Working through the body in metacognitive interpersonal therapy to change relational patterns in dependent personality disorder: The case of Lia.

Persons with dependent personality disorder (DPD) have difficulties describing their inner world, and in realizing their negative ideas about the self, such as being weak, unworthy or powerless are just ideas. As a consequence, they tend to over-rely on others and may lose control over their emotions. Treating these persons can gain benefits from including body-focused techniques as they can promote a) awareness of internal states, b) better emotion regulation, c) the capacity to consider their negative ideas about themselves as not necessarily true, and d) gain power of and agency. We will describe the therapist used body-focused techniques in the context of Metacognitive Interpersonal Therapy when treating Lia, a 40-year-old woman suffering from DPD who also suffered from generalized anxiety disorder and had difficulties in making autonomous choices. She had a romantic relationship with a man she described as distant and judgmental so she felt lonely and not entitled to express her discomfort or capable to break up. The therapist used body-focused techniques, together with behavioural exposure, mindfulness and guided imagery, to let Lia be more aware of her thoughts and feelings, and then to regulate affects and realize she had previously capacities. At therapy termination anxiety diminished and she could break up with the partner and start a new one where she felt free to express herself. We suggest how bodily-focused techniques can be used to enhance therapy effectiveness in DPD.

Psychotherapy of Dependent Personality Disorder: The Relationship of Patient-Therapist Interactions to Outcome.

OBJECTIVE: So far, only a few studies have focused on psychotherapy for Dependent Personality Disorder (DPD). DPD is marked by a repetitive pattern of efforts aiming at maintaining close relationships, which may present as a lack of assertiveness and as a difficulty in making routine decisions. The present study aims at exploring processes of change taking place during the working phase of a clarification-oriented psychotherapy (COP) by focusing on the in-session patient-therapist interaction, as it changes during treatment and their links with treatment outcome. Methods: N = 74 patients with DPD were recruited in a naturalistic setting; they underwent long-term COP. Sessions 15, 20 and 25 were video- or audio-recorded and analyzed using the Process-Content-Relationship Scale, an observer-rated instrument that measures the quality of the interaction processes from patient's and therapist's perspectives. Therapy outcomes were assessed with the Personality Inventory - Dependency Subscale, Beck Depression Inventory, Inventory of Interpersonal Problems and Self-efficacy Scale at intake and discharge of therapy. Three-level Hierarchical Linear Modeling was applied to test the hypotheses. Results: Improvement in interaction processes was observed in all patient's and therapist's variables over the sessions 15, 20, 25. Overall, this increase in quality of interaction process was unrelated with outcome, but decrease in dependency traits was predicted by increase in therapist's quality of relationship offer, understanding of content and directivity over the course of the working phase of COP. Conclusions: Studying interaction processes in DPD provides an initial understanding of differential roles of potential mechanisms of change in effective treatment.

Cooperation in psychotherapy increases metacognitive abilities: a single-case study.

INTRODUCTION: Both clinical observations and empirical data suggest that the ability to think about the mental states of themselves and others (i.e., metacognition) is a crucial factor strongly associated to the outcome of individual psychotherapies. Although it has been hypothesized that the activation of cooperation between patient and psychotherapist within psychotherapy sessions may increase metacognitive abilities, few data is still available to support this hypothesis. METHODS: We explore the association between cooperation of patient and psychotherapist and the modifications of metacognition abilities along five sessions of a patient with a personality disorder using the Assessing Interpersonal Motivations in Transcripts method (AIMIT) and the Metacognition Assessment Scale (MAS). RESULTS: Our data showed that the activation of cooperation was positively associated with both the MAS total scores and all MAS sub-scales. DISCUSSION AND CONCLUSION: Our results demonstrate that the activation of the cooperation within therapeutic relationship can increase patient's metacognition and its subsystem (e.g. self-monitoring).

Dimensions of dependence and their influence on the outcome of cognitive behaviour therapy for health anxiety: randomized controlled trial.

