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REVIEW

CURRENT
OPINION Schema therapy conceptualization of personality
functioning and traits in ICD-11 and DSM-5
Bo Bach a and David P. Bernstein b

Purpose of review
Schema therapy conceptualizes personality disorders in terms of modes and underlying schemas. This
article reviews the literature on schema therapy conceptualization of personality disorder functioning and
traits, and proposes how these findings apply to novel personality disorder classification in ICD-11 and the
DSM-5 Alternative Model of Personality Disorders (AMPD).
Recent findings
Maladaptive schemas and modes are generally associated with personality dysfunction and traits in
conceptually coherent ways. The healthy adult mode, a transdiagnostic core concept in schema therapy,
corresponds to the ICD-11 and DSM-5-AMPD features of core personality functioning. Modes and
underlying schemas substantially overlap with specific ICD-11 and DSM-5-AMPD traits, which denote
individual themes and styles of personality dysfunction.
Summary
The dimensional personality disorder framework in ICD-11 and DSM-5-AMPD is largely compatible with the
schema therapy model. The ICD-11 and DSM-5-AMPD provide a scientifically derived and theory-free
framework for all practitioners, which may be connected to clinical theory of schema therapy in a coherent
manner. Level of personality functioning can be conceptualized as healthy adult functioning (e.g. sense of
identity, self-worth, emotion regulation, intimacy, and fulfillment), which inform intensity of treatment. Trait
qualifiers can be conceptualized by associated modes and underlying schemas (e.g. subjugation,
entitlement, or unrelenting standards), which inform focus and style of treatment.
Keywords
DSM-5, ICD-11, personality functioning, personality traits, schema therapy

INTRODUCTION The goal of the present article is to review the

The DSM-5 Alternative Model of Personality Disor-
ders (DSM-5-AMPD) in Section III and the nearly
identical ICD-11 Classification of Personality Disor-
ders (which must be used for coding purposes by all
WHO member countries) provide a scientifically
derived approach to diagnosing personality disor-
ders, which should address the scientific and
clinical shortcomings of the established personality
&
disorder categories in DSM-IV/5 and ICD-10 [1 ,2].
However, the ICD-11 and DSM-5-AMPD frameworks
are theory-free without explicit causal mechanisms
or treatment implications. Therefore, it seems impor-
tant to understand how the ICD-11 and DSM-5
frameworks align with concepts in evidence-based
treatment models in order to tailor treatment to these
new classification systems. As one of the most
recently developed approaches, schema therapy pro-
vides a theoretically integrative framework of person-
ality disorder psychopathology aimed at guiding
conceptualization and treatment [3].
most important and recent research on associations
of schema therapy core concepts (i.e. schemas and
modes) with aspects of personality disorder func-
tioning and traits. On this empirical ground, we aim
to propose how the Schema therapy model may be
used to conceptualize the ICD-11 and DSM-5-AMPD
classifications of personality disorders. We suggest
that this may add clinical theory to the new
a
Center of Excellence on Personality Disorder, Psychiatric Research Unit,
Slagelse Psychiatric Hospital, Region Zealand, Denmark and bExpertise
Center for Forensic Psychiatry, De Rooyse Wissel Forensic Psychiatric
Center, Forensic Psychology Section, Department of Clinical Psycho-
logical Science, Maastrict University, The Netherlands
Correspondence to Bo Bach, PhD, Center of Excellence on Personality
Disorder, Psychiatric Research Unit, Slagelse Psychiatric Hospital,
Region Zealand, Fælledvej 6, Bygning 3, 4. Sal., Slagelse, Denmark.
Tel: +45 30 29 33 81; e-mail: bobachsayad@gmail.com
Curr Opin Psychiatry 2018, 32:000–000
DOI:10.1097/YCO.0000000000000464

