Early maladaptive schemas and suicidal risk in an Iranian sample of patients with obsessive-compulsive disorder

The importance of examining early maladaptive schemas in the diagnosis and treatment of obsessive-compulsive disorder

Introduction

The aim of the study was twofolded: to identify the early maladaptive schemas characteristic of obsessive-compulsive disorder in a Hungarian sample and, to examine the presence and severity of comorbid anxiety and depressive symptoms in the light of early maladaptive schemas.

Methods

112 participants (58 men and 54 women) diagnosed with OCD were involved in the study. The questionnaire package consisted of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), the State-Trait Anxiety Inventory (STAI), the Beck Depression Inventory (BDI), the Penn State Worry Questionnaire (PSWQ) and the Schema Questionnaire (SQ).

Results

We identified five early maladaptive schemas with a direct effect on the manifestation of obsessive-compulsive symptoms: Mistrust-Abuse, Inferiority/Shame, Dependence/Incompetence, Insufficient Self-Control/Self-Discipline and Entitlement/Grandiosity (reversed effect). Based on the severity of the early maladaptive schemas, three significantly different groups could be identified in our sample: patients with mild, moderate and high schema-values. Among the groups significant differences can be found in the appearance and severity of compulsive symptoms, as well as in the presence of anxiety and depressive symptoms. But contrary to our expectations, not the severity, but the numberof the early maladaptive schemas showed a stronger correlation with the symptom variables. An additional result of our study derives from canonical correlation, addressing the relationship among early maladaptive schemas, OCD symptoms, anxiety and depressive symptoms from a new perspective. The results highlight that OCD is only one and not the most serious consequence of personality damage, indicated by early maladaptive schemas.

Discussion

The results of our study suggest that obsessive-compulsive disorder can be divided into several subgroups, which can be separated in terms of symptom severity, comorbid psychiatric symptoms and personality impairment patterns. The relationship between OCD symptom severity and personality impairment seems to be not directly proportional. Our results strengthen the new dimensional view of OCD, which can determine the selection of the appropriate therapeutic treatment method beyond the diagnostic process.

Early Maladaptive Schemas and Schema Modes among People with Histories of Suicidality and the Possibility of a Universal Pattern: A Systematic Review

BACKGROUND

The identification of variables affecting suicidality and the search for interventions to reduce suicide risk are priorities among mental health researchers. A promising direction for such research is schema therapy and its two main constructs, i.e., early maladaptive schemas (EMSs) and schema modes.

METHODS

This systematic review was designed in accordance with the PRISMA guidelines. It summarizes the studies conducted to date that describe the relationship between EMSs and schema modes and measures of suicidality in individuals over the age of 16.

RESULTS

The review confirmed that there are many significant associations between EMSs (especially from the Disconnection/Rejection domain) and suicide risk. Although only one study was found that explores the association between schema modes and suicidality, the correlations it identified are also confirmed here.

DISCUSSION

The results show the unquestionable importance of EMSs and schema modes in assessing suicide risk. The co-occurrence of these variables represents the first step in further assessing causality and introducing schema therapy techniques into work with patients who are at risk of suicide. This issue requires more extensive experimental research.

Effect Modification of Cortisol on the Associations Between Obsessive-Compulsive Symptoms on Suicidality in Patients With Acute Coronary Syndrome

OBJECTIVE

Obsessive-compulsive symptoms (OCS) and suicidal ideation (SI) are common in patients with acute coronary syndrome (ACS). This study investigated the associations of OCS and serum cortisol levels with SI, and further evaluated the possible modifying effects of cortisol on the associations between OCS and SI in acute and chronic phases of ACS.

METHODS

In total, 969 ACS patients were recruited from a tertiary university hospital in Korea within 2 weeks of disease onset and evaluated in terms of OCS (using the OCS dimension of the Symptom Checklist-90-Revised), serum cortisol levels, and SI (using the "suicidal thoughts" item of the Montgomery-Åsberg Depression Rating Scale). Covariates included sociodemographics, depression, vascular risk factors, and disease severity. After 1 year, 711 patients were re-evaluated in terms of SI. Logistic regression analysis was performed with adjustment for covariates.

