Schema therapy for borderline personality disorder: a comprehensive review of its empirical foundations, effectiveness and implementation possibilities

STAT: schema therapy for addiction treatment, a proposal for the integrative treatment of addictive disorders

The nature and origins of addictions and of their adjunctive behaviors, as well as their chronicity, call for treatments that conceptualize and treat them as the long-term and complex processes that they are. Addictions are often comorbid with personality problems and with trauma histories. Patients suffering from these disorders often show poor engagement with treatment and high rates of relapse, possibly because available treatments have yet to address the patient suffering from addiction in a more integrated or holistic manner. In particular, comprehensive treatment models for addictive disorders - like treatments for personality disorders or trauma - are likely to require the integration of behavioral, cognitive, and emotion-focused interventions within a facilitative therapeutic relationship. However, most current treatment models, including ones which are highly effective in stabilization or behavioral change, lack one or more components of treatment that could sustain longer term recovery, wellness, and health for a higher percentage of patients. In this article, I propose approaching addictions and their treatment from the perspective of schema therapy, an integrative, developmental model with a strong track record of positive outcomes in addressing personality disorder symptoms and long-standing trauma histories, commonly comorbid with addictive disorders. In advancing this proposal, I begin by providing some background tying together addictions, attachment, and personality, suggesting they be treated simultaneously to achieve improved outcomes. Then, after briefly reviewing the leading approaches to the treatment of addictions, I introduce the idea that schema therapy is well-situated - both theoretically and practically - to address many of the shortcomings of existing treatment options. In particular, I note how addictive and co-occurring colluding behaviors are deeply intertwined with both early and continued frustration of core developmental needs. I illustrate how the addictive cycle is perpetuated through the process of schema reinforcement and through the operation of schema modes. I then demonstrate how these key terms (i.e., needs, schemas, and modes) inform the patient's assessment and case formulation, guiding treatment interventions from a strong therapeutic relationship that focuses on integrating recovery behavior change, healing dysfunctional schemas and modes, and preventing relapse.

A Model of Core Emotional Needs and Toxic Experiences: Their Links with Schema Domains, Well-Being, and Ill-Being

This study examined the second-order schema domains of Early Maladaptive and Adaptive Schemas based on recent trends and compared them with the five theoretical second-order schema domains commonly used in schema therapy. Using six international Eastern and Western community samples-Singapore (n = 628), Malaysia (n = 229), USA (n = 396), South Africa (n = 390), Nigeria (n = 364), India (n = 306)-confirmatory factor analysis showed that the four second-order domains of EMSs and EASs, which ran almost parallel with each other, were the most robust models calling into question the validity of the five domain model. Given the hypothesized links between schemas and needs, these four categories of EMSs and EASs represent four categories of toxic experiences and core emotional needs, respectively. These categories were supported empirically and are useful to parents as well as to clinicians as they approach child rearing and the treatment of clients in schema therapy from the vantage point of needs. These four categories of psychological core emotional needs, as well as toxic experiences, were found, as expected, to be linked with various measures of well-being and ill-being.

Early maladaptive schemas and behavioural addictions: A systematic literature review

As observed in other mental health difficulties, behavioural addiction is a complex construct with several potential predisposing factors, which include biological factors (e.g., genetic predispositions), psychological factors (e.g., personality traits), and social factors (e.g., family, and social history). One factor that may play a significant role in both developing and perpetuating behavioural addiction is the activation of early maladaptive schemas (EMSs). The aim of the present review was to synthesize the evidence concerning the relationship between behavioural addiction and EMSs. A comprehensive literature search using keywords and subject headings was performed with three electronic databases, resulting in 20 studies that met the inclusion criteria. In relation to specific behavioural addiction, the 20 studies examined: binge-eating/food addiction (n = 6), sexual addiction/compulsive sexual behaviours (n = 3), multiple addictive behaviours (n = 2), internet addiction (n = 2), smartphone addiction (n = 2), social networking/Facebook addiction (n = 2), exercise dependence (n = 1), gambling (n = 1), and videogame addiction (n = 1). The patterns of association between EMS and behavioural addiction were examined in both clinical and non-clinical population. The 'Disconnection and Rejection' domain was the most strongly related schema domain across all addictive behaviours, followed by 'Impaired Limits'. The present review suggests a positive relationship between schema activation and several addictive behaviours, including addictions to gambling, gaming, social media use sex, exercise, and food. The clinical implications of the findings are discussed, but further research is needed to inform treatment plans and interventions for those who struggle with behavioural addictions.

Assessing the relationship between early maladaptive schemas and interpersonal problems using interpersonal scenarios depicting rejection

BACKGROUND

Early maladaptive schemas (EMSs) have been theorised to contribute to reoccurring interpersonal problems. This study developed a novel experimental paradigm that aimed to assess if EMSs moderate the impact of interpersonal situations on interpersonal responses by manipulating the degree of rejection in a series of interpersonal vignettes depicting acceptance, ambiguous rejection and rejection.

METHOD

In a sample of 158 first-year psychology students (27.2% male; 72.2% female; 0.6% other) participant responses to interpersonal scenarios were measured including degree of perceived rejection, emotional distress, conviction in varying cognitive appraisals consistent with attribution theory and behavioural responses to scenarios. Qualitative data was analysed using inductive content analysis and statistical analyses were conducted using multi-level mixed effect linear and logistic regression models using the software Jamovi.

RESULTS

People reporting higher EMSs reported increased emotional distress (F(1, 156) = 24.85, p < .001), perceptions of rejection (F(1, 156) = 34.33, p < .001), self-blame (F(1, 156) = 53.25, p < .001), other-blame (F(1, 156) = 13.16, p < .001) and more intentional (F(1, 156) = 9.24, p = .003), stable (F(1, 156) = 25.22, p < .001) and global (F(1, 156) = 19.55, p < .001) attributions but no differences in reported behavioural responses. The results also supported that EMSs moderate the relationship between interpersonal rejection and perceptions of rejection (F(2, 1252) = 18.43, p < .001), emotional distress (F(2, 1252) = 12.64, p < .001) and self-blame (F(2, 1252) = 14.00, p < .001).

CONCLUSION

Together these findings suggest that people with EMSs experience increased distress and select negative cognitions in situations where there are higher levels of rejection but that distress and negative cognitions are generally higher in people with EMSs irrespective of the situation.

The efficacy of schema therapy for personality disorders: a systematic review and meta-analysis

OBJECTIVE

Personality disorders (PDs) are prevalent and associated with functional impairment and psychological disability. Studies suggest that schema therapy (ST) may be an effective treatment for PDs. This review aimed to evaluate the efficacy of ST in treating PDs.

METHOD

We conducted a comprehensive literature search using PubMed, Embase, Web of Science, CENTRAL, PsycInfo, and Ovid Medline. We identified eight randomized controlled trials (587 participants) and seven single-group trials (163 participants).

RESULTS

Meta-analyses revealed that ST had a moderate effect size (g = 0.359) compared to control conditions in reducing symptoms of PDs. Subgroup analysis indicated that the effect of ST on different types of PDs varied slightly, and that group ST (g = 0.859) was more effective than individual ST (g = 0.163) in treating PDs. Secondary outcome analysis revealed a moderate effect size (g = 0.256) for ST compared to control conditions in improving quality of life, and ST was found to reduce early maladaptive schema (g = 0.590). Single-group trials analysis showed that ST had a positive effect on PDs (OR = 0.241).

CONCLUSION

ST appears to be an effective treatment for PDs, as it reduces symptoms and improves quality of life. This review provides support for the use of ST in the treatment of PDs.

