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van Vreeswijk MF, Spinhoven P, Zedlitz AMEE, Vugts MAP, Eurelings-Bontekoe EHM. A person-centered, transdiagnostic schema and mode profile approach to predict outcome in time-limited schema group therapy. Psychother Res 2024:1-14. [PMID: 39018493 DOI: 10.1080/10503307.2024.2375251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 06/25/2024] [Indexed: 07/19/2024] Open
Abstract
OBJECTIVE This study employs a person-centered transdiagnostic approach to examine how schema and mode profiles predict symptom severity reduction in schema group therapy for patients with personality disorders and enduring clinical syndromes. METHOD We analyzed symptom reduction in 248 patients across three formats of manualized, time-limited schema group therapy. Latent profile analysis and mixed multilevel modeling were used to determine the extent to which schema/mode classes predict symptom reduction, and whether the inclusion of individual schemas and modes enhances these predictions. RESULTS No significant differences in treatment outcomes were found across the group modalities. A three latent profile solution for schemas and modes showed external validity with clinical variables and demonstrated that declines in symptom severity varied by schema and mode class, even after adjusting for baseline symptom severity. Adding the Vulnerability to Harm schema and Vulnerable Child mode to the model increased the explained variance. CONCLUSION Patients with more severe personality problems show more substantial symptom reduction. Both schema and mode profiles significantly contribute to predicting post-treatment symptom levels. Understanding these profiles may help therapists tailor interventions more effectively, consistent with Young's theoretical model.Trial registration: ISRCTN.org identifier: ISRCTN17262253.
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Affiliation(s)
| | - P Spinhoven
- Institute of Psychology, Pieter de la Court gebouw, Leiden University, Leiden, The Netherlands
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
| | - A M E E Zedlitz
- G-kracht, Mental Health Care Institute, Delft, The Netherlands
- Institute of Psychology, Pieter de la Court gebouw, Leiden University, Leiden, The Netherlands
- Department of Medical, Health and Neuropsychology, Pieter de la Court gebouw, Leiden University, Leiden, The Netherlands
| | - M A P Vugts
- Department of Population Health and Health Services Research, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
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Tracy M, Penney E, Norton AR. Group schema therapy for personality disorders: Systematic review, research agenda and treatment implications. Psychother Res 2024:1-20. [PMID: 38862126 DOI: 10.1080/10503307.2024.2361451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 05/22/2024] [Indexed: 06/13/2024] Open
Abstract
OBJECTIVE There are significant temporal and financial barriers for individuals with personality disorders (PD) receiving evidence-based psychological treatments. Emerging research indicates Group Schema Therapy (GST) may be an accessible, efficient, and cost-effective PD intervention, however, there has been no synthesis of the available evidence to date. This review therefore aimed to investigate the efficacy of GST for PDs by systematically synthesizing available literature. METHOD Five electronic databases were screened with resulting studies subjected to a specific eligibility criteria, which yielded fourteen relevant studies. Characteristics were extracted and methodological quality rigorously assessed. RESULTS Strong support was evidenced for GST's ability to reduce Cluster B and C symptomology, particularly for Borderline and Avoidant PD. GST appeared to improve global symptom severity, quality of life and functional capacity, as well as treatment targets such as schemas and modes. CONCLUSION Although not without limitations and a moderate risk of bias, the current body of evidence supports GST as a potential solution to current service deficits in economical and evidence-based care for individuals with PD. Implications for treatment and future research are discussed.
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Affiliation(s)
- Mikaela Tracy
- Discipline of Clinical Psychology, Graduate School of Health, University of Technology Sydney, Sydney, Australia
- Faculty of Science, School of Psychology, The University of Sydney, Sydney, Australia
| | - Erika Penney
- Discipline of Clinical Psychology, Graduate School of Health, University of Technology Sydney, Sydney, Australia
| | - Alice R Norton
- Discipline of Clinical Psychology, Graduate School of Health, University of Technology Sydney, Sydney, Australia
- Faculty of Science, School of Psychology, The University of Sydney, Sydney, Australia
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Veenstra-Spruit MS, Bouman R, van Dijk SD, van Asselt ADI, van Alphen SP, Veenstra DH, de Ruiter M, Troost SE, Lammers MW, Vulker F, Smeets-Janssen MM, van den Brink RH, Voshaar RCO. Group schema therapy combined with psychomotor therapy for older adults with a personality disorder: an open-label, multicentre, randomised controlled trial. THE LANCET. HEALTHY LONGEVITY 2024; 5:e245-e254. [PMID: 38555919 DOI: 10.1016/s2666-7568(24)00001-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 12/24/2023] [Accepted: 01/02/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Although several types of psychotherapy effectively reduce psychological distress associated with personality disorders, randomised controlled trials (RCT) have systematically excluded older patients. We aimed to examine the effectiveness of group schema therapy combined with psychomotor therapy (GST + PMT) in later life compared with treatment as usual (TAU). METHODS We did an open-label, multicentre, RCT in eight outpatient clinics for geriatric psychiatry in the Netherlands. Adults aged 60 years or older with a full or subthreshold cluster B or C personality disorder according to DSM criteria were included and randomly assigned 1:1 to GST + PMT or TAU by an independent researcher applying a computer-generated sequence per study site when 8 to 16 patients had given informed consent; investigators and interviewers were kept blinded until end of follow-up. Included individuals received 20 weekly sessions of GST + PMT or TAU with 1 year of follow-up. The primary outcome was psychological distress, measured with the 53-item Brief Symptom Inventory. The trial was registered with International Clinical Trials Registry Platform, NTR6621. FINDINGS Of the 145 study participants recruited between Feb 21, 2018, and Jan 21, 2020, 102 patients (median age of 69 years [IQR 63-71], 62 [61%] female) who concluded therapy before the COVID-19 pandemic (cutoff March 20, 2020) were included in the intention-to-treat analysis (51 in each study group), because COVID-19 measures substantially disrupted delivery of group therapy. GST + PMT significantly improved psychological distress compared with TAU over the 6-month treatment period (Cohen's d 0·42, 95% CI 0·16 to 0·68; p=0·0016). The pre-post effect of GST + PMT remained stable during follow-up, whereas patients receiving TAU further improved, resulting in a non-significant difference between groups at 1 year (Cohen's d 0·21, 95% CI -0·07 to 0·48; p=0·14). No patients reported adverse events. INTERPRETATION Psychotherapy focused on personality disorders is effective in later life, resulting in a faster improvement in psychopathology than TAU. Future studies should focus on increasing effectiveness by intensifying or prolonging treatment. FUNDING Netherlands Organization for Health Research and Development. TRANSLATION For the Dutch translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Martine S Veenstra-Spruit
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Renske Bouman
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Silvia Dm van Dijk
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Antoinette DI van Asselt
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Sebastiaan Pj van Alphen
- Department of Psychology, Vrije Universiteit Brussel, Brussels, Belgium; Mondriaan Mental Health Center, Heerlen-Maastricht, Netherlands
| | | | | | | | | | | | | | - Rob Hs van den Brink
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Richard C Oude Voshaar
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.
