 2, 47, 64, 68, 73, 215

instability, 4, 21, 22, 59, 74, 92, 132, 157, 159, 162, 168 institutions, 20, 159, 174, 195 instruction, 106 instruments, vii, 1, 2, 3, 4, 9, 11, 17, 19, 21, 22, 25, 26, 27, 29, 33, 40, 42, 46, 47, 76, 105, 107, 118, 139, 178, 179 insurance, 46 integration, 21, 25, 73, 74, 216 integrity, 194, 215 intelligence, 12 intensity, 125, 129, 156, 190 interaction, ix, 5, 6, 17, 20, 28, 29, 30, 36, 38, 57, 95, 160, 171, 182 interactions, 32, 40, 152 interdisciplinary, 74 interface, 74 internal consistency, 12, 13, 14, 15, 80, 109, 112 internalization, 7, 16, 37 internalizing, 68, 73, 76, 156 international, 37, 154, 160, 161, 163, 185 interpersonal communication, 46 interpersonal relations, 7, 13, 16, 17, 19, 26, 30, 32, 34, 35, 37, 127, 152 interpersonal relationships, 7, 16, 17, 19, 30, 32, 35, 37, 127, 152 interpersonal skills, 161 interpretation, 31, 32, 33, 42, 107, 177, 187, 190, 209 interval, 78 intervention, 3, 7, 35, 37, 39, 45, 46, 175 interview, vii, viii, 1, 8, 14, 16, 19, 21, 23, 24, 30, 40, 53, 54, 61, 65, 82, 83, 85, 91, 92, 101, 103, 104, 105, 106, 107, 108, 110, 112, 113, 114, 115, 117, 119, 194, 214 interviews, viii, 4, 5, 7, 10, 16, 22, 24, 26, 35, 40, 45, 57, 65, 84, 85, 89, 92, 96, 101, 103, 104, 105, 106, 107, 109, 110, 112, 113, 114, 115, 116, 118, 119 intimacy, 73 intoxication, 125, 126 introspection, 2 introversion, 95, 137, 175, 179, 182 inventories, viii, 14, 17, 103, 107, 108, 109, 112, 113, 114, 117, 118, 138, 149, 208 investigations, 2, 35, 38 investment, 33 irritability, 4, 110, 116 Italy, 151, 213

J jobs, 115 joints, 45

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judge, 116 judgment, ix, 10, 116, 152

K Kentucky, 103, 135, 139 killing, 156 Korean, 67

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L lack of control, 156 language, 66, 193, 194, 195, 209 laterality, 214, 216 laws, 159 lead, 5, 22, 26, 28, 30, 33, 38, 65, 75, 152, 184 leakage, 16 learning, 73 left hemisphere, 215 left-handed, 214, 216 leisure, 117 lesions, 216 libido, 25 life satisfaction, 34 lifespan, 124 lifestyle, 131, 156 lifetime, 5, 91, 124, 130, 153, 154, 156, 157, 158, 160 likelihood, 86, 95, 97, 104, 105, 117, 198 limitation, 116, 117, 197 linear, 21, 136, 137, 140, 146, 147, 196 links, 10, 73 listening, 4 literature, viii, ix, 3, 9, 10, 19, 23, 31, 34, 35, 64, 65, 72, 73, 81, 85, 86, 94, 96, 100, 127, 136, 149, 151, 154, 158, 160, 161, 162, 163, 172, 195 lithium, 129, 163, 170 location, 144 London, 53, 188, 215 longitudinal studies, 95, 96, 173 longitudinal study, 29, 59, 132, 174, 175, 188 long-term, 28, 29, 32, 35, 44, 55, 170 love, 156

