Cognitive-Behavioral and Psychodynamic Therapy in Adolescents with Social Anxiety Disorder: A Multicenter Randomized Controlled Trial.

BACKGROUND: Although social anxiety disorder (SAD) has an early onset and is frequently found in adolescence, evidence for psychotherapeutic treatments of SAD in adolescents is rather scarce. Within the Social Phobia Psychotherapy Research Network (SOPHO-NET), we examined the efficacy of cognitive-behavioral (CBT) and psychodynamic therapy (PDT) compared to a waiting list (WL) in these patients. METHODS: In a multicenter randomized controlled superiority trial, 107 patients, aged 14-20 years, were randomized to CBT (n = 34), PDT (n = 34), or WL (n = 39). Assessments were made at baseline, at the end of treatment, and 6 and 12 months after termination. The Liebowitz Social Anxiety Scale for Children and Adolescents (LSAS-CA) applied by raters masked to the treatment condition was used as the primary outcome. As secondary outcomes, rates of response and remission and the Social Phobia Anxiety Inventory (SPAI) were used. RESULTS: Both treatments were superior to WL in the LSAS-CA (CBT: p = 0.0112, d = 0.61, 95% CI 0.14-1.08; PDT: p = 0.0261, d = 0.53, 95% CI 0.06-1.00). At the end of treatment, response rates were 66, 54, and 20% for CBT, PDT, and WL. The corresponding remission rates were 47, 34, and 6%, respectively. CBT and PDT were significantly superior to WL regarding remission (CBT: p = 0.0009, h = 1.0; PDT: p = 0.0135, h = 0.74), response (CBT: p = 0.0004, h = 0.97; PDT: p = 0.0056, h = 0.72), and the SPAI (CBT: p = 0.0021, d = 0.75, 95% CI 0.27-1.22; PDT: p = 0.0060, d = 0.66, 95% CI 0.19-1.13). Treatment effects were stable at 6- and 12-month follow-ups. CONCLUSIONS: These results are comparable to the large SOPHO-NET trial in adults (n = 495). Early treatments for social anxiety are needed in order to prevent chronic manifestation of SAD.

Optimal Cut Points for Remission and Response for the German Version of the Social Phobia Anxiety Inventory (SPAI).

OBJECTIVE: The German version of the Social Phobia and Anxiety Inventory (SPAI-G) is a validated measure for the detection of social anxiety disorder (SAD). The aim of the present study was to develop optimal cut points (OC) for remission and response to treatment for the SPAI-G. METHODS: We used Receiver Operating Characteristic methods and bootstrapping to analyse the data of 359 patients after psychotherapeutic treatment. OCs where defined as the cut points with the highest sensitivity and specificity after bootstrapping. RESULTS: For remission, an OC of 2.79 was found, and for response, a change in score from pre- to posttreatment by 11% yielded best results. CONCLUSIONS: The OC we identified for remissionmay be used to improve the diagnostic utility of the SPAI-G. However, the cut point for response achieved only borderline-acceptable levels of sensitivity and specificity, calling into doubt their utility in clinical and research setting.

Long-term cost-effectiveness of cognitive behavioral therapy versus psychodynamic therapy in social anxiety disorder.

BACKGROUND: To determine the cost-effectiveness of cognitive behavioral therapy (CBT) versus psychodynamic therapy (PDT) in the treatment of social anxiety disorder after a follow-up of 30 months from a societal perspective. METHODS: This analysis was conducted alongside the multicenter SOPHO-NET trial; adults with a primary diagnosis of social anxiety disorder received CBT (n = 209) or PDT (n = 207). Data on health care utilization and productivity loss were collected at baseline, after 6 months (posttreatment), and three further follow-ups to calculate direct and indirect costs. Anxiety-free days (AFDs) calculated based on remission and response were used as measure of effect. The incremental cost-effectiveness ratio (ICER) was determined. Net benefit regressions, adjusted for comorbidities and baseline differences, were applied to derive cost-effectiveness acceptability curves. RESULTS: In the descriptive analysis, the unadjusted ICER favored CBT over PDT and the adjusted analysis showed that CBT's cost-effectiveness relative to PDT depends on the willingness to pay (WTP) per AFD. As baseline costs differed substantially the unadjusted estimates might be deceptive. If additional WTPs for CBT of €0, €10, and €30 were assumed, the probability of CBT being cost-effective relative to PDT was 65, 83, and 96%. Direct costs increased compared to baseline across groups, whereas indirect costs did not change significantly. Results were sensitive to considered costs. CONCLUSIONS: If the society is willing to pay ≥€30 per additional AFD, CBT can be considered cost-effective, relative to PDT, with certainty. To further increase the cost-effectiveness more knowledge regarding predictors of treatment outcome seems essential.

