Measuring Change in Attachment Insecurity Using Short Forms of the ECR-R: Longitudinal Measurement Invariance and Sensitivity to Treatment.

Attachment insecurity is important for psychotherapy both as an aspect influencing the therapeutic process as well as potential outcome variable of a treatment. Two German short forms of the Experiences in Close Relationships - Revised (ECR-R) have been proposed to assess individual differences in attachment anxiety and avoidance. In this research, we examined whether these questionnaires are suitable for measuring change in attachment anxiety and avoidance by testing longitudinal measurement invariance in two independent clinical samples (N1 = 493, N2 = 273) using a pre-post design. Results indicated that strict longitudinal measurement invariance can be assumed for both measures. Thus, changes in scale scores before and after treatment can be interpreted as changes in the latent dimensions of attachment anxiety and avoidance. Both questionnaires were also sensitive to treatment in that attachment insecurity was overall reduced after therapy. Although both measures appear to be generally suitable for investigating treatment effects, they exhibited consistent problems with structural validity across samples that should be reexamined in future research.

[Personality functioning and physical health]. / Persönlichkeitsstruktur und körperliche Gesundheit.

Objectives: Considering direct and indirect evidence of associations between deficits in personality functioning and high somatic morbidity, our exploratory study determined whether and, if so, which physical illnesses may be associated with impairments in personality functioning. Method: A large sample of diagnostically heterogeneous psychotherapy inpatients (N = 5401) was assessed with the short version of the Structural Questionnaire of the Operationalized Psychodynamic Diagnosis (OPD-SQS) and the Work Ability Index (WAI). In addition, discharge diagnoses were recorded. For a subsample (N = 2582), levels of personality functioning were assessed by their therapists according to the OPD system. Results: While consistent associations were found between personality functioning and neurological, urogenital, dermatological, and musculoskeletal disorders, findings on possible associations with other disorders revealed inconsistencies. The number of diseases as surrogate marker for disease burden was significantly associated with several indicators of personality functioning. Conclusions: Our results suggest associations between impairments in personality functioning and poor physical health. We discuss potential mechanisms as well as clinical implications.

[Attachment predicts changes in the level of personality functioning after psychotherapeutic inpatient treatment]. / Bindung als Prädiktor von Strukturveränderungen im Verlauf von stationärer Psychotherapie.

Objectives: The relationship between patients' attachment strategies and the effectiveness of psychotherapy is empirically well established. However, studies on outcome measures other than symptomatic change are mostly lacking. The present study investigates if attachment anxiety and avoidance predict changes in personality functioning at the end of inpatient psychotherapy. Method: In two independent samples (the first sample consisting of N = 967 diagnostically heterogeneous patients, Fachklinikum Tiefenbrunn, and the second sample comprising N = 344 patients with personality impairments, Rehaklinik Bad Grönenbach), personality functioning was assessed by means of the short version of the OPD structure questionnaire OPD-SQS (OPD-Strukturfragebogen 12-Item-Screeningversion, OPD-SFK) at admission and discharge in a naturalistic study design. Data on the Brief Symptom Inventory (BSI) and the Inventory of Interpersonal Problems (IIP-32) were evaluated as additional outcome measures in the first sample. Patients' attachment strategies were assessed at admission using the German short version of the Experiences in Close Relationships (ECR-RD 12). Results: Attachment avoidance at baseline was inversely associated with improvements in personality functioning, psychopathology, and interpersonal problems. In the sample of patients diagnosed with personality disorders (sample 2), we found a negative association between attachment anxiety and improvements in the ability to make contact with others. Conclusions: Considering the limitations, our results underline the relevance of attachment for the treatment outcome of inpatient psychotherapy. The assessment of patient's attachment strategy as part of standardized diagnostics can be helpful in clinical practice regarding prognosis, therapy planning as well as the adjustment of the therapeutic relationship while treating patients suffering from impairments in personality functioning.

