Psychiatric Annals

CME 

Emerging Evidence for Intensive Short-Term Dynamic Psychotherapy with Personality Disorders and Somatic Disorders

Joel M. Town, DClinPsy; Ellen Driessen, PhD

Abstract

CME Educational Objectives

1. Review the outcome evidence of prior meta-analytic reviews of intensive short-term dynamic psychotherapy (ISTDP).

2. Provide an additional meta-analysis of ISTDP for the treatment of personality and somatic disorders.

3. Suggest areas for future study in the use of psychodynamic psychotherapy for personality and somatic disorders.

The literature reviewing studies of psychodynamic psychotherapy clearly demonstrates evidence for the efficacy of both short-term and long-term models. Meta-analytic reviews synthesizing effects across different psychodynamic psychotherapy formats have been conducted for common mental disorders, depression, depression in the setting of personality disorder, personality disorders, and somatic disorders. Psychodynamic psychotherapy demonstrates superiority to control condition, and no significant difference to other formal psychotherapies, including cognitive behavioral therapies. Building upon a recently published systematic review and meta-analysis,11 the aim of this article is to further examine the evidence for a contemporary psychodynamic psychotherapy treatment protocol, intensive short-term dynamic psychotherapy (ISTDP), in the treatment of personality and somatic disorders.

Abstract

CME Educational Objectives

1. Review the outcome evidence of prior meta-analytic reviews of intensive short-term dynamic psychotherapy (ISTDP).

2. Provide an additional meta-analysis of ISTDP for the treatment of personality and somatic disorders.

3. Suggest areas for future study in the use of psychodynamic psychotherapy for personality and somatic disorders.

The literature reviewing studies of psychodynamic psychotherapy clearly demonstrates evidence for the efficacy of both short-term and long-term models. Meta-analytic reviews synthesizing effects across different psychodynamic psychotherapy formats have been conducted for common mental disorders, depression, depression in the setting of personality disorder, personality disorders, and somatic disorders. Psychodynamic psychotherapy demonstrates superiority to control condition, and no significant difference to other formal psychotherapies, including cognitive behavioral therapies. Building upon a recently published systematic review and meta-analysis,11 the aim of this article is to further examine the evidence for a contemporary psychodynamic psychotherapy treatment protocol, intensive short-term dynamic psychotherapy (ISTDP), in the treatment of personality and somatic disorders.

The literature reviewing studies of psychodynamic psychotherapy clearly demonstrates evidence for the efficacy of both short-term and long-term models.1–3 Meta-analytic reviews synthesizing effects across different psychodynamic psychotherapy formats have been conducted for common mental disorders,1 depression,4,5 depression in the setting of personality disorder,6 personality disorders,7 and somatic disorders.8 Psychodynamic psychotherapy demonstrates superiority to control condition,1,9 and no significant difference to other formal psychotherapies, including cognitive behavioral therapies.4,5,7,9,10 Building upon a recently published systematic review and meta-analysis,11 the aim of this article is to further examine the evidence for a contemporary psychodynamic psychotherapy treatment protocol,12,13 intensive short-term dynamic psychotherapy (ISTDP), in the treatment of personality and somatic disorders.

Psychodynamic Psychotherapy for Personality Disorders

A central theme within the theoretical framework of psychodynamic psychotherapy is the fundamental role that mental presentations, derived from early relational experiences have in shaping personality organization. These are seen to underlie the development of capacities for emotional regulation, metacognition, and interpersonal interactions. Sustained and long lasting therapeutic change are said to be dependent on adaptations to these personality structures.14,15 Since psychodynamic interventions target these underlying processes, psychodynamic psychotherapy may be particularly well suited to the treatment of personality pathology.

Indeed, psychodynamic psychotherapy is one of the few classes of treatment with demonstrated efficacy in the remediation of personality disorders (PD) in sufficiently controlled research.16 A systematic review and meta-analysis by Leichsenring and Leibing7 provided preliminary evidence of the long-term effectiveness of psychodynamic therapy for personality disorders. Although only two randomized, controlled trials were included in that analysis, since then, additional efficacy trials have been conducted, reporting equally large treatment effects.17

More recently, Barber and colleagues18 selected only well-conducted studies for inclusion in their meta-analysis of the effectiveness of psychodynamic psychotherapies. The controlled effects, based on the analysis of post-treatment outcomes in seven studies, revealed that psychodynamic psychotherapy was more effective than control treatments (g = 0.59). Against formal psychotherapy comparison treatments, no difference between treatment categories was found across outcome domains, either at termination or short-term follow-up.

