The Role of Psychodynamic Assessment in Diagnosis and Treatment of Personality Disorders ...

108 Pages·2009·6.02 MB·English

The Role of Psychodynamic Assessment
in Diagnosis and Treatment of Personality Disorders
Reliability and Validity of the Developmental Profle
Theo Ingenhoven
Dedicated to Robert E. Abraham
for all his wise lessons
This thesis was supported by the Symfora group, Centers for Mental Healthcare Amersfoort, Erasmus
University Rotterdam, the Developmental Profle Foundation in Amsterdam, and the J.E. Jurriaanse Stichting.
Cover design: Harrald and Job Kerklaan: Ko-productions
Printed by: Spinhex & Industrie, Amsterdam
ISBN/EAN: 978-90-9024532-4
© Copyright: T.J.M. Ingenhoven. Utrecht, 2009.
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Promotiecommissie
Promotoren: Prof.dr. J. Passchier
The Role of Psychodynamic Assessment Prof.dr. W. van den Brink
in Diagnosis and Treatment of Personality Disorders
Overige leden: Prof.dr. J.J. van Busschbach
Reliability and Validity of the Developmental Profle Prof.dr. J. Dekker
Prof.dr. M. Hengeveld
De betekenis van psychodynamische diagnostiek voor
Co-promotor: Dr. H.J. Duivenvoorden
diagnose en behandeling van persoonlijkheidsstoornissen
Betrouwbaarheid en validiteit van het Ontwikkelingsprofel.
Proefschrift
ter verkrijging van de graad van Doctor aan de Erasmus Universiteit Rotterdam,
op gezag van de rector magnifcus Prof.dr. H.G. Schmidt en volgens besluit van het
College voor Promoties
De openbare verdediging zal plaatsvinden op dinsdag 24 november 2009
om 13.30 uur in Rotterdam.
door
Theodorus Josephus Maria Ingenhoven
geboren te Tilburg
Contents Chapter 7 T reatment Disrupting Behaviors during Psychotherapy of Patients
with Personality Disorders: The Predictive Power of Psychodynamic
Personality Diagnosis.
Theo Ingenhoven, Wim van den Brink, Jan Passchier & Hugo Duivenvoorden
Introduction
Chapter 8 P redictive Value of Psychodynamic Personality Assessment for
Chapter 1 Perspectives on Diagnosis of Personality. Scope of the Thesis Outcome of Inpatient Psychotherapy for Personality Disorders.
Theo Ingenhoven, Hugo Duivenvoorden, Jan Passchier & Wim van den Brink
Chapter 2 M aking Diagnosis more Meaningful. The Developmental Profle:
a Psychodynamic Assessment of Personality Epilogue
Theo Ingenhoven & Robert Abraham
Chapter 9 General Discussion
Reliability of Psychodynamic Personality Assessment Summary
Samenvatting
Chapter 3 The Developmental Profle: Preliminary Results on Interrater List of Publications
Reliability and Construct Validity Dankwoord
H enricus Van, Theo Ingenhoven, Ico van Foeken, Adriaan van ’t Spijker, Curriculum Vitae
Philip Spinhoven & Robert Abraham.
Chapter 4 Interrater Reliability for Kernberg’s Structural Interview for
Assessing Personality Organization
T heo Ingenhoven, Hugo Duivenvoorden, Janneke Brogtrop, Anne Lindenborn,
Wim van den Brink & Jan Passchier
Convergent Validity of the Developmental Profle
Chapter 5 “ Here and Now” or “There and Then”? Convergent Validity
of Psychodynamic Personality Assessments using Different
Interview Methods.
T heo Ingenhoven, Wim van den Brink, Jan Passchier & Hugo Duivenvoorden
Predictive Validity of the Developmental Profle
Chapter 6 Treatment Duration and Premature Termination of Psychotherapy
in Personality Disorders: Predictive Validity of the Developmental
Profle assessing Psychodynamic Personality Diagnosis.