Early Maladaptive Schemas and Schema Modes in clinical disorders: A systematic review

PURPOSE

Although schema therapy has been predominantly applied to treat personality disorders, interest into its application in other clinical disorders is growing. Central to schema therapy are Early Maladaptive Schemas (EMS) and Schema Modes. Since existing EMS and Schema Modes were primarily developed in the context of personality disorders, their relevance for clinical disorders is unclear.

METHODS

We conducted a systematic review of the presence of EMS and Schema Modes in clinical disorders according to DSM criteria. Per disorder, we evaluated which EMS and Schema Modes were more pronounced in comparison with clinical as well as non-clinical control groups and which EMS and Schema Modes were most highly endorsed within the disorder.

RESULTS

Although evidence concerning EMS was scarce for several disorders, and only few studies on Schema Modes survived inclusion criteria, we identified meaningful relationships and patterns for EMS and Schema Modes in various clinical disorders.

CONCLUSIONS

The present review highlights the relevance of EMS and Schema Modes for clinical disorders beyond personality disorders. Depending on the theme of the representation, EMS act as vulnerabilities both across diagnoses and for specific disorders. Thus, EMS and resulting Schema Modes are potential, valuable targets for the prevention and treatment of clinical disorders.

Uncovering the Social-Cognitive Contributors to Social Dysfunction in Borderline Personality Disorder Through Language Analysis

Borderline personality disorder (BPD) is characterized by severe interpersonal dysfunction, yet the underlying nature of such dysfunction remains poorly understood. The present study adopted a behavioral approach to more objectively describe the social-cognitive contributors to interpersonal dysfunction in BPD. Participants (N = 530) completed an online survey comprising validated measures of BPD features and other problematic interpersonal traits (e.g., narcissism), as well as a writing prompt where they were asked to share their personal thoughts about relationships. Computerized language analysis methods were used to quantify various psychosocial dimensions of participants' writing, which were incorporated into a principal component analysis. Analyses revealed four core social dimensions of thought: (1) Connectedness/Intimacy; (2) Immediacy; (3) Social Rumination; (4) Negative Affect. All four dimensions correlated with BPD features in intuitive ways, some of which were specific to BPD. This study highlights the value of natural language analysis to explore fundamental dimensions of personality disorder.

Music performance anxiety: the role of early parenting experiences and cognitive schemas

Music Performance Anxiety (MPA) is a common challenge for classical musicians, however its etiology has received minimal research, particularly in regards to caregiver experiences during childhood and adolescence. The aim of this research was to explore the impact of childhood experiences with parents along with patterns of dysfunctional cognitive schemas that develop through childhood ('Early Maladaptive Schemas'; EMSs) on the manifestation and severity of MPA in adulthood. Study 1 employed 100 adult professional, amateur, and tertiary student classical musicians from across Australia. Participants completed the Young Schema Questionnaire (YSQ) and the Kenny Music Performance Anxiety Inventory (K-MPAI). Study 2 included eight participants from Study 1, five of whom scored 1.5 standard deviations or more above the mean K-MPAI score and three of whom scored 1.5 standard deviations or more below the mean K-MPAI score. Participants were interviewed about experiences of parenting during childhood and adolescence, along with their experiences of MPA and musical training. Interpretative phenomenological analysis was used to explore themes in the interview data. Study 1 factor analysis revealed four higher-order EMS factors, F_{(4, 95)} = 13.74, p < 0.001, one of which was a significant predictor of MPA, t₍₉₉₎ = 3.06, p = 0.003. This factor comprised themes of failure, catastrophising, and incompetence/dependence. Study 2 qualitative analysis revealed various key parenting themes experienced in childhood that differentiated low- and high-MPA scorers in adulthood. Findings from both studies are discussed in light of clinical applications and interventions, and implications for both parents and music educators.

Individual psychotherapy for cluster-C personality disorders: protocol of a pragmatic RCT comparing short-term psychodynamic supportive psychotherapy, affect phobia therapy and schema therapy (I-FORCE)

BACKGROUND

Cluster-C personality disorders (PDs) are highly prevalent in clinical practice and are associated with unfavourable outcome and chronicity of all common mental health disorders (e.g. depression and anxiety disorders). Although several forms of individual psychotherapy are commonly offered in clinical practice for this population, evidence for differential effectiveness of different forms of psychotherapy is lacking. Also, very little is known about the underlying working mechanisms of these psychotherapies. Finding evidence on the differential (cost)-effectiveness for this group of patients and the working mechanisms of change is important to improve the quality of care for this vulnerable group of patients.

OBJECTIVE

In this study, we will compare the differential (cost)-effectiveness of three individual psychotherapies: short-term psychodynamic supportive psychotherapy (SPSP), affect phobia therapy (APT) and schema therapy (ST). Although these psychotherapies are commonly used in clinical practice, evidence for the Cluster-C PDs is limited. Additionally, we will investigate predictive factors, non-specific and therapy-specific mediators.

METHODS

This is a mono-centre randomized clinical trial with three parallel groups: (1) SPSP, (2) APT, (3) ST. Randomization on patient level will be pre-stratified according to type of PD. The total study population to be included consists of 264 patients with Cluster-C PDs or other specified PD with mainly Cluster-C traits, aged 18-65 years, seeking treatment at NPI, a Dutch mental health care institute specialized in PDs. SPSP, APT and ST (50 sessions per treatment) are offered twice a week in sessions of 50 min for the first 4 to 5 months. After that, session frequency decreases to once a week. All treatments have a maximum duration of 1 year. Change in the severity of the PD (ADP-IV) will be the primary outcome measure. Secondary outcome measures are personality functioning, psychiatric symptoms and quality of life. Several potential mediators, predictors and moderators of outcome are also assessed. The effectiveness study is complemented with a cost-effectiveness/utility study, using both clinical effects and quality-adjusted life-years, and primarily based on a societal approach. Assessments will take place at baseline, start of treatment and at 1, 3, 6, 9, 12, 18, 24 and 36 months.

DISCUSSION

This is the first study comparing psychodynamic treatment to schema therapy for Cluster-C PDs. The naturalistic design enhances the clinical validity of the outcome. A limitation is the lack of a control group for ethical reasons.

TRIAL REGISTRATION

NL72823.029.20 [Registry ID: CCMO]. Registered on 31 August 2020. First participant included on 23 October 2020.

A Systematic Review of the Heterogeneity of Schema Therapy

We aimed to explore the heterogeneity of schema therapy regarding (a) patient characteristics, (b) content, and (c) way of delivering schema therapy. A search was conducted of the electronic databases EMBASE, PsycINFO, Web of Science, MEDLINE, and COCHRANE up to June 15, 2022. Treatment studies were eligible if they (a) used schema therapy as (component of) the intervention examined, and (b) reported an outcome measure quantitatively. A total of 101 studies met the inclusion criteria, including randomized controlled trials (n = 30), non-randomized controlled trials (n = 8), pre-post designs (n = 22), cases series (n = 13), and case reports (n = 28), including 4006 patients. Good feasibility was consistently reported irrespective of format (group versus individual), setting (outpatient, day-treatment, inpatient), intensity of treatment, and the specific therapeutic components included. Schema therapy was applied to various (psychiatric) disorders. All studies presented promising results. Effectiveness of the different models of schema therapy as well as application beyond personality disorders should be examined more rigorously.

Are the schema modes suitable for explaining borderline and narcissistic behaviours?

