LEICHSENRING ET AL.

A DIMENTIONAL APPROACH TO PERSONALITY DISORDERS

Changes in Personality Functioning After Inpatient

Psychodynamic Therapy: A Dimensional Approach
to Personality Disorders

Falk Leichsenring, Ulrich Jaeger, Oliver Masuhr,

Andreas Dally, Michael Dümpelmann,
Christian Fricke-Neef, Christiane Steinert,
and Carsten Spitzer

Abstract: Objective: Patients with mental disorders do not only show specific
symptoms but also impairments in personality functioning, especially those
with personality disorders. Recent developments in DSM-5 and ICD-11 sug-
gest a dimensional approach to personality disorders. Few studies, however,
have examined changes in personality functioning. Methods: In a large sample
of 2,596 patients treated by inpatient psychodynamic therapy, changes in per-
sonality functioning were studied. Two patient groups were examined, one
with (N = 1152, BPO) and one without a presumptive diagnosis of a borderline
personality organization (N = 1444, NBPO). For the assessment of personality
functioning, the Borderline-Personality Inventory (BPI) was used. The BPI taps
personality functioning as defined by Kernberg’s structural criteria of person-
ality organization. Symptom distress and interpersonal problems were exam-
ined with the Symptom Checklist SCL-90-R and the Inventory of Interpersonal
Problems (IIP). Patients were assessed at admission and discharge. Results:
In the BPO sample significant and substantial pre-post effect sizes in overall

Statement of Ethics: All subjects have given their written informed consent. A study
protocol is not required since the data were collected as part of the usual assessment in
the clinic of Tiefenbrunn.
Disclosure Statement: The authors have no conflicts of interest to declare.
Funding: No funding.
Author Contributions: All authors contributed substantially and equally to the article.
Falk Leichsenring, University of Giessen, Germany.
Ulrich Jaeger, Asklepios Clinic Tiefenbrunn, Germany.
Oliver Masuhr, Asklepios Clinic Tiefenbrunn, Germany.
Andreas Dally, Asklepios Clinic Tiefenbrunn, Germany.
Michael Dümpelmann, Asklepios Clinic Tiefenbrunn, Germany.
Christian Fricke-Neef, Asklepios Clinic Tiefenbrunn, Germany.
Christiane Steinert, University of Giessen, Germany; Medical School Berlin, Germany.
Carsten Spitzer, Asklepios Clinic Tiefenbrunn, Germany; University Medicine Rostock,
Rostock, Germany.

Psychodynamic Psychiatry, 47(2) 183–196, 2019

© 2019 The American Academy of Psychodynamic Psychiatry and Psychoanalysis
184 LEICHSENRING ET AL.

personality functioning, identity integration, and defense mechanisms/object

relations were found (d = 0.68, 0.60, 0.78). In addition, large improvements in
symptoms (SCL-90-R) were achieved (d = 0.97). For interpersonal problems ef-
fect sizes were medium (0.56). At discharge 36% of the BPO patients scored
below the BPI-Cut-Off score for a BPO (remission). Pre-post effect sizes in the
NPBO sample (N = 1444) were significant but small for changes in personality
functioning (d = 0.31–0.46) and substantial for improvements in symptoms (d =
0.77). Conclusions: Both personality functioning and symptom distress can be
substantially improved by inpatient psychodynamic therapy. Future research
is recommended to study both improvements in symptoms and personality
functioning.

Keywords: personality functioning, personality disorders, psychodynamic

treatment

Patients with mental disorders do not only show specific symptoms

that can be used to make classificatory diagnoses but also impairments
in personality functioning (Tyrer, Crawford, & Mulder, 2011; Tyrer,
Reed, & Crawford, 2015). For this reason, DSM-5 included in the alter-
native model for personality disorders a scale for assessing the level of
personality functioning (American Psychiatric Asociation, 2013). The
proposed scale taps disturbances in self and interpersonal function-
ing, specifically impairments in identity and self-direction as well as
in empathy and intimacy. The ICD-11 Working Group for the Revision
of Classification of Personality Disorders suggests a dimensional ap-
proach, too (Tyrer, Crawford, & Mulder, 2011; Tyrer et al., 2011; Tyrer,
Reed, & Crawford, 2015; World Health Organization [WHO]). In ad-
dition, both DSM-5 and the ICD-11 Working Group suggest the rating
of several trait domains (negative affectivity, detachment antagonism/
dissociality, disinhibition, and/or psychoticism and anankastia; Ameri-
can Psychiatric Asociation, 2013; World Health Organization).
These approaches make reference to psychodynamic approaches
specifying levels of personality organization (Bellak, Hurvich, & Gedi-
man, 1973; Clarkin, Caligor, Stern, & Kernberg, 2004; Hopwood et al.,
2018; Kernberg, 1981). From an ego psychological perspective person-
ality functioning can be defined by the level of ego functions (Bellak,
Hurvich, & Gediman, 1973). From an object relational approach per-
sonality functioning is defined by structural criteria, that is levels of
identity integration, defense mechanisms and object relations, and by
the ability for reality testing (Kernberg, 1981). These approaches were
integrated into the Operationalized Psychodynamic Diagnosis System
(OPD; OPD Taskforce, 2008) and into the Psychodynamic Diagnostic
 A DIMENTIONAL APPROACH TO PERSONALITY DISORDERS 185

