- Research article
- Open Access
The prediction of treatment outcomes by early maladaptive schemas and schema modes in obsessive-compulsive disorder
BMC Psychiatry volume 14, Article number: 362 (2014)
Higher levels of early maladaptive schemas (EMS) and schema modes according to schematherapy by Jeffrey Young are present in obsessive-compulsive disorder (OCD) compared to healthy controls. This study examines the relationship of EMS and schema modes to OC symptom severity and the predictive value of EMS and schema modes on treatment outcome in inpatients receiving Cognitive-Behavioral Therapy (CBT) with Exposure and Response Prevention (ERP). The main assumption was a negative association between the EMS of the domain ‘disconnection’ and dysfunctional coping and parent schema modes and the treatment outcome.
EMS, schema modes, depression and traumatic childhood experiences were measured in 70 patients with OCD. To analyze the predictors, two regression analyses were conducted considering multiple variables, such as depression, as covariates.
Regression analyses demonstrated that higher scores on the EMS named failure and emotional inhibition and depressive symptom severity at pretreatment were significantly related to poor outcome and explained a high percentage of the variance in OC symptoms at posttreatment. No influence on the treatment outcome was observed for schema modes, other EMS or other covariates.
The results support the approach to extend the CBT with ERP treatment with therapeutic elements focusing on maladaptive schemas, particularly in non-responders.
Obsessive-compulsive disorder (OCD) is among the most common mental disorders, showing a lifetime prevalence of 2-3% . It is characterized by intrusive thoughts, images or impulses (obsessions) and ritualized repetitive behaviors (compulsions) that cause significant dysfunction and distress. If no adequate treatment is administered, OCD typically takes a chronic course . Cognitive-Behavioral Therapy (CBT) with Exposure and Response Prevention (ERP) is the first-line treatment for OCD according to standard guidelines -. Meta-analyses confirm that the main components of CBT, cognitive and behavioral interventions such as ERP are comparable in their efficacy -. More specifically, in meta-analyses, CBT with ERP displays large between group effect sizes of d = 1.3 to 1.5 in comparison with control groups and cognitive restructuring reveals effect sizes of d = 1.1 to 1.5 ,-. However, it should be taken into account that a strict separation of cognitive interventions in ERP treatment is difficult because cognitive techniques are associated with ERP in some way in most studies .
Over the past years, cognitive interventions that have been effective in the treatment of depression and anxiety disorders were adapted to a CBT model addressing typical dysfunctional assumptions in OCD, such as inflated responsibility, perfectionism, overestimation of threat and intolerance of uncertainty -. However, only a few studies have addressed the origin of these beliefs. Aaron Beck  assumed that negative and stressful experiences during childhood may lead to the consolidation of maladaptive core beliefs in individuals, so-called cognitive schemas, which determine affect and behavior. These schemas are assumed to be stable patterns of dysfunctional cognitive processing that may become reactivated by stressful situations . To our knowledge, in OCD, there is only one cognitive treatment approach focusing on schemas, demonstrating a long lasting constellation of inveterate dysfunctional core beliefs in treatment-resistant OCD patients . This integrative schema treatment approach showed clinically significant improvement for 32 patients who were resistant to standard CBT and revealed that maladaptive schemas improved for responders and did not change for non-responders .
According to the schema therapy developed by Young , schemas named early maladaptive schemas (EMS) are defined as self-perpetuating dysfunctional cognitive patterns that emerge from unmet basic needs and traumatic experiences during childhood . EMS consist of memories, emotions, cognitions and physical sensations that influence thinking and behavior in a dysfunctional way and are stable over time, even after evidence-based treatment of depressed patients ,. Young assumes 18 EMS and groups them into five domains: Disconnection, Impaired Autonomy, Impaired Limits, Other-Directedness and Overvigilance & Inhibition. For a detailed description of the 18 EMS and the domains, please refer to Young and colleagues .
Despite the effectiveness of CBT with ERP, studies demonstrate that 17 - 33% of OCD patients do not sufficiently respond to ERP, and 5-29% drop out or refuse treatment ,-. An increased knowledge about underlying EMS among patients with OCD, particularly among non-responders, is important to gain a deeper understanding of the relationship between core beliefs and treatment outcome and could indicate how to improve the treatment. Some literature has demonstrated the role of EMS in depression, anxiety and eating disorders ,,. Specifically, increased values in the first EMS domain, Disconnection, representing ones expectation that the basic need for security, safety and empathy by others will not be met, are often associated with particularly strong symptomatic impairment, and studies demonstrate a relation to depressive symptom severity ,.
Studies relating EMS to OCD are relatively sparse. Three studies examined EMS at a descriptive level -. In the first study, significantly higher scores in five of 15 EMS were found in OCD in comparison with trichotillomania (so-called mistrust, social isolation, shame, subjugation and emotional inhibition) . Atalay et al.  demonstrated that the EMS questionnaire total score, as well as the schemas social isolation, vulnerability and pessimism, were significantly increased in OCD in relation to healthy controls. Voderholzer et al.  examined 18 EMS in OCD compared to eating disorder, chronic pain disorder and healthy controls. The patient group could be significantly differentiated from the healthy controls in 17 of the EMS. In addition, OCD patients scored higher on four EMS (abandonment, dependence, vulnerability and insufficient self-control) than the eating and chronic pain disorders. In summary, higher levels of EMS in clinical samples compared to healthy controls were proven in all studies. Thus, there is preliminary evidence about the schema construct that inspired us to investigate the predictive value of EMS in treatment outcome. Currently available data are insufficiently stringent to make an accurate prediction. Only one study investigated EMS predictors in 88 OCD patients completing ERP treatment . The EMS named abandonment was identified as a negative predictor and the EMS self-sacrifice was related to a positive treatment outcome. This interesting study had the limitation that only pretreatment OCD severity and depression were considered as moderating factors in the regression analysis. Other proven predictors in OCD such as hoarding, number of comorbid Axis I disorders, age at onset or gender, which are described as predictors for treatment response in the OCD literature, were not included -. Moreover, the importance of traumatic life events for the development of OCD is discussed increasingly in the literature -. Even though findings on the relationship between traumatisation and OCD are still humble, there are results showing higher levels of ‘minor traumatisations’ such as emotional and physical neglect or emotional abuse in OCD  Since these traumas have an important part in the development of EMS, the predictive value of traumatisation should be included in the statistical analyses. At this stage, results on the predictive value of traumatisation in OCD are heterogeneous ,. Because these predictors are relevant, our study is of great importance in the replicability of the results of Haaland et al.  and the extension of the study design.
Since different EMS can be activated at the same time, and because the same patient can show distinct behaviors in specific situations, Young developed so-called schema modes . Schema modes are assumed to be predominant emotional states and coping responses that occur when EMS are triggered. They are assumed to consist of the current emotional and behavioral state of an individual, which can change rapidly and can be functional or dysfunctional . To date, approximately 22 schema modes have been identified and were grouped into four categories: so-called Child modes, Dysfunctional Coping modes, Dysfunctional Parent modes and the Healthy Adult mode ,. Currently, the schema mode concept in Axis I disorders is only rarely examined. Since schema modes can be active during psychotherapeutic sessions, influence the session structure in a negative or positive way and many clinicians align their schematherapeutic work more and more on schema modes than on EMS, it was of great interest to include schema modes in the analysis of this study . Only Voderholzer et al.  examined these coping responses called schema modes for the first time in OCD and proved that OCD patients scored significantly higher than healthy controls in 10 out of 13 schema modes and higher than the eating and chronic pain disorder group in four schema modes (so-called vulnerable child, angry child, punishing parent and demanding parent).
