Effectiveness of Day Treatment Group Schema Therapy for Personality Disorders: A Multiple Baseline Single-Case Study.

BACKGROUND: Schema therapy is effective for most outpatients with personality disorders (PDs). However, a subgroup does not sufficiently benefit from outpatient programmes. Despite its common clinical use, a thorough evaluation of day treatment group schema therapy (GST) is lacking. AIMS: This study aimed to investigate the effectiveness of day treatment GST for patients with PDs. METHODS AND PROCEDURES: Negative core beliefs were the primary outcome in a multiple baseline single-case design, measured weekly before and during 30 weeks of day treatment GST. Secondary outcomes included severity of primary PD, early maladaptive schemas (EMS), schema modes and general psychopathology measured before and after day treatment GST. Intervention effects were evaluated through visual inspection and randomization test analysis, with a reliable change index calculated for the secondary outcome measures. OUTCOMES AND RESULTS: A total of 79% of treatment completers showed a significant positive effect of day treatment GST with large effect sizes (Cohen's d: 0.96-10.04). Secondary outcomes supported these findings: 56% had a significant decrease in the severity of primary PD and 53% in general psychopathology. In addition, 63% of EMS and 72% of schema modes (87.5% for functional schema modes) showed significant positive reliable changes. CONCLUSIONS AND IMPLICATIONS: This is the first empirical study that demonstrated the effectiveness of day treatment GST in patients with severe PDs. Day treatment GST can serve as a stepped care treatment option for nonresponsive patients in outpatient programmes. Further randomized controlled (cost-)effectiveness research is necessary to substantiate these findings and investigate the specific patient populations for which day treatment is essential.

Timing of imagery rescripting during schema therapy for borderline personality disorder: the LUCY trial.

Background: Early childhood adversity plays an important role in the etiology of borderline personality disorder (BPD). Current evidence suggests that trauma treatment for patients with BPD can be performed safely and that early trauma treatment has a positive effect on the course of PD. However, there is a scarcity of RCTs comparing the effects of the timing of trauma treatment during schema therapy (ST) for BPD on BPD severity. Therefore, the LUCY trial investigates the effects of the timing of trauma treatment by comparing early trauma treatment using imagery rescripting (ImRs) on the course of BPD during ST to trauma treatment in the middle of the treatment course. Methods: In this multicenter RCT, two conditions are compared among 73 individuals with BPD. The participants receive combined individual and group ST in both conditions. However, in condition (A), participants directly start ImRs in the individual sessions in months 2-4, and in condition (B), participants receive ST-as-Usual (STAU), in which ImRs is not allowed during months 2-4. The treatment follows ST treatment protocols, consists of a fixed combination of individual sessions and group sessions with a maximum of nine patients, and has a maximum duration of 25 months. The primary outcome is change in BPD severity, which is assessed using the Borderline Personality Disorder Severity Index-5 by independent raters blinded to the treatment. Secondary outcome measures include treatment retention, disconnection/rejection schemas, general functioning, posttraumatic stress disorder symptoms, general psychopathological complaints, quality of life, happiness, schemas, and schema modes. Multilevel analysis will be performed to analyze and compare changes in BPD severity between conditions and generalized linear mixed model analyses to test predictors and moderators. Discussion: This study will increase the knowledge on whether trauma treatment early in therapy positively affects the course of BPD manifestations during ST. When the early application of ImRs leads to a faster decrease in BPD manifestations, the treatment of BPD patients might be shortened, leading to improved treatment outcomes and decreased healthcare expenses. Moreover, the planned sub-studies will expand our knowledge of how ST works and the factors that influence the outcome of treatment.

The role of dissociation-related beliefs about memory in trauma-focused treatment.

