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Von Der Tann, Mattias and Cierpka, M and Grande, T and Rudolf, G and Stasch, M
(2007) The operationalized psychodynamic diagnostics system. Clinical relevance,
reliability and validity. Psychopathology, 40 (4). pp. 209-220. ISSN 0254-4962

© 2007 Marcus Von der Tann

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 Original Paper

Psychopathology 2007;40:209–220 Received: May 30, 2005

Accepted after revision: February 23, 2006
DOI: 10.1159/000101363
Published online: March 29, 2007

The Operationalized Psychodynamic

Diagnostics System: Clinical Relevance,
Reliability and Validity
M. Cierpka T. Grande G. Rudolf M. von der Tann M. Stasch and the OPD Task Force1
Institut für Psychosomatische Kooperationsforschung und Familientherapie, Zentrum für Psychosoziale Medizin,
Universitätsklinikum Heidelberg, Heidelberg, Germany

Key Words Operationalization of Psychoanalytic Constructs

Operationalized psychodynamic diagnostics

Psychoanalytic constructs
Diagnostic reliability Classification schemes have been employed interna-
tionally to diagnose mental illness since 1980. The Diag-
nostic and Statistical Manuals (DSM) of the American
Abstract Psychiatric Association and the International Classifica-
In this paper, we present a multiaxial system for psychody- tion of Mental and Behavioral Disorders (ICD) of the
namic diagnosis, which has attained wide usage in Germany World Health Organization have attained wide usage.
in the last 10 years. First we will discuss the 4 operationalized Thus, communication among diagnosticians worldwide
psychodynamic diagnostics (OPD) axes: illness experience has been simplified because areas of agreement and dif-
and treatment assumptions, relationships, mental conflicts, ference have been transparent. Psychodynamic psycho-
and structure, then clinical applications will be outlined. Fo- therapists who see conflict and relationship problems as
cus psychodynamic formulations can be employed both causative for patients’ symptoms regret, however, the lack
with inpatients and with outpatients. Studies show good re- of relevance of the phenomenological and symptom-cen-
liability in a research context and acceptable reliability for tered diagnoses of ICD and DSM. These therapists, such
clinical purposes. Validity will be separately summarized as as the Group for the Advancement of Psychiatry in its
content, criterion, and construct validity. Validity studies in- statement in the American Journal of Psychiatry, call for a
dicate good validity for the individual axes. Numerous stud- multidimensional perspective of human problems in the
ies on the OPD indicate areas of possible improvement, for classification of mental disorders. In addition to the as-
example for clinical purposes the OPD should be more prac- sessment of symptoms, a psychodynamic formulation is
tically formulated. Copyright © 2007 S. Karger AG, Basel needed to explain the key developments of the patient on
the basis of intrapsychic and interpersonal mechanisms.
A further motive for the development of an addition-
al operationalized psychodynamic diagnosis system
emerged from the dissatisfaction of psychiatrists with the
1
Members of the Executive Committee and authors are Manfred divergence of psychoanalytic theory. Freud began to un-
Cierpka, Reiner W. Dahlbender, Harald J. Freyberger, Tilman Grande, derstand personality with the help of drive theory, ego,
Gereon Heuft, Paul L. Janssen, Franz Resch, Gerd Rudolf, Henning
Schauenburg, Wolfgang Schneider, Gerhard Schüssler, Michael Schulte- id, and superego and thus created the basis of psychoana-
Markwort, Michael Stasch, Matthias von der Tann. lytic classification. In case conceptualization, drive theo-

