The Role of Schema Processes in the Eating Disorders

Evidências de Validade do Inventário de Compensação de Young (YCI) para a População do Rio Grande do Sul

Resumo O objetivo deste estudo foi examinar a estrutura fatorial e as evidências de validade do Inventário de Compensação de Young (YCI) para a população do Rio Grande do Sul. Contou-se com a participação de 504 adultos da população geral, com média de idade de 34,2 anos (DP = 12,9). Os instrumentos utilizados foram o Questionário de Esquemas de Young - Versão Breve (YSQ-S3), a Escala de Avaliação dos Sintomas (SCL-90-R) e o YCI. Os dados foram coletados através de plataforma online. Realizou-se a análise fatorial exploratória, para verificar a distribuição dos itens em fatores comuns, e a validade convergente, com correlação não paramétrica de Spearman com a SCL-90-R e o YSQ-S3. Foram interpretados quatro fatores: Dominação e Manipulação (α =0,85 ω=0,71); Obsessão e Organização (α =0,75 ω=0,75); Rebeldia e Independência (α =0,73 ω=0,69); e Busca de Reconhecimento (α =0,81 ω=0,91). A validade de construto mostrou-se adequada conforme a teoria. Concluiu-se que a versão adaptada apresenta boas propriedades psicométricas.

The ethereal bodies of pro-Ana blogs: emotional communities and spaces of sociability on the web

The study presented in this paper aimed at understanding how anorexic young women use virtual environments as spaces of sociability in order to construct a narrative about anorexia, anchor their experiences through emotional mutuality and validate discourses. To do so, an analysis of the content found in the commenting and posting sections of pro-anorexia blogs was carried out. Three thematic categories were identified: body, personal identity and sociability on the web. It was observed that blogs are virtual spaces of sociability and construction of identity groups. The representations and the experiences lived by the corporal materiality feed cyberspace and are the starting point for understanding a phenomenon particular to the contemporaneity, that is the virtual exchanges. In blogs, one can find body narratives that seek to give coherence to an individual and to his or her existence as well as narratives that aim at anchoring and legitimizing personal experiences and validating pro-anorexia attitudes. Social ties are strengthened within the group, which becomes an emotional community. The meanings of the spreading discourses allow us to infer that in these groups, the materiality of anorexic bodies emancipates itself from the social stigmas of a disease.

Differences in the use of emotion regulation strategies between anorexia and bulimia nervosa: A systematic review and meta-analysis

OBJECTIVE

Research has identified abnormal emotion regulation (ER) as an underlying mechanism in the onset and maintenance of eating disorders. Yet, it still remains unclear whether different forms of ER, adaptive and maladaptive strategies, are similar across categories of eating disorders.

METHOD

A systematic review and meta-analysis were carried out to look at ER differences between anorexia nervosa (AN) and bulimia nervosa (BN), two common eating disorder pathologies with different eating patterns.

RESULTS

41 studies were included in the meta-analysis. The results revealed no differences in the use of maladaptive ER strategies between individuals with AN and BN, however patients with AN tend to use less adaptive ER strategies as compared to patients with BN.

CONCLUSIONS

Making less use of adaptive strategies in AN might be due to low body weight and high levels of alexithymia which define AN. In order to improve treatment outcome in individuals suffering from AN, these findings suggest to focus more on improving the use of adaptive ER strategies.

Childhood Memories in Eating Disorders: An Explorative Study Using Diagnostic Imagery

Together with socio-cultural components, the family environment and early parent-child interactions play a role in the development of eating disorders. The aim of this study was to explore the nature of early parent-daughter relationships in a sample of 49 female inpatients with an eating disorder. To acquire a detailed image description of the childhood experiences of the patient, we used diagnostic imagery, a schema therapy-derived experiential technique. This procedure allows exploring specific contents within the childhood memory (i.e., emotions and unmet core needs), bypassing rational control, commonly active during direct verbal questioning. Additionally, patients completed self-report measures to assess for eating disorder severity, general psychopathology, and individual and parental schemas pervasiveness. Finally, we explored possible differences in the diagnostic imagery content and self-report measures in two subgroups of patients with anorexia nervosa and bulimia nervosa. The results showed that the most frequently reported unmet needs within the childhood memories of patients were those of safety/protection, care/nurturance, and emotional expression, referred specifically to the maternal figure. Overall, mothers were described as more abandoning, but at the same time particularly enmeshed in the relationship with their daughters. Conversely, patients perceived their fathers as more emotionally inhibited and neglecting. Imagery-based techniques might represent a powerful tool to explore the nature of early life experiences in eating disorders, allowing a more detailed case conceptualization and addressing intervention on early-life vulnerability aspects in disorder treatment.

