Objectives Individuals with post-traumatic stress disorder related to childhood maltreatment (PTSD-CM) show limited response to treatment on pre-post-symptom measures. While a nuanced understanding of nonresponse is crucial for improving treatment, quantitative measures may not fully capture clinically meaningful processes of change from the patients' perspectives. We therefore explored how individuals with PTSD-CM who showed no or limited numerical improvement after trauma-focused psychodynamic psychotherapy (TF-PDT) experienced change.Design This qualitative study was embedded in a large randomized controlled trial on PTSD-CM (DRKS00021142).Method From 75 qualitative post-treatment interviews, we purposively sampled eight TF-PDT recipients meeting criteria for numerical nonresponse, defined as current PTSD diagnosis and less than 50% reduction in the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Client Change Interviews were analysed using Critical-Constructivist Grounded Theory.Results We derived two clusters ('Progress-A Double-Edged Sword', 'When Building Trust Collides with the Therapeutic Framework') and one overarching core category ('Unfinished Business'), which captured a dialectic process. Within a responsive therapeutic relationship, patients began confronting their relational trauma, experiencing relief, increased emotional regulation and hope. However, this very engagement surfaced emotional challenges that exceeded what could be addressed within the limited therapeutic framework, leaving the process meaningful but unfinished.Conclusion What is often labelled as numerical nonresponse in PTSD-CM may reflect a dynamic interplay of emerging improvement and emotional distress that needs more time to unfold. Moreover, the results underscore the value of integrating qualitative, patient-reported outcomes into treatment evaluation and relationship-focused treatment tailored to patients' individual needs.

BACKGROUND:People who have experienced childhood abuse and neglect are at risk of developing various mental problems or disorders including post-traumatic stress disorder (PTSD). To enhance therapeutic approaches for PTSD, patient participation in research is promising. OBJECTIVE:Since it remains unclear what patients with PTSD associated with childhood maltreatment find most beneficial within their respective trauma-focused psychotherapies, our study aims to identify these crucial elements. PARTICIPANTS AND SETTING:Data was collected within the ENHANCE study, a large-scale randomized controlled trial comparing two manual guided trauma-focused treatments, trauma-focused psychodynamic therapy and STAIR narrative therapy. METHODS:We conducted and analyzed semi-structured Client-Change Interviews post-treatment with 30 trial participants, employing a qualitative deductive-inductive content analysis. RESULTS:Our findings emphasize the importance of patients realizing the impact of trauma on their current lives. Moreover, therapeutic practices such as creating safety and understanding were found to be central. Equally important was the therapist's compassionate, containing, and validating attitude, supporting patients in acquiring coping skills, setting boundaries, and practicing self-care. Some of the patients who underwent trauma confrontation experienced it as relieving, even though they felt it was accompanied by distress. CONCLUSIONS:Our research shows that knowledge about helpful aspects of psychotherapy can be deepened through the active participation of patients, thereby being open for unexpected findings. Implications for integrating the findings in future studies are discussed.

OBJECTIVE:Randomized controlled trials (RCTs) are considered essential for establishing the efficacy of psychotherapies. However, these settings present practical challenges and conflicts, which have contributed to a gap between science and practice. To date little is known about how psychotherapists experience participation in RCTs and why they are hesitant to engage, therefore, we aimed to explore these issues. METHOD:This qualitative study is nested in a multicenter RCT within the ENHANCE research network, comparing two trauma-focused psychotherapies for adults with posttraumatic stress disorder related to childhood maltreatment (PTSD-CM). Interviews were conducted with study therapists from either cognitive behavioral or psychodynamic backgrounds and were analyzed using critical-constructivist Grounded Theory methodology. RESULTS:Analysis revealed one core category, centering around the pressure and negative emotions that therapists experienced and their attempts to manage the challenges triggering these feelings. Four clusters contributed to this core category: (1) negotiating tension between study protocol and patients' needs, (2) struggling with short-term treatment-manuals, (3) facing insecurities of deviating from everyday practice, and (4) developing greater trauma competence, given that participation in the study was subjectively experienced as successful. CONCLUSION:Results underscore the importance of balancing research requirements with therapeutic flexibility and highlight the need for intensive training, particularly in PTSD-CM contexts.