Differences by sexual orientation in treatment outcome and satisfaction with treatment among inpatients of a German psychiatric clinic.

A wealth of research suggests that sexual minority individuals experience stigma and lack of sexual minority specific competencies in mental health care, which could lead to less optimal treatment outcome. However, most related research suffers from methodological limitations, such as selected samples, retrospective design, or not assessing treatment outcome. To overcome some of these limitations, we explored if sexual minority patients have poorer treatment outcome and are less satisfied with treatment in a mental health care setting not specialized in sexual minority issues. The analytical sample comprised 5609 inpatients, including 11% sexual minority patients, from a German psychiatric clinic. Outcomes were improvement in well-being and depression from admission to discharge, and satisfaction with treatment judged at discharge. Nearly all sexual orientation differences were in a direction hinting at less improvement of depression and well-being and less satisfaction among sexual minority compared to heterosexual patients. However, the differences were generally small and not statistically significant. Stigma and lacking sexual orientation specific competency in healthcare may not be universally present or not as severe as studies with other research designs suggested. However, this needs to be investigated in more clinical settings by including sexual orientation as part of the routine assessment. Moreover, adequate sexual-minority specific competencies are important in any case, not just to prevent that sexual minority patients benefit less from treatment.

[Measurement of Change with the Short Form of the OPD Structure Questionnaire (OPD-SQS)]. / Veränderungsmessung mit der Kurzform des OPD-Strukturfragebogens (OPD-SFK).

The transdiagnostic concept of personality structure plays a key role in psychodynamic nosology, since many mental and psychosocial disorders are considered mainfestations of structural vulnerabilities and deficits. Therefore, structural diagnostics is of particular importance, especially with respect to the planning of tailor-made psychotherapeutic interventions. Because changes in personality structure are increasingly being considered as a relevant therapeutic goal, any measures employed towards achieving this goal should be sensitive enough to capture these changes appropriately. Although the short form of the OPD Structure Questionnaire (OPD-SQS) can easily be administered and is therefore frequently used in clinical and research settings, its sensitivity to change has not yet been analyzed. Two large, independent and diagnostically heterogeneous samples of inpatient psychotherapy patients (n=1183 and n=967, respectively) completed the OPD-SQS both at admission and before discharge. Standardized Effect Size (SES), Standardized Response Mean (SRM) and Smallest Real Difference (SRD) were computed as indicators of the measure's ability to capture change. For the OPD-SQS and its subscales, low effect sizes were found in both samples (SES between 0.23 and 0.48; SRM between 0.27 and 0.53). Additionally, it was demonstrated that greater changes among patients with structural deficits were detectable with the OPD-SQS compared to those without structural deficits, and that these group differences were significant. By means of the SRD, we determined a proportion of about 22% of patients with significantly structurally improved changes in both samples. Despite some methodological issues, our findings suggest that the OPD-SQS is suitable for measuring changes in personality structure in inpatients between the beginning and the end of treatment. Since studies on the sensitivity to change of similar assessment tools are still pending, it is not yet possible to formulate any empirically validated recommendations as to which of the measure best captures therapeutically induced changes in personality structure.

A psychometric evaluation of the Standardized Assessment of Severity of Personality Disorder (SASPD) in nonclinical and clinical German samples.

The Standardized Assessment of Severity of Personality Disorder (SASPD) is a 9-item self-report screening instrument and was developed to assess personality disorder (PD) severity according to the initial proposal of ICD-11. Our aim was to investigate the psychometric properties of the German version of the SASPD in nonclinical and clinical samples. A total of 1,991 participants (N = 888 from nonclinical and N = 1,103 from clinical samples) provided ratings on the SASPD as well as other measures of psychopathology and personality. We examined the SASPD regarding its factor structure, internal consistency, and construct validity. A unidimensional structure of the SASPD provided inadequate model fit, whereas a 3-factor solution provided good fit in both the nonclinical and clinical samples. Internal consistency of the SASPD total score was acceptable in the clinical and nonclinical samples based on this multifactorial model. In terms of convergent validity, SASPD scores correlated fairly with other measures of PD severity across samples. Discriminant validity with measures of general symptom distress and measures of (normal) personality traits was mixed. In addition, the SASPD scores predicted levels of PD severity above and beyond a measure of symptom distress. The SASPD captures some theoretically expected features of PD severity. However, the multidimensional structure and limited convergent and discriminant validity may hamper future usage of the SASPD as a short screening tool of PD severity according to ICD-11. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