© 2007 S. Karger AG, Basel Prof. Dr. med. Manfred Cierpka

0254–4962/07/0404–0209$23.50/0 Institut für Psychosomatische Kooperationsforschung und Familientherapie
Fax +41 61 306 12 34 Zentrum für Psychosoziale Medizin, Universitätsklinikum Heidelberg
E-Mail [email protected] Accessible online at: Bergheimerstrasse 54, DE–69115 Heidelberg (Germany), Tel. +49 6221 56 47 01
www.karger.com www.karger.com/psp Fax +49 6221 564 702, E-Mail [email protected]
ry, ego psychology and object relations theory are still medicine, and psychiatrists, was founded in 1990 in Ger-
used to differentiate personality. In the initial interview many. The goal was to broaden the ICD-10 classification,
and in history taking, psychotherapists use a multitude which is oriented to symptoms and descriptions, to in-
of (meta)-psychological categories to describe mental clude fundamental psychodynamic dimensions. This
functions and their disorders. Many of these metapsy- working party developed a diagnostic inventory as well as
chological theories were formulated in such an abstract a handbook [9] for experienced therapists for training and
way that they are more or less detached from clinical phe- clinical purposes. The OPD system is based on 4 psycho-
nomena and cannot be applied. This development doubt- dynamically relevant diagnostic axes with appropriate
lessly leads to theory heterogeneity and to confusion of categories to complement ICD classification:
concepts in psychoanalysis. Axis I: Experience of illness and prerequisites for treat-
There is already experience of psychotherapy research- ment
ers in the operationalization of relevant psychoanalytic Axis II: Interpersonal relations
constructs. Bellak and Hurvich [1] already attempted to Axis III: Conflicts
operationalize ego function and developed rating scales Axis IV: Structure
to enable judgment of the ego function as observed in Axis V: Syndromal, according to chapter V (F) of
clinical interviews. A series of research instruments as- ICD-10
sume that behavior patterns are not only represented During an initial 1- to 2-hour patient examination, the
with others but above all in the therapeutic relationship clinician (or external observer) evaluates the patient’s
and thus the empirical assessment of transference rela- psychodynamics and fills this in on the OPD evaluation
tionships is possible [2–4]. In psychotherapy research, sheet. There are interview guidelines to ensure the rele-
operationalization of conflict [5, 6] and of defense mech- vant information is obtained. These are flexible enough
anisms [7] has also been attempted. for the interview to be conducted as an open psychody-
Weinryb and Rössel developed a more comprehensive namic interview.
approach to achieve a psychodynamic profile based on op-
erationalized psychoanalytic constructs [8]. The 18 sub-
scales of the Karolinska Psychodynamic Profile were for- Brief Discussion of the Axes
mulated with the goal of comprehensively assessing men-
tal function and personality traits as they are reflected in Axis I: Experience of Illness and Prerequisites for
a patient’s perception of himself and his relationships with Treatment
others. The subscales are formulated on different levels of Items relating to this axis concern the patient’s moti-
abstraction, and the interpretation required for each sub- vation and the indications for psychodynamic psycho-
scale also varies. It is clear that psychodynamic operation- therapy. Items are judged on a scale – absent (0), low (1),
alization cannot remain at the behavioral level, but inter- medium (2), high (3). There is also a category unassess-
pretation contributes to the judgment, since mental/intra- able. The individual diagnostic dimensions are filled into
psychic conflict cannot be directly observed. a glossary. Anchor examples are used with the intention
to improve diagnostic reliability.
1 Severity of somatic illness
The Operationalized Psychodynamic Diagnostics 2 Severity of mental illness
System 3 Patient’s subjective suffering
4 Impairment of self-experience
The Operationalized Psychodynamic Diagnostics 5 Secondary benefit illness
(OPD) system is intended as an empirical and theory-in- 6 Extent of physical impairment/disability
dependent instrument which promotes communication 7 Comprehending and accepting psychodynamic and
within psychoanalysis and with related disciplines. An psychosomatic associations
important aspect, therefore, was the agreement in the 8 Comprehending and accepting psychodynamic so-
OPD group regarding the extent to which indirect conclu- matopsychic associations
sion, for example unconscious components, are permitted 9 Evaluation of appropriate treatment (psychotherapy)
in the clinical evaluation of behavior patterns. A working 10 Evaluation of appropriate treatment (medical treat-
group: Operationalized Psychodynamic Diagnosis, con- ment)
sisting of psychoanalysts, specialists in psychosomatic 11 Motivation for psychotherapy

210 Psychopathology 2007;40:209–220 Cierpka/Grande/Rudolf/von der Tann/

Stasch
12 Motivation for physical treatment The categories come from the tradition of the inter-
13 Compliance personal circle model, and depict relationships regarding
14 Presentation of symptoms affection and control [10, 13–15].
15 – somatic symptoms to the fore Diagnostic integration of various experience perspec-
16 – mental symptoms to the fore tives enables the description of habitual behavior pat-
17 Psychosocial integration terns, although emphasis is on dysfunctional patterns, as
18 Personal resources is commonly the focus in psychotherapies.
19 Social support
20 Appropriateness of subjective impairment related to Axis III: Conflicts
the severity of the illness. OPD distinguishes seven mental conflicts and has a
This axis illustrates the experience that illness course category for limited conflict perception:
is not only determined by syndrome and symptoms but 1 Dependence vs. autonomy
by the subjective and social context of the affected per- 2 Submission vs. control
son. Social support and personal understanding of the 3 Desire for care vs. autarchy
illness have a great influence on the course, especially 4 Conflicts of self-value
with regard to the psychotherapeutic treatment options. 5 Guilt conflicts
6 Oedipal sexual conflicts
Axis II: Interpersonal Relations 7 Identity conflicts
Mental disorders are ‘relationship disorders’, thus tra- 8 Limited perception of conflicts and feelings
ditional interpersonal behavior is central for the genesis These seven basic conflicts and the last category (e.g.
and maintenance of mental disorders. Representation of with somatizing patients) are judged on the basis of ideal-
dysfunctional or maladaptive behavior has therefore be- type descriptions according to presence (dimensional
come the focus of psychodynamic and psychotherapeutic evaluation from ‘not present’ to ‘present and not signifi-
research in recent years [3, 4, 10]. Lifelong ‘accumulation’ cant’ to ‘present and significant’ to ‘present and very sig-
of relationship experience in the form of cognitive affec- nificant’). Furthermore, for each patient the two main
tive schemata [11, 12] is therefore the foundation for what areas of conflict (category value) is given. Description of
in psychoanalysis is conceptualized as transference and the basic conflicts and their method of processing occurs
countertransference. in the OPD system in connection with central life areas
The basic structure of the OPD relationship axis de- such as relationship to partner, family of origin, profes-
picts the circular or the transactional character of human sion, ownership, behavior in groups and illness experi-
interaction (interchange of subjective experience and re- ence. Not only lasting conflicts but also other major con-
sponse to the environment). A framework was developed flict can arise in response to acute life-changing stressors.
which encapsulates subjective experience concerning self If such stressors cause the conflict, there is an appropriate
and others on the initial level. On a second level, it is pos- category and long-lasting conflicts should not be rated.
sible to represent the experience of this other person (sig- Conflict can be judged in history-taking on the basis
nificant other, interviewer): how is the patient experi- of perceived behavior and experience ways (scene, trans-
enced by his objects or the interviewer and which im- ference, countertransference) and manifest themselves
pulses does he generate in them? The construction of the on subject and object level (inner mental) and in interac-
OPD instrument is achieved from the following two per- tion with others. Conflicts are often connected to prom-
spectives: how does the patient experience himself in re- inent affect (e.g. anger in narcissistic disorders). There is
lationships? The interviewer judges behavior patterns as a glossary for the conflicts in various forms (active or
experienced by the patient vis-à-vis others. How does the passive) in different life areas as well as a checklist.
patient experience the behavior of others? The OPD conflict definitions are illustrated on the ba-
The therapist also evaluates transference and counter- sis of the passive modality of desire for care vs. autarchy:
transference from these two perspectives: how does the In the passive mode, the patient is strongly bound to
therapist experience the initiation of the relationship other people and expresses wishes concerning security
through the patient? How does the therapist experience and care. Separation and rejection are responded to with
himself in the relationship to the patient? depressive mood and/or fear. The patient is very depen-
Items of the OPD relationship axis help to define the dent and needy. In the countertransference, the therapist
variety of behaviors seen in relationships. experiences worry, blackmail and helplessness. Intimate

