Elsevier

Eating Behaviors

Volume 16, January 2015, Pages 64-71
Eating Behaviors

Maladaptive schemas in adolescent females with anorexia nervosa and implications for treatment

https://doi.org/10.1016/j.eatbeh.2014.10.016Get rights and content

Highlights

  • Maladaptive schemas were present in adolescent females with anorexia nervosa.

  • Higher scores were reported by anorexia nervosa patients than healthy controls.

  • Patients with greater general psychopathology reported more maladaptive schemas.

  • Treatment of anorexia nervosa may be enhanced by incorporating schema therapy.

Abstract

Recent research has highlighted the presence of Young's Early Maladaptive Schemas (EMSs) in individuals with an eating disorder (ED). This study assessed the EMSs reported by adolescent females with Anorexia Nervosa (AN) compared with a community group. Thirty-six adolescent females diagnosed with AN or subthreshold AN and 111 female secondary school students completed a questionnaire that included the Young Schema Questionnaire, the Behavior Assessment System for Children Self-report of Personality, and the Eating Disorder Screen for Primary Care. Two independent AN subtypes and two community subtypes were derived from responses to the questionnaire, and significant differences between the four comparison groups were found. High Pathology AN participants reported the highest level of psychological maladjustment. Social Isolation and Emotional Inhibition appeared to be most characteristic of adolescent AN in this sample. The results suggest that EMSs may require attention in the treatment of AN in adolescent females, and that different AN subtypes may require individualized treatment approaches.

Introduction

Individuals with an eating disorder (ED) have a tendency to base their self-worth largely on their eating, weight, or body shape, as well as their ability to control these aspects of their lives (Fairburn, Cooper, & Shafran, 2003). As such, cognitive theories of the development and maintenance of EDs suggest that ED symptoms are developed and maintained by negative automatic thoughts and dysfunctional assumptions about eating, weight, and body shape (Beck, 1976). This theory, however, has more recently been challenged by the proposal that eating, weight, and shape-related cognitions alone do not provide a sufficient account of the range of psychopathology experienced by individuals with an ED (Jones, Leung, & Harris, 2007). Maladaptive schemas that are not about eating, weight, and shape, have been suggested to underpin these ED cognitions (e.g., Waller, Kennerley, & Ohanian, 2007).

Young devised a theory of Early Maladaptive Schemas (EMSs), which are the dysfunctional and unconditional frameworks by which an individual perceives and processes their experiences and environment (Young, Klosko, & Weisharr, 2003). Young has thus far identified 18 EMSs (see Table 1), which are hypothesised to develop if one or more of the five universal emotional needs defined by Young are unmet during childhood (Young et al., 2003). These universal emotional childhood needs include: (1) secure attachments to others; (2) autonomy, competence, and sense of identity; (3) freedom to express valid needs and emotions; (4) spontaneity and play; and (5) realistic limits and self-control (Young et al., 2003).

There is a growing body of recent research that has demonstrated the presence of Young's EMSs in ED groups (e.g., Cooper et al., 2006, Deas et al., 2011, Jones et al., 2005, Leung et al., 1999, Waller et al., 2000). This research has identified that adult women diagnosed with an ED with bulimic symptoms have reported significantly higher levels of a number of EMSs compared with healthy control participants (e.g., Leung et al., 1999, Waller, 2003, Waller et al., 2000). Limited studies, however, have examined the presence of EMSs in adolescent females. The few studies with adolescents that have demonstrated a greater presence of EMSs in adolescents presenting with eating psychopathology have, however, included only community samples (Cooper et al., 2006, Muris, 2006). Waller, Cordery, et al. (2007), Waller, Kennerley, and Ohanian (2007) and Muris (2006) argue that there is a significant gap in studies examining EMSs in clinical adolescent samples, and that future research must concentrate on understanding the profile of EMSs in adolescent samples. Additionally, little is known about the EMSs specifically pertaining to AN. Given that AN most commonly develops during adolescence, an understanding of the presence of EMSs in adolescents with AN is warranted.

Importantly, EMSs are typically resistant to change because individuals attempt to maintain cognitive consistency by distorting their perceptions of themselves and their environment in order to validate their schemas (Rafaeli et al., 2011, Young, 1999, Young et al., 2003). Hence, schema therapy was developed to treat typically treatment resistant disorders, such as personality disorders, not responding to traditional cognitive behavioural therapy (CBT; Young, 1999), and has shown to be particularly effective in samples of patients with borderline personality disorder (e.g., Farrell, Shaw, & Webber, 2009). Given that EDs are also typically resistant to treatment, often due to the complex and ingrained features of the disorder, such as poor self-esteem (Waller, Kennerley, & Ohanian, 2007), schema therapy has been proposed as a plausible addition to existing ED therapies (Waller, Cordery, et al., 2007, Waller, Kennerley and Ohanian, 2007). Thus far, schema-focused therapy has been explored as an enhancement to CBT with adult samples presenting with bulimic behaviours, and preliminary investigations into its effectiveness have demonstrated clinically significant improvements in ED symptomatology (e.g., Simpson, Morrow, van Vreeswijk, & Reid, 2010). Given the typically treatment resistant nature of AN and the need to improve treatment in adolescents, it is proposed that the use of schema therapy be considered in collaboration with existing AN treatments.

