Introduction: In the treatment of borderline personality disorder (BPD), there is empirical support for both dialectical behavior therapy (DBT) and schema therapy (ST); these treatments have never been compared directly. This study examines whether either of them is more effective than the other in treating patients with BPD. Methods: In this randomized, parallel-group, rater-blind clinical trial, outpatients aged between 18 and 65 years with a primary diagnosis of BPD were recruited in a tertiary outpatient treatment center (Lübeck, Germany). Participants were randomized to DBT or ST with one individual and one group session per week over 1.5 years. The primary outcome was the BPD symptom severity assessed with the mean score of the Borderline Personality Disorder Severity Index at 1-year naturalistic follow-up. Results: Between November 26, 2014, and December 14, 2018, we enrolled 164 patients (mean age = 33.7 [SD = 10.61] years). Of these, 81 (49.4%) were treated with ST and 83 (50.6%) with DBT, overall, 130 (79.3%) were female. Intention-to-treat analysis with generalized linear mixed models did not show a significant difference at 1-year naturalistic follow-up between DBT and ST for the BPDSI total score (mean difference 3.32 [95% CI: –0.58–7.22], p = 0.094, d = −24 [–0.69; 0.20]) with lower scores for DBT. Pre-to-follow-up effect sizes were large in both groups (DBT: d = 2.45 [1.88–3.02], ST: d = 1.78 [1.26–2.29]). Conclusion: Patients in both treatment groups showed substantial improvements indicating that even severely affected patients with BPD and various comorbid disorders can be treated successfully with DBT and ST. An additional non-inferiority trial is needed to show if both treatments are equally effective. The trial was retrospectively registered on the German Clinical Trials Register, DRKS00011534 without protocol changes.

BACKGROUND:Pain medicine is an interdisciplinary and interprofessional field of specialisation. Due to concerns about new recruits and an aging workforce, especially among physicians, it is important to better understand professional and career pathways in pain medicine. OBJECTIVES:The aim of this study was to record the occupational routes of people working in an institution specialised in pain medicine/pain management as well as their motivation and job satisfaction. MATERIALS AND METHODS:A standardised online questionnaire was used to survey members via cooperating scientific societies and organisations. RESULTS:Data from 398 physicians, 78 psychologists, 62 physiotherapists, three occupational therapists and 23 nursing professionals were included in the analysis. The age distribution skewed towards higher age groups, with the majority of respondents aged between 51 and 60 years. The respondents usually first came into clinical contact with pain medicine after many years of work. In the case of physicians in particular, there was a delay of almost a decade after their licence to practise. With regard to motivational factors, intrinsic aspects were rated higher than monetary ones. Work-life balance issues tended to be in the middle of the ranking. Regarding job satisfaction in pain medicine, the overall satisfaction of the respondents was high, with the lowest satisfaction ratings being given in the categories "opportunities for further career development", "additional income options" and "recognition by superiors". A significant proportion of respondents (1/3) stated that career changes were forthcoming-changes outside a pain medicine setting or in particular retirement. CONCLUSIONS:The results emphasise the critical perspectives regarding the future provision of care for people with chronic pain. The results provide, for the first time, an insight into the career routes of staff in the field of pain medicine and their motivations and job satisfaction, which should be considered in the discussion about ensuring personnel resources in the future.

