Background and Aims: Executive dysfunction is pervasive in substance-dependent individuals (Verdejo-García, Bechara, Recknor, & Perez-Garcia, 2006). As many as four-fifths of individuals in treatment for substance use disorders (SUDs) have co-existing lifetime psychopathology. Executive function deficits are tied to markers of decreased quality of life including increases in negative life events (Green, Kern, Braff, & Mintz, 2000), maladaptive social functioning (Kurtz, Moberg, Ragland, Gur, & Gur, 2005) and worsened treatment outcomes (Czuchry & Dansereau, 2003). Despite evidence of executive dysfunction across several mental disorders, few studies investigate how the co-occurrence of psychopathologies in SUDs impacts executive functioning. Methods: Here, we compare measures of executive function (i.e., the Iowa Gambling Test, Letter Number Sequencing Test, Stroop Test, Wisconsin Card Sorting Test, Continuous Performance Test, Towers Test, and Delay Discounting Test) in individuals with a) substance use disorder, b) substance use disorder and co-occurring major depressive disorder, c) substance use disorder and co-occurring antisocial personality disorder, d) substance use disorder and co-occurring major depressive disorder and antisocial personality disorder and e) no substance use disorder or co-occurring psychopathology. Results: Regression models of respective executive function measure outcomes as a function of education, income, age, and group membership indicated that the Delay Discounting Test and Continuous Performance Test were the only significant overall models (F(4, 313) = 12.699, p < 0.001 and F(4, 307) = 2.659, p = 0.033, respectively). Conclusions: Overall the Delay Discounting Test and Continuous Performance Test were the most sensitive to differences between substance use and psychopathology profiles assessed. / Master of Science

Childhood trauma experiences (sexual abuse, physical abuse, witnessed violence, and early separation experiences) and family environment characteristics were assessed via questionnaire from a sample of depressed borderline (N=17) and depressed nonborderline (N=19) female inpatients. Significantly more borderline individuals than nonborderlines gave histories of sexual abuse (76%) and physical abuse (93%) and these traumatic experiences were more severe in nature as demonstrated by significantly greater composite scores. While the presence of witnessed violence did not differentiate the two groups, borderline individuals witnessed violence more frequently than nonborderline individuals if there was violence in the home. Early separation experiences were relatively common in both groups suggesting that these experiences may be associated with both BPD and depression. The BPD group was also distinctive on family environment measures, evidencing significantly less family cohesiveness and expressiveness and significantly more conflict and control. The two groups were similar on indices of current stressors, typically associated with onset of depression, providing more support for the role of childhood trauma in the etiology of BPD. / Master of Science

Borderline personality disorder (BPD) is an impairing mental illness and has a core component of emotional dysregulation. Evidence suggests the emotional cascade model describes how this emotional dysregulation leads to engaging in risky and life-threatening behaviors, such as non-suicidal self-injury (NSSI). Specifically, this model describes rumination as a cognitive component that links the emotional and behavioral dysregulation. The current study aimed to expand the model by investigating how individuals with heightened BPD traits engage in NSSI and in cognitive strategies to cope with their negative affect. Specifically, it was investigated whether behaviors like suicide attempts and cognitions differentiated between those with mild/moderate and severe NSSI. Criterion for severe NSSI was hospitalization or medical care because of NSSI. Participants (N = 292) were screened to endorse a history of NSSI and then self-selected to take a self-report survey through Mturk. Correlations and a binomial logistic regression were completed. Results indicated suicide attempts, BPD symptoms, and anger rumination differentiated mild/moderate and severe NSSI. Evidence reinforces the strong relationships between NSSI, suicide attempts, and BPD. Additionally, it reinforces anger rumination as a potential cognitive mechanism in NSSI. Future research can continue to test this model and include other potential thought processes to increase efficiency in assessment and treatment of BPD and NSSI.

The issue of psychiatric co-morbidity is a serious public health problem occurring more and more frequently in the treatment of addiction and bringing with it various complications and often premature termination of treatment. The scoring system with a fixed set regime is still being used as the main instrument for treatment of addicted clients on the most specialized departments of psychiatric hospitals, although the effectiveness of the scoring system has not yet been clinically verified. The aim of this pilot study is to demonstrate and verify of the individual cases of clients with different categories of dual diagnosis, how they perceive the balance of the sanctions and rewards and fair setting in the context of the scoring system. Other goals are to find out and verify what is the influence of the scoring system on the motivation to change the behavior and success of treatment, what weaknesses clients with dual diagnosis perceive in this system and how they represent the treatment system, which would make them more fit and motivated to change behavior. Further, this study seeks to establish whether difficulties and obstacles on the way to stand up and go through the scoring system are different for individual dual diagnoses. A qualitative approach is used in the research part of the thesis....

