The moderating effects of cluster B personality traits on violence reduction training: a mixed-model analysis.

Cognitive behavioral therapies have positive effects on anger and aggression; however, individuals differ in their response to treatment. The authors previously found that dynamic factors, such as increases in readiness to change, are associated with enhanced outcomes for violence reduction training. This study investigated how less dynamic factors, specifically Cluster B personality traits, moderate the effects of violence reduction training. The authors used mixed modeling to fit growth curves to 14 weeks of anger strategies data and evaluated whether the presence of Cluster B traits affected pretreatment anger levels and rates of change. As expected, overall levels of negative anger strategies decreased across the 14-week treatment. Participants with antisocial, borderline, and histrionic personality features reported higher rates of negative anger strategies, whereas those with narcissistic personality features reported fewer negative anger strategies. Those with antisocial personality features improved at a rate similar to the overall trend of those without Cluster B traits. Those with borderline and histrionic features improved at an accelerated rate.

Successful and rapid response to electroconvulsive therapy of a suicidal patient with comorbid bipolar I disorder and histrionic personality disorder.

A woman with bipolar disorder I, histrionic personality disorder, and suicidal ideation with repeated suicide attempts, who had been treated for 2 years with mood stabilizers, antipsychotics, and benzodiazepines, received a total of 8 bitemporal-biparietal electroconvulsive therapy sessions. Her suicidal ideation and self-harm behavior disappeared immediately after the first session and her psychopathology soon after. This supports the existence of a relatively independent suicidal syndrome and confirms data on its immediate responsiveness to electroconvulsive therapy. Electroconvulsive therapy must not be long withheld from patients with such characteristics to reduce unnecessary sufferance and suicidality.

Electroconvulsive therapy in a physically restrained man with comorbid major depression, severe agoraphobia with panic disorder, and histrionic personality disorder.

A 36-year-old man with comorbid panic disorder with agoraphobia, major depression, and histrionic personality disorder since age 21 was resistant to combined drug and psychotherapy treatment. His conditions had progressively worsened with time, causing him to withdraw socially and to simultaneously require continuous physical restraint, which further worsened his functioning. He spent almost 3 consecutive years in restraint, until he consented to receive bilateral ECT treatment. He improved after 13 sessions in all areas (social and role functioning, and panic, depressive, and histrionic symptoms) and is well 3 months later with a lithium-atypical antipsychotic combination.

[Affective dependency and psychiatry: a discord]. / La dépendance affective et la psychiatrie : une mésentente.

INTRODUCTION: The term "loving dependence" is increasingly used by professionals of the relation of help and the patients themselves. It joins in the wider spectre of the interpersonal dependency. More and more patients suffering from this disorder are coming for psychiatric consultation. However, this notion remains vague and absent in the vocabulary of the psychiatrists. Globally, this term describes the functioning of certain patients who present a fear of not being loved and a dependency on another person. The fear of not being loved provokes a fear of abandonment or incites development of strategies to be loved (seduce, help). Dependency on another person is a consequence of the lack of confidence in the capabilities of the individual. The other person reassures them because this person does what the patient is afraid of doing, because he/she does not feel capable. The lack of confidence in own's capabilities can also incite the individual to become a perfectionist and successful. The fear of not being loved and of not being competent is determined partly in the person's childhood. These impressions are real and/or the individuals are hypersensitive. AIM OF THE PAPER: The article describes the emotional, cognitive and behavioural levels, the various types of interpersonal dependency: dependences of type "umbilical cord", "rescuer", "stereotype" and "against dependence". The objective is to specify the concept better on clinical level, with the aim of defining criteria and pathological limits. This is the first stage before beginning rigorous scientific research. The stakes are high. There are relationships with anxiety, depressive disorders, alcoholism, food behaviour disorders, suicide and somatic pathologies. DISCUSSION: Dependency seems to be the consequence of a pathological expression of the normal dimensions of the personality: the need to be loved and valued (admired). The onset of dependency occurs in stages, when the person is weakened by events of life or by depression. The impression not to have been loved and/or valued in childhood is vulnerability. We detail the common points and the differences between the types of described dependences and the diagnostic categories of the DSM. The category-specific classification of the DSM is not adapted to making a diagnosis in these patients. To diagnose a pathological personality, the patient has to be constantly in a functioning of pathological intensity, which is not still the case. This is a real problem, because these clinical situations are very frequent. We defend a dimensional approach of the personality disorders. A meeting between the psychiatry and the relationally dependent person is possible, on one hand in a dimensional classification of personality disorders and, on the other, by working on self-esteem. The relational dependency and self-esteem share the same appearances and the same causes. There are two different names from the same identity.