Schmerzmedizin ist eine interdisziplinäre und interprofessionelle Spezialisierung. Aufgrund von Nachwuchssorgen und Überalterung, insbesondere bei Ärzten, ist es von Bedeutung, berufliche Entwicklung und Karrierewege in die Schmerzmedizin besser zu verstehen. Ziel dieser Untersuchung ist es, die beruflichen Wege von Menschen, die in einer Einrichtung der spezialisierten schmerzmedizinischen/schmerztherapeutischen Versorgung tätig sind, deren Motivation und Arbeitszufriedenheit zu erfassen. Mit einem standardisierten Online-Fragebogen wurden über kooperierende Fachgesellschaften und Verbände deren Mitglieder befragt. Es wurden Angaben von 398 Ärzten, 78 Psychologen, 62 Physiotherapeuten, 3 Ergotherapeuten und 23 Pflegefachpersonen in die Auswertung einbezogen. Die Altersverteilung lag eher in höheren Altersgruppen, der größte Anteil an Antwortenden war zwischen 51 und 60 Lebensjahren. Auf den Karrierewegen kamen die Teilnehmenden erst nach vielen Jahren Berufstätigkeit klinisch mit der Schmerzmedizin in Kontakt. Gerade bei Ärzten zeigt sich dabei eine Latenz von fast einem Jahrzehnt nach Approbation (8 ± 6 Jahre (max. 30) bzw. 5 ± 6 (min. 0, max. 28) Jahre), bzw. bereits als Facharzt gearbeitet zu haben, bis zur ersten klinischen Tätigkeit in einer spezialisierten schmerzmedizinischen Einrichtung (Psychologen 5 ± 5 (min. 0, max. 22) Jahre nach ihrem Studienabschluss bzw. 4 ± 5 (min. 0, max. 16) Jahre nach Approbation; PEP 1 ± 9 (min. 0, max. 37) Jahre nach Ausbildungsabschluss). Hinsichtlich motivationaler Faktoren werden intrinsische Aspekte höher bewertet als monetäre. Vereinbarkeitsfragen standen eher im Mittelfeld der Gewichtung. Bzgl. der Arbeitszufriedenheit in der Schmerzmedizin zeichnet sich bei den Antwortenden ein Bild mit insgesamt höheren Werten bei der Angabe der Zufriedenheit ab, wobei in den Kategorien „Aufstiegsmöglichkeiten“, „Zusatzverdienstmöglichkeiten“ und „Anerkennung der Tätigkeit bei Vorgesetzten“ die niedrigsten Zufriedenheitswerte angegeben werden. Über 1/3 der Befragten gab an, dass berufliche Änderungen mit Wechsel aus der Schmerzmedizin anstehen, insbesondere der Rentenbeginn. Die Ergebnisse unterstreichen die Wahrnehmung kritischer Zukunftsaussichten und lassen Risiken hinsichtlich der zukünftigen Versorgungssicherung von Menschen mit chronischen Schmerzen erkennen. Sie liefern erstmals einen Einblick in die Wege von Mitarbeitenden in die Schmerzmedizin und zu deren Motivationen und Arbeitsplatzzufriedenheit, die bei der Diskussion um die personelle Zukunftssicherung Berücksichtigung finden sollten.

BACKGROUND:Interdisciplinary multimodal pain treatment (IMPT) is an essential element in the treatment of people with chronic pain. Although IMST is defined in terms of content, it is evident that its practical design is very heterogeneous. This refers not only to the composition of the contents of the treatment but also to the concrete distribution of tasks among the professions involved. This article deals with the attribution of the effect of the activities of the three professional groups involved in IMPT: medicine, psychology and physiotherapy. The aim of this work is to examine how the professions of medicine, psychology and physiotherapy assess the effectiveness of their work and the effectiveness of the other two disciplines in the care of chronic pain patients. MATERIAL AND METHODS:A newly designed questionnaire with 19 items was used. Each item describes a possible effect that treatment by the professions of medicine, psychology and physiotherapy can have. Based on factor analysis, items were combined for which the three effect attributions had the same items. The restriction to factor analysis areas was intended to avoid redundancies in the presentation and interpretation of results. The evaluation was carried out by means of a variance analysis for the impact areas with the factors "profession" and "attribution of impact". RESULTS:A total of 233 participants from the 3 disciplines (medicine, n = 78; psychology, n = 76; physiotherapy, n = 79) answered the questionnaire. The three areas of effect "pain reduction", "strength and movement" and "functional pain coping" could be identified by factor analysis. The impact areas attributed to the different professions are largely reflected in the participants' answers. The variance analysis revealed significant main effects for the two factors "profession" and "attribution of impact" and for their interactions. CONCLUSION:Professionals in medicine, psychology and physiotherapy have clear expectations of their own and the other professions mentioned here with respect to their effectiveness in certain areas of change. Overall, the three professions agree in their assessment of the contribution of medicine, psychology and physiotherapy to the areas of pain reduction, gain in strength and movement and functional pain coping.

Although psychosocial factors have a profound impact on the experience of pain and pain recovery, the transfer to clinical application has so far been insufficient. With this article, a task force of the special interest group "Psychosocial Aspects of Pain" of the German Pain Society (Deutsche Schmerzgesellschaft e. V.) would like to draw attention to the considerable discrepancy between existing scientific evidence on the importance of psychosocial factors in the development of chronic pain disorders and the translation of these findings into the care of pain patients. Our objective is a stronger integration of psychological and psychosomatic expertise in pain treatment and research, as well as the improvement of structural and institutional conditions, to achieve an increased consideration of psychosocial aspects. In this way, modern, integrative and complex pain concepts can reach the patient. Based on these fundamental findings on the importance of psychosocial factors in pain and pain treatment, implications for the transfer to clinic and further research will be shown.