In the paradigm of evidence-based medicine, psychotherapies are subjected to efficacy tests using randomised controlled trials. For outcome measurement, standardised interview procedures are usually used, which allow a statistical comparison between interventions. The present study pursues a unique explorative methodology by extending this quantitative procedure to a qualitative level within the framework of a mixed-methods approach. Four patients participated in a semi-structured interview about their treatment experience after completion. The data are derived from a large multi-centre randomised controlled trial comparing two trauma-focused short-term therapies (psychodynamic and cognitive-behavioural) for adults with post-traumatic stress disorder related to childhood maltreatment. A clinical interview served as the quantitative measure of symptomatology, while a depth hermeneutic approach guided the qualitative analysis through the interpretation group. It became apparent that the chosen mixed-methods design added crucial layers to numerical measurement and challenged researchers' implicit presuppositions (e.g. equating good measurement results with good therapy experience). Our chosen approach is not about an 'either-or' but an epistemological addition in the sense of a 'both-and' which ties in with current methodological debates in psychotherapy research. These discussions call for more significant consideration of study patients' subjective experience and underlying psychodynamics.

BACKGROUND:Childhood maltreatment (CM) significantly increases the risk of developing post-traumatic stress disorder (PTSD) for which the prevalence in Europe is higher than initially assumed. While the high economic burden of PTSD is well-documented, little is known about the health care cost differences between individuals with PTSD-CM and those without PTSD in Germany. This study aimed to determine the excess health care and absenteeism costs associated with PTSD-CM in Germany. METHODS:Baseline data from a multi-center randomized controlled trial on individuals with PTSD-CM (n = 361) were combined with data from individuals without PTSD (n = 4760). Entropy balancing was used to balance the data sets with regard to sociodemographic characteristics. Six-month excess health care costs from a societal perspective were calculated for 2022, using two-part models with logit specification for the first part and a generalized linear model for the second part. RESULTS:The total six-month excess costs associated with PTSD-CM were €8864 (95% CI: €6855 to €10,873) per person. Of this, the excess health care costs accounted for €4647 (95% CI €3296 to €5997) and the excess costs of absenteeism for €4217 (95% CI: €3121 to €5314). Individuals with mild to moderate PTSD symptoms incurred total excess costs of €6038 (95% CI: €3879 to €8197), while those with severe to extreme symptoms faced €11,433 (95% CI: €8220 to €14,646). CONCLUSIONS:Excess health care and absenteeism costs associated with PTSD-CM were substantial, with absenteeism accounting for roughly half of the total excess costs.

Borderline personality disorder (BPD) was introduced in the DSM-III in 1980. From the DSM-III to the DSM-5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self-image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self-mutilation behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi-structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self-mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic-like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high-quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.

Randomized controlled trials are routinely used to assess the efficacy of psychotherapy. To date, our knowledge about how patients experience participation in such a trial is scant. Therefore, the present analysis aims at an in-depth exploration of patients' perspectives on how a trial environment affects them. This study was conducted within the framework of the ENHANCE study, a large randomized controlled trial comparing two trauma-focused treatments, that is, psychodynamic and cognitive behavioral therapy, for patients diagnosed with posttraumatic stress disorder resulting from childhood maltreatment. We analyzed 17 posttherapy interviews with trial participants, employing an extended version of the Client Change Interview and grounded theory methodology for analysis. Analysis yielded one core category, revolving around the extent to which participants needed to conform to the external research framework to obtain personal benefits. This ambivalence was intertwined with trauma-related characteristics specific to this patient group. Three clusters fed into the core category: (1) positive and negative fantasies aroused by the research framework, (2) basic needs of patients colliding with the study conditions, and (3) inner and outer confrontations prompted by participation in the study. Study participation affects patients at various intrapsychic levels, resulting in specific dilemmas. Participation primarily serves as a means to obtain a therapy spot. Patients willingly accept the challenges associated with the study setting, viewing them as the trade-off for treatment access. Due to a positive therapy experience, participants maintain a favorable attitude toward study participation at large. Implications for integrating our findings in future studies are discussed.

