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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.
Am J Psychiatry 2014;171:305-322. doi:10.1176/appi.ajp.2013.12040518
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The authors report no financial relationships with commercial interests.

Supported by grant 945-06-406 from the Netherlands Organization for Health Research and Development (ZonMw) (to Dr. Arntz) and by the Research Institute Experimental Psychopathology, Maastricht University, the Netherlands.

Netherlands Trial Register 566 (www.trialregister.nl).

From the Department of Clinical Psychological Science, Maastricht University, Maastricht, the Netherlands.

Previously presented in part at the 40th Annual Congress of the Dutch Society for Psychiatry, April 3–5, 2012, Maastricht, the Netherlands; the 20th Annual European Congress of Psychiatry, March 3–6, 2012, Prague; the 41st Annual Congress of the European Association for Behavioural and Cognitive Therapies, Aug. 31–Sept. 3, 2011, Reykjavik, Iceland; the 6th Annual World Congress of Behavioral and Cognitive Therapies, June 2–5, 2010, Boston; the Annual Congress of the Dutch Society for Behavioral and Cognitive Therapy, Nov. 12–13, 2009, Veldhoven, the Netherlands; and the Annual Congress of the Dutch Society for Behavioral and Cognitive Therapy, Nov. 13–14, 2008, Veldhoven, the Netherlands.

Address correspondence to Dr. Bamelis (l.bamelis@maastrichtuniversity.nl).

Copyright © 2014 by the American Psychiatric Association

Received April 19, 2012; Revised August 17, 2012; Revised February 28, 2013; Revised July 31, 2013; Accepted September 12, 2013.


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 lecture-based training.

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FIGURE 1. Descriptions of Schema Therapy and Clarification-Oriented Psychotherapy

FIGURE 2. Study CONSORT Diagram

FIGURE 3. Proportion of Patients in Indicated Principal Treatment (Schema Therapy, Treatment as Usual, or Clarification-Oriented Psychotherapy)a

a Successful termination of indicated therapy was not coded as dropout.

FIGURE 4. Recovery Rate Per Treatment Conditiona

a Estimated proportions are based on primary analysis; error bars represent 95% confidence intervals.

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TABLE 1.Comparison of Schema Therapy and Clarification-Oriented Psychotherapy
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TABLE 2.Baseline Demographic and Clinical Characteristics of Patients With Personality Disorders by Treatment Received
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a Value is based on analysis of variance F test.

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b Value is based on the Pearson’s chi-square test unless otherwise indicated.

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c Value is based on the Kruskal-Wallis test.

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d Secondary treatments are therapies given to patients alongside principal treatments.

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e Schema therapy differs significantly from treatment as usual and clarification-oriented psychotherapy (p<0.05).

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f Value is based on an F test from mixed logistic regression.

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g Schema therapy differs significantly from treatment as usual and clarification-oriented psychotherapy (p<0.01).

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h Clarification-oriented psychotherapy differs significantly from schema therapy and treatment as usual (p<0.01).

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i Treatment as usual differs significantly from schema therapy (p<0.05) and from clarification-oriented psychotherapy (p<0.01).

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TABLE 3.Mixed Logistic Regression Analyses of Recovery and Dropout Among Patients With Personality Disorders Randomly Assigned to Schema Therapy (ST), Clarification-Oriented Psychotherapy (COP), or Treatment as Usual (TAU)a