Effects of Imagery Rescripting (ImRs) and Eye Movement Desensitization and Reprocessing (EMDR) in Adults with Childhood Trauma-Related Post-Traumatic Stress Disorder (Ch-PTSD): Effects on Schema Modes

Effects of Imagery Rescripting (ImRs) and Eye Movement Desensitization and Reprocessing (EMDR) in Adults with Childhood Trauma-Related Post-Traumatic Stress Disorder (Ch-PTSD): Effects on Schema Modes - Imagery Rescripting (ImRs) and Eye Movement Desensitization and Reprocessing (EMDR) as treatment of childhood-trauma related post-traumatic stress disorder (Ch-PTSD) in adults: effects on Schema Modes

 

Authors: Martine Daniëls, Marie-Louise Meewisse, Annet Nugter, Sophie A. Rameckers, Eva Fassbinder and Arnoud Arntz

Translated by: Specialist Psychologist Gizem Pozam

ABSTRACT

Background:

Many clients with childhood trauma-related post-traumatic stress disorder (Ch-PTSD) also suffer from co-occurring personality pathology. However, little is known about how effective treatments for Ch-PTSD are in reducing this co-occurring personality pathology. Schema Modes are a concept that operationalizes personality pathology within schema therapy and can be measured using the Schema Mode Inventory (SMI). We therefore evaluated the effects on Schema Modes of two treatments delivered to adult clients with childhood trauma-related PTSD.

Method:

The 114 clients participating in the Imagery Rescripting and Eye Movement Desensitization and Reprocessing (IREM) Randomized Clinical Trial (Boterhoven de Haan et al., 2017, 2020) completed the Schema Mode Inventory (SMI), among other measures, and were randomly assigned to 12 sessions of either Imagery Rescripting (ImRs) or Eye Movement Desensitization and Reprocessing (EMDR). SMI measurements were collected at waitlist, pretreatment, mid-treatment, post-treatment, 8-week follow-up, and 1-year follow-up.

Results:

Both treatments produced significant reductions in Maladaptive Schema Modes and improvements in Adaptive Schema Modes (Cohen’s d = 0.94–1.18), with these effects persisting from pretreatment to post-treatment, 8-week follow-up, and 1-year follow-up. No statistically significant difference was found between ImRs and EMDR in changes in Schema Modes. No significant changes were observed during the waitlist period.

Conclusions:

ImRs and EMDR targeting Ch-PTSD led to significant improvements in Schema Modes. The results suggest that both treatments may have potential value in reducing co-occurring personality pathology.

Key Findings (HIGHLIGHTS)

• This is the first study to compare the effects of ImRs and EMDR on childhood trauma-related PTSD (Ch-PTSD) in terms of Schema Modes.


• Both ImRs and EMDR improved Schema Modes when delivered for Ch-PTSD; no significant change was observed in the waitlist group.


• No significant difference was found between ImRs and EMDR in Maladaptive and Adaptive Schema Modes.


• The results suggest that EMDR and ImRs may have potential value in reducing co-occurring personality pathology.


• One recommendation for clinical practice is to assess whether clients with Ch-PTSD and co-occurring personality problems need additional personality disorder-specific treatment after completing PTSD treatment.

1. Introduction

Childhood trauma (e.g., sexual, physical, and emotional abuse and neglect) is associated not only with the development of Post-Traumatic Stress Disorder (PTSD) (Carr et al., 2013; Ullman & Brecklin, 2002), but also with the development of personality pathology (Carr et al., 2013; Lobbestael, Arntz et al., 2010; Martins et al., 2011). For example, parental neglect is considered a predictor of both current PTSD (Meewisse et al., 2011) and borderline personality disorder (BPD) (Stepp et al., 2016). In addition, childhood sexual abuse is associated with the development of both PTSD and BPD (Bohus et al., 2013; Scheiderer et al., 2015). Childhood emotional abuse is an important factor in increasing PTSD severity (Rameckers et al., 2021) and predicts cluster C personality disorders (PDs) and BPD (Lobbestael, Arntz et al., 2010).

Indeed, many clients diagnosed with childhood trauma-related PTSD (Ch-PTSD) also suffer from co-occurring personality pathology (Friborg et al., 2013; MacIntosh et al., 2015). Both PTSD and PDs substantially reduce clients’ ability to function healthily across all areas of life (MacIntosh et al., 2015). It is therefore important to know whether treatments for Ch-PTSD reduce not only PTSD symptoms but also co-occurring personality pathology.