Introduction Long-term psychodynamic/psychoanalytic psychotherapy (LTPP) is a prevalent treatment option for complex mental disorders. Yet, little is known about the role of treatment intensity in LTPP. We present a study protocol for a systematic review and individual participant data (IPD) meta-analysis aggregating and analysing individual data from randomised and quasi-experimental trials by meta-analysis. The purpose is to (1) determine the treatment effectiveness of LTPP with low versus high intensity (up to 2 weekly sessions vs three or more), (2) compare their joint effectiveness to shorter therapies and treatments as usual, (3) identify predictors and moderators of treatment outcomes and (4) determine reciprocal relationships between different outcome domains (symptomatic and structural/personality change) over the courses of LTPP. Methods and analysis We include studies from (randomised controlled trial, RCT) and quasi-experimental trials, where at least one condition was LTPP of high or low frequency. Long-term treatment is defined as ≥1 year or ≥50 sessions. To be eligible studies must include a standardised outcome measure of symptoms (global or disorder specific) with at least one proof of reliability. The primary outcome is symptom reduction (global or specific), secondary outcome criteria are reliable change, remission, functional capacities, personality, personality functioning and interpersonal pathology. Relevant studies will mainly be identified by searching relevant databases: PubMed, PsycINFO (via EBSCO), Web of Science (via Elsevier), Chochrane’s Central Register of Controlled Trials (via Wiley). Risk of bias will be evaluated in line with the Cochrane assessments tools for quasi-experimental trials and RCTs, respectively. Ethics and dissemination Aggregation of data from primary trials collected based on ethics votes. Dissemination into clinical practice via open access publications of findings. PROSPERO registration number CRD42022304982; Pre-results.

Im Rahmen einer randomisiert-kontrollierten Studie von 2007 bis 2011 in der Klinik für Psychiatrie und Psychotherapie des Kindes- und Jugendalters des Asklepios Fachklinikums Tiefenbrunn wurde die Wirksamkeit eines manualisierten stationären psychodynamischen Behandlungskonzepts für jugendliche Patienten mit einer kombinierten Störung des Sozialverhaltens und der Emotionen (F92 nach ICD-10) untersucht. 66 Patienten im Alter von 14 bis 19 Jahren wurden randomisiert einer Behandlungsgruppe (n = 32) oder einer Wartekontrollgruppe/TAU (n = 34) zugewiesen. In der Behandlungsgruppe kam es zu signifikant höheren Remissionsraten als in der Kontrollgruppe (primäres Outcome-Maß).

•Shame plays an important role in the understanding of social anxiety disorders.•Shame contributes significantly to the variation in social anxiety disorders over and above depression.•Guilt does not seem to have a notable association with social anxiety disorder, at least not contextual-legitimate guilt. For maladaptive forms of guilt, further research is required.

This chapter describes a psychodynamic treatment of generalized anxiety disorder (GAD). After presenting a psychodynamic model of GAD, the empirically supported GAD-specific psychodynamic treatment are described in the form of six treatment modules which can be flexibly applied to the individual patient's needs. In psychodynamic psychotherapy, mental symptoms are regarded as being determined by an interaction between biological and psychological factors. The psychodynamic concept of conflict which is central to the former model was operationalized by L. Luborsky by the core conflictual relationship theme method. Supportive–expressive (SE) therapy is among the empirically best-supported methods of psychodynamic therapy. Recently, a model for short-term psychodynamic therapy (STPP) for the treatment of obsessive–compulsive disorder based on SE therapy was presented. STPP may be differentiated from long-term psychodynamic therapy by including up to 25 sessions.

