The current study was the first to compare early maladaptive schemas (EMS) and schema modes using the YSQ-S3 and revised SMI, respectively, in normal weight controls and individuals with obesity attending a tertiary weight intervention service. This study also investigated differences in childhood trauma and PTSD symptoms among treatment-seeking individuals with obesity and normal weight controls.
First, consistent with our hypotheses and previous research [15, 16], individuals with obesity endorsed significantly higher scores on the Abandonment, Mistrust/Abuse, Emotional Deprivation, Defectiveness/Shame, Social Isolation/Alienation, Dependence/Incompetence, Failure, Insufficient Self-Control, and Subjugation schemas compared to normal weight controls. Unexpectedly, individuals with obesity also demonstrated significantly higher scores on the Vulnerability to Harm and Illness, Self-Sacrifice, Negativity/Pessimism, and Emotional Inhibition schemas. Notably, our findings revealed that all schemas in the Disconnection and Rejection domain were significantly higher in the obesity group, with medium to large effect sizes. The Disconnection and Rejection domain primarily reflects difficulties with developing secure attachments to others [7, 8]. Previous research has demonstrated that elevations in this schema domain is related to eating disorders and predicts food addiction symptoms among women with overweight and obesity [36, 37].
Specifically, these results suggested that compared to normal weight individuals, those with obesity may perceive their important relationships with others as more unstable (i.e., Abandonment) or may believe that others are more likely to abuse and treat them poorly (i.e., Mistrust/Abuse) and that their emotional needs will remain unsatisfied (i.e., Emotional Deprivation) [7, 8]. They may also experience more shame or perceive themselves as more defective (i.e., Defectiveness/Shame) or have a stronger sense of not belonging to communities and social groups due to feeling dissimilar (i.e., Social Isolation/Alienation) [7, 8]. In addition, they may believe they are less capable of independently managing daily responsibilities (i.e., Dependence/Incompetence), that catastrophic illness and injury (e.g., heart attack) is unpreventable and imminent (i.e., Vulnerability to Harm and Illness), and that they will inevitably fail and be less successful than peers (i.e., Failure) [7, 8]. Furthermore, they may experience greater difficulties with self-control (i.e., Insufficient Self-Control), may be more likely to surrender control to others (i.e., Subjugation), or more likely to prioritise the needs of others at the expense of their own (i.e., Self-Sacrifice) [7, 8]. Moreover, they may exhibit a greater preoccupation with negative aspects of life (i.e., Negativity/Pessimism) as well as a greater inhibition of emotion due to the belief that emotions are unnecessary or unpleasant to display (i.e., Emotional Inhibition) [7, 8].
Second, consistent with our predictions and previous research [16], individuals with obesity demonstrated significantly higher scores on the Vulnerable Child, Impulsive Child, and Detached Protector modes as well as significantly lower scores on the Happy Child and Healthy Adult modes relative to normal weight individuals. Unexpectedly, individuals with obesity also displayed significantly higher scores on the Angry Child, Undisciplined Child, Compliant Surrender, and Punitive Parent modes. Specifically, these findings suggested that individuals with obesity experience a higher degree of sadness and desperation (i.e., Vulnerable Child) and may be more likely to act in anger and frustration due to unmet needs (i.e., Angry Child) or to behave in impulsive and uncontrolled ways to satisfy their needs (i.e., Undisciplined and Impulsive Child), but not in a more aggressive or violent manner than normal weight individuals (i.e., Enraged Child) [7, 8]. In addition, individuals with obesity more frequently experience a harsh, unforgiving, and critical internalised parent/caregiver voice (i.e., Punitive Parent) but place a degree of pressure on themselves to meet high standards that is similar to normal weight individuals (i.e., Demanding Parent) [7, 8]. Further, individuals with obesity adopt a more passive, submissive, and compliant coping method (i.e., Compliant Surrender) as well as a more avoidant, emotionally withdrawn, and detached coping style (i.e., Detached Protector). Moreover, normal weight individuals demonstrate less activated schemas, more satisfied core emotional needs, and more appropriate adult functioning than individuals with obesity (i.e., Happy Child, Healthy Adult) [7, 8].
