Liebowitz Social Anxiety Scale (LSAS): Optimal cut points for remission and response in a German sample.

The Liebowitz Social Anxiety Scale (LSAS) is the most frequently used instrument to assess social anxiety disorder (SAD) in clinical research and practice. Both a self-reported (LSAS-SR) and a clinician-administered (LSAS-CA) version are available. The aim of the present study was to define optimal cut-off (OC) scores for remission and response to treatment for the LSAS in a German sample. Data of N = 311 patients with SAD were used who had completed psychotherapeutic treatment within a multicentre randomized controlled trial. Diagnosis of SAD and reduction in symptom severity according to the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th edition, served as gold standard. OCs yielding the best balance between sensitivity and specificity were determined using receiver operating characteristics. The variability of the resulting OCs was estimated by nonparametric bootstrapping. Using diagnosis of SAD (present vs. absent) as a criterion, results for remission indicated cut-off values of 35 for the LSAS-SR and 30 for the LSAS-CA, with acceptable sensitivity (LSAS-SR: .83, LSAS-CA: .88) and specificity (LSAS-SR: .82, LSAS-CA: .87). For detection of response to treatment, assessed by a 1-point reduction in the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th edition, rating, a reduction of 28% for the LSAS-SR and 29% for the LSAS-CA yielded the best balance between sensitivity (LSAS-SR: .75, LSAS-CA: .83) and specificity (LSAS-SR: .76, LSAS-CA: .80). To our knowledge, we are the first to define cut points for the LSAS in a German sample. Overall, the cut points for remission and response corroborate previously reported cut points, now building on a broader data basis.

Biases in research: risk factors for non-replicability in psychotherapy and pharmacotherapy research.

Replicability of findings is an essential prerequisite of research. For both basic and clinical research, however, low replicability of findings has recently been reported. Replicability may be affected by research biases not sufficiently controlled for by the existing research standards. Several biases such as researcher allegiance or selective reporting are well-known for affecting results. For psychotherapy and pharmacotherapy research, specific additional biases may affect outcome (e.g. therapist allegiance, therapist effects or impairments in treatment implementation). For meta-analyses further specific biases are relevant. In psychotherapy and pharmacotherapy research these biases have not yet been systematically discussed in the context of replicability. Using a list of 13 biases as a starting point, we discuss each bias's impact on replicability. We illustrate each bias by selective findings of recent research, showing that (1) several biases are not yet sufficiently controlled for by the presently applied research standards, (2) these biases have a pernicious effect on replicability of findings. For the sake of research credibility, it is critical to avoid these biases in future research. To control for biases and to improve replicability, we propose to systematically implement several measures in psychotherapy and pharmacotherapy research, such as adversarial collaboration (inviting academic rivals to collaborate), reviewing study design prior to knowing the results, triple-blind data analysis (including subjects, investigators and data managers/statisticians), data analysis by other research teams (crowdsourcing), and, last not least, updating reporting standards such as CONSORT or the Template for Intervention Description and Replication (TIDieR).

Resource activation for treating post-traumatic stress disorder, co-morbid symptoms and impaired functioning: a randomized controlled trial in Cambodia.

BACKGROUND: Mental health morbidity in post-conflict settings is high. Nevertheless, randomized controlled trials of psychotherapy on site are rare. Our aim was to integrate rigorous research procedures into a humanitarian programme and test the efficacy of resource activation (ROTATE) in treating post-traumatic stress disorder (PTSD), co-morbid symptoms and impaired functioning in Cambodia. METHOD: A total of 86 out-patients with PTSD were randomly assigned to five sessions of ROTATE (n = 53) or a 5-week waiting-list control (WLC) condition (n = 33). Treatment was provided by six Cambodian psychologists who had received extensive training in ROTATE. Masked assessments were made before and after therapy. RESULTS: PTSD remission rates according to the DSM-IV algorithm of the Harvard Trauma Questionnaire were 95.9% in ROTATE and 24.1% in the WLC condition. Thus, patients receiving ROTATE had a significantly higher likelihood of PTSD remission (odds ratio 0.012, 95% confidence interval 0.002-0.071, p < 0.00001). Additionally, levels of anxiety, depression and impaired functioning were significantly reduced compared with the WLC condition (p < 0.00001, between-group effect sizes d = 2.41, 2.26 and 2.54, respectively). No harms were reported. CONCLUSIONS: ROTATE was efficacious in treating Cambodian patients with high symptom levels of PTSD, emotional distress and impaired functioning. ROTATE is a brief, culturally adaptable intervention focusing on stabilization and strengthening resources rather than trauma confrontation. It can be taught to local professionals and paraprofessionals and enhance access to mental health care for patients in need.

