Association Between Attachment Patterns and Personality Disorders: A Multimethod Multi-Informant Study Using a Clinical Sample.

ABSTRACT: We investigated the association between personality disorders (PDs) and attachment patterns, and examined the construct validity of attachment patterns against adaptive functioning. We used a multimeasure multi-informant approach, which allowed us to disentangle the effects of the methods and to examine the utility of the various methods for measuring these constructs. The participants included 80 clinicians and 170 clinical outpatients, recruited via convenience sampling. Results showed that secure attachment was positively associated with adaptive functioning, whereas insecure patterns were negatively associated with adaptive functioning. Both categorical and dimensional PD diagnoses were associated with insecure attachment patterns. However, after controlling for comorbidity among the PD diagnoses, only some findings remained significant, most notably the association between borderline PD and the clinicians' assessment of preoccupied and incoherent/disorganized attachment, and the patients' self-reported attachment anxiety. Our findings underscore the importance of controlling for comorbidity in examining the associations between attachment patterns and PDs.

Unpacking childhood experiences of abuse: Can clinicians identify their patients' History of Abuse?

Emotional, physical and sexual abuse, have been consistently linked to mental health problems in adults. Previous research found that mental health providers rarely ask their patients about their childhood experiences of abuse. No study to date has examined the convergence of clinicians' and patients' reports of childhood abuse. The current study applied a multi-method, multi-informant approach to explore the concordance between patients' reports of childhood experiences of abuse and clinicians' identification of their patients' history of abuse. Assessment of an independent interviewer was included. A convenience sample of clinicians (N = 80) and their patients (N = 170) in mental health clinics in care-as-usual settings participated in the study. To assess the history of abuse clinicians and patients completed the Clinical Data Form, patients additionally completed the Childhood Trauma Questionnaire. Independent interviewer completed the Familial Experiences Interview. Findings show that across all informants, exposure to emotional abuse was most prevalent, followed by physical abuse and least prevalent was sexual abuse. Additionally, clinicians reported lower prevalence of physical and sexual abuse among their patients as compared with the patient and independent interviewer's reports. Moderate to strong correlations were observed between clinicians, patients and independent interviewer reports of emotional, physical and sexual childhood abuse. Moreover, the severity of the patient's history of abuse was related to greater accuracy in clinicians' reports. Clinicians are advised to collect explicit information regarding childhood abuse through interviews or valid measures. Clinicians should pay special attention when assessing patients with moderate severity of childhood abuse since they are frequently under-identified.

The Association Between Deaf Identity and Emotional Distress Among Adolescents.

The sociocultural approach regards being deaf as a cultural characteristic in the identity of a deaf/hard-of-hearing (D/HH) person. The degree to which one integrates the hearing and Deaf cultures ("acculturation") is an important factor for the well-being of deaf adolescents. We examined the relationship between acculturation patterns and emotional distress among D/HH (n = 69) compared to hearing (n = 60) adolescents in Israel. We used culturally and linguistically accessible measures. Our findings showed no significant differences in emotional distress between D/HH and their hearing counterparts. Acculturation played an important role predicting emotional distress. Identification with both the Deaf and hearing cultures was associated with reduced somatization. Exposure to discrimination and social support was also associated with emotional distress in predictable ways. Findings are interpreted within the specific context of Israeli society and highlight the importance of using adaptive linguistic and cultural assessment tools with D/HH populations.

Reliability of DSM and empirically derived prototype diagnosis for mood, anxiety and personality disorders.

