Twelve sessions for childhood trauma, and the schema modes moved too
- In a secondary analysis of the IREM trial, 114 adults with PTSD related to childhood trauma in the Netherlands and Germany received up to 12 sessions of imagery rescripting (n = 57) or EMDR (n = 57). Neither treatment targets personality.
- From pre-treatment to post-treatment, the 8-week and the 1-year follow-up, maladaptive schema modes fell and adaptive modes rose (Cohen's d = .94–1.18). No change occurred during the waitlist period, and the two therapies did not differ.
- With CAPS-5 PTSD severity added as a covariate, the fall in maladaptive modes was significant only at mid-treatment and post-treatment, and the rise in adaptive modes was not significant at either follow-up: at those points the change was explained by PTSD severity.
- Across mode clusters, 11 of 24 decreases remained significant after the CAPS-5 adjustment; at one year only overcompensating and overcontrolling modes changed independently of PTSD severity.
Clients with PTSD from childhood abuse often arrive with a personality diagnosis attached, and the usual plan treats the two in sequence. A Dutch-German group checked what happens to personality pathology, measured as schema modes, when only the trauma is treated.
Twelve sessions aimed at memories
The data come from the IREM trial, recruited between March 2015 and June 2019 at five Dutch sites and one German site. 114 adults were randomised to imagery rescripting or EMDR, 57 in each arm, with up to 12 sessions of 90 minutes twice a week. Mean age was 38.81, 76.3% were women, and 65.8% had a comorbid mood disorder. Modes were measured with the 143-item Schema Mode Inventory at six points, from the waitlist to one year; PTSD severity with the CAPS-5.
Modes moved with the symptoms
Before treatment, maladaptive modes averaged 3.20 with EMDR and 3.28 with imagery rescripting, close to the clinical reference of 3.00 and well above the non-clinical 2.04. Nothing changed during the wait. After it, maladaptive modes fell and adaptive modes rose, d = .94–1.18, with no difference between the two methods. EMDR reduced avoidant coping modes more up to the 8-week follow-up; by one year that gap had closed.
Once CAPS-5 was controlled for, the drop in maladaptive modes held only at mid-treatment and post-treatment, and the follow-up gains in adaptive modes were explained by PTSD severity. At one year, only overcompensating and overcontrolling modes moved on their own.
Where one diagnosis ends
My reading is that in these clients part of what we chart as personality pathology may be the trauma itself, seen through a personality questionnaire. A clinical-level profile shifted after twelve sessions aimed at childhood memories, and much of the shift tracked PTSD severity. Two diagnoses on the chart can describe one process. In practice I would treat the trauma first and reassess modes afterwards, as the authors recommend, before committing a client to long PD-specific therapy. What remains, in this sample overcompensation and overcontrol, becomes the target for the next stage.
Treating the childhood trauma moved the personality profile, and much of that movement tracked PTSD severity, so the line between the two diagnoses may be thinner than our charts draw it.
The authors note the absence of an inactive control group, although modes did not change during the waitlist period. Schema modes are a self-reported proxy for personality pathology, and patients with strong overcompensating modes may underreport child and parent modes. The mid-treatment CAPS-5 score was estimated by linear interpolation.