Interpersonal problems and social dysfunction: Examining patients with avoidant and borderline personality disorder symptoms.

OBJECTIVE(S): Interpersonal problems are one of the most persistent difficulties facing those with personality disorders (PDs) and are linked with dysfunction across numerous social domains. Using an interpersonal model of PDs, we examined the indirect effects of Avoidant PD (AvPD) symptoms and social dysfunction through interpersonal problems, as well as Borderline PD (BPD) symptoms and social dysfunction. METHODS: Participants were 226 adults taking part in an outpatient treatment program. RESULTS: Using cross-sectional data from self-reported measures, we found that cold (b = 0.10, 95% confidence interval (CI) [0.038, 0.176]) and overly nurturant (b = 0.04, 95% CI [0.001, 0.090]) interpersonal problems showed an indirect association between AvPD symptoms and social dysfunction. The only significant indirect association between BPD symptoms and social dysfunction was overly nurturant (b = 0.05, 95% CI [0.001, 0.120]). CONCLUSIONS: Results may aid in the development of more individualized treatments for AvPD and BPD symptoms.

Different fixation constructs and the risk of non-union following first metatarsophalangeal joint arthrodesis.

BACKGROUND: The aim of this study was to determine if a single or separate construct with interfragmentary screw was associated with higher rates non-union following first metatarsophalangeal joint (MTPJ) arthrodesis. METHODS: A retrospective analysis of patients undergoing first MTPJ arthrodesis between April 2010 and June 2017 was performed. Patients who received either a single (Stryker Anchorage 1 MTP Cross Plate) or separate (Stryker Anchorage 1 MTP locking plate with one Asnis partially threaded compression screw) construct locking plate and interfragmentary compression screw were reviewed. Descriptive statistics were generated for sample demographics and between-group differences were calculated. Multivariable regressions explored internal fixation type and association with non-union. RESULTS: A total of 280 first MTPJ arthrodesis met the inclusion criteria and were reviewed. The incidence of non-union was 7.9% of procedures (22 joints). Following multivariable binary logistic regression, the single construct locking plate with interfragmentary compression screw was associated with an increased risk of non-union (OR 3.43, 95% CI 1.26-9.33), adjusting for age, gender and comorbidity. CONCLUSIONS: A single construct interfragmentary screw and locking plate (Stryker Anchorage 1 MTP Cross Plate) was associated with an increased incidence of non-union following first MTPJ arthrodesis.

Narcissism and Quality of Life: The Mediating Role of Relationship Patterns.

Pathological narcissism is associated with decreased quality of life, even when accounting for psychiatric comorbidity, but the processes behind this association are unclear. Here, we evaluate whether disturbed relatedness accounts for the negative association between narcissistic pathology and quality of life. Patients in day hospital treatment for personality pathology (N = 218, 70% female; mean age, 37.3 years) completed measures of personality disorder features, quality of life, and global symptoms before beginning treatment. Quality of object relations was assessed through semistructured interviews. Regression-based mediation analyses showed that narcissistic personality traits relate to quality of life through quality of object relations, controlling for other personality disorders and psychiatric distress. These results highlight the importance of problematic relationship patterns for the low quality of life associated with pathological narcissism. Clinicians working with narcissistic individuals should consider psychotherapies that promote mature relatedness and should attend to facilitating the quality of patients' relationships.

The Effect of Hopelessness and Perceived Group Compatibility on Treatment Outcome for Patients With Personality Dysfunction.

Improvement in life satisfaction is hard to achieve for any patient with personality psychopathology, and possibly even moreso for those who feel hopeless at the start of treatment. The present research investigated the potential influence of hopelessness in the treatment of patients with personality dysfunction, using data from patients who completed an intensive group therapy program designed to reduce symptom distress and support optimal psychosocial functioning (N = 80). In the present study, we sought to examine whether hopelessness would moderate (i.e., strengthen or weaken) relations between compatibility ratings and life satisfaction outcome. Hopelessness had a significant moderating effect on the relationship between compatibility and outcome, suggesting that, for patients who entered treatment feeling more hopeless, higher appraisals of fit within the group facilitated better gains in life satisfaction. If replicated, the findings underlie the importance of focusing on increasing hope and perceived group affiliation in the treatment of personality dysfunction.

Improving social functioning and life satisfaction among patients with personality dysfunction: Connectedness and engagement in integrative group treatment.