Problematic axis I behaviour such as pathological drinking or gambling, binge eating or obsessive-compulsive behaviour is assigned to the Dysfunctional Coping modes according to the schema theory. They are defined by an overuse of unhealthy coping styles or defense mechanisms, such as avoidance or overcompensation to be distracted by negative emotions . Increased distinct psychopathology and being strongly caught up in the problem behaviour, as it is often the case in OCD patients, implies that the corresponding schema mode is stronger pronounced. Since obsessive-compulsive symptom severity is a negative predictor for treatment outcome and patients with increased levels of these modes, typically show avoiding behaviour such as forgetting sessions or homework, talking about superficialities or discontinue the therapy, we assume that pronounced Dysfunctional Coping modes predict treatment failure. Being in a Dysfunctional Parent mode, patients put extremely high pressure upon themselves or experience self-devaluation and self-hatred. Unhealthy behaviours and destructive rules determine the behavior, something that can be observed in OCD patients as well. Patients in these conditions are often difficult to reach, address problems that they do not work out and frequently reject cooperation in treatment leading to early dropouts in therapy . Based on this definition of Dysfunctional Parent modes, we expect a negative correlation with treatment outcome. In general, it was of great interest to examine, for the first time, the predictive value of schema modes in OCD.
In the present study, we sought to further examine the relationship between EMS and schema modes with OC symptom severity at baseline as well as the predictive value of EMS and schema modes on the treatment outcome in inpatients with OCD receiving CBT with ERP. Three hypotheses will be examined. First, we assume that the degree of EMS and schema modes show a positive relationship with the OCD symptom severity at baseline. Second, we hypothesized that treatment non-responders present higher levels of EMS and schema modes at baseline than responders, and third, we expected that the EMS of the first domain, related to basic safety and high levels of the Dysfunctional Coping and Parent modes, are negatively related to the treatment outcome.
Eighty-four inpatients diagnosed with OCD were recruited from the Department of Psychiatry and Psychotherapy, University Medical Center in Freiburg and the Schoen Clinic Roseneck in Prien. The inclusion criteria were ages between 18 and 65 years and a primary diagnosis of OCD as assessed by the Structured Clinical Interview for DSM-IV (SCID-I) . The SCID-I was administered by trained and experienced raters. All raters attended a SCID-I and –II training consisting of a two-day theoretical training and scoring videos by a certified trainer for SCID. The inpatients were excluded if they had a primary diagnosis other than OCD, a current or lifetime history of psychotic episodes, substantial neurological impairment, severe cognitive dysfunction, acute suicidal symptoms and insufficient German language skills. Four patients refused to participate in the investigation, four were excluded due to other primary diagnoses, two due to cognitive dysfunction, two because of comorbid psychotic episodes and two could not fill out the questionnaires because of compulsive behavior. Thus, 70 inpatients fulfilled the inclusion criteria and were included in the present study. Three patients dropped out during treatment at their own request and did not participate in the posttreatment evaluation. A detailed description of the demographic and clinical characteristics is presented in Table 1.
At pretreatment, the sample was characterized by moderate to severe levels of obsessive-compulsive symptom severity (M = 23.97, SD = 5.28) according to the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) . The mean duration of the OCD in years was 15.1 (SD = 11.3). The study was approved by the local Ethics Committee for research with human subjects. Written informed consent was obtained from all participants prior to baseline assessment after the rationale of the study was fully explained to the subjects.
The Y-BOCS  is a semi-structured, clinically-administered interview that is considered the gold standard to assess OCD symptom severity ,. It has demonstrated a high inter-rater reliability, internal consistency and convergent validity ,. The first 10 items were used as primary outcomes and are suitable to demonstrate symptom changes over the course of treatment . Internal consistency for baseline scores for the current sample was α = 0.89.
Young Schema Questionnaire - Short Form 3 (YSQ-S3)
The YSQ-S3  is a 90-item self-report instrument that investigates the presence of 18 EMS with five items per scale. Each item is a statement of a character issue that the patient scores on a 6-step Likert-type response format ranging from completely untrue for me to describes me perfectly. Higher scores indicate a stronger presence of the respective schema. Adequate reliability, convergent, factorial and discriminant validity have been demonstrated for the German version . In the current sample, Cronbach’s alpha for the baseline YSQ-total was α = 0.96.
Schema Mode Inventory (SMI-r)
The SMI-r  is a 124-item self-report questionnaire that investigates the presence of 14 schema modes with 4 to 10 items in each subscale. Each item is rated on a 6-step Likert-type scale. Higher scores indicate a stronger presence of the schema mode. The so-called perfectionistic and the suspicious overcontroller mode were added as explorative scales because the manifestation of the perfectionistic overcontroller mode seemed particularly interesting in patients with OCD. For a brief description of the schema modes, see Young, Klosko and Weishaar . The German version demonstrated good-to-excellent internal consistency and construct validity. Furthermore, the 14-factor structure was approved . Internal consistency for baseline scores for the current sample was α = 0.91.
Beck Depression Inventory-II (BDI-II)
The BDI-II  is a well-known 21 item self-report measure of the severity of depressive symptoms. It has demonstrated high internal consistency, test-retest reliability and construct validity that also applies to the German version . In the current sample, Cronbach’s alpha for the BDI at baseline was α = 0.93.
Obsessive Compulsive Inventory-revised (OCI-r)
The OCI-R  is a self-report measure for assessing symptoms of OCD. It contains 18 Items and six subscales and has good psychometric properties -. These apply likewise for the German version . In the current sample, Cronbach’s alpha for the OCI-r total score at baseline was α = 0.82.
Childhood Trauma Questionnaire (CTQ)
The CTQ  is a 31-item self-report instrument that retrospectively assesses the subjective frequency of five forms of childhood trauma experienced with good psychometric properties. The CTQ measures five domains: emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect. For the German version, the factor structure, good reliability and validity were demonstrated . In the current sample, Cronbach’s alpha for the CTQ total score at baseline was α = 0.67.
Life satisfaction was assessed by a self-rating ranging from ‘very dissatisfied’ (1) to ‘very satisfied’ with my life’ (10).
Every patient admitted to one of the two hospitals for an OCD treatment was informed about the study. If the patient agreed to participate, the Axis I disorders diagnoses were confirmed by the SCID-I within the first seven days of treatment. If the inpatient met the inclusion criteria, the severity of the OC symptoms was assessed based on the Y-BOCS, and the questionnaires (see 2.2) were handed out. All patients participated in a multimodal inpatient CBT with ERP treatment for OCD according to the treatment manual by Lakatos and Reinecker . The treatment consisted of twice-weekly individual therapy sessions (50 min each) and a weekly educational group (90 min) conducted by experienced therapists having weekly team meetings to discuss ongoing cases and difficulties. After the general education regarding OCD and the development of an individual disease model, a fear hierarchy was constructed. The exposure began with moderately anxiety-provoking situations and increased to the most distressing fear and was conducted therapist-accompanied within the therapy sessions as well as in homework assignments. The ERP was combined with the identification of negative beliefs and appraisals as well as cognitive restructuring. A total of 46 inpatients (65,7%) received selective serotonin-reuptake inhibitors (SSRI) or selective serotonin-noradrenalin reuptake inhibitors (SNRI). The mean duration of the inpatient stay in the current sample was 10.6 weeks (SD = 4.4), 21 individual therapy sessions. OC symptom severity was again evaluated posttreatment.
