Schema therapy is an integrative psychotherapy approach that combines elements of cognitive-behavioral, attachment, psychodynamic, and emotion-focused therapies. It focuses on identifying and modifying early maladaptive schemas (self-defeating emotional and cognitive patterns) and schema modes (moment-to-moment emotional states) that are thought to underlie chronic psychological disorders. The goal is to help patients develop healthier schemas and coping strategies to improve their interpersonal relationships and overall functioning.
Peeters, N., van Passel, B., & Krans, J. (2022). The effectiveness of schema therapy for patients with anxiety disorders, OCD, or PTSD: A systematic review and research agenda. British Journal of Clinical Psychology, 61(3), 579-597. https://doi.org/10.1111/bjc.12324
Key Points
- This systematic review examined the effectiveness of schema therapy (ST) for anxiety disorders, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD).
- Only six studies (comprising 316 anxiety, OCD, and PTSD patients) met the inclusion criteria despite lenient methodological inclusion/exclusion criteria.
- Results showed that ST can lead to beneficial effects in disorder-specific symptoms and early maladaptive schemas. However, the included studies had substantial methodological limitations.
- The authors concluded that ST is a promising treatment for anxiety, OCD, and PTSD, but there is a systematic problem in the quality of research despite growing clinical interest and application.
- A research agenda with recommendations for future research is presented to help build a solid evidence base for ST in chronic anxiety, OCD, and PTSD.
Rationale
Cognitive behavioral therapy (CBT) is the most established evidence-based psychological treatment for anxiety, OCD, and PTSD.
However, approximately 50% of patients do not respond sufficiently to CBT, and CBT has an average dropout rate of 26.2% (Loerinc et al., 2015). For patients who do not recover with guideline treatments, a different approach is required.
Schema therapy (ST) has been suggested as an alternative treatment, as it addresses maladaptive schemas thought to maintain these disorders (Dadomo et al., 2016; Hoffart, 2012).
However, a comprehensive and up-to-date review of ST’s effectiveness for anxiety, OCD, and PTSD is lacking.
This systematic review aimed to provide an overview of the current evidence regarding ST’s effectiveness for these disorders.
Method
A systematic literature search was conducted in PsycINFO, MEDLINE, EMBASE, WEB OF SCIENCE, and Academic Search Ultimate databases up to April 2, 2021.
The search included keywords related to ST and anxiety disorders, OCD, and PTSD.
Studies were included if they examined ST (or in combination with a guideline treatment) in adult patients with a diagnosis of any anxiety disorder, OCD, and/or PTSD.
This systematic review followed recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher, Liberati, Tetzlaff, & Altman, 2009).
Procedure
Titles, abstracts, and full-text articles were independently screened by two authors according to the inclusion criteria.
Data extraction included study characteristics, participant demographics, intervention details, outcomes, and effect sizes. Methodological quality was assessed independently by two authors using the Psychotherapy Outcome study Methodology Rating Form (POMRF).
Sample
The six included studies had a total of 316 participants with diagnoses of panic disorder and/or agoraphobia, generalized anxiety disorder, OCD, or PTSD. Sample sizes ranged from 10 to 181 participants per study.
Outcomes
Primary outcomes were changes in anxiety, OCD, and/or PTSD symptoms and corresponding effect sizes. Secondary outcomes were changes in early maladaptive schemas. Disorder-specific symptom measures and schema measures were used.
Results
The results provide some preliminary evidence for the effectiveness of ST in OCD and PTSD, but the evidence for GAD is very limited and questionable due to severe methodological issues. More high-quality research is needed to establish the effectiveness of ST for these disorders.
Obsessive-compulsive disorder (OCD)
One study (Thiel et al., 2016) tested a 12-week inpatient treatment program augmenting exposure and response prevention with schema therapy (ST) in 10 OCD patients who were non-responders to at least one CBT treatment and first-line medication.
Patients significantly improved on OCD severity measures from pre- to post-treatment, and these gains were maintained at 6-month follow-up.
Four of the 10 patients were considered full responders, and another two were partial responders based on the Yale-Brown Obsessive-Compulsive Scale scores.
Despite the lack of a control group and small sample size, the study had a reasonable level of generalizability based on its POMRF score of 22 out of 40.
Posttraumatic stress disorder (PTSD)
Two studies examined ST for PTSD.
Tapia et al. (2017) investigated the effectiveness of combining ST with eye movement desensitization and reprocessing (EMDR) in 15 female patients with substance use disorder and PTSD.
PTSD severity and early maladaptive schemas (EMS) improved significantly during the first treatment phase focused on trauma memory, but not during the second phase focused on addiction memory.
Gains in PTSD severity and EMS were maintained at 1-year follow-up. However, the study had a low POMRF score of 10 out of 40, related to a small sample size, lack of control group, unclear ST content description, and incomplete reporting of statistical quantities.
Cockram, Drummond, and Lee (2010) compared ST with traditional CBT (TCBT) in a historically controlled trial with 181 male veterans with PTSD.
Within both therapy groups, PTSD and anxiety symptoms decreased from pre-treatment to 3-month follow-up, with a greater decrease in the ST group. In the ST group, 17 out of 18 EMS reduced from pre-treatment to follow-up.