Jeffrey Young assumes that people suffering from personality disorders differ from healthy ones in schema modes intensity but not diversity. Besides, healthy people also present behaviours typical for personality disorders, but to a lesser extent. However, research lacks the interrelationships between modes, especially in healthy individuals. The presented study aimed to investigate the mutual relations between the schema modes using path analysis to understand better problematic behaviour in borderline and narcissistic types in a non-clinical sample and to verify Young assumption about the continuum of the schema modes. A sample of 467 healthy adults aged 18–50 (M = 32.87, SD = 10.56), 52.9% of whom were women, completed SMI 1.1 and SCID-II. Descriptive statistics, matrix of correlation and structural equation modelling were used. Results confirmed the significance of the theoretically assumed and previously empirically proved schema modes also for healthy people. The most important modes for both borderline and narcissistic behaviours are the Punitive Parent, the Angry Child and the Enraged Child modes. For borderline behaviour, the Detached Protector coping mode, connected to a sense of emptiness, is significant. Narcissistic behaviour relates to Bully and Attack, and Self-Aggrandiser modes and is connected to aggressive and dominant behaviour. The obtained models explain 47% of the variance in borderline and 44% in narcissistic behaviours. The study indicates the validity of analysing the modes among people with lower intensity of behaviours typical for personality disorders and also confirms Young’s assumptions about the universality of schema modes. Results are discussed in the context of their relevance for practitioners.

A Systematic Review of Scientific Studies on the Effects of Music in People with Personality Disorders

Personality Disorders (PDs) are psychiatric conditions involving maladaptive personality traits and behaviours. Previous research has shown that musical preferences and the use of music may be related to personality traits. Additionally, music therapy is increasingly being used as a treatment option for people with PDs. Using the PRISMA guidelines, a systematic literature search was undertaken using three databases: PubMed, Web of Science, and PsycInfo. The following search terms were used: PubMed: "personality disorder" AND (music OR "music therapy"); Web of Science (advanced search): TS = (personality disorder) AND TS = (music or "music therapy"); PsycInfo: "personality disorder" AND (music OR "music therapy"). A total of 24 studies were included in this review and summarised into four categories: music preference, music therapy, music performance, and music imagery, all in relation to PDs or traits associated with PDs. The analysis found that individuals with personality traits associated with PDs may prefer different types or genres of music or interact with music differently than those without these traits. Additionally, music therapy (MT) was found to offer a potentially useful treatment option for PDs. The power of these findings was limited by the small number of included studies. This review offers a useful foundation upon which further research looking at MT as a potential treatment option for PDs can be built.

The Use of Computer-Driven Technologies in the Treatment of Borderline Personality Disorder: A Systematic Review

The objective of this study was to perform a systematic review of the effectiveness of computer-driven technologies for treatment of patients suffering from BPD. A systematic literature review was conducted using the Pubmed, EMBASE, PsycNET (PsycINFO), CINAHL and Google Scholar electronic databases for the period from their inception dates until 2022. Thirty studies were selected for abstract screening. Seven studies were excluded for not meeting inclusion criteria. The remaining 23 studies were fully assessed, and 12 were excluded. Therefore, 11 studies were included in the analysis of the effectiveness of computer-driven technologies, which encompassed mobile applications, telehealth interventions, internet-based interventions, virtual reality MBT and dialogue-based integrated interventions. Computer-driven interventions are showing signs of effectiveness in the treatment of BPD symptoms. The limited number of articles found on the subject demonstrates a need for further exploration of this subject.

An Explorative Study of Atypical Social Interaction Styles in Adult Men with Autism Spectrum Disorder, Men with Personality Disorders and Men from the General Population

Different atypical social interaction styles (SISs) were defined and tested in children and adolescents with autism spectrum disorder (ASD). Whether these styles can also be distinguished in adults with ASD has not yet been explored. In men with ASD, men with personality disorder (PD), and men from the general population (N = 90), aged 18-65 years, we tested which SISs can be distinguished and how they relate to the presence of PD traits. We found a significant distinction in allocation to atypical SISs between the three groups. This study shows the presence of atypical SISs in adults with ASD, and complements previous SIS findings in children and adolescents with ASD.Trial registration The Netherlands National Trial Register NTR6391. Registered 04 May 2017.

Towards optimal treatment selection for borderline personality disorder patients (BOOTS): a study protocol for a multicenter randomized clinical trial comparing schema therapy and dialectical behavior therapy

BACKGROUND

Specialized evidence-based treatments have been developed and evaluated for borderline personality disorder (BPD), including Dialectical Behavior Therapy (DBT) and Schema Therapy (ST). Individual differences in treatment response to both ST and DBT have been observed across studies, but the factors driving these differences are largely unknown. Understanding which treatment works best for whom and why remain central issues in psychotherapy research. The aim of the present study is to improve treatment response of DBT and ST for BPD patients by a) identifying patient characteristics that predict (differential) treatment response (i.e., treatment selection) and b) understanding how both treatments lead to change (i.e., mechanisms of change). Moreover, the clinical effectiveness and cost-effectiveness of DBT and ST will be evaluated.

METHODS

The BOOTS trial is a multicenter randomized clinical trial conducted in a routine clinical setting in several outpatient clinics in the Netherlands. We aim to recruit 200 participants, to be randomized to DBT or ST. Patients receive a combined program of individual and group sessions for a maximum duration of 25 months. Data are collected at baseline until three-year follow-up. Candidate predictors of (differential) treatment response have been selected based on the literature, a patient representative of the Borderline Foundation of the Netherlands, and semi-structured interviews among 18 expert clinicians. In addition, BPD-treatment-specific (ST: beliefs and schema modes; DBT: emotion regulation and skills use), BPD-treatment-generic (therapeutic environment characterized by genuineness, safety, and equality), and non-specific (attachment and therapeutic alliance) mechanisms of change are assessed. The primary outcome measure is change in BPD manifestations. Secondary outcome measures include functioning, additional self-reported symptoms, and well-being.

DISCUSSION

The current study contributes to the optimization of treatments for BPD patients by extending our knowledge on "Which treatment - DBT or ST - works the best for which BPD patient, and why?", which is likely to yield important benefits for both BPD patients (e.g., prevention of overtreatment and potential harm of treatments) and society (e.g., increased economic productivity of patients and efficient use of treatments).

TRIAL REGISTRATION

Netherlands Trial Register, NL7699 , registered 25/04/2019 - retrospectively registered.

Borderline Personality Disorder With Versus Without Alcohol Use Disorder: Comparing Impulsivity and Schema Modes

Substance use disorders (SUDs) and borderline personality disorder (BPD) are highly comorbid. In the present study, an attempt was made to understand the differences between BPD and BPD with comorbid SUD (BPD + alcohol use disorder [AUD]), by studying impulsivity and schema modes (i.e., maladaptive moment-to-moment emotional states and coping responses). BPD patients, BPD+AUD patients, and nonpatients (NP) were compared regarding behavioral impulsivity (motor impulsivity, risk taking, delay discounting), and schema modes. The two patient groups displayed greater delay discounting than the NP group. Further, BPD and BPD+AUD groups were different from the NP group regarding all schema modes investigated. However, no differences were found on any of the dependent variables between the two patient groups. It is suggested that although BPD patients are in general more impulsive and have more maladaptive moment-to-moment emotional states and coping responses, BPD patients with and without AUD seem not to be different in this respect.

