Associations between patient personality, symptomatic change and therapy dropout.

BACKGROUND: Studies show that 16% to 77% of psychotherapy patients abandon therapy within the first sessions. The aim of this study is to examine how patient personality variables, specifically the patients' structural integration and the personality traits dependency and self-criticism, are associated with symptomatic change and therapy dropout. METHOD: We analysed data from 96 patients (age: M = 30.56, SD = 11.39; 78.5% women; 44.6% students, 28.3% employees). A hierarchical logistic regression analysis was carried out to determine whether patients' structural integration (assessed via the OPD-SQ) and their level of dependency and self-criticism (DEQ) can predict therapy dropout. In addition, a multiple regression was used to analyse how these variables affect symptomatic change (OQ-45.2 symptom subscale). RESULTS: The interaction of structural integration level and dependency best predicts therapy dropout. For the prediction of symptomatic change, both structural integration and dependency were significant. However, their interaction showed no significant results. DISCUSSION: The patient's structural integration was associated to both symptomatic change and dropout. Therapists' training should include techniques addressing patients' structural integration and degree of dependency to prevent patient dropout from therapy.

Suicidal patients in a psychiatric emergency unit: clinical characteristics and aggression profile / Pacientes suicidas em uma unidade de emergência psiquiátrica: características clínicas e perfil de agressão

Abstract Objective To explore and describe a profile of patients admitted to a psychiatric emergency facility, comparing patients with and without a recent suicide attempt in terms of their clinical characteristics and aggression. Methods This was an exploratory comparative study where patients were assessed using the Brief Psychiatric Rating Scale (BPRS) and the Overt Aggression Scale (OAS). Participants with a suicide attempt in the last 24 hours (SA) were compared to participants with a prior history of suicide attempt but no recent attempt (PHSA). Results 63 individuals (SA: 26; PHSA: 37) were selected. Both groups had similar demographic and clinical characteristics. The most prevalent diagnoses were mood (57.1%) and personality (50.8%) disorders. The majority of patients in both groups had a history of aggression episodes. Physical aggression in the week prior to admission was more prevalent in the PHSA group (51.4 vs. 19.2%, p = 0.017). The PHSA group also presented higher activation scores (p = 0.025), while the SA group presented higher affect scores on BPRS dimensions (p = 0.002). Conclusion The majority of individuals with a history of suicide attempt also presented a history of aggression. Inpatients with recent suicide attempt were hospitalized mainly due to the risk of suicide, while those with no recent suicide attempt were hospitalized mainly due to the risk of hetero-aggression. These findings support the hypothesis of an aggressive profile in suicidal patients and may open up a path for future research.

Resumo Objetivo Explorar e descrever o perfil de pacientes internados em uma unidade de emergência psiquiátrica, comparando os pacientes com e sem tentativa recente de suicídio em termos de suas características clínicas e agressividade. Métodos Trata-se de um estudo exploratório comparativo, onde os pacientes foram avaliados por meio da Escala Breve de Avaliação Psiquiátrica (BPRS) e da Escala de Agressividade Declarada (OAS). Os participantes com tentativa de suicídio (TS) nas últimas 24 horas foram comparados com participantes com história prévia de tentativa de suicídio, mas sem tentativa recente (HPTS). Resultados Foram selecionados 63 indivíduos (TS: 26; HPTS: 37). Ambos os grupos tinham características demográficas e clínicas semelhantes. Os diagnósticos mais prevalentes foram transtornos de humor (57,1%) e de personalidade (50,8%). A maioria dos pacientes em ambos os grupos apresentava história de agressão. A agressão física na semana anterior à internação foi mais prevalente no grupo HPTS (51,4 vs. 19,2%, p = 0,017). O grupo HPTS também apresentou maior ativação (p = 0,025), enquanto o grupo TS apresentou maior afetividade nas dimensões da BPRS (p = 0,002). Conclusão A maioria dos indivíduos com história de tentativa de suicídio também apresentou história de agressão. Os pacientes internados com tentativa recente de suicídio foram hospitalizados principalmente devido ao risco de suicídio, enquanto aqueles sem tentativa recente de suicídio foram hospitalizados principalmente devido ao risco de heteroagressão. Esses achados apoiam a hipótese de um perfil agressivo em pacientes suicidas e podem abrir caminho para pesquisas futuras.