BACKGROUND: Prominent psychiatric diagnostic systems such as the DSM-IV and ICD-10 have shown low reliability in clinical practice. An alternative approach to classification of psychiatric disorders is prototype matching. In the current study, we examined reliability of assessing mood, anxiety and personality disorders using a multi-method multi informant approach. More specifically, we examined diagnosis made by treating clinician and independent expert clinical interviewer, using three different diagnostic systems (DSM symptom count, DSM-IV prototype diagnosis and empirically derived prototype diagnosis). METHODS: A convenience sample of clinicians (N = 80) and patients (N = 170) from eight community mental health clinics in Israel participated in the study. RESULTS: Our findings show fair to excellent interrater reliability for prototype dimensional diagnostic systems (ranged from 0.40 to 0.79) for most mood and anxiety disorders examined. Overall, dimensional diagnostic systems, yielded better interrater reliability for mood, anxiety and personality disorders, as compared with categorical diagnosis. There were no significant differences between dimensional systems. CONCLUSIONS: Our findings provide further support to the advantages of dimensional over categorical models in increasing reliability.

Agreement Among Clinician, Patient, and Independent Interviewer Ratings of Adaptive Functioning.

We examined the interrater reliability and diagnostic efficiency of clinician report (both the treating clinician and independent expert clinical interviewer) and patient self-report of clinically meaningful information pertaining to adaptive functioning. A convenience sample of clinicians (N = 80) and patients (N = 170) from eight community mental health clinics in Israel participated in the study. Our findings suggest that clinicians overall reliably report on adaptive functioning of patients (overall correct classification rates range, 0.74-0.98). Yet, in some areas, they may fail to collect necessary information such as self-mutilation history, loss of job in the past 5 years, and adult physical abuse. The patterns of higher versus lower diagnostic efficiency suggest that both treating clinicians and independent clinician interviewers tend to make judgments conservatively, essentially sacrificing sensitivity for specificity, not diagnosing events unless they were certain, thus maximizing false-negatives and minimizing false-positives.

"Why Come for Treatment?" Clients' and Therapists' Accounts of the Presenting Problems When Seeking Mental Health Care.

Although identification of main problems is the foundation for treatment planning, limited research has examined reasons for seeking mental health care. We identified reasons for seeking mental health care as reported by clients and therapists upon initial contact with mental health services. We conducted in-depth interviews with clients and their therapists immediately following the intake. We analyzed 117 therapist and 112 client interviews using thematic analysis. Overall interrater reliability among three raters who coded the interviews was high (kappa = 0.72). Our findings suggest that, overall, clients and therapists report similar main area problems that bring clients to care. Emotional distress and other psychiatric symptoms as well as interpersonal problems were most prevalent. Therapists tended to ignore some problem areas that clients highlighted, including physical problems and socioeconomic strains. Raising awareness to potential gaps in perception of main problems that bring clients to care will promote a shared understanding and improve quality of care.

Assessment of diagnostic information and quality of working alliance with clients diagnosed with personality disorders during the mental health intake.

BACKGROUND: A primary purpose of diagnostic systems is to improve care, yet, little is known about how providers use it routine clinical care. AIMS: We investigated specific DSM-IV personality disorders (PDs) diagnostic information therapists collected during intake visits and the association between a therapist PD diagnosis and clients' and therapists' reports of the quality of working alliance during the intake. METHOD: A total of 122 intakes (n = 34, 27.9% were diagnosed with PD) in four community mental health clinics in Israel were audiotaped. Immediately following the intake, clients and therapists completed the working alliance inventory (WAI). Independent clinicians coded the intakes using an information checklist. RESULTS: Despite the relatively high prevalence of PD in regular psychiatric care, very limited PD diagnostic information was directly assessed during the intake. Therapists evaluated the quality of the working alliance when they saw a client they diagnosed with PD as significantly lower than the rating of a client without a PD, while the clients' ratings did not differ as a result of their diagnosis. CONCLUSIONS: Therapists do not collect sufficient explicit diagnostic information to base their PD diagnostic decisions. Yet, the presence of PD diagnosis affects their rapport with their clients as early as the intake.

"What should we talk about?" The association between the information exchanged during the mental health intake and the quality of the working alliance.

