Personalidad, afecto y estilo de afrontamiento: interacciones en trastorno de personalidad grave / Personality, Affect, and Coping Style: Interactions in Severe Personality Disorder

Interiorización y exteriorización han sido estudiados como tendencias o rasgos de la personalidad, próximos a los conceptos de neuroticismo y extraversión, relacionados con la estructura bifactorial del afecto y con el estilo de afrontamiento. Este trabajo examina su interacción en personas con trastorno de personalidad (n= 358). El afecto negativo (AN) es superior en los interiorizadores que en los exteriorizadores (g= 0,62); también la gravedad sintomatológica (GSI: g= 0,60). Los análisis de mediación muestran que el efecto del tipo de personalidad sobre el GSI está mediado parcialmente por la disposición afectiva y por el estilo de afrontamiento. El 88,1% de la muestra presenta un estilo de afrontamiento desfavorable y su frecuencia es mayor entre los interiorizadores (93% vs 83%; χ2= 7,23; p= 0,007). Pero el subgrupo de interiorizadores con estilo de afrontamiento favorable (EAF) no se diferencia de los exteriorizadores con EAF en AN (p= 0,428) ni en GSI (p= 0,082). Independientemente de la estructura de la personalidad, el aprendizaje de estrategias favorables y adaptativas puede mejorar el estado psicopatológico de pacientes graves (AU)

The concepts of internalization and externalization have been proposed as personality tendencies or traits related to the constructs of neuroticism and extraversion. They have been associated to the bifactorial structure of affect and also to the coping style. This paper examines the interaction of personality, affect and coping in a sample of people diagnosed with personality disorder (n= 358). Negative affect (NA) in internalizers is higher than in externalizers (g= 0.62), and so is the severity of symptoms (GSI: g= 0.60). Mediation analyses show that personality type produces an indirect effect on GSI, with NA and coping style as partial mediators. 88.1 % of the sample has an unfavourable coping style (U-CS). The frequency of U-CS among internalizers is bigger than among externalizers (93% vs 83%; χ2= 7.23, p= .007). However, the subgroup of internalizers with a favourable coping style (F-CS) shows no difference with externalizers with the same F-CS, either in NA (p= .428) or in GSI (p= .082). Regardless of personality structure, promoting adaptive strategies of coping can alleviate the psycopathology of severe patients (AU)

La Personalidad como Vulnerabilidad Unidimensional y Bidimensional: el Papel Mediador de las Variables Cognitivas en la Gravedad Sintomatológica en una Muestra de Personas con Trastorno Grave de Personalidad / Personality as unidimensional and bidimensional vulnerability: The mediator role of cognitive variables in symptom severity in a sample of people with severe personality disorder

Los problemas de conceptualización de los trastornos de personalidad (TP) y su acomodo con el resto de las patologías siguen suscitando un prometedor esfuerzo investigador y clínico que va dando frutos al identificar procesos transdiagnósticos y proponer modelos heurísticos de interacción. Desde el marco de la personalidad como diátesis, estudiamos en una muestra de personas con TP grave (N = 310) el papel mediador de diversas variables en la gravedad sintomatológica. Mediante análisis de conglomerados hallamos una tipología bidimensional que divide de manera exhaustiva y exclusiva al 100% de los participantes. El análisis de mediación revela que el efecto de la personalidad como continuum unidimensional en gravedad sintomatológica está mediado por pensamientos automáticos negativos y fusión cognitiva; su efecto como tipología bidimensional (internalización y externalización) parece mediado solo por pensamientos automáticos. Se discuten los hallazgos e implicaciones de cara al nuevo paradigma de una ciencia clínica basada en procesos

