De Saeger, H.

English

The degree to which clinical assessment has treatment utility (i.e. enhances meaningful outcomes for patients) is a topic of ongoing controversy. Empirical data from well-designed studies on this issue are quite scarce. However, accumulating evidence suggests that Therapeutic Assessment (TA) can be an effective intervention in a diversity of populations (Aschieri, De Saeger, &amp; Durosini, 2015). TA is an assessment-driven therapeutic intervention that helps clients to develop new representation of themselves and the world (Finn, 1996). The full model of TA was never tested and most research did not conduct randomized comparisons and/ or were of low sample size. Moreover, the efficacy of TA in clients with Personality Disorders (PD) has not yet been examined. We present a conceptual analysis suggesting that features of TA and the specific clinical needs of clients with PD are well matched. In short, the main objective of this thesis was to conduct a stringent test of the treatment utility of the full model of TA in patients with personality disorder. Part A of this thesis provides a general description of the TA model and provides a clinical case example. Part B reports on a Randomized Controlled Trial (RCT). To get a deeper understanding of the findings of the RCT we conducted a qualitative follow-up study asking these clients what they deemed memorable about their TA experience

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UvA-DARE is a service provided by the library of the University of Amsterdam (https://dare.uva.nl)UvA-DARE (Digital Academic Repository)Therapeutic assessment in patients with personality disordersDe Saeger, H.Publication date2019Document VersionOther versionLicenseOtherLink to publicationCitation for published version (APA):De Saeger, H. (2019). Therapeutic assessment in patients with personality disorders. [Thesis,externally prepared, Universiteit van Amsterdam].General rightsIt is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s)and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an opencontent license (like Creative Commons).Disclaimer/Complaints regulationsIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, pleaselet the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the materialinaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letterto: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. Youwill be contacted as soon as possible.Download date:09 Mar 20236Cluster C Personality Disorder as seen from theMMPI-2-RF Scale Hierarchy: Clinical and Theoretical Utility11 This article is submitted as: De Saeger, H., Kamphuis, J.H., Anderson, JL. (2018). Cluster C Personality Disorder as seen from the MMPI-2-RF Scale Hierarchy: Clinical and The-oretical Utility. Submitted to European Journal of Psychological Assessment.Hilde De SaegerJan H. KamphuisJamie L. Anderson124Chapter 6AbstractSeveral studies have addressed the associations between the Minnesota Multiphasic Personality Inventory-2 Restructured form (MMPI-2-RF; Ben-Porath & Tellegen, 2008) scale scores and the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) Section II personality disorder (PD) criterion counts. While these studies show which variables are associated with the PDs as well as their combined predictive potency, no information is available on mean patterns of elevation associated with these conditions. As a test of clinical and for the DSM-IV (SCID-II). Highly divergent patterns of elevation were observed across the three levels of the MMPI-2-RF that were consistently in line with theoretical expectation. In addition, elevated scores on several somatic/cognitive scales were noted. It is concluded that the MMPI-2-RF and the DSM Personality disorder models amplify each other.125Cluster C Personality Disorder as seen from the MMPI-2-RFIntroductionA growing body of research documents how the recently developed full MMPI-2-RF categorical personality disorders (PD). Early studies focused on the clinical utility of the RC scales in the assessment of PD (Eaton et al., 2011; Kamphuis et al., 2008; the empirical associations between MMPI-2-RF scales and the DSM-IV or DSM-5 personality disorders (Anderson et al., 2015; Sellbom et al., 2014). First, Sellbom and colleagues (Sellbom, et al., 2014) mapped the PSY-5 abnormal personality scales onto DSM-IV PDs in both clinical and forensic samples. Next, Anderson (2015) presented an in-depth conceptual analysis of how MMPI-2-RF variables would be associated with each