Feasibility of Group Schema Therapy for Outpatients with Severe Borderline Personality Disorder in Germany: A Pilot Study with Three Year Follow-Up

General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. Borderline Personality Disorder (BPD) is a severe, challenging to treat mental disorder. Schema therapy (ST) as an individual therapy has been proven to be an effective psychological treatment for BPD. A group format of ST (GST) has been developed and evaluated in a randomized controlled trial in the United States and piloted in The Netherlands. These results suggest that GST speeds up and amplifies treatment effects of ST and might reduce delivery costs. However, feasibility in the German health care system and with BPD patients with high BPD severity and comorbidity, and frequent hospitalization, has not been tested to date. We investigated GST in 10 severely impaired, highly comorbid female patients with BPD, that needed frequent hospital admission. Patients received an outpatient ST-treatment program with weekly group and individual sessions for 1 year. Outcome measures including BPD severity, general psychopathology, psychosocial functioning, quality of life, happiness, schemas, and modes, and days of hospitalization were assessed at the start of treatment and 6, 12, and 36 months later with semi-structured interviews and self-report measures. We observed significant decreases in severity of BPD symptoms, general symptom severity, dysfunctional BPD-specific modes and schemas, and days of hospitalization. Functional modes, quality of live and happiness improved. The results of this feasibility study are promising and encourage further implementation of ST outpatient treatment programs even for patients with severe BPD and high hospitalization risk. However, small sample size and the missing of a control group do not allow the generalizability of these findings

Chairwork in schema therapy for patients with borderline personality disorder—A qualitative study of patients' perceptions

ObjectiveChairwork is one of the core experiential techniques of Schema Therapy (ST) which is used in the treatment of patients with borderline personality disorder (BPD). However, little is known about how people with BPD experience chairwork. The aim of this study was to explore the experiences of patients with BPD with chairwork in ST.MethodQualitative data were collected through semi-structured interviews with 29 participants with a primary diagnosis of BPD who experienced chairwork as part of their ST treatment. The interview data were analyzed using qualitative content analysis.FindingsMany participants reported initial skepticism, and difficulties with engaging in chairwork. Specific therapist behaviors as well as some external (e.g., restricted facilities, noise) and internal factors (especially feeling ashamed or ridiculous) were named as hindering factors. Participants described several therapist behaviors facilitating chairwork such as providing safety, clear guidance through the process as well as flexible application of the technique according to their needs, and sufficient time for debriefing. Participants experienced emotional pain and exhaustion as short-term effects of the technique. All participants reported positive long-term effects including an improved understanding of their mode model as well as positive mode changes (e.g., less Punitive Parent and more Healthy Adult Mode), greater self-acceptance, improvements in coping with emotions and needs as well as improvements in interpersonal relationships.ConclusionsChairwork is experienced as an emotionally demanding but valuable technique. Based on the participants' statements, the delivery of chairwork can be optimized which can help to improve treatment outcome

Emotion Regulation in Schema Therapy and Dialectical Behavior Therapy

Schema therapy (ST) and dialectical behavior therapy (DBT) have both shown to be effective treatment methods especially for borderline personality disorder. Both, ST and DBT, have their roots in cognitive behavioral therapy and aim at helping patient to deal with emotional dysregulation. However, there are major differences in the terminology, explanatory models and techniques used in the both methods. This article gives an overview of the major therapeutic techniques used in ST and DBT with respect to emotion regulation and systematically puts them in the context of James Gross' process model of emotion regulation. Similarities and differences of the two methods are highlighted and illustrated with a case example. A core difference of the two approaches is that DBT directly focusses on the acquisition of emotion regulation skills, whereas ST does seldom address emotion regulation directly. All DBT-modules (mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness) are intended to improve emotion regulation skills and patients are encouraged to train these skills on a regular basis. DBT assumes that improved skills and skills use will result in better emotion regulation. In ST problems in emotion regulation are seen as a consequence of adverse early experiences (e.g., lack of safe attachment, childhood abuse or emotional neglect). These negative experiences have led to unprocessed psychological traumas and fear of emotions and result in attempts to avoid emotions and dysfunctional meta-cognitive schemas about the meaning of emotions. ST assumes that when these underlying problems are addressed, emotion regulation improves. Major ST techniques for trauma processing, emotional avoidance and dysregulation are limited reparenting, empathic confrontation and experiential techniques like chair dialogs and imagery rescripting

Protocol for the REVISIT-BPD Trial, a Randomized Controlled Trial Testing the Effectiveness of an Internet-Based Self-Management Intervention in the Treatment of Borderline Personality Disorder (BPD)

