Peer Reviewed Journal Articles on Dependent Personality Disorders

• Loading metrics

Open Access

Peer-reviewed

Research Article

Personality Disorder and Changes in Touch on Consciousness: A 3-Twelvemonth Follow-Up Study of Patients with Avoidant and Borderline Personality Disorder

• Eivind Normann-Eide,
• Merete Selsbakk Johansen,
• Tone Normann-Eide,
• Jens Egeland,
• Theresa Wilberg

ten

• Published: December 23, 2015
• https://doi.org/x.1371/journal.pone.0145625

Figures

Abstract

Personality disorders (PDs) are highly prevalent in patients receiving psychiatric services, and are associated with meaning personal and social costs. Over the past two decades, an increasing number of handling studies have documented the effectiveness of handling for patients with PDs, especially when it comes to reduction of symptom distress, adventure taking behavior, self-damage, or suicide attempts. However, less is known about the more complex aims of improving the personality structure itself, such as identity- and interpersonal disturbances. Emotional dysfunction is closely associated with PD pathology. The present study investigated changes in bear on consciousness (AC) in patients with avoidant or borderline PD, and how these changes were associated with clinical status after iii years of follow-up. The study included 52 individuals; 79 per centum were females, and mean age was 30 years. The evaluations included the Affect Consciousness Interview, Symptom Checklist-ninety-R, Circumplex of Interpersonal Problems, the Index of Self-Esteem, and iii domains (Identity Integration, Relational Capacities, and Cocky-Command) of the Severity Indices of Personality Problems (SIPP-118). There was a significant increase in the Global Ac and AC scores for most of the specific affects from baseline to follow-up. As the nowadays study did not include a control grouping, it cannot be ended that changes in Ac are effects of psychotherapy, and the possibility of age-related maturation processes cannot exist excluded. The change in Global Air conditioning contributed significantly to explained variance in the follow-upward levels of Circumplex of Interpersonal Problems, and the two SIPP-118 domains Relational Capacities and Identity Integration. Improved AC was not associated with change in the Self-Control domain or the Global Severity Alphabetize of Symptom Checklist-ninety-R. The results suggest that Air conditioning may exist altered for patients with deadline and avoidant PDs, and this is the first study to written report that improvement in AC contribute significantly to the variance in the self- and interpersonal domains of personality performance.

Citation: Normann-Eide E, Johansen MS, Normann-Eide T, Egeland J, Wilberg T (2015) Personality Disorder and Changes in Bear on Consciousness: A 3-Twelvemonth Follow-Upwards Study of Patients with Avoidant and Borderline Personality Disorder. PLoS I 10(12): e0145625. https://doi.org/10.1371/periodical.pone.0145625

Editor: Christian Schmahl, Central Establish of Mental Health, GERMANY

Received: June 24, 2015; Accustomed: December 7, 2015; Published: December 23, 2015

Copyright: © 2015 Normann-Eide et al. This is an open access commodity distributed under the terms of the Creative Commons Attribution License, which permits unrestricted employ, distribution, and reproduction in any medium, provided the original author and source are credited

Data Availability: Due to restrictions imposed past the Regional Medical Ideals Committee regarding patient confidentiality, data are bachelor upon asking. Requests for data may exist sent to the hospital'southward Privacy and Data Protection Officer at: personvern@ous-hf.no.

Funding: This inquiry was funded by the Vestfold Infirmary Trust and Oslo Academy Hospital. The funding sources had no further function in the report design; drove, assay or interpretation of information; the writing of the report; or the determination to submit the paper for publication.

Competing interests: The authors have declared that no competing interests be.

Abbreviations: AC, affect consciousness; ACI, Affect Consciousness Interview; PD, Personality Disorder; APD, avoidant personality disorder; BPD, borderline personality disorder; CIP, Circumplex of Interpersonal Issues; SCL-90-R, Symptom Checklist-90-R; GSI, Global Severity Index; ISE, Index of Self-Esteem; SIPP-118, Severity Indices for Personality Bug; ES, effect size; UPP, Ulleval Personality Project

Introduction

Personality disorders (PDs) are prevalent in the general population and in those receiving psychiatric services, and are associated with significant personal and social costs due to astringent symptom distress and dumb psychosocial functioning [1–4]. Information technology was previously thought that patients with PDs gain little benefit from psychotherapy; although, an increasing number of randomized controlled treatment studies during the final 2 decades have led to a more optimistic view regarding the treatment potential for these patients [5–11]. However, most treatments are aimed at reducing acute symptoms and PD related epiphenomena, such as self-damage, suicide attempts, or risk taking behavior; while, less is known about the more complex aims of improving aspects of the personality construction itself, such as identity disturbances and interpersonal dysfunction [12].

The general definition of a PD in the DSM-5 describes problems in the area of affectivity (i.eastward., the range, intensity, lability, and appropriateness of emotional responses) and emphasizes this equally one of iv cadre PD features, together with deviations in noesis, interpersonal functioning, and impulse control [13]. Accordingly, even if most studies of emotional problems in PDs have focused on borderline personality disorder (BPD), there is increasing empirical evidence that other types of PDs are associated with maladaptive affect regulation also [xiv–sixteen], including difficulties in identifying, tolerating, and distinguishing affects, and in communicating affects to others [17–21]. However, it is unclear to what extent such affective difficulties may improve over time in patients with PDs, mainly due to a lack of empirical studies. As information technology is hypothesized that patients with BPD and avoidant personality disorder (APD) are characterized by different kinds of affective dysfunction [17, 21, 22], they represent a potential variety of emotional difficulties. Moreover, BPD and APD are amidst the most common PDs in clinical settings [iii, 23–25], and thereby of particular interest when studying affects in the context of psychotherapy.

Several psychotherapeutic orientations are directed at the patient's affective experiences and recognize that overcoming bear on avoidance and improving the ability to regulate and arrange emotional responses to current contexts are the main routes to irresolute the individual's cocky-experience and his/her relations to others [26–31]. Yet, with a few notable exceptions, there are few empirical investigations of the relationship between actual change in affective experiences and treatment issue in patients with PDs.

In a study of patients with BPD who received either Dialectic Behavioral Therapy or General Psychiatric Management, which included psychodynamic individual therapy as ane of its elements, McMain and colleges [32] found that the patients, in both treatment conditions, achieved a better balance betwixt positive and negative emotions and an increased ability to identify feelings. The improved ability to experience positive relative to negative affects was associated with reductions in symptom distress and interpersonal problems after one twelvemonth of treatment. In a sample of patients with cluster C PDs (i.e., avoidant, dependent, and obsessive-compulsive PDs) allocated to short term dynamic therapy or cerebral therapy, decreases in the levels of inhibitory affects (i.e., anxiety, shame, guilt) and increases in levels of previously avoided activating affects (i.e., sadness, anger, closeness) predicted higher cocky-pity towards the end of therapy [33]. In the same sample, Berggraf and colleges [34] found that a higher than usual feel of activating affects (i.e., anger, pride, closeness, grief, healthy fright, and sexual needs) in a given therapy session was associated with more realistic and compassionate views of self and others in the next session.

Ane approach to the study of affects in psychotherapy is represented by the concept of affect consciousness (AC), defined as the private's capacity to consciously perceive, tolerate, reflect upon, and express experiences of basic affective activation [28, 35]. Accordingly, the AC concept encompasses several aspects of bear on processing and integration that are assumed to be crucial for adequate affect regulation [36]. As emphasized by Choi-Kain and Gunderson [37], AC is related to other "conceptual cousins", such as mentalized affectivity and alexithymia. Yet, levels of AC are operationalized and assessed by the semi-structured Impact Consciousness Interview (ACI) [38], which enables an evaluation of Air conditioning based on the test of sensation, tolerance, and non-verbal as well as verbal expression of eleven specific affects. Using this methodology, empirical studies have shown that impaired Air conditioning is related to a wide range of psychological and interpersonal disturbances, supporting the validity of the Air-conditioning construct [35, 39–51].