[Psychodynamic Oriented Multimodal Therapy for Inpatients with Borderline Personality Disorder: Effectiveness, Response, and Dropout]. / Stationäre psychodynamisch orientierte multimodale Therapie von Patienten mit Borderline-Persönlichkeitsstörung: Wirksamkeit, Response und Drop-out.

Psychodynamically oriented multimodal therapy approaches are efficacious for outpatients with borderline personality disorder (BPD). Until now, no study has reported the effectiveness, response, and dropout in a psychodynamic oriented multimodal therapy program for inpatients (PDOMT). In this study, we compared the results of 269 individuals seeking a 3-month inpatient treatment with previous studies for BPD inpatients by examining 269 individuals. The Borderline Personality Index (CUT-20-R) was used as the main outcome measure. Therapy outcome was defined in effect size (ES), response, and remission rates. In the pre-post comparison of the CUT-20-R, the ES was 0.74. The response and the remission rates were 34.6% and 2.6%. 50.6% of participants remained unchanged, 6.7% deteriorated, and 27.5% finished treatment prematurely. Male gender and patients with a dependent personality disorder increased the dropout risk. The results suggest that PDOMT might be effective for some, but not all BPD patients. Due to methodological shortcomings of the chosen strategy, future research should examine the effectiveness of PDOMT in a randomized controlled trial.

[Treatment Outcome in Female In-Patients with Anorexia nervosa and Comorbid Personality Disorders Prevalence - Therapy Drop out and Weight Gain]. / Stationärer Therapieerfolg bei Patientinnen mit Anorexia Nervosa und komorbiden Persönlichkeitsstörungen.

Introduction Personality disorders (PD) are among the most common comorbid disorders in female patients with Anorexia Nervosa (AN). Recent research findings suggest that comorbid PD are associated with a higher treatment drop-out rate and a worse therapeutic outcome. However, no study to date has distinguished between certain age groups concerning these issues. Research questions Therefore, the present study focuses on the prevalence of PD (1), treatment drop-out rates (2) and weight gain (3) in female in-patients with AN. Thereby, we differentiate among three age groups (17-24 years; 25-34 years; 35-65 years). Material & Methods We assessed female in-patients (N=331) with AN at the Helios Clinic in Bad Grönenbach in Germany using the Eating Disorders Inventory-2 and the psychotherapeutic-medical basic documentation at the beginning and at the end of their treatment. Furthermore, we investigated the drop-out rate and weight gain by comparing anorexic patients with and without comorbid PD that were diagnosed by clinicians using ICD-10 criteria. Results In sum, our patients with AN demonstrated a prevalence rate of 34% for one or more comorbid PD. Interestingly, patients between 17-24 years showed a lower prevalence rate of 22% compared to those between 25-34 years (42%) and 35-65 years (41%). Furthermore, younger age and comorbid PD seemed to be significant predictors for treatment dropout. One of the most striking results was that younger patients (17-24) without a comorbid PD had the highest weight gain during treatment. This could not be observed in patients with a comorbid PD, who demonstrated the highest weight gain between 25 and 34 years of age. Conclusion Our findings support the hypothesis that comorbid PD are related to a worse outcome in patients with eating disorders. Future studies might do well in assessing dimensional scores of personality disorders and other relevant aspects like for example the amount of social support to draw further conclusions on these associations. Our results emphasize the need for more disorder-specific interventions tailoring at patients with AN and comorbid PD to improve treatment outcome.

