Diagnóstico psicodinâmico operacionalizado (OPD-II) : aplicação e avaliação do uso em pacientes com transtornos mentais graves submetidos à psicoterapia

Introdução: No intuito de expandir a classificação descritiva de sintomas das perturbações mentais, trazendo consistência empírica a modelos psicodinâmicos/psicanalíticos de diagnóstico nosológico foi formulado o “Operacionalized Psychodynamic Diagnosis” (OPD), instrumento multiaxial que possibilita abarcar a complexidade e a inter-relação de condições e fatores que determinam os fenômenos e as patologias mentais do ponto de vista psicodinâmico. Composto por quatro eixos psicodinâmicos: experiência da doença e pré-requisitos para o tratamento (Eixo I); relações interpessoais (Eixo II); conflito (Eixo III); estrutura (Eixo IV) e um eixo descritivo: transtornos mentais e psicossomáticas (Eixo V), estando em sua segunda versão (OPD-2). Objetivo: Este estudo se propõe a aplicar e avaliar o uso do OPD-2 em uma amostra brasileira de pacientes com transtorno mental grave acompanhados em psicoterapia em hospital terciário de referência do Sistema Único de Saúde (SUS). Metodologia: Estudo naturalístico longitudinal com pacientes em atendimento nos ambulatórios de psicoterapia deste hospital, nas modalidades psicoterápicas de Psicoterapia de Orientação Analítica (POA), Terapia Interpessoal (TIP) e Terapia Cognitivo Comportamental (TCC). Para esta amostra adotou-se como medidas de desfecho dois momentos de avaliação (baseline e 6 meses), analisando de validades de critério e preditiva. Na intensão de avaliar o índice de concordância e fidedignidade entre diferentes avaliadores, adotou-se o delineamento de estudo naturalístico transversal com pacientes que estiveram em atendimento nos ambulatórios de triagem para psicoterapia deste mesmo hospital, ou seja, que não tivessem iniciado acompanhamento psicoterápico e adotando como medida de desfecho a pontuação de 4 avaliadores distintos baseados em entrevista única. Resultados: Uma amostra de 80 participantes foi avaliada. Observou-se correlação significativa entre redução de sintomas avaliado pelo OPD-2 e os domínios psicológico (r=0.339; p=0.010), social (r=0.350; p=0.008) e ambiental (r=0.265; p=0.048) WHOQOL-BREF; e também de itens que avaliaram conflito de necessidade de cuidado versus autossuficiência (r = 0.314; p = 0.019), conflito de identidade (r = 0.308; p = 0.024) e WHOQOL-BREF. Verificou-se correlação significativa entre todos os itens que avaliam as condições estruturais da personalidade e o índice de psicoticismo da SCL- 11 90R. Em relação à fidedignidade dos itens que compõem o Eixo IV, obteve-se um Alfa de Cronbach de α=0.922. Em relação às análises de validade de critério preditiva, observou-se diferença das médias na avaliação estrutural de pacientes com histórico de tentativa de suicídio (̅= 22.2; ±4.4; t=2.487; gl=56; p= 0.016) e história prévia de internação (̅=22.4; ±4.1; t= −2.337; gl=59; p=0.023 ). Acerca do nível de concordância do OPD-2 entre avaliadores os valores de kappa não identificaram concordância inter-avaliador representativos. Conclusões: Os resultados deste estudo demonstraram que a avaliação realizada pelo OPD-2 acompanha os resultados de instrumentos autoaplicáveis já validados. O OPD-2 quando administrado por avaliadores preparados e treinados para o preenchimento preconizado pelo manual o OPD-2 mostrou boa qualidade de avaliar os conflitos e as questões estruturais dos sujeitos. Os resultados obtidos sugerem que a versão brasileira do OPD-2 tem boa condição de avaliar propriedades psicodinâmicas, podendo ser um instrumento útil dentro dos contextos clínico e em pesquisa.Background: In order to expand the descriptive classification of symptoms in mental disorders and to bring empirical consistency to psychodynamic/psychoanalytic models, a multiaxial instrument called Operationalized Psychodynamic Diagnosis (OPD) was formulated, allowing psychotherapy research to encompass the complexity of the relation between conditions and factors that determine the phenomena of mental pathologies from a psychodynamic point of view. OPD comprises four psychodynamic axes: experience of the illness and prerequisites for the treatment (Axis I); interpersonal relationships (Axis II); conflict (Axis III); structure (Axis IV); and a descriptive axis: mental and psychosomatic disorders (Axis V), currently being in its second version (OPD-2). Objectives: This study intend to apply and evaluate the use of OPD-2 in a Brazilian sample of patients with severe mental disorder who attend the psychotherapy outpatient clinic in a tertiary referral hospital of the Unified Health System (SUS). Methodology: 12 A longitudinal naturalistic study with patients who are attending the psychotherapy outpatient clinic. Those patients were attended in differents modalities of psychotherapy: Psychodynamic Psychotherapy, Interpersonal Psychotherapy and Cognitive Behaviorial Therapy. For this sample the outcome measures were assessment baseline and 6 months after participant study inclusion, verifying criteria and predictive validities. Intent to verify reliability levels, subsequently, was conducted a transversal naturalistic approach with a sample of patients that were attending the outpatient screening clinic, patients that didn´t start a psychotherapy treatment, and adopting as outcome measure the score of four different raters based on a single interview. Results: A total of 80 individuals participated in the study. Significant correlations between symptom reduction and psychological (r=0.339; p=0.010); social relationship (r=0.350; p=0.008) and environmental (r=0.265; p=0.048) domains of WHOQOL-BREF and items that assessed conflict desire for care versus autarchy (r = 0.314; p = 0.019), identity conflict (r = 0.308; p = 0.024) and WHOQOL-BREF was observed. There was a significant correlation between all the items that evaluated personality structural and the SCL-90R psychotic index. In addition, concerning the reliability of the items that compose Axis IV, we found a Cronbach's alpha of α = 0.922. Regarding predictive validity analysis, we observed mean differences in the structural evaluation of patients with a history of suicide attempt (̅= 22.2; ±4.4; t=2.487; gl=56; p= 0.016) and previous history of hospitalization (̅ 22 4 4 1 t 2 337 gl 59 p 0 023023). In relation to the OPD-2 reliability level between evaluators, the kappa value did not identify representative inter-rater agreement. Conclusion: Our results demonstrated that the evaluation performed by OPD-2 accompanies the results of validated self-administered instruments. When administered by evaluators prepared and trained to fill the manual as recommended by OPD-2, the instrument displayed good quality in assessing the conflicts and the structural issues of the subjects. These results suggest that the Brazilian version of OPD-2 is a valid, reliable instrument in evaluating psychodynamic properties and can be a useful tool within the clinical and research contexts