Improved Ac refers to more adaptive implicit and explicit means of coping with activated affects, and therapeutic change is hypothesized to occur when the basic organizing principles of maladaptive bear upon processes are changed [52]. However, despite this assumption, only a few studies have investigated the degree to which Air-conditioning actually changes during handling. Monsen and colleges [xl, 41] found an improvement in Ac in a minor sample of patients with PDs and psychosis with Air-conditioning evaluations at the handling start, handling termination, and at follow-up 5 years afterward the stop of treatment. Focusing on AC was i of the fundamental elements in the psychotherapy, and the effect size (ES) for the overall change in Air conditioning was large (ES = 2.30). The patients also improved with respect to both Axis I and Axis II disorders; however, the authors did not investigate whether such improvements were associated with changes in Air conditioning.

In a second treatment study of individuals with chronic hurting disorders, Ac-oriented psychotherapy was compared with physical therapy and pain-reducing medication [42]. Significant improvement was found in the grouping receiving AC-oriented treatment, in terms of reduced somatic hurting, symptom distress, interpersonal bug, general psychopathology, and peculiarly regarding Air-conditioning (ES = two.63). No change in AC was found in the command group. As at that place were statistically significant differences in upshot between the treatment groups in all clinical variables, the authors argued that the amelioration of psychopathology in the AC handling grouping was related to the Air-conditioning-focused psychotherapy. However, the relationship between the change in AC and change in other clinical variables was not investigated.

The final, and to our knowledge the only, written report that has investigated whether improved AC is associated with clinical change was a treatment study of patients with anxiety disorders, with approximately half having co-occurring cluster C PDs [43]. All patients were treated with schema-focused psychotherapy, comprising both group and individual sessions aimed at changing schemas and affective abstention, as well every bit behavioral experiments. A pregnant change in AC between treatment initiation and 1-year follow-up was reported. However, although the results showed that higher levels of AC at baseline predicted a reduction of avoidant personality traits, changes in AC during treatment were not associated with changes in any of the cluster C indexes. As an increased likelihood of having alexithymia problems and low levels of Ac are reported in patients with cluster C pathology [17, 21], information technology might exist that the treatment period in this study, but above one year, was also limited for the patients with relatively low levels of AC in item, to benefit in the same way as the patients with relatively loftier initial level of Air-conditioning. Moreover, change in affective function might be related to other factors, such as fourth dimension, or age-related maturation, and these conditions were not controlled for in the previous studies of alter in melancholia office. Hence, even though at that place is incipient testify that AC may change during psychotherapy for patients with PDs, the relationship between change in Ac and clinical comeback remains unclear.

In a previous written report of the present sample, we found that lower levels of Air-conditioning were associated with more interpersonal and self-esteem issues when measured cross-sectionally at two points of time, while at that place was no significant clan between AC and general symptom distress [46]. The present report is an extension of our previous report and aimed to analyze changes in Air-conditioning and its association with clinical status. The sample comprised patients with BPD and APD who participated in a treatment study and, every bit a grouping, improved clinically in from baseline evaluation to iii-year follow-upwards.

Furthermore, information technology is widely recognized that there is a dimensional continuum betwixt normal and pathological personalities, and that the clinical manifestations of PDs may vary depending on the severity of the personality pathology [53–55]. In the alternative model of PDs in the DSM-v, (section Iii, for further study), PD severity is defined by varying levels of personality functioning [thirteen]. According to this model, disturbances in the self and relational domains of personality functioning constitute the cadre of personality psychopathology. To date, surprisingly few empirical studies have investigated associations betwixt changes in affective functioning and such central aspects of personality performance.

The outset aim of the present study was to investigate the extent to which AC inverse from the handling start to the 3-year follow-up in the sample of patients with BPD and APD. Based on our literature review, we hypothesized that there will be pregnant changes in AC. The second aim was to analyze the associations between changes in Air-conditioning and clinical status at follow-up, with regard to reduction in symptom distress and improvements in self and relational operation. We expected that in that location would exist a main effect of pretreatment clinical status. Nevertheless, we also expected that acquired changes in the way of handling affects would exert a moderate but significant boosted effect on clinical improvement, over and higher up what could be predicted from pretreatment status.

Methods

Setting and Design

The present study is part of the Ulleval Personality Project (UPP), a randomized clinical study of long-term handling for patients with PDs, conducted at the Section for Personality Psychiatry, Oslo University Hospital [56–lx]. The overall aim of the UPP was to investigate the effect of a footstep-down day hospital treatment program compared with outpatient private psychotherapy. All participants were randomly allocated to ane of the two treatment atmospheric condition. The participants were referred from outpatient clinics, psychotherapists in individual practise, or general practitioners. Exclusion criteria were schizotypal PD, antisocial PD, ongoing drug or alcohol dependence, psychotic disorder, bipolar I disorder, untreated ADHD (adult type), pervasive developmental disorder (e.yard., Asperger's syndrome), organically contingent symptoms, and homelessness. The participants went through an extensive evaluation at baseline, with repeated assessments after eight months, 18 months, 3 years, and six years. In the subsample of patients with either BPD or APD, Air conditioning was assessed at baseline and at the 3-year follow-upwards. Written informed consent was obtained from participants after complete clarification of the study. The written report was approved by the Norwegian Land Data Inspectorate and the Regional Committee for Medical Research Ideals.

Assessments

Affect Consciousness.

The Air conditioning was assessed using the ACI, a one and a half to two hours semi-structured interview, adult to appraise the consciousness and integration of 11 bones affects: (one) Interest/Excitement, (ii) Enjoyment/Joy, (three) Fear/Panic, (4) Acrimony/Rage, (5) Disdain/Contempt, (6) Shame/Humiliation, (seven) Sadness/Despair, (8) Green-eyed/Jealousy, (9) Guilt/Remorse, (ten) Cloy/Revulsion, and (eleven) Tenderness/Care. Each bear upon was assessed using a 9-point Affect Consciousness Calibration (1 = low, 9 = high) regarding the following aspects: Sensation, Tolerance, Emotional (nonverbal) expression, and Conceptual (verbal) expression [38]. To examine each aspect, the interviewer asked most the following for each touch on: (i) social or interpersonal scenes in which the affect is activated; (ii) how the patient becomes aware of and recognizes the affect in terms of physical and mental sensations/thoughts (Awareness); (iii) how the affect impacts upon the patient, how the patient copes with the impact, and to what extent the patient utilizes the signal office of affects (Tolerance); (iv) to what extent and how the bear upon is expressed nonverbally (Emotional expression); and finally, (5) to what extent and how the affect is expressed verbally (Conceptual expression). From these ratings, 1 tin differentiate scores on three levels of specificity:

1. The mean score of all attribute scores across all affects (i.e., Global AC).
2. The mean score of each aspect measured across all affects (i.e., Awareness, Tolerance, Emotional expression, and Conceptual expression).
3. The hateful score of each impact category, measured across the four aspects (due east.one thousand., Involvement/Excitement or Acrimony/Rage).

All interviews were videotaped and scored according to the manual for the ACI [38]. Three experienced psychotherapists specifically trained in the ACI conducted the interviews at baseline and at the 3-yr follow-up. Two of the three interviewers performed the ratings (neither rated their ain interviews). Both raters were blinded to each patient's background, diagnosis, and treatment condition. 20 interviews were rated past a third, external, independent rater. Ten interviews were randomly selected from baseline and follow-up. The reliability coefficients (ICC ii.i) were 0.74 for the Global Ac index, and 0.53, 0.65, 0.73, and 0.88 for Awareness, Tolerance, Emotional expression, and Conceptual expression, respectively. The reliability was satisfactory for nine of the eleven specific affects, ranging from 0.67 for Disdain/Contempt to 0.87 for Tenderness/Devotion. Withal, the reliability was unsatisfactory for Sadness/Despair (0.54) and Envy/Jealousy (0.55).

Axis I and centrality II diagnoses.

