Download Schema Therapy for Forensic Patients with

Journal of Affective Disorders 151 (2013) 500–505
Contents lists available at ScienceDirect
Journal of Affective Disorders
journal homepage: www.elsevier.com/locate/jad
Research report
Psychotherapy for depression: A randomized clinical trial comparing
schema therapy and cognitive behavior therapy
Janet D Carter a,n, Virginia V McIntosh b, Jennifer Jordan b, Richard J Porter b,
Christopher M Frampton b, Peter R Joyce b
a
b
Department of Psychology, University of Canterbury, P.O. Box 4800, Christchurch, New Zealand
Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
art ic l e i nf o
abstract
Article history:
Received 14 December 2011
Received in revised form
19 June 2013
Accepted 19 June 2013
Available online 17 July 2013
Background: The efficacy of Cognitive Behavior Therapy (CBT) for depression has been robustly supported,
however, up to fifty percent of individuals do not respond fully. A growing body of research indicates Schema
Therapy (ST) is an effective treatment for difficult and entrenched problems, and as such, may be an effective
therapy for depression.
Methods: In this randomized clinical trial the comparative efficacy of CBT and ST for depression was examined.
100 participants with major depression received weekly cognitive behavioral therapy or schema therapy
sessions for 6 months, followed by monthly therapy sessions for 6 months. Key outcomes were comparisons
over the weekly and monthly sessions of therapy along with remission and recovery rates. Additional analyses
examined outcome for those with chronic depression and comorbid personality disorders.
Results: ST was not significantly better (nor worse) than CBT for the treatment of depression. The therapies
were of comparable efficacy on all key outcomes. There were no differential treatment effects for those with
chronic depression or comorbid personality disorders. Limitations: This study needs replication.
Conclusions: This preliminary research indicates that ST may provide an effective alternative therapy for
depression.
& 2013 Elsevier B.V. All rights reserved.
Keywords:
Psychotherapy
Schema
CBT
Depression: RCT
Author's personal copy
1. Introduction
J. Behav. Ther. & Exp. Psychiat. 45 (2014) 319e329
disorders (Kelly et al., 2009; Kool et al., 2005; Niemeyer and
Musch, 2013; van den Hout et al., 2006).
in the effectiveness of traditional CBT for depression,
Cognitive behavior therapy (CBT) is recommended
as onelists
of the
Contents
available Limitations
at ScienceDirect
and growing recognition that depression is a chronic and/or recurrent
first-line treatments for individuals with major depression (Ellis
disorder for many people often associated with other comorbid axis
et al., 2003; National Institute for Clinical Excellence (NICE), 2004).
I and II problems, has led to increased use by clinicians of Schema
Despite the proven effectiveness of CBT only 40–50% with depresTherapy (ST) in the treatment of depression. Schema Therapy was
sion will make a full recovery with their first course of treatment,
initially developed by Young (1990) for the treatment of personality
and some are likely to have a poor outcome despite completing
j o uar nchronic
al hom
e p a g course
e : w w w . edysfunction.
l s e v i e r . c oInmcontrast
/ l o c a t eto
/jb
tep
traditional
CBT, ST concentrates immeditreatment. Moreover, 3–5% may develop
clinical
ately and specifically on the schema and related developmental
of depression which is resistant to treatment (Fournier et al., 2009;
processes that prevent individuals having their core needs met in an
Hollon et al., 2005; Kessler et al., 1994). Other than chronicity, a
adaptive manner. It has been proposed that these schema must be
number of other factors have been proposed to limit the effecmodified in order to bring about lasting change, particularly for
tiveness of CBT. Perhaps with the most contradictory evidence, is
individuals with more difficult or entrenched problems such as
the treatment outcome when personality disorders are comorbid.
chronic or recurrent depression (Overholser, 1997; Riso et al., 2003;
A number of studies indicate that treatments are less effective
Safran and Segal, 1990; Young, 1990). Further, it has been proposed
when a comorbid personality disorder is present (e.g. Bagby et al.,
that any treatment that fails to reorganize or disrupt these funda2008; Gorwood et al., 2010), with a recent meta analysis reporting
a, b, *
c
a
a, b
Ioannis
Malogiannis
Arnoud Arntz
, Areti
, Eirini
, at risk for the reactivamental assumptions
leavesTsartsara
people cognitively
the risk ofA.poor
outcome doubles ,(Newton-Howes
et al.,
2006). Spyropoulou
b
b in outcome
b
a personal stress (Segal
tion
of
maladaptive
schemas
during
times
Other
studies
and
reviews
report
no
difference
,
Aikaterini Aggeli , Spyridoula Karveli , Miranda Vlavianou , Artemios Pehlivanidis of
et al., 1988), and therefore at increased risk of depression reoccurring.