RESULTS

Higher OCS was significantly associated with SI both at baseline and follow-up. Serum cortisol showed no such association, but modified the association between OCS and SI. That was the associations were significant only in the higher but not in the lower serum cortisol levels, with significant interaction terms after adjusted for relevant covariates.

CONCLUSION

Evaluating OCS and serum cortisol levels at the acute phase could improve the accuracy of clinical predictions of SI both in the acute and chronic phases of ACS.

Exploring the associations between early maladaptive schemas and impulsive and compulsive buying tendencies

The main purpose of this preliminary study was to investigate a potential relationship between early maladaptive schemas (EMSs) and impulsive and compulsive buying tendencies in a sample of young adults (college students). This research adds to the cognitive perspective of consumer behavior that the cognitive schemas putatively associated with early experiences may have a strong impact on impulsive and compulsive buying. Data was obtained from 365 participants in a cross-sectional study design. Participants completed an online survey with the following instruments: Young Schema Questionnaire; Impulsive Buying Tendency Measurement Scale; Richmond Compulsive Buying Scale; and Hospital Anxiety and Depression Scale. Using multiple linear hierarchical regressions, we confirmed that the domain of over vigilance and inhibition schemas was positively associated with impulsive and compulsive buying tendencies, while an opposite association was found for the domain of impaired limits. Being a female was also a predictor of impulsive buying and compulsive buying. The results were discussed in terms of the coping mechanisms to deal with negative emotions, as a way to obtain rewards, or as a way to escape painful self-awareness. Other mechanisms related to the internalization of perfectionist expectations and the propensity to shame were also explored.

Suicidal Behavior and Early Maladaptive Schemas and Schema Domains

ABSTRACT

Suicidal behavior is a risk factor for suicide attempts. Identifying the factors that increase suicidal behavior risk is paramount for overall suicide prevention efforts. One model that may contribute to our understanding of the relationship between early life experiences and suicidal behavior is the schema theory. This study aimed to examine suicidal behavior, early maladaptive schemas (EMSs), and schema domains using a large Brazilian nonclinical sample. The study included 19,060 individuals. We assessed sociodemographic variables, suicidal behavior (Suicidal Behavior Questionnaire), and EMSs (Young Schema Questionnaire) using an online, Web-based survey. Our results showed that, when comparing participants with no ideation with those with serious suicide attempts, we found significant statistical differences in all EMSs (all p 's < 0.05), with higher scores in those with serious suicide attempts. Our results suggest that specific unmet emotional needs during childhood can affect mental health and result in serious suicide attempts in adulthood.

Core clinical symptoms and suicidal ideation in patients with obsessive-compulsive disorder: A network analysis

INTRODUCTION

Suicidality in obsessive-compulsive disorder (OCD) is underestimated and it is important for clinicians to understand the factors that contribute to suicidal ideation. The present study aimed to estimate a network of the core clinical symptoms of OCD including obsessions, compulsions, and obsessive-compulsive (OC) symptom dimensions, depressive symptoms, and psychological traits, and to examine which symptoms contribute to suicidal ideation in patients with a primary diagnosis of obsessive-compulsive disorder.

METHODS

A total of 444 patients with OCD were assessed with the Yale-Brown Obsessive-Compulsive Scale, the Montgomery-Asberg Depression Rating Scale, and various other measures. Network analysis was conducted to estimate the network of obsessive-compulsive and depressive symptoms, psychological traits including alexithymia and impulsivity, and demographic covariates. Symptoms directly related to suicidal ideation in the network were examined for their relative contribution to suicidal ideation.

