Non-suicidal self-injury and attachment trauma in adolescent inpatients with psychiatric disorders.

This study examined how non-suicidal self-injury disorder (NSSID) differs with respect to mental disorders, gender and attachment status in adolescent psychiatric patients. In particular, we analyzed attachment-related traumatic material underlying adolescent NSSID. Our sample consisted of 137 in-patient adolescents aged 12 to 18 years (73% female, Mage = 15.09, SD = 1.44; 27% male, Mage = 14.65, SD = 1.53). Forty-four patients (32.1%) fulfilled the diagnostic criteria for NSSID according to the DSM-5 and ninety-three patients (67.9%) did not meet diagnostic criteria for NSSID. Our results revealed a higher prevalence of NSSID in female patients and in patients with mood disorders. In the total sample, 52% of our in-patients were classified with an unresolved attachment status. The diagnostic subgroup analysis demonstrated a higher percentage of unresolved attachment status only in patients with eating disorders and NSSID. However, our in-depth analysis of the total sample revealed that patients with NSSID demonstrated more traumatic material in their attachment interviews indicating a greater severity of attachment trauma. In particular the theme of helplessness in interpersonal conflicts left them in a state of attachment dysregulation. Intervention strategies targeting traumatic attachment-related themes might be useful to reduce the number of adolescents engaging in NSSI.

[Multiple Substance Abuse as a Form of High Risk Behavior in Adolescence]. / Multipler Substanzmissbrauch als Variante von Hochrisikoverhalten im Jugendalter.

Multiple Substance Abuse as a Form of High Risk Behavior in Adolescence We identify multiple substance abuse as a form of high risk behavior in adolescence based on a sample of in-patient adolescents. 43 adolescents were treated for substance abuse over the course of 20 months. 70 % reported the use of three or more different drugs, with an average of 5,35 consumed substances. The most commonly abused substance was cannabis, followed by synthetic drugs such as cocaine or ecstasy. We observed a high rate of non-suicidal self-injury as a comorbidity of multiple substance abuse in our sample. 73,3 % of adolescents with high risk, multiple substance abuse fulfilled diagnostic criteria for non-suicidal self-injury.

Unresolved Attachment Mediates the Relationship Between Childhood Trauma and Impaired Personality Functioning in Adolescence.

The present study investigates the mediating effect of attachment trauma on the relationship between childhood maltreatment and personality functioning in 199 adolescents (12-18 years) using a novel approach of an in-depth analysis of attachment-related traumatic contents during an attachment interview (AAP). Our findings demonstrate that adolescents with a high amount of traumatic attachment-related material show a lower resilience when facing traumatic childhood experiences, resulting in a greater severity of personality dysfunction. In particular, the associations between emotional abuse and neglect and the domains of identity, empathy, self-direction, and intimacy were mediated by the severity of attachment trauma. These results advance our understanding of the different nuances of attachment-related traumatic material and how they might shape personality structure in an adolescent age group.

[Levels of structural integration in adolescents and the relationship to later mental disorders - A longitudinal study]. / Psychisches Strukturniveau im Jugendalter und der Zusammenhang mit späterer psychischer Erkrankung ­ eine Langzeitstudie.

Levels of structural integration in adolescents and the relationship to later mental disorders - A longitudinal study Abstract. Objective: Psychological disorders frequently manifest during adolescence. Because of the multifactorial influencing factors, the courses of the diseases are heterogeneous, from relapsing-remitting to chronic. This study investigated whether the level of structural integration of the Operationalized Psychodynamic Diagnostics in Childhood and Adolescence (OPD-CA) correlates with later symptomatic burden. Method: This long-term study assessed the levels of structural integration according to the OPD-CA of 60 adolescents (mean age = 15.6; SD = 0.9). Seven years later, we then measured symptomatic burden (SCID axis I and II) and overall burden (GAF, BSI-GSI) (73.3 % follow-up participation rate). Results: The results showed high correlations between deficient structural integration in adolescence and later symptoms and overall burden in early adulthood. Conclusion: The follow-up examination after a 7-year time period showed significant correlations, which argue for the predictive value of structural integration. This suggests that early specific treatment, e.g., in the form of intensive psychotherapy, be urgently recommended in order to influence this course.

