International Journal of Psychiatry in Clinical Practice, 2009; 13(2): 153
165

ORIGINAL ARTICLE

Follow-up psychotherapy outcome of patients with dependent, avoidant and obsessive-compulsive personality disorders: A meta-analytic review

WITOLD SIMON Institute of Psychiatry and Neurology, Department of Neurotic Disorders and Psychotherapy, Warsaw, Poland, Brigham Young University, Department of Clinical Psychology, Provo, UT, USA

Abstract Assessing the number of patients who maintain their gains after the completion of therapy has been of interest to psychotherapy outcome researchers. The current study examines evidence related to the maintenance of treatment gains in individuals diagnosed with Cluster C personality disorders. Fifteen studies, published between 1982 and 2006, met the criteria for inclusion. The effect size standardized mean difference statistic was applied. In the majority of cases, most of the improvement occurred between pretreatment and posttreatment. However, social skills training often produced effect sizes that were larger for posttreatment follow-up. The study indicates that therapy gains are usually maintained at follow-up for Cluster C clients treated with cognitive-behavioral and psychodynamic approaches as well as social skills training. Uncertainty remains whether DPD, AVPD or OCPD patients benefited most from therapy.

Key Words: Psychotherapy, follow-up, cluster C, meta-analysis

Objectives Assessing the number of patients who maintain gains after the completion of treatment is an important aspect of patient psychotherapy outcomes [1]. Some researchers [2,3] go so far as to claim that measuring patients’ capacity to maintain improvement after therapy is terminated is an ethical requirement. Therefore, follow-up studies are of particular interest, especially for such hard to modify patterns as those common among personality disordered patients [4]. Avoidant AVPD, dependent DPD, and obsessivecompulsive OCPD personality disorders, which belong to Cluster C, are described as anxious or fearful personalities. Between 1.1 and 13.3% of the general population [5] is diagnosed with AVPD, 1.5 and 2.5% with DPD [3] and 1.7 and 2.2% with OCPD [3]. Cluster C PDs may be the most prevalent in the general population with estimates of 10% [6]. In the outpatient populations, Cluster C ranges between 48 and 82% [7]. Cluster C clients tend to respond particularly slowly to treatment and,

even after effective treatment, may still function below normative levels [8]. Some issues related to the treatment outcomes of Cluster C personality disordered patients have been addressed, e.g., change in OCPD and AVPD patients following time-limited supportive-expressive therapy [9], impact of Cluster C PDs on outcomes in late-life depression [10], and alliance and symptom change due to cognitive therapy for AVPD and OCPD clients [11]. Unfortunately, these findings are limited only to changes achieved at the end of treatment; no follow-up data were provided. However, given the chronic nature of Cluster C disorders, it is especially important to understand the longterm consequences of treatment, especially since the most studied treatments are brief skill building interventions [3]. This meta-analytic review addresses the following research questions: (1) Is there improvement, in terms of symptom severity, general social functioning and personality psychopathology, by the end of therapy, both focused and not focused on personality

Correspondence: Witold Simon, Brigham Young University, Clinical Psychology, 284 Taylor Building, P.O. Box 28626, Provo, UT 84602-8626, USA. Tel: 1 801 8306916. E-mail: [email protected]

(Received 8 May 2008; accepted 18 October 2008) ISSN 1365-1501 print/ISSN 1471-1788 online # 2009 Informa UK Ltd. DOI: 10.1080/13651500802570972

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W. Simon

functioning, for Cluster C patients? (2) Is there any evidence of follow-up improvement relative to the end of therapy in regard to symptoms, social functioning, or core personality psychopathology for Cluster C patients, or do treatment gains diminish during the follow-up period? (3) Does any type of Cluster C personality disorder benefit more from the treatment with reference to symptoms, social functioning and personality features, at the end of therapy or at followup, than other types of Cluster C disorders? (4) Is any therapeutic approach more efficacious at follow-up than others for patients with Cluster C? The above research questions cover a relatively broad spectrum of treatment outcomes, as well as diverse therapy styles. It is assumed that such an approach will enable readers to adequately capture the complexity of symptomatology of Cluster C individuals, as well as contribute to the conceptualization of treatments effectively tailored for those clients.

variables based on guidelines for meta-analysis [18,19], and for treatment of Cluster C personality disordered patients [20,21]. Each paper was coded by two independent coders, undergraduate students who received extensive training to increase reliability. Codes with unacceptably low inter-rater reliability were rewritten. To minimize the likelihood of rater bias, method sections of studies were coded separately from the effect sizes. Any possible interrater discrepancies were resolved by discussion. The inter-rater reliability coefficient was calculated by the author himself. Inter-rater agreement for categorical variables was Cohen’s k 0.52
1.00 across variables, mean k 0.85, and for continuous variables the intraclass correlation was r 0.88
1.00, mean 0.99. Percentage of agreement ranged from 70 to 100%, with a median of 95%, which with regard to k, represents an excellent agreement beyond chance. Effect size calculation