OBJECTIVE: Dysfunctional cognitions play a central role in the development of post-traumatic stress disorder (PTSD). However the role of specific dissociation-related beliefs about memory has not been previously investigated. This study aimed to investigate the role of dissociation-related beliefs about memory in trauma-focused treatment. It was hypothesized that patients with the dissociative subtype of PTSD would show higher levels of dissociation-related beliefs, dissociation-related beliefs about memory would decrease after trauma-focused treatment, and higher pre-treatment dissociation-related beliefs would be associated with fewer changes in PTSD symptoms. METHOD: Post-traumatic symptoms, dissociative symptoms, and dissociation-related beliefs about memory were assessed in a sample of patients diagnosed with PTSD (n = 111) or the dissociative subtype of PTSD (n = 61). They underwent intensive trauma-focused treatment consisting of four or eight consecutive treatment days. On each treatment day, patients received 90 min of individual prolonged exposure (PE) in the morning and 90 min of individual eye movement desensitization and reprocessing (EMDR) therapy in the afternoon. The relationship between dissociation-related beliefs about memory and the effects of trauma-focused treatment was investigated. RESULTS: Dissociation-related beliefs about memory were significantly associated with PTSD and its dissociative symptoms. In addition, consistent with our hypothesis, patients with the dissociative subtype of PTSD scored significantly higher on dissociation-related beliefs about memory pre-treatment than those without the dissociative subtype. Additionally, the severity of these beliefs decreased significantly after trauma-related treatment. Contrary to our hypothesis, elevated dissociation-related beliefs did not negatively influence treatment outcome. CONCLUSION: The results of the current study suggest that dissociation-related beliefs do not influence the outcome of trauma-focused treatment, and that trauma-focused treatment does not need to be altered specifically for patients experiencing more dissociation-related beliefs about memory because these beliefs decrease in association with treatment.

This study investigated the role of dissociation-related beliefs about memory on trauma-focused treatment.Dissociation-related beliefs were related to post-traumatic and dissociative symptoms, and were especially prominent in patients with the dissociative subtype of post-traumatic stress disorder.Dissociation-related beliefs about memory do not impact the effectiveness of trauma-focused treatment. In fact, trauma-focused treatment effectively decreased these beliefs, suggesting that dissociation-related beliefs about memory should not be a determining factor in withholding patients from receiving trauma-focused therapy.

Group schema therapy for cluster-C personality disorders: A multicentre open pilot study.

BACKGROUND: Group schema therapy (GST) is increasingly popular as a treatment for personality disorders (PDs), including Cluster-C PDs. Individual ST has proven to be effective for Cluster-C PD patients, while the evidence for GST is limited. This study aimed to investigate the effectiveness of GST for Cluster-C PD. Moreover, differences between the specific Cluster-C PDs (avoidant PD, dependent PD and obsessive-compulsive PD) were explored. METHODS: A multicentre open trial was conducted, including 137 patients with a Cluster-C PD (avoidant PD: n = 107, dependent PD: n = 11 and obsessive-compulsive PD: n = 19). Patients received 30 weekly GST sessions with a maximum of 180 min of individual ST and five optional monthly booster sessions. Outcome measures including Cluster-C PD severity, general psychopathological symptoms, quality of life, functional impairment, happiness, PD-related beliefs, self-esteem, self-ideal discrepancy, schemas and schema modes were assessed at baseline until 2-year follow-up with semi-structured interviews and self-report measures. Change over time and differences between the specific Cluster-C PDs were analysed with mixed regression analyses. RESULTS: The outcome measures showed significant improvements for all Cluster-C PDs, with medium to large effect sizes after 2 years. A treatment dropout rate of 11.7% was found. There were some indications for differences between the Cluster-C PDs in severity at baseline, change trajectories and effectiveness of GST. CONCLUSIONS: This study demonstrated that GST is a promising treatment for Cluster-C PDs. The following step is a randomized controlled trial to further document the (cost-)effectiveness of GST.

Personality disorder traits, maladaptive schemas, modes and coping styles in participants with complex dissociative disorders, borderline personality disorder and avoidant personality disorder.

OBJECTIVE: The schema mode model offers a new conceptualisation of complex dissociative disorders (CDD) as it explains shifts between identities as shifts between schema modes. Furthermore, in this model CDD is conceived as personality pathology, incorporating core features of personality disorders. This study tested the assumptions of this schema mode model of CDD. METHOD: Questionnaires measuring personality disorder traits, schemas, schema modes and coping styles were filled out by patients with CDD, borderline personality disorder and avoidant personality disorder (N = 210), and their scores on the various constructs were compared. RESULTS: Participants with CDD were characterised by specific schizoid, schizotypal, borderline and avoidant personality traits and early maladaptive schemas in the domains of disconnection and rejection and over-vigilance and inhibition. The most pronounced schema modes were the dysfunctional parent modes, avoidant coping modes and the vulnerable child mode. For coping styles, no differences were found between the diagnostic groups. CONCLUSION AND DISCUSSION: On all outcome measures participants with CDD scored at the level of personality disorders and showed a unique pattern different from participants with borderline and avoidant personality disorder. This suggests that CDD shows features akin to a personality disorder. A clinical implication is that an adapted form of schema therapy might present a viable treatment option for CDD.