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Personality disorders
KEY POINTS
 The novel approaches to personality disorders in ICD-
11 and DSM-5-AMPD, including global level of
personality functioning and specific stylistic traits, align
with schema therapy concepts of healthy adult
functioning and specific schemas/modes, respectively.
 Level of personality functioning in ICD-11 and DSM-5-
AMPD may be used to denote healthy adult functioning
(e.g. capacity for coherent identity, self-worth, emotion
regulation, intimacy, and fulfillment).
 Classification of personality disorder severity (e.g. mild,
moderate, severe) may help schema therapists consider
intensity and style of treatment according to level of
healthy adult capacities (e.g. how to apply ‘limited
reparenting’).
 Specification of trait qualifiers (e.g. submissiveness,
grandiosity, or rigid perfectionism) may be used to
inform focus of treatment including targeting associated
modes (e.g. compliant surrenderer, self-aggrandizer, or
perfectionistic overcontroller) and underlying schemas
(e.g., subjugation, entitlement, or unrelenting
standards).
 Since the ICD-11 and DSM-5-AMPD models provide
information related to capacity for mentalization
(i.e. internal emotional experience and understanding
others’ perspective), the schema therapy framework
may benefit from emphasizing such features in the
conceptualization of personality disorders.
diagnostic classifications and advance future
research on cause and treatment.
PERSONALITY DISORDER
CLASSIFICATION IN ICD-11 AND
DSM-5 ALTERNATIVE MODEL OF
PERSONALITY DISORDERS
The ICD-11 includes a classification of personality
disorders according to severity of personality dys-
function (i.e. mild, moderate, severe), which also
allows the option of specifying one or more trait
qualifiers (i.e. negative affectivity, disinhibition,
detachment, dissociality, and anankastia; to facili-
tate clinical utility and continuity, the user of ICD-
11 is also allowed to specify a borderline pattern
qualifier corresponding to the familiar diagnosis of
borderline personality disorder). Essentially, this
classification relies on impairment of core personal-
ity functioning including the degree and pervasive-
ness of disturbances in self-functioning (i.e.
identity, accuracy of self-view, self-worth, self-direc-
tion), interpersonal functioning (e.g. parent–child,
romantic relationships, school/work, family, friend-
ships, peer contexts), emotional, cognitive, and
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behavioural manifestations (e.g. emotion regula-
tion, impulse control, distortions in situational
appraisals, and paranoid ideas or dissociation),
and associated distress or functional impairment
(e.g. personal, educational, occupational, and fam-
&&
ily areas of functioning) [4 ,5]. The AMPD, in DSM-
5 Section III, includes a nearly identical approach to
personality disorders, involving assessment of level
of personality functioning (Criterion A) and descrip-
tion of 25 trait facets organized in five domains of
Negative Affectivity, Detachment, Antagonism, Dis-
inhibition, and Psychoticism (Criterion B). The
DSM-5-AMPD is not in Section III’s ‘Conditions
for Further Study’ chapter. Therefore, practitioners
can regard it as a true ‘alternative’ to the standard
approach in Section II and can use it for patient
assessment and diagnosis. For this reason, the DSM-
5-AMPD is prominently featured in recent clinician-
oriented textbooks and handbooks [6–8], and struc-
tured interviews and patient-report measures have
&
been developed to assist practitioners [9,10 ,11].
As presented in Table 1, the severity of global
personality impairment is measured dimensionally
and a certain level of impairment is a diagnostic
requirement for a personality disorder diagnosis,
whereas trait qualifiers contribute to the specific
expression of personality dysfunction. The function-
ing/severity component is particularly based on the
psychodynamic tradition of personality organization
&
[10 ,12] as well as the empirical identification of
&&
a general personality disorder factor [13 ,14], whereas
the trait component constitutes a pathological variant
of the empirically derived Five-Factor Model (FFM)
(Negative Affectivity corresponds to Neuroticism,
Detachment corresponds to low Extraversion, Disso-
ciality/Antagonism corresponds to low Agreableness,
Disinhibition corresponds to low Conscientiousness,
and Anankastia corresponds to high Conscientious-
& & & &&
ness) [15 ,16 ,17,18 ,19 ]. To date, this approach has
been supported by a large body of empirical evidence
&& &
[see reviews [19 ,20,21 ]]. Table 1 presents the overall
aspects of the ICD-11 and DSM-5-AMPD models,
whereas specific features of personality functioning
and traits are elaborated in the respective diagnostic
guidelines.
SCHEMA THERAPY MODEL OF
PERSONALITY DISORDERS
The schema therapy model of personality disorders is
essentially based on a taxonomy of schemas (inner
models of self and others) and modes (activated sche-
mas and coping responses; ‘self-states’), which are
derived from clinical observations and theory, and
subsequently empirically supported [22]. See Tables 2
and 3 for a detailed overview of schemas and modes.
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Schema therapy conceptualization Bach and Bernstein

Table 1. ICD-11 and DSM-5 Alternative Model of Personality Disorders classifications of personality disorders

Diagnosis ICD-11 severity of personality dysfunction DSM-5 AMPD Criterion A: level of personality functioning

No disorder None 0: No impairment (healthy functioning)