Reduced social impairment and improved life satisfaction are important objectives in group treatment for patients with personality dysfunction. Knowledge regarding patient characteristics and group treatment processes that contribute to these outcomes, however, remains limited. Dispositional connectedness, the valuing of interpersonal connections, may be an important patient factor that influences patients' experience of group treatment in ways that facilitate therapeutic benefits. The present study investigated the roles of dispositional connectedness and group engagement in contributing to improvement in social functioning and life satisfaction through integrative group treatment for personality dysfunction. Seventy-nine patients who completed an integrative group treatment programme were assessed for dispositional connectedness at baseline and social functioning and life satisfaction at pretreatment and posttreatment; each also provided ratings of group engagement during treatment. Regression analyses using bootstrap confidence intervals found significant indirect effects for dispositional connectedness regarding improvement in both social functioning and life satisfaction, through the mediating effect of group engagement. Thus, patients who entered treatment with tendencies towards interpersonal connectedness perceived a higher level of engagement in the group environment. Group engagement in turn contributed to greater improvement in social functioning and to greater improvement in life satisfaction following treatment. The findings indicate dispositional connectedness as a salient characteristic in selecting patients for group treatment and highlight the role of an engaged interpersonal climate in facilitating improvement in social functioning and life satisfaction.

The attenuating effect of depression symptoms on negative-affect expression: Individual and group effects in group psychotherapy for personality disorders.

Across a breadth of psychotherapeutic approaches, feeling affect intensely and then talking about those feelings is a common means for increasing insight and other desired outcomes. While several naturalistic and laboratory studies have found that depression symptoms attenuate (i.e., weaken) the association between negative-affect intensity and negative-affect expression, depression's attenuating effect has not been examined in a psychotherapeutic context. The first aim of the present study was to examine if depression symptoms' attenuating effect on the association between negative-affect intensity and negative-affect expression extended into group psychotherapy. Our second aim was to examine group effects on patients' negative-affect expression. Participants (N = 239) were patients consecutively admitted into a psychodynamic group-psychotherapy day treatment program for people with personality disorders. Patients indicated their negative-affect intensity and negative-affect expression each week that they were in treatment. Depression symptoms were assessed at baseline. Results indicated that depression symptoms attenuated (i.e., moderated) the association between negative-affect intensity and negative-affect expression. Further, while the association between patient intensity and expression increased over the course of treatment, the moderating effect of depression on this association did not vary over treatment. Regarding group effects, group negative-affect intensity was associated with higher levels of patient negative-affect expression. Inversely, group affect expression was associated with lower levels of patient affect expression. Patient depression symptoms did not moderate the association between group negative-affect intensity and patient negative-affect expression. Our findings indicate that while group affect intensity and affect expression impacts patients' expression, depression's attenuating effect on negative-affect expression extends to patient effects but not group effects. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Improving self-esteem through integrative group therapy for personality dysfunction: Investigating the role of the therapeutic alliance and quality of object relations.

OBJECTIVE: We aimed to investigate change in self-esteem through intensive group treatment for personality dysfunction, by exploring: (a) the relationship between patients' experience of therapeutic alliance and improvement in self-esteem during treatment, including patients' quality of object-relations (QOR) as a possible moderator; and (b) the association between improvement in self-esteem during treatment, and depressive symptoms 9 months later. METHOD: Eighty patients with personality dysfunction, consecutively enrolled in a group-oriented treatment program, were assessed at pretreatment, posttreatment, and 9 months follow-up. RESULTS: Especially for patients with lower QOR, alliance predicted self-esteem change during treatment. In addition, change in self-esteem during treatment predicted follow-up depression severity, even when controlling for within-treatment symptom change. CONCLUSIONS: Patients with impoverished inner relational representations may benefit more from a secure alliance in terms of improving their self-esteem. Change in self-esteem may also be important in preventing relapse of depressive symptoms in people with personality dysfunction.

Individual goal achievement in group psychotherapy: The roles of psychological mindedness and group process in interpretive and supportive therapy for complicated grief.