A Spectrum of Selves Reinforced in Multilevel Coherence: A Contextual Behavioural Response to the Challenges of Psychedelic-Assisted Therapy Development

Psychedelic-assisted therapy research for depression and PTSD has been fast tracked in the United States with the Food and Drugs Administration (FDA) granting breakthrough designations for MDMA (post-traumatic stress disorder) and psilocybin (major depressive disorder). The psychotherapeutic treatments accompanying these psychedelics have not been well-studied and remain controversial. This article reviews the challenges unique to psychedelic-assisted therapy and introduces a newly optimised psychological flexibility model that adapts Contextual Behavioural Science (CBS)/Acceptance and Commitment Therapy (ACT) to those multiple challenges, including ego inflation, traumatic memories, and the perceived presence of entities. A methodology aligned with biological mechanisms, psychological processes and therapeutic contexts may be advantageous for improving outcomes. This model expands ACT by integrating practices and data from psychedelic-assisted therapy research into a Contextual Behavioural Science framework, allowing both fields to inform each other. Psychological flexibility processes are questioned and adapted to a psychedelic context, and interventions that operationalise these processes are considered. The principle through-line of the paper is to consider varied constructs of Self, as understood by these fields, and integrates respective elements of varied self-models, interventions and data into a Spectrum of Selves model for psychedelic-assisted therapy. Secondly the paper examines how to select and retain new self-perspectives and their corresponding behaviours systemically, drawing from evolutionary science principles. A case example of such behavioural reinforcement is provided, as well as a psychedelic integration checklist to guide the practical implementation of such an approach. This method can enable a coherent therapeutic framework with clear operational relationships between (1) problematic behaviour patterns that an individual wishes to address (2) the guided psychedelic experiences of that individual, and (3) the barriers to maintaining any changes, thus increasing theoretical-practical coherence, broadening treatment benefits and reducing relapse in psychedelic-assisted therapy. Research questions for further developing a CBS-consistent psychedelic-assisted therapy are offered.

Early maladaptive schemas in young people who self-injure

BACKGROUND

There is emerging evidence that early maladaptive schemas (EMS) may be a cognitive vulnerability factor in nonsuicidal self-injury (NSSI). The current study sought to examine the relationship between EMS and NSSI history, and whether this is moderated by gender, in a community youth sample.

METHOD

Participants were 403 Australian secondary and university students aged between 16 and 25 years, who completed a survey of NSSI history, EMS, and general emotional distress.

RESULTS

Logistic regression analysis indicated that being female, depression, and EMS scores were useful for differentiating between youth reporting NSSI history and those who did not. High levels of Defectiveness/Shame and Abandonment/Instability schema scores, and low levels of Emotional Inhibition schema scores, were associated with NSSI history. Gender did not moderate the relationships between these EMS scores and NSSI history.

CONCLUSIONS

Present results suggest that aspects of the schema domain of Disconnection and Rejection are important for identifying NSSI history beyond young people's emotional distress. This provides researchers and clinicians with an opportunity to better target key EMS, especially beliefs about self-defectiveness and feelings of shame, that may be driving the regulatory function of self-injury among youth.

The network structure of schema modes

A fundamental question in psychotherapy is whether interventions should target client problems (i.e., problem-focused approaches) or client strengths (i.e., strength-focused approaches). In this study, we first propose to address this question from a network perspective on schema modes (i.e., healthy or dysfunctional patterns of co-occurring emotions, cognitions, and behaviours). From this perspective, schema modes mutually influence each other (e.g., healthy modes reduce dysfunctional modes). Recent evidence suggests that changes in modes that are strongly associated to other modes (i.e., central modes) could be associated with greater treatment effects. We therefore suggest research should investigate the relative centrality of healthy and dysfunctional modes. To make an exploratory start, we investigated the cross-sectional network structure of schema modes in a clinical (comprising individuals diagnosed with paranoid, narcissistic, histrionic, and Cluster C personality disorders) and non-clinical sample. Results showed that, in both samples, the Healthy Adult was significantly less central than several dysfunctional modes (e.g., Undisciplined Child and Abandoned and Abused Child). Although our study cannot draw causal conclusions, this finding could suggest that weakening dysfunctional modes (compared to strengthening the Healthy Adult) might be more effective in decreasing other dysfunctional modes. Our study further indicates that several schema modes are negatively associated, which could suggest that decreasing one might increase another. Finally, the Healthy Adult was among the modes that most strongly discriminated between clinical and non-clinical individuals. Longitudinal and experimental research into the network structure of schema modes is required to further clarify the relative influence of schema modes.

Towards a Reformulated Theory Underlying Schema Therapy: Position Paper of an International Workgroup

Background

A central construct in Schema Therapy (ST) is that of a schema mode, describing the current emotional-cognitive-behavioral state. Initially, 10 modes were described. Over time, with the world-wide increasing and broader application of ST to various disorders, additional schema modes were identified, mainly based on clinical impressions. Thus, the need for a new, theoretically based, cross-cultural taxonomy of modes emerged.

Methods

An international workgroup started from scratch to identify an extensive taxonomy of modes, based on (a) extending the theory underlying ST with new insights on needs, and (b) recent research on ST theory supporting that modes represent combinations of activated schemas and coping.

Results

We propose to add two emotional needs to the original five core needs that theoretically underpin the development of early maladaptive schemas (EMSs), i.e., the need for Self-Coherence, and the need for Fairness, leading to three new EMSs, i.e. Lack of a Coherent Identity, Lack of a Meaningful World, and Unfairness. When rethinking the purpose behind the different ways of coping with EMS-activation, we came up with new labels for two of those: Resignation instead of Surrender, and Inversion instead of Overcompensation. By systematically combining EMSs and ways of coping we derived a set of schema modes that can be empirically tested.

Conclusions

With this project, we hope to contribute to the further development of ST and its application across the world.

A preliminary study: designing and validating projective images of Young's early maladaptive schema (EMS) domains

BACKGROUND

This study aims to design and validate ten projective images of Young's Early Maladaptive Schema (EMS) domains. For this purpose, two questions are to be addressed. (1) How is the factorial structure of the projective images of EMS domains? (2) Do the images designed in the domains of disconnection and rejection, impaired autonomy and performance, impaired limits, other-directedness, and over-vigilance and inhibition have sufficient validity?

METHODS

This is an applied mixed-methods exploratory study, in which the statistical population consisted of psychologists from Tehran Province in the qualitative section (n = 8) as well as other individuals aged between 18 and 65 years (mean age = 33) from Qazvin in the quantitative section (n = 102) in 2018. The research questions were analyzed through principal axis factoring with a varimax rotation, confirmatory factor analysis, Pearson correlation coefficient, and Cronbach's alpha.

RESULTS

According to the results, ten images and five domains of Young's EMSs contribute to a simple structure. Accounting for 70.35% of the total variance of EMSs, the five dimensions include disconnection and rejection, impaired autonomy and performance, impaired limits, other-directedness, and over-vigilance and inhibition.

CONCLUSIONS

The results indicated that the designed projective images yielded acceptable construct validity.

The Good Enough Parenting early intervention schema therapy based program: Participant experience

Background and objectives

Schema therapy (ST) has become a mainstream therapy for the treatment of psychopathology and has been validated through a series of large scale, international randomized control trials. Among other things, schema therapy emphasizes the meeting of core emotional needs in children by primary caregivers as these unmet needs continue to adversely affect their lives into adulthood. An early intervention parenting program has been developed to help parents meet these core emotional needs in order to prevent the development of psychopathology in the first place. The program, Good Enough Parenting, is equally focused on reducing problems and strengthening parenting practices, regardless of where the child is on the “disordered to well-being continuum”. This study aims to explore “patient experience” by users of this program. Best clinical research guidelines advocate that participants should be used as collaborators rather than pure recipients; this process should predate large scale trials.