Methods Procedure The following databases were searched: PsycINFO, MEDLINE, and Dissertation Abstracts International. The criteria for inclusion were: Cluster C patients, follow-up psychotherapy outcome data. The subsequent key words were applied, in all possible dual combinations: Cluster C, AVPD, avoidant, OCPD, obsessive-compulsive, DPD, dependent, follow-up, catamnesis, after-treatment, long-term, psychotherapy, therapy, treatment, counseling. Studies published prior to DSM-III were not screened. The author located 35 studies where psychotherapy was administered to Cluster C patients. The reference sections of the studies were examined manually, and their authors were questioned about any relevant unpublished studies. No dissertations were found. The inclusion criteria were finally matched for 15 studies. Due to the limited number of studies, not only randomized but also nonrandomized studies were included in this meta-analytic review. Some clinically interesting studies were dismissed because they did not match the inclusion criteria, e.g., only two or three respondents were diagnosed with Cluster C [12,13]; pooled outcome for all clusters (e.g., Refs. [14
16]) or incomplete followup results were presented [17], and the authors, upon request, did not provide more specific data. Data coding The characteristics of identified studies (see Table I for details) were coded to facilitate classification of

The standardized mean difference statistic was used as the measure of effect size. Both unweighted and weighted effect sizes were computed by sample sizes, separately for randomized and nonrandomized studies, in order to yield unbiased estimators. General description of the studies The 15 studies [22
36] (see Tables II and III for details) were published between 1982 and 2006, in English language journals. All but two studies were conducted outside of the USA, with six studies from Norway, four from Canada, two from the UK and one from Holland. The huge diversity of research designs, treatment orientations, modalities, settings, and patient populations reveals, on one hand, the richness of clinical approaches. On the other hand, replications hardly ever occurred, and it certainly limits the generalizations. Eight randomized controlled trials address all four research questions, and seven non-randomized studies relate to the first two concerns. Four randomized studies researched the population of patients who exclusively met criteria for AVPD. Four other randomized trials investigated patients diagnosed with different Cluster C PDs. The nonrandomized samples often consisted of patients diagnosed with PDs from all three personality Clusters, or comorbid with Axis I disorders. Group treatment was dominant, with two-thirds of studies either using it alone or in combination with an individual modality. CBT was the most frequently applied orientation (ten times), followed by different forms of dynamic therapy (seven times). However,

Follow-up therapy outcome cluster c meta-analysis 155 Table I. Coded variables and the guidelines for the coders. Variable Biographic references Type of publication Coder Sample description Personality

Guidelines for the coders Last name of main author and the year, e.g. Fonagy 1998 1. Journal; 2. book or book chapter; 3. thesis or doctoral dissertation; 4. conference paper; 5. other Coder number: e.g., 1 Mean age of sample; female%; Caucasian%; other ethnic/racial group% (if
50% name the group was given); single%, divorced%, widowed%, separated% . % of patients with Cluster C PD in the whole study sample . %AVPD;% DPD;% OCPD . Diagnostic criteria (1. DSM-III; 2. DSM-III-R; 3. DSM-IV; 4. DSM-IV-R; 5. other)

Treatment description

Research design Control, comparison group

Effect size

. Modality (1. individual; 2. group; 3. group and individual mixed; 4. other) . Orientation (1. psychodynamic; 2. psychoanalysis or analysis; 3. cognitive-behavioral or cognitive therapy; 4. dialectic-behavioral; 5. eclectic; 6. social skill training; 7. other). Note: code multiple orientation if necessary . Setting (1. inpatient or hospitalization; 2. outpatient or day treatment or private practice; 3. mixed; 4. other) . Number of sessions (#). Note: code only real number of sessions, not the number from initial design . Follow-up (# months) . Follow-up conditions (1. with therapy; 2. without therapy; 3. mixed) . Assignment to treatment (1. random; 2. naturalistic; 3. other) . Assignment to control/comparison conditions (1. random; 2. naturalistic; 3. other) . Nature of control/comparison group during therapy period (1. waiting list; 2. receives nothing; 3. treatment as usual; 4. minimal contact; 5. attention placebo; 6. pharmacotherapy; 7. relaxation; 8. comparative treatment; 9. diagnosis other then Cluster C; 10. other type of control; 11. without control group) . Nature of control/comparison group during follow-up (the same coding as for therapy period) . Effect size type (1. pre/post comparison; 2. post/post comparison, treatment vs. control; 3. pre/follow-up comparison; 4. post/follow-up comparison; 5. follow-up/follow-up, treatment vs. control) . Effect size based on (1. means and SD; 2. t value; 3. F value ANOVA; 4. chi-square; 5. frequencies or dichotomous proportions; 6. frequencies or polychotomous proportions; 7. partial correlations, regression, path coefficients; 8. ANCOVA; 9. other; 10. combination) . Outcome measures

Data

Other

. Treatment group Mean, N, SD at the start of therapy, at the end of therapy and at the follow-up . Control/comparison group (the same as for the treatment group) . Effect size (d) final result clarifications of problematic coding issues.

