ARTICLE IN PRESS

www.elsevier.com/locate/comppsych

Comprehensive Psych

Early maladaptive schemas and body mass index in subgroups of

eating disorders: a differential association

Zsolt Unokaa,4, Tamas Tflgyesa, Pal Czobora,baDepartment of Psychiatry and Psychotherapy, Faculty of General Medicine Semmelweis University, 1083 Budapest, Hungary

bNathan S. Kline Institute for Psychiatric Research, Orangeburg, NY 10962, USA

Abstract

Objective: The objectives were (1) to examine whether 3 eating disorder subgroups, as defined by the Diagnostic and Statistical Manual

of Mental Disorders, Fourth Edition (DSM-IV) classification system, exhibit a specific profile in terms of early maladaptive schema

(EMS) factors, and (2) to investigate the relationship between body mass index (BMI) and EMS factors in each of the individual eating

disorder subgroups.

Methods: The presence of EMS was measured by the Young Schema Questionnaire Long Form among patients affected by restrictive

anorexia nervosa, binge/purging-type anorexia nervosa, and bulimia nervosa. Principal component factor analysis was used to investigate

the factor structure of the EMS across eating disorder subgroups. General linear model analysis was applied to examine the differences

of the subgroups in terms of their EMS factors. Differential association between BMI and schema factors was tested by analysis

of covariance.

Results: Four EMS factors were extracted, which accounted for approximately 72% of the variance. The 3 eating disorder subgroups

differed in terms of their EMS factor profiles. The analysis of covariance resulted in a significant negative relationship between BMI and

EMS factor 2 in the bulimia nervosa group (P b .0099), indicating that higher severity on defectiveness, failure, dependence,

enmeshments, subjugation, approval-seeking (EMS factor 2) was associated with lower values on BMI.

Conclusion: The findings of this study indicate that EMSs based on Young’s conceptualization of EMS, as measured by the Young Schema

Questionnaire, differ significantly among eating disorder subgroups defined by the phenomenological approach used by the DSM-IV

diagnoses. These results are consistent with the notion that dysfunctional cognitions may play an important role in the development and

maintenance of the symptoms that underlie the DSM-IV classification of the eating disorder subtypes.

D 2007 Published by Elsevier Inc.

1. Introduction

Cognitive-behavioral models of eating disorders assume

that dysfunctional cognitions that patients sustain play an

important role in the development and maintenance of the

symptoms that underlie the Diagnostic and Statistical

Manual of Mental Disorders, Fourth Edition (DSM-IV)

classification of these disorders [1,17]. Some models focus

on the group of cognitions that are related to food, weight,

and shape, and are specific to patients with eating disorders

[1,2]. Some other cognitive-behavioral conceptualization of

eating disorders integrates into their models core beliefs

that concern beliefs on attachment to others, autonomy,

0010-440X/$ – see front matter D 2007 Published by Elsevier Inc.

doi:10.1016/j.comppsych.2006.09.002

4 Corresponding author. Tel.: +1 00 36 1 239 49 93; fax: +1 00 36 1

210 0336.

E-mail address: unoka@psych.sote.hu (Z. Unoka).

competence, sense of identity, ability to express valid needs

and emotions, limit setting capacity, and self-control [3-5].

These types of dysfunctional cognitive contents are not

specific to eating disorders and were found in other mental

disorders as well [6]. Young [7] identified 19 unconditional

schema-level representations that cover the aforementioned

topics of self-representations and he labeled them early

maladaptive schemas (EMSs). An EMS is a pervasive

pattern composed of cognitions regarding oneself and one’s

relationships with others developed during childhood or

adolescence, elaborated throughout one’s lifetime and

dysfunctional to a significant degree [8]. Young hypothe-

sized that EMS might be at the core of personality

disorders, milder characterological problems, and many

chronic Axis I disorders [8].