Die interdisziplinäre multimodale Schmerztherapie (IMST) stellt ein wesentliches Element in der Behandlung von Menschen mit chronischen Schmerzen dar. Obwohl die IMST inhaltlich definiert ist, zeigt sich, dass ihre praktische Ausgestaltung sehr heterogen ist. Dies bezieht sich neben der Zusammenstellung der Therapieinhalte auch auf die konkrete Aufgabenverteilung unter den beteiligten Professionen. Die vorliegende Arbeit beschäftigt sich mit der Zuschreibung der Wirkung der Tätigkeiten der drei an einer IMST beteiligten Berufsgruppen Medizin, Psychologie und Physiotherapie. In dieser Arbeit soll untersucht werden, wie die Professionen der Medizin, Psychologie und Physiotherapie die Wirksamkeit ihrer Arbeit bzw. die Wirksamkeit der anderen beiden Disziplinen in der Versorgung von Patient*innen mit chronischem Schmerz einschätzen. Zur Anwendung kommt ein neu konzipierter Fragebogen mit 19 Items. Jedes Item beschreibt einen möglichen Effekt, den eine Behandlung durch die Professionen Medizin, Psychologie und Physiotherapie bewirken kann. Faktorenanalytisch wurden Items zusammengefasst, für die die drei Wirkungszuschreibungen gleiche Items aufwiesen. Durch die Einschränkung auf faktorenanalytische Bereiche sollte erreicht werden, dass Redundanzen in der Ergebnisdarstellung und Interpretation vermieden werden. Die Auswertung erfolgte varianzanalytisch für die Wirkungsbereiche mit den Faktoren „Profession“ und „Wirkungszuschreibung“. Insgesamt beantworteten 233 Teilnehmer*innen der drei Disziplinen (Medizin: n = 78; Psychologie: n = 76; Physiotherapie: n = 79) den Fragebogen. Faktorenanalytisch ließen sich die drei Wirkungsbereiche „Schmerzreduktion“, „Kraft und Bewegung“ sowie „funktionales Schmerzcoping“ identifizieren. Die den unterschiedlichen Professionen zugeschriebenen Wirkungsbereiche spiegeln sich größtenteils in den Antworten der Teilnehmenden wider. Die varianzanalytische Auswertung ergab signifikante Haupteffekte für die zwei Faktoren „Profession“ und „Wirkungszuschreibung“ sowie für ihre Interaktionen. Berufstätige der Medizin, Psychologie und Physiotherapie haben hinsichtlich der Wirksamkeit bei bestimmten Veränderungsbereichen klare Erwartungen an die eigene und an die anderen hier genannten Professionen. Dabei stimmen die drei Professionen in der Beurteilung des Wirkungsbeitrags der Medizin, der Psychologie und der Physiotherapie für die Bereiche Schmerzreduktion, Zugewinn an Kraft und Bewegung sowie funktionales Schmerzcoping insgesamt überein.

ZusammenfassungPsychosoziale Faktoren beeinflussen Schmerzerleben und Schmerzgenesung weitreichend, trotzdem ist der Transfer in die klinische Anwendung bisher unzureichend. Mit diesem Beitrag möchte eine Arbeitsgruppe des Arbeitskreises „Psychosoziale Aspekte bei Schmerz“ der Deutschen Schmerzgesellschaft e. V. auf die erhebliche Diskrepanz zwischen bestehender wissenschaftlicher Evidenz zur Bedeutung psychosozialer Faktoren bei der Entstehung chronischer Schmerzstörungen und der Translation dieser Ergebnisse in die Versorgung von Schmerzpatienten aufmerksam machen. Unsere Ziele sind eine stärkere Integration psychologischer und psychosomatischer Expertise in die Schmerzbehandlung und -forschung sowie die Verbesserung der strukturellen und institutionellen Voraussetzungen, um zu einer vermehrten Berücksichtigung psychosozialer Aspekte zu kommen. Nur so können die modernen, integrativen und komplexen Schmerzkonzepte beim Patienten ankommen. Basierend auf diesen grundlegenden Erkenntnissen zur Bedeutung psychosozialer Faktoren bei Schmerz und Schmerzbehandlung sollen Implikationen für den Transfer in die Klinik und die weitere Forschung aufgezeigt werden.

