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J Psychother Pract Res 7:23-34, January 1998
© 1998 American Psychiatric Press, Inc.

Regular Article

Symptoms and Character Traits in Patients Selected for Long-term Psychodynamic Psychotherapy

Alexander Wilczek, M.D., Robert M. Weinryb, M.D., PH.D., Petter J. Gustavsson, PH.D., Jacques P. Barber, PH.D., Johan Schubert, M.D., PH.D. and Marie ÅSBERG, M.D., PH.D.

Received April 18, 1996; revised March 27, 1997; accepted April 1, 1997. From the Department of Clinical Neuroscience, Psychiatry Section, and Department of Psychotherapy, Karolinska Institute, Stockholm, Sweden; and the Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania. Address correspondence to Dr. Wilczek, Bastugatan 19, S-118 25 Stockholm, Sweden; e-mail: alexander.wilczek{at}pi.ki.se


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
In this naturalistic study of 55 outpatients selected for long-term psychodynamic psychotherapy, two Swedish assessment instruments are presented (the Karolinska Psychodynamic Profile and the Karolinska Scales of Personality), and the significance of psychodynamic criteria for the selection of patients is discussed. Thirty patients (55%) fulfilled criteria for a DSM-III-R diagnosis. The most prominent psychodynamically defined character pathology was found in the areas of coping with aggressive affects; dependency and separation; frustration tolerance; and impulse control. Some psychodynamically defined character traits, particularly poor frustration tolerance, were related to symptomatic suffering.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
In current psychotherapy research, investigators tend to use experimental or quasi-experimental designs to control factors of interest, resulting in a relative lack of naturalistic studies. Controlled studies, however, do not allow us to investigate how patients are selected for psychotherapy in clinical practice in general and for psychodynamic psychotherapy in particular.

In addition to psychological suffering, the traditional selection criteria for psychoanalysis and psychodynamic psychotherapy have been a high general level of functioning, good ego strength, good reality testing, good capacity to regress in the service of the ego, good object relations in the outer world, and stable object constancy in the inner world. Moreover, suitable patients should be curious about their inner life, be able to tolerate a high degree of frustration, and show "psychological mindedness."1 Although these criteria have been revised and expanded by several authors, e.g., Kernberg,2 in Sweden and probably in many other Western countries, they still remain generally accepted guidelines in clinical practice for the diagnosis and selection of patients suitable for both short-term and long-term psychodynamic psychotherapy.

Instruments have been developed to study several aspects of these dynamic diagnostic criteria, including defense mechanisms,3 ego strength,4 object relations,5 and overall psychological health.6 Nevertheless, phenomenological diagnosis, today most often the DSM-IV,7 is the most commonly used for pretreatment diagnosis in psychotherapy research. Undoubtedly, the DSM system is a very valuable instrument for defining diagnostic subgroups. However, because it is not based on any specific theory, there is also a need for assessment tools based on theories underlying specific psychotherapies.8, 9

Diagnostic instruments based on psychodynamic theory often assess aspects of human behavior, such as object relations, defense patterns, and various modes of mental functioning, that could also be described as character traits. In psychoanalytical theory, character is conceived of as the individual's attempt to bring the tasks presented by internal demands and by the external world into harmony, resulting in a typical constellation of traits by which we recognize the particular person.10,11 When the individual's habitual character does not permit successful handling of these tasks, symptoms may evolve.12,13 The relationship between symptoms and character has always been an important subject of investigation within a psychoanalytical frame of reference. Several typical relationships between character and clinical syndromes have been described,14 such as the classical associations described by Freud between the hysterical character and conversion15 and between the anal character and obsessive-compulsive neurosis.16 There are, however, psychoanalysts who advocate the opposite view, that no such determined associations between character and symptom exist.17,18

The aim of the present naturalistic study was twofold. The first goal was to describe a sample of patients selected for long-term dynamic psychotherapy from a psychiatric and a psychodynamic point of view. In addition to the DSM, we introduce an interview-based psychodynamic instrument and a personality inventory commonly used in Scandinavia but not often discussed in the North American literature. The second goal was to study the relationship between DSM-defined symptoms and psychodynamic aspects of character.