M maintenance, 6, 33, 36, 176, 180, 181, 187 major depression, 15, 80, 93, 119, 126, 153, 154, 156, 157, 159, 160, 164, 165, 169, 195, 201, 202, 203, 204, 205, 206, 207 major depressive disorder, 99, 163, 170 males, 11, 86, 139, 155, 167, 174, 181, 195

management, 27, 54, 83, 161, 162 manic, 201, 202, 203, 204, 205, 206 marriage, 156 masculinity, 182 maternal care, 23 matrix, 17 maturation, 125, 129, 183 measurement, 48, 51, 59, 60, 77, 81, 83, 124, 138 measures, viii, ix, x, 10, 33, 35, 64, 65, 67, 68, 69, 70, 71, 78, 83, 85, 86, 88, 91, 92, 94, 96, 98, 101, 112, 118, 130, 135, 136, 152, 157, 162, 193, 198, 199, 204, 205 median, 19, 20, 21, 40, 41, 44, 69, 105, 107 mediators, 28, 30, 35 medication, x, 20, 40, 42, 45, 107, 129, 162, 171, 183, 184, 188, 190 medicine, 45, 46 men, viii, 3, 9, 12, 19, 20, 39, 44, 51, 79, 85, 94, 96, 132, 153, 165, 177, 214 mental disorder, vii, 34, 52, 76, 79, 97, 118, 130, 152, 153, 156, 164, 165, 166, 175, 184, 186, 187, 196, 208 mental health, 9, 34, 109, 122, 157, 186 mental health professionals, 122 mental illness, 11, 22 mental life, 73 mental representation, 74 mental retardation, 152, 215 mental state, 8, 53 mental states, 8 meta-analysis, 35, 55, 56, 68, 75, 136, 155, 163, 164, 167 metacognitive, 7, 8, 37 metaphors, 106 metric, 199 Microsoft, 17 middle class, 13 migraine, 45 military, 95, 155 Millon Clinical Multiaxial Inventory, ix, x, 80, 82, 98, 100, 114, 135, 137, 139, 148, 149, 178, 187, 189, 193, 208, 209, 210 Mini International Neuropsychiatric Interview, 154 Minnesota, 97, 118, 131, 148, 173 misleading, 29 models, x, 6, 21, 36, 54, 66, 67, 68, 69, 70, 72, 75, 81, 82, 94, 96, 171, 174, 175, 182, 184, 210 moderators, 27, 28, 30 modules, vii molecules, 162 monotherapy, 163 mood, 4, 20, 23, 35, 45, 46, 73, 75, 78, 81, 93, 98, 99, 125, 126, 156, 158, 162, 165, 196

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Index mood disorder, 20, 45, 78, 93, 125, 156, 165 moral standards, 16 morality, 73 morals, 60 morbidity, 191 morning, 39, 40, 46, 105 mortality, 154, 157 mortality rate, 157 motivation, 5, 6, 36, 45, 47, 71, 72, 74 motor function, 215 motor system, 216 movement, 215 multiple personality, 181 multiple personality disorder, 181 multiplicity, 176 multivariate, 38 muscle relaxation, 46 music, 39, 46 music therapy, 39 myocardial infarction, 94, 97

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N narcissism, 23, 136, 143 narcissistic, ix, 3, 24, 25, 33, 38, 42, 43, 55, 71, 72, 81, 88, 94, 105, 117, 135, 137, 138, 139, 140, 143, 144, 146, 147, 148, 151, 154, 155, 160, 165, 166, 177, 178, 180, 181, 184, 194, 200, 202, 203, 204, 205, 206, 207, 208, 209 narcissistic personality disorder, ix, 3, 24, 25, 38, 42, 55, 135, 139, 146, 147, 148, 151, 154, 155, 160, 166, 178, 207 natural, 66, 73, 157, 191 negative affectivity, 99 negative emotions, 16, 22, 56 negative mood, 6, 36 negative predictive power (NPP), 194, 198, 199, 201, 202, 203, 207, 210, 211 negativity, 93 Netherlands, 210 network, 215 neurobehavioral, 74, 82 neurobiological, x, 171, 185 neurobiology, 59 neuroimaging, 188 neuromotor, 215 neurophysiology, 8 neurotic, 14, 45, 174, 184 neuroticism, 15, 73, 93, 94, 95, 136, 137, 139, 140, 143, 144, 145, 146, 147, 173, 179 neurotoxic, 163 neurotransmitter, 67, 74, 215 New Jersey, 151

