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Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : Journal of Behavior Therapy and Experimental Psychiatry, Volume 36, Issue 3, September 2005, Pages 226–239
Young has proposed a schema mode model of borderline personality disorder (BPD), hypothesizing that BPD patients tend to flip from 1 of 4 maladaptive schema modes to another. The present study is the first empirical test of this model, investigating whether these 4 modes are specific for BPD patients and whether BPD-relevant stress specifically increases one of the modes, the detached protector mode. Eighteen BPD patients, 18 cluster-C personality disorder (PD) patients and 18 non-patient controls (all women) filled out trait and state versions of a newly developed schema mode questionnaire, assessing cognitions, feelings and behaviors characteristic of 7 schema modes. Using a cross over design, subjects subsequently watched a neutral and a BPD-specific emotional movie fragment (order balanced). After watching each movie, subjects again filled out the schema mode questionnaire, state version. Trait as well as state versions indicated that BPD patients were indeed characterized by the hypothesized four maladaptive modes (Detached Protector, Punitive Parent, Abused/Abandoned Child, Angry/Impulsive Child). BPD patients were lowest on the Healthy Adult mode. The stress induction induced negative emotions in all groups, but the BPD group was unique in that the Detached Protector mode increased significantly more than in both control groups.
The dramatic shifts in emotional and behavioral states shown by borderline personality disorder (BPD) patients, has puzzled clinicians and researchers for years. This phenomenon is so central to the disorder, that the DSM IV states that the essential feature of BPD is “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity” (APA, 1994, p. 650). Various theoretical accounts for this phenomenon have been given. Emotional or serotenergic dysregulation has been suggested as an underlying factor (Coccaro et al., 1989; Hansenne et al., 2002; Linehan, 1993; Siever & Davis, 1991; Soloff, Meltzer, Greer, Constantine, & Kelly, 2000). Psychodynamic theorists have suggested that the primitive defense mechanism of splitting, leading to fragmented object relation representations (including self-representations), underlies the abrupt shifts (Kernberg, 1976; Kernberg, Selzer, Koenigsberg, Carr, & Appelbaum, 1989). Cognitive accounts hypothesize that dichotomous thinking and the paradoxical combination of core beliefs that the patient needs others to be safe because he/she is unable to rely on him/herself, but that others cannot be trusted (in a dangerous world) lead to vacillation between different strategies and emotional states (Beck, Freeman, & Associates, 1990; Veen & Arntz, 2000). Recently, Young has developed a model of BPD that might be particularly useful in understanding the dramatic shifts of these patients (McGinn & Young, 1996; Young, Klosko, & Weishaar, 2003). Young elaborated on the idea, already in the 1980s used by Aaron Beck in clinical workshops (D.M. Clark, pers. commun.), that some pathological states of BPD patients are a sort of regression into intense emotional states experienced as a child. Young conceptualized such states as schema modes, and in addition to the child-like regressive states, he also stipulated less regressive schema modes. A schema mode is an organized pattern of thinking, feeling and behaving based on a set of schemas, relatively independent from other schema modes. BPD patients are assumed to flip suddenly from one mode to the other. As Beck observed, some of these states appear highly childish and may be very confusing for both the patient and other people. Young hypothesized that four schema modes are central to BPD: the Abandoned Child mode (the present first author suggested to label it the Abused and Abandoned Child); the Angry/Impulsive Child mode; the Punitive Parent mode, and the Detached Protector mode. In addition, there is a Healthy Adult mode, denominating the healthy side of the patient, which is of course, given the extreme psychopathology of these patients, weak. According to the model, the Abused and Abandoned Child mode denotes the desperate state the patient may be in. Its roots are related to (threatened) abandonment and abuse the patient has experienced as a child. Typical core beliefs are that other people are malevolent, cannot be trusted and will abandon or punish you, especially when you become intimate with them. Other core beliefs are: “My emotional pain will never stop”, “I will always be alone”, and “There will be nobody who cares for me”. The patient may behave like an upset and desperate child, longing for consolation and nurturance, but also fearing it. Usually the patients fear this mode, not only because of the intense emotional pain and the reactivation of trauma-related memories and feelings, but also because its activation can be followed by an activation of the Punitive Parent mode. This indicates a severe self-punitive state, during which the patient seems to condemn herself