Axis I diagnoses were based on the Mini International Neuropsychiatric Interview [61]. Axis II diagnoses were determined according to the 4^th edition of the Diagnostic and Statistical Manual of Mental Disorders and the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II) [62]. Experienced clinicians performed the interviews at the treatment start. An external independent rater evaluated 24 videotaped SCID-II interviews. Kappa values were 0.75 for APD and 0.66 for BPD, indicating acceptable diagnostic reliability.

Symptom distress.

The Symptom Checklist-90-Revised (SCL-90-R) [63] was used to measure symptom distress. The SCL-90-R is a self-reported questionnaire with a 0 to four Likert scale. Information technology is designed to cover the major symptoms of psychological distress, represented in ix dimensions that can exist meaningfully summarized in a Global Severity Alphabetize (GSI). A higher score indicates more than symptom distress.

Interpersonal problems.

The Circumplex of Interpersonal Problems (CIP) [64] was used to assess interpersonal personal problems. This self-reported questionnaire is a 48-item version of the Inventory of Interpersonal Problems [65]. It comprises eight subscales that are summarized in a CIP alphabetize. The items are rated on a five-point Likert scale from 0 to iv; a college score indicates more interpersonal problems.

Self-Esteem.

Self-esteem was assessed using the Alphabetize of Self-Esteem (ISE) [66, 67]. The ISE is a 25-item self-evaluative questionnaire that measures the degree or severity of a respondent's self-esteem problems. The scale is scored from 0 to 100; a score of 0 indicates that the respondent has none of the attributes and 100 represents the highest possible distress level. Respondents that score >xxx are assumed to accept clinically significant self-esteem problems. Cronbach's blastoff of the Norwegian ISE calibration in the UPP sample was 0.91, which indicated adept internal consistency [23].

Personality functioning.

Severity Indices of Personality Problems (SIPP-118) is a self-report questionnaire for the assessment of core components of (mal)adaptive personality performance that are believed to exist child-bearing [68–seventy]. The instrument covers many of the personality domains conceptualized as core aspects of the personality pathology in the alternative model in the DSM-5 [13, 69]. The SIPP-118 consists of 118 4-betoken Likert scale items roofing 16 facets of personality functioning that cluster in five college-order domains [68]. Higher scores indicate more adaptive operation. The SIPP-118 questionnaire was translated from English to Norwegian past our research grouping and so translated back to English past an contained bilingual translator. Although the factor structure of SIPP-118 has non been fully settled [69], three studies accept reported good psychometric properties in adults and adolescents [68, 71], including cantankerous-national consistency in adult PD populations [72]. In the present study we utilized three of the five personality functioning domains in the SIPP-118, i.due east., Identity Integration, Relational Capacities, and Self-Control, based on the assumption that changes in Ac would be particularly relevant to these areas of performance [70].

Participants

Eighty-one patients with BPD or APD were included in the UPP study. For four of these patients, the ACI was not feasible due to technical failure of the video recordings on two occasions, and the inability to acquit the interview on two other occasions. Three other patients were initially included, only were excluded afterward initial treatment; one received a diagnosis of Asperger's disorder, another had prefrontal organic brain impairment, and the 3rd was judged to be on the border of mental retardation. Of the remaining 74 patients, 52 (70%) attended the 3-twelvemonth follow-upward examination and were included in the nowadays analyses. Withal, ane more patient was excluded in the analyses of the SIPP-118 domains. This patient's scores on SIPP-118 were judged equally invalid due to the measurement of astringent personality operation in several other clinical assessments combined with extremely high values on the SIPP domains.

The socio-demographic and clinical characteristics at baseline are presented in Table 1. Lx-five pct of the patients had BPD and 50% had APD. Thirty-seven percent of the patients had two or more than PD diagnoses and the distribution of co-occurring PD diagnoses was: Paranoid PD 12%, Obsessive Compulsive PD 12%, Dependent PD 6%, Egotistic PD two%, and Schizoid PD 2%. The mean number of PD traits was 16 (SD = 6.2). Of the included patients, 28 (54%) were randomly allocated to the Pace-down condition and 24 (46%) to the Outpatient condition. In that location were no statistically meaning differences between the two treatment conditions in socio-demographic or clinical characteristics at baseline, except for a higher charge per unit of patients with self-harm behaviors over the concluding year in the Step-down status (48%) compared with the outpatient condition (17%) (P = .021). The patients who did non nourish the 3-year follow-up (Footstep-down 33%, Outpatient 26%, ns) had a significantly college GSI (P = .009) at baseline, had a higher number of Axis I disorders (P = .001), and were more frequently diagnosed with substance abuse (P = .008), alcohol abuse (P = .006), and panic disorder (P = .042) compared with those included.

Treatments and treatment received

Pace-downwards treatment.

The patients allocated to Step-downwards treatment first attended an 18-week mean solar day-hospital treatment that utilized a combination of psychodynamic and cognitive-behavioral group therapies three to 4 days a week. Most therapists were trained and experienced group psychotherapists [57]. After the initial day-infirmary treatment, the patients continued with outpatient combined psychotherapy consisting of weekly grouping therapy (1.v hours) for a maximum of 4 years combined with weekly individual therapy for a maximum of 2.5 years.

The individual therapists, more often than not located exterior the infirmary setting, were invited to participate in the written report and to select whether they preferred to be involved in the Step-downwards treatment or the Outpatient treatment status. For the therapists in the Stride-down treatment condition, written handling guidelines adhered to relational psychotherapy, with references to group assay, self-psychology, and mentalization, but they did non serve every bit a standard for treatment adherence. However, clinical and theoretical 1-twenty-four hour period seminars, including case presentations, were organized twice a year for all therapists. Xi percent of the patients dropped out of the Footstep-downwardly treatment before starting outpatient combined therapy. Of the remaining patients, 44% were nevertheless attending weekly group therapy at the 3-year follow-up and 32% were even so in private therapy. The median number of grouping therapy sessions in the outpatient combined treatment at the 3-twelvemonth follow-up was 52 (range, seven–110). The median number of private therapy sessions was 45 (range, 5–117).

Outpatient handling.

The patients allocated to Outpatient treatment attended open up-ended individual psychotherapy that was conducted mainly by specialists in private practice. The therapists were instructed to treat patients according to their own preferred method and practice, and the researchers provided no instructions to the therapists regarding the duration or intensity of psychotherapy, nor did they interfere with any treatment decisions. Thirty-eight per centum of the patients in Outpatient treatment were all the same in individual therapy at the iii-year follow-upwards. The median number of private psychotherapy sessions during the iii-year period was 46 (range, 5–258). More detailed descriptions of the two handling conditions and therapists have been reported elsewhere [57–59].

Statistical Assay

All the analyses were performed using SPSS statistics version eighteen. We used independent sample t-tests to evaluate statistical relationships between continuous and categorical variables, chi-foursquare statistics to test associations betwixt categorical variables, and Pearson's correlation coefficients for the association between continuous variables. The rank society stability of global Air conditioning from baseline to follow-up was assessed past Spearman's rho; whereas, changes in Global AC and the xi specific affects were examined using paired sample t-tests. Within-grouping pre-mail event sizes (ES) were computed using Cohen's d with baseline SDs every bit standardization. According to Cohen [73], the ES may be characterized as modest (0.2–0.5), medium (0.5–0.8), or big (>0.8).

To investigate the human relationship between change in Global AC and clinical status at follow-upwardly, nosotros computed an AC modify score and ran multiple linear regression analyses with GSI, CIP, ISE, and SIPP-118 domains at the 3-twelvemonth follow-up as dependent variables. At baseline, AC was positively correlated with age (r = 0.30, P = .034) and the female person participants had significantly higher AC scores than the males (Ac = 3.66, SD = 0.45 versus AC = iii.29, SD = 0.59; P = .026). Therefore, gender and age were entered as contained variables, followed by the baseline level of the dependent variable, and the baseline level of Global Air conditioning. The AC change score was entered every bit the last independent variable to examine whether an altered AC contributed to explained variance at 3-years follow-up beyond the control variables. Finally, as the reliability was unsatisfactory for the AC aspect of Awareness and the affects Sadness/Despair and Envy/Jealousy nosotros computed a new Global Air conditioning score, excluding these variables. The regression analyses were and so repeated with the new Global AC variable. In that location were pocket-size variations in n beyond analyses attributable to some missing data.