There is research evidence suggesting the presence of

EMS in restricting anorexia nervosa (RAN), binging/

iatry xx (2007) xxx–xxx

ARTICLE IN PRESSZs. Unoka et al. / Comprehensive Psychiatry xx (2007) xxx–xxx2

purging anorexia nervosa (BPAN), and bulimia nervosa

(BN) [3,4]. Early maladaptive schemas are more strongly

held by patients affected by eating disorders than by

healthy controls. In different studies, different EMSs were

found to effectively differentiate the eating disorder

subgroups [3,4]. In nonclinical adolescent girls with high

and low symptom severity on eating disorders, as

measured by the Eating Attitude Test (EAT), it has been

reported that the high-EAT group had significantly higher

scores than the low-EAT group on the Young Schema

Questionnaire (YSQ) [9]. In addition, strong associations

were found between certain EMS and specific cognitions

reflecting eating behavior, such as weight and shape [5].

The outcome of group cognitive-behavior therapy for BN

on most indices was associated with pretreatment levels of

EMSs [10].

Several studies found different personality profiles in the

3 eating disorder groups [11-14]. Restrictive anorexia

nervosa was shown to be linked to personality traits such

as introversion, conformity, perfectionism, rigidity, and

obsessive-compulsive features [14]. The results concerning

patients with BN are more mixed; they have often been

found to be extroverted, histrionic, and affectively unstable

[11]. Individuals with BPAN, or with a history of both

anorexia and bulimia, tend to show severe and diffuse

pathologies, and to be more impaired than people with

either RAN alone or with BN alone [13]. In sum, previous

studies suggest that subgroups of eating disorders are

characterized with specific schema profiles. In addition to

these differences, specific schema profiles were found to be

associated with specific personality variables, which in turn

have been shown to be related to eating disorders.

The body mass index (BMI) is one of the most important

marker of eating disorders, and its relevance has been

recognized from a general health perspective as well. In

previous studies, it was found that dysfunctional cognitions

concerning weight and shape play an important role in the

maintenance of low BMI. Studies on YSQ found that EMS

are related to the ability of sustaining weight control [5,15].

Despite the associations between eating disorders and

cognitive schemas reported in the aforementioned studies,

the previous literature has certain shortcomings. The total

sample size and the sample in each of the eating disorder

subgroups were generally small, which question the

robustness and generalizability of the results [3,4]. Fur-

thermore, in some of the studies, a large number of

individual measures were tested, which raises the possibil-

ity of an increase in type I error (ie, a inflation); in

addition, in some studies, the univariate and the multivar-

iate approaches yielded contradictory results [4]. We now

conduct a large study with sufficient number of patients

within each of the eating disorder subgroups to investigate

the above associations further.

Specifically, our study had 2 specific objectives. The

first objective was to examine whether the 3 eating disorder

subgroups display a specific profile in terms of EMS

factors. Based on empirical evidence concerning the

relationships between different personality variables and

EMS [6,16], we assumed that the 3 eating disorder

subgroups would differ in terms of their schema profiles.

The second objective of the study was to investigate the

relationship between BMI and EMS factors in each of the

individual eating disorder subgroups. In light of previous

studies, we assumed that there would be a significant

relationship between the BMI and the individual schema

factors, and that this relationship would be manifested in

each of the eating disorder subgroups.

2. Materials and methods

2.1. Sample

The subjects were inpatients in a study of psychopa-

thology of eating disorders. They were referred to an

inpatient psychotherapy unit specialized for treating eating

disorder at the Department of Psychiatry and Psychother-

apy, Faculty of General Medicine, Semmelweis University,

Budapest Hungary, and all participated voluntarily after

informed consent was obtained. The women participating

in the study were white.

The patients were diagnosed by an experienced investi-

gator and clinical psychiatrist specialized in the psychother-

apy of eating disorders using the DSM-IV [17] criteria.

Patients with binge-eating disorder, eating disorder not

otherwise specified (NOS), and, because of the small sample

size (1 RAN, 1 BPAN), male patients were excluded from

the study.