RESULTS

Suicidal ideation was directly related to degree of control over compulsive behaviors, distress associated with compulsive behaviors, time spent performing compulsive behaviors, and unacceptable thoughts, along with depressive symptoms and alexithymia. In the network of OC and depressive symptoms the most central symptoms among the former were interference due to compulsive behaviors and interference due to obsessive thoughts, and among the latter were pessimistic thoughts and reported sadness.

CONCLUSION

The findings suggest that along with depressive symptoms and alexithymia, compulsions and unacceptable thoughts dimension may contribute to suicidality, and thus, should be carefully monitored in patients with OCD.

Childhood emotional maltreatment, maladaptive coping and obsessive-compulsive symptoms in patients with obsessive-compulsive disorder

Previous studies have reported childhood emotional maltreatment (CEM) to be associated with specific obsessive-compulsive (OC) symptoms, but maladaptive coping, which may be the underlying mechanism in this relationship, has not been evaluated yet. Thus, the present study aimed to examine the effects of CEM on the OC symptoms of responsibility for harm and unacceptable thoughts, as well as obsessive-compulsive disorder (OCD) severity, through maladaptive coping, including cognitive avoidance, experiential avoidance and emotional suppression in OCD patients (n = 360). The results showed that CEM had direct effects, as well as indirect effects via cognitive and experiential avoidance and emotional suppression, on responsibility for harm and unacceptable thoughts. In addition, the indirect effect of CEM on OCD severity was significantly mediated by the roles of cognitive avoidance and experiential avoidance. The present study adds new literature to evidence indicating the role of early childhood events in developing and maintaining OCD in which adverse maladaptive coping related to unpleasant childhood abuse plays an important role in OCD. More precisely, OCD patients who experience a history of CEM may further use maladaptive coping to cope with their distress and subsequently experience responsibility for harm, unacceptable thoughts and severe OCD.

Suicidal Ideation and Obsessive-Compulsive Disorder: Links and Knowledge

Suicidal ideation (SI) is understudied in obsessive-compulsive disorder (OCD). Nonetheless, evidence suggests increased risk for SI in individuals with OCD compared to the general population. Understanding the relationship between SI and OCD involves investigating risk factors associated with SI. Furthering knowledge of links is essential for enhancing outcomes and decreasing experiences of SI through improving treatment interventions. Additionally, increasing awareness of factors that lead SI to suicide attempts (SA) is vital. To best illustrate the current state of knowledge, this scoping review examines risk factors for SI, including symptom profiles or phenotypes, comorbid diagnoses, sociodemographic and lifestyle factors, childhood trauma, and genetic and familial contributions. Important treatment considerations for targeting SI within the context of OCD are detailed with respect to the current evidence for psychotherapy, pharmacology, brain stimulation, and neurosurgery. Gaps in the literature and future directions are identified, broadly with respect to studies examining the treatment of SI within the context of OCD, particular OCD phenotypes, and factors influencing SI in pediatric OCD. Due to the relative novelty of this area of exploration, many unknowns persist regarding onset of SI in OCD, factors contributing to the maintenance of SI in OCD, and relevant treatment protocols. Findings suggest that individuals with previous SI or SA, history of childhood trauma, significant life stress, and psychiatric comorbidities, particularly depression, should be closely monitored and screened for SI.

The associations of obsessive-compulsive symptom dimensions and general severity with suicidal ideation in patients with obsessive-compulsive disorder: The role of specific stress responses to COVID-19

Suicidal ideation is prevalent in patients with obsessive–compulsive disorder (OCD); but, during COVID‐19, it may be increased. The present study aimed to examine the effects of obsessive–compulsive (OC) symptom dimensions and OCD severity on suicidal ideation by considering the role of stress responses in reaction to COVID‐19 in a clinical sample of patients with OCD. In a cross‐sectional study, 304 patients with OCD completed measures of OC symptom dimensions, OCD severity, general mental health (depression and anxiety), and COVID‐19‐related stress. Results showed that after controlling for depression, anxiety, comorbidity, and lifetime suicide attempts, the OC symptom dimensions of responsibility for harm and unacceptable obsessional thoughts as well as general severity had indirect effects on suicidal ideation through the specific stress responses to COVID‐19, including traumatic stress and compulsive checking. The study shows that OCD patients with specific OC symptom dimensions and severe OCD are more likely to have suicidal ideation during the pandemic. Further, the specific stress responses to COVID‐19 may be an underlying mechanism. Clinicians should carefully assess suicidal ideation in patients with OCD who experience responsibility for harm and unacceptable thoughts, particularly during the pandemic.