Baseline Patient Characteristics Predicting Outcome and Attrition in Cognitive Therapy for Social Phobia: Results from a Large Multicentre Trial.

UNLABELLED: We examined the role of baseline patient characteristics as predictors of outcome (end-state functioning, response and remission) and attrition for cognitive therapy (CT) in social anxiety disorder (SAD). Beyond socio-demographic and clinical variables such as symptom severity and comorbidity status, previously neglected patient characteristics (e.g., personality, self-esteem, shame, interpersonal problems and attachment style) were analysed. METHOD: Data came from the CT arm of a multicentre RCT with n = 244 patients having DSM-IV SAD. CT was conducted according to the manual by Clark and Wells. Severity of SAD was assessed at baseline and end of treatment with the Liebowitz Social Anxiety Scale (LSAS). Multiple linear regression analyses and logistic regression analyses were applied. RESULTS: Up to 37% of the post-treatment variance (LSAS) could be explained by all pre-treatment variables combined. Symptom severity (baseline LSAS) was consistently negatively associated with end-state functioning and remission, but not with response. Number of comorbid diagnoses was negatively associated with end-state functioning and response, but not with remission. Self-esteem was positively associated with higher end-state functioning and more shame with better response. Attrition could not be significantly predicted. CONCLUSIONS: The results indicate that the initial probability for treatment success mainly depends on severity of disorder and comorbid conditions while other psychological variables are of minor importance, at least on a nomothetic level. This stands in contrast with efforts to arrive at an empirical-based foundation for differential indication and argues to search for more potent moderators of therapeutic change rather on the process level. KEY PRACTITIONER MESSAGE: Personality, self-esteem, shame, attachment style and interpersonal problems do not or only marginally moderate the effects of interventions in CT of social phobia. Symptom severity and comorbid diagnoses might affect treatment outcome negatively. Beyond these two factors, most patients share a similar likelihood of treatment success when treated according to the manual by Clark and Wells. Copyright © 2014 John Wiley & Sons, Ltd.

[The self-concept of patients with Social Anxiety Disorder: manifestation and change through psychotherapy ]. / Das Selbstkonzept von Patienten mit sozialer Angststörung:Ausprägung und Veränderung durch Psychotherapie.

OBJECTIVES: To determine whether the self-concept of patients with Social Anxiety Disorder deviates significantly from that found in the normative sample, to what extent it changes through psychotherapeutic short-term interventions and how such changes in self-concept relate to changes in the level of social anxiety. METHODS: The self-concept of N = 86 patients with Social Anxiety Disorder was assessed using the Frankfurter-Selbstkonzeptskalen (FSKN; Deusinger 1986). Patients were treated with a manualized cognitive (CT) or psychodynamic (PDT) short-term intervention. The level of social anxiety was assessed pre-therapy and post-therapy via the Liebowitz Social Anxiety Scale (Stangier & Heidenreich 2004) and the Social Phobia and Anxiety Scale (Fydrich 2002). RESULTS: Patients with Social Anxiety Disorder exhibited a significantly more negative self-concept than the norm (all ps0.001). Their self-concept improved significantly in all facets following psychotherapeutic short-term intervention (all ps0.01). No significant difference was found between cognitive and psychodynamic therapy. Improvements in self-concept correlate with reductions in social anxiety. CONCLUSIONS: The results confirm the relevance of self-concept in Social Anxiety Disorder and its susceptibility to short-term-therapy.

