Psychiatric Annals

TREATMENTS REDUCING PERSONALITY DISORDERS 

Cognitive Therapy of Personality Disorders in Patients With Histories of Emotional Abuse or Neglect

David P Bernstein, PhD

Abstract

Much of the theoretical and empirical literature on trauma and personality disorders has concerned the relationship between child sexual abuse and borderline personality disorder.1 The impact of other forms of maltreatment such as emotional abuse, emotional neglect, physical abuse, and physical neglect has received far less attention. Many patients with personality disorders report that emotional maltreatment by family members was a central and painful aspect of their upbringing.2 Yet, few attempts have been made to develop conceptual models of the way in which childhood emotional abuse and neglect might contribute to the development of personality disorders. This article presents a cognitive model of the relationship between emotional maltreatment and personality disorders, using Jeffrey Young's notion of early maladaptive schémas (EMSs)3 as a conceptual framework; discusses the types of maltreatment experiences, EMSs, and coping mechanisms that contribute to the development of selfdefeating behavior patterns in patients with different types of personality disorders; and presents a case that illustrates many of these issues, and briefly discusses the schematherapy treatment approach that Young developed to treat patients with personality disorders.

EMOTIONAL MALTREATMENT: THEORETICAL AND DEFINITIONAL ISSUES

Emotional maltreatment is a relatively recent construct and one that raises several definitional issues. First, there is no universally accepted definition of emotional maltreatment. Rohner4 has suggested that emotional maltreatment should be conceptualized as lying on a single continuous warmth dimension, with parental acceptance at one pole and parental rejection at the other. Alternatively, emotional maltreatment may be conceptualized as a multifaceted construct, with components such as demeaning, terrorizing, rejecting, and depriving.5 Another unresolved issue is how broadly or narrowly emotional maltreatment should be defined. A narrow definition would restrict emotional maltreatment to verbal behavior, such as verbally demeaning or humiliating a child (ie, verbal abuse). Alternatively, emotional maltreatment could be broadly conceptualized as a component of all forms of maltreatment, including sexual and physical abuse. To make matters even more complicated, there is no universally accepted threshold for clinically significant emotional maltreatment. We can usually agree on clear-cut cases of emotional abuse when we see them. But what about parents who are highly critical, but not demeaning, or emotionally distant but not rejecting? Should these be counted as cases of emotional maltreatment too?

One solution to this definitional problem is to posit the existence of two distinct but related dimensions of maltreatment in childhood: emotional abuse and emotional neglect. Based on a review of the literature, Bernstein et al.*7 proposed the following definitions of emotional abuse and neglect: Emotional abuse was defined as "verbal assaults on a child's sense of worth or well-being or any humiliating or demeaning behavior directed toward a child by an adult or older person." Emotional neglect was defined as "the failure of caretakers to meet children's basic emotional and psychological needs, including love, belonging, nurturance, and support." Clinicians who were trained to use these definitions achieved high levels of inter-rater agreement in two different studies.6,7

According to Rohner,4 emotional abuse and neglect are forms of parental rejection, and therefore exemplify the negative pole of the acceptance versus rejection continuum. In support of this theory, items for emotional abuse and emotional neglect loaded on two separate but highly intercorrelated dimensions of the Childhood Trauma Questionnaire, a retrospective measure of child abuse and neglect8 in four different clinical and community samples.9 In another factor analytic study, Scher et al.10 found that the five factors of the Childhood Trauma Questionnaire (emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect) were better regarded as separate but intercorrelated maltreatment dimensions, rather than as a single global maltreatment construct. These findings support the idea that…

Much of the theoretical and empirical literature on trauma and personality disorders has concerned the relationship between child sexual abuse and borderline personality disorder.1 The impact of other forms of maltreatment such as emotional abuse, emotional neglect, physical abuse, and physical neglect has received far less attention. Many patients with personality disorders report that emotional maltreatment by family members was a central and painful aspect of their upbringing.2 Yet, few attempts have been made to develop conceptual models of the way in which childhood emotional abuse and neglect might contribute to the development of personality disorders. This article presents a cognitive model of the relationship between emotional maltreatment and personality disorders, using Jeffrey Young's notion of early maladaptive schémas (EMSs)3 as a conceptual framework; discusses the types of maltreatment experiences, EMSs, and coping mechanisms that contribute to the development of selfdefeating behavior patterns in patients with different types of personality disorders; and presents a case that illustrates many of these issues, and briefly discusses the schematherapy treatment approach that Young developed to treat patients with personality disorders.