[Prevalence and characteristics of peer victimisation in adolescent psychiatric inpatients]. / Prävalenz und Charakteristika von Mobbingerfahrungen in einer klinischen Stichprobe von Jugendlichen.

Prevalence and characteristics of peer victimisation in adolescent psychiatric inpatients Abstract. Objective: Repeated and long-lasting victimisation, as defined by bullying, represents a wide spread health hazard. The aim of the present study was to present the prevalence of bullying in adolescent psychiatric inpatients. We analysed relations between bullying and sociodemographic and psychopathological variables. Furthermore, we investigated the number and nature of bullies, feasible resources, and parental perception on bullying in adolescence. Method: In total, 128 adolescent inpatients were surveyed with a bullying questionnaire and youth self-report. In addition, their clinical symptomatology was investigated. Results: Bullying affected one third of our sample. Male and female victims showed significantly more internal problems. Girls in addition revealed more external behaviour problems. Unlike non-suicidal, self-harming behaviour, suicidal ideation and suicidal behaviour occurred significantly more in patients with bullying experience. Conclusion: A significant number of adolescent in our sample experienced bullying and associated psychological strains. This should especially be considered in child and adolescent anamnesis.

[Operationalized Psychodynamic Diagnosis - Structure Questionnaire (OPD-SQ) in Youth: First Results on Reliability and Validity]. / Der OPD-Strukturfragebogen (OPD-SF) in Anwendung auf eine jugendliche Schul- und klinische Stichprobe: Ergebnisse zu Reliabilität und Validität.

Operationalized Psychodynamic Diagnosis - Structure Questionnaire (OPD-SQ) in Youth: First Results on Reliability and Validity The OPD structure axis questionnaire (OPD-SQ) demonstrated good empirical findings and usability in therapeutic work. Therefore, the aim of this study was to verify the OPD-SQ for an adolescent sample in order to further implement the questionnaire as an economic instrument in clinical childhood and adolescence psychiatry routine. The overall sample consisted of 180 adolescent inpatients (72.8 % female) and 152 pupils (57.9 % female). In order to test reliability, Cronbach's alpha and discriminatory power were assessed. To test validity, YSR11-18 data was collected for the overall sample, and further data (AIDA, LoPF Q12-18, SKID-II, WISC-IV) was collected for the inpatient-sample. Cronbach's alpha was satisfactory for overall OPD-SQ, and all dimensions and sub-dimensions. The differences in mean values between inpatients and pupils were as expected. When controlled for overall symptom severity, gender differences lost significance. Adolescents with one or more SCID-II diagnoses had significantly lower psychic structure. Both construct-related questionnaires (AIDA, LoPF Q12-18) correlated high with OPD-SQ, no correlations were found for psychic structure and intelligence. OPD-SQ proved to be well applicable for the use on adolescents and can be implemented as an economic instrument for the measure of psychic structure in clinical adolescent psychiatry routine.

Pathological Internet Use-An Important Comorbidity in Child and Adolescent Psychiatry: Prevalence and Correlation Patterns in a Naturalistic Sample of Adolescent Inpatients.

BACKGROUND: Few studies have examined the prevalence of problematic internet use (PIU) in young people undergoing inpatient treatment in child and adolescent psychiatry centers. The aims of our study were thus (a) to assess the frequency of comorbid PIU in a sample of adolescent psychiatric inpatients and compare it with a control group of nonreferred adolescents and (b) to gain insights into correlations between PIU and psychiatric comorbidities. METHODS: 111 child and adolescent psychiatry inpatients (CAP-IP, mean age 15.1 ± 1.4 years; female : male 72.4% : 27.6%) undergoing routine psychodiagnostics were screened for the presence of PIU. The widely used Compulsive Internet Use Scale (CIUS) was chosen for this purpose. Prevalence rates of PIU were then compared to matched nonreferred control subjects from a school sample. Additionally, comorbidities of inpatients with PIU were compared to inpatients without PIU. RESULTS: Our inpatient sample showed a much higher prevalence of PIU than that found in previous populational samples of young people. Compared with a matched school sample, addictive internet use was 7.8 times higher and problematic internet use 3.3 times higher among our adolescent sample. PIU was significantly associated with characteristic patterns of psychopathology, that is, suicidality, difficulties in establishing stable and consolidated identity, and peer victimization. CONCLUSION: PIU among adolescents undergoing inpatient psychiatric treatment is much more frequent than among their peers in the general population and is associated with specific patterns of psychopathology.

