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Different measures of attachment are usually weakly correlated. In a subsample of an RCT comparing short-term cognitive-behavioural therapy (CBT) and psychodynamic therapy (PDT), we examined the association between attachment and outcome using two attachment measures. The sample comprises 148 patients with social anxiety disorder who were treated in the SOPHO-NET trial. Pretreatment attachment was assessed using the Adult Attachment Prototype Rating (AAPR) and the Bielefeld Questionnaire of Client Expectations (BQCE). Regression models were used to predict the therapeutic alliance (HAQ) at session 8, the Liebowitz Social Anxiety Scale (LSAS) at the end of therapy and a 6-month follow-up. Attachment groups (secure, avoidant, and ambivalent) classified with the AAPR and the BQCE were not significantly correlated (Cohen's κ = 0.08). Only the BQCE was associated with the HAQ indicating avoidantly attached patients showing lower HAQ scores than securely attached (Cohen's d = 0.722). Regarding the AAPR, we found an interaction effect of treatment and attachment related to the post-treatment LSAS scores. Post hoc tests revealed that securely attached patients in CBT had lower scores than securely attached in PDT (d = 0.922) and, on a trend level, avoidantly attached in CBT (d = 0.782). We conclude that attachment-outcome associations are affected by the applied measure. The identified differential effects suggest that psychotherapists should adapt the interventions on the attachment of their patients.

We tested the hypothesis that structural integration, as assessed in the Operationalized Psychodynamic Diagnosis (OPD) system, and emotional intelligence (EI), as studied in personality psychology, might be closely related constructs at a general level, as both might assess general personality functioning. In three studies (n 1 = 166, n 2 = 204, n 3 = 349), we used a self-report measure of OPD structural integration and measures of Trait and Ability EI. Structural integration and Trait EI display very high correlation at general factor level (r = .77 - .82) and almost perfect latent correlation (r = .85 - .90). This correlation cannot be explained away by the general positivity of self-views or socially desirable responding. There is also substantial latent correlation between structural integration and Ability EI (r = .20 - .65). Results replicate over different samples from different countries and extend to the DSM-5 self-report personality functioning scale.

The alliance is dyadic in its nature with both the patient and the therapist contributing. Relatively little is known about the effects of congruence between patient and therapist perception of alliance on treatment outcome. The current study investigated how patient and therapist agreement and disagreement about the alliance predict symptom severity over the course of long-term psychotherapy. We investigated N = 361 patients nested within N = 102 therapists longitudinally every 5th session across long-term treatment. Multilevel polynomial regression with response surface analysis was used to predict symptom severity five sessions later from congruence of the alliance ratings. Throughout treatment, patient and therapist agreement about stronger alliances significantly predicted lower subsequent patient-reported symptom distress. Patient and therapist disagreement was a marginally significant predictor of subsequent symptom distress. There was no significant difference in the effects of alliance agreement and disagreement on symptoms across time in long-term treatment. Findings support the importance of alliance agreement and disagreement as predictors of subsequent patient symptom severity. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Although the relationship between insecure attachment patterns and eating disorder (ED) psychopathology has repeatedly been demonstrated, the underlying mechanisms of this association are not fully understood. Therefore, the current study aimed to examine personality functioning, defined as an impairment in self and interpersonal functioning, as a mediator between attachment insecurity and ED psychopathology.In a representative population-based sample (N = 2508; age range 14-92 years) ED symptomatology, personality functioning, and attachment insecurity (anxiety and avoidance) were assessed. Besides descriptive uni-/bivariate analysis, path analysis was used to test a mediation model while controlling for the effects of age, gender, mental distress, and BMI.ED symptomatology was associated with lower levels of personality functioning (r = 0.22) and higher levels of attachment anxiety (r = 0.14) but did not correlate with attachment avoidance (r = 0.02). Path analysis revealed that personality functioning fully mediated the effect of attachment anxiety on ED symptomatology: The indirect effect via personality functioning (β = 0.04, p .001) accounted for 77% of the total effect. Fit indices were excellent. Sensitivity analyses revealed that the main results were mainly applicable to women and the middle age group.The present findings contribute to the growing body of research using dimensional conceptualizations of personality functioning, suggesting that it provides an informative, overarching framework for understanding and treating ED psychopathology. Findings indicate that underlying individual differences, e.g., with respect to insecure attachment configurations, have relevant implications for symptom manifestations. Potential clinical implications and avenues for future research are discussed.