To test the first hypothesis, correlation analyses were conducted to investigate the relationship between EMS, schema modes and obsessive-compulsive symptoms at pretreatment. To verify the second hypothesis, in a first step, responders were defined as those subjects who showed clinically significant change (CSC) after treatment according to the two-fold criterion provided by Jacobson and Truax . CSC is fulfilled if (a) a symptom score is under a calculated cut-off score at posttreatment and (b) a symptom score had decreased by a reliable amount of change exceeding the measurement error (reliable change index (RCI)). The RCI was calculated based on the test-retest reliability of the Y-BOCS (r = 0.61) according to Woody et al. . The calculated cut-off score in the present study to determine the non-clinical range was Y-BOCS = 13 or below . To achieve CSC and therefore be classified as a responder, a patient’s individual change score had to be above 1.96 and the post Y-BOCS score had to be 13 or less. In a second step, an exploratory one factorial multivariate analysis of variance (MANOVA) was computed investigating the distribution of the EMS, schema modes and other variables in the responder- and non-responder groups. The third hypothesis concerning the identification of EMS and schema modes as predictors of treatment outcome was tested based on two regression analyses. Stepwise multivariate regression analyses were conducted to test whether EMS and schema modes predicted treatment outcome using the posttreatment Y-BOCS as the dependent variable. Because increased depression rates affect the completion of self-rating questionnaires, depressive symptom severity (BDI-II) was included as a covariate. Furthermore, in all statistical calculations, we controlled for several covariates. Since baseline obsessive-compulsive symptom severity (Y-BOCS), number of comorbid Axis I disorders (SCID-I), age at onset (first onset of symptom measured by self-rating and alignment with data from previous clinical reports), gender and hoarding subtype (OCI-r) are consistent described as negative predictors for treatment response in the OCD literature, they were taken into account -.
Traumatisation (CTQ) is considered due to the possible relevance of the development of EMS. Although specific personality disorders (Cluster A, schizotypal, narcissistic, two or more comorbid personality disorders) are associated with poor treatment outcome in patients with OCD, these predictors were not included in the analyses because too few patients presented these specific personality disorders .
The statistical assumptions for the regression analyses were verified with residual plots and histograms for residuals, which showed a normal distribution of the residuals. Prior to the regression analyses, multicollinearity among the predictor variables was statistically investigated by computing Variance inflation factors (VIF). As a general rule, a VIF above the cut-off value of 10 indicates a collinearity problem . The VIF was above 1.8 in none of the predictor indicating no significant multicollinearity problem. In all analyses, the level of significance was set at p ≤ 0.01 (two-tailed tests). The Statistical Package for Social Sciences (SPSS), version 18, was used for all calculations. Inter-rater reliability for the Y-BOCS was determined for a subset of 5 patients with two raters from Freiburg sitting in the same room, with no communication between the two during the interview. The inter-rater reliability between the two raters was high with intraclass correlation coefficients (ICCs) of >0.86.
Hypothesis 1: Positive correlations of EMS and schema modes with the OC symptom severity at baseline
As expected, significant positive correlations of the EMS and schema modes with the Y-BOCS prior to treatment (Total score: YSQ ρ = 0.26; p = 0.014 and SMI r = 0.25, p = 0.018), as well as a highly positive correlation with the OCI-r pre (Total score: YSQ ρ = 0.45; p < 0.001 and SMI r = 0.44, p < 0.001), were proven.
Hypothesis 2: Higher levels of EMS and schema modes in the non-responder than in the responder group
Analyses with paired sample t-tests showed a significant reduction of obsessive-compulsive symptoms (T = 10,006; df = 67; p < 0.001) in the Y-BOCS from pre- (M = 24, sd = 6.2) to posttreatment (M = 14.6, sd = 7.0). The mean Y-BOCS reduction was 37,5%, indicating a positive outcome of the ERP and pharmacotherapy treatment, as a symptom reduction of 35% in the literature is designated as treatment response . According to the 35% symptom reduction criterion, 53% of the patients (N = 37) achieved treatment response, and 43% (N = 30) were non-responders. According to the criteria of clinically significant change (CSC), response was achieved in 27 of the 67 patients who completed the treatment (38,6% responders; 57,1% non-responders).
In an exploratory one factorial MANOVA, the distributions of the EMS, schema modes and other variables in the responder- and non-responder groups were investigated (see Table 2). The MANOVA yielded a significant main effect in the YBOCS post between responders and non-responders (F = 76.6; p < 0.001) and not in the YBOCS pre. Moreover, non-responders had significantly higher pretreatment scores on four EMS (emotional inhibition, social isolation, mistrust/ abuse and defectiveness) and 4 schema mode variables (vulnerable child, detached protector, bully and attack and schema mode global score). In the schema mode named happy child, non-responders showed significantly lower scores at pretreatment than responders. For all other EMS and schema modes, the differences were not significant. Concerning psychopathological scores, non-responders showed a significantly lower score in depression symptom severity and lower scores in life satisfaction at posttreatment. For complete results, see Table 2.
Hypothesis 3: Predictive value of pretreatment EMS and schema modes on treatment outcome
In a first step, two separate stepwise multivariate regression analyses were computed to reduce the large number of predictors . First, the 18 EMS and second, the 16 schema modes were entered as predictors, while the posttreatment Y-BOCS acted as the dependent variable. Variables with a significance level below p < 0.1 were included in further analyses. Concerning the EMS variables, this was obtained for the EMS constructs of emotional inhibition, failure and emotional deprivation. For the schema modes, the vulnerable child and perfectionistic overcompensator met these criteria.
In a second step, two stepwise multivariate regression analyses were calculated including the set of covariates described in 2.4. The aim was to identify the independent involvement of each variable in the prediction of the treatment outcome. The first regression explored the impact of the three EMS and the controlling variables. The EMS failure explained 21% of the variance of the treatment outcome, while emotional inhibition explained an additional 6%. The set of covariates and the EMS emotional deprivation did not make a significant contribution.
In the second regression, the predictive value of two schema modes and the covariates on the treatment outcome was computed. Depressive symptom severity was the only variable approved in the analysis, explaining 20% of the variance. The remaining variables were excluded as predictors. A summary of the regression analyses is provided in Table 3.
The present findings on the EMS and schema mode construct in OCD extend previous research. Consistent with our first hypothesis, we demonstrated significant positive correlations between the degree of EMS and schema modes with the severity of obsessive-compulsive symptoms. The second hypothesis received mixed support. Statistically higher levels of EMS in the non-responder group could only be detected in four out of 18 EMS, but responders and non-responders did not differ in the EMS total score. Concerning schema modes, non-responders presented significantly higher scores in 4 out of 15 variables and on the schema mode global score compared to responders. The third hypothesis concerning the predictive value of EMS of the first domain and the Dysfunctional Coping and Parent modes could not be confirmed. Although non-responders showed significantly stronger presence of three out of five EMS in first domain, these EMS could not be identified as treatment predictors. However, findings demonstrated that higher scores on the EMS failure, of the second domain, and emotional inhibition, of the fifth domain, were related to poorer outcomes in ERP treatment for OCD. Concerning the calculations regarding the schema modes, only depressive symptom severity was identified as a negative predictor.
