Article

Results of a Multicenter Randomized Controlled Trial of the Clinical Effectiveness of Schema Therapy for Personality Disorders

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Objective: The authors compared the effectiveness of 50 sessions of schema therapy with clarification-oriented psychotherapy and with treatment as usual among patients with cluster C, paranoid, histrionic, or narcissistic personality disorder. Method: A multicenter randomized controlled trial, with a single-blind parallel design, was conducted between 2006 and 2011 in 12 Dutch mental health institutes. A total of 323 patients with personality disorders were randomly assigned (schema therapy, N=147; treatment as usual, N=135; clarification-oriented psychotherapy, N=41). There were two cohorts of schema therapy therapists, with the first trained primarily with lectures and the second primarily with exercises. The primary outcome was recovery from personality disorder 3 years after treatment started (assessed by blinded interviewers). Secondary outcomes were dropout rates and measures of personality disorder traits, depressive and anxiety disorders, general psychological complaints, general and social functioning, self-ideal discrepancy, and quality of life. Results: A significantly greater proportion of patients recovered in schema therapy compared with treatment as usual and clarification-oriented psychotherapy. Second-cohort schema therapists had better results than first-cohort therapists. Clarification-oriented psychotherapy and treatment as usual did not differ. Findings did not vary with specific personality disorder diagnosis. Dropout was lower in the schema therapy and clarification-oriented psychotherapy conditions. All treatments showed improvements on secondary outcomes. Schema therapy patients had less depressive disorder and higher general and social functioning at follow-up. While interview-based measures demonstrated significant differences between treatments, differences were not found with self-report measures. Conclusions: Schema therapy was superior to treatment as usual on recovery, other interview-based outcomes, and dropout. Exercise-based schema therapy training was superior to lecture-based training.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Each study was given a score on three different elements: Randomization, Blinding, and Accounting for all patients. Two of the studies received a total of one score [36,37], two of them obtained two [38,39], three of them reached three [40][41][42], and one of them achieved the maximum, five scores [43]. ...
... The authors read each publication to identify whether they contained sufficient information about ethical considerations. Six studies reported on obtaining written consent from participants and receiving ethical approval from an independent committee [36,38,[40][41][42][43]]. ...
... Three studies used schema therapy (ST), comparing it with TAU [42,43], clarification-oriented psychotherapy (COT) [43], and substance abuse counseling [39]. Three studies used PDT; two of them compared it with psychoanalytic therapy (PAT) [37,41] and one compared it with supportive-expressive psychotherapy [40]. ...
... Up to this point, there have not been any randomized clinical trials conducted to assess the effectiveness of any treatment for narcissism with one exception (Bamelis et al., 2014;Levy et al., 2009). A study conducted by Bamelis et al. (2014) compared the efficacy of Schema therapy and Clarification-oriented psychotherapy (COP) in comparison to treatment as usual among patients with NPD, histrionic, paranoid, or cluster C disorders. ...
... Up to this point, there have not been any randomized clinical trials conducted to assess the effectiveness of any treatment for narcissism with one exception (Bamelis et al., 2014;Levy et al., 2009). A study conducted by Bamelis et al. (2014) compared the efficacy of Schema therapy and Clarification-oriented psychotherapy (COP) in comparison to treatment as usual among patients with NPD, histrionic, paranoid, or cluster C disorders. ...
... However, this does not apply to the effectiveness of Transference-focused psychotherapy (TFP) for the treatment of other personality disorders, especially borderline personality disorder, which is empirically validated. The effectiveness of TFP in treating personality disorders, apart from borderline personality disorder, is yet to be assessed (Bamelis et al., 2014;Clarkin et al., 2007;Doering et al., 2010). ...
... The superiority of an integrated treatment of BPD and SUD is suggested by several authors (van den Bosch and Verheul 2007;Zanarini et al. 2004), but evidence is scarce (see, e.g., studies on treatment of this comorbidity using dialectical behaviour therapy, deconstructive dynamic psychotherapy and mentalization-based treatment; Gregory et al. 2008;Linehan et al. 2002;Philips et al. 2018). Schema Therapy (ST), an evidence-based form of psychotherapy for personality disorders, especially BPD (Bamelis et al. 2014;Giesen-Bloo et al. 2006;Jacob and Arntz 2013), has been investigated in personality disorders and comorbid SUDs, initially yielding mixed results (Ball et al. 2005;Ball et al. 2011). Recently, more positive results were obtained in a case series study, in which ST was applied thoroughly in patients with BPD and AUD (Boog et al. 2023). ...
... It was a naturalistic follow-up; many patients received psychological interventions during the year after the investigational treatment. Prior research into ST for personality disorders indicates that therapeutic improvements are preserved, or deepened, at follow-ups after treatment cessation (Bamelis et al. 2014;Fassbinder et al. 2016;van Asselt et al. 2008). We therefore hypothesized that the 1-year follow-up results still showed considerable improvements compared to baseline. ...
Article
This article describes the 1‐year follow‐up of a study into the effectiveness of Schema Therapy (ST) for borderline personality disorder (BPD) and comorbid alcohol use disorder (AUD). In the original study, 20 of these patients participated in a multiple baseline case series design study. The results of the original study were promising (a significant decrease of BPD and AUD symptoms). The present study is aimed at examining the longer term benefits of ST for BPD and comorbid AUD. One year after the cessation of the investigational therapy, 17 of the original participants agreed to participate in this follow‐up study. T ‐ or Wilcoxon signed rank tests were performed to compare 1‐year follow‐up to start of therapy (baseline). The results suggest that the main therapeutic improvements were generally preserved at 1‐year follow‐up. These findings add to the idea that integrated ST for BPD and comorbid AUD might be effective, also in the long term. A randomized clinical trial is indicated to substantiate this idea.
... Schema therapy (ST) has been shown to be effective in the treatment of both personality disorders (Bamelis et al. 2014;Nadort et al. 2009;Sempertegui et al. 2013) and affective disorders (Hawke et al. 2013;Wang et al. 2010). Research into ST and its theory has thus far focused almost entirely on what goes wrong in early childhood as it relates to later adult or adolescent functioning. ...
... There are several real-world applications of these findings. First, the identification of these four core emotional needs has implications in the treatment of ST, a fastgrowing psychotherapy approach for the treatment of personality disorders, dysfunctional life patterns, disordered attachment, and chronic anxiety and depression (Bamelis et al. 2014;Nadort et al. 2009;Sempertegui et al. 2013). Based on clinical impressions, Young et al. (2003) postulated five categories of maladaptive schemas and implied core emotional needs. ...
... Some findings call for questioning such an interpretation. In a Dutch study (21) comparing ST to clarification-oriented psychotherapy, a second cohort of therapists had to be recruited for ST to increase the number of participants. ST was shown to be superior to clarificationoriented psychotherapy; however, this superiority was entirely due to the second cohort of therapists. ...
... The authors interpreted these findings as reflecting organizational changes between the two periods (22). Both studies (21,22) also questioned whether treatment outcome variation within methods could have been substantially reduced even if adaptations of the formats of specialized programs had been prohibited in order to reflect the original evidence-based formats. ...
Article
Treatment guidelines for personality disorders have typically recommended specialized psychotherapeutic interventions. In this review, the author suggests that an intervention's effectiveness may be determined less by the specific method than by therapist competence, team culture, clinical process structure, and institutional context. The author argues that these elements determine variance in effectiveness between and within methods. Whereas initial studies of a specialized treatment may reflect the exceptional competencies of the treatment's developers and early adopters, in daily clinical practice, therapists with an average level of skill may struggle with the theoretical and methodological complexities of these treatments, which can hinder genuine connection with patients. This interference may particularly affect treatment outcomes when therapists encounter the intense emotions and interpersonal hypersensitivity experienced by patients with personality disorders. Most therapists would benefit from a set of simple generalist principles that determine the context for their work and offer a framework for dealing with clinical challenges while enabling them to be true to themselves and use their previously learned competencies. The Guideline-Informed Treatment for Personality Disorders is an enhanced common-factors approach that summarizes the core principles of effective treatment and can be feasibly implemented by most therapists.
... Duration of treatment was limited to maximum two years due to practicality. The treatment resembles the treatment in the Bamelis study (Bamelis et al., 2014) which was also structured in four phases with similar target objectives, however their treatment duration was limited to 50 sessions. ...
... The lack of successful experiential interventions was of course problematic, since particularly imagery work is a wellresearched and effective method for targeting unmet emotional needs, emotional inhibition, and experiential avoidance (Fassbinder, Schweiger, Martius, Brand-de Wilde & Arntz, 2016;Morina, Lancee & Arntz, 2017). Extensive processing of negative childhood experiences (including trauma) with specific techniques (e.g., imagery rescripting) was also emphasized in the protocol for cluster C, paranoid, histrionic, and narcissistic personality disorders (Bamelis et al., 2014), Further, trauma work with patients in risk of psychosis is well-established as both safe and beneficial (van den Berg et al., 2016), including good tolerability for experiential techniques such as imagery rescripting for treating emotional trauma in people with psychosis (Clarke, Kelly & Hardy, 2022;Ison, Medoro, Keen & Kuipers, 2014;Newman-Taylor, 2020;Paulik, Steel & Arntz, 2019). It is advised to consistently apply experiential techniques when working with traumatized psychotic patients (Paulik, Newman-Taylor, Steel & Arntz, 2022), and with Dissociative Identity Disorder (DID) patients (Huntjens, Rijkeboer & Arntz, 2019), despite risk of dissociating. ...
... Randomized studies, specifically on ST for AVPD, are lacking. However, Bamelis et al. (2014) examined ST in a large mixed personality disorder (PD) sample that included 51% AVPD patients. ST was found to be superior, compared with treatment as usual (TAU) and clarification-oriented psychotherapy, on recovery of PD, and this also held for the AVPD subsample (N = 163). ...
... The question remains why the outcomes of this RCT did not confirm the originally hypothesized superiority of GST over GCBT. Following findings in a large RCT on mixed PDs, Bamelis et al. (2014) mentions the extensive processing of aversive childhood experiences as a possible explanation for the significantly higher recovery of PDs in individual ST compared to TAU and clarification-oriented psychotherapy. The absence of superiority in our trial was possibly caused by fewer sessions (30 versus 50), the inclusion of only AVPD patients, the group format, and CBT being an established effective treatment. ...
