The aim of this study was to examine the association between eating disorders (ED) and schema modes, and identify which specific schema modes are associated with particular eating disorders, including anorexia nervosa (AN), bulimia nervosa (BN) and other specified feeding or eating disorder (OSFED).
A total of forty seven women with eating disorders and 89 women from the community participated in this study. Eating disorder diagnosis was determined by a clinician treating the eating disorder and was confirmed on the basis of Body Mass Index (BMI) and the Eating Disorder Examination Questionnaire (EDE-Q). The Schema Mode Inventory (SMI) was used to explore the association between schema modes and eating disorder diagnostic status.
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The current study shows a tendency for females with eating disorders to rely on maladaptive schema modes more frequently, and more adaptive schema modes less frequently compared to a community sample. These findings provide initial empirical support for a schema mode model of eating disorders.
Schema-mode therapy seeks to address these universal core emotional needs by strengthening adaptive schema modes and weakening maladaptive schema modes, [9] and has been found to be an effective treatment for a variety of mental health and personality difficulties [10, 11]. Schema modes can be clustered into four categories: (1) innate child modes that can become maladaptive as a result of significant unmet core childhood needs, (2) maladaptive coping modes, (3) maladaptive (internalised) parent modes, and (4) adaptive modes.
Evidence suggests that maladaptive schemas are more strongly held by individuals with anorexia nervosa (AN) and bulimia nervosa (BN) compared to healthy controls [12], and there is some evidence of schema-mode therapy being effective for EDs [13]. One study suggests that individuals with EDs display a greater prevalence of maladaptive schema modes compared to individuals without EDs, and different pattern of modes compared to obsessive compulsive disorder [14].
The current study aimed to provide further evidence for the association between schema modes and EDs. It was hypothesised, in line with previous findings [14], that individuals with EDs would score significantly higher on maladaptive schema modes, and lower on adaptive schema modes, compared to a community sample, as measured by the Schema Mode Inventory (SMI). This study also sought to explore the differences in schema modes amongst individuals with AN, BN, and other specified feeding or eating disorder (OSFED) compared to a community sample.
This study aimed to examine whether EDs have higher schema modes compared to a community sample, and to explore the relations between AN, BN, OSFED, and individual schema modes, each compared to a community sample.
These numerous associations, combined with early success in clinical trials [13, 23, 24], highlight the notion that a mode-focused approach to schema therapy could be beneficial to individuals with EDs. Findings could also be used to further develop a mode-focused model of eating pathology that could potentially be akin to the mode-focused model of personality disorder proposed by Young [9, 24].
Limitations of this study include the use of a small sample size and the lack of a BED group. There are also limitations relating to the SMI in that it was designed for personality disorders, which may not highlight some of the coping modes present in ED patients. We are in the process of developing a schema mode inventory for EDs.
Despite some limitations the current study showed a tendency for females with EDs to rely on maladaptive schema modes more frequently, and adaptive schema modes less frequently compared to a community sample. When comparing particular EDs (AN, BN, and OSFED groups) to a community sample, results were generally comparable. These conclusions provide preliminary support for mode-focused schema therapy in the treatment of individuals with EDs.
A central construct in Schema Therapy (ST) is that of a schema mode, describing the current emotional-cognitive-behavioral state. Initially, 10 modes were described. Over time, with the world-wide increasing and broader application of ST to various disorders, additional schema modes were identified, mainly based on clinical impressions. Thus, the need for a new, theoretically based, cross-cultural taxonomy of modes emerged.
An international workgroup started from scratch to identify an extensive taxonomy of modes, based on (a) extending the theory underlying ST with new insights on needs, and (b) recent research on ST theory supporting that modes represent combinations of activated schemas and coping.
We propose to add two emotional needs to the original five core needs that theoretically underpin the development of early maladaptive schemas (EMSs), i.e., the need for Self-Coherence, and the need for Fairness, leading to three new EMSs, i.e. Lack of a Coherent Identity, Lack of a Meaningful World, and Unfairness. When rethinking the purpose behind the different ways of coping with EMS-activation, we came up with new labels for two of those: Resignation instead of Surrender, and Inversion instead of Overcompensation. By systematically combining EMSs and ways of coping we derived a set of schema modes that can be empirically tested.