Objective We aimed to investigate change in self-esteem through intensive group treatment for personality dysfunction, by exploring: (a) the relationship between patients' experience of therapeutic alliance and improvement in self-esteem during treatment, including patients' quality of object-relations (QOR) as a possible moderator; and (b) the association between improvement in self-esteem during treatment, and depressive symptoms 9 months later. Method Eighty patients with personality dysfunction, consecutively enrolled in a group-oriented treatment program, were assessed at pretreatment, posttreatment, and 9 months follow-up. Results Especially for patients with lower QOR, alliance predicted self-esteem change during treatment. In addition, change in self-esteem during treatment predicted follow-up depression severity, even when controlling for within-treatment symptom change. Conclusions Patients with impoverished inner relational representations may benefit more from a secure alliance in terms of improving their self-esteem. Change in self-esteem may also be important in preventing relapse of depressive symptoms in people with personality dysfunction.

Background The broad range of adverse health outcomes following child maltreatment (child maltreatment) underscores the need to investigate shared trajectories that contribute to associated physical and mental health problems. Previous research focused on different mechanisms, such as emotion regulation or attachment. In the present study, we propose personality functioning, comprising self- and interpersonal regulation and perception, to mediate between child maltreatment and mental and physical health. Methods In a German representative sample (N = 2,508), we assessed remembered child maltreatment, levels of personality functioning, and different health outcomes in adulthood, namely somatic symptoms, general mental distress, and body dysmorphic concern. We conducted path analyses to investigate mediation effects in the total sample as well as in female and male subsamples. Results Child maltreatment significantly predicted the assessed health outcomes and showed significant associations with lower levels of personality functioning. Personality functioning partially mediated all health outcomes assessed by significant indirect effects and lowered direct effects of child maltreatment on health outcomes. An exploratory analysis of different facets of personality functioning revealed a pronounced impact of identity perception and self-reflective capacities in mediating between child maltreatment and physical and mental health. Comparable results were found in female and male participants. Limitations Major limitations of the study are the reliance on cross-sectional data and the use of a screening measure to assess experienced child maltreatment. Conclusion Personality functioning may represent a transdiagnostic link to different somatic and psychological symptoms in the aftermath of child maltreatment.

Background This is the validation of the Operationalized Psychodynamic Diagnosis—Structure Questionnaire (OPD-SQ). Methods A clinical sample of 399 adults and a nonclinical general population sample of 50 healthy adults completed measures of depression, attachment, psychiatric symptomatology and distress. Internal consistency and concurrent validity were assessed. Test–retest and Reliable Change Index were also calculated, as was the ability of the OPD-SQ to distinguish between the clinical and general population groups. Results High internal consistencies were found; significant differences between clinical and nonclinical samples, and significant associations with psychiatric symptomatology, depression and psychological distress. Conclusion The Chilean OPD-SQ has good reliability, and discriminates between clinical and healthy samples.

Improvement in life satisfaction is hard to achieve for any patient with personality psychopathology, and possibly even moreso for those who feel hopeless at the start of treatment. The present research investigated the potential influence of hopelessness in the treatment of patients with personality dysfunction, using data from patients who completed an intensive group therapy program designed to reduce symptom distress and support optimal psychosocial functioning (N = 80). In the present study, we sought to examine whether hopelessness would moderate (i.e., strengthen or weaken) relations between compatibility ratings and life satisfaction outcome. Hopelessness had a significant moderating effect on the relationship between compatibility and outcome, suggesting that, for patients who entered treatment feeling more hopeless, higher appraisals of fit within the group facilitated better gains in life satisfaction. If replicated, the findings underlie the importance of focusing on increasing hope and perceived group affiliation in the treatment of personality dysfunction.

Objectives: Therapeutic agency is defined as a patient’s intentional influence over the process of psychotherapeutic change. However, there is a lack of conceptually sound self-report measures with...

In this study, we explored whether attachment insecurity moderates the effects of adverse childhood experiences on stress-reactivity in the context of Borderline Personality Disorder (BPD). Participants were 113 women (39 with BPD, 15 with some BPD criteria present, 59 without any BPD symptoms) who participated in the Trier Social Stress Test. Saliva samples were collected before and after the stressor, and assayed for alpha-amylase and cortisol. Adverse childhood experiences were measured using the Childhood Trauma Questionnaire, and Attachment by the Experiences in Close Relationships-Revised questionnaire. Results revealed that attachment avoidance, and a combination of more adverse childhood experiences and attachment insecurity (anxiety and avoidance) resulted in higher salivary alpha-amylase (sAA) levels as well as differences in reactivity to the stressor. Interactions between attachment anxiety and adverse childhood experiences were related to blunted cortisol reactivity. The results suggest that the influence of adverse childhood experiences on stress-regulation in BPD may be moderated by attachment-related regulatory processes.