Expanding the Nomological Net of the Pathological Narcissism Inventory: German Validation and Extension in a Clinical Inpatient Sample.

The Pathological Narcissism Inventory (PNI) is a multidimensional measure for assessing grandiose and vulnerable features in narcissistic pathology. The aim of the present research was to construct and validate a German translation of the PNI and to provide further information on the PNI's nomological net. Findings from a first study confirm the psychometric soundness of the PNI and replicate its seven-factor first-order structure. A second-order structure was also supported but with several equivalent models. A second study investigating associations with a broad range of measures ( DSM Axis I and II constructs, emotions, personality traits, interpersonal and dysfunctional behaviors, and well-being) supported the concurrent validity of the PNI. Discriminant validity with the Narcissistic Personality Inventory was also shown. Finally, in a third study an extension in a clinical inpatient sample provided further evidence that the PNI is a useful tool to assess the more pathological end of narcissism.

[Patterns of dysfunctional parenting styles and psychological disturbances in offspring]. / Muster dysfunktionaler Erziehungsstile und psychische Storungen im Erwachsenenalter.

OBJECTIVES: Dysfunctional parenting styles represent a risk factor for the development of psychological disturbances. The present study investigated the differential validity of the German language Fragebogen zur Erfassung dysfunktionaler Erziehungsstile (FDEB; Measurement of Parental Styles, MOPS) and determined whether different forms of psychological disorders are associated with specific patterns of parenting styles. METHODS: 145 inpatients, 108 outpatients and a control group of 633 representative individuals from the general population were investigated by adapting the FDEB. RESULTS: A comparison of dysfunctional parenting styles showed different distress levels within the diagnostic groups: Patients suffering from depression reported high levels of maternal indifference and over protectiveness together with an abusive rearing behavior on the part of both parents. Patients with anxiety disorders reported having overprotective mothers. Bulimic patients as well as those with personality disorders significantly exhibited stress in almost all areas. However, anorexic patients did not differ significantly from the control group, which appeared to be the least affected of all. CONCLUSION: The FDEB showed a satisfactory differential validity. There was evidence that specific patterns of dysfunctional parenting styles were associated with different diagnostic groups.

Does a more specified version of the HoNOS (Health of the Nation Outcome Scales) increase psychometric properties of the inventory?

BACKGROUND: The Health of the Nation Outcome Scales (HoNOS) is a clinician-rated instrument for the differentiated measurement of severity in patients with mental disorder. Item 8 of the instrument, assessing 'Other mental and behavioral problems', is particularly relevant for patients with affective disorders, anxiety disorders, and eating and personality disorders. However, some studies have shown that the scale possesses unsatisfactory psychometric properties. The objective of the present study was therefore to validate the psychometric properties of a more specified version of the HoNOS-D item 8. METHODS: The instrument's reliability and validity were tested using a large, representative, clinical sample of patients with mental disorders (study 1: n = 1,918 and n = 1,357). Additional tests of reliability and criterion validity were performed using a further clinical sample of patients with mental disorders (study 2: N = 55). RESULTS: The extended version of the HoNOS provides a differentiated picture of additional problem areas for the patient. Although inter-rater reliability indicates a need for more detailed instructions, the problem areas of item 8 proved on the whole to be suitable for measuring the extent and severity of mental problems that are present in addition to the primary problem. CONCLUSION: In order to make the extended assessment of the HoNOS useful for clinical routine practice, a supplemental glossary is needed.

The validity of the German version of the Health of the Nation Outcome Scales (HoNOS-D): a clinician-rating for the differential assessment of the severity of mental disorders.

