Operationalized psychodynamic diagnosis: a systematic review of the literature

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.

Keywords
Diagnosis; assessment; psychodynamics; review

Axes	Dimension	Indicator
Axis I - Illness experience and prerequisites for treatment	Objective assessment of illness/problem	1.Current severity of illness/ problem
	Objective assessment 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
	Resources and resistance to change	7. Resistances to change
Axis II - Interpersonal relations	Perspective A: Patient experience	The patient perceives himself as...
	Perspective A: Patient experience	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
		5. Conflict of guilt
		6. Oedipal conflict
		7. Identity conflict
	How the main conflict is handled	Predominantly active
		Mixed more active
		Mixed more passive
		Predominantly passive
Axis IV - Structure	Cognitive abilities	1a. Self-perception
	Cognitive abilities	1b. Perception of the object
	Regulation	2a. Self-regulation
	Regulation	2b. Regulation of the object relation
	Emotional communication	3a. Internal communication
	Emotional communication	3b. Communication with the outside world
	Attachment	4a. Internal objects
	Attachment	4b. External objects
Axis V - Mental and psychosomatic disorders	Mental disorders	Main/additional diagnostics
Axis V - Mental and psychosomatic disorders	Personality disorders	Main/additional diagnostics

Article	Objective	Method	Results	Conclusion
Alvarado⁷7. Alvarado L. Adherence to treatment in epilepsy. An assessment of subjective representations of Illness and psychodynamic conflicts [thesis]. Heidelberg: Institut für Psychosomatische Kooperationsforschung und Familientherapie der Universität Heidelberg; 2015.	To identify the psychodynamic and cognitive factors associated with adherence to medical treatment in non-refractory epileptic outpatients.	Non-experimental, comparative and cross-sectional study. 33 Chilean epilepsy patients (23 adherents, 10 non-adherents). Instruments: Morisky Medication Assessment Scale-4, OPD-2.	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 non-adherent 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.
Both⁸8. Both LM, Favaretto TC, Benetti SPC. Operationalized Psychodynamic Diagnosis (OPD-2) of an adolescent in conflict with the law. J Psychol Res. 2017;9:471-80.	To identify psychodynamic characteristics from an audio-recorded treatment session with an 18-year-old teenager in conflict with the law, serving detention Without the Possibility of External Activities.	Systematic case of an 18-year-old. Fonagy Mentalization-Based Treatment. Instrument: OPD-2. Analysis of a 45-minute session.	Median problem severity, but with almost no suffering. Experiences others as controllers, who disqualify and neglect him, thus, keeps to himself by maintaining distance; there are uncontrolled impulses and exposures to risk. Conflict: “need for care versus self-sufficiency”. Median structure level. ICD F91.	It was possible to develop a dimensional understanding of the adolescent, to complement the nosological diagnosis, from the OPD-2. The instrument was useful in assessment and treatment planning of adolescents in conflict with the law.
Both⁹9. Both LM, Malgarim BG, Freitas LH. Avaliação psicodinâmica de pacientes com Transtorno de Estresse Agudo e Pós-Traumático em uma instituição pública. “In press”.	To assess the psychodynamic functioning of patients with stress disorder through OPD-2, regarding the structure, intrapsychic conflict, and interactional pattern of the subject.	Cross-sectional quantitative study. Three patients with PTSD or ASD symptoms, selected by convenience. Instrument: OPD-2. Test-retest reliability.	Moderate level of subjective suffering, with limitations in daily activities. Excessive self-care and constant state of alert. Remains distant from others. Conflict: “need for care versus self-sufficiency”. Median structure level. ASD or PTSD.	OPD provided an understanding of the patients’ psychodynamic functioning in a clearer form that may facilitate the understanding of the clinical context of stress.
Crempien⁶6. Crempien C. Psychological and relational functioning in Chilean women victims of domestic violence, with different levels of childhood relational adversity [thesis]. Heidelberg/Santiago: Faculty of Behavioural and Cultural Studies, Heidelberg University/Pontificia Universidad Católica de Chile; 2012.	To characterize a Chilean sample of victims of domestic violence through an operationalized psychodynamic diagnosis, exploring structural functions, interpersonal dysfunctions and intrapsychic conflicts.	Non-experimental, correlational and cross-sectional study Instrument: OPD. 28 women from a care center for domestic violence victims in Santiago.	Women with greater severity of violence reported higher levels of depressive symptoms, PTSD and low education. Conflict: “need for care versus self-sufficiency”. Vulnerable structure level.	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.
