Patient personality and therapist responses in the psychotherapy of adolescents with depressive disorders: toward the Psychodynamic Diagnostic Manual - third edition.

Depressive disorders in adolescence pose unique challenges for assessment and treatment, particularly due to their high comorbidity with various personality disorders. Moreover, young depressed patients may elicit very intense and difficult-to-manage emotional responses in therapists (in this context, countertransference). This study aimed at empirically identifying specific personality disorders (or subtypes) among adolescents with depressive pathology and exploring distinct countertransference patterns emerging in their psychotherapy: 100 adolescents (58 with depressive disorders; 42 with other clinical conditions) were assessed by their respective clinicians (n=100) using the psychodiagnostic chart-adolescent of the Psychodynamic Diagnostic Manual (PDM) - second edition, and the therapist response questionnaire for adolescents. Results showed that depressed adolescent patients exhibited marked traits of four personality subtypes (i.e., depressive, anxious-avoidant, narcissistic, and borderline) characterized by different levels of mental functioning and personality organization. These subtypes were predictably related to specific clinicians' emotional responses, even when controlling for the intensity of depressive symptomatology. Patients with depressive or anxious-avoidant personality subtypes evoked more positive countertransference responses, whereas patients with narcissistic or borderline subtypes elicited strong and hard-to-face emotional responses in therapists. Consistent with the next edition of the PDM, the study emphasizes the importance of comprehensive psychodynamic assessment in the developmental age, which frames depressive disorders in the context of accurate emerging personality and mental functioning profiles. This approach, which also relies heavily on the clinician's subjective experience in therapy, provides crucial information on how to specifically tailor interventions that more effectively meet the needs of adolescents with these heterogeneous and complex clinical conditions.

Patient personality dimensions, relational patterns and therapeutic alliance in clinical practice: An empirical investigation.

INTRODUCTION: Transference (meant in this context, as the patient relational patterns expressed towards the clinician) and therapeutic alliance play a crucial role in the treatment of personality pathology. To date, no empirical study examined the association between these two dimensions of the clinical relationship and patients' personality maladaptive traits in psychotherapy. METHODS: A national sample of therapists (N = 100) of different theoretical orientations assessed dysfunctional personality features of a patient in their care using a comprehensive and empirically grounded dimensional diagnostic approach from the Shedler-Westen Assessment Procedure-200 (SWAP-200). Moreover, they filled in the Psychotherapy Relationship Questionnaire (PRQ) to identify interpersonal patterns expressed early in treatment by the patients and the Working Alliance Inventory (WAI-T) to evaluate quality of therapeutic alliance. RESULTS: Overall, the most severe and maladaptive dimensions of patients' personality were associated with more negative clinician-patient dynamics and poorer levels of therapeutic alliance in statistically significant and clinically relevant ways. Notably, the hostile transference was predicted by both SWAP Hostility and Psychopathy, whereas the SWAP Narcissism was the strongest predictor of the special/entitled transference. The latter was also predicted by SWAP Emotional Dysregulation; conversely, the SWAP Dysphoria was the most robust predictor of anxious/preoccupied pattern. The SWAP Schizoid Orientation and Psychopathy predicted avoidant/dismissing attachment pattern; moreover, they were strongly and negatively related to the SWAP Psychological Health that was the best predictor of positive transference and alliance. CONCLUSIONS: Findings support that therapists' careful understanding of patients' interpersonal ways during early treatment stages may meaningfully inform diagnostic and therapeutic processes.

Personality Traits and Disorders in Adolescents at Clinical High Risk for Psychosis: Toward a Clinically Meaningful Diagnosis.