Objective The study represents a conceptual replication of the study by Eng et al. (2001) in a sample of adult patients diagnosed with social anxiety disorder as primary diagnosis. Methods Two different attachment questionnaires (Bielefeld Questionnaire of Client Expectations (BQCE) and Experiences in Close Relationships (ECR-RD)) were applied to examine whether the effect of attachment on depression (measured by the BDI) is mediated by social anxiety (measured by the LSAS) in a cross-sectional study. Results The data confirms such a mediation. The effect of attachment measured with the BQCE on depression was completely mediated, whereas the effect of both scales of the ECR-RD (attachment related avoidance and anxiety) on depression was only partially mediated by social anxiety disorder. Conclusion The study supports the association of attachment, social anxiety, and depressive symptoms and the need to consider different perspectives on attachment.

Zusammenfassung

Reduced social impairment and improved life satisfaction are important objectives in group treatment for patients with personality dysfunction. Knowledge regarding patient characteristics and group treatment processes that contribute to these outcomes, however, remains limited. Dispositional connectedness, the valuing of interpersonal connections, may be an important patient factor that influences patients' experience of group treatment in ways that facilitate therapeutic benefits. The present study investigated the roles of dispositional connectedness and group engagement in contributing to improvement in social functioning and life satisfaction through integrative group treatment for personality dysfunction. Seventy-nine patients who completed an integrative group treatment programme were assessed for dispositional connectedness at baseline and social functioning and life satisfaction at pretreatment and posttreatment; each also provided ratings of group engagement during treatment. Regression analyses using bootstrap confidence intervals found significant indirect effects for dispositional connectedness regarding improvement in both social functioning and life satisfaction, through the mediating effect of group engagement. Thus, patients who entered treatment with tendencies towards interpersonal connectedness perceived a higher level of engagement in the group environment. Group engagement in turn contributed to greater improvement in social functioning and to greater improvement in life satisfaction following treatment. The findings indicate dispositional connectedness as a salient characteristic in selecting patients for group treatment and highlight the role of an engaged interpersonal climate in facilitating improvement in social functioning and life satisfaction.

OBJECTIVE The aim of this study was to investigate associations between patients' subjective agency, their observable in-session behavior, and the patient-therapist interaction during the early phase of psychotherapy. METHODS The sample included 52 depressed patients in psychodynamic psychotherapy. After Session 5, the patients' agency and the quality of the therapeutic alliance were assessed. Based on session recordings, two independent observers rated the patients' involvement, their interpersonal behavior, and the therapists' directiveness. RESULTS Higher agency was associated with stronger therapeutic alliances. Patients who indicated higher agency in their therapy participated more actively in the session and showed less hostile impact messages. Patients' agency was not related to therapists' directiveness. CONCLUSIONS Patients' sense of agency in psychotherapy was associated with more active involvement and affiliative interaction. The findings support the idea that patients need to feel capable of acting within and having an influence on their therapy to benefit from it.

Interpersonal characteristics contribute to therapists' ability to form helpful working alliances with their patients. But how are attachment styles and interpersonal motives distributed among therapist trainees? This study examines attachment styles and interpersonal motives of therapist trainees by comparing them with matched reference samples from representative surveys. A total sample of 285 trainees, who were enrolled in either cognitive-behavioral or psychodynamic therapy training programs, was recruited via their training institutes. Participants answered questionnaires on attachment (Experiences in Close Relationships-Revised, 36-item version, and Experiences in Close Relationships-Revised, 8-item version) and interpersonal motives (Circumplex Scales of Interpersonal Values). Compared with 2 matched nonclinical reference samples from representative surveys, therapist trainees reported lower scores on attachment-related avoidance and higher scores on harmonious interpersonal motives. Therapist trainees are characterized by a wish for warm proximity with others and feel comfortable in close relationships. (PsycINFO Database Record

