Is schema therapy effective for adults with eating disorders? A systematic review into the evidence

Early maladaptive schemas mediate the relationship between severe childhood trauma and eating disorder symptoms: evidence from an exploratory study

BACKGROUND

Childhood trauma history has frequently been linked to eating disorders (EDs); nevertheless, the scientific literature calls for extending knowledge regarding mediators between EDs and childhood trauma. This study explored whether ED symptoms and early maladaptive schemas were more severe in ED patients with severe childhood trauma than in ED patients with no/mild childhood trauma and whether early maladaptive schemas mediated the relationship between childhood trauma and ED symptom severity.

METHODS

Data were extracted from the Regional Centre for Eating Disorders registry at the University Hospital of Verona. The extracted data included self-reported data, including the Eating Disorder Inventory-3 score, Young Schema Questionnaire score, Childhood Experience and Experience of Care and Abuse Questionnaire score, and sociodemographic and clinical information on the ED outpatients seeking care. A mediation analysis using the structural equation modeling procedure was conducted.

RESULTS

Forty-two outpatients, 31% of whom exhibited severe childhood trauma, satisfied the criteria for registry data extraction. The severity of ED symptoms, as well as the early maladaptive schemas' scores for emotional deprivation, defectiveness, failure, vulnerability, insufficient self-control, and negativity, were greater in ED outpatients with severe childhood trauma. Furthermore, early maladaptive schemas related to defectiveness, failure, and negativity had a mediating role in the relationship between severe childhood trauma and ED symptom severity.

CONCLUSIONS

This exploratory study provides preliminary evidence about the importance of early maladaptive schemas in the relationship between trauma history and ED psychopathology. In addition, ED symptoms may represent a dysfunctional attempt to avoid unpleasant emotions associated with schema activation. The results support the need to consider early maladaptive schemas in the treatment of traumatized patients with ED symptoms. Study limitations, research and clinical implications are discussed.

Early adaptive schemas, emotional regulation, and cognitive flexibility in eating disorders: subtype specific predictors of eating disorder symptoms using hierarchical linear regression

PURPOSE

Understanding how early adaptive schemas, cognitive flexibility, and emotional regulation influence eating disorder (ED) symptoms, and whether this differs across diagnostic subtypes is critical to optimising treatment. The current study investigated the relationship between these variables and ED symptomology in individuals self-reporting an ED diagnosis and healthy controls.

METHODS

A dataset of 1576 online survey responses yielded subsamples for anorexia nervosa (n = 155), bulimia nervosa (n = 55), binge eating disorder (n = 33), other specified feeding or eating disorder (n = 93), and healthy participants (n = 505). The hierarchical linear regression analysis included Eating Disorder Examination Questionnaire 6.0 Global Score as the dependent variable; Young Positive Schema Questionnaire, Emotional Regulation Questionnaire, and Cognitive Flexibility Inventory subscale scores as the independent variables; and demographic measures as the covariates.

RESULTS

The number of significant predictors varied considerably by ED sub-group. Amongst the anorexia nervosa, bulimia nervosa, and healthy subsamples, the adaptive schema Self-Compassion and Realistic Expectations was associated with lower ED symptom severity. In comparison, age and body mass index were the strongest predictors for binge eating disorder, whilst the Expressive Suppression (a subscale of the Emotional Regulation Questionnaire) was the strongest predictor for other specified feeding or eating disorders.

CONCLUSION

Early adaptive schemas, cognitive flexibility, and emotional regulation vary across ED subtype, suggesting the need for tailored treatment that disrupts the self-reinforcing cycle of ED psychopathology. Future research investigating how early adaptive schemas may predict or be associated with treatment response across diagnostic subtypes is needed.

LEVEL OF EVIDENCE

Level IV, evidence obtained from multiple time-series with or without the intervention, such as case studies.

Schema therapy versus treatment as usual for outpatients with difficult-to-treat depression: study protocol for a parallel group randomized clinical trial (DEPRE-ST)

BACKGROUND

About one third of patients with depression are in a condition that can be termed as "difficult-to-treat". Some evidence suggests that difficult-to-treat depression is associated with a higher frequency of childhood trauma and comorbid personality disorders or accentuated features. However, the condition is understudied, and the effects of psychotherapy for difficult-to-treat depression are currently uncertain. The aim of this trial is to investigate the beneficial and harmful effects of 30 sessions of individual schema therapy versus treatment as usual for difficult-to-treat depression in the Danish secondary, public mental health sector.