... For instance, cognitive analytic therapy (Kellett & Hardy, 2014) and metacognitive interpersonal therapy (MIT; Cheli, Cavalletti, Popolo, et al., 2021) have shown promising feasibility in conceptualizing and treating PPD through individual case studies. Additionally, a large randomized controlled trial (RCT) testing the effectiveness of a transdiagnostic schema therapy (ST) protocol included eight individuals diagnosed with PPD, with five of them experiencing remission from the diagnosis (Bamelis et al., 2014). ...
... Recent advances in psychotherapy, however, have challenged this assumption. For instance, encouraging results have been reported for ST (Bamelis et al., 2014) and MIT (Cheli, Cavalletti, Popolo, et al., 2021) in treating PPD, even with limited sample sizes (ST: five out of eight achieved remission from diagnosis; MIT: one severe single case successfully treated). Notably, the patients recruited for our study did not receive any psychopharmacological treatment, and all reported significant changes in personality pathology and paranoid ideation. ...
Article
Little is known about effective psychosocial treatments for paranoid personality disorder. This study explores the feasibility of a novel treatment, namely Evolutionary Systems Therapy, in supporting individuals diagnosed with paranoid personality disorder. Seven patients attended 10 months of individual therapy without receiving any psychopharmacological treatment. The primary outcome was the feasibility of the intervention, while the secondary outcomes were remission from the diagnosis and reliable changes in personality pathology and paranoid ideation. All recruited patients completed the intervention and did not report any adverse events. Six out of seven patients experienced remission from the diagnosis of paranoid personality disorder. All participants showed reliable changes in personality pathology and paranoid ideation, which were maintained at the 1-month follow-up. Further research is needed to confirm these encouraging results.
... Using these theoretical foundations, ST is either delivered individually or in a group setting (GST) in clinical practice. While individual ST [16,17] and GST [18] were already found to be clinically effective and cost-effective for treating personality disorders, the rationale underlying their application for effectively treating EDs has also been documented [19]. The hypothesis is that EDs are characterized by overdeveloped coping modes that either avoid schema activation or manage affect when schemas are triggered. ...
... In short, ST provides an integrative approach that is fundamentally geared towards treating people with deeply entrenched self-identity difficulties and interpersonal problems, which are reflected through maladaptive schemas and schema modes [15]. In clinical practice, ST was deemed effective for treating personality disorders [16], including ST in a group setting [18]. On the one hand, maladaptive schemas refer to a pervasive pattern of beliefs regarding oneself and one's relationship with others consisting of one's memories, emotions, cognitions and bodily sensations. ...
Article
Full-text available
Background Eating disorders (EDs), such as (atypical) Anorexia (AN) and Bulimia Nervosa (BN), are difficult to treat, causing socioeconomic impediments. Although enhanced cognitive behavioral therapy (CBT-E) is widely considered clinically effective, it may not be the most beneficial treatment for (atypical) AN and BN patients who do not show a rapid response after the first 4 weeks (8 sessions) of a CBT-E treatment. Alternatively, group schema therapy (GST) may be a valuable treatment for this ED population. Even though GST for EDs has yielded promising preliminary findings, the current body of evidence requires expansion. On top of that, data on cost-effectiveness is lacking. In light of these gaps, we aim to describe a protocol to examine whether GST is more (1) clinically effective and (2) cost-effective than CBT-E for (atypical) AN and BN patients, who do not show a rapid response after the first 4 weeks of treatment. Additionally, we will conduct (3) process evaluations for both treatments. Methods Using a multicenter RCT design, 232 Dutch (atypical) AN and BN patients with a CBT-E referral will be recruited from five treatment centers. Clinical effectiveness and cost-effectiveness will be measured before treatment, directly after treatment, at 6 and at 12 months follow-up. In order to rate process evaluation, patient experiences and the degree to which treatments are implemented according to protocol will be measured. In order to assess the quality of life and the achievement of personalized goals, interviews will be conducted at the end of treatment. Data will be analyzed, using a regression-based approach to mixed modelling, multivariate sensitivity analyses and coding trees for qualitative data. We hypothesize GST to be superior to CBT-E in terms of clinical effectiveness and cost-effectiveness for patients who do not show a rapid response to the first 4 weeks of a CBT-E treatment. Discussion To our knowledge, this is the first study protocol describing a multicenter RCT to explore the three aforementioned objectives. Related risks in performing the study protocol have been outlined. The expected findings may serve as a guide for healthcare stakeholders to optimize ED care trajectories. Trial registration clinicaltrials.gov (NCT05812950).
... Recently, ST has been extended to several other disorders, such as anxiety disorders [13], eating disorders [14], and post-traumatic stress disorders [15]. A growing body of research supports ST's overall effectiveness, albeit the vast majority of randomized controlled trials (RCTs) on ST are focused on personality disorders [16]. Nevertheless, the first evidence suggests that ST also reduces depressive symptoms [17][18][19]. ...
... ST has further advantages over others treatments, such as high acceptance among patients [16]. Since statistically significant differences in treatment effects are not necessarily clinically relevant [25], we additionally tested ST against the first-line treatment of severe depression, cognitive behavioral therapy (CBT) [26]. ...
Article
Full-text available
Introduction: Schema therapy (ST) reduces depressive symptoms, but clinical trials have not investigated its effectiveness for patients suffering from severe forms of depression and high rates of comorbidities. There is high demand for exploring and improving treatments for this patient group. The objective of the current study was to evaluate whether ST is more effective than individual supportive therapy (IST) and noninferior compared with cog-nitive behavioral therapy (CBT) in treating depression. Methods: For this clinical trial, medicated patients were recruited in inpatient and day clinic settings. The major inclusion criteria were age between 18 and 75 years and primary diagnosis of depression without psychotic symptoms. A total of 292 participants were randomized to ST, CBT, or IST and received 7 weeks of psychotherapy (up to 14 individual and 14 group sessions). The primary outcome was change in depression severity after treatment measured by Beck Depression Inventory-II. Primary test for efficacy was superiority of ST over IST. Secondary test was noninferiority of ST compared with CBT. Multilevel modeling was conducted. The results at 6-month follow-up were explored. Results: Across treatment, ST was not superior to IST. Secondary outcome analyses and completer analyses showed similar results. However, ST showed clinically relevant noninferiority compared with CBT. Conclusion: ST for depression as part of a psychiatric care program showed clinical noninferiority compared to CBT, without being superior to IST. ST represents a potentially useful addition to the therapeutic repertoire for the treatment of depression but its efficacy, including long-term efficacy, should be evaluated further.
... Schema therapy, developed as an integrative approach for chronic psychological issues, offers a promising framework for addressing these underlying vulnerabilities [10,11]. Through its focus on modifying early maladaptive schemas (EMS)-pervasive patterns comprising memories, emotions, cognitions, and bodily sensations about oneself and relationships-this approach has demonstrated effectiveness not only for personality disorders [12][13][14][15] but also for various mental health conditions [16]. While various evidencebased approaches effectively address trauma symptoms, schema therapy uniquely focuses on how early experiences shape both trauma responses and coping patterns. ...
Article
Full-text available
This report presents the follow-up treatment course of a previously published case that demonstrated the effectiveness of prolonged exposure (PE) therapy for a disaster relief worker. The patient, a municipal employee in Fukushima Prefecture, developed post-traumatic stress disorder (PTSD) and mood disorders after the 2011 Great East Japan Earthquake and subsequent disasters. This follow-up focuses on the period from 2021 to early 2024, during which the patient experienced symptom recurrence after his father’s death. This event revealed psychological patterns similar to his disaster-related responses. Schema therapy was introduced to address over-adaptive work behaviors and vulnerabilities in relationships, identified as relapse risk factors. Combined with antidepressants, schema therapy achieved sustained improvement. This longitudinal perspective demonstrates schema therapy’s effectiveness in addressing underlying vulnerabilities when symptoms re-emerge after trauma-focused treatment. The findings underscore how initial trauma responses may interact with subsequent life events and suggest schema therapy’s potential as a secondary intervention for disaster relief workers facing complex challenges.
... Schema therapy is quite a long-term therapy that has been shown to be effective in reducing symptoms in people with personality disorders in various contexts. Effectiveness has mostly been shown for those with borderline traits but there is also evidence for patients with avoidant, dependent, obsessivecompulsive, histrionic, narcissistic and paranoid traits (Bamelis 2014). The mechanism of change seems to be the working through of childhood experiences and unmet emotional needs through reimagining techniques. ...
Article
Cognitive–behavioural therapy (CBT) has been widely used for a broad range of mental health problems for several decades and has been researched extensively. Its techniques are relatively easy to learn and follow in treatment protocols. Many new CBT-based psychotherapies have been developed that go further than traditional CBT, some specifically addressing personality disorders. These so-called third-wave approaches target emotional responses to situations by using strategies such as mindfulness exercises and acceptance of unpleasant thoughts and feelings (observing thoughts as ‘from afar’). In this article, we discuss the historical context of these therapies, dissect common and specific factors in some treatment modalities often used to treat personality disorders, and suggest potential future directions for research and treatment.
... ST has been found effective for several personality disorders, most notably for borderline personality disorder (Sempértegui et al., 2013). It has also demonstrated efficacy for cluster C personality disorders (Bamelis et al., 2014), which frequently co-occur with anxiety disorders and OCD (Cain et al., 2013). However, research on the effect of ST for chronic psychological problems other than personality disorders is limited. ...
... Both treatments have improved interpersonal functioning among patients with BPD. 78,79 Although CBT researchers have not often studied attachment insecurity as a mechanism of change, evidence of its transdiagnostic relevance, malleability in treatment, and associations with symptom reduction warrant further inquiry. 13 ...
Preprint
Full-text available
Cognitive-behavior therapies (CBTs) are the gold-standard treatment for many psychiatric conditions. However, relatively little is known about how CBTs work. By characterizing these mechanisms, researchers can ensure CBTs retain their potency across diagnoses and delivery contexts. We review three classes of putative mechanisms: CBT-specific skills (e.g., cognitive restructuring, behavioral activation), transtheoretical mechanisms (e.g., therapeutic alliance, treatment expectancies, self-efficacy beliefs), and psychopathological mechanisms (aversive reactivity, positive affect, attachment style). We point to future research within each class and emphasize the need for more intensive longitudinal designs to capture how each class of mechanisms interacts with the others to improve outcomes.
... Moreover, CPD are associated with high levels of impairment, economic costs, interpersonal problems, suicidality, all-cause mortality and low quality of life (de Reus & Emmelkamp, 2012;Disney, 2013;Lampe & Malhi, 2018). Yet, they are underrecognized and poorly studied, although some evidence suggests that schema therapy is effective (Bamelis et al., 2014) and more research is currently being conducted (Baljé et al., 2016;Daniëls et al., 2023;Groot et al., 2022). From a clinical perspective, the pervasive behavioral and experiential avoidance, passivity, control mechanisms, and hypersensitivity to rejection and criticism exhibited by patients with CPD may complicate PTSD treatment, in which exposure to fear-eliciting stimuli is an important element. ...