Meta-analyses show that trauma-focused treatments (TFT) are effective in reducing Ch-PTSD (Dorrepaal et al., 2014; Ehring et al., 2014). However, little is known about the effects of these treatments on co-occurring personality pathology. To date, only six studies have been conducted, some of which also included PTSD related to trauma in adulthood.

In a recent randomized controlled trial, Van den End et al. (2024) compared the effectiveness of TFT alone with TFT combined with an intervention for personality disorders. Both treatments were effective in reducing PTSD and personality pathology, but no significant difference was found between the two conditions. A study by Markowitz et al. (2015) found that 43% of clients initially diagnosed with a personality disorder no longer met the diagnostic criteria after 14 weeks of psychotherapy for chronic PTSD. Among clients who showed marked improvement in PTSD symptoms, this proportion rose to 56%.

Bovin et al. (2017) demonstrated that, following TFT delivered to women who had experienced rape, reductions in PTSD symptom severity were associated with reductions in the severity of co-occurring personality disorders (including BPD and antisocial PD). Kleindienst et al. (2021) compared dialectical behavior therapy for PTSD (DBT-PTSD) with cognitive processing therapy (CPT) for clients diagnosed with Ch-PTSD and BPD. The DBT-PTSD protocol targeted both PTSD and BPD symptoms. Both treatments significantly reduced PTSD and BPD symptoms, but DBT-PTSD was more effective than CPT on both outcomes.

Finally, two open cohort studies conducted by De Jongh et al. (2020) and Kolthof et al. (2022) examined the effects of brief, intensive TFT for PTSD on co-occurring BPD symptoms. Both studies observed significant reductions in BPD and PTSD symptoms.

Thus, although the available evidence is limited, findings suggest that TFT for PTSD may reduce co-occurring personality pathology.

Effects of Imagery Rescripting (ImRs) and Eye Movement Desensitization and Reprocessing (EMDR) on Ch-PTSD and Personality Pathology

In clinical practice, Imagery Rescripting (ImRs) and Eye Movement Desensitization and Reprocessing (EMDR) are used to treat both Ch-PTSD and personality pathology.

Both treatments focus on changing maladaptive information (including thoughts, sensations, and emotions) associated with traumatic events that lead to PTSD or personality pathology. However, the two treatments rely on different mechanisms.

• EMDR taxes working memory by diverting the client’s attention while they recall traumatic memories. According to the working memory hypothesis, overloading working memory reduces the vividness and emotional intensity of the traumatic memory (Gunter & Bodner, 2008; Shapiro, 2018).


• ImRs, on the other hand, focuses on changing the meaning of the memory and the emotional response to it by replacing the traumatic narrative with a more positive or empowering version. While EMDR focuses on desensitization by weakening the memory, ImRs aims to meet the child’s unmet needs and change the dysfunctional meanings associated with the memory (Arntz & Jacob, 2017).

Both methods have been found effective in treating PTSD (Arntz et al., 2013; Bisson et al., 2013; Lewis et al., 2020; Raabe et al., 2015). The IREM study demonstrated that the two methods were equally effective in treating Ch-PTSD (Boterhoven de Haan et al., 2020).

In addition, some studies provide (indirect) evidence that ImRs and EMDR may reduce personality pathology. For example, Hafkemeijer et al. (2020) showed that EMDR produced significant improvements in personality functioning. Weertman and Arntz (2007) demonstrated that ImRs was effective for clients with personality disorders.

Schema Therapy and Schema Modes

Schema Modes are one of the concepts closely associated with personality pathology. Schema Modes are one of the three core elements of schema therapy (the other two being schemas and schema coping strategies) (Arntz & Jacob, 2017).

Consequently, Schema Modes are an important tool in conceptualizing personality pathology. This study will therefore use Schema Modes as an indicator of personality pathology.

In summary, childhood trauma-related PTSD (Ch-PTSD) and personality pathology frequently co-occur and have similar developmental roots. Although research has demonstrated the effectiveness of trauma-focused treatments (TFT) for Ch-PTSD, little is known about the course of personality pathology during Ch-PTSD treatment or whether specific types of TFT differ in their effects on personality pathology.

We therefore examined whether treating Ch-PTSD with ImRs and EMDR was associated with improvements in Schema Modes and whether there was a difference between the two treatments.

