The effectiveness of adapted schema therapy for cluster C personality disorders in older adults – integrating positive schemas

Schema therapy (ST) has shown to be an effective therapy for personality disorders (PDs) in adults. Research on treatment for PD’s has focused mainly on adults so far. Given the substantial increase of elderly people, including the group of older adults with PD, more research is needed that covers the full age-span. Preliminary results have shown that schema therapy is also applicable in older adults with PDs, more specifically cluster C PDs. Suggestions were made to increase the efficacy of ST in older adults, including adjusting the case conceptualization, modifying the experiential techniques, making use of the patient’s wisdom by placing their problems in a lifespan perspective and next asking them how they have coped with problems successfully earlier in life. Also by reactivating previous positive schemas, which are specific paterns consisting of emotions, cognitions, bodily sensations and neurobiological reactions in relation to self and others. . These schemas are hypothesized to develop when individuals grow up and develop in environments where their core emotional needs are met by primary caregivers.
A multiple baseline design is used with credibility of positive and negative core beliefs as primary outcome measures. After a randomized baseline phase, participants receive weekly an adapted form of ST for one year, followed by monthly follow-up booster sessions for six months. Symptomatic distress, schema modes, early maladaptive schemas and early adaptive schemas (EAS) are secondary outcome measures. Personality disorder will be diagnosed before baseline and after follow-up phase. To assess EAS we first develop a Dutch version of the Young Positive Schema Questionnaire (YPSQ) according to standard procedures.

The aim of this study is to investigate the effectiveness of adapted ST for individuals as a treatment for cluster C PDs in older adults (aged 60 and older). More specifically, we will examine whether older patients with cluster C PDs benefit from adapted ST by using a compact version of the CC that integrates positive schemas and adding a specific intervention to ST which contextualizes positive schemas to lifespan to re-actualize the EAS. The primary objective of the study is to examine the effect of adapted ST on the strength of both positive and negative core beliefs. It is hypothesized that adapted ST reduces the strength of negative core beliefs and increases the strength of positive core beliefs. Also, we hypothesize that dysfunctional schemas and modes will decrease as a result of adapted ST and that positive schemas will increase. Finally, it is expected that patients will no longer meet the criteria of a PD after adapted ST treatment.

SCID-5-P is completed before baseline and after therapy. HAP is completed only before baseline. Patients will be asked to complete the YSQ, SMI, BSI and YPSQ at I) baseline, II) six months after the start of ST, III) after termination of therapy and IV) after six months follow-up. In addition, during the treatment phase, participants will fill out the ultra short credibility of each statement on a weekly basis. During the baseline and follow-up phase, participants will also provide credibility scores for which they receive forms to fill in weekly (in baseline phase) or monthly (follow up phase) at home.

We will use a multiple-baseline case series design. The design consists of three phases, starting with a baseline phase varying in length from four to eight weeks. The length of the baseline phase is randomized across participants to increase the internal validity. No therapeutic interventions will take place during this phase. The variation in baseline length offers the possibility to differentiate between time effects and experimental effects of the treatment. The second phase is the treatment phase and consists of ST for PD according to the model of Young and colleagues (2003), that is adapted for older adults and will take one year. The adaptions are based on the earlier mentioned suggested adaptions by Videler (2018). It consists of (1) a compromised version of the CC which uses the patients spontaneous language instead of the precise ST terminology and includes positive schemas and (2) an intervention that aims to activate wisdom using principles of life review (Bhar, 2014), to include positive schemas and use these EAS in imaginary rescripting (see appendix 1). The third and final phase is a six months follow-up with monthly booster sessions.