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Leichsenring F, Fonagy P, Heim N, Kernberg OF, Leweke F, Luyten P, Salzer S, Spitzer C, Steinert C. Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies. World Psychiatry 2024; 23:4-25. [PMID: 38214629 PMCID: PMC10786009 DOI: 10.1002/wps.21156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2024] Open
Abstract
Borderline personality disorder (BPD) was introduced in the DSM-III in 1980. From the DSM-III to the DSM-5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self-image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self-mutilation behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi-structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self-mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic-like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high-quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.
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Affiliation(s)
- Falk Leichsenring
- Department of Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany
- Department of Psychosomatics and Psychotherapy, University of Rostock, Rostock, Germany
| | - Peter Fonagy
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Nikolas Heim
- International Psychoanalytic University, Berlin, Germany
| | - Otto F Kernberg
- Personality Disorders Institute, Weill Cornell Medical College, New York, NY, USA
| | - Frank Leweke
- Department of Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany
| | - Patrick Luyten
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
- Faculty of Psychology and Educational Sciences, University of Leuven, Leuven, Belgium
| | - Simone Salzer
- International Psychoanalytic University, Berlin, Germany
| | - Carsten Spitzer
- Department of Psychosomatics and Psychotherapy, University of Rostock, Rostock, Germany
| | - Christiane Steinert
- Department of Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany
- International Psychoanalytic University, Berlin, Germany
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Zhang K, Hu X, Ma L, Xie Q, Wang Z, Fan C, Li X. The efficacy of schema therapy for personality disorders: a systematic review and meta-analysis. Nord J Psychiatry 2023; 77:641-650. [PMID: 37402124 DOI: 10.1080/08039488.2023.2228304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/12/2023] [Accepted: 06/19/2023] [Indexed: 07/05/2023]
Abstract
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.
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Affiliation(s)
- Kaiyuan Zhang
- Affiliated Mental Health Center & Hangzhou Seventh People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xinyang Hu
- Department of Clinical Medical, First Clinical Medical College, Anhui Medical University, Hefei, Anhui, China
| | - Lijun Ma
- Research Centre for Translational Medicine, the Second Affiliated Hospital, Anhui Medical University, Hefei, Anhui, China
- Department of Medical Psychology, School of Mental Health and Psychological Science, Anhui Medical University, Hefei, Anhui, China
| | - Qihang Xie
- Department of Clinical Medical, First Clinical Medical College, Anhui Medical University, Hefei, Anhui, China
| | - Zhipeng Wang
- Department of Clinical Medical, First Clinical Medical College, Anhui Medical University, Hefei, Anhui, China
| | - Chuan Fan
- Department of Psychiatry, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiaoming Li
- Research Centre for Translational Medicine, the Second Affiliated Hospital, Anhui Medical University, Hefei, Anhui, China
- Department of Medical Psychology, School of Mental Health and Psychological Science, Anhui Medical University, Hefei, Anhui, China
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Exploring the effect of group schema therapy and comorbidity on the treatment course of personality disorders. Curr Opin Psychiatry 2023; 36:80-85. [PMID: 36165960 DOI: 10.1097/yco.0000000000000828] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To provide an update of outcome studies of schema group therapy for personality disorders and the effect of comorbidity in order to explore whether schema group therapy might be effective for this patient group and what dosage is required. RECENT FINDINGS Studies of short-term schema group therapy for personality disorders with or without comorbidity show moderately effective results but the majority of patients fail to achieve full remission from global psychological symptom distress. Preliminary findings revealed that those unremitted patients might benefit from 40 to 60 sessions. Patients with severe personality disorders (such as borderline personality disorders) seem to need longer and/or more intensive treatment dosage to recover. SUMMARY We advocate short-term schema therapy in groups as a valuable first step in a stepped-care programme for patients with moderate personality disorders and comorbidity.Treatment extension or treatment intensification may be indicated in patients who do not recover. Patients with severe personality disorders seem to require long-term outpatient group treatment, with a combination of group and individual treatment being preferable. High-quality randomized controlled trials are needed in order to determine which treatment dosage is necessary for whom.
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