Theo Ingenhoven, Hugo Duivenvoorden, Jan Passchier & Wim van den Brink
Introduction
Chapter 1
Perspectives on Diagnosis of Personality
Scope of the Thesis
12 introduction | chapter 1 introduction | chapter 1 13
The aim of this thesis is to improve our understanding of the role of
psychodynamic models, and their assessment procedures, in diagnosis and
treatment of patients with personality disorders. In this introduction we briefy
describe the current status of personality disorders and their treatment (1.1);
diagnostic strategies for personality disorders (1.2); the Developmental Profle
as the instrument for psychodynamic personality diagnosis in study (1.3); a
Contents of this chapter
comprehensive model for establishing reliability and validity by empirical research
(1.4); and the treatment center where we conducted our research (1.5). Finally,
we present the aims of this thesis and the research questions involved (1.6), and
1.1 Personality disorders and their current treatment
briefy outline the contents of this thesis (1.7)
1.2 Diagnostic strategies for personality disorders
1.3 Psychodynamic diagnosis and the Developmental Profle
1.4 V alidation strategies for diagnostic models and their assessment
procedures 1.1 Personality disorders and their current treatment
1.5 Intensive treatment for personality disorders
1.6 Scope of this thesis: aims and research questions Personality disorder is a common psychiatric diagnosis, whether as a primary focus
1.7 Contents of the thesis for therapy, or as a co-morbid diagnosis complicating the course and outcome of
1.8 References the treatment of other psychiatric disorders. The lifetime prevalence of personality
disorders within the general population is estimated to be about 10-12%. Its presence
is associated with substantial impairment, loss of social functioning, increased family
burden and high health care costs. Limited evidence available so far suggests that
patients with personality disorder are extensive users of psychiatric services and other
mental health care resources (Soeteman et al., 2008).
The effectiveness of psychotherapy and pharmacotherapy for personality disorders
is well documented with favorable randomized clinical trails, meta-analyses and
systematic reviews (CBO, 2008; Leichsenring et al., 2008; Rinne & Ingenhoven, 2007;
a and b
Ingenhoven et al., 2009 ).
Generally, psychotherapy is advocated as a cost-effective and necessary intervention
(Beecham et al., 2005; Bartak et al., 2007). But not every patient with a personality
disorder seems to beneft from psychotherapeutic treatment. Research suggests
that improvement during psychotherapy is signifcantly associated with the length
of treatment duration (number of outpatient sessions, weeks in day hospital or
inpatient treatment), but outcome does not seem to be systematically correlated with
sociodemographic features, pre-treatment descriptive psychiatric diagnoses on DSM IV
Axis I and Axis II, and with symptom severity at admission (Ford, Fisher and Larson,
1997; Bateman & Fonagy, 1999; Vermote, 2005; Leichsenring & Rabung, 2008;
Spinhoven, Giesen-Bloo, van Dyck & Arntz, 2008).
Yet, it is of clinical interest to know which personality disorder patients will beneft
from intensive psychotherapy programs, and which patients will not. Research
fndings suggest that different types of patients may respond in different ways to
14 introduction | chapter 1 introduction | chapter 1 15
different kinds of treatments (Blatt, 1992, 1994), and that the major determinants disorders (although some DSM-IV instruments for the assessment of personality
of therapeutic success appear to depend on the patients’ personality characteristics. disorders, like SCID-II, have partly incorporated this strategy).
The psychological qualities a patient brings in to the treatment are often assumed 3) T he strategy of exhaustion “depicts diagnosis as a two-stage process” (Sackett, 1991,
to be highly important in determining treatment outcome (Lambert & Asay, 1984). p. 13). The frst step of this dragnet strategy is to collect all relevant data (without
However, very little is known about which personality characteristics have the power paying immediate attention to them), followed by the second step of “sifting
to predict the outcome of psychotherapy in personality disorder patients. Personality through the data for the diagnosis”. In clinical interviews this strategy is seldom
characteristics are regarded as one of the most relevant clinical factors predicting the used, but in the use of self-report questionnaires for the assessment of personality
course and outcome of treatment. Although DSM-IV is still regarded to be the standard traits, this strategy is rather common.
when it comes to the diagnostic classifcation of personality disorders, there is no 4) T he hypothetico-deductive strategy is the most common strategy in the diagnostic process
evidence for the clinical utility of Axis II diagnosis in individual case formulations, in routine clinical practice. “It is the formulation, from the earliest clues of a short
or clinical decision making like planning the most appropriate psychotherapeutic list of potential diagnoses…., followed by…. maneuvers that will best reduce the
treatment offer. As today, it is unclear which patient will beneft most from what kind length of the list” (Sackett, 1991, p. 16). This is done by gathering data that disprove
of treatment. Therefore, emphasis is placed on the development of diagnostic models or support working hypotheses. In the personality domain this strategy is explicitly
and assessment strategies to unfold relevant personality characteristics in predicting used as a specifc assessment procedure for diagnostic purposes in the “Structural
longitudinal course and treatment effectiveness, i.e. patient-treatment matching. Interview” as developed by Kernberg (1984).