as being bad and evil, deserving punishment. Expressions of (negative) emotions, opinions and wishes were usually punished by upbringers, attributing these to character, either explicitly (“you are a bad (or evil) child”), or implicitly (e.g., ignoring the child for days). Threats of abandonment (“I’ll send you to an orphan home”), verbal or physical aggression, and (threats of) severe punishments by upbringers are supposed to be internalized in this mode. Typical core beliefs are “You are bad (evil) and deserve punishment”; “Your opinions/wishes/emotions are ill founded”; “You have no right to express your opinions/wishes/emotions”; “You are only manipulating”. Often the patient not only experiences these punishing thoughts but adds punishing acts to them, like self-mutilation and damaging the good things in her life. One of the other modes the patient (and others!) is typically afraid of is the Angry/Impulsive Child mode. This denotes a state of childish rage or self-gratifying impulsiveness that is in the long run damaging for the patient and her relationships. Whereas Young states that BPD patients typically avoid the experience and expression of anger, the suppressed anger may build up and suddenly be expressed in a relatively uncontrolled way. Impulsive immediate need-gratifying behaviors are also attributed to this mode. Underlying beliefs are: “My basic rights are deprived”; “Other people are evil and mean”; “I have to fight, or just take what I need, to survive”. Whereas BPD patients are notorious for their crises and anger, therapists who work for longer periods with these patients have observed that they tend to be detached most of the time. They do not seem to really make contact with other people, nor with their own feelings and opinions. According to Young, they are in the Detached Protector mode, a sort of protective style the child developed to survive in a dangerous world. This mode is hypothesized to serve to protect the patient from attachment (since attachments will be followed by pain: abandonment, punishment, or abuse), emotional experience (since the pain is hard to bear and acknowledgement of emotion is usually followed by an activation of the punitive mode), and self-assertiveness and development (also followed by activation of painful other modes). Core beliefs are that it makes no sense to feel emotions and to connect to other people; that it is even dangerous to do so; that being detached is the only way to survive and to control your life. Often the patient uses a bulk of strategies to maintain this mode, including cognitive avoidance of feeling and thinking; not talking; avoidance of other people and activities; sleeping; developing and complaining about somatic complaints; use of drugs and alcohol; and even (para)suicide. Superficially, the patient may seem rational and healthy, but these strategies are really healthy since the patient suppresses important issues. So far Young et al. (2003) have hypothesized 10 schema modes to be important in complex personality disorders (PDs). Among them are two schema modes that were also investigated in the present study as control characteristics, as they are presumed not to be specific to BPD: the Overcompensator mode and the Compliant Surrender mode. Both the Overcompensator and the Compliant Surrender modes are the so-called dysfunctional coping modes, as the detached protector is. Coping modes are hypothesized to stem from ways in which a child tries to cope with extreme stress. The Overcompensator mode deals with problems by fighting back and trying to prove the opposite (“counterattack”). There are various ways of overcompensation, here we addressed the perfectionistic, critical, controlling and pushing variant (Young et al., 2003, pp. 275–276). The Compliant Surrender mode is one in which the person deals with problems by submitting, and being obedient, passive and dependent (Young et al., 2003, pp. 275–276). Although the schema mode model has been proven to be clinically useful to help therapists and patients to understand the patients’ feelings and behaviors, and underlies successful treatment of BPD (Nordahl & Nysæter, 2005; Giesen-Bloo et al., 2005), to the best of the present authors’ knowledge, the model has not been put to a direct empirical test. The aim of the present study was to fill this gap. This was done in two ways. First, by comparing self-reports of cognitions, feelings and behaviors hypothesized to be characteristic for several modes by BPD patients with the reports by two control groups, cluster-C PD patients, and non-patient controls. And secondly, by testing the hypothesis that confronting BPD patients with a specifically stressful movie would lead to an activation of the Detached Protector mode, more strongly than in both control groups. To measure the schema modes, the schema mode questionnaire was developed, which assessed cognitions, feelings and behaviors of four BPD modes, two control modes (Overcompensator and Compliant Surrender modes), and the Healthy Adult mode (Klokman, Arntz, & Sieswerda, 2001). Two versions of this questionnaire were used: a trait and a state version.