Schema therapy for violent PD offenders: a randomized clinical trial.

BACKGROUND: Violent criminal offenders with personality disorders (PD's) can cause immense harm, but are often deemed untreatable. This study aimed to conduct a randomized clinical trial to test the effectiveness of long-term psychotherapy for rehabilitating offenders with PDs. METHODS: We compared schema therapy (ST), an evidence-based psychotherapy for PDs, to treatment-as-usual (TAU) at eight high-security forensic hospitals in the Netherlands. Patients in both conditions received multiple treatment modalities and differed only in the individual, study-specific therapy they received. One-hundred-three male offenders with antisocial, narcissistic, borderline, or paranoid PDs, or Cluster B PD-not-otherwise-specified, were assigned to 3 years of ST or TAU and assessed every 6 months. Primary outcomes were rehabilitation, involving gradual reintegration into the community, and PD symptoms. RESULTS: Patients in both conditions showed moderate to large improvements in outcomes. ST was superior to TAU on both primary outcomes - rehabilitation (i.e. attaining supervised and unsupervised leave) and PD symptoms - and six of nine secondary outcomes, with small to moderate advantages over TAU. ST patients moved more rapidly through rehabilitation (supervised leave, treatment*time: F(5308) = 9.40, p < 0.001; unsupervised leave, treatment*time: F(5472) = 3.45, p = 0.004), and showed faster improvements on PD scales (treatment*time: t(1387) = -2.85, p = 0.005). CONCLUSIONS: These findings contradict pessimistic views on the treatability of violent offenders with PDs, and support the effectiveness of long-term psychotherapy for rehabilitating these patients, facilitating their re-entry into the community.

Narcissistic traits and compassion: Embracing oneself while devoiding others.

Grandiose narcissistic traits refer to exploitative and arrogant attitudes, while vulnerable narcissistic traits entail hypersensitivity to judgment and low self-esteem. Little is known about how individuals with narcissistic traits can improve their attitudes toward themselves and others. The current research puts self- and other compassion forward as possible targets to alleviate some of destructive patterns of narcissism. Generally, self-compassion (SC) has previously been associated with beneficial effects on psychological wellbeing, while other compassion (OC) is advantageous for interpersonal relationships. This study explored the relationship between narcissistic traits and the efficacy of experimental compassion inductions. Student and community participants (N = 230, M age = 27.41, 65.2% female) completed grandiose and vulnerable narcissistic trait, SC and OC state questionnaires, and either an SC or OC induction. It was expected that individuals with higher narcissistic traits (particularly grandiose traits) would benefit from the inductions and show higher SC after but would have greater difficulty showing meaningful increases in OC (especially OC directed at the general population). The results indicated that individual differences in grandiose and vulnerable narcissistic traits are related to the magnitude of improvements following the inductions: the theorized lack of SC in individuals with vulnerable oversensitivity to judgment traits seems possible to be counteracted through different types of compassion exercises. Moreover, higher grandiose exploitativeness-entitlement and global vulnerable narcissistic traits related to less increases than others. However, directly inducing OC in individuals with these traits was linked to greater OC improvements than improvements after inducing SC. Overall, the present findings suggest that self-compassionate behavior can be improved in individuals with high oversensitivity and that other compassionate behavior could potentially be increased if, specifically, other compassion exercises are utilized when higher levels of certain narcissistic traits are present.

Psychometric Properties of the German Version of the Young Positive Schema Questionnaire (YPSQ) in the General Population and Psychiatric Patients.

Early adaptive schemas (EAS) are resilience-oriented counterparts to early maladaptive schemas (EMS), which are central in schema therapy. The Young Positive Schema Questionnaire (YPSQ) was developed as a measure of EAS but has been evaluated neither in relation to a clinical population nor in a German-speaking sample. Objectives of this study were therefore the psychometric validation of a German YPSQ in a community sample and the comparison of EAS to psychiatric patients. Participants were 1,418 individuals from a community sample and 182 psychiatric patients with a main diagnosis of major depressive disorder. A factor structure of 10 EAS, instead of the original 14, demonstrated satisfactory factorial validity and internal consistency in both samples. EAS exhibited divergent validity to EMS, childhood trauma, and psychopathology. Convergent validity was evident with resilience, self-efficacy, and satisfaction with life. Support for incremental validity beyond EMS was especially shown for resilience, self-efficacy, and satisfaction with life, and was also evident for several dimensions of psychopathology. Individuals in the community sample exhibited more pronounced EAS compared to psychiatric patients with the exception of empathic consideration. Especially for concepts associated with mental health, the YPSQ has the potential to be a highly valuable addition to current research and practice.