We investigated the association between the content of the information exchanged between clients and therapists during mental health intake and the quality of the therapeutic alliance. Thirty-eight therapists and 107 clients from four mental health clinics in Israel participated in the study. The content of information discussed was coded directly from the recorded intakes by blinded raters. Clients and therapists completed the Working Alliance Inventory immediately following the intake. Therapists spent the majority of intake time in collecting information about their clients' diagnostic symptoms and personal history and sociocultural background. Due to the high negative correlation between these factors, r(107) = -.68, p < .001, we created a measure of delta score with higher scores reflecting more discussion of personal history and sociocultural background and less discussion of diagnostic symptoms. We computed three-level hierarchical linear model analysis, with intakes nested within therapists and therapists nested within sites, to examine the association between the delta score and the working alliance, while controlling for intake duration. Results showed significant association between the delta score and clients' rating of the working alliance (γ200 = 0.014, p = .02), indicating that discussing more personal history and sociocultural background and less diagnostic symptoms was associated with better clients' rating of the working alliance. Therapists' rating of the working alliance was not significantly associated with the content of the information exchanged. The restricted intake time allocated to therapists dictates use of strategies to deal with time trade-offs to complete a thorough diagnostic assessment while allowing clients to tell their personal story.

The association between acculturation patterns and mental health symptoms among Eritrean and Sudanese asylum seekers in Israel.

Past research has documented the role acculturation plays in the process of adjustment to new cultures among migrants. Yet little attention has been paid thus far to the role of acculturation in the context of forced migration. In this study we examined the association between acculturation patterns and mental health symptoms among a convenience sample of Eritrean and Sudanese asylum seekers (n = 118) who accessed health services at the Physicians for Human Rights Open-Clinic in Israel. Participants completed measures on sociodemographic information as well as detention history, mental health symptoms, exposure to traumatic events, and acculturation pattern, in their native language upon accessing services. Consistent with our predictions, findings showed that acculturation predicted depressive symptoms among asylum seekers beyond the effect of history of detention and reports of experiences of traumatic events. Assimilated compared with integrated asylum seekers reported higher depressive symptoms. Findings draw attention to the paradox of assimilation, and the mental health risks it poses among those wishing to integrate into the new culture at the expanse of their original culture. Asylum seekers may be particularly vulnerable to the risks of assimilation in the restrictive policies that characterize many industrial countries in recent years.

Smoke your troubles away: exploring the effects of death cognitions on cannabis craving and consumption.

Two studies informed by the terror management health model were conducted to examine the question of how death cognition affects cannabis craving and whether actual cannabis smoking alleviates death cognitions. The first study examined whether priming thoughts of death are associated with subjective cannabis craving among 42 frequent cannabis users randomly assigned to either a mortality salience or control task. When reminded of their death, participants craved cannabis, even though there was no change in their conscious negative mood. The second study examined the effect of cannabis smoking on death cognitions in an exploratory field setting. Fifty frequent cannabis users were randomly assigned to either mortality reminders or control task and completed death-related words accessibility measures before and after smoking cannabis. Results indicate that cannabis served as a buffer and prevented death-related thoughts from entering consciousness, thus acting as a defense mechanism against death anxiety. These findings indicate that death-related concerns may play a hitherto unsuspected role in cannabis craving and consumption. Also discussed are the implications of a terror management perspective in communication of negative health consequences of recreational cannabis smoking and in the use of cannabis for medical purposes among people with terminal illness.

Predictors of mental health care stigma and its association with the therapeutic alliance during the initial intake session.

OBJECTIVE: We investigated the association between socio-demographic and clinical variables with mental health care stigma, and the impact of the latter on the quality of the therapeutic alliance measured at intake. METHOD: Consecutive clients (N = 236) filled questionnaires upon accessing services for a new episode of care. Immediately following the intake, a randomly selected sample of clients and their corresponding therapists (n = 102) completed the Working Alliance Inventory - Bond Scale. RESULTS: Lower mean years of education and higher emotional distress (both partial r = .17) were significantly associated with higher stigma. Higher care stigma negatively correlated with therapists' ratings of the therapeutic alliance during the intake (partial r = -.22), but not with those of clients. CONCLUSIONS: Care stigma is present among service-users and may affect outcomes of the intake.

