Changes in schemas of patients with severe borderline personality disorder: The Oulu BPD study

Borderline personality disorder (BPD) is a relatively common and severe psychiatric disorder that can impair quality of life in many ways. The aim of this study was to determine whether a combined treatment model for BPD patients, utilising major principles from schema‐focused therapy (SFT) and dialectical behavioral therapy (DBT), could be more effective in relieving early maladaptive schemas of BPD patients, compared to treatment as usual (TAU). This study is a part of the Oulu BPD study conducted at mental health care services run by Oulu city social and health care services. The study is a multisite, randomized controlled trial conducted over a one year period, involving two groups of patients with severe BPD: (1) Community Treatment By Experts (CTBE) patients (n = 18) receiving the combined treatment model, and 2) TAU patients (n = 27). The patients' schemas were assessed using the Young Schema Questionnaire (YSQ‐L3a) before and after one year of treatment. The results reveal that CTBE patients who attended the combined treatment model showed a statistically significant reduction in eight out of 18 early maladaptive schemas, while patients receiving treatment as usual did not demonstrate any significant changes in schemas. The cognitive therapeutic treatment model can be applied for clinical use in public mental health settings using existing professionals, and appears to produce positive changes in patients with BPD.     

Schematherapie

Schema therapy is a cognitive behavioral therapy (CBT) development mainly for the treatment of personality disorders and other chronic mental disorders. It is characterized by an integration of cognitive, emotional and behavioral intervention methods derived from different therapeutic approaches with an emphasis on a specifically supportive therapeutic relationship. The original approach focused mainly on early maladaptive schemas. Current developments, however, concentrate on the concept of schema modes, describing different schema-associated emotional states. The schema mode approach is also used for specific case concepts for personality disorders. Effectiveness of schema therapy has been shown for borderline personality disorder. Current studies investigate the effectiveness of schema therapy for patients with other chronic mental conditions and as a group therapy approach. This paper provides an overview about case conceptualization and treatment, presents main research findings and discusses open questions and problems.     

Schémas cognitifs, croyances addictives et défenses dans la consommation et l’addiction au cannabis de jeunes adultes

Theoretical background

Integrating the cognitive approaches based on the model of Beck et al. (1993) information treatment, the Young (1994) model of maladapted schemas, the integrative approach of Plutchik (1995) and the clinical approach based on defense mechanisms (Bond, 1995), this study aimed at investigating: (a) the role of the hyperactivated maladapted schemas, (b) the addictive beliefs, (c) the suractivation of the conscious derives of defensive mechanisms and (d) the relationships between these cognitive and defensive variables, in young people's cannabis intensity addiction.

Method

Forty-four young adults, 25 females and 19 males, have completed a self-reported questionnaire estimating: (a) the intensity of cannabis addiction (Décamps et al., 2008), (b) the Rusinek (2006) adaptation of Young's maladapted schemas and (c) the questionnaire of addictive beliefs of Tison and Hautekeete (1998) and the defensive styles questionnaire of Bond et al. (1983) and Bond (1995). Non-parametric statistical analysis has been conducted on three subject's groups (“non-users”, “users non addicted”, “users-addicted”) to test the implications and the links between hypothesized psychological factors (e.g., schemas, beliefs and defences) in cannabis use intensity.

Results and discussion

The intensity of cannabis addiction is correlated significantly with: (a) an hyperactivation of three maladapted schemas: inadequate autocontrol, dependence and fear of lose the control, (b) a hyperactivation of permissive, anticipatory and relief oriented beliefs and (c) a higher activation of the defence “sublimation” and a lower activation of the “displacement”. “sublimation” is correlated with the global activation of 13 schemas that are correlated with the positive relief-oriented beliefs, which are correlated with the “displacement” defence, which is correlated with the anticipatory beliefs. The results showed that the permissive beliefs have the power to differentiate the “non-consumption”, the “consumption without addiction” and “the addiction” to cannabis. Our interpretation displays that greater attention to the dysfunctional beliefs will be required in future researches and should be essential targets in cognitive therapy of this substance use disorder.     

Schematherapie bei antisozialem Verhalten und Psychopathie

In the Netherlands schema therapy is the first evidence-based treatment to be recommended for patients with personality disorders in forensic settings. Initial results show that schema therapy can even be effective in cases of “psychopathy”. The central concept in schema therapy are schema modes which can also be seen as emotional states or “parts of the personality”, which dominate temporary thoughts, emotions and behavior. Schema modes are the basis of individual mode models, which guide understanding and treatment of the disorder throughout the complete therapy. The schema therapeutic analysis of delinquency is part of the schema mode model and connects the sequences of the crime with the offender’s schema modes. With respect to the mode treatment, emotion-focused techniques and the therapeutic relationship are of special importance. The schema therapeutic treatment plan combines short-term behavior-related therapeutic goals with the underlying themes (needs and modes) in order to plan concrete interventions based on this. This has to be embedded into the individual structure of therapeutic options in the respective institutions (e.?g. individual psychotherapy, nursing staff, occupational therapy). This article demonstrates the practice of the schema therapeutic approach with a forensic case study and discusses resources and limits of the schema therapeutic approach in a forensic setting.     

