Operationalized psychodynamic diagnosis: a systematic review of the literature

Introduction: The Operationalized Psychodynamic Diagnosis (OPD-2) is an operational multiaxial diagnostic assessment and treatment planning tool. This systematic review sought to analyze empirical studies that used the OPD as an instrument. In addition to identifying the studies, we analyzed the topics covered and the results of research that used the OPD empirically. Method: Articles, dissertations and empirical theses that mentioned or used the OPD instrument in the last five years (2012-2017) were included in this review. The strategy included searching with combinations of the descriptors “Operationalized and psychodynamic and diagnosis” from the Portal de Periódicos CAPES on the PubMed, Google Scholar, and ResearchGate databases for work published in English, Portuguese or Spanish in the last five years. Results: The search returned a total of 189 papers, but only 20 were included. The studies selected discussed the validity and reliability of the instrument, the therapeutic process and analysis of outcomes, assessment of different mental disorders, and also included studies comparing different instruments and techniques. Considerable scientific effort has evidently been dedicated to accumulating more consistent data on psychodynamic diagnosis. Conclusion: It was demonstrated that the OPD is an essential clinical tool for dimensional comprehension of the subject and for scientific research. However, the number of publications on the subject is not yet significant and the methods employed are diverse. Nevertheless, there is a growing body of data on topics such as applicability in different contexts and to different pathologies, promoting greater visibility and with greater representativeness of professionals who have experience with the instrument.


Introduction
The current version of the operationalized manual is the 2nd edition and it has been validated in the following languages: German, Spanish, Portuguese (Portugal and Brazil), [1][2][3] and English.
The OPD-2 is a multiaxial diagnostic system comprising five axes; the first four focused on psychodynamic understanding and the last one on description, as follows: I) experience of illness and prerequisites for treatment; II) interpersonal relationships; III) psychic conflict; IV) psychic structure; V) traditional nosological diagnosis, such as DSM-5 and ICD-10.Each axis has specific assessment categories, as shown in Table 1.The objective of the OPD-2 is a psychodynamic formulation, describing the patient's main problems and identifying their resources and skills.More specifically, the OPD complements the descriptive indicators of the DSM and ICD from

Axes Dimension Indicator
Axis I -Illness experience and prerequisites for treatment Considering the important contribution made by the OPD, from the perspectives of both diagnostic assessment and of psychotherapeutic planning, and also to operationalization of psychodynamic concepts, this systematic review sought to analyze empirical studies that used the OPD as an instrument.Therefore, in addition to identifying the studies, we also analyzed the topics covered and the results of research that used OPD empirically.

Method
A systematic review of the scientific production was carried out according to PRISMA Platform guidelines.

Results
Selection of studies from among the 189 identified by searches took place in two stages: 1st screening, reading of abstracts only; 2nd screening, a complete reading of the study.Thus, 166 studies were excluded, and then four unpublished studies were included in the databases.
Hence, a total of 20 studies were analyzed (Figure 1).Adherent patients were: younger; had higher education; had higher GAF scores, suggesting better psychosocial adjustment; and lower scores on the EQ-5D; they express their disorder mainly psychologically, while nonadherent patients tend to express themselves in somatic ways.
The main conflict for both groups was "Need for care versus self-sufficiency".
Adherence to treatment has become an issue on its own.There are seven variables associated with adherence to medical treatment: years of education attained, psychosocial adjustment, health-related quality of life, psychological and social concept of illness, desired psychological treatment, and submission/control conflict.Women with greater severity of violence reported higher levels of depressive symptoms, PTSD and low education.
Understanding of the psychological difficulties and vulnerable relationships of the victims associated with their traumatic experiences promotes more systematized care that prevents the re-victimization, based on the therapeutic focus and planning.

