Neuroimaging studies of depression have demonstrated treatment-specific changes involving the limbic system and regulatory regions in the prefrontal cortex. While these studies have examined the effect of short-term, interpersonal or cognitive-behavioural psychotherapy, the effect of long-term, psychodynamic intervention has never been assessed. Here, we investigated recurrently depressed (DSM-IV) unmedicated outpatients (N = 16) and control participants matched for sex, age, and education (N = 17) before and after 15 months of psychodynamic psychotherapy. Participants were scanned at two time points, during which presentations of attachment-related scenes with neutral descriptions alternated with descriptions containing personal core sentences previously extracted from an attachment interview. Outcome measure was the interaction of the signal difference between personal and neutral presentations with group and time, and its association with symptom improvement during therapy. Signal associated with processing personalized attachment material varied in patients from baseline to endpoint, but not in healthy controls. Patients showed a higher activation in the left anterior hippocampus/amygdala, subgenual cingulate, and medial prefrontal cortex before treatment and a reduction in these areas after 15 months. This reduction was associated with improvement in depressiveness specifically, and in the medial prefrontal cortex with symptom improvement more generally. This is the first study documenting neurobiological changes in circuits implicated in emotional reactivity and control after long-term psychodynamic psychotherapy.

Mentalization has been proposed as a key concept in understanding therapeutic change in patients with Borderline Personality Disorder (BPD). However, little is known about mentalization in chronic depression. This study investigated the role of mentalization in the long-term psychoanalytic treatment of chronic depression. Mentalization measured with the Reflective Functioning Scale (RFS) was examined in patients with chronic depression (n = 20) in long-term psychoanalytic treatment and compared to healthy controls (n = 20). Results show that global RF scores did not differ significantly between patients and controls. However, depressed patients tended to have lower RF scores concerning issues of loss. Furthermore, RF was unrelated to symptoms and distress as assessed by the Beck Depression Inventory (BDI) and the SCL-90. RF did not predict therapeutic outcome as measured with the BDI but predicted changes in general distress after 8 months of psychoanalytic treatment as measured by the SCL-90. Moreover, correlations between RF and the Helping Alliance Questionnaire indicated that patients with higher RF were able to establish a therapeutic alliance more easily compared to patients with low RF.

Borderline personality disorder is associated with deficits in personality functioning and mentalisation. In a randomised controlled trial 104 people with borderline personality disorder received either transference-focused psychotherapy (TFP) or treatment by experienced community therapists. Among other outcome variables, mentalisation was assessed by means of the Reflective Functioning Scale (RF Scale). Findings revealed only significant improvements in reflective function in the TFP group within 1 year of treatment. The between-group effect was of medium size (d = 0.45). Improvements in reflective function were significantly correlated with improvements in personality organisation.

The Reflective Functioning Scale (RFS) was developed to assess individual differences in the ability to mentalize attachment relationships. The RFS assesses mentalization from transcripts of the Adult Attachment Interview (AAI). A global score is given by trained coders on an 11-point scale ranging from antireflective to exceptionally reflective. Coding procedures rely on a distinction of demand and permit questions during the AAI. Demand questions directly probe for reflective functioning (RF), whereas permit questions do not. Coding focuses on detecting qualitative markers of RF and qualitative markers of absent RF, respectively. Despite its relevant empirical contributions in clinical research, several psychometric properties of the RFS are still unclear. In this article, we present data on the reliability and internal structure of the RFS based on a combined sample of 196 subjects. We were able to show that (a) the global score can be assessed with good interrater reliability, is relatively stable across time, and is significantly reduced in persons with mental disorders; (b) demand questions are based on a single latent factor; (c) demand questions do not differ in terms of difficulty; (d) all demand questions but 1 are incrementally predictive of the global score; (e) 5 permit questions contribute to the global score over and above demand questions; and (f) the number of qualitative markers of RF is also predictive of the global score. Our results have important conceptual and methodological implications for future studies using the RFS.

Personality disorders (PD) are common and burdensome mental disorders. The treatment of individuals with PD represents one of the more challenging areas in the field of mental health and health care providers need evidencebased recommendations to best support patients with PDs. Clinical guidelines serve this purpose and are formulated by expert consensus and/or systematic reviews of the current evidence. In this review, European guidelines for the treatment of PDs are summarized and evaluated. To date, eight countries in Europe have developed and published guidelines that differ in quality with regard to recency and completeness, transparency of methods, combination of expert knowledge with empirical data, and patient/service user involvement. Five of the guidelines are about Borderline personality disorder (BPD), one is about antisocial personality disorder and three concern PD in general. After evaluating the methodological quality of the nine European guidelines from eight countries, results in the domains of diagnosis, psychotherapy and pharmacological treatment of PD are discussed. Our comparison of guidelines reveals important contradictions between recommendations in relation to diagnosis, length and setting of treatment, as well as the use of pharmacological treatment. All the guidelines recommend psychotherapy as the treatment of first choice. Future guidelines should rigorously follow internationally accepted methodology and should more systematically include the views of patients and users.