Reliability, validity and responsiveness of the EQ-5D in assessing and valuing health status in patients with social phobia.

OBJECTIVE: The aim of the study was to analyse the psychometric properties of the EQ-5D in patients with social phobia. METHODS: We used a sample of 445 patients with social phobia with five measurement points over a 30 month period. The discriminative ability of the EQ-5D was analysed by comparing the patients' responses with the general population and between different disease severity levels. For test-retest reliability we assessed the level of agreement in patients' responses over time, when there was no change in the Liebowitz Social Anxiety Scale (LSAS). Construct validity was analysed by identifying correlations of the EQ-5D with more specific instruments. For responsiveness we compared the means of EQ VAS/EQ-5D index anchored on improved (deteriorated) health status and computed effect sizes as well as a receiver operating characteristic (ROC) curve. RESULTS: Compared to the general population, patients with social phobia reported more problems in the dimensions "usual activities", "pain/discomfort", and "anxiety/depression" and less problems in "mobility" and "self-care". The EQ-5D was able to distinguish between different disease severity levels. The test-retest reliability was moderate (intraclass correlation coefficient > 0.6). Correlations between the EQ-5D and other instruments were mostly small except for correlations with Beck Depression Inventory. The EQ-5D index seemed to be more responsive than the EQ VAS, but with only medium effect sizes (0.5 < effect size < 0.8) in the British EQ-5D index and only significant in patients with improved health status. The ROC analysis revealed no significant results. CONCLUSIONS: The EQ-5D was moderately reliable and responsive in patients with improved health status. Construct validity was limited. TRIAL REGISTRATION: Current controlled trials ISRCTN53517394.

Patterns of interpersonal problems in borderline personality disorder.

Borderline personality disorder (BPD) is characterized by a wide variety of interpersonal problems. We examined whether there are different characteristic interpersonal patterns in BPD and how these patterns are related to symptom distress and therapeutic alliance. In 228 inpatients with diagnoses of BPD, interpersonal subtypes based on the Inventory of Interpersonal Problems (Horowitz et al., Inventar zur Erfassung Interpersonaler Probleme, 2000) were examined through cluster analyses. The global symptom severity and therapeutic alliance were also assessed. We identified five characteristic interpersonal patterns, which we labeled as follows: Cluster 1, "Vindictive"; Cluster 2, "Moderate Submissive"; Cluster 3, "Nonassertive"; Cluster 4, "Exploitable"; and Cluster 5, "Socially Avoidant." The clusters differed significantly in terms of interpersonal distress, interpersonal differentiation, and severity of global symptoms. The ratings of the therapeutic alliance by therapists during treatment significantly differed between the interpersonal subtypes, and the lowest ratings for patients were in the "Socially Avoidant" cluster. Our results stress the impact of interpersonal style on the appearance and treatment of BPD.

Baseline Severity as a Moderator of the Waiting List-Controlled Association of Cognitive Behavioral Therapy With Symptom Change in Social Anxiety Disorder: A Systematic Review and Individual Patient Data Meta-analysis.