Operationalized Psychodynamic Psychopathology 2007;40:209–220 211

Diagnostics System
relationships are organized that separation appears im- sire for care vs. autarchy, r = 0.24 (p ! 0.05); guilt conflict,
possible (e.g. financial linkage) and can be characterized r = 0.19 (n.s.); self- vs. object value, r = –0.23 (p ! 0.05);
by claustrophobic closeness. Grasping tendencies are re- dependence vs. autonomy, r = –0.61 (p ! 0.01). This
actively defended by frequently changing relationships. means that the dependence vs. autonomy conflict is very
Need to be looked after means that the patient remains frequently associated with a lower level of structure. With
long and excessively loyally in the family of origin. In regard to the correlations between the axes relationship
professional life, the patient seeks accomplices and help- and structure, two groups with low and high levels of
ers, professional demands are understood as withdrawal structure were tested according to the clustering of the
of support and responded to with depression. In social relationship items within different octants of the inter-
situations, the patient seeks caring relationships, and is personal circumplex model. The results show significant
regarded as demanding and tiring by others due to his correlations between the lower level of integration and
wishes and demands. In times of illness, the patient shows modes of devaluation and isolation, whereas in the high-
a passive, grasping expectant approach to the doctor and er-level group modes of protection and clinging were
is difficult to rehabilitate. found significantly more frequent. The relations between
the axes conflict and relation are complex and specific for
Axis IV: Structure each conflict.
OPD differentiates four levels of structure (well inte-
grated, moderately integrated, low, disintegrated). Good
integration means that an autonomous self possesses a Status or Process Diagnosis: Focus Possibilities
mental internal space in which mental conflicts can be
carried out. Moderate integration implies lower availabil- OPD diagnostics can be used as status diagnostics in
ity of regulating function and a weaker differentiation of personality or psychotherapy research. The individual
mental substructures. With low integration, the mental OPD axes are judged concerning the dysfunctional pat-
inner space and substructures are less developed, thus tern of the relationship (axis I), the life-determining con-
conflicts are barely mentally worked out, but are mainly flicts (axis II), and the integration of the personality
worked out in the interpersonal sphere. Disintegration is structure (axis IV). These psychodynamic dimensions
characterized by fragmentation and psychotic restitution complete the ICD-10 syndromal description (axis V).
of structure. Axis I is especially suitable for patient populations con-
Operationalization of structure is based on 6 struc- cerning their subjective experience and their suitability
tural categories: for psychotherapy. Status diagnostics on the individual
1 Self-perception OPD axes or with the full OPD system are especially use-
2 Self-regulation ful where a standardized psychodynamic point of view
3 Defense from individual patients or samples and, for example,
4 Object perception with personality diagnostics should be coupled with oth-
5 Communication er approaches.
6 Bonding Apart from research-oriented status diagnostics, the
For each structural category, the manual allows deter- most important goal of the OPD system is in the clinical
mination of the level of integration. Finally the structur- therapeutic area. The OPD findings can supply the clini-
al profile as well as the total structural level can be deter- cian with information to aid in deciding on differential
mined. Additionally there is a checklist for each item and therapy indication and treatment planning [18]. Axis I
every subcategory for the rating [16]. can help clarify the patient’s basic assumptions regarding
eventual psychotherapy. Judgments of structure level
(axis IV) are decisive for the choice of suitable psycho-
Relations between the Axes therapy methods above all regarding the alternative be-
tween more supportive structural or meaning-uncover-
In a study on 81 patients [17] the relations between ing processes, as well as in particular circumstances for
axes II–IV were investigated. The following correlations deciding between in- or outpatient psychotherapy. OPD
between the overall score of the level of structure and a findings can also indicate the topics to be worked on in
given conflict could be shown: oedipal conflict, r = 0.45 psychotherapy: dysfunctional relationship patterns (axis
(p ! 0.01); submission vs. control, r = 0.37 (p ! 0.01); de- II) in the sense of pathogenic beliefs require special ther-