Design

An exploratory qualitative study with 55 parent-participants of Good Enough Parenting was conducted.

Methods

One-to-one interviews were conducted with participants, using critical incident technique and guided by semi-structured interview schedule, to explore their experiences with the program. Transcripts were then analyzed using thematic analysis.

Results

Coding showed a high degree of inter-rater reliability (kappa value of 0.78). The themes that emerged were Cultivating Awareness of Parents’ Own Schemas, Cultivating Intentionality, Working through Developmental Issues, Responses to Challenges at Home, Performing Multiple Roles, and the Learning Process. Participants overwhelmingly reported satisfaction within these key themes.

Conclusions

The results support the development of the program and the choice of “participant reported outcome measures” for use in subsequent randomized controlled trials.

Schema therapy versus cognitive behavioral therapy versus individual supportive therapy for depression in an inpatient and day clinic setting: study protocol of the OPTIMA-RCT

BACKGROUND

Major depressive disorder represents (MDD) a major cause of disability and disease burden. Beside antidepressant medication, psychotherapy is a key approach of treatment. Schema therapy has been shown to be effective in the treatment of psychiatric disorders, especially personality disorders, in a variety of settings and patient groups. Nevertheless, there is no evidence on its effectiveness for MDD in an inpatient nor day clinic setting and little is known about the factors that drive treatment response in such a target group.

METHODS

In the current protocol, we outline OPTIMA (OPtimized Treatment Identification at the MAx Planck Institute): a single-center randomized controlled trial of schema therapy as a treatment approach for MDD in an inpatient and day clinic setting. Over the course of 7 weeks, we compare schema therapy with cognitive behavioral therapy and individual supportive therapy, conducted in individual and group sessions and with no restrictions regarding concurrent antidepressant medication, thus approximating real-life treatment conditions. N = 300 depressed patients are included. All study therapists undergo a specific training and supervision and therapy adherence is assessed. Primary outcome is depressive symptom severity as self-assessment (Beck Depression Inventory-II) and secondary outcomes are clinical ratings of MDD (Montgomery-Asberg Depression Rating Scale), recovery rates after 7 weeks according to the Munich-Composite International Diagnostic Interview, general psychopathology (Brief Symptom Inventory), global functioning (World Health Organization Disability Assessment Schedule), and clinical parameters such as dropout rates. Further parameters on a behavioral, cognitive, psychophysiological, and biological level are measured before, during and after treatment and in 2 follow-up assessments after 6 and 24 months after end of treatment.

DISCUSSION

To our knowledge, the OPTIMA-Trial is the first to investigate the effectiveness of schema therapy as a treatment approach of MDD, to investigate mechanisms of change, and explore predictors of treatment response in an inpatient and day clinic setting by using such a wide range of parameters. Insights from OPTIMA will allow more integrative approaches of psychotherapy of MDD. Especially, the identification of intervention-specific markers of treatment response can improve evidence-based clinical decision for individualizing treatment.

TRIAL REGISTRATION

Identifier on clinicaltrials.gov : NCT03287362 ; September, 12, 2017.

Reducing consequences of child maltreatment during adulthood by public health actions: a Delphi study

BACKGROUND

Child maltreatment (CM) is associated with long-lasting poor health outcomes, as well as increased levels of disability and health-services consumption across the life-span. However, less is known about how CM consequences can be reduced during adulthood. We investigated professional opinions on how to mitigate long-term consequences of CM in a public health (PH) perspective.

METHODS

Using the Delphi method in three rounds, we inquired 91 professionals, mostly European researchers and clinicians about potential PH actions to mitigate CM consequences during adulthood.

RESULTS

Most experts agreed that PH actions are needed. Increasing community awareness and training emotional regulation in affected adults were prioritized strategies. Enlarging curricular knowledge about CM for professionals and developing evidence-based interventions were considered preferred methods. Reducing the barriers for access to interventions for adults, such as those provided by trauma-informed services were also suggested. Participants highlighted the possibility to reduce CM consequences across generations as a significant benefit.

CONCLUSIONS

PH programmes to reduce the burden of CM can be enhanced by specific actions to facilitate the recognition of difficulties in affected adults and to expand the availability of helpful resources. The application of these programmes could be assisted by the use of modern information-technology.

Schema modes mediate the effect of emotional abuse in childhood on the differential expression of personality disorders

BACKGROUND

There is sound evidence that childhood maltreatment increases the likelihood of developing personality disorders (PDs). However, research on the possible mechanisms involved in the relationship between childhood maltreatment and PDs is scarce. One potential mediator of the maltreatment-PD relationship are schema modes, reflecting dynamic states of cognition, emotion, and behaviour.

AIMS

The current study aimed to explore the mediating effect of schema modes on the association between childhood maltreatment and the expression of Cluster B (borderline and antisocial) and C (avoidant and dependent) PDs.

METHOD

Within a mixed sample of N = 120 clinical PD patients and non-clinical participants, a multivariate path model including interview-assessed childhood maltreatment (emotional abuse, emotional neglect, sexual abuse, and physical abuse), schema modes (child, parent, coping and healthy modes), and borderline, antisocial, avoidant and dependent PDs was explored.

RESULTS

The path model depicted five significant indirect links from emotional abuse on PDs via distinct schema modes. The impact of emotional abuse on borderline PD was mediated by child and coping modes, while parent modes mediated the link to antisocial PD. Healthy modes acted as a mediator on dependent and avoidant PDs.

CONCLUSIONS

The results indicate emotional abuse as a main predictor of schema mode clusters and emphasize the mediating role of schema modes on the maltreatment-related pathways towards PDs. Therapeutic implications are discussed with a special focus on healthy modes.

The Potential Role of the Early Maladaptive Schema in Behavioral Addictions Among Late Adolescents and Young Adults

Background

Behavioral addiction (BA) is a recent concept in psychiatry. Few studies have investigated the relationship between BA and early maladaptive schemas (EMSs). EMS is the core of Schema Therapy (ST). According to the ST model, psychiatric disorders result from the development of EMSs in response to unmet emotional needs in childhood. Bach et al. (2018) grouped the 18 EMSs into four domains: (1) disconnection and rejection; (2) impaired autonomy and performance; (3) excessive responsibility and standards; and (4) impaired limits. This study aims to assess the possible association of the most frequent BAs with EMSs in a large group of late adolescents and young adults and to evaluate their self-perceived quality of life (QoL).

Methods

A battery of psychological tests assessing food addiction (FA), gambling disorder (GD), internet addiction (IA), and QoL was administered to 1,075 late adolescents and young adults (N = 637; 59.3% women). A forward-stepwise logistic regression model was run to identify which variables were associated with BAs.

Results

Food addiction was more frequent among women and GD among men, while IA was equally distributed. Regarding the EMSs, participants with FA or IA showed significantly higher scores on all four-schema domains, whereas those with GD exhibited higher scores on impaired autonomy and performance and impaired limits. Besides, average scores of all domains increased with the association of two or more comorbid BAs. Self-perceived QoL was lower for participants with FA and IA, but not for those with GD; the presence of comorbid BAs was associated with lower Physical Component Summary (PCS) and Mental Component Summary (MCS) scores. Finally, specific EMS domains and demographic variables were associated with each BA.

Conclusion

Late adolescents and young adults with FA or IA have a lower perception of their mental and physical health. The most striking result is that FA appears to be associated with the disconnection and rejection schema domain, IA with all the schema domains (except for impaired autonomy and performance), and GD with impaired autonomy and performance schema domain. In conclusion, our findings suggest that EMS should be systematically assessed during psychotherapy of patients with BAs.