Psychometric Properties of the Turkish Young-Rygh Avoidance Inventory

Coping styles such as overcompensation and avoidance are attempts that developed as survival mechanisms in difficult childhood environments. The objective of this study is to examine the psychometric properties of the Turkish version of the Young-Rygh Avoidance Inventory (YRAI). The sample (n = 1,555) randomly split into two groups to run principal component and confirmatory factor analyses (CFA). A parallel analysis was run to determine the factor number. CFA was carried out with maximum likelihood estimation robust method. Eight factors with 30 items were the final form of the Turkish YRAI. Cronbach alpha levels of each factor and inter-correlations with the Turkish Young Schema Questionnaire, Symptom Check List-90 revised, Beck Depression Inventory, and Beck Anxiety Inventory were calculated. Internal consistency analysis revealed acceptable coefficients. As to convergent validity, the correlational analysis showed statistically significant coefficients. Overall, the Turkish YRAI was found to have acceptable levels of reliability and validity.

Are Schemas Passed on? A Study on the Association Between Early Maladaptive Schemas in Parents and Their Offspring and the Putative Translating Mechanisms

Background: According to Young's schema theory, Early Maladaptive Schemas (EMSs) arise due to the violation of core emotional needs during childhood. It seems likely that parents have difficulties in satisfying their children's emotional needs if they have high levels of EMSs themselves. Aims: This study investigated whether the extent of EMSs in parents is associated with the extent of EMSs in their offspring. Moreover, we tested for two putative mechanisms that account for this association: parental coping styles and parenting behaviour. Methods: Sixty dyads of parents (mother or father) and their adult children (N = 120), recruited from the general population, completed the Young Schema Questionnaire. The parents rated their schema coping styles and the children retrospectively rated the parenting of the participating parent. Results: As expected, parents' EMSs were significantly associated with EMSs in their offspring. This association was accounted for by the parental coping style Overcompensation and the adverse parenting that the child remembered. The parental coping style Avoidance did not account for the association. Conclusions: This study provides preliminary evidence for the notion that EMSs are passed on from one generation to the next via parental coping and parenting. Our findings thus support the assumption of schema theory that EMSs are connected to the family environment in terms of adverse parenting. If further confirmed, this has relevant implications for family-based interventions.

Group schema therapy for eating disorders: study protocol

BACKGROUND

The treatment of eating disorders is a difficult endeavor, with only a relatively small proportion of clients responding to and completing standard cognitive behavioural therapy (CBT). Given the prevalence of co-morbidity and complex personality traits in this population, Schema Therapy has been identified as a potentially viable treatment option. A case series of Group Schema Therapy for Eating Disorders (ST-E-g) yielded positive findings and the study protocol outlined in this article aims to extend upon these preliminary findings to evaluate group Schema Therapy for eating disorders in a larger sample (n = 40).

METHODS/DESIGN

Participants undergo a two-hour assessment where they complete a number of standard questionnaires and their diagnostic status is ascertained using the Eating Disorder Examination. Participants then commence treatment, which consists of 25 weekly group sessions lasting for 1.5 h and four individual sessions. Each group consists of five to eight participants and is facilitated by two therapists, at least one of who is a registered psychologist trained on schema therapy. The primary outcome in this study is eating disorder symptom severity. Secondary outcomes include: cognitive schemas, self-objectification, general quality of life, self-compassion, schema mode presentations, and Personality Disorder features. Participants complete psychological measures and questionnaires at pre, post, six-month and 1-year follow-up.

DISCUSSION

This study will expand upon preliminary research into the efficacy of group Schema Therapy for individuals with eating disorders. If group Schema Therapy is shown to reduce eating disorder symptoms, it will hold considerable promise as an intervention option for a group of disorders that is typically difficult to treat.