No clear data: coded as: ‘‘999’’.

there really was no consensus treatment within the general rubric of CBT or psychodynamic treatments. The usage of medications was acknowledged in six studies but was probably more widespread. The most common follow-up was 6 or 12 months (range between 3 months and 12 years). During the follow-up period, some patients from five studies were participating in additional therapy or were even rehospitalized, as noted in two studies. Only two studies report no-treatment during the follow-up period, but it is unlikely that the patients in any of the studies were actually denied treatment. Measures Thirty-eight scales were used at the follow-up stage. Only three scales were used more than twice: Symptoms Checklist-90-Revised (SCL-90-R) [25
30,35,36], Inventory of Interpersonal Problems (IIP) [26
28,31,35,36], and Global Assessment of Functioning (GAF) [27,28,30,36]. Both at termina-

tion and at follow-up, GAF produced the highest d, followed by IIP and by SCL-90. This diversity reveals the complexity of applied operational definitions of outcomes. Diversity is often the norm across psychotherapy outcome studies, since many researchers develop a measure, most likely self report, just for one particular study [37].

Results Treatment orientations On average, Cluster C patients from all treatment conditions display significantly more improvement at the end of the treatment than control subjects (see Tables IV and V for details). The exception is noted for brief dynamic therapy, which shows no better results than the waiting list [24]. The follow-up results indicate that improvement continues after termination, regardless of the treatment orientation applied.

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Table II. Description of the psychotherapy follow-up outcome studies of Cluster C personality disordered patients: Part I. Other diagnosis than Cluster C PD, total N at the baseline

Randomized, comparative, three treatment conditions, waiting list control. Uncontrolled, naturalistic, no control group.

27.5

AVPD (n80), 100%

Millon Clinical Multiaxial Inventory, PDE, DSM-III

Not indicated

33.4 (19
56)

AVPD (n12), 27% (data were calculated only for AVPD), DPD 12%, OCPD 2
4%

SCID-II, DSM-III-R

Emmelkamp et al. 2006 [24]

Randomized, controlled, comparative, two treatment conditions, waiting list.

34.3 (8.9)

AVPD (n62), 21 in CBT, 23 in BDT, 18 in WLC

Gude and Vaglum 2001 [25] Hardy et al. 1995 [26]

37.0 (10.0)

Karterud et al. 2003 [27]

Prospective, naturalistic, no control group. Randomized, four treatment conditions, no control group. Naturalistic, no control group.

Personality Diagnostic Questionnaire-4 for DSM-IV, SCID-II for DSM-IV SCID II, DSM-III-R

n51 Primary: agoraphobia, panic disorder. Secondary: dysthymia, depression, GAD, social phobia. PDs: histrionic, BPD, passive, paranoid, narcissistic. Not indicated

34 (9)

Lorentzen et al. 2002 [28]

Naturalistic, no control group.

35.1 (8.3)

Mehlum et al. 1991 [29]

Prospective, no control group.

35 (9)
for the whole sample

Pure C (n251), comorbid C (n 138) n27, 24% (all PDE. DSM-III-R comorbid with depression) AVPD n206, subjects before 1996: OCPD n 34, DPD n32, SCID-II for DSM-III, others: DSM-IV AVPD n9, DPD n 2, DSM-III R, OCPD n 4, Passive-Aggressive n 2 n17 SCID, DSM-III-R

Narud et al. 2005 [30]

Naturalistic, prospective, comparative.

35.4 (10.2)

n42

Not specified

n20

35
total sample

Alden 1989 [22]

Chambless et al. 2000 [23]

Design
during therapy period

Rosenthal et al. 1999 [31]

Randomized, prospective, no control group. Seivewright et al. 2002 [32] Prospective, randomized, comparative. Stravynski et al. 1982 [33] Randomized, controlled, two treatment conditions. Stravynski et al. 1994 [34]

Randomized, controlled, two treatment conditions.

40.25 (9.5)

34 (22
56) ISSTCM, 31 (23
57) ISST 32 (18
55) in clinic; 31 (18
59) in vivo

Cluster A n 21, Cluster B n 67 Main diagnosis: depression n87, 76% NoPD. n1244 mood disorders, anxiety, substance related disorder n69 Axis I: affective, anxiety disorder. Axis II: A, B, mixed. n97 Axis I: dysthymia, panic, agoraphobia, depression, GAD, alcohol dependency, social phobia, OCD. Cluster AB n46, Axis I n24

PDE, International Neuropsychiatric Interview, DSM-IV SCID, DSM-III-R

Not indicated

OCPD n 9, AVPD n 8, DPD n 7. AVPD n22

SCID, DSM-III

n202 AB

DSM-III

AVPD n31

DSM-III

Social phobia, adjustment disorder (all comorbid with AVPD) Not indicated

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Mean age, (SD or range) Cluster C diagnosis, N and for Cluster C % of the sample (at the Intake diagnostic criteria baseline)

Study

Wilberg et al. 1999 [36]

In some cases [28,36] data for Cluster C PDs were obtained from personal communication. AVPD, avoidant personality disorder; DPD, dependent personality disorder; OCPD, obsessive-compulsive personality disorder; BPD, borderline personality disorder; NOS, personality disorder not otherwise specified; NoPD, no personality disorder; OCD, obsessive-compulsive disorder; GAD, general anxiety disorder; ISST, interpersonal social skill training; CM, cognitive modification; PDE, Personality Disorder Examination; SCID, Structured Clinical Interview.