Schema therapy conceptualization of personality functioning and traits in ICD-11 and DSM-5.

PURPOSE OF REVIEW: Schema therapy conceptualizes personality disorders in terms of modes and underlying schemas. This article reviews the literature on schema therapy conceptualization of personality disorder functioning and traits, and proposes how these findings apply to novel personality disorder classification in ICD-11 and the DSM-5 Alternative Model of Personality Disorders (AMPD). RECENT FINDINGS: Maladaptive schemas and modes are generally associated with personality dysfunction and traits in conceptually coherent ways. The healthy adult mode, a transdiagnostic core concept in schema therapy, corresponds to the ICD-11 and DSM-5-AMPD features of core personality functioning. Modes and underlying schemas substantially overlap with specific ICD-11 and DSM-5-AMPD traits, which denote individual themes and styles of personality dysfunction. SUMMARY: The dimensional personality disorder framework in ICD-11 and DSM-5-AMPD is largely compatible with the schema therapy model. The ICD-11 and DSM-5-AMPD provide a scientifically derived and theory-free framework for all practitioners, which may be connected to clinical theory of schema therapy in a coherent manner. Level of personality functioning can be conceptualized as healthy adult functioning (e.g. sense of identity, self-worth, emotion regulation, intimacy, and fulfillment), which inform intensity of treatment. Trait qualifiers can be conceptualized by associated modes (e.g., compliant surrender) and underlying schemas (e.g. abandonment), which inform focus and style of treatment.

Correction to: Internalizing and Externalizing Behaviors Share a Common Predictor: the Effects of Early Maladaptive Schemas Are Mediated by Coping Responses and Schema Modes.

The authors would like to note that one of the co-author's names was displayed incorrectly. Not Arnoud A. Arntz, but Arnoud Arntz co-authored this article as shown above.

Internalizing and Externalizing Behaviors Share a Common Predictor: the Effects of Early Maladaptive Schemas Are Mediated by Coping Responses and Schema Modes.

We investigated the relationships of adolescents' internalizing and externalizing behaviors with their early maladaptive schemas (EMS), coping responses, and schema modes. We focused on EMS related to experiences of disconnection and rejection that comprise vulnerable emotions, such as shame, mistrust, deprivation, abandonment, and isolation/alienation. This cross-sectional study included a total of 699 adolescents (combined clinical and non-referred sample) who were 11 to 18 years old (M = 14.6; SD = 1.6), and of which 45% was male. All participants completed self-report questionnaires on EMS, coping responses, schema modes, and behavior problems. We aimed to clarify the relationships between these variables by testing mediation, moderation, and moderated mediation models. In general, coping responses functioned as mediators rather than moderators in the relationships between EMS and schema modes. Furthermore, EMS regarding experiences of disconnection and rejection were related to both internalizing and externalizing behavior problems, and coping responses and schema modes mediated these effects. In conclusion, although adolescent internalizing and externalizing behavior problems manifest quite differently, they seem related to the same EMS.

Validation of Schema Coping Inventory and Schema Mode Inventory in Adolescents.

This study investigated whether the schema therapy constructs of schema coping and schema modes have val dity in adolescents. We examined the validity and reliability of the Schema Coping Inventory (SCI) and an 80-item version of the Schema Mode Inventory (SMI) in a mixed sample of adolescents. Confirmatory factor analyse showed that the first-order factor structures of the SCI and SMI were replicated, but that the hypothesized higher-order models of the SMI were not confirmed. Instead, we proposed an alternative higher-order model of Internalizing, Externalizing, Overachieving, and Healthy modes. In general, the SCI and SMI scales were able o distinguish the clinical sample from the community sample, and meaningful relationships were found between oping styles, schema modes, and behavior problems. In conclusion, our study supports the theorized relations ips between schema coping styles, schema modes, and behavior, problems in adolescents, and provides initial validation for the SCI and the, 80-item SMI in adolescent populations.

