طرحواره درمانی برای بیماران مبتلا به اختلال شخصیت مرزی: یک سری مورد منفرد

Abstract The effectiveness of schema therapy for patients with borderline personality disorder (BPD) developed by Young was investigated using a single case series trial of six patients who all had primarily a DSM-IV BPD diagnosis. The treatment approach comprised the core elements of schema therapy with an emphasis on schema mode work and limited re-parenting. An A–B direct replication series with follow-up assessments at 12 months was implemented. From baseline to follow-up improvement was large, as indicated by large effect sizes, and improvement was clinically meaningful for five of the six patients included. Three of the six patients did not any longer fulfill the criteria for BPD by the end of the treatment.

Introduction Borderline personality disorder (BPD) is one of the most prevalent personality disorders in both in- and out-patient clinics (Maier, Lichtermann, Klingler, Heun, & Hallmayer, 1992Maier et al., 1992; Moldin, Rice, Erlenmeyer-Kimling, & Squires-Wheeler, 1994). Many approaches for treatment are proposed for BPD, but there is no single treatment approach that seems to be the treatment of choice, although therapy in the form of psychodynamic psychotherapy or dialectical behavior therapy (DBT) is suggested (Oldham et al., 2001). New approaches are emerging and during the last decade several cognitively oriented approaches have been developed for treating patients with BPD. Among these are cognitive therapy (Beck, Freeman, & Associates, 1990; Layden, Newman, Freeman, & Byers Morse, 1993; Freeman & Fusco, 2003), rational emotive therapy (Ellis, 2001), cognitive coping therapy (Sharoff, 2002), cognitive evolutionary therapy (Liotti, 2002) and schema therapy (Young, 1996; Young & Behari, 1998; Young, Klosko, & Weishaar, 2003; Arntz, 2004). Schema therapy is based on a cognitive–integrative conceptualization of personality disorders using a broader and more eclectic approach than the usual cognitive therapy approaches, integrating various theoretical formulations (Young, 1994; Arntz, 1994; Young, Klosko, & Weishaar, 2003). Schema therapy targets the establishment of a working relationship through emphasizing the patient's emotions and bonding issues. By specific interventions such as limited re-parenting combined with experiential techniques on adverse childhood interpersonal experiences the patient learns to contain and endure the negative effects of abandonment and despair. In the therapeutic model, the schema mode change is emphasized, where the patient learns to deal with his or her various modes (abandoned child, angry child, punitive parent and detached protector) through experiential techniques and the therapy relationship. By working with a modification of schema modes and maladaptive coping styles the patients are treated for periods of 1–4 years (Young & Behari, 1998; Young, Klosko, & Weishaar, 2003). Schema therapy has rapidly developed into a therapy of wide interest, particularly in the United Kingdom, Scandinavia and the Netherlands. However, schema therapy is not yet a comprehensive and fully empirically-validated theory and therapy of personality pathology in general or of BPD in particular. The concepts used in schema therapy, such as early maladaptive schemas or schema modes, were not developed to correspond directly to any specific personality disorder, but are supposed to define core structures of personality pathology (Young & Gluhoski, 1996). Validation of the role of early maladaptive schemas and schema modes, and relationship to the various personality disorders are now published in several recent studies (Petrocelli et al., 2001; Jovev & Jackson, 2004; Rijkeboer, van den Bergh, & van den Bout, 2005; Nordahl, Holthe, & Haugum, 2005: Arntz, Klokman, & Sieswerda, 2005; Lobbestael, Arntz, & Sieserda, 2005), and the findings are consistent in showing the strong sensitivity of personality pathology. There is, to our knowledge, no published randomized and controlled study of the efficacy of schema therapy for BPD or for any other specific personality disorder. However, there is one unpublished study conducted by Giesen-Bloo, Arntz, van Dijck, Spinhoven, & van Tilburg (2004), comparing schema therapy with transference focused psychotherapy (TFP). In a multi-site trial, 88 patients were randomized either to schema therapy or to TFP, and they were all treated for a maximum of 3 years. By comparing the treatments on cost-effectiveness, changes in borderline criteria and quality of life, the authors found that schema therapy was superior to TFP. In addition, the dropout rate was significantly lower in the schema therapy condition (Giesen-Bloo et al., 2004). Due to the great efforts needed to test the validity and effect of schema therapy of BPD in a randomized controlled trial, a natural first step was to do a preliminary study of the effectiveness of schema therapy of BPD in a single case series. Thus, the purpose of the present study was to evaluate the effectiveness of Young's schema therapy with a limited number of patients with primarily a diagnosis of BPD. In order to do so we set up a study measuring baseline levels of symptoms, and subsequently the pre-, post- and follow-up levels of clinical changes in BPD criteria, clinical impairment, global symptomatic distress and interpersonal problems.

3. Results The patients’ scores on the anxiety symptoms, depressive symptoms, general symptomatic distress, interpersonal distress during pre-treatment, treatment periods, at post-treatment and follow-up are shown in Fig. 1. For the patients’ depressive (BDI) and anxiety (BAI) symptoms the baseline measures are also shown. Baseline scores of all patients on depressive or anxiety symptoms indicate that there was no evidence of spontaneous recovery over a 10 weeks period before the commencement of schema therapy. Note that the global scores of the SCL-90-R and the IIP were multiplied by 10 in order to fit them into Fig. 1. Scores on the standardized measures at baseline, pre-treatment, 20th session, ... Scores on the standardized measures at baseline, pre-treatment, 20th session, ... Fig. 1. Scores on the standardized measures at baseline, pre-treatment, 20th session, 40th session, post-treatment and follow up for each patient. Figure options Effect size (ES) is the effect vs. standard deviation (s.d.) ratio, and is calculated on the mean change in the individual test scores for pre- and post- or follow-up scores divided by the pooled s.d. of the scores (Cohen, 1992). By using Cohen's d for estimating the size of changes in the group of 6 patients as a whole, the results show that the pre-treatment to follow-up effects were large, with effect size ranging from 1.8 to 2.9. Based on the self-report scores, five of the six patients had greatly improved on general symptomatic and interpersonal distress 12–16 months after treatment. However, patient 1 had only small changes from pre-treatment to follow-up, and relapsed during the follow-up period. By post-treatment, the patients were re-diagnosed on the SCID-II. Three of the six patients did not fulfill the criteria of DSM-IV BPD any longer (patients 2, 4 and 6), whereas the rest still fulfilled the criteria, but to a lesser extent (for a criterion to be rated absent, there should not be any evidence of it during the last 6 weeks). The pre-treatment to follow-up changes on maladaptive schemas for the six patients were significant with an effect size of 1.8. The most interesting finding, considering the often-reported variability of symptomatic distress in patients with BPD (Gunderson, 2001), is that, the gains after therapy ended were maintained during the follow-up period. Only one patient (patient 1) relapsed. No one had attempted suicide, and self-mutilation and self-damaging behaviors were significantly reduced. The general adaptive level of functioning (GAF score) increased from a mean score of 52 to 68, which is a relatively large improvement (Es=2.8)(Es=2.8). However, overall there were still some residual symptoms and mild impairments in functioning by the end of the therapy and the follow-up, for all the six patients.