Total n47, single PD: AVPD n 18, DPD n 1, Passive-Aggressive n1. Two PD: n 6. Comorbid with B or A: n21 32.7 (8.0) (20
50)

Longitudinal Expert All Data DSM-III-R and DSM-IV, SCID for DSM-III-R

Most common: GAD, major depression. (all comorbid with Cluster C) n 183 BDP, NOS, Paranoid PD. Axis I: mood disorder, anxiety, eating disorder, substance. SCID-II, DSM-III-R n 50 33.4 (9.7)
dynamic, 34.6 (7.9)
cognitive

Randomized, no control group, comparative, two treatment conditions. Prospective, naturalistic, no control group. Svartberg et al. 2004 [35]

Study

Table II (Continued)

Design
during therapy period

Mean age, (SD or range) Cluster C diagnosis, N and for Cluster C % of the sample (at the Intake diagnostic criteria baseline)

Other diagnosis than Cluster C PD, total N at the baseline

Follow-up therapy outcome cluster c meta-analysis 157 The interpersonal social skills training (ISST) is found to be significantly effective for Cluster C patients [22,33,34], and is superior to intimacy focus and to gradual exposure conditions at the 3month follow-up [22]. ISST combined with cognitive modification does not improve its treatment outcomes at the end of therapy; however, the outcome is significantly enhanced at the 6-month follow-up, when compared to ISST alone [33]. Also, at the end of treatment, ISST produces better outcomes when administered simultaneously in the clinic and in real life, than ISST applied solely in the clinic, even though improvements in both approaches are significant [34]. There is no consistent evidence favoring CBT or psychodynamic therapy for Cluster C patients [24,26,35]. Some findings indicate that patients who received CBT improve, on average, significantly more than those who receive brief dynamic psychotherapy [24]. Other studies reveal contradictory results while comparing CBT with psychodynamicinterpersonal therapy [26] or cognitive therapy with short-term dynamic therapy [35]. Follow-up results are not consistent whether CBT patients maintain more gains than those with psychodynamic experience. On one hand, at the 6month follow-up, CBT is found to be significantly superior to BDT [24], and more effective than PI at the 12-month follow-up [26]. On the other hand, STDT maintains more gains at 6 months, and 1 and 2 years after the end of the therapy [35]. Different diagnoses The results, with regards to the differential outcomes of the Cluster C disorders, (see Tables IV and V for details) are inconsistent. For example, Chambless et al.’s [23] report indicates that AVPD clients improved more than clients with generalized anxiety disorder (GAD) on the Avoidance Alone scale (AAL); however, with results measured by Behavioral Avoidance Test, they perform worse than GAD individuals. At follow-up, AVPD clients improve less on AAL than other clients. Some findings suggest that patients diagnosed with Cluster C, both at the end of the treatment and at follow-up, benefit significantly from psychotherapy [28]. Yet, it appears that they score lower on most of the measures than do clients without Cluster C psychopathology at the end of treatment and at the 12-month follow-up [26]. In addition, there is no consistency as to whether AVPD, DPD or OCPD patients benefit more from therapy. One trial [32] indicates that DPD clients maintains more gains 12 years after the end of treatment than AVPD and OCPD individuals. The

158

Table III. Description of the psychotherapy follow-up outcome studies of Cluster C personality disordered patients: Part II. Modality

Orientation

Setting

Duration

Follow-up

Follow-up conditions

Attrition

Alden 1989 [22]

Group

Outpatient, university clinic

10 weeks, weekly sessions, 2
2.5 h each

3 months

Not specified

5% during treatment, not specified for follow-up

Chambless et al. 2000 [23]

Group, individual

Cognitive-behavioral graduate exposure, interpersonal skills training, intimacy focus Behavioral (exposure in vivo, anxiety management training, relaxation, mindfulness); cognitive (integrative model) Cognitive-behavioral (collaborative interactions, Socratic dialogue, monitoring of beliefs), brief dynamic (therapeutic alliance, directed at defense and affect restructuring) Psychodynamic, cognitive, medications

Outpatient, center for: agoraphobia and anxiety

7
10 days (8 h daily)

6 months

Individual therapy 0% n37, exposure therapy n9, anxiolytics n 10

Emmelkamp et al. 2006 Individual [24]

Gude and Vaglum 2001 Group, [25] individual

Hardy 1995 [26]

Individual

Karterud et al. 2003 [27]

Group

Lorentzen et al. 2002 [28]

Group

Mehlum et al. 1991 [29]

Group, individual

Outpatient, community 6 months (20 weekly 6 months mental health center sessions), each session 45 minutes once a week

No treatment

Start-end: 9.68%, n6; end-foll: 14.29%, n8

Inpatient

3 months (10
221 12
15 months days)
group 3 times a week, individual once a week 8 or 16 sessions 3 months, 12 months

41% a new treatment, 38.5% on medications

0%

Not specified

Start n 27, end n27, foll n 24

PD25% during treatment, not specified for followup 29.41% (start-foll), start n17, end n 17, foll n 12 5,88%, n 1 start n17 end n17 foll n16