212 Psychopathology 2007;40:209–220 Cierpka/Grande/Rudolf/von der Tann/

Stasch
apeutic attention and interventions so that therapy does process and success from a specific psychoanalytic point
not fail due to complications in the therapeutic relation- of view [31].
ship. By stressing the most prominent conflicts (axis III) This logic is especially developed for the determina-
and/or the most prominent structural deficiencies which tion of the focus and therapy in axis IV, but there are also
illuminate vulnerability and available resources to be concrete recommendations for therapeutic work [31, 32],
taken into account, therapy goals can be identified and thus in a broader sense it is a therapy manual. Some re-
therapeutic planning can be derived on the basis of the search has already been done on the clinical implementa-
assessment. tion of an OPD axis II-based treatment approach in inpa-
The psychotherapeutic consequences of OPD diag- tient psychotherapy [33–35]. One study [33] aimed to ex-
nostics are especially concrete in the logic of focus formu- plore the effects of a systematic focus conference and
lation and the formulation of therapy goals related to this. relationship-focused intervention in comparison to the
In clinical research projects such as the Practice Study of ‘treatment as usual’. The modified relationship-focused
Analytic Longtime Therapy [19–22], this process was treatment produces better improvements not in the symp-
used and evaluated in an outpatient setting. Determina- tomatic, but in the interpersonally oriented outcome
tion of a dynamic relationship focus in the therapist group measures (Inventory of Interpersonal Problems, IIP;
also allows team-centered behavior vis-à-vis the patient GARF). Moreover, significant changes were achieved in
on the ward [23, 24]. shorter treatment duration.
On the basis of individual OPD diagnostics, therapeu-
tic foci can be named. The causative characteristics which
maintain the disorder and therefore play a decisive role in Reliability Measures (Axis I–IV)
the psychodynamics of the clinical picture are the foci of
therapy. It seems that 5 foci are enough [19, 20, 22, 25] to In developing OPD, we tried to operationalize central
capture the different aspects of a disorder; it appears ad- concepts of psychodynamic diagnostics using empirical
vantageous to choose one relationship focus and at least and simple criteria to enable objective and reliable judg-
one conflict (the most prominent conflict assessed in axis ment of patients, but not at the expense of essential con-
III) and one structure focus (the most prominent struc- tent. The outcome was a diagnostic system which requires
tural deficiency assessed in axis IV). In the research proj- complex clinical judgments but which can be learned
ects, independent observers interviewed the patients at through intensive training. As experience shows, apart
regular intervals to assess their development concerning from training the quality of the data assessed as well as
the foci; in the practice projects, the therapists chose both the clinical training and professional experience play an
foci and arranged treatment. In contrast to traditional important role in the quality of the evaluations.
psychoanalysis, which retrospectively describes often un- In a study [36] with 269 patients from 6 psychosomatic
desired developments of the patient (and emphasizes that clinics, the reliability of OPD axes I–IV was investigated.
these should be allowed to happen without therapeutic Since rater conditions were different from clinic to clinic,
intervention), the OPD group employs the logic that the it was also possible to determine which conditions im-
therapist and the patient determine together at the begin- prove or do not improve reliability. The measure used was
ning of treatment the important psychodynamic foci for weighted kappa [37]. For axes I, III and IV in the fixing of
the particular problem and choose the suitable therapeu- the weighting, equal distance was assumed between each
tic approaches to restructure these foci. of the 4 stages of the rating scales; in this way, a kappa
The Heidelberg Structural Change Scale [26] was de- value was obtained which can be similarly interpreted to
veloped to differentiate therapeutic change in OPD find- a Pearson correlation coefficient [38]. A weighted kappa
ings above and beyond the simple dichotomy of present/ was also reckoned for axis II. In this case, this procedure
not present. This scale is related to the Assimilation of corresponds to that described in the Structural Analysis
Problematic Experiences Scales [27] and allows through of Social Behavior (SASB) [10]. The standard deviation
its fine gradations a quantitative weighting of therapeutic weights are according to a procedure of circumplex mod-
change in each individual focus [28, 29]. Furthermore, a els as described by Grawe-Gerber and Benjamin [39].
structure [16] and a conflict checklist [30] were devel- Interviews that were conducted for diagnostic purpos-
oped which simplify the judgment of these two dimen- es and video-recorded were independently rated and
sions for the clinician. Use of these instruments especial- showed good reliability values. For axis II, these condi-
ly allows a differentiated description of the therapeutic tions were obtained for 2 of 6 clinics; kappa values were

Operationalized Psychodynamic Psychopathology 2007;40:209–220 213

Diagnostics System
Table 1. Empirical studies on reliability and validity

OPD Axes Criterion Concurrent/ Predictive validity Construct validity Clinical validity Reliabilty
validity concordant validity

Axis I: Experience Franz et al., Franz et al., 2000 [47] Franz et al., 2000 [47] Schneider et al., 2002 [18] Cierpka et al.,
of illness and 2000 [47] von Wietersheim, 2001 [36]
prerequisites Schneider et al., 2000 [48]
for treatment 1998 [46]
Schneider et al.,
2002 [18]