New York, 53, 55, 56, 58, 60, 79, 80, 81, 83, 98, 99, 100, 118, 119, 132, 149, 165, 169, 170, 187, 188, 189, 191, 208, 209, 210 New Zealand, 56, 57, 59 non-clinical population, 136 non-linear, 136, 147 norepinephrine, 74 normal development, 7, 37 North America, 58, 131, 132, 133 Northern Ireland, 164 Norway, 158 novelty, 160, 174, 175, 184 novelty seeking, 160 nurses, 46 nutrition, 46

O objectivity, 14 observations, 4, 26, 75, 92, 106, 107, 113, 115, 213 observed behavior, 74 obsessive-compulsive, 48 obsessive-compulsive disorder (OCD), 45, 169, 178, 213 occupational, 5, 35, 39, 122, 152, 159 occupational therapy, 39 odds ratio, 156, 199 offenders, 13, 154, 167, 168 olanzapine, 162, 163 old age, 129 openness, 12, 13, 75, 139 openness to experience, 139 opiates, 173, 177, 179, 189 optimism, 99 organization, 33, 45, 57, 67, 74, 75, 131, 196, 216 organizations, 209 orientation, 12 outpatient, 2, 3, 30, 64, 66, 76, 87, 88, 89, 90, 91, 109, 156, 180, 191 outpatients, viii, 3, 30, 59, 69, 78, 79, 87, 90, 91, 99, 103, 104, 107, 131, 148, 156, 195

P pain, 45, 75, 127 panic attack, 15, 16 panic disorder, 156 parameter, vii, 2, 9, 38, 39 paranoia, 95 paranoid personality disorder, 105, 160, 177 parents, 9, 75, 159 Paris, 35, 58, 158, 165, 166, 169

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Index

partnership, 44 passive, 34, 86, 88, 91, 92, 100, 105, 181 passive-aggressive, 86, 88, 91, 92, 100, 105, 181 pathology, vii, x, 3, 4, 7, 10, 24, 32, 35, 40, 41, 53, 59, 63, 65, 67, 68, 69, 71, 72, 74, 77, 81, 82, 83, 96, 124, 130, 171, 176, 182, 196, 201, 207 pathways, 216 Pearson correlations, 41, 47, 137, 140, 141 peers, 75 percentile, 10 perception(s), 2, 9, 21, 22, 23, 26, 30, 72, 79, 96, 98, 162 perceptual processing, 71 perfectionism, 98, 124 performance, 71, 78, 194, 198 periodic, 122, 129 personal, vii, 5, 28, 35, 38, 183 personality characteristics, 64, 71, 98, 175, 181, 182 personality constructs, 73 personality differences, 160 personality dimensions, 70, 98, 124, 173, 178 Personality Disorder Interview (PDI), 104, 106, 107, 108, 109, 110, 111, 112, 113, 115, 116 personality factors, 74, 82, 174 personality inventories, 187 personality research, 19, 83 personality scales, ix, 86, 135, 181 personality test, 11 personality traits, ix, x, 3, 10, 65, 66, 67, 77, 78, 80, 81, 88, 93, 94, 95, 118, 119, 135, 136, 137, 138, 140, 146, 152, 155, 164, 171, 172, 173, 175, 176, 177, 185 personality type, 68 pessimism, 93 pharmacological, 40, 46, 162 pharmacological treatment, 40, 46, 162 pharmacotherapy, 133, 167, 169 phenomenology, 133, 167 phobia, 156 physical abuse, 11, 153 physical therapy, 39 physicians, 75 pilot study, 81, 169, 197 placebo, 170 planning, vii, 1, 2, 3, 6, 8, 9, 22, 24, 57, 71, 157 play, 24, 26 policymakers, 56, 58 political, 34 poor, 19, 28, 29, 64, 131 poor health, 131 population, ix, x, 20, 31, 33, 76, 123, 148, 152, 155, 159, 176, 177, 178, 180, 189, 191, 200, 213, 214 positive correlation, 94, 128