of the different PDs. For example, in the context of Avoidant PD, an inspection of the DSM criteria yielded the following concepts: hypersensitivity to criticism, fear of negative evaluation and rejection, extreme social withdrawal and alienation, feelings of inadequacy and ineptitude, and general emotional misery. Each of these was translated to putative MMPI-2-RF scales, at the various levels of the overarching hierarchy. These educated conjectures were subsequently put to the empirical test (Anderson et al., 2015). Generally, results from these analyses emerged as conceptually expected, and provided evidence that the MMPI-2-RF scales can be useful in assessing regression analyses included Demoralization (RCd), Low Positive Emotions (RC2), and Dysfunctional Negative Emotions (RC7), as well as several matching facet scales.translate to information that is useful to the clinician waiting to assess his or her next with regard to expected levels of scale elevation. Moreover, when multiple variables are included in the same regression equation, only yield “above and beyond” the other Accordingly, we wanted to examine whether the MMPI-2-RF yields a descriptive portrait in the context of PDs; in the present sample, as limited to cluster C PD. Our main interest was to examine to what extent the pattern of elevations a) made 6126Chapter 6may yield theoretically valuable hypotheses for diagnostic formulations beyond the some broad expectations for scale elevation for the indices that we considered consistent with emotional internalizing pathology at each level of the hierarchy (see for Emotional Internalizing Dysfunction (EID); at the RC level, we expected elevation for Demoralization (RCd), Low Positive Emotions (RC2), and Dysfunctional Negative Internalizing scales, but not for the Externalizing scales. Finally, of special interest for the PDs are the special problem scales that address interpersonal functioning, as well as the abnormal personality scale set provided by the PSY-5. With regard to the former, we expected elevations on Shyness and Avoidance among the Interpersonal SPs (core features or the cluster C pathology); with regard to the PSY-5, we expected high scores on Negative Emotionality-Revised (NEGE-r) and Introversion/ Low Positive Emotionality-Revised (INTR-r), while low scores for instrumental Aggressiveness (AGGR-r).MethodParticipantsPatient records between 2005 and 2010 from De Viersprong, a tertiary mental health facility specialized in the assessment and treatment of adolescents and adults with personality pathology, were retrieved when both structured clinical interview data and MMPI protocols were available. As part of the standard intake procedure, all De Viersprong patients are administered Structured Clinical Interviews for the DSM-IV Axis-I and Axis-II (SCID-I, II; First, Gibbon, Spitzer, William, & Benjamin, 1997), but only patients (N = 239 valid cases)1 who were referred to treatments addressing primary cluster C (the so-called anxious cluster) personality pathology or mixed anxious/ externalizing (Cluster B and C) were also administered the Minnesota Multiphasic Personality Inventory-Revised (MMPI-2). From these, we selected “pure” Cluster 1 39 invalid protocols were excluded conform the standard criteria outlined in the MMPI-2-RF; cannot say >17; VRIN or TRIN > 79T; F-r =120T; Fp-r > 99T; see Ben-Porath & Tell-egen, 2008)127Cluster C Personality Disorder as seen from the MMPI-2-RFC records (N = 73); i.e., patient who met criteria for Avoidant PD (79.5%, or n = 58), Obsessive Compulsive PD (24.7%, or n = 19), and/ or Dependent PD (4.1%, or n = 3), but no cluster B or Cluster A personality disorder. Slightly over half of the sample (56.2%) was female, with a mean age of 28.8 (  = 9.5). Eighty percent of the sample had comorbid Axis-I disorders, most notably unipolar mood disorders (28.8%, or n = 21), social phobia (31.5%, or n = 23), and/or Post Traumatic Stress Disorder (13.7%, or n =10).MeasuresMMPI-2-RF (Ben-Porath & Tellegen, 2008/ 2011)Patients were administered the Dutch MMPI-2, from which the MMPI-2-RF scales can be scored without decrement in psychometric functioning (van der Heijden, Egger, & Derksen, 2010). The MMPI-2-RF consists of 338 binary items, and comprises nine validity scales, three Higher-Order scales (H-O), nine Restructured Clinical Scales Psychopathology Five scales (PSY-5).SCID-II (First, Gibbon, Spitzer, William, & Benjamin, 1997; Weertman, Arntz, & Kerkhofs, 2000)The SCID-II is widely used semi-structured