The Novaco Anger Scale-Provocation Inventory (1994 version) in Dutch forensic psychiatric patients

We examined the psychometric properties of the Novaco Anger Scale-Provocation Inventory (NAS-PI, 1994 version) in Dutch violent forensic psychiatric patients and secondary vocational students. A confirmatory factor analysis of the subscale structure of the NAS was carried out, reliability was investigated, and relations were calculated between NAS-PI scores and other measures of personality traits and problem behaviors. The 3-subscale structure of the original NAS could not be confirmed. However, the internal consistency of the NAS and the PI was excellent, and the test-retest reliability of the NAS was good. The validity of the NAS and the PI was supported by a meaningful pattern of correlations with alternative measures of anger and personality traits. Forensic psychiatric outpatients displayed higher NAS scores than secondary vocational students, but inpatients scored even lower than this nonclinical control group. Our preliminary conclusion is that the NAS-PI is a valuable instrument for the assessment of anger in Dutch violent forensic psychiatric patients.     

Perceptions of Turkish psychiatric inpatients about therapeutic factors of group psychotherapy

Many studies on therapeutic factors in group psychotherapy were done during the 1970s and 1980s, primarily with Western samples, The present study was carried out in a psychiatric inpatient clinic in Turkey. Using Yalom's (1975) therapeutic factor questionnaire administered at discharge, patients rated existential factor, instillation of hope and self-understanding as the most helpful factors and identification as the least helpful. There were significant differences among patients with regard to gender, age, education, comorbid personality disorder, but not with Axis I diagnosis or number of attended sessions. Patients' and psychiatrist's rating showed significant differences. Differences between this Turkish sample and those reported in common Western literature are discussed under the light of relatedness psychology, which is an important concept of cross-cultural psychology.     

Early maladaptive schemas of personality disorder subtypes.

This investigation attempted to examine the cognitive schemas of five distinct clusters that emerged from a cluster analysis of the personality disorder scales of the Millon Clinical Multiaxial Inventory-II (Millon, 1987). Specifically, the degree to which early maladaptive schemas, as measured by the Cognitive Schema Questionnaire-Short Form (Young, 1994), could correctly identify empirically derived patterns of personality disorders was examined. Between-cluster differences centered on five personality components and five schemas. Discriminant analyses revealed two significant functions composed of cognitive schemas, which correctly identified 61.2% of the entire sample in terms of cluster group membership. The total proportion of variance in the two significant functions associated with cluster group differences was 76.8%. Findings are discussed in relation to the domain theory of personality disorders posited by Millon and Davis (1996).     

Avoidant personality disorder and implicit schema-congruent information processing bias: a pilot study with a pragmatic inference task.

Cognitive theory of personality disorders hypothesizes that each personality disorder is characterized by typical maladaptive schemes and that these schemas direct the processing of information resulting in schema-congruent biases. With regard to the avoidant personality disorder, these hypotheses were put to an initial test in a pilot study, using a self-report questionnaire to asses DSM-III-R personality pathology, a belief questionnaire to assess avoidant schemas and a pragmatic inference task to assess schema-congruent implicit attributional bias. Participants were students (n = 57) who scored high or low on DSM-III-R avoidant personality pathology. As predicted from cognitive theory, DSM-III-R avoidant personality pathology was associated with avoidant beliefs (t(45.1) = 4.68, p < 0.001) and avoidant beliefs were associated with schema-congruent information processing bias (t(55) = 2.17, p = 0.02, one-tailed test). However, DSM-III-R avoidant personality pathology was not associated with schema-congruent information processing bias (t(55) = 0.17, p = 0.43, one-tailed test). In addition to avoidant beliefs, low self-esteem was also related to the information processing bias. Social phobia and general personality pathology, two other control variables, were not. The findings warrant further study using the pragmatic inference task in a clinical group.     