The social phobia psychotherapy research network. The first multicenter randomized controlled trial of psychotherapy for social phobia: rationale, methods and patient characteristics.

This paper presents the Social Phobia Psychotherapy Research Network. The research program encompasses a coordinated group of studies adopting a standard protocol and an agreed-on set of standardized measures for the assessment and treatment of social phobia (SP). In the central project (study A), a multicenter randomized controlled trial, refined models of manualized cognitive-behavioral therapy and manualized short-term psychodynamic psychotherapy are compared in the treatment of SP. A sample of 512 outpatients will be randomized to either cognitive-behavioral therapy, short-term psychodynamic psychotherapy or waiting list. Assessments will be made at baseline, at the end of treatment and 6 and 12 months after the end of treatment. For quality assurance and treatment integrity, a specific project using highly elaborated measures has been established (project Q). Study A is complemented by 4 interrelated add-on projects focusing on attachment style (study B1), on cost-effectiveness (study B2), on variation in the serotonin transporter gene in SP (study C1) and on structural and functional deviations of the hippocampus and amygdala (study C2). Thus, the Social Phobia Psychotherapy Research Network program enables a highly interdisciplinary research into SP. The unique sample size achieved by the multicenter approach allows for studies of subgroups (e.g. comorbid disorders, isolated vs. generalized SP), of responders and nonresponders of each treatment approach, for generalization of results and for a sufficient power to detect differences between treatments. Psychological and biological parameters will be related to treatment outcome, and variables for differential treatment indication will be gained. Thus, the results provided by the network may have an important impact on the treatment of SP and on the development of treatment guidelines for SP.

[On the efficacy of long-term psychodynamic psychotherapy for complex psychological disorders]. / Zur Wirksamkeit psychodynamischer Langzeittherapie bei komplexen psychischen Störungen.

Rief and Hofmann (Nervenarzt 80:593-597) criticize in a very detailed comment our meta-analysis of long-term psychodynamic psychotherapy (JAMA 300:1551-1565). Although our article clearly included information that our meta-analysis addressed long-term psychodynamic psychotherapy of at least 50 sessions or at least 1 year duration, Rief and Hofmann allege that we studied "psychoanalysis" or "long-term psychoanalysis". Then they "show" for some of the studies we included that these studies did not address "psychoanalysis" or "long-term psychoanalysis" - which they did indeed not, but had never been claimed by us. For all other points of criticism put forward by the authors we show that they are not tenable as well. In addition, we show that Rief and Hofmann use omissions and allegations that give the impression that we deliberately violated principles of good scientific practice. This is reputation-damaging behaviour that clearly goes beyond a scientific discussion among researchers and constitutes a special act which itself violates the principles of good scientific practice.

Is psychotherapy effective? A re-analysis of treatments for depression.

AimsThe aim of this study was to reanalyse the data from Cuijpers et al.'s (2018) meta-analysis, to examine Eysenck's claim that psychotherapy is not effective. Cuijpers et al., after correcting for bias, concluded that the effect of psychotherapy for depression was small (standardised mean difference, SMD, between 0.20 and 0.30), providing evidence that psychotherapy is not as effective as generally accepted. METHODS: The data for this study were the effect sizes included in Cuijpers et al. (2018). We removed outliers from the data set of effects, corrected for publication bias and segregated psychotherapy from other interventions. In our study, we considered wait-list (WL) controls as the most appropriate estimate of the natural history of depression without intervention. RESULTS: The SMD for all interventions and for psychotherapy compared to WL controls was approximately 0.70, a value consistent with past estimates of the effectiveness of psychotherapy. Psychotherapy was also more effective than care-as-usual (SMD = 0.31) and other control groups (SMD = 0.43). CONCLUSIONS: The re-analysis reveals that psychotherapy for adult patients diagnosed with depression is effective.

Comparative effects of short-term psychodynamic psychotherapy and cognitive-behavioral therapy in depression: a meta-analytic approach.