Results

The hateful level of Global Air conditioning changed from 3.58 (SD = 0.50) at baseline to 4.00 (SD = 0.58) at the 3-year follow-up. This change was statistically significant (P < .001) (Tabular array 2). There were statistically significant increases in AC for eight of the eleven specific affects: Involvement/Excitement (P = .001), Enjoyment/Joy (P < .001), Fear/Panic (P < .001), Anger/Rage (P < .001), Shame/Humiliation (P = .002), Sadness/Despair (P = .010), Guilt/Remorse (P = .006), and Tenderness/Devotion (P = .004). The ES was in the large range for the changes in Global AC (d = 0.84) and the affects Fear/Panic (d = 1.05) and Anger/Rage (d = 0.77), while the ES was in the medium range for Interest/Excitement (d = 0.47), Enjoyment/Joy (d = 0.57), Shame/Humiliation (d = 0.61), Sadness/Despair (d = 0.46), and Guilt/Remorse (d = 0.48). There were statistically meaning increases in all aspects of Air-conditioning; Sensation (P = .028), Tolerance (P < .001), Emotional expressivity (P < .001), and Conceptual expressivity (P < .001). The magnitude of the changes was largest for Tolerance (d = 0.87) and Conceptual expressivity (d = 0.92), and smallest for Awareness (d = 0.37). The correlation (rho) between the Global Air-conditioning at baseline and follow-up was 0.59 (P < .001), indicating moderate rank order stability.

As all participants in the sample either had BPD, APD or both PD diagnoses, nosotros investigated whether the PD groups differed regarding modify in Global Air-conditioning. We start compared patients who had either BPD (n = 26) or APD (n = 18). The change in Ac did not differ significantly between the groups (P = 0.173). And so, nosotros included the patients with both diagnoses, starting time, in the BPD group, and then in the APD group. Neither of the between-grouping differences were significant (P = 0.180 and P = 0.296, respectively).

Taking into account the potential effect of age, a linear regression assay was conducted. Change in Global Air-conditioning score was entered equally the dependent variable, whereas age and Global Air-conditioning at baseline were entered as contained variables. Age did not contribute statistical significantly to the explained variance of modify in Global Air-conditioning (P = 0.466).

At baseline, 72% of the patients were treated with medications, mostly antidepressants. From baseline to follow-up at that place was a reduction in use of antidepressants from 53% to 33% (P<0.001). However, modify in use of antidepressants was not associated with alter in Global AC (P = 0.200).

The sample improved in both symptoms and personality functioning during the follow-up menstruum, equally indicated past meaning decreases in levels of GSI (from 1.68 (SD = 0.64) to 1.17 (SD = 0.71); P < .001; ES = 0.eighty), CIP (from one.71 (SD = 0.50) to 1.42 (SD = 0.55); P = .001; ES = 0.58), and ISE (from 58.69 (SD = xi.07) to 50.29 (SD = 13.89); P < .001; ES = 0.76), as well every bit increases in the SIPP-118 domains Identity Integration (from 2.04 (SD = 0.51) to 2.77 (SD = 0.73); P < .001; ES = 1.43), Relation Capacities (from ii.35 (SD = 0.64) to two.80 (SD = 0.70); P < .001; ES = 0.70), and Cocky-Control (from two.44 (SD = 0.62) to 2.98 (SD = 0.60); P < .001; ES = 0.87).

To investigate whether change in the Global Air conditioning score was associated with clinical status, the 3-year follow-upward scores on the GSI, CIP, ISE, and the SIPP-118 domains—Identity Integration, Relational Capacities, and Self-Command were entered as dependent variables in six divide linear regression analyses. The independent variables were entered in the following order: gender, historic period, baseline scores for the respective clinical measure, baseline Global Ac, and finally Ac modify. Equally shown in Table 3, for all clinical measures, the respective baseline levels explained a significant function of the variance at the iii-year follow-up (GSI: 25.9%, P < .001; CIP: 19.5%, P = .002; ISE: 28.3%, P < .001; Identity Integration: 8.5%, P = .047, Relational Capacities: 38.v%, P < .001; Self-Control: 27.v%, P < .001). Gender and age were non associated with the follow-upwardly scores on the GSI, CIP, or ISE. After controlling for the previous variables, the AC modify explained an additional 7.7% of the variance in CIP (P = .033), 8.6% of the variance in Identity Integration (P = .026), and 8.7% of the variance in Relational Capacities (P = .005) at follow-upwardly. The AC change was not significantly related to follow-up scores on the GSI or Self-Control levels. The contribution of the Air conditioning change was shut to significant (P = .076) for the variance in ISE at follow-up.

Table 3. Multiple Regression Analyses Using the GSI, CIP, ISE, and SIPP-118 Domains (Identity Integration, Relational Capacities, and Self-control domain) at the 3-Year Follow-Up as Dependent Variables.

https://doi.org/10.1371/journal.pone.0145625.t003

To account for whatever possible influence of insufficient reliability of some aspects of the Air conditioning measure, we repeated the analyses with the revised Global Air-conditioning. The significance levels of the onetime analyses were confirmed and strengthened in nearly respects, especially regarding the ISE. Under this condition, the contribution of the AC change to the ISE at the 3-year follow-up was significant and explained an additional 7.2% of the variance (P = .030).

Discussion

Nosotros establish support for the first hypothesis that the participants Air-conditioning would better from baseline to follow-up, iii-years after treatment start. We interpret this equally testify that it is possible to modify from non-adaptive to more adaptive ways of utilizing one's affects, which is i aspect of what constitute personality disorders. Such a change may be valuable by itself, but the chief question remains: Is change in Ac associated with clinical improvement or less interpersonal conflicts? The 2nd expectation, that an altered Air conditioning would also be related to positive changes in clinical status, i.e., severity of interpersonal and self-related problems, and symptom distress, was partly supported. In this section, we will discuss the ii main findings in more detail, and compare the results with previous comparable research.

The finding that the Global AC score improved from baseline to the 3-year follow-upwardly concurs with previous psychotherapy studies reporting improved Air conditioning in samples of patients with PDs, feet disorders and chronic pain disorders, measured after treatment- and follow-up periods, ranging from 1 to 7 years [40–43]. Furthermore, there were improvements in AC for most affects; for instance, the ESs were large for Fear/Panic and Anger/Rage, and ranged from depression to moderate for the other affects. The increase in AC did not achieve the level of statistical significance for Disdain/Contempt, Disgust/Revulsion, or Envy/Jealousy, suggesting that changes in these particular affects are more difficult than for others.

Still, it might be that particular affects, such as fear and anger, are more regularly addressed in psychotherapy, while green-eyed, disgust, or contempt are experienced as more chaotic, elusive, or associated with shame, and may demand special attention and intervention, or a particularly trustful therapeutic relationship to exist brought forwards and become a subject for exploration in the therapeutic dialogue. Influenced by Silvan Tomkins' script theory, Magai [74] suggests that shame, if repeatedly socialized and associated with other affects, creates affect-shame binds. Equally a result, when the affect associated with shame is activated, shame is experienced and the initial affect is inhibited. In the present study, the absence of alter in AC for particular affects could exist due to such affect-shame binds, inhibiting the exposure of these affects in psychotherapy.

Despite the meaning changes in AC, the ESs did not reach the same levels every bit in previous studies of AC [xl–43]. This discrepancy might be related to the different versions of the AC scale and scoring procedures used in the erstwhile and present study, making comparisons betwixt studies somewhat difficult. In the present and most recent version of the ACI, eleven affects are scored on a nine-point calibration; while, in the previous studies nine affects were scored on a 5-point calibration. There is a demand for more cognition of the psychometric properties of the final version of the Air-conditioning scales, their sensitivity to alter, and what might be expected as a normal Ac level.