Abstract Maternal depressed mood during pregnancy is common, but studies on the offspring of antenatally depressed mothers, with a long follow-up, are scarce. The aim was to study whether the adult offspring of antenatally depressed mothers are at an elevated risk of psychoses, depression, bipolar disorder, antisocial and borderline personality disorder, and schizotypal and affective traits. Parental severe mental disorder was considered as both a genetic and environmental risk factor for mental disorders. The data are based on the unselected, prospective, population-based Northern Finland 1966 Birth Cohort of 12,058 live-born children. The data were collected beginning from pregnancy and ending mid-adulthood. The mothers were asked about their mood during pregnancy at the antenatal clinic at 24–28 gestational weeks. Of the mothers, 13.9% rated themselves as depressed (11.8%) or very depressed (2.1%) during pregnancy. Parents’ severe, hospital-treated mental disorders, and the cohort members’ mental disorders were identified mainly by using the Finnish Care Register for Health Care. In this study, the adult offspring of antenatally depressed mothers had an increased risk of depression, and the male offspring for antisocial personality disorder, compared to cohort members without antenatally depressed mothers. The offspring with both maternal antenatal depressed mood and parental severe mental disorder had a markedly elevated risk of schizophrenia and depression, compared to cohort members without one or both of the risk factors. This is the first study where the offspring of antenatally depressed mothers were followed till mid-adulthood, also taking into account parental severe mental disorders. Based on the findings, the prevention of and early intervention in antenatal depression, especially in families with severe mental illness, might present an opportunity to reduce the risk of mental disorders in the offspring. / Tiivistelmä Äitien raskausajan masennus on yleistä, mutta pitkiä seurantatutkimuksia raskausaikana masentuneiden äitien lapsista on vähän. Tutkimuksen tavoitteena oli selvittää, onko raskausaikana masentuneiden äitien aikuisilla jälkeläisillä kohonnut riski sairastua skitsofreniaan, masennukseen, kaksisuuntaiseen mielialahäiriöön, epäsosiaaliseen tai epävakaaseen persoonallisuushäiriöön, ja ilmeneekö heillä enemmän skitsotyyppisiä tai affektiivisia piirteitä. Vanhempien vakavien mielenterveydenhäiriöiden katsottiin olevan sekä mahdollisia geneettisiä että ympäristöön liittyviä riskitekijöitä jälkeläisten mielenterveyshäiriöille. Tutkimus perustuu yleisväestöön pohjautuvaan, prospektiiviseen Pohjois-Suomen vuoden 1966 syntymäkohorttiin, johon kuuluu 12 058 elävänä syntynyttä lasta. Kohortin jäseniä on seurattu sikiöajalta keski-ikään, aina 49 ikävuoteen saakka. Äitien raskaudenaikaista mielialaa tiedusteltiin raskausviikoilla 24–28 neuvolassa. 13,9 % äideistä raportoi mielialansa masentuneeksi (11,8 %) tai hyvin masentuneeksi (2.1%) raskausaikana. Vanhempien vakavat mielenterveydenhäiriöt ja kohortin jäsenten mielenterveyshäiriöt selvitettiin pääosin hoitoilmoitusrekisteritiedoista. Tutkimuksessa raskaudenaikana masentuneiden äitien lapsilla havaittiin kohonnut depressioriski sekä kohonnut epäsosiaalisen persoonallisuushäiriön riski miehillä, verrattuna kohortin jäseniin, joiden äitien mieliala ei ollut masentunut raskausaikana. Kohortin jäsenillä, joiden äideillä oli raskausajan masennusta ja toisella vanhemmista vakava mielenterveyshäiriö, oli kohonnut riski sairastua skitsofreniaan ja depressioon, verrattuna heihin, joilla oli vain yksi tai ei kumpaakaan näistä riskitekijöistä. Tämä on ensimmäinen tutkimus, jossa raskausaikana masentuneiden äitien lapsia on seurattu keski-ikään saakka, huomioiden myös vanhempien vakavat mielenterveydenhäiriöt. Tutkimuksen tulosten perusteella äidin raskausajan masennusoireiden varhaisen tunnistamisen ja hoidon voitaisiin ajatella vähentävien jälkeläisten mielenterveysongelmien riskiä, etenkin perheissä, joissa on vakavia mielenterveysongelmia.