EMOTIONAL MALTREATMENT: THEORETICAL AND DEFINITIONAL ISSUES

Emotional maltreatment is a relatively recent construct and one that raises several definitional issues. First, there is no universally accepted definition of emotional maltreatment. Rohner4 has suggested that emotional maltreatment should be conceptualized as lying on a single continuous warmth dimension, with parental acceptance at one pole and parental rejection at the other. Alternatively, emotional maltreatment may be conceptualized as a multifaceted construct, with components such as demeaning, terrorizing, rejecting, and depriving.5 Another unresolved issue is how broadly or narrowly emotional maltreatment should be defined. A narrow definition would restrict emotional maltreatment to verbal behavior, such as verbally demeaning or humiliating a child (ie, verbal abuse). Alternatively, emotional maltreatment could be broadly conceptualized as a component of all forms of maltreatment, including sexual and physical abuse. To make matters even more complicated, there is no universally accepted threshold for clinically significant emotional maltreatment. We can usually agree on clear-cut cases of emotional abuse when we see them. But what about parents who are highly critical, but not demeaning, or emotionally distant but not rejecting? Should these be counted as cases of emotional maltreatment too?

One solution to this definitional problem is to posit the existence of two distinct but related dimensions of maltreatment in childhood: emotional abuse and emotional neglect. Based on a review of the literature, Bernstein et al.*7 proposed the following definitions of emotional abuse and neglect: Emotional abuse was defined as "verbal assaults on a child's sense of worth or well-being or any humiliating or demeaning behavior directed toward a child by an adult or older person." Emotional neglect was defined as "the failure of caretakers to meet children's basic emotional and psychological needs, including love, belonging, nurturance, and support." Clinicians who were trained to use these definitions achieved high levels of inter-rater agreement in two different studies.6,7

According to Rohner,4 emotional abuse and neglect are forms of parental rejection, and therefore exemplify the negative pole of the acceptance versus rejection continuum. In support of this theory, items for emotional abuse and emotional neglect loaded on two separate but highly intercorrelated dimensions of the Childhood Trauma Questionnaire, a retrospective measure of child abuse and neglect8 in four different clinical and community samples.9 In another factor analytic study, Scher et al.10 found that the five factors of the Childhood Trauma Questionnaire (emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect) were better regarded as separate but intercorrelated maltreatment dimensions, rather than as a single global maltreatment construct. These findings support the idea that emotional abuse and neglect are separate but intercorrelated maltreatment dimensions, and are distinct from, but correlated with, other types of childhood trauma.

Only a few empirical studies of the effects of emotional abuse or neglect have been conducted.211 However, the available evidence suggests that they may be distinct from those of other forms of maltreatment. In a study of college-aged women, for example, Briere et al.12 found that histories of verbal abuse were associated with self-esteem problems, whereas histories of sexual abuse and physical abuse were associated with sexual problems and anger problems, respectively. Thus, the long-term consequences of emotional abuse were different from those of physical or sexual abuse when emotional abuse was defined as verbal behavior.

Few studies have examined the independent effects of emotional abuse and neglect on personality disorders, but these have generally found differential effects.13,14 For example, in a retrospective study of drug abusers, Bernstein et al.13 found that emotional abuse was broadly associated with personality pathology, predicting personality disorders in all three DSM-III-R clusters (odd cluster, dramatic cluster, and anxious cluster personality disorders). In contrast, emotional neglect was specifically related to schizoid personality disorder, a disorder characterized by emotional detachment. These findings suggest that emotional abuse and emotional neglect may have different effects on personality disorder pathology.