Schema in older adults: does the schema mode model apply?

BACKGROUND

The relevance of schema theory to psychopathology, in particular personality disorder, in younger adults is established. Investigations into the relevance of schema theory to older adults, however, is highly limited.

AIMS

To consider the relationship of schema modes to psychopathology in older adults and establish whether maladaptive schema modes are associated with unmet needs and that this relationship is mediated by the healthy adult mode of responding in this population.

METHOD

One hundred and four older adults were recruited from an established database. Participants completed questionnaires assessing psychopathology, schema modes (YAMI: Young-Atkinson Mode Inventory) and basic psychological needs (BPNS: Basic Psychological Needs Scale - autonomy, competence and relatedness). Ninety-four responses were included after applying exclusion criteria.

RESULTS

The healthy adult schema mode was found to be associated with reduced psychopathology, and maladaptive child modes (angry and vulnerable child) to increased psychopathology. The healthy adult schema mode mediated the relationship between maladaptive child modes and needs satisfaction.

CONCLUSIONS

As predicted by schema theory, the presence of one of the maladaptive child modes makes it difficult for an older individual to have their needs met, but the presence of healthy adult mode works to support this process.

Early maladaptive schemas and borderline personality disorder features in a nonclinical sample: A network analysis

Borderline personality disorder (BPD) is a challenging problem. Early maladaptive schemas (EMSs) are considered as important vulnerability factors for the development and maintenance of BPD. Literature suggests a complex relationship between BPD and EMSs. The current study employed network analysis to model the complex associations between central BPD features (i.e., affective instability, identity problems, negative relations, and self-harm) and EMSs in 706 undergraduate students. The severity of BPD symptoms was assessed using the Personality Assessment Inventory-Borderline subscale; the Young Schema Questionnaire-Short Form was used to assess EMSs. Results suggest that specific EMSs show unique associations with different BPD features. Interestingly, affective instability showed no unique associations with EMSs. Identity problems were uniquely associated with abandonment, insufficient self-control, dependence/incompetence, and vulnerability to harm/illness schemas. Negative relations in BPD showed unique connections with mistrust/abuse and abandonment. Finally, BPD self-harm was connected to emotional deprivation and failure. These findings indicate potential pathways between EMSs and specific BPD features that could improve our understanding of BPD theoretically and clinically.

The clinical trait self-criticism and its relation to psychopathology: A systematic review - Update

BACKGROUND

Self-criticism represents a central phenomenon in a variety of mental disorders. The review looks at the recent body of literature (2012-2018) to summarize the relation of self-criticism and psychopathology beyond depression and aims at detecting how different conceptualizations of self-criticism with psychoanalytical, psychodynamic, or cognitive-evolutionary background are related to psychopathology. Furthermore, latest treatment approaches for dysfunctional forms of self-criticism are reviewed.

METHODS

The literature research of five databases (PsycINFO, PSYNDEX, PubMed, Medline, and Cochrane Library) took place in August 2018. Inclusion criteria for studies to enter the review narrative were an adult sample, non-clinical samples as well as clinical samples, and an empirical approach, which resulted in quantitative data.

RESULTS

48 studies entered the review. Besides depressive symptoms, self-criticism showed positive relations to symptoms of eating disorders, social anxiety disorder, and personality disorders as well as to psychotic symptoms or interpersonal problems through different conceptualizations of self-criticism. Regarding the treatment of self-criticism, compassion- or emotion-focused therapy interventions were investigated in most of the reviewed studies and both reduced self-criticism in clinical and non-clinical samples. However, harsh forms of self-criticism were more persistent and difficult to change.

LIMITATIONS

The review focused only on the latest empirical findings regarding self-criticism and psychopathology.

CONCLUSION

Potentially functional forms and functions of self-criticism need further consideration, as they represent a possible goal of psychotherapeutic treatment. Future research should address specific questions regarding antecedents and consequences of self-criticism.

The effects of Toxic Early Childhood Experiences on Depression according to Young Schema Model: A Scoping Review

BACKGROUND

Young Schema Model (YSM) emphasizes Toxic Early Childhood Experiences (TECE) as vulnerability factors to depression. However, the lack of consensus on how to define and measure TECE is likely to have led to inconsistent findings in current literature. This review maps supported and unsupported pathways to depression and measures used.

METHODS

A scoping review was conducted in accordance with the Joanna Briggs Institute protocol to identify primary research studies that examined developmental and maintenance pathways to depression within the YSM framework. 2463 articles were identified with 49 primary research studies selected for inclusion. As a subset of the overall review, this paper focuses on the 14 studies that examined effects of TECE on depression in context of YSM.

RESULTS

The studies used 11 different measures to examine the role of TECE in depression. Effects of maltreatment (i.e., physical abuse, emotional abuse, emotional neglect,) and perceived parenting (i.e., low care, high rejection, high overprotection and/or control, maladaptive parenting styles) on depression are well supported. Effects of sexual abuse and physical neglect on depression are currently inconclusive.

CONCLUSION

In conclusion, findings revealed the inconsistent definition and measurement of TECE (with 11 different measures) in current literature. Findings support the effects of physical abuse, emotional abuse, emotional neglect, low care, high rejection, high overprotection and/or control, and maladaptive parenting styles on depression. Limitations of existing studies include researchers' inconsistent definition and measurement of TECE, under-examined TECE sub-constructs, possible moderating relationships, predominant cross-sectional design, and homogeneous sampling. Limitations of the scoping review include its small number of studies and the absence of evaluation of the measures used. Nevertheless, this review represents the first step in the systematic examination of the empirical basis of YSM and is an important contribution to depression treatment and innovation.

Schema therapy for Dissociative Identity Disorder (DID): rationale and study protocol

Background: A category of disorders frequently associated with a history of trauma are the dissociative disorders, of which Dissociative Identity Disorder (DID) is the most severe and chronic form. DID is associated with high levels of impairment, treatment utilization, and treatment costs, yet systematic research into treatment effects is scarce. Practice-based clinical guidelines advise a phase-based approach which is lengthy and has rather high reported dropout rates. Therefore, in the current proposal the efficacy of an alternative treatment for DID (i.e. schema therapy) is tested. Objective: The aim of this study is to critically test the effectiveness of schema therapy for DID patients, for whom at present no evidence-based treatment is available. Method: In light of the low prevalence of DID, and the proposed treatment length of three years, a case series experimental approach is used (non-concurrent multiple baseline design). Ten outpatients are included, who are diagnosed with DID by an independent rater using the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D-R), which is double-checked by another independent expert. Primary outcomes are a (bi)weekly assessed state measure of dissociative symptoms, a pre-, post- and follow-up measure of the presence of the DID diagnosis, and drop-out rate. Secondary outcomes include various measures of trait dissociative symptoms, comorbid symptomatology, and global symptomatic distress. Trial registration: Netherlands Trial Register (NTR): NTR4496.

Young Schema Questionnaire - Short Form Version 3 (YSQ-S3): Preliminary validation in older adults

OBJECTIVES

The aim of the current study was to establish the reliability and validity of one of the most used schema questionnaires, Young Schema Questionnaire Short Form Version 3 (YSQ-S3) in older adults.

METHOD

104 participants aged 60-84 years were recruited. They were administered a battery of questionnaires, including the YSQ-S3, Young-Atkinson Mode Inventory (YAMI), Germans (Personality) Screener, the Geriatric Depression Scale (GDS), The Geriatric Anxiety Inventory (GAI) and the Basic Psychological Needs Scale (BPNS). The YSQ-S3 was completed a second time by 83 participants a median of 12 days later.