Schema therapy for Dissociative Identity Disorder: a case report.

Treatment for Dissociative Identity Disorder (DID) often follows a practice-based psychodynamic psychotherapy approach that is conducted in three phases: symptom stabilization, trauma processing, and identity integration and rehabilitation. The percentage of patients that reach the third phase is relatively low, treatment duration is long, and the effects of this treatment on the core DID symptoms have been found to be small or absent, leaving room for improvement in the treatment of DID. Schema Therapy (ST) is an integrative psychotherapy that has been proposed as a treatment for DID. This approach is currently being investigated in several studies and has the potential to become an evidence-based treatment for DID. This case report presents an overview of the protocol adaptations for DID ST treatment. The presented case concerns a 43-year-old female patient with DID, depressive disorder (recurrent type), PTSD, cannabis use disorder, and BPD. Functioning was very low. She received 220 sessions of ST, which included direct trauma processing through Imagery Rescripting (ImRs). The patient improved in several domains: she experienced a reduction of PTSD symptoms, as well as dissociative symptoms, there were structural changes in the beliefs about the self, and loss of suicidal behaviors. After treatment she was able to stop her punitive mode, to express her feelings and needs to others, and to participate adequately in social interaction. This case report indicates that ST might be a viable treatment for DID, adding to a broader scope of treatment options for this patient group.

Predictors and moderators of treatment outcomes in phase-based treatment and trauma-focused treatments in patients with childhood abuse-related post-traumatic stress disorder.

Background: Knowledge of treatment predictors and moderators is important for improving the effectiveness of treatment for PTSD due to childhood abuse.Objective: The first aim of this study was to test the potential predictive value of variables commonly associated with PTSD resulting from a history of repeated childhood abuse, in relation to treatment outcomes. The second aim was to examine if complex PTSD symptoms act as potential moderators between treatment conditions and outcomes.Method: Data were obtained from a randomized controlled trial comparing a phase-based treatment (Skills Training in Affect and Interpersonal Regulation [STAIR] followed by Eye Movement Desensitization and Reprocessing [EMDR] therapy; n = 57) with a direct trauma-focused treatment (EMDR therapy only; n = 64) in people with PTSD due to childhood abuse. The possible predictive effects of the presence of borderline personality disorder, dissociative symptoms, and suicidal and self-injurious behaviours were examined. In addition, it was determined whether symptoms of emotion regulation difficulties, self-esteem, and interpersonal problems moderated the relation between the treatment condition and PTSD post-treatment, corrected for pre-treatment PTSD severity.Results: Pre-treatment PTSD severity proved to be a significant predictor of less profitable PTSD treatment outcomes. The same was true for the severity of dissociative symptoms, but only post-treatment, and not when corrected for false positives. Complex PTSD symptoms did not moderate the relationship between the treatment conditions and PTSD treatment outcomes.Conclusions: The current findings suggest that regardless of the common comorbid symptoms studied, immediate trauma-focused treatment is a safe and effective option for individuals with childhood-related PTSD. However, individuals experiencing severe symptoms of PTSD may benefit from additional treatment sessions or the addition of other evidence-based PTSD treatment approaches. The predictive influence of dissociative sequelae needs further research.The study design was registered in The Dutch trial register (https://www.trialregister.nl/trialreg/admin/rctview.asp?TC = 5991) NTR5991 and was approved by the medical ethics committee of Twente NL 56641.044.16 CCMO.

One of first studies that aimed to identify multiple potential predictors and moderators in patients with PTSD related to childhood abuse.Only severe PTSD predicted worse treatment outcomes.The predictive influence of dissociative sequelae needs further research.

Blended Delivery of Imagery Rescripting for Childhood PTSD: A Case Study During the COVID-19 Pandemic.