Can I Leave the Past Behind? Associations between Childhood Abuse and Adult Psychopathology.

BACKGROUND: Research consistently shows that abuse during childhood is related to adult psychopathology. Information regarding childhood abuse is frequently collected from either previous documentation or from participants' self-reports. OBJECTIVE: In the current study, we combined information on reports of childhood abuse from several informants (patients, treating clinicians, and independent interviewer), as well as diagnostic assessments of adult patients based on independent interviewer assessments based on structured diagnostic interviews (SCID) and clinician judgments, to better examine the association between exposure to abuse during childhood and adult psychopathology. PARTICIPANTS AND SETTING: A convenience sample of patients in community mental health and hospital-based clinics (N = 170) and their clinicians (N = 80) participated in the study. METHODS: Patients and clinicians completed the Clinical Data Form. Patients also completed the Childhood Trauma Questionnaire. Independent interviewer-assessed patients and completed the Familial Experiences Interview. Clinicians completed a diagnostic assessment of their patients based on clinical judgment. Independent interviewers completed the Structured Clinical Interview (SCID). RESULTS: Reports of exposure to physical, emotional, and sexual abuse during childhood from all informants correlated with the treating clinician's diagnosis of borderline personality disorder (BPD; r range 0.23-0.37, p < 0.05), but not with SCID diagnosis of BPD. Clinician and SCID diagnosis of post-traumatic stress disorder (PTSD) correlated with patient and interviewer reports of childhood sexual abuse (r range 0.23-0.30, p < 0.05), but there were no correlations with treating clinician's reports of sexual abuse. CONCLUSIONS: The association between BPD and childhood abuse is consistent across different ratings and measurements. The study raises questions of the ability of a structured interview to accurately capture BPD and highlights the connection between sexual abuse and PTSD, and the importance of treating clinicians' examination of childhood sexual abuse among their patients.

Dehumanization of stigmatized targets of ostracism.

The study explored people's reactions to observing the ostracism of stigmatized targets. Participants (n = 198) who observed ostracism experienced need threat regardless of the target's identity. Participants regarded included addicts more positively than ostracized addicts, especially on traits that are considered unique to humans. As for dehumanization, subtle measures demonstrate that ostracized targets are perceived as less human. In contrast, our original measure of blatant dehumanization suggests that targets of ostracism are perceived as more human. The study stresses the inconsistency between dehumanization measurements and the need to specify what each measure taps into and how each contributes to the theory.

Ethnic differentials in mental health needs and service utilization among persons with cancer.

PURPOSE: Improving the assessment of and access to appropriate care for mental health problems among persons with cancer is essential, particularly for population groups that are at high risk for psychopathology. This study characterized ethnic differentials regarding needs and service utilization by Jewish (n = 1,430) and Arab-Israeli (n = 141) persons with cancer. METHODS: We reviewed 284 randomly selected active medical charts in an oncology clinic in a large public hospital (November 2010-April 2011). RESULTS: While 12% of the charts of the Jewish-Israeli sample included a record of psychiatric disorders or symptoms, only 5% of the charts of the Arab-Israeli sample had a similar record (χ² = 4.4, p < .05). Similarly, in a higher percentage of the charts of the Jewish-Israeli sample, the current utilization of psychotropics (18.2 and 5.6%, respectively; χ² = 6.7; p < .01) and/or psychotherapy (7.8 and 1.4%, respectively; χ² = 3.6; p < .05) was noted compared with the Arab-Israeli sample. Also, in a higher percentage of the charts of the Jewish-Israeli patients, a referral for psychotherapy was recorded compared with their Arab counterparts (9.1 and 4.3% respectively; χ² = 6.3; p < .05). In contrast, 19.1% of the Arab-Israelis were recommended with welfare assistance compared to their Jewish-Israeli counterparts, 10.5% (χ² = 5.35; p < .05). CONCLUSIONS: Despite methodological limitations, findings confirm past research showing that disadvantaged ethnic minorities may receive differential recommendations for mental health problems among persons with cancer. This may contribute to the differential treatment gap in mental health care among persons with cancer of contrasting ethnic groups.