Article Objective Method Results Conclusion
Crempien 10 To analyze the effects of personality functioning on the quality of life in depressed patients.
High level depressive severity symptoms are associated with low levels of personality functioning and poor quality of life.Sociodemographic variables showed no effect on quality of life.
Depressive symptoms mediate the effect of personality functioning on mental quality of life of depressive patients.The lower the level of personality functioning, the higher the severity of depressive symptoms, and the latter have a detrimental effect on patients' quality of life.The specific contribution of each structural function to this impairment should be further studied.
Dagnino 11 To describe the therapeutic process of four successful therapies, considering the change with reference to the subjective theory and integration of therapeutic foci and to compare and relate the two methods for assessing therapeutic change.
4 women with individual brief dynamic psychotherapy sessions, therapists with over 30 years of experience.
Instruments: Generic Indicators of Therapeutic Change, Scale of Structural Change, OPD-2.
The change, in subjective theory, proved to be an irregular but progressive process, with integration of the therapeutic foci.There is a significant relationship between the models of assessing therapeutic change.
It is suggested that foci should be identified in each episode of change that the patient and the therapist are working on, in order to establish a relationship between a specific focus, its level of integration and the subjective change in the patient.
Dagnino 12 To determine the presence of therapeutic foci, their level of integration and their relationship with subjective change in four successful brief dynamic psychotherapies.
Study of multiple unique cases.4 brief dynamic psychotherapies.
The focus of OPD was identified in all the occurrences of therapeutic change.The focus on the relational pattern is more present in early stages, while the focus on structural vulnerabilities predominates in the final stage.
The consistency of successful psychotherapeutic processes allowed conclusions on certain common aspects of focalizations, their level of integration and their evolution during the process.The focus was the need to abbreviate the therapeutic processes.
Dagnino 13 To explore the association between structural functions and self-criticism and dependency dimensions of depressive experience.Preliminary results indicated that axes III and IV predominated in identifying the problem (conflict x structure) and axis II in the patient's expectations regarding treatment.

Cross
OPD-2 was useful in classifying key elements of the conceptualization process of a GAD case and was sensitive to identify patient's particularities.
Kehyayan 17 To investigate the concept of "psychodynamic conflict" using a method of free association to potentially conflict-related contents inside a functional MRI scanner.
There was agreement between the report of conflict-related sentences, with high levels of behavioral, neural reactions, mainly in the anterior cingulate cortex, involving emotional processing, monitoring of conflict and the problems mentioned.
Free association has shown to be a powerful technique for investigating conflict with neuroimaging.The content assessment considered the items clear in terms of language and theoretically pertinent.Axes III and IV showed greater interrater agreement.Axes I, III and IV obtained a significant correlation in some categories with the results of SCL-90-R and WHOQOL-bref.
The psychometric properties of the OPD-2 are adequate for application to the Brazilian population.

Paulo & Pires 5
To test diagnostic assessment using the notes from a patient's psychoanalysis sessions.
One patient, 40 years old, with higher education.Descriptive notes from psychoanalysis sessions.
Treatment period: 3 years and 8 months with frequency of three times a week.The first 10 and the last 12 sessions were analyzed.
The patient had a lot of counseled psychological suffering, dysfunctional relational patterns, oedipal conflict and structural level that varied between moderate/high.There was significant improvement at the end of treatment on all axes.
OPD can be applied to descriptive notes of psychoanalytic sessions.
Vicente 3 To describe the methodological aspects of the process of cross-cultural adaptation of the OPD-2 to the Portuguese language (Portugal and Brazil).
To evaluate inter-rater agreement for the different axes of the instrument in the scoring of clinical interviews.

Independent translation and comparison of the different versions of the final version in
Portuguese.Agreement between three independent evaluators of two interviews of five participants with mean age of 40 years.
Inter-rater agreement of Axis I was 66%, Axis III was 57.7%, and Axis IV was 78%.Axis II was not evaluated.
Results are similar to other studies with an acceptable inter-rater agreement.Further studies are recommended to investigate the instrument's reliability.
Wiswede 19 To compare the changes in depressive patients' brain reactions before and after eight months of psychodynamic psychotherapy.
Experimental When confronted with the sentences from the OPD (as stimulus) at T1, the patients showed greater activation in the limbic system and in the subcortical regions compared to the control group.At T2, the differences in brain activities between the control group and the patients were no longer significant.The patient group's depression score improved.
Brain activity of depressive patients, in the case of hyperactivity of the limbic system, normalized after treatment; changes were attributed to psychodynamic psychotherapy.
Zimmermann 20 To contribute to the conceptual and empirical discussion of the Levels of Personality Functioning Scale from the perspective of the OPD system Review of studies that used OPD-LSIA to investigate reliability and validity.A meta-analysis was conducted of 8 studies that assessed the association between the overall OPD-LSIA score and PDs.
OPD-LSIA is reliable and valid for the assessment of personality structure and has a high association with classification of PDs (severity).
Highlights implications of OPD-LSIA for future revisions to the DSM-5 proposal.
Zuccarino 21 This ongoing study aimed to investigate the existence of psychopathologically significant dimensions in a sample of patients with eating disorders, using the OPD-2 system.

