Despite the availability of effective treatments for personality disorders (PDs), recovery rates are modest. A better understanding is therefore needed of what patients, significant others and therapists consider to be impediments to PD treatment. We used concept mapping to create a conceptual framework of factors that impede PD treatment. The perspectives of patients, significant others, and therapists with respect to impediments were collected in brainstorm sessions and then formulated as statements by an expert team. The participants subsequently prioritized and sorted these statements prior to analysis with multidimensional scaling and grouping on a two-dimensional concept map using hierarchical cluster analyses. Fifty-four statements were defined and assigned to 11 clusters that were grouped in five metaclusters: (a) lack of trust in the therapeutic relationship, (b) perceived therapist incompetence (c) shortcomings in the mental health care system, (d) patient-related conflicting factors, and (e) insufficient involvement of significant others. This study provides a conceptual framework of factors that are perceived to impede PD treatment. Our findings potentially contribute to an awareness of impediments in clinical practice and suggest that therapists should actively inquire about the expectations, needs, and treatment difficulties of patients and their significant others. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

OBJECTIVE:Intensive short-term dynamic psychotherapy (ISTDP) has been shown to be effective with patients with common mental disorders, including personality disorders. In the Netherlands, a 6-month residential version (R-ISTDP) of this traditionally outpatient therapy for patients with treatment-resistant personality disorders was developed and tested. This study focused on changes that occurred directly after treatment and 1-10 years after discharge. METHODS:All patients admitted to the R-ISTDP program between 1995 and 2005 were assessed at admission, discharge, and a variable follow-up of 1-10 years. In this single-arm trial, treatment outcome was measured in terms of symptom severity (with the Symptom Checklist-90-R [SCL-90-R]), general functioning (with the Global Assessment of Functioning [GAF] Scale), employment status, social welfare benefits, and living situation. Demographic variables and psychopathology indicators were included as predictors. Because of the variable distribution of length of follow-up, outcome data from 155 patients were evaluated by using mixed-models analysis. RESULTS:From admission to discharge, significant and large improvements were seen in SCL-90-R total scores (d=1.2) and GAF scores (d=0.9). From discharge over the course of 10-year follow-up, SCL-90-R total scores remained stable, and GAF scores further improved (d=1.5). At follow-up 1-10 years after discharge, more patients had returned to work compared with pretreatment. No statistically significant association between any of the predictors and outcome was found. CONCLUSIONS:Patients with treatment-resistant personality disorders showed substantial improvements at discharge from R-ISTDP. Although several limitations of this naturalistic study design must be considered, these findings are important in demonstrating stable long-term improvement after R-ISTDP.

Background Higher intensity of psychotherapy might improve treatment outcome in depression, especially in those with comorbid personality disorder. Aims To compare the effects of 25 individual sessions (weekly) of two forms of psychotherapy – short-term psychoanalytic supportive psychotherapy (SPSP) and schema therapy – with the same treatments given for 50 sessions (twice weekly) in people with depression and personality disorder. Trial registration: NTR5941. Method We conducted a pragmatic, double-randomised clinical trial and, over 37 months, recruited 246 adult out-patients with comorbid depression/dysthymia and personality disorder. A 2 × 2 factorial design randomised participants to 25 or 50 sessions of SPSP or schema therapy. The primary outcome was change in depression severity over 1 year on the Beck Depression Inventory II (BDI-II). Secondary outcomes were remission both of depression and personality disorder. Results Compared with 25 sessions, participants who received 50 sessions showed a significantly greater decrease in depressive symptoms over time (time × session dosage, P < 0.001), with a mean difference of 5.6 BDI points after 1 year (d = −0.53, 95% CI −0.18 to 0.882, P = 0.003). Remission from depression was also greater in the 50-session group (74% v. 58%, P = 0.025), as was remission of personality disorder (74% v. 56%, P = 0.010). Conclusions Greater intensity of psychotherapy leads to better outcomes of both depression and personality status in people with comorbid depression and personality disorder.