In the consulting room, clinicians traditionally rely heavily on the hypothetical-
1.2 Diagnostic strategies for personality disorders deductive approach to construct a clear picture of the unique complains and problems
of the individual in the light of his/her habitual behavioral patterns and social
From the perspective of a traditional medical approach Sacket et al. (1991) performances (van Yperen & Hirs, 1995). During the diagnostic process (fgure 1),
distinguishes four clinical strategies to come to a diagnosis: pattern recognition; the clinicians integrate data derived from all different domains: disease specifc clinical
multiple-branching or arborization strategy; the strategy of exhaustion or dragnet history, biography, psychiatric and family history, self-report questionnaires and
strategy; and the hypothetico-deductive approach. other specifc assessment procedures (Gabbard, 1994). These data can be obtained
1) Pattern recognition is described as “the instantaneous realization that the patient’s from a direct confrontation with the patient, his/her relatives or by reports of earlier
presentation conforms to a previously learned picture (or pattern) of disease” treatment efforts. During this hypothetico-deductive and integrative process clinicians
(Sackett, 1991, p. 5). In psychiatry, examples of this “gestalt method” are the are infuenced by “explanatory ideas” (Sackett, 1991, p16), schemata and paradigms
instantaneous recognition of schizophrenic catatonia or severe Parkinsonism induced derived from current classifcation systems based on a variety of theoretical models.
by anti-psychotic medication. Most of the time personality disorders are not reliable These models give guidance through the labyrinth of concepts and constructs that
recognized at frst glance since the outwardly presentation of the persona, the mask, crosses their minds.
can represent the facade behind which maladaptive personality traits can be hidden. Assessment procedures for personality characteristics, such as self-report
The patient can present himself stronger than he is (“faking good”), or even worse questionnaires, specifc semi-structured interview methods, and inferential techniques
(“faking bad”). So, more time and other information are needed to build up a like projection tests can be helpful to gather data in a more specifc and formalized
clear picture before drawing fnal conclusions and, therefore, pattern recognition is way, which enable us to bring to the surface underlying traits, structural derivates or
probably not the most suitable strategy for identifying personality disorder diagnosis. psychodynamic characteristics of the patients’ personality. Most of these instruments
2) In the multiple-branching or arborization strategy, the diagnostic process follows “preset rely on the dragnet strategy.
paths by a method in which the response to each diagnostic inquiry automatically Data derived from different sources should be integrated, during the diagnostic
determines the next inquiry to be carried out and, ultimately, the correct diagnosis” process, to enable the clinician to come to a fnal conclusion, the individualized
(Sackett, 1991, p. 6). In DSM-IV we fnd several decision trees for the differential diagnostic case formulation. So, theory based classifcations, diagnostic processes
diagnosis of axis I disorders, but not for personality disorders on Axis II. However, and assessment procedures are not fully mutual exchangeable, but have their own
such algorithms are not common in the literature on the diagnosis of personality underpinnings and can be complementary to one another. Today, our multi-conceptual,
16 introduction | chapter 1 introduction | chapter 1 17
multi-method and multi-trait approach relies on integration of information derived from
Figure 2
divergent sources during the diagnostic process.
Personality: diagnostic instruments
As stated elsewhere (Abraham et al, 2001; Abraham, 2005; Ingenhoven, 2005),
Theoretical explanation
Figure 1
Assessment? Diagnosis? Classification?
Diagnostic process
Assessment Classification
intake Ideal
Nosologic
instrument
system
interviews global problem description
Hypothesis
tests hypothesis
type disorder
questionnaires specific diagnostics
Clinical Empirical
etc. deduction observation validation
Diagnostic
case formulation
classification
advise
e.g. DSM IV
treatment
purposes. However, the explicit “a-theoretical” background of these efforts limit the
van Yperen & Giel, 1995
possibility to explain the way people with specif c personality disorders feel, think and
act. Unfortunately, these diagnostic labels also do not give suff cient information to
instruments and methods for personality diagnostics should (1) be related to relevant allocate patients to specif c treatment approaches, and the predictive power of these
clinical observations to make the functional signif cance of habitual behavior explicit; instruments with respect to effective treatment allocation has never been established.
(2) have a theoretical-explanatory frame of reference to arrange the observations Although these descriptive phenomenological and a-theoretical approaches have
in a meaningful hierarchical way in order to explain their clinical signif cance, and attributed to a common nosologic nomenclature, and to basic epidemiological
(3) should be constructed in a way that empirical research is feasible to establish knowledge about personality disorders, it is unlikely that they will contribute to the
its reliability and aspects of its internal and external validity. An ideal instrument for process of indication and treatment allocation to specif c treatment approaches in
personality diagnosis should simultaneously satisfy all three conditions (f gure 2), but clinical practice, because of the lack of an explanatory framework.