Longitudinal investigation of psychotherapy outcomes (LIPO) : description of the study protocol

Background: Despite extensive research in the field of psychotherapies, few studies have compared the primary psychotherapies of naturalistic design, which represents real-life situations. Objective: The objectives of this study were to evaluate three modalities of evidence-based psychotherapy for clinical, psychosocial, and biological outcomes and to identify the mediators and confounders of this process. Our primary hypothesis is that all psychotherapies will improve clinical and psychosocial outcomes and will increase BDNF levels. Methods: Design: longitudinal, naturalistic. Participants: One hundred twenty-six patients who underwent one of three evidence-based modalities of individual psychotherapy [psychodynamic psychotherapy (PDT), interpersonal psychotherapy (IPT), and cognitive–behavioral psychotherapy (CBT)] were included. Measure: Primary outcomes are divided into three domains of variables: clinical (general psychiatric symptoms), biological (serum BDNF levels), and psychosocial (resilience, quality of life, coping strategies, social support, and quality of life-adjusted years of life). Confounding/mediator variables included clinical (personality traits, type of psychotherapy, number of sessions, concomitant use of pharmacological treatment, history of previous psychotherapeutic treatment, medical and psychiatric comorbidities, and psychiatric diagnosis), psychosocial (psychosocial stressors, therapeutic alliance, and defense mechanism style), and other (religiosity) factors. Procedure: The follow-up period will be baseline and 6 months and 1 year after entering the study. The study will include 42 controls for biological variables only. Sample size calculation considered a significance level of 5% and a power of 80% to detect a difference of 0.22 with a standard deviation of 0.43, assuming losses of 20–30% of patients. The comparison between the modalities of psychotherapy will be by generalized estimating equations (GEE) model, the analysis of mediators by the Hayes method, and confounders by multivariate logistic regression. Discussion: The findings of this study are intended to demonstrate the outcomes of evidence-based psychotherapies for clinical, psychosocial, and biological parameters and to understand the mediators and confounders of this process in a real-life setting for patients with severe mental illness, thus contributing to the establishment of evidence-based public health policies in the field of psychological interventions