The effect of acculturation and discrimination on mental health symptoms and risk behaviors among adolescent migrants in Israel.

This study examines the role of acculturation, perceived discrimination, and self-esteem in predicting the mental health symptoms and risk behaviors among 1.5 and second generation non-Jewish adolescents born to migrant families compared with native-born Jewish Israeli adolescents in Israel. Participants included n = 65 1.5 migrant adolescents, n = 60 second generation migrant adolescents, and n = 146 age, gender, and socioeconomic matched sample of native-born Jewish Israelis. Participants completed measures of acculturation pattern, perceived discrimination, and self-esteem as well as measures of mental health symptoms and risk behaviors. Results show that migrant adolescents across generations reported worse mental health symptoms compared with native-born Jewish Israelis. However, only the 1.5 generation migrants reported higher engagement in risk behaviors compared with second generation migrants and native-born Jewish Israelis. Our findings further showed that acculturation plays an important role in predicting the mental health status of migrant youth, with those characterized with integrated acculturative pattern reporting lower mental health symptoms compared with assimilated acculturation pattern. Importantly, contextual factors, such as higher perception of discrimination in the receiving culture as well as individual factors such as lower self-esteem and female gender were strongly associated with worse mental health symptoms. The findings manifest the complex relationship between contextual factors and individual level variables in the acculturative process of migrants as well as the importance of examining the effect of migration generation on mental health outcomes.

"Degrees of Freedom": Comparing Mental Distress of Populations with Different Levels of Access to Care-Prisoners, Psychiatric Patients and General Population.

OBJECTIVES: The study presents an analysis of the risk for common mental disorders (CMDs) in populations with different levels of access to mental health care. METHODS: We merged and statistically compared the representative data of prisoners to data collected from psychiatric clinics and the general population. Participants across all samples completed the General Health Questionnaire. RESULTS: More than half of the inmates met the criteria for CMDs, while rates were 25% in the general population and 80% among psychiatric patients. The odds of prisoners being five times more likely to meet the criteria for CMDs were five times higher than the odds of the general population while controlling for demographic variables. CONCLUSIONS: The study highlights the need for prisoners for mental health services. Prisoners face stressful life conditions before and during incarceration while having limited access to medical and psychological treatment stresses the need for systemic interventions.

Would victims blame victims? Effects of ostracism, sexual objectification, and empathy on victim blaming.

In the current research, we examined whether ostracism and sexual objectification affect the tendency to blame the victim of sexual harassment. Previous research concerning victim blame examined the attribution of blame considering the characteristics of the victim, the perpetrator, and the relation between them. However, no research to date examined whether situational factors of the perceiver can affect their perception and judgment of blame. We propose that sexual objectification and ostracism may elicit empathy toward the victim, and in turn, reduce victim blame. In two experimental studies, women were instructed to imagine interacting with a videotaped man who either gazed at their body (objectification), away from them (ostracism), or at their face (treated well). Then, they were asked to read a newspaper article (study 1) or watch a video (study 2) portraying encounters in which the man's sexual advances continued after the woman expressed discomfort and lack of interest. In study 1, we found that sexually objectified women attributed less blame to the woman compared with the women who were treated well, with ostracized women falling in between and marginally different from both. In study 2, using mediation analysis we found an indirect effect such that sexually objectified women experienced greater empathy toward the victim, which was associated with reduced attribution of blame. It appears that greater similarity between the situation of the perceiver and the situation of the victim elicits greater empathy. This adds to the previous knowledge that personality similarities result in higher empathy.

The dosing procedure that "makes the poison": Comparing the effects of single versus cumulative alcohol administration methods on emotion recognition.