Article
Full-text available
Background: Posttraumatic stress disorder (PTSD) is associated with high rates of cluster C personality disorders (PD), which may negatively affect PTSD treatment. It is unknown whether concurrent treatment for PTSD and comorbid PD leads to superior treatment effects, compared to standard trauma-focused treatment. Objective: The objective was to test the efficacy of adding personality disorder treatment (group schema therapy; GST) to individual trauma-focused treatment (imagery rescripting; ImRs). Method: A two-arm randomized clinical trial (1:1 allocation ratio) was conducted between 2018 and 2023 at two sites of a mental health institution in the Netherlands. Raters were blind to treatment allocation. Adult outpatients with PTSD and comorbid cluster C personality disorders were randomized to receive either ImRs (12–18 sessions) or ImRs + GST (12–18 ImRs + 52–58 GST). The main outcome was PTSD severity one year after start of treatment measured with the Clinician-Administered PTSD Scale for DSM-5. Results: Of 130 patients (mean [SD] age = 40.6 [11.2], 110 [85%] females), 66 were assigned to ImRs and 64 to ImRs + GST. At 12 months, there were large decreases in PTSD severity (dImRs = 2.42, 95%CI = 1.97–2.87; dImRs + GST = 2.44, 95%CI = 1.99–2.90), but there was no significant difference between conditions (d = 0.02, 95%CI = −0.33–0.36, p = .944). Reductions in personality disorder symptoms and all other secondary outcomes were observed in both conditions. There were no significant differences between conditions on any of the secondary outcomes at 12 months. Conclusion: The more intensive concurrent trauma-focused and personality disorder treatment (ImRs + GST) was not superior to trauma-focused treatment alone (ImRs) for patients with PTSD and comorbid CPD. This suggests that trauma-focused treatment is the preferred primary treatment in patients presenting with both internalizing personality disorder and PTSD, reserving the stepping up to more intensive psychotherapy aimed at the personality disorder as a second line of treatment. Trial registration: ClinicalTrials.gov identifier: NCT03833531
... Schema Therapy (ST) is well positioned to treat addictive disorders comorbid with attachment and personality problems (Sempértegui et al., 2013). It has a substantial evidence base for treating patients with maladaptive behaviors, personality disorders, or complex trauma holistically (Sempértegui et al., 2013;Bamelis et al., 2014;Arntz, 2015;Arntz and Simpson, 2020). It can even address what used to be seen as a "habit" driven by cues or emotional pain, as theorized by (Boog and Tibbeoel, 2023). ...
Article
Full-text available
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.
... The majority of randomized controlled studies of the effectiveness of therapies either did not assess NPD or did not include a sufficient number of NPD participants to conduct separate statistical analyses in NPD subsamples (e.g., Bamelis et al., 2014). There are no empirical investigations that tested effectiveness of psychotherapy for NPD in randomized controlled studies (Dhawan et al., 2010;Weinberg and Ronningstam, 2022). ...
Article
Full-text available
The study was set out to establish the potential for psychotherapy to effect improvements in patients with narcissistic personality disorder (NPD). Eight patients with NPD who improved in treatment were identified. Consensus clinician/investigator diagnostic scores from before and after the psychotherapies were retroactively established on the Diagnostic Interview for Narcissism (DIN) and the Diagnostic Statistic Manual for Psychiatric Disorders, 5th Edition (DSM-5) Personality Disorder Section II criteria. Psychosocial functioning (work or school, romantic relationships) before and after the psychotherapies was retroactively evaluated as well. At the completion of the therapies after 2.5 to 5 years, all patients had improved, no longer met DIN or DSM-5 criteria for NPD, and showed better psychosocial functioning. Symptomatic improvements were associated with large effect sizes. In conclusion, changes in NPD can occur in treatment after 2.5 to 5 years. Future research should identify patient characteristics, interventions, and common processes in such improved cases that could help with development of treatments.
... Schema therapy is a fast-growing, effective approach to psychotherapy [8][9][10][11][12]. The core tenet of schema therapy is that a toxic and highly stressful environment, primarily in early childhood periods, will result in the development of strong, rigid negative schemas that will impede healthy development. ...
Article
Full-text available
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.
... A review of the literature indicates that mindfulness-based interventions have been promising in reducing pain and psychological symptoms under various conditions (Pardos-Gascón et al., 2021;Veehof et al., 2016). Additionally, mindfulness-based interventions are associated with a reduction in experiential avoidance, which mediates various psychological problems (Bamelis et al., 2014). Given the aforementioned points, the current study aims to investigate the effectiveness of mindfulness-based schema therapy on mental pain and experiential avoidance in patients with cardiovascular diseases. ...
Article
Full-text available
Objective: Cardiovascular diseases are the primary cause of premature death worldwide, causing 18 million deaths annually. The present study aimed to investigate the effectiveness of mindfulness-based schema therapy on mental pain and experiential avoidance in patients with cardiovascular diseases. Methods and Materials: The current study was a quasi-experimental pre-test, post-test design with a control group and a two-month follow-up period. The statistical population included patients visiting the Tehran Heart Center during March to May 2023. Thirty patients were randomly selected and assigned to experimental and control groups. The experimental group received mindfulness-based schema therapy in ten 90-minute sessions, once a week. The instruments used included the Orbach & Co (2003) Mental Pain questionnaire and the Bond & Co (2011) Experiential Avoidance questionnaire. Data were analyzed using repeated measures ANOVA with SPSS software version 26. Findings: The results showed that mindfulness-based schema therapy has a significant effect on mental pain and experiential avoidance in patients with cardiovascular diseases (p < 0.001). Conclusion: Based on the findings, it can be concluded that mindfulness-based schema therapy can be used as an effective intervention for reducing mental pain and experiential avoidance.
... First, the effectiveness of schema therapy was found to be independent of age among younger and middle aged patients. 11,12 Second, among existing psychotherapies for personality disorders, schema therapy can be considered most relevant for geriatric practice, because it reduces psychological distress and affective symptoms associated with comorbid, often longstanding affective disorders. 10,13 Third, uncontrolled studies have shown that schema therapy is feasible in later life, including a case-report of a cognitively impaired nursing home resident, 10 a multiple-baseline study of eight older people with cluster C personality disorder, 10 and two observational studies on group schema therapy for mixed personality disorders, which showed that improvement of maladaptive schemas precedes improvement of psychological distress in older adults. ...
... This aligns with the inclusion criteria for day treatment as defined by Muste, Weertman, and Claassen (2009). In contrast, Bamelis et al. (2014) reported an average treatment duration of approximately 2.5 years under the ST condition. Comparatively, our study yielded similar results to a 1-year inpatient GST for severe PDs (instead of 8 months of day treatment GST), including increased adaptive modes, decreased psychological distress and reduced dysfunctional modes (Wolterink and Westerhof 2018). ...
Article
Full-text available
Background Schema therapy is effective for most outpatients with personality disorders (PDs). However, a subgroup does not sufficiently benefit from outpatient programmes. Despite its common clinical use, a thorough evaluation of day treatment group schema therapy (GST) is lacking. Aims This study aimed to investigate the effectiveness of day treatment GST for patients with PDs. Methods and Procedures Negative core beliefs were the primary outcome in a multiple baseline single‐case design, measured weekly before and during 30 weeks of day treatment GST. Secondary outcomes included severity of primary PD, early maladaptive schemas (EMS), schema modes and general psychopathology measured before and after day treatment GST. Intervention effects were evaluated through visual inspection and randomization test analysis, with a reliable change index calculated for the secondary outcome measures. Outcomes and Results A total of 79% of treatment completers showed a significant positive effect of day treatment GST with large effect sizes (Cohen's d : 0.96–10.04). Secondary outcomes supported these findings: 56% had a significant decrease in the severity of primary PD and 53% in general psychopathology. In addition, 63% of EMS and 72% of schema modes (87.5% for functional schema modes) showed significant positive reliable changes. Conclusions and Implications This is the first empirical study that demonstrated the effectiveness of day treatment GST in patients with severe PDs. Day treatment GST can serve as a stepped care treatment option for nonresponsive patients in outpatient programmes. Further randomized controlled (cost‐)effectiveness research is necessary to substantiate these findings and investigate the specific patient populations for which day treatment is essential.
... Schema therapy was initially conceptualized for individuals non-responsive to cognitive therapy and patients suffering from personality disorders (Young & Brown, 2017;Young et al., 2003). Bamelis and colleagues found positive initial results of schema therapy as a treatment for personality disorders in reducing depressive symptoms as a secondary outcome in follow-ups (Bamelis et al., 2014). Considering further evidence on schema therapy for treating major depressive disorder (Fassbinder et al., 2016;Renner et al., 2016), it was hypothesized that schema therapy is a promising approach in treating depression and overcoming the weaknesses of cognitive behavioral therapy approaches, especially for more severe and complex manifestations of major depressive disorder, including those with personality disorders, as they present clinical manifestations in inpatient and clinical settings (Kopf-Beck et al., 2020). ...
Article
Full-text available
Objective: The aim of this study was to compare the efficacy of cognitive behavioral therapy and schema therapy on cognitive emotion regulation in patients with major depressive disorder. Methods and Materials: The research employed a quasi-experimental pre-test-post-test design with a control group and a one-month follow-up. The study population included all patients visiting Entekhab-e No and Aryaz clinics in Tehran during the period from February 2021 to May 2021, who were diagnosed with major depressive disorder by a psychiatrist. Forty-five individuals were purposively selected and randomly assigned to two experimental groups and one control group (15 per group). The first and second experimental groups underwent 12 and 8 sessions of cognitive behavioral therapy based on the Rosello protocol (2015) and schema therapy based on Young's protocol (2003), respectively. The research instrument was the Cognitive Emotion Regulation Questionnaire (CERQ) (Garnefski & Kraaij, 2006). Data were analyzed using repeated measures ANOVA, Bonferroni test, and SPSS version 24. Findings: Results showed that both cognitive behavioral and schema therapy interventions significantly improved scores of adaptive emotion regulation and decreased scores of maladaptive emotion regulation compared to the control group (P<0.001), with these effects maintained up to the one-month follow-up period. Additionally, there was a difference in the efficacy of the two intervention methods in increasing adaptive emotion regulation scores and decreasing maladaptive emotion regulation scores (P<0.001), with cognitive behavioral therapy being more effective than schema therapy. Conclusion: Thus, utilizing cognitive behavioral therapy and schema therapy can take an important step in reducing the negative outcomes of emotion regulation deficits in depressed patients.
