Diagnóstico y formulación de casos en terapia psicodinámica: una revisión sobre herramientas actuales.

En las últimas dos décadas, diversos grupos de trabajo de la comunidad psicoanalítica internacional se han interesado por el desarrollo de herramientas sistemáticas para el diagnóstico, la formulación de los casos y la planificación del tratamiento psicodinámico. Este tipo de manuales diagnósticos psicodinámicos son esfuerzos de integración sistemática de una enorme y rica cantidad de información históricamente parcializada y dispersa, pero que constituye el aporte sustancial del psicoanálisis al campo de la salud mental. El objetivo del presente artículo es ofrecer una revisión actualizada sobre esta clase de herramientas sistemáticas de diagnóstico, formulación del caso y planificación terapéutica, diseñadas para el campo de los abordajes psicodinámicos. A estos fines, se describe la estructura y los objetivos de: 1) el Manual Diagnóstico Psicodinámico 2 (PDM-2), 2) el Diagnóstico Psicodinámico Operacionalizado (OPD-2/OPD-3) y 3) el Diagnóstico Psicodinámico Operacionalizado Infanto-Juvenil 2 (OPD-IJ-2).Se discuten las contribuciones de estas herramientas actuales para la práctica clínica y la investigación empírica, así como la necesidad de difundir este tipo de instrumentos en nuestro contexto regional.

Impact of personality style changes on CBT and PDT treatment responses in major depression.

This study examines the influence of depressive personality styles on treatment responses in patients with major depression receiving cognitive behavioural therapy and psychodynamic therapy. We assessed changes in personality styles, including dependency, self-criticism, sociotropy, and autonomy, and their association with treatment response. Both treatment modalities led to significant reductions in self-criticism and sociotropy scores. Depressive symptom severity decreased overall, with a more pronounced reduction observed in the cognitive behavioural therapy group. Notably, reduced self-criticism and sociotropy were associated with better treatment outcomes in the cognitive behavioural therapy group. Our findings highlight the role of personality styles in influencing treatment outcomes for major depression. The study suggests an association between changes in personality styles and the reduction of symptoms. Our results support the idea that unique pathways of change are activated depending on the therapeutic intervention. These insights are critical in tailoring treatments to individual needs, addressing the central question of 'what works for whom'.

Changes in mentalization in patients with personality disorders during sequential brief-Adlerian psychodynamic psychotherapy: The role of therapists' technique and countertransference.

Mentalization, that is the capacity to understand our and others' behaviors in terms of intentional mental states, represents one of the core features of personality disorders (PDs) and can be related to therapists' countertransference (CT) and interventions. AIMS: The aim of the present work was to study the relationship between therapists' technique, therapists' CT, and patients' mentalization, in a sample of patients with PDs undergoing a 40-session program of sequential brief-adlerian psychodynamic psychotherapy, a psychodynamic therapeutic model specifically developed for the treatment of PDs in public mental health services. METHOD: Eighty-seven patients with PD and their therapists completed ratings of mentalization (mentalization imbalances scale and reflective functioning questionnaire), CT (therapist response questionnaire), and therapists' intervention (comparative psychotherapy process scale) at five different time points (Sessions 5, 10, 20, 30, and 40). RESULTS: Results showed that patients' mentalizing problematics decreased over time. Moreover, we found a reduction of therapists' disengaged CT, and an increase in positive CT over time. Regarding therapists' techniques, psychodynamic-interpersonal interventions were on average higher than cognitive-behavioral, but both techniques were used increasingly over time. Our results also showed significant and clinically coherent interactions between therapist's CT and techniques and between patient's mentalization imbalance and therapist's response. Our results highlighted the importance of early stages in therapy, since the most significant relationships between the various process variables (patient's mentalizing imbalances, therapist's techniques, and emotional responses) are observed between t1 and t2, corresponding to the initial phases of the treatments. Clinical implications will be discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

When one tool is not enough: An integrative psychotherapeutic approach to treating complex PTSD.