Background Long-term results following liposuction in patients with lipedema were available only for an average period of 8 years. Objective To find out whether the improvements persist for a further 4 years. Methods In 60 patients with lipedema a single-centre study with a mail questionnaire – often in combination with clinical controls – was performed after an average period of 12 years following liposuction(s). All patients in this group had already been surveyed 4 and 8 years after surgery. Results Compared with the earlier results improvement persisted with regard to spontaneous pain, sensitivity to pressure, edema, bruising and restriction of movement; similar outcomes were observed for self-assessment of cosmetic impairment, reduction in quality of life and overall impairment. While in the period from 4 to 8 years postoperatively complaints slightly increased, this was not the case for the period 8 to 12 years postoperatively. In addition a similar reduction of conservative treatment (decongestive therapy, compression garments) was observed as after 4 and 8 years postoperatively. Compared with the body weight before liposuction, 55% of the patients showed a reduction of 6.2 kg on average and 43.3% had a weight increase with an average of 7.9 kg. Conclusion The results show, that the positive effects of liposuction last 12 years postoperatively without relevant worsening. They imply that liposuction for lipedema leads to a permanent reduction of symptom severity and need for conservative therapy.

Isosorbide mononitrate (ISMN) is effective in the short-term for decreasing systolic blood pressure, pulse pressure, and pulse wave reflection in patients with systolic hypertension. To determine whether tolerance negates the efficacy of this nitrate in the long-term, a placebo-controlled study was performed in which ISMN was withdrawn briefly in a group of patients (n=16) who had received extended-release ISMN 60 to 120 mg once daily for 16 to 109 months. Blood pressure and wave reflection were determined by 24-hour ambulatory recorder and tonometer, respectively. During a 4-hour delay of the regular morning dose of ISMN, mean systolic blood pressure was higher than with the regular ISMN dosing schedule (P<0.0001). The maximum placebo-active difference was 16+/-4 mm Hg. The corresponding difference in augmentation index (a measure of pulse wave reflection) corrected for heart rate was 25+/-4% (P<0.001). The difference in pulse pressure was 13+/-3 mm Hg (P<0.001). There was no significant difference in diastolic blood pressure. For a subgroup (n=12) in which the effects of a single ISMN dose had been determined at the initiation of regular ISMN therapy, the mean change in augmentation index was of similar magnitude to that observed in their initial study. Thus, tolerance does not seriously diminish the antihypertensive efficacy of ISMN used as adjunct therapy in the chronic treatment of systolic hypertension. This agent lowers systolic blood pressure sufficiently to achieve therapeutic goal in some patients refractory to conventional treatment regimens.

Zusammenfassung. Hintergrund: In der Behandlung der persistierenden depressiven Störung (PDD) werden Psychotherapien mit interpersonellem Schwerpunkt empfohlen. Ein Beispiel dafür ist das Cognitive Behavioral Analysis System of Psychotherapy (CBASP), was davon ausgeht, dass Menschen mit PDD zu einem präoperatorischen Denkstil neigen. Das Ziel dieser Arbeit ist herauszufinden, ob dieser Denkstil auch bei Menschen mit einer Panikstörung oder einem chronischen Rückenschmerz beobachtet werden kann. Methodik: In einer Studie wurden Patient_innen mit einer Panikstörung ( n = 20) verglichen mit Patient_innen mit einer depressiven Störung ( n = 20) und gesunden Kontrollen ( n = 20). In einer weiteren Studie wurden Patient_innen mit chronischem Rückenschmerz ( n = 30) verglichen mit gesunden Kontrollen ( n = 32). Alle Proband_innen wurden mit dem Lübecker Fragebogen Präoperatorisches Denken (LFPD) befragt. Daneben wurden die Angehörigen der Proband_innen gebeten, das Interaktionsverhalten der Probandin bzw. des Probanden mit dem Interpersonal Message Inventory (IMI) zu beurteilen. Ergebnis: Die erste Studie kam zu dem Ergebnis, dass sich nur die depressiven Patient_innen im LFPD signifikant von den gesunden Kontrollen unterschieden ( p < .001). In der Subskala „feindselig“ des IMI unterschieden sich die Kontrollen von beiden Patient_innengruppen, allerdings war nur der Befund für die Panikstörung signifikant ( p = .008). In der zweiten Studie unterschieden sich die Patient_innen mit der Schmerzstörung von den gesunden Kontrollen nur im Bezug auf die IMI Subskala „feindselig“ ( p = .005), aber nicht im LFPD. Schlussfolgerung: Das präoperatorische Denken wurde nur bei Patient_innen mit depressiver Störung beobachtet, obwohl die anderen beiden Patient_innengruppen von ihren Angehörigen ebenfalls als feindselig wahrgenommen wurden. Diese Befunde sprechen dafür, dass interpersonelle Defizite bei psychischen Störungen nicht immer auf das dem CBASP zugrundeliegende Modell des präoperatorischen Denkens zurückzuführen sind.