No directional hypothesis was formulated. We also explored whether changes differed across Schema Mode clusters. Finally, we evaluated the extent to which changes in Schema Modes could be (statistically) explained by changes in PTSD severity. This tested whether changes in Schema Modes were independent of changes in PTSD severity.

Examining the effects of ImRs and EMDR on changing Schema Modes in Ch-PTSD may provide new insights into the effects of PTSD treatment on co-occurring personality pathology. This knowledge will contribute to developing better treatment plans for clients with both Ch-PTSD and dysfunctional Schema Modes.

2. Method

2.1. Study Design and Participants

This study is part of the IREM study, an international multicenter randomized clinical trial (Boterhoven de Haan et al., 2017). The IREM study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000750684).

Ethical approval for the study was obtained in all participating countries. An additional amendment for this secondary analysis was approved by the Ethics Review Committee Psychology and Neuroscience (ECP) at Maastricht University. However, one center did not participate in this substudy because it was already recruiting patients. Of the 155 clients in the IREM study, 114 were evaluated in this secondary analysis.

Participants were selected from individuals aged 18 to 70 with a primary diagnosis of PTSD related to trauma before the age of 16.

Exclusion Criteria:

• Acute PTSD,


• Alcohol or substance dependence,


• Benzodiazepine use,


• Co-occurring psychotic disorder or DSM-IV Bipolar I Disorder,


• Imminent suicide risk,


• IQ below 80,


• Having received treatment for PTSD within the past three months or having received no more than two sessions of EMDR or ImRs before the study.

Participants were not permitted to start any evidence-based PTSD treatment or medication during screening and treatment.

 

2.2. Measures and Interventions

2.2.1. Measures

Measuring Schema Modes

The Schema Mode Inventory (SMI-143) was used to measure Schema Modes (Bamelis et al., 2011).

• The SMI-143 is an extended version of the Schema Mode Inventory (SMI-118).


• Both the Dutch and German versions of the SMI-118 have been validated and shown to have acceptable psychometric properties (Lobbestael, van Vreeswijk et al., 2010; Reiss et al., 2012).


• Two new Schema Modes were added and validated in the SMI-143 (Bamelis et al., 2011).

The number of items in the SMI subscales ranges from 4 to 10.

The mean subscale score ranges from 1 (minimum, never) to 6 (maximum, always).

Schema Modes were classified as follows:

Adaptive Modes:

• Healthy Adult Mode


• Happy Child Mode

Maladaptive Schema Modes:

1. Vulnerable Child Mode


2. Externalizing Child Modes (Angry Child, Enraged Child, Impulsive Child, Undisciplined Child)


3. Dysfunctional Parent Modes (Demanding Parent, Punitive Parent)


4. Avoidant Coping Modes (Compliant Surrenderer, Detached Protector, Detached Self-Soother)


5. Overcompensatory Modes (Self-Aggrandizer, Bully and Attack)


6. Overcontroller Modes (Perfectionistic Overcontroller, Suspicious Overcontroller)

Clinician-Administered PTSD Scale for DSM-5 (CAPS-5)

The CAPS-5 is a structured interview that assesses PTSD symptoms according to DSM-5 criteria (Weathers et al., 2013).

• It assesses PTSD symptoms over the past month using 30 items.


• It determines an overall PTSD severity score, a separate score for each symptom cluster, and diagnostic status.


• The CAPS-5 has high internal consistency, strong interrater and test–retest reliability, and good validity (Boeschoten et al., 2018; Weathers et al., 2018).

2.2.2. Interventions and Therapists

ImRs and EMDR treatments were delivered in up to 12 twice-weekly, 90-minute sessions.

Imagery Rescripting (ImRs):

• It was based on the protocol described by Arntz and Weertman (1999).


• The client is asked to recall the traumatic memory and is then guided to imagine an alternative scenario that meets their unmet childhood needs.


• During the first six sessions, the therapist provides guidance, while in the final six sessions, the client’s adult self intervenes.


• In the final stage, the client re-experiences the new scenario from the child’s perspective.

Eye Movement Desensitization and Reprocessing (EMDR):

• It was based on Shapiro’s (2001) eight-phase protocol.


• The first session includes a safe place exercise and target assessment.


• Desensitization begins in the second session; the client performs eye-tracking movements while focusing on the traumatic memory.


• When the level of distress falls to zero or one, a positive cognition is installed, followed by a body scan.