OBJECTIVES Limited empirical attention has been devoted to individualized treatment objectives in intensive group therapy for personality dysfunction. This study investigated patients' ratings of distress associated with individual therapy goals - referred to as target object severity - in an intensive Evening Treatment Programme for patients with personality dysfunction. DESIGN Change in target objective severity was examined in a sample of 81 patients who completed treatment in an intensive, integrative group therapy programme. METHODS Correlation and regression analyses were used to examine associations between change in target object severity and patients' pre-treatment diagnosis, symptom distress, and treatment outcome expectancy, and between change in target objective severity and patients' ratings of group therapy process (group climate, therapeutic alliance, group cohesion). The relationship between change in target objective severity and longer-range life satisfaction was also examined in a subsample of patients who rated life satisfaction at follow-up. RESULTS While change in target objective severity was not significantly related to pre-treatment variables, significant associations were found with several aspects of group therapy process. Patients' experience of a highly engaged group climate was uniquely associated with improvement in target object severity. Such improvement was significantly related to longer-term life satisfaction after controlling for general symptom change. CONCLUSION The working atmosphere in group therapy contributes to patients' progress regarding individual treatment targets, and such progress is an important factor in later satisfaction. Attention to individualized treatment targets deserves further clinical and research attention in the context of integrative group therapy for personality dysfunction. PRACTITIONER POINTS This study found that patients attending an integrative group treatment programme for personality dysfunction experienced significant improvement in severity of distress related to individual treatment objectives. Improvement in severity of distress related to individual treatment objectives was uniquely associated with patients' experience of an engaged, collaborative working atmosphere. Improvement in individual target objective severity was associated with patients' ratings of overall life satisfaction, rated an average of 9 months following termination, after controlling for change in general symptom severity.

Objective Periodontal disease is associated with a wide range of psychosocial risk-factors. Disease-related tooth-loss has been associated with an increase in depressive symptoms in cross-sectional studies. However, while depression is a known risk-factor for the outcome of chronic diseases, it remains unclear if tooth loss can also predict depressive symptoms over the course of treatment. Aim of the current pilot study was to test, to what extend the number of teeth predict depressive symptoms several years later. Methods Tooth status of 310 patients with chronic and aggressive periodontitis was evaluated at the beginning of a specialized, university based outpatient treatment. We assessed depressive symptoms with the Patient Heath Questionnaire (PHQ) on average 13 years later. Regression analyses were used to relate initial number of teeth to self-reported depression scores. Results Fewer teeth at the beginning of the treatment were related to higher scores of depressive symptoms, even when controlling for several covariates. Conclusions Tooth loss is a potential risk-factor for the development of depression in periodontal disease. Further longitudinal studies that control for initial depressive symptoms are needed to identify disease mechanisms.

Reduced self-esteem is a core symptom of depression, but few studies have investigated within-treatment change of self-esteem as a predictor of long-term outcome in depression. This study investigated change in self-esteem during 8 weeks of multimodal, psychodynamically oriented psychotherapy for 40 depressed patients and tested whether it would predict outcome 6 months after termination. Data was drawn from a randomized clinical pilot trial on day-clinic versus inpatient psychotherapy for depression. Findings supported the association between change in self-esteem and follow-up depression severity, even when controlling for within-treatment symptom change. Change in self-esteem was not related to overall symptoms and interpersonal problems at follow-up. Thus, change in self-esteem may be an important variable in preventing relapse for depression. Key Practitioner Message Self-esteem is related to depressive symptoms and interpersonal problems. Improvement of self-esteem during psychotherapy correlates with improvements of symptoms and interpersonal problems. Change of self-esteem during psychotherapy predicts depressive symptoms 6 months after termination of therapy. When treating depressed patients, psychotherapists should work towards an improvement of self-esteem in order to prevent relapse.

Maternal depression poses a risk for the developing mother-infant relationship. Similarly, maternal insecure attachment styles may limit the ability to adequately connect with the newborn during the postpartum period. The aim of this study was to investigate the effect of maternal depression and insecure attachment (insecure and dual/disorganized) on maternal bonding in a sample of n = 34 women with depression according to DSM-IV and n = 59 healthy women. Maternal depression was assessed 3 to 4 months postpartum with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), bonding with the Postpartum Bonding Questionnaire, and maternal attachment style with the Attachment Style Interview. Women with current and lifetime depression as well as women with dual/disorganized attachment style reported lower bonding. Explorative analysis revealed that depression partially mediated the link between dual/disorganized attachment style and bonding with a medium-sized mediation effect. The combination of maternal depression and dual/disorganized attachment style may pose a special risk constellation for the developing mother-infant bond that should be addressed in prevention and early intervention programs.