METHODS

In this randomized, multi-centre, parallel-group, superiority clinical trial, 129 outpatients with difficult-to-treat depression will be randomized (1:1) to 30 sessions of individual schema therapy or treatment as usual; in this context mainly group-based, short-term cognitive behaviour or psychodynamic therapy. The primary outcome is the change from baseline in depressive symptoms 12 months after randomization, measured on the observer-rated 6-item Hamilton Rating Scale for Depression. The secondary outcomes are health-related quality of life assessed with the European Quality of Life 5 Dimensions 5 Level Version, functional impairment assessed with the Work and Social Adjustment Scale, psychological wellbeing assessed with the WHO-5 Well-being Index, and negative effects of treatment assessed with the Negative Effects Questionnaire. Exploratory outcomes are improvement on patient self-defined outcomes, personal recovery, anxiety symptoms, anger reactions, metacognitive beliefs about anger, and perseverative negative thinking. Outcomes will be assessed at 6, 12, and 24 months after randomization; the 12-month time-point being the primary time-point of interest. Outcome assessors performing the depression-rating, data managers, statisticians, the data safety and monitoring committee, and conclusion makers for the outcome article will be blinded to treatment allocation and results. To assess cost-effectiveness of the intervention, a health economic analysis will be performed.

DISCUSSION

This trial will provide evidence on the beneficial and harmful effects, as well as the cost-effectiveness of schema therapy versus treatment as usual for outpatients with difficult-to-treat depression. The results can potentially improve treatment for a large and understudied patient group.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05833087. Registered on 15th April 2023 (approved without prompts for revision on 27th April 2023).

Clinical effectiveness, cost-effectiveness and process evaluation of group schema therapy for eating disorders: study protocol for a multicenter randomized controlled trial

BACKGROUND

Eating disorders (EDs), such as (atypical) Anorexia (AN) and Bulimia Nervosa (BN), are difficult to treat, causing socioeconomic impediments. Although enhanced cognitive behavioral therapy (CBT-E) is widely considered clinically effective, it may not be the most beneficial treatment for (atypical) AN and BN patients who do not show a rapid response after the first 4 weeks (8 sessions) of a CBT-E treatment. Alternatively, group schema therapy (GST) may be a valuable treatment for this ED population. Even though GST for EDs has yielded promising preliminary findings, the current body of evidence requires expansion. On top of that, data on cost-effectiveness is lacking. In light of these gaps, we aim to describe a protocol to examine whether GST is more (1) clinically effective and (2) cost-effective than CBT-E for (atypical) AN and BN patients, who do not show a rapid response after the first 4 weeks of treatment. Additionally, we will conduct (3) process evaluations for both treatments.

METHODS

Using a multicenter RCT design, 232 Dutch (atypical) AN and BN patients with a CBT-E referral will be recruited from five treatment centers. Clinical effectiveness and cost-effectiveness will be measured before treatment, directly after treatment, at 6 and at 12 months follow-up. In order to rate process evaluation, patient experiences and the degree to which treatments are implemented according to protocol will be measured. In order to assess the quality of life and the achievement of personalized goals, interviews will be conducted at the end of treatment. Data will be analyzed, using a regression-based approach to mixed modelling, multivariate sensitivity analyses and coding trees for qualitative data. We hypothesize GST to be superior to CBT-E in terms of clinical effectiveness and cost-effectiveness for patients who do not show a rapid response to the first 4 weeks of a CBT-E treatment.

DISCUSSION

To our knowledge, this is the first study protocol describing a multicenter RCT to explore the three aforementioned objectives. Related risks in performing the study protocol have been outlined. The expected findings may serve as a guide for healthcare stakeholders to optimize ED care trajectories.

TRIAL REGISTRATION

clinicaltrials.gov (NCT05812950).