... Both treatments have improved interpersonal functioning among patients with BPD. 78,79 Although CBT researchers have not often studied attachment insecurity as a mechanism of change, evidence of its transdiagnostic relevance, malleability in treatment, and associations with symptom reduction warrant further inquiry. ...
... First, the effectiveness of schema therapy was found to be independent of age among younger and middle aged patients. 11,12 Second, among existing psychotherapies for personality disorders, schema therapy can be considered most relevant for geriatric practice, because it reduces psychological distress and affective symptoms associated with comorbid, often longstanding affective disorders. 10,13 Third, uncontrolled studies have shown that schema therapy is feasible in later life, including a case-report of a cognitively impaired nursing home resident, 10 a multiple-baseline study of eight older people with cluster C personality disorder, 10 and two observational studies on group schema therapy for mixed personality disorders, which showed that improvement of maladaptive schemas precedes improvement of psychological distress in older adults. ...
Article
Full-text available
Background:Different types of psychotherapy have been shown to be successful in treating personality disorders in younger age groups. Nevertheless, well-powered, randomized controlled trials evaluating effectiveness of these therapies in older are lacking. That is why we set up the first randomized controlled trial worldwide into the effect and cost-effectiveness of psychotherapy in older patients with a personality disorder. Method:We randomized 145 patients (mean age 68 years, range 60 – 80, 65% females) with a cluster B and/or C personality disorder to either group schema therapy enriched with psychomotor therapy (GST+PMT) or to usual care (UC) in specialized geriatric mental health care. The effects were measured after 6 months (end of therapy) and 12 and 18 months (one-year follow-up). Primary outcome measure was psychological distress, as measured with the 53-item Brief Symptom Inventory (BSI-53). Secondary outcome measures were mental well-being, assessed with the Warwick-Edinburgh Mental Well-being Scale, and personality functioning assessed with the Severity Indices of Personality Problems – Short Form (SIPP-SF). Intention to treat analyses using linear mixed models were applied to compare GST+PMT with UC. Results:Group schema therapy significantly outperformed usual care with an medium effect-size of 0.4 post-treatment, which faded out to a small effect-size of 0.2 at the end of follow-up on the primary outcome parameter. Interestingly, the lower effect-size during follow-up could be explained by a slower treatment response in the usual care condition as post-treatment results of schema therapy were fully maintained during follow-up. Similar results were found with respect to improvement of mental well-being and improvement of personality functioning, although effect-sizes of the latter were a little bit smaller. Age, sex, level of education, and/or cognitive functioning had no impact of these outcomes. Conclusion:Schema therapy enriched with psychomotor therapy is more effective for the treatment of personality disorder in later life than usual care (which often consists of drug treatment combined with supportive nurse-led care and/or individual psychotherapy).
... Several theories outline therapeutic approaches to NPD; however, none of them have been tested in randomised controlled trials, and when pwNPDs were included in the survey sample, their figure was so small that statistical results could not be generalised [11][12][13][14][15][16]. Existing treatments are limited in terms of effectiveness and are frequently associated with no progress or an unfortunate treatment outcome, with a high rate of premature and sudden discontinuation [17,18] and increased persistence of symptoms after psychotherapy [19]. ...
Article
Full-text available
The characteristics and obstacles that literature has identified in the narcissistic personality disorder (NPD) can be traced back to a motivation, often underlying but omnipresent: the priority for dominance, which shapes thoughts, actions, desires and communication style in the patient with narcissistic personality disorder (pwNPD). This priority, being in pwNPDs a veritable compulsion to dominance, blinds the patients, often preventing them from relying on the others, recognising their problems and embarking on a path of personal change. Several theories outline therapeutic approaches to NPD, but existing treatments are limited in terms of effectiveness, and are frequently associated with no progress or an unfortunate outcome. However, some authors, on the basis of their own clinical experience and a careful analysis of the scientific literature on the subject, have identified some guidelines, and highlighted some common traps. They aim at promoting the development of more effective psychotherapeutic approaches inspired by more pragmatic principles, rather than being rigidly anchored to their own theoretical frameworks of reference.
Chapter
Schema therapy, developed originally as individual psychotherapy, is an integrative psychotherapy approach indicated to be effective in overcoming the clinical challenges with moderate to severe personality issues and chronic complicated psychiatric disorders, which was first applied to patients diagnosed with borderline personality disorder over 20 years ago. Based on the schema model, early maladaptive schemas (EMSs) have been presented as a core psychopathological structure in the development of personality pathology, especially borderline personality disorder (BPD), and encompass five domains including 18 EMS, which have shown substantially key roles in the development and maintenance of self-destructive emotional and cognitive patterns among individuals with BPD. Moreover, early maladaptive schema modes have shown substantial roles in the etiology of other psychiatric disorders, and personality disorders, as well. Different complicated manifestations of BPD can be elucidated through schema and schema mode models, including rapid mood turbulences, shifts in behavior patterns, and remarkable fluctuations in the emotional and psychological states of BPD patients. Furthermore, according to several empirical and clinical investigations, schema therapy, and schema mode therapy have demonstrated significant effectiveness in decreasing the severity and frequency of BPD clinical features, such as fear of abandonment, impulsivity, and self-destructive behaviors.
Chapter
This chapter explores the integration of acceptance and commitment therapy (ACT) and schema therapy (ST) within a unified therapeutic framework. ACT, a third-generation cognitive-behavioural therapy, emphasizes psychological flexibility through acceptance and mindfulness strategies. Schema therapy, developed by Jeffrey Young, addresses persistent and maladaptive schemas developed in childhood. This integrated approach aims to enhance treatment outcomes by combining ACT’s focus on experiential avoidance and value-based action with ST’s structured methodology for identifying and altering deep-seated schemas. The therapeutic synergy of ACT and ST provides a comprehensive model for addressing complex psychological issues, particularly personality disorders and chronic mental health conditions. This chapter discusses theoretical underpinnings, practical applications and the potential benefits of this integrative model in fostering long-term psychological well-being and resilience.
Article
Full-text available
Le esperienze traumatica, sia quelle episodiche che quelle continuate nel tempo, specie durante lo sviluppo, possono generare quadri clinici specifici come il Disturbo da Stress Post-Traumatico (PTSD), il Disturbo Acuto da Stress (ASD) e il Disturbo da Stress Post-Traumatico complesso (CPTSD), ma anche costituire una dimensione psicopatologica che diffonde in tutti i quadri clinici peggiorandone la prognosi e gli esiti del trattamento. Le linee guida presentate in questa rassegna sono state sviluppate per il trattamento delle specifiche categorie diagnostiche. In particolare per il PTSD dall'American Psychiatric Association (APA; 2017), dal National Institute for Health and Care Excellence britannico (NICE; 2018), dal Department of Veterans Affairs (VA) and Department of Defense (DoD) of United States of America (VA/DoD; 2017). Per quanto riguarda invece l'ASD, indicazioni per la gestione dei pazienti con tale disturbo sono riportate nelle linee guida APA del 2004. La UK Psychological Trauma Society (2017), l'International Society for Traumatic Stress Studies (ISTSS; 2019), e il NICE (2018) forniscono linee guida per il cPTSD.
Article
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.
Article
Aim: This study aimed to compare the effect of Schema Mode Therapy (SMT) and Emotional-Focused Therapy (HMT model) on emotional adjustment of new married couples with conflict. Methods: This study was a quasi-experimental study with a multi-group pre-test/post-test design with a control and follow-up group. The statistical population of this study included couples with marital conflict who had been married for less than 6 years and had been referred to counseling centers in city of Astara in 2019. Thirty couples were selected through convenience sampling method and assigned randomly into control and experimental groups. The Rubio et al (2007) Emotional Adjustment Measure (EAM) was used as research instruments in this study. Follow-up was performed after 3 months from the end of the interventions, and multivariate analysis of covariance statistical tests with repeated measures and SPSS-24 software were used to analyze the hypotheses. Results: Schema mode therapy and emotional-focused therapy (HMT), separately, reduced components of lack of discipline (P<0.05) and lack of hope (P<0.01). Conclusions: Both methods increases emotional adjustment in general state, and there is no significant difference between the effectiveness of two intervention methods.
Article
Objectives. This case study endeavors to provide an in-depth understanding of the schema and mode structure of narcissistic personality disorder (NPD) and to illustrate a possible therapeutic approach using schema therapy (ST). Material and methods. The recorded material from a 2-year therapeutic journey of a 38-year-old female client diagnosed with NPD was transcribed and systematically analyzed, together with the results of questionnaires that were given to the client at the start of therapy and at the end of the process. Results. The Millon Clinical Multiaxial Inventory (MCMI-III) was initially used to confirm the presence of NPD in the client. Concurrently, the Young Schema Questionnaire (YSQ) and Schema Mode Inventory (SMI) were employed to measure changes across the course of treatment. The MCMI-III confirmed the existence of NPD. The YSQ revealed a high presence of schemas in the domains of disconnection and rejection, as well as schemas of subjugation, entitlement, and approval seeking. The SMI indicated elevated scores on Vulnerable and Angry Child Modes, Detached Self-Soother and Self-Aggrandizer, Punitive and Demanding Parent. The scores for Happy Child and Healthy Adult were medium. Upon completion of therapy, a reevaluation of the questionnaire’s scores demonstrated a reduction in narcissism on MCMI-III from 89 to 78, indicating that the client no longer met the criteria for NPD but only for narcissistic personality traits. The scores for YSQ and SMI also decreased significantly. Conclusions. The use of schema therapy was an adaptive and successful approach to addressing the narcissistic personality pathology of the client. The utilization of a limited reparenting stance allowed empathic confrontation of the main narcissistic modes. The utilization of mode conceptualization and schema understanding reduced feelings of shame and promoted participation of the client’s Healthy Adult Mode in the therapeutic process. Keywords: personality disorders, narcissistic personality disorder, schema therapy, coping modes.
