The Effectiveness of Psychodynamic Therapy and Cognitive Behavior Therapy in the

Treatment of Personality Disorders: A Meta-Analysis.

By Falk Leichsenring, D.Sc.Eric Leibing, D.Sc.

(Am J Psychiatry 2003; 160:1223-1232)

Presented By: Lauren Coe

Purpose

There is a considerable lack of empirical research on treatment of personality disorders with psychotherapy, with only a few randomized controlled studies.

To address concerns about costs of mental health services, empirical data about the efficacy of psychotherapy in the treatment of personality disorders are needed.

Method

Studies published between 1974 and 2001 were collected.– MEDLINE– PsycINFO– Current Contents

14 of psychodynamic therapy and 11 studies of cognitive behavior therapy were included.

Literature Review Questions:

What is the evidence of improvement in symptoms, social functioning, or core psychopathology after either type of therapy?

Is there evidence of improvement in specific types of personality disorders after either type of therapy?

Do individuals with personality disorders recover after either type of therapy?

Literature Review Questions:

Are there differences between self-report and observational measures?

Are there differences between outcome and duration of treatment?

What other factors are connected with outcome (gender, inpatient vs. outpatient status, use of therapy manuals, experience of therapists)?

Correlations

Calculate correlations between outcome and the following factors:– Length of therapy– Patient gender– Inpatient vs. outpatient status– Use of therapy manuals– Clinical experience of therapists– Study design (randomized vs. naturalistic)

Issues To Consider

Small number of studies Many variables Grouped personality disorders Effect sizes (statistics) not comparable This is “preliminary”

Included Studies

Studies focusing on:– Either psychodynamic or cognitive therapy– Men and women– Personality disorders– Inpatients, outpatients– Sufficient length of time– Randomized and naturalistic designs

Results

Therapy Type

Mean Length

Number of Sessions

Psychodynamic Therapy 37.18 6

Cognitive Therapy 16.36 7

Results - Psychodynamic

Improvement Effect Size

Number of Studies

Mean (D) SD Range

Overall 15 1.46 0.73 0.34 - 2.70

Self-Report 12 1.08 0.36 0.65 - 1.67

Observer Report

12 1.79 1.07 0.34 - 4.02

Results – Cognitive

Improvement Effect Size

Number of Studies

Mean (D) SD Range

Overall 10 1.00 0.48 0.34 - 2.13

Self-Report 8 1.20 0.38 0.81 - 1.85

Observer Report

8 0.87 0.71 0.19 - 2.40

Effectiveness of Therapy on Treatment – Beck Depression Scale

Psychodynamic # studies Mean SD

PD6 1.44 0.51

No PD2 2.39 0.54

Effectiveness of Therapy on Treatment – Beck Depression Scale

Cognitive # studies Mean SD

PD 3 1.49 0.28

No PD 1 2.04 --

Other Conclusions

For cognitive behavioral therapy, the largest effect sizes were found with the Beck Depression Inventory.

A calculated recovery rate from personality disorders of 59% after a mean of 15 months of treatment (psychodynamic therapy).

47% of the patients were no longer diagnosed with avoidant personality disorder (cognitive behavioral therapy).

More random conclusions

Dropout rates are relevant: Mean dropout rates

Psychodynamic therapy = 15%Cognitive therapy = 17%.

Total number treated Psychodynamic therapy = 417Cognitive therapy = 231.

Limitations of the Study

Small number of studies that could be included (25 total)

The small number of studies reduces both the results’ potential generalization and the statistical power.

Thus, the conclusions that can be drawn are only preliminary.

Limitations of the Study

Effect sizes cannot be compared directly between cognitive behavior therapy and psychodynamic therapy because the data do not come from the same experimental comparisons.

Within-group effect sizes may be an overestimate of the true change because of unspecific therapeutic factors, spontaneous remission, or regression to the mean.

Limitations of the Study

Significant fluctuations over time may occur that may be state dependent rather than showing lasting remission of the personality disorder in question.

Several studies reported more improvement in personality disorder patients after longer treatment durations.

Meta-Analysis Conclusions

There is evidence that both psychodynamic therapy and cognitive behavior therapy are effective treatments of personality disorders.

There is evidence that treatment with psychotherapy in personality disorder patients is relevant to the cost of health care utilization.

Further Conclusions

Further studies are necessary. Both longer treatments and follow-up studies

should be included. Further research should examine specific

forms of psychotherapy for specific types of personality disorder.

Data on health economics should be included.