 

Eye Movement Desensitization and Reprocessing (EMDR) Treatment

EMDR treatment is based on the eight-phase protocol established by Shapiro (2001).

• The first session involves preparation, including target assessment and emotional resilience training. A safe place exercise is used during this process.


• Desensitization begins in the second session. The client is asked to focus on the traumatic memory while simultaneously performing eye-tracking movements.


• When the level of distress falls to 0 or 1, the client’s preferred positive cognition is installed, followed by a body scan.

To prevent contamination between treatment conditions, certain strategies for overcoming blocks, particularly interventions involving imagery, were restricted. For further details on the treatment conditions and treatment adherence, reference was made to the study protocol described by Boterhoven de Haan et al. (2017).

2.3. Procedure

Clients were screened at the participating centers.

• During screening, the client’s motivation was assessed, informed consent was signed, and additional information was provided.


• Random assignment took place after this process was completed, using block randomization (n = 2, 4, 6 people/block) to ensure balanced allocation within each center and over time.


• Clients completed the Schema Mode Inventory (SMI) on a computer.


• Assessments were conducted at the following stages:
  
  
  
  • Before the waiting period (only if the waiting period before starting treatment exceeded three weeks),
  
  
  • Pretreatment,
  
  
  • Mid-treatment,
  
  
  • Post-treatment,
  
  
  • 8-week follow-up,
  
  
  • 1-year follow-up.
  
  
  
  

Assessments were conducted by research assistants who were blind to treatment allocation. Client recruitment took place between March 2015 and June 2019.

2.4. Data Analysis Approach

Similar analyses were performed to improve consistency between this study and the IREM study.

• Data were analyzed using a mixed regression model.


• Time was included in the model as a random factor nested within center, and an unstructured covariance structure was applied to repeated measures (if the model converged).


• When the model did not converge, a center-level random intercept was added.


• If necessary, the fit of different covariance structures was tested (AR(1), heterogeneous AR(1), ARMA(1,1), and compound symmetry).


• Adding a center level allowed control for specific effects associated with the treatment center (e.g., patient population characteristics, therapists, referral procedures).

The main analyses were conducted separately for Maladaptive Modes and Adaptive Modes.

Exploratory analyses were also conducted on six different Maladaptive Schema Mode clusters:

1. Avoidant Coping Modes,


2. Overcompensatory Coping Modes,


3. Dysfunctional Parent Modes,


4. Vulnerable Child Mode,


5. Overcontroller Modes,


6. Externalizing Child Modes.

Model comparisons were based on the following statistical tests:

• -2 log-likelihood chi-square tests,


• Akaike Information Criterion (AIC),


• Bayesian Information Criterion (BIC).

Model assumptions were tested as follows:

• Model residuals and predicted values were examined.


• The influence of outliers with Pearson residuals > |3| on the analysis results was examined (Blatná, 2006).

The statistical significance threshold was set at p < .05.

Because numerous exploratory analyses were performed (24 interaction analyses), additional statistical checks were applied to account for the increased risk of Type I error.

Sensitivity analyses were conducted as follows:

• CAPS-5 scores were added as covariates at each measurement point to test whether changes in PTSD severity explained changes in Schema Modes.


• However, because the CAPS-5 was not administered at mid-treatment, linear interpolation was used to estimate the missing data.


• These estimates were made only for participants with both pretreatment and post-treatment measurements available.

3. Results

3.1. Participants

A total of 114 participants from two countries (n = 57 in each treatment group) were included in the analyses:

• The Netherlands (n = 92, 5 centers)


• Germany (n = 22, 1 center)

Participants’ demographic variables are presented in Table 1.

3.2. Maladaptive and Adaptive Modes

All assumptions for the main analyses were met.

• Table 2 shows the mean scores for all Schema Mode categories by assessment and treatment.


• Table 3 presents the results of the main analyses.


• Figure 1 shows changes in Maladaptive and Adaptive Modes across assessments.


• Unless otherwise indicated, no outliers were detected in the analyses.

Figure 1. Changes in Maladaptive Schema Modes (A) and Adaptive Schema Modes (B) from Waitlist to the Second Follow-Up Assessment, by Treatment Condition

Note: Error bars indicate the 95% confidence interval.
EMDR = Eye Movement Desensitization and Reprocessing, ImRs = Imagery Rescripting.