Thesis
La Schema Therapy è un innovativo approccio psicoterapeutico interdisciplinare metodicamente sviluppato per il trattamento di una vasta gamma di disturbi psicologici. Il presente elaborato, con riferimento allo stato della letteratura, si propone di contribuire alla validazione internazionale dello strumento Young Schema Questionnaire Revised Plus (YSQ-R Plus), implementato per la valutazione degli Schemi Maladattivi Precoci, definiti come “un concetto o modello omnicomprensivo formato da ricordi, emozioni, pensieri e sensazioni somatiche utilizzato per comprendere se stessi e il rapporto con gli altri” (Young et al. 2003, trad. it. 2018, p.7). Nello specifico, lo studio si è concentrato nella fase di adattamento e validazione degli item all’interno del contesto italiano, al fine di esplorarne la comprensibilità, verificarne la rilevanza culturale e identificare le possibili limitazioni circa l’utilizzo del questionario. Per tale intento, sono stati coinvolti partecipanti di diversa età e provenienza, al fine di identificare eventuali differenze nella percezione dei costrutti di interesse. I risultati attesi concorrono a delineare l’ottimizzazione degli item per la futura applicazione dello strumento all’interno dell’assetto socioculturale italiano, oltre che a promuovere nuove prospettive di ricerca e di intervento clinico per giungere a un’accurata comprensione degli schemi attraverso l’utilizzo della Schema Therapy.
Article
Full-text available
Background Higher intensity of psychotherapy might improve treatment outcome in depression, especially in those with comorbid personality disorder. Aims To compare the effects of 25 individual sessions (weekly) of two forms of psychotherapy – short-term psychoanalytic supportive psychotherapy (SPSP) and schema therapy – with the same treatments given for 50 sessions (twice weekly) in people with depression and personality disorder. Trial registration: NTR5941. Method We conducted a pragmatic, double-randomised clinical trial and, over 37 months, recruited 246 adult out-patients with comorbid depression/dysthymia and personality disorder. A 2 × 2 factorial design randomised participants to 25 or 50 sessions of SPSP or schema therapy. The primary outcome was change in depression severity over 1 year on the Beck Depression Inventory II (BDI-II). Secondary outcomes were remission both of depression and personality disorder. Results Compared with 25 sessions, participants who received 50 sessions showed a significantly greater decrease in depressive symptoms over time (time × session dosage, P < 0.001), with a mean difference of 5.6 BDI points after 1 year ( d = −0.53, 95% CI −0.18 to 0.882, P = 0.003). Remission from depression was also greater in the 50-session group (74% v. 58%, P = 0.025), as was remission of personality disorder (74% v. 56%, P = 0.010). Conclusions Greater intensity of psychotherapy leads to better outcomes of both depression and personality status in people with comorbid depression and personality disorder.
Article
This study investigated the effectiveness of brief individual experiential schema therapy (ST) in 12 adult outpatients with cluster C personality disorders (PD) using randomised multiple baseline design. Waitlist period was followed by five explorative sessions, 18 experiential ST sessions, two treatment follow‐up (FU) booster sessions and a 6‐month FU assessment. Overall well‐being (ORS), behavioural treatment goals and negative core beliefs were assessed 60–91 times, global symptomatic distress (BSI) six times. PD severity (SCID‐5‐PD) was pre‐post‐analysed. Randomisation and non‐parametric tests showed large significant effects ( d = 1.08–2.38, r = .53–.66 ) on all outcomes at treatment‐FU and 6‐month FU assessment. This is the first study providing preliminary evidence of effectiveness of brief individual experiential ST for patients with cluster C PD, tentatively challenging the common tenet that long treatment duration is required. Due to limitations, replication is recommended.
Article
Background. The evidence base for schema therapy has evolved significantly since it was first developed by Jeffrey Young in the 1990s. The aim of this bibliometric analysis was to summarize the trends and characteristics of the quantitative literature on schema therapy. Method. PsycINFO, PubMed, and CINAHL Complete databases were last searched on 1 June 2023 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement to identify peer-reviewed journal articles written in English that reported on original quantitative research on schema therapy or schema therapy constructs. NVivo was used to complete a descriptive analysis of the bibliographic, sample, and study characteristics, and a coding framework was applied to capture the aspect of the schema therapy model that was the focus of each study, as well as the study context (e.g., the population or outcomes under investigation). SciVal was used to complete citations and authorship analyses. VOSviewer was used to examine co-authorship networks. Results. A total of 704 quantitative studies on schema therapy were published by 483 unique first authors between 1994 and mid-2023. Studies predominantly used correlational designs with small samples (Mdn N = 153) of mostly females aged 18 years or older. The articles tended to focus on early maladaptive schemas, rather than schema domains or schema modes. Schema therapy and its concepts were most frequently studied in the context of depression and personality disorders. SciVal analyses indicated that, on average, articles were cited 27 times, with a Field Weighted Citation Impact of 1.02. Conclusions. Schema therapy research output appears to have slowed in recent years and several critical research gaps were evident. Areas of high priority for future research include schema modes and coping responses, and the use of developmental and longitudinal designs to evaluate several key causal assumptions in the theory underpinning schema therapy.
Article
Full-text available
Cluster-C personality disorders (PD) can be a challenge for therapists. This paper presents a novel Schema Therapy approach to the treatment of Cluster-C PDs. First an overview of schema mode models of the 3 cluster C PDs is presented, and it is discussed how idiosyncratic case formulations based on schema modes can be made. The most important survival strategies of each disorder (avoidance, control, dependency) are mirrored in the respective coping modes, but also underlying historical factors, represented in child-modes and internalized parental-modes. Next, the main schema therapy interventions, and the ways of dealing with typical clinical problems with these disorders are discussed. First study results demonstrate good applicability of this approach in cluster C PD.
Article
Full-text available
Psychotherapy is regarded as the first-line treatment for people with borderline personality disorder. In recent years, several disorder-specific interventions have been developed. This is an update of a review published in the Cochrane Database of Systematic Reviews in 2006. To assess the effects of psychological interventions for borderline personality disorder (BPD). We searched the following databases: CENTRAL 2010(3), MEDLINE (1950 to October 2010), EMBASE (1980 to 2010, week 39), ASSIA (1987 to November 2010), BIOSIS (1985 to October 2010), CINAHL (1982 to October 2010), Dissertation Abstracts International (31 January 2011), National Criminal Justice Reference Service Abstracts (15 October 2010), PsycINFO (1872 to October Week 1 2010), Science Citation Index (1970 to 10 October 2010), Social Science Citation Index (1970 to 10 October 2010), Sociological Abstracts (1963 to October 2010), ZETOC (15 October 2010) and the metaRegister of Controlled Trials (15 October 2010). In addition, we searched Dissertation Abstracts International in January 2011 and ICTRP in August 2011. Randomised studies with samples of patients with BPD comparing a specific psychotherapeutic intervention against a control intervention without any specific mode of action or against a comparative specific psychotherapeutic intervention. Outcomes included overall BPD severity, BPD symptoms (DSM-IV criteria), psychopathology associated with but not specific to BPD, attrition and adverse effects. Two review authors independently selected studies, assessed the risk of bias in the studies and extracted data. Twenty-eight studies involving a total of 1804 participants with BPD were included. Interventions were classified as comprehensive psychotherapies if they included individual psychotherapy as a substantial part of the treatment programme, or as non-comprehensive if they did not.Among comprehensive psychotherapies, dialectical behaviour therapy (DBT), mentalisation-based treatment in a partial hospitalisation setting (MBT-PH), outpatient MBT (MBT-out), transference-focused therapy (TFP), cognitive behavioural therapy (CBT), dynamic deconstructive psychotherapy (DDP), interpersonal psychotherapy (IPT) and interpersonal therapy for BPD (IPT-BPD) were tested against a control condition. Direct comparisons of comprehensive psychotherapies included DBT versus client-centered therapy (CCT); schema-focused therapy (SFT) versus TFP; SFT versus SFT plus telephone availability of therapist in case of crisis (SFT+TA); cognitive therapy (CT) versus CCT, and CT versus IPT.Non-comprehensive psychotherapeutic interventions comprised DBT-group skills training only (DBT-ST), emotion regulation group therapy (ERG), schema-focused group therapy (SFT-G), systems training for emotional predictability and problem solving for borderline personality disorder (STEPPS), STEPPS plus individual therapy (STEPPS+IT), manual-assisted cognitive treatment (MACT) and psychoeducation (PE). The only direct comparison of an non-comprehensive psychotherapeutic intervention against another was MACT versus MACT plus therapeutic assessment (MACT+). Inpatient treatment was examined in one study where DBT for PTSD (DBT-PTSD) was compared with a waiting list control. No trials were identified for cognitive analytical therapy (CAT).Data were sparse for individual interventions, and allowed for meta-analytic pooling only for DBT compared with treatment as usual (TAU) for four outcomes. There were moderate to large statistically significant effects indicating a beneficial effect of DBT over TAU for anger (n = 46, two RCTs; standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.43 to -0.22; I(2) = 0%), parasuicidality (n = 110, three RCTs; SMD -0.54, 95% CI -0.92 to -0.16; I(2) = 0%) and mental health (n = 74, two RCTs; SMD 0.65, 95% CI 0.07 to 1.24 I(2) = 30%). There was no indication of statistical superiority of DBT over TAU in terms of keeping participants in treatment (n = 252, five RCTs; risk ratio 1.25, 95% CI 0.54 to 2.92).All remaining findings were based on single study estimates of effect. Statistically significant between-group differences for comparisons of psychotherapies against controls were observed for BPD core pathology and associated psychopathology for the following interventions: DBT, DBT-PTSD, MBT-PH, MBT-out, TFP and IPT-BPD. IPT was only indicated as being effective in the treatment of associated depression. No statistically significant effects were found for CBT and DDP interventions on either outcome, with the effect sizes moderate for DDP and small for CBT. For comparisons between different comprehensive psychotherapies, statistically significant superiority was demonstrated for DBT over CCT (core and associated pathology) and SFT over TFP (BPD severity and treatment retention). There were also encouraging results for each of the non-comprehensive psychotherapeutic interventions investigated in terms of both core and associated pathology.No data were available for adverse effects of any psychotherapy. There are indications of beneficial effects for both comprehensive psychotherapies as well as non-comprehensive psychotherapeutic interventions for BPD core pathology and associated general psychopathology. DBT has been studied most intensely, followed by MBT, TFP, SFT and STEPPS. However, none of the treatments has a very robust evidence base, and there are some concerns regarding the quality of individual studies. Overall, the findings support a substantial role for psychotherapy in the treatment of people with BPD but clearly indicate a need for replicatory studies.
