The Structure of Maladaptive Schemas: A Confirmatory ... - Springer Link

C 2006), pp. 627–644 Cognitive Therapy and Research, Vol. 29, No. 6, December 2005 ( DOI: 10.1007/s10608-005-9630-0

The Structure of Maladaptive Schemas: A Confirmatory Factor Analysis and a Psychometric Evaluation of Factor-Derived Scales Asle Hoffart,1,8 Harold Sexton,2 Liv M. Hedley,1 Catharina E. Wang,3 Harald Holthe,4 Jon A. Haugum,4 Hans M. Nordahl,5 Ole Johan Hovland,6 and Arne Holte7

One thousand and thirty-seven psychiatric patients and non-patients from six different sites completed the 205-item Young Schema Questionnaire or its shortended form, the 75-item Young Schema Questionnaire-S. Among 888 of the subjects, who all were patients, a confirmatory factor analysis (CFA) of the 75 items included in both forms of the questionnaire clearly yielded the 15 Early Maladaptive Schema (EMS) factors rationally developed by J. E. Young (1990). Confirmatory factor analyses, testing three models of the higher-order structure of the 15 EMSs, indicated that a fourfactor model was the best alternative. The results slightly favored a correlated four second-order factor model over one also including a third-order global factor. The four factors or schema domains were Disconnection, Impaired Autonomy, Exaggerated Standards, and Impaired Limits. Scales derived from the four higher-order factors had good internal and test–retest reliabilities and were related to DSM-IV Cluster C personality traits, agoraphobic avoidance behavior, and depressive symptoms. KEY WORDS: maladaptive schemas; Young Schema Questionnaire; factor structure; confirmatory factor analysis; validation.

Cognitive therapy has proved to be effective for a variety of symptom disorders (Beck, 1997). Recently, standard cognitive therapy has been extended and modified to adapt to the specific needs of patients with personality disorders and/or 1 Research

Institute, Modum Bad, Vikersund, Norway. ˚ ard ˚ Hospital, Tromsø, Norway. Research Center for Finnmark and Troms, Asg 3 Department of Psychology, University of Tromsø, Tromsø, Norway. 4 Psychiatric Outpatient Clinic, Innherred Hospital, Levanger, Norway. 5 Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway. 6 Nordhordland Outpatient Clinic, Isdalstø, Norway. 7 Department of Psychology, University of Oslo, Oslo, Norway. 8 Correspondence should be directed to Asle Hoffart, Research Institute, Modum Bad, N-3370 Vikersund, Norway; e-mail: [email protected]. 2 Psychiatric

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more chronic anxiety and depressive disorders (Beck, Freeman, & Associates, 1990; Young, 1990). Central to Young’s schema-focused approach is the concept of Early Maladaptive Schemas (EMSs). EMSs refer to the deepest level of cognitive structures representing the self in relation to other persons and the environment. Although genetic dispositions and biological factors play a role, Young (1990) emphasizes that one of the most important etiological pathways of developing an EMS are adverse experiences with parents, siblings, or peers during childhood. He hypothesizes five primary tasks that the child must negotiate in order to develop in a healthy manner: Connectedness, autonomy, worthiness, reasonable expectations, and realistic limits. He proposes that EMSs develop when caregivers make it difficult to achieve one or more of these five objectives. For instance, a child may be overly criticized when he/she does not meet parental standards and develop a defectiveness/shame EMS, expressed in self-attitudes like “I am not lovable.” When an EMS is triggered, high levels of negative affect are generated. To cope with the EMS and the associated distressed state, the child will engage in a variety of strategies such as avoiding certain situations or distracting oneself from thinking about EMS-related issues. Although the EMSs and the coping strategies are means for the child to comprehend and manage the environment, they tend to become highly dysfunctional in adulthood. The EMSs may selectively filter for corroborating experiences and lead to clinical symptom states, such as anxiety or depression when activated by situations relevant to the individual’s particular EMS(s). For instance, an adult characterized by an abandonment EMS may react with despair to temporary separations from close persons. The EMS and the coping strategies may also lead to distress through their role in the development of addiction, destructive relationships, and inadequate performance at work or school. A dependency EMS may lead to enmeshed, dysfunctional relationships, and avoidance of schema-related situations may result in isolation and loneliness. Within the schema model, personality problems and disorders are viewed mainly as expressions of generalized maladaptive coping strategies. Based on clinical experience, Young (1990) has identified 16 schemas. These are grouped within five domains reflecting the childhood tasks referred to above: Disconnection, Impaired Autonomy, Undesirability, Restricted Self-Expression, and Impaired Limits. In this way, the domains are connected to their hypothesized childhood origin. To each schema, Young (1992) has developed a detailed list of treatment strategies, formulated on an experiential, interpersonal, cognitive, and behavioral level. A description of each domain and its associated schemas is provided in Table I. The EMSs and domains are assumed to characterize and explain a range of personality disorders, to represent predisposing factors for the development and maintenance of clinical symptom states, to explain various types of interpersonal problems, and to relate to and be explained by specific types of childhood experiences. Before studying the theoretically interesting relationships between Young’s schema model, personality disorders, interpersonal relations, and childhood development, a firm basis for the structure of the EMSs needs to be developed. Several possibilities of the relationships between the EMSs exist. In Young’s model,