Introduction: The opioid epidemic in North America challenges national guidelines worldwide to define the importance of opioids for the management of chronic noncancer pain (CNCP). Methods: The second update of the German guidelines on long-term opioid therapy for CNCP was developed by 26 scientific associations and 2 patient self-help organizations. A systematic literature search in CENTRAL, Medline, and Scopus (to May 2019) was performed. Meta-analyses of randomized controlled trials and open-label extension studies with opioids for CNCP were conducted. Levels of evidence were assigned according to the Oxford Centre for Evidence-Based Medicine classification system. The formulation and strength of recommendations were established by multistep formalized procedures to reach a consensus according to German Association of the Medical Scientific Societies regulations. The guidelines underwent external review by 4 experts and public commentary. Results: Opioids are one drug-based treatment option for short- (4–12 weeks), intermediate- (13–26 weeks), and long-term (>26 weeks) therapy of chronic pain in osteoarthritis, diabetic polyneuropathy, postherpetic neuralgia, and low back pain. Contraindications are primary headaches, functional somatic syndromes, and mental disorders with the (cardinal) symptom of pain. For specified other clinical pain conditions, short- and long-term therapy with opioids should be evaluated on an individual basis. Long-term therapy with opioids is associated with relevant risks. Conclusion: Responsible application of opioids requires consideration of possible indications and contraindications, as well as regular assessment of clinical response and adverse effects. Neither uncritical opioid prescription nor general rejection of opioids is justified in patients with CNCP.

Background: In the treatment of persistent depressive disorder (PDD) psychotherapies with an interpersonal focus are recommended. An example of this is the Cognitive Behavioral Analysis System of Psychotherapy (CBASP), which assumes that people with PDD tend to have a preoperational thinking style. The aim of this work is to examine if this style of thinking can also be observed in people with panic disorder or chronic back pain. Methods: In one study, patients with panic disorder (n = 20) were compared with patients with depressive disorder (n = 20) and healthy controls (n = 20). In a separate study, patients with a chronic back pain (n = 30) were compared with healthy controls (n = 32). All participants were interviewed with the Lubeck Questionnaire of Preoperational Thinking (LQPT). In addition, the significant others of participants were asked to rate the participants' interpersonal behavior with the Interpersonal Message Inventory (IMI). Results: The first study found that only the depressed patients differed significantly from the healthy controls on the LQPT (p < .001). In the "hostile - subscale of the IMI, controls differed from both patient groups, but only the finding for panic disorder was statistically significant (p = .008). In the second study, the patients with pain disorder differed from the healthy controls only on the IMI subscale "hostile" (p = .005) but not on the LQPT. Conclusion: Preoperational thinking was only observed in patients with depressive disorder, although the other two groups of patients were also perceived as hostile by their significant others. These findings suggest that the interpersonal problems of patients with mental disorders are not always due to preoperational thinking.

The long-term usage of opioid analgesics (> 3 months) for chronic, non-cancer related pain is critically discussed nationally and internationally. There are indications of under- and oversupply as well as misuse of opioids in Germany, but an "opioid epidemic" such as is evident in the USA cannot be detected at present.The S3-guideline LONTS (long-term usage of opioid analgesics for non-cancer related pain)serves as an orientation to improve provision of opioids and contains statements about the available evidence, indications and contraindications of use, as well as practical recommendations for managing a long-term opioid therapy.