Importance: Social anxiety disorder (SAD) can be adequately treated with cognitive behavioral therapy (CBT). However, there is a large gap in knowledge on factors associated with prognosis, and it is unclear whether symptom severity predicts response to CBT for SAD. Objective: To examine baseline SAD symptom severity as a moderator of the association between CBT and symptom change in patients with SAD. Data Sources: For this systematic review and individual patient data meta-analysis (IPDMA), PubMed, PsycInfo, Embase, and the Cochrane Library were searched from January 1, 1990, to January 13, 2023. Primary search topics were social anxiety disorder, cognitive behavior therapy, and randomized controlled trial. Study Selection: Inclusion criteria were randomized clinical trials comparing CBT with being on a waiting list and using the Liebowitz Social Anxiety Scale (LSAS) in adults with a primary clinical diagnosis of SAD. Data Extraction and Synthesis: Authors of included studies were approached to provide individual-level data. Data were extracted by pairs of authors following the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline, and risk of bias was assessed using the Cochrane tool. An IPDMA was conducted using a 2-stage approach for the association of CBT with change in LSAS scores from baseline to posttreatment and for the interaction effect of baseline LSAS score by condition using random-effects models. Main Outcomes and Measures: The main outcome was the baseline to posttreatment change in symptom severity measured by the LSAS. Results: A total of 12 studies including 1246 patients with SAD (mean [SD] age, 35.3 [10.9] years; 738 [59.2%] female) were included in the meta-analysis. A waiting list-controlled association between CBT and pretreatment to posttreatment LSAS change was found (b = -20.3; 95% CI, -24.9 to -15.6; P < .001; Cohen d = -0.95; 95% CI, -1.16 to -0.73). Baseline LSAS scores moderated the differences between CBT and waiting list with respect to pretreatment to posttreatment symptom reductions (b = -0.22; 95% CI, -0.39 to -0.06; P = .009), indicating that individuals with severe symptoms had larger waiting list-controlled symptom reductions after CBT (Cohen d = -1.13 [95% CI, -1.39 to -0.88] for patients with very severe SAD; Cohen d = -0.54 [95% CI, -0.80 to -0.29] for patients with mild SAD). Conclusions and Relevance: In this systematic review and IPDMA, higher baseline SAD symptom severity was associated with greater (absolute but not relative) symptom reductions after CBT in patients with SAD. The findings contribute to personalized care by suggesting that clinicians can confidently offer CBT to individuals with severe SAD symptoms.

Borderline personality disorder.

Recent research findings have contributed to an improved understanding and treatment of borderline personality disorder. This disorder is characterised by severe functional impairments, a high risk of suicide, a negative effect on the course of depressive disorders, extensive use of treatment, and high costs to society. The course of this disorder is less stable than expected for personality disorders. The causes are not yet clear, but genetic factors and adverse life events seem to interact to lead to the disorder. Neurobiological research suggests that abnormalities in the frontolimbic networks are associated with many of the symptoms. Data for the effectiveness of pharmacotherapy vary and evidence is not yet robust. Specific forms of psychotherapy seem to be beneficial for at least some of the problems frequently reported in patients with borderline personality disorder. At present, there is no evidence to suggest that one specific form of psychotherapy is more effective than another. Further research is needed on the diagnosis, neurobiology, and treatment of borderline personality disorder.

Long-term effects of short-term psychodynamic psychotherapy and cognitive-behavioural therapy in generalized anxiety disorder: 12-month follow-up.

OBJECTIVE: In a previous randomized controlled trial (RCT), short-term efficacy of cognitive-behavioural therapy (CBT) and short-term psychodynamic psychotherapy (STPP) in generalized anxiety disorder (GAD) was demonstrated. In this article, long-term stability of these effects will be examined. Effects of CBT and STPP will be compared. METHOD: In the original RCT, patients with GAD were treated with either CBT (n = 29) or STPP (n = 28). Treatments were carried out according to manuals and included up to 30 sessions. As the primary outcome measure the Hamilton Anxiety Rating Scale was used. In addition to short-term outcome previously reported, treatment effects were assessed 12 months after termination of treatment. RESULTS: Both CBT and STPP yielded large improvements at 12-month follow-up. No significant differences were found between treatments concerning the primary outcome measure. This result was corroborated by 3 self-report measures of anxiety. However, in measures of trait anxiety and worry, CBT was superior. Concerning depression, differences reported at posttreatment were no longer significant at 12-month follow-up. CONCLUSIONS: In GAD, both CBT and STPP yield large and stable effects 12 months after treatment. Concerning trait anxiety and worry, CBT seems to be superior. For STPP, further studies should be carried out to confirm the results.

Alexithymia and script-driven emotional imagery in healthy female subjects: no support for deficiencies in imagination.