Manual (PDM Taskforce, 2006). In the OPD system, for example, levels
of structural integration are defined which cover several dimensions of
self and interpersonal regulation (OPD Taskforce, 2008). An empirically
derived taxonomy of personality diagnosis was developed by Westen,
Shedler, Bradley, and DeFife (2012).
Severe personality disorders such as borderline or antisocial per-
sonality disorder are primarily defined by marked impairments in self
and interpersonal functioning (American Psychiatric Asociation, 2013;
Bellak, Hurvich, & Gediman, 1973; Kernberg, 1981; World Health Or-
ganization). They primarily correspond to DSM-5 and ICD-10 level 3
(“severe impairment”) of personality functioning.1 For these severe
personality disorders several methods of psychotherapy have been
developed that proved to be efficacious in randomized controlled tri-
als. For psychodynamic therapies this applies to mentalization-based
therapy, transference-focused psychotherapy, and psychoanalytic-in-
teractional therapy (Bateman & Fonagy, 1999; Bateman & Fonagy, 2009;
Clarkin, Levy, Lenzenweger, & Kernberg, 2007; Doering et al., 2010;
Leichsenring et al., 2016). In the area of cognitive behavioral therapy
evidence is available for dialectical behavior therapy (DBT) and schema
therapy (Linehan et al., 2006; Young, 1994).
However, only a few studies examined changes in personality func-
tioning. In some studies psychodynamic therapy was shown to improve
personality functioning, specifically reflective functioning and patterns
of attachment (Buchheim et al., 2017; Clarkin et al., 2007; Fischer-Kern
et al., 2015; Levy et al., 2006).
Thus, the effects of psychotherapy (or pharmacotherapy) on personal-
ity functioning are understudied, both in axis I and axis II disorders. This
is the more concerning since personality functioning affects the patients´
functioning in everyday life including interpersonal relationships and
working ability (American Psychiatric Asociation, 2013, pp. 775–778; Bel-
lak, Hurvich, & Gediman, 1973; Tyrer, Crawford, & Mulder, 2011; Tyrer,
Reed, & Crawford, 2015; World Health Organization).
For this reason a large sample of patients (N = 2596) treated by in-
patient psychotherapy was studied with regard to changes in person-
ality functioning. For personality functioning the structural criteria of
personality organization proposed by Kernberg (1981) were applied,

1. It is an interesting question whether DSM-5 and ICD-11 level 4 of personality

functioning really represents functioning within the area of personality disorders or
rather a psychotic level of personality organization according to Kernberg (Kernberg,
1981, 1984). In a similar way, schizotypal personality disorder does not really represent a
personality disorder but a condition within the schizophrenia spectrum (Kernberg, 1984;
Tyrer et al., 2011).
186 LEICHSENRING ET AL.

that is levels of identity integration, defense mechanisms, and object

relations and reality testing which is consistent with the psychody-
namically inspired focus of DSM-5 and ICD-11 on aspects of the self
and interpersonal relationships. These criteria (identity integration, de-
fense mechanisms, and object relations and reality testing) were dimen-
sionally assessed by use of the Borderline-Personality Inventory (BPI;
Leichsenring, 1999), consistent with the proposals for a dimensional
assessment of personality disorders (American Psychiatric Asociation,
2013; Hopwood et al., 2018; Tyrer, Crawford, & Mulder, 2011; Tyrer,
Reed, & Crawford, 2015; WHO.int/classifications/icd/revision/en/).
As there is no evidence for the assumption that personality disorders
are categorical or that a specific number of discrete types of personality
disorders exist (Hopwood et al., 2018), the broader concept of border-
line personality organization (Clarkin et al., 2004; Kernberg, 1981) was
used in this study.
Results are reported for a sample of patients with a presumptive bor-
derline personality organization and for a sample for whom this is not
the case. For the first group we hypothesized substantial improvements
in both personality functioning and symptom distress. For the latter
group, primarily improvements in symptom distress were expected.