UNLABELLED: This article reviews the efficacy of short-term psychodynamic psychotherapy (STPP) in depression compared to cognitive-behavioral therapy (CBT) or behavioral therapy (BT). In this review, only studies in which at least 13 therapy sessions were performed have been included, and a sufficient number of patients per group were treated (N > or = 20). With regard to outcome criteria, the results were reviewed for improvements in depressive symptoms, general psychiatric symptoms, and social functioning. Six studies met the inclusion criteria. RESULTS: In 58 of the 60 comparisons (97%) performed in the six studies and their follow-ups, no significant difference could be detected between STPP and CBT/BT concerning the effects in depressive symptoms, general psychiatric symptomatology, and social functioning. Furthermore, STPP and CBT/BT did not differ significantly with regard to the patients that were judged as remitted or improved. According to a meta-analytic procedure described by R. Rosenthal (1991) the studies do not differ significantly with regard to the patients that were judged as remitted or improved after treatment with STPP or CBT/BT. The mean difference between STPP and CBT/BT concerning the number of patients that were judged as remitted or improved corresponds to a small effect size (post-assessment: phi = 0.08, follow-up assessment: phi = 0.12). Thus, STPP and CBT/BT seem to be equally effective methods in the treatment of depression. However, because of the small number of studies which met the inclusion criteria, this result can only be preliminary. Furthermore, it applies only to the specific forms of STPP that were examined in the selected studies and cannot be generalized to other forms of STPP. Further studies are needed to examine the effects of specific forms of STPP in both controlled and naturalistic settings. Furthermore, there are findings indicating that 16-20 sessions of both STPP and CBT/BT are insufficient for most patients to achieve lasting remission. Future studies should address the effects of longer treatments of depression.

Splitting: an empirical study.

In this study, the Rorschach scoring system for splitting developed by Lerner, Sugarman, and Gaughran (1981) was applied to the Holtzman Inkblot Technique (HIT). Normal individuals (n = 30), patients with neurotic disorders (n = 30), patients with borderline personality disorder (n = 30), patients with acute schizophrenia (n = 25), and patients with chronic schizophrenia (n = 25) were studied with respect to their use of splitting. Sufficient interrater reliability was demonstrated for the scoring of splitting in the HIT. Significant differences between borderline patients, acute schizophrenic patients, and chronic schizophrenic patients, on the one hand, and patients with neurotic disorders, on the other hand, were demonstrated. Furthermore, it was shown that the indicators of splitting were associated with measures of identity diffusion, primitive defense mechanisms, and other measures of psychopathology. The Lerner indicator of splitting proved to be multidimensional. Different forms of splitting seem to be characteristic of borderline patients and schizophrenic patients. The application of the Lerner criteria of primitive defenses to the HIT appears to be promising.

Primary process thinking, primitive defensive operations and object relationships in borderline and neurotic patients.

In the present paper Kernberg's hypothesis concerning the connection between primary process thinking on the one hand and primitive defense mechanisms and modes of object relationships on the other hand were tested empirically in a sample of 30 hospitalized borderline and 30 hospitalized neurotic patients. The diagnoses of the patients were given according to the 'Diagnostic Interview for Borderlines' of Gunderson and Kolb, the functions mentioned above were assessed on the basis of the Holtzman Inkblot Technique applying scoring systems of Lerner and coworkers for primitive defense mechanisms and of Urist for the scoring of object relationships to the Holtzman Inkblot Technique. According to the results the hypothesis derived from assumptions of Kernberg could be corroborated. Primary process thinking in borderline patients seems to be closely connected with high levels of anxiety and hostility, projective identification/projection, primitive denial and sadomasochistic relationships. A model for the coming about of primary process thinking in borderline patients is proposed.

[Internalized object relations in schizophrenics]. / Verinnerlichte Objektbeziehungen bei Schizophrenen.

In the present study, schizophrenic persons were studied with regard to internalised object relations. A rating method developed by Urist was applied to the Holtzman Inkblot Technique, a modification of the Rorschach-Test. A sample of acute schizophrenic patients (n = 25) and a sample of chronic schizophrenics (n = 25) were studied and compared to a sample of borderline patients (n = 30) with regard to ratings of internalised object relations. According to the results, borderline patients showed significantly higher ratings of object relations in which one figure was tortured, damaged, or devoured by another. Furthermore, it could be demonstrated that severe forms of primary process thinking correlated significantly with ratings of primitive object relations not only in borderline patients, but also in acute schizophrenics and chronic schizophrenics. The results are discussed with regard to Kernbergs's theory of primary process thinking.

Development and first results of the Borderline Personality Inventory: a self-report instrument for assessing borderline personality organization.