The effect of childhood maltreatment on suicidal ideation through cognitive emotion regulation strategies and specific obsessive-compulsive symptoms in obsessive-compulsive disorder

Childhood maltreatment is thought to be associated with suicidality in patients with obsessive-compulsive disorder (OCD). Although the underlying mechanism of this relationship is not clear, cognitive emotion regulation strategies (CERSs) and the specific OC symptoms including unacceptable obsessional thoughts (UOTs) and responsibility for harm (RFH) may underlie this link. Accordingly, the study aimed to assess the effect of childhood maltreatment on suicidal ideation through UOTs, RFH and adaptive and maladaptive CERSs in OCD patients. Three hundred patients meeting a DSM-5 diagnosis of OCD were selected and completed the scales measuring childhood maltreatment, OCD, suicidality and depressive symptoms. After controlling for depressive symptoms and OCD severity, childhood maltreatment was shown to affect suicidal ideation directly. Also, the indirect effect of childhood maltreatment on suicidal ideation was mediated by adaptive CERSs, UOTs and RFH. The findings show that OCD patients with a history of childhood maltreatment, less use of adaptive CERSs and the experiences of UOTs and RFH should be carefully considered regarding suicidal risk.

Suicide attempts and suicidal ideation in patients with obsessive-compulsive disorder: A systematic review and meta-analysis

INTRODUCTION

There is controversy on the magnitude of suicide risk in OCD and on the psychopathological features that raise the risk. This systematic review and meta-analysis aims to estimate the pooled prevalence of suicide attempts and suicidal ideation (current/lifetime) in subjects with OCD and identify sociodemographic and clinical factors associated with greater risk.

METHODS

We conducted a literature search in PubMed/Medline, PsycINFO, Web of Science and CINAHL databases up to June 20, 2019, according to PRISMA guidelines. Stata statistical software (Version 15) was used to obtain forest plots, execute subgroup analyses and perform univariate and multivariate meta-regressions.

RESULTS

We found 61 eligible studies including OCD patients: 52 investigated suicide attempts and reported a pooled prevalence of 0.135 (95% CI 0.123-0.147); 26 explored current suicidal ideation and reported a pooled prevalence of 0.273 (95% CI 0.214-0.335); 22 researched lifetime suicidal ideation and reported a pooled prevalence of 0.473 (95% CI 0.397-0.548). Severity of obsessions, comorbid substance use and depressive/anxious symptoms increased the risk, whereas compulsions had a comparatively protective effect.

LIMITATIONS

Owing to the small number of studies reporting completed suicide rates, this metric was not included in the meta-analysis. The degree of heterogeneity between the studies was high.

CONCLUSION

Clinicians should keep in mind that one out of ten patients with OCD attempts suicide during his/her lifetime, about one third has current suicidal ideation and about half has had suicidal ideation in the past. Several clinical features are associated with increased risk and should be factored into clinical risk management.

