The impact of COVID-19 pandemic on patients with personality disorders

Three years after the outbreak of COVID-19 pandemic, numerous epidemiological studies confirm its significant psychological impact. Recent meta-analyses with 50,000-70000 participants noted the increase in anxiety, depression and feelings of loneliness in the general population.1 Patients with pre-existing mental disorders were a vulnerable group at high risk of deterioration.1,2 As part of the measures to combat the pandemic, the operation of mental health services was reduced, the access to them became more difficult and the provision of supportive and psychotherapeutic interventions continued through telepsychiatry.2 Of particular interest is the study of the impact of the pandemic on patients with personality disorders (PD).3 These patients experience severe difficulties related to interpersonal relationships and identity, which lie at the basis of intense affective and behavioral manifestations.4,5 Most studies on the impact of the pandemic on patients with personality pathology have focused on borderline personality disorder (BPD).6 Social distancing measures during the pandemic and increased sense of loneliness are serious aggravating factors for patients with BPD and may cause anxieties of abandonment and rejection, social withdrawal, and feelings of emptiness. Consequently, the patients' susceptibility to risky behaviors and substance use increases.3,7 The anxieties caused by the condition, as well as the feeling of not being in control of the situation by the subject, may mobilize paranoid ideation in patients with BPD, which further exacerbates the difficulties in their interpersonal relationships.7 In a Nordic multicenter study of 1120 outpatients with PD during the first wave of the pandemic, results showed an increase in anxiety, depression, aggression, substance use, social isolation and a decrease in work activity, while the rates of suicidal behaviors remained the same.8 On the other hand, for some patients the restricted exposure to interpersonal triggers could lead to amelioration of symptoms.7 Several papers have studied the number of visits of patients with PD or patients with self-harm to hospital emergency departments during the pandemic.6,9 In the studies that examined self-injury, the psychiatric diagnosis was not recorded, but they are mentioned here because the presence of self-harm is closely associated with PD.10 The number of emergency department visits of patients with PD or self-harm was found to be increased in some papers, decreased in others, and stable in others, compared to the previous year.6,9 During the same period, however, both the distress of patients with PD and rates of self-harm thoughts in the general population increased.3,6-8 The decreased number of emergency department visits could be the result of reduced access to services or amelioration of symptomatology due to decreased social contact or sufficient remote therapy through telepsychiatry. A critical issue that mental health services providing therapy to patients with PD had to encounter was the need to discontinue in person psychotherapy and continue by telephone or online. Patients with PD are particularly sensitive to therapeutic setting modifications and this was an aggravating factor.7 In several studies, discontinuation of in person psychotherapy for BPD patients was accompanied by worsening symptomatology, feelings of anxiety, sadness, and feelings of helplessness.6,11 When it was not possible to continue sessions by telephone or online, there was an increase in the number of emergency department visits.6,11 In contrast, continuation of sessions via tele-psychiatry was considered satisfactory by patients and in some cases their clinical picture, after the initial nuance, returned and maintained at previous level.6,11 In the above studies, the discontinuation of sessions involved a period of 2-3 months. In a study conducted at the PD services of the First Psychiatric Department of the National and Kapodistrian University of Athens, at Eginition Hospital, at the start of the restriction measures, 51 BPD patients were attending group psychoanalytic psychotherapy sessions. The face-to-face sessions were discontinued and continued online for 4 months. During this time, no self-harm incidents, suicide attempts or hospitalizations occurred; 2 patients discontinued treatment. In crises, patients used telephone communication with therapists and no emergency department visits were recorded.12 In conclusion, the pandemic had a significant psychological impact on patients with PD. However, it should be emphasized that in cases where the therapeutic setting remained alive and the continuity of therapeutic collaboration was maintained, patients with PD, despite the severity of their pathology, showed good adaptation and were able to withstand the tensions caused by the pandemic.

Fear of COVID-19 Impact on Professional Quality of Life among Mental Health Workers

Several studies have examined the impact of the COVID-19 pandemic on healthcare workers' mental health, but only a few have investigated its detrimental effect on the mental well-being of mental health workers (MHWs).

BACKGROUND

The current study aimed to explore the effect of the fear of COVID-19 (FCV-19) on professional quality of life dimensions, namely compassion satisfaction (CS), burnout (BO), and secondary traumatic stress (STS) in MHWs above and beyond sociodemographic and professional factors.

METHODS

Hierarchical linear regression models were employed to examine the relationship of extreme FCV-19 with CS, BO, and STS in MHWs (n = 224), after considering sociodemographic variables as potential confounding factors. Extreme FCV-19 was operationalized as a binary variable with a cut-off score of ≥16.5 considered as extreme fear.

RESULTS

We found that extreme FCV-19 in MHWs is linked with increased compassion fatigue (BO and STS), and this relationship is exacerbated by younger age in regard to BO and by female gender concerning STS. CS remains unaffected by severe FCV-19, and it is higher in older participants.