Article
Full-text available
Despite international guidelines describing psychotherapy as first choice for people with personality disorders (PDs), well-designed research on the effectiveness and cost-effectiveness of psychotherapy for PD is scarce. Schema therapy (ST) is a specific form of psychological treatment that proved to be effective for borderline PD. Randomized controlled studies on the effectiveness of ST for other PDs are lacking. Another not yet tested new specialized treatment is Clarification Oriented Psychotherapy (COP). The aim of this project is to perform an effectiveness study as well as an economic evaluation study (cost effectiveness as well as cost-utility) comparing ST versus COP versus treatment as usual (TAU). In this study, we focus on avoidant, dependent, obsessive-compulsive, paranoid, histrionic and narcissistic PD. In a multicentered randomized controlled trial, ST, and COP as an extra experimental condition, are compared to TAU. Minimal 300 patients are recruited in 12 mental health institutes throughout the Netherlands, and receive an extensive screening prior to enrolment in the study. When eligible, they are randomly assigned to one of the intervention groups. An economic evaluation and a qualitative research study on patient and therapist perspectives on ST are embedded in this trial. Outcome assessments (both for clinical effectiveness and economic evaluation) take place at 6,12,18,24 and 36 months after start of treatment. Primary outcome is recovery from PD; secondary measures include general psychopathological complaints, social functioning and quality of life. Data for the cost-effectiveness and cost-utility analyses are collected by using a retrospective cost interview. Information on patient and therapist perspectives is gathered using in-depth interviews and focus groups, and focuses on possible helpful and impeding aspects of ST. This trial is the first to compare ST and COP head-to-head with TAU for people with a cluster C, paranoid, histrionic and/or narcissistic PD. By combining clinical effectiveness data with an economic evaluation and with direct information from primary stakeholders, this trial offers a complete and thorough view on ST as a contribution to the improvement of treatment for this PD patient group. Netherlands Trial Register (NTR): NTR566.
Article
Full-text available
The relationship between autism spectrum disorders/pervasive developmental disorders and personality disorders is not completely clear, although both concepts imply lifelong impairment. The purpose of the present study was to investigate the presence of possible personality disorders in a group of young adults with Asperger syndrome. Fifty-four young adults with a clinical diagnosis of Asperger syndrome were assessed with Structured Clinical Interview for DSM-IV Axis II disorders to evaluate the presence of a concomitant personality disorder and completed the Autism Spectrum Quotient to measure level of autistic features. Autism spectrum diagnosis was confirmed by Diagnostic Interview for Social and Communication Disorders with a collateral informant. Approximately half of the study group fulfilled criteria for a personality disorder, all belonging to cluster A or C. There was a significant difference across sex: men with Asperger syndrome meeting personality disorder criteria much more often than women with Asperger syndrome (65% vs 32%). Participants fulfilling criteria for a personality disorder showed more marked autistic features according to the Autism Spectrum Quotient. There is a considerable overlap in symptoms between Asperger syndrome and certain personality disorders. Similarities and differences of the two concepts are discussed in the framework of the Diagnostic and Statistical Manual of Mental Disorders classification system.
Article
Full-text available
Dose-effect relationship data suggest that short-term psychotherapy is insufficient for many patients with chronic distress or personality disorders (complex mental disorders). To examine the comparative efficacy of long-term psychodynamic psychotherapy (LTPP) in complex mental disorders. We conducted a meta-analysis of controlled trials of LTPP fulfilling the following inclusion criteria: therapy lasting for at least a year or 50 sessions; active comparison conditions; prospective design; reliable and valid outcome measures; treatments terminated. Ten studies with 971 patients were included. Between-group effect sizes in favour of LTPP compared with less intensive (lower dose) forms of psychotherapy ranged between 0.44 and 0.68. Results suggest that LTPP is superior to less intensive forms of psychotherapy in complex mental disorders. Further research on long-term psychotherapy is needed, not only for psychodynamic psychotherapy, but also for other therapies.
Article
Full-text available
Little is known about the cross-national population prevalence or correlates of personality disorders. To estimate prevalence and correlates of DSM-IV personality disorder clusters in the World Health Organization World Mental Health (WMH) Surveys. International Personality Disorder Examination (IPDE) screening questions in 13 countries (n = 21 162) were calibrated to masked IPDE clinical diagnoses. Prevalence and correlates were estimated using multiple imputation. Prevalence estimates are 6.1% (s.e. = 0.3) for any personality disorder and 3.6% (s.e. = 0.3), 1.5% (s.e. = 0.1) and 2.7% (s.e. = 0.2) for Clusters A, B and C respectively. Personality disorders are significantly elevated among males, the previously married (Cluster C), unemployed (Cluster C), the young (Clusters A and B) and the poorly educated. Personality disorders are highly comorbid with Axis I disorders. Impairments associated with personality disorders are only partially explained by comorbidity. Personality disorders are relatively common disorders that often co-occur with Axis I disorders and are associated with significant role impairments beyond those due to comorbidity.
Article
Full-text available
The use of growth-modeling analysis (GMA)--including hierarchical linear models, latent growth models, and general estimating equations--to evaluate interventions in psychology, psychiatry, and prevention science has grown rapidly over the last decade. However, an effect size associated with the difference between the trajectories of the intervention and control groups that captures the treatment effect is rarely reported. This article first reviews 2 classes of formulas for effect sizes associated with classical repeated-measures designs that use the standard deviation of either change scores or raw scores for the denominator. It then broadens the scope to subsume GMA and demonstrates that the independent groups, within-subjects, pretest-posttest control-group, and GMA designs all estimate the same effect size when the standard deviation of raw scores is uniformly used. Finally, the article shows that the correct effect size for treatment efficacy in GMA--the difference between the estimated means of the 2 groups at end of study (determined from the coefficient for the slope difference and length of study) divided by the baseline standard deviation--is not reported in clinical trials.
Article
Full-text available
This study tests the effectiveness of adding an eight-month, thirty-session schema-focused therapy (SFT) group to treatment-as-usual (TAU) individual psychotherapy for borderline personality disorder (BPD). Patients (N=32) were randomly assigned to SFT-TAU and TAU alone. Dropout was 0% SFT, 25% TAU. Significant reductions in BPD symptoms and global severity of psychiatric symptoms, and improved global functioning with large treatment effect sizes were found in the SFT-TAU group. At the end of treatment, 94% of SFT-TAU compared to 16% of TAU no longer met BPD diagnosis criteria (p<.001). This study supports group SFT as an effective treatment for BPD that leads to recovery and improved overall functioning.
Article
Full-text available
The purpose of this study was to compare psychosocial functioning in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder and patients with major depressive disorder and no personality disorder. Patients (N=668) were recruited by the four clinical sites of the Collaborative Longitudinal Personality Disorders Study. The carefully diagnosed study groups were compared on an array of domains of psychosocial functioning, as measured by the Longitudinal Interval Follow-Up Evaluation--Baseline Version and the Social Adjustment Scale. Patients with schizotypal personality disorder and borderline personality disorder were found to have significantly more impairment at work, in social relationships, and at leisure than patients with obsessive-compulsive personality disorder or major depressive disorder; patients with avoidant personality disorder were intermediate. These differences were found across assessment modalities and remained significant after covarying for demographic differences and comorbid axis I psychopathology. Personality disorders are a significant source of psychiatric morbidity, accounting for more impairment in functioning than major depressive disorder alone.
Article
Full-text available
The Assessment of DSM-IV Personality Disorders questionnaire (ADP-IV) is a self-report measure of the DSM-IV Axis II personality disorders (PDs). The ADP-IV assesses for each DSM-IV criterion its typicality as well as the accompanying distress and impairment. This study investigates two important aspects of the construct validity of the ADP-IV: (a) the differential validity (i.e., the ability to differentiate between a sample of the general Flemish population ( n = 659) and a sample of psychiatric inpatients ( n = 487) with a high prevalence of clinical PD diagnoses, and patients with and without a PD in the psychiatric sample; (b) the convergent validity with the SCID-II semi-structured interview in a population of psychiatric inpatients ( n = 59). The results indicate a good differential validity: the dimensional scales and the categorical measures discriminated well between both groups and between patients with and without a PD diagnosis in the psychiatric sample. Concerning the concordance with the SCID-II, a decent level of agreement is exemplified by a correlation of.67 between the dimensional total scores of both instruments and by kappa coefficients for an "any" Axis II diagnosis at the.50 level. In conclusion, the results indicate that the ADP-IV is an efficient method for assessing PD in dimensional and categorical ways.
Article
Full-text available
Borderline personality disorder is a severe and chronic psychiatric condition, prevalent throughout health care settings. Only limited effects of current treatments have been documented. To compare the effectiveness of schema-focused therapy (SFT) and psychodynamically based transference-focused psychotherapy (TFP) in patients with borderline personality disorder. A multicenter, randomized, 2-group design. Four general community mental health centers. Eighty-eight patients with a Borderline Personality Disorder Severity Index, fourth version, score greater than a predetermined cutoff score. Three years of either SFT or TFP with sessions twice a week. Borderline Personality Disorder Severity Index, fourth version, score; quality of life; general psychopathologic dysfunction; and measures of SFT/TFP personality concepts. Patient assessments were made before randomization and then every 3 months for 3 years. Data on 44 SFT patients and 42 TFP patients were available. The sociodemographic and clinical characteristics of the groups were similar at baseline. Survival analyses revealed a higher dropout risk for TFP patients than for SFT patients (P = .01). Using an intention-to-treat approach, statistically and clinically significant improvements were found for both treatments on all measures after 1-, 2-, and 3-year treatment periods. After 3 years of treatment, survival analyses demonstrated that significantly more SFT patients recovered (relative risk = 2.18; P = .04) or showed reliable clinical improvement (relative risk = 2.33; P = .009) on the Borderline Personality Disorder Severity Index, fourth version. Robust analysis of covariance (ANCOVA) showed that they also improved more in general psychopathologic dysfunction and measures of SFT/TFP personality concepts (P<.001). Finally, SFT patients showed greater increases in quality of life than TFP patients (robust ANCOVAs, P=.03 and P<.001). Three years of SFT or TFP proved to be effective in reducing borderline personality disorder-specific and general psychopathologic dysfunction and measures of SFT/TFP concepts and in improving quality of life; SFT is more effective than TFP for all measures.
Article
Full-text available
This article reviews psychotherapy studies published between 2003 and 2006 directed at psychotherapy for personality disorders (PDs). Over the past 3 years, there has been a substantial increase in these studies compared with previous decades. Psychodynamic therapy, cognitive-behavioral therapy, and variants of these approaches have been evaluated and shown to have positive results. Borderline personality disorder continues to garner the most attention and has been shown to respond favorably to several types of therapeutic interventions on a range of outcomes. Avoidant personality disorder and obsessive-compulsive personality disorder also respond positively to psychotherapy. Although growing attention to the treatment of PDs is encouraging, further research is indicated. A summary of recent empirical findings and their implications for clinical practice are discussed.