Although more adequately powered trials are needed to replicate and extend these findings, Barber and colleagues18 argued that this provides unambiguous evidence for the efficacy of psychodynamic psychotherapies of personality disorders.

Psychodynamic Psychotherapy for Somatic Disorders

Studies suggest that as many as half of new outpatients presenting to specialty medical clinics have somatic complaints that are medically unexplained.19 Psychodynamic psychotherapy posits that psychosocial and biological processes can be interrelated. More specifically, psychological factors can be directly connected to altered autonomic, endocrine, and immune activity related to the development of somatic symptoms or disease. Psychodynamic theory suggests that somatic distress can reflect an indirect means of communicating a psychological state of emotional difficulty.

A previously published systematic review and meta-analysis identified 23 studies of psychodynamic psychotherapy for a range of somatic disorders.8 Fourteen studies demonstrated significant post-treatment effects on physical symptoms, psychiatric symptoms, depression, and anxiety. In three studies, long-term follow-up outcome data were provided, suggesting that gains were maintained on measures of both general psychiatric and somatic symptoms after treatment had ended. These findings suggest that psychodynamic psychotherapy may be effective for a variety of medical and physical conditions.

Outcome Research in ISTDP

ISTDP is a brief format of psychodynamic psychotherapy that integrates fundamental psychodynamic concepts into a system of specific techniques. Abbass and colleagues11 recently published findings of a systematic review and meta-analysis of ISTDP outcome studies. Twenty-one studies reported therapeutic effects in patients with mood, anxiety, personality, and somatic disorders. Thirteen studies of variable quality, which comprised 664 participants, were included in meta-analyses using a random effects model. Pre- to post-treatment effect sizes were large, ranging from 0.84 (interpersonal functioning) to 1.51 (depression), indicating substantial improvement for patients receiving ISTDP on all outcome measures. Post-treatment to follow-up effect sizes for general psycho-pathology and interpersonal functioning measures indicated that gains were maintained for these outcomes. ISTDP was significantly more efficacious than control conditions in three studies (d = 1.81, general psychopathology measures). Eight studies using various measures suggested that ISTDP was cost-effective. However, the quality of the included studies was highly variable, and there was significant heterogeneity in some of the analyses, indicating that results varied from study to study. Therefore, the authors concluded that the findings supported the application of IST-DP across a broad range of populations, with further rigorous and targeted research warranted.

The results of this review pointed to the effectiveness of ISTDP in the treatment of patients with personality and somatic symptom disorders. In light of these observations, we performed a secondary set of analyses to report on the effectiveness of ISTDP for patients with these diagnoses.

Methods

This article reports a new meta-analysis specifically focused on the area of personality and somatic disorders. Except where indicated, the same search strategy, study selection, and meta-analysis methods utilized herein were applied as in the previous meta-analysis.11 All ISTDP studies previously reviewed and meta-analyzed were examined for inclusion. The same search terms were used to search for more recent publications (2011 to present), resulting in 74 citations (PsycINFO 45; CINAHL 4; PubMed 27). Experts in the field were contacted for new or unpublished studies. Finally, authors of ISTDP studies were contacted to request additional outcome data for subsamples of patients with personality or somatic disorders when these data were not directly reported. All studies were examined according to selection criteria detailed in the original systematic review. For the purposes of this review, included studies reported patient samples where either, (a) more than 80% of patients had one or more diagnosis of a personality disorder, or (b) the primary treated complaint was a somatic disorder.

Results

Description of Studies

Thirty-one articles reporting outcomes of ISTDP were identified in total, including nine new studies not reported in the previous meta-analysis. This also included 17 articles on ISTDP for personality or somatic disorders. Five new studies, either in press or currently unpublished, were provided by experts in the field. Nine studies on personality disorders comprised 450 patients, and eight studies on somatic disorders comprised 360 patients. The mean number of patients treated with ISTDP in each study was 50 (range, 10–148) and 51 (range, 9–168), respectively. Mean duration of ISTDP treatment of PD was 18.7 (SD = 12.9) sessions and 9.7 (SD = 5.8) sessions for somatic disorders. Table 1 and Table 2 provide a detailed description of the study characteristics.