between depressed individuals awith and without apersonality
George
N. Papadimitriou , Iannis Zervas , b
These propositions are supported by research indicating that therapy
a
1st Department of Psychiatry, Eginition Hospital, Athens Medical School, Athens, Greece that focuses more on interpersonal and developmental issues prob
Greek
Society
of
Schema
Therapy,
10555
Athens,
Greece
motes long lasting recovery from depression and, importantly, reduces
n
Corresponding author. Tel.: +64 3 366 7001; fax: +64 3 364 2181.
c
Maastricht University, The Netherlands
the risk of relapse (Hayes et al., 1996). Schema change has been
E-mail address: [email protected] (J. Carter).
Journal of Behavior Therapy and
Experimental Psychiatry
Schema therapy for patients with chronic depression: A single case
series study
0165-0327/$ - see front matter & 2013 Elsevier B.V. All rights reserved.
ahttp://dx.doi.org/10.1016/j.jad.2013.06.034
r t i c l e i n f o
a b s t r a c t
Article history:
Received 26 November 2013
Received in revised form
6 February 2014
Accepted 9 February 2014
Background and objectives: This study tested the effectiveness of schema therapy (ST) for patients with
chronic depression.
Methods: Twelve patients with a diagnosis of chronic depression participated. The treatment protocol
consisted of 60 sessions, with the first 55 sessions offered weekly and the last five sessions on a biweekly
basis. A single case series AeBeC design, with 6 months follow-up was used. Baseline (A) was a wait
period of 8 weeks. Baseline was followed by introduction to ST and bonding to therapist (phase B) with
individually tailored length of 12e16 sessions, after which further ST was provided (phase C) up to 60
sessions (included the sessions given as introduction). Patients were assessed with Hamilton Rating Scale
for Depression three times during baseline, at the end of phase B, then every 12 weeks until the end of
treatment and at 6 months follow-up. Secondary outcome measures were the Hamilton Rating Scale for
Anxiety and the Young Schema Questionnaire.
Results: At the end of treatment 7 patients (approximately 60%) remitted or satisfactorily responded. The
mean HRSD dropped from 21.07 during baseline to 9.40 at post-treatment and 10.75 at follow-up. The
effects were large and the gains of treatment were maintained at 6-month follow-up. Only one patient
dropped out for reasons not related to treatment.
Limitations: The lack of control group, the small sample and the lack of a multiple baseline case series.
Conclusions: This preliminary study supports the use of ST as an effective treatment for chronic
depression.
! 2014 Elsevier Ltd. All rights reserved.
Keywords:
Chronic depression
Schema therapy
CBT
Single case series
Early maladaptive schemas
1. Introduction
Approximately 20% of all depressed individuals develop a chronic
course (Arnow & Constantino, 2003; Gilmer et al., 2005). This implies that 2.5e6% of the adult population in the community suffers
health care utilization, hospitalization and economic costs (Berndt
et al., 2000; Gilmer et al., 2005; Howland, 1993; Klein et al., 2000;
Smit et al., 2006) compared with non-chronic forms of depression.
Four types of chronic depression are usually distinguished in the
literature: 1) dysthymic disorder, 2) chronic major depressive dis-
Treatment for Chronic Depression Using Schema Therapy
Fritz Renner and Arnoud Arntz, Department of Clinical Psychological Science, Maastricht
University
Ina Leeuw, Academic Community Mental Health Centre (RIAGG) Maastricht
Marcus Huibers, Department of Clinical Psychology, VU University Amsterdam,
Department of Clinical Psychological Science, Maastricht University
Treatment for Chronic Depression Using Schema Therapy
Fritz Renner and Arnoud Arntz, Department of Clinical Psychological Science, Maastricht
University
Ina Leeuw, Academic Community Mental Health Centre (RIAGG) Maastricht
Marcus Huibers, Department of Clinical Psychology, VU University Amsterdam,
Department of Clinical Psychological Science, Maastricht University
schema concept and developed ST as a novel treatment
for clients with chronic psychological disorders. Empirapproach to chronic lifelong problems with an estabical research on the effectiveness of ST is in its initial
lished
effectiveness
personality
disorders.
schema concept and developed ST as a novel treatment
Schema
therapy
(ST)for
is treating
an
integrative
treatment
for clients
with chronic
disorders.
Empirapproach to chronic lifelong problems with an estabstage.
While psychological
there is evidence
for
the effectiveness of
This article describes the adaptation of ST to chronic
ical research on the effectiveness of ST is in its initial
lished effectiveness for treating personality disorders.