TRIAL REGISTRATION

ACTRN12615001323516. Registered: 2/12/2015 (retrospectively registered, still recruiting).

Do dysfunctional coping modes mediate the relationship between perceived parenting style and disordered eating behaviours?

BACKGROUND

Preliminary studies suggest that both childhood experiences and coping behaviours may be linked to eating disorder symptoms.

METHODS

In this study maladaptive schema coping modes were investigated as mediators in the relationship between perceived negative parenting and disordered eating. A total of 174 adults with eating and/or body image concerns completed questionnaires measuring parenting experiences, schema modes, and disordered eating behaviours.

RESULTS

Perfectionistic Overcontroller, Self-Aggrandiser, Compliant Surrenderer, Detached Protector and Detached Self-Soother coping modes partially explained the variance in the relationships between perceived negative parenting experiences and the behaviours of restricting and compensation (purging and overexercising).

CONCLUSIONS

Our findings suggest that Overcompensatory, Avoidant and Surrender coping mechanisms all appear to play a role in the maintenance of eating disorder symptoms, and that there are multiple complex relationships between these and Early Maladaptive Schemas that warrant further investigation.

Early Maladaptive Schemas in Eating Disordered Patients With or Without Non-Suicidal Self-Injury

This study investigates early maladaptive schemas (EMSs) in function of eating disorder (ED) subtypes (restrictive/bulimic) and the presence/absence of non-suicidal self-injury (NSSI). Female inpatients (N = 491) completed the Young Schema Questionnaire and the Self-Injury Questionnaire. The influence of ED subtype and the presence/absence of NSSI and their interaction on the EMS were investigated by means of a MANCOVA. The results showed main effects of ED subtype and the presence of NSSI on EMS. Patients with bulimia scored significantly higher on insufficient self-control and emotional deprivation, which are more related to cluster B compared with restrictive patients, whereas restrictive patients scored significantly higher on social undesirability, failure to achieve, subjugation and unrelenting standards compared with patients with bulimia that are more related to cluster C. Patients with ED with NSSI reported significantly higher EMS levels compared with patients without NSSI, suggesting that they could be of particular interest to benefit from schema therapy. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

The influence of eating psychopathology on autobiographical memory specificity and social problem-solving

The primary aim was to examine the influence of subclinical disordered eating on autobiographical memory specificity (AMS) and social problem solving (SPS). A further aim was to establish if AMS mediated the relationship between eating psychopathology and SPS. A non-clinical sample of 52 females completed the autobiographical memory test (AMT), where they were asked to retrieve specific memories of events from their past in response to cue words, and the means-end problem-solving task (MEPS), where they were asked to generate means of solving a series of social problems. Participants also completed the Eating Disorders Inventory (EDI) and Hospital Anxiety and Depression Scale. After controlling for mood, high scores on the EDI subscales, particularly Drive-for-Thinness, were associated with the retrieval of fewer specific and a greater proportion of categorical memories on the AMT and with the generation of fewer and less effective means on the MEPS. Memory specificity fully mediated the relationship between eating psychopathology and SPS. These findings have implications for individuals exhibiting high levels of disordered eating, as poor AMS and SPS are likely to impact negatively on their psychological wellbeing and everyday social functioning and could represent a risk factor for the development of clinically significant eating disorders.

A narrative review of schemas and schema therapy outcomes in the eating disorders

Whilst cognitive-behavioural therapy has demonstrated efficacy in the treatment of eating disorders, therapy outcomes and current conceptualizations still remain inadequate. In light of these shortcomings there has been growing interest in the utility of schema therapy applied to eating pathology. The present article first provides a narrative review of empirical literature exploring schemas and schema processes in eating disorders. Secondly, it critically evaluates outcome studies assessing schema therapy applied to eating disorders. Current evidence lends support to schema-focused conceptualizations of eating pathology and confirms that eating disorders are characterised by pronounced maladaptive schemas. Treatment outcomes also indicate that schema therapy, the schema-mode approach, and associated techniques are promising interventions for complex eating disorders. Implications for clinical practice and future directions for research are discussed.

