Medication overuse headache, addiction and personality pathology: a controlled study by SWAP-200

Background: Medication Overuse Headache (MOH) is a type of chronic headache, whose mechanisms are still unknown. Some empirical investigations examining the addiction-like behaviors and processes, as well as personality characteristics underlying MOH development, reached contrasting findings. This study aimed at detecting personality and its disorders (PDs) in MOH patients, with a specific attention to the features of addiction. Methods: Eighty-eight MOH patients have been compared with two clinical populations including 99 patients with Substance Use Disorder (SUD) and 91 with PDs using the Shedler-Westen Assessment Procedure-200 (SWAP-200). MANCOVAs were performed to evaluate personality differences among MOH, SUD and PD groups, controlling for age and gender. Results: MOH patients showed lower traits of the SWAP-200’s clusters A and B disorders than SUD and PD patients, whom presented more severe levels of personality impairment. No differences in the SWAP-200’s cluster C have been found, indicating common personality features in these populations. At levels of specific PDs, MOH patients presented higher obsessive and dysphoric traits, as well as better overall psychological functioning than SUD and PD patients. Conclusions: The study supported the presence of a specific pattern of personality in MOH patients including obsessive (perfectionist) and dysphoric characteristics, as well as good enough psychological resources. No similarities with drug addicted and personality-disordered patients were found. Practitioners’ careful understanding of the personality of MOH patients may be useful to provide more effective treatment strategies and patient-tailored intervention programs

PATIENT PERSONALITY AND THERAPIST EMOTIONAL RESPONSES IN THE PSYCHOTHERAPY WITH ADOLESCENTS: AN EMPIRICAL INVESTIGATION

Therapist’s emotional responses to the patient (or countertransference) can be considered as a source of valuable diagnostic and therapeutic information, as well as play a crucial role in the psychotherapy process and outcome, especially with the adolescent patient. However, empirical literature has paid little attention, to date, to the therapist-patient relationship in the treatment of adolescents and only a few studies has sought to explore countetransference reactions elicited by this patient population. The aim of this study was to examine the relationship between therapist’s emotional responses and personality pathology and psychological functioning of the adolescent patient. A random national sample of clinical psychologists (N=70) completed the Therapist Response Questionnaire for Adolescents (TRQ-A) to identify patterns of countertransference, and the Shedler-Westen Assessment Procedure-200 for Adolescents (SWAP-200-A) to assess personality disorders and styles in a randomly selected patient currently in their care and with whom they had worked for a minimum of eight sessions and a maximum of ten months. Results showed that there were significant relationships between therapists’ responses and patients’ personality pathology and psychological functioning. Antisocial-psychopathic and narcissistic personality disorder were associated with angry/frustrated countertransference. Emotionally dysregulated personality disorder was associated with overinvested/worried therapist response. Bored/angry at parents therapist response was associated with avoidant-constricted personality disorder. Healthy and inhibited-self critical personality styles were associated with warm/competent countertransference. Overall, personality pathology of the adolescent patient are mostly related to consistent therapists’ emotional responses, which suggests that clinicians can make diagnostic and therapeutic use of their responses in the psychotherapy with adolescents

Clinician emotional responses and therapeutic alliance when treating adolescent patients with narcissistic personality disorder subtypes: a clinically meaningful empirical investigation

This study examined clinician emotional responses and therapeutic alliance in psychotherapy with adolescent patients with specific subtypes of narcissistic personality disorder (NPD). A national sample of therapists (N = 58) completed the Therapist Response Questionnaire for Adolescents to identify patterns of clinician response, the Working Alliance Inventory to evaluate the quality of alliance, and the Shedler-Westen Assessment Procedure-II for Adolescents to assess the personality pathology of a patient in their care. The results showed that the grandiose narcissistic subtype was positively related to angry/criticized and disengaged/hopeless therapist responses and negatively related to warm/attuned response. The fragile subtype was positively related to overinvolved/worried therapist response. The high-functioning/exhibitionistic subtype was negatively related to angry/criticized response. Lower levels of therapeutic alliance were positively associated with the grandiose subtype. Moreover, the empirically founded prototypes of therapist responses to adolescent patients with NPD subtypes strongly resembles theoretical-clinical accounts. The clinical implications were addressed

