Randomized, Controlled Trial of the Effectiveness of Short-Term Dynamic Psychotherapy and Cognitive Therapy for Cluster C Personality Disorders
Abstract
Method
Patients
Treatments and therapists
Treatment integrity and differentiability
Outcome measures
Statistical analysis
Results
Descriptive and preliminary analyses
Effectiveness
Clinically significant change
Discussion
Patients Who Received Short-Term Dynamic Psychotherapy (N=25) | Patients Who Received Cognitive Therapy (N=25) | |||
---|---|---|---|---|
Mean | SD | Mean | SD | |
Age (years) | 33.4 | 9.7 | 34.6 | 7.9 |
N | % | N | % | |
Female sex | 14 | 56 | 11 | 44 |
Single marital status | 9 | 36 | 8 | 32 |
Caucasian race | 25 | 100 | 25 | 100 |
College education (completed or uncompleted) | 16 | 64 | 15 | 60 |
Axis I diagnosisb | ||||
Major depression, current episode | 7 | 28 | 12 | 48 |
Major depression, previous episode(s) | 8 | 32 | 12 | 48 |
Dysthymia | 7 | 28 | 3 | 12 |
Panic disorderc | 2 | 8 | 3 | 2 |
Agoraphobiad | 3 | 12 | 2 | 8 |
Social phobia | 7 | 28 | 12 | 48 |
Obsessive-compulsive disorder | 3 | 12 | 4 | 16 |
Generalized anxiety disorder | 12 | 48 | 16 | 64 |
Somatization disorder | 1 | 4 | 3 | 12 |
No diagnosis | 2 | 8 | 1 | 4 |
Axis II diagnosise | ||||
Avoidant personality disorder | 16 | 64 | 15 | 60 |
Obsessive-compulsive personality disorder | 8 | 32 | 9 | 36 |
Dependent personality disorder | 4 | 16 | 6 | 24 |
Passive-aggressive personality disorder | 1 | 4 | 2 | 8 |
Self-defeating personality disorder | 1 | 4 | 2 | 8 |
More than one personality disorder | 4 | 16 | 7 | 28 |
a Treatment groups did not differ significantly on any characteristic.
b Patients may have received more than one axis I diagnosis. Although no significant differences between groups in frequencies of axis I disorders were found, the largest differences between groups were observed for current major depression (p=0.36), social phobia (p=0.36), and generalized anxiety disorder (p=0.40).
c With or without agoraphobia.
d Without history of panic disorder.
e Patients may have received more than one axis II diagnosis.
SCL-90-Ra | Inventory of Interpersonal Problemsb | Millon Clinical Multiaxial Inventoryc | |||||||
---|---|---|---|---|---|---|---|---|---|
Score | Score | Score | |||||||
Time and Group | N | Mean | SD | N | Mean | SD | N | Mean | SD |
Baselined | |||||||||
Short-term dynamic psychotherapy patients | 25 | 1.15 | 0.60 | 25 | 1.52 | 0.45 | 25 | 64.2 | 11.6 |
Cognitive therapy patients | 25 | 1.26 | 0.68 | 25 | 1.68 | 0.49 | 24 | 64.7 | 13.4 |
Midtherapy | |||||||||
Short-term dynamic psychotherapy patients | 25 | 1.01 | 0.58 | 25 | 1.44 | 0.54 | — | — | — |
Cognitive therapy patients | 25 | 1.08 | 0.72 | 25 | 1.56 | 0.56 | — | — | — |
Termination | |||||||||
Short-term dynamic psychotherapy patients | 25 | 0.76 | 0.49 | 25 | 1.22 | 0.54 | 25 | 55.0 | 13.0 |
Cognitive therapy patients | 25 | 0.82 | 0.61 | 25 | 1.30 | 0.58 | 24 | 58.8 | 17.2 |
6-month follow-up | |||||||||
Short-term dynamic psychotherapy patients | 22 | 0.61 | 0.46 | 22 | 1.12 | 0.52 | — | — | — |
Cognitive therapy patients | 24 | 0.84 | 0.60 | 24 | 1.31 | 0.65 | — | — | — |
12-month follow-up | |||||||||
Short-term dynamic psychotherapy patients | 24 | 0.63 | 0.50 | 24 | 0.99 | 0.61 | — | — | — |
Cognitive therapy patients | 22 | 0.73 | 0.52 | 22 | 1.15 | 0.59 | — | — | — |
24-month follow-up | |||||||||
Short-term dynamic psychotherapy patients | 23 | 0.61 | 0.54 | 23 | 0.98 | 0.58 | 24 | 50.6 | 16.2 |
Cognitive therapy patients | 21 | 0.67 | 0.66 | 21 | 1.09 | 0.63 | 24 | 53.3 | 15.4 |
a Scored on a scale from 0 to 4; 4=extreme symptom distress.