interview for the assessment of Axis II PDs. The inter-rater reliability of the Dutch SCID II has been demonstrated in several studies (Lobbestael, Leurgans, & Arntz, 2010; Weertman, et al, 2000), but unfortunately concern, we note that all SCID-II interviewers were extensively trained (e.g., including national trainers), and Cronbach alphas indicated satisfactory internal consistency for the SCID-II PD dimensional scores (ranging from .74 to .84).ResultsConsistent with expectation, an exclusive elevation on Emotional Internalizing Dysfunction was observed at the higher order level (EID; = 79.8,  = 9.0). Elevations on RC scales included Demoralization (RCd;  = 78.1,  = 8.0), Somatic Complaints (RC1; = 69.5, = 13), Low Positive Emotions (RC2;  = 81, = 11.9), and Dysfunctional Negative Emotions (RC7;  = 69.1,  = 11.2); See Figure 1.6128Chapter 6Figure 1: MMPI-2-RF Higher-Order (H-O) and Restructured Clinical 129Cluster C Personality Disorder as seen from the MMPI-2-RFFigure 2: MMPI-2-RF Somatic/Cognitive and Internalizing Scales 6130Chapter 6Figure 3: MMPI-2-RF Externalizing and Interpersonal Scales Mean As can be seen from Figure 2, the following Somatic/Cognitive scales showed mean scores above the T=65 cut-off point: Malaise (MLS; = 75.4,  = 9.5), Gastrointestinal Complaints (GIC; = 67.6, SD = 16.9), Neurological Complaints (NUC; = 66.2, = 10.8), Cognitive Complaints (COG; = 69.1, = 12.6). As might be expected, several internalizing SPS were elevated: Suicidal/Death Ideation (SUI; = 75.1, = 23.0), Helplessness (HLP; = 69.3, SD = 12.2), Self-Doubt (SFD; = 72.1, = 7.5), and Anxiety (AXY; = 71.2, =16.9).No elevations were noted for any of the externalizing SPS; see Figure 3. Elevated Interpersonal Problems Scales include Social Avoidance (SAV;  = 67,  =11.4), Shyness (SHY; = 65.3, =11.3).Finally, at the level of abnormal personality pathology (PSY-5), as depicted in Figure 4, Negative Emotionality (NEGE-r;  = 68.2,  = 11.1), Introversion/Low Positive 131Cluster C Personality Disorder as seen from the MMPI-2-RFEmotions (INTR-r; =74.4,  = 12.9) were elevated. Conversely, a low mean score on (instrumental) Aggressiveness (AGGR-r;  = 40,  = 7.5) was noted.Figure 4: MMPI-2-RF Personality Psychopathology Five (PSY-5) Discussionorder broadest level, our results indicate that these patients are likely to experience a emotions, and high negative emotional experiences (e.g. low morale, depression, anxiety, feeling overwhelmed, helpless, and pessimistic). Narrowing down to the core dimensions of psychopathology as captured by the RCs, mean scores in our sample were indicative of individuals who tend to be pessimistic, socially introverted and disengaged, and lacking in energy (RC2); and who tend to be behaviorally inhibited, stress reactive, and prone to excessive worry. They are likely to perceive others as 6132Chapter 6overly critical, and are themselves intropunitive and self-critical and guilt prone (RC7). While these results are fully consistent with a priori conceptual analysis, more surprising was the robust evidence for these patients to experience multiple somatic complaints, including fatigue that may be associated with stress responses (RC1). The may relate to sleep disturbance, fatigue, and low energy (MLS); dizziness and sensory problems (GIC). From the plane provided by internalizing SP scales, particularly the Demoralization-related facets were endorsed (suicidal ideation, hopelessness, feelings of insecurity and inferiority; SUI, HLP, SFD) as well as general anxiety (AXY).As noted, given the nature of personality pathology, the Interpersonal SPS and As expected, elevations were observed for both Social Avoidance (SAV) and Shyness (SHY), indicating that our sample (more than 92% of the general population; i.e. T > 65) do not enjoy social events and avoid social situations and report being shy, easily embarrassed, and uncomfortable around others, respectively. Also, in line with expectation were the elevated scores on NEGE-r and INTR-r, indicating anxiety, insecurity and worry, as well as a lack of positive emotional experiences, interests, asserting themselves (Low AGGR-r).With regards to discriminant validity, it bears mentioning that no elevations were noted for any of the extant indices of thought (THD; RC6, RC8) or behavioral disorders (BXD, RC4, RC9, and its facets at the special problems scale level). In fact, were not elevated) were not elevated, while more trait like facets (Anxiety [AXY], and the success and yield of separating