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

Early maladaptive schemas and obsessive-compulsive disorder: A systematic review and meta-analysis

BACKGROUND

Obsessive-compulsive disorder (OCD) is a condition with poor treatment outcomes. Improved understanding of the aetiology can inform prevention and treatment approaches; hence several studies have assessed early maladaptive schemas (EMSs) in OCD. This systematic review and meta-analysis aimed to synthesise the evidence on relationships between the 18 EMSs and OCD.

METHODS

The study was conducted according to PRISMA guidelines and registered on PROSPERO (CRD42022329337). A systematic search of PubMed, PsycINFO, and CINAHL Complete was conducted on 4 June 2022. Studies in peer-reviewed journal articles were included if they assessed EMSs and OCD (diagnosis or symptom severity) in adults with a mean age of 18 years or older. Studies were excluded if they were not in English, did not include original quantitative data, or reported on case studies. Study details were tabulated and the meta-analysis findings were presented using forest plots. Methodological quality was assessed using the Appraisal tool for Cross-Sectional Studies (AXIS).

RESULTS

Based on 22 studies (pooled N = 3699), all 18 EMSs were positively correlated with OCD. The largest associations were with the dependence/incompetence (r = 0.40 95 % CI [0.32, 0.47]), vulnerability to harm or illness (r = 0.40 95 % CI [0.32, 0.48]), and negativity/pessimism schemas (r = 0.42 95 % CI [0.22, 0.58]).

LIMITATIONS

Several meta-analyses showed considerable heterogeneity and publication bias.

CONCLUSIONS

The findings suggest all EMSs, particularly those relating to disproportionate negative expectations and a perceived inability to cope, are implicated in OCD. Psychological prevention and treatment for OCD may benefit from targeting these schemas.

Naïve Theories of Emotions: Why People Might (Not) Be Uncertain or in Conflict About Felt Emotions

Beliefs about conflict and uncertainty over felt emotions-for Joy, Pride, Sadness, Jealousy and Envy events-were studied by means of Yes/No and Why questions. Each participant (N = 1,156) judged a typical antecedent for a single emotion-e.g., Jealousy: story protagonist SP sees his or her partner kiss someone. The Yes/No results showed that SP was frequently expected to experience both phenomena, the more so the greater the event impact (Yes range: 40-86%). Beliefs associated with Yes answers (BY) were categorized into 4 categories: (BY1) reason-emotion opposition-felt emotions are unreasonable, inadequate ways of reacting; (BY2) ambivalent emotions-e.g., joy and sadness; (BY3) unclear emotions; (BY4) other causes-e.g., focused on event implications, SP's personality. No conflict or uncertainty answers (BN; range 14-60%) mirrored BY categories: (BN1) no reason-emotion opposition, (BN2) no ambivalent emotions, (BN3) clear emotions, (BN4) other causes. Attributions and beliefs about causes did not generally differ by gender. As a collective entity, expressed beliefs were complex, focusing on one or more emotion component-e.g., appraisal, regulation, expression-as well as on emotion intensity, duration, and on self-concept issues. Overall, expressed beliefs seemed to imply a malleability theory of emotions, and emotion awareness. Results overall confirmed the hypotheses that conflict and uncertainty attributions are more likely for: unpleasant experiences; when emotions are norm-incongruent for the judged event; when mixed, ambivalent emotions are felt. The study confirms that people interpret emotion processes according to their lay theories.

Early maladaptive schemas in eating disorders: A systematic review

OBJECTIVE

Research and theory suggest the aetiological nature and symptomatic profile of eating disorders (EDs) can be explained by multiple factors, including the development of early maladaptive schemas (EMS). Yet, there is lack of consensus regarding the evidence supporting the relationship between EMS and EDs. Therefore, this systematic review aimed to examine existing literature concerning the relationship between different ED diagnoses and EMS to provide a synthesis and evaluation of relevant research.

METHOD

A comprehensive literature search of four electronic databases was conducted and studies were included that examined the association between EMS and EDs. Studies were required to use a variant of Young Schema Questionnaire and establish ED diagnosis or symptomology using self-report questionnaires or clinical interview.