This article reports the development of a short 53-item true-false self-report instrument, the Borderline Personality Inventory (BPI). The BPI is based on Kernberg's (1984) concept of borderline personality organization. However, the diagnostic criteria are compatible with both the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) and Gunderson's (Gunderson & Kolb, 1978) concept of borderline personality disorder (BPD). The BPI contains scales for assessing identity diffusion, primitive defense mechanisms, and reality testing. Another scale refers to the fear of closeness. The construction of the scales is based on the results of a factor analysis. As a result of several studies, a cutoff score is proposed to make the diagnosis of a BPD. Thus, the BPI combines dimensional and categorical models of BPD. The BPI was tested in several studies. According to the results, internal consistency and retest reliability are satisfactory (Cronbach's alpha = .68-.91, rtt = .73-.89). Results for sensitivity are .85 to .89, and results for specificity .78 to .89. The BPI identifies borderline patients in high agreement with Kernberg's criteria of borderline personality organization, Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Association, 1987) criteria of BPD and Gunderson's criteria of BPD. The BPI is recommended as a screening instrument for borderline personality organization and BPD and for dimensional research of borderline features in Axis I and Axis II disorders.

Primitive defense mechanisms in schizophrenics and borderline patients.

In this study, patients with neurotic disorders, borderline patients, acute schizophrenics, and chronic schizophrenics were studied with regard to primitive defense mechanisms. Primitive defense mechanisms were assessed by means of the Lerner Defense Scale (LDS). In this study, the LDS was applied to the Holtzman Inkblot Technique. With the exception of primitive idealization, borderline patients used all primitive defense mechanisms significantly more frequently than patients with neurotic disorders, that is, splitting, projective identification, primitive denial, and primitive devaluation. Compared with both acute and chronic schizophrenics, borderline patients used primitive devaluation at a significantly higher degree of frequency. Both acute and chronic schizophrenics differed from patients with neurotic disorders by using splitting and projective identification significantly more frequently. However, there were differences concerning primitive devaluation and idealization. The defense structure of chronic schizophrenics was heterogenous. Except for primitive idealization, all primitive defense mechanisms correlated significantly with self-report measures of identity diffusion and impaired reality testing, which is consistent with theoretical assumptions. By a discriminant analysis, 90% of the borderline patients, 80% of the patients with neurotic disorders, 76% of the acute schizophrenics, and 92% of the chronic schizophrenics were classified correctly.

Discriminating borderline from neurotic patients. A study with the Holtzman Inkblot Technique.

The present study tried to separate 30 hospitalized borderline and 30 hospitalized neurotic patients by indicators of deviant thinking. Kolb and Gunderson's diagnostic interview for borderlines and the Holtzman Inkblot Technique (HIT) were applied as diagnostic instruments. It was possible to separate the two groups by the more severe degrees of deviant thinking with relatively high values for sensitivity and specificity (83 and 93%). If these results can be corroborated in cross-validations with independent samples, the HIT would be a very useful instrument for the discrimination of the two diagnostic groups.

Discriminating schizophrenics from borderline patients: study with the Holtzman Inkblot technique.

The present study tried to discriminate acute (n = 25) and chronic schizophrenics (n = 25) from borderline patients (BLP; n = 30) on the basis of deviant verbalizations as assessed by the Holtzman Inkblot Technique (HIT). A 30-card version of the HIT was used. It was possible to separate BLPs and schizophrenics with quite good results: 77% of the BLPs, 80% of the acute schizophrenics and 92% of the chronic schizophrenics could be classified correctly based on the less severe deviant verbalizations (DVs) which were more frequent in the BLPs and based on the most severe forms of DVs, i.e. Incoherence, neologism and Perseveration (which were more frequent in the schizophrenic patients). Furthermore, it could be demonstrated that BLPs can be separated from neurotics using the 30-card version of the HIT, the resulting scores being nearly as high as those on the basis of the 45-card version. In another comparison, neurotics (n = 30) were discriminated from normals (n = 35) using the less severe DVs, which were more frequent in the neurotics: here, 74% of the normals and 73% of the neurotics could be classified correctly.

[Dimensions of bizarre, idiosyncratic thinking. Relationship between thought disorders and affect]. / Dimensionen bizarr-idiosynkratischen Denkens. Zusammenhänge zwischen Denkstörungen und Affekten.

In the present study disorders of thinking were studied in normals, patients with neurotic disorders, borderline patients and both acute and chronic schizophrenics. Disorders of thinking were assessed by the Holtzman Inkblot Technique. By a factor analysis, different dimensions of disordered thinking characteristic of the different diagnostic groups could be identified. Among others two dimensions of schizophrenic thought disorder and one of borderline thought disorder could be identified. This latter dimension showed high correlations with anxiety and hostility. This was true for a dimension of productive schizophrenics thought disorders, but not for a dimension of negative schizophrenics thought disorders.