Complex posttraumatic stress disorder (CPTSD) is a term representing the psychopathological implications of exposure to chronic, inter-personal trauma. These include the main symptoms of PTSD, as well as changes in identity, emotion regulation, and inter-personal relationships. Self-harm and dissociation (i.e., disintegration of mental processes) are also quite common in CPTSD. Considering this complex and often severe clinical picture, mental health professionals often find it difficult to effectively treat CPTSD. In this paper, we present an integrative approach to the treatment of CPTSD based on a combination of techniques from several psychotherapy approaches. The case described here illustrates the need for therapeutic flexibility and eclecticism when treating individuals exposed to chronic trauma. We show the advantages of flexible therapeutic attunement, which enables the therapist to respond to the changing need of the patient, as well as her fluid clinical picture and symptom manifestation. The case also illustrates how interventions taken from psychodynamic therapy, Dialectical behavior therapy, and Eye Movement Desensitization and Reprocessing may be applicable in various stages of treatment, alleviating the patient's distress in several psychological and physical domains.

The predictive value of cortisol in psychodynamic psychotherapy for social anxiety disorder: Extended results of the SOPHONET-Study.

Psychotherapy is an effective treatment for anxiety disorders (AD), yet a vast majority of patients do not respond to therapy, necessitating the identification of predictors to enhance outcomes. Several studies have explored the relationship between stress response and treatment outcome, as a potential treatment mechanism. However, the latter remains under-researched in patients with social anxiety disorder (SAD). We studied N = 29 patients undergoing psychodynamic psychotherapy (PDT) within the SOPHONET-Study. Stress reactivity (i.e., area under the curve with respect to the increase; AUCi) was induced by a standardized psychosocial stressor (Trier Social Stress Test; TSST) and assessed by means of adrenocorticotropic hormone (ACTH), blood and salivary cortisol samples before (t1) treatment. Samples of these biomarkers were taken -1 min prior stress exposure and six more blood samples were collected post-TSST ( + 1, + 10, + 20, + 30, + 45, + 60 min.). The participants were diagnosed with SAD based on the Structured Clinical Interview for DSM-IV (SCID) and completed the Liebowitz Social Anxiety Scale as well as the Beck Depression Inventory before (t1) and after psychotherapy (t2). Pre-treatment stress reactivity significantly predicted changes in depression (salivary p < 0.001 and blood cortisol p = 0.001), as well as in avoidance behavior (blood cortisol p = 0.001). None of the biomarkers revealed significant results in fear or in the total LSAS-scores, except for ACTH with a trend finding (p = 0.06). Regarding therapy success, symptoms of social anxiety (p = 0.005) and depression (p < 0.001) were significantly reduced from pre (t1) to post-treatment (t2). Our study showed that stress reactivity pre-treatment may serve as a predictor of psychotherapy outcome. In this regard, alterations in stress response relate to changes in symptoms of social anxiety and depression after PDT. This implies that patients with chronic stress might benefit from a targeted interventions during psychotherapy, especially to manage fear in social contexts.

Therapist contribution, client reflective functioning, and alliance rupture-repair: A microprocess case study of psychodynamic therapy for pregnancy after loss.

Meta-analysis has found a significant relation between rupture-repair and client outcome (Eubanks et al., 2018). Rupture-repair processes may be particularly important in psychotherapy for pregnancy loss wherein ruptures related to client feelings of shame and inadequacy, the societal invalidation of perinatal grief, and reenactments in the therapy relationship of early attachment experiences have been theorized to be common and important events (Markin, 2024). Thus, it is important to understand what occurs on a microlevel during the process of therapy to ultimately explain the rupture resolution (RR) and treatment outcome association. In particular, while both the therapist and client are believed to contribute to ruptures and to their repair (Safran & Muran, 2000), little is known about how therapist contributions impact rupture events, rupture resolution, and treatment progress. Further, client reflective functioning (RF) may represent a set of capacities that contribute to and are increased by rupture resolution yet vary depending on the role of the therapist in the rupture. The current investigation examined how observer-rated therapist contribution to ruptures and client RF were related to rupture events, rupture resolution, and client-reported symptom change and session quality over 22 sessions of psychodynamic therapy for pregnancy after loss. Therapist contribution to ruptures predicted rupture significance, high and steady within-session client RF scores, and symptom change. Client RF and rupture resolution predicted symptom change differently, often depending on type of symptom. Importantly, client RF and rupture resolution may predict successful outcomes through ameliorating commonly reported symptoms during pregnancies after loss. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Character Change in Less Frequent Therapies: Psychodynamic and Transference Implications.

An approach to a once-weekly, or bimonthly (every second week), ongoing psychodynamic psychotherapy is described. The detailed description of individual sessions is intended to show the process of the uncovering of unconscious phenomena using this approach, though the therapies described are not complete. Important changes that have already occurred are described. The approach is characterized by a direct method of discovery of early painful situations that underlie specific problematic experiences in the present. The therapeutic stance is designed to establish a collaborative relationship with the patient that becomes the substrate of the relationship and often leads to an identification with the therapist who becomes an ongoing presence in the patient's life.

