The Emotional Bank Account and the Four Horsemen of the Apocalypse in Romantic Relationships of People with Borderline Personality Disorder: A Dyadic Observational Study.

Few studies have examined behaviors in romantic relationships associated with borderline personality disorder (BPD). We assessed critical variables from marital research: the "emotional bank account" (positive-to-negative behaviors; Gottman, 1993) and the "four horsemen of the apocalypse" (criticism, defensiveness, contempt, and stonewalling; Gottman & Silver, 1999; Gottman & Krokoff, 1989). Couples (N = 130, or 260 participants) engaged in a conflict task and reported relationship satisfaction at intake and 12-months. Clinician-rated BPD and avoidant PD (APD) criteria were examined. People with more BPD symptoms and their partners were less satisfied, which worsened by follow-up. Conflict behaviors partially explained these associations. Partners of people with more BPD symptoms had a worse emotional bank account, which then predicted (a) poorer satisfaction for both members and (b) worsening partner satisfaction. People with more BPD symptoms criticized more; their partners defended and stonewalled more. APD predicted worsening satisfaction. BPD appears to link specifically with relationship dysfunction, partly through associations with partner behavior.

Attachment styles and personality disorders as predictors of symptom course.

Adult attachment styles and personality disorders (PDs) show some conceptual and empirical overlap and both may complicate the course of symptoms among psychiatric patients. In this naturalistic prospective study, 149 patients with affective, anxiety, substance use, and other disorders were interviewed shortly after entering treatment, which included psychotherapy, pharmacotherapy, or both. Follow-up interviews were conducted 6 and 12 months later. Attachment styles, DSM-III-R PDs, and symptoms were assessed using structured interviews and consensus ratings. At intake, borderline, avoidant, and dependent PD features correlated consistently with symptom severity and secure attachment correlated inversely with two of four symptom scales. Secure attachment was linked with greater relative improvement in global functioning and a more benign course of anxiety symptoms over 6 months. Borderline PD features predicted less relative improvement of depressive symptoms over 6 months. These findings clarify the relations between attachment styles and PD features and they point to potential mediators of treatment response.

Anger and parent-to-child aggression in mood and anxiety disorders.

The relationship between anger and parent-to-child aggression (PTCA) was examined in mothers presenting for treatment of mood and anxiety disorders, because parental anger may have adverse effects on children and anger may decrease with treatment. Anger's role as mediator and moderator of the effects of the following predictors on PTCA was assessed: depression, anxiety, and ecologic variables that can induce or buffer against stress (partner verbal aggression, satisfaction with and perceived availability of social support, socioeconomic status, and number of children). Anger was found to mediate the effects of depression, partner verbal aggression, satisfaction with social support, and number of children on PTCA. Anger also had significant effects on PTCA after controlling for these variables. The other predictors did not have effects on PTCA, and anger did not moderate their effects. If replicated, these findings suggest the importance of examining whether treatment to reduce parental anger will reduce PTCA.

Psychotherapy for depression: current and future directions in research, theory, practice and public policy.

This article is based on a symposium held at the 1998 Annual Meeting of Society for Psychotherapy Research (Snow Bird, Utah). Recognized experts addressed current and future directions in psychotherapy for depression from the perspectives of process and outcome research, basic research, theoretical models, clinical practice and training, and public policy. The specific issues discussed at the symposium included the strengths and limitations of major forms of psychotherapy; the therapeutic factors common and unique to different approaches; the future viability of current theories of depression; the role of treatment manuals in clinical practice and training; the development of new interventions based on basic research; and the priorities that should guide federal funding.

Anger attacks: correlates and significance of an underrecognized symptom.