Transference and Personality Pathology: Toward the Empirically Derived and Clinically Useful Prototypes of Relational Patterns

Since Freud’s initial recognition that patients may enact interpersonal patterns in the relationship with the analyst, the concept of transference has revised radically. In contemporary terms, it refers broadly to patterns of thought, feeling, motivation and behavior that emerge in the therapeutic relationship and reflect enduring aspects of the patient’s personality and interpersonal functioning. Although the clinical literature on transference phenomena in psychotherapy is rich and the body of research is not limited, little interest has been shown in empirical investigation of patients’ relational patterns related to their personality pathology. The aims of this study was to: 1) examine the stability of the factor structure and psychometric properties of the Psychotherapy Relationship Questionnaire (PRQ; Bradley et al. 2005), a clinician-report measure of transference phenomena in the treatment; 2) investigate the relationship between patients’ relational patterns and specific personality disorders; 3) provide the empirically derived prototypes of relation patterns in patients with personality pathology. A national sample of psychiatrists and clinical psychologists (N=300) of psychodynamic and cognitive-behavioral orientation completed the PRQ, as well as the Shedler–Westen Assessment Procedure–200 (Westen, Shedler, 1999) to assess personality disorders and level of psychological functioning, regarding a patient currently in their care. Exploratory and confirmatory factor analyses identified five distinct transference patterns that were conceptually coherent and psychometrically robust. They were associated with specific personality disorders. Finally, the prototypes of relational patterns in personality-disordered patients provided an empirically derived and clinically useful description of transference processes that strongly resembled clinical theories. The relevant diagnostic and clinical implications of these findings were addressed

Therapist responses and therapeutic alliance in the psychotherapy of adolescent patients with narcissistic personality disorder: An empirical investigation

Aim: Although the clinical literature on countertransference reactions and therapeutic alliance with adolescent patients with personality pathology is quite extensive, the corresponding empirical literature is limited. This study examined these relational variables in psychotherapy with adolescent patients with three subtypes of the narcissistic personality disorder (NPD). Methods: Fifty-eight clinicians completed the Psychodiagnostic Chart–Adolescent (PDC-A) of the Psychodynamic Diagnostic Manual (PDM-2), the Shedler-Westen Assessment Procedure-II for Adolescents (SWAP-II-A), the Therapist Response Questionnaire for Adolescents (TRQ-A), and the Working Alliance Inventory (WAI), to provide a comprehensive diagnostic assessment of adolescent patients in their care as well as to evaluate countertransference patterns and quality of alliance in their treatment. Results: The grandiose narcissistic subtype was negatively associated with warm/attuned therapist response and positively associated with angry/criticized and disengaged/hopeless responses. The fragile subtype was positively associated with overinvolved/worried response. The high-functioning/exhibitionistic subtype was negatively associated with angry/criticized response. Moreover, the grandiose subtype was positively related to lower quality of therapeutic alliance, that was negatively related to the high-functioning/exhibitionistic subtypes. No significant association was found between therapeutic alliance and the fragile subtype. Moreover, the empirically founded prototypes of therapist responses to adolescent patients with NPD subtypes strongly resembles theoretical-clinical accounts. Discussion: This study provides a nuanced view of countertransference reactions evoked by adolescent patients with specific NPD subtypes, and extends knowledge on therapeutic alliance in their treatment. Therapists could use the information derived from the therapeutic relationship to generate clinically meaningful diagnosis of adolescent patients and promote therapies tailored on their core psychological features

THERAPIST RESPONSES, PATIENT EMERGING PERSONALITY PATTERNS AND MENTALIZED AFFECTIVITY IN THE PSYCHOTHERAPY OF ADOLESCENTS WITH DEPRESSIVE DISORDERS

