Abstract
The aim of this study was to investigate whether (a) baseline levels of panic-specific reflection function (PSRF; i.e. patients’ capacity to reflect on their panic symptoms) and improvement in this capacity over treatment, (b) baseline borderline personality disorder (BPD) traits and pre–post treatment improvement in BPD traits predict change in patients’ quality of object relations (QORs). A subsample of 102 patients diagnosed with panic disorder from a larger randomized controlled trial received either Cognitive-Behavioral Therapy or Panic-Focused Psychodynamic Psychotherapy. We investigated whether baseline levels and change in both PSRF and BPD traits (as measured by the Structured Clinical Interview for DSM-IV Axis II) predicted pre–post change in QORs, while controlling for pre–post treatment change in panic symptoms assessed by the Panic Disorder Severity Scale. In both treatments, higher baseline levels of PSRF and lower levels of BPD traits, as well as pre–post decrease in BPD traits, predicted improvement in QOR when controlling for symptomatic change. The findings suggest that reduction in comorbid BPD traits can facilitate improvement in patients’ QORs even in brief symptom-focused psychotherapies. Additionally, patients with higher baseline levels of symptom-focused reflective function and lower BPD traits are more likely to demonstrate interpersonal change over the course of psychotherapy for panic disorder. Finally, our study highlights the importance of examining therapeutic change beyond reduction in symptoms, particularly in domains of interpersonal functioning.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Allen, J., Fonagy, P., & Bateman, A. (2008). Mentalizing in clinical practice. Washington, DC: American Psychiatric Publishing, Inc.
Azim, H. F. A., Piper, W. E., Segal, P. M., Nixon, G. W. H., & Duncan, S. C. (1991). The quality of object relations scale. Bulletin of the Menninger Clinic; Topeka Kansas, 55, 323–343.
Barber, J. P., Milrod, B., Gallop, R., Solomonov, N., Rudden, M. G., McCarthy K. S., & Chambless, D. L. (2019). Processes of therapeutic change: Results from the Cornell-Penn Study of Psychotherapies for Panic Disorder.
Bateman, A. W., & Fonagy, P. (2012). Handbook of mentalizing in mental health practice. Washington, DC: American Psychiatric Publishing, Inc.
Bateman, A., & Fonagy, P. (2013). Impact of clinical severity on outcomes of mentalisation-based treatment for borderline personality disorder. The British Journal of Psychiatry, 203, 221–227. https://doi.org/10.1192/bjp.bp.112.121129.
Bateman, A., & Fonagy, P. (2015). Borderline personality disorder and mood disorders: Mentalizing as a framework for integrated treatment. Journal of Clinical Psychology, 71, 792–804. https://doi.org/10.1002/jclp.22206.
Bateman, A., & Fonagy, P. (2016). Mentalization-based treatment for personality disorders: A practical guide. Oxford: Oxford University Press.
Bouchard, M.-A., Target, M., Lecours, S., Fonagy, P., Tremblay, L.-M., Schachter, A., et al. (2008). Mentalization in adult attachment narratives: Reflective functioning, mental states, and affect elaboration compared. Psychoanalytic Psychology, 25, 47–66. https://doi.org/10.1037/0736-9735.25.1.47.
Bowlby, J. (1969). Attachment and loss: Attachment (Vol. 1). New York: Basic Books.
Busch, F. N., Milrod, B. L., Singer, M. B., & Aronson, A. C. (2012). Manual of panic focused psychodynamic psychotherapy—Extended range (1st ed.). New York: Routledge. https://doi.org/10.4324/9780203868560.
Carter, M. M., Turovsky, J., & Barlow, D. H. (1994). Interpersonal relationships in panic disorder with agoraphobia: A review of empirical evidence. Clinical Psychology: Science and Practice, 1, 25–34. https://doi.org/10.1111/j.1468-2850.1994.tb00004.x.
Choi-Kain, L. W., Zanarini, M. C., Frankenburg, F. R., Fitzmaurice, G. M., & Reich, D. B. (2010). A longitudinal study of the 10-year course of interpersonal features in borderline personality disorder. Journal of Personality Disorders, 24, 365–376. https://doi.org/10.1521/pedi.2010.24.3.365.