   METHODS
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
Subjects
The study was conducted at the Institute of Psychotherapy in Stockholm, which provides long- and short-term psychodynamic psychotherapy. Patients applied by telephone, and a brief interview was conducted during the call. About one-third of the patients who applied were offered one to three exploratory interviews. One-third of these patients (11% of the patients who phoned) were considered suitable for long-term dynamic psychotherapy and were put on a waiting list for treatment at the Institute. Patients with severe psychopathology were referred to other psychiatric clinics, and patients lacking "psychological mindedness" were referred elsewhere for supportive treatment. Thus, the patients were selected in three steps: self-selection (the patients themselves decide to apply for psychotherapy), telephone interview, and exploratory interviews.

By telephone and mail, the first author (A.W.) asked 58 consecutive patients from the waiting list to participate. Fifty-five patients (95%) decided to take part in the study. Patient characteristics are presented in Table 1.


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  		TABLE 1.
 
A sample of 65 patients with ulcerative colitis was used as the control group.19 There were two reasons for using this control group: first, contrary to what is commonly believed, a recent review of 138 studies examining the relation between ulcerative colitis and psychiatric factors concluded that ulcerative colitis patients had the same prevalence of psychopathology as normal control subjects.20 Second, data that had been obtained with the same instruments as those used in the present study were available for the ulcerative colitis sample.

Assessments
Psychodynamic Character Assessment:
 The Karolinska Psychodynamic Profile (KAPP) was used for psychodynamic character assessment.21,22 The KAPP is a rating instrument based on psychoanalytical theory that assesses relatively stable modes of mental functioning and character traits as they appear in self-perception and in interpersonal relationships. The instrument consists of 18 subscales. Seventeen of the subscales are on a low level of abstraction and could be considered to represent character traits; the last subscale refers to character as organization. Each subscale is provided with a definition and three defined levels. Two additional intermediate levels may be used, resulting in a five-point scale, (1, 1.5, 2, 2.5, and 3). On all subscales, level 1 represents most normal and level 3 least normal. The definitions of the KAPP subscales are presented in Table 2.


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  		TABLE 2.
 
Factor analysis of the KAPP in the control group has yielded five factors, which suggests that the KAPP assesses more than one dimension of psychological health or psychiatric severity.23

The validity of the KAPP has also been examined by correlating independent KAPP ratings based on material obtained through projective testing with ratings obtained by interview. This analysis yielded significant results.23 Furthermore, the KAPP has been found to discriminate between patients with and without a DSM diagnosis.19 Stability over time has been examined by comparing KAPP scores before a major life event (abdominal surgery) and at an average of 22 months later. Scores on 14 of the 18 subscales were similar before and after surgery.24 Predictive validity has been evaluated by examining the ability of the KAPP to predict long-term outcome after surgery. Results suggested that preoperative character traits could predict the patients' postoperative quality of life beyond what could be predicted by surgical outcome alone. Poor frustration tolerance and the absence of alexithymic traits were found to predict poor postoperative quality of life, indicating that alexithymic traits might actually be adaptive.25,26

In the present study, the reliability of the KAPP was tested in three different ways: 1) The first author (A.W.) independently rated 12 audiotaped KAPP interviews made by the second author (R.M.W., one of the developers of the instrument) for another study.27 The mean intraclass correlation was 0.69 (median 0.69, range 0.33–0.89). 2) A psychologist independently rated 15 audiotaped KAPP interviews made by the first author for the present study. The mean intraclass correlation was 0.53 (median 0.57, range 0.23–0.76). 3) To investigate the stability of the first author's ratings, he rerated 14 of his own audiotaped KAPP interviews from the present study 1.5–2.5 years after his first ratings. On this rerating, the mean intraclass correlation was 0.70 (median 0.78, range –0.02 to 1.00). The lowest correlation was on the subscale Coping With Aggressive Affects, which had a very restricted range of KAPP scores (Table 3). The second lowest intraclass correlation was on the subscale Impulse Control (0.40).


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  		TABLE 3.
 