The assessment of depressive disorders is challenging in adolescence. This study explored the relationship between patients’ personality patterns, mentalized affectivity, and the therapists’ responses in the treatment of this clinical population. One hundred clinicians completed the Psychodiagnostic Chart-Adolescent of the PDM-2 and the Therapist Response Questionnaire for Adolescents. Adolescent patients filled in the Mentalized Affectivity Scale. Four emerging personality profiles were identified: depressive/introjective, anxious–avoidant, emotionally dysregulated and narcissistic. Adolescents presenting with emotionally dysregulated, and narcissistic personality patterns show greater impairment in the mentalized affectivity and tend to evoke in the therapist negative emotional reactions. Patients with depressive/introjective pattern show better capacities in the mentalized affectivity domain and elicit less negative countertransference reactions. The study extends knowledge on the personality patterns, mentalized affectivity and countertransference reactions related to depressive disorders in adolescents. Therapists should use the information derived from an accurate psychodynamic assessment to promote tailored treatments

Personality syles, depressive disorders and therapist responses in adolescent psychotherapy: A PDM-2 empirically oriented and clinically meaningful investigation.

Introduction: The assessment of personality pathology and depressive disorders in adolescence is very challenging due to the high prevalence and comorbidity of these psychopathological conditions in young people. This study explored the relationship among personality patterns, depressive disorders, and therapists’ responses in adolescent treatment according to the PDM-2 diagnostic framework. Method: Fifty clinicians completed the Psychodiagnostic Chart-Adolescent, the Shedler-Westen Assessment Procedure-II for Adolescents and the Therapist Response Questionnaire for Adolescents to provide a comprehensive assessment of psychological functioning and countertransference responses of an adolescent patient in their care. Results: Four emerging personality profiles related to depressive pathology in adolescence were identified: depressive/introjective, anxious–avoidant, emotionally dysregulated, and narcissistic. The latter two subtypes significantly correlated with a borderline personality organization, whereas the others showed a trend toward significance with a neurotic level of personality organization. Moreover, adolescents presenting with emotionally dysregulated and narcissistic personality patterns tended to evoke negative emotional reactions characterized by anger, irritation, worry, and sense of inadequacy. Patients with depressive/introjective pattern elicited less intense and negative countertransference reactions, whereas patients with anxious–avoidant pattern tended to evoke protective reactions in their clinicians. Conclusions: The study extends knowledge on emerging personality patterns related to depressive disorders in adolescents, and provides a nuanced view of countertransference reactions evoked by these patients in psychotherapy. Therapists should use the information derived from the therapeutic relationship to generate clinically meaningful diagnosis and promote treatments tailored on adolescents’ psychological functioning

ASSESSING BORDERLINE PERSONALITY DISORDER IN ADOLESCENCE ACCORDING TO THE PSYCHODYNAMIC DIAGNOSTIC MANUAL-2 (PDM-2) CLINICAL FRAMEWORK

Assessing borderline personality disorder (BPD) in adolescence is very difficult due to its high symptom heterogeneity and severity. This study aimed to provide an empirically valid and clinically rich portrait of BPD identifying specific subtypes in borderline adolescent patients according to the PDM-2 framework. Fifty clinicians completed the Psychodiagnostic Chart-Adolescents of the PDM and the Therapist Response Questionnaire-Adolescents. Patients filled in the Defense Mechanisms Rating Scales-Self-Report-30. Three emerging personality profiles were identified. The emotionally dysregulated subtype, characterized by the strong use of splitting, projective identification, acting, was positively related to angry/criticized and disorganized therapist responses. The impulsive–histrionic subtype, characterized by disavowal and minor image-distorting defenses, acting, was positively related to angry/criticized and sexualized therapist responses. The dependent–victimized subtype, characterized by depressive defenses, was negatively related to overinvolved/ worried therapist response. A more differentiated view of BPD may have relevant treatment implications and may help plan individualized and effective interventions in adolescence

Patient personality and therapist responses in the adolescent psychotherapy: The validation of the Therapist Response Questionnaire for adolescents