The prediction of treatment outcomes by early maladaptive schemas and schema modes in obsessive-compulsive disorder

BACKGROUND

Higher levels of early maladaptive schemas (EMS) and schema modes according to schematherapy by Jeffrey Young are present in obsessive-compulsive disorder (OCD) compared to healthy controls. This study examines the relationship of EMS and schema modes to OC symptom severity and the predictive value of EMS and schema modes on treatment outcome in inpatients receiving Cognitive-Behavioral Therapy (CBT) with Exposure and Response Prevention (ERP). The main assumption was a negative association between the EMS of the domain 'disconnection' and dysfunctional coping and parent schema modes and the treatment outcome.

METHODS

EMS, schema modes, depression and traumatic childhood experiences were measured in 70 patients with OCD. To analyze the predictors, two regression analyses were conducted considering multiple variables, such as depression, as covariates.

RESULTS

Regression analyses demonstrated that higher scores on the EMS named failure and emotional inhibition and depressive symptom severity at pretreatment were significantly related to poor outcome and explained a high percentage of the variance in OC symptoms at posttreatment. No influence on the treatment outcome was observed for schema modes, other EMS or other covariates.

CONCLUSIONS

The results support the approach to extend the CBT with ERP treatment with therapeutic elements focusing on maladaptive schemas, particularly in non-responders.

Attentional biases to body shape images in adolescents with anorexia nervosa: an exploratory eye-tracking study

Body image distortion (BID) plays an important role in the etiology and maintenance of anorexia nervosa (AN). Previous studies of BID in AN showed small biases in visual scanning behavior (VSB) towards images of body shapes. The aim of this study is to investigate biases in VSB when body shape images compete with images with a different theme (social interactions) for subjects׳ attention. When images of thin body shapes (TBS) were presented alongside images of social interactions, AN patients (n=13) spent significantly more time looking at TBSs rather than at social interactions, but controls (n=20) did not. When images of fat body shapes (FBS) were presented alongside images of social interactions, AN patients spent significantly more time looking at FBSs rather than at social interactions, but controls did not. When images of TBSs, FBSs and social interactions were presented alongside each other, AN patients demonstrated a hierarchy in their attention allocation, choosing to spend the most viewing time on TBS images, followed by FBS images and then images with social interactions. Under the three experimental conditions, AN patients demonstrated large biases in their visual scanning behavior (VSB). Biases in VSB may provide physiologically objective measures that characterize patients with AN.

Emotion dysregulation and symptoms of anorexia nervosa: the unique roles of lack of emotional awareness and impulse control difficulties when upset

OBJECTIVE

Extant research suggests that individuals with anorexia nervosa (AN) have deficits in emotion regulation across a variety of domains. The current study investigated associations between specific difficulties with emotion regulation and the core symptoms of AN.

METHOD

Participants were 192 patients with AN presenting to an intensive eating disorder treatment facility. Emotion regulation was assessed using the multidimensional Difficulties in Emotion Regulation Scale, and associations with body mass index (BMI) at admission, eating disorder cognitions, objective binge eating, subjective binge eating, and purging were examined.

RESULTS

Eating disorder cognitions were significantly associated with multiple forms of emotion dysregulation; however, only lack of emotional awareness was independently related to these symptoms. In contrast, impulse control difficulties when upset was the only emotion regulation impairment associated with the presence of recurrent objective binge eating and recurrent purging in AN. No significant relationships between emotion regulation and BMI or subjective binge eating were detected.

DISCUSSION

Results point to differential associations between specific emotion regulation deficits and core symptoms of AN. These findings suggest that parsing the construct of emotion regulation as well as the AN phenotype can help to identify the unique ways in which eating disorder symptoms may function to regulate emotions.

Neural response to angry and disgusted facial expressions in bulimia nervosa

BACKGROUND

Processing emotional facial expressions is of interest in eating disorders (EDs) as impairments in recognizing and understanding social cues might underlie the interpersonal difficulties experienced by these patients. Disgust and anger are of particular theoretical and clinical interest. The current study investigated the neural response to facial expressions of anger and disgust in bulimia nervosa (BN).

METHOD

Participants were 12 medication-free women with BN in an acute episode (mean age 24 years), and 16 age-, gender- and IQ-matched healthy volunteers (HVs). Functional magnetic resonance imaging (fMRI) was used to examine neural responses to angry and disgusted facial expressions.

RESULTS

Compared with HVs, patients with BN had a decreased neural response in the precuneus to facial expressions of both anger and disgust and a decreased neural response to angry facial expressions in the right amygdala.