BACKGROUND: The personality trait of dependence is common in health-seeking behaviour. We therefore examined its impact in a large randomized controlled trial of psychological treatment for health anxiety. AIMS: To test whether dependent personality traits were positive or negative in determining the outcome of an adapted form of cognitive behaviour therapy for health anxiety (CBT-HA) over the course of 5 years and whether dependent personality dysfunction could be viewed dimensionally in a similar way to the new ICD-11 diagnostic system for general personality disorder. METHOD: Dependent personality dysfunction was assessed using a self-rated questionnaire, the Dependent Personality Questionnaire, at baseline in a randomized controlled trial of 444 patients from medical clinics with pathological health anxiety treated with a modified form of CBT-HA or standard treatment in the medical clinics, with assessment on five occasions over 5 years. Dependent personality dysfunction was assessed using four severity groups. RESULTS: Patients with mild and moderate dependent personality disorder treated with CBT-HA showed the greatest reduction in health anxiety compared with standard care, and those with no dependent dysfunction showed the least benefit. Patients with higher dependent traits received significantly more treatment sessions (8.6) than those with low trait levels (5.4) (p < 0.01). CONCLUSION: The results suggest that patients treated with cognitive behaviour therapy for health anxiety respond better if they have moderate dependent personality. The reasons for this may be related to better adherence to psychological treatment and greater negative effects of frequent reassurance and excessive consultation in those treated in standard care. Copyright © 2016 John Wiley & Sons, Ltd.

[Affective dependency]. / La dépendance affective.

Affective dependency is characterized by emotional distress (insecure attachment) and dependency to another person with a low self-esteem and reassurance need. The paper proposes a reflection on the definition of emotional dependency and the confusion caused by various denominations. Overprotective and authoritarian parenting, cultural and socio-environmental factors may contribute to the development of dependent personality. Psychological epigenetic factors, such as early socio-emotional trauma could > on neuronal circuits in prefronto-limbic regions that are essential for emotional behaviour.We also focus on the interrelations between dependent personality, domestic violence and addictions. The objective for the clinician is to propose a restoration of self-esteem and therapeutic strategies focused on autonomy.

Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and axis II comparison subjects: a 16-year prospective follow-up study.

OBJECTIVE: The purposes of this study were to determine time to attainment of symptom remission and to recovery lasting 2, 4, 6, or 8 years among patients with borderline personality disorder and comparison subjects with other personality disorders and to determine the stability of these outcomes. METHOD: A total of 290 inpatients with borderline personality disorder and 72 comparison subjects with other axis II disorders were assessed during their index admission using a series of semistructured interviews, which were administered again at eight successive 2-year follow-up sessions. For inclusion in the study, patients with borderline personality disorder had to meet criteria for both the Revised Diagnostic Interview for Borderlines and DSM-III-R. RESULTS: Borderline patients were significantly slower to achieve remission or recovery (which involved good social and vocational functioning as well as symptomatic remission) than axis II comparison subjects. However, by the time of the 16-year follow-up assessment, both groups had achieved similarly high rates of remission (range for borderline patients: 78%-99%; range for axis II comparison subjects: 97%-99%) but not recovery (40%-60% compared with 75%-85%). In contrast, symptomatic recurrence and loss of recovery occurred more rapidly and at substantially higher rates among borderline patients than axis II comparison subjects (recurrence: 10%-36% compared with 4%-7%; loss of recovery: 20%-44% compared with 9%-28%). CONCLUSIONS: Our results suggest that sustained symptomatic remission is substantially more common than sustained recovery from borderline personality disorder and that sustained remissions and recoveries are substantially more difficult for individuals with borderline personality disorder to attain and maintain than for individuals with other forms of personality disorder.

[Dependent patient and interpersonal dependency: psychotherapeutic strategies]. / Personnalité dépendante et dépendance affective : stratégies psychothérapeutiques.