ST
in
treating
clients
with
borderline
personality disorstage. While there is evidence for the effectiveness of
This article by
describes
the the
adaptation
of ST
chronic
depression
reviewing
literature
ontothe
underlying
ST in treating
clients with
borderline
der (Farrell,
Shaw,
& personality
Webber, disor2009; Giesen-Bloo
depression by reviewing the literature on the underlying
der (Farrell, Shaw, & Webber, 2009; Giesen-Bloo
risk
factors to chronic depression. A model of chronic
risk factors to chronic depression. A model of chronic
et al.,
2006;
Nadort
al., 2009;
Nordahl,
Holthe, &
et al., 2006;
Nadort
et al.,
2009; et
Nordahl,
Holthe,
&
depression
is
the
interplay
depression
is presented,
presented,describing
describing
the
interplay
Haugum, 2005) and clients with Cluster-C, paranoid,
Haugum,
2005)
and
clients
with
Cluster-C,
paranoid,
between empirically supported risk factors to chronic
histrionic, and narcissistic personality disorders (Bamebetween
empirically
supported
risk
factors
to chronic
depression
(early adversity,
cognitive
factors,
personallis, Evers,
Spinhoven,and
& Arntz,
2012), there
is a lack of
histrionic,
narcissistic
personality
disorders (Bameity pathology, interpersonal factors). We provide a
research on ST for chronic Axis I disorders. In addition
depression
(early adversity, cognitive factors, personallis, Evers, Spinhoven, & Arntz, 2012), there is a lack of
treatment protocol of ST for chronic depression describto the effects of ST on personality pathology, a recent
ityingpathology,
interpersonal
factors).
We
provide
a randomized
techniques that can be used in ST to target these
large
trial
found that
STIalso
has
researchcontrolled
on ST for
chronic
Axis
disorders.
In addition
underlying risk factors. Based on the current body of
positive effects on comorbid depression in clients with
treatment
protocol of ST for chronic depression describto
the
effects
of
ST
on
personality
pathology,
a recent
primarily Cluster-C personality disorders (Bamelis
empirical evidence for the underlying risk factors to
et al., 2012).
findings raise
the question
chronic
depression,
appears
to be in
a promising
new these
ing
techniques
thatSTcan
be used
ST to target
largeSuch
randomized
controlled
trial whether
found that ST also has
ST is also a valuable treatment for clients with primary
treatment approach to chronic depression, as it directly
underlying
risk factors. Based on the current body depressive
of
positive
effects on comorbid depression in clients with
symptoms.
targets these underlying risk factors.
Chronic depression is a relatively common (affecting
Key words:
chronic
early maladaptive
primarily
Cluster-C personality disorders (Bamelis
empirical
evidence
fordepression,
the underlying
risk factors to
19% of depressed clients; Keller & Hanks, 1995) and
schemas, risk factors, schema therapy. [Clin Psychol Sci
et
al.,
2012).
Such Riso
findings
raise the
question whether
difficult
to
treat
(Kocsis,
2003;
& Newman,
2003)
chronic
ST appears to be a promising new
Prac 20:depression,
166–180, 2013]
mental disorder. Four types of chronic depression are
ST
is
also
a
valuable
treatment
for
clients
with primary
treatment approach to chronic depression, as it directly
distinguished in the literature: chronic major depressive
Schema therapy (ST) is an integrative treatment
disorder,depressive
dysthymic symptoms.
disorder, double depression, and
targets
these
underlying
risk factors.
approach
combining
cognitive,
behavioral, experiential,
recurrent major depressive disorder (MDD) without
Chronic
depression
is a relatively
common (affecting
and psychodynamic elements and techniques (Young,
full interepisode
recovery
(Klein, 2010).
Whereas these
Key words: chronic depression, early maladaptive
Klosko, & Weishaar, 2003). Influenced by the cognisubtypes 19%
appearofto depressed
be rather homogenous
with respect
clients;
Keller
&
Hanks, 1995) and
[ClinonPsychol
Scietiology and clinical features, they can be clinically
schemas,
riskoffactors,
schema
therapy.
tive theory
depression,
Young
elaborated
the
to
difficult
to
treat
(Kocsis,
2003;
Riso
&
distinguished
from
episodic
forms
of
depressionNewman, 2003)
Prac 20: 166–180, 2013]
(McCullough et al., 2003). Compared with episodic
Address correspondence to Fritz Renner, Maastricht Univermental
disorder.