CONCLUSION

Organizational support is required to protect MHWs' mental well-being and ensure the quality of care they provide during prolonged crises, such as the COVID-19 pandemic. Measures that intensify a sense of safety, protection, and control against COVID-19 infections in mental health services should be included in the recommendations that may reduce BO and STS among MHWs.

Effectiveness of Predominantly Group Schema Therapy and Combined Individual and Group Schema Therapy for Borderline Personality Disorder: A Randomized Clinical Trial

IMPORTANCE

Schema therapy (ST), delivered either in an individual or group format, has been compared with other active treatments for borderline personality disorder (BPD). To our knowledge, the 2 formats have not been compared with treatment as usual (TAU) or with each other. Such comparisons help determine best treatment practices.

OBJECTIVE

To evaluate whether ST is more effectively delivered in a predominantly group or combined individual and group format and whether ST is more effective than optimal TAU for BPD.

DESIGN, SETTING, AND PARTICIPANTS

In this multicenter, 3-arm randomized clinical trial conducted at 15 sites in 5 countries (Australia, Germany, Greece, the Netherlands, and the UK), outpatients aged 18 to 65 years who had BPD were recruited between June 29, 2010, and May 18, 2016, to receive either predominantly group ST (PGST), combined individual and group ST (IGST), or optimal TAU. Data were analyzed from June 4, 2019, to December 29, 2021.

INTERVENTIONS

At each site, cohorts of 16 to 18 participants were randomized 1:1 to PGST vs TAU or IGST vs TAU. Both ST formats were delivered over 2 years, with 2 sessions per week in year 1 and the frequency gradually decreasing during year 2. Assessments were collected by blinded assessors.

MAIN OUTCOMES AND MEASURES

The primary outcome was the change in BPD severity over time, assessed with the Borderline Personality Disorder Severity Index (BPDSI) total score. Treatment retention was analyzed as a secondary outcome using generalized linear mixed model survival analysis.

RESULTS

Of 495 participants (mean [SD] age, 33.6 [9.4] years; 426 [86.2%] female), 246 (49.7%) received TAU, 125 (25.2%) received PGST, and 124 (25.0%) received IGST (1 of whom later withdrew consent). PGST and IGST combined were superior to TAU with regard to reduced BPD severity (Cohen d, 0.73; 95% CI, 0.29-1.18; P < .001). For this outcome, IGST was superior to TAU (Cohen d, 1.14; 95% CI, 0.57-1.71; P < .001) and PGST (Cohen d, 0.84; 95% CI, 0.09-1.59; P = .03), whereas PGST did not differ significantly from TAU (Cohen d, 0.30; 95% CI, -0.29 to 0.89; P = .32). Treatment retention was greater in the IGST arm than in the PGST (1 year: 0.82 vs 0.72; 2 years: 0.74 vs. 0.62) and TAU (1 year: 0.82 vs 0.73; 2 years: 0.74 vs 0.64) arms, and there was no significant difference between the TAU and PGST arms (1 year: 0.73 vs 0.72; 2 years: 0.64 vs 0.62).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, IGST was more effective and had greater treatment retention compared with TAU and PGST. These findings suggest that IGST is the preferred ST format, with high retention and continuation of improvement in BPD severity after the completion of treatment.

TRIAL REGISTRATION

trialregister.nl Identifier: NTR2392.

Validation of the greek version of the Young Schema Questionnaire-Short Form 3: Internal consistency reliability and validity

Schema therapy (ST) is an integrative therapy, which combines elements of cognitive behavior therapy, attachment theory, object relations theory and emotional-focused models. Schema therapy is an effective treatment for patients with personality disorders and other chronic psychological disorders. Early Maladaptive Schemas (EMSs) are a main concept in schema theory referring to self-defeating, core themes or patterns. They develop as a result of traumatic or toxic childhood experiences and the frustration of the core emotional needs in childhood. To date 18 EMSs have been identified and grouped into five higher order structures, known as domains. For the evaluation of the EMSs, Young developed a self-report inventory, the Young Schema Questionnaire (YSQ). There are two forms of the YSQ, the Young Schema Questionnaire - Long Form 3 (YSQ-L3) a 232-item inventory and the Young Schema Questionnaire - Short form 3 (YSQ-S3), a 90-item inventory, which is a subset of the Long form. The aim of this study was to validate the Greek Version of the YSQ-S3. A non-clinical sample of 1,236 undergraduate students completed the YSQ-S3 and 124 patients with Axis-I, Axis II or comorbid diagnosis, completed the YSQ-L3. Moreover, both samples completed the second part of the Adults Self Report (ASR). Internal consistency reliability, discriminative, convergent and predictive validity were examined. The internal consistency reliability of the schema factors was satisfactory with a Cronbach's alpha coefficient of 0.70 or above, for all factors in both student's and clinical sample. The effect sizes were high for most of the scales, regarding the differences between clinical and non-clinical sample. Emotional Deprivation, Vulnerability to harm or Illness, Subjugation, Social Isolation/Alienation and Defectiveness/Shame had the highest effect sizes in the clinical sample and in the non-clinical sample according to whether they had ever visited a mental health specialist. This may suggest that these EMSs are more sensitive and useful markers of psychological problems. In addition, patients with Axis II pathology scored significantly higher on Emotional Deprivation, Abandonment, Mistrust/Abuse, Social Isolation/Alienation compared to patients with only Axis I pathology. This finding is consistent with Schema theory, as these EMSs are associated with earlier in life traumatic experiences and insecure attachment and lie in the core of personality pathology. YSQ-S3 factors were significantly correlated with all ASR dimension and linear regression analysis showed that certain EMSs could predict Depressive and Anxiety problems. In total, the greek version of the YSQ-S3 showed good reliability and validity.