Longitudinal Investigation of Psychotherapy Outcomes (LIPO): Description of the Study Protocol

Background: Despite extensive research in the field of psychotherapies, few studies have compared the primary psychotherapies of naturalistic design, which represents real-life situations.Objective: The objectives of this study were to evaluate three modalities of evidence-based psychotherapy for clinical, psychosocial, and biological outcomes and to identify the mediators and confounders of this process. Our primary hypothesis is that all psychotherapies will improve clinical and psychosocial outcomes and will increase BDNF levels.Methods:Design: longitudinal, naturalistic. Participants: One hundred twenty-six patients who underwent one of three evidence-based modalities of individual psychotherapy [psychodynamic psychotherapy (PDT), interpersonal psychotherapy (IPT), and cognitive–behavioral psychotherapy (CBT)] were included. Measure: Primary outcomes are divided into three domains of variables: clinical (general psychiatric symptoms), biological (serum BDNF levels), and psychosocial (resilience, quality of life, coping strategies, social support, and quality of life-adjusted years of life). Confounding/mediator variables included clinical (personality traits, type of psychotherapy, number of sessions, concomitant use of pharmacological treatment, history of previous psychotherapeutic treatment, medical and psychiatric comorbidities, and psychiatric diagnosis), psychosocial (psychosocial stressors, therapeutic alliance, and defense mechanism style), and other (religiosity) factors. Procedure: The follow-up period will be baseline and 6 months and 1 year after entering the study. The study will include 42 controls for biological variables only. Sample size calculation considered a significance level of 5% and a power of 80% to detect a difference of 0.22 with a standard deviation of 0.43, assuming losses of 20–30% of patients. The comparison between the modalities of psychotherapy will be by generalized estimating equations (GEE) model, the analysis of mediators by the Hayes method, and confounders by multivariate logistic regression.Discussion: The findings of this study are intended to demonstrate the outcomes of evidence-based psychotherapies for clinical, psychosocial, and biological parameters and to understand the mediators and confounders of this process in a real-life setting for patients with severe mental illness, thus contributing to the establishment of evidence-based public health policies in the field of psychological interventions

Positive association between therapeutic alliance and quality of life in psychodynamic psychotherapy, cognitive behavior therapy, and interpersonal therapy : the patient’s perspective

Background: The therapeutic alliance (TA) is considered a common psychotherapeutic factor associated with positive results in psychotherapies. There are no studies relating the TA with quality of life (Qol). Objectives: Our objective was to evaluate whether there is an association between the TA and Qol across three different psychotherapies. Methods: A cross-sectional study, which included outpatients undergoing individual psychotherapeutic treatment was conducted. When analyzing the total sample, the correlation of the TA with Qol domains did not present statistical significance. When considering only the sample of patients who were undergoing treatment in psychodynamic psychotherapy (PP), there was a statistically significant association between the TA and the psychological domain of Qol (p < 0.05). When using a regression model for adjusting for confounding factors, the association between psychological domain with the TA on the PP patients sample lost significance (p = 0.221). Discussion: These findings suggest that the TA seems to be more strongly related to better QoL in PP