3.2.1. Maladaptive Modes

• Pretreatment mean Maladaptive Mode scores:
  
  
  
  
  • EMDR: 3.20
  
  
  • ImRs: 3.28
  
  
  
  


• These scores are similar to the clinical population mean (3.00), but higher than the nonclinical population mean (2.04) (see Table 2, Bamelis et al., 2011).


• Compared with pretreatment, statistically significant reductions in Maladaptive Mode scores were found from mid-treatment through the second follow-up assessment.


• No significant changes were observed during the waiting period.


• The time × treatment interaction was not significant, meaning that no significant difference in Maladaptive Schema Modes was detected between EMDR and ImRs.


• When CAPS-5 scores were added to the model as a covariate, statistically significant reductions in Maladaptive Modes were found only at mid-treatment and post-treatment.


• Changes in Maladaptive Modes at follow-up assessments were explained solely by changes in CAPS-5 scores.

3.2.2. Adaptive Modes

• Pretreatment mean Adaptive Mode scores:
  
  
  
  
  • EMDR: 3.32
  
  
  • ImRs: 3.15
  
  
  
  


• These scores are similar to the clinical population mean (3.00), but lower than the nonclinical population mean (4.49) (see Table 2, Bamelis et al., 2011).


• Statistically significant increases in Adaptive Mode scores were found from mid-treatment through the second follow-up assessment.


• No significant changes were observed during the waiting period.


• The time × treatment interaction was not significant, meaning that no significant difference in changes in Adaptive Schema Modes was detected between EMDR and ImRs.


• When CAPS-5 scores were added to the model as a covariate, no statistically significant increases in Adaptive Modes were observed at follow-up assessments.


• This indicates that changes at the relevant assessments were explained by CAPS-5 scores.

3.3. Exploring Specific Mode Clusters

• Positive changes were observed in all Maladaptive Schema Mode clusters from mid-treatment through the final follow-up assessment compared with pretreatment (see Table 4).


• Time × treatment interactions were not statistically significant for most Schema Mode Clusters.


• However, three treatment interactions were significant for Avoidant Modes.


• Changes in Avoidant Modes from mid-treatment through the first follow-up assessment were stronger for EMDR than for ImRs (see Figure 2).

- Three of the 24 interactions tested were statistically significant.
- An analysis using a binomial test (n = 24, k = 3, p = .05) calculated the probability of three or more significant effects occurring by chance across 24 tests as 0.12.
- Therefore, at the 5% significance level, the possibility that these three significant effects occurred by chance cannot be ruled out.

Figure 2. Visualization of the Time × Treatment Interaction for Avoidant Modes over the Course of Treatment

Note: Error bars indicate the 95% confidence interval.
EMDR = Eye Movement Desensitization and Reprocessing, ImRs = Imagery Rescripting.

 

• Some changes in Maladaptive Schema Mode Clusters were explained by changes in CAPS-5 scores (see Table 4).


• First, the time × treatment interaction for Avoidant Modes was no longer significant at the post-treatment assessment.


• At mid-treatment, only Child Modes showed significant change when controlling for the effect of CAPS-5.


• At post-treatment, changes in most Schema Mode clusters remained significant, but significance was lost for the Vulnerable Child Mode.


• At the one-year follow-up assessment, most changes were no longer significant, but changes in Overcontroller and Overcompensatory Modes remained significant.


• Overall, after controlling for PTSD symptom severity as assessed by the CAPS-5, 11 of the 24 reductions in Maladaptive Schema Mode Clusters remained statistically significant.


• The binomial test indicated that finding 11 significant effects across 24 tests at the 5% significance level was statistically significant (p < .0001).


• Thus, it seems unlikely that all reductions in Schema Modes were solely a consequence of reductions in CAPS-5 scores.

4. Discussion

This study investigated the effects of Imagery Rescripting (ImRs) and Eye Movement Desensitization and Reprocessing (EMDR) on childhood trauma-related PTSD (Ch-PTSD) and their effectiveness in changing Schema Modes.

• Our findings indicate that both ImRs and EMDR are associated with large reductions in Maladaptive Schema Modes and improvements in Adaptive Schema Modes.


• These findings support the view that these trauma-focused treatments (TFT) reduce not only Ch-PTSD symptoms but also co-occurring personality pathology.


• The absence of changes during the waitlist period suggests a causal effect of treatment.