Prior to investigating whether schema therapy may be effective in treating adolescents with AN, however, the presence of EMSs in adolescents with AN must first be investigated. To do so it is important to compare the EMSs of a clinical AN sample with those of healthy controls. Given that previous findings suggest that up to 14.6% of the general community have an ED (e.g., Favaro et al., 2003, Fernandez et al., 2007, Keel et al., 2005), we will endeavour to divide the community sample in to those at-risk and not at-risk of an ED based on the results of an ED screen, to ensure that a sample of healthy controls, at low risk of an ED, is compared with the clinical sample.

It is also necessary to understand how EMSs may differ between AN subtypes to better understand the potential use of schema therapy to treat adolescent AN. The previous research that has examined the presence of EMSs in ED samples has showed inconsistent results, with Waller et al. (2000) reporting no differences in EMSs among Bulimia Nervosa (BN), AN binge–purging subtype, and Binge-Eating Disorder (BED) patients, while Waller (2003) revealed that BED patients reported significantly higher scores on some EMSs than BN patients. These differences may be due to the different methodologies used in these studies. For example, Waller (2003) had a larger sample of BN and BED patients and participants were matched by age and gender, which was not applied in Waller et al.'s (2000) study.

Alternatively, these inconsistent findings may be due to the limitation of making comparisons among the diagnostic categories defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 2013), rather than empirically derived ED subtypes based on psychological and behavioural characteristics related to the wider clinical presentation of EDs. Previous research has shown that clustering individuals with an ED based on characteristics beyond ED diagnostic criteria provides more clinically relevant subtypes of ED, which has implications for applying different treatment approaches to these derived subtypes (e.g., Turner, Bryant-Waugh, & Peveler, 2010). For example, researchers have identified the important role that negative affect can play in discriminating individuals on their eating psychopathology (Carrard, Crepin, Ceschi, Golay, & Linden, 2012). Specifically, Damiano, Reece, Reid, Atkins, and Patton (in press) used a two-step cluster analysis based on the general psychopathology of adolescent females with AN and found two clusters, namely Low Pathology AN and High Pathology AN, that differed on ED pathology. The High Pathology AN subtype reported a significantly more maladaptive profile in terms of eating pathology, general psychopathology, and family functioning, than the Low Pathology AN subtype (Damiano et al., in press). It was concluded that the statistically derived clusters somewhat resembled the existing DSM AN subtypes; however, they were derived on general psychopathology characteristics rather than ED symptoms (Damiano et al., in press). This highlights the need to better understand the underlying cognitions of this cohort. The present study endeavoured to explore AN subtypes based on general psychopathology in order to determine the associations with underlying cognitions.

The aim of this study was to identify the EMSs associated with adolescent AN by comparing the EMSs of adolescent females with AN and a community group. Based on the review of relevant literature, two statistically derived subtypes of AN and two community groups were compared. The AN subgroups were derived by replicating the methodology of Damiano et al. (in press) and labelled as Low Pathology AN and High Pathology AN. The community subgroups were derived from high and low scores on an ED screen. Following the division of samples into four participant groups, a number of hypotheses were tested: (1) the High Pathology AN patients would score significantly higher on EMSs than Low Pathology AN patients; (2) both AN groups would score significantly higher on EMSs than both community groups; and (3) the high scorers on the ED screen would score significantly higher on EMSs than the low scorers.

Section snippets

Participants

Two participant groups were recruited for this study, an AN clinic group and a community group. One hundred and thirteen adolescent females with AN were invited to participate between February 2010 and March 2011 from two regionalised hospital outpatient clinics, one of which is in the North Western and the other in the South East Metropolitan Regions of Melbourne, in addition to three private clinics in Melbourne, Australia. AN participants were 36 adolescent females aged between 13 and 19 

Results of cluster analysis

A two-step cluster analysis was conducted using the five composite scales of the BASC-2 SRP, with no restriction on the data as to the number of clusters to be derived. Two clusters were derived, with 17 AN participants in Cluster 1, of which 59% were diagnosed with full AN, and 19 in Cluster 2, of which 53% were diagnosed with full AN; hence, all AN participants were effectively clustered. To determine the nature of these clusters, the BASC-2 SRP scales that produced group separation were

Overview

The aim of this study was to identify the EMSs reported by adolescent females with AN. As hypothesised, significant differences were found among the four groups, which are to be explored below. Two AN subtypes were derived based on the results of the BASC-2 SRP, labelled as High Pathology AN and Low Pathology AN, which supports the usefulness of establishing AN subtypes based on general psychopathology. Two community groups were also derived based on high and low scores on the ED screen.

Role of funding sources

Funding for this research was provided via an Australian Postgraduate Award and the Butterfly Foundation distinction top-up scholarship. The funding sources had no involvement in the study design, collection, analysis, or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

Contributors

All authors were involved in designing the study. SD conducted literature searches. SD was involved in collecting data. SD conducted the statistical analyses in close consultation with JR. All authors were involved in interpretation of results. SD wrote the first draft of the manuscript and all authors contributed to and have approved the final manuscript.

Conflict of interest

All authors declare that they have no conflicts of interest.

Acknowledgements

The authors would like to thank a number of individuals for their assistance in recruiting participants for this study, including Dr Jacinta Coleman, Dr Catherine Lynch, Michelle Caughney, and Stephanie Campbell, in addition to the paediatricians who assisted from the Royal Children's Hospital and Monash Medical Centre and participating schools within Melbourne, Australia. Funding for this research was provided via an Australian Postgraduate Award and the Butterfly Foundation distinction

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