A SCHEMA-FOCUSED COGNITIVE MODEL OF THE EFFECTS OF EMOTIONAL· MALTREATMENT ON PERSONAUTY DISORDERS

How can the impact of emotional maltreatment on personality disorders be understood from a cognitive perspective? When emotional maltreatment occurs in childhood, it can result in distorted, maladaptive beliefs (ie, cognitive schémas) about the self and others. Jeffrey Young3 has conceptualized these maladaptive beliefs in terms of early maladaptive schémas. Early maladaptive schémas are pervasive and enduring themes or patterns that have their origins in early adverse experiences, are elaborated over the course of a lifetime, and are dysfunctional to a significant degree.3 They include cognitive biases that cause individuals to perceive themselves and others in unrealistic, self-defeating ways. Early maladaptive schémas are self-perpetuating, in that they lead to selective processing of information that confirms pre-existing maladaptive beliefs. Young has proposed that EMSs form the cognitive and affective core of personality disorders.3 Early maladaptive schémas may prove to be a critical cognitive link between childhood emotional maltreatment and personality disorders.

Young has proposed the existence of 18 different EMSs that fall into 5 schema domains: disconnection and rejection; impaired autonomy and performance; impaired limits; other-directedness; overvigilance and inhibition3 (Table 1). The first of these domains, disconnection and rejection, is particularly pertinent to the effects of child emotional abuse and emotional neglect. This domain contains five specific early maladaptive schémas: abandonment; emotional deprivation (of nurturance, autonomy, and protection); abuse /mistrust; defectiveness /shame; and social isolation. The abandonment schema is the belief that one will be abandoned. The emotional deprivation schema is the expectation that others will not meet one's emotional needs. According to Young,3 emotional deprivation can be of three kinds: deprivation of nurturance; autonomy; and protection. The abuse/ mistrust schema is the belief that others will act abusively toward the self. The defectiveness /shame schema is the belief that the self is damaged and unworthy. The social isolation schema is the belief that one will always be alone and alienated from others.

Emotionally abused children may come to believe that they are inherently flawed, defective (defectiveness /shame schema), and that others will attack and demean them (mistrust/ abuse schema), or abandon them (abandonment schema). Emotionally neglected children, on the other hand, may come to believe that others are never truly interested in meeting their emotional needs (emotional deprivation schema), and that they will always end up alone and alienated from other people (social isolation schema). In addition, emotional maltreatment may lead to EMSs in one or more of the other four schema domains. For example, emotionally maltreated children may engage in desperate but unrewarding attempts to gain their caregiver's approval (approval seeking schema), or sacrifice their own needs to take care of the needs of others (self-sacrifice schema). Emotionally neglected children may be given insufficient guidance and support to separate and individuate from their parents (enmeshment/ undeveloped self schema), fail to develop an independent, competent sense of self (dependence /incompetence schema), or lack the firm limit setting needed to develop self-discipline and self-control (insufficient self-control /self-discipline schema). Alternatively, emotionally maltreated children may develop a self-centered, entitled orientation towards others (entitlement schema), because of the lack of empathy they received as children, and to compensate for underlying feelings of defectiveness (defectiveness shame schema) and deprivation (emotional deprivation schema).

Table

TABLE 1Early Maladaptive Schema and Schema Domains

TABLE 1

Early Maladaptive Schema and Schema Domains

Young's model includes both schémas and coping mechanisms. When EMSs are triggered, they produce intense, disruptive affects. Three coping mechanisms are used to manage the potentially disruptive effects of schematic activation: schema surrender, schema avoidance, and schema overcompensation. Schema surrender is the tendency to give in to the schema. For example, people with a defectiveness /shame schema sometimes are attracted to people and situations that trigger their schema. For example, someone may continue to work for an emotionally abusive employer despite the frequent humiliations that come with the position because these episodes are unpleasant but familiar, conrmning a core belief that the self is unworthy. This coping mechanism is largely automatic and nonconscious. It is a habitual way of coping with the schema, but one that is self-defeating, because it confirms and perpetuates the schema.

Schema avoidance is the tendency to avoid people and situations that trigger one's schema. For example, people with a failure schema avoid taking on new challenges at which they might fail because the risk of f ailure is one that is likely to trigger their schema. Schema overcompensation means doing the opposite of the schema. For example, people with a defectiveness /shame schema sometimes attempt to make other people feel ashamed, as a way of compensating for their own feeling of defectiveness. All of these coping mechanisms develop in childhood as a means of coping with EMSs, but ultimately serve to perpetuate schémas, rather than to resolve them.