Discussion
Traditionally, the use of the instrument is operationalized and the usefulness of this technique was confirmed in investigation of axis III. 17 Observation of the brain during a psychoanalytic treatment is a fertile field of investigation.16,19 However, it is also considered a challenge, since it requires operationalization of psychodynamic constructs, and the OPD provides a method for this type of research, developing and proving the effectiveness of this approach.
It was observed that the OPD system has been Regarding the neurobiology of these cases, it was possible to observe that depressive patients in psychodynamic psychotherapy treatment normalized their brain activity, characterized by hyperactivity of the limbic system, after 8 months of treatment, without medication.This study used sentences from the OPD as a stimulus for the assessment of brain activity in the patients and control group. 19 psychiatric patients, Axis IV of the instrument showed good reliability; results demonstrated that patients with personality disorders have the most vulnerable mental functions. 15From the perspective of personality disorders in the DSM-IV classification, Dinger The studies cited are German, 14,19,20 where it can be observed that researchers are currently more focused on understanding the personality and subject structure.
Concomitant with this, Germans have also conducted research on unconscious conflicts -Axis III -the understanding of which is identified as a fundamental factor in understanding of the genesis and maintenance of mental disorders, since they provoke behavioral, emotional and neural reactions.Each conflict comprises affections, thoughts, beliefs, behavior, relationship, and transference-countertransference characteristics, among others. 17In this sense, conflict was also used in an attempt to investigate repression; a central concept in psychodynamic theory.It proved possible to propose a way to assess repression using free association of sentences related to the intrapsychic conflict. 18 can be observed that these studies are developing each dimensional axis separately and in the most varied of contexts: neuroscience, OPD-SQ, and OPD-LSIA.Additionally, in an attempt to correlate the OPD constructs with another instrument, the Americans Gordon and Stoffey chose the Psychodiagnostic Chart (PDC), a preliminary instrument developed to operationalize the Psychodynamic Diagnostic Manual (PDM).In their results, the PDC correlated significantly with the OPD-Axis IV. 16 The OPD-2 was also used to assess adherence to treatment among epileptic patients.In this study, the authors found that adherence to treatment is influenced by aspects of experience of the disease -Axis I -and by conflict -Axis III -in epileptic patients. 7Chilean research, especially that involving the researcher Paula Dagnino, investigated the context of therapeutic focus and change.The authors pointed out that the focus on the OPD promoted therapeutic change 12 and this change was progressive and irregular. 11 another Chilean context, the OPD was adapted to domestic violence, using Axis I. Here, the author evaluated the psychodynamic functioning of 28 women recruited from a center for domestic violence victims in Santiago.The women who demonstrated the greatest severity of violence were those who reported higher presence of depressive symptoms, PTSD, and low education.Complementarily, the main conflict that prevailed was need for care versus self-sufficiency (39%), followed by the secondary conflict submission vs. control (50%), which may be related to re-victimization.Also, the overall functioning of women who had been victims of sexual violence was worse than that of other victims, because they suffered from psychological and physical violence concurrently; with an accumulation of multiple traumas.Furthermore, the vulnerable structure due to the trauma suffered is considered an obstacle to victims dealing with their emotions and stress. 6lso in the context of violence, in Brazil the OPD-2 also proved useful with adolescents in conflict with the law, for identifying the psychodynamic characteristics of the case, complementing the diagnosis of Conduct Disorder.These authors developed an evaluative comprehension of the adolescent, pointing out that the predominant intrapsychic conflict was his need for care versus self-sufficiency active mode.He sought independence because of fragile primary affective bonds; which led him to perceive others as controllers and so he isolated himself or acted impulsively, perhaps as an attempt to avoid another possible abandonment.
Nevertheless, the patient presented a median psychic structure, which did not lack mentalization ability.
These aspects demonstrate the complexity of the psychodynamic diagnostic assessment that surpasses the common psychiatric diagnosis. 8 In several studies reviewed, when conflicts were evaluated with the OPD, the conflict need for care versus self sufficiency was the most frequent.This was observed in patients with eating disorder, 21 acute stress disorder and posttraumatic stress disorder, 6,9 and conduct disorder. 8These data raise the hypothesis that there are common characteristics among different pathologies that need to be better investigated, including through use of OPD in different contexts.
Finally, another Brazilian study from the Universidade Federal do Rio Grande do Sul (UFRGS) complemented the Portuguese sample and presented the Brazilian version of the instrument. 2 The validation study found agreement between judges.In this validation study for Portugal/Brazil, reliability was calculated for each axis as follows: 78% in axis IV, 66% in axis I, 57.7% in axis III, and axis II was excluded. 3We questioned the exclusion of axis II, but it is understood that the 32 categories make reliability difficult to achieve.Nevertheless, the instrument was validated for use in Brazil.
It was observed that empirical production is increasing, since this is a recent instrument and it is increasingly spreading internationally.Chile and Germany are leading research on the subject.In Germany this is possibly because the group that created this instrument is from Germany and because it is already more widespread in their scientific community.
Next is Brazil, where production is concentrated on understanding psychodynamic functioning in situations of stress, besides proposing its applicability to psychoanalysis notes.
Another aspect that is notable is related to academic Therefore, the OPD is an instrument that integrates psychodynamic constructs in an operationalized manner using multiaxial assessment forms.This operationalization provides understanding of and application to the psychodynamics of the patient, offering greater clarity in planning of treatment for the subject and also facilitating communication within the scientific community. 1There are few instruments that operationalize the psychodynamic constructs, whether internationally or domestically. 2Therefore, we emphasize the need for research using the OPD instrument in the most varied of contexts, since the results can serve as tools for diagnostic investigation, contributing to improvement of psychotherapy and to understanding patients' dynamic functioning.