Aims: Recent meta-analytic data show that approximately 40% of individuals at clinical high risk for psychosis (CHR) receive at least one personality disorder (PD) diagnosis. Personality pathology could significantly influence CHR patients' prognosis and response to treatment. We aimed at exploring the PD traits of CHR adolescents, in order to outline a prototypic description of their most frequently observed personality characteristics. Methods: One hundred and twenty-three psychiatrists and psychologists used a Q-sort procedure [i.e., the Shedler-Westen Assessment Procedure-200 for Adolescents (SWAP-200-A)] to assess personality traits and disorders in 58 (30 male; mean age = 16 years, range = 13-19 years) CHR adolescents and two gender- and age-matched samples, respectively, with (n = 60) and without PDs (n = 59). Results: Differences between the CHR, PD, and clinical groups showed that CHR adolescents had pervasive and more clinically relevant schizoid, schizotypal, borderline, and avoidant traits, as well as poorer adaptive functioning. Moreover, by collecting the highest mean SWAP-200-A items, we empirically outlined a prototypic description of CHR youths, comprised of avoidance of social relationships; suspiciousness; obsessional thoughts; lack of psychological insight; dysphoric and overwhelming feelings of anxiety and depression; odd and anomalous reasoning processes or perceptual experiences; symptoms of depersonalization and derealization; and negative symptoms of avolition, abulia, blunted affects, and impaired role functioning. Conclusions: The results suggest that avoidant interpersonal strategies, impaired mentalization, and difficulties in emotional regulation could become important targets for psychosocial interventions with CHR adolescent populations.

Clinician Emotional Responses and Therapeutic Alliance When Treating Adolescent Patients With Narcissistic Personality Disorder Subtypes: A Clinically Meaningful Empirical Investigation.

This study examined clinician emotional responses and therapeutic alliance in psychotherapy with adolescent patients with specific subtypes of narcissistic personality disorder (NPD). A national sample of therapists (N = 58) completed the Therapist Response Questionnaire for Adolescents to identify patterns of clinician response, the Working Alliance Inventory to evaluate the quality of alliance, and the Shedler-Westen Assessment Procedure-II for Adolescents to assess the personality pathology of a patient in their care. The results showed that the grandiose narcissistic subtype was positively related to angry/criticized and disengaged/hopeless therapist responses and negatively related to warm/attuned response. The fragile subtype was positively related to overinvolved/worried therapist response. The high-functioning/exhibitionistic subtype was negatively related to angry/criticized response. Lower quality of therapeutic alliance was positively associated with the grandiose subtype. Moreover, the empirically founded prototypes of therapist responses to adolescent patients with NPD subtypes strongly resemble theoretical-clinical accounts. The clinical implications are addressed.

Clinician Reactions When Working with Adolescent Patients: The Therapist Response Questionnaire for Adolescents.

This study examined the factor structure and psychometric properties of the Therapist Response Questionnaire for Adolescents (TRQ-A), an 86-item clinician-report instrument measuring a wide range of thoughts, feelings, and behaviors expressed by therapists toward their adolescent patients. A sample of psychodynamic and cognitive-behavioral clinicians (N = 192) filled in the TRQ-A and the latest version of the Shedler-Westen Assessment Procedure for Adolescents (SWAP-II-A) in order to assess the personality styles/disorders of a randomly selected adolescent patient in their care. Factor analysis identified six conceptually coherent and internally consistent countertransference patterns: warm/attuned, angry/criticized, disorganized/frightened, overinvolved/worried, disengaged/hopeless, and sexualized. These patterns were significantly related to patients' personality styles/disorders in a clinically meaningful and systematically predictable manner. The results support the TRQ-A's validity and internal reliability in evaluating the complex portrait of multifaceted reactions that clinicians typically experience toward adolescent patients, and its potential to improve diagnostic accuracy and guide clinicians in planning effective therapeutic interventions. The TRQ-A promises to significantly contribute to this less explored research area and encourage systematic studies of youth treatment, promoting best practice for successful therapeutic outcomes.

Personality and Personality Disorders in Medication-Overuse Headache: A Controlled Study by SWAP-200.