positive predictive power (PPP), 194, 198, 199, 201, 202, 203, 207, 210 positive reinforcement, 184 postmortem, 167 posttraumatic stress, 97, 98, 99, 100, 101, 107, 133 posttraumatic stress disorder (PTSD), viii, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 133, 156 power, vii, 2, 3, 5, 26, 29, 35, 57, 172, 194, 198, 207, 208 pragmatic, 123 praxis, 61, 215 prediction, 3, 69, 83, 99, 132, 152, 164 predictors, 3, 19, 37, 38, 58, 95, 98, 101, 131, 175, 191 predisposing factors, 174 preference, 214, 215 pressure, 11 prevention, ix, 152, 161, 164 primary care, 9 prisons, 195 probability, 95, 198, 199, 200, 202, 203 problem solving, 56, 161 procedural knowledge, 6, 36 procedures, 3, 6, 8, 15, 27, 36, 38, 51, 210 prognosis, 2 program, 39, 42, 46, 100, 155, 176, 180, 197 progressive, 46, 179 prototype, 10, 26, 196, 210 psyche, 25, 172 psychiatric diagnosis, 26, 58, 122 psychiatric disorders, 58, 86, 122, 131, 152, 155, 176, 188, 213 psychiatric hospitals, 159, 195 psychiatric patients, 28, 29, 30, 39, 52, 104, 137, 152, 194, 216 psychiatrist, 11, 16, 20, 45, 46, 162 psychiatrists, 22, 52 psychiatry, 9, 39, 46, 60, 160 psychoactive, 159, 175 psychoanalysis, 7, 32, 36, 37, 53, 56, 60 Psychoanalysis, 1, 28, 30 psychoanalytic theories, 8 psychobiology, 187 psychological development, 20 psychological health, 10, 136 psychological resources, 5, 72 psychologist, 46, 197 psychology, 8, 32, 33, 79, 139, 197 psychometric properties, 67 psychopathic, 10, 78, 95, 173, 182

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Index

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psychopathology, 6, 23, 36, 60, 68, 73, 74, 75, 76, 77, 78, 79, 81, 83, 119, 126, 130, 133, 156, 158, 163, 168, 169, 183 psychopaths, 166 psychopathy, 10, 156 psychopharmacology, 55, 129 psychophysiological, 132 psychoses, 213 psychosis, 10, 45, 74 psychosocial, 31, 125, 126, 127, 129, 162, 164, 166, 188 psychosocial development, 188 psychosocial stress, 125, 126, 127, 129 psychosomatic, 3, 13, 27, 28, 30, 38, 44, 45, 46, 51 psychotherapeutic, vii, 1, 2, 3, 6, 7, 15, 20, 21, 29, 30, 31, 37, 40, 44, 46, 47, 48, 51, 53, 54, 57, 59, 161, 164 psychotherapy, vii, 1, 2, 3, 5, 6, 7, 8, 9, 13, 14, 19, 24, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 45, 46, 53, 54, 55, 56, 57, 58, 59, 60, 61, 81, 125, 128, 129 psychotic, 20, 39, 45, 53, 81, 105, 162, 170, 182, 207 psychotic symptoms, 81, 162, 207 psychoticism, 40, 162, 179 psychotropic drugs, 162, 164 psychotropic medications, 125, 129 public, ix, 31, 152, 160, 180, 209 public health, ix, 31, 152, 160 Public Health Service, 30 public welfare, 209

Q quality of life, 99 questionnaire, x, 21, 22, 25, 27, 40, 41, 47, 51, 61, 92, 99, 114, 139, 140, 148, 178, 181, 213, 214 questionnaires, viii, 9, 11, 21, 22, 23, 24, 25, 40, 92, 103, 108, 109, 117, 176, 181, 207 quetiapine, 170