Propriedades psicométricas do protocolo de sistema diagnóstico Operationalization of Psychodynamic Diagnosis 2 (OPD-2) em pacientes com transtorno mental grave em psicoterapia

Introduction: In order to expand the descriptive classification of symptoms in mental disorders, and to bring empirical consistency to psychodynamic/psychoanalytic models, a multiaxial instrument called Operationalized Psychodynamic Diagnosis (OPD-2) has been developed, allowing psychotherapy research to encompass the complexity of the relationships between conditions and factors that determine the phenomena of mental pathologies, from a psychodynamic point of view. Methodology: Longitudinal naturalistic study with 80 outpatients with severe mental disorders, who were treated with a) psychodynamic psychotherapy, b) interpersonal psychotherapy and c) cognitive behavioral psychotherapy. All patients were interviewed at baseline and after six months, according to OPD-2’s criteria. They all also completed two self-report measures (WHOQOL-BREF and SCL-90R) to evaluate symptoms and quality of life at each assessment point. Results: According to OPD-2’s axis I, better personal resources, psychosocial support, and introspective capacity significantly correlated with fewer symptoms in the BDI’s and SCL-90’s measures. Also, symptoms’ reduction and quality of life’s domains significantly correlated with items that assessed OPD-2’s “desire for care versus autarchy” and “identity” conflicts. There was also a significant correlation between all items that evaluate structural functioning according to OPD-2 and the SCL-90R’s psychotic index. Regarding predictive validity analysis, we observed mean differences in the structural functioning of patients with a history of suicide attempt and previous history of hospitalization. Discussion: results support that OPD-2’s criteria significantly correlates with data from validated self-report measures. When administered by trained raters, OPD-2 displayed good quality in assessing patients’ conflicts and structural issues. This evidence suggests that the Brazilian version of OPD-2 is a valid and reliable instrument in evaluating psychodynamic properties and can be a useful tool within the clinical and research contexts

Longitudinal investigation of psychotherapy outcomes (LIPO) : description of the study protocol

Background: Despite extensive research in the field of psychotherapies, few studies have compared the primary psychotherapies of naturalistic design, which represents real-life situations. Objective: The objectives of this study were to evaluate three modalities of evidence-based psychotherapy for clinical, psychosocial, and biological outcomes and to identify the mediators and confounders of this process. Our primary hypothesis is that all psychotherapies will improve clinical and psychosocial outcomes and will increase BDNF levels. Methods: Design: longitudinal, naturalistic. Participants: One hundred twenty-six patients who underwent one of three evidence-based modalities of individual psychotherapy [psychodynamic psychotherapy (PDT), interpersonal psychotherapy (IPT), and cognitive–behavioral psychotherapy (CBT)] were included. Measure: Primary outcomes are divided into three domains of variables: clinical (general psychiatric symptoms), biological (serum BDNF levels), and psychosocial (resilience, quality of life, coping strategies, social support, and quality of life-adjusted years of life). Confounding/mediator variables included clinical (personality traits, type of psychotherapy, number of sessions, concomitant use of pharmacological treatment, history of previous psychotherapeutic treatment, medical and psychiatric comorbidities, and psychiatric diagnosis), psychosocial (psychosocial stressors, therapeutic alliance, and defense mechanism style), and other (religiosity) factors. Procedure: The follow-up period will be baseline and 6 months and 1 year after entering the study. The study will include 42 controls for biological variables only. Sample size calculation considered a significance level of 5% and a power of 80% to detect a difference of 0.22 with a standard deviation of 0.43, assuming losses of 20–30% of patients. The comparison between the modalities of psychotherapy will be by generalized estimating equations (GEE) model, the analysis of mediators by the Hayes method, and confounders by multivariate logistic regression. Discussion: The findings of this study are intended to demonstrate the outcomes of evidence-based psychotherapies for clinical, psychosocial, and biological parameters and to understand the mediators and confounders of this process in a real-life setting for patients with severe mental illness, thus contributing to the establishment of evidence-based public health policies in the field of psychological interventions