CBT (anxiety controlling, self-management, cognitive reconstructing, job-strain), vs. psychodynamic-interpersonal therapy (relationship oriented, conversational model), medications Mixture of psychodynamic and CBT, antidepressants

Outpatient, research clinic

Eight different units of day treatment, outside university setting

18 weeks, 2 units 41 weeks, (8
16.6 h/per week)

12 months

46%, outpatient group psychotherapy, 59%, medications

Analytic psychotherapy, with the focus on intrapsychic and interp ersonal events Psychodynamic, in addition art therapy and body awareness therapy

Outpatients, private practice

32.5 (SD 20) months, weekly sessions: each 1.5 h

12 months

Medication sporadically n2, medication regularly n 5

Day unit, specializing in PD

Average 5.5 months, session 5 days a week

Average 3 years, mean Rehospitalization 2.8 years, range 1.6
4.9 18.8%, medications 46.6%.

W. Simon

Study

Table III (Continued) Study

Modality

Orientation

Setting

Duration

Follow-up

Follow-up conditions

Narud et al. 2005 [30]

Majority: individual, some: group

Supportive psychodynamic therapy, antidepressants

Outpatient, clinic

24 months

Individual therapy 92%, 41.46% drug therapy 26%

Rosenthal et al. 1999 [31]

Individual

Outpatient, research center

6 months

Not specified

Seivewright et al. 2002 [32] Stravynski et al. 1982 [33]

Not specified Group, individual

12 years

Outpatient, university hospital

10 weeks, 5 one h sessions 12 weeks, each session 90 minutes

75% continued the same 9%, n 20 treatment One booster session 9,09%, n2

Stravynski et al. 1994 [34]

Group

Outpatient, research center

14.5 h in total
session 3 month; 6 months a week for 8 weeks

One session monthly

start-end 9.68%, n 3; end-foll: 35.71%, n 10

Svartberg et al. 2004 [35]

Individual

Brief supportive psychotherapy (conversational dyadic treatment). CBT, self help groups, medications Social skill training (instruction, modeling, role-rehearsal, feedback, self-monitoring), cognitive modification Social skill training (instruction, modeling, role-rehearsal, feedback, self-monitoring-in vivo or in the clinic), behavioral therapy Short-term dynamic (confronts defenses, exposes underlying affect, regulates anxiety) cognitive (evaluates negative automatic thoughts, trusting relationship, schema reconstructing techniques), medications
for minority of subjects Analytically oriented and cognitive-behavioral
part of comprehensive group therapy program

4
36 months, median 18 months, mean 17.796.7 months. One session a week 40 weeks, once a week,

Ordinary outpatient settings

40 weekly sessions

6, 12, 24 months

Psychotherapy n2; antidepressants n 1

start n 50, end n 50, foll6 n 46, foll12 n 46, foll24 n 44, end-foll6 8%, n 4; end-foll12 8%, n-4; end-foll24 12%, n 6

Day treatment

18 weeks,

12 months

Not specified.

0%, cluster C

6 months,

40%, n8

Some data for Cluster C PDs were obtained from personal communication [36].Start, beginning of the therapy; end, termination of the therapy; foll, follow-up of the therapy; start-end, period between the beginning and the termination; end-follow, period between the termination and follow-up; start-foll, period between the beginning and follow-up; foll6, foll12, foll24, follow-up investigation at 6, 12 and 24 months, respectively.

Follow-up therapy outcome cluster c meta-analysis 159

Wilberg et al. 1999 [36] Group

Not specified

Attrition

160

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Table IV. Effect sizes in randomized studies. Controlled (vs. untreated clients)

Study

Experiential treatment

Controlled condition

Alden 1989 [22]

GE, ISST, IF

WLC

Emmelkamp et al. 2006 [24]

CBT, BDT

WLC

Study

Experiential treatment PI; CBT

Hardy et al. 1995 [26]

Not specified

NoPD

ISST ISSTCM

Between conditions Between conditions

Svartberg et al. 2004 [35]

STD CBT

Study Rosenthal et al. 1999 [31]

Brief supportive psychotherapy

Start-foll

GE
0.29 ISST GE
0.43
0.14 IF
0.54 ISST
0.24 IF
0.49 CBT 1.41 BDT Data not available 0.97

Comparative (vs. other treatments or other diagnosis) Comparative Start-end Start-foll condition NCPD PI 0.81, 3m: PI 0.53, CBT 0.65 CBT 0.32; 12 m: PI 0.36, CBT 0.43

Seivewright et al. 2002 [32] Stravynski et al. 1982 [33] Stravynski et al. 1994 [34]

Clinic Clinicin vivo

Start-end

Between conditions

No post data available 0.68 ISST, 0.65 ISSTCM 3.84 Clinic, 4.62 Clinicin vivo 0.69 STD, 0.66 CBT

Naturalistic Start-end No comparative 2.39 condition

AVPD 1.42, OCPD 0.32, DPD 2.26 0.66 ISST, 1.56 ISSTCM 4.57 Clinic, 3.50 Clinicin vivo