Neuropattern: a new translational tool to detect and treat stress pathology. II. The Teltow study

The present study was designed to test the clinical utility of Neuropattern (NP), a newly developed translational diagnostic tool. NP consists of biological and psychological measures that facilitate the identification of functional changes (called "neuropatterns") in patients with stress-related health problems. In this prospective, randomized control trial, we expected NP to improve therapeutic efficacy, as compared with the usual treatment. NP was applied to 101 in-patients suffering from various mental disorders (mainly depression, anxiety disorders, and adjustment disorders), and scoring high on the Symptom Checklist-90-R (SCL-90-R) somatization scale. The patients (73% females, mean?±?standard deviation age 46?±?9.03 years) were randomly assigned to two groups: in the experimental group (n?=?51), physicians received results from NP diagnostics, while in the control group (n?=?50), this information was not available until discharge from the hospital. Improvements of symptoms in consequence of treatment were monitored by two self-rating scales, the SCL-90-R and Short Form-12 health survey, and a physician's clinical global rating (Beeintr?chtigungs-Schwere Score). There was a significantly greater improvement in the experimental group in the self-rating assessments on symptom severity (p?=?0.03) and quality of life (p?=?0.05), but not in the observer rating of emotional, physical, and social-communicative functioning (p?=?0.13). Treatment efficacy in patients can be improved by providing the attendant physician and the patient with diagnostic information and treatment recommendations by NP. The role of concrete mediators of treatment efficacy awaits further research.     

Addicted patients with personality disorders: traits, schemas, and presenting problems

We evaluated the association of Structure Clinical Interview for the DSM-IV Axis II (SCID-II) severity and personality traits, early maladaptive schemas, and presenting symptoms in 41 methadone-maintained patients meeting criteria for either antisocial, borderline, avoidant, or depressive personality disorder. Correlational analyses indicated that the severity of each personality disorder was associated with a unique profile of presenting problems and underlying traits and schemas. The evaluation of multiple psychological indicators appears to be a useful method for case conceptualization and planning interventions within a promising individual therapy model that focuses both on substance abuse and psychiatric symptoms and maladaptive schemas and coping styles.     

Hypervigilance in patients with borderline personality disorder: specificity, automaticity, and predictors

According to cognitive theory, an important factor in borderline personality disorder (BPD) is hypervigilance. The aim of the present study was to test whether BPD patients show schema-related biases, and to explore relations with childhood trauma, schemas, and BPD symptoms. Sixteen BPD patients were compared with 18 patients with a cluster C personality disorder, 16 patients with an axis I disorder, and 16 normal controls. An emotional Stroop task was applied with schema-related and unrelated, negative and positive, supra- and subliminal person-related stimuli. BPD patients showed hypervigilance for both negative and positive cues, but were specifically biased towards schema-related negative cues. Predictors were BPD schemas, childhood sexual traumas, and BPD anxiety symptoms. Both BPD and axis I disorder patients showed a trend for a bias for negative schema-related subliminal stimuli. More attention to hypervigilance in BPD is recommended for clinical practice.     

Pathological Altruism, Narcicissm, and Dissociation as Prerequisite for Infanticide

The international literature about neonaticide, infanticide, and familicide has arrived at a tripartite classification on the basis of the typical pathogenesis and the therapeutic and forensic challenges connected with the emerging situation. The categories can be characterized by altruistic or narcissistic attitudes and those of unawareness and dissociative states towards imminent delivery or the postpartum situation. The psychopathological counterparts to these attitudes are major depressive disorder with melancholia, narcissistic personality disorder, and an immature personality, often in socially disadvantaged environments equivalent to borderline personality disorder with dissociative states and diminished impulse control. Aspects of perinatal bonding disturbances between mother and child play a major role for the focus of psychotherapy and forensic assessment in all three categories. They need differential characterization according to the different pathogenetic pathways of inadequate experience of guilt, inadequate self-esteem regulation, and dissociative neglect and diminished impulse control. Preventive and therapeutic perspectives of intervention are discussed.     

Personality disorders in a Dutch forensic psychiatric sample: convergence of interview and self-report measures

Convergence of PDQ-R- and SIDP-R-derived personality disorder diagnoses was studied in a sample of 85 forensic psychiatric patients. For categorical diagnoses, the mean kappa was .34, but on a dimensional level convergence was somewhat higher. Paranoid, antisocial and borderline personality disorders had prevalence rates around 40%; the other personality disorders occurred with much lower frequency. The PDQ-R yielded more diagnoses, except for antisocial, histrionic, narcissistic, and sadistic personality disorder. Because the latter disorders are among the most prevalent in forensic settings, and because they have important risk and treatment implications, the PDQ-R is not suitable as a screening device in forensic populations. Semistructured interviews that make use of collateral information are recommended for diagnosing personality disorders in forensic subjects.     

