No abstract

A key ingredient in the current proposal of the DSM-5 Work Group on Personality and Personality Disorders is the assessment of overall severity of impairment in personality functioning: the Levels of Personality Functioning Scale (LPFS). The aim of this article is to contribute a conceptual and empirical discussion of the LPFS from the perspective of the Operationalized Psychodynamic Diagnosis (OPD) system (OPD Task Force, 2008 ). First, we introduce the OPD Levels of Structural Integration Axis (OPD-LSIA), a measure of individual differences in severity of personality dysfunction that is rooted in psychodynamic theory. We show that the OPD-LSIA is reliable, valid, and highly associated with observer ratings of personality disorders. In the second part, we present results from an OPD expert consensus study exploring potential limitations of the current LPFS item set from the perspective of the OPD-LSIA. We conclude with highlighting implications for future revisions of the DSM-5 proposal.

Several authors have raised the concern that the DSM-5 Level of Personality Functioning Scale (LPFS) is relatively complex and theory laden, and thus might put high requirements on raters. We addressed this concern by having 22 untrained and clinically inexperienced students assess the personality functioning of 10 female psychotherapy inpatients from videotaped clinical interviews, using a multi-item version of the LPFS. Individual raters' LPFS total scores showed acceptable interrater reliability, and were significantly associated with 2 distinct expert-rated measures of the severity of personality pathology. These findings suggest that, contrary to the previously mentioned concerns, successfully applying the LPFS to clinical cases might require neither extensive clinical experience nor training.

The concept of psychic structure plays a central role in the Operationalised Psychodynamic Diagnosis (OPD) system. Until recently, its reliable and valid assessment had to be based on expert ratings of clinical interviews, limiting the use of the OPD in routine measurements and research, and excluding the patients' perspective. The current study describes the development and evaluation of a questionnaire on the OPD structure axis (OPD-SQ) in several clinical and non-clinical samples (N = 1 112). The questionnaire demonstrated good internal consistency for all the sub-scales of the OPD-SQ. Differences in mean values between the samples and between patients with vs. without personality disorders were as expected. We also found correlations with other relevant aspects of personality (attachment security, neuroticism). There were no to minimal effect of age and gender. The OPD-SQ is a helpful tool for a broad use in clinical routine as well as research projects.

The Adult Attachment Interview (AAI) was used to study 31 psychotherapists who treated 1,381 patients in intensive multimodal inpatient psychotherapy. AAI dimensional ratings of security versus insecurity and dismissiveness versus preoccupation were used to predict alliance and outcome via multilevel regression techniques (hierarchical linear modeling). There were no main effects of therapists' attachment dimensions. However, higher attachment security of the therapist was associated with both better alliance and outcome in more severely impaired patients. Implications of the findings as well as limitations of the study are discussed.

The "Experiences in Close Relationships--Revised" (ECR-R) is a well developed instrument for assessing attachment in adults, which is used in different research areas around the world. In this paper the German version (ECR-RD) was evaluated in a large non-clinical (N = 1006) and a clinical sample (N = 225). Overall, the good psychometrical properties were confirmed (Cronbach's alpha = 0,91/0,92), we also found evidence for construct validity. There was a substantial difference between the two samples in the ECR-RD as well as a specific impact of comorbid personality disorders. The ECR-RD can be seen as a reliable, internationally comparable instrument for assessing romantic attachment representations that can be used in clinical samples.

As an addition to the ongoing discussion concerning the magnitude of therapist effects on outcome in psychotherapy, we investigated therapist variability in a large inpatient psychotherapy sample. We included global symptomatic outcome (Global Severity Index of the Symptom Checklist-90 Revised [SCL-90-R]; German version, Franke, 1995) and alliance (Helping Alliance Questionnaire; German version, Bassler, Potratz & Krauthauser, 1995) ratings of 2554 inpatients who were treated by 50 psychotherapists. Multilevel regression analyses (HLM; Raudenbush, Bryk, Cheong, & Congdon, 2004) were used for analyses. Overall, therapists accounted for a much greater variability on alliance (33%) than on outcome (3%). Therapists were differentially effective with regard to their patients' symptom severity at the beginning of treatment, and therapists differed in the degree that a positive alliance was associated with therapeutic outcome. The relatively small therapist effect on outcome is attributed to compensatory mechanisms in the specific context of inpatient therapy.

Background: Despite a long tradition of discussions on the evaluation of psychotherapy, there is still a lack of agreement for measuring change after psychological treatment. In this paper we describe the concept of statistical and clinical significance of change. We use the Symptom Checklist 90 R as a commonly administered instrument to propose conventions and cutoff points for psychological symptoms and their change after therapy. Method: A German norm population and several psychotherapy samples have been aggregated to calculate cutoffs and confidence intervals (reliable change indices) for statistically and clinically significant changes after psychotherapy. Results: The cutoff point between a ‘functional’ and a ‘dysfunctional’ population was calculated as C = 0.57 (Global Severity Index, GSI). Patients above this score need a change of at least RCI = 0.43 (GSI difference) for a statististically significant change. Below this score the RCI = 0.16. The use of multiple clinical groups (e.g. inpatients and outpatients) for a more realistic determination of a ‘stepwise’ clinically significant change, as proposed by Tingey et al. in the USA, is not possible in the German samples collected so far. Initial SCL 90-R scores in these groups do not show enough differences to call a move from one group to the other a clinically significant change. Conclusion: In the German samples investigated the move from a ‘functional’ to a ‘dysfunctional’ population and vice versa has to be taken as the criterion for a clinically significant change up to now.