Implicit vs. explicit dimensions of guilt and dominance in criminal psychopathy.

The current study investigated the relationship between psychopathy and two concepts that hold a central position in conceptualizations of this disorder, being guilt and dominance. Both constructs were measured using explicit measures (i.e., self-report), as well as indirect assessment (i.e., the Single Category Implicit Association Test; Sc-IAT). Our sample consisted of 43 psychopathic offenders, 42 nonpsychopathic offenders, and 26 nonoffender controls. Although no overall group differences emerged, the lifestyle/antisocial traits of psychopathy (Factor 2) predicted reduced self-reported guilt on a dimensional level. As hypothesized, such a relationship was absent for the interpersonal/affective dimension of psychopathy (Factor 1). Psychopathy was unrelated to implicit self-guilt associations. Regarding dominance, psychopathy was not significantly associated with indirectly or explicitly assessed dominance. These findings are interpreted in the light of empirical knowledge on moral emotions, insight and response distortion in highly antisocial offenders.

The Mask of Sanity: Facial Expressive, Self-Reported, and Physiological Consequences of Emotion Regulation in Psychopathic Offenders.

This study investigated the physiological, self-reported, and facial correlates of emotion regulation in psychopathy. Specifically, we compared psychopathic offenders (n = 42), nonpsychopathic offenders (n = 42), and nonoffender controls (n = 26) in their ability to inhibit and express emotion while watching affective films (fear, happy, and sad). Results showed that all participants were capable of drastically diminishing facial emotions under inhibition instructions. Contrary to expectation, psychopaths were not superior in adopting such a "poker face." Further, the inhibition of emotion was associated with cardiovascular changes, an effect that was also not dependent on psychopathy (or its factors), suggesting emotion inhibition to be an effortful process in psychopaths as well. Interestingly, psychopathic offenders did not differ from nonpsychopaths in the capacity to show content-appropriate facial emotions during the expression condition. Taken together, these data challenge the view that psychopathy is associated with either superior emotional inhibitory capacities or a generalized impairment in showing facial affect.

Theory of Mind, Social Desirability, and Unlikely Symptom Reporting in Offenders With and Without Psychopathy.

The current study investigated the relationship between psychopathy and theory of mind (ToM), by comparing the performance of nonpsychopathic offenders (n = 40), psychopathic offenders (n = 42), and nonoffender controls (n = 26) on Happé's test of ToM (Happé, 1994). In addition, we investigated whether offenders' ToM skills would moderate the association between the antisocial psychopathy component (Factor 2) and self-presentation (i.e., the tendency to report social desirability and unlikely symptoms). Results showed groups did not differ in ToM performance. As expected though, ToM moderated the association between psychopathy and self-presentation: only for offenders relatively high in ToM, Factor 2 was strongly related to less social desirability and more unlikely symptom reporting. These results could indicate that offenders who are high in both ToM and Factor 2 exaggerate their mental dysfunction to express their need for clinical attention. Results are used to critically evaluate the interpretation of occurrences in which offenders overplay their psychopathology.

Antisocial features and "faking bad": A critical note.

We critically review the literature on antisocial personality features and symptom fabrication (i.e., faking bad; e.g., malingering). A widespread assumption is that these constructs are intimately related. Some studies have, indeed, found that antisocial individuals score higher on instruments detecting faking bad, but others have been unable to replicate this pattern. In addition, studies exploring whether antisocial individuals are especially talented in faking bad have generally come up with null results. The notion of an intrinsic link between antisocial features and faking bad is difficult to test and research in this domain is sensitive to selection bias. We argue that research on faking bad would profit from further theoretical articulation. One topic that deserves scrutiny is how antisocial features affect the cognitive dissonance typically induced by faking bad. We illustrate our points with preliminary data and discuss their implications.

Childhood Trauma Questionnaire: factor structure, measurement invariance, and validity across emotional disorders.