Note. A condensed version of Young’s (1990) list. The means and standard deviations in a sample of 871 psychiatric patients are provided in parentheses.

Disconnection: The belief that one’s needs for security, safety, stability, nurturance, empathy, sharing of feelings, acceptance, and respect will not be met in a predictable manner. 1. Emotional deprivation: The belief that one’s normal degree of emotional support will not be adequately met (M = 2.71, SD = 1.40). 2. Abandonment/instability: The belief that significant others will not be able to continue providing emotional support because they are emotionally unstable or because they will die or abandon the person (M = 2.62, SD = 1.34). 3. Mistrust/abuse: The belief that others are abusive, humiliating, and manipulative (M = 2.14, SD = 1.15). 4. Social isolation/alienation: The belief that one is isolated from the rest of the world and different from other people (M = 2.51, SD = 1.38). Impaired autonomy: Beliefs regarding one’s ability to separate and function independently from others. 5. Dependence/incompetence: The belief that one is unable to handle one’s everyday responsibilities in a competent manner, without considerable help from others (M = 2.04, SD = 1.06). 6. Subjugation: The belief that personal desires are unimportant compared to the preferences of others (M = 2.65, SD = 1.32). 7. Vulnerability to harm/illness: An exaggerated fear that “random” catastrophe could strike at any time and that one will be unable to prevent it (M = 2.28, SD = 1.18). 8. Enmeshment/undeveloped self: Excessive emotional involvement with others due to the belief that at least one of the enmeshed individuals cannot survive, or be happy, without the constant support of the other (M = 2.01, SD = 1.13). Undesirability: The belief that one is different from others and undesirable in terms of physical attractiveness, social skills, moral integrity, or personality. 9. Defectiveness/shame: The belief that one is internally defective and fundamentally unlovable (M = 2.10, SD = 1.23). 10. Social undesirability: The belief that one is isolated from others due to some outwardly undesirable feature (e.g., ugly, dull) (not included in YSQ-S). 11. Failure to achieve: The belief that one is fundamentally inadequate relative to others and, therefore, destined to fail in areas of achievement (e.g., school, career, sports) (M = 2.37, SD = 1.36). Restricted self-expression: Excessive restriction or suppression of emotion. 12. Emotional inhibition: The belief that emotional expression will lead to negative consequences such as embarrassment or harm to others (M = 2.53, SD = 1.29). 13. Self-sacrifice: Involves exaggerated beliefs of duty and responsibility to others (M = 3.13, SD = 1.13). 14. Unrelenting standards: The belief that one must meet unrealistically and impossibly high standards (M = 3.01, SD = 1.19). Impaired limits: Deficiencies in self-discipline and in setting emotional and interpersonal limits. 15. Entitlement: The belief that one should be able to act without regard for others (M = 1.85, SD = 0.80). 16. Insufficient self-control: The belief that self-discipline is unimportant and that emotions and impulses require little restraint (M = 2.42, SD = 1.08).