RESULTS

A total of 29 studies were included in the review. Compared to healthy controls and varying clinical populations, individuals with EDs generally reported significantly higher scores across all EMS except for Entitlement. Furthermore, Unrelenting Standards consistently appeared as a significant EMS across all ED diagnoses whilst Insufficient Self-Control was significantly lower in ED diagnoses with restrictive behaviour compared to diagnoses with binge eating or purging behaviour.

DISCUSSION

Research supports significant associations between EMS and EDs, which may contribute to our understanding of ED aetiology, including different diagnostic categories. This review underscores the need for studies to explore more gender and age diverse samples and highlights important implications for practitioners.

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.

Obligatory exercise and coping in treatment-seeking women with poor body image

PURPOSE

Obligatory exercise is characterized by continued exercise despite negative consequences, and intense negative affect when unable to exercise. Research suggests psychosocial differences between individuals that exercise in an obligatory manner and those that do not. It also has been speculated that obligatory exercise may serve coping and affect regulation functions, yet these factors have not been routinely examined in community women with poor body image. The purpose of the current study was to investigate psychosocial differences between obligatory and non-obligatory exercisers, and to examine the use of obligatory exercise as an avoidant coping strategy in a sample of women with poor body image.

METHODS

Women (n = 70) seeking treatment for body dissatisfaction were divided into obligatory and non-obligatory exercise groups based on their scores on the Obligatory Exercise Questionnaire. Participants then completed an assessment battery about eating pathology, body image, reasons for exercise, coping strategies, and negative affect.

RESULTS

Independent t test analyses indicated that obligatory exercisers had significantly greater eating disorder symptomatology, avoidant coping, and appearance- and mood-related reasons for exercise than non-obligatory exercisers. Multiple regression analyses revealed that eating disorder symptomatology and avoidant coping were significant predictors of obligatory exercise.

CONCLUSIONS

There are distinct psychosocial differences between women with poor body image who exercise in an obligatory fashion and those who do not. The current study suggests that obligatory exercise may serve as an avoidant coping strategy for women with poor body image. Enhancing healthy coping strategies may be an important addition to body image improvement programs.

LEVEL OF EVIDENCE

V, cross-sectional descriptive study.

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).

'Feelings stronger than reason': conflicting experiences of exercise in women with anorexia nervosa

BACKGROUND

Individuals with anorexia nervosa frequently feel ambivalent about treatment and weight restoration, and drop out and relapse rates in treatment are high. Increased insight into the function of the eating disorder is considered essential for achieving long-lasting, meaningful change. However, research investigating the functions of anorexia nervosa tends to focus on the role of the disease per se. Distinctions are rarely made across features. In particular, the subjective experience, understanding and sense making of the engagement in compulsive exercise in individuals with anorexia nervosa has received little attention. By using a qualitative methodological approach, this paper aims to expand on prior findings by examining how patients with anorexia nervosa understand and make sense of the experience of exercise in the context of their lives and treatment programme.

METHODS

Semi-structured interviews were conducted with six females, four of whom were former athletes. Transcripts were subjected to interpretative phenomenological analysis (IPA).

RESULTS

Two overarching themes emerged in the analysis of the larger study of which this paper is a part; 'paradoxical functions of exercise' and 'diverging experiences of exercise'. Diverging experiences of exercise is the focus of this paper. Firstly, in spite of being severely underweight and suffering from exhaustion, as well as having a clear awareness of the associated negative health effects, participants were engaged in a continuous cycle of rigorous and excessive exercise, which consumed extensive amounts of time and energy. Secondly, the results demonstrate how exercise routines negatively control and interfere with the participants' involvement in the social world. Thirdly, the manner in which participants speak about their exercise reveals their wording to be characterized by efforts to downplay the extent of their actual immersion in exercise. Issues of control and ambivalence about treatment and recovery can be considered potential triggers for the participants' engagement with exercise. Implicit meanings are elaborated upon and discussed in relation to existing literature.