To study the psychometric properties of the Childhood Trauma Questionnaire-Short Form (CTQ-SF), we determined its dimensional structure, measurement invariance across presence of emotional disorders, the association of the CTQ-SF with an analogous interview-based measure (CTI) across presence of emotional disorders, and the incremental value of combining both instruments in determining associations with severity of psychopathology. The sample included 2,308 adults, ages 18-65, consisting of unaffected controls and chronically affected and intermittently affected persons with an emotional disorder at Time 0 (T0) or 4 years later at T4. Childhood maltreatment was measured at T0 with an interview and at T4 with the CTQ-SF. At each wave, patients were assessed for Diagnostic and Statistical Manual of Mental Disorders (4th ed., or DSM-IV; American Psychiatric Association, 1994)-based emotional disorders (Composite Interview Diagnostic Instrument) and symptom severity (Inventory of Depressive Symptomatology, Beck Anxiety Inventory, Fear Questionnaire). Besides the correlated original 5-factor solution, an indirect higher order and direct bifactorial model also showed a good fit to the data. The 5-factor solution proved to be invariant across disordered-control comparison groups. The CTQ-SF was moderately associated with the CTI, and this association was not attenuated by disorder status. The CTQ-SF was more sensitive in detecting emotional abuse and emotional neglect than the CTI. Combined CTQ-SF/CTI factor scores showed a higher association with severity of psychopathology. We conclude that although the original 5-factor model fits the data well, results of the hierarchical analyses suggest that the total CTQ scale adequately captures a broad dimension of childhood maltreatment. A 2-step measurement approach in the assessment of childhood trauma is recommended in which screening by a self-report questionnaire is followed by a (semi-)structured diagnostic interview.

Treating the untreatable: a single case study of a psychopathic inpatient treated with schema therapy.

From its first conceptualization in modern psychiatry, psychopathy has been considered difficult if not impossible to treat. Schema Therapy (ST) is a psychotherapeutic approach that has shown efficacy in patients with borderline personality disorder. ST has recently been adapted for personality disordered forensic patients, including patients with high levels of psychopathy. The present case study examined the process of individual ST, combined with movement therapy and milieu therapy by the nursing staff, with a forensic inpatient with psychopathic features (Psychopathy Checklist-Revised total score = 28.4). The patient had been sentenced to a mandatory treatment order in relation to a sexual assault. We assessed change using independent assessments of psychopathic traits, cognitive schemas, and risk-related behaviors over the 4-year treatment period and a 3-year follow-up. We also assessed the quality of the working alliance. Reliable change analyses showed significant improvements in psychopathic traits, cognitive schemas, and risk-related outcomes. At 3 years posttreatment, the patient was living independently outside of the forensic institution without judicial supervision and he had not reoffended. While many questions remain about the effectiveness of psychotherapeutic treatment for psychopathic patients, our study challenges the view that they are untreatable.

Factor structure, reliability, and known groups validity of the German version of the Childhood Trauma Questionnaire (Short-form) in Swiss patients and nonpatients.

The Childhood Trauma Questionnaire-Short Form is the most widely used instrument to assess childhood trauma and has been translated into 10 languages. However, research into validity and reliability of these translated versions is scarce. The present study aimed to investigate the factor structure, internal consistency, reliability, and known-groups validity of the German Childhood Trauma Questionnaire-Short Form (Bernstein & Fink, 1998). Six-hundred and sixty-one clinical and nonclinical participants completed the German Childhood Trauma Questionnaire-Short Form. A confirmatory factor analysis was conducted to assess the 5-factor structure of the original Childhood Trauma Questionnaire-Short Form. To investigate known-groups validity, the confirmatory factor analysis latent factor levels between clinical and nonclinical participants were compared. The original 5-factor structure was confirmed, with only the Physical Neglect scale showing rather poor fit. As a conclusion, the results support the validity and reliability of the German Childhood Trauma Questionnaire-Short Form. It is recommended to use the German Childhood Trauma Questionnaire-Short Form to assess experiences of childhood trauma.

Early maladaptive cognitive schemas in child sexual offenders compared with sexual offenders against adults and nonsexual violent offenders: an exploratory study.