Personality Traits Assessment:
The Karolinska Scales of Personality28 (KSP) is a 135-item personality inventory designed to measure dimensions of temperament, especially those believed to be markers for vulnerability to psychopathology.29–31 The KSP has been constructed within a biologically oriented frame of reference and has been widely used in a large number of studies in Scandinavia and other countries on various clinical groups and healthy volunteers. The 15 mutually exclusive KSP scales have been classified into three categories: anxiety-proneness scales (Somatic Anxiety, Psychic Anxiety, Muscular Tension, Psychasthenia, and Lack of Assertiveness), extraversion-related scales (Impulsiveness, Monotony Avoidance, Detachment, Socialization, and Social Desirability) and aggression–hostility scales (Indirect Aggression, Verbal Aggression, Irritability, Suspicion, and Guilt). The KSP measures longitudinally stable personality traits24,32 and has been validated in healthy subjects against other commonly used questionnaires.28,33 It has also been applied for predicting outcome in clinical studies and for differentiating between various patient samples.25,34–37 The KSP scales are presented in af Klinteberg et al.38

Diagnosis and KAPP Interview Procedures:
The DSM-III-R was used to diagnose clinical syndromes (Axis I), personality disorders (Axis II), and global assessment of function (GAF Axis V).39

One rater (A.W., a specialist in psychiatry and a trained psychoanalyst) conducted all of the KAPP interviews. Each interview took approximately 2 hours and was audiotaped. Information was also collected for DSM-III-R diagnoses. The KAPP was scored immediately after the interview without listening to the tape. The personality inventory was filled out by the patient the same day.


   RESULTS
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
Description of the Psychotherapy Patients
Personality Traits as Assessed by Personality Inventory, the KSP:
The KSP scales were used to compare traits in the psychotherapy patients with those of a normal sample. Raw scores have been standardized to T-scores by using normative data obtained from approximately 200 women and 200 men (ages 20 to 65 years) randomly sampled from the Swedish population (mean = 50, SD = 1.0).

For the psychotherapy patients, the T-scores deviated substantially (defined as more than 0.5 SD; Rosenthal,40 p. 138) from normative data on 9 of the 15 KSP scales. The patients in the present study had higher T-scores on 4 of the 5 anxiety-proneness scales (Somatic Anxiety, Psychic Anxiety, Muscular Tension, and Psychasthenia). Lower T-scores were found on the Socialization (signifying resentment over childhood experiences and present life situation) and Social Desirability (social conformity versus rebelliousness) scales, and higher on the Monotony Avoidance (excitement seeking) scale. The psychotherapy patients also had higher T-scores on the Irritability and Suspicion scales.

The same differences were found when comparing the psychotherapy patients and the control group, with two exceptions: no difference was found on the Monotony Avoidance scale, and the psychotherapy patients scored higher than the control subjects on the Guilt scale (Figure 1).



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  		FIGURE 1.

 
Character Traits as Assessed by a Psychodynamic Interview–Based Instrument, the KAPP:
There were very few KAPP ratings above level 2 on any subscale. The mean KAPP scores of the psychotherapy patients were above 1.5 only on 4 of the 18 subscales (Figure 2): Coping With Aggressive Affects (expressed as inhibition of aggression), Dependency and Separation (difficulties in forming mature dependent relationships and in separating), Frustration Tolerance (often expressed by restriction of the ego in order to avoid frustration), and Impulse Control (mostly expressed as an exaggerated inhibition of impulses). A minimal level of pathology was found on the Alexithymia and the Normopathy subscales.



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  		FIGURE 2.

 
To ascertain how character traits in the psychotherapy patients compared with a nonpsychiatric sample, we used Weinryb and colleagues' published KAPP data of the aforementioned sample of ulcerative colitis patients.19 Only on the subscale Frustration Tolerance did the psychotherapy patients show more pathology than the ulcerative colitis patients (t = 3.34, P < 0.001). On 6 KAPP subscales, the psychotherapy patients were less disturbed (i.e., had significantly lower mean scores) than the ulcerative colitis patients (Figure 2). These 6 subscales were Controlling Personality Traits, Regression in the Service of the Ego, Alexithymia, Normopathy, Current Body Image, and Sexual Satisfaction.