The problems of conceptualization of personality disorders (PD) and their adjustment within the rest of pathologies continue to boost a promising research and clinical effort that helps to identify transdiagnostic processes and suggestheuristic interaction models. Understanting personality from the framework of diathesis, we analized the mediating role of a number of variables in symptom severity in a sample of people with severe PD (N = 310). By means of cluster analysis, we found a two-dimension typology that divides exhaustively and exclusively 100% of the participants. Mediation analyses found that personality as a one-dimension continuum has an effect on symptomatic severity mediated by negative automatic thoughts and by cognitive fusion; its effect as a two-dimension typology (internalization and externalization) appears to be mediated only by automatic thoughts. These findings and their implications are discussed in the context of a new paradigm of a process-based clinical science

Differential Outcome of a Therapeutic Community Program for Internalizing and Externalizing Personality Disorders: A Change in Cognitive Processes Mediates Symptom Improvement / Eficacia diferencial para internalizadores y externalizadores de un programa de comunidad terapéutica para trastornos de personalidad

The identification of transdiagnostic mediating processes involved in a therapeutic change and their relationship with personality can contribute to a better adjustment of a therapeutic technique, enhancing its effectiveness. In a sample of 158 adults diagnosed with personality disorder who complete an inpatient therapeutic community program for 6 months, the hypothesis of a differential reduction in symptom intensity according to the externalizer/internalizer typology is tested, and cognitive variables mediating change are explored. A pre-post change (p = .000, etap2 = .50) is observed, along with a difference between externalizers and internalizers (p = .002, etap2 = .06), and an interaction effect (p = .037, etap2 = .03). The effect of personality type on symptom change (Beta = .43, p = .009) is no longer significant when negative automatic thoughts and dysfunctional attitudes are considered as mediators (Beta = .06, p = .549). Findings are discussed from the perspective of personality disorder as a vulnerability factor

La identificación de procesos mediadores transdiagnósticos intervinientes en el cambio terapéutico y su relación con la personalidad puede contribuir a un mejor ajuste de la técnica terapéutica, potenciando su eficacia. En una muestra de 158 adultos diagnosticados de trastorno de personalidad inscritos en un programa de comunidad terapéutica hospitalaria durante 6 meses se pone a prueba la hipótesis de una reducción diferencial de laintensidad sintomatológica según la tipología externalizador/internalizador y se exploran las variables cognitivas mediadoras del cambio. Se observa un cambio pre-post (p = .000, Etap2 = .50), la diferencia entre externalizadores e internalizadores (p = .002, Etap2 = .06) y el efecto de interacción (p = .037, Etap2 = .03). El efecto del tipo de personalidad sobre el cambio en los síntomas (Beta = .43, p = .009) deja de ser significativo cuando se consideran los pensamientos automáticos negativos y las actitudes disfuncionales (Beta = .06, p = .549) como mediadores. Se discuten los resultados desde la perspectiva del trastorno de personalidad como factor de vulnerabilidad

Fusión Cognitiva en Trastornos de Personalidad: una Contribución a la Investigación sobre Mecanismos de Cambio / Cognitive fusion in personality disorders: A contribution to research on mechanisms of change

Diversos abordajes terapéuticos para personas con trastorno de personalidad (TP) postulan diferentes mecanismos de cambio. Investigamos si el constructo fusión cognitiva (FC) es relevante en el cambio terapéutico detectado en un grupo de personas diagnosticadas de TP grave (N = 110) tras 6 meses de intervención hospitalaria. Su nivel de FC es superior al de otras muestras publicadas (M = 38.5, DT = 8.98) y se asocia a mayor patología. Está relacionado con otros constructos como pensamientos automáticos (r = .529; p < .01) y actitudes disfuncionales (r = .368, p < .01). La FC se reduce tras el tratamiento (t = 4.897, p = .000, d = 0.65), pero no se confirma el supuesto del efecto obstaculizador de la FC sobre el cambio sintomático en la depresión, la perturbación global o la gravedad del TP. Se discuten los hallazgos en el contexto del solapamiento de variables como posible explicación de la constatación de que diferentes terapias produzcan beneficios similares y como acicate para seguir construyendo una práctica terapéutica basada en la evidencia