On the other manus, the differences in ESs could be influenced by patient characteristics. It might exist that AC problems are more chronic, or resistant to change in certain disorders or types of PDs. The present sample comprised patients with BPD and APD, which are assumed to be characterized with affect dysregulation and bear upon avoidance respectively [21, 27, 75, 76]. Interestingly, in this sample of poorly functioning patients, we did not find any departure in Air conditioning alter between the PD groups.

Finally, differences in ESs between the studies could also exist due to handling features. In 2 of the former studies evaluating changes in Air-conditioning [40–42], the patients received psychotherapy especially developed to heighten Ac. Working with affects, both within the therapeutic relationship and in other meaning relationships in the patient'south life, is key to many forms of contemporary psychotherapies, beyond different theoretical perspectives. Withal, common clinical sense would propose that AC focused psychotherapy, which is adult inside the context of the AC methodology (i.e., in which the therapist consistently focuses on helping the patient to recognize and label individual affects, and subsequently facilitates reflection and a more than constructive communication of affects) enhances the potential for change in Air conditioning. Regarding the present report, even so, the results must be interpreted with caution every bit it did not include a no-treatment clinical control group. Even though the nowadays modify in Ac was not related to age, we can not exclude the possible effects of age-related maturation, and more studies are needed regarding this upshot.

The 2nd main finding of the present written report was how clinical status at follow-upwardly were related to the improvement in AC. Cross-sectional studies on Air conditioning have reported an clan between the level of AC and severity of the psychopathology, i.e., cocky-esteem and interpersonal problems [35, 44–46]. The present results complement these studies, and to our noesis this is the outset study to written report that improved Air-conditioning is related to follow-up measures of cocky-relatedness and interpersonal role, which are some of the core markers of maladaptive personality functioning.

More specifically, improved AC was associated with the Identity Integration domain of the SIPP-118, and this explained almost 9% of the variance at follow-upward, whereas the relationship with self-esteem problems was significant in the control analysis, i.east., after removing the affects and attribute with bereft reliability. Identity Integration, as defined by the SIPP-118, refers to the ability to tolerate frustration, enjoyment, and to see i'southward life equally stable, integrated, and purposeful [68, lxx]. Furthermore, a relationship betwixt low scores on the Identity Integration domain and the presence of PD has been found in studies of both adults and adolescents [68, 71, 77]. Inside the alternative model of the DSM-v (section Three) [13], identity constitutes i of two main elements of self-performance, and the capability of experiencing, tolerating, and regulating a full range of emotions is defined as an attribute of mature, well-integrated identity. So far, even so, few empirical studies have investigated the human relationship between emotional functioning and identity. The present results support the notion in section III that adaptive means of utilizing one'south affects is meaning for an individual's experience of a coherent and purposeful cocky.

However, the relationship between emotional processing and identity is probably complex. For example, the sense of identity in subjects with low Air conditioning may be depleted by reduced sensation of various affects and their inherent motivational aspects. On the other hand, subjects with depression Ac may occasionally be so overwhelmed past their affects that their sense of identity is temporarily lost. Nevertheless, increased levels of Identity Integration have been reported in patients with PDs who have received psychotherapy [68, 77–79], and the nowadays results suggest that improvements in Air-conditioning may contribute to such strengthening of identity.

In regards to interpersonal office, improved Ac explained a significant part of the variance at follow-up, when measured with the CIP and the SIPP-118 domain Relational Capacities, which evaluates the chapters for intimacy, enduring relationships, and the power to feel recognized by others [68, 70]. These results strengthen the evidence from previous clinical studies of the relationships between changes in emotional awareness, balance, and expression and improved interpersonal function in patients with BPD [32] and patients with cluster C PDs [34]. The present results also concur with findings that communication and the sharing of emotions are associated with intimacy and strengthening of social bonds [fourscore–82].

Co-ordinate to Bastiaansen and colleges [69], the SIPP-118 Identity Integration domain captures virtually of the self-components in the DSM-5, section III; Identity and Self-Direction, whereas, the SIPP-118 Relational Capacities domain covers the relational components; Intimacy and Empathy. Thus, these preliminary findings suggest that improved Ac is associated with follow-upwards measures for the two core domains of personality psychopathology. Accordingly, psychotherapies with patients with PDs that integrate an melancholia focus and succeed in increasing emotional sensation and recognition, as well as an ability to reflect upon and express a broad range of affects, might help the patients to develop more adaptive personality functioning. However, there is a need for further exam of the potential links between psychotherapeutic processes and emotional and personality growth. Time to come studies should investigate to what extent, and how these processes are related in diverse treatments and patient populations.

The lack of human relationship between a modify in Ac and follow-up level of the SIPP-118 Self-Control domain was surprising. This domain includes emotion regulation, effortful control, and aggression regulation [68]. Based on theoretical expectation and clinical intuition, it was expected that improved AC would be related to follow-up levels of this domain too. There may exist several explanations for this finding. Beginning, information technology has been suggested that patients with APD are characterized with affect phobia or a general suppression of affects [17, 83], while patients with BPD are less able to suppress, or regulate, unpleasant experiences of affects [75, 84, 85]. Thus, the two PD groups in the present sample might stand for extremes with respect to either depression or high self-command, and neutralize the relationship between AC change and Cocky-Command. Furthermore, the Global AC summarizes different aspects of emotional functioning and the SIPP-118 domains are also multi-faceted. The present sample was too small to explore whether changes in the different aspects of AC were related to Cocky-control or certain facets of Cocky-control. As well, the psychometric properties of the SIPP-118 domains have not been confirmed; for instance, the primary cistron loadings of the Aggression Regulation facet on the Self-command domain have differed between samples [68–71]. All the same, as indicated by our effect, there is a possibility that in that location is no strong human relationship between enhanced Air conditioning and improved self-control. More studies are needed to clarify these issues.

Theoretically, AC is causeless to be associated with symptom distress [28], and some clinical studies take supported this [35, 44, 45, 51]. Similarly, McMain and colleges [32] reported that an increment in positive versus negative affects was associated with improvements in both general symptom distress and interpersonal function in a sample of patients with BPD. However, in the nowadays written report, a change in Air-conditioning was not, under any conditions, associated with the follow-up level of symptomatic distress, and this outcome might exist related to sample selection. In more than narrow psychiatric samples, such as patients with eating disorders [49] or in our previous study based on the present sample [46], Air conditioning was non related to symptom distress. Hence, even though patients with more than severe PD pathology experience high levels of psychological symptoms overall [86], the clinical variation in a PD sample might be too limited to illuminate a relationship betwixt changes in the level of AC and symptom distress.

The present results should be interpreted in light of some limitations. First, as there was no untreated control group included in the nowadays study, we do non know whether the changes in Air conditioning or clinical measures could be attributed to psychotherapy effects, or whether the improvements were due to alterations over time, e.g. age-related maturation. Second, study inclusion was restricted to patients with APD or BPD as their main PD diagnosis. Even though the participants had other co-occurring PD diagnoses, the results may not be generalized to other PD populations or to less disturbed patients. Third, the pocket-size sample size increases the possibility of type 2 error. Appropriately, the present results need to be replicated in larger studies and samples that contain mixed clinical populations and different PDs. Fourth, the present results may exist influenced by attrition bias, as the group of patients that did not attend the 3-year follow-up investigation had more than severe symptoms and more frequent substance use disorders. Finally, the reliability was not satisfactory for three variables, and the command analyses suggested a stronger relationship between changes in AC and self-esteem in item.