In the following, the identified predictors will be discussed in detail. Young and colleagues  theorized that the EMS failure involves the perception that one will inevitably fail or is less successful than others. Moreover, persons who score high on this schema often assume that they are inept or untalented. Understandably persons with these assumptions about themselves interfere with their own efforts in therapy and thus negatively influence the treatment outcome. The expectation of slight success becomes a self-fulfilling prophecy, as discussed in the concept of perceived self-efficacy . A considerable number of studies demonstrated the role of higher treatment expectations in improved outcomes -, whereas low expectations were associated with poor treatment outcomes in CBT of anxiety and depressive disorders -. Clinicians working with patients presenting a high failure EMS should articulate the typical assumptions which are accompanied with this EMS to prevent the reconfirming of the EMS. In OCD treatment, results regarding treatment expectations are inconsistent and refer to a limited number of studies with small sample sizes ,-. Our results support the assumption that negative expectations about failure affect treatment success adversely. In addition, previous research has shown that failure was one of the five EMS explaining most of the variance in anxiety symptoms, and cognitive avoidance was predicted by failure in people suffering from posttraumatic stress ,. Furthermore, failure predicted depressive symptoms and anxiety in nonclinical samples and was associated with depression severity ,.
Individuals scoring high on the so-called emotional inhibition schema typically inhibit the expression of feelings to avoid disapproval by others or shame, seem very controlled and aim for perfect self-regulation . Typically, anger, aggression, joy, sexual excitement and play are inhibited. In ERP treatment feared stimuli are confronted, the experience of anxiety is desired and the therapist supports emotional processes . The inhibition of feelings is often considered as an indication of incorrect treatment or a lack of involvement of the patient. In line with these principles of ERP, our results indicate that the suppression of emotions adversely affects the treatment outcome and supports the concept of experiential avoidance. Therapists should be aware, if this EMS is prevalent in the patient, to counteract treatment failures and should take time to build up a strong therapeutic relationship to encourage inhibited patients to reveal emotions and guide them in emotion regulation without the use of maladaptive coping strategies.
Also in the present study, non-responders scored significantly higher on this EMS prior to treatment than responders. Furthermore, the emotional inhibition EMS was previously declared as one of the key EMS in obsessive-compulsive, anxiety and avoidant personality disorders, explained a great part of the variance of anxiety symptoms, correlated significantly with PTSD symptoms and was identified as a negative predictor in bipolar disorder ,,-. In addition, this EMS appeared to be more resistant to short-term SSRI treatment than other EMS in a sample of major depressive patients .
Our results regarding the EMS as predictors for treatment outcomes in OCD are not in line with previous results identifying the abandonment and self-sacrifice schemas as outcome predictors . This may be because these authors only considered two covariates in their analyses. Moreover, the participants presented only mild depressive symptoms and only a few fulfilled the criteria for a depressive disorder. Furthermore, the results might also diverge due to cultural influences that may exist between Norwegian and German samples.
It should be taken into consideration that the encountered results regarding the EMS may not only due to the obsessive-compulsive psychopathology, but also to the moderate depression severity of the patients since Atalay et al.  demonstrated that depressive dispositions activated EMS rather than anxious dispositions. Moreover, it was proven that already short-term SSRI treatment reduced EMS activation levels for some EMS significantly especially for patients suffering from severe depressive symptoms .
Studies investigating schema modes in Axis I disorders are very limited, with a total of only two studies ,,,. The present study revealed no relation between schema modes and treatment outcomes. Schema modes reflect a current state rather than a trait and are less stable than EMS . An explanation for the missing relation to the treatment outcome could be that patients were not triggered by situations while answering the questionnaires and thus the schema modes were inactive. Depression severity emerged as the most prominent predictive factor for treatment failure in the analyses of the schema modes but not in the calculations concerning the EMS. Even prior to treatment, non-responders presented significantly higher depression values than later responders. According to the literature, the predictive value of depressive symptoms is inconclusive with studies observing a relation to treatment failure ,,, while others did not ,,,,. However, severe depression and the presence of a Major Depressive Disorder (MDD) are continuously linked with negative treatment outcomes ,. In our study, 41.2% of the patients fulfilled the criteria for a MDD, with the majority of patients (58.6%) suffering from moderate MDD. This explains why some part of the patients received additional pharmacotherapy treatment. Abramowitz  assumes that the negative impact of depression on treatment outcome could be explained by the over-excitation some depressive patients present, as this negatively affects the habituation process during exposure therapy. Others assume that patients with OCD and comorbid depression are not sufficiently motivated for the challenging ERP treatment, suffer more severe distress and functional impairment or have a greater disposition to misinterpret innocuous intrusive thoughts as being significant ,. Identifying depressive symptom severity as a negative predictor for treatment outcome is thus in line with one aspect of previous research results. The number of comorbid axis I diagnoses was not associated with treatment outcome in the present study most likely because all axis I diagnoses were taken into account. Our results indicate that depressive symptoms in OCD must receive greater attention and be treated in more detail.
The limitations of this study include the use of merely self-report measures to assess EMS and schema modes. Self-report measures only allow the assessment of conscious aspects of EMS and schema modes. Furthermore, those subjectively measured constructs are surveyed retrospectively. Further possible difficulties with this type of measurement are strategic reporting, response styles and the feeling of shame. Another limitation is the relatively small sample size compared to the number of predictors included in the analysis. Thus, the risk for unstable linear regression models and the possibility for type I errors are enhanced. A replication with larger sample sizes is needed to demonstrate the robustness of the identified EMS predictors. Moreover, no follow-up data were gathered. In the future, the investigations of long-term effects of EMS and schema modes on the treatment outcome in OCD are desirable. Moreover, previously identified outcome predictors in OCD treatment, such as treatment motivation, patient adherence and expectations, low insight and expressed emotions were not included in the study because these variables were not gathered. They may explain some of the variance of the present predictors failure, emotional inhibition and depression . Besides, the identification of a predictor may lead to unwarranted hypotheses about possible causalities. Lastly, no formal fidelity analyses were conducted.
The strengths of the present study are that comorbidities, such as severe depressive or personality disorders, were not excluded, as in most investigations. As a result, it can be assumed that the examined OCD sample is representative, which leads to the increased generalizability of the results. Furthermore, important variables that were identified as predictors for treatment outcome in previous studies, such as depression, axis I comorbidity, traumatization, etc. were included in the current statistical analysis to identify potential influences. In addition, the results are based on a phase IV study conducting the effective first-line treatment CBT with ERP for OCD under real inpatient treatment conditions treating seriously burdened patients.
The present study successfully detected negative predictors in OCD treatment. Based on the results, we suggest the application of the EMS questionnaire and BDI-II prior to treatment in OCD patients to identify the degree of the EMS failure and emotional inhibition together with depression as potential negative influencing treatment variables. Since non-responders additionally showed a higher activation level in three EMS of the first domain, emotional inhibition and different schema modes compared to responders, the awareness about the activation levels of EMS and schema modes may provide an indication of patients responding well and poor to treatment. If clinicians are aware of potential non-responders at an early stage of treatment, an adjustment of the treatment is possible to generate a more satisfactory treatment outcome and to minimize subsequent treatments. But there is good news for clinicians working with patients with a general higher EMS activation level. Based on the data, we assume that these patients will not be automatically non-responders.