2.2. Measures

The YSQ Long Form (YSQ-L) [16], a 240-item, self-

administered questionnaire, was used to assess the presence

of EMS. The items are answered on a 6-point scale, with

higher item scores (range, 1-6) reflecting a more unhealthy

level of maladaptive schemas. The YSQ-L measures

19 cognitive schemas reflecting different broad areas such

as unconditional, schema-level cognitions about oneself,

others, and the world. The psychometric properties of the

YSQ-L have been reported to be acceptable with patients

with BN or anorexia of the bulimic subtype and control

subjects with no known clinical disorders [18], with an

internal consistency reliability (Cronbach a) of .986 and

discriminant validity regarding a statistically significant

separation between bulimic and control subjects. In our

prior studies, the discriminant and convergent validity of

the Hungarian YSQ-L was supported by demonstrating an

association of the scale with the Temperament and

Character Inventory and Symptom Checklist-90 in a

normal and a mixed clinical sample with depression and

anxiety, and personality and eating disorders [19]. In

addition, the Hungarian version of the YSQ-L scale was

shown to have an acceptable internal consistency reliability

(Cronbach a = .988).

ARTICLE IN PRESS

able 1

rincipal component factor analysis (VARIMAX rotation) of YSQ-L

bscales

Factor 1 Factor 2 Factor 3 Factor 4

igenvalue 9.96 1.35 1.29 1.12

xplained variance (%) 52.4 7.1 6.8 5.9

ariable

Emotional deprivation 0.78 0.22 0.01 0.13

Abandonment 0.66 0.43 0.22 0.23

Mistrust/abuse 0.72 0.09 0.27 0.35

Social isolation 0.58 0.54 0.21 0.24

Defectiveness 0.50 0.59 0.21 0.31

Social undesiredness 0.62 0.63 0.08 0.04

Failure 0.24 0.73 0.14 0.19

Dependence 0.38 0.79 0.14 0.11

Vulnerability to harm 0.61 0.28 0.41 �0.08

Enmeshments 0.03 0.75 0.31 0.10

Subjugation 0.39 0.71 0.28 �0.09

Self-sacrifice 0.27 0.12 0.82 �0.11

Emotional inhibition 0.67 0.25 0.20 0.19

Unrelenting standards 0.04 0.31 0.77 0.31

Entitlement 0.18 0.05 0.09 0.89

Impulsivity 0.49 0.41 0.03 0.49

Approval-seeking 0.32 0.54 0.15 0.47

Pessimism 0.62 0.29 0.48 0.15

Punitiveness 0.29 0.29 0.61 0.43

actors were selected based on the rule of an eigenvalue of more than 1;

variables with a factor loading of more than 0.4 are in boldface.

Zs. Unoka et al. / Comprehensive Psychiatry xx (2007) xxx–xxx 3

The 19 YSQ-L subscales (and their definitions) are

emotional deprivation (the expectation that one’s desire for a

normal degree of emotional support will not be adequately

met by others); abandonment/instability (the perceived

instability or unreliability of those available for support

and connection); mistrust/abuse (the expectation that others

will hurt, abuse, humiliate, cheat, lie, manipulate, or take

advantage); defectiveness/shame (the feeling that one is

defective, bad, unwanted, inferior, or invalid in important

respects or that one would be unlovable to significant others

if exposed); Social isolation/alienation (the feeling that one

is isolated from the rest of the world, different from other

people, and/or not part of any group or community); social

undesirability (belief that one is isolated from others due to

some outwardly undesirable feature); dependence/incompe-

tence (belief that one is unable to handle one’s everyday

responsibilities in a competent manner, without considerable

help of the others); vulnerability to harm or illness

(exaggerated fear that imminent catastrophe will strike at

any time and that one will be unable to prevent it);