Article
Full-text available
The aim of this paper is to review the level of empirical evidence for four different formats and settings that are available for psychotherapy delivery, i.e., group psychotherapy, out-patient individual psychotherapy, day hospital psychotherapy, and in-patient psychotherapy. The focus is on studies which include a wide range of DSM-IV-TR Axis II personality disorders. The results show that various psychotherapeutic treatments have proven to be efficacious with respect to reducing symptomatology and personality pathology, and improving social functioning in patients with Cluster A, B, C, or not-otherwise-specified personality disorders. This is especially true for cognitive-behaviorally or psychodynamically oriented out-patient individual psychotherapies. However, some evidence indicates that this also applies to (1) long-term, psychodynamically oriented group psychotherapy, (2) short-term, psychodynamically oriented psychotherapy in a day hospital setting, and (3) various duration variants of psychodynamically oriented, in-patient psychotherapy programmes. The available evidence mostly applies to borderline, dependent, avoidant and not-otherwise-specified personality disorder, and perhaps also paranoid, obsessive-compulsive, and schizotypal personality disorder. It is unknown whether these conclusions also apply to schizoid, antisocial, narcissistic, and histrionic personality disorder.
Article
Full-text available
Interview methods are widely regarded as the standard for the diagnosis of borderline personality disorder (BPD), whereas self-report methods are considered a time-efficient alternative. However, the relative validity of these methods has not been sufficiently tested. The current study used data from the Collaborative Longitudinal Personality disorder Study to compare diagnostic base rates and the relative validity of interview and self-report methods for assessing functional outcome in BPD. Although self-report yielded higher base rates of criteria endorsement, results did not support the common assumption that diagnostic interviews are more valid than self-reports, but instead indicated the combined use of these methods optimally identifies BPD criteria.
Article
Full-text available
Some evidence suggests that personality disorders are associated with a high economic burden due to, for example, a high demand on psychiatric, health, and social care services. However, state-of-the-art cost studies for the broad range of personality disorder diagnoses are lacking. The present study examines the direct medical costs, as well as the indirect costs, of patients seeking mental health treatment with DSM-IV personality disorders. The 1740 subjects included in this study were recruited from March 2003 to March 2006 from 6 different mental health care institutes in the Netherlands specializing in the psychotherapeutic treatment of personality disorders. The direct and indirect costs were assessed using the Trimbos and Institute for Medical Technology Assessment Questionnaire on Costs Associated with Psychiatric Illness. Personality disorders were diagnosed using the Structured Interview for DSM-IV Personality. The mean total costs of the personality disorder group in the 12 months prior to treatment were 11,126 euros per patient. Two thirds (66.5%) of these costs consisted of direct medical costs, while the remaining costs were related to productivity losses. Borderline and obsessive-compulsive personality disorders were uniquely associated with increased mean total costs. Treatment-seeking patients with personality disorders pose a high economic burden on society, a burden substantially higher than that found in, for instance, depression or generalized anxiety disorder. These high societal costs present a strong argument in favor of prioritizing effective personality disorder treatments in reimbursement decisions.
Article
Full-text available
Schema-focused therapy (SFT) and transference-focused psychotherapy (TFP) for borderline personality disorder were recently compared in a randomised multicentre trial. To assess the societal cost-effectiveness of SFT v. TFP in treating borderline personality disorder. Costs were assessed by interview. Health-related quality of life was measured using EQ-5D. Outcomes were costs per recovered patient (recovery assessed with the Borderline Personality Disorder Severity Index) and costs per quality-adjusted life-year (QALY). Mean 4-year bootstrapped costs were euro37 826 for SFT and euro46 795 for TFP (95% uncertainty interval for difference -21 775 to 3546); QALYs were 2.15 for SFT and 2.27 for TFP (95% UI -0.51 to 0.28). The percentages of patients who recovered were 52% and 29% respectively. The SFT intervention was less costly and more effective than TFP (dominant), for recovery; it saved euro90 457 for one QALY loss. Despite the initial slight disadvantage in QALYs, there is a high probability that compared with TFP, SFT is a cost-effective treatment for borderline personality disorder.
Article
Full-text available
A generic quality of life measure was used to investigate the burden of disease in a large sample of patients with personality disorders. The 1,708 subjects included in this study were recruited from six different mental health care institutes in the Netherlands. The burden of disease was measured using the EuroQol EQ-5D. Personality disorders were diagnosed using the Structured Interview for DSM-IV Personality (SIDP-IV). The mean EQ-5D index value was 0.56. Primarily the total number of personality disorder diagnoses rather than the specific type determined the quality of life. Notably borderline personality disorder was not associated with the highest burden. The findings indicate that patients with personality disorders experience a high burden of disease, comparable to that of severe somatic illnesses. The results call into question the primary focus in literature on borderline personality disorder. The current study yields a strong argument in favor of reimbursing (effective) treatments for this patient population.
Article
The Assessment of DSM-IV Personality Disorders questionnaire (ADP-IV) is a self-report measure of the DSM-IV Axis II personality disorders (PDs). The ADP-IV assesses for each DSM-IV criterion its typicality as well as the accompanying distress and impairment. This study investigates two important aspects of the construct validity of the ADP-IV: (a) the differential validity (i.e., the ability to differentiate between [1] a sample of the general Flemish population (n = 659) and a sample of psychiatric inpatients (n = 487) with a high prevalence of clinical PD diagnoses, and [2] patients with and without a PD in the psychiatric sample; (b) the convergent validity with the SCID-II semi-structured interview in a population of psychiatric inpatients (n = 59). The results indicate a good differential validity: the dimensional scales and the categorical measures discriminated well between both groups and between patients with and without a PD diagnosis in the psychiatric sample. Concerning the concordance with the SCID-II, a decent level of agreement is exemplified by a correlation of .67 between the dimensional total scores of both instruments and by kappa coefficients for an "any" Axis II diagnosis at the .50 level. In conclusion, the results indicate that the ADP-IV is an efficient method for assessing PD in dimensional and categorical ways.
Article
Background: The paper reports on the development of the WHOQOL-BREF, an abbreyiated version of the WHOQOL-100 quality of life assessment. Method: The WHOQOL-BREF was derived from data collected using the WHOQOL-100. It produces scores for four domains related to quality of life: physical health, psychological, social relationships and environment. It also includes one facet on overall quality of life and general health. Results: Domain scores produced by the WHOQOL-BREF correlate highly (0.89 or above) with WHOQOL-100 domain scores (calculated on a four domain structure). WHOQOL-BREF domain scores demonstrated good discriminant validity, content validity, internal consistency and test-retest reliability. Conclusion: These data suggest that the WHOQOL-BREF provides a valid and reliable alternative to the assessment of domain profiles using the WHOQOL-100. It is envisaged that the WHOQOL-BREF will be most useful in studies that require a brief assessment of quality of life, for example, in large epidemiological studies and clinical trials where quality of life is of interest. In addition, the WHOQOL-BREF may be of use to health professionals in the assessment and evaluation of treatment efficacy.
Article
Background: The observer-rated Hamilton depression scale (HamD) and the self-report Beck Depression Inventory (BDI) are among the most commonly used rating scales for depression, and both have well demonstrated reliability and validity. However, many depressed subjects have discrepant scores on these two assessment methods. The present study evaluated the ability of demographic, clinical and personality factors to account for the discrepancies observed between BDI and HamD ratings. Method: The study group consisted of 94 SCID-diagnosed outpatients with a current major depressive disorder. Subjects were rated with the 21-item HamD and completed the BDI and the NEO-Five Factor Inventory. Results: Younger age, higher educational attainment, and depressive subtype (atypical, non-melancholic) were predictive of higher BDI scores relative to HamD observer ratings. In addition, high neuroticism, low extraversion and low agreeableness were associated with higher endorsement of depressive symptoms on the BDI relative to the HamD. In general, these predictive variables showed a greater ability to explain discrepancies between self and observer ratings of psychological symptoms of depression compared to somatic symptoms of depression. Limitations: The study does not determine which aspects of neuroticism and extraversion contribute to the observed BDI/HamD discrepancies. Conclusions: Depression ratings obtained with the BDI and HamD are frequently discordant and a number of patient characteristics robustly predict the discrepancy between these two rating methods. The value of multi-modal assessment in the conduct of research on depressive disorders is re-affirmed.
Article
Randomised controlled studies in research environments have demonstrated dialectical behaviour therapy (DBT) to be more efficacious than treatment as usual in reducing suicidal behaviour in patients with borderline personality disorder (BPD). Limited evidence exists for the effectiveness of DBT in the treatment of BPD within routine clinical settings. This study examines the clinical and cost effectiveness of providing DBT over treatment as usual in a routine Australian public mental health service. Forty-three adult patients with BPD were provided with outpatient DBT for six months with patient outcomes compared to those obtained from patients in a wait list group receiving treatment as usual (TAU) from the same service. After six months of treatment the DBT group showed significantly greater reductions in suicidal/non-suicidal self-injury, emergency department visits, psychiatric admissions and bed days. Self-report measures were administered to a reduced sample of patients. With this group, DBT patients demonstrated significantly improved depression, anxiety and general symptom severity scores compared to TAU at six months. Average treatment costs were significantly lower for those patients in DBT than those receiving TAU. Therapists who received intensive DBT training were shown to produce significantly greater improvements in patients' suicidal and non-suicidal self-injury than therapists who received only 4 day basic training. Further clinical improvements were achieved in patients offered an additional six months of DBT. This study demonstrates that providing DBT to patients within routine public mental health settings can be both clinically effective and cost effective.
Article
To provide a narrative review of recent research on the psychotherapeutic treatment of patients with personality disorders (PDs). We conducted PubMed and PsycINFO searches of recently published articles that reported on the treatment outcomes of psychotherapies for PDs. Our focus was on studies that used randomized controlled trial (RCT) methodology. The search period was from January 2006 to June 2009. The effectiveness of various psychotherapy treatment packages for PDs is well supported by favourable results from RCTs. Beneficial effects of psychotherapy included reduced symptomatology, improved social and interpersonal functioning, reduced frequency of maladaptive behaviours, and decreased hospitalization. Equivalent effects among the interventions we compared were common. Many of the treatments studied required only limited training by therapists. Most studies were focused on treating patients with borderline personality disorder (BPD). Some findings were suggestive of psychotherapy being cost-effective; however, few studies actually included formal cost analyses. Only one study included follow-up of treated patients beyond 1-year posttreatment. There is strong support for the use of psychotherapy to treat patients with PDs. However, most of the evidence is limited to BPD. The findings of recent studies hold promise for training and practice. Future research should attend to identification of appropriate patient-treatment matches, elucidation of active treatment ingredients, and illumination of factors that are common among treatments that account for their equivalent effects.