Nonsuicidal self-injury in a naturalistic sample of adolescents undergoing inpatient psychiatric treatment: prevalence, gender distribution and comorbidities.

BACKGROUND: A growing body of research points toward nonsuicidal self-injury (NSSI) in adolescents as an important and frequent health-related risk factor. In 2013, NSSI was proposed in section 3 of the DSM-5 as a new diagnostic entity warranting further study. In line with that goal, the present study was conducted in order to evaluate prevalence, gender distribution and comorbidities of NSSI in a sample of adolescent psychiatric inpatients. SUBJECTS AND METHODS: The study included 130 adolescents (mean age 15.09 years, SD ± 1.47; 71.5% female) undergoing inpatient psychiatric treatment at a specialized facility. The factors assessed were sociodemographic data, the presence of NSSI according to the proposed DSM-5 criteria, clinical psychiatric diagnosis, the presence of suicidality and the presence of personality disorder. RESULTS: A large percentage, 38.5%, of the sample fulfilled DSM-5 criteria for NSSI, and more than half (50.8%) of the adolescents indicated having injured themselves at least once in the past. Patients with NSSI were predominantly young women and clustered in a spectrum of diagnostic entities including not only borderline personality disorders but also substance use disorders and affective disorders. A strong association was found between suicidality (suicidal ideation, history of suicide attempt) and NSSI. CONCLUSIONS: In line with previous findings, NSSI among adolescent psychiatric inpatients was found to be a frequent phenomenon associated with a broad spectrum of comorbidities. Moreover, while NSSI is conceptualized as an act without suicidal intent, it commonly occurs in patient groups with suicidal ideation or with a history of suicide attempts.

[Mentalization Based Treatment of an Adolescent Girl with Conduct Disorder]. / Mentalisierungsbasierte Therapie einer Jugendlichen mit Störung des Sozialverhaltens.

Mentalization Based Treatment of an Adolescent Girl with Conduct Disorder This paper will give a short overview on the theoretical concept of mentalization and its specific characteristics in adolescence. A previous study on Mentalization based treatment for adolescents (MBT-A) demonstrated the effectiveness of MBT-A for the treatment of adolescents with symptoms of deliberate self-harm (Rossouw u. Fonagy, 2012). Based on the results of this study Taubner, Gablonski, Sevecke, and Volkert (in preparation) developed a manual for mentalization based treatment for adolescents with conduct disorders (MBT-CD). This manual represents the foundation for a future study on the efficacy of the MBT-A for this specific disorder in young people. The present case report demonstrates the application of specific MBT interventions, as well as the therapeutic course over one year in a 16-year old girl who fulfilled all criteria of a conduct disorder. During the course of treatment, the de-escalating relationship-oriented therapeutic approach can be considered as a great strength of MBT-A, especially for patients with conduct disorders. The clinical picture, as well as the psychological assessment, showed a positive progress over the course of treatment. Despite frequent escalations, forced placements due to acute endangerment of self and others, and a precarious situation with the patient's place of residence towards the end of therapy, MBT-A treatment enabled the patient to continually use the evolved mentalizing capabilities as a resource.

Levels of Structural Integration and Facial Expressions of Negative Emotions.