Axis II: Inter- Schneider et al., Leising et al., 2000 [51] Stasch and Cierpka, Grande et al., 1998 [17] Grande et al., 2001 [29] Cierpka et al.,
personal relations 2002 [18] 2000 [54] Stasch et al., 2004 [50] Grande et al., 2003 [25] 2001 [36]
Grande et al., 2004 [20] Rudolf et al.,
Grünberger et al., 2001 [34] 1996 [61]
Rudolf et al., 2002 [22] Stasch et al.,
Schneider et al., 2002 [18] 2002 [40]
Stasch et al., 2005 [33]
Stasch, 2003 [23]
Stasch, 2004a [24]
Stasch, 2004b [35]
Wilmers et al., 2005 [31]

Axis III: Conflicts Schneider et al., Grande et al., 2002 [63] Strauss et al., 1997 [65] Grande et al., 1998 [17] Grande et al., 2001 [29] Cierpka et al.,
2002 [18] Leising et al., 2000 [51] Rudolf et al., 1996 [61] Grande et al., 1998 [71] Grande et al., 2003 [25] 2001 [36]
Müller, 1999 [59] Grande et al., 2004 [20] Rudolf et al.,
Rudolf et al., 1996 [61] Rudolf et al., 2002 [22] 1996 [61]
Schneider et al., 2002 [18] Rudolf et al., 2004 [70]
Zlatanovic, 2000 [60] Schneider et al., 2002 [18]
Wilmers et al., 2005 [31]

Axis IV: Structure Schneider et al., Grande et al., 2002 [63] Rudolf et al., 1996 [61] Grande et al., 2000 [28] Grande et al., 2001 [29] Cierpka et al.,
2002 [18] Grütering and Schauenburg Grande et al., 1998 [17] Grande et al., 2003 [25] 2001 [36]
[in press] Grande et al., 2004 [20] Rudolf et al.,
Nitzgen and Brünger, Rudolf et al., 2002 [22] 1996 [61]
2000 [66] Rudolf et al., 2004 [70]
Reymann et al., 2000 [67] Rudolf, 2004 [32]
Rudolf et al., 1996 [61] Schneider et al., 2002 [18]
Schauenburg, 2000 [68] Wilmers et al., 2005 [31]

from 0.62 to 0.56 [40]. The reliability of axis III was ex- In these 2 clinics, mean reliability values for all 4 axes be-
amined in a single clinic under these conditions. A mean tween 0.30 and 0.50 were obtained. These values corre-
value of 0.61 was achieved for all 9 conflicts of this axis; spond approximately to the results of an earlier OPD prac-
the range was 0.48–0.71. The reliability values for axis IV ticability study by Michels et al. [44], which was also con-
was the best. In 2 clinics for all 6 structure dimensions ducted under the conditions of clinical routine.
mean reliability, values of 0.71 (range 0.62–0.78) and 0.70 In another clinic, the ratings took place likewise on the
(range 0.60–0.81), respectively, were achieved. To date basis of videotaped interviews; however, the raters were
there have been no investigations of axis I based on re- clinically inexperienced students. Here the mean values
corded diagnostic interviews. for axis II were 0.42, for the conflict axis 0.33 and for the
According to Fleiss [41] and Chicchetti [42], kappa structure axis 0.55. Since these students had undergone
values between 0.40 and 0.59 can be judged as fair and the standard training, it can be assumed that clinical in-
values between 0.60 and 0.74 as good. Higher values are experience is disadvantageous for the OPD rating. Ac-
deemed excellent. This corresponds approximately to the cording to these studies at least 2–3 years clinical experi-
evaluations of Landis and Koch [43], although the latter ence are necessary for an adequately reliable use of
set the value for excellent somewhat higher at 0.80. Thus, OPD.
the reliability values for axis II and axis III are fair or In summary, the reliability for axis II and axis III are
good, for axis IV good or excellent. satisfactory and for axis IV good, when the judgment is
In 2 of the 6 clinics, the interviews were conducted un- based on interviews conducted under research condi-
der the conditions of clinical routine. This means the in- tions. Concerning the reliability in clinical routine, it
terviews were conducted rather pragmatically with lim- should be noted that ICD-10 is also only moderately reli-
ited time resources. Ratings were performed by the inter- able in clinical day-to-day use [44].
viewer and a second rater who was present in the interview.