CONCLUSIONS

The neural response to emotional facial expressions in BN differs from that found in HVs. The precuneus response may be consistent with the application of mentalization theory to EDs, and the amygdala response with relevant ED theory. The findings are preliminary, but novel, and require replication in a larger sample.

The role of imagery-based techniques in cognitive-behavioural therapy for adults with eating disorders

Disorder-specific and transdiagnostic cognitive-behavioural models and treatments primarily target surface-level maintaining factors in order to effect symptom change. Despite this approach resulting in the most effective evidence-based approach for most eating disordered patients, a significant proportion of sufferers fail to benefit from such treatments. This conclusion suggests that deeper-level causal factors might also need to be addressed in some cases. Theoretical and empirical findings are considered in terms of the clinical applicability of imagery-based techniques and their ability to enhance cognitive-behavioural treatment of the eating disorders. Imagery techniques (particularly, but not only, imagery rescripting) are proposed as a means to enhance current treatments and improve existing outcomes. Potential treatment targets include core beliefs, emotional regulation difficulties and body image disturbance. The existing literature is limited but early indications suggest that imagery rescripting is effective in modifying core beliefs in this population, and that other imagery-based methods are potentially beneficial. Areas for further clinical application and investigation are identified.

Eating disorder behavior and early maladaptive schemas in subgroups of eating disorders

To examine relationship between Eating Disorder Behaviors (EDB) and Early Maladaptive Schemas (EMS) across eating disorder (ED) subgroups. EMS and ED behaviors were measured by Young Schema Questionnaire and Eating Behavior Severity Scale, respectively, among patients diagnosed with Restrictive or Binge/purging Anorexia, or bulimia nervosa. Canonical component analysis showed significant association between ED behaviors and EMSs. Canonical factor-pairs (EDB and EMS) revealed specific associations between certain patterns of EDBs, including binge-purging and physical exercise, and certain patterns of maladaptive cognitive schema, including Emotional deprivation, Abandonment, Enmeshments, Subjugation, and Emotional inhibition. ED subgroups significantly differred between the EMS and EDB canonical factors, respectively. Our findings indicate that EMS and EDB are associated, and that the factors that potentially mediate the association differ significantly among ED subgroups. These results are consistent with the notion that EMSs play a specific role in the development and maintenance of ED behaviors.

Confirmatory and exploratory factor analysis of the distress tolerance scale (DTS) in a clinical sample of eating disorder patients

A confirmatory factor analysis of the factor structure of the Distress Tolerance Scale (DTS) created by Corstorphine et al. [Corstorphine, E., Mountford, V., Tomlinson, S., Waller, G., & Meyer, C. (2007). Distress tolerance in the eating disorders. Eating Behaviors, 8, 91-97.] was conducted to assess whether the scale's purported three factors emerged in a clinical sample of patients with a DSM-IV diagnosed eating disorder. The original three-factor model was generally considered to be a poor fit for the data. Subsequent exploratory factor analysis indicated that a better fit emerged using a four-factor structure. Significant associations were observed between behavioral avoidance of positive affect and eating disorder psychopathology. Implications for use of the DTS with eating disorder patients are discussed.

Do schema processes mediate links between parenting and eating pathology?

OBJECTIVE

Adverse parenting experiences are commonly linked to eating pathology. A schema-based model of the development and maintenance of eating pathology proposes that one of the potential mediators of the link between parenting and eating pathology might be the development of schema maintenance processes--mechanisms that operate to help the individual avoid intolerable emotions.

METHOD

To test this hypothesis, 353 female students and 124 female eating-disordered clients were recruited. They completed a measure of perceived parenting experiences as related to schema development (Young Parenting Inventory-Revised (YPI-R)), two measures of schema processes (Young Compensatory Inventory; Young-Rygh Avoidance Inventory (YRAI)) and a measure of eating pathology (Eating Disorders Inventory (EDI)).

RESULTS

In support of the hypothesis, certain schema processes did mediate the relationship between specific perceptions of parenting and particular forms of eating pathology, although these were different for the clinical and non-clinical samples.

DISCUSSION

In those patients where parenting is implicated in the development of eating pathology, treatment might need to target the cognitive processes that can explain this link.

