Early maladaptive schemas in overweight and obesity: A schema mode model

Using latent class analysis to identify different clinical profiles according to food addiction symptoms in obesity with and without binge eating disorder

Background and aims

Existing research suggests that food addiction (FA) is associated with binge eating disorder (BED) and obesity, but the clinical significance of this relationship remains unclear. This study aims to investigate the different clinical profiles of FA symptoms among patients who have obesity with/without BED using latent class analysis (LCA).

Methods

307 patients (n = 152 obesity and BED, n = 155 obesity without BED) completed a battery of self-report measures investigating eating psychopathology, depression, emotional dysregulation, alexithymia, schema domains, and FA. LCA and ANOVAs were conducted to identify profiles according to FA symptoms and examine differences between classes.

Results

LCA identified five meaningful classes labeled as the "non-addicted" (40.4%), the "attempters" (20.2%), the "interpersonal problems" (7.2%), the "high-functioning addicted" (19.5%) and the "fully addicted" (12.7%) classes. Patients with BED and obesity appeared overrepresented in the "high-functioning addicted" and "fully addicted" classes; conversely, patients with obesity without BED were most frequently included in the "non-addicted" class. The most significant differences between the "high-functioning addicted" and "fully addicted" classes versus the "non-addicted" class regarded heightened severity of eating and general psychopathology.

Discussion and conclusions

The results bring to light distinct clinical profiles based on FA symptoms. Notably, the "high-functioning addicted" class is particularly intriguing as its members demonstrate physical symptoms of FA (i.e., tolerance and withdrawal) and psychological ones (i.e., craving and consequences) but are not as functionally impaired as the "fully addicted" class. Identifying different profiles according to FA symptoms holds potential value in providing tailored and timely interventions.

Early maladaptive schemas and behavioural addictions: A systematic literature review

As observed in other mental health difficulties, behavioural addiction is a complex construct with several potential predisposing factors, which include biological factors (e.g., genetic predispositions), psychological factors (e.g., personality traits), and social factors (e.g., family, and social history). One factor that may play a significant role in both developing and perpetuating behavioural addiction is the activation of early maladaptive schemas (EMSs). The aim of the present review was to synthesize the evidence concerning the relationship between behavioural addiction and EMSs. A comprehensive literature search using keywords and subject headings was performed with three electronic databases, resulting in 20 studies that met the inclusion criteria. In relation to specific behavioural addiction, the 20 studies examined: binge-eating/food addiction (n = 6), sexual addiction/compulsive sexual behaviours (n = 3), multiple addictive behaviours (n = 2), internet addiction (n = 2), smartphone addiction (n = 2), social networking/Facebook addiction (n = 2), exercise dependence (n = 1), gambling (n = 1), and videogame addiction (n = 1). The patterns of association between EMS and behavioural addiction were examined in both clinical and non-clinical population. The 'Disconnection and Rejection' domain was the most strongly related schema domain across all addictive behaviours, followed by 'Impaired Limits'. The present review suggests a positive relationship between schema activation and several addictive behaviours, including addictions to gambling, gaming, social media use sex, exercise, and food. The clinical implications of the findings are discussed, but further research is needed to inform treatment plans and interventions for those who struggle with behavioural addictions.

The association between early maladaptive schemas and glycaemic control in patients with type 2 diabetes mellitus: A cross-sectional study

INTRODUCTION

Diabetes is a disease with high prevalence and causes heavy economic burden. Mental and physical health are tied together and their interaction determines one's health or sickness. Early maladaptive schemas (EMSs) are suitable indicators of mental health. We investigated the association between EMSs and glycaemic control in type 2 diabetes mellitus (T2DM) patients.

METHODS

We conducted a cross-sectional study in 2021 on 150 patients with T2DM. We used two questionnaires a demographic data questionnaire, and a Young Schema Questionnaire 2 - Short Form for gathering the data. We also performed laboratory tests on our participants and used the results of fasting blood sugar and haemoglobin A1 c to evaluate glycaemic control.

RESULTS

Most of our participants were females (66%). Most of our patients were 41-60 years old (54%). There were only three single participants, and 86.6% of our individuals did not have a university degree. Total mean ± SD for EMSs score was 192.45 ± 55.66; self-sacrifice (19.09 ± 4.64) and defectiveness/shame (8.72 ± 4.45) had the highest and lowest EMSs scores, respectively. None of the demographic data had any significant impact on EMSs scores or glycaemic control, but generally, younger patients with higher levels of education had better glycaemic control. Participants with higher scores for defectiveness/shame and insufficient self-control had significantly worse glycaemic control.

CONCLUSION

Mental and physical health are tied together, and paying attention to psychological aspects in prevention and management of physical disorders is crucial. EMSs, especially defectiveness/shame and insufficient self-control are associated with glycaemic control of T2DM patients.

The effectiveness of an online video-based group schema therapy in improvement of the cognitive emotion regulation strategies in women who have undergone bariatric surgery

BACKGROUND

Adaptive cognitive emotion regulation (CER) strategies toward eating play a very important role in obesity and according to schema therapy, patients with obesity learn that don't respond to their emotional stimuli by eating. Thus, this study aimed to evaluate the effectiveness of an online video-based group schema therapy in improvement of the CER strategies and body mass index (BMI) in women who had undergone bariatric surgery.