enmeshment/undeveloped self (excessive emotional in-

volvement and closeness with one or more significant

others at the expense of full individuation or normal social

development); failure (the belief that one has failed, will

inevitably fail, or is fundamentally inadequate relative to

one’s peers in areas of achievement); entitlement/grandiosity

(the belief that one is superior to other people, entitled to

special rights and privileges, or not bound by the rules of

reciprocity that guide normal social interaction); insufficient

self-control/self-discipline (pervasive difficulty or refusal to

exercise sufficient self-control and frustration tolerance to

achieve one’s personal goals or to restrain the excessive

expression of one’s emotions and impulses); subjugation

(excessive surrendering of control to others because one

feels coerced—submitting to avoid anger, retaliation, or

abandonment); self-sacrifice (excessive focus on voluntarily

meeting the needs of others in daily situations at the expense

of one’s own gratification); approval-seeking/recognition-

seeking (excessive emphasis on gaining approval, recogni-

tion, or attention from other people at the expense of

developing a secure and true sense of self); negativity/

pessimism (a pervasive, lifelong focus on the negative

aspects of life while minimizing or neglecting the positive or

optimistic aspects); emotional inhibition (the excessive

inhibition of spontaneous action, feeling, or communication,

usually to avoid disapproval by others, feelings of shame, or

loosing control of one’s impulses); unrelenting standards/

hypercriticalness (the underlying belief that one must strive

to meet very high internalized standards of behavior and

performance, usually to avoid criticism); and punitiveness

(the belief that people should be harshly punished for

making mistakes) [8]. Based on data from current investi-

gation, all subscales of the YSQ-L showed acceptable

internal consistencies, ranging from Cronbach a = .85 for

the emotional inhibition subscale to Cronbach a =.96 for

the failure subscale.

2.3. Statistical analysis

The factor structure of EMS scales was studied by

principal component factor analysis (with VARIMAX

rotation, eigenvalue N1, factor loading N 0.4). Differences

among the 3 eating disorder subgroups in terms of their

schema profiles were investigated by the general linear

model (GLM) analysis. Eating disorder subtype categories

were used as independent variables in the GLM model,

whereas the EMS factors served as dependent variables.

Differential associations between BMI and EMS factors

were investigated by analysis of covariance (ANCOVA).

Body mass index was used as a dependent variable in the

ANCOVA model; EMS factors served as independent

variables. Interactions between EMS factors and eating

disorder subtypes were used in the model to test whether the

associations differed among the subgroups. SAS Software

(version 9.1, SAS, Cary, NC) was used.

3. Results

3.1. Demographic and descriptive characteristics

The participants were 114 women with eating disorders

(RAN = 35, BPAN = 30, BN = 49). There was no

significant difference between the 3 subgroups in terms of

their age (F2,106 = 0.17; P = .85). The mean age of the

patients with RAN was 24.0 years (SD, 4.9 years), with

BPAN 24.1 years (SD, 5.7 years), and with BN 24.8 years

(SD, 7.2 years). The level of education in the 3 subgroups

was essentially identical (v28 = 3.56, P = .89). Approxi-

mately 89% of the total population had a high school

T

P

su

E

E

V

F

ARTICLE IN PRESSZs. Unoka et al. / Comprehensive Psychiatry xx (2007) xxx–xxx4

education or higher. The mean BMI of the patients with

RAN was 15.6 (SD, 2.9; range, 11.1-21.6), with BPAN 16.4

(SD, 2.6; range, 11.0-23.1), and with BN 23.02 (SD, 8.54;

range, 13.9-51.8). As expected, the difference between RAN

and BPAN and BN reached statistical significance (P b .05

for both comparisons).

3.2. Factor structure of EMS questionnaire’s subscales

The result of factor analysis is shown in Table 1. The

4 EMS factors, retained based on the rule of an eigenvalue

of more than 1, accounted for 72.2% of the total variance.

As shown by the table, EMS factor 1 comprises emotional

deprivation, abandonment, mistrust/abuse, social isolation,

vulnerability to harm, emotional inhibition, negativity/

pessimism subscales. Early maladaptive schema factor 2

comprises defectiveness/shame, social undesiredness, fail-

ure, dependence/incompetence, enmeshments, subjugation,

and approval-seeking subscales. Early maladaptive schema

factor 3 comprises self-sacrifice, unrelenting standards, and

punitiveness subscales. Entitlement/grandiosity and impul-

sivity subscales constituted EMS factor 4.