Four
types
of
chronic depression are
sity, P.O. Box 616, 6200 MD Maastricht, The Netherlands.
forms of depression, chronic depression has a stronger
E-mail: [email protected].
distinguished in the literature: chronic major depressive
Schema therapy (ST) is an integrative treatment
disorder, dysthymic disorder, double depression, and
approach combining cognitive, behavioral, experiential,
recurrent major depressive disorder (MDD) without
© 2013 American Psychological Association. Published by Wiley Periodicals, Inc., on behalf of the American Psychological Association.
and
psychodynamic
elements
[email protected].
techniques (Young,
All rights
reserved. For permissions,
please email:
166 Whereas these
full interepisode recovery (Klein, 2010).
Klosko, & Weishaar, 2003). Influenced by the cognisubtypes appear to be rather homogenous with respect
tive theory of depression, Young elaborated on the
to etiology and clinical features, they can be clinically
distinguished from episodic forms of depression
(McCullough et al., 2003). Compared with episodic
Address correspondence to Fritz Renner, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands.
forms of depression, chronic depression has a stronger
Schema
therapy
(ST)
is
an
integrative
treatment
E-mail: [email protected].
© 2013 American Psychological Association. Published by Wiley Periodicals, Inc., on behalf of the American Psychological Association.
All rights reserved. For permissions, please email: [email protected].
166
ORIGINAL ARTICLE
Outpatient Psychotherapy
for Borderline Personality Disorder
Randomized Trial of Schema-Focused Therapy
vs Transference-Focused Psychotherapy
Josephine Giesen-Bloo, MSc; Richard van Dyck, MD, PhD; Philip Spinhoven, PhD; Willem van Tilburg, MD, PhD;
Carmen Dirksen, PhD; Thea van Asselt, MSc; Ismay Kremers, PhD; Marjon Nadort, MSc; Arnoud Arntz, PhD
Context: Borderline personality disorder is a severe and
chronic psychiatric condition, prevalent throughout health
care settings. Only limited effects of current treatments
have been documented.
Objective: To compare the effectiveness of schemafocused therapy (SFT) and psychodynamically based
transference-focused psychotherapy (TFP) in patients with
borderline personality disorder.
Design: A multicenter, randomized, 2-group design.
Setting: Four general community mental health centers.
Participants: Eighty-eight patients with a Borderline Personality Disorder Severity Index, fourth version, score
greater than a predetermined cutoff score.
Intervention: Three years of either SFT or TFP with
sessions twice a week.
Main Outcome Measures: Borderline Personality Dis-
order 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.
B
Author Affiliations are listed at
the end of this article.
Results: 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 intentionto-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).
Conclusions: 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.
Arch Gen Psychiatry. 2006;63:649-658
ORDERLINE PERSONALITY DIS-
order (BPD) is marked by
chronicinstabilityinmultiple
areas (ie, emotional dysregulation,self-harm,impulsivity,
and identity disturbance). The prevalence
of BPD is estimated to be 1% to 2.5% in the
general population and 10% to 50% in psychiatric outpatient and inpatient settings.1
The medical and other societal costs of BPD
are substantial2 (also T.V.A., C.D., A.A., and
Johannis Severens, PhD, unpublished data,
September 2005). Suicide risk is estimated
to be up to 10%.3 A few treatments—
outpatientdialecticalbehaviortherapy4-8 and
psychoanalytically oriented treatments9-11—
have demonstrated some effectiveness in
(REPRINTED) ARCH GEN PSYCHIATRY/ VOL 63, JUNE 2006
649
randomized clinical trials of patients with
BPD, as manifested by good treatment retention and reduced suicide attempts, acts
of self-harm, and hospitalizations. However, no pharmacologic or psychosocial
treatment has demonstrated efficacy for all
aspects of BPD, such as affective, identity,
and interpersonal disturbances.12
We compared the effectiveness of 2 prolonged outpatient treatments that aim at
achieving full recovery from BPD: schemafocused therapy (SFT)13-15 and transference-focused psychotherapy (TFP).16,17
Schema-focused therapy is an integrative
cognitive therapy, and TFP is a psychodynamically based psychotherapy. Both
treatments intend to bring about a struc-
WWW.ARCHGENPSYCHIATRY.COM
©2006 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a Utrecht University Library User on 09/21/2014
International Journal of Cognitive Therapy, 6(2), 171–185, 2013
© 2013 International Association for Cognitive Psychotherapy
SCHEMA THERAPY
JACOB AND ARNTZ
Schema Therapy for
Personality Disorders—A Review
Gitta A. Jacob
University of Freiburg, Germany
Arnoud Arntz
Maastricht University, T he Netherlands
Schema therapy (ST) with the schema mode approach is currently one of the major
developments in CBT for personality disorders. The schema mode model includes
both a general approach to treatment as well as specific variants for each personality
disorder. The first specific mode model has been defined for borderline personality disorder. Treatment based on this model has been found to be very effective in
several studies. A meta-analysis of these studies is presented. Further mode models
have also been defined for most personality disorders and for forensic patients.