METHODS

Forty women who had undergone sleeve gastrectomy were selected and randomly divided into two groups of control and experimental. The experimental group received 10 weekly 90-min sessions of group schema therapy, the control group did not receive any intervention at all. Both groups completed the CER strategies questionnaire during pre-test, post-test and follow-up stages, and the data were analyzed using a multivariate analysis of covariance (MANCOVA) through SPSS software (version 20).

RESULTS

Our results indicated that the experimental group demonstrated significantly higher adaptive CER strategies (P = 0.0001, F = 31.15) and significantly lower maladaptive CER strategies (P = 0.001, F = 9.42), significantly lower BMI (P = 0.001, F = 23.48), as compared to the control condition, following the group schema therapy after the follow-up stage.

CONCLUSION

The findings demonstrated that group schema therapy could lead to an increases in adaptive CER strategies and a decrease in maladaptive CER strategies and BMI in women who had undergone bariatric surgery.

TRIAL REGISTRATION

IRCT, IRCT20180523039802N2. Registered 5 August 2020, http://www.irct.com/IRCT20180523039802N2 .

Childhood Maltreatment in Patients Undergoing Bariatric Surgery: Implications for Weight Loss, Depression and Eating Behavior

We aimed to explore the relationships between childhood maltreatment and changes in weight, depressive symptoms and eating behavior post-bariatric surgery (BS). Participants (n = 111, 85% females) were evaluated pre-surgery, and at 6 months (6 M) and 12 months (12 M) post-BS. History of maltreatment was assessed at baseline (Childhood Trauma Questionnaire), and depressive symptoms (Beck Depression Inventory-II) and eating behavior (Dutch Eating Behavior Questionnaire) were assessed at all time points. Participants' mean age and median BMI were 45.1 ± 11.7 years and 46.7 (IQR 42.4-51.9) kg/m², respectively. Histories of emotional (EA), physical (PA) and sexual abuse (SA) and emotional (EN) and physical (PN) neglect were reported by 47.7%, 25.2%, 39.6%, 51.4% and 40.5%, respectively, with 78.4% reporting at least one form of maltreatment. Changes in weight and depressive symptoms were not different between patients with vs. without a history of maltreatment. However, those with vs. without SA demonstrated limited changes in emotional eating (EE) at 12 M, while those without showed improvements. Conversely, patients with vs. without EN showed greater improvements in external eating (ExE) at 6 M, but differences were no longer observed by 12 M. Results indicate that histories of SA and EN are associated with changes in eating behaviors post-BS and have implications for assessment, monitoring and potential intervention development.

Childhood trauma, posttraumatic stress disorder symptoms, early maladaptive schemas, and schema modes: a comparison of individuals with obesity and normal weight controls

BACKGROUND

Previous research on the psychological mechanisms of obesity has primarily focused on acute psychopathology. However, there is limited literature on the role of more complex and entrenched psychological processes in weight management. The current study aimed to expand previous research by examining more enduring psychological constructs, including early maladaptive schemas (EMS), schemas modes, and trauma.

METHODS

Participants (N = 125) comprised adults with normal weight (n = 40) and obesity (n = 85) from community and clinical settings in Australia. Eligible participants completed a series of self-report questionnaires via Research Electronic Data Capture (REDCap). Two, separate, one-way multivariate analysis of variance (MANOVA) were conducted to examine group differences on the outcome variables.

RESULTS

Findings indicated a significant effect of group on EMS and schema modes, V = .51, F(32, 92) = 2.97, p < .001, partial η² = .51. Follow-up univariate tests revealed that individuals with obesity endorsed significantly more maladaptive schemas and schema modes and significantly less healthy schema modes than individuals with normal weight. In addition, results demonstrated a significant effect of group on childhood trauma and posttraumatic stress disorder (PTSD) symptoms, V = .19, F(6, 118) = 4.70, p < .001, partial η² = .19. Subsequent univariate tests and chi-square analyses indicated that individuals with obesity reported significantly more childhood trauma as well as significantly more PTSD symptoms within the last month than normal weight individuals.

CONCLUSION

This was the first study to compare EMS and schema modes in treatment-seeking individuals with obesity and normal weight controls using the short form version 3 of the Young Schema Questionnaire and revised, 118-item, Schema Mode Inventory. Overall, findings revealed that individuals with obesity experience more complex and enduring psychological difficulties than normal weight individuals. Increased assessment and targeted treatment of these underlying mental health concerns may contribute to a more holistic conceptualisation of obesity and could improve the long-term success of weight management.

The Cyberball task in people after obesity surgery: preliminary evaluation of cognitive effects of social inclusion and exclusion with a laboratory task

BACKGROUND

Social cognition and temperamental and interpretative styles could play a role in the outcome of bariatric surgery. This study aims to assess preliminary evidence about how obesity surgery patients evaluate social inclusion and exclusion through a ball-tossing game called Cyberball, looking at the influence of early maladaptive schemas.