214 Psychopathology 2007;40:209–220 Cierpka/Grande/Rudolf/von der Tann/

Stasch
 Validity sible and confirms the constructs on which the axes are
based.
Axis I In summary, these results illustrate the high clinical rel-
Criterion Validity evance of axis I. They allow statements about capacity and
To assess criterion validity of the axes, only partial test readiness of the patient to engage in psychotherapeutic-
methods with a related question are available which can psychosomatic intervention. On this basis, specific inter-
serve as outside criteria. The ‘Fragebogen zur Psycho- ventions can be undertaken as required which serve to pre-
therapiemotivation’ [45] shows at least in part a content pare the patient for psychotherapy in a narrower sense.
that is highly related to items or characteristics of axis I.
There are good indications for the clinical validity of axis Axis II
I from the results of different clinical disorders, treatment Concurrent Validity
settings and age groups [46]. Axis I discriminates these The diagnostic window of the OPD relationship axis
groups according to the previously formulated expecta- is related to dysfunctionalities in interpersonal areas. The
tions. Older patients or those from psychosomatic con- IIP [49] and the SASB [10] are recognized as valid meth-
sultation-liaison service have less insight into psychody- ods for this criterion area and were therefore introduced
namic and psychosomatic associations and less motiva- for the purposes of concurrent validity (in the sense of an
tion for psychotherapy and higher motivation for physical internal criterion-related validity) [50]. The resultant va-
treatments. Franz et al. [47] were able to determine that lidity coefficients are acceptable with a mean correlation
the psychosomatic and physical limitations as well as the of 0.21 for a comparison of a self- vs. observer-rated meth-
difficulties in communication, as assessed by the OPD, od. In another study [51], the question of how well the
are found in the SCL-90 R. OPD relationship diagnosis and the independent results
of the SASB are in accordance with the relationship epi-
Predictive Validity sodes as represented in the OPD interviews was ad-
To investigate the predictive validity, psychotherapy dressed. It was shown that in the OPD relationship diag-
inpatients were examined before and after treatment, and nosis there was a higher than chance concordance with
parallel to this SCR-90 R and IIP were determined. The the SASB rating of the individual episodes. Furthermore,
best predictor of therapy success was the characteristic it can be deduced that the judgment of the experience
mental symptom presentation of axis I. perspective of the patient (perspective A) in OPD axis II
is oriented to the way of behavior most commonly named
Construct Validity by the patient.
Factor analyses were performed to test the construct
validity of axis I [47]. A three-factor model with the Predictive Validity
components insight, resources and body-related items For an interpersonal understanding of psychopathol-
explained 54% of the variance. Another factor analysis ogy, it is relevant of what quality relationship fantasies
[48] yielded five factors (break off criterion eigenvalue and treatment readiness are in the current interpersonal
!1) which explained 68% of the variance. Factor I (so- relationships of the patient. The wishes the patient brings
matic experience and illness processing) comprises se- to the relationship are notably less flexibly described than
verity of the somatic findings, extent of physical disabil- the reaction of the interaction partner [52]. Cierpka et al.
ity as well as the physical symptom expression and a [53] proved that the rigidity of the interpersonal wishes
rather physically oriented treatment motivation. Factor is positively associated with the degree of psychopathol-
II (mental experience and illness processing) contains ogy. Assuming the circular variance of the behavior clus-
limitation through physical symptoms and self experi- ter pictured by the OPD circumplex model, 100 psycho-
ence as well as motivation for psychotherapy. Factor III therapy inpatients were examined regarding change in
(capacity for insight) represents the insight capability of interpersonal flexibility [54]. Individual diagnostic sub-
the patient for psychodynamic, psychosomatic and so- groups were separately compared before and after exam-
matopsychic associations. The fourth factor (resources ination and the correlations of interpersonal outcome
and support) comprises the items for psychosocial inte- were calculated. It was shown that for affectively dis-
gration and support. The last factor (compliance) con- turbed persons (n = 28) and patients with adjustment dis-
sists of compliance and secondary illness gain (nega- orders (n = 13) the increase in interpersonal flexibility is
tively correlated). This factor analysis seems very plau- positively associated with symptomatic improvement.

Operationalized Psychodynamic Psychopathology 2007;40:209–220 215

Diagnostics System
For the subgroup of depressive patients, the Pearson cor- ambivalent attachment (increased dependence, impul-
relation for a one-tailed p was 0.02 between symptomatic sive-unstable and increased neediness) and avoidant at-
improvement (measured by the Global Severity Index tachment (anxious-avoidant, rational-controlled and in-
GSI of the SCL-90 R) and change in interpersonal vari- creased striving for autonomy) can be distinguished. Fif-
ability 0.39. The group with adjustment disorder had r = ty-five women with personality disorders were examined
0.57 and p (one tailed) = 0.02; for those with anxiety dis- according to the OPD and the Attachment Prototype
orders (n = 12) there was, however, an opposite trend. In Rating [59]. The rater concordances for the autonomy de-
this group, the symptomatic improvement correlated pendence conflict as well as for the care vs. autarchy con-
negatively with an increase in variability (r = 0.42, one- flict (kappa = 0.56) could be judged as good. Since this
tailed p = 0.08). This means that patients with anxiety was a sample of very sick patients, there were, as expected,
disorders benefit from increasing rigidity in interperson- no securely attached patients, 22% were ambivalent, 31%
al self-experience; a finding that can be explained through avoidant and 47% showed a mixed attachment pattern.
increasing self-expression and definition from the wishes The more ambivalent the attachment-style, the more
of others. These results show that the OPD relationship prominent was the conflict care vs. autarchy; the more
diagnostics and the emerging measures thereof are ca- avoidant the attachment-style, the more prominent was
pable of discriminating between different diagnostic the conflict autonomy vs. dependence and the less was
groups concerning symptomatic outcomes. the conflict care vs. autarchy. In the global rating of the
security of the attachment, it was clear that the more se-
Construct Validity cure the attachment was judged to be, the more the con-
The OPD relationship diagnostic is based on the so- flict care vs. autarchy was prominent, and the less secure
called circumplex model of interpersonal behavior [13, the attachment, the more prominent the conflict auton-
15], which has a long tradition in personality, social and omy vs. dependence. These results give initial indications
clinical psychology and has been accordingly validated. for the validity of the conflict differentiation autonomy/
As various authors have shown [55, 56], the circumplex dependence vs. care/autarchy. In a study from Ulm [60],
model is a good predictive model and represents a nomo- there was good agreement of the OPD conflicts with the
logical network which can be used for construct valida- Core Conflictual Relationship Theme [3] in 44 psycho-
tion. The construct validation was assumed on the basis therapy inpatients. The investigations in Heidelberg and
of the German version of the IIP, the circumplex struc- Münster [46, 61] showed predominance of conflicts I–IV.
ture of which has been empirically proven [50]. The re- On the other hand, more of the conflict-limited percep-
sults relate to the sample described under Concordant tion of conflicts and feelings is associated with greater
Validity. It was shown that the majority of the OPD rela- physical impairment; this finding also supports the de-
tionship axis clusters conform to the construct, i.e. are scription of the conflicts. To validate the concept of the
circular and possess specific interpersonal content. In a typical leading affect as described in axis III, a study from
criterion-specific comparison between the relationship Leising et al. [51] used the methods already described: on
axis and IIP, some content differences were shown re- the basis of a clinical emotion list [62] a frequency profile
garding some behavior and experience clusters. of self-reported affective experience was produced. An
independent rater had the task of comparing this profile
Axis III with the information on the 2 most important conflicts
Concordant Validity and the mode. By chance, a further foreign emotion was
For the validation through other methods of the con- included. In 13 attempts, correct allocation occurred 9
cordant validity of the unconscious conflicts described in times (p = 0.087). The authors conclude that the relation-
the OPD, there was a basic problem: there are no other ship between mental conflict and the predominance of
instruments which assess unconscious conflict in a gen- certain leading affects is at least not as clear as assumed
erally approved way [57]. The bonding styles assessed in in the OPD manual. A further validation study [63] in a
adults can be compared with individual conflicts, in par- sample of 48 psychosomatic inpatients correlated estima-
ticular with conflict I autonomy vs. dependence and con- tions of conflict using the Scale of Psychological Capaci-
flict III care vs. autarchy. Both conflicts deal with the ties (SPC) from Wallerstein [64]. In contrast to the OPD,
basic conflict topic of attachment; however, with different in the SPC apart from structural vulnerabilities which
manifestations. According to the Attachment Prototype comprise the content of the OPD structure axis, habitual
Rating [58] three main categories of secure attachment, modes of conflict processing or defense formation are

