Lotte Bamelis

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

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.

Parental rearing as a function of parent's own, partner's, and child's anxiety status: Fathers make the difference

Parents of children with anxiety disorders are found to be over controlling and more rejecting in parent–child interactions than parents of control children. However, most studies included mothers, and the rearing behaviour of fathers of anxious children is largely unknown. Also, it remains unclear whether parents’ control and rejection is a response to childs anxiety, or (also) results from parents’ own anxiety. Participants were 121 children referred with anxiety disorders and 38 control children, and their parents. The diagnostic status of all parents was assessed. Each child conducted discussions around issues of disagreement, with father, with mother, and with both parents. Compared to parents of control children, fathers and mothers of clinically anxious children displayed more control to their child, but not more rejection, and fathers supported their partner less. Effect sizes, however, were small. In families of fathers with anxiety disorders, fathers were borderline more controlling and rejecting and mothers more rejecting towards their anxious child than in families of fathers without anxiety disorders. Fathers with anxiety disorders dominated the conversation relative to mothers, which was associated with greater controlling of the child. Effect sizes were medium. Mothers’ anxiety status was not associated with different rearing behaviours in both parents. It is concluded that fathers’ anxiety status seems to make the difference in raising an anxious child.

Extended Schema Mode Conceptualizations for Specific Personality Disorders: An Empirical Study

The aim of this study was to investigate newly formulated schema mode models for cluster-C, paranoid, histrionic and narcissistic personality disorders. In order to assess 18 hypothesized modes, the Schema Mode Inventory (SMI) was modified into the SMI-2. The SMI-2 was administered to a sample of 323 patients (with a main diagnosis on one of the PDs mentioned) and 121 nonpatients. The SMI-2 was successful in distinguishing patients and controls. Newly formulated modes proved to be appropriate for histrionic, avoidant, and dependent PD. The modification of the Overcontroller mode into the Perfectionistic and Suspicious Overcontroller mode was valuable for characterizing paranoid and obsessive-compulsive PD. The results support recent theoretical developments in Schema Therapy, and are useful for application in clinical practice.

Reduced Specificity of Autobiographical Memory in Cluster C Personality Disorders and the Role of Depression, Worry, and Experiential Avoidance

The study objective was to investigate whether, compared with nonclinical controls, participants with an avoidant, dependent, or obsessive-compulsive Cluster C personality disorder (PD) manifested reduced levels of memory specificity and whether the association of Cluster C PDs with memory specificity is mediated by repetitive negative thoughts and experiential avoidance. The Autobiographical Memory Test (R. J. McNally, N. B. Lasko, M. L. Macklin, & R. K. Pitman, 1995) was administered along with self-report measures (translated into Dutch) for repetitive, uncontrollable, and negative thinking in the form of worry (Penn State Worry Questionnaire; T. J. Meyer, M. L. Miller, R. L. Metzger, & T. D. Borkovec, 1990) and experiential avoidance (Acceptance and Action Questionnaire; S. C. Hayes et al., 2004) to 294 clinical participants diagnosed with Axis I disorders (assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders [SCID-I]; M. B. First, R. L. Spitzer, M. Gibbon, & J. B. W. Williams, 1994) and Axis II disorders (assessed with the SCID-II; M. B. First, R. L. Spitzer, M. Gibbon, & J. B. W. Williams, 1997)--202 with avoidant, 49 with dependent, and 120 with obsessive-compulsive PD--and to 108 matched nonclinical controls. Participants with a Cluster C PD showed lower levels of memory specificity than did nonclinical controls. Depression and worry mediated the effect of Cluster C PDs on memory specificity. Besides depression severity, repetitive, uncontrollable, and negative thinking may constitute a general mechanism mediating the association of various Axis I and II disorders with memory specificity.

Changes in natural language use as an indicator of psychotherapeutic change in personality disorders

Word use has been shown to reflect various psychological processes and psychological change. This study examines the self-view in personality disorders (PDs) and its change over the course of therapy using the Linguistic Inquiry and Word Count analysis procedure. A sample of 299 participants with PDs and 108 community control participants wrote short essays about their lives. Patients repeated the assignment three times over two years and completed assessments of PD-pathology, general psychopathology, PD-beliefs, and quality of life. Results show that as hypothesized the use of words in the 1st Person Singular Pronouns, Negative Emotion, Causation, Past and Future Tense Verbs categories significantly declines over the course of treatment, while the use of Present Tense Verbs and Positive Emotion increases. These categories tend to distinguish patients from non-patients prior to treatment. We also found 12 additional word categories changing over time, including Word Count and Negations. Change in word use statistically predicts better treatment outcome on all outcome measures (p < .001). Reductions in the use of Negative Emotion Words and Negations are the strongest predictors of outcome. The non-hypothesized role of Negations was explored and seemed to reflect that PD-patients miss a lot in their lives. Reduction of what they miss seems central to recovery. This issue seems relatively neglected in theoretical and treatment models of PDs. An increased focus on what patients miss in their lives might improve our understanding and treatment of PDs. In sum, Negative Emotion and Negation word categories appear to reflect key treatment targets.