Introduction: Borderline Personality Disorder (BPD) is a prevalent condition that is often under-treated. This is partly because very few psychotherapists offer treatment for this disabling disorder. Internet-based self-management interventions could contribute to reducing the treatment gap but—mainly due to safety concerns—these have never been tested for BPD in controlled trials.Methods: Patients with BPD will be recruited primarily via the internet and randomized to two groups: care as usual (CAU) alone) or the self-management intervention priovi® in addition to CAU. At the end of the diagnostic interview, all participants will discuss an emergency plan. The main outcome measure is the clinician-rated symptom severity using the BPD Severity Index (BPDSI). Secondary outcome measures include a range of self-reported scales, an SCID-diagnosis of BPD and several safety parameters including serious adverse events (e.g., a life-threatening event, hospitalization or suicide attempt).Discussion: This trial will evaluate the effectiveness of the self-management intervention, priovi, in reducing symptoms of BPD. It will also assess the safety of its use in this target population. If successful, this intervention would be the first comprehensive internet intervention for the treatment of BPD and complement the wide range of internet interventions effective in treating other mental disorders, particularly depression and anxiety disorders.Trial Registration: NCT03418142 (clinicaltrials.gov) on January 23rd 2018.Trial status: recruiting, currently N = 108 (July 2018)

Effectiveness and safety of the adjunctive use of an internet-based self-management intervention for borderline personality disorder in addition to care as usual: results from a randomised controlled trial.

IMPORTANCE: Borderline personality disorder (BPD) is a severe mental disorder that is often inadequately treated. OBJECTIVE: To determine if adding a self-management intervention to care as usual (CAU) is effective and safe. DESIGN: Randomised, controlled, rater-blind trial. Duration of treatment and assessments: 12 months. SETTING: Secondary care, recruited mainly via the internet. PARTICIPANTS: Patients with BPD and BPD Severity Index (BPDSI) of at least 15. INTERVENTIONS: CAU by treating psychiatrist and/or psychotherapist alone or adjunctive use of an internet-based self-management intervention that is based on schema therapy (priovi). MAIN OUTCOME MEASURE: Outcomes were assessed by trained raters. The primary outcome was change in BPDSI. The safety outcome was the number of serious adverse events (SAEs). The primary outcome time point was 12 months after randomisation. RESULTS: Of 383 participants assessed for eligibility, 204 were included (91.7% female, mean age: 32.4 years; 74% were in psychotherapy and 26% were in psychiatric treatment). The slope of BPDSI change did not differ significantly between groups from baseline to 12 months (F3,248= 1.857, p=0.14). At 12 months, the within-group effect sizes were d=1.38 (95% CI 1.07 to 1.68) for the intervention group and d=1.02 (95% CI 0.73 to 1.31) for the control group. The between-group effect size was d=0.27 (95% CI 0.00 to 0.55) in the intention-to-treat sample and d=0.39 (95% CI 0.09 to 0.68) for those who used the intervention for at least 3 hours (per-protocol sample). We found no significant differences in SAEs. CONCLUSIONS: We have not found a significant effect in favour of the intervention. This might be due to the unexpectedly large effect in the group receiving CAU by a psychiatrist and/or psychotherapist alone

Integration of e-Health Tools Into Face-to-Face Psychotherapy for Borderline Personality Disorder: A Chance to Close the Gap Between Demand and Supply?

Borderline personality disorder (BPD) is a severe, highly prevalent mental disorder. Effective psychological treatments for BPD are available. However, most patients do not receive evidence-based treatments partly because of high treatment delivery costs and lack of specialized therapists. By integrating specialized e-health tools into BPD-specific treatments, treatment intensity can be increased, frequency of face-to-face sessions and burden for psychotherapists can be reduced, and implementation of new skills and experiences in the everyday life of these patients can be promoted. This bears great potential to increase the availability of evidenced-based psychotherapy for BPD patients and close the gap between demand and supply. In this article we present such an innovative e-health tool, priovi, which has been developed for schema therapy. The concept and application of priovi are described and illustrated with a case example

Differential associations between patterns of child maltreatment and comorbidity in adult depressed patients

BACKGROUND: Types of maltreatment often co-occur and it is unclear how maltreatment patterns impact on comorbidity in depressed patients. METHODS: We analysed associations of maltreatment patterns with a broad range of comorbidities assessed with diagnostic interviews in 311 treatment-seeking depressed outpatients. RESULTS: Latent class analyses identified a "no maltreatment class" (39%), a "mild to moderate abuse and neglect class" (34%), a "severe abuse and neglect class" (14%) and a "severe neglect class" (13%). We found a dose-response association for the first three classes with comorbid disorders, a general psychopathology factor and an interpersonal insecurity factor. Patients in the "severe abuse and neglect" class had increased odds ratios (OR) of suffering from an anxiety disorder (OR 3.58), PTSD (OR 7.09), Borderline personality disorder (OR 7.97) and suicidality (OR 10.04) compared to those without child maltreatment. Patients in the "severe neglect" class did not have a higher risk for comorbidity than those in the "no maltreatment" class. LIMITATIONS: Class sizes in the "severe abuse and neglect" and the "severe neglect" classes were small and findings should be replicated with other clinical and population samples. CONCLUSIONS: A higher severity rather than the constellation of types of child abuse and neglect was associated with more comorbid disorders. An exception were patients reporting solely severe emotional and physical neglect who had a similar risk for comorbidity as patients without a history of child maltreatment. This may be associated with distinct learning experiences and may inform treatment decisions