Personality difficulty 1: Some impairment
Disorder Mild personality disorder 2: Moderate impairment
Moderate personality disorder 3: Severe impairment
Severe personality disorder 4: Extreme impairment

Higher Order ICD-11 trait domain qualifiers DSM-5 AMPD Criterion B: trait domains

Internalizing Negative Affectivity Negative Affectivity

Detachment Detachment
Anankastia (Rigid Perfectionism and Perseveration)a
Externalizating Dissociality Antagonism
Disinhibition Disinhibition
Borderline patternb Psychoticismc

AMPD, Alternative Model of Personality Disorders.

a
These are facets from the domains of (low) Disinhibition and (high) Negative Affectivity, respectively.
b
This additional pattern is not a trait domain, but was included for the purpose of continuity with clinical practice.
c
These domain features are only included in the DSM-5 model consistent with the DSM tradition of considering schizotypal disorder as a personality disorder
feature.

Table 2. Definitions of schemas and their organization into higher order domains
Disconnection and Rejection domain
Emotional deprivation Other people are not going to meet my emotional needs
Social isolation/alienation I am different from other people and not a part of a group
Emotional inhibition Inhibition in expression of emotions and spontaneity
Defectiveness/shame I am worthless because of feelings of being bad, inferior, or invalid
Mistrust/abused Other people will harm, abuse or take advantage of me
Pessimism/negativity I expect that everything will turn out badly
Impaired Autonomy and Performance domain
Dependence/incompetence I am unable to handle daily tasks without help from others
Failure to achieve I am a failure in school/career and will eventually fail in life
Subjugation I must comply with others in order to avoid feared consequences
Abandonment/instability Significant others will be lost or leave me emotionally or physically
Enmeshment I must constantly be involved with or have support from close others
Vulnerability to harm Bad things will happen and I cannot prevent it or cope with it
Excessive Responsibility and Standards domain
Self-sacrifice I prefer taking care of others instead of myself
Unrelenting standards I must always follow a certain standard of productivity, performance, or behaviour
Self-punitiveness I expect and deserve negative consequences for my imperfection
Impaired Limits domain
Entitlement I am entitled to special rights, I am superior
Approval/admiration-seeking My worth/significance depends on positive attention from others
Insufficient self-control Delayed gratification and perseverance is hard for me

Schemas are described from condensing item-content from the Young Schema Questionnaire 3 – Short Form (YSQ-S3). Domain organization is defined according
to recent revision and research [23,24].

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Personality disorders

Table 3. Definition of modes

Child modes
Vulnerable child (abused, abandoned, Frequently feeling sad, afraid, or worthless representing the distressing negative emotions a
humiliated, dependent) person experiences when schemas are triggered. As the core of schema therapy, this
mode is what the therapist wants to get to, which usually is complicated by the remaining
modes.
Lonely child Feeling loneliness and emptiness; the feeling that no one can understand, soothe, comfort,
or make real contact with the person.
Angry child Frequently feeling anger because of frustration of needs representing the underlying
vulnerability seen in the vulnerable child, but externalized so that individuals in this mode
may act demanding and hostile.
Enraged child A more externalized form of angry child involving more extreme emotions of rage often
resulting in destroying objects as well as hurting or even killing another person.
Impulsive child Attempts to have a need fulfilled but done in an almost childlike impulsive and immediate
manner without considering consequences.
Undisciplined child Not being capable of completing routine or boring tasks; gets easily frustrated and gives
up.
Maladaptive parent modes
Punitive parent/critical parent Shame and self-disgust considered as internalized childhood experiences of criticism or
punishment; closely related to vulnerable child.
Demanding parent Perfectionism and pursuit of high standards considered as internalized experiences of too
high demands; closely related to vulnerable child.
Avoidant and surrender coping modes
Compliant surrender Often being complicit with authority figures in an automated manner, which is triggered in
any situation of power imbalance.
Detached protector Withdraws from others and disconnects emotions; often associated with depersonalization,
feelings of emptiness, and use of cannabis or heroin; avoids distress associated with
schema-activation.
Avoidant protector Interpersonal and situational avoidance.
Angry protector Involves keeping others, who are perceived as threatening or dangerous, at a distance by
using a ‘wall of anger.’ Unlike the angry and enraged child mode, this anger is quite
controllable and serves a goal of ‘protecting’ the self from others.
Detached self-soother/self-stimulator Disconnects emotions by means of high level of soothing, distracting or stimulation; often
associated with workaholism, binging, promiscuity, and use of cocaine or amphetamine;
avoidance of distress associated with schemas
Overcompensatory coping modes
Self-aggrandizer Behaving selfish, entitled, or root; over-compensating for distress associated with schema-
activation.
Bully and attack Strategically dominating, bullying, or hurting others; over-compensating for distress
associated with schema-activation.
Conning and manipulative Lies to, manipulates with, or cons others to achieve specific goals, such as victimizing
others, gaining power, or escaping punishment.
Predator Using ruthless, cold, and calculating behaviours to eliminate real or potential obstacles or
threats.
Perfectionistic overcontroller Exercising extreme control and order, repetition, or rituals to divert attention from or protect
one self from real or perceived threats.
Attention-seeker Seeks other people’s attention and approval by extravagant, exaggerated, and
inappropriate behaviour. Usually compensates for underlying loneliness.
Suspicious overcontroller Seeks to protect the self from real or perceived threat through overcontrol while concerned
with locating or uncovering hidden, real, or perceived treat.