Conclusion
Analyses of studies related to the OPD showed that the number of publications on the subject is not yet ), integrating the psychodynamic dimension with descriptive symptomatology.One of the reasons for creating the OPD was the existence of limitations affecting previous diagnostic classifications such as the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Classification of Diseases and Related Health Problems (ICD-10), which employ symptom-centered diagnosis.

Objective assessment of illness/problem 1 . 3
Current severity of illness/ problem 2. Period of illness/problem Patient experience, presentation and conceptualization of the illness 3. Experience and presentation of the disease 4. Conceptualization of the illness by the patient 5. Conceptualization of change by the patient Resources and resistance to change 6. Resources for change 7. Resistances to change Axis II -Interpersonal relations Perspective A: Patient experience The patient perceives himself as...The patient perceives others as... Perspective B: The perception of others (including of the researcher) Others perceive the patient as... Others perceive themselves as... Axis III -Conflict Repetitive dysfunctional conflicts 1. Individuation versus dependency 2. Submission versus control 3.The need for care versus self-sufficiency 4. Conflict of self-esteem 5with the outside world Attachment 4a.Internal objects 4b.External objects Axis V -Mental and psychosomatic disorders Mental disorders Main/additional diagnostics Personality disorders Main/additional diagnostics Adapted from Vicente et al. 3 a psychodynamic point of view, proposing therapeutic foci and treatment plans tailored to each patient, linking a cross-sectional diagnostic evaluation (five diagnostic axes) with a longitudinal evaluation (assessment of the process of change in each axis with treatment planning) and supporting a diagnostic and therapeutic classification of change in empirical investigations with a psychoanalytic focus. 1-6The OPD-2 is considered one of the main instruments for clinical diagnosis, planning, and scientific research in the international context.It's also used for training future psychotherapists.It is a rigorous and standardized psychodynamic diagnostic method with specific assessment criteria to facilitate communication in the scientific community and for applying research to clinical practice. 5In Germany and Switzerland, the OPD-2 is considered an essential resource for certifying the quality of interventions, both in the hospital setting and in the traditional clinic, to assess the evolution and progress of treatment, and from this point on provide a new plan and psychodynamic understanding of the patient. 3This diagnostic tool enables assessment, both quantitatively and qualitatively, of change variables (symptoms, relational patterns, conflicts, and structure), efficacy, and the therapeutic relationship in an operationalized form, and also adjustment of treatment planning; it therefore enables process and outcome research. 1