Background: Medication-overuse headache (MOH) is a type of chronic headache, whose mechanisms are still unknown. The impact of psychological factors has been matter of debate from different perspectives. The role of personality and personality pathology in processes involved in MOH development has been advanced but was poorly studied. The hypothesis of addiction-like behaviors sustaining the drug misuse has been examined and reached contrasting findings. Objectives: This study is aimed at detecting personality and its disorders (PDs) in MOH, with a specific attention to the addiction aspect. Methods: Eighty-eight MOH patients have been compared with two clinical populations including 99 patients with substance use disorder (SUD) and 91 with PDs using the Shedler-Westen Assessment Procedure-200 (SWAP-200), a clinician-report tool that assesses both normal and pathological personality. MANCOVAs were performed to evaluate personality differences among MOH, SUD, and PD groups, controlling for age and gender. Results: MOH patients were predominantly women and older. They showed lower traits of the SWAP-200's cluster A and B disorders than SUD and PD patients, who presented more severe levels of personality impairment. No differences in the SWAP-200's cluster C have been found, indicating common personality features in these populations. At levels of specific PDs, MOH patients showed higher obsessive and dysphoric traits and better overall psychological functioning than SUD and PD patients. Conclusion: Although MOH, SUD, and PD populations have been evaluated in multiple sites with different levels of expertise, the study supported the presence of a specific constellation of personality in MOH patients including obsessive (perfectionist) and dysphoric characteristics, as well as good enough psychological resources. No similarities to drug-addicted and personality-disordered patients were found. Practitioners' careful understanding of the personality characteristics of MOH patients may be useful to provide a road map for the implementation of more effective treatment strategies and intervention programs.

Patient Personality and Relational Patterns in Psychotherapy: Factor Structure, Reliability, and Validity of the Psychotherapy Relationship Questionnaire.

The aim of this study was to examine the factor structure and the psychometric properties of the Psychotherapy Relationship Questionnaire (PRQ; Bradley, Heim, & Westen, 2005 ), a clinician report instrument that measures a wide spectrum of thoughts, feelings, motives, conflicts, and behaviors expressed by patients toward their therapists in psychotherapy. A national sample of psychiatrists and clinical psychologists (N = 314) of different theoretical orientations completed the PRQ, as well as the Shedler-Westen Assessment Procedure-200 (SWAP-200; Westen & Shedler, 1999a , 1999b ) to assess the personality of a patient in their care. Factor-analytic procedures identified 6 transference dimensions that showed excellent internal consistencies: (a) hostile, (b) positive/working alliance, (c) special/entitled, (d) anxious/preoccupied, (e) avoidant/dismissing attachment, and (f) sexualized. Factor scores were significantly related to patients' personality characteristics and psychological functioning, regardless of the clinicians' orientations. The findings support that the PRQ is a valid and reliable tool for evaluating the patients' relational patterns emerging in clinical practice in a clinically coherent and psychometrically robust way. Clinicians' careful understanding of these patterns can be very useful for making accurate diagnostic formulations, as well as for providing a roadmap for effective therapeutic intervention.

Empirically Derived Relational Pattern Prototypes in the Treatment of Personality Disorders.

BACKGROUND: Patient transference patterns play a central role in the psychotherapy of personality disorders. OBJECTIVE: The aims of this study were to: (1) explore the relationship between patients' personality disorders and specific relational patterns and (2) construct empirically derived prototypes of relational patterns for each personality disorder. SAMPLING AND METHODS: A random national sample of 314 clinicians completed the Psychotherapy Relationship Questionnaire, which evaluates patients' relational patterns, and the Shedler-Westen Assessment Procedure-200, which assesses personality disorders in a randomly selected patient currently in the clinician's care and with whom the clinician has worked for a minimum of 8 sessions and a maximum of 6 months (1 session per week). RESULTS: The avoidant/counterdependent transference pattern was associated with all cluster A personality disorders; the angry/entitled transference pattern was strongly positively associated with all cluster B personality disorders, and the anxious/preoccupied transference pattern was positively associated in a significant way with all cluster C personality disorders. Moreover, our empirically derived prototypes showed how the transference phenomena characteristic of each personality disorder are strongly coherent with the personality traits and mental and relational functioning of each specific disorder. CONCLUSIONS: The results strongly support a fundamental hypothesis that the patterns emerging in the therapeutic relationship are not arbitrary, and they clearly reflect patterns seen elsewhere in patients' lives that can be crucial to address. Regarding limitations, the same clinician provided data on both the personality pathology and the transference phenomena for each patient.