Table I. Early Maladaptive Schemas Ordered Within Schema Domains

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it is assumed that the EMSs are partly independent, but cluster together in five higher-order themes. However, as most of these schemas contain negative beliefs about self, a negative self-image may represent a common factor across the schemas/domains. The EMSs may be redundant and reducible to the higher-order domains, or be largely an expression of a common underlying factor. The Young Schema Questionnaire (YSQ; Young, 1990) is a self-report inventory designed to measure the 16 EMSs. Schmidt, Joiner, Young, and Telch (1995) studied the YSQ in American patient and student samples. In the patient sample (N = 187), a 15-factor solution was found preferable, and these factors closely matched Young’s rationally derived schemas. Only the Social Undesirability schema did not emerge. In the student sample (N = 1129), 13 primary factors emerged, 12 of which matched Young’s schemas and one, Fear of Losing Control, was new. A hierarchical factor analysis conducted with the student sample condensed the higher-order factors proposed by Young to Disconnection (Emotional Deprivation, Abandonment, Mistrust, Defectiveness, Emotional Inhibition, Fear of Losing Control); Overconnection (Dependence, Vulnerability, Enmeshment, Failure); and Exaggerated Standards (Unrelenting Standards, Self-Sacrifice). The schema Insufficient Self-Control loaded on all three factors. In an Australian patient sample (N = 433), 16 EMS factors emerged (Lee, Taylor, & Dunn, 1999). Fifteen of these corresponded to the 15 factors found in Schmidt et al.’s (1995) patient sample and to the schemas of Young’s (1990) system. As in Schmidt et al.’s samples, the Social Undesirability factor did not emerge. A higher-order factor analysis indicated four factors: Disconnection, Impaired Autonomy, Over Control (comprising the same schemas as Schmidt et al.’s Exaggerated Standards factor), and Impaired Limits. This solution closely matches Schmidt et al.’s solution, except that Impaired Limits did not emerge as an independent factor in their student sample. A possible reason for this is that the Entitlement schema failed to emerge in the first-order solution among students and was therefore not included in Schmidt et al.’s second-order analysis, whereas it clearly emerged as a separate entity in Lee et al.’s (1999) patient sample. A limitation of both these studies of the second-order factors was the exclusive use of exploratory factor analysis as a data-analytic strategy. Thus, the extent to which each of the EMS scales represented a unique concept, in additon to the common content expressed in their second-order relationships, could not be fully assessed. Contrasting the hypothetical model of Young (1990) and that of Lee et al. (1999) requires a confirmatory factor analytic approach to determine which best represents the EMSs in the YSQ. In the present study, we examined these three models with confirmatory factor analysis (CFA). We used the shortened version of the 75-item Young Schema Questionnaire-Short (YSQ-S; Young, 1998). It is comprised of the five items that loaded highest on each of the 15 factors derived in Schmidt et al.’s (1995) patient sample. The CFA was performed on a pooled sample of five different psychiatric patient samples. We tested Young’s rationally derived 15 first-order factor model of the YSQ-S in a large clinical sample. Second, we compared Young’s (1990) five second-order factor model and Lee et al.’s (1999) empirical four second-order factor model for the