Abstract Background Patients with comorbid depression and personality disorders suffer from a heavy disease burden while tailored treatment options are limited, accounting for a high psychological and economic burden. Little is known about the effect of treatment dosage and type of psychotherapy for this specific co-morbid patient population, in terms of treatment-effect and cost-effectiveness. This study aims to compare treatment outcome of 25 versus 50 individual therapy sessions in a year. We expect the 50-session condition to be more effective in treating depression and maintaining the effect. Secondary objectives will be addressed in order to find therapy-specific and non-specific mechanisms of change. Methods In a mono-center pragmatic randomized controlled trial with a 2 × 2 factorial design, 200 patients with a depressive disorder and personality disorder(s) will be included. Patients will be recruited from a Dutch mental health care institute for personality disorders. They will be randomized over therapy dosage (25 vs 50 sessions in a year) and type of therapy (schema therapy vs short-term psychodynamic supportive psychotherapy). The primary clinical outcome measure will be depression severity and remission. Changes in personality functioning and quality of life will be investigated as secondary outcomes. A priori postulated effect moderators and mediators will be collected as well. All patients are assessed at baseline and at 1, 2, 3, 6, 9–12 months (end of therapy) and at follow up (6 and 12 months after end of treatment). Alongside the trial, an economic evaluation will be conducted. Costs will be collected from a societal perspective. Discussion This trial will be the first to compare two psychotherapy dosages in patients with both depression and personality disorders. Insight in the effect of treatment dosage for this patient group will contribute to both higher treatment effectiveness and lower costs. In addition, this study will contribute to the limited evidence base on treating patients with both depression and personality disorders. Understanding the processes that account for the therapeutic changes could help to gain insight in what works for whom. Trial registration This trial has been registered on July 20th 2016, Netherlands Trial Register, part of the Dutch Cochrane Centre (NTR5941).

Accumulating evidence documents the efficacy of Therapeutic Assessment (TA) in terms of symptom reduction and other outcomes, but only minimal data speak to the patient's perspective of what is memorable, or potentially important, about this intervention. In line with the humanistic and phenomenological philosophy of TA, we solicited patient input by asking personality disorder (PD) patients who participated in a recent randomized controlled trial (De Saeger et al., 2014) about their experiences. We report on 10 PD patients who were administered semistructured interviews designed to assess an in-depth perspective of undergoing TA. Our methodological approach can be described as phenomenological and integrative, approximating guidelines provided by the Consensual Qualitative Research paradigm (Hill, 2012). Four core content domains emerged from the transcribed and coded interview protocols: (a) relationship aspects, (b) new insight into personal dynamics, (c) sense of empowerment, and (d) validation of self. Novel experiences were mostly of a relational nature, and pertained to feeling of being treated like an equal and essential partner in a highly individualized venture. Research and clinical implications of these patient reports of TA participation are discussed.

Objective: Our aim was to demonstrate the feasibility of the univariate and generalized propensity score (PS) method in subgroup analysis of outcomes research. Methods: First, to estimate subgroup effects, we tested the performance of 2 different PS methods, using Monte Carlo simulations: (1) the univariate PS with additional adjustment on the subgroup; and (2) the generalized PS, estimated by crossing the treatment options with a subgroup variable. The subgroup effects were estimated in a linear regression model using the 2 PS adjustments. We further explored whether the subgroup variable should be included in the univariate PS. Second, the 2 methods were compared using data from a large effectiveness study on psychotherapy in personality disorders. Using these data we tested the differences between short-term and long-term treatment, with the severity of patients’ problems defining the subgroups of interest. Results: The Monte Carlo simulations showed minor differences between both PS methods, with the bias and mean squared error overall marginally lower for the generalized PS. When considering the univariate PS, the subgroup variable can be excluded from the PS estimation and only adjusted for in the outcome equation. When applied to the psychotherapy data, the univariate and generalized PS estimations gave similar results. Conclusion: The results support the use of the generalized PS as a feasible method, compared with the univariate PS, to find certain subgroup effects in nonrandomized outcomes research.