Aggression in Psychodynamic Psychotherapy and Supervision: Becoming a More Effective Therapist.

Access to one's healthy aggression is critical for both patient and therapist. On the patient's end, the ability to access and modulate aggression is fundamental to the establishment of healthy self-esteem and the capacity to sustain relationships and pursue life goals. On the therapist's end, access to aggression allows for the setting of a secure therapeutic frame and the subsequent conduct of the deep work of therapy. Conversely, lack of access to aggression creates burdensome and problematic situations that may subvert the treatment. Beginning therapists have a particular susceptibility to minimize their own aggression given certain factors in their choice of profession. Supervisors' modeling of the experience of aggression, as well as the provision of a safe atmosphere in which new clinicians become comfortably aware of their own and their patients' aggression, will help fortify beginning therapists' capacity to harness their aggression in the service of the work.

Psychodynamic Psychiatry and the Care of Persons with Vision Loss and Blindness.

The authors describe the clinical relevance of the psychiatric concept of bidirectionality when caring for persons with comorbid disorders, and they propose a psychodynamic framework to guide the treatment of persons with vision loss and blindness. Since persons with vision loss have an increased risk of depressive and anxiety disorders, they recommend targeted screening, integrated services, and a biopsychosocial approach to clinical care. The psychoanalytic concept of aphanisis, first described by Ernest Jones and later developed by Lacan and Kohut, is briefly discussed. Common psychotherapy themes in the treatment of persons who experience vision loss from systemic illness include reactivation of memories of past traumas resulting in avoidance, social withdrawal, depressive states, catastrophic thinking, a sense of foreshortened future, anhedonia, and fear of disintegration and invisibility. Psychotherapy also serves to correct negative introjects from ableist societal attitudes.

A practice-based study of relational virtues and alliance correspondence in psychodynamic psychotherapy.

OBJECTIVE: Treatment outcome monitoring typically emphasizes pathology. In contrast, we responded to the need to establish psychodynamic psychotherapy as evidence-based by modeling changes in gratitude and forgiveness. METHOD: We utilized a practice-based research design involving non-manualized outpatient treatment. We employed a longitudinal mixture modeling approach to evaluate treatment effectiveness. We did so by testing the theorized role for relational virtues (i.e., gratitude, forgiveness) as signs of progress in psychodynamic treatment, with relational virtues referring to the application of character strengths to specific situations. We modeled clients' self-reported level on the virtues as a joint process over five time points, and examined the influence of early treatment alliance correspondence on patterns of change using a sample of outpatient clients (N = 185; Mage = 40.12; 60% female; 74.1% White). RESULTS: A 3-class solution best fit the data, with one class exhibiting growth in gratitude and forgiveness, improved symptoms, and a greater likelihood of symptom improvement relative to well-being gains. Alliance correspondence predicted the classes of change patterns, with greater similarity between clinicians' and clients' perceptions about the alliance predicting greater likelihood of belonging to the subgroup showing highest levels of virtues and well-being, lowest symptoms, and improved well-being. CONCLUSION: Clinical implications involve monitoring gratitude and forgiveness as signs of progress and navigating the dialectic between implicit alliance processes and explicit virtue interventions. The former involves nurturing a strong alliance and repairing ruptures, whereas the latter involves direct in-session conversation and/or the practice of virtue interventions in and/or outside of session.

The effect of individual short- and long-term psychotherapy on perceived social support: analysis of secondary outcomes of a randomized clinical trial.

PURPOSE: Social support is important for maintaining and restoring psychological well-being but the effects of individual psychotherapies on perceived social support are not well known. In this analysis of secondary outcomes from a randomized clinical study, we compared the effects of long-term psychotherapy and two short-term psychotherapies on social support during a 5-year follow-up. MATERIALS AND METHODS: Altogether 326 adult outpatients suffering from depressive and/or anxiety disorders were randomly assigned to long-term psychodynamic psychotherapy (LPP, n = 126), short-term psychodynamic psychotherapy (SPP, n = 101) and solution-focused therapy (SFT, n = 97). Outcome was measured by the global index and six subscores of the self-reported Brief Inventory of Social Support and Integration scale (BISSI) at baseline and at 1, 2, 3, 4 and 5 years after the beginning of the therapy. RESULTS: Social support improved in all therapy groups and the improvement was relatively stable, lasting several years after the end of therapy. Little difference in improvement was observed either between therapy orientations or durations. CONCLUSIONS: While no major differences were observed between treatment groups, the slight differences call for further research to verify these findings and to better understand how different therapies may improve perceived social support.