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higher-order relationships among the EMSs. Third, we examined different versions of the higher-order models, such as whether there might be a third-order common factor, or whether the EMSs might be parsimoniously reduced to their second-order domains. Fourth, we examined the conceptual structure of the EMSs, after taking measurement error and the higher-order factors into account to examine the extent to which each of the EMS scales represented a unique concept. Finally, we derived scales from the higher-order factors representing schema domains and examined their reliability and predicitive capacity. This was investigated in two samples. One sample consisted of psychiatric inpatients receiving treatment for panic disorder and/or agoraphobia and DSM-IV Cluster C personality traits. The other sample consisted of currently depressed, previously depressed, and never depressed persons recruited from a population of university students and persons that had consulted their general practioner. The first sample was included in the confirmatory analysis, whereas the other sample was not. Based on theories of panic disorder and agoraphobia (Andrews, Steward, Morris-Yates, Holt, & Henderson, 1990; Beck et al., 1990), depression (Blatt, Quinlan, Pilkonis, & Shea, 1995; Beck, 1983), and personality disorders (Young, 1990), the following hypotheses were set up for construct validation: 1. Impaired Autonomy will be related to agoraphobic symptomatology, avoidant traits, and dependent traits. 2. Exaggerated standards will be related to obsessive-compulsive traits. 3. Disconnection, Impaired Autonomy, and Exaggerated Standards will be related to depressive symptomatology. 4. Currently asymptomatic but previously depressed persons will score higher on Disconnection, Impaired Autonomy, and Exaggerated Standards than asymptomatic persons who never have met criteria for a depression diagnosis. Hypotheses 1 and 2 were tested in the sample of inpatients with panic disorder, agoraphobia, and Cluster C traits, and hypothesis 3 and 4 in the community sample of persons varying in depression status. The report of maladaptive schemas and attitudes may be state-dependent, either because the negative attitudes expressed in the schemas are a result of depression and/or other negative emotions (Coyne & Gotlib, 1983) or because schemas are latent and relatively inaccessible when not activated by depressed mood (Miranda & Gross, 1997). Therefore, and where possible, we performed the analyses a second time, controlling for depressive symptom level.

METHOD Participants and Procedure The participants were 1037 psychiatric patients and non-patients from six samples from six different sites. The amount and quality of the information collected varied across these samples. Diagnostic inter-rater agreement testing was performed

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in some of the samples, but not in others. It is therefore not reported, except in Sample 5, where personality disorder indices were used in the psychometric investigations. Sample 1 consisted of 462 consecutive patients from a psychiatric outpatient clinic. The first 82 of these, 46 females (56%) and 36 males (44%) with a mean age of 37.7 years (SD = 10.7), were administered the DSM-IV SCID-I (First, Spitzer, Gibbon, & Williams, 1995) and SCID-II (First, Spitzer, Gibbon, Williams, & Benjamin, 1994) interviews (Nordahl, Holthe, & Haugum, 2005). Patients were excluded if they were suicidal or had a diagnosis of substance abuse or psychotic disorder. The most prevalent Axis I diagnoses were social phobia (n = 29, 35%), major depression (n = 23, 28%), and dysthymia (n = 15, 18%). The most prevalent Axis II diagnoses were avoidant personality disorder (PD) (n = 18, 22%), PD Not Otherwise Specified (n = 15, 18%), and paranoid PD (n = 6, 7%). After the first 82 patients were included, the therapists continued to use the same inclusion criteria, but without systematic use of formal SCID-interviews. Sample 2 consisted of 40 outpatients participating in a schema-focused group therapy program for patients with personality disorders at another outpatient clinic. The mean age of the 25 (63%) women and 15 (38%) men was 34.0 years (SD = 8.5). Treatment candidates were administered the MINI interview (Sheehan & Lecrubier, 1994) for assessing DSM-IV Axis I diagnoses and the SCID-II interview for assessing DSM-IV Axis II diagnoses. They also completed the YSQ-S, as well as other self-report measures. Each interview was scored by two evaluators, and, in cases of disagreement, the ratings were discussed until consensus was reached. The inclusion criteria were signs of persistent psychological problems, motivation for treatment, and ability to take responsibility for their own activities. The most prevalent Axis I diagnoses were dysthymia (n = 22, 55%), generalized anxiety disorder (n = 15, 38%), and post-traumatic stress disorder (n = 10, 25%). The most prevalent Axis II diagnoses were avoidant PD (n = 14, 35%), borderline PD (n = 13, 33%), and PD Not Otherwise Specified (n = 12, 30%). Sample 3 consisted of 71 female patients evaluated for treatment in a third outpatient clinic in which the YSQ was completed as part of the evaluation procedure. Sample 4 consisted of 92 consecutive patients who completed the YSQ as part of an evaluation for treatment in a day-patient clinic specializing in the treatment of personality disorders. There were 66 (72%) women and 26 (28%) men. Of the 92 patients, 58 were admitted to the treatment and administered the DSM-IV SCIDII interview by their individual therapist. Of these, 29 (50%) met the criteria for avoidant, 15 (27%) for borderline, and 10 (17%) for antisocial personality disorder. Sample 5 consisted of 223 consecutive inpatients attending a hospital-based 11week cognitive therapy program for panic disorder with agoraphobia and anxious (DSM-IV Cluster C) personality disorders and traits. The hospital received patients from the entire country. The mean age of the 151 (68%) women and 72 (32%) men was 40.7 years (SD = 9.0). The mean age at onset of the treated anxiety disorder was 25.2 years (SD = 10.5). The SCID-I was performed by the first or the third author on the 118 first admitted patients within a week after admission to the program. The SCID-II was conducted within a week after admission by the first author or by one of two other researchers. An independent researcher scored 20 randomly selected