Personer med diagnosen emotionell instabil personlighetsstörning är högkonsumenter av psykiatrisk akutvård. Diagnosen kännetecknas av ett ihållande mönster av instabilitet vad gäller självbild, känslor och relationer med andra, samt en hög grad av impulsivitet. Vidare förekommer ofta självskadebeteende och suicidala handlingar som ett sätt att reglera affekter. Symtombilden kan göra mötet mellan patient och vårdpersonal svårt. Syftet med denna studie var att utifrån lidandeperspektiv belysa hur personer med diagnosen Emotionellt instabilt personlighetssyndrom upplever och erfar personalens bemötande när de söker akut vård. Metoden som användes var en kvalitativ intervjustudie med fenomenologisk ansats.  Huvudresultatet visade att fenomenets centrala teman är att respekteras som människa med symtom, att inte bli tagen på allvar och att bli stigmatiserad. Varje tema kunde kopplas till ett lidandeperspektiv; sjukdomslidande lindras av att respekteras som människa med symtom, men att inte bli tagen på allvar orsakade vårdlidande och att bli stigmatiserad orsakade ett livslidande. Samtidigt gick lidandeformerna in i varandra, på så vis att vårdlidande lades till den levda erfarenhet som är livslidandet, och livslidandet hade betydelse för hur sjukdomslidandet hanterades och upplevdes. Slutsatsen är att personer med EIPS som söker akut psykiatrisk vård upplever vårdpersonalens bemötande som att de antingen respekteras som människa med symtom och får sitt sjukdomslidande lindrat, eller inte tas på allvar och stigmatiseras med vård- respektive livslidande, som ökar på symtombördan, som följd. / People with Borderline Personality Disorder [BPD] are among the consumers of psychiatric emergency care. BPD is characterized by a persistent pattern of impulsivity and instability with regard to self-image, emotions and relationships with others. Furthermore, self-harm and suicidal behaviour often occur as a way to regulate emotions. The symptoms can make interaction between patients and healthcare professionals difficult. The aim of this study was to gain insight into how, from a perspective of suffering, people with BPD who seek psychiatric emergency care experience and sense the approach. The method used was a qualitative interview study with a descriptive phenomenological approach. The main results consisted of three central themes: to be respected as a human being with symptoms, to not be taken seriously, and to be stigmatized. Each theme was linked to a perspective of suffering; being respected as a human being with symptoms alleviated suffering from symptoms, while not being taken seriously caused suffering related to care, and getting stigmatized added to the existential suffering. The different dimensions of suffering interacted; suffering related to care was added to the existential suffering, which in turn had implications for the ability to deal with suffering from symptoms. The conclusion is that individuals with BPD experience either a treatment with respect for being a human being with symptoms, and thus having those symptoms alleviated, or experience not being taken seriously and being stigmatized, with the consequences of suffering related to care and existential suffering, both which add on to the symptom burden.

Submitted by Viviane Lima da Cunha (viviane@biblioteca.ufpb.br) on 2017-06-20T12:56:49Z No. of bitstreams: 1 arquivototal.pdf: 1797753 bytes, checksum: b91b2cba56e365efc84ec01eeccdd920 (MD5) / Made available in DSpace on 2017-06-20T12:56:49Z (GMT). No. of bitstreams: 1 arquivototal.pdf: 1797753 bytes, checksum: b91b2cba56e365efc84ec01eeccdd920 (MD5) Previous issue date: 2017-02-20 / Personality can be defined as a set of relatively long traits that influence the interactions of the subject with the environment and adaptations to the intrapsychic, physical and social. Thus, only when inflexible and maladaptive do personality traits cause significant functional impairment or subjective suffering, which constitutes Personality Disorder (PD). According to the definition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), PDs begin in adolescence or early adulthood, are stable over time and lead to losses and are characterized by the following types: Paranoid; Schizoid; Schizotypal; Antisocial; Borderline; Histrionic; Narcissist; Evitative; Dependent and Obsessive-Compulsive. Recently, with regard to the measurement of PD, the Personality Disorders Assessment Instrument (IATP) was built and validated, which is part of the general evaluation of all the PT groups, but there were no psychometric Consonant with the literature, capable of interpreting the disorder of the Histrionic personality. Therefore, this dissertation had, as a general objective, to obtain evidence of validity of the modified and reduced version of the Inventory for Evaluation of Personality Disorders - IATP-R, including histrionic TP items. The present study had a total sample of 373 participants, of which 343 were university students (non-clinical sample) selected for convenience and 30 patients