The ability to infer psychological meaning in behaviour-referred to as psychological mindedness-has been posited as a patient characteristic that contributes to the therapy process and consequently to therapeutic success. The present study was developed to examine the relationship between patients' psychological mindedness and improvement in patients' personal treatment goals in interpretive and supportive group therapies for complicated grief, along with patients' importance to group process. The study was conducted with a clinical sample of 109 patients (79% female; average 45 years old) receiving treatment for complicated grief. Patients provided severity of distress ratings for individual target objectives at pretreatment and posttreatment. Psychological mindedness was assessed prior to treatment using the video-based, interviewer-rated Psychological Mindedness Assessment Procedure. Patients' importance to the therapy process was rated by therapists and other patients in interpretive and supportive group therapy for complicated grief. Conditional process modelling tested whether psychological mindedness would contribute to patients' goal achievement through patients' importance to group process, moderated by type of therapy. A significant, conditional indirect effect was observed for psychological mindedness as a predictor of improvement in individual target objectives, through patients' importance to group process as rated by therapists, specifically in interpretive therapy. The findings indicate that patients' psychological mindedness significantly contributes to their achievement of individual goals through their contributions to group process in interpretive group therapy. Further research is needed to understand the facilitation of individual goal achievement in supportive therapy.

Where does it hurt? Location of pain, psychological distress, and alexithymia among outpatients seeking psychotherapy.

Objectives: Physical pain is prevalent among psychiatric outpatients, yet there has been little research regarding the types of pain reported. The purpose of this study was to survey outpatients seeking psychotherapy regarding pain locations and to examine associations between number of pain locations and psychiatric distress and alexithymia.Methods: Two hundred and seventeen patients were recruited from three Canadian hospitals that offer outpatient psychiatry services and short-term therapies. Participants were surveyed about their current physical pain using the Brief Pain Inventory. Participants also completed measures of psychiatric distress (Brief Symptom Inventory-18) and alexithymia (Toronto Alexithymia Scale-20).Results: The three most commonly reported pain locations were lower back, head, and neck. Findings revealed that anxiety, depression and alexithymia were associated with number of reported pain locations. Specifically, participants with three or more pain locations reported significantly higher depression, anxiety and alexithymia in comparison to those with no pain.Conclusions: Back, head and neck pains are highly prevalent among psychiatric outpatients. Multiple pain sites may reflect higher levels of psychiatric distress and greater impairment in emotional processing among psychiatric outpatients.

Narcissism and Interpersonal Problems Among Psychiatric Outpatients: What Is the Role of Defensive Style?

A growing body of evidence points to significant interpersonal problems associated with narcissism in clinical samples. Less well understood are the mechanisms by which narcissism negatively impacts one's interpersonal functioning. The present study investigated defensive style as a possible mediator of the relationship between narcissism and interpersonal problems. A sample of 53 adult psychiatric outpatients completed measures of narcissism, defensive style, interpersonal problems, and current symptom distress. Mediation analysis was conducted, controlling for current symptom distress, using 95% bootstrapped confidence intervals to examine the indirect effect of narcissism on interpersonal problems via defensive style. Narcissism was significantly associated with immature and neurotic defensive styles. Although narcissism was not directly related to interpersonal problems, a significant indirect effect was observed for narcissism on interpersonal problems via neurotic defensive style. This finding suggests that narcissism contributes to the use of neurotic defenses, which in turn influence one's interpersonal functioning.

The therapeutic factor inventory-8: Using item response theory to create a brief scale for continuous process monitoring for group psychotherapy.

OBJECTIVE: We tested a very brief version of the 23-item Therapeutic Factors Inventory-Short Form (TFI-S), and describe the use of Item Response Theory (IRT) for the purpose of developing short and reliable scales for group psychotherapy. METHOD: Group therapy patients (N = 578) completed the TFI-S on one occasion, and their data were used for the IRT analysis. Of those, 304 completed the TFI-S and other measures on more than one occasion to assess sensitivity to change, concurrent, and predictive validity of the brief version. RESULTS: Results suggest that the new TFI-8 is a brief, reliable, and valid measure of a higher-order group therapeutic factor. CONCLUSION: The TFI-8 may be used for continuous process measurement and feedback to improve the functioning of therapy groups.

Partial hospitalization treatment of the alexithymic patient: a case study.

Patients with alexithymia are a challenge to engage in treatment and require a diverse range of interventions to realize benefit. A partial hospitalization treatment program, offering multiple forms of group therapy in an integrated system, may be particularly helpful for patients with alexithymia. We examine the course of treatment for one alexithymic patient who participated in an 18-week intensive group- and dynamically oriented treatment program in Edmonton. Group support and feedback emerged as important elements in the treatment approach. Other features of the approach overlap with treatment guidelines for alexithymia found in the literature.