In decision, the nowadays results suggest that patients with PDs have the potential for improvements in AC, and this is the starting time study to report that such improvement is related to clinical condition at follow-upwards, especially within the self and interpersonal domains of personality performance. Thus, psychotherapies that succeed in increasing the patients' level of bear upon integration might have the potential to aid patients with PDs to develop more than adaptive personality functioning. Future studies should be conducted in controlled settings, aimed at expanding our noesis of how various forms of psychotherapy and treatment programs tin facilitate the sensation, tolerance, and communication of affective experiences, too as investigate the assumed mediating effect of Air conditioning on psychotherapy outcome. Although Air-conditioning is relevant for a broad range of clinical disorders and populations, information technology may be especially important for the treatment of patients with PDs, for whom emotional dysfunction is a fundamental characteristic.

Author Contributions

Conceived and designed the experiments: MSJ TW. Performed the experiments: ENE MSJ TNE. Analyzed the data: ENE TW. Contributed reagents/materials/analysis tools: ENE MSJ TNE JE TW. Wrote the paper: ENE JE TW.

References

1. 1. Johnson JG, Cohen P, Kasen S, Skodol AE, Oldham JM. Cumulative prevalence of personality disorders between adolescence and adulthood. Acta Psychiatr Scand. 2008;118: 410–413. pmid:18644003
   • View Article
   • PubMed/NCBI
   • Google Scholar
2. 2. Torgersen S. The nature (and nurture) of personality disorders. Scand J Psychol. 2009;50: 624–632. pmid:19930262
   • View Article
   • PubMed/NCBI
   • Google Scholar
3. 3. Zimmerman M, Rothschild L, Chelminski I. The prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry. 2005;162: 1911–1918. pmid:16199838
   • View Article
   • PubMed/NCBI
   • Google Scholar
4. 4. Skodol AE; Pagano ME; Bender DS; Shea MT; Gunderson JG; Yen S, et al. Stability of functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder over two years. Psychol Med. 2005; 35: 443–451. pmid:15841879
   • View Article
   • PubMed/NCBI
   • Google Scholar
5. 5. Svartberg K, Stiles TC, Seltzer MH. Randomized controlled trail of the effectiveness of short-term dynamic psychotherapy and cerebral therapy for cluster C personality disorders. Am J Psychiatry. 2004;161: 810–817. pmid:15121645
   • View Article
   • PubMed/NCBI
   • Google Scholar
6. 6. Giesen-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Dirksen C, tin Asselt T, et al. Outpatient psychotherapy for borderline personality disorder: randomized trail of schema-focused therapy vs transference-focused therapy. Curvation Gen Psychiatry. 2006;63: 649–658. pmid:16754838
   • View Article
   • PubMed/NCBI
   • Google Scholar
7. seven. Kernberg OF, Yeomans FE, Clarkin JF. Levy KN. Transference focused psychotherapy: Overview and update. Int J Psychoanal. 2008;89: 601–620. pmid:18558958
   • View Commodity
   • PubMed/NCBI
   • Google Scholar
8. 8. Bateman A, Fonagy P. eight-year follow-upwardly of patients treated for borderline personality disorder: mentalization-based treatmet versus treatment as usual. Am J Psychiatry. 2008;165: 631–638. pmid:18347003
   • View Article
   • PubMed/NCBI
   • Google Scholar
9. nine. McMain SF, Links PS, Gnam WH, Guimond T, Cardish R, Korman L, et al. A randomized trial of dialectical behavior therapy versus general psychiatric direction for borderline personality disorder. Am J Psychiatry. 2009;166: 1365–1374. pmid:19755574
   • View Article
   • PubMed/NCBI
   • Google Scholar
10. ten. Sempertegui GA, Karreman A, Arntz A, Bekker MH. 2013. Schema therapy for deadline personality disorder: a comprehensive review of its empirical foundations, effectiveness and implementation possibilities. Clin Psychol Rev. 2013;33: 426–447. pmid:23422036
    • View Article
    • PubMed/NCBI
    • Google Scholar
11. xi. Dimaggio G, Nicolò G, Semerari A, Carcione A. Investigating the personality disorder psychotherapy process. Psychother Res. 2013;23: 625–632.
    • View Article
    • Google Scholar
12. 12. Bateman A, Gunderson J, Mulder R. Treatment of personality disorder. Lancet. 2015;385: 735–743. pmid:25706219
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
13. 13. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th Ed.). Washington, DC; 2013.
14. xiv. Gross JJ. The emerging field of emotion regulation: An integrative review. Rev Gen Psychol. 1998;2: 271–299.
    • View Commodity
    • Google Scholar
15. 15. Joyce AS, Fujiwara E, Cristall G, Cerise C, Ogrodniczuk JS. Clinical correlates of alexithymia among patients with personality disorder. Psychother Res 2013;23: 690–704. pmid:23731378
    • View Article
    • PubMed/NCBI
    • Google Scholar
16. 16. Pedersen G, Johansen MS, Wilberg T & Karterud S. Testing Different Versions of the Affective Neuroscience Personality Scales in a Clinical Sample. PLOS One. 2014;9: e109394. pmid:25289939
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
17. 17. Nicolò G, Semerari A, Lysaker PH, Dimaggio G, Conti L, D'Angerio S, et al. Alexithymia in personality disorders: correlations with symptoms and interpersonal functioning. Psychiatry Res 2011;190: 37–42. pmid:20800288
    • View Article
    • PubMed/NCBI
    • Google Scholar
18. xviii. Lecours S, Bouchard MA. Verbal elaboration of distinct bear on categories and BPD symptoms. Psychol Psychother T. 2011;84: 26–41.
    • View Article
    • Google Scholar
19. 19. Berkin M, Wupperman P. Emotion regulation and mental health. Curr Opin Psychiatry. 2012;25: 128–134. pmid:22262030
    • View Article
    • PubMed/NCBI
    • Google Scholar
20. 20. Ridings LE, Lutz-Zois CJ. Emotional dysregulation and Borderline Personality Disorder: Explaining the link between secondary psychopathy and alexithymia. Pers Individ Dif. 2014;57: fourteen–xix.
    • View Article
    • Google Scholar
21. 21. Johansen MS, Normann-Eide E, Normann-Eide T, Wilberg T. Emotional dysfunction in avoidant compared to borderline personality disorder: A written report of impact consciousness. Scand J Psychol. 2013;54: 515–521. pmid:24107113
    • View Article
    • PubMed/NCBI
    • Google Scholar
22. 22. Koenigsberg HW, Denny BT, Fan J, Liu X, Guerreri Southward, Mayson SJ, et al. The Neural Correlates of Dissonant Habituation to Negative Emotional Pictures in Borderline and Avoidant Personality Disorder Patients. Am J Psychiatry. 2014;171: 82–ninety. pmid:24275960
    • View Article
    • PubMed/NCBI
    • Google Scholar
23. 23. Lynum LI, Wilberg T, Karterud S. Self-esteem in patients with deadline and avoidant personality disorders. Scand J Psychol. 2008;49: 469–477. pmid:18564322
    • View Article
    • PubMed/NCBI
    • Google Scholar
24. 24. Hummelen B, Wilberg T, Pedersen , Karterud S. An investigation of the validity of the Diagnostic and Statistical Manual of Mental Disorders, Forth Edition avoidant personality disorder construct as a epitome category and the psychometric properties of the diagnostic criteria. Compr Psychiatry. 2006; 47:376–383. pmid:16905400
    • View Article
    • PubMed/NCBI
    • Google Scholar
25. 25. Chiesa Thou, Bateman A, Wilberg T, Friis S. Patients' characteristics, outcome and cost-do good of infirmary-based handling for patients with personality disorder: A comparing of 3 different programmes. Psychol Psychother-T. 2002; 75:381–392
    • View Article
    • Google Scholar
