Handbook of personality disorders
Chapter 8
Cognitive structures and processes in personality disorders

Introduction

It is assumed that cognitive structures underlie personality disorders (PDs). These have a more pervasive and permanent character. They are assumed to emerge early in development from the interaction between temperament and environmental influences.

Schemas can be defined as generalized knowledge structures that is represented in memory and governs information processing. They consists of verbal and nonverbal knowledge.

Schemas and information processing constitute the basis for our subjective experience.

Three layers of the beliefs that are part of schemas central to PDs are: 1) unconditional beliefs, represent basic assumptions about the self, others, and the world. 2) conditional assumptions, beliefs about conditional relationships 3) instrumental beliefs, beliefs about how to act to avoid bad things and acquire good things

Patients with PD report elevated levels of specific maladaptive beliefs.

Early maladaptive schemas (EMSs) are thought to arise form experiences during early childhood when basic needs are not met. They are not considered to be related to specific DSM-5 PDs.

Coping styles reflect the way individuals deal with activation of a schemas. Early maladaptive schema-related copings styles are thought to be built on primitive responses that animals exhibit under high levels of threat. Coping responses are grouped into three clusters: 1) overcompensation, fight. The person behaves and thinks in a way that is the opposite of the triggered schema. 2) avoidance, flight. Prevent triggering of the schema, or avoiding the emotions and thoughts that are aroused. 3) surrender, freeze, submitting to what the schema dictates.

Schema mode is the emotional-cognitive-behavioural state of the person. Some schema modes show a specific relationship to certain PDs. A schema mode is a combination of an activated specific EMS and a specific coping style. Sudden switches in schema modes are ‘mode switches’.

In schema therapy, therapist and patient make an idiosyncratic case conceptualization that explains the problems with which the patient is struggling and link these, through these models, to the early experiences that lie at their root. Through the session, the therapist tries to detect what mode is activated, and next chooses among a specific set of techniques developed to deal with that mode.

Origins and content of schemas

Schemas that are central to PDs are assumed to develop during childhood from the interaction of biological and environmental influences. Children differ in their innate sensitivity to environmental influences and in how they response to stressors. These responses are likely to evoke responses in the environment that foster adaptation to the stressor or exacerbate the problem.

The environmental influences on the development of PDs are broad and include: maltreatment, emotional and physical neglect, parenting practices and lack of parental supervision.

During development, schematic representations of the world and other people, the self, and the meaning of needs and emotions, about strategies to avoid negative and attain positive experiences are formed. These schemas influence the relationships of the child and emotional experiences and how they are processed. Important aspects of schemas related to PDs include: 1) how the self is experienced, 2) how others are viewed 3) how the person thinks that others view him 4) how emotional needs are understood.

Schema activation

Specific stimuli are needed to trigger a schema that then influences information processing and coping.

Schemas in PDs are relatively inflexible and remain activated even if they lead to problems. It is often the lack of alternative, functional schemas and/or the overwhelming strength of the activated schema that leads to problems.

Dysfunctional cognitive biases play a role in causing and maintaining the disorder. They create the subjective reality for the individual that underlies the dysfunctional patterns.

Cognitive biases

The different phases of information processes and the biases influencing each phase are: 1) people have to select information that is important. These attentional processes can be biased. Priority is given to specific stimuli even what this isn’t functional. 2) Meaning is given to the information. Automatic associations may play a role 3) An evaluation is made, this can be influenced by evaluative biases 4) a coping response if chosen, influenced by preferred coping styles 5) the information is encoded in autobiographical memory. Encoding bias plays are role. 6) Memories are retrieved, retrieval bias for specific memories or aspects of memories.

Attentional bias

Attentional bias is the process in which attentional resources are allocated to specific classes of stimuli consistent with existing schemas at the expense of other stimuli.

Interpretational bias

Interpretational biases are manifested when information is systematically interpreted in a way that differs from what is usual in a specific culture. Preexisting schemas attach meaning to what is perceived.

Interpretations might be related to implicit and explicit associations that people make when confronted with specific stimuli. Implicit processes result from automatic processes and may reflect otherwise unobservable schemas.

Cognitive schemas rule interpretational processes even when the participant cannot explicitly assess the content or deny the content for strategic reasons.

Evaluation biases

There are several evaluation styles

Response styles

When confronted with stressful events that activate relevant schemas, people may respond in specific ways that reflect their habitual coping.

Memory bias

Biased memory encoding and retrieval is related to schemas relevant for PDs.

Causal status of cognitive processes

Attentional and interpretational biases are causal with regard to responses to  stressful events. Directly reducing attentional or interpretational biases reduced psychopathology.