Effectiveness of outpatient, day hospital, and inpatient psychotherapeutic treatment for patients with cluster B personality disorders.

BACKGROUND: For patients with cluster B personality disorders there is no consensus regarding the optimal treatment setting. The aim of this study was to compare the effectiveness of different psychotherapeutic settings for patients with cluster B personality disorders, i.e. outpatient, day hospital, and inpatient treatment. METHODS: The study was conducted between March 2003 and June 2008 in 6 mental health care centres in the Netherlands, with a sample of 207 patients with a DSM-IV-TR axis II cluster B diagnosis. Patients were assigned to 3 different settings of psychotherapeutic treatment and effectiveness was assessed at 18 months after baseline. An intention-to-treat analysis was conducted for psychiatric symptoms (Brief Symptom Inventory), psychosocial functioning (Outcome Questionnaire-45), and quality of life (EQ-5D), using multilevel statistical modelling. As the study was non-randomised, the propensity score method was used to control for initial differences. RESULTS: Patients in all 3 settings improved significantly in terms of psychiatric symptoms, social and interpersonal functioning, and quality of life 18 months after baseline. The inpatient group showed the largest improvements. The comparison of outpatient and inpatient treatment regarding psychiatric symptoms showed a marginally significant result (p = 0.057) in favour of inpatient treatment. CONCLUSIONS: Patients with cluster B personality disorders improved in all investigated treatment settings, with a trend towards larger improvements of psychiatric symptoms in the inpatient setting compared to the outpatient setting. Specialised inpatient treatment should be considered as a valuable treatment option for cluster B personality disorders, both in research and in clinical practice.

[Hysteria I. Histrionic personality disorder. A psychotherapeutic challenge]. / Hysterie I: Histrionische Persönlichkeitsstörung. Eine psychotherapeutische Herausforderung.

What is left of Freud's hysteria in modern diagnostics is the histrionic personality. Psychological and somatic functional disorders, such as dissociative and somatoform disorders are freed from the label of being hysterical, but even the histrionic personality disorder does not enjoy professional agreement as far as diagnostics and therapy are concerned. This disorder is characterized by dramatization, suggestibility, superficial changing affects, impressionist cognitive style, preoccupation with outward appearance, seductive behavior and the wish to take centre stage, a compensatory attitude resulting from important childhood relationships. A comorbidity with narcissistic and antisocial personality exists and also with ADHS.

A micro-process analysis of Functional Analytic Psychotherapy's mechanism of change.

This study sought to clarify the micro-process of Functional Analytic Psychotherapy (FAP) by using the Functional Analytic Psychotherapy Rating Scale (FAPRS) to code every client and therapist turn of speech over the course of successful treatment of an individual meeting diagnostic criteria for depression and histrionic personality disorder. Treatment consisted of cognitive behavioral therapy alone followed by the addition of FAP techniques in a unique A / A+B design. In-session client behavior improved following the shift to FAP techniques, and micro-process data suggested that client behavior was effectively shaped by in-vivo FAP procedures. These results support FAP's purported mechanisms of change and highlight the advantages of utilizing molecular coding systems to explore these mechanisms.

Assessment and emergency management of suicidality in personality disorders.

This article examines the association between suicidal behavior and personality disorders. It updates the review of epidemiological evidence for the association between suicidal behavior and suicide in individuals who have a personality disorder diagnosis, particularly in borderline personality disorder (BPD). The second part of the article presents new empirical evidence that characterizes suicidal behavior in patients who have BPD, specifically examining patient characteristics that differentiate patients who have BPD with a history of high versus low lethality suicide attempts. Finally, the article discusses the approach to a patient who has BPD and presents to the emergency department because of an increased risk of suicide.

Prediction of medium-term outcome in cluster B personality disorder following residential and outpatient psychosocial treatment.