Personality Disorder Study Characteristics

Table 1.

Personality Disorder Study Characteristics

Somatic Disorder Study Characteristics

Table 2.

Somatic Disorder Study Characteristics

ISTDP for Personality Disorders

Five studies, including three randomized controlled trials (RCTs) for PD and two non-randomized designs consisting primarily of patients with personality disorders, were included in the original meta-analysis.11 The interested reader can find a description of these studies in recently published reviews.11,20

Several key points can be distilled from this literature: First, the RCTs, which were of adequate quality3 to use as the basis for evidence-based recommendations, demonstrated efficacy of ISTDP for personality disorders. ISTDP was efficacious when compared to control,22,22 and no significant differences were found compared to other formal psychotherapy treatment.23 Effects were typically large at termination and maintained at follow-up. Second, the available research was largely conducted with cluster C personality disorders. However, approximately 25% of the treated sample in the three RCTs met criteria for a cluster A or B personality disorders, and patients with borderline disorders were included in the two open studies. Third, preliminary evidence suggests that cost savings are accrued following ISTDP.22

Four new datasets were obtained for the treatment of personality disorders using ISTDP. Each of these studies represented naturalistic data from a diverse range of public health care services, including a hospital-based outpatient psychotherapy service in Canada,24 an acute care psychiatric inpatient services based in Canada25 and another in Norway (Solbakken and Abbass, see page 516 in this issue) and a community based mental health service for patients with enduring psychiatric problems in England.26 One study confirmed a diagnosis of personality disorder using a standardized diagnostic tool and the other studies used clinical based diagnoses informed by DSM-IV criteria. Therapists across studies had at least 1 year of formal training experience in ISTDP and received ongoing supervision of video-recorded case material during the study period. Treatment adherence was monitored in three of the five studies.

Meta-Analysis of ISTDP for Personality Disorders

The results of the meta-analyses are listed in Table 3. Effect sizes (Cohen’s d) for ISTDP pre- to post-treatment change among patients with PDs ranged from 0.72 to 1.16, indicating moderately large to large improvements on measures of general psychopathology, interpersonal functioning, depression, and anxiety. Significant heterogeneity was seen in three of the four outcome categories, indicating that results differed from study to study. A sensitivity analysis in which all outcome measures were combined showed that effect sizes were significantly larger in the group of studies employing intention-to-treat analyses (d = 1.41; 0.99–1.82; n = 3) than in the group of studies employing completers-only analyses (d = 0.70; 0.51–0.90; n = 5) (P < .01). A second sensitivity analysis showed no differences between effect sizes in the group of RCT studies (d = 1.19; 0.63–1.75; n = 3) and non-RCT studies (d = 0.98; 0.61–1.35; n = 6) (P = .55). Post-treatment to follow-up effect sizes for general psychopathology and interpersonal functioning outcome measures were non-significant, indicating that symptoms did not decrease or increase significantly and that pre- to post-treatment gains were thus maintained.

Meta-Analyses of Studies Examining the Effects of ISTDP for Patients with Personality Disorders and Somatic Disorders

Table 3.

Meta-Analyses of Studies Examining the Effects of ISTDP for Patients with Personality Disorders and Somatic Disorders

ISTDP for Somatic Disorders

The previous systematic review and meta-analysis of ISTDP outcome studies11 identified six published studies for somatic disorders. This sample comprised conditions affecting genitourinary, musculoskeletal, vascular, and immunological systems, as well as one sample with medically unexplained symptoms. These studies are thoroughly described in two recently published articles.11,20

Several findings were evident across the literature. First, patients treated with IST-DP had significant improvements in target symptom ratings post-treatment, including measures of chronic back pain, psychogenic movement disorder, general somatic symptomology, and urinary symptoms or pelvic pain. Second, this patient population frequently had simultaneously occurring psychiatric symptoms (eg, depression and anxiety) that significantly improved following ISTDP.