BACKGROUND: Anger attacks over provocations described as trivial by the individual are an underrecognized symptom associated with aggressive acts. They are usually followed by guilt and regret. Anger attacks among mothers are an important problem because they are often directed at the woman's spouse and/or children. This study examines the prevalence and correlates of anger attacks in a psychiatric clinic for women who are either pregnant or up to 18 months postpartum. METHOD: Fifty consecutive consenting patients were assessed at initial presentation with the Structured Clinical Interview for DSM-IV Axis I Disorders, a modified Anger Attacks Questionnaire, self-reports of psychiatric symptoms and psychosocial variables, and clinician ratings. RESULTS: Thirty (60%) of 50 patients reported anger attacks. Of those with anger attacks, 76.7% worried about them, and 73.3% had tried to prevent them. Compared with women without anger attacks, those with anger attacks were significantly more likely to report higher state and trait anger (p < .001), have a diagnosis of unipolar depression (p < .01), report more aggression directed at immediate family, and avoid their children. Both groups displayed little angry affect in the interview, thus appearing similar at assessment. CONCLUSION: Anger attacks in response to children and spouse were common in this group of women and were associated with subjective distress. Because those with and without anger attacks appear similar at interview, inquiring about the presence of anger attacks is important to ensure that they become a focus of treatment.

Selecting the most informative items in the IIP scales for personality disorders: an application of item response theory.

The first goal of the present analyses was to shorten the five scales (Pilkonis, P. A., Kim, Y., Proietti, J. M., & Barkham, M. [1996]. Journal of Personality Disorders, 10, 355-369) for personality disorders (PDs) developed from the Inventory of Interpersonal Problems (IIP), thereby increasing their attractiveness for screening purposes. The second goal was to illustrate, for more general purposes, the utility of item response theory (IRT) for such scale refinement. IRT analyses were performed using data collected from six different samples (N = 1149) at five sites and a two-parameter (2P) graded model designed for multiple response items like those on the IIP. The five most informative items from each scale were identified, based on the magnitude of item discrimination parameters and the range and elevation of individual item information functions. Preliminary analyses of the reliability and validity of the short forms of the scales (totaling 25 items) supported their value as alternatives to the longer forms (consisting of 47 items), although definitive tests of their psychometric properties await crossvalidation in independent samples. Analyses of the quality receiver operating characteristics (QROC) of the long and short forms showed that both versions can be useful in predicting the presence versus absence of any PD diagnosis arrived at by using either a "best estimate" clinical consensus method or a structured Axis II interview.

Consensus criteria for traumatic grief. A preliminary empirical test.

BACKGROUND: Studies suggest that symptoms of traumatic grief constitute a distinct syndrome worthy of diagnosis. AIMS: A consensus conference aimed to develop and test a criteria set for traumatic grief. METHOD: The expert panel proposed consensus criteria for traumatic grief. Receiver operator characteristic (ROC) analyses tested the performance of the proposed criteria on 306 widowed respondents at seven months post loss. RESULTS: ROC analyses indicated that three of four separation distress symptoms (e.g. yearning, searching, loneliness) had to be endorsed as at least 'sometimes true' and four of the final eight traumatic distress symptoms (e.g. numbness, disbelief, distrust, anger, sense of futility about the future) had to be endorsed as at least 'mostly true' to yield a sensitivity of 0.93 and a specificity of 0.93 for a diagnosis of traumatic grief. CONCLUSIONS: Preliminary analyses suggest the consensus criteria for traumatic grief have satisfactory operating characteristics, and point to directions for further refinement of the criteria set.

Vulnerability to depression: reexamining state dependence and relative stability.

Treatment-related decreases in Dysfunctional Attitudes Scale (DAS; Weissman & Beck, 1978) scores have been interpreted as evidence that dysfunctional attitudes are state-dependent concomitants of depression. Data from the National Institute of Mental Health Treatment of Depression Collaborative Research Program were used to reexamine the stability of dysfunctional attitudes. Mean scores for Perfectionism, Need for Approval, and total DAS decreased after 16 weeks of treatment. However, test-retest correlations showed that the DAS variables displayed considerable relative stability. Structural equation models demonstrated that dysfunctional attitudes after treatment were significantly predicted by initial level of dysfunctional attitudes as well as by posttreatment depression. The relative stability of dysfunctional attitudes was even higher during the 18-month follow-up period. The results were consistent with Beck's (1967) and Blatt's (1974) theories of vulnerability.

Screening for personality disorders in a nonclinical population.