Low perception of control as a cognitive factor of eating disorders. Its independent effects on measures of eating disorders and its interactive effects with perfectionism and self-esteem

OBJECTIVE

There is a large body of research about perfectionism and low self-esteem in eating disorders (ED). However, little is known about the influence in ED of a distorted cognition in the domain of control: the perception of low control. The present study examined the main and interactive effects of concern over mistakes (an important dimension of perfectionism), self-esteem, and perception of control on drive for thinness, bulimia, and body dissatisfaction.

METHOD

Forty individuals with ED and 55 controls completed the Multidimensional Perfectionism Scale, the Anxiety Control Questionnaire, the Rosenberg self-esteem scale, and the three symptomatic scales of the Eating Disorder Inventory, which are drive for thinness, bulimia and body dissatisfaction. Multiple linear regression was used to test the hypothesis that perception of low control has a significant effect on the symptomatic scales of the EDI.

RESULTS

The ED group had significantly lower perception of control and self-esteem and higher concern over mistakes, drive for thinness, bulimia, and body dissatisfaction than the control group. Analysis of interactive effects suggested that a combination of a low perception of control and a low self-esteem seems to moderate the effects of concern over mistakes on drive for thinness, bulimia, and body dissatisfaction.

DISCUSSION

ED are associated with a tendency to worry about mistakes, a low sense of self-esteem, and a low perception of control over internal feelings and external events. Perception of control and self-esteem seems to moderate the predictive power of concern mistakes on symptoms of ED. The results suggest that a low perception of control is an important cognitive factor in ED.

Body checking in the eating disorders: association with narcissistic characteristics

There is substantial evidence that body image is a clinically important element of eating pathology, and that patients' body checking cognitions and behaviours are key elements in the maintenance of that body image. However, there is little understanding of individual differences in body checking. This study considered the potential role of narcissism and narcissistic defences in driving body checking cognitions and behaviours. 68 eating-disordered and 70 non-clinical women completed well-validated measures of body checking and narcissism. There were specific patterns of association between different elements of narcissism and different aspects of body checking. These patterns are compatible with a model where body checking serves the defensive function of maintaining self-esteem, rather than promoting positive levels of narcissistic self-esteem.

Early maladaptive schemas activated in patients with obsessive compulsive disorder: A cross-sectional study

Aim. The aim of the present article is to investigate the activation patterns of early maladaptive schemas (EMSs) in patients with obsessive-compulsive disorder (OCD). Method. During the time between 1 January 2006 and 1 April 2006, 45 consecutive patients from an outpatient facility of a general hospital and 45 age- and gender-matched healthy control subjects from the hospital staff were included in the study. They were administered the Structured Clinical Interview for Diagnosis of DSM-IV Mental Disorders (SCID-1), the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-2), the Young Schema Questionnaire-Short Form (YSQ-SF), the Young Parenting Inventory (YPI) and the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). The results were assessed using GraphPad Prisma V.3 statistical program. Results. The YSQ total score of the OCD group was significantly higher than the control group (t=3.62, P<0.0001). The average scores of the patients with OCD on certain schemas were significantly higher than the average scores of the control group, although the others did not make any difference between the OCD and control groups. Conclusion. The study demonstrates that, in the patients with OCD, most of the early maladaptive schemas including social isolation, vulnerability and pessimism, are prominently activated.

Cognitive content and process in eating-disordered patients with obsessive-compulsive features

OBJECTIVE

This study examined the schema-level cognitive content and processes that might explain the presence of compulsive behaviours among patients with eating disorders.

METHOD

Each of 62 eating-disordered women completed standardised measures of schema-level core beliefs and cognitive processes, and was interviewed for diagnosis and obsessive compulsive features.

RESULTS

Compulsive behaviours were associated with four core beliefs--'mistrust/abuse', 'defectiveness/shame', 'dependence/incompetence' and 'subjugation'. Higher levels of avoidance of emotional arousal were also associated with compulsivity.

DISCUSSION

Schema-level beliefs and processes are associated with the presence of compulsivity. The key cognitions might impact via the activation of negative affect, meaning that the compulsive behaviours serve the function of emotion regulation. Such cognitions are likely to be a necessary target in CBT for those presenting with compulsive behaviours in the eating disorders.