OBJECTIVEAlthough personality disorder not otherwise specified (PDNOS) is highly prevalent and associated with a high burden of disease, only a few treatment studies in this patient group exist. This study is the first to investigate the effectiveness of different modalities of psychotherapy in patients with PDNOS, i.e., short-term (up to 6 months) and long-term (more than 6 months) outpatient, day hospital, and inpatient psychotherapy.METHODA total of 205 patients with PDNOS were assigned to one of six treatment modalities. Effectiveness was assessed over 60 months after baseline. The primary outcome measure was symptom severity, and the secondary outcome measures included psychosocial functioning and quality of life. The study design was quasi-experimental, and the multiple propensity score was used to control for initial differences between treatment groups.RESULTSAll treatment modalities showed positive outcomes, especially in terms of improvements of symptom severity and social role functioning. At 12-month follow-up, after adjustment for initial differences between the treatment groups, short-term outpatient psychotherapy and short-term inpatient psychotherapy showed most improvement and generally outperformed the other modalities concerning symptom severity. At 60 months after baseline, effectiveness remained but observed differences between modalities mostly diminished.CONCLUSIONPatients with PDNOS benefit from psychotherapy both at short-term and long-term follow-up. Short-term outpatient psychotherapy and short-term inpatient psychotherapy seem to be superior to the other treatment modalities at 12-month follow-up. At 60-month follow-up, treatments showed mostly comparable effectiveness.KEY PRACTITIONER MESSAGESThe effectiveness of different modalities of psychotherapy in patients with PDNOS (i.e., short-term vs long-term; outpatient versus day hospital versus inpatient psychotherapy) has not yet been compared. Different modalities of psychotherapy are effective for patients with PDNOS, and positive effects remain after 5 years. In patients with PDNOS short-term (less than 6 months) outpatient psychotherapy and short-term inpatient psychotherapy seem to be superior to the four other treatment modalities at 12-month follow-up. At 60-month follow-up, treatments showed mostly comparable effectiveness.

Background: While psychopharmacological studies are common in patients with cluster A personality disorders, the effects of psychotherapy have received little attention. The aim of this study is to explore whether psychotherapeutic treatment yields health gains for these patients. Methods: The study was conducted between March 2003 and June 2008 in 6 mental health care centres in the Netherlands, with a sample of 57 patients with a DSM-IV-TR axis II cluster A diagnosis. Patients were assigned to 3 settings of psychotherapeutic treatment (outpatient, day hospital, inpatient), and effectiveness was assessed at 18 months after baseline. An intention-to-treat analysis was conducted for psychiatric symptoms (Brief Symptom Inventory), psychosocial functioning (Outcome Questionnaire-45) and quality of life (EQ-5D), using multilevel statistical modelling. As the study was non-randomised, the propensity score method was used to control for initial differences. Results: Patients in the day hospital and inpatient group improved substantially in terms of psychiatric symptoms, social and interpersonal functioning, and quality of life. Patients in the outpatient group showed less improvement. Direct comparison of the improvement of psychiatric symptoms showed significant results in favour of day hospital (p = 0.046) and inpatient (p = 0.01) treatment, as compared to outpatient treatment. However, due to substantial baseline differences, this direct comparison should be judged carefully. Conclusions: Cluster A psychopathology is not a contraindication to benefit from psychotherapy. This is especially true for more intensive forms like inpatient and day hospital treatment. Future research should focus more on psychotherapeutic treatment to gain further insight into effective treatment options for this patient group.