METHODS

Study Design and Subjects

The study was carried out at the Asklepios Clinic Tiefenbrunn in

Germany. In Tiefenbrunn patients are routinely assessed at admission
and at discharge by use of a battery of reliable and validated diagnostic
instruments. Between 2009 and 2016, 4,034 patients were treated in the
clinic of Tiefenbrunn.

Assessment

ICD-10 diagnoses were given by trained raters using research di-

agnostic criteria of ICD-10 to ensure reliability (Dilling & Freyberger,
2001). A borderline personality organization was assessed by use of
the cut-off score of the Borderline-Personality Inventory (BPI; Leich-
senring, 1999). The BPI is a 51-item self-report instrument that taps
the level of personality organization according to Kernberg (Kernberg,
1981; Leichsenring, 1999). In addition to a total score, it provides an
 A DIMENTIONAL APPROACH TO PERSONALITY DISORDERS 187

empirically validated cut-off score which allows one to make the di-
agnosis of borderline personality organization (Cut-20 ≥10). The BPI
cut-off consists of the 20 most discriminating items of the BPI. In addi-
tion, the BPI includes subscales for identity diffusion, primitive defense
mechanisms/object relations and reality testing, that is for personality
functioning (Leichsenring, 1999). The BPI has proved to be reliable and
valid in several studies, showing, for example, significant correlations
with relevant self- and observer-rated measures (Chabrol & Leich-
senring, 2006; Konig, Dahlbender, Holzinger, Topitz, & Doering, 2016;
Leichsenring, 1999; Spitzer, Michels-Lucht, Siebel, & Freyberger, 2002).
The BPI showed a high discriminative power with sufficient rates for
sensitivity and specificity (Leichsenring, 1999).
General symptom distress and interpersonal problems were exam-
ined as secondary outcomes. General symptom distress was assessed
by use of the Global Severity Index (GSI) of the Symptom Checklist-
90-Revised (SCL-90-R; Derogatis, Lipman, Rickels, Uhlenhuth, & Covi,
1974; Franke, 1995). The SCL-90-R is a frequently used, 90-item self-re-
port symptom inventory, aiming at the assessment of a broad range of
current psychopathology. Each item relates to a symptom and is rated
on a five-point scale (“not at all” to “extremely”). The checklist com-
prises nine symptom dimensions (e.g., depression, somatization, anxi-
ety). A global severity index (GSI) is obtained by averaging the scores
over the total number of answered items. The SCL-90-R GSI represents
a measure of overall psychological distress.
Interpersonal problems were examined by use of the Inventory of
Interpersonal Problems (IIP; Horowitz et al., 1994). The IIP is a well-
established instrument for the assessment of interpersonal problems.
It consists of eight circumplex-scales (domineering, vindictive, cold,
socially avoidant, nonassertive, exploitable, overly nurturant, and in-
trusive) which are assessed via 64-items that are rated on a five-point
scale (“not at all” to “extremely”). A full-scale score is calculated as the
mean rating over all items. A higher score indicates more interpersonal
problems.

Treatment

The clinic of Tiefenbrunn is specialized in the treatment of patients

with severe structural impairments including patients with personal-
ity disorders. The key method of psychotherapy applied in the clinic
of Tiefenbrunn is psychoanalytic-interactional therapy (PIT; Streeck,
2002; Streeck & Leichsenring, 2009). The interventions used in PIT are
188 LEICHSENRING ET AL.