In addition to EMSs, it seems likely that a variety of factors will mediate the relationship between emotional maltreatment and personality disorders. These include the intensity and type of emotional maltreatment experiences, which of the EMSs appear to be core or central to the personality organization, which of the three coping mechanisms are used most prominently, early temperament, other types of childhood trauma that might have occurred in addition to emotional maltreatment, and a variety of protective factors that might mitigate the worst effects of emotional maltreatment. Table 2 presents possible relationships between these factors and some of the personality disorders in the DSM-IV.

Avoidant Personality Disorder

Patients with avoidant personality disorder avoid social contact because they fear being evaluated by others.15 They often fear that others can "see through them," and would reject them if they could see their flaws (defectiveness /shame schema). They often feel as if they don't belong or fit in, as if they are outsiders looking in, even in groups whose members they know well (social isolation schema). These patients are often preoccupied with whether others like them and will go to great lengths to win the approval of others (approval seeking schema), including sacrificing their own needs to take care of the needs of others (self- sacrifice schema). One of the hallmarks of avoidant personality disorder is an avoidance of situations in which the patient fears being judged or embarrassed (avoidance coping mechanism).

Avoidant personality disorders usually stem from moderate emotional maltreatment experiences. For example, having a harsh, critical, verbally abusive parent, or being ignored or socially excluded within one's own family can produce painful feelings of defectiveness (defectiveness/ shame schema), of being an outsider (social isolation schema), of desperately wanting to earn others' approval (approval seeking schema), and of avoiding potentially humiliating social situations (avoidance coping mechanism).

Table

TABLE 2Relationship Among Personality Disorders, Early Maladaptlve Schemas, Coping Mechanisms, Childhood Maltreatment, and Temperament

TABLE 2

Relationship Among Personality Disorders, Early Maladaptlve Schemas, Coping Mechanisms, Childhood Maltreatment, and Temperament

Dependent Personality Disorder

Patients with dependent personality disorder, like patients with avoidant personality disorder, usually suffer from core feelings of defectiveness (defectiveness /shame schema). However, in addition they often suffer from feelings of incompetence, as if they are unable to manage the routine tasks Of life without excessive help, advice, reassurance, or support from others (dependence/ incompetence schema).16 Moreover, dependent personality disorder patients cope with these feelings by seeking out relationships in which they can depend on other people whom they perceive as stronger, wiser, or more competent than themselves (schema surrender coping mechanism). To maintain these relationships, patients with dependent personality disorder often feel that they must sacrifice their own needs, as the price for being loved or liked (self-sacrifice and approval seeking schémas).

Like patients with avoidant personality disorder, patients with dependent personality disorder have often suffered from moderate experiences of emotional maltreatment. For example, repeatedly leaving a child alone for extended periods of time, before she is prepared to handle such experiences, or failing to provide a child with appropriate guidance and support, can foster lifelong feelings of incompetence and helplessness in the face of even minor decisions (dependence /incompetence schema), of turning to others to solve problems (schema surrender coping mechanism), and of feelings of loneliness and neediness (social isolation and emotional deprivation schémas).

Obsessive-Compulsive Personality Disorder

Patients with obsessive-compulsive personality disorder are perfectionistic, and have an extraordinary need for neatness, orderliness, and cleanliness.17 They are overly conscientiousness, having rigid, inflexible standards, and are scrupulous about following rules (unrelenting standards schema). They often believe that people who break rules or behave in unreliable, undisciplined ways are deserving of harsh punishments (punitiveness schema). They are often experienced by others as cerebral, cold, unemotional, or control freaks (emotional inhibition schema).

Patients with obsessive-compulsive personality disorders typically report having grown up either in families that were cold, distant, and controlling, or families that were chaotic and abusive. In the first type of family, the children were subjected to rigid standards for behavior, and expected to exercise an excessive degree of self-control over their emotions and impulses. Violations of family rules and norms were often responded to with harsh disapproval, including the withdrawal of love. In these families, the children internalize their parents' rigid standards (unrelenting standards schema), and learn to inhibit their emotions and over-control their behavior (emotional inhibition schema). Oftentimes, they cope with their schémas by avoiding any situation involving spontaneity or strong emotions, for example, by becoming workaholics (schema avoidance).