Background: The concept of attachment is relevant for the onset and development of chronic pain. Insecure attachment styles negatively affect therapeutic outcome. Insecurely attached patients seem to be less able to sustain positive effects of a multimodal treatment program. However, it has never been tested before if an attachment-oriented approach can improve treatment results of insecurely attached patients in a multimodal outpatient setting. To test this assumption, we compare the short- and long-term outcomes for pain patients who will receive multidisciplinary, attachment-oriented treatment with the outcomes for patients in a control group, who will receive the multidisciplinary state-of-the-art treatment. Methods: Two patient groups (baseline, attachment intervention) are assessed before treatment, after treatment, and at a 6 month follow-up. The study is conducted in a block design: After data collection of the first block (controls) and before as well as during data collection for the second block (treatment group), the health care personnel of the outpatient pain clinic receives training on attachment theory and its use in the therapeutic context. Pain intensity as measured with visual analogue scales and physical functioning will serve as the primary outcome measures. Discussion: The design of our study allows for a continuous exchange of experienced team members, which may help bring about concrete attachment related guidelines for the enhancement of therapeutic outcome. This would be the first attempt at an attachment-oriented improvement of multimodal pain programs. Conclusion: An attachment-based approach may be a promising way to enhance long-term treatment outcomes for insecurely attached pain patients. Trial registration: DRKS00008715 (registered on the 3rd of June 2015).

The Inpatient and Day-Clinic Experience Scale (IDES) was developed to assess common factors in a multimodal psychotherapy setting from the patients' perspective. The questionnaire measures different aspects of therapeutic relationships, a positive self-view and a critical attitude towards therapy.Three samples (total N = 821) were used to evaluate the psychometric properties and factor structure of the questionnaire.Confirmatory analyses show a good model fit and support the proposed structure with 25 items and seven scales. In addition, reliability indices were stable throughout multiple assessments over time. Concerning validity, early IDES process measures were moderately associated with symptomatic improvement.The IDES is a psychometrically reliable questionnaire for the evaluation of process factors in inpatient and day-clinic psychotherapy settings.

The quality of depression in borderline personality disorder (BPD) was reported to differ from that in patients with major depressive disorder (MDD) only. However, little is known about affect dynamics in "borderline-depression." The authors assessed affective instability and reactivity in 20 MDD patients with BPD and in 21 MDD patients without BPD by Ambulatory Assessment. Participants reported on current affect, daily events, and attribution of affective states to events five times per day over a 7-day period. The results do not indicate higher affective instability in MDD patients with BPD comorbidity. Depressed patients with BPD reported less subjectively perceived affective reactivity, while observed associations between events and affect were not different between groups, except for one finding: In depressed patients with BPD, overall mood was lower after being alone. These findings suggest impaired attribution of mood changes and less tolerance of being alone as specific for depression in BPD.

Attachment theory helps us to understand patients´ health behavior. Attachment styles might explain patient differences in coping behavior, self-treatment, or patient-provider relationships. In primary care time constrains are relevant. A short instrument may facilitate screening and assessment in daily medical practice. The aim of this study was to evaluate a 12-item short version of the Experience in Close Relationships-revised (ECR-R-D) to be used in primary care settings. We included 249 patients from ten general practices in central Germany into a cross-sectional study. Exploratory factor analysis was performed to evaluate the factor structure of the ECR-items. Cronbach's alpha was used to assess internal consistency. The results related to the short form of the ECR are in line with those of the German full-length version of the measure (ECR-RD 36). Internal consistencies were in an adequate range. The ECR short form can be recommended as a screening measure of attachment styles in primary care.

Screening for personality dysfunction is relevant to treatment planning in psychotherapy, psychosomatic medicine and psychiatry. This makes short versions of field-tested approaches such as the OPD Structure Questionnaire (OPD-SQ) necessary.With the aim of developing a screening version, the original sample of the OPD-SQ was divided into two subsamples. After developing a preliminary 12-item version in one subsample, we used confirmatory factor-analysis in the second subsample as well as an independent sample to test the factor structure.The analyses confirmed a structure of three correlating factors with adequate fit indices. Other findings relating to the validity of the long version were replicated as well. In addition, data from an independent sample of psychotherapy inpatients confirmed the factor structure and provided further evidence for its validity.The OPD-SQS is a viable screening instrument for supporting clinical decision making in stepped-care approaches in psychotherapy, psychosomatic medicine and psychiatry.