Clarkin, J. F., Lenzenweger, M. F., Yeomans, F., Levy, K. N., & Kernberg, O. F. (2007a). An object relations model of borderline pathology. Journal of Personality Disorders, 21, 474–499. https://doi.org/10.1521/pedi.2007.21.5.474.
Clarkin, J. F., Yeomans, F. E., & Kernberg, O. F. (2007b). Psychotherapy for borderline personality: Focusing on object relations. Washington, DC: American Psychiatric Publishing, Inc.
Craske, M., Barlow, D. H., & Meadows, L. A. (2000). Mastery of your anxiety and panic (3rd ed.). Albany, NY: TherapyWorks.
DiNardo, P. A., Brown, T. A., & Barlow, D. H. (1994). Anxiety disorders interview schedule for DSM-IV. Lifetime version: Client interview schedule. San Antonio, TX: Psychological Corporation.
Ekeblad, A., Falkenström, F., & Holmqvist, R. (2016). Reflective functioning as predictor of working alliance and outcome in the treatment of depression. Journal of Consulting and Clinical Psychology, 84, 67–78. https://doi.org/10.1037/ccp0000055.
Ellison, W. D., Rosenstein, L., Chelminski, I., Dalrymple, K., & Zimmerman, M. (2016). The clinical significance of single features of borderline personality disorder: Anger, affective instability, impulsivity, and chronic emptiness in psychiatric outpatients. Journal of Personality Disorders, 30, 261–270. https://doi.org/10.1521/pedi_2015_29_193.
Ensink, K., Berthelot, N., Bernazzani, O., Normandin, L., & Fonagy, P. (2014). Another step closer to measuring the ghosts in the nursery: Preliminary validation of the Trauma Reflective Functioning Scale. Frontiers in Psychology, 5, 1471. https://doi.org/10.3389/fpsyg.2014.01471.
Falkenström, F., Finkel, S., Sandell, R., Rubel, J. A., & Holmqvist, R. (2017). Dynamic models of individual change in psychotherapy process research. Journal of Consulting and Clinical Psychology, 85, 537–549. https://doi.org/10.1037/ccp0000203.
Faul, F., Erdfelder, E., Buchner, A., & Lang, A.-G. (2009). Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses. Behavior Research Methods, 41, 1149–1160. https://doi.org/10.3758/BRM.41.4.1149.
First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W., & Benjamin, L. S. (1997). Structured clinical interview for DSM-IV Axis II personality disorders (1st ed.). Arlington, VA: American Psychiatric Publishing, Inc.
Fischer-Kern, M., Buchheim, A., Hörz, S., Schuster, P., Doering, S., Kapusta, N. D., et al. (2010). The relationship between personality organization, reflective functioning, and psychiatric classification in borderline personality disorder. Psychoanalytic Psychology, 27, 395–409. https://doi.org/10.1037/a0020862.
Fischer-Kern, M., Tmej, A., Kapusta, N. D., Naderer, A., Leithner-Dziubas, K., Löffler-Stastka, H., et al. (2008). The capacity for mentalization in depressive patients: A pilot study. Zeitschrift fur Psychosomatische Medizin und Psychotherapie, 54, 368–380. https://doi.org/10.13109/zptm.2008.54.4.368.
Fonagy, P., Gergely, G., Jurist, E. L., & Target, M. (2002). Affect regulation, mentalization and the development of the self. New York: Routledge.
Fonagy, P., Leigh, T., Steele, M., Steele, H., Kennedy, R., Mattoon, G., et al. (1996). The relation of attachment status, psychiatric classification, and response to psychotherapy. Journal of Consulting and Clinical Psychology, 64, 22–31. https://doi.org/10.1037/0022-006X.64.1.22.
Fonagy, P., Luyten, P., & Bateman, A. (2015). Translation: Mentalizing as treatment target in borderline personality disorder. Personality Disorders, 6, 380–392. https://doi.org/10.1037/per0000113.
Fonagy, P., Steele, M., Steele, H., Moran, G. S., & Higgitt, A. C. (1991). The capacity for understanding mental states: The reflective self in parent and child and its significance for security of attachment. Infant Mental Health Journal, 12, 201–218. https://doi.org/10.1002/1097-0355(199123)12:3%3c201:AID-IMHJ2280120307%3e3.0.CO;2-7.
Fonagy, P., & Target, M. (1997). Attachment and reflective function: Their role in self-organization. Development and Psychopathology, 9, 679–700. https://doi.org/10.1017/S0954579497001399.