The effect sizes observed in this study are comparable to or greater than those reported in a systematic review of the effectiveness of schema therapy for personality disorders (Taylor et al., 2017).

These findings are also consistent with other studies examining the effects of TFT on co-occurring personality pathology (De Jongh et al., 2020; Kleindienst et al., 2021; Kolthof et al., 2022; Van den End et al., 2024).

• These studies found simultaneous symptom reductions in both PTSD and personality pathology, with effect sizes for reductions in co-occurring personality pathology ranging from d = 0.50 to d = 2.90.


• In this study, mean Adaptive and Maladaptive Schema Mode scores were similar to those of a clinical personality disorder population at pretreatment, while post-treatment scores shifted to a level between those of nonclinical (M = 4.49, Adaptive Modes; M = 2.04, Maladaptive Modes) and clinical populations (M = 3.00, both modes) (Bamelis et al., 2011).

 

Furthermore, no significant difference was found between ImRs and EMDR in their effectiveness on Adaptive and Maladaptive Schema Modes.

• This finding is also consistent with the absence of significant differences between the two treatments in their effects on primary and secondary outcomes in the main study (Boterhoven de Haan et al., 2020).


• A detailed examination of Maladaptive Schema Mode clusters found no significant difference between ImRs and EMDR for almost all modes.


• However, EMDR appeared more effective than ImRs for Avoidant Coping Modes up to the 8-week follow-up.


• This difference disappeared at the 1-year follow-up assessment, with no significant difference remaining between EMDR and ImRs.

The initial difference in effectiveness on Avoidant Coping Modes may be explained by EMDR’s more explicit strategy of interrupting avoidant coping by focusing on the most distressing image, whereas the ImRs protocol is less explicit in this respect.

However, the possibility that this difference was a chance finding cannot be ruled out because:

• The significance level was not adjusted for the number of tests.


• The binomial test performed did not reach significance when accounting for the number of tests.

The finding in this study that Schema Modes decreased alongside reductions in PTSD severity may be related to the overlap in the etiology of PTSD and personality pathology. Childhood trauma is known to play an important role in the development of these disorders (Carr et al., 2013). In addition, symptom overlap between these pathologies is an important factor.

• For example, emotional dysregulation is a core feature of both Ch-PTSD and personality pathology (Dvir et al., 2014).


• PTSD is more likely to develop in individuals who lack social support and has a negative impact on interpersonal functioning (Wang et al., 2021).


• Reducing Ch-PTSD symptoms (e.g., social withdrawal, flashbacks) may enable clients to focus more on their current environment, increasing access to sources of social support.


• This may contribute to improvements in interpersonal functioning, one of the core problems in personality pathology.

However, although PTSD and Schema Modes are linked, changes in PTSD severity were found not to fully explain changes in Schema Modes.

• Analyses including CAPS-5 as an additional covariate showed that Child Modes decreased in the early stages of treatment independently of changes in PTSD severity.


• At post-treatment, almost all changes in Schema Modes were independent of changes in PTSD severity.


• This suggests that both treatments directly lead to changes in Schema Modes.


• Schema Modes may also play a role in the processes of change that lead to reductions in PTSD symptoms.


• Interestingly, at the 1-year follow-up assessment, only changes in Overcompensatory and Overcontroller Modes remained independent of CAPS-5.


• This may indicate that these Modes are distinct from PTSD pathology.

Future Research on the Mechanisms Underlying Treatment Effects on Schema Modes

Research into the underlying mechanisms of action may help us better understand how treatments change Schema Modes.

• In ImRs, expressing and meeting childhood needs may be an important factor (Arntz et al., 2014; Koetsier et al., 2024).
  
  
  
  • For example, focusing on soothing the child’s emotions and standing up to critical caregivers during imagery work on the traumatic memory may reduce Child Modes and Dysfunctional Parent Modes.
  
  
  
  


• In EMDR, directly activating the most distressing moments while taxing working memory reduces the intensity of negative emotions (see working memory theory (Gunter & Bodner, 2008)).
  
  
  
  • This mechanism may explain reductions in Child Modes and, as noted earlier, Avoidant Coping Modes.
  
  
  • Addressing negative cognitions and installing more positive cognitions may change Dysfunctional Parent Modes and strengthen Adaptive Modes (for example, Healthy Adult).
  
  
  
  


• Both treatments also addressed negative childhood memories that did not meet the DSM-5 definition of PTSD but were important to the client.
  