Background: Despite the growing evidence that trauma-focused treatments can be applied as first-line approaches for individuals with childhood trauma-related PTSD (Ch-PTSD), many therapists are still reluctant to provide trauma-focused treatments as a first-choice intervention for individuals with Ch-PTSD, especially by telehealth. The current manuscript will therefore give an overview of the evidence for the effectiveness of trauma-focused therapies for individuals with Ch-PTSD, the delivery of trauma-focused treatments via telehealth, and a case example on how a specific form of trauma focused therapy: Imagery Rescripting (ImRs) can be applied by telehealth. Method: This article presents a clinical illustration of a blended telehealth trajectory of imagery rescripting (ImRs) Ch-PTSD delivered during the COVID-19 pandemic. Results: The presented case shows that ImRs can be safely and effectively performed by telehealth for ch-PTSD, no stabilization phase was needed and only seven sessions were needed to drastically reduce Ch-PTSD and depressive symptoms, and to increase quality of life. Conclusion: This case report shows the effectiveness of ImRs by telehealth for Ch-PTSD, which gives hope and additional possibilities to reach out to patients with ch-PTDS. Telehealth treatment might have some of advantages for specific patients, especially, but certainly not only, during the pandemic.

Design of an RCT on cost-effectiveness of group schema therapy versus individual schema therapy for patients with Cluster-C personality disorder: the QUEST-CLC study protocol.

BACKGROUND: Given the high prevalence of Cluster-C Personality Disorders (PDs) in clinical populations, disease burden, high societal costs and poor prognosis of comorbid disorders, a major gain in health care can be achieved if Cluster-C PDs are adequately treated. The only controlled cost-effectiveness study published so far found Individual Schema Therapy (IST) to be superior to Treatment as Usual (TAU). Group ST (GST) might improve cost-effectiveness as larger numbers can be treated in (>50%) less time compared to IST. However, to date there is no RCT supporting its (cost-) effectiveness. The overall aim of this study is to assess the evidence for GST for Cluster-C PDs and to improve treatment allocation for individual patients. Three main questions are addressed: 1) Is GST for Cluster-C PDs (cost-)effective compared to TAU? 2) Is GST for Cluster-C PDs (cost-) effective compared to IST? 3) Which patient-characteristics predict better response to GST, IST, or TAU? METHODS: In a multicenter RCT, the treatment conditions GST, IST, and TAU are compared in 378 Cluster-C PD patients within 10 sites. GST and IST follow treatment protocols and are completed within 1 year. TAU is the optimal alternative treatment available at the site according to regular procedures. Severity of the Cluster-C PD is the primary outcome, assessed with clinical interviews by independent raters blind for treatment. Functioning and wellbeing are important secondary outcomes. Assessments take place at week 0 (baseline), 17 (mid-GST), 34 (post-GST), 51 (post-booster sessions of GST), and 2 years (FU). Patient characteristics predicting better response to a specific treatment are studied, e.g., childhood trauma, autistic features, and introversion. A tool supporting patients and clinicians in matching treatment to patient will be developed. An economic evaluation investigates the cost-effectiveness and cost-utility from a societal perspective. A process evaluation by qualitative methods explores experiences of participants, loved ones and therapists regarding recovery, quality of life, and improving treatment. DISCUSSION: This study will determine the (cost-)effectiveness of treatments for Cluster-C PDs regarding treatment type as well as optimal matching of patient to treatment and deliver insight into which aspects help Cluster-C-PD patients recover and create a fulfilling life. TRIAL REGISTRATION: Dutch Trial Register: NL9209 . Registered on 28-01-2021.

[Alarming situation amongst mental health care employees; mental health issues with possible resignation as a consequence]. / Alarmerend beeld onder personeel ggz; uitputting, angst- en somberheidsklachten met mogelijk vertrek uit de ggz als gevolg: Wat kan de ggz doen?

While the COVID-19 pandemic integrates more and more into daily life and hospitalizations decrease, the consequence for mental health care personnel is becoming clearer. 50% of the employees in mental health care institutes experience stress and 30% have signs of depression. Simultaneously more patients present themselves at the mental health care institutes with complaints as a result of the COVID-19 pandemic. This increases workload even more while the waiting lists are already very long. To prevent sick leave and/or even resigning, social support in the working environment, prevention measures for mental complaints, and support have to be initiated by every level of the mental health care institutes.