Treatment preferences among men attending outpatient psychiatric services.

BACKGROUND: The assumption that men dislike psychotherapy has been espoused by clinicians, health care administrators, and those in the popular media. Whether this assumption holds true among help-seeking men has not been tested. AIMS: Treatment preferences of men attending outpatient psychiatric clinics were investigated to assess their willingness to engage in psychotherapy. METHODS: In three different studies (total N = 407; 170 men), male and female outpatients completed various self-report measures that assessed their treatment preferences, as well as psychiatric symptoms. RESULTS: Across all three studies, men indicated a preference for psychotherapy over medication or no treatment/wait and see; a preference pattern that did not differ significantly from that of women. The only between-sex difference to emerge regarding preferences was in study 2; a greater proportion of men preferred individual therapy over group therapy compared to women. There were no between-sex differences with regard to symptoms. CONCLUSIONS: Contrary to assumptions that portray men, generally, as unwilling or uninterested to engage in psychotherapy, men that have sought mental health services appear to prefer psychotherapy as their intervention of choice to address their mental health problems.

Clinical correlates of alexithymia among patients with personality disorder.

The literature portrays patients with alexithymia as unusual and difficult to treat; research to date has not clarified the nature of this condition. This study addressed associations between alexithymia and constructs relevant to clinical intervention, namely attachment, quality of object relations, emotion regulation, defense style, personality disorder, and treatment outcome. Fifty-one patients admitted to an intensive group-oriented day treatment program were recruited. Prior to therapy, patients were administered self-report and structured interview measures of predictor and outcome variables; outcome measures were re-administered at completion of the 18-week program. Alexithymia was common in this sample, with four of five patients endorsing moderate or greater problems. Associations with attachment avoidance, primitive object relations, suppression of emotional expression, use of immature defenses, and severity of borderline personality disorder were identified. Alexithymia did not, however, predict outcome. Findings are considered in terms of how the construct informs views of personality disorder.

A Preliminary Study of the Interactive Effect of Avoidant Personality Disorder Symptoms and Expressive Suppression on the Outcome of a Psychodynamically Oriented Day Treatment Program.

Introduction: Patients with avoidant personality disorder (AvPD) pathology tend to have poor prognosis in psychotherapy, yet there has been little research conducted to better understand why their outcomes are limited, making it difficult to improve treatments for them. Expressive suppression is a dysfunctional emotion regulation strategy that may exacerbate avoidant tendencies, further complicating the therapeutic process. Methods: Using data from a naturalistic study (N = 34) of a group-based day treatment program, we examined whether there was an interactive effect of AvPD symptoms and expressive suppression on treatment outcome. Results: Findings revealed a significant moderating effect of expressive suppression on the association between AvPD symptoms and treatment outcome. The outcome for patients with more severe AvPD symptoms was particularly poor when they engaged in high levels of expressive suppression. Discussion: The findings suggest that the combination of significant AvPD pathology and high expressive suppression is associated with poorer responsiveness to treatment.

A review of the psychotherapeutic 'common factors' model and its application in physical therapy: the need to consider general effects in physical therapy practice.

This article explores the common factors model of psychotherapeutic intervention and discusses its relevance for physical therapy practice. The model provides an explanation for why the effects associated with specific technical approaches only minimally explain successful psychotherapy clinical outcomes. It postulates that factors common across diverse interventions (i.e. 'nonspecific' mechanisms) are responsible for a larger component of treatment efficacy. We outline the applicability of the common factors model to physical therapy and provide supportive evidence from evaluation and prognostic research on interventions for conditions seen in musculoskeletal physical therapy practice. The relevancy and consequences of applying the common factors model to physical therapy practice and research are discussed. The continued advance and evolution of the physical therapy profession requires creative and comprehensive analysis of all factors impacting clinical effectiveness. Additional research is needed to more clearly delineate the common factors that are operational in physical therapy practice and to measure their relative impact on clinical outcomes.

The Relationship Between Patients' Personality Traits, the Alliance, and Change in Interpersonal Distress in Intensive Group Treatment for Personality Dysfunction.