Integration of e-Health Tools Into Face-to-Face Psychotherapy for Borderline Personality Disorder:A Chance to Close the Gap Between Demand and Supply?

Borderline personality disorder (BPD) is a severe, highly prevalent mental disorder. Effective psychological treatments for BPD are available. However, most patients do not receive evidence-based treatments partly because of high treatment delivery costs and lack of specialized therapists. By integrating specialized e-health tools into BPD-specific treatments, treatment intensity can be increased, frequency of face-to-face sessions and burden for psychotherapists can be reduced, and implementation of new skills and experiences in the everyday life of these patients can be promoted. This bears great potential to increase the availability of evidenced-based psychotherapy for BPD patients and close the gap between demand and supply. In this article we present such an innovative e-health tool, priovi, which has been developed for schema therapy. The concept and application of priovi are described and illustrated with a case example

Towards a Reformulated Theory Underlying Schema Therapy:Position Paper of an International Workgroup

Background A central construct in Schema Therapy (ST) is that of a schema mode, describing the current emotional-cognitive-behavioral state. Initially, 10 modes were described. Over time, with the world-wide increasing and broader application of ST to various disorders, additional schema modes were identified, mainly based on clinical impressions. Thus, the need for a new, theoretically based, cross-cultural taxonomy of modes emerged. Methods An international workgroup started from scratch to identify an extensive taxonomy of modes, based on (a) extending the theory underlying ST with new insights on needs, and (b) recent research on ST theory supporting that modes represent combinations of activated schemas and coping. Results We propose to add two emotional needs to the original five core needs that theoretically underpin the development of early maladaptive schemas (EMSs), i.e., the need for Self-Coherence, and the need for Fairness, leading to three new EMSs, i.e. Lack of a Coherent Identity, Lack of a Meaningful World, and Unfairness. When rethinking the purpose behind the different ways of coping with EMS-activation, we came up with new labels for two of those: Resignation instead of Surrender, and Inversion instead of Overcompensation. By systematically combining EMSs and ways of coping we derived a set of schema modes that can be empirically tested. Conclusions With this project, we hope to contribute to the further development of ST and its application across the world

Change in Interpersonal and Metacognitive Skills During Treatment With Cognitive Behavioral Analysis System of Psychotherapy and Metacognitive Therapy: Results From an Observational Study

Background: Interpersonal skills deficits and dysfunctional metacognitive beliefs have been implicated in the etiology and maintenance of depression. This study aimed to investigate the association between changes in these skills deficits and change in depressive symptoms over the course of treatment with Cognitive Behavioral Analysis System of Psychotherapy (CBASP) and Metacognitive Therapy (MCT). Methods: In this prospective, parallel group observational study, data was collected at baseline and after 8 weeks of an intensive day clinic psychotherapy program. Based on a shared decision between patients and clinicians, patients received either CBASP or MCT. Ninety patients were included in the analyses (CBASP: age M = 38.7, 40.5% female, MCT: age M = 44.7, 43.3% female). Interpersonal deficits were assessed with the short-form of the Luebeck Questionnaire for Recording Preoperational Thinking (LQPT-SF) and the Impact Message Inventory (IMI-R). Metacognitive beliefs were assessed with the Metacognition Questionnaire-30 (MCQ-30). The Quick Inventory of Depressive Symptomatology (QIDS-SR16) was utilized to assess depressive symptoms. A regression analysis was conducted to assess variables associated with outcome. ANCOVAs were utilized to investigate whether improvement in skills deficits is dependent on type of treatment received. Results: Improvements in preoperational thinking and increases in friendly-dominant behavior were associated with change in depressive symptoms. There was no association between reductions in dysfunctional metacognitive beliefs and a decrease in depressive symptoms. While both treatment groups showed significant improvements in interpersonal and metacognitive skills, there was no significant between-group difference in the change scores for either of these skills. Conclusion: Our findings suggest that changes in interpersonal skills seem to be of particular relevance in the treatment of depression. These results have to be replicated in a randomized-controlled design before firm conclusions can be drawn