described in treatment manuals (Leichsenring, Masuhr, Jaeger, Dally,

& Streeck, 2010; Streeck, 2002; Streeck & Leichsenring, 2009). The main
principle of intervention used in PIT is called the “responsive mode.“
The responsive mode characterizes the therapist’s technical attitude: he
or she presents him- or herself as “another (feeling) person” in a dyadic
interaction. Instead of interpreting the patient’s behavior the therapist
selectively verbalizes the effects that the patient´s behavior has on him
or her. After psychotherapeutic reflection the therapist selectively allows
the patient to participate in the experiences and feelings that he or she
perceives in him- or herself as a reaction to the behavior presented by
the patient either to him/her or to another person (e.g., “I am feeling
misunderstood when you attack me in this way” or “I am wonder-
ing whether this woman felt blamed by the way you behaved toward
her“). In PIT selective self-disclosure is neither employed spontaneous-
ly nor does it aim at making the therapeutic dialogue more egalitarian.
The therapist in PIT needs to decide if any and which aspects of his
or her countertransference may be beneficial for making the patient’s
interpersonal world more transparent. The responsive mode fosters the
development of several psycho-social functions, such as differentiating
between self and object, or realizing the effects of one´s own behavior
on others. It also shows that the therapist is able to protect his or her
own boundaries, thus many severely disordered patients are relieved
from their overpowering fear of the strength of their impulses (Ott,
2001).
In contrast to transference-focused therapy (Clarkin, Yeomans, &
Kernberg, 1999), PIT does not make use of interpretations, but uses
the responsive mode as described above. Compared to mentalization-
based therapy (Bateman & Fonagy, 2004), behavior and feelings are not
attributed to motives or other characteristics of the individual person,
but to the interactional context in which these behaviors and feelings
occur. The principle type of intervention that discriminates PIT from
mentalization-based therapy is the use of the responsive mode. In a
randomized controlled trial PIT proved to be efficacious in the treat-
ment of Cluster B personality disorders (Leichsenring et al., 2016).
As part of the inpatient treatment, PIT is applied in both an individual
and in a group setting, with one or two sessions per week in individual
therapy and three sessions per week in group therapy. Within a coor-
dinated treatment plan all patients additionally received art therapy or
body therapy (one or two sessions per week), and consultations with a
social worker if needed. In cases of severe symptoms of depression or
anxiety, additional pharmacotherapy was given temporarily. This ap-
plies to both groups of patients described in the following (BPO and
NBPO).
 A DIMENTIONAL APPROACH TO PERSONALITY DISORDERS 189

Table 1. Patient Flow

4034
total sample
2596 1438
data for both admission and data for both admission and
discharge available discharge not available
1444
BPI-Cut < 10
1152
BPI-Cut ≥ 10

Statistical Analysis

Changes in the BPI, SCL-90-R, and IIP were examined by t-tests for
dependent measures. In order to avoid type I error inflation, the signifi-
cance level was adjusted by dividing 0.05 by the number of tests car-
ried out. Effect sizes were calculated for each measure by dividing the
pre- to post difference in means by the standard deviation at baseline
(admission; Becker, 1988). In order to examine the impact of age and
gender, Pearson correlations were calculated.

RESULTS

Between 2009 and 2016 a sample of 4,034 patients were hospitalized

and treated in the clinic of Tiefenbrunn. For 2,596 patients of the total
sample data at both admission and discharge were available (Table 1).
Missing data are due to administrative or technical problems (e.g., pa-
tients missed the assessment at discharge). Of the 2,596 patients, 1,152
(44%) fulfilled the criterion of the BPI Cutoff ≥10 (Leichsenring, 1999)
and 1,444 patients showed a score < 10. In the following, the first sam-
ple will be referred to as BPO (borderline personality organization), the
second as NBPO (non-borderline personality organization). These data
show a relative high prevalence of borderline personality organization
among the patients treated at Tiefenbrunn. The two samples are de-
scribed in Table 2. The mean number of axis I disorders was 2.30 (SD =
1.09) in the NBPO sample and 2.61 (SD = 1.15) in the BPO sample. In the
NBPO sample, 74% of the patients had more than one axis I disorder, in
the BPO sample this was true for 83% of the patients.
The inpatient treatment lasted for a mean of 87.61 days (SD = 30.00)
in the BPO sample and 76.80 days (SD = 29.60) in the NBPO sample.
As a first step, we tested whether those patients for whom BPI data at
190 LEICHSENRING ET AL.

Table 2. Baseline Demographic and Clinical Data of the Included Samples

Patients scoring ≥ 10 in BPI-cutoff score (N = 1152)
%
Age M (SD) 34.20 (11.79)
female 799 69
ICD-10 Diagnosis
F33+ F32 579 50.2
F40+F41+F42 165 14.3
F43 140 12.2
F44 11 1
F60 680 59
Patients scoring < 10 in BPI-cutoff score (N = 1444)
Age M (SD) 36. 64 (12.50)
female 825 57
ICD-10 Diagnosis
F33+ F32 859 59.5
F40+F41+F42 199 13.8
F43 99 6.9
F44 12 0.8
ICD-10 F60 628 44