It was possible to add two new datasets from unpublished manuscripts reporting outcome data for the treatment of somatic symptoms using ISTDP. The first involved data for 70 consecutively treated patients in a hospital-based outpatient psychotherapy service for medically unexplained symptoms (Town, unpublished data) The second study included a subsample of patients (n = 168) who had a primary clinical diagnosis of somatoform disorder from a large naturalistic study of ISTDP carried out in a hospital-based outpatient psychotherapy service.24

Meta-Analysis of ISTDP for Somatic Disorders

Effect sizes (Cohen’s d) for ISTDP pre- to post-treatment change among patients with somatic symptom disorders ranged from 0.72 to 1.03, indicating moderately large to large improvements on measures of target symptoms, depression, general psychopathology, and anxiety. Significant heterogeneity was seen in all outcome categories, indicating that results differed from study to study. Sensitivity analyses in which all outcome measures were combined showed no differences between effect sizes in the group of studies employing intention-to-treat analyses (d = 0.84; 0.37–1.31; n = 4) and the group of studies employing completers-only analyses (d = 0.81; 0.33–1.29; n = 3; P = .93).

Discussion

It has been noted that the most compelling evidence for the efficacy of ISTDP is in the treatment of PDs.11 This meta-analysis of nine studies for general personality disorders provides evidence suggesting that ISTDP might be designated as at least probably efficacious, according to American Psychological Association Division 12 (2012) criteria. This analysis also demonstrates the impact of ISTDP on the reduction of both physical and psychological symptoms in a range of somatic disorders.

Inclusion of a greater number of studies with larger samples would increase the power of the findings of this meta-analysis. Significant heterogeneity in three of the analyses for personality disorders suggests that our results may be dependent on differences between studies. We conducted sensitivity analyses to examine two possible moderating variables. There was no significant impact of studies using randomized allocation versus non-randomized allocation to group. However, we found a significant positive effect favoring studies utilizing intention to treat analyses. This suggests factors other than ISTDP, connected to study methodology, or variables not accounted for may contribute to outcome variance.

Evidence for somatic disorders is more limited for several reasons. This meta-analysis included primarily naturalistic studies which lacked long-term follow-up assessments. Although analyses are typically based upon completer-only samples, which might overestimate effects, sensitivity analyses conducted for intention to treat analyses were non-significant.

An unanswered question about the generalizability of psychodynamic psychotherapy exists, given variation in specific treatment protocols. The positive efficacy findings following the specific format of ISTDP replicate those of previous meta-analyses of general psychodynamic psychotherapy. This study may therefore be cited as evidence that the consistent empirical support for psychodynamic psychotherapy is also present for specific psychodynamic models. Interestingly, when one examines the effects sizes from similar outcome measures, the effect sizes reported in this meta-analysis (d = 0.72–1.03) of ISTDP are somewhat larger than those found for general psychodynamic psychotherapy with somatic disorders (d = 0.58–0.78). When treating personality disorders, ISTDP (d = 0.92–1.16) and psychodynamic psychotherapy (d = 0.81–1.44) appear more comparable. There are multiple methodological reasons why the interpretation of such comparisons between studies must be considered purely observational. For all types of psychotherapy, including cognitive behavioral therapies and psychodynamic psychotherapy, sufficiently powered studies to detect equivalence are required to address questions around the importance of common and specific factors of psychotherapy related to outcome.

Research estimates recovery for individuals with a personality disorder requires long-term psychotherapy,27 and that long-term psychodynamic psychotherapy may outperform brief treatment models for complex mental disorders.2 However, this analysis suggests that long-term treatment is not the only option. Treatment dose may be better conceptualized as the occurrence and achievement of putative treatment factors rather than session number. Future studies could address whether more intensive, but not necessarily longer-term, methods may deliver effects of equal magnitude for some patients. The lower direct costs associated with intensive short-term treatment could become an important outcome variable, should research find therapeutic effects are maintained long-term.

References

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Personality Disorder Study Characteristics