OBJECTIVES: This article is a review of psychotherapies for patients suffering from dependent personality and interpersonal dependency. METHOD: We synthesized articles making reference to this question, notably those written by Bornstein, author who refers to the dependent personality. We highlighted the psychotherapies that have been the object of an evaluation. The research on the subject is sparse: only eight studies permitting assessment of psychotherapies in this indication in 2005. Besides these psychotherapies, we detailed other approaches which are used by practitioners in these indications. RESULTS: The therapy does not aim at autonomy "at all costs", but that the patient finds a dependence "adapted" to his/her environment. Before starting a therapy, an evaluation is useful to specify the type of dependence. First of all, is there a "pathological" dependence? Is the suffering of the patient secondary to his personality or not supportive enough? Does insight exist? What is the reaction of the patient if we suggest the hypothesis of a dependence on his/her part? Does he/she consider this idea or reject it? Finally, is the dependence primary or secondary? For that purpose, it is necessary to study the biography of the patient and the appearance of the comorbidity over time. The primary dependence is seen in childhood and precedes the other psychological disorders. The secondary dependence follows after the comorbidity and events of life that alter self-esteem (depression, for example). Various therapeutic strategies arise from various currents. The therapies of analytical inspiration recommend replaying the relationship of object and explicitly evoking the transfer. The behavioural and cognitive psychotherapies aim at making the patient identify the cognitions which underlie the dependence, then leading the patient to modify his/her cognition and to behave in a more autonomous way, using the theory of learning. The humanist therapies aim at a therapeutic relationship of acceptance and respect for the patient, so that he/she increases self-esteem and finds autonomy. The brief systemic therapy develops tools to deviate from the relationship of dependence in the therapy. It aims at the change through a modification in the beliefs of the patient. The dependence can be envisaged as a way of adapting itself, of compensating for altered self-esteem. In this way, the psychotherapy must also attempt to restore self-esteem in an implicit or explicit way. CONCLUSION: The evaluation of the type of dependence helps the therapeutic approach. It is necessary to look for the comorbidity and its appearance over time with regard to the dependence. So, in primary dependence, the therapy focuses on the increase of self-esteem. In the secondary dependence, the therapy focuses on the adaptation to this event, the treatment of the mental illness, and then to the accompaniment in restoring and autonomy. If the patient doesn't have insight, it is necessary either to enhance it, or to work in an indirect way.

Introduction to the special feature on the integrated treatment of personality disorder.

The solid evidence that personality disorders can be treated effectively goes side by side with, on the one hand, sparse evidence for disorders other than borderline and for personality disorders co-occurrent with one another, and, on the other hand, with a relative lack of knowledge about the actual effective mechanisms of change that underpin successful psychotherapies. In this introduction we present the rationale for this special feature, advocating for an integrated treatment of personality pathology in which empirically-supported strategies and techniques are selected from different traditions on the basis of the pragmatic principle of what works.

[Mutation voice disorders conditioned by psychic factors]. / Zaburzenia glosu mutacyjnego uwarunkowane czynnikami psychicznymi.

The case of 17 year old boy with mutational falsetto conditioned by a complex of psychic factors particulary with personality disorders and strong emotional bond with his mother was described. Phonation exercises lowered the average voice pitch. The stable results of phoniatric rehabilitation is dependent on effectiveness of psychological therapy of the whole family. Acoustic voice analysis demonstrates objectively the results of rehabilitation.

Pre-treatment predictors and in-treatment factors associated with change in avoidant and dependent personality disorder traits among patients with social phobia.

We examined changes in avoidant and dependent personality disorder dimensions, and pre-treatment and in-treatment factors associated with such changes in 77 patients, randomized to medication-free residential cognitive (CT) or residential interpersonal therapy for social phobia. Personality disorders and personality dimensions according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) were assessed at pre-treatment and at one-year post-treatment. Both treatments were associated with a decrease in avoidant and dependent personality dimensions; dependent dimension decreased more in CT. Changes in cognitive factors predicted changes in both personality dimensions, whereas changes in symptoms or interpersonal factors did not. Change in the cognitive factor estimated cost was the most powerful predictor in the avoidant dimension, as it was the only predictor that remained significant in the forward regression analyses. Change in the cognitive factor estimated cost, and treatment were the most powerful predictors of change in the dependent dimension. Pre-treatment use of anxiolytics predicted larger changes in both PD dimensions.

The role of transference work, the therapeutic alliance, and their interaction in reducing interpersonal problems among psychotherapy patients with Cluster C personality disorders.