discharge were missing differ at baseline in the applied outcome mea-

sures (BPI, SCL-90, IIP) from those for whom these data at discharge
are available. Very few differences were found which corresponded to
small effect sizes. In sample BPO (Cut-20 ≥ 10), the patients for whom
data at discharge were missing scored slightly higher in the BPI-Total
(d = 0.19), in the BPI reality testing scale (d = 0.12), and in the IIP-Total
(d = 0.17). In sample NBPO (Cut-20 < 10), the only differences emerged
in the BPI identity scale (d = 0.12) and the IIP-Total (d = 0.11), with those
patients for whom data at discharge were missing scoring slightly lower
on the identity scale and slightly higher on the IIP. Thus, no substantial
differences in outcome measures were found between those patients
for whom data at discharge were available from those for whom these
data were missing. The sample for which data at both admission and
discharge are available seems to be representative of the total sample.
As a next step of analysis we tested whether the total score of the BPI
and the subscales for identity diffusion, primitive defense mechanisms
and object relations and reality testing showed significant changes be-
tween admission and discharge by t-tests for dependent measures. This
analysis was carried out separately for the samples BPO and NBPO.
 A DIMENTIONAL APPROACH TO PERSONALITY DISORDERS 191

Table 3. Outcomes in Personality Functioning, Symptom Distress,

and Interpersonal Problems
Patients scoring ≥ 10 in BPI-cutoff score (N = 1152)
Admission Discharge
Outcome Measures (M, SD) (M, SD) t d
BPI-Total 25.86 (6.29) 21.56 (8.66) 20.46*** 0.68
BPI Identity Diffusion Scale 7.33 (2.39) 5.89 (3.15) 17.85*** 0.60
BPI Primitive Defense Mechanisms 5.21 (1.66) 3.91 (2.21) 22.37*** 0.78
and Object Relations Scale
BPI Reality Testing Scale 0.90 (1.28) 0.77 (1.26) 4.02*** 0.10
SCL-90 GSI 1.75 (0.59) 1.18 (0.70) 32.22*** 0.97
IIP-Total 16.02 (3.45) 14.13 (4.29) 17.25*** 0.65
Patients scoring < 10 in BPI-cutoff score (N = 1444)
BPI-Total 12.16 (5.54) 10.31 (6.78) 13.01*** 0.33
BPI Identity Diffusion Scale 3.10 (2.06) 2.47 (2.33) 11.38 ***
0.31
BPI Primitive Defense 2.70 (1.71) 1.91 (1.87) 17.75*** 0.46
Mechanisms and Object
Relations Scale
BPI Reality Testing Scale 0.24 (0.64) 0.20 (0.61) 2.17 0.06
SCL-90 GSI 1.04 (0.53) 0.67 (0.53) 33.06 ***
0.77
IIP-Total 12.31 (4.05) 10.66 4.61 17.25*** 0.41
Note. ***p ≤ .0001

In the BPO sample (N = 1152) all BPI scales showed a significant im-
provement (Table 3). Pre-Post effect sizes were medium to large for the
BPI-total (d = 0.68), identity diffusion (0.60), primitive defense mecha-
nisms and object relations (0.78), and small for reality testing (0.10).
Significant improvements were also found in global symptom distress
(SCL-GSI) and interpersonal problems (IIP-total) with a large effect size
for the SCL-GSI (0.97) and a medium effect size for the IIP (0.56). At dis-
charge, 412 of 1,152 patients (36%) scored 9 or below in the BPI-Cutoff
(remission), that is about one third.
In the NBPO sample somewhat increased values in the BPI were
found as well, with, for example, a BPI-Total of 12.16 (Table 3)—thus,
some functional impairments seem to also exist in axis I patients com-
pared to normative data (Leichsenring, 1999): in a sample of the general
population, the mean BPI-Total was 10.54 (Leichsenring, 1999). The dif-
ference between the NBPO sample and the general population sample
is statistically significant (t = 3.15, p < 0.01), but the effect size is small
(d = 0.24). In the NBPO sample the BPI-Total, identity diffusion scale,
primitive defense mechanisms and object relations scale showed a sig-
nificant decrease as well after treatment in Tiefenbrunn. Only in the
192 LEICHSENRING ET AL.