216 Psychopathology 2007;40:209–220 Cierpka/Grande/Rudolf/von der Tann/

Stasch
also assessed and subsumed under the term ‘structural tained by the first mentioned study with respect to con-
capacity’. For these subscales of the SPC, significant as- cordance with ICD-10 diagnoses. Patients who had ICD
sociations with individual OPD conflicts were found, for diagnoses of neuroses (mean = 1.97) showed themselves
example a correlation of r = 0.41, p ! 0.01 between the to be better structured than patients with personality dis-
SPC scale moralism and the conflict submission vs. con- orders (mean = 2.37, p ! 0.01). Rudolf et al. [61] showed
trol or a correlation of r = 0.37, p ! 0.05 between the SPC that a lower structural level is associated with longer du-
scale attribution of responsibility and the conflict guilt. ration of mental illness (–0.38, p = 0.06), which may be
In total, 5 of 7 associations which were surmised on the due to the structurally determined poorer regulation of
basis of a conceptual comparison of the scales could be these patients. To the second group of validation studies,
significantly proven. which chose inner validity criteria, belongs a study of
Schauenburg [68]. In this study, 49 consecutively admit-
Predictive Validity ted psychotherapy inpatients were examined. Secure at-
In 30 psychotherapeutically treated in patients, there tachment (Pilkonis attachment diagnosis; –0.30, p =
were no essential associations between prominent con- 0.05) as well as excessive striving for independence
flicts and treatment success, with the exception of the (–0.29, p = 0.06) were associated with better structural
conflict category deficient conflict and feeling percep- level, whilst borderline traits (0.27, p = 0.08), excessive
tion, which was obtained in none of the patients of the autonomy strivings (0.32, p = 0.03) and antisocial traits
group with pronounced treatment success [65]. In the in- (0.55, p = 0.00) were associated with poorer structural
vestigation of Rudolf et al. [61], the patients with predom- level. In the same sample, Grütering and Schauenburg
inant autonomy vs. dependence had less success. The [69] compared with independent judgments the scales of
conflicts oedipal/sexual conflicts and control vs. submis- the Karolinska Psychodynamic Profile with the dimen-
sion on the other hand showed a positive association with sions of the structure axis and found expected correla-
treatment success. tions concerning content: the capacity of self-control was
In conclusion, it can be determined that the scientific associated with the scales intimacy and tolerance of frus-
difficulties in the testing of the validity are great since for tration. Likewise there was an association between high-
every conflict there are only external criteria or appropri- er integration and object perception or communication
ate encircling test methods to assess whether unconscious and the capacity to experience intimacy. In the study of
conflicts are not present. The conflict systematics is prac- Grande et al. [63], the SPCs were compared with the
ticable and useful for training and for clinical questions. structural characteristics measured by the OPD. There
To date, examined individual conflicts show good concor- were numerous associations which were to be expected
dance and differentiation with related tests. Adequate con- on the basis of a conceptual comparison of the scales of
nection between the defined operationalized conflicts and both instruments e.g. a correlation of r = 0.30, p ! 0.05
the construct dynamic conflict can therefore be assumed. between the OPD scale drive and the dimension self-con-
trol. Furthermore there was a significant concordance
Axis IV between low structure level according to OPD and the
Concordant Validity SPC scales emotional blunting (r = 0.41, p ! 0.01) and
A number of studies dealt with the agreement between rarely able to rely on others (r = 0.43, p ! 0.01). These two
structure evaluation and other concurrently obtained items relate more than other items of the SPC to the in-
data. Nitzgen and Brünger [66] examined 137 male pa- terpersonal capacity of a person and are therefore espe-
tients with chronic substance abuse at the start of an in- cially related to the theoretical concept of the OPD struc-
patient admission and showed that these patients had the ture axis, which places the capabilities and vulnerabili-
poorest values in the area of self-control (mean = 2.2; 2 ties of the self in its relationship to others in the center of
corresponds to moderate, 3 to poorly integrated). This the structural analysis.
result was also theoretically expected since this structure
area comprises among others the aspects tolerance of af- Predictive Validity
fect and impulse control. These findings are confirmed The already mentioned study of Rudolf et al. [61] ad-
by a study of Reymann et al. [67] where structural weak- dresses the predictive validity. The structure evaluation
ness in self-control as well as in object perception was at the beginning of inpatient treatment was shown to be
ascertained in 22 alcohol-dependent males on a detoxifi- a very good predictor of the treatment success as judged
cation ward. Further indications of validity were ob- by both the patient (0.30) and the therapist (0.40, p !