OBJECTIVES: For a clinically relevant understanding of facial displays of patients with mental disorders it is crucial to go beyond merely counting frequencies of facial expressions, but include the contextual information of the expression. We assume that patients with different levels of structural integration differ in the contextual embedding of their negative facial expressions of emotions. METHODS: Facial affective behaviour of 80 female participants during an OPD interview was analysed using FACS (Facial Action Coding System) and the RFE coding system (Referencesof- Facial-Expression coding system; Bock et al. 2015).Using the RFE coding system, 2192 negative facial expressions of emotions were attributed to different references (e.g., interactive, self-related, object-related) by relying on contextual variables. RESULTS: Pure frequency of negative facial affect was not related to level of structural integration. Negative facial expressions of emotions directed towards the interviewer (interactive reference), as well as negative facial expressions directed towards the displayer's whole self were associated with lower levels of structural integration. In contrast, negative facial affects directed to single aspects of the self, to single aspects of objects, or to external situations were associated with higher levels of structural integration. CONCLUSIONS: The differentiation of references of facial affective behavior allows a deeper understanding of the connection between facial displays and structural levels of psychic integration.

Written on the Face: Self- and Expert-Rated Impairments in Personality Functioning Are Differently Related to the Expression of Disgust Toward an Interviewer.

Although current theories suggest that impairments in personality functioning are at the core of personality pathology, there is a lack of research on how these impairments play out behaviorally. The aim of the present study was to investigate disgust expressions as indicators of personality dysfunction. Facial expressions were investigated in a sample of 78 female participants during an in-depth clinical interview and coded with the Facial Action Coding System. Personality dysfunction was assessed with self- and expert ratings. By applying a joint regression analysis, the authors found that disgust expressions toward the interviewer were positively associated with expert ratings but negatively associated with self-ratings. In other words, disgust expressions were indicative of an underestimation of personality dysfunction by participants as compared with experts. This suggests that interactional expressions of disgust might be a behavioral marker of personality dysfunction when individuals are unaware of or deny impairments.

[Facial expressions of negative emotions in clinical interviews: The development, reliability and validity of a categorical system for the attribution of functions to facial expressions of negative emotions]. / Negative mimische Affekte im Kontext klinischer Interviews: Entwicklung, Reliabilität und Validität einer Methode zur Funktionsbestimmung negativer Affektmimik.

OBJECTIVES: The development (Study 1) and validation (Study 2) of a categorical system for the attribution of facial expressions of negative emotions to specific functions. METHOD: The facial expressions observed inOPDinterviews (OPD-Task-Force 2009) are coded according to the Facial Action Coding System (FACS; Ekman et al. 2002) and attributed to categories of basic emotional displays using EmFACS (Friesen & Ekman 1984). In Study 1 we analyze a partial sample of 20 interviews and postulate 10 categories of functions that can be arranged into three main categories (interactive, self and object). In Study 2 we rate the facial expressions (n=2320) from the OPD interviews (10 minutes each interview) of 80 female subjects (16 healthy, 64 with DSM-IV diagnosis; age: 18-57 years) according to the categorical system and correlate them with problematic relationship experiences (measured with IIP,Horowitz et al. 2000). RESULTS: Functions of negative facial expressions can be attributed reliably and validly with the RFE-Coding System. CONCLUSIONS: The attribution of interactive, self-related and object-related functions allows for a deeper understanding of the emotional facial expressions of patients with mental disorders.

Is It All about the Higher Dose? Why Psychoanalytic Therapy Is an Effective Treatment for Major Depression.

UNLABELLED: Empirical evidence for the effectiveness of long-term psychodynamic psychotherapy (LTPP) in patients with mood disorders is growing. However, it is unclear whether the effectiveness of LTPP is due to distinctive features of psychodynamic/psychoanalytic techniques or to a higher number of sessions. We tested these rival hypotheses in a quasi-experimental study comparing psychoanalytic therapy (i.e., high-dose LTPP) with psychodynamic therapy (i.e., low-dose LTPP) and cognitive-behavioural therapy (CBT) for depression. Analyses were based on a subsample of 77 subjects, with 27 receiving psychoanalytic therapy, 26 receiving psychodynamic therapy and 24 receiving CBT. Depressive symptoms, interpersonal problems and introject affiliation were assessed prior to treatment, after treatment and at the 1-, 2- and 3-year follow-ups. Psychoanalytic techniques were assessed from three audiotaped middle sessions per treatment using the Psychotherapy Process Q-Set. Subjects receiving psychoanalytic therapy reported having fewer interpersonal problems, treated themselves in a more affiliative way directly after treatment and tended to improve in depressive symptoms and interpersonal problems during follow-up as compared with patients receiving psychodynamic therapy and/or CBT. Multilevel mediation analyses suggested that post-treatment differences in interpersonal problems and introject affiliation were mediated by the higher number of sessions, and follow-up differences in depressive symptoms were mediated by the more pronounced application of psychoanalytic techniques. We also found some evidence for indirect treatment effects via psychoanalytic techniques on changes in introject affiliation during follow-up. These results provide support for the prediction that both a high dose and the application of psychoanalytic techniques facilitate therapeutic change in patients with major depression. KEY PRACTITIONER MESSAGE: Psychoanalytic therapy is an effective treatment for major depression, especially in the long run. The differential effectiveness of psychoanalytic therapy cannot be fully explained by its higher dose. Distinctive features of psychoanalytic technique (e.g., focusing on patients' dreams, fantasies, sexual experiences or childhood memories) may play an important role in establishing sustained therapeutic change.