Age and Gender Differences in KAPP Scores:
Men had significantly higher ("less normal") mean KAPP scores than women on the subscales Alexithymia (t = 2.06; P < 0.05) and Conceptions of Bodily Function and Their Significance for Self-Esteem (t = 2.71; P < 0.01). Women had higher mean KAPP scores on the subscale Sexual Satisfaction (t = –2.03; P < 0.05). With the exception of the subscale Sense of Belonging (r = 0.36; P < 0.001), no significant association was found between age and the KAPP subscales.

Character Traits and DSM-III-R Psychopathology
To examine the relationship between symptoms and character—that is, between psychiatric syndromes and psychodynamically defined character traits—we compared the KAPP scores of patients who had a DSM-III-R diagnosis and those of patients without such a diagnosis.

The decision to use the presence of any DSM-III-R diagnosis as a comprehensive expression of "symptoms" was made after performing separate t-tests comparing patients with and without mood disorders, and also comparing patients with and without Axis II disorders. These separate t-tests yielded similar differences in KAPP scores. (Only one of the patients with an Axis II diagnosis did not have a concomitant Axis I diagnosis.)

Thus, we found that patients with a DSM-III-R Axis I or II diagnosis (n = 30) had significantly higher (less normal) mean KAPP scores than those without Axis I or II pathology (n = 25) on the subscales Intimacy and Reciprocity, Frustration Tolerance, and Personality Organization (Table 4).


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  		TABLE 4.
 
Finally, the relationship between KAPP scores and general level of functioning was analyzed. The Global Assessment of Functioning (GAF) scores were significantly and negatively correlated with 7 KAPP subscales. These were Intimacy and Reciprocity, Dependency and Separation, Frustration Tolerance, Conceptions of Bodily Appearance and Their Significance for Self-Esteem, Current Body Image, and Personality Organization (Table 4).


   DISCUSSION
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
In this naturalistic study of 55 outpatients who were selected in a "traditional" psychodynamic manner for long-term psychodynamic psychotherapy, we found 30 patients (55%) who fulfilled criteria for a DSM-III-R diagnosis, the majority of whom suffered from a mood disorder. From a psychodynamic point of view, there was a low general level of character pathology. The most prominent pathology was found on the KAPP subscales Coping With Aggressive Affects (inhibition), Dependency and Separation, Frustration Tolerance (restrictions of the ego), and Impulse Control (inhibition). Some KAPP-defined character problems were found to be related to symptoms as defined by the DSM-III-R: specifically, poor Frustration Tolerance, problems with Intimacy and Reciprocity, and a more disturbed Personality Organization were related to DSM-III-R diagnosis and a lower general level of function (GAF scores). In addition, problems with Dependency and Separation, Conceptions of Bodily Appearance and Their Significance for Self-Esteem, and Current Body Image were related to lower GAF scores.

Some similarities were found between the present sample and those of other naturalistic studies.41–43 For example, the sociodemographic characteristics of the patients in the Penn Psychotherapy Project were similar to those of the patients in our sample, with the exception that the patients in the present study were a few years older. The most prevalent diagnosis in the Penn Psychotherapy Project was dysthymia; in our study it was mood disorders. The general level of function appears to be lower in the Penn Psychotherapy Project patients than in our sample (59.5 as measured by the Health–Sickness Rating Scale and 70 by the GAF scale, respectively).

The "traditional" selection of the present sample seems to have favored the inclusion of patients with stable personality organization, good capacity for regression in the service of the ego, and hardly any alexithymic or normopathic traits. That is, these were patients with character traits traditionally considered favorable for psychodynamic psychotherapy.1

There was a discrepancy between the low prevalence of severe KAPP-defined character pathology and the relatively higher prevalence of symptomatic psychopathology as defined by the DSM-III-R. We do not know whether this discrepancy is due to the selection process. Our findings do, however, raise the question of whether patients with character pathology, in contrast to patients with symptoms, are excluded in the "traditional" selection process.