tured discussion including IFP members Margarete Haass-Wiesegart (Heidelberg), Limas Sutanto (Indonesia) and Jian Qiu (China). Here is the abstract: ‘Psychotherapy is by far not spread evenly over the world. For example, until recently China, a country with a multi-million population undergoing rapid change with much tension also for the individual, had only 200 certified psychotherapists, in spite of a long history of contact with psychotherapy. What kind of psychotherapy would be needed as a solid basis for building up psychotherapy delivery in such countries, what kind of research can be done by established psychotherapy researchers from other countries, what kind of research can be done by psychotherapists working in these countries? This is, apart from practical and methodological questions, of course also a question of culture.’ Any comments on what aspects should be covered in this discussion are welcome (caspar @ psy.unibe.ch). Finally, as always, all our members, meaning individual members of the IFP as well as individual members of associations who have membership status with the IFP, are offered the IFP’s official journal, Psychotherapy and Psychosomatics, at a substantially reduced subscription rate. For details, please contact S. Karger directly at: The board met in Zurich in early October. The new members, Prof. Sabine Herpertz (Heidelberg) and Prof. Stephan Zipfel (Tübingen), were introduced in person. Prof. David Orlinsky (Chicago) had been intensely involved in an email discussion about the issues to be treated before the meeting. Prof. Orlinsky will be vice president, Prof. Herpertz will be general secretary, Prof. Zipfel will be editor of the newsletter. The topics of the board meeting, in short: The secretariat will remain with Mrs. Erpenbeck in Zurich. The finances are solid. Applications by two new individual members and an association (Institute of Relational Psychotherapy; Prof. Avila, Spain) for membership have been approved. Gerhard Grobler, Alfried Längle, Mechthild Neises and Fritz Hohagen will be new council members. The IFP will collaborate for the Deutsche Kongress für Psychosomatische Medizin und Psychotherapie, March 23–26, 2011, in Essen. There will be a collaboration with Dr. Sutanto (Indonesia) on the organization of psychotherapy training for psychiatrists and other professionals. Locations under discussion for the 2014 IFP conference are Shanghai and South Africa. The engagement of the IFP in research shall be strengthened: a research award will be created; the precise form is still under discussion in the council. A new form of membership has been proposed for psychotherapy researchers; a concrete proposal will be elaborated and discussed with the council. There is a plan to install a research committee. Former president Prof. Ueli Schnyder will represent the IFP in the Philippine Psychiatric Association and the Asia Pacific Association for Psychotherapists in Manila at the end of January 2011. The upcoming conference of the Society for Psychotherapy Research – organized by IFP president Franz Caspar in Bern, Switzerland, from June 29 to July 2, 2011 – will include a strucPublished online: February 3, 2011

BACKGROUND AND OBJECTIVE:The propensity score method (PS) has proven to be an effective tool to reduce bias in nonrandomized studies, especially when the number of (potential) confounders is large and dimensionality problems arise. The PS method introduced by Rosenbaum and Rubin is described in detail for studies with 2 treatment options. Since in clinical practice we are often interested in the comparison of multiple interventions, there was a need to extend the PS method to multiple treatments. It has been shown that in theory a multiple PS method is possible. So far, its practical application is rare and a practical introduction lacking.METHODS:A practical guideline to illustrate the use of the multiple PS method is provided with data from a mental health study. The multiple PS is estimated with a multinomial logistic regression analysis. The multiple PS is the probability of assignment to each treatment category. Subsequently, to estimate the treatment effects while controlling for initial differences, the multiple PSs, calculated for each treatment category, are included as extra predictors in the regression analysis.RESULTS:With the multiple PS method, balance was achieved in all relevant pretreatment variables. The corrected estimated treatment effects were somewhat different from the results without control for initial differences.CONCLUSIONS:Our results indicate that the multiple PS method is a feasible method to adjust for observed pretreatment differences in nonrandomized studies where the number of pretreatment differences is large and multiple treatments are compared.

Background: For patients with cluster B personality disorders there is no consensus regarding the optimal treatment setting. The aim of this study was to compare the effectiveness of different psychotherapeutic settings for patients with cluster B personality disorders, i.e. outpatient, day hospital, and inpatient treatment. Methods: The study was conducted between March 2003 and June 2008 in 6 mental health care centres in the Netherlands, with a sample of 207 patients with a DSM-IV-TR axis II cluster B diagnosis. Patients were assigned to 3 different settings of psychotherapeutic treatment and effectiveness was assessed at 18 months after baseline. An intention-to-treat analysis was conducted for psychiatric symptoms (Brief Symptom Inventory), psychosocial functioning (Outcome Questionnaire-45), and quality of life (EQ-5D), using multilevel statistical modelling. As the study was non-randomised, the propensity score method was used to control for initial differences. Results: Patients in all 3 settings improved significantly in terms of psychiatric symptoms, social and interpersonal functioning, and quality of life 18 months after baseline. The inpatient group showed the largest improvements. The comparison of outpatient and inpatient treatment regarding psychiatric symptoms showed a marginally significant result (p = 0.057) in favour of inpatient treatment. Conclusions: Patients with cluster B personality disorders improved in all investigated treatment settings, with a trend towards larger improvements of psychiatric symptoms in the inpatient setting compared to the outpatient setting. Specialised inpatient treatment should be considered as a valuable treatment option for cluster B personality disorders, both in research and in clinical practice.