Study / Year Study Type Outcome Measure n Mean NSe (SD) Mean Follow-Up (months) Adherence Video Training Outcome Analysis
*Winston et al21 / 1994 RCT SCL-90-R, Target complaint 25 40.3 (8.6) 18 Yes Yes Yes CO
*Hellerstein et al23 / 1998 RCT SCL-90-R, Target complaint, IIP 25 29 (14.7) 6 Yes Yes Yes CO
*Abbass et al1 / 2006 Open HAM-D, BSI-D, CGI- S, IIP, BSI, BSI-A 10 27.7(20) 6 No Yes Yes ITT
*Abbass et al22 / 2008 RCT BSI, BSI-D, BSI-A, IIP, GAF 27 13.6 (6.3) 24 Yes Yes Yes ITT
*Cornelissen (unpublished data) Open SCL-90-R, GAF 148 unclear 1–10 years No Yes Yes ITT
*Hajkowski and Buller27 / 2012 Open PHQ-9, GAD-7, CORE-OM, GAF 23 8.6 (4.4) na No Yes Yes CO
*Abbass et al20 / 2013 Open BSI, BSI-A, BSI-D, IIP 147 7.3 (12.4) na Yes Yes Mixed CO
*Abbass et al 25 / 2013 Open BSI, BSI-A, BSI-D, IIP 23 9 (8.7) na Yes Yes Yes CO
*Solbakken and Abbass (see this issue, page 516) Open BSI, IIP 22 14.45 (1.3) na No Yes Yes ITT

Somatic Disorder Study Characteristics

Study Diagnosis Study Type Outcome Measure n Mean NSe (SD) Mean Follow-Up (Years) Adherence Video Training Outcome Analyses
*Baldoni et al28 / 1995 Urethal syndrome RCT SQ-A, SQ-S, SQ-D 11 14 4 No No Unclear CO
*Abbass29 / 2002 Headache, IBS Open BSI, BSI-A, BSI- D, BSI-S 29 19.7 (21.2) na No Yes Yes ITT/CO
*Hawkins30 / 2003 Chronic back pain Open MPQ, MAS 47 8 na No No Unclear CO
*Hinson et al31 / 2006 Psychogenic movement d/o Open PMDRS, BAI, HAM-D, GAF 9 12 na No No Unclear CO
Abbass et al32 / 2008 Headache Open BSI, BSI-S 29 19.7 na No Yes Yes ITT
*Abbass et al33 / 2009 MUS Open BSI, BSI-S 26 3.8 (5.3) na No Yes Yes CO/ITT
*Abbass et al25 / 2013 Mixed Open BSI, BSI-A, BSI- D, BSI-S 168 3.9 (8.3) na Yes Yes Mixed CO
*Town (unpublished data) MUS Open SOMS-7, GAD-7, PHQ-9 70 6.7 (5.9) na Yes Yes Yes ITT

Meta-Analyses of Studies Examining the Effects of ISTDP for Patients with Personality Disorders and Somatic Disorders

Comparison Studies Participants d 95% CI Z Q I2
Personality disorders
ISTDP pre- to post-treatment change
General psychopathology 9 449 1.16 0.83–1.49 6.95 30.89 74.10
Interpersonal functioning 6 229 0.72 0.36–1.07 3.93 12.28* 59.28
Depression 5 230 0.92 0.49–1.36 4.16 12.55* 68.13
Anxiety 4 219 0.73 0.48–0.98 5.68 3.87 22.40
ISTDP post-treatment to follow-up change
General psychopathology 6 238 0.02 −0.34 to 0.38 0.10 12.69* 60.58
Interpersonal functioning 4 73 0.08 −0.24 to 0.41 0.50 0.53 0.00
Somatic disorders
ISTDP pre- to post-treatment change
Target symptoms / somatic symptoms 6 330 0.72 0.51–0.93 6.65 6.89 27.41
Depression 5 287 1.03 0.62–1.43 4.94 13.33* 69.99
General psychopathology 4 225 0.79 0.47–1.11 4.87 4.71 36.25
Anxiety 6 330 0.92 0.49–1.34 4.21 24.39 79.50
Authors

Joel M. Town, DClinPsy, is an Assistant Professor, Departments of Psychiatry and Psychology, Dalhousie University. Ellen Driessen, PhD, is a Post-doctoral Researcher, Department of Clinical Psychology, Faculty of Psychology and Education, VU University Amsterdam.

Address correspondence to: Joel M. Town, DClinPsy, Centre for Emotions & Health, Abbie J. Lane Building, 7th Floor, Room 7516, 5909 Veteran’s Memorial Lane, Halifax, Nova Scotia, Canada B3H 2N1; email: joel.town@dal.ca.

Disclosure: This research was supported by the Dalhousie University Department of Psychiatry and Capital District Health Authority. The authors have no other relevant financial relationships to disclose.

10.3928/00485713-20131105-05

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