Fonagy, P., & Target, M. (2000). Playing with reality: III. The persistence of dual psychic reality in borderline patients. The International Journal of Psychoanalysis, 81, 853–873. https://doi.org/10.1516/0020757001600165.
Fonagy, P., Target, M., Steele, H., & Steele, M. (1998). Reflective-functioning manual, version 5.0, for application to adult attachment interviews. London: University College London.
Goldstein, A. J., & Chambless, D. L. (1978). A reanalysis of agoraphobia. Behavior Therapy, 9, 47–59. https://doi.org/10.1016/S0005-7894(78)80053-7.
Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., et al. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: Results from the wave 2 National Epidemiologic Survey on alcohol and related conditions. The Journal of Clinical Psychiatry, 69, 533–545.
Hagtvet, K. A., & Heglend, P. A. (2008). Assessing precision of change scores in psychodynamic psychotherapy: A generalizability theory approach. Measurement and Evaluation in Counseling and Development, 41, 162–178. https://doi.org/10.1080/07481756.2008.11909828.
Hamaker, E. L., Kuiper, R. M., & Grasman, R. P. (2015). A critique of the cross-lagged panel model. Psychological Methods, 20, 102–116. https://doi.org/10.4088/JCP.v69n0404.
Høglend, P. (2003). Long-term effects of brief dynamic psychotherapy. Psychotherapy Research, 13, 271–292. https://doi.org/10.1093/ptr/kpg031.
Høglend, P., Amlo, S., Marble, A., Bøgwald, K.-P., Sørbye, Ø., Sjaastad, M. C., et al. (2006). Analysis of the patient–therapist relationship in dynamic psychotherapy: An experimental study of transference interpretations. The American Journal of Psychiatry, 163, 1739–1746. https://doi.org/10.1176/appi.ajp.163.10.1739.
Høglend, P., Bøgwald, K.-P., Amlo, S., Marble, A., Ulberg, R., Sjaastad, M. C., et al. (2008). Transference interpretations in dynamic psychotherapy: Do they really yield sustained effects? The American Journal of Psychiatry, 165, 763–771. https://doi.org/10.1176/appi.ajp.2008.07061028.
Høglend, P., & Piper, W. E. (1995). Focal adherence in brief dynamic psychotherapy: A comparison of findings from two independent studies. Psychotherapy: Theory, Research, Practice, Training, 32, 618–628. https://doi.org/10.1037/0033-3204.32.4.618.
Jacobson, E. (1964). The self and the object world. Oxford: International Universities Press.
Johansson, P., Høglend, P., Ulberg, R., Amlo, S., Marble, A., Bøgwald, K.-P., et al. (2010). The mediating role of insight for long-term improvements in psychodynamic therapy. Journal of Consulting and Clinical Psychology, 78, 438–448. https://doi.org/10.1037/a0019245.
Jurist, E. L., & Meehan, K. B. (2008). Attachment, mentalization and reflective functioning. In J. H. Obegi & E. Berant (Eds.), Clinical applications of adult attachment. New York: Guilford Press.
Katznelson, H. (2014). Reflective functioning: A review. Clinical Psychology Review, 34, 107–117. https://doi.org/10.1016/j.cpr.2013.12.003.
Keefe, J. R., Milrod, B. L., Gallop, R., Barber, J. P., & Chambless, D. L. (2018). What is the effect on comorbid personality disorder of brief panic-focused psychotherapy in patients with panic disorder? Depression and Anxiety, 35, 239–247. https://doi.org/10.1002/da.22708.
Kernberg, O. F. (1980). Internal world and external reality: Object relations theory applied. New York: Aronson.
Kleiner, L., & Marshall, W. L. (1985). Relationship difficulties and agoraphobia. Clinical Psychology Review, 5, 581–595. https://doi.org/10.1016/0272-7358(85)90036-4.
Kullgard, N., Persson, P., Möller, C., Falkenström, F., & Holmqvist, R. (2013). Reflective functioning in patients with obsessive–compulsive disorder (OCD)—Preliminary findings of a comparison between reflective functioning (RF) in general and OCD-specific reflective functioning. Psychoanalytic Psychotherapy, 27, 154–169. https://doi.org/10.1080/02668734.2013.795909.