BACKGROUND: Most people often consume alcohol cumulatively and gradually. Yet almost scientific knowledge about alcohol's acute effects on cognition, behavior, and affect stems from laboratory studies that employ a single beverage administration procedure. OBJECTIVE: This study tests the hypothesis that alcohol's acute effects depend on both methods of administration and alcohol blood level. We introduce a new laboratory procedure for studying cumulative alcohol drinking and examine alcohol's effects on emotion recognition as a function of both alcohol administration method and alcohol blood level. METHODS: Participants were recruited for one of two studies. One study employed a between-subject design using a single alcoholic dose. Participants were randomly assigned to drink either placebo (0.00%), low (0.03%), moderate (0.06%), or high (0.09%) alcohol levels. The second study employed a within-subject design using a cumulative alcoholic administration method, in which each participant drank four drinks (placebo, followed by three alcoholic drinks). Both groups reached similar breath alcohol concentrations. In both studies, participants attended a single study session, in which emotion recognition was examined following alcohol administration. RESULTS: Single alcoholic beverage administration method caused greater impairment in emotion recognition ability, specifically for anger, happiness, and fear, as compared with cumulative administration method, even though breath alcohol levels were similar in both conditions. CONCLUSIONS: This paper presents questions concerning the internal validity of previous laboratory studies that use a single beverage administration procedure. Insights into the effects of alcohol on behavior, as well as regarding our knowledge about models of addiction are presented.

Validity and clinical utility of DSM and empirically derived prototype diagnosis for personality disorders in predicting adaptive functioning.

Prototype matching, which involves comparing a patient clinical presentation with a prototype description of the disorder addresses some of the clinical limitations of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases symptom-count approach. Here, we investigated the validity and clinical utility of three diagnostic systems in predicting patient adaptive functioning using a multimethod multi-informant approach. Specifically, we compared a prototype matching approach based on DSM criteria, an empirically derived prototype matching approach, and DSM symptom count diagnostic systems. A convenience sample of clinicians (N = 80) and patients (N = 170) participated in the study. We imposed minimal exclusion criteria for patient participation to maximize generalizability. Clinicians completed assessment of their active patients using two prototype matching diagnoses, one based on DSM and another that was empirically derived. Independent interviewers completed the Structured Clinical Interview to provide DSM symptom count. Patient global composite assessment of adaptive functioning, rated across the clinician, patient self-report, and independent interviewer, served as outcome variable. Prototype diagnosis for personality disorders, both one that is based on DSM criteria and one that was empirically derived, demonstrates some incremental validity over and above the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition symptom count, in predicting patient's adaptive functioning. Specifically, avoidant personality disorder prototype diagnosis significantly contributed to prediction of adaptive functioning. Furthermore, clinicians rated the prototype-matching approach as more useful in clinical practice compared with the current DSM-IV categorical approach. Using a dimensional approach, which is based on prototype matching that also preserves the advantages of categorical system offers a valid and efficient approach to psychiatric assessment for personality disorders. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Validity and clinical utility of DSM and prototype diagnosis for depressive and anxiety spectrum disorders in predicting adaptive functioning.

Prototype matching, which involves comparing a patient clinical presentation with a prototype description of the disorder, addresses some of the clinical limitations of categorical approaches. Most research to-date on prototype matching has been conducted with personality disorders. Here, we examined the validity and clinical utility of prototype diagnosis for mood and anxiety disorders. We compared clinicians prototype diagnosis (based on DSM IV and empirically derived) to categorical diagnosis (based on independent SCID interview) in predicting patient global adaptive functioning rated across the clinician, patient and independent interviewer among N = 80 clinicians and N = 170 patients. Our findings show that prototype diagnosis (both one that is based on DSM criteria and empirically derived) demonstrates some incremental validity over and above the categorical DSM IV, in predicting patient's global adaptive functioning. This is particularly pronounced for mood disorders (MDD and dysthymia) as well as several anxiety disorders (OCD, social phobia) across a range of experience level of diagnosticians. Furthermore, clinicians rated the prototype matching approach as more useful in clinical practice compared with the binary categorical system. Using a dimensional approach, which is based on prototype matching that also preserves the advantages of categorical system offers a valid and efficient approach to psychiatric assessment.