Different therapeutic approaches for people with personality disorder (PD) hypothesize different mechanisms of change. We studied whether the cognitive fusion (FC) construct is relevant in the therapeutic change identified in a group of people diagnosed with severe PD (N = 110) after 6 months of intervention. The FC level is higher than that of other published samples (M = 38.5, SD = 8.98) and is associated with a more serious pathology. FC is related to other constructs such as automatic thoughts (r = .529, p < .01) and dysfunctional attitudes (r = .368, p < .01). The FC level is reduced after treatment (t = 4.897, p = .000, d = 0.65), but the hypothesized hindering effect of FC on the symptomatic change in depression, global disturbance, or severity of TP is not supported. The findings are discussed in the context of the overlapping of variables as a possible explanation for the observation that different therapies produce similar benefits and as an incentive to continue building an evidence-based therapeutic practice

Influence of Core Affect in the Differential Efficacy of a Personality Disorder Intervention Program.

The usual emotional experience of the person (affective style) is an influential factor in therapeutic assimilation. Based on a dynamic model of affect shaped dimensionally by the valence and arousal axes (core affect) that fluctuate over time according to the specific context of the individual, its relationship with different variables was investigated and the changes after a 6-month intervention in a specialized hospital unit (N = 103) were observed. The orthogonal structure of core-affect was confirmed. Emotional valence appeared to be positively related to social skills (r = .375; p < .01) and self-esteem (r = .491; p < .01) and negatively to depressive symptoms (r = -.631; p < .01), general disturbance (r = -.395; p < .01) and suicidality (r = -.490; p < .01). Emotional arousal is associated with impulsivity (r = .345; p < .01). The group of patients with an affective style characterized by negative valence and low arousal core-affect gained less therapeutic benefit compared to those with positive valence core-affect (p < .05). Throughout the treatment, valence became more positive (d = .26; IC 95%: 1.9 - 7.2; p = .001), arousal increased (d = .23; IC 95%: 0.2 - 1.7; p = .015) and variability decreased (d = -.44; IC 95%: (-2.9) - (-1.1); p = .001). Changes in the core-affect are related to therapeutic improvement. Adjusting expectations of change can reduce therapeutic frustration, which is as common as it is harmful in the treatment of severe personality disorders.

Gravedad y cambio en los trastornos de la personalidad / Severity and change in personality disorders

El variado curso que caracteriza la evolución de los trastornos de la personalidad (TP) y la respuesta diversa de los pacientes a las intervenciones terapéuticas hacen que el concepto de gravedad de los TP esté en el debate actual de clínicos e investigadores. En un trabajo previo (Ramos, Sendra, Sánchez y Mena, 2015) propusimos un índice de gravedad basado en el solapamiento de rasgos patológicos; ahora analizamos el cambio en gravedad tras un tratamiento especializado de 6 meses. En 93 pacientes que completaron el programa (51,4% de la muestra total) hallamos una reducción de la perturbación general (d= 1,193) y afectiva (d= 0,990), de rasgos de TP y de gravedad (d= 0,753). Sin embargo, no aparecen efectos de interacción entre cambio y gravedad, ni ésta predice por sí sola el resultado terapéutico. Se discuten los datos a la luz de otros hallazgos. La estabilidad de los TP no parece residir en el cumplimiento de criterios diagnósticos, sino en un núcleo de vulnerabilidad compartido por todos los pacientes, independientemente de su categorización prototípica y de su fluctuación sintomatológica