26. 26. McCullough Vaillant L. Changing Character: Curt-Term Feet-Regulating Psychotherapy for Restructuring Defenses, Affects, and Zipper. New York, NT: Basic Books; 1997.
27. 27. McCullough Fifty, Kuhn North, Andrews Southward, Kaplan A, Wolf J, Hurley CL. Treating bear on phobia. A manual for short-term dynamic psychotherapy. New York: Guilford Press; 2003.
28. 28. Monsen JT, Monsen K. Touch and Affect Consciousness: A psychotherapy Model Integrating Silvan Tomkins's Touch on–and Script Theory Inside the Framework of Self Psychology. Goldberg A, editor. Pluralism in Self Psychology: Progress in Self-Psychology. 1999;xv: 287–306.
    • View Article
    • Google Scholar
29. 29. Jurist EL. Mentalized affectivity. Psychoanal Psychol. 2005;22: 426–444.
    • View Article
    • Google Scholar
30. 30. Greenberg L. The Clinical Application of Emotion in Psychotherapy. In: Lewis M, Haviland-Jones JM, Barrett LF, editors. Handbook of Emotions. The Guilford Press, New York. 2008. pp. 88–101.
31. 31. Dimaggio G, Montano A, Popolo R, Salvatore G. Metacognitive Interpersonal Therapy for Personality Disorders: A treatment manual. Routledge; 2015.
32. 32. McMain South, Links PS, Guimond T, Wnuk S, Eynan R, Bergmans Y, et al. An exploratory study of the human relationship between changes in emotion and cognitive processes and treatment consequence in borderline personality disorder. Psychother Res 2013;23: 658–673. pmid:24156526
    • View Article
    • PubMed/NCBI
    • Google Scholar
33. 33. Schanche Eastward, Stiles TC, McCullough L, Svartberg M, Nielsen GH. The human relationship betwixt activating affects, inhibitory affects, and self-compassion in psychotherapy patients with cluster C personality disorders. Psychotherapy. 2011;48: 293–303. pmid:21604900
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
34. 34. Berggraf L, Ulvenes PG, Oktedalen T, Hoffart A, Stiles T, McCullough L, et al. Experience of affects predicting sense of self and others in short-term dynamic and cerebral therapy. Psychotherapy, 2014;51: 246–257. pmid:24884340
    • View Article
    • PubMed/NCBI
    • Google Scholar
35. 35. Solbakken OA, Hansen RS, Monsen JT. Assessment of affect integration: Validation of the touch on consciousness construct. J Pers Assess. 2011;92: 257–265.
    • View Article
    • Google Scholar
36. 36. Mohaupt H, Holgersen H, Binder PE, Nielsen GH. Affect consciousness or mentalization? A coomparison of two concepts with reagrd to touch development and bear upon regulation. Scand J Psychol. 2006;47: 237–244. pmid:16869856
    • View Article
    • PubMed/NCBI
    • Google Scholar
37. 37. Choi-Kain LW, Gunderson JG. Mentalization: Ontogeny, assessment, and application to the handling of borderline personality disorder. Am J Psychiatry. 2008;165: 1127–1135. pmid:18676591
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
38. 38. Monsen JT, Monsen Thousand, Solbakken OA, Sandvik-Hansen R. The affect consciousness interview (ACI) and the bear on consciousness scale (ACS): Instructions for the interview and rating. Oslo, Kingdom of norway: Bachelor from the Department of Psychology, University of Oslo; 2008.
39. 39. Monsen JT, Ødegård P, Melgård T. Major psychological changes after intensive psychotherapy: Findings from the Tøyen project, Oslo. Psychoanal Psychother 1989;7: 171–180.
    • View Article
    • Google Scholar
40. 40. Monsen JT, Odland T, Faugli A, Daae East, Eilertsen DE. Personality disorders: Changes and stability afterward intensive psychotherapy focusing on affect consciousness. Psychother Res. 1995;v: 33–48.
    • View Article
    • Google Scholar
41. 41. Monsen JT, Odland T, Faugli A, Daae E, Eilertsen DE. Personality disorders and psychosocial changes later intensive psychotherapy: A prospective follow-up study of an outpatient psychotherapy project, 5 years subsequently cease of treatment. Scand J Psychol 1995;36: 256–268. pmid:7481598
    • View Article
    • PubMed/NCBI
    • Google Scholar
42. 42. Monsen Thou, Monsen JT. Chronic hurting and psychodynamic body therapy: A controlled outcome study. Psychother Theor Res Pract Train. 2000;37: 257–269.
    • View Article
    • Google Scholar
43. 43. Gude T, Monsen JT, Hoffart A. Schemas, affect consciousness, and cluster C personality pathology: A prospective i-year follow-up written report of patients in a schema-focused brusk-term handling program. Psychother Res. 2001;xi: 85–98. pmid:25849879
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
44. 44. Monsen JT, Eilertsen DE, Melgård T, Ødegård P. Affects and affect consciousness: Initial experience with the assessment of affect integration. J Psychother Pract Res. 1996;5: 238–249. pmid:22700292
    • View Article
    • PubMed/NCBI
    • Google Scholar
45. 45. Lech B, Andersson G, Holmqvist R. Consciousness well-nigh own and others' affects: A report of the validity of a revised version of the touch on consciousness interview. Scand J Psychol 2008;49: 515–521. pmid:18489533
    • View Article
    • PubMed/NCBI
    • Google Scholar
46. 46. Normann-Eide Due east, Johansen MS, Normann-Eide T, Egeland J, Wilberg T. Is depression affect consciousness related to severity of psychopathology? A cross-sectional study of patients with avoidant and borderline personality disorder. Compr Psychiatry 2013;54: 149–157. pmid:22998844
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
47. 47. Waller Eastward, Scheidt CE. Somatoform disorders as disorders of affect regulation: A report comparing the TAS-20 with non-self-report measures of alexithymia. J Psychosom Res. 2004;57: 239–247. pmid:15507250
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
48. 48. Holmqvist R. Psychopathy and affect consciousness in immature criminal offenders. J Interpers Violence 2008;23: 209–224. pmid:18162637
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
49. 49. Lech B, Holmqvist R, Andersson G. Affect consciousness and eating disorders. Curt Term Stability and Subgroup Characteristics. Eur Consume Disorders Rev 2012;20: e50–e55.
    • View Article
    • Google Scholar
50. fifty. Lech B, Andersson G, Holmqvist R. Touch consciousness and adult attachment. Psychology 2012;3: 675–680.
    • View Article
    • Google Scholar
51. 51. Solbakken OA, Hansen RS, Havik OE, Monsen JT. Affect integration equally a predictor of alter: Affect consciousness and treatment response in open-ended psychotherapy. Psychother Res. 2012;22: 656–672. pmid:22757634
    • View Article
    • PubMed/NCBI
    • Google Scholar
52. 52. Solbakken OA, Hansen RS, Monsen JT. Touch integration and reflective function: Clarification of central conceptual issues. Psychother Res. 2011;21: 482–496. pmid:21623546
    • View Article
    • PubMed/NCBI
    • Google Scholar
53. 53. Clark L. A. Stability and alter in personality disorder. Curr Dir Psychol Sci. 2009;18: 27–31.
    • View Commodity
    • Google Scholar
54. 54. Hopwood CJ, Malone JC, Ansell EB, Sanislow CA, Grilo CM, McGlashan Th, et al. Personality Cess in DSM-5: Empirical support for rating severity, manner, and traits. J Pers Disord. 2011;25: 305–320. pmid:21699393
    • View Article
    • PubMed/NCBI
    • Google Scholar
55. 55. Kvarstein EH, Karterud S. Large variation of severity and longitudinal change of symptom distress amidst patients with personality disorders. Personal Ment Health. 2013;vii: 265–276. pmid:24343976
    • View Article
    • PubMed/NCBI
    • Google Scholar
56. 56. Karterud S, Johansen MS, Wilberg T. Conjoint group and individual therapy in a research trial for patients with severe personality disorders. Group. 2007;31: 31–46.
    • View Article