Article
Researchers in clinical trials usually pay close attention to therapist selection, training, supervision and monitoring, but the extent of this input has not been systematically documented. To describe the extent of training and supervision activity within clinical trials, and to consider any implications for transporting therapies from research to routine clinical contexts. Twenty-seven randomized studies examining the efficacy of CBT interventions for people with depression or anxiety disorders were selected on the basis of their quality and impact on the field. Published and unpublished sources were used to gather information about therapist selection, training and supervision within these trials. The review identified the extent of investment by researchers in assuring therapist expertise, adherence and competence. It also indicated inconsistencies in the clarity with which this input was reported. The ubiquity of intervention-specific training in research contexts risks being overlooked when commissioning evidence-based therapies in routine practice. This has clear implications for the likely effectiveness of interventions. Greater consistency in the reporting of training in clinical trials may help to draw attention to the role of training and supervision in maximizing clinical outcomes.
Article
This study aimed to evaluate the success of implementing outpatient schema focused therapy (ST) for borderline patients in regular mental healthcare and to determine the added value of therapist telephone availability outside office hours in case of crisis (TTA). To enhance the implementation, the following adaptations regarding the original ST protocol were applied: a reduction in the frequency and duration of the therapy; training therapists of eight regular healthcare centers in ST with a structured and piloted program supported by a set of films (DVDs) with examples of ST techniques; training and supervision given by Dutch experts. Telephone availability outside office hours was randomly allocated to 50% of the therapists of each treatment center. Patient's outcome measures were assessed with a semi-structured interview and self-report measures on BPD, quality of life, general psychopathology and an ST questionnaire, before, during and after treatment. Data on 62 DSM-IV defined BPD patients were available. Intention-to-treat analyses showed that after 1.5 years of ST 42% of the patients had recovered from BPD. No added value of therapist telephone availability (TTA) was found on the BPDSI score nor on any other measure after 1.5 years of ST. ST for BPD can be successfully implemented in regular mental healthcare. Treatment results and dropout were comparable to a previous clinical trail. No additional effect of extra crisis support with TTA outside office hours ST was found.
Article
Empirically supported psychological treatments have been developed for a range of psychiatric disorders but there is evidence that patients are not receiving them in routine clinical care. Furthermore, even when patients do receive these treatments there is evidence that they are often not well delivered. The aim of this paper is to identify the barriers to the dissemination of evidence-based psychological treatments and then propose ways of overcoming them, hence potentially bridging the gap between research findings and clinical practice.
Article
Few studies have compared the psychosocial problems associated with different types of personality disorders (PDs). The aim of this study was to investigate the functional impairment and symptomatic distress associated with six PD diagnoses coded in DSM-IV: paranoid, borderline, avoidant, dependent, obsessive-compulsive PD and PD not otherwise specified, as well as a condition of non-psychotic symptom disorders with no PD. The study included 1023 patients from eight day treatment units specialized in the treatment of PDs. Eighty-one per cent had one or more PD diagnoses. At admission to day treatment, the patients were evaluated with respect to global functioning, symptomatic and interpersonal distress, education, quality of life, social support, legal problems and previous psychotic episodes and psychiatric hospitalizations. There were few differences in global functioning or symptomatic and interpersonal distress between patients with a single PD diagnosis. Avoidant PD and borderline PD was the diagnoses that contributed most to dysfunction in most variables when taking into account the presences of several co-occurrent PD diagnoses and axis I disorders. The psychosocial problems associated with avoidant and borderline PD were partly domain specific. The study indicates that avoidant PD is associated with severe dysfunction and subjective distress, at a level comparable to that of borderline PD. Avoidant PD deserves more attention, both with respect to the specific psychopathology and dynamics underlying the disorder and the development of treatment approaches.
Article
The present investigation was intended principally as a concurrent validation study for a new self-report symptom inventory: the SCL-90. A sample of 209 'symptomatic volunteers' served as subjects and were administered both the SCL-90 and the MMPI prior to participation in clinical therapeutic drug trials. The MMPI was scored for the Wiggins content scales and the Tryon cluster scales in addition to the standard clinical scales. Comparisons of the nine primary symptom dimensions of the SCL-90 with the set of MMPI scales reflected very high convergent validity for the SCL-90. Peak correlations were observed with like constructs on eight of the nine scales, with secondary patterns of correlations showing high interpretative consistency.
Article
Adaptive biased urn randomization, applied in, e.g., a clinical trial, has certain attractive properties. If stratified randomization is desired, a good balance between group sizes can be guaranteed, even in (very) small strata. Yet treatment assignment may be kept unpredictable, which is necessary to avoid selection bias if blinding is impossible. In the present paper a more flexible urn model is described. The investigator may choose assignment probabilities that strongly depend on the degree of imbalance when the groups are still small, but with a tendency toward complete randomization when the groups become large. It is also possible to keep the difference in group size below a chosen maximum, which is useful if population characteristics may change during the course of a trial. The new urn model includes random permutations and complete randomization as special cases. An extension of the model allows the promotion of unequal group sizes. Some attention is paid to a randomized version of the minimization method.
Article
The observer-rated Hamilton depression scale (HamD) and the self-report Beck Depression Inventory (BDI) are among the most commonly used rating scales for depression, and both have well demonstrated reliability and validity. However, many depressed subjects have discrepant scores on these two assessment methods. The present study evaluated the ability of demographic, clinical and personality factors to account for the discrepancies observed between BDI and HamD ratings. The study group consisted of 94 SCID-diagnosed outpatients with a current major depressive disorder. Subjects were rated with the 21-item HamD and completed the BDI and the NEO-Five Factor Inventory. Younger age, higher educational attainment, and depressive subtype (atypical, non-melancholic) were predictive of higher BDI scores relative to HamD observer ratings. In addition, high neuroticism, low extraversion and low agreeableness were associated with higher endorsement of depressive symptoms on the BDI relative to the HamD. In general, these predictive variables showed a greater ability to explain discrepancies between self and observer ratings of psychological symptoms of depression compared to somatic symptoms of depression. The study does not determine which aspects of neuroticism and extraversion contribute to the observed BDI/HamD discrepancies. Depression ratings obtained with the BDI and HamD are frequently discordant and a number of patient characteristics robustly predict the discrepancy between these two rating methods. The value of multi-modal assessment in the conduct of research on depressive disorders is re-affirmed.
Article
Patients' perspectives concerning impaired functioning provide important information. AIMS; To evaluate the reliability and validity of the Work and Social Adjustment Scale (WSAS). Data from two studies were analysed. Reliability analyses included internal scale consistency, test-retest and parallel forms. Convergent and criterion validities were examined with respect to disorder severity. Cronbach's alpha measure of internal scale consistency ranged from 0.70 to 0.94. Test-retest correlation was 0.73. Interactive voice response administrations of the WSAS gave correlations of 0.81 and 0.86 with clinician interviews. Correlations of WSAS with severity of depression and obsessive-compulsive disorder symptoms were 0.76 and 0.61, respectively. The scores were sensitive to patient differences in disorder severity and treatment-related change. The WSAS is a simple, reliable and valid measure of impaired functioning. It is a sensitive and useful outcome measure offering the potential for readily interpretable comparisons across studies and disorders.
Article
The purpose of this study was to describe the psychiatric treatment received by a well-defined sample of patients with borderline personality disorder and Axis II comparison subjects over 6 years of prospective follow-up. 362 inpatients were interviewed about their treatment histories during their index admission (1992-1995). 290 patients met both Revised Diagnostic Interview for Borderlines and DSM-III-R criteria for borderline personality disorder and 72 met DSM-III-R criteria for at least 1 nonborderline Axis II disorder (and neither criteria set for borderline personality disorder). Over 94% of surviving patients were re-interviewed about their psychiatric treatment histories 2, 4, and 6 years later. Only 33% of borderline patients were hospitalized during the final 2 years of the 6-year follow-up, a substantial decline from the 79% who had prior hospitalizations at baseline. Much the same pattern emerged for day and/or residential treatment (from 55% to 22%). In contrast, about three quarters of borderline patients were still in psychotherapy and taking psychotropic medications after 6 years of follow-up. Additionally, over 70% of borderline patients participating in these outpatient modalities did so for at least 75% of each follow-up period. While rates of intensive psychotherapy declined significantly over time (from 36% to 16%), rates of intensive polypharmacy remained relatively stable over time, with about 40% of borderline patients taking 3 or more concurrent standing medications during each follow-up period, about 20% taking 4 or more, and about 10% taking 5 or more. The results of this study suggest that the majority of borderline patients continue to use outpatient treatment in a sustained manner through 6 years of follow-up, but only a declining minority use more restrictive and costly forms of treatment.
Article
This study tested the hypothesis that treatment of childhood memories is an effective way to change personality disorder related schemas and psychopathology in cognitive therapy for personality disorders. To test this hypothesis, a crossover design was used to compare the effectiveness of methods focusing on the present and methods focusing on childhood memories. After the exploration period, the therapist focused either first on the present during 24 sessions and than for 24 sessions on childhood memories, or followed the reverse order. Twenty-one patients with one or more Axis II disorders were included. Participants were randomly assigned to order of focus. Results indicate that CT methods focusing on childhood memories produce good outcomes, comparable to those of methods focusing on the present. There was no significant effect of order, but both patients and therapists preferred the past-present order. Total effects of the package were large and were maintained till one-year follow-up (d's 0.97-1.90). Experience of the therapist with CT for personality disorders was related to better outcome (d=0.73).
Systems for rating therapies for depression
  • S D Hollon
  • I E Waskow
  • M Evans
  • A Lowery
Hollon SD, Waskow IE, Evans M, Lowery A: Systems for rating therapies for depression, Proceedings of the 137th Annual Meeting of the American Psychiatric Association, Los Angeles, 1984.
Multidisciplinaire richtlijn persoonlijkheidsstoornissen (Multidisciplinary Clinical Guideline of Personality Disorders)
  • Landelijke Stuurgroep Richtlijnontwikkeling In De
Landelijke Stuurgroep Richtlijnontwikkeling in de GGZ: Multidisciplinaire richtlijn persoonlijkheidsstoornissen (Multidisciplinary Clinical Guideline of Personality Disorders). Utrecht, Trimbos-Instituut, 2008