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audiotapes of the pretreatment and follow-up SCID-II interviews. One hundred and five (89%) of the 118 patients met criteria for panic disorder with agoraphobia, three (3%) for panic disorder without agoraphobia, and 10 (8%) for agoraphobia without panic disorder. The most prevalent comorbid Axis I diagnoses were major depression (n = 84, 71%), social phobia (n = 47, 40%), and simple phobia (n = 35, 30%). Sixty-five (55%) had at least one Axis II disorder, with 46 (39%) meeting the criteria for avoidant PD, 14 (12%) for obsessive-compulsive PD, and 11 (9%) for dependent PD. The patients completed self-report measures including the YSQ within a week after admission. Forty-five patients also completed these measures at a precare evaluation interview. The mean duration from the evaluation interview to hospital admission was 72.6 days (SD = 58.2). Sample 6 consisted of 149 individuals (122 women and 27 men, aged 18–54, M = 28.6, SD = 9.6) that were recruited from university students and patients consulting their general practitioner. After a screening procedure, selected individuals were then administered the DSM-IV SCID-I sections relating to Mood Disorder to assess inclusion criteria and the SCID-I section related to Psychotic Symptoms to assess exclusion criteria. The 149 participants (71 patients and 78 students) included in the study were assigned to three groups: Currently depressed, previously depressed, and never depressed. The SCID interviews were administered by four interviewers who had been individually trained by a highly qualified supervisor in the administration of the SCID. All the interviews were audiotaped, and subsequently, 30 of these interviews, 10 from each group, were randomly sampled for reliability testing. The inter-rater agreement (kappa) between two raters for groups (currently depressed, previously depressed, and never depressed) was .90, indicating excellent reliability of the group assignment. The sample consisted of 61 currently depressed, (36 patients and 25 students; 52 women and 9 men; M = 30.9 years, SD = 10.3), 42 previously depressed (17 patients and 25 students; 35 women and 7 men; M = 27.0 years, SD = 8.3) and 46 never depressed (18 patients and 28 students; 35 women and 11 men; M = 26.9 years, SD = 9.5). None of the participants were inpatients. Eleven of the participants were attending outpatient psychiatric treatment (psychiatrist/psychologist in private practice, outpatient psychiatric unit). The participants took part in a larger project on cognitive processes in depression, which also included the BDI and the YSQ (Wang, Brennen, & Holte, 2005). When comparing previously depressed and never depressed participants, we excluded those who had a BDI score above 9 to ensure that the presence of depressive symptoms could not interfere with the ratings. This procedure left 32 asymptomatic previously depressed (BDI: M = 4.4, SD = 2.8) and 46 asymptomatic never depressed (BDI: M = 1.1, SD = 1.7) individuals to be compared. Measures The Young Schema Questionnaire (Young, 1990) is a 205-item self-report questionnaire designed to measure the 16 EMSs described above. Items for the YSQ were generated by its author and other practicing therapists based upon clinical experience with chronic and/or difficult psychotherapy patients. Each item is rated using a six-point scale (1: completely untrue of me; 2: mostly untrue of me; 3: slightly