In the second type of family, the child develops an obsessive-compulsive style as a means of coping with a tumultuous, frightening family environment. In these chaotic families, children who develop obsessive-compulsive personality disorder are frequently the most resilient and resourceful family members; they are often family heroes or rescuers who take care of others in the family, while their own needs are neglected (self-sacrifice schema). Perfectionism (unrelenting standards schema) and excessive self-control (emotional inhibition schema) develop as a means of exerting control in an otherwise unpredictable environment (schema overcompensation).

Borderline Personality Disorder

Patients with borderline personality disorder tend to have had severe experiences of emotional abuse and /or neglect.18 They invariably exhibit one or more of the schémas in the disconnection /rejection domain: abandonment, defectiveness /shame, mistrust/ abuse, emotional deprivation, and social isolation. They have often experienced traumas other than emotional maltreatment, such as sexual or physical abuse, physical neglect, or early losses.18 In addition, many authors have suggested that difficulties with the regulation of affects and impulses are core deficits in borderline personality disorder, and may have a heritable basis.19

Patients with borderline personality disorder show a pronounced tendency to cope with their schémas by overcompensating (schema overcompensation). The borderline patient pre-emptively attacks others to avoid being attacked, or attacks in retaliation over real or imagined instances of abuse or abandonment. In addition, borderline patients often attempt to escape from or avoid feelings of painful inner turmoil by engaging in self-numbing/self-soothing behaviors, such as drinking, drug use, pathological gambling, compulsive sexual activity, binge eating, or self-mutilation (schema avoidance). A case of borderline personality disorder in a patient with a history of severe emotional maltreatment is described below.

Narcissistic Personality Disorder

The hallmark of narcissistic personality disorder is the belief that one is special and is therefore deserving of special treatment from others (entitlement schema).20 Developmentally, narcissistic pathology can be thought of as a compensation for core feelings of defectiveness and shame (defectiveness /shame schema), emotional deprivation (emotional deprivation schema), or other schémas in the disconnection/ rejection domain.21 Almost invariably, these patients have suffered from early emotional maltreatment, and frequently from other early traumas as well. A theme in the stories of almost all narcissistic patients is the feeling that others didn't empathize with them, weren't attuned to their needs or inner feelings (emotional deprivation schema). At its extreme, this can take the form of parents who used their children as objects to serve their own self-centered needs, or parents who rejected their children completely, treating them with cold disdain, rage, or showing no interest in them at all. Not surprisingly, these parents often were highly narcissistic themselves, or suffered from other forms of severe psychopathology.

Narcissistic patients suffer from profound feelings of inner loneliness, emptiness, or neediness, stemming from these early experiences of rejection and disconnection, as well as the disconnection from others they have created through their own narcissistic distancing (emotional deprivation schema). However, their feelings of entitlement and superiority typically protect them from awareness of these feelings (schema overcompensation), except when narcissistic injuries (ie, disappointments, humiliations, losses) deflate them. In such instances, narcissistic individuals often attempt to restore their narcissistic equilibrium by engaging in self-soothing/ self-numbing behaviors (schema avoidance), or counterattacking those who have wounded them to regain the one-up position (schema overcompensation).

Histrionic Personality Disorder

Histrionic personality disorder is characterized by superficial, exaggerated expression of emotions.16 Histrionic patients tend to make mountains out of mole hills, but their dramatic emotional episodes are usually fleeting, suggesting a lack of emotional depth. Such individuals are frequently self-centered and attention seeking, attempting to be on center stage whenever possible, and sexually seductive. They are often unusually physically attractive.

Patients with histrionic personality often grow up in families where their vivid displays of emotion are reinforced by parents or others, for example, by gaining parental approval, attention or special treatment. These children sometimes have a flair for the theatrical, which is explicitly encouraged. In some cases, exaggerated emotional displays are part of a familial style of interacting in which emotions are intensely and dramatically expressed (eg, loud, dramatic fights, followed by effusive reconciliations). In many instances, however, a histrionic style serves as a compensatory means of seeking attention and approval (approval seeking schema), in response to emotional abuse and /or neglect (schema overcompensation coping mechanism). Histrionic personality disorder is often comorbid with narcissistic personality and /or borderline personality disorder;16 such patients frequently share similar histories of childhood emotional maltreatment. Like narcissistic patients, histrionic individuals frequently report having had parents who were self-centered, aloof, and emotionally unavailable, leading to intense feelings of emotional deprivation and defectiveness (emotional deprivation and defectiveness /shame schémas). Often such patients cultivate a flair for the dramatic (eg, staging elaborate performances to gain parental attention) or behave seductively toward the opposite sex parent as a means of obtaining the parental approval and acceptance that they crave (schema overcompensation).