Background: No previous studies have compared the effectiveness of different modalities of psychotherapeutic treatment, as defined by different settings and durations, for patients with cluster C personality disorders. The aim of this multicentre study was to compare the effectiveness of 5 treatment modalities for patients with cluster C personality disorders in terms of psychiatric symptoms, psychosocial functioning, and quality of life. The following treatment modalities were compared: long-term outpatient (more than 6 months), short-term day hospital (up to 6 months), long-term day hospital, short-term inpatient, and long-term inpatient psychotherapy. Methods: The study was conducted between March 2003 and June 2008 in 6 mental health care centres in the Netherlands, with a sample of 371 patients with a DSM-IV-TR axis-II cluster C diagnosis. Patients were assigned to 5 different modalities of psychotherapeutic treatment, and effectiveness was assessed at 12 months after baseline. An intention-to-treat analysis was conducted for psychiatric symptoms (Brief Symptom Inventory), psychosocial functioning (Outcome Questionnaire-45), and quality of life (EQ-5D), using multilevel statistical modelling. As the study was non-randomised, the propensity score method was used to control for initial differences. Results: Patients in all treatment groups had improved on all outcomes 12 months after baseline. Patients receiving short-term inpatient treatment showed more improvement than patients receiving other treatment modalities. Conclusions: Psychotherapeutic treatment, especially in the short-term inpatient modality, is an effective treatment for patients with cluster C personality disorders.

Background: Randomized controlled trials are considered the best scientific proof of effectiveness. There is increasing concern, though, about their feasibility in psychotherapy research. We discuss a quasi-experimental study design for situations in which a randomized controlled trial is not feasible. Here, as an alternative strategy, the propensity score (PS) method is used to correct for selection bias. Methods: We used data from a Dutch research project, SCEPTRE (Study on Cost-Effectiveness of Personality Disorder Treatment). The sample consisted of 749 psychotherapy patients with personality pathology. We tested whether the PS method was useful and applicable. We examined differences between 2 treatment groups (short vs. long treatment duration) in pretreatment characteristics before and after PS correction. This revealed the impact of the PS on outcome differences. Results: The PS offered statistical control over observed pretreatment differences between patients in a non-randomized study. Conclusions: When a randomized controlled trial is not possible, this quasi-experimental design using the PS could be a feasible alternative. Its advantages and limitations are discussed. Implemented carefully, this method is promising for future effectiveness research.

Objective: Despite scientific evidence of effectiveness, psychotherapy for personality disorders is not yet fully deployed, nor is its reimbursement self-evident. Both clinicians and health care policy-makers increasingly rely on evidence-based medicine and health economics when determining a treatment of choice and reimbursement. This article aims to contribute to that understanding by applying these criteria on psychotherapy as a treatment for patients with personality disorder. Method: We have evaluated the available empirical evidence on effectiveness and cost-effectiveness, and integrated this with necessity of treatment as a moderating factor. Results: The effectiveness of psychotherapy for personality disorders is well documented with favourable randomized trial results, 2 metaanalyses, and a Cochrane review. However, the evidence does not yet fully live up to modern standards of evidence-based medicine and is mostly limited to borderline and avoidant personality disorders. Data on cost-effectiveness suggest that psychotherapy for personality disorders may lead to cost-savings. However, state-of-the-art cost-effectiveness data are still scarce. An encouraging factor is that the available studies indicate that patients with personality disorder experience a high burden of disease, stressing the necessity of treatment. Conclusions: When applying an integrated vision on outcome, psychotherapy can be considered not only an effective treatment for patients with personality disorder but also most likely a cost-effective and necessary intervention. However, more state-of-the-art research is required before clinicians and health care policy-makers can fully appreciate the benefits of psychotherapy for personality disorders. Considerable progress is possible if researchers focus their efforts on evidence-based medicine and cost-effectiveness research.