As described above, CBT with ERP is successful in the treatment of OCD. Changes in clinical symptoms and most likely the underlying schemas are achieved, but non-responders exist and relapses are known. Because schema therapy (ST) was especially developed for patients not responding optimally to traditional CBT, and because first studies yielded good results ,,, the use of schema therapeutic elements in the treatment of OCD could help to specifically treat the identified negative EMS predictors and subsequently further improve the treatment outcome. Particularly in patients presenting the EMS emotional inhibition, a schema therapeutic approach might be beneficial, because it is an emotion-focused method that prevents emotional avoidance through the use of techniques named imagery rescripting or chair work. Future research would benefit from the examination of the application of the schema therapeutic approach in CBT or the comparison of CBT and ST in their efficacy in OCD treatment, especially in non-responders. To date, only one study concerning axis I disorders exists, which compares ST with traditional CBT in veterans suffering from PTSD and demonstrates ST to be more effective . Lastly, further studies should examine to what extent depressive symptom severity is a mediator or moderator of EMS and schema modes based on a mediator analysis with a predefined structural equation model.
Ruscio AM, Stein DJ, Chiu WT, Kessler RC: The epidemiology of obsessive compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry. 2010, 15 (1): 53-63. 10.1038/mp.2008.94.
Abramowitz JS: The psychological treatment of obsessive-compulsive disorder. Can J Psychiatr Rev Canad Psychiatr. 2006, 51 (7): 407-416.
Foa EB, Liebowitz MR, Kozak MJ, Davies S, Campeas R, Franklin ME, Huppert JD, Kjernisted K, Rowan V, Schmidt AB, Simpson HB, Tu X: Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. Am J Psychiatr. 2005, 162 (1): 151-161. 10.1176/appi.ajp.162.1.151.
Khodarahimi S: Satiation therapy and exposure response prevention in the treatment of obsessive compulsive disorder. J Contemp Psychother. 2009, 39 (3): 203-207. 10.1007/s10879-009-9110-z.
National Institute for Health and Clinical Excellence (NICE) (2006). Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. The British Psychological Society & The Roya l College of Psychiatrists. [http//www.nice.org.uk]
Ponniah K, Magiati I, Holloh S: An update on the efficacy of psychological treatment for obsessive-compulsive disorder in adults. J Obsessive Compuls Relat Disord. 2013, 2 (2): 207-218. 10.1016/j.jocrd.2013.02.005.
Simpson H, Foa EB, Liebowitz MR, Ledley D, Huppert JD, Cahill S, Vermes D, Schmidt AB, Hembree E, Franklin M, Campeas R, Hahn CG, Petkova E: A randomized, controlled trial of cognitive-behavioral therapy for augmenting pharmacotherapy in obsessive-compulsive disorder. Am J Psychiatr. 2008, 165 (5): 621-630. 10.1176/appi.ajp.2007.07091440.
Abramowitz JS, Franklin ME, Foa EB: Empirical status of cognitive-behavioral therapy for obsessive-compulsive disorder: a meta-analytic review. Romanian J Cognit Behav Psychother. 2002, 2 (2): 89-104.
Belloch A, Cabedo E, Carrió C: Cognitive versus behaviour therapy in the individual treatment of obsessive-compulsive disorder: changes in cognitions and clinically significant outcomes at post-treatment and one-year follow-up. Behav Cognit Psychother. 2008, 36 (5): 521-540. 10.1017/S1352465808004451.
Eddy KT, Dutra L, Bradley R, Westen D: A multidimensional meta-analysis of psychotherapy and pharmacotherapy for obsessive-compulsive disorder. Clin Psychol Rev. 2004, 24 (8): 1011-1030. 10.1016/j.cpr.2004.08.004.
Rosa-Alcázar AI, Sánchez-Meca J, Gómez-Conesa A, Marín-Martínez F: Psychological treatment of obsessive-compulsive disorder: a meta-analysis. Clin Psychol Rev. 2008, 28 (8): 1310-1325. 10.1016/j.cpr.2008.07.001.
Olatunji BO, Davis ML, Powers MB, Smits JJ: Cognitive-behavioral therapy for obsessive-compulsive disorder: a meta-analysis of treatment outcome and moderators. J Psychiatr Res. 2013, 47 (1): 33-41. 10.1016/j.jpsychires.2012.08.020.
Lawrence PJ, Williams TI: Pathways to inflated responsibility beliefs in adolescent obsessive-compulsive disorder: a preliminary investigation. Behav Cogn Psychother. 2011, 39 (2): 229-234. 10.1017/S1352465810000810.
Rachman SS: A critique of cognitive therapy for anxiety disorders. J Behav Ther Exp Psychiatr. 1993, 24 (4): 279-288. 10.1016/0005-7916(93)90052-X.
Salkovskis PM, Warwick HM: Cognitive therapy of obsessive-compulsive disorder: treating treatment failures. Behav Psychother. 1985, 13 (3): 243-255. 10.1017/S0141347300011095.
Sookman D, Steketee G: Directions in specialized cognitive behavior therapy for resistant obsessive-compulsive disorder: theory and practice of two approaches. Cognit BehavPract. 2007, 14 (1): 1-17.
Van Oppen P, de Haan E, Van Balkom AM, Spinhoven P, Hoogduin K, Van Dyck R: Cognitive therapy and exposure in vivo in the treatment of obsessive compulsive disorder. Behav Res Ther. 1995, 33 (4): 379-390. 10.1016/0005-7967(94)00052-L.
Wilhelm S, Steketee G, Reilly-Harrington NA, Deckersbach T, Buhlmann U, Baer L: Effectiveness of cognitive therapy for obsessive-compulsive disorder: an open trial. J Cognit Psychother. 2005, 19 (2): 173-179. 10.1891/jcop.18.104.22.168792.
Beck AT: The Development of Depression: A Cognitive Model. The Psychology of Depression: Contemporary Theory and Research. Edited by: Friedman RA, Katz MM. 1974, John Wiley & Sons, Oxford England
Beck AT, Rush AJ, Shaw BF, Emery G: Kognitive Therapie der Depression. 1996, 5. Auflage, Psychologie Verlags Union, Weinheim
Sookman D, Pinard G: Integrative cognitive therapy for obsessive-compulsive disorder: a focus on multiple schemas. Cognit Behav Pract. 1999, 6 (4): 351-362. 10.1016/S1077-7229(99)80055-8.
Young JE: Cognitive Therapy for Personality Disorders: A Schema-Focused Approach. 1990, Professional Resource Exchange, Sarasota
Young JE, Klosko JS, Weishaar ME: Schema Therapy: A Practitioner’s Guide. 2003, The Guilford Press, New York
Renner F, Lobbestael J, Peeters F, Arntz A, Huibers M: Early maladaptive schemas in depressed patients: Stability and relation with depressive symptoms over the course of treatment. J Affect Disord. 2012, 136 (3): 581-590. 10.1016/j.jad.2011.10.027.