Antisocial Personality Disorder

Like borderline patients, patients with antisocial personality disorder often have histories of severe childhood maltreatment.22 In addition to emotional maltreatment, many antisocial patients have experienced severe physical abuse, sexual abuse, or physical neglect. They often report a chaotic and unstable family life, with traumatic losses, abandonments, multiple surrogate caregivers (eg, living in foster families or group homes, being raised by relatives), witnessing parental domestic violence, and a lack of proper parental supervision.23 In some instances, their parents' criminal activity or propensity for violence provides a model for their own antisocial behavior.

Antisocial patients often view life as a violent struggle for survival of the fittest; to show any outward signs of weakness, or feel any feelings of vulnerability, is to make oneself a potential victim (abuse /mistrust schema). The surest way to avoid being victimized is to assume the role of victimizer: to mtimidate, hurt, manipulate, and exploit others who are more vulnerable than oneself (schema overcompensation). Psychopaths, the most severely antisocial patients, are extremely ruthless, callous, and remorseless.24 Psychopaths treat other human beings as objects to be used, manipulated, and exploited, often with great cruelty (entitlement schema). Many antisocial individuals show little ability to tolerate frustration or defer gratification (insufficient self-control /self-discipline schema). Although antisocial patients may have contempt for those weaker and more vulnerable than themselves (schema overcompensation), underneath they often see themselves as losers, at the bottom of the social heap, unfit to function in normal society (defectiveness /shame schema), and as unwanted social outcasts (social isolation schema).

Schizotypal Personality Disorder

Schizotypal personality disorder is characterized by oddness and eccentricity, and has been conceptualized as a schizophrenia-spectrum disorder.25 There is considerable evidence that schizophrenia and schizotypal personality disorder share a common genetic basis.25 There is little theoretical reason to believe that childhood trauma is a specific etiological factor for schizotypal symptoms such as suspiciousness and interpersonal isolation, which are probably attributable to genetic predispositions, rather than to abuse or neglect. However, childhood trauma may act as a nonspecific stressor that increases the severity of schizotypal symptoms in genetically predisposed individuals. Moreover, the high rate of diagnostic comorbidity between schizotypal and borderline personality disorder25 raises the possibility that childhood trauma may play a more specific etiological role in this subgroup of schizotypal patients.

Paranoid Personality Disorder

Qtildhood trauma may play a more specific role in the distorted cognitions of patients with paranoid personality disorder, a disorder that appears to have less of a genetic basis than schizotypal personality disorder.26 Patients with paranoid personality disorder tend to be emotionally cold, hostile, hypersensitive to perceived slights, and show a pervasive mistrust of the motives of other people.26 Such patients believe that others are out to get them (mistrust /abuse schema), and seek to humiliate or demean them (defectiveness /shame schema). Not surprisingly, such feelings are sometimes rooted in experiences of childhood emotional maltreatment. Parents who routinely shame and humiliate their children can produce lifelong feelings of defectiveness, mistrust, and anger. In addition, many paranoid patients have histories of child physical abuse, which may account for their expectation that others will harm them (abuse /mistrust schema) as well as for their hostility and aggression. Paranoid patients attempt to cope with their schémas by overcompensating: by pre-emptively attacking or retaliating against those whom they perceive as malevolent.

Schizoid Personality Disorder

Patients with schizoid personality disorder are emotionally and interpersonally detached.15 They are often socially isolated, have no close friends, and indicate a preference for solitary activities. Unlike patients with avoidant personality disorder, who desire closeness but avoid interpersonal situations because of fear of others' negative evaluations, schizoid patients show little apparent interest in intimacy.