Objective: The aim of this study was to explore the factor structure and psychometric properties of the Therapist Response Questionnaire for Adolescents (TRQ-A; Satir et al., 2009), a clinician-report instrument able to measure the clinician’s emotional reactions (or countertransference) to the adolescent patient in psychotherapy. Methods: A national sample of psychiatrists and psychologists (N = 185) completed the TRQ-A, as well as the Psychodiagnostic Chart for Adolescents (PDC-A; Malberg et al., 2017) from the PDM-2 (Lingiardi, McWilliams, 2017), to assess levels of emerging personality organization and emerging personality styles/syndromes regarding an adolescent patient in their care. An exploratory factor analysis (EFA) was carried out to identify the factor structure of the TRQ-A. Reliability of the TRQ-A’s scales was calculated using the Cronbach’s alpha coefficients. Bivariate correlations between these scales and variables of personality were conducted to assess the criterion validity. Results: EFA revealed six distinct countertransference scales: hostile/devaluated, positive, bored/failing, overwhelmed/scared, overinvolved, sexualized. These scales showed excellent reliability and good validity. They were significantly associated with patients’ levels of personality organization and emerging personality styles/syndromes. In particular, more severe levels of personality organization were related to the bored/failing and overwhelmed/scared countertransference. Narcissistic and antisocial/psychopathic personality styles/syndromes were associated with the hostile/devaluated and overwhelmed/scared therapist responses, and borderline style/syndrome was related to the overwhelmed/scared and overinvolved countertransference. Schizoid personality style/syndrome was associated with the bored/failing countertransference, while impulsive/histrionic style/syndrome was related to the sexualized therapist response. Positive countertransference was related to the obsessional personality style. Conclusion: The TRQ-A is a very useful instrument to evaluate countertransference reactions in clinically sensitive and psychometrically robust ways. Moreover, adolescents’ emerging personality styles/syndromes were consistently associated with specific emotional responses, which suggests that clinicians can make diagnostic and therapeutic use of their responses to patients

Therapist responsiveness and clinical relationship in the treatment of patients with personality disorders: An empirical investigation

Introduction: Therapist responsiveness refers to a crucial component of the clinician-patient relationship, defining how the therapist is with the patient and manifests flexibility, sensitivity, empathy, and availability. Being a responsive therapist means getting emotionally attuned to the patient, being able to read the interpersonal dynamics developing in the hic et nunc of the clinical interaction, and providing the most appropriate interventions consistent with the emerging relational context. Recent studies have emphasized the impact of this dimension in the treatment of patients with personality disorders (PD), but knowledge in this field of investigation is very limited. This research aimed to investigate the association between therapist responsiveness and some characteristics of the therapist, patient, and clinical relationship in the early stages of the psychotherapy. Methods: 82 pairs of therapists and patients (with PD) completed two instrument batteries consisting of the patient and therapist versions of the Patient’s Experience of Attunement and Responsiveness Scale, the Working Alliance Inventory-SF, the Depth Scale of the SEQ, respectively. The therapists’ battery also included the Therapist Response Questionnaire and the Comparative Psychotherapy Process Scale, while the patients’ battery included the Defense Mechanisms Rating Scale-SF-30. Results: Overall, therapist responsiveness was related to the quality of the therapeutic alliance and the depth of content processing that emerged during the psychotherapy sessions. Good therapist responsiveness was strongly associated with the use of psychodynamic techniques. A negative correlation was found between therapist responsiveness, helpless/inadequate and disengaged countertransference patterns, and patients’ worse defensive functioning. Finally, a statistically significant patient-therapist divergence was found in the assessment of therapist responsiveness. Patients tended to evaluate therapists’ responsiveness more positively than the clinicians themselves. Discussion: This study seeks to shed light on the interpersonal processes in the patient-therapist dyads that help guide the therapeutic process toward better outcomes. The findings have clinically significant implications and promote the development of best practices for planning effective individualized treatments for patients with PD