The Health of the Nation Outcome Scales (HoNOS) is an internationally-established clinician-rating instrument for the differential assessment of the severity of patients with mental disorders. The aim of this study was to examine the validity of the German version of the HoNOS (HoNOS-D). Evaluation of validity, including factor validity, convergent and discriminant validity and sensitivity to change, was conducted on a large, virtually representative, clinical sample of patients with mental disorders in inpatient psychotherapy (Study 1, N = 3169). Additional assessment of criterion-based validity was completed using another clinical sample of patients with mental disorders (Study 2, N = 55). Although factor validity of the HoNOS-D and its total score could not be confirmed as expected, the majority of single items of the HoNOS-D proved to be valid in terms of convergent validity, criterion-based validity and sensitivity to change. Hence, single items, rather than the total score of the HoNOS-D, can be recommended for obtaining a picture of the impairment of patients with mental disorders in the clinical setting.

Validity of routine clinical DSM-IV diagnoses (Axis I/II) in inpatients with mental disorders.

The assessment of diagnoses is a central issue in the treatment of patients with mental disorders. The aim of this study was to validate routine clinical diagnoses by means of a semi-standardized and structured interview. Semi-standardized and structured interview diagnoses were based on videos of 55 inpatients. The routine clinical diagnoses were given by therapists during the course of psychotherapy. Validation was carried out through proportional agreement, Cohen's kappa, Yule's Y, as well as the sensitivity and specificity of the diagnosis. Agreement rates between diagnoses given in semi-standardized structured interviews and those given in routine clinical assessment were low for the majority of specific disorders (e.g., major depressive disorder). Higher agreement rates were found for major diagnostic categories (e.g., eating disorders or adjustment disorders). In comparison to diagnoses according to structured interviews for inpatients with mental disorders, the validity of diagnoses given in routine clinical interviews is limited and should be improved.

Associations among attachment characteristics, patients' assessment of therapeutic factors, and treatment outcome following inpatient psychodynamic group psychotherapy.

Within a multisite study, including 289 inpatients from six different hospitals who underwent interpersonal-psychodynamic group psychotherapy, associations among attachment characteristics, therapeutic factors, and treatment outcome were investigated. Attachment characteristics were assessed with an interview-based measure (Adult Attachment Prototype Rating [AAPR]) as well as an attachment self-report (Bielefeld Questionnaire of Client Expectations [BQCE]). Therapeutic factors were measured retrospectively with the Dusseldorf Therapeutic Factors Questionnaire and treated as an individual- as well as a hospital-specific characteristic. On an individual level, only the group climate factor independently predicted treatment outcome (i.e., Symptom Checklist-90-R Global Severity Index and Inventory of Interpersonal Problems mean). If simultaneously but separately included into a path model, analyses revealed independent significant effects of AAPR-Security and BQCE-Security on group climate. If modeled as a latent variable (common attachment security), a substantially higher proportion of group climate variance could be explained. Further analyses revealed interactions between particular therapeutic factors and attachment characteristics, indicating a particular importance of these therapeutic factors for different attachment categories.

[Screening and Measurement of Change of Dissociative Psychopathology: Psychometric Properties of the Short Version of the Fragebogen zu Dissoziativen Symptomen (FDS-20)]. / Screening und Veränderungsmessung dissoziativer Psychopathologie: Psychometrische Charakteristika der Kurzform des Fragebogens zu dissoziativen Symptomen (FDS-20).

Given the clinical and scientific relevance of dissociative experiences our study aimed to assess the psychometric properties of a short version of the German Dissociative Experience Scale (called FDS-20) as well as its ability to measure changes in dissociation. In a large sample (N = 1289) the FDS- 20 showed good internal consistency. A factor analysis indicated that the scale measures one single factor reflecting the general degree of dissociative psychopathology. Between-group-comparisons suggested a good discriminant validity between high and low dissociators; however, due to high standard deviations the FDS-20 is not well suited for an individual diagnosis and therefore, it should be used as a screening device. Low effect sizes (d < 0,3) between scores at the beginning and the end of inpatient treatment as well as low micro -indices pointed to a temporal stable construct and a trait scale, respectively. Alternatively to group comparisons, individual parameters of treatment success (statistical and clinical significance) were calculated. They proved to be more appropriate in measuring changes in dissociation.