The equivalence of psychodynamic therapy and cognitive behavioral therapy for depressive disorders in adults: A meta-analytic review.

BACKGROUND: Meta-analyses on the relative efficacy of psychodynamic psychotherapy (PDT) and cognitive behavioral therapy (CBT) for depressive disorders are limited by heterogeneity in diagnostic samples and comparators and a lack of equivalence testing. OBJECTIVE: We addressed this through a meta-analytic test of the equivalence of manualized PDT and CBT in treating adults with depressive disorders as determined by diagnostic interviews. Sensitivity analyses evaluated the impact of pretreatment differences, mixed diagnostic samples, author allegiance, study quality, year of publication and outliers on findings. METHOD: A comprehensive literature search across multiple databases using reliable screening methods identified nine randomized controlled trials directly comparing manualized PDT and CBT for diagnosed depressive disorders in adults. Following pre-registration, we employed random effect models for our meta-analyses and two one-sided test procedures for equivalence testing. RESULTS: Independent raters determined that all studies were of adequate quality. Immediately posttreatment, depressive symptoms were statistically equivalent across PDT and CBT (k = 9; g = -0.11, 90% confidence interval [90% CI]: -0.24 to 0.02, pequivalence = .048, pNHST = .212, I2 = 32.7). At follow-up, the longest time point within a year, depressive symptoms were neither statistically equivalent nor statistically different (k = 6; g = -0.16, 90% CI: -0.31 to -0.02, pequivalence = .184, pNHST = .126, I2 = 0.00). CONCLUSION: The efficacy of manualized PDT is equal to manualized CBT immediately at posttreatment for depressive disorders in the adult general population. Nevertheless, insufficient data exists to reach a conclusion regarding equivalence at follow-up.

Short-term Psychodynamic Psychotherapy in Addition to Standard Medical Therapy Increases Clinical Remission in Adolescents and Young Adults with Inflammatory Bowel Disease: a Randomised Controlled Trial.

BACKGROUND: Inflammatory bowel diseases [IBD] are chronic and pervasive conditions of the gastrointestinal tract with a rising incidence in paediatric and young adult populations. Evidence suggests that psychological disorders might be associated with relapse of disease activity. This study aims to evaluate the efficacy of short-term psychodynamic psychotherapy [STPP] in addition to standard medical therapy [SMT] in maintaining clinical remission in adolescents and young adults [AYA] with quiescent IBD, compared with SMT alone. METHODS: A two-arm, single-centre, randomised, controlled trial was conducted in 60 IBD AYA in clinical remission. Patients were randomised to receive an 8-week STPP + SMT [n = 30] or SMT alone [n = 30]. The primary outcome was the steroid-free remission rate at 52 weeks after treatment. Secondary outcomes included the overall hospitalisation rate within 52 weeks after treatment, and medication adherence obtained from patient's electronic medical records. RESULTS: Intention-to-treat analysis showed significant improvement in maintaining disease remission rates in the 8-week STPP + SMT group compared with the control one. The proportion of patients maintaining steroid-free remission at 52 weeks was higher in patients in STTP group [93.1%] compared with patients randomised to control group [64.3%; p = 0.01]. There were no significant differences in secondary outcomes, except for depression reduction in STPP + SMT group. CONCLUSIONS: An 8-week STPP intervention in addition to SMT effectively increases the steroid-free remission rates in AYA with quiescent IBD. Results do not support effects for other secondary outcomes, except for depression reduction.

Effects of panic-specific cognitive behavioural and psychodynamic psychotherapies on work ability in a doubly randomised clinical trial.