RESULTS

Satisfactory internal consistency reliability was found for 13 of the 18 early maladaptive schemas (EMS) of the YSQ-S3. Test-retest reliability was satisfactory for 17 of 18 EMS. Convergent validity was evident from significant correlations between the EMS of the YSQ-S3 and the vulnerable child and angry child schema modes from the YAMI. Congruent validity was evident from correlations of the majority of the EMS with the GDS, the GAI, German's (Personality) Screener and the BPNS measure.

CONCLUSIONS

By and large the YSQ-S3 demonstrates internal and test re-test reliability in as well as congruent and convergent validity, in older adults. This suggests the YSQ-S3 may be of use in work establishing the utility of schema therapy in this population, and that schema therapy with older people warrants further exploration. Notwithstanding this some re-development of some EMS items appears to be required for the YSQ-S3 to be more relevant to older people.

Schema therapy conceptualization of personality functioning and traits in ICD-11 and DSM-5

PURPOSE OF REVIEW

Schema therapy conceptualizes personality disorders in terms of modes and underlying schemas. This article reviews the literature on schema therapy conceptualization of personality disorder functioning and traits, and proposes how these findings apply to novel personality disorder classification in ICD-11 and the DSM-5 Alternative Model of Personality Disorders (AMPD).

RECENT FINDINGS

Maladaptive schemas and modes are generally associated with personality dysfunction and traits in conceptually coherent ways. The healthy adult mode, a transdiagnostic core concept in schema therapy, corresponds to the ICD-11 and DSM-5-AMPD features of core personality functioning. Modes and underlying schemas substantially overlap with specific ICD-11 and DSM-5-AMPD traits, which denote individual themes and styles of personality dysfunction.

SUMMARY

The dimensional personality disorder framework in ICD-11 and DSM-5-AMPD is largely compatible with the schema therapy model. The ICD-11 and DSM-5-AMPD provide a scientifically derived and theory-free framework for all practitioners, which may be connected to clinical theory of schema therapy in a coherent manner. Level of personality functioning can be conceptualized as healthy adult functioning (e.g. sense of identity, self-worth, emotion regulation, intimacy, and fulfillment), which inform intensity of treatment. Trait qualifiers can be conceptualized by associated modes (e.g., compliant surrender) and underlying schemas (e.g. abandonment), which inform focus and style of treatment.

Schema therapy for borderline personality disorder: A qualitative study of patients' perceptions

Schema therapy (ST) has been found to be effective in the treatment of borderline personality disorder (BPD). However very little is known about how the therapy is experienced by individuals with BPD including which specific elements of ST are helpful or unhelpful from their perspectives. The aim of this study is to explore BPD patients’ experiences of receiving ST, in intensive group or combined group-individual format. Qualitative data were collected through semi-structured interviews with 36 individuals with a primary diagnosis of BPD (78% females) who received ST for at least 12 months. Participants were recruited as part of an international, multicenter randomized controlled trial (RCT). Interview data (11 Australian, 12 Dutch, 13 German) were analyzed following the procedures of qualitative content analysis. Patients’ perceptions of the benefits gained in ST included improved self-understanding, and better awareness and management of their own emotional processes. While some aspects of ST, such as experiential techniques were perceived as emotionally confronting, patient narratives informed that this was necessary. Some recommendations for improved implementation of ST include the necessary adjunct of individual sessions to group ST and early discussion of therapy termination. Implications of the findings are also discussed, in particular the avenues for assessing the suitability of patients for group ST; management of group conflict and the optimal format for delivering treatment in the intensive group versus combined group-individual formats.

Psychometric validation of the Young Parenting Inventory - Revised (YPI-R2): Replication and Extension of a commonly used parenting scale in Schema Therapy (ST) research and practice

This study aimed at developing a revised validated version of the Young Parenting Inventory (YPI) known as YPI-R2 that had 17 theoretical subscales. Using separate ratings for fathers and mothers samples from Singapore (n = 582, 617), Manila (n = 520, 538), Jakarta (n = 366, 383), and the USA (n = 204, 214), exploratory and confirmatory factor analysis (CFA) were conducted. This resulted in five subscales for fathers and six for mothers. The 17 theoretical subscales were not supported. Construct, convergent, and divergent validity of this new revised alternative YPI-R2 were also demonstrated. The stringent incremental validity test showed that the YPI-R2 accounted for additional statistically significant variance over and above that contributed by gender and three other established parenting instruments in predicting clinically relevant outcomes. Partial invariance of its factor structure was demonstrated through multigroup CFA using Eastern and Western samples. Finally, significant correlations with the 18 Early Maladaptive Schemas (EMSs) supported a central tenet of schema therapy that these are associated with early negative parenting patterns. Parenting norms in both Eastern and Western cultures that were associated with ill-being were also discussed thus showing the cross-cultural relevance of the YPI-R2.

PRO*BPD: effectiveness of outpatient treatment programs for borderline personality disorder: a comparison of Schema therapy and dialectical behavior therapy: study protocol for a randomized trial

BACKGROUND

Borderline Personality Disorder (BPD) is a severe mental illness that is associated with low quality of life, low psychosocial functioning, and high societal costs. Treatments for BPD have improved in the last decades. Dialectical behavior therapy (DBT) and Schema therapy (ST) have demonstrated efficacy in reducing BPD symptoms and costs. However, research has not compared these two treatment approaches. In addition, there is a lack of 'real world studies' that replicate positive findings in regular mental healthcare settings. Thus, the PROgrams for Borderline Personality Disorder (PRO*BPD) study will compare the (cost-) effectiveness of DBT and ST in structured outpatient treatment programs in the routine clinical setting of an outpatient clinic.

METHODS/DESIGN

We aim to recruit 160 BPD patients, who will be randomly assigned to either DBT or ST. In both conditions, patients receive one group therapy and one individual therapy session/week for a maximum of 18 months. Both treatment programs have similar frameworks, which guarantee clinical equipoise. The primary outcome is a reduction of BPD-symptoms. Also, the costs related to BPD are assessed and an economic evaluation is performed from a societal perspective. Secondary outcomes examine other measures of BPD-typical and general psychopathology, comorbidity, quality of life, psychosocial functioning and participation. Data are collected prior to the beginning therapy and every six months until the end of therapy, as well as at six months, one year and two years of follow-up after the end of therapy. Finally, we conduct a qualitative study to understand patients' experiences with the two methods.

DISCUSSION

The PRO*BPD study is the first randomized trial to compare the (cost-) effectiveness of DBT and ST. By examining the clinical effectiveness of a broad spectrum of outcome parameters, conducting an economic evaluation and assessing patients' experiences, this study will significantly advance our knowledge on psychotherapy for BPD and will provide insight into the treatment approaches that should be offered to different BPD patients from clinical, economic and stakeholder's perspectives.

TRIAL REGISTRATION

German Clinical Trial Register, DRKS00011534 , Date of registration: 11/01/2017, retrospectively registered.

Development and Validation of the Positive Parenting Schema Inventory (PPSI) to Complement the Young Parenting Inventory (YPI) for Schema Therapy (ST)

The factor structure of an initial item pool of 207 positive parenting items was investigated (Manila; n = 520, 538) to develop the Positive Parenting Schema Inventory. Single group and multigroup confirmatory factor analyses of the Positive Parenting Schema Inventory showed invariance of the factor structure in six out of the seven levels on two other independent samples (Eastern, Indonesia; n = 366, 383; Western, the United States; n = 204, 214). Good values for reliability were obtained for its seven subscales (50 items) using coefficient omegas (.71 to .95). Evidence of validity based on test content, response processes (item responses to desired inferences), internal structure (exploratory and confirmatory factor analyses), relations to other variables (correlations with other instruments), and consequences of testing (correlations with positive schemas) were demonstrated. A core tenet of schema therapy theory was supported in that recall of past positive parenting patterns were associated with current levels of positive schemas.