Direct and Indirect Effects of Behavioral Inhibition/Activation Systems on Depression and Current Suicidal Ideation Through Rumination and Self-Reflection

This study aimed to evaluate direct and indirect effects of the behavioral inhibition system (BIS) and the behavioral activation system (BAS) on depression and current suicidal ideation through rumination and self-reflection in a sample of suicide attempters. Three hundred suicide attempters completed the Rumination/Reflection Questionnaire (RRQ), the Carver and White BIS/BAS scales, the Beck Scale for Suicide Ideation (BSSI), and the Beck Depression Inventory-II (BDI-II). Results revealed that the BAS and BIS had direct effects on suicidal ideation but not depression. Low BAS had an indirect effect on depression through decreased self-reflection. High BIS had an indirect effect on depression via increased rumination. Low BAS and high BIS had indirect effects on suicidal ideation through decreased self-reflection. The findings suggest that low BAS and high BIS may be associated with depression and suicidal ideation in suicide attempters who have decreased self-reflection and increased rumination. Also, increasing self-reflection and reducing rumination as respectively adaptive and maladaptive self-focused attention strategies may prohibit depression and suicidal ideation.

Impulsivity, hostility and suicidality in patients diagnosed with obsessive compulsive disorder

Background: There are limited data on suicidal behaviour in obsessive-compulsive disorder (OCD). This study aimed to evaluate several aspects affecting suicidality in OCD patients and determine whether impulsivity or hostility are associated with suicide attempts in this vulnerable group.Methods: Eighty-one patients with OCD were assessed by structured clinical interview for DSM-IV (SCID I), Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Suicide Probability Scale (SPS), Barratt impulsivity scale-11 (BIS) and Scale for suicide ideation (SSI).Results: Of the 81 patients, 22 (27%) had suicide ideation, 29 (33%) attempted suicides with OCD and 30 (37%) OCD patients who never experienced suicide ideation nor attempted suicide. Suicide ideation was associated with high hopelessness, higher severity of OCD and the presence of aggressive obsessions. On the other hand, suicide attempts were associated with longer duration of untreated illness, cognitive impulsivity, higher severity of OCD symptoms and the presence of religious obsessions.Conclusion: Higher severity of OCD symptoms is associated with both suicide ideation and attempts. And while hopelessness was related to suicidal thoughts, cognitive impulsivity may have acted as a facilitating factor for suicide attempts. Higher frequency of symptoms like religious/ aggressive obsessions was also associated with suicidality. It is vital that patients with OCD undergo detailed assessment for suicide risk.Key pointsOCD is associated with a high risk for suicidal behaviour.Suicide ideation was associated with high levels of hopelessness, OCD severity, and the presence of aggressive obsessions.Suicide attempts were associated with longer duration of untreated illness, cognitive impulsivity, severity of OCD, and the presence of religious obsessions.

Suicide Risk in Obsessive-Compulsive Disorder and Exploration of Risk Factors: A Systematic Review

BACKGROUND

Historically, OCD has been considered to be associated with a relatively low risk of suicide. Recent studies, on the contrary, revealed a significant association between OCD and suicide attempts and ideation. A huge variation in prevalence rates, however, is reported.

OBJECTIVE

To estimate prevalence rates of suicide attempts and suicidal ideation in individuals with OCD, and to identify predictors of suicide risk among subjects with OCD.

METHODS

We systematically reviewed the literature on suicide risk (ideation and/or attempts) and OCD. We included studies with appropriate definition of OCD, cross-sectional or prospective design, separating clinical samples from epidemiological studies, that employed a quantitative measure of suicidality and/or reported an outcome measure of the association between suicidality and OCD or examined factors associated with suicidality.

RESULTS

In clinical samples, the mean rate of lifetime suicide attempts is 14.2% (31 studies: range 6- 51.7%). Suicidal ideation is referred by 26.3-73.5% of individuals (17 studies, mean 44.1%); current suicidal ideation rate ranges between 6.4 and 75% (13 studies, mean 25.9). Epidemiological studies found that OCD increases significantly the odds of having a lifetime suicidal ideation as compared to the general population (OR: 1.9-10.3) and a history of lifetime suicide attempts (OR: 1.6- 9.9). Predictors of greater suicide risk are severity of OCD, the symptom dimension of unacceptable thoughts, comorbid Axis I disorders, severity of comorbid depressive and anxiety symptoms, past history of suicidality and some emotion-cognitive factors such as alexithymia and hopelessness.