Design of a multicentered randomized controlled trial on the clinical and cost effectiveness of schema therapy for personality disorders

BackgroundDespite 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.Methods/DesignIn 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.DiscussionThis 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.Trial registrationNetherlands Trial Register (NTR): NTR566

Word use of outpatients with a personality disorder and concurrent or previous major depressive disorder.

In a recent study, Rude, Gortner, and Pennebaker (2004) found word use to be related to depression and vulnerability to depression in the essays of college students. We sought to replicate and extend these findings in a clinical sample. Written essays of 304 psychiatric outpatients with a personality disorder and a mixed psychiatric profile on DSM-IV axis-I and 108 healthy controls were examined with word count software. Data on the tendency to be discrepant about the current self compared to a more ideal self were also gathered. We found that psychiatric outpatients in general used more words referring to the self and negative emotion words and fewer positive emotion words, compared to healthy controls. However, word-use proved unrelated to depression specifically. Actual-ideal self discrepancies were related to patient status and to current depression. Contrary to our hypothesis, these discrepancies did not correlate with the use of words referring to the self. We conclude that the negative content and self-focus of written essays and high levels of discrepancy reflect a negative thinking style that is common to a range of psychiatric disorders rather than being specific to depression.

Economic evaluation of schema therapy and clarification-oriented psychotherapy for personality disorders: A multicenter, randomized controlled trial

PURPOSE To compare from a societal perspective the cost-effectiveness and cost-utility of schema therapy, clarification-oriented psychotherapy, and treatment as usual for patients with avoidant, dependent, obsessive-compulsive, paranoid, histrionic, and/or narcissistic personality disorder. METHOD A multicenter, randomized controlled trial, single-blind parallel design, was conducted between May 2006 and December 2011 in 12 Dutch mental health institutes. Data from 320 patients (diagnosed according to DSM-IV criteria) randomly assigned to schema therapy (n = 145), treatment as usual (n = 134), or clarification-oriented psychotherapy (n = 41) were analyzed. Costs were repeatedly measured during 36 months by interview and patient registries. Primary outcome measures were proportion of recovered patients as measured with the Structured Clinical Interview for DSM-IV Axis II Personality Disorders for the cost-effectiveness analysis, and quality-adjusted life-years (QALYs) for the cost-utility analysis. Bootstrap replications in the cost-effectiveness and the cost-utility planes were used to estimate the probability that one treatment was more cost-effective than the other. Mixed gamma regression on net monetary benefit for different levels of willingness to pay for extra effects was used as sensitivity analysis. Additional sensitivity analyses were done to assess robustness of the results. RESULTS Due to higher clinical effects and lower costs, schema therapy was dominant over the other treatments in the cost-effectiveness analyses. Schema therapy has the probability of being the most cost-effective treatment (78% at €0 to 96% at €37,500 [

Consistency of reporting sexual and physical abuse during psychological treatment of personality disorder: An explorative study

27,375] willingness to pay per extra recovery). Treatment as usual was more cost-effective than clarification-oriented psychotherapy due to lower costs. In the cost-utility analysis, schema therapy had a stable 75% probability of being cost-effective. Sensitivity analyses confirmed these findings. CONCLUSIONS The results support the cost-effectiveness of schema therapy but not of clarification-oriented psychotherapy. TRIAL REGISTRATION Netherlands Trial Register NTR566.

On the Links Between Attachment Style, Parental Rearing Behaviors, and Internalizing and Externalizing Problems in Non-Clinical Children

The objective of this study was to assess the prevalence of decreasing, consistent and increasing reports of sexual and physical abuse after 12 months of long-term psychological treatment of personality disorders, to investigate demographic and clinical characteristics predictive of inconsistency of reporting abuse, and to explore whether autobiographical memory may account for this inconsistency. In 229 clinical participants with an SCID II diagnosed personality disorder, 180 (78.6%) reported the same instances of invasive sexual and/or physical abuse on a trauma questionnaire (SPAQ) at baseline and follow-up, 25 (10.9%) decreased and 24 (10.4%) increased their abuse reports. Consistency of reporting abuse did not differ between schema-focused therapy, clarification-oriented psychotherapy and treatment-as-usual. Current depressive episode (SCID-I) and decreased capacity to produce specific negative memories on the Autobiographical Memory Test were characteristic of decreasing abuse reporters, while increasing abuse reporters showed higher levels of Cluster A personality pathology (in particular schizotypal traits) on the Assessment of DSM-IV Personality Disorders (ADP-IV). These results suggest that even in treatment procedures directed at exploring someones personal past with abuse-related imagery consistency of reporting abuse is quite stable. However, certain clinical characteristics may make some persons more likely to change their trauma reports. Moreover, reduced negative memory specificity may represent an avoidant strategy associated with no longer reporting instances of abuse.