3.3. General linear model analysis of eating disorder

subtypes based on EMS factors

The general linear model analysis indicated 2 differences

between eating disorder subtypes involving EMS factor 3

and EMS factor 4, respectively (Table 2). Specifically, the

GLM results indicated that on EMS factor 3, both anorexia

subgroups had a significantly higher mean score than the

BN group. On EMS factor 4, the BPAN group had

significantly higher mean scores than the RAN group, and

marginally significantly higher scores than the BN group. In

addition, the BN group had marginally significantly higher

scores than the RAN group on this factor.

3.4. Between-group comparison on BMI

As described in Materials and methods, association

between BMI and EMS factors was investigated by

ANCOVA analysis. The ANCOVA yielded a statistically

significant interaction between eating disorder subtypes and

EMS factor 2 (F92 = 5.71, P = .004). Post hoc analyses

were conducted to further investigate the interaction; to this

end, a separate regression analysis was performed between

Table 2

General linear model analysis of eating disorder subtypes based on EMS factors

Measure Diagnostic groups

RAN BPAN BN

Mean SD Mean SD Mean

Factor 1 �0.17 1.02 0.01 0.91 0.11

Factor 2 �0.13 1.14 0.20 0.97 �0.03

Factor 3 0.35 1.03 0.14 1.04 �0.32

Factor 4 �0.39 0.77 0.41 0.74 0.02

NS indicates not significant; A, post hoc analyses indicated that BN was significa

hoc analyses indicated a significant difference ( P b .05) between groups RAN an

and BPAN and BN, respectively.

EMS factor 2 and BMI in each of the eating disorder

subgroups. The analysis yielded a significant negative

relationship in the BN group (P b .0099), indicating that

higher values on EMS factor 2 were associated with lower

values on BMI. No such association was found in the RAN

group or the BPAN group, respectively. To further examine

which of the items were responsible for the association, we

performed additional ANCOVA analyses for the items that

factor 2 comprises. The ANCOVAs showed a statistical

significance for 3 of the items of EMS factor 2, including

social undesirability (F98 = 5.00, P b .008), dependence/

incompetence (F98 = 3.14, P b .048), subjugation (F98 =

6.81, P b .0017), and a marginally significant difference for

enmeshment/undeveloped self (F98 = 2.56, P b .083).

4. Discussion

This study aimed at examining the 3 eating disorder

subgroups in terms of EMS factors and the association

between BMI and EMS factors in each of 3 eating disorder

subgroups. Overall, the findings from this study indicate

that the 3 subgroups differed on EMS factors, and there was

an association between BMI and EMS factors among the

patients with BN.

In particular, the GLM analysis indicated that both types

of anorexia (RAN, BPAN) had significantly higher scores

than the group of BN on EMS factor 3. Because factor 3

showed high loadings for self-sacrifice, unrelenting stand-

ards, punitiveness, these results mean that, on the schema

level of cognitions, both groups of AN patients differ from

patients with BN in that they have a tendency to self-

sacrifice, that is, an excessive focus on voluntarily meeting

the needs of others in daily situations at the expense of their

own gratification. In addition, they have the underlying

belief that one must strive to meet very high internalized

standards of behavior and performance, usually to avoid

criticism, and following from the punitiveness EMS they

have the belief that people should be harshly punished for

making mistakes. These results are in accordance with

previous studies where patients with RAN and BPAN were

found to be more perfectionist than patients with BN [20].

Furthermore, on EMS factor 4 (entitlement, impulsivity)

the BPAN group had significantly higher scores than the

Difference among diagnostic subgroups

Test statistic (F) df P

SD

1.05 0.75 2,106 .48 (NS)

0.91 0.85 2,106 .43 (NS)

0.86 5.07 2,106 b .0001 A

1.17 5,22 2,106 b .0001 B

ntly different ( P b .05) from groups RAN and BPAN, respectively; B, post

d BPAN, and marginal differences ( P b .1) between groups RAN and BN,

ARTICLE IN PRESSZs. Unoka et al. / Comprehensive Psychiatry xx (2007) xxx–xxx 5

RAN group and marginally higher scores than the BN

group, which in turn had marginally significantly higher

scores than the RAN group. With respect to the schema-

level cognitions, this means that compared with patients

with RAN, patients with BPAN (following from their

entitlement EMS) significantly more intensely have the

belief that they are superior to other people, entitled to

special rights and privileges. They consider themselves as

not bound by the rules of reciprocity that guide normal

social interaction. In addition, as a consequence of their

strongly held impulsivity EMS, we think that patients with

BPAN have significantly more pervasive difficulty or

refusal to exercise sufficient self-control. They also exhibit

low tolerance to frustration to achieve personal goals, or to

restrain the excessive expression of emotions and impulses.