Foa EB, Kozak MJ: Psychological Treatment for Obsessive-Compulsive Disorder. Long-Term Treatments of Anxiety Disorders. Edited by: Mavissakalian MR, Prien RF. 1996, American Psychiatric Association, Arlington: US, 285-309.
Kobak KA, Greist JH, Jefferson JW, Katzelnick DJ, Henk HJ: Behavioral versus pharmacological treatments of obsessive compulsive disorder: a meta-analysis. Psychopharmacology (Berl). 1998, 136 (3): 205-216. 10.1007/s002130050558.
Steketee G, Henninger NJ, Pollard C: Predicting Treatment Outcomes for Obsessive-Compulsive Disorder: Effects of Comorbidity. Obsessive-Compulsive Disorder: Contemporary Issues in Treatment. Edited by: Goodman WK, Rudorfer MV, Maser JD. 2000, Lawrence Erlbaum Associates Publishers, Mahwah, 257-274.
Whittal ML, Thordarson DS, McLean PD: Treatment of obsessive-compulsive disorder: cognitive behavior therapy vs. exposure and response prevention. Behav Res Ther. 2005, 43 (12): 1559-1576. 10.1016/j.brat.2004.11.012.
Luck A, Waller G, Meyer C, Ussher M, Lacey H: The role of schema processes in the eating disorders. Cognit Ther Res. 2005, 29 (6): 717-732. 10.1007/s10608-005-9635-8.
Pinto-Gouveia J, Castilho P, Galhardo A, Cunha M: Early maladaptive schemas and social phobia. Cognit Ther Res. 2006, 30 (5): 571-584. 10.1007/s10608-006-9027-8.
Atalay H, Atalay F, Karahan D, Çaliskan M: Early maladaptive schemas activated in patients with obsessive compulsive disorder: a cross-sectional study. Int J Psychiatr Clin Pract. 2008, 12 (4): 268-279. 10.1080/13651500802095004.
Lochner C, Seedat S, du Toit PL, Nel DG, Niehaus DH, Sandler R, Stein DJ: Obsessive-compulsive disorder and trichotillomania: a phenomenological comparison. BMC Psychiatry 2005, 5:1–10 PsycINFO, EBSCOhost, viewed 1 September 2014.,
Voderholzer U, Schwartz C, Thiel N, Kuelz AK, Hartmann A, Scheidt C, Zeeck A: A comparison of schemas, schema modes and childhood traumas in obsessive-compulsive disorder, chronic pain disorder and eating disorders. Psychopathology. 2014, 47 (1): 24-31. 10.1159/000348484.
Haaland A, Vogel PA, Launes G, Haaland V, Hansen B, Solem S, Himle JA: The role of early maladaptive schemas in predicting exposure and response prevention outcome for obsessive-compulsive disorder. Behav Res Ther. 2011, 49 (11): 781-788. 10.1016/j.brat.2011.08.007.
Davidson JRT, Kudler HS, Saunders WB, Smith RD: Symptom and comorbidity patterns in World War II and Vietnam veterans with posttraumatic stress disorder. Compr Psychiatry. 1990, 31: 162-170. 10.1016/0010-440X(90)90020-S.
Grabe HJ, Meye C, Hapke U, Rumpf H-J, Freyberger HJ, Dilling H, John U: Lifetime comorbidity of obsessive- compulsive disorder and subclinical obsessive- compulsive disorder in northern Germany. Eur Arch Psychiatr Clin Neurosci. 2001, 251: 130-135. 10.1007/s004060170047.
Grabe HJ, Ruhrmann S, Spitzer C, Josepeit J, Ettelt S, Buhtz F, Hochrein A, Schulze-Rauschenbach S, Meyer K, Kraft S, Reck C, Pukrop R, Klosterkötter J, Falkai P, Maier W, Wagner M, John U, Feraberger HJ: Obsessive- compulsive disorder and posttraumatic stress disorder. Psychopathology. 2008, 41 (2): 129-134. 10.1159/000112029.
Cromer K, Schmidt N, Murphy D: An investigation of traumatic life events and obsessive-compulsive disorder. Behav Res Ther. 2007, 45 (7): 1683-1691. 10.1016/j.brat.2006.08.018.
Fricke S, Köhler S, Moritz S: Frühe interpersonale Traumatisierung bei Zwangserkrankungen. Eine Pilotstudie. = Early traumatic experience in obsessive-compulsive disorders: a pilot study. Verhaltenstherapie. 2007, 17 (4): 243-250. 10.1159/000109739.
Lochner C, DuToit PL, Zungu-Dirwayi N, Marais A, van Kradenburg J, Curr B, Seedat S, Niehaus D, Stein DJ: Childhood trauma in obsessive- compulsive disorder, trichotillomania and controls. Depress Anxiety. 2002, 15: 66-68. 10.1002/da.10028.
Maier S, Kuelz AK, Voderholzer U: Traumatisierung und Dissoziationsneigung bei Zwangserkrankten: Ein Üeberblick. = Trauma and dissociation in patients with obsessive-compulsive disorder: an overview. Verhaltenstherapie 2009, 19(4):219–227.,
Gerushy BS, Baer L, Radomsky AS, Wilson KA, Jenike MA: Connections among symptoms of obsessive- compulsive disorder and posttraumatic stress disorder: a case series. Behav Res Ther. 2003, 41: 1029-1041. 10.1016/S0005-7967(02)00178-X.
Jacob G, Arntz A: Schematherapie in der Praxis. 2011, Weinheim, Beltz Verlag
Lobbestael J, van Vreeswijk M, Arntz A: Shedding light on schema modes: a clarification of the mode concept and its current research status. Neth J Psychol. 2007, 63 (3): 76-85.
Wittchen HU, Zaudig M, Fydrich T: Strukturiertes Klinisches Interview für DSM-IV (SKID-I und SKID-II) Handanweisung. 1997, Hogrefe, Göttingen
Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, Hill CL, Charney DS: The Yale-Brown obsessive compulsive scale: I. Development, use, and reliability. Arch Gen Psychiatry. 1989, 46 (11): 1006-1011. 10.1001/archpsyc.1989.01810110048007.
Jacobsen DD, Kloss MM, Fricke SS, Hand II, Moritz SS: Reliabilität der deutschen Version der Yale-Brown obsessive compulsive scale. Verhaltenstherapie. 2003, 13 (2): 111-113. 10.1159/000072184.
Taylor S: Assessment of Obsessive–Compulsive Disorder. Obsessive-Compulsive Disorder: Theory, Research, and Treatment. Edited by: Swinson RP, Antony MM, Rachman SS, Richter MA. 1998, Guilford Press, New York, 229-257.
Woody SR, Steketee G, Chambless DL: Reliability and validity of the Yale-Brown obsessive-compulsive scale. Behav Res Ther. 1995, 33 (5): 597-605. 10.1016/0005-7967(94)00076-V.
DeVeaugh-Geiss J, Landau P, Katz R: Treatment of obsessive compulsive disorder with clomipramine. Psychiatr Ann. 1989, 19 (2): 97-101. 10.3928/0048-5713-19890201-11.
Young JE: Young Schema Questionnaire (YSQ-S3). (Berbalk H., Grutschpalk J, Party E, Zarbock G, Trans.). 2006, Institut für Schematherapie, Eckernförde
Kriston L, Schäfer J, Jacob GA, Härter M, Hölzel LP: Reliability and validity of the German Version of the Young Schema Questionnaire-Short Form 3 (YSQ-S3). Eur J Psychol Assess. 2013, 29 (3): 205-212. 10.1027/1015-5759/a000143.