End-foll GE
0.14 ISST
0.07 IF 0.02 Only few data available: BDT in PDBQ 0.93 End-foll 3 m: PI 0.05, CBT 0.06; 12 m: PI
0.12, CBT 0.02 No post data available 0.08 ISST, 0.52 ISSTCM
0.17 Clinic,
1.17 Clinicin vivo

6 m: 0.92 STD 0.65 CBT 12 m: 0.97 STD 0.93 CBT 24 m: 0.97 STD 0.91 CBT

6 m: 0.26 STD
0.03 CBT 12 m: 0.33 STD 0.21 CBT 24 m: 0.34 STD 0.31 CBT

Start-foll 1.40

End-foll No data available

GE, gradual exposure; ISST, interpersonal social skill training; IF, intimacy focus; CBT, cognitive-behavioral therapy; BDT, brief dynamic therapy; WLC, waiting list control; CM, cognitive modification; PI, psychodynamic-interpersonal therapy; STD, short-term dynamic therapy; PDBQ, Personality Disorder Belief Questionnaire; NoPD, no personality disorder; NCPD, no Cluster C personality disorder; start-end, period between the beginning and the termination; end-foll, period between the termination and follow-up; start-foll, period between the beginning and follow-up.

other study [27] suggests, however, that AVPD clients do better than OCPD and DPD clients with results measured on the SCL-90. Yet, with results measured by GAF, OCPD individuals obtain the highest d. There is some ambiguity with comparisons between Clusters A, B, and C treatment outcomes. Analyzed studies [25,29,36] indicate that Cluster C individuals, on most of the measures, have superior treatment outcomes when compared to Cluster A and B patients. However, the follow-up comparisons between Clusters are much more ambiguous. Some studies [29,30] indicate that Cluster C patients show more improvement than Cluster A or B clients, while other reports [25,36] support the notion that Cluster C patients perform significantly worse than Cluster B and Cluster A ones.

Comparing treatment and follow-up outcomes In most of the studies, clients continue to improve significantly after termination of therapy, with the majority of observed improvements occurring between pretreatment and posttreatment. However, the effect size is sometimes higher for the follow-up period for some specific measures, e.g., of ISST patients on the Structured and Scaled Interview to Assess Maladjustment dependence on the family subscale [33]. Extended follow-up More improvement occurs during extended followups, e.g., continuous improvement is noted between 3- and 12-month follow-ups [26], or between 6-, 12and 24-month follow-ups, for both dynamic and

Follow-up therapy outcome cluster c meta-analysis 161 Table V. Effect sizes in nonrandomized studies Comparative (vs. other treatments or other diagnosis)

Study Gude and Vaglum 2001 [25] Narud et al. 2005 [30]

Experiential treatment

Comparative condition

Pure C, 1Comorbid C, Total C Cluster C

Cluster A, Cluster B

Study Chambless et al. 2000 [23]

AVPD

Karterud et al. 2003 [27]

AVPD OCPD DPD

Lorentzen et al. 2002 [28] Mehlum et al. 1991 [29] Wilberg et al. 1999 [36]

Cluster C

AB Axis I

GAD, dysthymia, depression, no comorbid PPD, BPD, NOS

Start-end

Start-foll

End-foll

Pure C 0.98, Comorbid C 0.83, Total C 0.91 No end data available

Pure C 0.66, Comorbid C 0.82, Total C 0.72 0.07

Pure C -0.24, Comorbid C 0.02, Total C
0.13 No end data available

Start-foll 0.96

End-foll 0.21

AVPD
0.33, OCPD
0.01, DPD
0.15 0.11

AVPD
0.17, OCPD
0.12, DPD
0.30 0.11

0.15

0.14

AVPD
0.30, 2C
0.07, comorbid AB 0.00

AVPD
0.17, 2 C
0.31, comorbid AB
0.02

Naturalistic Start-end 0.79

AVPD
0.26, OCPD
0.30, DPD 0.06 0.43

Cluster C

No comparative group BPD, STPD, NoPD 0.31

AVPD, 2 C, comorbid AB

No comparative group

AVPD
0.12, 2C 0.00, comorbid AB 0.03

2C, two types of Cluster C personality disorders; AB, Cluster A and B personality disorders; GAD, general anxiety disorders; AVPD, avoidant personality disorder; DPD, dependent personality disorder; OCPD, obsessive-compulsive personality disorder; NOS, personality disorder not otherwise specified; PPD, paranoid personality disorder; BPD, borderline personality disorder; STPD, schizotypal personality disorder; NoPD, no personality disorder; start-end, period between the beginning and the termination; end-follow, period between the termination and follow-up; start-foll, period between the beginning and follow-up.