Third, as hypothesised, individuals with obesity demonstrated significantly higher scores on Emotional Abuse, Physical Abuse, Sexual Abuse, Emotional Neglect, Physical Neglect, and PTSD symptoms compared to normal weight individuals. Significant differences between groups were also observed on childhood trauma and provisional PTSD diagnosis using the dichotomous scoring methods on the CTQ-SF and PCL-5. Specifically, 58.8% of individuals with obesity reported the presence of Emotional Abuse, 49.4% reported the presence of Physical Abuse, 28.2% reported the presence of Sexual Abuse, 31.8% reported the presence of Emotional Neglect, 54.1% reported the presence of Physical Neglect, and 37.6% reported PTSD symptoms within the last month that were above the cut-off criteria to suggest a provisional diagnosis of PTSD. These results support previous studies that found an increased probability of developing obesity for those with childhood traumatic experiences and PTSD [10,11,12, 38]. Similarly, these results are comparable with Walsh et al. [13], who found that one-third of their pre-bariatric surgery sample endorsed a history of physical or sexual abuse in childhood. Together, these findings reiterate that individuals with obesity experience considerably more traumatic experiences and current trauma symptoms than the general population, which may prove detrimental to their mental health and weight management.
Implications
Previous research on the psychological mechanisms of obesity has primarily concentrated on acute psychopathology. This study contributes to elucidating the relationship between obesity and more complex and entrenched psychological processes. Overall, our findings indicated 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, individuals with obesity reported significantly more childhood trauma as well as significantly more PTSD symptoms within the last month than normal weight individuals. These findings have several clinical implications for the management of obesity and mental health more broadly.
First, they highlight the importance of comprehensively assessing maladaptive schemas and schema modes in weight intervention programs. Identifying how patients view themselves, others, and the world, and their primary coping strategies, may provide valuable insight for targeted intervention. For instance, our findings revealed that individuals with obesity principally display a psychologically withdrawn and submissive or passive coping style. This suggests that patients have developed ways to emotionally detach from their experiences, but do not employ effective strategies to manage their emotional difficulties. These maladaptive coping mechanisms may be activated by underlying schemas and schema modes that are entrenched within the patient (e.g., Punitive Parent, Vulnerable Child). This formulation is conceptually consistent with the schema mode model of obesity proposed by Basile et al. [16], which theorises that the Compliant Surrender and Detached Protector/Detached Self-Soother modes arise from the patient’s attempt to cope with the Punitive Parent and Impulsive Child modes. Importantly, this pattern of functioning may interfere with weight management over time. Therefore, identifying entrenched schemas and schema modes, including their origins and triggers, could be a critical first step to improving long-term weight management for individuals with obesity.
Second, as part of weight intervention, maladaptive schemas and schema modes should be addressed through psychological treatments such as schema therapy. Schema therapy integrates cognitive, behavioural, and experiential techniques to modify maladaptive coping strategies, reduce the influence of the internalised parent modes, satisfy unmet core emotional needs, and foster healthy functioning [7, 8]. Importantly, schema therapy focuses on establishing a safe therapeutic relationship that acknowledges the previously functional role of current maladaptive coping methods (e.g., in response to trauma) and substitutes them with more helpful coping strategies. If untreated, however, underlying schemas and schema modes may interfere with longer-term outcomes due to their pervasive and enduring nature. Therefore, intervention for obesity must inevitably replace maladaptive coping methods (e.g., binge eating) with more functional and adaptive responses. By developing more adaptive coping strategies and minimising maladaptive schema modes, individuals with obesity could remove barriers that potentially impede diet and physical activity and improve longer-term weight management.
Third, these findings emphasise the importance of comprehensively assessing trauma history in weight intervention programs. Research indicates that individuals with obesity with a history of childhood abuse and PTSD demonstrate significantly more eating psychopathology, physical health concerns, and psychological difficulties (e.g., substance misuse, body image) than those without a history of trauma or PTSD [13]. Further, childhood and adulthood trauma has been linked to eating disorders such as BED [12, 14]. If untreated, BED may hinder weight loss outcomes and contribute to weight regain for those undertaking bariatric surgery [39, 40]. Therefore, identifying individuals with a history of trauma may be critical to detecting those vulnerable to adverse medical and psychological outcomes. Importantly, however, individuals with obesity may underreport their clinical symptoms to appear more favourable during psychological assessments [41]. Similarly, they may require intensive intervention over time to accurately recall their traumatic experiences. As a result, it is essential for all health professionals within multidisciplinary teams to be cognisant of the markers of trauma to identify those at increased risk of less successful outcomes.
Finally, these findings reinforce the importance of treating mental health difficulties in weight intervention programs. Psychological difficulties (e.g., eating psychopathology, depression, anxiety, binge eating) have been linked to weight regain after bariatric surgery [5, 42] and may interfere with longer-term weight management. As evidenced in our study, individuals with obesity also experience more complex and enduring psychological difficulties, including increased childhood trauma, PTSD symptoms, and maladaptive schemas and schema modes. Childhood trauma may also represent a transdiagnostic risk factor for other mental health concerns, including depression and psychosis [43]. Future obesity treatment models could consider routine screening for childhood trauma, PTSD, and maladaptive coping strategies, to identify those requiring more intensive intervention. This will contribute to a more holistic and individualised conceptualisation of weight management and could attenuate the influence of psychological mechanisms on long-term weight maintenance.