INTRODUCTION: Although there is a growing body of research on the role of offense supporting cognitive distortions in child sexual offending, little is known about the origins of these distortions. According to cognitive theory, maladaptive cognitive schemas originating in adverse childhood experiences with caregivers have been hypothesized to underlie these cognitive distortions. AIM: This exploratory study investigates early maladaptive schemas (EMSs) in child sexual offenders compared with sexual offenders against adults and nonsexual offenders. MAIN OUTCOME MEASURES: EMSs were measured with the Young Schema Questionnaire, and psychopathy was measured with the Psychopathy Checklist-Revised. METHODS: Three groups of forensic inpatients-23 child sexual offenders, 19 sexual offenders against adults, and 24 nonsexual violent offenders-were assessed. Multivariate analyses of covariance were used to examine the hypothesized group differences in EMSs. RESULTS: Results showed that, after controlling for level of psychopathy, EMSs related to Abandonment (M = 2.61 vs. M = 1.73, P < 0.01), Social Isolation (M = 2.50 vs. M = 1.62, P < 0.01), Defectiveness/Shame (M = 2.05 vs. M = 1.42, P < 0.05), Subjugation (M = 2.28 vs. M = 1.57, P < 0.05), and Self-Sacrifice (M = 3.29 vs. M = 2.41, P < 0.05) were more prevalent in child sexual offenders compared with nonsexual violent offenders. Compared with sexual offenders against adults, child sexual offenders showed a trend to have higher scores on EMSs related to Social Isolation (M = 2.50 vs. M = 1.88, P = 0.066). CONCLUSIONS: Our findings suggest that EMSs may play a role in offending behavior in child sexual offenders and offer the possibility of informing treatment strategies.

Initial validation of the Spanish childhood trauma questionnaire-short form: factor structure, reliability and association with parenting.

The present study examines the internal consistency and factor structure of the Spanish version of the Childhood Trauma Questionnaire-Short Form (CTQ-SF) and the association between the CTQ-SF subscales and parenting style. Cronbach's α and confirmatory factor analyses (CFA) were performed in a female clinical sample (n = 185). Kendall's ι correlations were calculated between the maltreatment and parenting scales in a subsample of 109 patients. The Spanish CTQ-SF showed adequate psychometric properties and a good fit of the 5-factor structure. The neglect and abuse scales were negatively associated with parental care and positively associated with overprotection scales. The results of this study provide initial support for the reliability and validity of the Spanish CTQ-SF.

Femtosecond single-shot imaging of nanoscale ferromagnetic order in Co/Pd multilayers using resonant x-ray holography.

We present the first single-shot images of ferromagnetic, nanoscale spin order taken with femtosecond x-ray pulses. X-ray-induced electron and spin dynamics can be outrun with pulses shorter than 80 fs in the investigated fluence regime, and no permanent aftereffects in the samples are observed below a fluence of 25 mJ/cm(2). Employing resonant spatially muliplexed x-ray holography results in a low imaging threshold of 5 mJ/cm(2). Our results open new ways to combine ultrafast laser spectroscopy with sequential snapshot imaging on a single sample, generating a movie of excited state dynamics.

Retention or deletion of personality disorder diagnoses for DSM-5: an expert consensus approach.

One of the official proposals for the fifth edition of the American Psychiatric Association's (APA) diagnostic manual (DSM-5) is to delete half of the existing personality disorders (i.e., dependent, histrionic, narcissistic, paranoid, and schizoid). Within the APA guidelines for DSM-5 decisions, it is stated that there should be expert consensus agreement for the deletion of a diagnostic category. Additionally, categories to be deleted should have low clinical utility and/or minimal evidence for validity. The current study surveyed members of two personality disorder associations (n = 146) with respect to the utility, validity, and status of each DSM-IV-TR personality disorder diagnosis. Findings indicated that the proposal to delete five of the personality disorders lacks consensus support within the personality disorder community.

Disentangling the relationship between different types of childhood maltreatment and personality disorders.

This study investigated the relationship between five forms of childhood maltreatment (sexual, physical and emotional abuse, emotional and physical neglect) and 10 personality disorders (PDs). PDs were assessed by means of SCID II, and childhood maltreatment was retrospectively measured with the Interview for Traumatic Events in Childhood. Both PDs and childhood maltreatment were expressed continuously, and relations were assessed by means of structural equation modelling in a sample of 409 participants. Results indicated that sexual abuse was associated with symptoms of paranoid, schizoid, borderline, and avoidant PD; physical abuse with antisocial PD; emotional abuse with paranoid, schizotypal, borderline, and cluster C PD; and emotional neglect with histrionic and borderline PD. No independent relationships between physical neglect and PDs were found. The findings provide clear, albeit retrospective, evidence that different forms of childhood maltreatment have differential effects on PD pathology.