The aim of the present study was to examine whether transference work, the therapeutic alliance, and their interaction predicted a reduction in interpersonal problems at treatment termination. Forty-nine patients with Cluster C personality disorders from a randomized controlled trial investigating the effectiveness of short-term dynamic psychotherapy and cognitive therapy were included. Transference work was measured with the Inventory of Therapeutic Strategies (Gaston & Ring, 1992), while the therapeutic alliance was measured with the Helping Alliance Questionnaire (Luborsky, Crits-Christoph, Alexander, Margolis & Cohen, 1983). Less emphasis on transference work predicted overall reduced interpersonal problems, whereas the effects of the therapeutic alliance did not reach statistical significance. An interaction effect was also demonstrated, indicating that greater emphasis on transference work performed on patients with lower therapeutic alliance ratings was associated with a smaller reduction in interpersonal problems at termination. However, the results also indicate that a low dose of transference work may be beneficial in reducing interpersonal problems.

Effectiveness of different modalities of psychotherapeutic treatment for patients with cluster C personality disorders: results of a large prospective multicentre study.

BACKGROUND: No previous studies have compared the effectiveness of different modalities of psychotherapeutic treatment, as defined by different settings and durations, for patients with cluster C personality disorders. The aim of this multicentre study was to compare the effectiveness of 5 treatment modalities for patients with cluster C personality disorders in terms of psychiatric symptoms, psychosocial functioning, and quality of life. The following treatment modalities were compared: long-term outpatient (more than 6 months), short-term day hospital (up to 6 months), long-term day hospital, short-term inpatient, and long-term inpatient psychotherapy. METHODS: The study was conducted between March 2003 and June 2008 in 6 mental health care centres in the Netherlands, with a sample of 371 patients with a DSM-IV-TR axis-II cluster C diagnosis. Patients were assigned to 5 different modalities of psychotherapeutic treatment, and effectiveness was assessed at 12 months after baseline. An intention-to-treat analysis was conducted for psychiatric symptoms (Brief Symptom Inventory), psychosocial functioning (Outcome Questionnaire-45), and quality of life (EQ-5D), using multilevel statistical modelling. As the study was non-randomised, the propensity score method was used to control for initial differences. RESULTS: Patients in all treatment groups had improved on all outcomes 12 months after baseline. Patients receiving short-term inpatient treatment showed more improvement than patients receiving other treatment modalities. CONCLUSIONS: Psychotherapeutic treatment, especially in the short-term inpatient modality, is an effective treatment for patients with cluster C personality disorders.

Integrated therapy for complex cases of personality disorder.

In this article, the author presents and illustrates the treatment of a patient with dependent and borderline personality disorders and other maladaptive traits using an integrated and eclectic approach tailored to the patient's psychopathology and personality. Interventions are selected where possible based on evidence of what works. However, because empirical evidence on treatment efficacy for personality disorder is limited, interventions were often selected based on a rational analysis of the most effective way to treat a given problem. The delivery of an eclectic array of interventions was integrated and coordinated through an emphasis on generic methods and on a phases of change model that targets symptoms and problems in a systematic way based on evidence of the stability of symptoms and personality.

When what I wish makes me worse ... to make coherence flexible.

This paper describes a psychotherapeutic constructivist intervention oriented to the resolution of implicative dilemmas, in order to promote personal change. It presents a clinical case study of a client with depression and with some dependent and obsessive functioning. The Repertory Grid Technique was administered along with symptom assessment (SCL-90-R) both at beginning and end of the psychotherapeutic process. Exploring themes emerged from Repgrid, several narratives, experiential and metaphoric strategies were used in order to explore and reconstruct meanings associated with the five implicative dilemmas found. The therapeutic process succeeds at solving dilemmas as found in the post-therapy assessment. This resolution was accompanied by symptom reduction. In conclusion, the utility of implicative dilemmas as a marker to understand the therapeutic impasse and dysfunctional system coherence is discussed, as well as the efficacy of the strategies used in this clinical case concerning its adaptation to working with implicative dilemmas that prevent therapeutic process.

The quality of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition dependent personality disorder prototype.