Preliminary results of studies in these patient groups are also promising. Important
current and future developments include applications of ST in other treatment settings (i.e., group and inpatient treatment), and the development of approaches for
chronic Axis I disorders. Important topics for future research include direct comparisons of ST to other active treatment conditions, dismantling studies, and more
fundamental investigations of experiential treatment techniques.
Recent developments in psychotherapy for personality disorders have focused on
Borderline Personality Disorder (BPD). Several treatment approaches have proposed clinical models of BPD and several treatment models have shown efficacy
varying degrees, including Dialectical Behavior Therapy (review in Kliem, Kröger,
& Kosfelder, 2010), Mentalization-Based Treatment (MBT; Bateman & Fonagy,
2009), Transference-Focused Therapy (TFT; Doering et al., 2010), and Schema
Therapy (ST; Young, Klosko, & Weishaar, 2003). However, very few approaches
have extended their application to other personality disorders. To the best of our
knowledge, only the schema therapy approach has explicated models for the majority of the personality disorders. Hence this paper focuses on ST as a major
current development in the field of cognitive therapies for personality disorders.
This work was supported by a grant from the European Social Fund and the Ministry Of Science, Research
and the Arts Baden-Württemberg awarded to the first author.
Address correspondence to Prof. Arnoud Arntz, Clinical Psychological Science, Maastricht University, PO
Box 616, 6200 MD Maastricht, The Netherlands; E-mail: [email protected]
171
J. Behav. Ther. & Exp. Psychiat. 40 (2009) 317–328
Contents lists available at ScienceDirect
Journal of Behavior Therapy
and Experimental Psychiatry
journal homepage: www.elsevier.com/locate/jbtep
A schema-focused approach to group psychotherapy
for outpatients with borderline personality disorder:
A randomized controlled trial
Joan M. Farrell a, *, Ida A. Shaw b, Michael A. Webber a
a
Indiana University School of Medicine, Department of Psychiatry, Center for Borderline Personality Disorder Treatment & Research,
Larue D. Carter Memorial Hospital, 2601 Cold Spring Road, Indianapolis, IN 46222, USA
b
BASE Consulting Group, LLC, 6551 Carrollton Avenue, Indianapolis, IN 46220, USA
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 2 December 2008
Received in revised form 30 December 2008
Accepted 4 January 2009
This study tests the effectiveness of adding an eight-month, thirtysession schema-focused therapy (SFT) group to treatment-as-usual
(TAU) individual psychotherapy for borderline personality disorder
(BPD). Patients (N ¼ 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 SFTTAU 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.
! 2009 Elsevier Ltd. All rights reserved.
Keywords:
Borderline personality disorder
Schema-focused therapy
Schema therapy
Cognitive behavioral therapy
Group psychotherapy
1. Introduction
Borderline personality disorder (BPD) is a disabling and prevalent psychiatric disorder, which is
characterized by substantial distress and disruptions in functioning. Patients with BPD experience
a chronic pervasive pattern of instability in areas of affect, behavior, interpersonal relationships,
identity, and cognition. It is a disorder with high prevalence – 1–2% in the general population and up to
25% or more in clinical populations, depending upon the study (Lieb, Zanarini, Schmahl, Linehan, &
Bohus, 2004). Prevalence appears to be increasing, as recently the Wave 2 National Epidemiologic
Survey on Alcohol and Related Conditions found a prevalence rate of 5.9% for BPD in the general
population (Grant, Chou, Goldstein, Huang, Stinson, Saha, et al., 2008). Although several medications
* Corresponding author. Tel.: þ1 317 941 4331.
E-mail address: [email protected] (J.M. Farrell).
0005-7916/$ – see front matter ! 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbtep.2009.01.002
The British Journal of Psychiatry (2008)
192, 450–457. doi: 10.1192/bjp.bp.106.033597
Out-patient psychotherapy for borderline
personality disorder: cost-effectiveness of
schema-focused therapy v. transference-focused
psychotherapy
Antoinette D. I. van Asselt, Carmen D. Dirksen, Arnoud Arntz, Josephine H. Giesen-Bloo,
Richard van Dyck, Philip Spinhoven, Willem van Tilburg, Ismay P. Kremers, Marjon Nadort
and Johan L. Severens
Background
Schema-focused therapy (SFT) and transference-focused
psychotherapy (TFP) for borderline personality disorder were
recently compared in a randomised multicentre trial.