It is noteworthy that the self-report KSP revealed significant elevation on 9 of the 15 scales compared with the control group, whereas the interviewer's KAPP ratings were significantly higher than the control on only one scale. This discrepancy may reflect differences relevant to the background and aims of the two instruments or to the different methods of collecting the data. The theory underlying the KSP is biological; that underlying the KAPP is psychodynamic. With the KAPP, an assessment is made of the patient's function in a specific area, using manifest as well as inferred material from the patient's behavior during the interview, while the KSP score reflects the patient's responses to very specific questions, a format that also is more in line with the DSM system. Thus, DSM diagnoses and the KSP self-ratings might reflect the kinds of issues that are reported by patients directly and of which the patients are consciously aware, whereas the KAPP ratings are not only related to the patient's complaints but also to what clinicians infer from the patient. Since the KAPP does not aim at assessing the patient's distress per se, but rather how he or she handles such distress, it is possible that one selection criterion for suitability for psychotherapy might have been how well the patients could contain larger amounts of distress.

Problems with frustration tolerance were prevalent in our sample. Poor frustration tolerance was related to the presence of a DSM-III-R diagnosis and to a lower general level of functioning, which is consistent with earlier findings of Weinryb et al.22 The most common character problems found on the KAPP frustration tolerance subscale were ego restrictions, implying the patients were using active defensive operations in order to avoid potentially frustrating situations and challenges. The presence of psychiatric suffering indicated that the patients' attempts to avoid problematic and painful situations were unsuccessful. Constructs similar to frustration tolerance have also been considered important by other authors. Thus, Clark et al.44 have advanced the notion of a general distress factor (implying negative emotionality or neuroticism; that is, a temperamental sensitivity to negative stimuli) similar to the KAPP frustration tolerance scale. A general distress factor was found to be a vulnerability factor for the development of anxiety and depression.44 Poor frustration tolerance might also be an aspect of the general neurotic syndrome described by Andrews et al.45 Moreover, poor frustration tolerance preoperatively has been found to predict quality of life after pelvic pouch surgery.25,26

Problems with intimacy and reciprocity, and a more disturbed overall personality organization, were found to be related both to DSM-III-R diagnosis and to lower general functioning (GAF scores). The level of pathology on these two subscales was very low in our sample, and reliable conclusions can hardly be drawn. However, the character pathology found on the KAPP intimacy subscale concerned part-object relations expressed by problems in having mutual and close relationships with others and by an impaired capacity to experience conflict and ambivalence. This finding may suggest that even minor disturbances in object relations may contribute to psychopathology. Further investigation of this question is needed.

The KAPP subscales Dependency and Separation, Conceptions of Bodily Appearance and Their Significance for Self-Esteem, and Current Body Image were associated with lower GAF scores. It is not surprising that patients who expressed strong separation anxiety and struggled with dependency showed a lower general level of functioning; however, the association between two of the subscales for assessing the body's importance for self-esteem and low GAF scores is more intriguing. Those subscales assess fantasies of bodily perfection and the individual's narcissistic striving to reach this perfection. Freud46 believed that depression could be the result of a consciously or unconsciously experienced loss of an object. Narcissistic patients, however, can suffer as a result of an experienced loss of perfection. In these patients, an experienced loss of beauty may result in a depressive reaction or an impaired level of general functioning.47,48

In the present study we found that some psychodynamically defined character traits, particularly poor frustration tolerance, were related to symptomatic suffering. The relationship between poor frustration tolerance and psychopathology has recently been reported by several researchers. Whether frustration tolerance is important for the outcome of psychodynamic psychotherapy remains to be demonstrated in future research.