Lazarus, S. A., Cheavens, J. S., Festa, F., & Rosenthal, M. Z. (2014). Interpersonal functioning in borderline personality disorder: A systematic review of behavioral and laboratory-based assessments. Clinical Psychology Review, 34, 193–205. https://doi.org/10.1016/j.cpr.2014.01.007.
Levy, K. N., Meehan, K. B., Kelly, K. M., Reynoso, J. S., Weber, M., Clarkin, J. F., et al. (2006). Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 74, 1027–1040. https://doi.org/10.1037/0022-006X.74.6.1027.
Linehan, M. M. (2018). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Publications.
Lowyck, B., Luyten, P., Vanwalleghem, D., Vermote, R., Mayes, L. C., & Crowley, M. J. (2016). What’s in a face? Mentalizing in borderline personality disorder based on dynamically changing facial expressions. Personality Disorders: Theory, Research, and Treatment, 7, 72–79. https://doi.org/10.1037/per0000144.
Main, M., Hesse, E., & Goldwyn, R. (2008). Studying differences in language usage in recounting attachment history: An introduction to the AAI. Clinical applications of the Adult Attachment Interview (pp. 31–68). New York: Guilford Press.
Meins, E., Fernyhough, C., Russell, J., & Clark-Carter, D. (1998). Security of attachment as a predictor of symbolic and mentalising abilities: A longitudinal study. Social Development, 7, 1–24. https://doi.org/10.1111/1467-9507.00047.
Milrod, B. L., Busch, F. N., Cooper, A. M., & Shapiro, T. (1997). Manual of panic-focused psychodynamic psychotherapy. Arlington, VA: American Psychiatric Publishing, Inc.
Milrod, B., Chambless, D. L., Gallop, R., Busch, F. N., Schwalberg, M., McCarthy, K. S., et al. (2016). Psychotherapies for panic disorder: A tale of two sites. The Journal of Clinical Psychiatry, 77, 927–935. https://doi.org/10.4088/JCP.14m09507.
Milrod, B., Leon, A. C., & Shear, M. K. (2004). Can interpersonal loss precipitate panic disorder? The American Journal of Psychiatry, 161, 758–759. https://doi.org/10.1176/appi.ajp.161.4.758.
Minges, M. V., Solomonov, N., & Barber, J. P. (2017). What makes psychodynamic psychotherapy work? A review of five perspectives. Psychoanalytic Inquiry, 37, 191–201. https://doi.org/10.1080/07351690.2017.1285188.
Moras, K., & Strupp, H. H. (1982). Pretherapy interpersonal relations, patients’ alliance, and outcome in brief therapy. Archives of General Psychiatry, 39, 405–409. https://doi.org/10.1001/archpsyc.1982.04290040019003.
Nay, W., Brown, R., & Roberson-Nay, R. (2013). Longitudinal course of panic disorder with and without agoraphobia using the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Psychiatry Research, 208, 54–61. https://doi.org/10.1016/j.psychres.2013.03.006.
Ogden, T. H. (1983). The concept of internal object relations. The International Journal of Psychoanalysis, 64, 227–241.
Petersen, R., Brakoulias, V., & Langdon, R. (2016). An experimental investigation of mentalization ability in borderline personality disorder. Comprehensive Psychiatry, 64, 12–21. https://doi.org/10.1016/j.comppsych.2015.10.004.
Piper, W. E., & Duncan, S. C. (1999). Object relations theory and short-term dynamic psychotherapy: Findings from the Quality of Object Relations Scale. Clinical Psychology Review, 19, 669–685. https://doi.org/10.1016/S0272-7358(98)00080-4.
Piper, W. E., McCallum, M., Azim, H. F. A., & Joyce, A. S. (1993). Understanding the relationship between transference interpretation and outcome in the context of other variables. American Journal of Psychotherapy, 47, 479–493. https://doi.org/10.1176/appi.psychotherapy.1993.47.4.479.
Piper, W. E., Ogrodniczuk, J. S., & Joyce, A. S. (2004). Quality of object relations as a moderator of the relationship between pattern of alliance and outcome in short-term individual psychotherapy. Journal of Personality Assessment, 83, 345–356. https://doi.org/10.1207/s15327752jpa8303_15.
R Core Team. (2017). R: A language and environment for statistical computing. Vienna: R Foundation for Statistical Computing. Retrieved from https://www.R-project.org/. Accessed 1 Aug 2018.