Design of an international multicentre RCT on group schema therapy for borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is a severe and highly prevalent mental disorder. Schema therapy (ST) has been found effective in the treatment of BPD and is commonly delivered through an individual format. A group format (group schema therapy, GST) has also been developed. GST has been found to speed up and amplify the treatment effects found for individual ST. Delivery in a group format may lead to improved cost-effectiveness. An important question is how GST compares to treatment as usual (TAU) and what format for delivery of schema therapy (format A; intensive group therapy only, or format B; a combination of group and individual therapy) produces the best outcomes.

METHODS/DESIGN

An international, multicentre randomized controlled trial (RCT) will be conducted with a minimum of fourteen participating centres. Each centre will recruit multiple cohorts of at least sixteen patients. GST formats as well as the orders in which they are delivered to successive cohorts will be balanced. Within countries that contribute an uneven number of sites, the orders of GST formats will be balanced within a difference of one. The RCT is designed to include a minimum of 448 patients with BPD. The primary clinical outcome measure will be BPD severity. Secondary clinical outcome measures will include measures of BPD and general psychiatric symptoms, schemas and schema modes, social functioning and quality of life. Furthermore, an economic evaluation that consists of cost-effectiveness and cost-utility analyses will be performed using a societal perspective. Lastly, additional investigations will be carried out that include an assessment of the integrity of GST, a qualitative study on patients' and therapists' experiences with GST, and studies on variables that might influence the effectiveness of GST.

DISCUSSION

This trial will compare GST to TAU for patients with BPD as well as two different formats for the delivery of GST. By combining an evaluation of clinical effectiveness, an economic evaluation and additional investigations, it will contribute to an evidence-based understanding of which treatment should be offered to patients with BPD from clinical, economic, and stakeholders' perspectives.

TRIAL REGISTRATION

Netherlands Trial Register NTR2392. Registered 25 June 2010.

Schema therapy for patients with chronic depression: a single case series study

BACKGROUND AND OBJECTIVES

This study tested the effectiveness of schema therapy (ST) for patients with chronic depression.

METHODS

Twelve patients with a diagnosis of chronic depression participated. The treatment protocol consisted of 60 sessions, with the first 55 sessions offered weekly and the last five sessions on a biweekly basis. A single case series A-B-C design, with 6 months follow-up was used. Baseline (A) was a wait period of 8 weeks. Baseline was followed by introduction to ST and bonding to therapist (phase B) with individually tailored length of 12-16 sessions, after which further ST was provided (phase C) up to 60 sessions (included the sessions given as introduction). Patients were assessed with Hamilton Rating Scale for Depression three times during baseline, at the end of phase B, then every 12 weeks until the end of treatment and at 6 months follow-up. Secondary outcome measures were the Hamilton Rating Scale for Anxiety and the Young Schema Questionnaire.

RESULTS

At the end of treatment 7 patients (approximately 60%) remitted or satisfactorily responded. The mean HRSD dropped from 21.07 during baseline to 9.40 at post-treatment and 10.75 at follow-up. The effects were large and the gains of treatment were maintained at 6-month follow-up. Only one patient dropped out for reasons not related to treatment.

LIMITATIONS

The lack of control group, the small sample and the lack of a multiple baseline case series.

CONCLUSIONS

This preliminary study supports the use of ST as an effective treatment for chronic depression.

Attentional facilitation of response is impaired for antisaccades but not for saccades in patients with schizophrenia: implications for cortical dysfunction

The facilitation of response known as the "gap effect" (a decrease of response latency), observed for saccades and antisaccades when attention is modulated prior to such eye movements, was studied in patients with schizophrenia and in controls. The hypothesis tested was whether patients would show a deficient attentional facilitation in response latency. Fifteen patients with schizophrenia and 17 healthy controls performed blocks of saccades and antisaccades in a "gap" condition and an "overlap" condition. Saccade and antisaccade response latencies as well as the error rate for antisaccades were measured for each subject. A similar gap effect (decrease in latency for the gap compared to the overlap condition) was present in the saccade task for patients and controls. In contrast the gap effect in the antisaccade task was absent in 50% of patients compared to none of the controls. This finding was interpreted as indicative of deficient preprocessing in antisaccade-specific cortical areas in schizophrenia (such as the prefrontal cortex), while visually guided saccade processing remained intact. Our results, in addition to many other recent findings, could lead to specific hypotheses on cortical dysfunction in schizophrenia.