   Acknowledgments
 
The staff of the Institute of Psychotherapy are gratefully acknowledged for their generous support. Financial support was received from the LJ Boethius Foundation, the Sö;derströ;m-Kö;nig Foundation, PraktikertjÄ;nst AB, the Bror Gadelius Foundation, the Salus Foundation, the Magn. Bergvall Foundation, the Swedish Medical Research Council (Grants 10592 and 5454), the Thuring Foundation, the Karolinska Institute, and the Swedish Council for Planning and Coordination of Research.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

  1. Crits-Christoph P, Connolly MB: Patients' pretreatment predictors of outcome, in Psychodynamic Treatment Research, edited by Miller NE, Luborsky L, Barber JP, et al. New York, Basic Books, 1993, pp 177–190
  2. Kernberg O: Severe Personality Disorders: Psychotherapeutic Strategies. New Haven, CT, Yale University Press, 1984
  3. Perry JC: Defense Mechanisms Rating Scales, 5th edition. Cambridge, MA, The Cambridge Hospital and the Harvard Medical School, 1990
  4. Bellak L, Goldsmith LA (ed): The Broad Scope of Ego Function Assessment. New York, Wiley, 1984
  5. Piper WE, Azim HFA, Joyce AS, et al: Quality of object relations versus interpersonal functioning as predictors of therapeutic alliance and psychotherapy outcome. J Nerv Ment Dis 1991; 179:432–438[Medline]
  6. Luborsky L: Clinicians' judgment of mental health: a proposed scale. Arch Gen Psychiatry 1962; 7:407–417
  7. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Washington, DC, American Psychiatric Association, 1994
  8. Kazdin AE: Methodology, design, and evaluation in psychotherapy research, in Handbook of Psychotherapy and Behavior Change, edited by Bergin AE, Garfield SL. New York, Wiley, 1994, pp 19–71
  9. Barber J: Efficacy of short-term dynamic psychotherapy: past, present, and future. J Psychother Pract Res 1994; 3:108–121[Abstract/Free Full Text]
  10. Baudry F: Character, character type, and character organization. J Am Psychoanal Assoc 1989; 37:655–686[Medline]
  11. Fenichel O: The Psychoanalytic Theory of Neurosis (1946). St Edmunds, UK, St Edmundsbury Press, 1982
  12. Greenson RR: The Technique and Practice of Psychoanalysis, 6th edition, vol 1. London, Hogarth Press, 1967
  13. Freud S: Inhibitions, symptoms and anxiety (1925), in The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol 20, translated and edited by Strachey J. London, Hogarth Press, 1959, pp 77–174
  14. Kets de Vries MFR, Persow S (ed): Handbook of Character Studies: Psychoanalytic Explorations. Madison, CT, International Universities Press, 1991
  15. Freud S: Fragments of an analysis of a case of hysteria (1905), in The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol 7, translated and edited by Strachey J. London, Hogarth Press, 1953, pp 3–122
  16. Freud S: Character and anal erotism (1908), in The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol 9, translated and edited by Strachey J. London, Hogarth Press, 1959, pp 167–175
  17. Zetzel E: The so-called good hysteric. Int J Psychoanal 1968; 49:250–260[Medline]
  18. Kernberg O: Borderline Conditions and Pathological Narcissism. New York, Jason Aronson, 1975
  19. Weinryb RM, Gustavsson JP, Âsberg M, et al: The concept of alexithymia: an empirical study using psychodynamic ratings and self reports. Acta Psychiatr Scand 1992; 85:153–162[Medline]
  20. North CS, Clouse RE, Spitznagel EL, et al: The relation of ulcerative colitis to psychiatric factors: a review of findings and methods. Am J Psychiatry 1990; 147:974–981[Abstract/Free Full Text]
  21. Weinryb RM, Rö;ssel RJ: Karolinska Psychodynamic Profile–KAPP. Acta Psychiatr Scand 1991; 83(suppl 363):1–23
  22. Weinryb RM, Rö;ssel RJ, Âsberg M, et al: The Karolinska Psychodynamic Profile (KAPP): studies of character and well-being. Psychoanalytic Psychology (in press)
  23. Weinryb RM, Rö;ssel RJ, Âsberg M: The Karolinska Psychodynamic Profile, I: validity and dimensionality. Acta Psychiatr Scand 1991; 83:64–72[Medline]
  24. Weinryb RM, Gustavsson JP, Âsberg M, et al: Stability over time of character assessment using a psychodynamic instrument and personality inventories. Acta Psychiatr Scand 1992; 86:179–184[Medline]