Working with clients at the intersection of depression and personality dysfunction: Scientific and clinical findings regarding complex depression.

Depression is often complicated by concurrent personality dysfunction, which poses significant challenges for clinicians and researchers. Complicated depression is thus broadly presented as a useful clinical and scientific entity, describing clients presenting with depressive symptoms that are further complicated by personality dysfunction or personality pathology. The article introduces a collection of research-based papers addressing the clinical management of patients with complicated depression. The articles in the issue provide an up-to-date framework for understanding different forms of complicated depression and provide useful clinical information to illuminate the treatment of clients presenting with difficulties at the intersection of depression and personality dysfunction.

Suicidal patients in a psychiatric emergency unit: clinical characteristics and aggression profile.

OBJECTIVE: To explore and describe a profile of patients admitted to a psychiatric emergency facility, comparing patients with and without a recent suicide attempt in terms of their clinical characteristics and aggression. METHODS: This was an exploratory comparative study where patients were assessed using the Brief Psychiatric Rating Scale (BPRS) and the Overt Aggression Scale (OAS). Participants with a suicide attempt in the last 24 hours (SA) were compared to participants with a prior history of suicide attempt but no recent attempt (PHSA). RESULTS: 63 individuals (SA: 26; PHSA: 37) were selected. Both groups had similar demographic and clinical characteristics. The most prevalent diagnoses were mood (57.1%) and personality (50.8%) disorders. The majority of patients in both groups had a history of aggression episodes. Physical aggression in the week prior to admission was more prevalent in the PHSA group (51.4 vs. 19.2%, p = 0.017). The PHSA group also presented higher activation scores (p = 0.025), while the SA group presented higher affect scores on BPRS dimensions (p = 0.002). CONCLUSION: The majority of individuals with a history of suicide attempt also presented a history of aggression. Inpatients with recent suicide attempt were hospitalized mainly due to the risk of suicide, while those with no recent suicide attempt were hospitalized mainly due to the risk of hetero-aggression. These findings support the hypothesis of an aggressive profile in suicidal patients and may open up a path for future research.

Las dificultades que ofrecen los pacientes con difusión de identidad al tratamiento psiquiátrico / Difficulties that patients with identity diffusion offer to psychiatric treatment

En este artículo describiremos brevemente ciertos pacientes que consultan por cuadros psiquiátricos agudos y que además sufren de difusión de identidad. Estos pacientes ofrecen dificultades importantes a su propio tratamiento porque tienden a no persistir en una tarea, no cuidar de sí mismos, no confiar en las personas y a no recuperarse de las fallas de mentalización que puedan tener en sus relaciones interpersonales, produciendo graves complicaciones en el proceso terapéutico. Describiremos el Programa de Intervención Psicoeducativa y Control Farmacológico en Grupo que hemos implementado en el Instituto Psiquiátrico José Horwitz Barak para manejar de mejor forma las dificultades terapéuticas que estos pacientes ofrecen.

In this article we will briefly describe certain patients who consult for acute psychiatric symptoms and who also suffer from identity diffusion. These patients offer significant difficulties to their own treatment because they tend not to persist in a task, do not take care of themselves, do not trust people and do not recover from the mentalization failures they may have in their interpersonal relationships, producing serious complications in the therapeutic process. We will describe the Program of Psychoeducative Intervention and Pharmacological Control in Group that we have implemented in the José Horwitz Barak Psychiatric Institute to better manage the therapeutic difficulties that these patients offer.