CONCLUSIONS

The material provides increased insight into the multi-layered meanings of exercise for individuals with anorexia nervosa. It also suggests alternatives to current ways of understanding and approaching exercise that may enable this issue to be addressed in a more meaningful way in therapy. Qualitative approaches can make a valuable contribution to furthering such understanding.

Comparison of Perfectionism and Related Positive-Negative Dimension in People With High Traits on Obsessive Compulsive and Eating Disorder Characteristics

BACKGROUND

Psychopathological perfectionism is often correlated with obsessive compulsive eating disorders.

OBJECTIVES

The purpose of this study was to investigate perfectionism in people with high traits of obsessive compulsive and eating disorder characteristics.

MATERIALS AND METHODS

This study was an expo fact research. The statistical population of the research comprised of male and female undergraduate students at Tabriz and Sarab branches of Payam- e- Noor University, Tabriz Islamic University and Azarbaijan Shahid Madani university in the academic year 2012 - 2013. A group of 640 university students, using the stratified random sampling method were screened by the obsessive compulsive inventory and the eating attitude test, then a group of 143 participants with high obsessive compulsive traits with another 137 participants with high eating disorder characteristics were selected and assessed with the Perfectionism Inventory. Data were analyzed using one way analysis of variance.

RESULTS

The results showed that perfectionism and related negative dimension are more commonly found in people with high obsessive-compulsive traits than eating disorder characteristics (P < 0.02). The results showed the highest contribution of maladaptive perfectionism in predicting obsessive-compulsive features and pathological eating attitude. Also, no difference was found between the two groups in terms of negative perfectionism.

CONCLUSIONS

The greater association of perfectionism with symptoms of obsessive-compulsive is consistent with its phenomenological feature. Fear of failure may motivate the behavioral components of perfectionism that aim to focus on careful checking, reassurance seeking and excessive consideration before making a decision.

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.

A process-oriented measure of habit strength for moderate-to-vigorous physical activity

Purpose: Habitual action is an important aspect of health behaviour, but the relevance of various habit strength indicators continues to be debated. This study focused specifically on moderate-to-vigorous physical activity (MVPA) and evaluated the construct validity of a framework emphasizing patterned action, stimulus-response bonding, automaticity, and negative consequences for nonperformance as indicators of habit strength for this form of exercise. Methods: Upper-level undergraduates (N = 124) provided demographic information and responded to questionnaire items assessing historical MVPA involvement, current MVPA involvement, and the four proposed habit strength dimensions. Factor analyses were used to examine the latent structure of the habit strength indicators, and the model's construct validity was evaluated via an examination of relationships with repetition history and current behaviour. Results: At a measurement level, findings indicated that the proposed four-component model possessed psychometric integrity as a coherent set of factors. Criterion-related validity was also demonstrated via significant changes in three of the four factors as a function of past involvement in MVPA and significant correlations with the frequency, duration, and intensity of current MVPA. Conclusions: These findings support the construct validity of this exercise habit strength model and suggest that it could provide a template for future research on how MVPA habits are developed and maintained.

A comparison of schemas, schema modes and childhood traumas in obsessive-compulsive disorder, chronic pain disorder and eating disorders

BACKGROUND

In this study, we investigated early maladaptive schemas (EMS), schema modes and childhood traumas in patients suffering from obsessive-compulsive disorder (OCD) in contrast to patients with other Axis I disorders. Based on cognitive theories on OCD, our main research question was whether schemas belonging to the domain of 'impaired autonomy and performance' are more prevalent in OCD than in both eating disorders (ED) and chronic pain disorder (CPD).

SAMPLING AND METHODS

EMS, schema modes and traumatic childhood experiences were measured in 60 patients with OCD, 41 with ED, 40 with CPD and 142 healthy controls. To analyze differences between the groups, MANCOVAs were conducted followed by deviation contrasts. Depression level, age and gender were considered as possible covariates.

RESULTS

OCD patients scored higher on 4 EMS, 2 of which belong to the domain 'impaired autonomy and performance'. ED patients had higher scores in the EMS 'emotional inhibition' and CPD patients on the Childhood Trauma Questionnaire subscale 'physical neglect'.