CONCLUSION

Overall, suicidality appears a relevant phenomenon in OCD.

Early maladaptive schemas in patients with schizophrenia and non-patients with high and low schizotypal traits and their differences based on depression severity

BACKGROUND

The aims of this study were to predict positive and negative symptoms of psychosis via early maladaptive schemas (EMSs) in patients with schizophrenia (SZ); to compare EMSs among SZ patients, non-patients with high schizotypal traits, and non-patients with low schizotypal traits; and to compare EMSs among subgroups concerning depression severity.

METHODS

We applied three groups of participants including SZ patients (n = 105), non-patients with low schizotypal traits (n = 90), and non-patients with high schizotypal traits (n = 90). Participants completed the Young Schema Questionnaire-Short Form (YSQ-SF), the Positive and Negative Syndrome Scale (PANSS), the Schizotypal Personality Scale (STA), and the Beck Depression Inventory-II (BDI-II).

RESULTS

The results indicated that the mistrust/abuse and social isolation schemas were significant predictors of positive and negative symptoms in SZ patients respectively. SZ patients and non-patients with high schizotypal traits exceeded non-patients with low schizotypal traits on all EMSs. There were no differences between SZ patients and non-patients with high schizotypal traits regarding EMSs. In the subgroups with high depression, SZ patients showed higher levels of EMSs than non-patients with low and high schizotypal traits. In the subgroups with low depression, both SZ patients and non-patients with high schizotypal traits had higher scores on EMSs than non-patients with low schizotypal traits.

CONCLUSION

The findings suggest that mistrust/abuse and social isolation may be specific to psychosis symptoms. Also, SZ and schizotypal traits may overlap in relation to EMSs. In addition, the activated EMSs may contribute to high depression in SZ.

Early maladaptive schemas and suicidal risk in inpatients with bipolar disorder

The present study aimed to assess the associations of early maladaptive schemas (EMSs) and clinical factors (hypomanic/manic and depressive symptoms) with suicidal risk (current suicidal ideation and lifetime suicide attempts) in inpatients with bipolar disorder (BD). One hundred inpatients with BD completed the Young Schema Questionnaire-Short Form (YSQ-SF), the Bipolar Depression Rating Scale (BDRS), the Young Mania Rating Scale (YMRS), and the Beck Scale for Suicide Ideation (BSSI). 59% of patients had lifetime suicide attempts and 59% showed high suicidal risk (BSSI ≥ 6). BD patients with lifetime suicide attempts had higher scores on the entitlement and social isolation schemas, depression, and hypomanic/manic symptoms than those without such attempts. Patients with high suicidal risk had higher levels of depressive and hypomanic/manic symptoms as well as some EMSs than those without high suicidal risk. Logistic regression analyses revealed that hypomanic/manic symptoms as well as the entitlement and defectiveness schemas were significantly associated with current suicidal ideation. Also, the entitlement and social isolation schemas were associated with lifetime suicide attempts. These results suggest that the entitlement, social isolation, and defectiveness schemas may relate to suicidal risk in patients with BD.

Schema therapy conceptualization of personality functioning and traits in ICD-11 and DSM-5

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 (e.g., compliant surrender) and underlying schemas (e.g. abandonment), which inform focus and style of treatment.

When patients with OCD decide to seek, and not to avoid harm: The problem of suicidality in OCD

Obsessive-compulsive disorder (OCD) is a chronic, distressing, and disabling condition associated with a high risk of suicidal behavior and death by suicide. In this study, the authors describe two cases of OCD patients who developed recurrent suicidal behaviors in response to stressful life events that appeared to “confirm” their obsessive beliefs (termed “confirmatory events”). In both cases, the authors used accepted strategies for treating suicidality in other contexts (such as antidepressants, lithium, and electroconvulsive therapy), which proved unsuccessful. Future studies should investigate personalized strategies to treat suicidality and prevent suicide in OCD patients.