Adapted from Bernstein and Clercx [3] and Bamelis et al. [32].

Schemas are trait-like dysfunctional inner mod-
els of self and others developed from an interaction
between innate temperament and childhood experi-
ences. As presented in Table 2, the current schema
therapy-model includes 18 schemas, which are best
organized into four domains that are consistent with
empirical evidence and theory [23,24]: Disconnec-
tion and Rejection, Impaired Autonomy and Perfor-
mance, Excessive Responsibility and Standards, and
Impaired Limits. Each domain reflects a theme of

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unfulfilled needs that may have contributed to the
development of the subordinate schemas.
Modes constitute state-like and fluctuating fea-
tures of personality disorders reflecting a configura-
tion of activated schemas, associated affect, and
coping responses. The mode concept was introduced
into schema therapy because the trait-like schemas
were inadequate for working with severe/complex
personality disorder patients who exhibit frequent
shifts of state-like modes related to a poorly inte-
grated personality [3,25]. Thus, modes are regarded
as dynamic and moment-to-moment self-states of
personality problems, which can be even of dissocia-
tive proportions (e.g. Detached Protector) [3].
Research supports the validity of both schemas
& & & &
[23,26 ,27,28 ,29 ,30 ] and modes [31–33,34 ,35 ,
&&
&
36–39,40 ] including their ability to differentiate
personality disorders from non-personality disorders
& &
[33,41 ,42 ,43]. Like other measures of personality
problems, schemas are associated with various kinds
& &
of psychopathology including depression [44 ,45 ],
& &
OCD [46 ], ADHD [47 ], and psychotic symptoms
& &&
[48 ,49 ]. Moreover, a number of studies indicate
that schemas account for the association between
childhood adversity and current psychopathology,
& &&
including personality disorder [48 ,50,51–58,59 ,
60,61], and that the link between schemas and psy-
chopathology is further mediated by dysfunctional
&
modes [62 ]. For a complete description of the roles of
schemas and modes in schema therapy treatment of
personality disorders, we refer to contemporary lit-
&
erature on this topic [3,63 ].
CLINICAL SIGNIFICANCE OF
CONCEPTUALIZING HEALTHY ADULT
FUNCTIONING IN SCHEMA THERAPY
Most healthy people have the capacity to reflect on
and modulate their emotional responses. By con-
trast, people with personality disorders seem to lack
some of this capacity, especially when they are
schematically triggered. In schema therapy terms,
they lack a Healthy Adult mode that can integrate
their various emotional states (i.e. modes) and keep
them from going to extremes [3]. As exemplified in
Table 4, this Healthy Adult part of the patient is able
to see the patient’s needs, detect and regulate emo-
tions and impulses, understand reality, maintain a
coherent and positive self-concept, and be self-
directed. A central goal of schema therapy is to assess
and empower the Healthy Adult mode so that it may
take care of the needs experienced by the vulnerable
part of the self [64].
Notably, when the Healthy Adult mode is unde-
veloped, compromised, or impaired, there is weak
‘‘control’’ over the remaining modes, including
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Schema therapy conceptualization Bach and Bernstein
activated schemas, which typically result in emo-
tional turmoil and harmful coping. Therefore, dom-
inance of various dysfunctional modes (e.g. Enraged
Child, Self-Aggrandizer) and underlying schemas
(e.g. domain of Disconnection and Rejection) usu-
ally indicates a weakly established Healthy Adult
mode [3]. Finally, experimental research shows that
the Healthy Adult mode is less fluctuating (i.e. more
stable) than all other modes during therapy seg-
&&
ments [65 ], which might underscore its ever-
present nature.
HEALTHY ADULT MODE AS
TRANSDIAGNOSTIC FEATURE OF
&
PERSONALITY FUNCTIONING
Recent research supports that the Healthy Adult
mode is not so much a disorder-specific mode,
but rather a transdiagnostic mode that reflects the
core of healthy functioning, including the ability to
regulate own emotions and impulses, and to ensure
& &
own fulfillment in life [10 ,66 ]. Accordingly, the
Healthy Adult mode is substantially associated with
quality of life [38] and global psychopathology [36],
which may reflect aspects of fulfillment and general
distress. Moreover, psychotherapy research has
shown that the level of Healthy Adult mode
increases during and after effective treatment of
mixed personality disorders (including at follow-
up) [67], which may underscore that the Healthy
Adult functioning is what psychotherapists should
aim to boost in all types of patients.
Despite the anticipated transdiagnostic features,
research also suggests that Healthy Adult function-
ing is most compromised in borderline personality
disorder patients compared with non-borderline
&
personality disorder patients [33,42 ,68–70]. More-
over, research supports that personality disorder
patients generally have lower levels of Healthy Adult
functioning in comparison with matched patients
&
without personality disorder [39,42 ]. According to
Kernberg’s traditional conceptualization of border-
line-level and neurotic-level organization, these
general findings suggest that the level of Healthy
Adult functioning somewhat denotes level of per-
sonality disorder severity or impairment [71]. In
support of this way of framing it, empirical research
also suggests that Borderline personality disorder is
best conceptualized as a personality disorder sever-
ity index rather than a distinct homogenous per-
sonality disorder type [14]. Moreover, borderline
personality disorder patients with parasuicidal
behavior have been found to show lower levels of
Healthy Adult functioning than borderline person-
ality disorder patients without parasuicidal behavior
[72]. This may indicate that the Healthy Adult mode
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Personality disorders