cognitive therapy, with the highest d obtained for the period between 12 and 24 months [35]. The effect size of randomized trials is larger, than the effect size for nonrandomized studies. Those effect sizes are weighted in order to avoid the overestimation of treatment effects. The weighted effect sizes across randomized studies are 0.82 for therapy duration and 0.13 for the follow-up period, and for nonrandomized studies 0.30 for therapy and 0.31 for follow-up. Conclusions Due to the limited number of studies which meet even liberal inclusion criteria, this meta-analysis cannot meet the highest of standards [38] and is not restricted only to studies that directly compare different treatments within the same study, using the same measurements, and controlling for treatment duration and other methodological features. Therefore, the available evidence is relatively limited in respect to separate questions. Moreover, the existing studies often produce contradictory results, making it difficult to draw general conclusions about the amount and durability of patient improvements, major ingredients of particular therapy orientations,

or details of treatment processes. Yet, some interesting findings and observations are noted. The improvement at the end of the psychotherapy The obtained effect sizes indicate that the investigated treatments applied for Cluster C individuals are effective, but only to a certain extent in most of the cases. Using Cohen’s classification of d effect sizes as large (above 0.80), medium (between 0.50 and 0.79) or small (below 0.49) the overall effect sizes obtained at the end of the treatments range from small to large. The effect sizes indicate, with regard to percent of patients who are better off, that the success rate of the treated persons is 0.69 for randomized and 0.57 for nonrandomized studies. Effect sizes obtained from the studies, but not included in this meta-analysis due to lack of followup data, are large in general [9,11]. The improvement between the end of psychotherapy and follow-up In general, treatment effects are maintained across all of the studies after the termination of therapy. In some instances, the gains even deepen after therapy; however, most of the time, the improvements are minor.

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In a majority of the studies, most of the improvements occur during therapy. In this regard, the pattern of change in Cluster C patients is similar to that of many other diagnostic groups [1,2]. This suggests that participation in the various treatments provides lasting benefit, rather than temporary relief of symptoms. It remains unclear, whether these findings are related to the specific interventions or to the specific properties of measures used in the studies. Within the psychotherapy explanations, Alden [22] claims that clients indicate meeting and talking with others who had similar problems is the most helpful factor in reducing their social isolation. This seems to be particularly relevant because AVPD patients often report that they feel different from others. In addition, it is not uncommon for patients receiving social skills training to continue to make gains during follow-up. Mersch et al.’s [39] study suggests that the skills learned may be directly responsible for continued gains. This may occur as a result of clients’ increased activity, motivational factor related to the satisfaction of mastering new coping skills [40]. Extended follow-up The findings suggest that longer follow-ups may capture data supporting the conjectures that therapeutic gains are maintained for a longer period of time than previously expected. Yet, only two studies [26,35] examine the issue of different follow-up durations. Gradual and consistent improvement is detected on most of the measures. It seems that gains in terms of interpersonal functioning and symptoms reduction are maintained for a relatively long time, even 1 or 2 years after termination. Future research should emphasize extension of the length of follow-up investigation beyond a 1-year standard, as already suggested by Lambert and Ogles [1]. Follow-up periods, perhaps in the neighborhood of 2
5 years, would enable therapists and researchers to more precisely capture the long-term dynamics of treatment gains. Different diagnoses The literature supports the notion that OCPD patients tend to improve more than any other Cluster C PDs [9]. Effect sizes obtained in this meta-analysis sometimes favor DPD patients [32], other times AVPD ones [27]. Importantly, in most of the studies, the AVPD patients do not fulfill DSM-IV criteria for AVPD [24] or for Cluster C [35] at the end of treatment. However, they are usually still below the normative means on various outcome measures [22]. Nevertheless, in spite of the fact that different authors have drawn different

conclusions, it seems that AVPD, DPD and OCPD clients are making significant progress during therapy and in most cases also during the posttreatment period. However, the extent and durability of this change in comparison to clients with other diagnoses is debatable, which may be due to the comorbidity issue, personality disorders overlapping symptomatology, as well as possible diagnostic imprecision. DPD patients most likely benefit more than AVPD and OCPD ones. Studies which favor DPD clients have more rigorous, randomized, and controlled research designs, and they obtain higher effect sizes. The existing body of literature supports, in general, the assumption that Cluster C patients benefit more from therapy than Cluster B ones [3]. Yet, other studies show that AVPD is found to be extremely persistent [8]. Although most of the researchers maintain rigorous diagnostic criteria, determining the exact nature of Cluster C patients is difficult due to frequent comorbid disorders: depression, substance abuse, and anxiety disorders. The other difficulty stems from the fact that PD symptom status may change more than once during the follow-up period [41]. Taking the above concerns into consideration, the effect sizes obtained in this meta-analysis indicate that Cluster C patients benefit more from therapy than Cluster A or Cluster B individuals, but less than patients without personality disorder symptomatology. Treatment orientations The therapies offered to patients vary from different forms of behavior and cognitive-behavioral approaches to all sorts of psychodynamic therapy. Unfortunately Cluster C researchers have neglected other treatment orientations. The treatment effect sizes obtained in this meta-analysis do not seem to vary consistently as a function of orientation, and results do not lead to a definitive conclusion about which treatment, CBT or psychodynamic, is the most effective approach for Cluster C patients. Some of the results might also be clouded by possible researcher’s therapy allegiance effect [42]. Studies not included in this meta-analysis indicate that cognitive-behavioral or psychodynamic psychotherapies are proven to be equally efficacious with respect to reducing personality pathology [43]. Limitations The generalizations of the findings driven from this meta-analysis are limited in a number of ways, allowing the conclusions to be only speculative. The major diagnostic limitation relates to the notion that