Background: Studies have shown the practicality of diagnosing borderline personality disorder (BPD) in children from the age of 12 years (cf. ICD-11, DSM-5). Research in the psychodynamic therapy of adolescents with BPD has been rare to date, however, there do exist some studies on the efficacy and effectiveness of psychodynamic therapy in adults with borderline personality disorder. Methods: We adapted the psychoanalytic-interactional method ( PiM), originally developed in the treatment of severely disturbed adults, to the conditions of adolescents diagnosed with borderline personality disorder or structural deficits. Randomized controlled trial in an inpatient setting (Salzer et al., 2013; Salzer et al., 2014) showed that PIM is efficacious for adolescents with BPD symptoms. We describe the approach to treatment in detail. Results: The results of the therapeutic study and the short case vignette show that PiM is a useful method in both inpatient and outpatient treatment and meets the specific requirements of adolescent treatment.

Introduction Success rates of psychotherapy in post-traumatic stress disorder related to childhood maltreatment (PTSD-CM) are limited. Methods and analysis Observer-blind multicentre randomised clinical trial (A-1) of 4-year duration comparing enhanced methods of STAIR Narrative Therapy (SNT) and of trauma-focused psychodynamic therapy (TF-PDT) each of up to 24 sessions with each other and a minimal attention waiting list in PTSD-CM. Primary outcome is severity of PTSD (Clinician-Administered PTSD Scale for DSM-5 total) assessed by masked raters. For SNT and TF-PDT, both superiority and non-inferiority will be tested. Intention-to-treat analysis (primary) and per-protocol analysis (secondary). Assessments at baseline, after 10 sessions, post-therapy/waiting period and at 6 and 12 months of follow-up. Adult patients of all sexes between 18 and 65 years with PTSD-CM will be included. Continuing stable medication is permitted. To be excluded: psychotic disorders, risk of suicide, ongoing abuse, acute substance related disorder, borderline personality disorder, dissociative identity disorder, organic mental disorder, severe medical conditions and concurrent psychotherapy. To be assessed for eligibility: n=600 patients, to be e randomly allocated to the study conditions: n=328. Data management, randomisation and monitoring will be performed by an independent European Clinical Research Infrastructure Network (ECRIN)-certified data coordinating centre for clinical trials (KKS Marburg). Report of AEs to a data monitoring and safety board. Complementing study A-1, four inter-related add-on projects, including subsamples of the treatment study A-1, will examine (1) treatment integrity (adherence and competence) and moderators and mediators of outcome (B-1); (2) biological parameters (B-2, eg, DNA damage, reactive oxygen species and telomere shortening); (3) structural and functional neural changes by neuroimaging (B-3) and (4) cost-effectiveness of the treatments (B-4, costs and utilities). Ethics and dissemination Approval by the institutional review board of the University of Giessen (AZ 168/19). Following the Consolidated Standards of Reporting Trials statement for non-pharmacological trials, results will be reported in peer-reviewed scientific journals and disseminated to patient organisations and media. Trial registration number DRKS 00021142.

The investigation of interindividual differences in the effects of a treatment is challenging, because many constructs-of-interest in psychological research such as depression or anxiety are latent variables and modeling heterogeneity in treatment effects requires interactions and potentially nonlinear relationships. In this paper, we present a tutorial of the EffectLiteR approach (Mayer, Dietzfelbinger, Rosseel, & Steyer, 2016) that allows for estimating individual treatment effects based on latent variable models. We describe step by step how to apply the approach using the EffectLiteR software package with data from the multicenter randomized controlled trial of the Social Phobia Psychotherapy Network (SOPHO-NET) and provide guidelines and recommendations for researchers. The focus of the paper is on explaining the results of a comprehensive effect analysis in an accessible language and on highlighting the opportunities the EffectLiteR approach offers for analyzing interindividual differences in treatment effects.