Table 4. Tentative correspondence of healthy adult mode with ICD-11 and DSM-5- Alternative Model of Personality Disorder
personality functioning
Healthy Adult Mode ICD-11 personality functioning DSM-5 personality functioning

Sense of coherent self Having a good sense of who
and identity one is, and what is needed to
make one happy (Item 118).
Stability of self-worth Capacity for having a positive
self-concept (Item 114).
Capacity for emotion Ability to solve own problems
regulation without being overwhelmed
by emotions (Item 28); ability
to express emotions
appropriately (Item 58);
nurtures, validates and affirms
the vulnerable child mode (i.e.
the part of the person
experiencing hurtful emotions
and unfulfilled needs).
Ability to set and Persevering in and taking
pursue goals responsibility for solving own
problems (Item 20); capable
of taking care of self (Item
76); ability to learn, grow,
and change (Item 81);
enduring demanding or
boring tasks in order to
accomplish valued things (Item
115); performs appropriate
adult functions such as
working, parenting, taking
responsibility, and committing;
intellectual, esthetic, and
cultural interests; health
maintenance and athletic
activities.
Prosocial internal Expressing own needs without
standards going overboard (Item 69);
sets limits for the angry and
impulsive child modes.
Capacity for intimacy Ability to stand up for one self
and mutuality when feeling unfairly
criticized, abused, or taken
advantage of (Item 111);
pursues pleasurable adult
activities such as sex.
Stability and coherence of one’s
sense of identity.
Ability to maintain an overall
positive and stable sense of
self-worth; accuracy of one’s
view of one’s characteristics,
strengths, limitations.
Ability to experience a range of
appropriate emotional
experiences and expressions,
without being emotionally
overreactive or underreactive.
Capacity for self-direction (ability
to plan, choose, and
implement appropriate goals);
ability to set appropriate goals
and to work towards them;
exhibits genuine interest in or
efforts toward sustained
employment.
Appropriateness of behavioural
responses to intense emotions
and stressful circumstances;
flexibility in controlling
impulses and modulating
behaviour based on the
situation and consideration of
the consequences.
Ability to develop and maintain
close and mutually satisfying
relationships; ability to
manage conflict in
relationships without just
giving into others at the cost
to oneself.
Experience of oneself as unique, with
clear boundaries between self and
others.
Stability of self-esteem and accuracy
of self-appraisal.
Capacity for, and ability to regulate, a
range of emotional experience.
Pursuit of coherent and meaningful
short-term and life goals based on
realistic assessment of own
capacities; capacity for attaining
fulfillment and authenticity.
Utilization of constructive and
prosocial internal standards of
behavior while attaining own
fulfillment in multiple realms.
Mutuality of regard reflected in
interpersonal behavior (e.g. social/
interpersonal behavior is reciprocal
and seeks fulfillment of basic needs
or escape from pain); desires and
engages in a number of caring,
close, and reciprocal relationships.