Lobbestael J, van Vreeswijk M, Spinhoven P, Schouten E, Arntz A: Reliability and validity of the Short Schema Mode Inventory (SMI). Behav Cognit Psychother. 2010, 38 (4): 437-458. 10.1017/S1352465810000226.
Reiss N, Dominiak P, Harris D, Knörnschild C, Schouten E, Jacob GA: Reliability and validity of the German version of the Schema Mode Inventory. Eur J Psychol Assess. 2012, 28 (4): 297-304. 10.1027/1015-5759/a000110.
Beck AT, Steer RA, Ball R, Ranieri WF: Comparison of Beck Depression Inventories–IA and –II in psychiatric outpatients. J Pers Assess. 1996, 67 (3): 588-597. 10.1207/s15327752jpa6703_13.
Kühner CC, Bürger CC, Keller FF, Hautzinger MM: Reliabilität und Validität des revidierten Beck-Depressions-Inventars (BDI-II). Befunde aus deutschsprachigen Stichproben. Nervenarzt. 2007, 78 (6): 651-656. 10.1007/s00115-006-2098-7.
Foa EB, Huppert JD, Leiberg S, Langner R, Kichic R, Hajcak G, Salkovskis PM: The obsessive-compulsive inventory: development and validation of a short version. Psychol Assess. 2002, 14 (4): 485-496. 10.1037/1040-3522.214.171.1245.
Abramowitz JS, Deacon BJ: Psychometric properties and construct validity of the obsessive-compulsive inventory–revised: replication and extension with a clinical sample. J Anxiety Disord. 2006, 20 (8): 1016-1035. 10.1016/j.janxdis.2006.03.001.
Huppert JD, Walther MR, Hajcak G, Yadin E, Foa EB, Simpson H, Liebowitz MR: The OCI-R: validation of the subscales in a clinical sample. J Anxiety Disord. 2007, 21 (3): 394-406. 10.1016/j.janxdis.2006.05.006.
Gönner S, Leonhart R, Ecker W: The Obsessive-Compulsive Inventory-Revised (OCI-R): validation of the German version in a sample of patients with OCD, anxiety disorders, and depressive disorders. J Anxiety Disord. 2008, 22 (4): 734-749. 10.1016/j.janxdis.2007.07.007.
Bernstein DP, Ahluvalia T, Pogge D, Handelsman L: Validity of the Childhood Trauma Questionnaire in an adolescent psychiatric population. J Am Acad Child Adolesc Psychiatr. 1997, 36 (3): 340-348. 10.1097/00004583-199703000-00012.
Wingenfeld K, Spitzer C, Mensebach C, Grabe H, Hill A, Gast U, Driessen M: Die deutsche Version des Childhood Trauma Questionnaire (CTQ): Erste Befunde zu den psychometrischen Kennwerten. Psychother Psychosom Med Psychol. 2010, 60 (11): 442-450. 10.1055/s-0030-1247564.
Lakatos A, Reinecker H: Kognitive Verhaltenstherapie bei Zwangsstörungen. 2007, Hogrefe, 3. Auflage, Göttingen
Jacobson NS, Truax P: Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol. 1991, 59 (1): 12-19. 10.1037/0022-006X.59.1.12.
Abramowitz JS, Franklin ME, Street GP, Kozak MJ, Foa EB: Effects of comorbid depression on response to treatment for obsessive-compulsive disorder. Behav Ther. 2000, 31 (3): 517-528. 10.1016/S0005-7894(00)80028-3.
Abramowitz JS, Franklin ME, Schwartz SA, Furr JM: Symptom presentation and outcome of cognitive-behavioral therapy for obsessive-compulsive disorder. J Consult Clin Psychol. 2003, 71 (6): 1049-1057. 10.1037/0022-006X.71.6.1049.
Franklin ME, Abramowitz JS, Kozak MJ, Levitt JT, Foa EB: Effectiveness of exposure and ritual prevention for obsessive-compulsive disorder: randomized compared with nonrandomized samples. J Consult Clin Psychol. 2000, 68 (4): 594-602. 10.1037/0022-006X.68.4.594.
Keeley ML, Storch EA, Merlo LJ, Geffken GR: Clinical predictors of response to cognitive-behavioral therapy for obsessive-compulsive disorder. Clin Psychol Rev. 2008, 28 (1): 118-130. 10.1016/j.cpr.2007.04.003.
Keijsers GJ, Hoogduin CL, Schaap CR: Predictors of treatment outcome in the behavioural treatment of obsessive-compulsive disorder. Br J Psychiatr. 1994, 165 (6): 781-786. 10.1192/bjp.165.6.781.
Thiel N, Hertenstein E, Nissen C, Herbst N, Külz A, Voderholzer U: The effect of personality disorders on treatment outcomes in patients with obsessive-compulsive disorders. J Pers Disord. 2013, 27 (6): 697-715. 10.1521/pedi_2013_27_104.
Bortz J, Schuster C: Statistik für Human- und Sozialwissenschaftler. 2010, Springer, 7. Auflage Heidelberg
O’Brien RM: A caution regarding rules of thumb for variance inflation factors. Qual Quant Int J Methodol. 2007, 41 (5): 673-690. 10.1007/s11135-006-9018-6.
Bandura A: Regulation of cognitive processes through perceived self-efficacy. Dev Psychol. 1989, 25 (5): 729-735. 10.1037/0012-16126.96.36.1999.
Lewin AB, Peris TS, Bergman R, McCracken JT, Piacentini J: The role of treatment expectancy in youth receiving exposure-based CBT for obsessive compulsive disorder. Behav Res Ther. 2011, 49 (9): 536-543. 10.1016/j.brat.2011.06.001.
Krell HV, Leuchter AF, Morgan M, Cook IA, Abrams M: Subject expectations of treatment effectiveness and outcome of treatment with an experimental antidepressant. J Clin Psychiatr. 2004, 65 (9): 1174-1179. 10.4088/JCP.v65n0904.
Mondloch MV, Cole DC, Frank JW: Does how you do depend on how you think you’ll do? A systematic review of the evidence for a relation between patients’ recovery expectations and health outcomes. Can Med Assoc J. 2001, 165 (2): 174-179.
Newman MG, Fisher AJ: Expectancy/credibility change as a mediator of cognitive behavioral therapy for generalized anxiety disorder: Mechanism of action or proxy for symptom change?. Int J Cognit Ther. 2010, 3 (3): 245-261. 10.1521/ijct.2010.3.3.245.
Price M, Anderson P, Henrich CC, Rothbaum B: Greater expectations: using hierarchical linear modeling to examine expectancy for treatment outcome as a predictor of treatment response. Behav Ther. 2008, 39 (4): 398-405. 10.1016/j.beth.2007.12.002.
Westra HA, Dozois DA, Marcus M: Expectancy, homework compliance, and initial change in cognitive-behavioral therapy for anxiety. J Consult Clin Psychol. 2007, 75 (3): 363-373. 10.1037/0022-006X.75.3.363.
Lax T, Başoğlu M, Marks IM: Expectancy and compliance as predictors of outcome in obsessive-compulsive disorder. Behav Psychother. 1992, 20 (3): 257-266. 10.1017/S0141347300017237.