Aims
To assess the societal cost-effectiveness of SFT v. TFP in
treating borderline personality disorder.
e46 795 for TFP (95% uncertainty interval for difference
721 775 to 3546); QALYs were 2.15 for SFT and 2.27 for
TFP (95% UI 70.51 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 e90 457 for one QALY
loss.
Method
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 qualityadjusted life-year (QALY).
Conclusions
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.
Results
Mean 4-year bootstrapped costs were e37 826 for SFT and
Declaration of interest
None. Funding detailed in Acknowledgements.
Borderline personality disorder is well known as a severe psychiatric condition. The prevalence of this disorder is estimated at
1–2.5% in the worldwide population,1 and at 10–50% among
psychiatric patients. Societal costs associated with borderline
personality disorder are substantial.2 Recently, the effectiveness
of two out-patient psychotherapies – schema-focused therapy
(SFT) and transference-focused psychotherapy (TFP) – was compared.3 Both treatments aim to achieve full recovery from the
disorder, unlike other therapies.4 In that comparison both forms
of therapy succeeded in reducing disorder-specific and general
psychopathologic dysfunction, and improving health-related
quality of life, with SFT being more effective on all measures.
However, the most effective treatment is not necessarily the most
cost-effective treatment. In the context of healthcare budget
constraints, an economic evaluation can inform decisions concerning which healthcare services to offer to patients. Therefore,
a cost-effectiveness analysis was performed comparing these two
forms of therapy.
Method
Patients and assessments
In a multicentre trial in The Netherlands, 86 patients from four
study locations were randomly allocated to either SFT (n=44) or
TFP (n=42). A pre-randomisation assessment was performed;
subsequently, 3-monthly assessments were made for 3 years, with
a final follow-up assessment 4 years after the baseline interviews.
Both interventions were individual therapies consisting of 50
min sessions twice a week for 3 years. Central to SFT is the
450
assumption of four schema modes specific to borderline personality disorder; recovery is achieved when dysfunctional schemas no
longer control or rule the patient’s life. Central to TFP is a
negotiated treatment contract between patient and therapist,
being the treatment frame; recovery is reached when good and
bad representations of self (and others) are integrated and when
fixed, primitive internalised object relations are resolved. Twelve
participants in the SFT group and 22 in the TFP group left the
study early. A further 6 (14%) participants in the SFT group
and 2 (5%) in the TFP group successfully (according to therapist
and patient) terminated treatment within 3 years. For details, see
Giesen-Bloo et al.3
Resources used
At every assessment a structured cost interview was administered
by an independent research assistant. Formal registries such as
hospital information systems or insurer’s databases are considered
to be incomplete, since a considerable amount of resource use is
situated outside (mental) healthcare institutions.5 Besides, individual patient data cannot be traced from registries. Therefore,
patient-reported prospective cost diaries,6 or retrospective cost
interviews,7 are the preferred instruments covering all relevant
events. We chose a 3-month recall interview,8 since a prospective
cost diary was expected to lead to more missing items, given the
patient characteristics. From a societal perspective, the cost
interview covered work status and absence, sources of income,
domestic activities, informal care, medication use, alcohol and
drugs, out-of-pocket expenses, and consumption of healthcare
and societal resources (including visits to general practitioners,
Behaviour Research and Therapy 47 (2009) 961–973
Contents lists available at ScienceDirect
Behaviour Research and Therapy
journal homepage: www.elsevier.com/locate/brat
Implementation of outpatient schema therapy for borderline personality
disorder with versus without crisis support by the therapist outside
office hours: A randomized trial
Marjon Nadort a, *, Arnoud Arntz b, Johannes H. Smit a, Josephine Giesen-Bloo b, Merijn Eikelenboom a,
Philip Spinhoven d, Thea van Asselt e, Michel Wensing c, Richard van Dyck a
a
GGZ inGeest, Department of Psychiatry and EMGO Institute, VU University Medical Center Amsterdam, A.J. Ernststraat 887, 1081 HL Amsterdam, The Netherlands
Maastricht University, Department of Clinical Psychological Science, The Netherlands
c
Radboud University Nijmegen Medical Centre, Scientific Institute for Quality of Healthcare, The Netherlands
d
Leiden University, Department of Psychology, The Netherlands
e
Department KEMTA Academic Hospital Maastricht, The Netherlands
b
a b s t r a c t
Keywords:
Borderline personality disorder
Outpatient therapy
Schema therapy
Implementation
Crisis support outside office hours
Objective: 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).
Methods: 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.
Results: 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.
Conclusions: 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.
! 2009 Elsevier Ltd. All rights reserved.