Healthy Adult Mode is defined by item content from the Healthy Adult Mode scale (indicated with specific item numbers) and supplemented with the original
definition of the Healthy Adult Mode by Young and First [64], whereas DSM-5 and ICD-11 definitions of personality functioning are adapted from designated and
abbreviated features from the two diagnostic models [5,12].

denotes important aspects of functioning in terms harm to self or others into account when classifying
of capacity for healthy emotion regulation. Notably, global personality disorder severity [5].
the ICD-11 diagnostic guidelines for personality In addition to the Healthy Adult mode, other
disorders explicitly takes frequency and severity of specific modes have also been found to capture

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aspects of personality functioning, which applies to
nonsuicidal self-injury (e.g. Punitive Parent) [73]
and dissociation (e.g. Detached Protector)
&&
[74 ,75]. This may indicate impaired capacities
for emotion regulation and appropriate situational
appraisals, respectively. As previously mentioned,
the dominance of such dysfunctional modes usually
reflects a weakly developed Healthy Adult mode.
Table 4 proposes a tentative cross-walk between
Healthy Adult functions and capacities of ICD-11
and DSM-5-AMPD personality functioning.
DISCONNECTION AND REJECTION
SCHEMAS ARE RELATED TO
PERSONALITY FUNCTIONING
Recent research shows that impaired personality
functioning, as defined in the ICD-11 and DSM-5-
AMPD, is predominantly associated with the schema
& &
domain of Disconnection and Rejection [10 ,66 ].
This is consistent with a systematic review highlight-
ing that schemas of Disconnection and Rejection are
most prevalent in borderline personality disorder
[76], a disorder characterized by considerably
impaired personality functioning [71]. This is par-
tially supported by a recent study, which identified
schemas of Disconnection and Rejection (i.e. Mis-
trust/Abuse and Defectiveness/Shame) to uniquely
differentiate borderline personality disorder from
&
other personality disorders [42 ]. Likewise, another
recent study among borderline personality disorder
patients found Disconnection and Rejection to pre-
dict suicidal ideation, physical/overt aggressiveness,
psychotic-like symptoms, comorbidity with eating
&&
disorder, and posttraumatic stress disorder [77 ].
These findings may support the proposition that
the activation of Disconnection and Rejection sche-
mas (e.g. Defectiveness and Mistrust/Abused) com-
promises the patient’s ability to function as a Healthy
Adult, which is typically seen in borderline personal-
ity disorder patients in terms of impaired personality
functioning and -integration [3].
SCHEMAS AND MODES IN RELATION TO
SPECIFIC PERSONALITY TRAITS
Several studies suggest that the majority of schemas
are substantially associated with trait features of Neg-
&&
ative Affectivity or Neuroticism [34 ,78–83], which
naturally reflects the vulnerability and emotional
distress related to most schemas. However, specific
associations with other traits have also been identi-
fied. For example, research among psychiatric out-
patients [82] found Neuroticism to be predominantly
related to schemas of Defectiveness, Subjugation,
Dependence, and Subjugation; Extraversion was
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Schema therapy conceptualization Bach and Bernstein
negatively related to schemas of Emotional inhibi-
tion, Social isolation, and Failure; Agreeableness was
positively related to Self-sacrifice and negatively
related to Entitlement, Insufficient self-control,
and Mistrust; Conscientiousness was positively
related to Unrelenting standards and Self-sacrifice,
and negatively related to Insufficient self-control.
Recently, a team of researchers and schema
therapists developed a model of adaptive schemas
&&
[84 ], which describes the positive counterpart of a
schema, corresponding to the adaptive features that
naturally emerge when emotional needs are fulfilled
during upbringing. Accordingly, Neuroticism is
negatively associated with positive schemas of
Stable Attachments and Basic Health/Optimism;
Aggreableness is associated with Social Belonging
and Empathic Consideration; Conscientiousness is
associated with Healthy Self-Control/Discipline,
Healthy Self-Reliance/Competence, Self-Directed-
ness, and Success; Extraversion is associated with
schemas of Social Belonging and Emotional Open-
ness and Spontaneity.
&&
In a recent study [34 ], modes were empirically
organized into three higher order domains that were
related to FFM traits. A domain of internalization
(e.g. Abandoned Child and Avoidant Protector) was
primarily related to Neuroticism and low Extraver-
sion. A domain of externalization (e.g. Impulsive
Child and Bully and Attack) was primarily related to
low Agreeableness, low Conscientiousness, and
Extraversion. Finally, a domain of Compulsivity
(e.g. Perfectionistic Overcontroller and Demanding
Parent) was primarily related to Conscientiousness
and Neuroticism. Notably, this three-factor struc-
ture of modes not only aligns with higher order ICD-
& &
11 and DSM-5-AMPD traits [16 ,18 ], but also with
the novel Hierarchical Taxonomy of Psychopathol-
&& &
ogy (HiTOP) framework [34 ,85 ].
Essentially, the aforementioned pattern of align-
ment with conventional FFM traits have also been
supported when using a pathological variant of the
FMM model (i.e. DSM-5-AMPD traits), which delin-
eates the trait qualifiers included in the ICD-11 and
DSM-5-AMPD classification [83]. The most substan-
tial associations identified in this study are pre-
sented in Tables 5 and 6. In support of the
considerable overlap, the DSM-5-AMPD traits
account for 89.4% of the variance in schema therapy
concepts [83].
SCHEMA THERAPY CONCEPTUALIZATION
OF ICD-11 AND DSM-5 ALTERNATIVE
MODEL OF PERSONALITY DISORDERS
The transdiagnostic quality of Healthy Adult func-
tioning (e.g. self-direction and ability to stand up for
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Personality disorders