Alexithymia is associated with a limited access to inner emotional processes. Furthermore, alexithymia is assumed to be characterized by a limited ability to use imagination. To evaluate the frequently proposed thesis of a reduced imagination ability in alexithymic persons, 25 high and 24 low alexithymic women self-rated their imagination ability. Furthermore, the electrodermal activity (EDA) during script-driven emotional imagination was determined and valence, arousal, and vividness of the respective imaginations were rated. Our results indicate no significant differences between high and low alexithymic women in the self-rated imagination ability, the EDA during imagination and the ratings of valence, arousal and vividness. The study provides evidence that healthy high alexithymic women are capable of differentiated emotional imagination.

Reduced amygdalar and hippocampal size in adults with generalized social phobia.

BACKGROUND: Structural and functional brain imaging studies suggest abnormalities of the amygdala and hippocampus in posttraumatic stress disorder and major depressive disorder. However, structural brain imaging studies in social phobia are lacking. METHODS: In total, 24 patients with generalized social phobia (GSP) and 24 healthy controls underwent 3-dimensional structural magnetic resonance imaging of the amygdala and hippocampus and a clinical investigation. RESULTS: Compared with controls, GSP patients had significantly reduced amygdalar (13%) and hippocampal (8%) size. The reduction in the size of the amygdala was statistically significant for men but not women. Smaller right-sided hippocampal volumes of GSP patients were significantly related to stronger disorder severity. LIMITATIONS: Our sample included only patients with the generalized subtype of social phobia. Because we excluded patients with comorbid depression, our sample may not be representative. CONCLUSION: We report for the first time volumetric results in patients with GSP. Future assessment of these patients will clarify whether these changes are reversed after successful treatment and whether they predict treatment response.

[The relationship between interpersonal subtypes and the modification of interpersonal problems in psychotherapy inpatients]. / Der Zusammenhang von interpersonalen Subtypen und der Veränderung interpersonaler Probleme am Beispiel stationärer Psychotherapiepatienten.

OBJECTIVES: Interpersonal problems are typically assessed with the Inventory of interpersonal Problems (IIP; Horowitz et al. 2000). Although patients show different interpersonal profiles, these have to date not been considered in outcome evaluation. We examined whether interpersonal subtypes can be found in inpatients, and whether they differ in the modification of interpersonal problems. Furthermore, we examined the impact of subtypes regarding overall outcome. METHODS: The Structural Summary Method for Circumplex Data was used to examine the interpersonal problems of N=2809 inpatients from the Asklepios Clinic Tiefenbrunn. Subtypes of interpersonal problems were determined by the centroid method of cluster analysis and were compared with regard to treatment effects. RESULTS: Patients were distributed in the interpersonal Circumplex and were assigned to eight IIP subtypes, which differed in improvement with regard to interpersonal problems and overall outcome. CONCLUSIONS: According to the circumplex structure of IIP data, for group level evaluation it is necessary to generate interpersonal subtypes so that clinically relevant results can be demonstrated.

Typical symptom change patterns and their predictors in patients with social anxiety disorder: A latent class analysis.

OBJECTIVES: The use of trajectories and analysis of change patterns is a promising way toward better differentiation of subgroups in psychotherapy studies. Research on change patterns in social anxiety disorder (SAD) are still rare, although SAD is one of the most common mental disorders. In a secondary analysis of data from the SOPHO-NET-trial (ISRCTN53517394) this study aimed to investigate change patterns and their predictors in a sample of SAD patients. METHODS: Patients with SAD (N = 357) were randomly assigned to cognitive-behavioral or psychodynamic therapy. The Liebowitz Social Anxiety Scale (LSAS) was assessed at 1st session (pre), 8th session, 15th session and at the end of treatment (post). We used latent state variables and latent class analysis for the classification of change patterns and logistic regression for the identification of different predictors. RESULTS: Analyses revealed three typical patterns: (i.) responders with a high initial impairment (N = 57), (ii.) responders with a moderate initial impairment (N = 225), and (iii.) patients with a high initial impairment and no remission (N = 75). Among other significant predicators, patient´s attachment anxiety and therapeutic alliance at session eight contributed to the prediction of change patterns. DISCUSSION: Psychotherapy of SAD should consider patient's attachment and focus on the establishment of a solid therapeutic alliance in an early therapy stage.