Introduction
Borderline Personality Disorder (BPD) has long been viewed as
severe and difficult to treat. However, during recent years several
promising treatment possibilities have been developed. Among
them, Schema Therapy (ST) was found to be effective regarding all
aspects of BPD. How well ST can be delivered in regular mental
healthcare practice is unknown, but it was expected that its
implementation poses challenges. BPD is marked by chronic
instability in multiple areas (emotional dysregulation, self-harm,
* Corresponding author.
E-mail address: [email protected] (M. Nadort).
0005-7967/$ – see front matter ! 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.brat.2009.07.013
impulsivity and identity disturbance). The lifetime prevalence of
BPD in the general population is 2%. In psychiatric outpatient
settings 10% of the patients suffer from BPD, in psychiatric inpatients settings 20% (APA, 2005). The medical and societal costs for
BPD are substantial (Ten Have, Lorsheyd, van Bijl, & Osterthun,
1995; van Asselt, Dirksen, Arntz, Giesen-Bloo, & van Dyck, 2008;
van Asselt, Dirksen, Arntz, & Severens, 2007). About 10% of the BPD
patients die because of suicide (Paris, 1993, 2008).
However, recent years showed progress in the development of
treatment options (Arntz & van Genderen, 2009; Bateman &
Fonagy, 2004; Linehan, 1993a, 1993b; van Genderen & Arntz, 2005;
Yeomans, Clarkin, & Kernberg, 2002; Young, Klosko, & Weishaar,
2003) that are supported by randomized controlled trials (Bateman
& Fonagy, 1999; Giesen-Bloo et al., 2006; Linehan, Armstrong,
Article
Results of a Multicenter Randomized Controlled Trial
of the Clinical Effectiveness of Schema Therapy
for Personality Disorders
Lotte L.M. Bamelis, Ph.D.
Silvia M.A.A. Evers, Ph.D.
Philip Spinhoven, Ph.D.
Arnoud Arntz, Ph.D.
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 lecturebased training.
(Am J Psychiatry 2014; 171:305–322)
P
ersonality disorders are complex mental health problems associated with chronic dysfunction in several life
domains (social, work, self-care) (1, 2), reduced quality of
life (3), high societal costs (4), and a high prevalence rate
(3%–15% in the general population) (5). Although psychological treatment is considered to be the treatment of
choice for personality disorders (6, 7), research into its
effectiveness is still in its infancy, troubled with methodological issues and strongly focused on borderline personality disorder. Studying the effectiveness of treatment
for understudied personality disorders is a highly prioritized recommendation in several reviews (8–10).
Schema therapy is a form of psychotherapy that has
proven to be efficacious for borderline personality disorder.
A randomized controlled trial comparing schema therapy
with transference-focused psychotherapy found dominance of schema therapy over transference-focused psychotherapy on all outcome measures and a significantly
lower dropout rate in schema therapy (11). Schema therapy
also proved to be a more cost-effective treatment (12). A
subsequent study found that schema therapy can be
successfully implemented in regular mental health care
(13). Another study reported superiority of schema therapy
over treatment as usual for borderline personality disorder
(14). However, the effectiveness of schema therapy for
personality disorders other than borderline personality
disorder remains to be evaluated.
The main objective of the present randomized controlled trial was to examine the clinical effectiveness of
schema therapy for a group of six personality disorders:
cluster C (avoidant, dependent, and obsessive-compulsive),
histrionic, narcissistic, and paranoid personality disorders.
Other personality disorders were excluded because they
were deemed to require highly specialized and lengthier
treatment protocols. A treatment protocol of 50 schema
therapy sessions was compared with treatment as usual,
This article is featured in this month’s AJP Audio
Am J Psychiatry 171:3, March 2014
ajp.psychiatryonline.org
305
International Journal of Forensic Mental Health
Volume 11, Issue 4, 2012
Special Issue: The 2nd Bergen Conference on the
Treatment of Psychopathy
Selecteer een taal ▼
Translator disclaimer
David P. Bernsteinabc, Henk L.I. Nijmande, Kai Karosa, Marije Keulen-de Vosab, Viviënne de
Vogelb & Tanja P. Luckerb
pages 312-324
Schema Therapy for Forensic Patients with
Personality Disorders: Design and Preliminary
Findings of a Multicenter Randomized Clinical Trial in
the Netherlands
Abstract
According to Dutch Law, patients committing severe crimes justifying imprisonment of
four years or more who cannot be held (fully) accountable for these acts can be
sentenced to compulsory hospitalization in a specialized TBS hospital in the Netherlands.