out the general demoralization variance that was core to the original restructuring project (Tellegen et al., 2008).Of theoretical interest are the observed marked elevations on Low Positive met criteria for Avoidant PD, which is often hard to differentiate from generalized 133Cluster C Personality Disorder as seen from the MMPI-2-RFas an anxiety disorder, tends to align itself in studies on latent psychopathology dimensions (e.g. Krueger, 2000) more with the unipolar mood disorders than with the anxiety disorders; the same appears to hold for the present sample of cluster C PD patients.Finally, to offer some speculative theorizing, we surmise that high scores on indices of stress-related somatic complaints may point to an area for further study for or cognitive problems. This may be because of many reasons, not least of which is purposes. In a different diagnostic system, perhaps using dimensions, as opposed to symptom / criteria counts, these symptoms may deserve more attention in describing the psychological functioning of this patient group. The undifferentiated somatic symptoms may harken back to what Freud (Freud, 1914) and other psychodynamic thinkers thought of as so-called in to handle arousal processes in a representational way. Alternatively, they may also be related to the comorbid conditions present in our sample (e.g. about one in three patients suffered from a unipolar mood disorder); these conjectures are in need of further empirical testing.Overall, we believe the present report shows that the MMPI-2-RF provides the clinician with a clinically coherent portrait of cluster C personality pathology that robust elevation of somatic/ cognitive indicators provides an interesting theoretical hypothesis with respect to the nature of the more internalizing personality disorders.6134Chapter 6ReferencesAmerican Psychiatric Association. (2013). . American Psychiatric Association.Anderson, J. L., Sellbom, M., Pymont, C., Smid, W., De Saeger, H., & Kamphuis, J. H. (2015). Measurement of DSM-5 section II personality disorder constructs using the MMPI-2-RF in clinical and forensic samples. , (3), doi:10.1037/pas0000103Ben-Porath, Y. S. (2012). . U of Minnesota Press.786.Ben-Porath, Y.S., & Tellegen, A. (2008/2011). . Minneapolis, University of Minnesota Press.Eaton, N. R., Krueger, R. F., South, S. C., Simms, L. J., & Clark, L. A. (2011). Contrasting that dimensions, but not prototypes, are robust. , (06), 1151-1163. doi:10.1017/S0033291710001650First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. (1997). . American Psychiatric Pub.First, M. B., Gibbon, M., Spitzer, R. L., & Benjamin, L. S. (1997). . American Psychiatric Pub.Kamphuis, J. H., Arbisi, P. A., Ben-Porath, Y. S., & McNulty, J. L. (2008). Detecting comorbid Axis II status among inpatients using the MMPI-2 Restructured Clinical Scales. European Journal , (3), 157-164. Doi:10.1027/1015-5759.24.3.157Lobbestael, J., Leurgans, M., & Arntz, A. (2011). Inter-rater reliability of the Structured Clinical Interview for DSM-IV Axis I disorders (SCID I) and Axis II disorders (SCID II).  (1), 75-79. doi:10.1002/cpp.693135Cluster C Personality Disorder as seen from the MMPI-2-RFSellbom, M., Smid, W., De Saeger, H., Smit, N., & Kamphuis, J. H. (2014). Mapping the Personality Psychopathology Five domains onto DSM–IV personality disorders in Dutch clinical and forensic samples: Implications for DSM–5. Journal of personality assessment, 96(2), 185-191. Doi:10.1080/00223891.2013.825625Tellegen, A., & Ben-Porath, Y. S. (2008). . Minneapolis: University of Minnesota Press.van der Heijden, P. T., Egger, J. I. M., & Derkson, J. J. L (2010). Comparability of scores on the MMPI-2-RF scales generated with the MMPI-2 and MMPI-2-RF booklets. Journal of Personality Assessment, 92, 254-259. Doi: 10.1080/00223891003670208van der Heijden, P. T., Egger, J. I., Rossi, G. M., van der Veld, W. M., & Derksen, J. J. (2013)Personality and psychopathology: Mapping the MMPI-2-RF on Cloninger’s psychobiological model of personality. Assessment, Doi:10.1177/1073191113490791Weertman, A., Arntz, A., & Kerkhofs, M. L. M. (2000). Gestructureerd diagnostisch interview voor DSM-IV persoonlijkheidsstoornissen (SCID II)[Structural and Clinical Interview for DSM-IV personality disorders (SCID II)]. .6

Therapeutic assessment in patients with personality disorders

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Therapeutic assessment in patients with personality disorders

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