R random, 194, 199 range, 5, 12, 14, 15, 35, 69, 70, 72, 73, 94, 110, 140, 152, 154, 194, 195, 196, 197, 199, 202 rating scale, 19, 21, 53, 60 ratings, vii, 1, 2, 8, 9, 16, 17, 19, 21, 22, 25, 69, 71, 81, 113, 114, 162, 194, 195, 196, 197, 198, 201, 214 reactivity, 4, 127 reality, 17, 21, 30, 42, 161 reasoning, 106

227

recall, 96 recession, 126, 127, 129 recovery, 132, 191 recreational, 116 reduction, x, 6, 36, 42, 43, 44, 51, 128, 129, 161, 162, 163, 171, 179, 183 reflection, 161 refuge, 9 regression, vii, 1, 3, 21, 42, 153 regulation, vii, 1, 3, 6, 8, 9, 11, 16, 21, 23, 26, 28, 29, 30, 35, 36, 39, 57, 59, 60, 73, 132, 177 rejection, 127, 147, 179 relationship, viii, ix, 5, 7, 8, 9, 16, 19, 27, 28, 30, 33, 34, 37, 38, 39, 40, 43, 44, 47, 48, 53, 58, 68, 69, 74, 85, 86, 92, 93, 94, 95, 97, 98, 99, 115, 125, 128, 135, 136, 137, 138, 140, 143, 145, 146, 148, 153, 156, 157, 159, 161, 165, 182 relationships, viii, ix, 5, 7, 8, 13, 16, 17, 24, 25, 35, 37, 73, 85, 91, 93, 94, 95, 97, 128, 131, 135, 136, 137, 146, 148, 160, 196 relatives, 10, 99, 153 relaxation, 46 relevance, viii, 2, 28, 29, 35, 85 reliability, 10, 11, 12, 13, 14, 15, 16, 17, 40, 41, 53, 64, 67, 70, 78, 80, 96, 100, 104, 114, 115, 118, 194, 197, 198 religious, 160 religious beliefs, 160 remission, 123, 125, 126, 127, 129, 130 replication, 132, 140, 143, 145 reprocessing, 128 research design, 197 researchers, 4, 58, 66, 70, 71, 74, 75, 94, 96, 130, 153, 157, 174, 175, 176, 179, 181, 194, 197 residential, 34, 153, 191 resilience, 27, 28 resistance, 2, 24 resolution, 6, 36, 161 resources, 8, 160, 183 respiratory, 15 responsiveness, 127 retention, 6, 36 rewards, 174, 175 right hemisphere, x, 213 risk, ix, 31, 33, 79, 95, 101, 147, 152, 153, 154, 155, 157, 158, 159, 160, 161, 162, 163, 164, 166, 167, 168, 170, 173, 175, 177, 183, 184 risk behaviors, 95 risk factors, ix, 31, 79, 95, 152, 154, 158, 159, 160, 161, 166, 168 risperidone, 170 romantic relationship, 127, 131 Rome, 151

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Russian, 67

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S safety, 111, 116, 156 sales, 146 sample, vii, 1, 2, 3, 9, 10, 11, 13, 14, 15, 19, 20, 22, 24, 26, 27, 28, 29, 30, 33, 40, 41, 42, 47, 53, 66, 69, 70, 81, 83, 85, 88, 90, 91, 93, 94, 95, 98, 137, 138, 139, 146, 148, 153, 154, 155, 158, 160, 168, 169, 173, 174, 175, 177, 178, 179, 180, 181, 182, 187, 190, 194, 195, 196, 197, 198, 200, 201, 214, 215, 216 sample mean, 137, 146 scaling, 14 scandal, 155 Scandinavia, 76, 82 scatter, 22 Schedule for Nonadaptive and Adaptive Personality (SNAP), 89, 90, 91, 107, 108, 109, 110, 111, 112, 113, 114, 117, 124, 136, 139, 140, 141, 142, 143, 144, 145, 146, 147 scheduling, 72 schema, viii, 63 schizoaffective disorder, 162, 163 schizoid personality disorder, 3, 137, 155, 160, 177, 210 schizophrenia, 31, 39, 74, 153, 162, 163, 170, 173, 182 schizotypal personality disorder, 119, 160, 169, 178 Schizotypal Personality Disorder, 4 schizotypy, 10 school, 9, 20, 39, 44, 172, 175 science, viii, 13, 14, 63, 75, 81, 149, 197 scores, x, 10, 15, 16, 25, 26, 40, 41, 42, 43, 47, 48, 51, 53, 66, 67, 68, 69, 71, 76, 86, 88, 90, 95, 101, 126, 136, 137, 138, 140, 143, 146, 148, 160, 174, 175, 179, 181, 182, 188, 190, 191, 193, 194, 197, 198, 199, 201, 207 search, 154, 161 search engine, 161 search terms, 154 searches, ix, 151, 154 searching, 16, 17 secondary students, 179 sedatives, 158 seeds, 23 selecting, 174 self-assessment, 8, 9, 22, 24 self-awareness, 42, 46 self-concept, 2, 21, 22 self-confidence, 73, 147 self-destructive behavior, 158