reality testing scale no significant decrease (p = 0.03) was found after

adjusting for type I error inflation (0.05/4). Effect sizes were small (0.34,
0.32, 0.46, 0.04), with an almost medium effect size for improvements in
primitive defense mechanisms and object relations (0.46). For reduction
of symptom distress (GSI), however, effect sizes were (almost) large
(0.77) and small to medium for the reduction of interpersonal prob-
lems (0.41). Thus, symptom distress was reduced considerably in these
patients as well. The improvements showed no significant correlations
with either sex or age, neither in the BPO nor in the NBPO sample (p >
0.05).
Symptom distress at admission was significantly higher in the BPO
sample than in the NBPO sample (Table 3). This was true for interper-
sonal problems as well (Table 3). The differences between BPO and
NBPO patients correspond to large effect sizes (1.20 and 1.06). Thus,
patients with BPO showed considerably more symptom distress and
interpersonal problems than NBPO patients which is consistent with
the concept of borderline personality organization (Kernberg, 1975).

DISCUSSION

Impairments in personality functioning can be associated with severe

problems in everyday life including symptom distress, interpersonal
relationships, and working ability. Thus, the reduction of impaired per-
sonality function is of some importance, for both the individual and
society. In contrast to other characteristics of patients with mental dis-
orders, improvement in personality functioning is understudied.
In this study, a large sample of patients treated with inpatient psy-
chodynamic therapy was examined. In those patients for whom a bor-
derline personality organization was likely, the inpatient treatment
achieved substantial improvements in the overall level of personality
functioning (BPI-total) and specifically in identity integration, defense
mechanisms, and object relations. Following Kernberg (1984), the real-
ity testing scale of the BPI taps psychotic impairments of reality test-
ing (e.g., auditory hallucinations) and is used to discriminate patients
with a borderline personality organization from those with a psychotic
level of personality organization (Leichsenring, 1999). For this reason,
larger improvements in the reality scale are not to be expected in non-
psychotic patients. In addition to the structural improvements, a large
reduction in symptom distress was achieved (d = 0.97). Improvements
in interpersonal problems were substantial as well (d = 0.65). As expect-
 A DIMENTIONAL APPROACH TO PERSONALITY DISORDERS 193

ed, improvements in structural criteria of personality functioning in

patients for whom a borderline personality organization was unlikely
were small. Improvement in symptom distress, however, was substan-
tial in these patients as well (d = 0.75).
Thus, in both groups patients improved in those areas that are rel-
evant for them, patients with a presumptive BPO in personality func-
tioning, symptom distress, and interpersonal problems and patients
without a BPO primarily in symptom distress.
While it is true that BPI-51 scores were significantly and substantially
reduced in the BPO groups, a value of 21.56 at discharge was still high,
showing the need for further outpatient treatment. As a promising re-
sult, however, 412 of 1,152 participants (36%) showed a score of or be-
low 10 in the BPI-Cutoff at discharge (remission).
The present study shows both some strengths and limitations. It was
carried out under the conditions of clinical practice. Thus, not all fac-
tors possibly influencing the results can be controlled for to the same
degree as in a randomized controlled trial. Treatment integrity (Yea-
ton & Sechrest, 1981), for example, was not formally examined. In a
previous randomized controlled trial carried out at the Clinic of Tief-
enbrunn, therapists were shown to apply the techniques of psychoan-
alytic-interactional therapy to a high degree (Leichsenring et al., 2016).
On the other hand, it can be regarded as a strength that the study was
carried out under the conditions of clinical practice, yielding results
that are representative of both patients and treatments of clinical prac-
tice. Furthermore, with sample sizes of 1,152 and 1,444 patients, quite
large samples were included. As another limitation, no follow-up was
included. Finally, the exclusive reliance on a self-report measure for the
assessment of personality functioning might represent a drawback.
From a research perspective, the results provide further support to a
dimensional conceptualization and assessment of personality disorders
(American Psychiatric Asociation, 2013; Kernberg, 1981; Tyrer, Reed, &
Crawford, 2015; World Health Organization). The studies showed that
core features such as the level of identity integration, defense mecha-
nisms, and object relations cannot only be assessed empirically but are
also sensitive to change.
Future studies are recommended to also include observer-rated
measures of personality functioning such as the axis of personality
structure of the Operationalized Psychodynamic Diagnostics (OPD
Taskforce, 2008) or instruments based on the personality functioning
approach of DSM-5 or ICD-11 (American Psychiatric Asociation, 2013;
World Health Organization).
194 LEICHSENRING ET AL.

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Prof. Dr. Falk Leichsenring

Department of Psychosomatics and Psychotherapy
University of Giessen
Ludwigstrasse 76
35392 Giessen
Germany
[email protected]