Based on the Inventory of Interpersonal Problems (IIP), the IIP-PD and the IIP-C screening scales were developed to distinguish personality disorder (PD) from non-PD and Cluster C from other PD, respectively, in a clinic population. Two studies were conducted to determine (a) validity and reliability of these IIP scales for PD screening in a nonclinical population, (b) specificity of IIP-C for identifying Cluster C, and (c) usefulness of the IIP scales for screening Cluster A. College students were screened using the IIP scales (Study 1, N = 454, Study 2, N = 87). High and low scorers completed PD-related questionnaires in Study 1 and a clinical interview for PD symptomatology in Study 2. Results indicated strong test-retest reliability, internal consistency, and factorial, convergent, and external validity. The scales tapped a common deficit in interpersonal relatedness, with some distinction between externalizing and internalizing dimensions, respectively, and both scales were positively and significantly associated with schizotypal traits. In conclusion, the IIP-PD and IIP-C are useful and valid screening instruments for identifying any versus no PD in nonclinical populations.

When and how perfectionism impedes the brief treatment of depression: further analyses of the National Institute of Mental Health Treatment of Depression Collaborative Research Program.

Perfectionism has previously been identified as having a significant negative impact on therapeutic outcome at termination in the brief (16-week) treatment of depression (S. J. Blatt, D. M. Quinlan, P. A. Pilkonis, & T. Shea, 1995) as measured by the 5 primary outcome measures used in the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP). The present analyses of other data from the TDCRP indicated that this impact of perfectionism on therapeutic outcome was also found in ratings by therapists, independent clinical evaluators, and the patients and that this effect persisted 18 months after termination. In addition, analyses of comprehensive, independent assessments made during the treatment process indicated that perfectionism began to impede therapeutic gain in approximately 2/3 of the sample, in the latter half of treatment, between the 9th and 12th sessions. Implications of these findings are discussed, including the possibility that more perfectionistic patients may be negatively impacted by anticipation of an arbitrary, externally imposed termination date.

Empirically supported treatments: implications for training.

This article discusses the role of empirically supported treatments (ESTs) in the training of clinical psychologists. Training in ESTs can be integrated in ways that vary depending on the level of training and setting. Predoctoral programs, internships, postdoctoral programs, and continuing education are discussed in regard to special challenges and sequencing of training. A preliminary set of guidelines for training in ESTs is suggested.

The severity of major depression and choice of treatment in primary care practice.

The Agency for Health Care Policy and Research Depression Guideline Panel recommended pharmacotherapy as the 1st-line treatment for more severely depressed primary care patients, but research supporting its recommendation has not been conducted with this population. A post hoc analysis was conducted, therefore, with data gathered in a randomized controlled trial about the relationship between initial level of depressive severity and functional ability, treatment with nortriptyline hydrochloride (NT) or interpersonal psychotherapy (IPT), and clinical course over 8 months among primary care patients experiencing major depression. Treatment type was unrelated to clinical course among more severely depressed patients (baseline 17-item Hamilton Rating Scale for Depression [HRSD] score > or = 20). However, less severely depressed patients (baseline 17-item HRSD score < or = 19) who were prescribed NT improved significantly more rapidly during the initial 3 months of treatment than patients provided with IPT.

Confirmatory factor analysis of the personality disorder subscales from the Inventory of Interpersonal Problems.

The purpose of this study was to identify the best fitting hierarchical factor structure of the subscales for personality disorders developed from the Inventory of Interpersonal Problems (IIP). In earlier work, 5 subscales associated with a diagnosis of personality disorder (PD) had been developed. With data collected from 5 additional samples at 4 sites (N = 1004), relations among the IIP-PD subscales were investigated using confirmatory factor analysis. Several competing models were tested, and a second-order model with 1 second-order factor and 5 first-order factors provided the best fit to the data. The results support the hypothesis of a single latent construct reflecting general personality dysfunction. Measures of this construct may be useful for screening patients into yes versus no PD groups.

Treatment of major depression with psychotherapy or psychotherapy-pharmacotherapy combinations.

