The state dependency of cognitive schemas in antisocial patients - Lobbestale & Arntz (2012) - Article

Cognitive and health psychology are emphasizing the importance of separating ‘cold’ rational beliefs from affectively loaded ‘hot’ beliefs. Research showed that insulting participants high in trait aggression caused them to display increased attention for anger-eliciting stimuli, while no such bias was present before provocation. There is not much research on both cold and hot cognitions. Self-report of hot cognitions does not reveal psychopathology possibly because ASPD might be better conceptualized as a reactive pathology and maybe also because of deception or lack of self-insight. In the current study it is hypothesized that low psychopathology levels typically reported by ASPD-patients possibly adequately reflect ASPD-patients cold cognitions, but not their hot cognitions, that is what these patients think and believe under emotionally challenging circumstances. This study assessed the impact of an emotional change on cognitions. Anger has the strongest link to aggression and is therefore chosen out of the emotions. The cognitive outcomes are schema modes.

Schema modes are thematically organized clusters of momentary cognitions presumed to underlie severe personality disorders. At the moment 14 different schema modes have been determined. This study hypothesizes that ASPD patients will have maladaptive schema modes in response to anger-recollection, while the presence of adaptive schema modes will reduce. In this article it is addressed whether ASPD is characterized by high levels of healthy mode reports at baseline, and a reduction of these reports, together with an increase in dysfunctional reports after an anger induction.

Method

Participants

Participants were patients with ASPD, borderline, cluster C personality disorder and non-patient controls without psychopathology.

Screening instruments

Personality psychopathology was assessed with Dutch versions of the Structured Clinical Interview (SCID).

Social desirability

Social desirability was measured with a subscale of the Supernormality Scale-Revised.

Schema modes

Schema modes are the predominant emotional states and coping responses triggered by situations to which people are oversensitive. These were measured with an abbreviated version of the Schema Mode Inventory (SMI).

Anger recollection

Anger induction existed of an interview about an previous upsetting conflict to induce anger. Participants indicated a person who they disliked or had conflicts with. They recalled and verbally described the conflict guided by the interviewer.

Procedure

During the first session the participants completed the SCID. The second session consisted of 3 phases (1) neutral phase, used as baseline (2) anger induction through the interview (3) positive induction phase, watching Mr. Bean video. After the neutral and anger phase the participants completed the short SMI.

Statistical analysis

Differences in baseline schema mode scores between groups were compared by means of ANOVAs. To define which group differed from the mean deviation contrasts were used. Gender was included as an extra factor and only the main effect of gender was evaluated. Social desirability was included as a covariate in all analyses.

Results

Social desirability

ASPD and BPD groups displayed higher levels and NpCs displayed lower levels of social desirability.

Baseline values

There was a main effect of gender on the baseline schema mode level of the Self-Aggrandizer mode and the Detached Self-soother modes. The ASPD group scored lower than average on baseline levels of 5 maladaptive modes and higher than average on the Healthy Adult mode. None of the groups deviated from the overall mean in baseline Self-Aggrandizer and Bully- and attack scores. The BPD-group scored higher on all 12 other maladaptive modes compared to the overall mean and lower on the adaptive modes. NpCs displayed a complete opposite pattern. They scored lower on baseline schema mode scores on all maladaptive modes compared to the overall mean, except Self-Aggrandizer and Bully- and Attack modes and higher on adaptive modes than the overall mean.

Change scores

The ASPD-group displayed a stronger decrease in the in the Impulsive Child and Healthy Adult schema modes after anger induction. The BPD-group showed stronger increase in Angry Child and Detached Self-Soother mode. All observed scores had small effect sizes.

Discussion

The main finding is that high baseline levels of health cognitions in ASPD-patients decreased severely after autobiographical recall of an anger-inducing event. Reviving past anger episodes seems to be a possible break down to the healthy veneer of ASPD-patients. The results suggest that ASPD-patients may have healthy cognitions but that these adaptive cognitions decrease emotional triggers are present. In ASPD-patients also a decrease in impulsive cognitions was found, this might be due to the autobiographical recall method that made the participants more reflective and cognitively focused. This was also found in the non-patient control group. Not in line with the expectation, the autobiographical anger-recall did not cause significant increase in ASPD-patients’ dysfunctional schema mode report. A limitation of the study is that there was no self-report assessment of the predator mode included. Maybe an implicit association task might have been better to assess cognitions of socially unacceptable constructs. ASPD-patients showed strong healthy cognitions under neutral emotional conditions that lowered after autobiographical anger was recalled. As a clinical implication it might be of advantage to increase focus on state dependence of cognitions to enhance effectiveness of CBT.