Objective: The effects of panic-specific psychotherapy on occupational functioning remain under-researched. This study tests whether two brief psychotherapies for Panic Disorder with or without Agoraphobia (PD/A) may generate improvement in work ability. Methods: Adults (N = 221) with a primary diagnosis of PD/A were randomised to wait-list, panic-focused psychodynamic psychotherapy (PFPP), panic control treatment (PCT), or to the choice between the two treatments. Participants completed the Work Ability Inventory (WAI) at baseline, post-treatment, and during 24-month follow-ups. Change in WAI scores were assessed using segmented multilevel linear growth models, and mediation was explored through path analysis. Results: WAI scores changed from the moderate to good range between baseline and post-treatment (SMD = 0.45; 95% CI [0.33, 0.57]) and continued to increase throughout the follow-up (SMD = 0.16; 95% CI [0.03, 0.28]) with no differences between treatments or allocation forms. In PFPP (but not in PCT) pre- to post-treatment change in WAI was mediated by reduction in panic symptoms and WAI predicted employment status and absences. Conclusions: Two brief panic specific psychotherapies, one cognitive behavioural and one psychodynamic, produced short and long-term increases in work ability.

Development of a psychotherapy process prototype for the Real Relationship.

OBJECTIVE: The Real Relationship (RR) describes the aspect of the psychotherapy relationship that is based on a genuine connection and a realistic view between patient and therapist. In the current study, we aimed to develop a Psychotherapy Process Q-set (PQS) prototype of the RR to facilitate post-hoc assessment of the RR in psychotherapy session recordings. We also aimed to measure the association between the RR-PQS and current PQS measures of theoretical treatment principles and the working alliance. METHOD: We developed an RR-PQS prototype based on ratings of an ideal RR session by eight RR experts. We assessed the associations between the RR-PQS and existing cognitive behavioral and psychodynamic process prototypes, and seven PQS items known to predict the working alliance. RESULTS: RR experts agreed on the ideal RR session ratings to a high degree (ICC = 0.89). The RR-PQS was moderately related to both cognitive behavioral (r = 0.66, p < 0.01), and psychodynamic prototypes (r = 0.56, p < 0.01). PQS items predictive of the working alliance were characteristic of the RR-PQS. CONCLUSION: The RR-PQS prototype appears to behave in theoretically predicted ways and may be a valid measure of the RR.

Can new approaches to synthesising evidence help achieve a consensus in psychotherapy research?

OBJECTIVE: The recent debate around the College's Clinical Practice Guidelines on mood disorders have highlighted differences in opinion on interpreting evidence from randomised control trials (RCTs) for psychodynamic psychotherapy. This paper discusses new techniques of synthesising research evidence (e.g., umbrella reviews) that may help minimise disagreements in the interpretation of RCTs and foster greater consensus on treatment guidelines. CONCLUSIONS: Findings from the latest umbrella review suggest that psychodynamic therapy is an evidence-based approach, among several, for common mental disorders.

Integrative group psychotherapy for patients with somatic symptom disorder: A randomized controlled trial.

The study aimed to determine whether specific integrative group psychotherapy (IGPT), based on CBT, combined with techniques of psychodynamic therapy and mindful body and emotional awareness is more effective than non-specific supportive group psychotherapy (SGPT) and treatment as usual (TAU) alone. A total of 120 SSD patients were randomly assigned to IGPT, SGPT or TAU groups. Both IGPT and SGPT showed significantly lower SSD-12 scores at the 4, 8, and 12-week follow-ups compared to TAU. No significant differences were observed between IGPT and SGPT at any follow-up point. These findings highlight the potential benefits of group psychotherapy in SSD treatment.

Repairing alliance ruptures in psychodynamic psychotherapy with young people: The development of a rational-empirical model to support youth therapists.

Alliance ruptures in youth psychotherapy can have a significant impact on treatment outcomes. However, there is currently limited guidance on how to effectively repair these ruptures with young people. This study aims to address this gap specifically in the context of psychodynamic psychotherapy with adolescents. The objectives of the study are (a) to understand the therapeutic interventions and attitudes that either facilitate or hinder the resolution of alliance ruptures and (b) to develop a model for repairing these ruptures within this particular treatment approach. To accomplish this, a task analysis of a previously developed rational model of resolving alliance ruptures was conducted using 16 sessions from short-term psychodynamic psychotherapy with depressed adolescents. The analysis supported some stages of the hypothesized rational model while revealing the need for revisions. As a result, the study developed a rational-empirical model that includes flexible strategies that therapists can use to repair alliance ruptures. This model emphasizes the significance of a collaborative, open, and empathetic approach to resolving ruptures. In contrast, rigid, defensive, or invalidating therapist attitudes can hinder the resolution process. The evidence-based model developed from the study can provide valuable guidance to psychodynamic psychotherapists working with young people, offering insights on how to approach ruptures and employ effective strategies to promote their resolution. (PsycInfo Database Record (c) 2024 APA, all rights reserved).