[Aspects of object relations in borderline and neurotic patients: an empirical study using the Holtzman Inkblot technic]. / Aspekte von Objektbeziehungen bei Borderline- und neurotischen Patienten: Eine empirische Untersuchung mit der Holtzman-Inkblot-Technik.

In the present study hospitalized borderline and neurotic patients were compared concerning certain aspects of object relations. The diagnosis of a borderline disorder was given on the basis of the "Diagnostic Interview for Borderlines" (Gunderson u. Kolb 1978). Certain aspects of object relations were assessed by applying the 7-point scale developed by Urist (1977) to responses in the Holtzman Inkblot Technique. According to the results the two diagnostic groups differ with regard to 5 of the 7 scale levels which are connected with the following interpersonal themes: Being supplied and guided; controlling; sucking out, devouring and damaging; engulfing and overwhelming. The results are interpreted referring to object relation theory. Furthermore hit rates were assessed on the basis of the Urist scale data with relatively good results for sensitivity and specifity.

[Primary and secondary process thinking in normal probands, neurotic and borderline patients]. / Primär- und sekundärprozesshaftes Denken bei Normalen, Neurotikern und Borderline-Patienten.

In the present paper normals, neurotics and borderline patients were compared with respect to primary and secondary process thinking. The Holtzman Inkblot Technique was used to assess the different modes of functioning. As it was expected, normals had more indicators of the most severe levels of primary process thinking than neurotics, but less than borderline patients. On the other hand it could be demonstrated that in normals the reality testing ability and synthetic functioning were not impaired compared to neurotics. In the contrary, the normals exceeded the neurotics concerning indicators of abstractive abilities. The results are discussed with regard to the hypothesis of a continuum of normal and deviant thinking and with regard to the concept of adaptive regression in the service of the ego.

[Reducing ambiguity: semantic statistical studies of "normal" probands, neurotic patients, borderline patients and schizophrenic patients]. / Reduzierung von Ambiguität: sprachstatistische Untersuchungen an "Normalen", Neurotikern, Borderline-Patienten und Schizophrenen.

The present study tries to answer three questions: 1.) Do patients with neurotic disorders differ from normals by a stronger tendency to avoid or reduce ambiguity? 2.) Does the tendency to avoid or reduce ambiguity increase with increasing ambiguity of the stimulus? 3.) Does the avoidance or reduction of ambiguity increase with affects of anxiety and hostility? In order to answer these questions, Ertel's dogmatism-dictionary was applied to the answers of 30 normals, 30 patients with neurotic disorders, 30 borderline-patients, 25 acute and 25 chronic schizophrenics in the Holtzman Inkblot Technique (HIT). According to the results, (1) patients with neurotic disorders do not differ from normals by a stronger tendency to avoid or reduce ambiguity. 2.) The tendency to avoid or reduce ambiguity increases with measures of increasing stimulus ambiguity of the HIT cards in all diagnostic groups studied with the exception of chronic schizophrenics. As far as response ambiguity (variability of interpretation) is concerned, only in chronic schizophrenics the tendency to avoid or reduce ambiguity decreases with increasing response ambiguity. 3.) The avoidance or reduction of ambiguity increases with affects of anxiety and/or aggression assessed by HIT-measures in all diagnostic groups studied with the exception of normals and chronic schizophrenics. In both normals and chronic schizophrenics, the reduction of ambiguity decreases significantly with increasing anxiety, in chronic schizophrenics the reduction of ambiguity decreases significantly with an increase of low levels of aggression.

[Empirical findings on the personality structure of borderline patients]. / Empirische Befunde zur Persönlichkeitsstruktur von Borderlinepatienten.

In the present study the question of personality structure in borderline patients is studied empirically. The "Diagnostic Interview for Borderlines" of Gunderson and Kolb is used to classify the patients. In an inpatient sample of borderline patients (n = 26) the clinical diagnoses of personality structure according to psychoanalytic criteria are investigated and compared to those of an inpatient sample of patients with neurotic disorders (n = 24). According to the results most of the borderline patients (88%) had received a diagnosis of a schizoid personality structure according to psychoanalytic criteria, in contrast to the neurotic patients. The results are compared to those of studies using descriptive psychiatric criteria.