Coping responses to EMSs result in so-called schema modes, which describe the momentary emotional-cognitive-behavioral state of the person, whereas EMSs are more trait like. Furthermore, in contrast to EMSs, schema modes include behavior and are more directly connected to the problems (symptoms) of the patient.
After having discussed basic needs and based on that analysis having added three EMSs to the 18 proposed by Young et al. (2003), we will now discuss how different ways of dealing with activation of an EMS lead to different schema modes.
Surrendering to an EMS activation leads to a state of feeling, thinking, and behaving as if the EMS is true. Two main groups of schema modes can result. First, a dysfunctional child mode can result from yielding to an EMS activation: the person feels as if (s)he is a child in a world defined by the representation of the EMS. For instance, an EMS of Abandonment can lead to the Abandoned Child mode when surrender is the way of coping. In this mode, the person feels the panic and desolation that is normal and functional for a little child that is abandoned, and which creates a strong drive to restore the connection with the caregiver. Second, if the EMS is based on the internalization of moral or achievement values, an internalized parent mode can result. For instance, surrendering to the EMS Punitiveness can lead to activation of the Punitive Parent Mode.
Please note that schema activation is not a dichotomous, but a dimensional issue. When a schema is activated to a certain extent, people can deal with it in a healthy adult way, which leads to healthy modes such as the Healthy Adult. Notwithstanding the importance of healthy handling EMS activation and the accompanying healthy modes, we decided to restrict ourselves in this paper to maladaptive mental strategies of dealing with EMS activation and the resulting unhealthy modes.
Figure 2 is a diagrammatical representation of the model, where a trigger leads to the (threat of) activation of an EMS, dealt with by a specific way of coping, resulting in the listed types of schema modes. In addition to its function and motivation each schema mode has a cognitive, emotional, and behavioral element:
The reformulated schema mode model. A trigger leads to (threat of) EMS activation, which is dealt with by the person using a specific way of coping: resignation, avoidance, or inversion. This leads to the activation of specific schema modes, defined by function/motivation, cognitive content, feelings, and behaviors
The same accounts for the child modes; resignation to an activated schema, e.g., Abandonment/Instability EMS leads to an Abandoned Child mode. One regresses towards a state that is normal for a child in specific emotional circumstances, but for an adult this is dysfunctional.
In sum, this would lead to an even larger number of schema modes than 63. On the other hand, many coping modes are the same for each EMS, as they do not depend on the specific content of EMSs, but are characterized by the typical way of dealing with EMS activation (Young et al. 2003). Similarly, we argue that many child modes are variations of a similar state. The Angry Child mode, for instance, might vary in cognitive content depending on what EMS underlies it, the feelings and behaviors might cut across the different EMSs.
In the next step of the project new inventories will be developed and data will be gathered in over 30 countries worldwide. This will enable the cross-cultural validation of all schema therapy related concepts, as well as a critical test of the different models concerning the relations between the various concepts.
In the last decades the application of schema therapy has evolved considerably; a broader range of disorders is treated in an increasing number of cultures worldwide and the focus has shifted gradually to mode models. Consequently, there is an urgent need for a cross-cultural valid and comprehensive taxonomy of modes. For that, an international workgroup was formed. A systematic approach was chosen, critically evaluating and updating the theory underlying ST, resulting in the present position paper.
Reviewing the literature two omissions were discovered in the original formulation of the theory, related to two core needs: self-coherence and fairness. On the basis of these additional needs, three new EMSs are proposed: Lack of a Coherent Identity, Lack of a Meaningful World, and Unfairness. Next, the workgroup reflected on the three ways of dealing with EMS-activation stipulated by Young et al. (2003), which highlighted the confusion surrounding these concepts. Therefore, we relabeled two of the three ways of maladaptive coping with schema activation, so that the focus was put on their function; that is, dealing with intrapsychic processes related to schema activation, and not with external threat. We tentatively labeled these two ways of maladaptive coping as resignation (formerly: surrender), and inversion (formerly: overcompensation). Hereafter, the workgroup derived schema modes by systematically combining each EMS with each way of handling schema activation, leading to over 63 schema modes, which we next reduced, by combining some of the modes within each need domain, to a list of 40 modes. Note that during this initial theoretical process, different views were expressed in the workgroup about the mediation of the relationship between externalizing child modes and EMSs by coping with EMS activation. Given a lack of consensus we developed different mediation models that we will test during the empirical phase of the project. 2ff7e9595c
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