As children, patients with schizoid personality disorder frequently suffered from emotional or physical neglect. They invariably suffer from profound feelings of loneliness, alienation, and isolation (emotional deprivation and social isolation schémas), and usually feel ashamed of themselves and inadequate (defectiveness /shame schema). These feelings are usually kept out of awareness, because schizoid patients are so adept at detaching themselves from their feelings and needs (schema avoidance). Schizoid patients avoid situations that involve all but superficial contact with other people, and run away from relationships that have the potential for developing true intimacy (schema avoidance). In addition, some schizoid patients have an undeveloped, diffuse, undifferentiated sense of self, which may stem from a failure to separate and individuate from caregivers (enmeshment/ undeveloped self schema). As a result, they fear being dominated by others in close relationships, or that their fragile sense of separateness will be lost if they let others get too close (subjugation schema). Temperamentally schizoid patients are typically passive, which accounts in part for their aimless approach to life.

Case Study: A Patient with Borderline Personality Disorder and a History of Severe Emotional Abuse and Neglect

Joan is a 27-year-old unmarried woman who is employed as a temporary office worker. She was the oldest of three children. She had been clinically depressed since high school, and had been treated with antidepressant medication and psychodynamic psychotherapy. She had become seriously overweight, and engaged in binge eating when she was feeling upset. Joan also reported many episodes of acting out impulsively besides binge eating, including self-destructive sexual behavior and angry outbursts at bosses and coworkers. She reported that she has always felt deeply ashamed of herself as if she has no worth as a person and no one would want to love her or befriend her (defectiveness! shame schema). She had no close friends, felt isolated and lonely, and unable to fit in with a group (social isolation schema). She is a chronic underachiever. Despite her high intelligence, she received medioae grades in college, and drifted from one underpaid job to another since graduating.

Joan reports that her mother was a vain, self-absorbed woman, who taunted and humiliated Joan from an early age. Joan's mother would fly off the handle almost daily, yelling or screaming at Joan or her siblings for no apparent reason. Everyone in the family was subjected to the mother's verbal abuse, but Joan appeared to be singled outpr particular derision. She lived in fear of her mother's verbal assaults (mistrust! abuse schema). By the time Joan was 8 or 9 years old, her mother had become obsessed with Joan's weight. Although Joan was not obese, being at most a little chubby for her age, her mother forbid her from having snacks, sweets, or desserts, and maintained a strict control over her diet (subjugation schema). This overcontrolling behavior led to running battles in which Joan would plead, use guilt, or attempt to cajole her mother into relenting, and her mother would refuse, calling Joan fat and threatening to send her to fat camp. Joan remembers numerous other occasions on which her mother ridiculed or humiliated her, calling her lazy when she wouldn't comply with her mother's demands, or telling embarrassing stories about Joan in front of Joan's friends.

In addition to experiencing emotional abuse, Joan reports that her mother showed her little affection. Joan recalls few instances in which her mother hugged her, kissed her, or told her that she loved her (emotional deprivation schema). Joan's mother was preoccupied with her own appearance, but rarely took the time to show her daughter how to use make-up, buy flattering clothes, or make lterself attractive. As a result, Joan always felt awkward about her appearance and often felt like a social misfit. She zoos socially inept, had few friends, was often teased, and attempted to compensate for her feelings of inadequacy by being the smart kid at school. Although Joan has many painful memories from childhood, her most painful recollection is of feeling that her mother never really loved her.

We can conceptualize Joan's case using the multi-factorial model presented in Table 2. Diagnostically she meets DSM-IV criteria for borderline personality disorder and an eating disorder. She has a history of severe emotional maltreatment, including emotional abuse and neglect. She has no other prominent childhood traumas in her history. Her core EMSs in the disconnection/rejection domain were defectiveness /shame, emotional deprivation, abuse /mistrust, and social isolation. She feels worthless, is lonely and emotionally needy, feels that others are trying to mistreat her, and does not fit in anywhere. In addition, she often feels like a failure (failure schema) and as if others are trying to control her (subjugation schema). She uses all three coping mechanisms - schema overcompensation, avoidance, and surrender - but her avoidance and overcompensation have had particularly selfdefeating consequences. As a child, she appears to have had a difficult temperament, and may have met diagnostic criteria for attentiondeficit/hyperactivity disorder. She has a number of personality strengths, including high intelligence, a sense of humor, and the capacity for psychological insight.