Rudden, M. G., Milrod, B., Meehan, K. B., & Falkenstrom, F. (2009). Symptom-specific reflective functioning: Incorporating psychoanalytic measures into clinical trials. Journal of the American Psychoanalytic Association, 57, 1473–1478. https://doi.org/10.1177/00030651090570060804.
Rudden, M. G., Milrod, B., & Target, M. (2005). The brief reflective functioning interview. New York: Weill Cornell Medical College.
Rudden, M., Milrod, B., Target, M., Ackerman, S., & Graf, E. (2006). Reflective functioning in panic disorder patients: A pilot study. Journal of the American Psychoanalytic Association, 54, 1339–1343. https://doi.org/10.1177/00030651060540040109.
Scocco, P., Barbieri, I., & Frank, E. (2007). Interpersonal problem areas and onset of panic disorder. Psychopathology, 40, 8–13. https://doi.org/10.1159/000096384.
Sharp, C., & Vanwoerden, S. (2015). Hypermentalizing in borderline personality disorder: A model and data. Journal of Infant, Child and Adolescent Psychotherapy, 14, 33–45. https://doi.org/10.1080/15289168.2015.1004890.
Shear, M. K., Brown, T. A., Barlow, D. H., Money, R., Sholomskas, D. E., Woods, S. W., et al. (1997). Multicenter collaborative Panic Disorder Severity Scale. The American Journal of Psychiatry, 154, 1571–1575. https://doi.org/10.1176/ajp.154.11.1571.
Skodol, A. E., Gunderson, J. G., Pfohl, B., Widiger, T. A., Livesley, W. J., & Siever, L. J. (2002). The borderline diagnosis I: Psychopathology, comorbidity, and personality structure. Biological Psychiatry, 51, 936–950. https://doi.org/10.1016/S0006-3223(02)01324-0.
Taubner, S., Kessler, H., Buchheim, A., Kächele, H., & Staun, L. (2011). The role of mentalization in the psychoanalytic treatment of chronic depression. Psychiatry: Interpersonal and Biological Processes, 74, 49–57. https://doi.org/10.1521/psyc.2011.74.1.49.
Tomko, R. L., Trull, T. J., Wood, P. K., & Sher, K. J. (2014). Characteristics of borderline personality disorder in a community sample: Comorbidity, treatment utilization, and general functioning. Journal of Personality Disorders, 28, 734–750. https://doi.org/10.1521/pedi_2012_26_093.
van Buuren, S., & Groothuis-Oudshoorn, K. (2011). MICE: Multivariate imputation by chained equations in R. Journal of Statistical Software, 45, 1–68. https://doi.org/10.18637/jss.v045.i03.
Zimmerman, M., Chelminski, I., Young, D., Dalrymple, K., & Martinez, J. (2012). Does the presence of one feature of borderline personality disorder have clinical significance? Implications for dimensional ratings of personality disorders. The Journal of Clinical Psychiatry, 73, 8–12. https://doi.org/10.4088/JCP.10m06784.
Zimmerman, M., & Mattia, J. I. (1999). Axis I diagnostic comorbidity and borderline personality disorder. Comprehensive Psychiatry, 40, 245–252. https://doi.org/10.1016/S0010-440X(99)90123-2.
Zinbarg, R. E., Craske, M. G., & Barlow, D. H. (2006). Mastery of your anxiety and worry (MAW): Therapist guide. Oxford: Oxford University Press.
Acknowledgements
We would like to thank Kevin McCarthy for his thoughtful comments on an earlier version of this manuscript. Barbara Milrod was supported by National Institute of Mental Health under Grant Nos. NCT00353470 and NCT00043550. Nili Solomonov was supported by National Institute of Mental Health under Grant Nos. T32 MH019132 and P50 MH113838 and American Psychological Foundation under Steven O. Walfish Grant.
Author information
Authors and Affiliations
Corresponding author
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Solomonov, N., Aafjes van-Doorn, K., Lipner, L.M. et al. Panic-Focused Reflective Functioning and Comorbid Borderline Traits as Predictors of Change in Quality of Object Relations in Panic Disorder Treatments. J Contemp Psychother 49, 255–264 (2019). https://doi.org/10.1007/s10879-019-09434-7
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10879-019-09434-7