CONCLUSIONS

These results suggest that there might be typical schema patterns associated with OCD and ED. We can also conclude that a higher prevalence of traumatic experiences does not necessarily coincide with more EMS and schema modes.

Hard exercise, affect lability, and personality among individuals with bulimia nervosa

The current study explores the personality traits of compulsivity (e.g., sense of orderliness and duty to perform tasks completely) and restricted expression (e.g., emotion expression difficulties) as potential moderators of the relation between affect lability and frequency of hard exercise episodes in a sample of individuals with bulimic pathology. Participants were 204 adult females recruited in five Midwestern cities who met criteria for threshold or subthreshold bulimia nervosa (BN). Compulsivity was found to significantly moderate the relation between affect lability and number of hard exercise episodes over the past 28 days, such that among those with high compulsivity, level of affect lability was associated with the number of hard exercise episodes; whereas, among those with low compulsivity, affect lability was not associated with the number of hard exercise episodes. The same pattern of findings emerged for restricted expression; however, this finding approached, but did not reach statistical significance. As such, it appears that affect lability is differentially related to hard exercise among individuals with BN depending upon the level of compulsivity and, to a more limited extent, restricted expression. These results suggest that, for individuals with BN with either compulsivity or restricted expression, focusing treatment on increasing flexibility and/or verbal expression of emotions may help in the context of intense, fluctuating affect.

The relationship between decision-making and perfectionism in obsessive-compulsive disorder and eating disorders

BACKGROUND AND OBJECTIVES

Obsessive-compulsive disorder (OCD) and eating disorders (EDs) show phenotypic similarities and have been independently associated with deficits in decision-making and maladaptive perfectionism. However, research directly comparing the two disorders is sparse and the significance of observed similarities remains in question. Therefore, the present study compared decision-making in OCD and EDs in relationship to perfectionistic personality traits.

METHODS

Sixty-one women were enrolled in the study comprising 3 mutually exclusive groups: 19 with OCD, 17 with EDs, and 21 healthy controls. Decision-making performance on the Iowa Gambling Task under two conditions, ambiguity and risk, was examined in relationship to perfectionistic traits.

RESULTS

Behavioral results indicated that EDs participants, relative to both OCD and control participants, were impaired in decision-making under conditions of risk. Heightened perfectionism was associated with less risky decision-making in OCD, but more risky decision-making in EDs.

LIMITATIONS

Sample size was small and all participants were women, which may limit generalizability.

CONCLUSION

Results support decision-making deficits in EDs, which may be related to a dysfunctional determination of risk versus reward. This study is the first to suggest that the relationship between perfectionism and risk taking may manifest differently in these phenotypically similar disorders.

Compulsive exercise and eating disorders

The aim of this review was to develop an empirically supported cognitive behavioural model of compulsive exercise within the context of the eating disorders. A systematic review of the correlates and predictors of compulsive exercise among eating disordered patients identified four key correlates. These were subsequently validated by a second review, incorporating both the clinical and non-clinical as well as the exercise science literatures. A proposed model is presented which is both evidence-based and testable.

Group schema therapy for eating disorders: a pilot study

This paper describes the use of Group Schema Therapy for Eating Disorders (ST-E-g) in a case series of eight participants with chronic eating disorders and high levels of co-morbidity. Treatment was comprised of 20 sessions which included cognitive, experiential, and interpersonal strategies, with an emphasis on behavioral change. Specific schema-based strategies focused on bodily felt-sense and body-image, as well as emotional regulation skills. Six attended until end of treatment, two dropped-out at mid-treatment. Eating disorder severity, global schema severity, shame, and anxiety levels were reduced between pre- and post-therapy, with a large effect size at follow-up. Clinically significant improvement in eating severity was found in four out of six completers. Group completers showed a mean reduction in schema severity of 43% at post-treatment, and 59% at follow-up. By follow-up, all completers had achieved over 60% improvement in schema severity. Self-report feedback suggests that group factors may catalyze the change process in schema therapy by increasing perceptions of support and encouragement to take risks and try out new behaviors, whilst providing a de-stigmatizing and de-shaming therapeutic experience.