This study examined patients' personality traits as operationalized by the five-factor model in relation to early alliance and reduction of interpersonal distress through an intensive group treatment program for personality dysfunction. A sample of 79 consecutively admitted psychiatric outpatients with personality dysfunction who attended an 18-week intensive group treatment program completed the NEO Five-Factor Inventory at pretreatment, the Inventory of Interpersonal Problems at pre- and posttreatment, and the Edmonton Therapeutic Alliance Scale, a measure of the therapeutic alliance with the program therapist, at Session 5. Results indicated that patients who were relatively extraverted tended to rate the alliance with their program therapist higher and subsequently reported more improvement of interpersonal distress. The presence of a personality disorder did not moderate this mediation. Patients' extraversion likely promotes a bonding with the therapist and facilitates the interpersonal group work necessary for improvement. Assessing patients' level of extraversion before starting intensive group treatment might indicate which intervention strategies could be useful with that patient within the program frame.

A randomized controlled trial evaluating the effect of an internet-based cognitive-behavioral program on anxiety symptoms in a community-based sample of adolescents.

Adolescents' use of online resources to self-manage anxiety is growing. The objective of the current trial was to assess the effectiveness of an online, primarily self-led cognitive behavioral therapy (CBT) program in reducing anxiety symptoms compared to an active comparator, access to anxiety resources on a static website. A total of 563 adolescents (13-19 years) with self-identified anxiety concerns were enrolled. Self-reported anxiety symptoms were assessed pre- and post-intervention (6 weeks). Adolescents were further assessed 3 months post-intervention. Other outcomes assessed at the three time-points were quality of life (QOL) and healthcare utilization. Both interventions reduced anxiety symptoms after use. Group differences in symptom change were not significant post-intervention (p = 0.16), but were at 3 months (favouring online CBT; p = 0.04) with male participants reporting more symptom change (p = 0.03). Across time-points, as anxiety symptoms decreased, QOL increased (p < 0.001). Among participants that provided healthcare utilization before and after intervention use, the greatest changes in use were among online CBT users particularly for mental health provider visits (psychiatrist, -41.0 % vs. +18.5 %; social worker, -42.5 % vs. -22.1 %), hospital-based care (emergency department visits, -80.0 % vs. +79.4 %; hospital admissions, -76.1 % vs. +42.9 %), and use of self-help or alternative treatments (-60.0 % vs. +6.6 %). Results suggest that, over time, use of online CBT by adolescents can result in improved anxiety symptoms and fewer use of other healthcare resources compared to traditional online information seeking.

Effect of alexithymia on the process and outcome of psychotherapy: a programmatic review.

Most psychotherapeutic approaches assume that individuals have some access to their emotions. Thus, patients who are unable to identify, differentiate, and articulate their emotions present therapists with a difficult challenge. Such patients may suffer from alexithymia. Despite much attention in the clinical literature, research on alexithymia in the treatment setting has been sparse. Thus, many of the assumptions about psychotherapeutic treatment of alexithymic patients remain untested. This article summarizes findings from a series of studies that examined the effect of alexithymia on various aspects of the psychotherapeutic enterprise. Findings indicated that alexithymia has little effect on patients' treatment preferences, yet there was some tendency for alexithymic patients to prefer group therapy. However, alexithymia was associated with poor outcome in both traditional psychodynamic psychotherapy and supportive therapy. This negative effect was found in individual and group psychotherapies. In the context of group therapy, higher levels of alexithymic features elicited negative reactions from one's therapist, which partially contributed to the poor outcome experienced by such patients. Finally, the negative reaction that therapists had toward patients with high alexithymia appeared to be in response to the lack of positive emotion expressed by these patients. Clinical implications and ideas for future research are considered.

Predicting response to day treatment for personality disorder.

OBJECTIVE: Efforts to improve the effectiveness of day treatment should attend to factors that influence treatment response. Our prospective study identified predictors of response to day treatment for personality disorder (PD). METHOD: Patients with a PD, consecutively admitted to a day treatment program, were assessed with self-report and interview measures. Predictors included personality characteristic, demographic, initial disturbance, and PD variables. Patients' overall response to treatment was classified as better, same, or worse, based on change in multiple outcome measures. A comprehensive approach to multivariate modelling was used. RESULTS: The likelihood of being classified as better significantly increased if the patient was more psychologically minded, used avoidance-oriented coping strategies, and had a high level of baseline symptom severity. Probability of being classified as better decreased if the patient had a substance use disorder and a history of high service use. CONCLUSIONS: Identifying factors that affect response to day treatment can help clinicians make better selection decisions or take measures to modify treatment.