[SOPHO-NET - a research network on psychotherapy for social phobia]. / SOPHO-NET - Forschungsverbund zur Psychotherapie der Sozialen Phobie.

This paper presents the Social Phobia Psychotherapy Research Network (SOPHO-NET). SOPHO-NET is among the five research networks on psychotherapy funded by "Bundesministerium für Bildung und Forschung". The research program encompasses a coordinated group of studies of social phobia. In the central project (Study A), a multi-center randomized controlled trial, refined models of manualized cognitive-behavioral therapy (CBT) and manualized short-term psychodynamic psychotherapy (STPP) are compared in the treatment of social phobia. A sample of n=512 outpatients will be randomized to either CBT, STPP or wait list. For quality assurance and treatment integrity, a specific project has been established (Project Q). Study A is complemented by four interrelated projects focusing on attachment style (Study B1), cost-effectiveness (Study B2), polymorphisms in the serotonin transporter gene (Study C1) and on structural and functional deviations of hippocampus and amygdala (Study C2). Thus, the SOPHO-NET program allows for a highly interdisciplinary research of psychotherapy in social phobia.

[Direct Costs of Social Phobia in Adolescents and Cost-Effectiveness of Psychotherapy]. / Direkte Kosten sozialer Angststörung bei Jugendlichen und Kosteneffektivität der Psychotherapie.

OBJECTIVES: Social anxiety disorder is one of the most prevalent mental disorders and often manifests in youth or adolescence. Our aim was to determine direct costs of adolescents with social anxiety disorder and the cost-effectiveness of cognitive-behavioral therapy (CBT) and psychodynamic therapy (PDT) compared to waiting list (WL). METHODS: Baseline data (n = 103) of a randomized controlled trial was used to determine direct costs. Cost-effectiveness of CBT and PDT compared to WL was analyzed using quality-adjusted life years (QALYs) based on the EQ-5D index as measure of health effects. RESULTS: Total six-month direct costs were 809 € (SE 508 €). Especially costs of outpatient physician treatment (325 €; SE 301 €) and psychiatric hospital stays (377 €; SE 258 €) were high. The incremental cost-effectiveness ratio (ICER) of CBT compared to WL was 18,824 €/QALY, with a probability of 63 % for the ICER being below 50,000 €/QALY. PDT did not prove to be cost-effective. CONCLUSIONS: Direct costs were mainly caused by psychiatric hospital stays and outpatient physician treatments. CBT is likely to be cost-effective compared to WL, whereas PDT is unlikely to be cost-effective.

Dimensions of personality--relationship between DSM-IV personality disorder symptoms, the five-factor model, and the biosocial model of personality.

Dimensional approaches regard personality disorders as extreme or maladaptive variants of traits that are commonly used to describe normal personality. Previous clinical and nonclinical studies identified four factors interpreted as Antisocial, Asocial, Asthenic, and Anankastic. To investigate the validity of this four-factor structure in healthy volunteers, 97 male and 98 female students completed versions of the NEO-PI-R and TPQ. Symptoms of personality disorders were assessed using the ADP-IV questionnaire. A factor analysis of the personality and symptom scales revealed a four-factor solution accounting for 71.55% of the total variance. These factors resembling the "four A's" were labelled Asthenic, Sociable vs. Asocial, Antisocial, and Disorderly vs. Anankastic. The results of this study support the presence of four factors in the description of adaptive as well as maladaptive personality traits.

Interpersonal subtypes within generalized anxiety disorder.