Revisión de caso clínico desde una mirada sistémica / Clinical case review from a systemic view: clinical meeting

Paciente ELENA, 21 años. embarazo 27 semanas, separada, 4 intentos suicidas previos. Fue usuaria del programa de salud mental infantil y adulto Hospital el Pino (HEP). Hospitalizada en H. de día el año 2017. Año 2013, Alucinaciones auditivas y visuales y desajustes conductuales: Grita, rompe cosas, se pega en la cabeza. Comienza a aislarse y a faltar al colegio y atribuye sus síntomas a consumo de marihuana. Principales focos de terapia son: Disminuir situaciones de crisis y adherencia al tratamiento. Presenta mala adherencia a controles y fármacos de salud mental. Se deriva a Hospital de día. Rorschach muestra desarrollo anormal de la personalidad con rasgos histriónicos, juicio de realidad conservado y dificultad en capacidad de empatizar. Salud mental adulto: (Julio, 2015): Heridas autolíticas (cortes y rasguños), Ideas pasivas de muerte. Intervenciones desde hospital de día: Manejo de crisis, trabajar en vínculo simbiótico con madre; recibe atención por psiquiatra, terapeuta ocupacional, psicólogo y nutricionista, incluyendo intervenciones en equipo. Controles en ambulatorio (Nov 2015): Impresiona mayor conciencia de enfermedad. Abandona fármacos al sentirse mejor. Foco orientado a: Autorregulación emocional y entrenamiento cognitivo para manejo de síntomas ansiosos.

ELENA, 21 years old. Pregnancy 27 weeks, separate, 4 previous suicide attempts. She was a member of the children and mental health program Hospital el Pino (HEP). Hospitalized in Day Hospital in year 2017. 2013: Auditory and visual hallucinations and behavioral maladjustments: Screams, breaks things, hits herself in the head. She begins to isolate and to miss to the school and attributes her symptoms to consumption of marijuana. Main focuses of therapy are: To reduce crisis situations and adherence to treatment. She has poor adherence to mental health drugs and controls. She is derived to day hospital. Rorschach shows abnormal personality development with histrionic traits, a reality-preserved judgment, and difficulty in empathizing. Adult mental health: (July, 2015): Self-injuries (cuts and scratches), Passive death ideas. Interventions in day hospital: Crisis management, working in symbiotic relationship with mother; receives attention by psychiatrist, occupational therapist, psychologist and nutritionist, Including team interventions. Outpatient Control (Nov 2015): Increased awareness of illness. Abandon drugs because of feeling better. Focus oriented to: Emotional self-regulation and cognitive training for the management of anxious symptoms.

The epidemiology of personality disorders in the Sao Paulo Megacity general population.

INTRODUCTION: Most studies on the epidemiology of personality disorders (PDs) have been conducted in high-income countries and may not represent what happens in most part of the world. In the last decades, population growth has been concentrated in low- and middle-income countries, with rapid urbanization, increasing inequalities and escalation of violence. Our aim is to estimate the prevalence of PDs in the Sao Paulo Metropolitan Area, one of the largest megacities of the world. We examined sociodemographic correlates, the influence of urban stressors, the comorbidity with other mental disorders, functional impairment and treatment. METHODS: A representative household sample of 2,942 adults was interviewed using the WHO-Composite International Diagnostic Interview and the International Personality Disorder Examination-Screening Questionnaire. Diagnoses were multiply imputed, and analyses used multivariable regression. RESULTS AND DISCUSSION: Prevalence estimates were 4.3% (Cluster A), 2.7% (Cluster B), 4.6% (Cluster C) and 6.8% (any PD). Cumulative exposure to violence was associated with all PDs except Cluster A, although urbanicity, migration and neighborhood social deprivation were not significant predictors. Comorbidity was the rule, and all clusters were associated with other mental disorders. Lack of treatment is a reality in Greater Sao Paulo, and this is especially true for PDs. With the exception of Cluster C, non-comorbid PDs remained largely untreated in spite of functional impairment independent of other mental disorders. CONCLUSION: Personality disorders are prevalent, clinically significant and undertreated, and public health strategies must address the unmet needs of these subjects. Our results may reflect what happens in other developing world megacities, and future studies are expected in other low- and middle-income countries.