self-efficacy, 2 self-esteem, 16, 25, 34, 93, 147, 179 self-image, 75, 112, 196 self-mutilation, 170 self-organization, 77 self-organizing, 82 self-presentation, 64 self-regard, 73 self-reports, 47, 68, 70, 71, 72, 79 semantic, 13 semi-structured interviews, viii, 103, 104, 105, 106, 107, 109, 110, 112, 113, 114, 115, 116, 117 sensation, 177 sensations, 46, 184 sensitivity, x, 5, 15, 48, 127, 171, 178, 183, 194, 198, 199, 201, 202, 203, 207, 211 sentences, 14, 25 separation, 159 series, 126, 172, 173, 176 serotonin, 67, 74, 162 severity, 14, 31, 33, 53, 65, 82, 95, 96, 99, 126, 155, 159, 162, 166, 181, 184, 186, 190 sex, 11, 13, 14, 96, 116, 152, 155, 166, 176 sexual abuse, 153 shame, 38 shape, ix, 135, 137, 143, 144, 145 short period, 46 side effects, 163 sign, 23 signal detection theory, 209 signs, 172 similarity, 93 sites, 162 skills, 72, 161, 215 skills training, 161 sleeping problems, 45 social activities, 159 social adjustment, 157, 159, 160, 169 social environment, 183 social group, 147 social impairment, 69 social norms, 16 social phobia, 156 social problems, 159, 174, 183 social situations, 5, 35, 147 social support, 96 social withdrawal, 88, 92, 93 social work, 46 socialization, 179 society, 60 sociology, 188 sociopath, 156 software, 209

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Index somatic symptoms, 15, 46, 122 somatization, 29, 40, 44, 97, 182 South Africa, 153 Spain, 186 specialists, 9, 39, 46 species, 67 specificity, 5, 34, 54, 72, 101, 131, 188, 194, 198, 199, 201, 203, 207, 211 spectra, 68, 73 spectrum, 15, 32, 39, 162, 177, 189 speech, 64, 74, 215 spine, 45 sprain, 75 SPSS, 17, 41, 47 St. Louis, 77, 131, 187 stability, 15, 17, 58, 78, 81, 99, 123, 124, 125, 129, 131, 138, 149, 180, 185 stabilization, 187 stabilizers, 46, 162 stages, 13, 172, 173, 181 standard deviation, 9, 13, 39, 47, 69, 199, 210 standard error, 70 standards, 15, 73, 198 starvation, 128 State/Trait Anxiety Inventory (STAI), 11, 17, 18, 19, 22 statistical analysis, 154 statistics, x, 193, 194, 195, 198, 199, 200, 201, 202, 203, 204, 207, 209 stereotypes, 3 stigma, 31 strain, 11, 25, 45 strategies, ix, 6, 36, 56, 152, 161, 189 strength, 25, 32, 114, 136, 137, 146, 179, 194 stress, viii, x, 72, 81, 85, 91, 97, 98, 159, 171, 183, 201, 202, 203, 204, 205, 206 stressful events, 160 stressors, 125, 127, 129, 164 student group, 179 students, 12, 39, 69, 88, 138, 139, 179 subgroups, 100, 175, 179, 181 subjective experience, 3, 71, 74 subjectivity, 27 substance abuse, ix, 76, 91, 128, 133, 152, 154, 156, 157, 158, 159, 161, 164, 168, 172, 175, 176, 178, 186, 189, 190, 191, 207, 208 substance use, 73, 79, 126, 128, 157, 168, 174, 176, 190, 191 substitutes, 183 substrates, 74 suffering, 21, 22, 23, 31, 155 suicidal behavior, ix, 55, 151, 153, 155, 156, 157, 158, 159, 160, 164, 165, 166, 168, 169