BACKGROUND: Few reliable correlates of treatment response in depression have emerged despite nearly 40 years of research. We examined the correlates of recovery in a "mega-analysis," or meta-analysis of original data, of 595 patients with major depressive disorder enrolled in 6 standardized treatment protocols. METHODS: All patients (mean age, 44 years; 31% male and 69% female) met criteria for nonbipolar, nonpsychotic primary major depressive disorder and were treated for 16 weeks with either cognitive behavior therapy or interpersonal psychotherapy alone (psychotherapy alone; n = 243) or interpersonal psychotherapy plus antidepressant pharmacotherapy (combined therapy; n = 352). The impact of treatment type, severity, study, and other covariates on recovery rates or time to recovery were examined by means of chi 2, log-rank tests, the Cox proportional hazards model, and sensitivity analyses. RESULTS: Whereas combined therapy was not significantly more effective than psychotherapy alone in milder depressions, a highly significant advantage was observed in more severe recurrent depressions. Poorer outcomes were also observed in women and older patients, although these effects were dependent on inclusion of particular studies. CONCLUSIONS: Mega-analysis is a powerful method for comparing the efficacy of treatments and examining correlates of response. Using this method, we found new evidence in support of the widespread clinical impression that combined therapy is superior to psychotherapy alone for treatment of more severe, recurrent depressions.

Characteristics of effective therapists: further analyses of data from the National Institute of Mental Health Treatment of Depression Collaborative Research Program.

Analyses of the data of the National Institute of Mental Health-sponsored Treatment of Depression Collaborative Research Program have primarily examined the effects of types of treatment and patient characteristics on outcome, but scant attention has been directed toward evaluating the contributions of the therapist. With an aggregate of residualized therapeutic change scores of the 5 primary outcome measures for each patient at termination as an overall measure of improvement, an average therapeutic effectiveness measure was derived for each of the 28 therapists based on the outcome of the patients they saw in active treatment. The distribution of the therapists was divided into thirds, and comparisons indicate that more effective therapists are more psychological minded, eschew biological interventions (i.e., medication and electroconvulsive therapy) in their ordinary clinical practice, and expect outpatient treatment of depression to take longer than did moderately and less effective therapists.

Gender, type of treatment, dysfunctional attitudes, social support, life events, and depressive symptoms over naturalistic follow-up.

OBJECTIVE: The present study investigated gender differences in depressive symptoms during a naturalistic follow-up for outpatients with major depressive disorder in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Specifically, the study investigated whether gender interacted with type of treatment received, dysfunctional attitudes, life events, or social support to predict severity of depressive symptoms. In addition, aspects of these psychosocial factors (need for approval, interpersonal life events, and close friendships), hypothesized to be more salient for women, were examined to determine if they had a differential impact on level of depressive symptoms in men and women. METHOD: Assessments conducted 6, 12, and 18 months after treatment included measures of depressive symptoms, dysfunctional attitudes, current life events, and social support. Data were available for 188 subjects (134 women and 54 men). Regression analyses were conducted to examine whether gender as a main effect, or interacting with dysfunctional attitudes, life events, social support, or subtypes of these variables, predicted cross-sectional or longitudinal measures of depressive symptoms during follow-up. RESULTS: A consistent finding of the study was that over the 18 months of this naturalistic follow-up, there were no main effects for gender or any significant interactions involving gender and any of the variables of interest. The study demonstrated that life events and social support were related to severity of depressive symptoms for both genders. CONCLUSIONS: Despite differential prevalence rates of major depression for men and women, findings do not support a different process in outcome of illness for men and women.

Psychotherapy of depression. Implications for reform of the health care system.

This article reviews the empirical evidence supporting the role of psychotherapy and psychosocial interventions in the treatment of patients with depression. Treatment models and the evidence for their effectiveness in the acute-and maintenance-treatment phases are reviewed. Whereas the sophistication of research designs and data analysis for the study of psychotherapy have substantially improved, the review highlights current gaps in our knowledge. Most important for reform of the health care system is the need for studies of efficacy to lead to large-scale investigations of effectiveness.

The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program.

The relationship between therapeutic alliance and treatment outcome was examined for depressed outpatients who received interpersonal psychotherapy, cognitive-behavior therapy, imipramine with clinical management, or placebo with clinical management. Clinical raters scored videotapes of early, middle, and late therapy sessions for 225 cases (619 sessions). Outcome was assessed from patients' and clinical evaluators' perspectives and from depressive symptomatology. Therapeutic alliance was found to have a significant effect on clinical outcome for both psychotherapies and for active and placebo pharmacotherapy. Ratings of patient contribution to the alliance were significantly related to treatment outcome; ratings of therapist contribution to the alliance and outcome were not significantly linked. These results indicate that the therapeutic alliance is a common factor with significant influence on outcome.