[Personality of argentinean outpatients in psychotherapy]. / La personalidad de pacientes argentinos en psicoterapia ambulatoria.

Personality differences between patients and non-patients were examined in order to make a contribution to the study of the dissemination of psychotherapies with empirical support in a country with a different cultural tradition. The NEO-PI-R test, which evaluates Costa and McCrae's Five Factor Model of Personality, was completed by both a community sample (N = 369), recruited through the "snowball" procedure and a clinical sample (N = 282), constituted by 14 successive outpatients of 20 different clinical psychologists, in the cities of Paraná and Santa Fe (Argentina). The personality profiles differed significantly. Patients scored higher in Neuroticism (proneness to experience negative emotions) (partial η² = 13%), due to differences in all facets, except Impulsivity; lower in Extraversion (proneness to experience positive emotions) (η² partial 6%), due to lower Activity, Excitement Seeking and Positive Emotions; and lower, as well, in Conscientiousness (η² partial 6%) due to lower Competence, Achievement Striving, Order and Self-discipline. Openness to Experience and Agreeableness showed similar results. Differences between patients and nonpatients were smaller than those found in meta-analyses performed in the United States. Hypotheses are posited trying to explain such differences.

Inhibitors and facilitators of compassion-focused imagery in personality disorder.

BACKGROUND: Compassion-focused therapy (CFT) has potential to benefit clients with a personality disorder (PD), given the inflated levels of shame and self-criticism in this population. However, clinical observation indicates that clients with PD may find techniques from this approach challenging. AIMS: The aim of this study is to trial one aspect of CFT, compassion-focused imagery (CFI), with this population, and identify factors that predict clients' ability to generate CFI and experience self-compassion during the task, including type of CFI exercise and, second, to establish whether CFI outcomes increase with practice. METHOD: In Study 1, 53 participants with a diagnosis of PD completed measures of self-compassion, self-reassurance, shame, self-criticism, fear of self-compassion, affect, anxious and avoidant attachment, and mental imagery abilities. Participants were assigned to trial CFI from memory (n = 25) or from imagination (n = 28), then rated their image's vividness, its compassionate traits, and ease of experiencing compassion. A negative mood manipulation was carried out, and CFI tasks and outcome measures were repeated. For Study 2, self-compassion and self-criticism were measured before and after 1 week of daily CFI practice. RESULTS: Study 1 found that negative mood and low mental imagery ability are significant inhibitors to generating compassionate images and affect. The 2 CFI exercises were equally effective. Study 2 suffered from high attrition, but regular practice was associated with significant improvement in self-compassion (though not self-criticism). CONCLUSIONS: CFI appears to be effective in improving self-compassion for some clients. However, it is less effective in the presence of negative affect. Clients with low mental imagery ability may benefit more from alternative CFT techniques.

Hombres violentos contra la pareja: ¿tienen un trastorno mental y requieren tratamiento psicológico? / Male batterers: are they mentally ill and are they needed of psychological treatment?

Hay muchas razones por las que los hombres maltratadores contra la pareja deben recibir tratamiento psicológico. En este artículo se analizan los transtornos más relevantes, tales como el abuso de alcohol/drogas, los celos patológicos y los transtornos de personalidad (antisocial, límite, narcisista y paranoide), así como los déficits psicológicos de estas personas, tales como el descontrol de la ira, las dificultades emocionales, las distorsiones cognitivas, la baja autoestima y los déficits de comunicación y de solución de problemas. Se describen las tipologías de hombres maltratadores más relevantes y se señala su importancia para la planificación del tratamiento individualizado. La inclusión de medidas penales y de tratamiento psicológico es posible. Se analiza la motivación para el tratamiento y se señalan las principales vías de intervención terapéutica, así como los resultados obtenidos. Por último, se comentan las líneas de investigación más urgentes para el futuro.