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more true than untrue; 4: moderately true of me; 5: mostly true of me; 6: describes me perfectly). The Young Schema Questionnaire-Short (Young, 1998) consists of 75 items of the YSQ. It has 15 subscales, measuring 15 of the 16 EMSs of the YSQ. As mentioned above, each subscale consists of the five items that loaded highest on the 15 factors derived in Schmidt et al.’s (1995) study (item examples: Emotional Deprivation subscale, “For much of my life, I have not felt special to anyone”; Unrelenting Standards subscale “I must meet all my responsibilities”). The psychometric properties of the YSQ-S have been compared to those of the 205-item YSQ (Waller, Meyer, & Ohanian, 2001; Welburn, Coristine, Dagg, Pontefract, & Jordan, 2002). The two forms appear to have similar levels of internal consistency, parallel levels of reliability and discriminant validity, and comparable levels of clinical utility. These findings support the use of the more convenient 75-item version in clinical and research settings. The Norwegian translation of the YSQ was back translated to English. The items of the American and the Norwegian versions did not have any substantial differences in meaning. The YSQ was completed by 968 of the participants of the present study, whereas 69 participants completed the YSQ-S. In this study, we focused the 75 items that were common across all the participants. In Sample 5, indices for each PD in DSM-IV Cluster C were obtained by averaging the SCID-II ratings across the criteria for each Cluster C disorder, where 1: absent or false; 2: subthreshold; and 3: threshold or true. The reliability based on the 20 tapes appeared to be satisfactory, the ICC (1,1) (Shrout & Fleiss, 1979) was .88 for the avoidant index, .91 for the dependent index, and .85 for the obsessivecompulsive index. The Cronbach’s alpha was .80 for the avoidant index, .64 for the dependent index, and .69 for the obsessive-compulsive index. The self-report Mobility Inventory for Agoraphobia (MI; Chambless, Caputo, Jasin, Gracely, & Williams, 1985) measures agoraphobic avoidance of a range of situations, both when the patients are alone (MI-AAL) and when they are accompanied (MI-ACC). Among the 118 SCID interviewed patients in Sample 5, alpha was .94 for the MI-AAL subscale. The self-report Beck Depression Inventory (BDI; Beck, Steer, & Garbin, 1988) was used to measure the degree of depressive symptoms. Alpha was .91 in Sample 5 and .92 in Sample 6. Statistical Analysis The samples of psychiatric patients (Samples 1–5; n = 888) were pooled and factor analyzed. Cases with more than 10% missing values on the 75 items of YSQS (n = 17) were removed. The EQS version 5.5 with maximum likelihood estimation was used to carry out all the CFAs in this study (Bentler, 1995). We first carried out a confirmatory factor analysis on the 75 YSQ-S items to test the 15 first-order factor model (Young, 1990) and compared a correlated (oblique) version of the 15 first-order factor model with an uncorrelated (orthogonal) version of it. We also calculated the internal consistencies of the individual scales. We then examined the higher-order structure of the primary subscales with CFA to test the two major models that have been proposed for the relationship