    • Google Scholar
57. 57. Arnevik E, Wilberg T, Urnes Ø, Johansen M, Monsen JT, Karterud S. Psychotherapy for personality disorders: Curt-term mean solar day hospital psychotherapy versus outpatient individual therapy–a randomized controlled written report. Eur Psychiatry. 2009;24: 71–78. pmid:19097870
    • View Article
    • PubMed/NCBI
    • Google Scholar
58. 58. Arnevik E, Wilberg T, Urnes Ø, Johansen M, Monsen JT, Karterud S. Psychotherapy for personality disorders: 18 months' follow-up of the Ullevål Personality Project. J Pers Disord. 2010;24: 188–203. pmid:20420475
    • View Article
    • PubMed/NCBI
    • Google Scholar
59. 59. Gullestad F, Wilberg T, Klungsøyr O, Urnes Ø, Karterud S. Is treatment in a day hospital stride-down program superior to outpatient private psychotherapy for patients with personality disorders? 36 months follow-up of a randomized clinical trail comparison dissimilar treatment modalities. Psychother Res. 2012;22: 426–441. pmid:22417131
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
60. sixty. Antonsen BT, Klungsøyr O, Kamps A, Hummelen B, Johansen MS, Pedersen G, et al. Step-down versus outpatient psychotherapeutic treatment for personality disorders: 6-year follow-upwardly of the Ullevål Personality Projection. BMC Psychiatry. 2014;14: 119 Available: http://www.biomedcentral.com/1471-244X/xiv/119. pmid:24758722
    • View Article
    • PubMed/NCBI
    • Google Scholar
61. 61. Sheehan DV, Lecrubier Y. Mini-international neuro-psychiatry interview (Thou.I.Northward.I.). Tampa (Fla): University of S Florida Institute for Research in Psychiatry/INSERM-Hospital de la Salpétrière; 1994.
62. 62. First MB. Structured clinical interview for DSM-Iv (version two.0). New York: New York State Psychiatry Institute; 1994.
63. 63. Derogatis LR. SCL-90-R manual: administration, scoring & procedures. Usa: Clinical Psychometric Research; 1983.
64. 64. Pedersen GA. Revised Norwegian version of inventory of interpersonal issues-Circumplex (IIP-C). Tidsskr Nor Psykologforen. 2002;39: 25–34.
    • View Article
    • Google Scholar
65. 65. Alden LE, Wiggins JS, Pincus AL. Construction of circumplex scales for the inventory of interpersonal issues. J Pers Assess. 1990;55: 521–536. pmid:2280321
    • View Article
    • PubMed/NCBI
    • Google Scholar
66. 66. Hudson WW. The clinical measurement packet: A field manual. Chicago, IL: The Dorsey Press; 1982.
67. 67. Hudson WW. The Wallmyr assessment scale scoring manual. Tempe, AZ: Walmyr Publishing Co; 1992.
68. 68. Verheul R, Andrea H, Berghout CC, Dolan C, van Busschbach JJ, van der Kroft PJA, et al. Severity indices of personality problems (SIPP- 118): Development, factor structure, reliability, and validity. Psychol Assessment. 2008;20: 23–34.
    • View Article
    • Google Scholar
69. 69. Bastiaansen 50, De Fruyt F, Rossi G, Schotte C, Hofmans J. Personality disorder dysfunction versus traits: Structural and conceptual issues. Personal Disord. 2013;4: 293–303. pmid:23834515
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
70. 70. Andrea H, Verheul R, Berghout CC, Dolan C, van der Kroft PJA, Bateman AW, et al. (2007). Measuring the core components of maladaptive personality: Severity indices of personality problems (SIPP-118). Report of the Viersprong Plant for Studies on Personality Disorders (VISPD) in cooperation with the Section of Medical Psychology & Psychotherapy, Erasmus University Rotterdam, The Netherlands; 2007. Available: http://hdl.handle.cyberspace/1765/10066.
71. 71. Feenstra DJ, Hutsebaut J, Verheul R, Busschbach JJV. Severity Indices of Personality Problems (SIPP-118) in Adolescents: Reliability and Validity. Psychol Assessment. 2011;23: 646–655.
    • View Article
    • Google Scholar
72. 72. Arnevik E, Wilberg T, Monsen JT, Andrea H, Karterud S. A cross-national validity report of the Severity Indices of Personality Problems (SIPP-118). Personal Ment Health. 2009;3: 41–55.
    • View Article
    • Google Scholar
73. 73. Cohen J. Statistical power analysis for the behavioral sciences. New York: Bookish; 1988.
74. 74. Magai C. Affect, imagery and attachment: Working models of interpersonal bear on and the socialization of emotion. Cassidy J, Shaver P, editors. Handbook of Zipper. New York: Guilford Press; 1999. pp. 787–802.
75. 75. Conklin CZ, Bradley R, Westen D. Touch regulation in borderline personality disorder. J Nerv Ment Disord. 2006;194: 69–77.
    • View Commodity
    • Google Scholar
76. 76. Gratz KL, Rosenthal MZ, Tull MT, Lejuez CW, Gunderson JG. An experimental investigation of emotion dysregulation in borderline personality disorder. J Abnorm Psychol. 2006;115: 850–855. pmid:17100543
    • View Article
    • PubMed/NCBI
    • Google Scholar
77. 77. Feenstra DJ, Hutsebaut J, Verheul R, van Limbeek J. Identity: Empirical contribution. Changes in the identity integration of adolescents in treatment for personality disorders. J Pers Disord. 2014;28: 101–112. pmid:24344891
    • View Article
    • PubMed/NCBI
    • Google Scholar
78. 78. Bales D, van Beck Due north, Smits One thousand, Willemsen South, van Busschbach JJ, Verheul R, et al. Handling outcome of 18-month, day hospital mentalization-based treatment (MBT) in patients with severe deadline personality disorder in the netherlands. J Pers Disord. 2012;26: 568–582. pmid:22867507
    • View Article
    • PubMed/NCBI
    • Google Scholar
79. 79. Bales DL, Timman R, Andrea H, van Busschbach JJ, Verheul R, Kamphuis JH. Effectiveness of Day Infirmary Mentalization-Based Treatment for Patients with Severe Borderline Personality Disorder: A Matched Control Study. Clin Psychol Psychother. 2014;
    • View Article
    • Google Scholar
80. 80. Laurenceau J-P, Feldman Barrett LA, Pietromonaco PR. Intimacy as an interpersonal process: The importance of cocky-disclosure and perceived partner responsiveness in interpersonal exchanges. J Pers Soc Psychol. 1998;74: 1238–1251. pmid:9599440
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
81. 81. Butler EA, Egloff B, Wilhelm FH, Smith NC, Erickson EA, Gross JJ. The social consequences of expressive suppression. Emotion. 2003;3: 48–67. pmid:12899316
    • View Article
    • PubMed/NCBI
    • Google Scholar
82. 82. Rimé B. Emotion elicits the social sharing of emotion: Theory and empirical review. Emot Rev. 2009;1: sixty–85.
    • View Commodity
    • Google Scholar
83. 83. Taylor CT, Laposa JM, Alden LE. Is avoidant personality disorder more than than but social abstention? J Pers Disord. 2004;18: 571–594. pmid:15615668
    • View Article
    • PubMed/NCBI
    • Google Scholar
84. 84. Glenn CR, Klonsky DE. Emotion dysregulation as a cadre characteristic of deadline personality disorder. J Pers Disord. 2009;23: 20–28. pmid:19267659
    • View Article
    • PubMed/NCBI
    • Google Scholar
85. 85. Beblo T, Fernando S, Kamper P, Griepenstroh J, Aschenbrenner S, Pastuszak A, et al. Increased attempts to suppress negative and positive amotions in Borderline Personality Disorder. Psychiat Res. 2013;210: 505–509.
    • View Article
    • Google Scholar
86. 86. Dimaggio G, Carcione A, Nicolò G, Lysaker PH, d'Angerio South., Coni M.L., et al. Differences in Axes depends on where you set the bar: associations amongst symptoms, interpersonal relationships and alexithymia with a number of personality disorder criteria. J Pers Disord. 2013;27: 371–382. pmid:23130814
    • View Commodity
    • PubMed/NCBI
    • Google Scholar

masonheres1989.blogspot.com

Source: https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0145625

Share this post