The effect of twice-weekly versus once-weekly sessions of either imagery rescripting or eye movement desensitization and reprocessing for adults with PTSD from childhood trauma (IREM-Freq): a study protocol for an international randomized clinical trial.

BACKGROUND: Trauma-focused treatments for posttraumatic stress disorder (PTSD) are commonly delivered either once or twice a week. Initial evidence suggests that session frequency affects treatment response, but very few trials have investigated the effect of session frequency. The present study's aim is to compare treatment outcomes of twice-weekly versus once-weekly sessions of two treatments for PTSD related to childhood trauma, imagery rescripting (ImRs) and eye movement desensitization and reprocessing (EMDR). We hypothesize that both treatments will be more effective when delivered twice than once a week. How session frequency impacts treatment response, whether treatment type moderates the frequency effect, and which treatment type and frequency works best for whom will also be investigated. METHODS: The IREM-Freq trial is an international multicenter randomized clinical trial conducted in mental healthcare centers across Australia, Germany, and the Netherlands. We aim to recruit 220 participants, who will be randomized to one of four conditions: (1) EMDR once a week, (2) EMDR twice a week, (3) ImRs once a week, or (4) ImRs twice a week. Treatment consists of 12 sessions. Data are collected at baseline until one-year follow-up. The primary outcome measure is clinician-rated PTSD symptom severity. Secondary outcome measures include self-reported PTSD symptom severity, complex PTSD symptoms, trauma-related cognitions and emotions, depressive symptoms, dissociation, quality of life, and functioning. Process measures include memory, learning, therapeutic alliance, motivation, reluctance, and avoidance. Additional investigations will focus on predictors of treatment outcome and PTSD severity, change mechanisms of EMDR and ImRs, the role of emotions, cognitions, and memory, the optimization of treatment selection, learned helplessness, perspectives of patients and therapists, the network structure of PTSD symptoms, and sudden treatment gains. DISCUSSION: This study will extend our knowledge on trauma-focused treatments for PTSD related to childhood trauma and, more specifically, the importance of session frequency. More insight into the optimal session frequency could lead to improved treatment outcomes and less dropout, and in turn, to a reduction of healthcare costs. Moreover, the additional investigations will broaden our understanding of how the treatments work and variables that affect treatment outcome. TRIAL REGISTRATION: Netherlands Trial Register NL6965, registered 25/04/2018.

The impact of childhood maltreatment on the severity of childhood-related posttraumatic stress disorder in adults.

BACKGROUND: Childhood maltreatment is relatively common and is related to a range of negative consequences, such as Posttraumatic Stress Disorder (PTSD). There are indications that various maltreatment types are related to PTSD severity, although not all types, such as emotional abuse, meet the PTSD Criterion-A. OBJECTIVE: The aim of the present study was to examine the relationship between 5 types of childhood maltreatment (i.e., sexual, physical, and emotional abuse, and physical and emotional neglect) and the severity of adult PTSD and PTSD symptoms. PARTICIPANTS AND SETTING: Adult participants (N = 147) with Childhood-related PTSD (Ch-PTSD) recruited from clinical sites completed the Childhood Trauma Questionnaire-short form (CTQ-sf) and 2 PTSD measures: The Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and the PTSD Checklist for DSM-5 (PCL-5). METHODS: Childhood maltreatment predictors and 2 covariates, age and gender, were analysed in multivariate multilevel models as participants were nested within sites. A model selection procedure, in which all combinations of predictors were examined, was used to select a final set of predictors. RESULTS: The results indicated that emotional abuse was the only trauma type that was significantly related to severity of PTSD and to the severity of specific PTSD symptom clusters (r between 0.130 and 0.338). The final models explained between 6.5% and 16.7% of the variance in PTSD severity. CONCLUSIONS: The findings suggest that emotional abuse plays a more important role in Ch-PTSD than hitherto assumed, and that treatment should not neglect processing of childhood emotional abuse.

Delivering Imagery Rescripting via Telehealth: Clinical Concerns, Benefits, and Recommendations.