  25. Weinryb RM, Gustavsson JP, Liljeqvist L, et al: A prospective study of personality as a predictor of quality of life after pelvic pouch surgery. Am J Surg 1997; 173:83–87[Medline]
  26. Weinryb RM, Gustavsson JP, Barber JP: Personality predictors of dimensions of psychosocial adjustment after surgery. Psychosom Med (in press)
  27. Weinryb RM, Rö;ssel RJ, Âsberg M: The Karolinska Psychodynamic Profile, II: interdisciplinary and cross-cultural reliability. Acta Psychiatr Scand 1991; 83:73–76[Medline]
  28. Schalling D, Âsberg M, Edman G, et al: Markers for vulnerability to psychopathology: temperament traits associated with platelet MAO activity. Acta Psychiatr Scand 1987; 76:172–182[Medline]
  29. Eysenck HJ: The Biological Basis of Personality. Springfield, IL, Charles C Thomas, 1967
  30. Schalling D: Psychopathy-related personality variables and the psychophysiology of socialization, in Psychopathic Behaviour: Approaches to Research, edited by Hare RD, Schalling D. Chichester, UK, 1978, pp 85–106
  31. Sjö;bring H: Personality structure and development: a model and its application. Acta Psychiatr Scand Suppl 1973; 43(suppl 244):13–195
  32. Brown SL, Svrakic DM, Przybeck TR, et al: The relationship of personality to mood and anxiety states: a dimensional approach. J Psychiatr Res 1992; 26:197–211[Medline]
  33. Curtin F, Walker JP, Badan M, et al: The relations between scores on analogous scales from four personality questionnaires in 50 normal men. Personality and Individual Differences 1995; 19:705–711
  34. af Klinteberg B, Humble K, Schalling D: Personality and psychopathy of males with a history of early criminal behavior. European Journal of Personality 1992; 6:245–266
  35. Ekselius L, Hetta J, von Knorring L: Relationship between personality traits as determined by means of the Karolinska Scales of Personality (KSP) and personality disorders according to DSM-III-R. Personality and Individual Differences 1994; 16:589–595
  36. Nordströ;m P, Schalling D, Âsberg M: Temperamental vulnerability in attempted suicide. Acta Psychiatr Scand 1995; 92:155–160[Medline]
  37. Uvnäs-Moberg K, Arn I, Theorell T, et al: Personality traits in a group of individuals with functional disorders of the gastrointestinal tract and their correlation with gastrin, somatostatin and oxytocin levels. J Psychosom Res 1991; 35:515–523[Medline]
  38. af Klinteberg B, Schalling D, Magnusson D: Childhood behavior and adult personality in male and female subjects. European Journal of Personality 1990; 4:57–71
  39. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised. Washington, DC, American Psychiatric Association, 1987
  40. Rosenthal R: Progress in clinical psychology: is there any? Clinical Psychology 1995; 2:133–150 (p 138)
  41. Luborsky L, Crits-Christoph P, Mintz J, et al: Who Will Benefit from Psychotherapy? New York, Basic Books, 1988
  42. Olfson M, Pincus HA: Outpatient Psychotherapy in the United States, I: volume, costs, and user characteristics. Am J Psychiatry 1994; 151:1281–1288
  43. Vessey JT, Howard KI: Who seeks psychotherapy? Psychotherapy 1993; 30:546–553
  44. Clark LA, Watson D, Mineka S: Temperament, personality, and the mood and anxiety disorders. J Abnorm Psychol 1994; 103:103–116[Medline]
  45. Andrews G, Stewart G, Morris-Yates A, et al: Evidence for a general neurotic syndrome. Br J Psychiatry 1990; 157:6–12[Abstract/Free Full Text]
  46. Freud S: Mourning and melancholia (1917), in The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol 14, translated and edited by Strachey J. London, Hogarth Press, 1957, pp 237–258
  47. Rothstein A: An exploration of the diagnostic term narcissistic personality disorder, in Handbook of Character Studies: Psychoanalytic Explorations, edited by Kets de Vries MFR, Perzow S. Madison, CT, International Universities Press, 1991, pp 303–318
  48. Grunberger B: Narcissism: Psychoanalytic Essays. New York, International Universities Press, 1979, pp 219–240



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