  
  
  
  • This broader focus may have contributed to changes in Schema Modes.
  
  
  
  

 

Study Limitations

This study has several limitations:

1️⃣ The absence of an inactive control group makes it difficult to establish definitively that the treatments caused changes in Schema Modes.

• However, the absence of changes during the waitlist period increases the likelihood that the changes can be attributed to treatment.

2️⃣ The absence of an active, non-trauma-focused control treatment,

• Prevents us from ruling out the possibility that any active treatment would produce similar changes.

3️⃣ The SMI-143 used to measure Schema Modes is a self-report measure and may be subject to bias.

• For example, Bamelis et al. (2011) found that some patients, particularly individuals with strong Overcompensatory Modes (e.g., histrionic, narcissistic, and obsessive-compulsive personality disorders), underreported Child and Parent Modes.


• It should also be considered that Schema Modes are an indirect measure of personality pathology.


• Although this conceptualization has theoretical foundations and empirical support, using an additional measure of personality pathology (for example, the Assessment of DSM-IV Personality Disorders (Schotte et al., 1998)) could have provided stronger results.

4️⃣ We could not control for the effects of the treatments on general distress.

• This variable was not assessed separately.


• However, because PTSD was the primary diagnosis in the study and the largest effect sizes were found on the CAPS-5, the CAPS-5 is considered the most appropriate measure for controlling for changes.

5️⃣ Mid-treatment CAPS-5 measurements had to be estimated using linear interpolation.

• An actual measurement would have been preferable, but this was not possible because of the need to avoid increasing patient burden and because the CAPS-5 assesses the past month.

Important Implications for Clinical Practice

This study has important clinical implications.

• Given the relatively large effect sizes for Maladaptive Schema Modes and the therapeutic gains achieved in a relatively short period, we recommend assessing personality pathology in patients with Ch-PTSD and co-occurring personality pathology after they complete PTSD treatment.


• In many cases, PTSD treatment may already have had a substantial effect on personality pathology, potentially eliminating the need for additional treatment.


• This recommendation is consistent with the findings of Van den End and colleagues (2024).
  
  
  
  • That study found that personality disorder (PD) treatment delivered in addition to trauma-focused treatment (TFT) for PTSD did not produce a significant difference in reductions in PTSD severity and PD symptoms.
  
  
  • These researchers recommend a stepped-care approach: TFT should be delivered first, with PD treatment added only when considered necessary.
  
  
  
  

These findings are also consistent with other studies on treating childhood-related (complex) PTSD.

• Trauma-focused treatments may also reduce symptoms that overlap with personality pathology (e.g., difficulties with emotion regulation, interpersonal problems, negative self-perception) (Jerud et al., 2014; Jerud et al., 2016; Oprel et al., 2021; Van Toorenburg et al., 2020).


• Potentially, all trauma-focused treatments may be effective in bringing about changes in co-occurring personality pathology.


• Therefore, in clinical practice, therapists can offer patients options, and clients can choose the treatment most suitable for them.

Future research should compare the effectiveness of PD-focused treatments and TFT in patients with Ch-PTSD and co-occurring personality pathology and identify the most cost-effective treatment for this population.

The Study’s Original Contribution and Future Research

• To our knowledge, this is the first study to compare the effects of two different trauma-focused treatments (ImRs and EMDR) for Ch-PTSD on improving Schema Modes.


• The findings indicate that both ImRs and EMDR are effective and that these treatments reduce co-occurring personality pathology.


• These findings need to be replicated, and the mechanisms of change in treating Ch-PTSD and co-occurring personality pathology need to be investigated in greater detail.


• This would allow treatment protocols to be tailored more specifically to this challenging patient group.

Declarations

Conflict of Interest Statement

• A. publishes scientific articles and books on ImRs and conducts workshops on this treatment.


• F. receives personal income from publishing articles, books, and videos on ImRs, schema therapy, and other experiential techniques, and from delivering workshops and lectures.


• D. provides training in schema therapy.


• L.M. receives personal income from training and supervision in trauma-focused treatments, CBT, ImRs, and EMDR.


• The other authors report no conflicts of interest.

Data Sharing Statement

• Because participants did not give explicit permission for their data to be shared with other researchers, the data are not shared in accordance with the current European Union General Data Protection Regulation (GDPR).

Additional Information

Funding

• This substudy was funded by the GGZ-Noord-Holland-Noord Mental Health Institution.