in clinical practice such an ideal instrument does not exist yet. All current instruments
have their advantages and disadvantages when it comes to the clinical-observational, Theory driven understanding of habitual behavioral patterns
theoretical-explanatory, and statistical-empirical requirements. The theoretical understanding of personality pathology can be approached from
a number of viewpoints, e.g. the psychodynamic, interpersonal, cognitive, and
Clinical observations as a conceptual point of departure evolutionary-biological perspective (Clarkin & Lenzenweger, 1996). Psychodynamic
Based on the descriptive-phenomenological tradition of clinical psychiatry we f nd models provide a rich frame of reference for understanding the “structural” or
the current operationalization of several personality disorders distinguished as discrete “motivational” aspects of human behavior. Based on principles of the object relation
categories within the Diagnostic and Statistical Manuals such as DSM-IV and ICD-10 theory, Kernberg (1984) signif cantly extended the traditional psychiatric interview
(f gure 3). Diagnostic instruments, such as the SCID-II and the IPDE, were developed in his Structural Interview (f gure 3). Relying both on direct clinical observations
in order to establish reliable measures for empirical research and clinical diagnostic and theoretical anchor points like reality testing, identity characteristics and
18 introduction | chapter 1 introduction | chapter 1 19
defense mechanisms, Kernberg uses a hypothetico-deductive strategy to f nd the Till today, its predictive and incremental value for treatment allocation is hardly tested.
patients’ underlying “personality organization”. This process takes place during the Despite its recommendations for clinical diagnosis and treatment planning, the
Structural Interview. Although, the reliability and validity of this clinical model and MMPI-2 lacks a solid theoretically based explanatory system (Eurelings-Bontekoe,
its accompanying assessment procedure were hardly empirical evaluated during the Onnink, Williams & Snellen, 2008).
last decades, this hierarchical model is frequently used by clinicians who search for a
global orientation with respect to their patients’ ego-strength.
Other efforts to bridge the gap between observational-exploratory models and 1.3 P sychodynamic diagnosis and the
empirical standards can be found in the ongoing research on defense mechanisms and Developmental Prof le
attachment styles, using self-questionnaires or specif c diagnostic interviews.
From a theoretical developmental-psychological stance the Developmental Prof le
(Abraham, 1993, 1997, 2005; Abraham et al, 2001) attempts to standardize
Figure 3
psychodynamic personality diagnostics for clinical diagnosis and treatment planning,
and to make it more accessible for empirical validation. Its semi-structured interview
Personality: diagnostic instruments
relies on the dragnet strategy and provides a comprehensive overview of adaptive and
Theoretical explanation
maladaptive behavioral patterns during the past ten years of life. The DP describes
Structural Interview
the degree to which psychosocial functioning is determined by mature adaptive and
by “early” maladaptive behavioral patterns (Abraham, 1993; Abraham & van Dam,
2004). DP consists of a matrix of 10 Developmental Levels (rows) and 9 Developmental Lines
TCI
Development Profile (columns) (Table 1). Each Developmental Level describes a central characteristic in the
development of psychosocial capacities. These central characteristics are, in ascending
order of development, Lack of Structure, Fragmentation, Self-centeredness, Symbiosis, Resistance,
Rivalry, Individuation, Solidarity, Generativity, and Maturity (Appendix 1; this chapter). Each
DP-level score is made on the basis of the nine psychosocial domains representing
the Developmental Lines (Appendix 2; this chapter), referring to Social Attitudes, Object
NEO-PI-R
Relations, Self-Images, Norms, Needs, Cognitions, Problem Solving (thoughts and feelings), Problem Solving
Clinical Empirical (actions), and Miscellaneous Themes. Developmental levels in the DP matrix are hierarchically
observation DSM-IV MMPI-2 validation organized, according to the degree to which they affect psychosocial functioning,
and range from a primarily primitive level (Lack of Structure) to ultimately mature
level (Maturity). These Levels are not assumed to be mutually exclusive. The lowest six
Developmental Levels (Lack of Structure, Fragmentation, Self-centeredness, Symbiosis, Resistance and
The empirical approach as the leading principle Rivalry) refer to maladaptive behaviors, while the highest four Developmental Levels
Current instruments for personality diagnostics that are primarily developed from (Individuation, Solidarity, Generativity and Maturity) refer to adaptive functioning.
an empirical perspective are for instance the NEO-PI-R (Big Five) and the MMPI-2, DP is assessed with a semi-structured interview. A detailed description is obtained
(f gure 3). Although the Big Five is based on a lexical theory of normal personality of the patients’ daily functioning over the past ten years, by focusing on the way the
characteristics and is extensively tested on its reliability and validity, it lacks a solid patient functions in the context of family and friendships, education and work, sports
theoretical-explanatory frame of reference to explain psychopathologic behavioral and hobbies. Other issues include distressing events and feelings of fear, anger, guilt,
patterns in a clinical useful way. This makes it diff cult for clinicians to rely directly on shame, and self-esteem. The interview lasts 2–3 hours and is usually spread over
the results of this instrument because the scorings on the domains and facets, and the two sessions. To interpret the verbatim information derived from the interviews, a
prof le derived from it, f rst have to be “translated” or “theoretically interpreted” for scoring protocol is used. This protocol describes in observational terms all 90 items
practical clinical purposes. The MMPI-2 is confronted with the same limitations. comprising the DP-matrix (10 DP-levels x 9 PD-lines). The rater indicates on a