suicidal ideation, 152, 155, 168 suicide, ix, 5, 10, 16, 31, 33, 131, 151, 152, 153, 154, 155, 156, 157, 158, 159, 160, 161, 162, 163, 164, 165, 166, 167, 168, 169, 170, 179 suicide attempters, 152, 153, 156, 158, 159, 160, 164, 165, 166 suicide attempts, 5, 10, 16, 31, 33, 131, 153, 154, 156, 157, 158, 159, 160, 161, 165, 166, 167, 168, 169 suicide rate, 158 superego, 7, 37, 179 superiority, 67 survival, 155 survivors, 87, 90, 91, 98, 99, 165 Sweden, 158, 166 sympathy, 13 symptom, viii, 14, 15, 25, 40, 71, 76, 77, 87, 88, 95, 96, 100, 121, 123, 125, 126, 127, 128, 129, 130, 152, 155, 157, 161, 166, 172, 195, 196, 199, 201, 202, 203 symptoms, viii, x, 6, 14, 15, 24, 29, 32, 34, 36, 39, 42, 45, 47, 48, 66, 67, 70, 71, 73, 92, 93, 94, 95, 97, 99, 101, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 148, 162, 163, 172, 184, 185, 196, 202, 207 syndrome, 40, 97, 98, 100, 127, 156, 163, 196, 197, 199, 204, 213 systems, 67, 74, 78, 79, 83, 131, 185

T taxonomic, 80, 118, 149 taxonomy, 4 teachers, 75 teaching, 161 telephone, 109 temperament, 67, 75, 81, 82, 108, 196 temporal, 96, 123, 124, 138, 185 tension, 15 test scores, 207 test-retest reliability, 77, 78, 119, 139 theoretical, ix, 7, 16, 17, 37, 47, 51, 70, 76, 114, 136, 182 theory, vii, viii, ix, 2, 4, 6, 7, 8, 13, 34, 36, 37, 39, 43, 44, 53, 54, 56, 58, 60, 72, 73, 79, 80, 82, 83, 121, 135, 138, 146, 148, 173, 184, 196, 209 therapeutic, 2, 12, 19, 24, 27, 28, 29, 31, 32, 33, 34, 35, 37, 44, 45, 46, 47, 51, 55, 58, 59, 159, 161, 162, 175, 182, 188, 194, 195, 197 therapeutic communities, 195 therapeutic community, 55, 182, 188 therapeutic interventions, 12 therapeutic process, 28, 37, 59