In the current paper, the effects of TBS treatment will be addressed in terms of
recidivism numbers after termination of TBS treatment, as well as in behavioral changes
that are observed during admission to TBS hospitals. Although these results offer some
indirect support suggesting that TBS is effective, no randomized controlled trials had
been conducted up until now that could confirm this. In the current study, preliminary
results are reported from a multicenter randomized clinical trial on the effectiveness of
Schema Therapy (ST) for hospitalized TBS patients with Antisocial, Borderline,
Narcissistic, or Paranoid Personality Disorders, including those with high levels of
psychopathy. Patients at seven TBS clinics were randomly assigned to receive three
years of either ST or Treatment As Usual (TAU), and are being assessed on several
outcome variables, such as recidivism risk (HCR-20, START), personality disorder
symptoms (SIDP-IV, SNAP), and successful re-integration into the community. A threeyear follow-up study will examine actual recidivism. One hundred and two patients are
participating in the study. The preliminary findings from the first 30 patients to complete
the three-year study suggest that ST is yielding better outcomes than TAU with regard to
reducing recidivism risk and promoting re-entry into the community. These findings are
not yet statistically significant, and thus need to be interpreted with caution until
confirmed in our complete sample and follow up. However, they suggest that ST may be
a promising treatment for offenders with personality disorders, including some
psychopathic ones.
Clinical Psychology Review 33 (2013) 426–447
Contents lists available at SciVerse ScienceDirect
Clinical Psychology Review
Schema therapy for borderline personality disorder: A comprehensive
review of its empirical foundations, effectiveness
and implementation possibilities
Gabriela A. Sempértegui a,⁎, Annemiek Karreman a, Arnoud Arntz b, Marrie H.J. Bekker
a
b
a
Tilburg University, The Netherlands
Maastricht University, The Netherlands
H I G H L I G H T S
►
►
►
►
►
Offers both theoretical description and empirical review of the schema model for BPD.
Evidence exists for a number of schema constructs and mechanisms.
The extant efficacy studies show positive outcomes of schema therapy for BPD.
Schema therapy seems a societal cost-effective approach.
Further work is required to achieve full empirical support of the model and therapy.
a r t i c l e
i n f o
Article history:
Received 29 March 2012
Received in revised form 23 November 2012
Accepted 26 November 2012
Available online 4 December 2012
Keywords:
Borderline personality disorder
Schema therapy
Young's schema model
Early maladaptive schema
Schema mode
Effectiveness
a b s t r a c t
Borderline personality disorder is a serious psychiatric disorder for which the effectiveness of the current
pharmacotherapeutical and psychotherapeutic approaches has shown to be limited. In the last decades, schema
therapy has increased in popularity as a treatment of borderline personality disorder; however, systematic
evaluation of both effectiveness and empirical evidence for the theoretical background of the therapy is limited.
This literature review comprehensively evaluates the current empirical status of schema therapy for borderline
personality disorder. We first described the theoretical framework and reviewed its empirical foundations. Next,
we examined the evidence regarding effectiveness and implementability. We found evidence for a considerable
number of elements of Young's schema model; however, the strength of the results varies and there are also
mixed results and some empirical blanks in the theory. The number of studies on effectiveness is small, but
reviewed findings suggest that schema therapy is a promising treatment. In Western-European societies, the
therapy could be readily implemented as a cost-effective strategy with positive economic consequences.
© 2012 Elsevier Ltd. All rights reserved.
Contents
1.
2.
3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1.
Development of schema therapy: Differentiating from pure cognitive therapy
3.2.
Early maladaptive schemas . . . . . . . . . . . . . . . . . . . . . . .
3.3.
Schema modes . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.4.
Empirical research on the theoretical concepts . . . . . . . . . . . . . .
3.4.1.
Origin of early maladaptive schemas and their relation to BPD . . .
3.4.2.
Development and specificity of EMSs in BPD . . . . . . . . . . .
3.4.3.
Specificity of BPD assumptions . . . . . . . . . . . . . . . . . .
3.4.4.
BPD interpretation bias . . . . . . . . . . . . . . . . . . . . .
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427
428
428
428
428
436
436
436
437
438
438
Abbreviations: BPD, Borderline personality disorder; ST, Schema therapy; EMS, Early maladaptive schema; TFP, Transference focused psychotherapy; TAU, Treatment as usual;
DBT, Dialectical behavior therapy; MBT, Mentalization based therapy; RCT, Randomized controlled trial.
⁎ Corresponding author at: Department of Medical and Clinical Psychology, Tilburg University, P.O. Box 90153, 5000 LE Tilburg, The Netherlands. Tel.: +31 13 466 3294; fax: +31
13 466 2067.
E-mail address: [email protected] (G.A. Sempértegui).
0272-7358/$ – see front matter © 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.cpr.2012.11.006