Psychometric Properties of the Italian Version of the Young Schema Questionnaire L-3: Preliminary Results

Schema Therapy (ST) is a well-known approach for the treatment of personality disorders. This therapy integrates different theories and techniques into an original and systematic treatment model. The Young Schema Questionnaire L-3 (YSQ-L3) is a self-report instrument, based on the ST model, designed to assess 18 Early Maladaptive Schemas (EMSs). During the last decade, it has been translated and validated in different countries and languages. This study aims to establish the psychometric properties of the Italian Version of the YSQ-L3. We enrolled two groups: a clinical (n = 148) and a non-clinical one (n = 918). We investigated the factor structure, reliability and convergent validity with anxiety and depression between clinical and non-clinical groups. The results highlighted a few relevant findings. Cronbach's alpha showed significant values for all the schemas. All of the factor models do not seem highly adequate, even if the hierarchical model has proven to be the most significant one. Furthermore, the questionnaire confirms the ability to discriminate between clinical and non-clinical groups and could represent a useful tool in the clinical practice. Limitations and future directions are discussed.

Comparison of early maladaptive schemas between borderline personality disorder and chronic depression

Borderline personality disorder (BPD) and chronic depression (CD) are common and challenging mental disorders. Maladaptive cognitive schemas have been proposed to increase vulnerability to both disorders. In order to elucidate the role of maladaptive cognitive schemas in BPD and CD, this study compared psychiatric outpatients with BPD (N = 30) and CD (N = 30) in terms of early maladaptive schemas (EMSs). The groups were compared using the Young Schema Questionnaire short form-extended (YSQ-S2-extended) and the 15D health status questionnaire. BPD patients showed higher endorsement on the majority of EMSs, poorer social functioning, and greater concurrent distress than CD patients. However, after controlling for concurrent effects of psychological distress, the groups did not differ in 14 out of the 18 EMSs. These findings point to significant similarities in maladaptive beliefs between the 2 disorders and do not support broad, specific patterns of EMSs associated with either disorder. The results highlight the need for further study of the role of maladaptive schemas in the development and treatment of chronic mental disorders.

Elucidating DSM-5 and ICD-11 Diagnostic Features of Borderline Personality Disorder Using Schemas and Modes

BACKGROUND

Borderline personality disorder (BPD) comprises a heterogeneous constellation of problems operationalized in the DSM-5 and the forthcoming ICD-11. In schema therapy, schemas and modes are employed to conceptualize and treat these problems.

AIM

The current study investigated whether the 9 diagnostic BPD features are associated with schemas and modes.

METHOD

Psychiatric outpatients with predominant BPD features (n = 142; 68% females) were administered the Structured Clinical Interview for DSM-IV Axis II (SCID-II) and self-report inventories for schemas and modes. Associations were investigated by means of bivariate point-biserial correlations and multiple logistic regression analysis.

RESULTS

BPD features were largely associated with conceptually related schemas and modes. Consistent with the schema therapy literature and previous research, we found schemas of Abandonment/Instability and Mistrust/Abuse along with modes of Angry/Enraged Child, (internalized) Punitive Parent, and Impulsive Child to uniquely predict thematically related BPD features including fear of abandonment, self-destructiveness, feelings of emptiness, stress-related paranoid ideation, inappropriate anger, and impulsivity.

CONCLUSION

Most of the 9 BPD features were related to conceptually meaningful schemas/modes, suggesting that BPD is composed of dormant themes along with salient affective-behavioral responses. Consequently, individual BPD features may be differentially conceptualized and targeted in therapy by means of schemas and modes.

Schema Modes and Personality Disorder Symptoms in Alcohol-Dependent and Cocaine-Dependent Patients

Substance use disorders (SUD) and personality disorders co-occur frequently. This relationship might be understood by studying schema modes (a key concept in Schema therapy), which explain the dysfunctions characterizing personality disorder patients. In the present study, we compared the schema modes and personality disorder symptoms between alcohol-dependent patients, cocaine-dependent patients and healthy controls. We found indications that specific schema modes are specific for SUD patients. However, no differences between specific subtypes of SUD patients (alcohol- vs. cocaine-dependent patients) could be found regarding schema modes. Further, it is suggested that borderline personality disorder symptoms are highly relevant for SUD patients. A first step is made in understanding the relationship between schema modes and SUD, which may contribute to the understanding of the problematic behaviour seen in patients with personality disorders and SUD (and may possibly contribute to the improvement of the treatment of this group of patients).

Schemas and modes in borderline personality disorder: The mistrustful, shameful, angry, impulsive, and unhappy child

In this study we investigated how early maladaptive schemas and schema modes uniquely characterize Borderline Personality Disorder (BPD) patients versus comparison groups. BPD patients (n = 101) were systematically matched with personality disordered patients without BPD (n = 101) and healthy controls (n = 101). Differences were investigated using one-way ANOVA and multinomial logistic regression analyses. Results indicated that schemas of Mistrust/Abuse and Defectiveness/Shame along with modes of Angry Child, Impulsive Child, and (low) Happy Child uniquely differentiated BPD patients from patients with other personality disorders. Likewise, schemas of Mistrust/Abuse, Defectiveness/Shame, and Insufficient Self-Control along with modes of Vulnerable Child, Enraged Child, and (low) Happy Child, uniquely differentiated BPD patients from healthy controls. The results are overall consistent with propositions in the schema therapy literature as well as previous findings, and suggest that underlying schemas of Mistrust/Abuse and Defectiveness/Shame as well as manifest modes of Angry/Enraged Child, Impulsive Child, and (low) Happy Child comprise key features of BPD. Consequently, these features may be important foci in the conceptualization and treatment of BPD.

Psychotherapeutic interventions and contemporary developments: common and specific factors

In this article we start with the effectiveness paradox between different psychotherapeutic modalities, considering common factors, before moving on to give a brief overview of the three main psychotherapeutic approaches – psychoanalytic, cognitive–behavioural and humanistic – and their developments. We conclude that it is the therapeutic relationship – considered in the context of the above – that is core to all therapeutic engagement, medical or otherwise.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None

To see in a mirror dimly. The looking glass self is self-shaming in borderline personality disorder

Symptoms of borderline personality disorder (BPD) can be conceptualized as the expression of and defenses against or response to the painful emotion of chronic shame, which may relate to early maladaptive schemas (EMS). The goal of this research is to examine levels of early maladaptive schemas, self-reported shame, and anxious or angry reactions to social put-downs as well as their associations. We also looked to assess the association of shame with BPD symptoms. Fifty-six patients with BPD completed self-report measures of EMSs, chronic shame, and reactions to put-downs. Comparison groups consisted of 24 patients without personality disorder (non-PD) and 80 healthy controls (HC). Those with BPD reported higher levels of EMSs, characterological, behavioral and bodily shame, and were more prone to react with anxiety and anger than non-PD patients and HC subjects. EMSs domains had specific associations with chronic shame and reaction types to social put-downs. Identity disturbances were associated with characterological, behavioral and bodily shame. Stormy relationships were associated with bodily shame. Chronic shame and anxious and angry reactions to social put-downs are prominent in patients with borderline personality disorder and are associated with specific EMS domains and with the symptoms of identity disturbance and stormy relationships.