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Index

therapeutic relationship, 33 therapists, 29, 31, 40, 43, 46, 47, 117 therapy, vii, 1, 3, 9, 19, 20, 22, 24, 27, 28, 29, 31, 32, 33, 34, 35, 37, 38, 39, 40, 42, 44, 45, 46, 47, 52, 55, 56, 57, 79, 128, 132, 161, 163, 164, 169 thinking, 2, 7, 16, 30, 37, 67, 72, 74, 115, 128 threatened, 71 threatening, 12 threats, 155, 161 threshold, 88, 125, 130 thresholds, viii, 121 tics, 213 time, viii, 25, 26, 32, 33, 34, 38, 39, 46, 47, 54, 70, 71, 75, 104, 105, 106, 107, 113, 117, 121, 122, 123, 129, 130, 143, 147, 153, 157, 159, 160, 162, 172, 173, 182, 197, 215 tinnitus, 45 tobacco, 173 trade, 100 training, 14, 17, 22, 46, 61, 72, 122, 161, 197 traits, x, 20, 27, 28, 29, 30, 35, 38, 57, 59, 65, 66, 67, 71, 75, 80, 92, 94, 98, 140, 146, 152, 155, 158, 159, 171, 172, 173, 175, 176, 178, 182, 184, 185, 186, 191, 202, 207 tranquilizers, 40, 45, 46, 177 transcendence, 175 transcription, 17 transference, 6, 24, 26, 27, 28, 29, 31, 32, 33, 36, 37, 38, 40, 43, 44, 47, 48, 51, 128 transformation, 14 transition, 68 translation, x, 81, 149, 193, 194 transmission, 78 trauma, 23, 85, 87, 89, 90, 91, 95, 96, 98, 99, 100, 101, 128, 133 traumatic events, 94, 96, 98, 99 traumatic experiences, 23, 153 treatment methods, 44 trend, 32, 43, 129, 137, 146 trial, 30, 33, 53, 54, 58, 81, 162, 169, 195 triggers, 127, 160 true/false, 108, 139 twin studies, 67 two-dimensional, 13 typology, 175, 186, 187, 189

U unconscious influence, 74 undergraduate, 69, 88, 137, 139, 197 unemployment, 20 unemployment rate, 20 unhappiness, 75

uniformity, 76 unilateral, 215 United States, 166, 188 users, 177, 181

V valence, 6, 22, 36 validation, 10, 71, 77, 99, 194, 197, 207, 209 validity, viii, x, 10, 12, 13, 14, 15, 22, 53, 65, 67, 77, 78, 82, 92, 93, 96, 98, 100, 103, 104, 105, 109, 110, 111, 112, 113, 116, 117, 118, 139, 140, 148, 149, 193, 194, 195, 196, 197, 198, 199, 202, 204, 207, 209 values, 12, 13, 14, 15, 19, 41, 47, 69, 75, 155, 174, 178, 196, 198, 201, 202, 203, 204, 207 variability, 69 variable, 70, 96, 105, 175 variables, x, 2, 10, 16, 22, 27, 28, 29, 33, 34, 35, 36, 38, 39, 51, 67, 97, 99, 171, 175, 176, 183, 184, 186, 189, 190 variance, 10, 21, 40, 41, 69, 71, 95, 113 variation, 8, 67, 70, 106, 107, 113, 114, 115, 117 vascular, 15 venlafaxine, 162 veterans, viii, 78, 85, 86, 87, 88, 89, 90, 95, 96, 97, 98, 99, 100, 101 victims, 85, 99, 152, 155 video, 46 Vietnam, 86, 87, 99, 100 violence, 32, 153, 161, 164 violent, 31, 97, 156, 160 violent crime, 97 virus, 31 visual, 106 vocational, 20, 44 voluntarism, 190 vulnerability, 75, 95, 155, 167, 185, 186

W walking, 46 war, 101 Washington, 52, 58, 76, 77, 82, 97, 98, 101, 118, 119, 130, 131, 132, 149, 186, 187, 208 weakness, 23 wealth, 95 welfare, 46 well-being, 46, 186 western countries, 152 WHO, 166 Wisconsin, 114, 118

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Index

Y yield, ix, 26, 70, 105, 124, 136 young adults, 54, 100, 168 young men, 164, 165 young women, 131

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withdrawal, 96 women, viii, 2, 3, 9, 12, 13, 19, 20, 31, 39, 44, 48, 79, 85, 88, 89, 90, 91, 94, 96, 97, 99, 133, 153, 177, 214, 215 workers, 72, 100 worry, 15

New Research on Personality Disorders, edited by Ida V. Halvorsen, and Sarah N. Olsen, Nova Science Publishers, Incorporated, 2008. ProQuest