Operationalized Psychodynamic Psychopathology 2007;40:209–220 217

Diagnostics System
0.05). The view of the individual structure dimensions development of the OPD system is directed towards im-
indicates that bonding capability (patient, 0.42; therapist proving focus formulation and the therapy goal defini-
0.46, p ! 0.01) is especially relevant for the prediction. tion and thus the clinical applicability, so the system can
Obviously, the capacity to imbue others with positive af- be more used in day-to-day practice. The new OPD-II
fect is a good guaranty for the success of the interperson- version was published in spring 2006 [73].
al therapeutic project. An operationalization of psychodynamic diagnostics
can overcome the boundaries of a purely descriptive psy-
Construct Validity chiatric classification and use the advantages of an op-
Regarding construct validity, a Heidelberg study erationalization of empirical psychodynamic constructs
showed in a factor analysis (unpublished) that the items in association with the phenomenological diagnostic.
are weighted on a single main factor with a very high ei- The OPD can:
genvalue. The internal consistency of 0.87 for the struc- 1 Give clinical-diagnostic guidelines for clinical use,
ture dimension and 0.96 for the structure foci points in a which because of relative openly formulated diagnos-
similar direction. These results also indicate that struc- tic criteria (guidelines) allow the user some freedom.
ture concerns an essentially unidimensional construct The OPD contributes thus to greater transparence in
and the various parts of structure act independently. Since the sense of quality assurance.
according to theoretical and clinical understanding struc- 2 Be very useful for psychodynamic psychotherapy
tural constitution represents a durable and stable person- training, since the operationalized mental phenomena
al characteristic, the construct validity of the structure are empirically formulated so the psychodynamic and
axis is also supported by the fact that an inpatient com- phenomenological classification can be practiced.
parison before and after a 12-week treatment showed sta- 3 Be used as a research instrument, to contribute to
ble structural values (for structure, in total a pre- and more homogenization of trial samples through strict-
posttreatment concordance of 84.4% was found) [28]. er diagnostic criteria.
In summary, the OPD structure axis according to cur- 4 Contribute to better communication within the scien-
rent experience seems suitable to describe a psychody- tific community (in a broader and a narrower sense)
namically conceptualized and interpersonal point of concerning psychodynamic constructs. Through clear-
view in the sense of object relations theory personality ly improved reliability, the OPD contributes to better
structure [70, 71]. communicability of psychodynamic formulations.
These studies on the validity of the OPD show that the The richness but also the limitations of the OPD diag-
OPD axes show no clear significant associations with the nostics are illustrated in the judgment of a videotaped
symptom diagnosis according to ICD-10. This corre- case and discussion thereof. The OPD is aimed to be no
sponds to the function of the OPD as an additional psy- more than a basic compendium of the relevant psychody-
chodynamic-diagnostic level. The reliability of the indi- namic constructs, which are allocated to 4 axes. The OPD
vidual axes as well as the validity studies underpin the manual provides only the basis for the clinical discussion,
empirical basis of the instrumentarium if used as a re- which is highly valued, however, by many clinics. Psycho-
search instrument. therapists with little experience have a basis for further
training. More complex psychoanalytic theories and de-
tailed psychoanalytic case conception can be built on the
Conclusion basis of the OPD.
Experience with the OPD system to date shows that
Since the OPD manual was published in 1996, many the constructed axes are practicable and reliable for clin-
psychotherapists have become acquainted with it and ical use in very different treatment fields. The working
have used it. Various translations are available. In 2003, group understands the operationalization of psychody-
the German child and adolescent version was published namic diagnostics as a process that should contribute to
[72]. More than 3,000 therapists have been trained in the further clarification and differentiation of the underlying
different training centers in German-speaking countries. constructs both in practice and in research.
In various psychosomatic clinics, abuse clinics, univer-
sity departments for psychotherapy and psychosomatics,
the OPD is used in research projects, but also in the clin-
ical day-to-day practice [18]. Current work on the further

218 Psychopathology 2007;40:209–220 Cierpka/Grande/Rudolf/von der Tann/

Stasch
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