PURPOSE OF THE REVIEW: Delivery of psychological therapies via telehealth has increased with the emergence of the COVID-19 pandemic. Therapists may be hesitant in moving to telehealth when delivering therapies targeting memories of traumatic experiences. This paper collates the clinical experiences of clinicians and clients who have delivered or received imagery rescripting, respectively, via telehealth across a range of clinical presentations, and describes key clinical considerations and recommendations. RECENT FINDINGS: It is important to consider perceived and real safety; practical and technological issues; therapeutic alliance; depth of emotional processing; and dissociation. There was support for the delivery of imagery rescripting via telehealth being no less effective than face-to-face delivery; however, telehealth delivery was not a viable option for many clients during COVID-19 lockdowns who were living in high density housing, old houses with thin walls, or with some complex disorders.

Group schema therapy for patients with cluster-C personality disorders: A case study on avoidant personality disorder.

This article presents a clinical illustration of group schema therapy (GST) for cluster-C personality disorders (CL-C PDs) to provide therapists an example on how one can perform GST for CL-C PDs and break through persistent avoidance and control mechanisms. A summary of evidence supporting the effectiveness of GST for CL-C PD's is given followed by an overview of basic principles of schema therapy and GST. A case presentation next illustrates the application of GST principles and interventions in the GST CL-C protocol, which improve clients understanding of emotional core needs and development of adaptive ways of getting needs better met, instead of avoiding life. Implications of the case for future applications of GST for CL-C PDs are discussed.

Improving access to and effectiveness of mental health care for personality disorders: the guideline-informed treatment for personality disorders (GIT-PD) initiative in the Netherlands.

Evidence-based treatment for patients suffering from personality disorders (PDs) is only available to a limited extend in the Netherlands. Consequently, most patients receive non-manualized, unspecialized care. This manuscript describes the background, rationale and design of the Guideline-Informed Treatment for Personality Disorders (GIT-PD) initiative. GIT-PD aims to provide a simple, principle-driven, 'common-factors' framework for the treatment of PDs. The GIT-PD framework integrates scientific knowledge, professional expertise and patient experience to design a good-enough practice, based on common factors. It offers a basic framework including general principles, a structured clinical pathway, a basic professional stance, interventions focused on common factors, and team and organizational strategies, based on common features of evidence-based treatments and generic competences of professionals. The GIT-PD initiative has had a large impact on the organization of treatment for PDs in the Netherlands. For countries with an interest in improving their health care system for PDs, it could serve as a template that requires only limited resources.

The role of sex and autonomy-connectedness in internalizing and externalizing personality pathology, coping and axis-I pathology: among psychiatric and healthy elderly.

OBJECTIVES: In the current study we investigated the relationship of sex and autonomy-connectedness with internalizing and externalizing personality disorder symptoms (PDS), coping and axis-I pathology in older age. METHOD: A path model was tested which was based on neo-analytical object relation, attachment- and primary-personality theory, among 100 clinical and 106 non-clinical elderly. RESULTS: In line with our model, autonomy-connectedness (self-awareness and capacity of managing new situations) was strongly associated to internalizing PDS in both groups. In both groups, neither sex nor autonomy-connectedness predicted externalizing PDS. Sex, internalizing as well as externalizing PDS and reactive defensive coping were associated to axis-I psychopathology. CONCLUSIONS: We conclude that sex and autonomy-connectedness were, similarly as in adult populations, associated to internalizing PDS and axis-I pathology. Treatment of elderly with internalizing PDS and axis-I psychopathology should therefore focus on enhancing autonomy-connectedness.

Anxiety, depression and autonomy-connectedness: The mediating role of alexithymia and assertiveness.

OBJECTIVE: Autonomy-connectedness (self-awareness, sensitivity to others, and capacity for managing new situations) reflects the capacity for self-governance, including in social relationships. Evidence showed that autonomy-connectedness is related to anxiety and depression. Little is known about the underlying mechanisms. We hypothesized that alexithymia and assertiveness would mediate the relationships between autonomy-connectedness and anxiety and depression. METHOD: Relationships among the variables were investigated in 100 patients with a mean age of 42.2 suffering from anxiety and/or depression using a cross-sectional design. RESULTS: The relationship between self-awareness and both anxiety and depression was mediated by alexithymia. For anxiety, there was also a direct effect of sensitivity to others that was not explained by either alexithymia or assertiveness. Assertiveness did not have any mediational effect. CONCLUSIONS: The results indicate that particularly alexithymia explains the association of autonomy-connectedness with anxiety and depression. PRACTITIONER POINTS: The study confirmed the relevance of autonomy-connectedness in anxiety and depression. In treating symptoms of anxiety, it is advisable to give attention to normalizing the patient's sensitivity to others. Treatment of patients with symptoms of anxiety and depression should include assessment of emotional awareness and, in the case of impaired emotional awareness, should be tailored as to promote increased awareness.