attended by psychologists and / or psychiatrists who used psychotropic medication, which characterized the clinical sample , Selected using the Simple Random Sampling technique (AAS). The investigation verified the unidimensionality of each set of items in the disorders through analysis. The factorial analysis (PA), using the factorial main axes method (PAF) and direct oblimin rotation, resulted in a final matrix composed by 8 factors that were organized as representative of the following personality disorders: Paranoid; Schizoid; Schizotypal; Narcissist; Evitative; Dependent and Obsessive-Compulsive. For the Anti-Social and Borderline factors, there were no psychometrically satisfactory items and in agreement with the literature capable of interpreting these TPs. The structure indicated a total explained variance of 50.2%, regarding the reliability index, which was calculated through Cronbach's alpha, scored between 0.70 and 0.83, presenting acceptable indexes for this measure. Regarding the TRI analysis, the factors that obtained the best discrimination and difficulty parameters were the TP: Histrionic; Narcissist; Dependent; Paranoid and Schizotypal; All medium to extremely difficult. It should be noted that, in the TRI, seven factors were analyzed, leaving out the schizoid TP factor, because it presented only two items after the FA. The value of the theta (ability) of subjects estimated from the TRI are presented in this investigation as a possible tool for decision making regarding the presence or absence of a specific TP. The results are generally considered satisfactory and the validated instrument can be used as a tool for research purposes in the evaluation of personality disorders. / A personalidade, pode ser definida como um conjunto de traços relativamente duradouros e que influencia as interações do sujeito com o ambiente e adaptações ao intrapsíquico, físico e social. Deste modo, somente quando inflexíveis e mal adaptativos, os traços de personalidade causam significativos prejuízos funcionais ou sofrimentos subjetivos, o que configura o Transtorno da Personalidade (TP). Segundo a definição do Manual Diagnóstico e Estatístico de Transtornos Mentais (DSM-5), os TP tem início na adolescência ou início da idade adulta, é estável ao longo do tempo e leva a prejuízos e são caracterizados pelos seguintes tipos: Paranoide; Esquizoide; Esquizotípica; Antissocial; Borderline; Histriônica; Narcisista; Evitativa; Dependente e Obsessivo-compulsiva. Recentemente, no que se refere à medida dos TP, foi construído e validado o Instrumento Avaliação dos Transtornos da Personalidade (IATP ) que se enquadra nos instrumentos voltados para a avaliação geral de todos os grupos de TP, porém não houve itens psicometricamente satisfatórios e em consonância com a literatura, capazes de interpretar o transtorno da personalidade Histriônica. Diante disso, esta dissertação teve, como objetivo geral, obter evidências de validade da versão modificada e reduzida do Inventário para Avaliação dos Transtornos da Personalidade – IATP-R, incluindo os itens do TP histriônica. O presente estudo contou com uma amostra total de 373 participantes, da qual 343 era de estudantes universitários (amostra não clínica) selecionados por conveniência e 30 pacientes atendidos por psicólogos e/ou psiquiatras que faziam uso de medicação psicotrópica, a qual caracterizou a amostra clínica, selecionada por meio da técnica de Amostragem Aleatória Simples (AAS). A investigação verificou a unidimensionalidade de cada conjunto de itens nos transtornos através de análises. A Análise fatorial (AF), realizada pelo método dos eixos principais fatoriais (PAF) e rotação direct oblimin, resultou em uma matriz final composta por 8 fatores que se organizaram como representativos dos seguintes transtornos da personalidade: Paranoide; Esquizoide; Esquizotípica; Narcisista; Evitativa; Dependente e Obssessivo-compulsiva. Para os fatores Antissocial e Borderline, não houve itens psicometricamente satisfatórios e em consonância com a literatura capazes de interpretar esses TP. A estrutura apontou uma variância total explicada de 50,2%, quanto ao índice de confiabilidade, que foi calculado através do alfa de Cronbach, pontuou entre 0,70 e 0,83, apresentando índices aceitáveis para esta medida. Quanto à análise da TRI, os fatores que obtiveram os melhores parâmetros de discriminação e dificuldade foram os TP: Histriônico; Narcisista; Dependente; Paranoide e Esquizotípica; todos entre medianos e extremamente difíceis. Cabe destacar que, na TRI, foram analisados sete fatores, ficando de fora o fator TP esquizoide, por apresentar apenas dois itens após a AF. O valor do teta (habilidade) dos sujeitos estimados a partir da TRI são apresentados nesta investigação como uma possível ferramenta para tomada de decisão quanto à presença ou ausência de um TP específico. Os resultados de modo geral são considerados satisfatórios e o instrumento validado pode ser utilizado como ferramenta para fins de pesquisa na avaliação dos transtornos da personalidade.