Depressions are frequent disorders in psychosomatic medicine and psychotherapy. However, there are only few controlled studies comparing different levels of care for depressed patients. Especially the efficacy of day-clinic psychotherapy for depression remains understudied. The pilot study aims to close this gap by examining the feasibility of a randomized-controlled trial comparing day-clinic and inpatient psychotherapy for depression in a routine hospital setting. The current paper adds the secondary outcome measures on patient self-reported symptoms and interpersonal problems. In addition, findings of a 6-month follow-up are analyzed. Overall, 44 patients were recruited and randomly allocated to either day clinic or inpatient psychotherapy for 8 weeks. Depressive symptoms and interpersonal problems decreased during treatment, and follow-up scores stayed below intake scores. There were no differences between the treatment groups in this pilot study. For the future, it is desirable to compare randomized patients with those patients who received their preferred treatment option. Although the findings need to be replicated in larger samples, they appear promising for day-clinic psychotherapy. The better understanding of differential effectiveness of different levels of care of patient subgroups remains an important goal.

Recent considerations around DSM-5 criteria of personality disorders (PDs) demand new concepts of assessing levels of personality functioning. Of special interest are multiperspective approaches accounting for clinicians' as well as patients' points of view. The study investigates observer-rated and self-assessed levels of personality functioning measured by the level of structural integration as defined by the Operationalized Psychodynamic Diagnosis System (OPD). Both perspectives were positively related. The combination of both measures was most efficient in discriminating among 3 diagnostic groups of varying degrees of personality dysfunction. Future studies should take into account expert ratings as well as self-report data.

Objectives Psychosocial variables have received increased attention in periodontology. Attachment theory adds to known risk factors by linking early interactional experiences with adult tendencies of stress-regulation, health behaviour, symptom reporting, and healthcare utilization. The study investigates associations between attachment patterns and periodontal parameters. Methods Within the context of a longitudinal study on periodontal diseases, 310 patients with aggressive (AgP) and chronic periodontitis (CP) filled out questionnaires on psychological attachment patterns. The influence of attachment style on health behaviour, treatment attendance and utilization, and periodontal variables was tested. Results We found associations between psychological attachment anxiety on smoking and higher number of session use, independent of disease severity, which was more pronounced for women. Patients with higher attachment avoidance attended periodontal treatment later when diagnosed with CP and earlier with AgP. For men, we found differential associations for attachment avoidance and anxiety and number of teeth at beginning of treatment. Conclusion Psychological attachment patterns are a promising target for understanding periodontal disease in addition to known psychosocial risk factors.

The concept of psychic structure plays a central role in the Operationalised Psychodynamic Diagnosis (OPD) system. Until recently, its reliable and valid assessment had to be based on expert ratings of clinical interviews, limiting the use of the OPD in routine measurements and research, and excluding the patients' perspective. The current study describes the development and evaluation of a questionnaire on the OPD structure axis (OPD-SQ) in several clinical and non-clinical samples (N = 1 112). The questionnaire demonstrated good internal consistency for all the sub-scales of the OPD-SQ. Differences in mean values between the samples and between patients with vs. without personality disorders were as expected. We also found correlations with other relevant aspects of personality (attachment security, neuroticism). There were no to minimal effect of age and gender. The OPD-SQ is a helpful tool for a broad use in clinical routine as well as research projects.

To test the possibility of predicting psychotherapy outcome by measures of cardiovascular adaptability to stress at the beginning of treatment we used a prospective, within-subject design with experimental induction of short-term stress. Cardiovascular data during induced stress (mental arithmetic, anger recall) and relaxation were assessed in 21 patients with a main diagnosis of depression at the beginning of their 12-week inpatient psychotherapy treatment. Lower change scores in blood pressure during induced stress at the beginning of therapy were significantly related to better treatment outcome, accounting for 41% of variance, even after controlling for several covariates. Furthermore, there was evidence for the impact of negative affect. Using cardiovascular stress testing as an additional area of information seems a feasible method of incorporating biological parameters in psychotherapy evaluation.