The study had a POMRF score of 14 out of 40, related to poor sample description, incomplete reporting about therapy/therapist quality, and different assessment points between groups.
Generalized anxiety disorder (GAD)
One study (Mohammadi & Moradi, 2016) compared the effectiveness of ST to neuro-linguistic programming (NLP) and a non-intervention control group on generalized anxiety symptoms in 30 GAD patients.
Both ST and NLP conditions were effective in reducing generalized anxiety compared to the control condition, with no differences between ST and NLP at post-treatment.
However, the study had a very low POMRF score of 5 out of 40 due to lack of clear sample description, unclear initial diagnosis and analyses, non-manualized treatments, and considerable doubts about the validity of the active control intervention (NLP).
Panic disorder and/or agoraphobia
Two studies investigated the effectiveness of schema therapy (ST) combined with cognitive therapy for panic disorder and/or agoraphobia with cluster C personality traits.
Gude et al. (2001) found that in 45 patients, agoraphobic avoidance scores improved from pre- to mid-treatment and further from mid- to post-treatment. These gains were maintained at 1-year follow-up. However, the study lacked a control group and had incomplete reporting, resulting in a low POMRF score of 13 out of 40.
Hoffart et al. (2002) examined 35 patients and found significant reductions in panic/agoraphobia symptoms, general anxiety, and early maladaptive schemas from pre- to post-treatment, with most improvements occurring during the schema-focused phase.
Schema scores further decreased during the 1-year follow-up, while other gains were maintained. The study had a POMRF score of 20 out of 40, suggesting a reasonable level of generalizability, but lacked a control group.
These studies provide preliminary evidence for the effectiveness of ST combined with cognitive therapy for panic disorder and/or agoraphobia, but more high-quality controlled studies are needed.
Insight
This systematic review provides preliminary evidence that ST may lead to beneficial effects in disorder-specific symptoms and early maladaptive schemas in patients with anxiety disorders, OCD, or PTSD.
The findings suggest that ST could be a promising alternative treatment for patients who do not respond sufficiently to CBT.
However, the serious methodological limitations of the included studies prevent drawing firm conclusions.
Future research should focus on well-controlled and well-powered studies, adherence to high-quality standards of scientific reporting, and investigating different elements of ST to gain insight into its working mechanisms.
Strengths
- The included studies used reliable and valid outcome measures with good psychometric properties.
- The review followed PRISMA guidelines and had a preregistered protocol, contributing to high reporting standards.
Limitations
- The small number of included studies and their low methodological quality seriously impair the conclusions that can be drawn.
- Most studies lacked a control group, had small sample sizes, and did not perform power analyses or dropout analyses.
- The variability in ST delivery across studies makes generalization of findings more difficult.
Implications
While ST shows promise as a treatment for anxiety, OCD, and PTSD, the current state of research is insufficient to provide conclusive empirical support for its use in these disorders. Clinicians should be aware of the limited evidence base when considering ST for these patient populations.
Researchers need to conduct high-quality studies to establish ST’s effectiveness and working mechanisms.
Policymakers and funding bodies should support such research efforts to improve treatment options for patients not responding to current guideline treatments.
References
Primary reference
Peeters, N., van Passel, B., & Krans, J. (2022). The effectiveness of schema therapy for patients with anxiety disorders, OCD, or PTSD: A systematic review and research agenda. British Journal of Clinical Psychology, 61(3), 579-597. https://doi.org/10.1111/bjc.12324
Other references
Dadomo, H., Grecucci, A., Giardini, I., Ugolini, E., Carmelita, A., & Panzeri, M. (2016). Schema therapy for emotional dysregulation: Theoretical implication and clinical applications. Frontiers in Psychology, 7, 1987. https://doi.org/10.3389/fpsyg.2016.01987
Hoffart, A. (2012). The case formulation process in schema therapy of chronic axis I disorder (affective/anxiety disorder). In M. van Vreeswijk, J. Broersen & M. Nadort (Eds.), The Wiley-Blackwell handbook of schema therapy: Theory, research, and practice. (pp. 67–80). Chichester: John Wiley and Sons, Ltd. https://doi.org/10.1002/9781119962830.ch4
Loerinc, A. G., Meuret, A. E., Twohig, M. P., Rosenfield, D., Bluett, E. J., & Craske, M. G. (2015). Response rates for CBT for anxiety disorders: Need for standardized criteria. Clinical Psychology Review, 42, 72–82. https://doi.org/10.1016/j.cpr.2015.08.004
Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., &The PRISMA Group (2009). Preferred Reporting
Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med, 6(7).
https://doi.org/10.1371/journal.pmed.1000097
Keep Learning
- What are the key differences between schema therapy and cognitive behavioral therapy in their approach to treating anxiety disorders, OCD, and PTSD?
- How can future research address the methodological limitations identified in this systematic review to provide more conclusive evidence for the effectiveness of schema therapy?
- Considering the promising preliminary findings but limited evidence base, how should clinicians approach the decision to use schema therapy for patients with anxiety disorders, OCD, or PTSD who have not responded to guideline treatments?
- What potential working mechanisms of schema therapy could be investigated in future research to gain a better understanding of how it leads to symptom improvement in these disorders?
- How can policymakers and funding bodies support high-quality research on schema therapy to improve treatment options for patients with anxiety disorders, OCD, and PTSD?