Text in English / Psychologists-in-training are often presented with textbook definitions and descriptions of individuals presenting with psychopathologies. A major challenge for such texts is to effectively convey the relational issues and interpersonal dynamics of the mental disorders. The current study explores the role of film in enhancing intern clinical psychologists’ understanding of borderline personality disorder by specifically utilising the films Sylvia and Black Butterflies. A qualitative, phenomenological study was conducted with 15 clinical psychology interns at a tertiary psychiatric hospital in Gauteng, South Africa. The collected data consisted of responses to open-ended questionnaires and semi-structured interviews and was analysed according to an interpretive phenomenological analysis. Although the analysis was conducted inductively, the researcher also made deductive inferences from the data based on contemplations about the link between archetypes and images and learning and archetypal experiences. The importance of and connection to 21st-century learning skills, the creative learning spiral and a pedagogy of play were also taken into consideration while analysing the data. The findings of the current study suggest the ability of the two films to draw one in and to cause one to emotionally connect with the characters. Furthermore, films form an opportunity for trainees to practice psychodynamic formulations and not only focus on biological reductionisms of the disorder. / Psychology / M.A. (Psychology)

Hintergrund: Die therapeutische Allianz wird seit vielen Jahrzehnten intensiv hinsichtlich ihres Einflusses auf den Therapieerfolg erforscht. Sie gilt inzwischen als empirisch gut gesicherter Einflussfaktor auf den Therapieerfolg, wobei sich in Metaanalysen kleine bis mittlere Effekte zeigen. Gleichzeitig zeigt sich in Metaanalysen jedoch oft eine große Varianz, was auf mögliche moderierende Einflussfaktoren hinweist. Hierbei können Faktoren sowohl auf Seiten des Patienten 1 als auch des Therapeuten und bezogen auf das Therapiesetting beteiligt sein, die in der bisherigen Forschung vielfach noch nicht ausreichend untersuchtwurden. Im ersten Teil der vorliegenden Arbeit soll die Bedeutung initial besonders gering eingeschätzter therapeutischer Allianz hinsichtlich des Zusammenhangs mit späterem Therapieerfolg analysiert werden. Im zweiten Teil der Arbeit sollen dann Unterschiede im Zusammenhang von therapeutischer Allianz und Therapieerfolg im Bereich verschiedener Persönlichkeitsstörungen betrachtet werden. Fragestellung: Im ersten Teil der Arbeit wurde als zentrale Fragestellung untersucht, inwiefern die Beziehungszufriedenheit in verschiedenen Teilstichproben unterschiedlich zufriedener Patienten eine vergleichbar bedeutsame Rolle als Prädiktor von Therapieerfolg hat. Darüber hinaus sollte anhand der Gesamtstichprobe der Zusammenhang von therapeutischer Allianz und Therapieerfolg in einem naturalistischen, tagesklinischen Setting repliziert werden. Im zweiten Teil der Arbeit wurde der Zusammenhang von therapeutischer Allianz und Therapieerfolg vergleichend anhand zweier Teilstichproben von Patienten mit Borderline Persönlichkeitsstörung respektive zwanghafter Persönlichkeitsstörung untersucht, mit der Hypothese, dass die prädiktive Validität einer singulären Erfassung der Qualität der therapeutischen Beziehung bei Patienten mit zwanghafter Persönlichkeitsstörung größer ist als bei Patienten mit Borderline Persönlichkeitsstörung. Material und Methoden: Grundlage der Arbeit ist eine Gesamtstichprobe von insgesamt n = 809 Patienten (Durchschnittsalter 34 Jahre, 72,6% Frauen), die sich zwischen November 2008 und April 2017 in tagesklinischer Behandlung in der Allgemeinen Tagesklinik der Klinik und Poliklinik für Psychotherapie und Psychosomatik am UKD Dresden befanden. Die Allgemeine Tagesklinik behandelt vorrangig Patienten mit Persönlichkeitsstörungen bzw. Achse-I-Störungen, bei denen eine Thematisierung der hintergründigen Persönlichkeitsakzentuierung therapeutisch sinnvoll ist, in einem multimodalen, multiprofessionellen Setting mittels dialektisch behavioraler und schematherapeutischer Therapiemethoden. Die Behandlungszeit betrug durchschnittlich elf Wochen. Die Diagnosevergabe erfolgte nach klinischer Urteilsbildung auf Grundlage strukturierter bzw. standardisierter Diagnostikinstrumente. Die verwendeten standardisierten Selbstbeurteilungsverfahren zur Erfassung von Symptombelastung (Brief Symptom Inventory-18) und Qualität der therapeutischen Allianz (Helping Alliance Questionnaire) waren Teil des internen klinischen Qualitätsmanagements mit den drei Erhebungszeitpunkten Therapieaufnahme, Zwischenerhebung und Entlassung. In der statistischen Prüfung der Hauptfragestellungen kamen vor allem multiple, lineare Regressionsanalysen zum Einsatz. Ergebnisse: In der Gesamtstichprobe (n = 809 Patienten) war die Qualität der therapeutischen Allianz nach drei Wochen ein signifikanter Prädiktor von Therapieerfolg. In der Extremgruppe des Dezils mit der initial niedrigsten Beziehungszufriedenheit zeigte sich dieser Zusammenhang als statistisch signifikant und stark, jedoch aufgrund des breiten