Table 5. Correspondence of ICD-11 and DSM-5 Alternative Model of Personality Disorders trait domains with schemas and
modes
Trait domains Underlying schema Manifest mode

Negative affectivity (e.g. facets of Defectiveness Vulnerable child (abandoned or lonely child)
emotional lability, anxiousness, Vulnerable to harm Angry child
depressivity, suspiciousness, Dependence Punitive parent
separation insecurity) Subjugation Compliant surrender
Self-punitiveness Suspicious overcontroller
Abandonment
Pessimism
Self-punitiveness
Mistrust/abuse
Enmeshment
Detachment (e.g. facets of Emotional inhibition Detached protector
withdrawal, intimacy avoidance, Mistrust/abused Vulnerable child (abused or humiliated child)
restricted affectivity, anhedonia) Social isolation/alienation Avoidant protector
Anankastia (e.g. facets of rigid Unrelenting standards Demanding parent
perfectionism and perseveration) Emotional inhibition Perfectionistic overcontroller
Angry child
Antagonism/dissociality (e.g. facets Entitlement Bully and attack
of callousness, attention-seeking, Admiration-seeking Self-aggrandizer
grandiosity, hostility, Angry child
manipulativeness, deceitfulness) Angry protector
Predator
Conning and manipulative
Disinhibition (e.g. facets of Insufficient self-control Impulsive child
impulsivity, risktaking, Undisciplined child
distractibility, irresponsibility)

The patterns of association have been empirically supported [83], except for the modes marked with an asterisk, which represent hypothesized associations that
have not yet been empirically tested.

oneself in relation to others) seems consistent with
established research identifying a general personality
disorder factor of severity/functioning, separable
from specific personality disorder factors of styles/
traits [14,86,87]. Such a general factor is most predic-
tive of psychosocial impairment, long-term progno-
sis, and clinical outcome [88,89]. Thus, whereas the
Healthy Adult mode resembles the general severity
factor of personality disturbance (i.e. functioning),
the specific modes and schemas are comparable with
different personality disorder factors (i.e. traits).
For more than two decades ago, before the official
plans of turning ICD and DSM into dimensional
classification systems, Young and Gluhoski [90] pro-
posed a so-called schema-focused diagnosis for per-
sonality disorders, which involved dimensional
assessment of a global functioning factor followed
by a separate portrayal of specific schemas. Likewise,
the most recently updated schema therapy case
conceptualization form (version 2.22) instructs the
clinician to rate the patient’s functioning in different
life areas (e.g. intimate and long-term relationships;
occupational roles; solitary functioning and alone-
ness). Subsequently, the therapist is requested to list
the most prominent schemas, modes, and triggering
situations [91]. This two-component procedure is not
very different from the diagnostic procedure in the
ICD-11 and DSM-5-AMPD classification of personal-
ity disorders, in which the overall functioning/sever-
ity is rated first, followed by specification of
prominent trait dimensions. In line with this, it
has specifically been proposed that the DSM-5-AMPD
dimensions will improve future schema therapy
research by providing more reliable and valid targets
for intervention, rather than targeting empirically
questionable personality disorder categories that
combine a mixture of traits (e.g. anxiousness) and
symptom-level functioning (e.g. self-harm) that do
&&
not go together, empirically speaking [7,92,93 ].
As proposed in Table 4, the conceptual content of
the Healthy Adult mode is highly comparable with the
transdiagnostic measure of core personality function-
ing as operationalized in the ICD-11 and DSM-5-
AMPD classifications of personality disorders. As evi-
dent from the correspondence between the Healthy
Adult mode features and the severity of personality
dysfunction (i.e. impaired personality capacities), the
ICD-11 and DSM-5-AMPD classification of personality
disorder severity may be carried out by practitioners
with Healthy Adult functioning in mind, and vice
versa. Likewise, as evident from the conceptual corre-
spondence between schemas/modes and maladaptive