New understandings meet old treatments: putting a contemporary face on established protocols

In the twenty years since the publication of the most widely used treatment manuals describing evidence-based therapies for eating disorders, there have been some substantial advances in the field. New methods of delivering treatments have been trialled and our perception of mental health has advanced; significant cultural changes have led to shifts in our societal landscape; and new technologies have allowed for more in-depth research to be conducted. As a result, our understanding of eating disorders and their treatment has broadened considerably. However, these new insights have not necessarily been translated into improved clinical practice. This paper highlights the changes we consider to have had the greatest impact on our work as experienced clinical psychologists in the field and suggests a list of new learnings that might be incorporated into clinical practice and research design.

Schema therapy in adults with autism spectrum disorder: A scoping review

BACKGROUND

Schema therapy (ST) in adults with autism spectrum disorder (ASD) have gained increasing interest in clinical practice and research. However, to date, there has been no synthesis of the literature on ST as treatment for adults with ASD. Through a scoping review, we aim to summarize the emerging research and literature on ST for adults with ASD.

METHODS

A comprehensive literature search of three electronic databases was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. Publications were included that examined ST in adults with ASD and non-clinical adults with autistic traits.

RESULTS

Systematic searches identified a total of 11 publications, all published since 2014, with the majority being conducted by Dutch and Japanese researchers. Of the 11 publications, 1 described an ST-informed social interaction training, 1 was an ST protocol, 2 described conceptual ST models, 2 were case examples, 2 examined early maladaptive schemas (EMSs) and 3 investigated the effectiveness of ST interventions. In summary, the theoretical exploration, practical examples of the application of ST and research findings with preliminary evidence of ST, EMSs and schema modes (SMs) in adults with ASD point towards the potential of ST for the treatment of adults with ASD.

DISCUSSION

The current scoping review highlights preliminary research findings and offers valuable suggestions for clinicians treating adults with ASD. This review underscores the need for development of and research in specialized ST protocols and programmes tailored to adults with ASD with chronic mental conditions, such as personality disorders (PDs).

What role do early life experiences play in eating disorders? The impact of parenting style, temperament and early maladaptive schemas

OBJECTIVE

Given that most eating disorders develop in adolescence and early adulthood, early life experiences are said to play a key role in the aetiology of eating disorders. There are well-documented relationships between early maladaptive schemas and eating disorders, early maladaptive schemas and temperament and temperament and perceived parenting style. The present study aimed to test a hypothesis that perceived parenting style predicts temperament, which predicts early maladaptive schemas, which predict eating disorder symptoms in young people.

METHOD

An online survey measured perceived parenting style, temperament, early maladaptive schemas and eating disorder symptoms in 397 people with disordered eating between the ages of 18 and 29. Path analysis was used to investigate the relationship between these elements.

RESULTS

The results found support for this hypothesis. Perceived maladaptive parenting ratings for mothers were a stronger predictor of temperament, and only two temperament factors were adequate predictors of early maladaptive schemas.

CONCLUSIONS

Overall, the present study found preliminary support for a linear relationship where perceived parenting style predicts temperament, which predicts early maladaptive schema levels, which predicts eating disorder symptoms. The present study was the first to propose and test this model; however, further research is required to confirm the nature and extent of this relationship.

The Impact of Anorexia Nervosa and the Basis for Non-Pharmacological Interventions

Anorexia nervosa is a psychiatric disorder with an unknown etiology that is characterized by an individual's preoccupation with their weight and body structure while denying the severity of their low body weight. Due to the fact that anorexia nervosa is multifaceted and may indicate the coexistence of genetic, social, hormonal, and psychiatric disorders, a description of non-pharmacological interventions can be used to ameliorate or reduce the symptoms of this condition. Consequently, the purpose of the present narrative review is to describe the profile's context in the anorexic person as well as the support they would require from their family and environment. In addition, it is aimed at examining preventative and non-pharmacological interventions, such as nutritional interventions, physical activity interventions, psychological interventions, psychosocial interventions, and physical therapy interventions. To reach the narrative review aims, a critical review was conducted utilizing both primary sources, such as scientific publications, and secondary sources, such as bibliographic indexes, web pages, and databases. Nutritional interventions include nutritional education and an individualized treatment for each patient, physical activity interventions include allowing patients to perform controlled physical activity, psychological interventions include family therapy and evaluation of the existence of other psychological disorders, psychosocial interventions include management of the relationship between the patient and social media and physical therapy interventions include relaxation massages and exercises to relieve pain. All these non-pharmacological interventions need to be individualized based on each patient's needs.