Konfidenzintervalls nicht praktikabel zur Prädiktion individueller Fälle. Dagegen ergab sich für die übrigen 90% der Fälle für die Beziehungszufriedenheit keine über die Aufklärung durch die Erfolgszufriedenheit hinausgehende Varianzaufklärung beim Therapieerfolg. Bezüglich der Substichproben von Patienten mit Borderline Persönlichkeitsstörung sowie zwanghafter Persönlichkeitsstörung zeigte sich über den Therapieverlauf insgesamt eine statistisch signifikante Symptomreduktion. Es fanden sich keine signifikanten Gruppenunterschiede in der Symptomschwere und der Einschätzung der therapeutischen Allianz zu den verschiedenen Erhebungszeitpunkten. Die nach drei Wochen erfasste therapeutische Allianz erwies sich als statistisch signifikanter Prädiktor der Symptomreduktion, allerdings nur in der Gruppe der Patienten mit zwanghafter Persönlichkeitsstörung. Schlussfolgerungen: Die Ergebnisse stützen zunächst die bisherigen Forschungsbefunde, die einen grundsätzlichen positiven Zusammenhang zwischen der Güte der therapeutischen Allianz und dem Therapieerfolg postulieren. Sie zeigen zudem, dass auch in einem teilstationären Behandlungssetting, in dem die zwei Einzelsitzungen pro Woche nur einen Teil der stattfindenden Interventionen während der Therapie ausmachen, der Qualität der therapeutischen Beziehung zum Bezugstherapeuten eine bedeutsame Rolle zukommt. Die Ergebnisse des Extremgruppenvergleichs weisen zum einen darauf hin, dass bei früh etablierter, ausreichend guter Beziehungszufriedenheit andere Prozessfaktoren von größerem prädiktivem Wert bzgl. des Therapieerfolgs sind. Zum anderen verweisen sie auf die hohe Bedeutung der Beziehungszufriedenheit bzgl. des Therapieerfolgs bei mit der Beziehung zu ihrem Bezugstherapeuten sehr unzufriedenen Patienten. Hier zeigt sich als praktische Implikation die Wichtigkeit, eine sich ungünstig entwickelnde therapeutische Beziehung frühzeitig zu erkennen und ihr entsprechend zu begegnen. Dabei gilt es zunächst, den Empfehlungen der „APA Task Force on Evidence-Based Relationship and Responsiveness“ folgend, den therapeutischen Wert einer standardisierten Erfassung von Therapiebeziehungsvariablen auch jenseits des forschungsorientierten universitären Kontextes zu betonen und breiter zu etablieren. Aufgrund des erhöhten Anteils von Patienten mit der Diagnose einer Persönlichkeitsstörung in der Substichprobe von Patienten mit besonders geringer Beziehungszufriedenheit, wurden im Rahmen des zweiten Papers Substichproben von Patienten mit Borderline Persönlichkeitsstörung und zwanghafter Persönlichkeitsstörung hinsichtlich des Zusammenhangs von therapeutischer Allianz und Therapieerfolg untersucht. Eine mögliche Erklärung dafür, dass die therapeutische Allianz in unserer Stichprobe nur bei Patienten mit zwanghafter und nicht bei Patienten mit Borderline Persönlichkeitsstörung einen Prädiktor des Therapieerfolges darstellte, könnte in den unterschiedlichen Mustern der Allianzentwicklung liegen, die für diese Persönlichkeitsstörungen charakteristisch sind. Die Ergebnisse der vorliegenden Arbeit zeigen, dass die einmalige Messung der therapeutischen Allianz in einer frühen Phase der Therapie einen guten Prädiktor für Therapieerfolg bei Patienten mit zwanghafter Persönlichkeitsstörung darstellt und somit auch aus therapiepraktischer Sicht gewinnbringend Verwendung finden könnte, um mögliche, eventuell verdeckt gebliebene Konflikte in der therapeutischen Beziehung frühzeitig zu erkennen. Bei Patienten mit Borderline Persönlichkeitsstörung scheint die einmalige Erfassung der therapeutischen Allianz bzgl. des späteren Therapieerfolges einen begrenzten prädiktiven Wert zu besitzen, weshalb hier eine kontinuierlichere Messung der therapeutischen Allianz ratsam ist. / Objective: The therapeutic alliance has been intensively researched for many decades with regard to its influence on therapeutic success. It is now considered to be an empirically well-established influencing factor on therapeutic success, with meta-analyses showing small to medium effects. At the same time, however, meta-analyses often show a large variance, which points to possible moderating effects. This may involve factors on the side of the patient, the therapist and related to the setting, which have not yet been sufficiently investigated in existing research. In the first part of the present work, the role of therapeutic alliance, which is initially assessed as particularly low, will be investigated with regard to its association with therapeutic success. In the second part, differences in the relationship between therapeutic alliance and therapeutic success in the context of different personality disorders will be analysed. Hypotheses: In the first part of the work, the central question investigated was to what extent relationship satisfaction has a comparably important role as a predictor of therapeutic success in different subsamples of differently satisfied patients. In addition, the relationship between therapeutic alliance and therapeutic success was replicated in a naturalistic, day hospital setting. In the second part of the work, the relationship between therapeutic alliance and therapeutic success was comparatively analysed using