b Scored on a scale from 0 to 4; 4=extreme interpersonal distress.
c Higher scores denote more severe personality pathology. The instrument was not administered at midtherapy, and the 6- and 12-month data were not analyzed. Because of missing data, the data for the 24-month follow-up contained four 12-month observations and one 6-month observation; the mean 24-month follow-up scores without these observations (short-term dynamic psychotherapy: 50.2; cognitive therapy: 52.9) differed very little from the mean scores with those observations.
d Groups were not significantly different in scores on the SCL-90-R (t=0.06, df=48, p<0.50), the Inventory of Interpersonal Problems (t=1.23, df=48, p=0.25), or the Millon Clinical Multiaxial Inventory (t=0.19, df=48, p<0.50).
Variable | SCL-90-R | Inventory of Interpersonal Problems | ||||
---|---|---|---|---|---|---|
Estimate | SE | da | Estimate | SE | da | |
Status at termination of treatment | ||||||
Mean score | 0.80** | 0.08 | 2.86 | 1.28** | 0.08 | 4.77 |
Effect of treatment typeb | 0.060 | 0.080 | 0.20 | 0.070 | 0.080 | 0.24 |
Change rate during treatmentc | ||||||
Mean change in score | −0.025** | 0.005 | 1.50 | −0.020** | 0.005 | 1.22 |
Effect of treatment typed | <0.001 | 0.005 | 0.02 | <−0.001 | 0.005 | 0.04 |
Change rate after treatmentc | ||||||
Mean change in score | −0.005* | 0.002 | 0.72 | −0.010** | 0.002 | 1.28 |
Effect of treatment type | 0.001 | 0.002 | 0.20 | <0.001 | 0.002 | 0.04 |
Variance | χ2 (df=48) | Variance | χ2 (df=48) | |||
Variance componentse | ||||||
Variance in status at termination | 0.283 | 877.0** | 0.277 | 685.5** | ||
Variance in change rates during treatment | 0.0007 | 200.2** | 0.0006 | 150.0** |
a Cohen’s effect size estimate (d>0.80=large, d>0.50=moderate, d>0.20=small) (19). The values of d associated with the change rates are within-group effect sizes, and those associated with the effect of treatment type are between-group effect sizes. Hence, they are not directly comparable.
b Treatment type is coded as −1 for short-term dynamic psychotherapy and 1 for cognitive therapy throughout.
c If treatments lasted 12 months, these estimates would translate into gains in scores on the SCL-90-R of 0.30 points during treatment and 0.15 points during follow-up for the short-term dynamic psychotherapy patients and 0.29 points during treatment and 0.09 points during follow-up for the cognitive therapy patients. Gains in scores on the Inventory of Interpersonal Problems would be 0.23 points during treatment and 0.25 during follow-up for the short-term dynamic psychotherapy patients and 0.25 points during treatment and 0.24 points during follow-up for the cognitive therapy patients.
d In separate hierarchical linear model analyses in which the influence of certain axis I diagnoses (major depression, social phobia, generalized anxiety disorder) was controlled, the estimates for the effect of treatment type changed very little and remained very small.
e Variances in change rates after treatment were constrained to zero since variances in absolute numbers were close to zero and results of likelihood ratio tests were nonsignificant.
*p <0.05. **p<0.001.