Figure 1 -
Figure 1 -Selection of articles included in and excluded from the systematic review.
from audio recordings of semi-structured interviews.Thus, Paulo & Pires, investigated the possibility of applying the instrument to psychoanalytic session notes of a patient when the follow-ups had already been completed.It proved possible to validate application of the OPD in this context.This type of assessment offers a more natural study that allows an independent assessment of the therapist, without the need to record the treatment; since recording can cause unnecessary anxiety in the patient and affect the treatment outcome.5It was also demonstrated that the OPD was sensitive for identifying the particularities of the patients and the construction of the conceptualization of the case (hypotheses, maintaining and precipitating influences of the psychological, interpersonal, and conflictual problems).4In the study byKehyayan et al., it proved possible to use the free association technique to identify unconscious conflict, with concurrent observation of neural behavior, along with psychological behavior; used to understand the structural functions of the personalities of depressive patients in terms of assessing their mental capacity for emotional regulation, cognitive abilities, internalized objects, and internal and external communication.In one study, it was observed that the structural level of personality function described in the OPD Structure Questionnaire (OPD-SQ) is associated with the quality of life of patients with depressive symptoms; data from the Chilean group study focused on the issue of depression because of its high prevalence in the country.Low levels of personality functioning correlated with high depressive severity and low quality of life.These results suggest a need to understand the detriment to quality of life of patients with depression, especially the most serious, in relation to their overall functioning of personality.10Also, the Chilean research group suggested that depression has a heterogeneous basis, requiring a different therapeutic plan for each patient.The severity of depressive symptomatology is influenced by the greater structural vulnerability of emotional self-regulation.13 et al. investigated depressive patients, and part of the sample also had personality disorder when assessed with the OPD (Axis IV) and OPD-SQ.It is noteworthy that both the OPD-SQ and the OPD Levels of Structural Integration Axis (OPD-LSIA) were useful for assessing the personality functioning of depressed patients with or without Personality Disorders according to DSM-IV diagnostic criteria. 14Regarding personality disorders, in studies conducted prior to publication of the DSM-5, Zimmermann et al.pointed out a possibility for better evaluation of these patients.They integrated the OPD perspective into the understanding of personality from the OPD-LSIA.The overall OPD-LSIA score was associated with severity of personality disorder, showing it to be a reliable and valid measure for assessment of personality structure.20 diagnosis of acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) it was observed that patients presented peculiar characteristics due to urban violence.The three patients assessed in the study by Both et al. from the perspective of the OPD-2 exhibited moderate subjective distress, with emotional and social difficulties, modifying their relational behavior: hypervigilance, and care of others as support.The main conflict was around the need for care versus self-sufficiency in the active and passive mode.Thus, they certify the attention and care they receive or givesubmissive or self-sufficient -with a desire for care and security or as a defense against them.Both participants demonstrated difficulty with mentalization and trying to remain stable by avoiding affection; nevertheless, there was emotional inflexibility.General assessment of patients using the OPD enriched the understanding of patients, facilitating comprehension of the clinical context of stress.9Only one study of eating disorders was found.These authors explored the psychodynamic diagnosis of 50 young women with eating disorders.The patients tended to perceive others as reproachful, controlling, belittling and neglectful.The predominant conflict was the need for care versus self-sufficiency.Most of the sample showed poorly integrated functioning.They pointed out that there is a need to consider the peculiarities of each patient, in addition to the nosological diagnosis.21 courses.For example, in Latin America, there is only an academic course in Santiago, Chile; which limits expansion of the pool of professionals who have access to and permission to use the OPD as a clinical and research tool.Chile was the first country in America to introduce the OPD-2.Chilean studies of note prior to this review include one by Pérez et al., in which they advanced understanding of the OPD and achieved excellent agreement among judges,22 and Chilean researchers are also a reference in studies with depressive patients and, more recently, with women who have been victims of domestic violence.6In Uruguay, Bernardi has made a relevant contribution in the area, with research that compares the personality diagnosis systems in the PDM, DSM, and OPD.23 In Argentina, relevant contributions to diagnosis of GADs have been made by Roussos.4Dimensional diagnosis in addition to descriptive diagnosis is a clinical necessity that facilitates both understanding of the subject and clinical planning, offering an assessment of the internal dynamics and the meaning of the symptomatology exhibited.
significant and the methods employed are diverse, but there is a growing body of data on topics such as applicability in different contexts and to different pathologies, promoting greater visibility and with greater representativeness of professionals who understand the instrument We emphasize the importance of investing in research on the subject and of setting up academic courses in different countries in order to promote greater visibility and development of knowledge in this area.There is a scientific effort in the development of assessment and interventional processes using psychodynamic constructs, under a multiaxial diagnosis, whose priority is to create empirical evidence of the use of OPD in different contexts, with different pathologies, and with adaptations and comparisons to various other techniques.The OPD-2 is being used in several different countries and cultures, such as Germany, England, Italy, Chile, Australia, Portugal, and Brazil, not all of which are represented in the studies selected for this review, and in different clinical contexts.The instrument provides a deeper understanding of the patient in terms of identification of the patient's psychic suffering (axis I), dysfunctional relational patterns (axis II), predominant motivational conflict (axis III) and structural conditions (axis IV), which is complementary to the description of the patient's symptoms.With regards to treatment, it is possible to determine the most appropriate treatment indication for the subject and to carry out treatment planning and define the focus of treatment.Finally, it also contributes to scientific research and communication, since it presents psychodynamic aspects codified in clear and specific worksheets, as well being useful for training future therapists.

Table 1 -
Description of the axes of the Operationalized Psychodynamic Diagnosis (OPD-2)

Table 2 -
Description of the selected articles