two subsamples of patients with borderline personality disorder and obsessive-compulsive personality disorder, respectively, with the hypothesis that the predictive validity of a singular assessment of the quality of the therapeutic alliance is greater in patients with obsessive-compulsive personality disorder than in patients with borderline personality disorder. Material and Methods: The work is based on a total sample of n = 809 patients (average age was 34, 72.6% women) who were treated in the Allgemeine Tagesklinik of the Department of Psychotherapy and Psychosomatics at the UKD Dresden between November 2008 and April 2017. The Allgemeine Tagesklinik primarily treats patients with personality disorders or Axis I disorders, in whom a focus on the underlying personality accentuation is therapeutically important, in a multimodal, multiprofessional setting using dialectical behavior and schema therapeutic methods. The average treatment duration was eleven weeks. Diagnoses were based on clinical judgment utilizing a structured or standardized diagnostic tool. The standardized questionnaires used to assess symptom burden (Brief Symptom Inventory-18) and the quality of the therapeutic alliance (Helping Alliance Questionnaire) were part of the internal clinical quality management with three survey points: therapy admission, interim survey after three weeks and discharge. Multiple linear regression analyses were primarily used in the statistical analyses of the main hypotheses. Results: In the total sample (n = 809 patients), the quality of the therapeutic alliance after three weeks was a significant predictor of treatment success. In the extreme group of the decile with the initially lowest relationship satisfaction, this relationship was found to be statistically significant and strong, but not feasible for predicting individual cases due to the large confidence interval. In contrast, for the remaining 90% of cases, there was no variance explanatory effect on treatment success beyond that explained by satisfaction with therapy success. Regarding the subsamples of patients with borderline personality disorder as well as obsessive-compulsive personality disorder, there was a statistically significant overall symptom reduction over the course of therapy. No significant group differences were found in symptom severity and assessment of therapeutic alliance at the different time points. Therapeutic alliance assessed after three weeks proved to be a statistically significant predictor of symptom reduction, but only in the group of patients with obsessive-compulsive personality disorder. Conclusion: The results support previous research postulating a generally positive correlation between the quality of the therapeutic alliance and therapy success. In addition, they show that also in a day-care setting the quality of the therapeutic relationship plays a significant role with regard to the success of therapy. Firstly, the results of the extreme group comparison indicate that in the case of sufficiently good relationship satisfaction established at an early stage, other process factors are of greater predictive value with regard to the success of the therapy. Secondly, they point to the high importance of relationship satisfaction with regard to therapy success in patients who are very dissatisfied with the relationship to their therapist. The practical implication of these findings is the need to recognize an unfavorably developing therapeutic relationship at an early stage and to address it appropriately. Following the recommendations of the 'APA Task Force on Evidence-Based Relationship and Responsiveness', the therapeutic benefit of a standardized assessment of therapeutic relationship variables should be emphasized and established beyond the research-oriented university context. Due to the increased percentage of patients with the diagnosis of a personality disorder in the subsample of patients with particularly low relationship satisfaction, the second paper examined subsamples of patients with borderline personality disorder and obsessive-compulsive personality disorder with regard to the relationship between therapeutic alliance and therapy success. One possible explanation for the fact that therapeutic alliance was a predictor of treatment success in our sample only in patients with obsessive-compulsive personality disorder and not in patients with borderline personality disorder may be found in the different patterns of alliance development characteristic of these personality disorders. The results show that the one-time measurement of therapeutic alliance in an early phase of therapy is a good predictor of therapeutic success in patients with obsessive-compulsive personality disorder and thus could be profitably used from a clinical point of view to identify possibly hidden conflicts in the therapeutic relationship at an early stage. In patients with borderline personality disorder, the one-time measurement of the therapeutic alliance seems to have a limited predictive value with regard to later therapy success, which is why a more continuous measurement of the therapeutic alliance is advisable for these patients.