BACKGROUND: There is a paucity of research concerning the identification of individual characteristics predictive of outcome in the treatment of personality disorders (PDs). METHODS: In this study, we carried out a predictor analysis of a sample of 73 hospitalized patients with a primary diagnosis of cluster B PD admitted to two different psychosocial programs for PD: (a) long-term inpatient treatment, and (b) a step-down program. RESULTS: Younger age, higher Global Assessment Scale intake scores, longer length of treatment, absence of self-mutilation and avoidant PDs were a significant predictor of outcome at 24-month follow-up. Self-harming patients allocated to the step-down program had higher rates of improvement compared with patients allocated to the long-term inpatient model. CONCLUSIONS: The findings may carry potential clinical implications concerning patient selection and treatment delivery for inpatient and outpatient psychosocial programs for cluster B PD. Limitations include a relatively low sample size for a regression analysis, and a larger sample of cluster B patients may be needed to ensure greater reliability of results.

A time series evaluation of the treatment of histrionic personality disorder with cognitive analytic therapy.

The central aim of this study was to assess the effectiveness of cognitive analytic therapy (CAT) with a patient presenting with Histrionic Personality Disorder (HPD). The methodology employed an A/B single case time-series experimental design, with additionally 6 months of continuous follow-up in the experimental measures. Five HPD experimental variables were collected on a daily basis, creating 357 days of continual data for analysis, across various phases of assessment baseline (A), treatment (B) and follow-up. The therapy contract was 24 sessions of CAT, with 4 additional follow-up sessions, spread over the 6-month's post-therapy period. Three out of the five HPD experimental variables (focus on physical appearance, emptiness and child inside) displayed statistically significant phase of treatment effects. Graphing of such data indicated that a 'sudden deterioration' occurred at the point of termination, with eventual recovery and maintenance of the progress made during the intervention. A battery of validated clinical measures were also completed at assessment, termination and final follow-up sessions; analysis of the general measures illustrated clinically significant change, indexing personality integration and reductions to depression. The study is discussed in terms of methodological and clinical limitations, the central importance of process issues and effective termination in HPD, plus the potential utility of CAT in the treatment of HPD presentations.

Characteristic interpersonal behavior in dependent and avoidant personality disorder can be observed within very short interaction sequences.

We present a behavior observation study of interpersonal behavior in 96 female subjects, who had been screened for the presence of dependent, avoidant, narcissistic and histrionic personality disorder features. Each subject took part in three short role-plays, taken from assertiveness training. Afterwards, both the subject and her role-play partner judged, how assertive the subject had been. Although observation time was very short, dependent and avoidant subjects could be easily identified from their overly submissive behavior in the role-plays. Histrionic and narcissistic subjects did not show distinctive interpersonal behavior. Contrary to a common belief, higher scores on some personality disorder (PD) scales were positively related to cross-situational variability of behavior. Results are discussed with regard to their implications for clinical diagnostics, therapy and the methodology of personality disorder research in general.

Distinguishing the drama from the histrionics in a case of hysteria with multiple tics.

The author describes a clinical experience with a hysterical patient with multiple tics, an upper-middle class, married woman, who when she started analysis at the age of 30 was in a state of profound tension and anxiety. The first eight years of this analysis are presented in order to describe how the analyst came to identify the dynamics of unconscious phantasies in a situation where analyst and patient found themselves involved in several roles of a drama dominated by theatrics. The insights and therapeutic benefits suggested that this patient unconsciously experienced her oral needs as intensely destructive and cruel, an experience she felt to have been exacerbated by her mother's lack of response to her emotional needs. This primitive cruel orality was accompanied by a split-off experience of a secret, mystical union with the primitive idealised mother. The author considers that this split experience of cruel and idealised orality suffused the patient's genital sexuality, hindering the evolution and realisation of her adult sexuality, giving her a distorted view of the primal scene as an impenetrable fused amalgam acting as an omnipotent, self-sufficient, excluding phallus. Gradually analysis enabled the patient to transform her bodily theatrics into thoughts and to broach the difficult task of relating to others instead of being either fused with them or totally excluded by them.