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Schema therapy conceptualization Bach and Bernstein

Table 6. Correspondence of designated DSM-5- Alternative Model of Personality Disorders trait facets with schemas and
modes
Trait facets Underlying schema Manifest mode

Separation insecurity Abandonment Vulnerable child (lonely/abandoned child)

Submissiveness Subjugation Compliant surrender
Vulnerable child (dependent child)
Depressivity Pessimism Vulnerable child
Self-punitiveness Punitive parent
Defectiveness/shame
Anxiousness Vulnerable to harm Avoidant protector
Vulnerable child
Suspiciousness Mistrust/abused Suspicious overcontroller
Vulnerable child (abused or humiliated child)
Withdrawal Social isolation Detached protector
Restricted affectivity Emotional inhibition
Rigid perfectionism Unrelenting Standards Perfectionistic over-controller
Demanding parent
Grandiosity Entitlement/Grandiosity Self-aggrandizer
Attention seeking Admiration-Seeking Attention/approval seeker
Deceitfulness - Conning and manipulative
Manipulativeness -
Hostility - Angry protector
Angry child
Bully and attack
Callousness - predator
Bully and attack
Impulsivity - Impulsive child
Distractibility Insufficient self-control -

The patterns of association have been empirically supported [83], except for the modes marked with an asterisk, which represent hypothesized associations that
have not yet been empirically tested.

traits, shown in Tables 5 and 6, it appears straight
forward to use ICD-11 and DSM-5-AMPD traits as
treatment targets reflecting associated modes and
underlying schemas. For example, the trait facet of
Separation Insecurity may be ‘treated’ in terms of an
underlying Abandonment schema.
Finally, in regards to treatment planning,
classification of personality disorder severity/
impairment may help schema therapists choose
intensity of treatment according to Healthy Adult
&&
capacities [93 ,94], whereas specification of trait
qualifiers may inform focus of treatment in terms
of associated modes and schemas [7,83]. Further-
more, the schema domain of Disconnection and
Rejection may also be employed as an index of
impaired personality and Healthy Adult functioning
based on its well established association with bor-
derline personality disorder.
sufficiently covered by schema therapy concepts. For
example, both ICD-11 and DSM-5-AMPD provide
information related to capacity for mentalization
(mentalization is the ability to make sense of self
and others in terms of mental processes and subjec-
tive states [95]), empathy, or reflective functioning
(i.e. understanding internal experience and others’
perspective), which is not emphasized in the schema
therapy model. Yet, the schema therapy focus on
integrating and regulating modes from a healthy
adult perspective may be viewed as processes that
foster mentalizing capacities [96]. Thus, the concep-
tualization and treatment of modes, schemas, and
their learning history may serve as a foundation for
improving mentalization through impowerment of
Healthy Adult capacities (e.g. capacity to reflect on
and modulate own emotional responses).

CONCLUSION
LIMITATIONS AND FUTURE DIRECTIONS The schema therapy model seems compatible with
Certain aspects of the ICD-11 and DSM-5-AMPD the new dimensionally oriented personality disor-
models of personality disorders do not seem to be der frameworks in ICD-11 and DSM-5-AMPD. Level

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YCO 320103
Personality disorders
of core personality functioning can be conceptual-
ized as Healthy Adult functioning, whereas trait
dimensions can be conceptualized by associated
modes and underlying schemas. Additionally,
the schema domain of Disconnection and
Rejection also seems related to impaired personality
functioning.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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