Résumé : Problématique : Le trouble de la personnalité limite (TPL) est une condition psychiatrique touchant environ 1 % de la population et 20 % de la clientèle recevant des services en psychiatrie (Gunderson et Links, 2008). L’un des domaines du fonctionnement dans la vie quotidienne le plus touché chez cette population est le travail (Gunderson et al., 2011; Larivière et al., 2010; Zanarini et al., 2012). À notre connaissance, aucune étude n’a décrit de façon approfondie la participation au travail des personnes présentant un TPL. Objectif : L’objectif général de cette étude vise à identifier et à décrire les obstacles, les facilitateurs de même que les solutions possibles de la participation au travail des personnes présentant un TPL selon leur point de vue et celui de leurs intervenants. Méthodologie : Une étude de cas multiples a été utilisée (Yin, 2009). Neuf cas ont été étudiés selon trois contextes socioprofessionnels de la participation au travail : A. Réintégration (personne en invalidité), B. Retour (personne en absence maladie) et C. Maintien au travail. Pour chacun des contextes, trois dyades incluant une personne avec un TPL (âgée de 18 à 55 ans) et son intervenant soutenant la participation au travail ont été interviewées. Résultats: Les résultats qualitatifs (n = 18) ont démontré que la participation au travail des personnes présentant un TPL est influencée par des facteurs individuels (p. ex., la réaction face à la pression et aux relations de travail, la régulation émotionnelle) ainsi que des facteurs liés aux acteurs et procédures des systèmes de l’assurance, organisationnel et de la santé (p. ex., la collaboration et la communication entre les acteurs, l’alliance de travail entre les acteurs et la personne présentant un TPL, les mesures d’accommodement et de soutien naturel dans le milieu de travail). Conclusions et implication clinique : Cette étude met en lumière le défi important et spécifique que représente la participation au travail pour les personnes présentant un TPL. Elle implique des facteurs personnels et environnementaux qui doivent être considérés par tous les acteurs impliqués (les utilisateurs de services, les professionnels de la santé, les assureurs et les employeurs). Les programmes de réadaptation au travail actuels devraient être bonifiés et coordonnés adéquatement avec les thérapies spécialisées afin d’aborder de manière optimale les enjeux liés à la participation au travail des personnes présentant un TPL. / Abstract : Background: Borderline personality disorder (BPD) affects around 1% of the population and 20% of psychiatric service users (Gunderson & Links, 2008). Recent studies show that work participation is the most impaired occupational domain and should be prioritized in rehabilitation (Gunderson et al., 2011; Larivière et al., 2010; Zanarini et al., 2012). However, to our knowledge, no study has examined in depth the specific issues regarding work participation for people with BPD. Objective: The overall purpose of this study was to identify and describe barriers and facilitators as well as possible solutions for enabling work participation of individuals with a borderline personality disorder (BPD) from their perspective and the perspective of their service providers. Methods: Using a qualitative multiple case study design (Yin, 2009), three contexts of work participation were considered: 1) work (re) integration, 2) return to work (after a sick leave), and 3) job tenure. Within each context, three dyads including an individual with BPD (aged 18 to 55) and their service provider supporting work participation were met for individual interviews. Results: Qualitative results (n = 18) showed that individual factors (e.g., reaction towards pressure and relationships at work, regulation of emotions) and factors related to stakeholders and procedures from insurance, organizational and health systems (e.g., poor collaboration and communication between stakeholders, working alliance between individuals with BPD and stakeholders, work accommodations and natural support in the workplace) influenced work participation of individuals with BPD. Conclusions and implication for practice: This study highlights that work participation presents specific challenges for individuals with BPD, including several personal and environmental factors to be considered by all stakeholders (service users, health care professionals, insurers and employers). Current work rehabilitation programs need to be improved to address more optimally the work participation issues of individuals with BPD and be well coordinated with current specialized psychotherapies.