About one in five patients with depression experiences a chronic course. Despite the great burden associated with this disease, there is no current screening instrument for Persistent Depressive Disorder (PDD). In the present study, we examine a short screening test, the persistent depression screener (PDS), that we developed for DSM-5 PDD. The PDS is comprised of one question that is administered following an initial self-assessment for depression. Ninety patients from an inpatient clinic/day clinic specialized in treating depression completed the PDS. They were also assessed using a structured clinical interview covering the DSM-5 criteria for PDD. Retest reliability was examined after two weeks (n = 69, 77%). In this sample, the prevalence of PDD was 64%. Sensitivity of the PDS was 85% with a positive predictive value of 80%. Specificity was 63%. Positive and negative likelihood ratios were 2.3 and .24, respectively. Agreement between the PDS results and the outcome of the clinical interview was moderate (Cohen’s Kappa κ = .48 ([95%-CI .28, .68], p < .001, SE = 0.10)). Prevalence-adjusted bias-adjusted Kappa was PABAK = .53. Retest reliability of the PDS was moderate (Cohen’s Kappa κ = .52 ([95%-CI .3, .74], p < .001, SE = 0.11)). The present study shows that the PDS - when applied following a self-rating depression scale - might be a valid and reliable way to detect PDD. However, the results of the PDS must be confirmed by a diagnostic interview.

Adverse childhood experiences have consistently been linked with poor mental and somatic health in adulthood. However, due to methodological restraints of the main lines of research using cumulative or selective models, little is known about the differential impact of different dimensions of adverse childhood experiences. Therefore, we gathered data from 396 psychiatric in-patients on the Adverse Childhood Experiences (ACE) questionnaire, extracted dimensions using factor analysis and compared this dimensional model of adverse childhood experiences to cumulative and selective models. Household Dysfunction (violence against the mother, parental divorce, substance abuse or incarceration of a household member) was associated with poor health behaviors (smoking, alcohol dependency and obesity as proxy marker for an imbalance between energy intake and physical activity) and with poorer socio-economic achievement (lower education and income) in adulthood. The previously reported associations of maltreatment and sexual abuse with these outcome criteria could not be corroborated. Both Maltreatment (emotional and physical neglect and abuse) and Sexual Abuse predicted BPD, PTSD and suicidal behavior. However, the two ACE dimensions showed sufficiently divergent validity to warrant separate consideration in future studies: Maltreatment was associated with affective and anxiety disorders such as social phobia, panic disorder and major depressive disorder, whereas Sexual Abuse was associated with dysregulation of bodily sensations such as pain intensity and hunger/satiation. Also, we found both quantitative and qualitative evidence for the superiority of the dimensional approach to exploring the consequences of adverse childhood experiences in comparison to the cumulative and selective approaches.

Borderline Personality Disorder (BPD) is a severe mental illness that is associated with low quality of life, low psychosocial functioning, and high societal costs. Treatments for BPD have improved in the last decades. Dialectical behavior therapy (DBT) and Schema therapy (ST) have demonstrated efficacy in reducing BPD symptoms and costs. However, research has not compared these two treatment approaches. In addition, there is a lack of ‘real world studies’ that replicate positive findings in regular mental healthcare settings. Thus, the PROgrams for Borderline Personality Disorder (PRO*BPD) study will compare the (cost-) effectiveness of DBT and ST in structured outpatient treatment programs in the routine clinical setting of an outpatient clinic.

Objective: Childhood maltreatment, interpersonal fear and a specific kind of interpersonal skills deficit (preoperational thinking) have all been associated with persistent depressive disorder (PDD). We hypothesize that interpersonal fears mediate the association between childhood maltreatment and preoperational thinking.Method: A total of 108 matched participants have been examined cross-sectionally (31 healthy controls, 30 patients with episodic depression and 47 patients with PDD) with the following instruments: the Childhood Trauma Questionnaire (CTQ-SF), a measure of interpersonal fear (CBASP Interpersonal Questionnaire) and the Lübeck Questionnaire of Preoperational Thinking.Results: Patients with PDD reported significantly more childhood maltreatment than patients with episodic depression (d = 0.65) and healthy controls (d = 1.29). They also had more interpersonal fears (d = 0.71 and d = 2.11 respectively) and higher levels of preoperational thinking (d = 0.90 and d = 2.78 respectively). The association between childhood maltreatment and preoperational thinking was mediated through interpersonal fears.Conclusions: Our findings might have important implications for psychotherapy of PDD because they demonstrate how specific problems in social interactions can be associated with interpersonal fears that arise secondary to childhood maltreatment.