Steketee G, Siev J, Fama JM, Keshaviah A, Chosak A, Wilhelm S: Predictors of treatment outcome in modular cognitive therapy for obsessive-compulsive disorder. Depress Anxiety. 2011, 28 (4): 333-341. 10.1002/da.20785.
Vogel PA, Hansen B, Stiles TC, Götestam K: Treatment motivation, treatment expectancy, and helping alliance as predictors of outcome in cognitive behavioral treatment of OCD. J Behav Ther Exp Psychiatr. 2006, 37 (3): 247-255. 10.1016/j.jbtep.2005.12.001.
Price JP: Cognitive schemas, defence mechanisms and post-traumatic stress symptomatology. Psychol Psychother Theor Res Pract. 2007, 80 (3): 343-353. 10.1348/147608306X144178.
Welburn K, Coristine M, Dagg P, Pontefract A, Jordan S: The Schema Questionnaire-Short form: factor analysis and relationship between schemas and symptoms. Cognit Ther Res. 2002, 26 (4): 519-530. 10.1023/A:1016231902020.
Calvete E, Estévez A, LópezdeArroyabe E, Ruiz P: The Schema questionnaire--short form: structure and relationship with automatic thoughts and symptoms of affective disorders. Eur J Psychol Assess. 2005, 21 (2): 90-99. 10.1027/1015-57188.8.131.52.
Petrocelli JV, Glaser BA, Calhoun GB, Campbell LF: Cognitive schemas as mediating variables of the relationship between the self-defeating personality and depression. J Psychopathol Behav Assess. 2001, 23 (3): 183-191. 10.1023/A:1010969321426.
Cockram MD, Drummond PD, Lee CW: Role and treatment of early maladaptive schemas in Vietnam veterans with PTSD. Clin Psychol Psychother. 2010, 17 (3): 165-182.
Dutra L, Callahan K, Forman E, Mendelsohn M, Herman J: Core schemas and suicidality in a chronically traumatized population. J Nerv Ment Dis. 2008, 196 (1): 71-74. 10.1097/NMD.0b013e31815fa4c1.
Hinrichsen H, Waller G, Emanuelli F: Social anxiety and agoraphobia in the eating disorders: associations with core beliefs. J Nerv Ment Dis. 2004, 192 (11): 784-787. 10.1097/01.nmd.0000144698.69316.02.
Schmidt NB, Joiner TE, Young JE, Telch MJ: The schema questionnaire: investigation of psychometric properties and the hierarchical structure of a measure of maladaptive schemas. Cognit Ther Res. 1995, 19 (3): 295-321. 10.1007/BF02230402.
Jovev M, Jackson HJ: Early maladaptive schemas in personality disordered individuals. J Pers Disord. 2004, 18 (5): 467-478. 10.1521/pedi.18.5.467.51325.
Hawke LD, Provencher MD: Early Maladaptive Schemas among patients diagnosed with bipolar disorder. J Affect Disord. 2012, 136 (3): 803-811. 10.1016/j.jad.2011.09.036.
Halvorsen M, Wang CE, Richter J, Myrland I, Pedersen SK, Eisemann M, Waterloo K: Early maladaptive schemas, temperament and character traits in clinically depressed and previously depressed subjects. Clinical Psychology & Psychotherapy 2009, 16(5):394–407,
Shah R, Waller G: Parental style and vulnerability to depression: the role of core beliefs. J Nerv Ment Dis. 2000, 188 (1): 19-25. 10.1097/00005053-200001000-00004.
Steketee G, Chambless DL, Tran GQ: Effects of axis I and II comorbidity on behavior therapy outcome for obsessive-compulsive disorder and agoraphobia. Compr Psychiatry. 2001, 42 (1): 76-86. 10.1053/comp.2001.19746.
Anholt GE, Aderka IM, van Balkom AM, Smit JH, Hermesh H, de Haan E, van Oppen P: The impact of depression on the treatment of obsessive–compulsive disorder: results from a 5-year follow-up. J Affect Disord. 2011, 135 (1–3): 201-207. 10.1016/j.jad.2011.07.018.
Benazon NR, Ager JJ, Rosenberg DR: Cognitive behavior therapy in treatment-naive children and adolescents with obsessive-compulsive disorder: an open trial. Behav Res Ther. 2002, 40 (5): 529-540. 10.1016/S0005-7967(01)00064-X.
Abramowitz JS: Treatment of obsessive-compulsive disorder in patients who have comorbid major depression. J Clin Psychol. 2004, 60 (11): 1133-1141. 10.1002/jclp.20078.
Rufer MM, Fricke SS, Moritz SS, Kloss MM, Hand II: Symptom dimensions in obsessive- compulsive disorder: prediction of cognitive-behavior therapy outcome. Acta Psychiatr Scand. 2006, 113 (5): 440-446. 10.1111/j.1600-0447.2005.00682.x.
Abramowitz JS, Foa EB: Does major depressive disorder influence outcome of exposure and response prevention for OCD?. Behav Ther. 2000, 31 (4): 795-800. 10.1016/S0005-7894(00)80045-3.
Atalay H, Atalay F, Bagdacicek S: Effects of short-term antidepressant treatment on early maladaptive schemas in patients with major depressive and panic disorder. Int J Psychiatr Clin Pract. 2011, 15: 97-105. 10.3109/13651501.2010.549234.
Abramowitz JS, Storch EA, Keeley M, Cordell E: Obsessive-compulsive disorder with comorbid major depression: what is the role of cognitive factors?. Behav Res Ther. 2007, 45 (10): 2257-2267. 10.1016/j.brat.2007.04.003.
Giesen-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Dirksen C, van Asselt T, Kremers I, Nadort M, Arntz A: Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Arch GenPsychiatr. 2006, 63 (6): 649-658. 10.1001/archpsyc.63.6.649.
Gude T, Hoffart A: Change in interpersonal problems after cognitive agoraphobia and schema-focused therapy versus psychodynamic treatment as usual of inpatients with agoraphobia and Cluster C personality disorders. Scand J Psychol. 2008, 49 (2): 195-199. 10.1111/j.1467-9450.2008.00629.x.
We want to thank the participants in our study and the therapeutic colleagues who have contributed to the acquisition of the data, especially Johanna Reiss and Kerstin Mueller. Moreover we want to acknowledge NH, CN, BTC, EH, UV, AKK, EG and NT for their contribution to the study and complementation of the manuscript. No financial support or funding source was provided for this study. The article processing charge was funded by the German Research Foundation (DFG) and the Albert Ludwigs University Freiburg in the funding programme Open Access Publishing.
The authors declare that they have no competing interests.
NT and NH carried out the study. CN, BTC and EH helped to draft the manuscript. UV and participated in the design and coordination of the study and drafted the manuscript. NT and AKK performed the statistical analysis. EG conceived the study. All authors read and approved the final manuscript.
About this article
Cite this article
Thiel, N., Tuschen-Caffier, B., Herbst, N. et al. The prediction of treatment outcomes by early maladaptive schemas and schema modes in obsessive-compulsive disorder. BMC Psychiatry 14, 362 (2014). https://doi.org/10.1186/s12888-014-0362-0
- Schema Mode
- Depressive Symptom Severity
- Emotional Inhibition
- Childhood Trauma Questionnaire
- Early Maladaptive Schema