OBJECTIVE: The aim of this study was to investigate the quality of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition dependent personality disorder (DPD) prototype with special reference to possible bidimensionality. METHOD: The sample included 1078 patients, 81% (n = 875) had 1 or more personality disorders. The proportion of patients with DPD was 11.3% (n = 122). Frequency distribution, chi2, correlations, reliability statistics, exploratory and confirmatory factor analyses were performed. RESULTS: Of the DPD criteria, criterion 3 showed a higher correlation with avoidant personality disorder than with DPD itself, whereas criterion 5 was weakly correlated with DPD, findings being confirmed by an exploratory factor analysis and a low internal consistency of all DPD criteria. An a priori hypothesized 2-factor model was confirmed by the confirmatory factor analysis. CONCLUSIONS: These results indicate a moderate to low quality of the DPD construct. The main objection is that DPD is based too heavily on a bidimensional model of perceived incompetence and dysfunctional attachment. Items should be revised, in particular, items 3 and 5.

Characteristic interpersonal behavior in dependent and avoidant personality disorder can be observed within very short interaction sequences.

We present a behavior observation study of interpersonal behavior in 96 female subjects, who had been screened for the presence of dependent, avoidant, narcissistic and histrionic personality disorder features. Each subject took part in three short role-plays, taken from assertiveness training. Afterwards, both the subject and her role-play partner judged, how assertive the subject had been. Although observation time was very short, dependent and avoidant subjects could be easily identified from their overly submissive behavior in the role-plays. Histrionic and narcissistic subjects did not show distinctive interpersonal behavior. Contrary to a common belief, higher scores on some personality disorder (PD) scales were positively related to cross-situational variability of behavior. Results are discussed with regard to their implications for clinical diagnostics, therapy and the methodology of personality disorder research in general.

Maladaptive dependency traits in men.

In this article, the authors intend to bring to the reader's attention the negative impact men's maladaptive dependency traits can have on their lives and methods by which these traits can be addressed in treatment. A review of the literature about dependence, dependency traits and dependent personality disorder is presented including the influence of early childhood experiences, gender differences, comorbidity with Axis I disorders, and assessment and treatment. Several clinical case examples highlighting the subtle expression of dependency traits in men are presented and discussed.

Precursors to masochistic and dependent character development.

Due to the extreme states of masochism, dependency, and narcissistic rage that these patients experience, the treatment must be attuned to the inevitable periods of regression and primitive defense. The patient feels compelled to be a servant to the object, yet is furious at this less than equal status. The alternating states of idealizing the object in a masochistic fashion, the anger at the lack of self importance, and the desperate hope for soothing from that object create an externally focused character structure, which generally leads to a pattern of acting out, the lack of internal linking processes, and a scarcity of interpersonal skills that foster mutuality. A fundamental lack of self soothing leads to a perpetual search and craving for the soothing talents of the object. It is often unconsciously believed that compliance and servitude will bring about this gift of soothing from the object. Hans Loewald (1962) had described internalization as a process whereby the child reaches out to take back from the environment what has been removed from him in an ever-increasing manner since his birth. For the forgotten hero, this theory is definitely true. Not only is the treatment of this type of patient one of gradual internalization of new internal object relationships and the working through of the older more pathological ones, but it is a true understanding between patient and analyst of the original nontolerable removal of the uniqueness of the self via reality and/or fantasy states. When this situation is focused upon and worked with, the taking back from the environment can occur in a spirit devoid of former states of envy, hate, resentment, and wild craving that were formally protected and disguised in a facade of dependent masochism. The patient has essentially experienced or perceived his parents, usually the mother, as not providing a soothing function or a proper fit for his developing ego. The patient has then gone about constructing various methods to compensate for this lack. The analyst is often experienced as not providing an adequate soothing function, but this emptiness is warded off from conscious expression with a compromise formation of dependent, masochistic, or narcissistic methods of relating. This style of compromise hides any envy, hunger, or rage and keeps alive the hopes of being rewarded with soothing. The patients expects to be used as a waste disposal unit and believes that this dumping by the object into him is the longed-for love. Ideally, interpretations focus upon the hunger for the soothing function of the object and the drive to obtain it at any cost. The patient will fiercely resist because he believes that in giving up his masochism and dependency, he would expose his envy and narcissistic injury. This patient believes he would then lose any hope of ever receiving the soothing function due to the fantasized destruction of the source of that soothing, his beloved object.