These scenarios illustrate the self-defeating manner in which her schémas and coping mechanisms play themselves out:

Sexual scenario A typical sexual scenario is that she is feeling lonely and needy (emotional deprivation and social isolation schémas). To deal with these feelings, she seeks out men for casual sexual relationships (overcompensation coping mechanism). These inevitably end badly, leaving her feeling used and mistreated, which leaves her feeling even more deprived, defective, and mistrustful, reinforcing her schémas.

Work scenario In a typical work scenario, her boss criticizes her, leaving her feeling defective and abused (defectiveness and abuse /mistrust schémas). To cope with these schémas, she overcompensates, belittling and provoking him, or even exploding in anger in a form of defensive counterattack (overcompensation coping mechanism). As a result, her boss becomes enraged with her or takes disciplinary action against her, confirming her core sense of defectiveness and her belief that others can't be trusted.

Eating scenario In a typical eating scenario, Joan spends too much time alone in her apartment, feeling lonely, unlovable, and unlikable (emotional deprivation, defectiveness, and social isolation schémas). She wants to get out and meet people, but she stays home and binge eats (avoidance coping mechanism). This leaves her feeling even more defective and deprived. She feels fat, is ashamed of her bulging, and feels like a social outcast, confirming her schémas.

Schematherapy Techniques in Personality Disorder Patients with Histories of Emotional Maltreatment

Schematherapy is an integrative form of treatment that combines cognitive, psychodynamic, experiential /humanistic, and behavioral techniques.3 Treatment begins with an assessment and case conceptualization phase that can last for several sessions. After the case conceptualization is made, it is shared with the patient, along with the basic concepts of schema therapy. This cognitive framework helps the patient understand his or her problem and helps strengthen the therapeutic alliance in that the therapist and patient share an understanding of the problem and can begin to work together toward mutually agreed upon goals.

In the case of Joan, schema change methods included cognitive restructuring (collaborative empiricism) to counter distorted beliefs regarding unworthiness, deprivation, mistrust, and other schémas; imagery exercises to release emotions and counter faulty inferences regarding experiences of abuse and neglect ("If my mother yelled and screamed at me all the time, it must have been my fault"); and homework assignments to counter avoidance and isolation, and to provide more effective means of self-soothing.

The therapy relationship is considered critically important in the schema therapy model.3 A key concept is limited reparenting, an active directive approach in which the therapist attempts to provide some of the warmth, guidance, and firm yet empathie limit setting that the patient may have lacked as a child. The aim of limited reparenting is to provide corrective emotional experiences within appropriate boundaries. In the case of Joan, as in many other cases of emotional maltreatment, empathy and compassion were crucial to counter feelings of shame and deprivation. The therapist's ability to genuinely like and care about Joan, to connect with her and help her feel understood, and to display acceptance for her and compassion for her suffering were crucial ingrethents in her ability to cultivate those attitudes towards herself. Other important aspects of limited reparenting are the therapist's reliability and consistency, and guidance to support healthy, responsible choices.

Another key ingrethent of the therapy relationship is what Young has called empathie confrontation,3 the therapist's ability to point out the patient's self-defeating or destructive behavior while maintaining an attitude of acceptance toward the patient. By helping the patient view self-defeating behavior in terms of schémas and coping mechanisms, the therapist is able to counter the patient's belief that these behaviors are a manifestation of her "badness." Instead, the patient can come to see them as unsuccessful and habitual ways of coping with painful experiences that the patient learned as a child that have become automatic and self-reinforcing. Thus, the patient was not responsible for the fact that these behaviors were learned in the first place, because the behaviors represent her attempts to cope with adverse experiences at an age when she was relatively powerless and her coping resources were limited. On the other hand, she is responsible for changing these behaviors, with the therapist's guidance and support, because she can now recognize that the patterns are self-defeating, and she has the choice to institute healthier forms of coping.

CONCLUSION

Early maladaptive schémas appear to play a critical role in the formation of personality disorders in people with histories of child emotional maltreatment. Schema-focused cognitive therapy provides a conceptual model and set of techniques that can help patients with histories of maltreatment recover and lead more satisfying lives.

REFERENCES

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TABLE 1

Early Maladaptive Schema and Schema Domains

TABLE 2

Relationship Among Personality Disorders, Early Maladaptlve Schemas, Coping Mechanisms, Childhood Maltreatment, and Temperament

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