[Inter-rater reliability and validity of the OPD-CA axes structure and conflict]. / Reliabilität und Validität der OPD-KJ-Achsen Struktur und Konflikt.

The manual of the Operationalized Psychodynamic Diagnostics in childhood and adolescence (OPD-CA) is an instrument meanwhile widespread in the clinical practice to assess psychodynamic dimensions. Publications of inter-rater agreement and validity are still outstanding. This study assessed the interrater-reliability and validity for the axis structure and the axis conflict. 60 adolescents between 14 and 17 years, with and without psychic disorders, were diagnosed with the Operationalized Psychodynamic Diagnostics in childhood and adolescence (Arbeitskreis OPD-KJ, 2007) and SCID-II-interviews and questionnaires. A partial sample of 36 OPD-CA-interviews was the data basis for the assessment of inter-rater agreement. Calculations of validity for axis structure and axis conflict were made with the whole sample. Inter-rater agreement for the axis structure and the axis conflict showed good to very good weighted Kappa coefficients among the trained raters. Validity of the axis structure showed good results. The Operationalized Psychodynamic Diagnostics in childhood and adolescence (OPD-CA) allows a reliable diagnostic of axis structure and axis conflict, if the ratings are done on the basis of semistructured videotaped interviews by trained raters. The axis structure shows validity, while the results concerning the validity of the axis conflict remain unclear.

[First results on the reliability and validity of the OPD-2 axis structure]. / Erste Ergebnisse zu Reliabilität und Validität der OPD-2 Strukturachse.

OBJECTIVES: In 2006, the manual of the Operationalized Psychodynamic Diagnostics (OPD) was revised and published in its second edition (OPD-2; Arbeitskreis OPD2006). In particular the axis structure was markedly changed. This study assessed the interrater reliability and validity. METHODS: Two independent raters judged 139 persons with OPD-2 on the axis structure (a third rater judged a partial sample of 20 persons). In addition, patients were investigated with SCID-Interviews for DSM-IV diagnosis and with the following questionnaires: Brief-Symptom-Checklist (BSI), Inventory of Personality Organisation (IPO), and Borderline Personality Inventory (BPI). RESULTS: Interrater agreement for the axis structure showed sufficient to good results for weighted kappas. The axis structure showed high correlations with the number of DSM-IV diagnoses and the main scales of the BSI, IPO, and BPI. CONCLUSION: The OPD-2 axis structure is a reliable and valid instrument for the assessment of the crucial clinical dimension of "psychic structure".

[A self report questionnaire for the assessment of emotional experience and emotion regulation]. / Emotionserleben und Emotionsregulation und ihr Zusammenhang mit psychischer Symptomatik.

In this article first results of a self report questionnaire to assess emotional experience and emotion regulation (EER) will be presented. The questionnaire assesses the emotional experience (first part), and the regulation of an emotion individually selected as difficult (second part). Psychometrical properties will be shown; a comparison between patients (n = 323) and healthy controls (n = 281) did show significant distinctions for emotional experience as well as for regulation of emotion. A first examination of validity was done with common clinical instruments (BSI, FBL and IIP), and show high relationship with symptomatic burden. The results show a satisfying quality of the questionnaire, good validity and a high clinical relevance.