Crempien¹⁰10. Crempien C, Grez M, Valdés C, López MJ, de la Parra G, Krause M. Role of Personality functioning in the quality of life of patients with depression. J Nerv Ment Dis. 2017;205:705-13.	To analyze the effects of personality functioning on the quality of life in depressed patients.	Cross-sectional, correlational study. 84 outpatients from Santiago, mean age 45 years, 89.3% women. Instruments: BDI, OPD-SQ and SF-36.	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.
Dagnino¹¹11. Dagnino P, De la Parra G, Jaramillo A, Crempien C, Padilla O, Gómez-Barris E, et al. El devenir del cambio: Cómo es y hacia dónde se dirige. Rev Arg Clin Psicol. 2014;23:23-40.	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.
Dagnino¹²12. Dagnino P. Focus in psychotherapy: characteristics and trajectories through the therapeutic process [thesis]. Heidelberg/Santiago: Faculty of Behavioural and Cultural Studies, Heidelberg University/Pontificia Universidad Católica de Chile; 2015.	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. Instruments: Generic Change Indicators, OPD-2, Heidelberg Structural Change Scale, Foci Presence Scale, Outcome Questionnaire.	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.
Dagnino¹³13. Dagnino P, Gómez-Barris E, Gallardo AM, Valdes C, De la Parra G. Dimensiones de la experiencia depresiva y funcionamiento estructural: ¿qué hay en la base de la heterogeneidad de la depresión? Rev Arg Clin Psicol. 2017;26:83-94.	To explore the association between structural functions and self-criticism and dependency dimensions of depressive experience.	Cross-sectional, non-experimental study. 43 Chilean depressive patients (83.7% women) Instruments: BDI, Depressive Experiences Questionnaire, OPD-SQ.	More severe depressive symptomatology, especially in the self-criticism dimension, is associated with worse structural functioning. Vulnerability in the self-regulation function was a predictor of depressive symptomatology.	The foundation of depression is heterogeneous, requiring different therapeutic strategies.
Dinger¹⁴14. Dinger U, Schauenburg H, Hörz-Sagstetter S, Rentrop M, Komo-Lang M, Klinkerfuß M, et al. Self-report and observer ratings of personality functioning: a study of the OPD system. J Person Assess. 2014;96:220-5.	To investigate the OPD classification of levels of personality functioning from different perspectives. To investigate the predictive value of classification of interviews for PD according to the DSM-IV.	79 clinical and 22 non-clinical depressive patients. Mean age 32 years, 70% women, 53% with comorbidity (PD). Measurements: OPD-LSIA corresponding to Axis IV from the Clinical Interview of the OPD. And OPD-SQ.	OPD-SQ correlated significantly with OPD-LSIA. The non-clinical classification was significantly lower than the depressive patients. OPD-SQ and OPD-LSIA were predictors for DSM-IV PDs.	There is agreement between OPD- LSIA and OPD-SQ regarding the assessment of personality functioning.
Doering¹⁵15. Doering S, Burgmer M, Heuft G, Menke D, Bäumer B, Lübking M, et al. Assessment of personality functioning: validity of the Operationalized Psychodynamic Diagnosis Axis IV (Structure). Psychopathology. 2014;47:185-93.	To evaluate the reliability and validity of the OPD-2 structure axis in 124 psychiatric patients.	124 psychiatric patients. Instruments: Structured Clinical Interview for DSM-IV, OPD-2.	The OPD-2 structure axis shows good interrater reliability. Patients with a PD showed significantly worse personality functioning than those without. In cluster B PD, personality functioning was more severely impaired than in cluster C PD.	The OPD-2 structure axis shows good reliability as well as concurrent and discriminant validity and can be recommended for clinical use and research purposes.
Gordon & Stoffey¹⁶16. Gordon R, Stoffey R. Operationalizing the psychodynamic diagnostic manual: a preliminary study of the psychodiagnostic chart. Bull Menninger Clin. 2014;78:1-15.	To evaluate the stability and validity of the PDC as an operationalization of the PDM.	104 subjects, 43 women, mean age 40.6 years. Instruments: MMPI-2; Karolinska Psychodynamic Profile; Axis IV from OPD.	The PDC contains the Overall Personality Organization Scale with 7 subscales and the Mental Functioning Scale with 9 subscales. Both were negatively correlated with MMPI-2, OPD, and the DSM-IV GAF scale (p<0.001).	PDC scales had high internal consistency, reliability and validity. The PDC can be used for diagnosis, treatment, psychodynamic formulation, outcome and process research based on PDM.
Juan⁴4. Juan S, Pescio N, Gómez Penedo JM, Roussos A. La conceptualización de un caso de trastorno de ansiedad generalizada (TAG) propuesta por terapeutas psicanalíticos. Análisis mediante los criterios del Diagnóstico Psicodinámico Operacionalizado 2 (OPD-2): resultados preliminares. Faculdad de Psicología – UBA, Secretaria de Investigaciones. Anu Investig. 2013;20:65-74.	To use the OPD-2 criteria for a secondary analysis of 15 psychoanalytic interviews conducted previously, using the multiaxial diagnostic classification.	15 psychoanalytic therapists, mean age 49 years, proposed prognostic inferences and a conceptualization of the case of a patient with GAD. Instrument: OPD-2.	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.	OPD-2 was useful in classifying key elements of the conceptualization process of a GAD case and was sensitive to identify patient’s particularities.