Personality Disorder Not Otherwise Specified (PDNOS) is one of the most frequently used Axis II diagnoses, yet explicit guidelines for its assessment are lacking. To investigate the prevalence and construct validity of various definitions of PDNOS, 1760 psychotherapy referrals were diagnosed using the Structured Interview for DSM-IV Personality Disorders (SIDP-IV). Construct validity parameters included severity of psychiatric complaints, personality symptoms, and functional impairment. Results show that PDNOS is highly prevalent in this sample (21.6% or 70.8%, depending on whether co-occurrence with formal PD is allowed). Patients with both formal PD and PDNOS have more severe problems than those with formal PD only. In terms of severity, PDNOS takes an intermediate position between formal and no PD. For mixed PD, a cut-off of 5 criteria would yield a large (12.0%) additional PD group with a similar level of functional impairment as compared to mixed PD with a cut-off of either 10 or 15 criteria. In conclusion, the high prevalence of PDNOS warrants proportional attention in science and practice. If PDNOS is retained in DSM-V, it is recommendable to develop explicit guidelines for its assessment.

achtergrond Behandelmogelijkheden voor persoonlijkheidsstoornissen verschillen aanzienlijk in termen van setting, duur en intensiteit. Hierdoor ontstaan ook verschillen in de verhouding tussen kosten en effecten – de kosteneffectiviteit. Zowel vanuit patiëntperspectief als vanuit maatschappelijk perspectief is het daarom wenselijk dat therapiekeuzes empirisch onderbouwd worden. De Trechter van Dunning, een bekend model voor besluitvorming in de zorg, biedt hiervoor een richtsnoer. doel Het in kaart brengen en integreren van empirische evidentie op het gebied van psychotherapie bij persoonlijkheidsstoornissen betreffende de vier onderdelen van de Trechter van Dunning: noodzakelijkheid, werkzaamheid, doelmatigheid en eigen rekening en verantwoording. methode Naast literatuuronderzoek in PubMed en Psycinfo met de zoektermen ‘personality disorder’, ‘psychotherapy’, ‘effectiveness’, ‘cost-effectiveness’, ‘cost-benefit analysis’, ‘dose-effect relations’ en ‘efficacy’,werd er een handmatig literatuuronderzoek uitgevoerd. resultaten De noodzakelijkheid van behandeling wordt onderbouwd door eerste resultaten die wijzen op de grote ziektelast die persoonlijkheidsstoornissen met zich meebrengen. De werkzaamheid van psychotherapeutische behandelingen is inmiddels overtuigend empirisch aangetoond. Voorlopige resultaten duiden er ook op dat psychotherapie kosteneffectief is, maar state-of-the-art-kosteneffectiviteitonderzoek ontbreekt nog. discussie en conclusie Psychotherapeutische behandelingen voor patiënten met persoonlijkheidsstoornissen blijken werkzaam en er zijn inmiddels sterke aanwijzingen gevonden dat deze zorg ook noodzakelijk en doelmatig is. Deze bevindingen staan in schril contrast met de recente bezuinigingen op de psychotherapie. Voor toekomstige beleidsbeslissingen is er meer onderzoek nodig dat kennis uit de verschillende terreinen van de Trechter van Dunning integreert.

Objective: Stalking can have a major psychosocial impact on its victims. Accumulating evidence suggests frequent post-traumatic stress (PTS) reactions. The present study aimed to detail the affective and cognitive responses following post-intimate stalking, and to assess the associations between stalking severity, person-related psychosocial variables and symptoms of PTS. Design: Female members ( N = 131) of a Dutch nation-wide support group were contacted by mail and completed questionnaires pertaining to their stalking history, Big Five personality traits, coping, social support, as well as PTS reactions and symptoms. Method: The Traumatic Constellation Identification Scale was used to elucidate emotional and cognitive responses to post-intimate stalking. To assess the associations between stalking severity indices, person-related psychosocial variables and PTS, a regression analysis was conducted using the Impact of Events Scale as a dependent variable. Results: Affective reactions included affective liability, fear, shame and loss. Associated maladaptive beliefs included decreased trust, increased alienation and isolation, and attributions of self-blame. Indices of stalking severity accounted for 22% of the PTS variance, with stalking violence being the most potent predictor. Another 8% of PTS variance was associated with a passive coping reaction and (lower) openness to experience. Conclusion: PTS following stalking was associated with both stressor-related and person-related variables. Risk factors for PTS included severe stalking including violence and passive coping. Prolonged post-intimate stalking may lead to personality adaptation (i.e. becoming more closed, cautious and reserved).