METHODS

Thirty-four patients with a history of obesity surgery interventions and 44 controls were recruited for this study. A psychological evaluation was performed before and after the Cyberball task with self-report questionnaires.

RESULTS

In the ostracism condition, significant differences were seen across all the patients' fundamental psychological needs with less perceived ostracization (p = 0.001) even if they recognized less interaction via fewer ball tosses than controls. Moreover, the ostracism paradigm resulted in patients experiencing a higher urge to binge (p = 0.010) and a higher urge to restrain (p = 0.012) than controls. Looking at differences due to the Cyberball paradigm applied, clear differences emerged only between controls subgroups at the specific self-report scales applied, corroborating the reduced perception of the exclusion. As evidenced by the schema domains, the study found a connection between the impaired limits-schema domain and the drive to binge.

CONCLUSION

The results show that obesity surgery patients reported different effects of the Cyberball task than controls. Different possible interpretations are discussed, and future directions for studies are exposed, both for the evaluation of social interactions effects and in the assessment of the role of specific cognitive schemas.

LEVEL OF EVIDENCE

Level III: evidence obtained from well-designed cohort or case-control analytic studies.

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.

Temporal discounting as a candidate behavioral marker of obesity

Although obesity is a result of processes operating at multiple levels, most forms result from decision-making behavior. The aim of this review was to examine the candidacy of temporal discounting (TD) (i.e. the reduction in the value of a reinforcer as a function of the delay to its receipt) as a behavioral marker of obesity. For this purpose, we assessed whether TD has the ability to: identify risk for obesity development, diagnose obesity, track obesity progression, predict treatment prognosis/outcomes, and measure treatment effectiveness. Three databases (Pubmed, PsycINFO, and Web of Science) were searched using a combination of terms related to TD and obesity. A total of 153 papers were reviewed. Several areas show strong evidence of TD's predictive utility as a behavioral marker of obesity (e.g., distinguishing obese from non obese). However, other areas have limited and/or mixed evidence (e.g., predicting weight change). Given the positive relationship for TD in the majority of domains examined, further consideration for TD as a behavioral marker of obesity is warranted.

Personality Features in Obesity

Obesity is a widespread and broadly consequential health condition associated with numerous medical complications that could increase mortality rates. As personality concerned individual's patterns of feeling, behavior, and thinking, it may help in understanding how people with obesity differ from people with normal-weight status in their typical weight-relevant behavior. So far, studies about personality and BMI associations have mainly focused on broad personality traits. The main purpose of this study was to explore the personality and health associations among a clinical group composed of 46 outpatients with overweight/obesity (mean age = 55.83; SD = 12.84) in comparison to a healthy control group that included 46 subjects (mean age = 54.96; SD = 12.60). Both the clinical and control groups were composed of 14 males and 32 females. Several personality and psychopathological aspects were assessed with the Personality Assessment Inventory (PAI). The results of the analysis of variance of aligned rank transformed (ART) showed that patients with overweight/obesity reported higher scores for Somatic Complaints, Depression, and Borderline Features than the control group. Logistic regression highlighted specifically that the subscales of the Borderline Features assessing the Negative Relationship contributed to the increased risk of belonging to the clinical group. For the purpose of this study, the role of gender was considered. The present findings highlight the importance of focusing on assessing personality functioning in the health context and on specific characteristics of interpersonal relationships to promote more tailored treatments.

Adaptive and Maladaptive Coping Mechanisms Used by Patients With Esophageal Cancer After Esophagectomy

BACKGROUND

Esophagectomy patients have high rates of postoperative complications. Maladaptive coping mechanisms such as smoking, alcoholism, and obesity-related reflux are risk factors for esophageal cancer and could affect recovery after surgery. In this study, coping mechanisms used among postesophagectomy patients were identified and maladaptive mechanisms correlated with smoking, alcohol use, or BMI.

MATERIALS AND METHODS

Patients who received an esophagectomy from 2017 to 2018 at an academic medical center were surveyed using the validated Brief Coping Orientation to Problems Experienced, which includes 14 coping mechanisms (both adaptive and maladaptive) using a 4-point Likert scale. A Fischer's exact and chi-square was performed to measure the significance of difference between groups.

RESULTS

There was a 67.2% response rate (43/64). 61.3% (27/43) were obese. Sixty-three percent (62.8%, 27/43) had at least 10 pack-years smoking tobacco history; average smoking tobacco usage was 27 pack-years. 30.2% (13/43) had alcohol use. All 14 coping strategies were used by at least one patient. Twenty patients used only adaptive coping strategies, with acceptance being the most used (100%, 20/20 patients). Twenty-three patients used at least one maladaptive coping strategy, with self-distraction being the most used (91.3%, 21/23). All patients used some adaptive coping. There was a significant difference in mean number of coping strategies between groups (P-value <0.0001). Patients with maladaptive coping also demonstrated greater rates of active coping and humor (P < 0.05). There was no correlation between maladaptive coping and smoking, alcohol use, or increased BMI.

CONCLUSIONS

Most postesophagectomy patients use at least one maladaptive coping strategy; however, history of smoking, alcohol use, or obesity does not predict maladaptive coping in the postesophagectomy period.