Limitations, Strengths, and Future Directions
Our results should be considered in the context of several limitations. First, we did not explicitly assess all types of childhood maltreatment (e.g., bullying, parental domestic violence, serious accident/death). As a result, some participants may have experienced childhood adversities that were not captured in this study. For example, MacDonald et al. [44] found that almost one-third of their participants experienced childhood adversities that were not identified by the CTQ-SF. In addition, childhood maltreatment is often assessed retrospectively, which may contribute to recall inaccuracies. These inaccuracies may be deliberate, due to fear of negative evaluation from others (e.g., stigma associated with the experience), or unintentional, because of an emotional avoidance of the traumatic experience. Future research could utilise longitudinal designs to minimise the potential effects of recall bias when assessing childhood trauma. Furthermore, as proposed by Pilkington et al. [9], future research could investigate the developmental period of maltreatment (e.g., first 12 months of life, adolescence) as well as the impact of different perpetrators (e.g., mother, father, grandparent, sibling, peer) on outcomes.
Second, responses on schema-related questionnaires may be influenced by active schemas or schema modes at the time of the assessment. For example, individuals in an avoidant coping mode (e.g., Detached Protector) may inadvertently minimise their clinical symptoms, whereas individuals in a Vulnerable Child mode may unintentionally inflate their concerns. Similarly, although EMS are considered relatively stable, it is unclear whether certain questions (e.g., trauma) prime responses or elicit emotional states that influence responding style. In addition, it is unclear whether certain psychiatric medication attenuates schema activation. The potential variability in schema activation at the time of the assessment may contribute to differences in outcomes across the literature, but future research is required to verify this claim. In addition, future research could examine these outcomes over multiple time points to circumvent potential response bias associated with active schemas and schemas modes.
Third, previous research has shown that treatment-seeking individuals with obesity may underreport their clinical symptoms due to fear of treatment ineligibility [41]. Supporting this claim, our findings indicated that 38.8% of participants in the obesity group provided scores that indicated possible underreporting of childhood maltreatment. This social desirability bias was also observed in the normal weight group, with 25% of participants possibly underreporting childhood maltreatment. Furthermore, we would expect that participants responded with a similar bias to the other questionnaires in our study; however, this was not formally assessed. Therefore, our results should be considered carefully, as they may underestimate the actual prevalence of childhood maltreatment in the current sample as well as the severity of EMS and schema modes. Future research could utilise a multi-method approach (e.g., self-report questionnaire, semi-structured interview) when assessing these constructs to mitigate potential social desirability bias.
Fourth, our sample predominantly consisted of female participants, with a large portion recruited from a clinical setting. Notably, this clinical setting resides in a lower socioeconomic area in Australia than the sample recruited by Anderson et al. [15] and is characterised by greater medical complexities than a community sample. Australian adults residing in lower socioeconomic regions have a greater likelihood of elevated psychological distress and adverse health complications such as obesity, relative to individuals from higher socioeconomic regions [45, 46]. Importantly, community participants were recruited from the same socioeconomic area in Australia to minimise sociodemographic variance across groups. In addition, we excluded participants with severe mental and physical illness and cognitive/intellectual impairment to circumvent the influence of more severe presentations on outcomes. Nonetheless, future research could replicate these findings in a community sample with similar sex distribution and socioeconomic factors, which may improve the external validity of these results. Future studies could also examine whether trauma exposure and coping responses vary among men and women, especially in the context of potential biological differences and culturally acceptable forms of coping. For example, previous research has found that men are more susceptible to environmental stressors (e.g., abuse, neglect) due to differences in neural development [47], which may have implications for longer-term outcomes. Moreover, future research could investigate the relationship between the onset of obesity (i.e., childhood, adolescence, adulthood) and childhood trauma, EMS, and schema modes.
Finally, there are several notable strengths in the current study. First, we utilised the YSQ-S3 and refined, 118-item SMI, which are the latest iterations of the schema questionnaires. This extends previous literature that compared EMS and schema modes in individuals with obesity and normal weight controls using the YSQ-S2 and 124-item Schema Mode Inventory, respectively [15,16,17]. Importantly, though, the motivation and time taken to complete these questionnaires may have contributed to respondent boredom or fatigue, possibly impacting recruitment and the completion rate. Second, our clinical sample comprised treatment-seeking individuals with obesity attending a tertiary weight intervention service, with all participants containing a BMI in the obesity range. This extends the findings of previous studies that combined overweight and obesity participants into one group [16]. The use of a combined overweight and obesity group may contribute to differences in outcomes, but future research is required to investigate this further. In addition, the inclusion of a treatment-seeking sample elaborates previous research that compared schema modes in normal weight controls and individuals with obesity from the community [16].