There are many reasons why men who batter should be psychologically treated. In this paper the most relevant mental disorders, such as substance use disorder, pathological jealousy, and antisocial, borderline, narcissistic and paranoid personality disorders, and psychological deficits of batterer men, such as anger, emotional difficulties, cognitive distortions, low self-esteem and deficits in social skills and problem solving, are analyzed. Male domestic violence offender typologies according to the most relevant classifications are commented. The role of these typologies for treatment is pointed out. An analysis of how to combine court intervention and psychological treatment to rehabilitate abusive men is also carried out. Motivational enhancement strategies and effective therapy for men who batter are discussed. Finally, the future perspectives and the most relevant goals of research are commented on.

[PERSONALITY DISORDERS AND GERIATRIC INSTITUTION]. / Los trastornos de personalidad y la institución geriatric.

Nursing Homes house a large number of residents with some kind of psychiatric disorder. The most complex cases are those involving personality disorders; these, known as difficult residents, often imply a challenge to the institution in every aspect and have a strong impact on the staff and on other residents. The present article considers the relevant aspects of personality disorders in the nursing home, with the nursing home, and from the nursing home, taking into account the difficulties presented by these personalities when faced aging. Moreover, possible approaches to these residents are proposed.

Intervenciones terapéuticas en trastornos del desarrollo de la personalidad en niños y adolescentes / Therapeutic interventions in personality disorders in children and adolescents

La personalidad puede ser entendida como una organización dinámica de los sistemas biológicos, psicológicos y sociales que determinan los modos de relación del individuo con su ambiente y las experiencias subjetivas concomitantes, que cumple una función adaptativa al intentar armonizar las necesidades internas con las exigencias externas. Su desarrollo anormal y perturbado, delimita los Trastornos del Desarrollo de la Personalidad (TDP). El abordaje terapéutico de los TDP, incluye intervenciones de diversa índole: Psicoeducación, Psicoterapia Individual, Terapia de Grupo, Terapia Familiar, Hospitalización, Hospitalización diurna y Psicofarmacológica. Estas intervenciones deben integrarse en un dispositivo terapéutico altamente estructurado e integrado, incorporando las consideraciones del desarrollo. El presente artículo pretende presentar evidencia disponible respecto de las intervenciones terapéuticas en población Infanto Juvenil con diagnóstico de TDP.

Personality can be understood as a dynamic organization of biological, social and psychological systems, which determine the ways an individual interacts with his environment and his subsequent subjective experiences, and it serves an adaptative function in that it attempts to harmonize internal needs with external demands. Personality development disorders (PDD) are defined by the personality's development in an abnormal and disturbed path. The treatment of PDD includes different types of interventions, such as: psychoeducation, individual psychotherapy, group therapy, family therapy, hospitalization, day time hospitalization and psychopharmacotherapy. These interventions must be integrated to a highly structured therapeutic device that considers developmental issues. This article attempts to review the available evidence of therapeutic interventions in children and adolescents with a PDD diagnosis.

Relationship between interpretation, alliance, and outcome in psychodynamic psychotherapy: control of therapist effects and assessment of moderator variable impact.

The current study examines the relationship between therapist interpretations in the early stages of psychodynamic psychotherapy and subsequent outcomes for 76 outpatients. Pre-treatment characteristics of global symptomatology, personality pathology, insight, and level of object relations were examined as possible significant patient characteristics. Independent clinicians reliably rated therapist use of interpretations over two early treatment sessions (third and ninth). Patient-rated alliance was also examined as a possible psychotherapy process predictor of change. Therapy outcomes were measured based on patients' changes in global symptomatology and estimates of improvement across a broad range of functioning at the end of treatment. An examination of the study independent variables revealed significant relationships between pre-treatment personality disorder symptomatology with patient object relations (OR), patient OR with pre-treatment insight, and pre-treatment insight with use of therapist interpretation. Pre-treatment symptomatology and early treatment interpretations predicted reliable change in global symptomatology. Patients' estimates of improvement across a broad band of functioning were most significantly impacted by quality of alliance. Analysis of these outcome relationships controlled for therapist effects. Statistical implications of therapist effects are discussed in regard to this area of research and future directions for investigation are explored.