Utilización de la hipnosis en el tratamiento de la depresión mayor / The use of hypnosis in depression treatments

Se ha estudiado la efectividad de la terapia cognitivo-conductual aplicada de forma aislada, aplicada bajo relajación y aplicada bajo hipnosis, para el tratamiento de la depresión mayor. La muestra utilizada fueron 21 pacientes, con una edad media de 32,95 años y una desviación típica de 12,43; todos ellos con un diagnóstico de Trastorno Depresivo Mayor con arreglo a los criterios del DSM-IV. Los resultados muestran claramente que la terapia cognitivo-conductual es más efectiva cuando se utiliza combinada con la hipnosis que cuando se utiliza de forma aislada o en combinación con técnicas de relajación. Esta efectividad se manifiesta en todas las variables clínicas estudiadas: Ansiedad, Neurosis Depresiva, Depresión Mayor, Histrionismo y Pensamiento Psicótico (AU)

The effectiveness of cognitive-behavioural therapy was studied under three different conditions: a) only cognitive-behavioural therapy, b) therapy plus relaxation and, c) therapy together with hypnosis. Twenty-one participants were used with age mean of 32,95 years and standard deviation of 12,43. All participants were diagnosed with a major depression according to the DSM-IV criteria. Results clearly show that cognitive-behavioural therapy is more effective when applied under hypnosis conditions. This effectiveness of the cognitive-behavioural therapy under hypnosis conditions was obtained for all clinical variables studied Anxiety, Depressive Neurosis, Major Depression, Histrionics, Psychotic Thinking (AU)

Psychotherapy for histrionic personality disorder.

The author uses a configurational analysis method for case formulation and to establish links between individualized formulation and treatment techniques. A prototype of formulation for the histrionic personality disorder is presented, using theories for formulation about states of mind, defensive control processes, and person schemas. A phase-oriented prototype of a treatment plan is linked to these levels of formulation. The result can provide a guideline for clinicians and a teaching document for trainees.

'How can we know the dancer from the dance?': hyperbole in hysteria.

In this paper the author discusses histrionic or hyperbolic behaviour, which she regards as specific to a certain type of hysterical character. Histrionic hysteria she sees as a pathological organisation. With the use of two clinical examples she examines the phenomenon of hyperbole or exaggeration and suggests that they convey a picture of the patient's internal objects and his relationship to them. Exaggeration can also be used by the patient to distance himself from what is going on in his mind and yet to make the object--the analyst in the session--aware of unrecognised emotions. To study hyperbolic behaviour the author constructs a model in which she divides manifestations of this type of behaviour into three parts; 'the observing self, the acting self and the audience' and examines the different identifications that are at the basis of each part. She considers that these areas of the personality encapsulate fragmenting processes that are continually active and threatening the patient. An exploration of this division into three areas should facilitate and deepen understanding of the processes involved in histrionic behaviour.

[Diagnosis, symptoms and follow-up of psychogenic tremor]. / Diagnose, Symptomatik und Verlauf des psychogenen Tremors.

A total of 21 patients with psychogenic tremor (PT) were asked to take part in a neurologic and psychosomatic assessment; for 17 patients follow-up information was also recorded. Women out-numbered men in the sample. In the majority of patients the tremor was associated with a variety of other conversion symptoms. The clinical picture of the tremor varied. After beginning exclusively in the extremities, it tended to spread to other parts of the body. Other psychopathology (depression and histrionic personality disorder) existed in almost a third of the sample. Many patients had retired from professional life, or planned to do so in the near future, because of PT. At follow up the initial diagnosis was confirmed in all patients although in some patients additional physical illness had developed during the follow-up period. When neurological and psychiatric/psychosomatic criteria are applied the diagnosis of PT can be established reliably. Studies that have questioned the validity of the conversion concept on the basis of frequent misdiagnoses may indicate problems in the diagnostic procedure rather than an invalid theoretical construct.

Paradise lost: a case of hysteria illustrating a specific dynamic of seduction trauma.

This paper presents extensive clinical data illustrating the case of a middle-aged woman, who as a child participated in an extended sexual relationship with her elder brother. The patient suffered from an hysterical personality disorder with somatic distress and a compulsion to repeat disastrous social and work situations. In her treatment, the patient re-enacted the seduction and subsequent experience in various ways. The analysis and understanding of her symptoms, social problems and re-enactments in the transference strongly suggested that the trauma of her seduction was the result of the loss of precociously stimulated and experienced pleasure rather than loss of impulse control. The compulsion to repeat apparently represented the wish not only to master, but the desire to return to the pleasure of the experience as a true compromise formation. Although many other dynamics were of course operative, interpretations of her wish to recreate the lost pleasures were most helpful.