Recent research published in General psychiatry provides evidence that improving an individual’s underlying personality functioning during treatment helps maintain improved mental health long after formal treatment ends. This study suggests that when patients experience improvements in their core abilities to regulate their emotions and relate to others, they are less likely to experience recurrence of depression, anxiety, and physical symptoms one year later.
Personality functioning is a psychological concept that serves as a structural framework for mental health. “Clinicians in the psychodynamic field work from the premise that symptoms often depend on something more fundamental: the ability to perceive oneself realistically, control emotions, and maintain contact with others, which is usually summarized as personality structure or, more commonly, personality functions,” said Jürgen Huschber, a researcher at the Department of Psychoanalysis and Psychotherapy at the Medical University of Vienna.
Disorders in this area often make it difficult to cope with stress. These problems are often associated with various psychiatric problems such as depression and anxiety.
In the context of psychotherapy, mental health professionals seek to understand how changes in these deeply ingrained personality traits influence symptoms that become more pronounced over time. Past research has shown that therapy can improve personality functioning. “In general, I have been interested in applying quantitative empirical methods to psychodynamic theory for some time,” Fushbar said. “The data from the samples examined in this study gave us the opportunity to really look deeper into some very interesting questions in this regard.”
Past studies have attempted to measure these changes, but have often struggled to pinpoint individual progress. “Early studies using these data showed that personality functioning and symptoms changed simultaneously during treatment,” Dr. Fuschber said. “While these results are valid and answer a different question than the one asked here, the method used did not allow us to separate stable differences between patients from variation within a single patient over time, as a random-intercept cross-lagged panel model could.”
This advanced statistical approach allowed the team to separate temporary, dynamic changes from a person’s general baseline characteristics. Scientists were particularly interested in the transition from care.
“We were also interested in what happens after hospital discharge, when the supportive effects of the therapeutic relationship wear off and patients are forced to rely on their own regulatory abilities,” Fuschbar explained. It is relatively easy for patients to feel better while in a highly supportive hospital environment. The real challenge often comes after patients are discharged from the hospital, when they must rely on their own internal coping skills.
To investigate these dynamics, scientists analyzed data from an existing large-scale project known as the Inpatient Psychosomatic Psychotherapy Treatment Multicenter Effectiveness Study. The study included 2,094 participants receiving mental health care at 19 different university hospitals in Germany. The sample was 68% female, with an average age of nearly 40 years. Patients received day admission or full inpatient treatment. Treatment includes a variety of approaches such as cognitive behavioral therapy and psychodynamic therapy.
The researchers tracked participants across three different time points. The first measurement was taken at baseline when the patient was admitted to the hospital. The second measurement was taken at hospital discharge after an average of approximately 50 days of treatment. Finally, a third measurement was taken at the 1-year follow-up time point.
At each time point, participants completed a series of standardized questionnaires. To measure personality functioning, the researchers used a 12-item self-report survey that assessed impairments in self-perception and relationship models. Higher scores on this survey indicate more severe impairment.
The research team also measured three specific categories of psychopathology. They used a widely recognized nine-item questionnaire to assess the severity of depressive symptoms. A similar 7-item survey was used to assess generalized anxiety. Finally, physical symptoms were measured using a 15-item questionnaire. Somatic symptoms are physical problems, such as pain or fatigue, that cause significant distress and can be associated with psychological stress.
The researchers applied complex statistical models to examine how variations in these variables interacted with each other over time. They controlled for factors such as age, gender, and length of hospital stay. During the active treatment phase, from admission to discharge, scientists did not find that changes in personality functioning predicted changes in symptoms.
“The treatment context turned out to be very important,” Hookschuber told Scipost. “During hospitalization or day clinic treatment, patients’ personality functioning did not predict how their symptoms progressed. Symptom changes at that stage were instead more strongly linked to depressive symptoms at the time of admission.”
Patients with higher initial depression scores tended to have less improvement in personality functioning. High baseline depression also predicts worse physical symptoms and increased anxiety at discharge.
The treatment environment itself appears to provide patients with the support they need, reducing the immediate need for internal coping skills. “A plausible interpretation is that the clinic itself provides considerable external structure and regulation, so individual differences in self-regulation matter less while patients are hospitalized, but become considerably more important once they become independent,” Fuschbar explained.
The most striking pattern emerged after the end of treatment, from discharge to 1-year follow-up. “After I was discharged from the hospital, things changed,” Fushbar said. “During that period, where patients were in their personality functioning at the end of treatment predicted their depression, anxiety, and physical symptoms one year later.”
If a patient’s personality functioning remains poorer than the individual average at the time of discharge, they are significantly more likely to experience increased depression, anxiety, and somatic symptoms one year later. On the other hand, patients who achieved above-average improvement in personality functioning by the end of their hospitalization tended to maintain symptom relief.
Additionally, depression at discharge strongly predicted increases in both anxiety and somatic symptoms 1 year later. This indicates that prolonged depressive symptoms can have far-reaching negative effects on a person’s overall physical and mental health long after treatment has ended. Interestingly, higher anxiety at admission predicted modest decreases in depression and somatic symptoms by discharge. The authors suggest that this may be a statistical anomaly caused by the overlapping nature of anxiety and depression, and that temporary spikes in anxiety may trigger compensatory coping mechanisms.
These interrelated findings provide concrete guidance for mental health professionals. “While we need early attention to treatments that suggest symptoms of depression, personality functioning is relevant to whether growth continues in the following year,” Fuschbar notes. “But of course, these are statistical patterns within large clinical samples and do not guarantee an individual course of treatment.”
Several limitations should be considered when interpreting these results. A notable issue is the amount of missing data at the 1-year follow-up. Nearly 40% of the initial patients did not complete the final questionnaire. Patients whose mental status worsens after discharge may be less likely to respond to follow-up surveys, potentially skewing long-term estimates.
The complex statistical model used in this study estimates many variables at once. Because of this complexity, some of the observed pathways were relatively small. The authors suggest that these specific long-term predictions need to be replicated in independent studies before clinical guidelines are formally changed.
Future research may investigate precisely which types of therapeutic interventions are most effective in improving personality functioning. Understanding these mechanisms may help mental health professionals tailor treatments to build deeper and more lasting coping skills in patients. Monitoring personality functioning throughout treatment may help clinicians identify individuals who may require more intensive aftercare.
The study, “How personality features shape symptom expression during and after treatment: A random-intercept cross-lagged panel analysis,” was conducted by Jürgen Fuchshuber, Henrik Kessler, Aram Kehyayan, Magdalena Pape, Tobias Hofmann, Matthias Rose, Katrin Imbierowicz, Franziska Geiser, Ilona Croy, Kerstin Weidner, Jörg Rademacher, Silke Written by. Michalek, Eva Morawa, Yesim Elim, Martin Teufel, Alexander Bauerle, Stanislav Heinzmann, Klaas Rahman, Eva Milena. Johanne Peters, Johannes Kruse, Dirk von Boetticher, Christoph Hermann-Lingen, Mariel Nehle, Martina de Zwaan, Ulrike Dinger, Hans-Christoph Friederich, Alexander Nieke, Christian Albus, Rüdiger Zwerenz, Manfred Bag, Casper Loenneberg, Peter Henningsen, Barbara Stein, Christiane Waller, Carsten Hake, Carsten Spitzer, Andreas Stengel, Stefan Ziffel, Katja Weimer, Harald Gündel, Stefan Herpertz, Stefan Doering.