Objectives. Despite its clinical importance and relevance for health care policy, the pathways between depression and stress regulation remain poorly understood. The objective of our study was to compare cardiovascular and autonomic responses to brief psychosocial stress in a group of severely depressed subjects without heart disease and a non-depressed controlgroup. Methods.We recorded cardiovascular and autonomic reactions to two different stress tasks including anger recall and mental arithmetic in a sample of 25 severely depressed and 25 non-depressed subjects. Aggregated data were compared with repeated-measures MANOVA. We used contrasts to evaluate different response patterns concerning cardiovascular and autonomic reactivity vs. recovery. Results. Depressed subjects showed overall reduced high-frequency heart rate variability and an altered cardiovascular adaptability concerning heart rate, blood pressure, cardiac output, and, on a trend level, peripheral resistance. With few exceptions, we found no differences between reactivity vs. recovery response patterns. Conclusions. Our results provide further evidence for altered cardiovascular reactivity and impaired cardiac autonomic functioning in depression. Further research is needed on psychophysiological response to either more disease-oriented or more personality-oriented stressors.

The "Experiences in Close Relationships--Revised" (ECR-R) is a well developed instrument for assessing attachment in adults, which is used in different research areas around the world. In this paper the German version (ECR-RD) was evaluated in a large non-clinical (N = 1006) and a clinical sample (N = 225). Overall, the good psychometrical properties were confirmed (Cronbach's alpha = 0,91/0,92), we also found evidence for construct validity. There was a substantial difference between the two samples in the ECR-RD as well as a specific impact of comorbid personality disorders. The ECR-RD can be seen as a reliable, internationally comparable instrument for assessing romantic attachment representations that can be used in clinical samples.

The psychoanalytically informed construct of 'defence mechanisms' is of central importance for the understanding of the dynamics of inner conflicts and the onset of neurotic symptoms. Objective and valid assessment of 'defence' is difficult. There are a number of observer rating instruments but only few self-report questionnaires. The German version of the 'Defence Style Questionnaire - DSQ 40' (Andrews, Singh, & Bond, 1993) was examined with regard to its factorial and content validity, and its sensitivity to change during inpatient psychotherapy. One hundred and fifty-five patients with mixed diagnoses were administered the DSQ 40 and the SCL-90-R before and after 3 months of inpatient psychotherapy. Diagnoses were mostly affective and anxiety disorders as well as eating disorders, and there was a high comorbidity of personality disorders. After deletion of some items due to insufficient pairwise item-intercorrelation or false classification to a defence mechanism by experienced clinicians, we found three stable factors of defence (maladaptive, intermediate-neurotic and adaptive) consistent with the previous research. After 3 months of therapy, a decrease in maladaptive mechanisms and an increase in adaptive patterns were found, while neurotic mechanisms did not change on average. Our shortened version of the DSQ 40 was shown to be a valid instrument for the assessment of defence mechanisms and change in these mechanisms after psychotherapy. Our design did not permit an assessment of whether or not the change in defence mechanisms was due to the therapeutic treatment.

BackgroundAttachment insecurity relates to the onset and course of chronic pain via dysfunctional reactions to pain. However, few studies have investigated the proportion of insecure attachment styles in different pain conditions, and results regarding associations between attachment, pain severity, and disability in chronic pain are inconsistent. This study aims to clarify the relationships between insecure attachment and occurrence or severity of chronic pain with and without clearly defined organic cause. To detect potential differences in the importance of global and romantic attachment representations, we included both concepts in our study.Methods85 patients with medically unexplained musculoskeletal pain (UMP) and 89 patients with joint pain from osteoarthritis (OA) completed self-report measures of global and romantic attachment, pain intensity, physical functioning, and depression.ResultsPatients reporting global insecure attachment representations were more likely to suffer from medically unexplained musculoskeletal pain (OR 3.4), compared to securely attached patients. Romantic attachment did not differ between pain conditions. Pain intensity was associated with romantic attachment anxiety, and this relationship was more pronounced in the OA group compared to the UMP group. Both global and romantic attachment anxiety predicted depression, accounting for 15% and 17% of the variance, respectively. Disability was independent from attachment patterns.ConclusionsOur results indicate that global insecure attachment is associated with the experience of medically unexplained musculoskeletal pain, but not with osteoarthritis. In contrast, insecure attachment patterns seem to be linked to pain intensity and pain-related depression in unexplained musculoskeletal pain and in osteoarthritis. These findings suggest that relationship-informed focused treatment strategies may alleviate pain severity and psychological distress in chronic pain independent of underlying pathology.