The varied course of evolution of personality disorders (PD) and patients’ different responses to therapeutic interventions position the concept of severity of PD amongst the greatest concerns to clinicians and researchers. In a previous study (Ramos, Sendra, Sánchez, & Mena, 2015) we proposed an index of severity of PD based on the overlap of pathological traits; now we analyze the change in severity after 6 months of specialized treatment. In 93 patients who completed the program (51.4% of the total sample) we found a reduction in general (d=1.193) and affective (d= 0.990) disturbance, also in PD traits and severity (d=0.753). Nevertheless, interaction effects between change and severity did not appear; neither did severity by itself predict therapeutic results. We discuss the data in the light of other findings. The stability of the PD does not seem to reside in the fulfillment of diagnostic criteria, but in a core of vulnerability shared by all the patients, independently of the prototypical categorization and the symptomatology fluctuation

Influence of core affect in the differential efficacy of a personality disorder intervention program

The usual emotional experience of the person (affective style) is an influential factor in therapeutic assimilation. Based on a dynamic model of affect shaped dimensionally by the valence and arousal axes (core affect) that fluctuate over time according to the specific context of the individual, its relationship with different variables was investigated and the changes after a 6-month intervention in a specialized hospital unit (N = 103) were observed. The orthogonal structure of core-affect was confirmed. Emotional valence appeared to be positively related to social skills (r = .375; p < .01) and self-esteem (r = .491; p < .01) and negatively to depressive symptoms (r = -.631; p < .01), general disturbance (r = -.395; p < .01) and suicidality (r = -.490; p < .01). Emotional arousal is associated with impulsivity (r = .345; p < .01). The group of patients with an affective style characterized by negative valence and low arousal core-affect gained less therapeutic benefit compared to those with positive valence core-affect (p < .05). Throughout the treatment, valence became more positive (d = .26; IC 95%: 1.9 - 7.2; p = .001), arousal increased (d = .23; IC 95%: 0.2 - 1.7; p = .015) and variability decreased (d = -.44; IC 95%: (-2.9) - (-1.1); p = .001). Changes in the core-affect are related to therapeutic improvement. Adjusting expectations of change can reduce therapeutic frustration, which is as common as it is harmful in the treatment of severe personality disorders (AU)

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Pertubación sintomática general y afectiva en los trastornos de la personalidad: influencia de la gravedad frente al tipo de trastorno / General and affective symptoms disturbance in personality disorder: influence of severity vs. type of disorder

Diversos modelos centrados en la gravedad del trastorno de personalidad (TP) se erigen como alternativa a los tradicionales planteamientos categoriales, confirmando su alto valor predictivo en la evaluación del funcionamiento social y en la comorbilidad con otros trastornos. En este trabajo examinamos la relación entre gravedad del TP (acumulación de diferentes rasgos de personalidad patológica e intensidad de cada uno de ellos) y grado de malestar sintomático en una muestra de 142 pacientes. El análisis bivariante confirma en el grupo de alta gravedad un mayor nivel de perturbación general (p= 0,013) y afectiva (p= 0,036). El análisis multivariante detecta, sin embargo, que la intensidad de rasgos esquizotípicos, autodestructivos y pasivo-agresivos explica la perturbación sintomática mejor que la acumulación de rasgos de personalidad patológica. Se discuten estos hallazgos en el contexto de la complejidad conceptual y evaluativa del constructo TP. La búsqueda de un índice adecuado de gravedad sigue pendiente en el esfuerzo por mejorar la planificación y una provisión objetiva de recursos sociosanitarios

Several models focused on the severity of personality disorders (PD) have been proposed as an alternative to the traditional categorical approach, confirming their high predictive value in the evaluation of social functioning and comorbidity with other disorders. In this work, we examined the relationship between personality severity (accumulation of different traits of pathological personality and intensity of each of them) and degree of symptomatic disturbance in a sample of 142 patients. The bivariate analysis confirms that the high personality severity group has higher level of affective (p= .036) and general (p=.013) disruption. However, multivariate analysis found that the intensity of schizotypal, self-destructive and passive-aggressive traits explains symptomatic disturbance better than the accumulation of traits. These findings are discussed in the context of conceptual and evaluative complexity of the personality disorder construct. The search for an appropriate index of severity is still pending in the effort to improve the planning and objective provision of social and health resources