In this study, we addressed the heterogeneity in interpersonal problems across patients with generalized anxiety disorder (GAD). We assessed interpersonal problems by the Inventory of Interpersonal Problems (IIP-C; Horowitz, Alden, Wiggins, & Pincus, 2000) in a sample of 78 GAD patients. We used IIP-C profiles describing interpersonal characteristics of the total GAD sample as well as clustered GAD interpersonal subtypes. Although the overall sample was located in the friendly submissive quadrant of the circumplex model, this was true only for the Exploitable cluster, which includes more than 50% of the patients. Importantly, clusters of GAD patients with other locations reporting predominantly Cold, Nonassertive, or Intrusive interpersonal problems were also identified. The 4 clusters did not differ in terms of gender, comorbid disorders, or the severity of depression or anxiety. Thus, the assessment of interpersonal problems provides additional diagnostic information covering the heterogeneity of GAD patients. This information could be used for differential indication and individual case formulation in GAD.

Changes of attachment characteristics during psychotherapy of patients with social anxiety disorder: Results from the SOPHO-Net trial.

OBJECTIVES: Within a randomized controlled trial contrasting the outcome of manualized cognitive-behavioral (CBT) and short term psychodynamic therapy (PDT) compared to a waiting list condition (the SOPHO-Net trial), we set out to test whether self-reported attachment characteristics change during the treatments and if these changes differ between treatments. RESEARCH DESIGN AND METHODS: 495 patients from the SOPHO-Net trial (54.5% female, mean age 35.2 years) who were randomized to either CBT, PDT or waiting list (WL) completed the partner-related revised Experiences in Close Relationships Questionnaire (ECR-R) before and after treatment and at 6 and 12 months follow-up. The Liebowitz Social Anxiety Scale (LSAS) was administered at pre-treatment, post-treatment, and at 6-month and 1-year follow-up. ECR-R scores were first compared to a representative healthy sample (n = 2508) in order to demonstrate that the clinical sample differed significantly from the non-clinical sample with respect to attachment anxiety and avoidance. RESULTS: LSAS scores correlated significantly with both ECR-R subscales. Post-therapy, patients treated with CBT revealed significant changes in attachment anxiety and avoidance whereas patients treated with PDT showed no significant changes. Changes between post-treatment and the two follow-ups were significant in both conditions, with minimal (insignificant) differences between treatments at the 12- month follow-up. CONCLUSIONS: The current study supports recent reviews of mostly naturalistic studies indicating changes in attachment as a result of psychotherapy. Although there were differences between conditions at the end of treatment, these largely disappeared during the follow-up period which is line with the other results of the SOPHO-NET trial. TRIAL REGISTRATION: Controlled-trials.com ISRCTN53517394.

Psychodynamic psychotherapy: a systematic review of techniques, indications and empirical evidence.

PURPOSE: Psychodynamic psychotherapy is one of the most frequently applied methods of psychotherapy in clinical practice. However, it is the subject of controversial discussion, especially with regard to empirical evidence. In this article we aim to give an up-to-date description of the treatment and to review the available empirical evidence. Evidence is reviewed for both efficacy and mechanisms of change of short- and moderate-term psychodynamic psychotherapy. Furthermore, results of effectiveness studies of long-term psychoanalytic therapy are reviewed. METHODS: With regard to efficacy, a protocol for a Cochrane review for (short-term) psychodynamic psychotherapy is available specifying inclusion criteria for efficacy studies. RESULTS: Twenty-three randomized controlled trials of manual-guided psychodynamic psychotherapy applied in specific psychiatric disorders provided evidence that psychodynamic psychotherapy is superior to control conditions (treatment-as-usual or wait list) and, on the whole, as effective as already established treatments (e.g. cognitive-behavioural therapy) in specific psychiatric disorders. With regard to process research, central assumptions of psychodynamic psychotherapy were confirmed by empirical studies. CONCLUSIONS: Further research should include both efficacy studies (on specific forms of psychodynamic psychotherapy in specific mental disorders) and effectiveness studies complementing the results from experimental research settings. Future process research should address the complex interactions among interventions, patient's level of functioning, helping alliance and outcome.