Patients Who Received Short-Term Dynamic Psychotherapy | Patients Who Received Cognitive Therapy | |||||
---|---|---|---|---|---|---|
Variable | Change Estimate | t | Effect Sizea | Change Estimate | t | Effect Sizea |
SCL-90-R scoreb | ||||||
During treatment | −0.025 | 4.30** | 1.76 | −0.024 | 4.00** | 1.63 |
After treatment | −0.006 | 2.43* | 1.01 | −0.004 | 1.18 | 0.49 |
Inventory of Interpersonal Problems scoreb | ||||||
During treatment | −0.019 | 2.90** | 1.19 | −0.021 | 3.18** | 1.29 |
After treatment | −0.010 | 2.57* | 1.07 | −0.010 | 3.08** | 1.29 |
Millon Clinical Multiaxial Inventory scorec | ||||||
During treatment | 4.10** | 1.67 | 2.30* | 0.96 | ||
After treatment | 1.60 | 0.65 | 1.50 | 0.61 |
a Cohen’s d (d>0.50=moderate effect size, d>0.80=large effect size).
b Change over time was estimated in a two-piece hierarchical linear model (df=24 for analyses of change during treatment and df=23 for analyses of change after treatment in both treatment conditions); the Millon Clinical Multiaxial Inventory score was not included in the hierarchical linear model.
c Change over time was assessed with paired t tests (df=23, except for the analyses of change during treatment for short-term dynamic psychotherapy patients, for which df=24).
*p<0.05. **p<0.01.
Percentage of Patients | |||||
---|---|---|---|---|---|
Baseline to Termination of Treatment | Baseline to 2-Year Follow-Up | ||||
Measure and Statusb | Patients Who Received Short-Term Dynamic Psychotherapy | Patients Who Received Cognitive Therapy | Patients Who Received Short-Term Dynamic Psychotherapy | Patients Who Received Cognitive Therapy | |
SCL-90-R | |||||
Recovered (functional status)c | 32 | 24 | 54 | 42 | |
Recovered (asymptomatic status)c | 16 | 12 | 38 | 17 | |
Improved but not recovered | 4 | 12 | 0 | 8 | |
Unchanged | 60 | 56 | 38 | 42 | |
Deteriorated | 0 | 4 | 4 | 8 | |
Inventory of Interpersonal Problems | |||||
Recovered (functional status)c | 28 | 24 | 38 | 38 | |
Recovered (asymptomatic status)c | 16 | 16 | 25 | 29 | |
Improved but not recovered | 12 | 16 | 13 | 21 | |
Unchanged | 48 | 52 | 38 | 38 | |
Deteriorated | 12 | 8 | 8 | 4 | |
Millon Clinical Multiaxial Inventoryd | |||||
Recovered (functional status) | 4 | 13 | 38 | 35 | |
Improved but not recovered | 32 | 17 | 25 | 13 | |
Unchanged | 60 | 67 | 33 | 43 | |
Deteriorated | 4 | 4 | 4 | 9 |
a All differences between treatment groups were nonsignificant (all p≥0.09, z test).
b Patients who recovered in a functional status sense attained statistically reliable improvement and, after treatment and follow-up, were more similar to the community population (mean score of 0.60 on the SCL-90-R [21] and 0.97 on the Inventory of Interpersonal Problems [22]) than the dysfunctional population (1.56 on the SCL-90-R and 1.48 on the Inventory of Interpersonal Problems). Patients who recovered in an asymptomatic status sense attained statistically reliable improvement and, after treatment and follow-up, were more similar to the asymptomatic part of the community population (mean score of 0.19 on the SCL-90-R and 0.57 on the Inventory of Interpersonal Problems [23]) than to the dysfunctional population. Patients who were improved but not recovered attained statistically reliable improvement but still, after treatment and follow-up, belonged to the dysfunctional population. Patients who were unchanged did not meet either of the two criteria for clinically significant change. Patients who were deteriorated had deteriorated in a statistically reliable way. Reliable change scores and cutoff scores used to determine whether the patients belonged to the functional populations are available from the first author.
c All patients who met the criteria for asymptomatic recovery also met the criteria for functional recovery and thus were counted in both categories.
d In the absence of available norms for the cluster C scales of the Millon Clinical Multiaxial Inventory, the reliable change index (20) was computed by relying on data from the study group and not on population norms. A base rate score below 74 was defined as an indicator of functional status.
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