Psychotherapie von Anpassungsstörungen

In this study we examined the effectiveness of an outpatient client-centered psychotherapy of patients with adjustment disorders (ICD-10 F43.2) limited to twelve sessions in comparison to an untreated control group. The patients of each group (n_treatment= 31 and n_control= 19) had been diagnosed with an adjustment disorder in response to one of the following stressful events: either the loss of an important person or performance deficits at work or university. Compared with the untreated control group the immediate therapy group improved significantly on rating scales and questionnaires. These positive treatment effects proved stable at a 3 months follow-up. Individual treatment gains were also analyzed for clinical and statistical significance. The improvements of the treatment group were significantly greater in all used measures than those of the control group. These improvements were interpreted as an effect of the client-centered treatment which resulted in high individual overall treatment gains and in high effectsizes.     

Möglichkeiten und Grenzen standardisierter Untersuchungsinstrumente

In general, psychological test procedures are standardized. This means that content and structure are fixed and even procedure, scoring and interpretation are subject to certain rules. Apart from classical methods, such as collecting the medical history directly from the patient or from third parties, or such as behavioral observation or file review, standardized methods have become more important within the fields of forensic psychiatric and forensic psychological expert evidence. The current contribution is meant to provide an overview of the use of standardized methods primarily dealing with the assessment of personality structure and paraphilia (more specifically pedophilia). As the authenticity of self-reports within the forensic domain is questionable, (semi)structured observer rating instruments are particularly relevant. These rating instruments comprise interview guides for personality disorder and file-based assessments of crime scene behavior with respect to pedophilia. In the current contribution statistical methods for single case assessment are highlighted that allow gauging whether diagnoses or prognoses are plausible and whether changes or differences in test scores are meaningful. If the indications for standardized measures are present, their use will typically be the method of choice, not merely an optional supplement.     

Personality of College Under-Achievers Who Improve with Group Psychotherapy

The 16 PF and a rating scale were given to a group of college underachievers and the following subgroups emerged: 38 test responders (TR) who were not interested in group therapy, an experimental (E) group containing 19 subjects who received group therapy, and a control (C) group containing 13 subjects who were interested in but did not receive group therapy. After an interval of about 17 weeks, and following the termination of group therapy for the E group, data on academic improvement were obtained. The results indicate: (a) significantly greater academic improvement in the E group than in the C group; (b) higher correlations between certain adaptive or “healthy” personality variables and academic improvement in the E group than in the TR and C groups.     

Multidimensional Analysis of Personality Theories

Factor and cluster analyses of the matrix of ratings for 19 personality theories provided by Hall and Lindzey converged on a six-group solution. The treatment was designed to respect the ordinal nature of the rating data. Distinguishing characteristics of the groups were identified, and dangers inherent in overinterpreting the present findings were discussed.     

Developing Pairwise Preference-Based Personality Test and Experimental Investigation of Its Resistance to Faking Effect by Item Response Model

Recent years have shown increased awareness of the importance of personality tests in educational, clinical, and occupational settings, and developing faking-resistant personality tests is a very pragmatic issue for achieving more precise measurement. Inspired by Stark (2002) and Stark, Chernyshenko, and Drasgow (2005), we develop a pairwise preference-based personality test that aims to measure multidimensional personality traits using a large-scale statement bank. An experiment compares the resistance of the developed personality test to faking with that of rating scale-based personality tests in the item response theory model framework. Results show that latent traits estimated from the personality test based on the rating scale method are severely biased, and that faking effect can be pragmatically ignored in the personality test developed based on the pairwise preference method.     

Note on the relationship between nude figure drawings and the MMPI scales

MMPI protocols of 40 asthmatic patients who produced nude DAPs were compared to a matched control group of equal number, Independent t tests computed for the validity and clinical scales of the MMPI between groups yielded not a single statistically significant difference. In contrast to the importance generally ascribed to global ratings of DAP figures, the global rating of nudity on DAP drawings did not differentiate any aspect of personality as measured by the MMPI.     

The Referential Process,Consciousness, and the Sense of Self

The concepts of multiple code theory and the referential process are examined in relation to levels of awareness and the sense of self as characterized in recent work in neuropsychology by Damasio. The juxtaposition of subsymbolic and symbolic systems in working memory, as this operates in the referential process, is central to both consciousness and the sense of self. The roots of pathology lie in dissociation within emotion schemas; this applies at different levels for all forms of neurosis. The goal of psychoanalytic treatment is integration of dissociated schemas; this requires activation of subsymbolic, including bodily experience, in the session itself, in relation to symbolic representations of present and past experience. Implications concerning repression, resistance, the primary process, the role of language in therapeutic change, and other psychoanalytic concepts are discussed.