The role of sex, attachment and autonomy-connectedness in personality functioning.

Previous studies have found significant relationships among sex, attachment and autonomy-connectedness and DSM-IV personality characteristics. In the present study, we aimed to add to the current knowledge about attachment-related aspects of personality pathology, by examining the relationships of these same variables with dimensions of pathological personality structure as conceptualized by Kernberg. The study was performed among 106 ambulatory patients from a Dutch mental healthcare institute. A path model based upon neo-analytical object relation theory and attachment theory was tested. We expected significant associations among sex, attachment, autonomy and aspects of personality functioning. Both insecure attachment styles as well as the autonomy-connectedness components of sensitivity to others (SO) and capacity of managing new situations predicted general personality dysfunctioning significantly. More specifically, reality testing was negatively predicted by the autonomy component of capacity of managing new situations, and aggression was significantly predicted by sex as well as both insecure attachment styles. We advise scientists as well as clinicians to be alert on sex differences in autonomy-connectedness and aspects of personality dysfunctioning. Taking sex-specific variations in attachment and autonomy into account next to a more explicit focus on insecure attachment styles and autonomy problems may enhance, the current relatively low, treatment effectiveness for personality pathology.

Autonomy-connectedness and internalizing-externalizing personality psychopathology, among outpatients.

OBJECTIVES: The aims of this research were to investigate gender differences in levels of autonomy-connectedness, Axis I Psychopathology, and higher order factors of internalizing and externalizing personality psychopathology and, second, to investigate the association between these variables. DESIGN: The design of this research is cross-sectional and multicentered. METHODS: We used self-report questionnaires, factor analysis, and regression analysis. RESULTS: We found evidence for a significant role of autonomy-connectedness in Axis I Psychopathology. This was especially true for women, who were found to be more sensitive to others and sensitivity to others was strongly associated with Axis I Psychopathology. Maybe due to the research sample no evidence was found for an association of autonomy-connectedness with externalizing psychopathology. As to the role of autonomy-connectedness in internalizing psychopathology, we found that a lack of self-awareness or a capacity of managing new situations, combined with a high sensitivity to others, were associated with internalizing psychopathology. Women appeared to be more sensitive to others and to report higher levels of Axis I Psychopathology than men. CONCLUSION: We conclude that autonomy-connectedness plays an important role in Axis I Psychopathology as well as in internalizing Axis II pathology. Treatment of Axis I and internalizing Axis II psychopathology should therefore also focus on autonomy problems.

Factor structure of self-reported clinical disorders and personality disorders: a review of the existing literature and a factor analytical study.

OBJECTIVES: The aim of this research is to add to the current understanding of the latent factor structure of personality disorders by performing a review of the existing literature (Study 1) and a factor analytical study on the factor structure and the relationship between self-reported Axis I and Axis II psychopathology (Study 2). DESIGN: The current research (Study 2) is cross-sectional and multicenter. RESULTS: We found support for the assumption that the borderline personality disorder is a multidimensional construct. Second, we found evidence for a single-factor structure of the narcissistic, dependent as well as the avoidant personality disorder. Third, we found support for the current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) distinction between Axis I and Axis II, Axis I psychopathology being explained by the factor neuroticism and Axis II disorders to be further subdivided into the higher order factors of internalizing and externalizing pathology. CONCLUSIONS: An adaptation to the current DSM-IV borderline personality criteria should be made, while various findings show that the borderline construct is multidimensional. Second, deletion of the dependent and narcissistic personality in the DSM-V might be unjust. Third, Axis I psychopathology can be explained by the factor neuroticism, and Axis II disorders should be further subdivided into the higher order factors of internalizing and externalizing pathology.