Our findings also suggest that patients with BN show

marginally more intensely the previously described 2 EMS

than the patients with RAN. Similar to our study, in some of

the previous studies, patients with BPAN were also found to

manifest simultaneously the trait of high perfectionism with

high impulsivity [20].

The differential association between BMI and EMS

factors was statistically significant for EMS factor 2, in

the bulimia subgroup, where higher values on EMS factor

2 were associated with lower values on BMI. The

following schema-level cognitions from EMS factor 2

may play a significant role, as potentially protective

factors against a higher BMI in bulimic patients, in the

association that we found: the belief that one is isolated

from the other due to some outwardly undesirable feature;

the belief that one is unable to handle one’s everyday

responsibilities in a competent manner, without consider-

able help of the others; excessive emotional involvement

and closeness with one or more significant others at the

expense of full individuation or normal social develop-

ment; and, finally, excessive surrendering of control to

others, because one feels coerced—submitting to avoid

anger, retaliation, or abandonment.

In 2 previous studies, the YSQ was used in the

comparison of the dysfunctional core beliefs of the eating

disorder subgroups. In the study of Leung et al [3], patients

with RAN, BPAN, and BN and normal controls were

compared. In Leung’s study [3], the BN subgroup showed

higher scores on the entitlement subscale than the RAN

subgroup. The inconsistency between the study of Leung

et al [3] and the present study might be explained by the

different samples and methodological differences. First, the

patients in the current study were sent to an inpatient unit

because they were not able to control their eating habits

without external help, whereas those in the study by Leung

et al [3] were offered outpatient group therapy, which may

indicate lower severity. Thus, the differing results of the

2 studies might be explained by the fact that our patients had

more severe symptoms, which were more likely to co-occur

with markedly higher impairments in terms of their

cognitive schema. This assumption is consistent with results

from previous studies [9,16]. Second, the total sample size

and the sample in each of the eating disorder subgroups

were larger in the current study, which increased the

sensitivity of our study. Finally, because we applied a prior

data reduction (factor analysis) in our study, we had a

smaller number of variables in the analyses, which reduces

the possibility of type I error.

The study of Waller et al [4] used different diagnostic

groups—RAN were not included, whereas binge eaters

were not recruited in the current study. In their study,

3 EMS (defectiveness/shame, failure to achieve, insufficient

self-control) were said to effectively differentiate the

subgroups, although the univariate and the multivariate

approaches yielded contradictory results and the total

sample size and the sample in each of the eating disorder

subgroups were generally smaller than in our study, which

question the robustness and generalizability of their results.

A number of limitations of this study should be noted.

First, because of the exclusion of male patients, our

findings may not generalize to male patients. Second, we

were not able to account for an effect of malnutrition on the

assessments because the current study did not obtain a

specific measure to examine this issue. However, although

personality traits may be influenced by malnutrition, some

findings fail to support this association [21]. Third, in

the current investigation, only schemas related to BMI

were measured, whereas eating behavior disturbances were

not investigated.

Our study, similar to previous reports in the literature that

focused on the YSQ, indicates that Young’s conceptualiza-

tion of EMS plays an important role in the understanding of

the schema-level psychopathology of patients affected with

different eating disorders, as defined by the phenomeno-

logical approach that underlie the DSM-IV classification.

These findings may lead to a schema-level cognitive

understanding of eating disorders and thus to a more

differentiated schema-focused case conceptualization,

which could be very helpful in planning specific

cognitive-behavioral treatment strategies for each eating

disorder subgroup.

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