Follow-up therapy outcome cluster c meta-analysis 163 the DSM-IV cluster system for organizing PDs has limited validity [3], and that, among the clusters, Cluster C appears to be the least homogeneous [44]. However, the choice of this group as an organizing framework for this meta-analysis is based on the fact that all the included studies organize participants in this way. The statistical power is sometimes too weak for detecting interaction effects due to a small number of patients. Also, PDs from other Clusters are seldom assessed, although it is likely that some clients would have obtained more than one of these diagnoses. The influences of important life events, as well as any additional therapies that may have occurred between the end of therapy and follow-up are not statistically controlled. Different lengths of follow-ups across studies also limit the generalizations. Therapists were often experienced, full-time clinicians and were receiving manually guided supervision, e.g., [28,35], or were trained specifically for a particular project, e.g., [22,24]. Therefore, it may be assumed that a particular therapy frequently was far from treatment as usual. It raises the question as to what extent the findings may be generalized for ordinary therapists in their daily practices. Some authors [45] claim that professional training does not enhance the therapy outcome, while others [46] suggest that it is beneficial, at least with regard to lowering dropout rates. Another limitation is related to the batteries of measures including mostly clients’ reports of social behavior. Relying only on a self-report questionnaire has been questioned because of clients’ tendency to augment or deny behaviors [37]. Also, a major concern relates to the power of univariate comparisons to detect differences, which can be limited by the size of the smallest sample, the number of comparison groups, and the nature of the dependent measure [38]. Yet another important limitation is related to research design. In every case, the initial randomization was lost during the follow-up period, most likely due to ethical issues involved in withholding treatment for patients assigned to the waiting list. It made it harder to attribute any group differences to treatment allocation. Therefore, the effect sizes obtained may relate to uncontrolled studies usually having a larger d than controlled studies. The same phenomenon applies also for analog populations, which produce larger effect sizes than clinical groups [3]. Last but not least, all the driven conclusions should be treated with caution, since a relatively small number of studies was found to be appropriate in order to address, at least to some degree, the research questions.

Directions for future research Taking into account the frequency of Cluster C personality disorders, and the suffering related to them, more studies on the effectiveness of psychotherapy for Cluster C patients are still needed. For instance, we still do not know enough about how long the changes last, or which ingredients of psychotherapy contribute most to positive and negative outcomes. First and foremost, the research design of such studies can be more rigorous: more respondents, also from ordinary therapists, need to be included, which should enhance the power analysis. The standardization of assessment methods, consisting of both observer-rated measures and self-reports, will make it possible to generalize the findings and draw more definitive conclusions. Studies assessing the effectiveness of psychotherapy for such persistent conditions as Cluster C, should investigate long follow-up periods. The most desirable length is still a matter of discussion, but it seems that even a 1-year follow-up period may not capture the complexity of the symptomatic and interpersonal dynamics, which happen after termination. Obtaining data on the patients who did not participate in follow-up examinations is important, since other reviews have suggested that gains are maintained at follow-up, but only for those patients who submitted their data at follow-up [47]. Future researchers also need to address the issue of validity for specific techniques which claim to be tailored for a specific personality disorder. A detailed description of intervention methods should therefore be included in each study. Otherwise, vagueness will raise serious interpretive concerns and most likely will severely limit therapists’ ability to implement the same treatment, whether CBT or a psychodynamic format, to other clients. The lack of Cluster C therapy outcome studies of other therapeutic orientations, e.g. client-centered, systemic, multimodal, or integrative approaches is a significant loss to the field. Although dynamic and cognitive-behavioral psychotherapies, as well as interpersonal social skill training, were found to be effective treatments for Cluster C individuals, there is not enough data to examine whether any specificity can be attributed to these orientations. Practitioners are left to assume that, clinically, they are equally effective, in spite of different effect sizes. This meta-analytic review addresses important and understudied issues related to long-term effects of different types of psychotherapy for a difficult to treat patient population. Hopefully, in spite of existing limitations, the above remarks may relevantly facilitate the future studies on psychotherapy

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of Cluster C individuals, as well as help clinicians in their daily practices.

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Key points . Fifteen studies meet inclusion criteria for the meta-analytic review of follow-up psychotherapy outcomes in Cluster C personality disordered individuals . In the majority of cases, most of the improvement occurs between pretreatment and posttreatment, and often during the follow-up period, although to a lesser extent . Cognitive-behavioral and psychodynamic approaches, along with social skills training, are found to be generally beneficial for Cluster C patients . Ambiguity remains whether DPD, AVPD or OCPD patients benefit more from the therapy.

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Acknowledgements The Fulbright Senior Grant supported this project. The author thanks Michael J. Lambert for reviewing previous versions of this paper. The author appreciates also work of the coders: Christopher Miller, Jason Southwick and Katharina Schneiber. Statement of interest

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The author has no conflict of interest with any commercial or other associations in connection with the submitted article.

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