Why the concept of distinct psychotherapeutic approaches is indispensable - and why the tool box concept of psychotherapy cannot work Background: In Germany, the official psychotherapy guidelines are oriented towards the model of distinct psychotherapeutic approaches. Within the German health care system this also applies to the training in psychotherapy. Some critics, however, are presently pleading in favour of abolishing the model of distinct psychotherapeutic approaches, which also implies to abolish the concept of the so called "Richtlinienverfahren" in Germany - approaches of psychotherapy which proved to be efficacious and whose costs are reimbursed by the insurance companies. Objective: The arguments put forward such as the heterogeneity of the approaches as well as the proposed alternatives, for example, an "integrative" model of both mental disorders and psychotherapeutic treatment are critically discussed. Results: Both the arguments and proposed alternatives are found to be not convincing, neither from a scientific nor from a psychotherapeutic perspective. From a scientific perspective, there is no evidence for efficacy of a "general" or "integrative" model of psychotherapy - which is in contrast to the Richtlinienverfahren for which evidence for efficacy exists. From a psychotherapeutic perspective psychotherapy cannot be taught, learnt and applied by use of tools or modules without a theoretical orientation. Conclusions: The concept of distinct psychotherapeutic approaches proves to be an in dispensable principal for orientation in psychotherapy, for both therapists and patients.

Over the last few decades Reflective Functioning (RF) has become an important construct for the understanding and treatment of several patient groups. While RF has been well studied in adult samples, few studies have been conducted on RF in adolescence. The present study is the first examining RF in an adolescent sample of 38 inpatients with comorbid disorders of conduct and emotions. Data were collected in a randomized controlled trial. A severe symptomatology and extremely low RF scores at admission (M = 1.39) characterized the adolescent patient group. RF scores of the clinical sample were significantly lower than those of non-hospitalized adolescent samples. During the inpatient psychodynamic treatment the adolescents’ RF capacities improved significantly (p = .04). The corresponding within-group effect size was medium (r = −0.33). The reported results must be regarded as preliminary because of some limitations of the study. Further research on RF in clinical adolescent samples is essential.

Background: In Germany, the official psychotherapy guidelines are oriented towards the model of distinct psychotherapeutic approaches. Within the German health care system this also applies to the training in psychotherapy. Some critics, however, are presently pleading in favour of abolishing the model of distinct psychotherapeutic approaches, which also implies to abolish the concept of the so called "Richtlinienverfahren" in Germany - approaches of psychotherapy which proved to be efficacious and whose costs are reimbursed by the insurance companies. Objective: The arguments put forward such as the heterogeneity of the approaches as well as the proposed alternatives, for example, an "integrative" model of both mental disorders and psychotherapeutic treatment are critically discussed. Results: Both the arguments and proposed alternatives are found to be not convincing, neither from a scientific nor from a psychotherapeutic perspective. From a scientific perspective, there is no evidence for efficacy of a "general" or "integrative" model of psychotherapy - which is in contrast to the Richtlinienverfahren for which evidence for efficacy exists. From a psychotherapeutic perspective psychotherapy cannot be taught, learnt and applied by use of tools or modules without a theoretical orientation. Conclusions: The concept of distinct psychotherapeutic approaches proves to be an in dispensable principal for orientation in psychotherapy, for both therapists and patients.

Die Generalisierte Angststörung ist die häufigste Angststörung des höheren Erwachsenenalters. Sie erzeugt einen hohen Leidensdruck und verläuft unbehandelt oft chronisch.

OBJECTIVES:Social anxiety disorder is one of the most prevalent mental disorders and often manifests in youth or adolescence. Our aim was to determine direct costs of adolescents with social anxiety disorder and the cost-effectiveness of cognitive-behavioral therapy (CBT) and psychodynamic therapy (PDT) compared to waiting list (WL). METHODS:Baseline data (n = 103) of a randomized controlled trial was used to determine direct costs. Cost-effectiveness of CBT and PDT compared to WL was analyzed using quality-adjusted life years (QALYs) based on the EQ-5D index as measure of health effects. RESULTS:Total six-month direct costs were 809 € (SE 508 €). Especially costs of outpatient physician treatment (325 €; SE 301 €) and psychiatric hospital stays (377 €; SE 258 €) were high. The incremental cost-effectiveness ratio (ICER) of CBT compared to WL was 18,824 €/QALY, with a probability of 63 % for the ICER being below 50,000 €/QALY. PDT did not prove to be cost-effective. CONCLUSIONS:Direct costs were mainly caused by psychiatric hospital stays and outpatient physician treatments. CBT is likely to be cost-effective compared to WL, whereas PDT is unlikely to be cost-effective.