Kehyayan¹⁷17. Kehyayan A, Best K, Axmacher N, Kessler H. Neural activity during association to conflict-related sentences. Front Hum Neur. 2013;7:705.	To investigate the concept of “psychodynamic conflict” using a method of free association to potentially conflict-related contents inside a functional MRI scanner.	18 participants, 10 women, mean age of 25.9 years. Instruments: OPD – conflict sentences –, SCL-90, BDI and DSQ-40. 24 stimulus sentences: 6 were “neutral”, 6 were “negative”, 12 were “conflict-related”.	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.
Kessler¹⁸18. Kessler H, Schmidt AC, Hildenbrand O, Scharf D, Kehyayan A, Axmacher N. Investigating behavioral and psychophysiological reactions to conflict-related and individualized stimuli as potential correlates of repression. Front Psychol. 2017;8:1511.	Operationalizing repression using individualized experimental conditions, observing behavioral potential (memory and reaction time) and psychophysiological correlates (skin conductance response).	29 healthy women were invited to associate to cue sentences. Instrument: OPD.	The OPD interview enabled identification of the psychodynamic conflicts. Associations to conflict-related sentences were associated with longer reaction times and increased skin conductance responses.	The results were interpreted as possible correlates of repression. It is suggested that this experimental paradigm may serve to investigate repression in clinical populations.
Krieger²2. Krieger DV. Operationalized Psychodynamic Diagnosis 2: apresentação da versão brasileira e estudos preliminares de validade e confiabilidade [dissertação]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2013.	To present the Brazilian version of the OPD-2 and conduct initial studies of content validity, concurrent validity and inter-rater reliability with the Brazilian version of the OPD-2.	Content assessment. Reliability: inter-rater agreement and test-retest of 53 interviews of psychodynamic psychotherapy. Concurrent validity: compared OPD-2 items to the results of WHOQOL-bref and SCL-90-R.	The Brazilian OPD was created by adapting the Portuguese version. The content assessment considered the items clear in terms of language and theoretically pertinent. Axes III and IV showed greater inter-rater 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 & Pires⁵5. Paulo AMR, Pires AP. Operacionalização psicodinâmica de diagnóstico (OPD-2) numa psicanálise. Psicol Clin. 2013;25:163-78.	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.
Vicente³3. Vicente CS, Oliveira RA, Silva F, Ferrajão P, Augusto S, Oliveira S, et al. Cross-cultural adaptation of the operationalized psychodynamic diagnosis (OPD-2) in Portugal. Trends Psychiatry Psychother. 2012;34:129-38.	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.
Wiswede¹⁹19. Wiswede D, Taubner S, Buchheim A, Münte T, Stasch M, Cierpka M, et al. Tracking functional brain changes in patients with depression under psychodynamic psychotherapy using individualized stimuli. PLoS One. 2014;9:e109037.	To compare the changes in depressive patients’ brain reactions before and after eight months of psychodynamic psychotherapy.	Experimental study with 18 patients with major depressive disorder, mean age of 39.8 years, not on medication, who underwent MRI before (T1) and 8 months after (T2) psychodynamic psychotherapeutic treatment. A control group of 17 subjects who were tested twice without intervention, mean age of 38 years. Instruments: BDI, OPD.	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.
Zimmermann²⁰20. Zimmermann J, Ehrenthal JC, Cierpka M, Schauenburg H, Doering S, Benecke C. Assessing the level of structural integration using operationalized psychodynamic diagnosis (OPD): implications for DSM-5. J Person Assess. 2012;94:522-32.	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.
Zuccarino²¹21. Zuccarino ML, Zuglian P, Magni M, Rosseti A, Manna G, Gentile MG, et al. Eating disorder subtypes in a young female sample using the operationalized psychodynamic diagnosis system: preliminary results. Adolesc Psychiatry. 2012;2:333-44.	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.	50 young women with eating disorders. Instrument: OPD-2, Eating Disorder Inventory 2.	Most patients were subjectively experiencing psychological suffering. 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.	The existence of different subgroups of patients with eating disorders differing from each other in respect to psychodynamic features. These data suggest that tailoring therapeutic approaches to the patients’ individual profiles could improve outcomes.

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[1] Correspondence: Luciane Maria Both. Rua Ramiro Barcelos, 2350 90035-903 - Porto Alegre - Brazil E-mail: lucianeboth@gmail.com