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among the 15 EMSs: Young’s (1990) rationally derived five-factor model and Lee et al.’s (1999) empirically derived four-factor model. The five second-order factor model of Young (1990) was constructed as he described it (see Table I). The four second-order factor model included only the factor loadings > |.30| from Lee et al.’s (1999) exploratory factor analysis. This was done to remove the more trivial relationships among the first- and second-order factors. Those YSQ-S scale factors that had standardized factor loadings > |.30| in the CFA were retained in the final fourfactor model. This model is unique and not nested within Young’s five second-order factor model. As the Lee et al. model (1999) had two highly correlated second-order factors, these two factors were combined into one factor while retaining the other two second-order factors. This was done to determine if a three-factor model would adequately portray the relationship among the 15 primary factors. This three-factor model was thus nested within the four-factor model. Three different versions of the second-order factor models were tested: With uncorrelated second-order factors, with correlated second-order factors, and with a third-order global factor included. In addition, to ensure that the first-order factors (the YSQ-S scales) were necessary in order to characterize the YSQ-S, we also examined models in which the individual items loaded directly on the respective second-order factors, where the YSQ-S scales were eliminated. To assess the stuctural invariance of the preferred solution, the loadings of the first-order factors on the four second-order factors were fixed to be equal in the two largest subsamples (Sample 1 and 5). The equality of factor loadings was then tested using Lagrange multiplier (LM) tests, the factor variances were set to 1, and the second-order factors, but not the first-order factors and the residuals, were allowed to correlate. The YSQ and the YSQ-S list items on the same scale one after another, which could lead to a false heightening of the interitem correlations. This problem was somewhat attenuated in this study, as the 75 items analyzed were spread out among the 205 items of the YSQ, the version that was completed by the majority of the patients. Nonetheless, we used the Lagrange multiplier test to determine if there were significant (p < .01) correlations between errors of successive items within the same subscale. The same 24 significant correlations were included in the three models. Robust standard errors were calculated in all models. We compared the fit of the models in this patient sample. The following fit indices were used: (1) the chi-square goodness-of-fit, (2) the robust comparative fit index (CFI), (3) the standardized root mean square residual (SRMR), and (4) the root mean squared error of approximation (RMSEA). The unique variance of each subscale is represented by the square of the disturbance term D (the unexplained variance) in the equations representing the 15 EMS scales after the effect of the second-order factors was taken into account. A 50% of the concept’s variance was considered a high degree, and a 25% of the concept’s variance was considered a low degree of unique variance. As it appeared that Lee et al.’s (1999) model best described the EMS interrelationships, schema domain scales corresponding to Lee et al.’s four higher-order factor solution were constructed. The loading of each item on its first-order EMS

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factor was multiplied with that EMS’s loading on the relevant second-order factor to find those items that best represented that second-order factor. We wanted to have an equal number of items in each scale and as few as possible, but with a Cronbach’s alpha of .80 or more. Items were added until this criterion was met. We used stepwise regression to examine the predictive capacity of the schema domain scales of MI-AAL and BDI among the panic/agoraphobic inpatients and the individuals varying in depression status, respectively. Age and sex were unrelated to MI-AAL and BDI. They were therefore not included in the regression analyses. Variables were allowed to enter the model if the probability of their partial F was p < .01 and were removed if the probability of their partial F was p > .05. Most never depressed individuals in Sample 6 scored very low on some of the schema domain scales, leading to highly skewed distribution of scores. Therefore, the nonparametric Mann–Whitney test was used to compare asymptomatic previously and never depressed individuals on these scales. A p-level of .01 was required for significance, and two-tailed tests were used.

RESULTS The First-Order Factor Structure of the Items The CFA of the 15 first-order factor model supported it in that all items loaded significantly on its factor. The lowest of these loadings was .50. The correlated version had much higher fit than the uncorrelated one (see Table II). The means (SDs) on the corresponding 15 scales are reported in Table I. The Cronbach’s alphas of the scales ranged from .76 to .95. Social Undesirability To examine whether the Social Undesirability factor was also absent in our sample, as in the samples studied by Schmidt et al. (1995) and Lee et al. (1999), the nine items of the Undesirability subscale of the YSQ were added to the 75 items of the YSQ-S in a separate exploratory factor analysis of the 819 patients who had completed the 205-item YSQ, requesting a 16-factor rotated solution. All the 75 items loaded (>.40) on its expected EMS factor. None of the 75 items loaded on an unexpected factor. The nine undesirability items spread out on several factors, although three of them (70–72) clustered alone on the additional factor. The common theme in the three items was bodily unattractiveness. The Higher-Order Factor Structure of the EMS Factors The elimination of the EMS factors led to a large reduction of fit (Table II), indicating that a second-order factor model was most appropriate. We then compared the fit of the five, four, and three second-order factor models (see Table II). Lee et al.’s (1999) four-factor model fit the data moderately well and better than Young’s five-factor model, as the chi-square difference of 133 favored the


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Table II. Fit Indices of the Tested Models of the Relationship Between Maladaptive Schemas Model Young’s 15 first-order factors Uncorrelated Correlated Young’s five second-order factors Uncorrelated Correlated Third-order global factor included LTD’s four second-order factors Uncorrelated Correlated Third-order global included Three second-order factors (LTD) Uncorrelated Correlated Third-order global included First-order factors not included in model Three factors with a global factor Four factors with a global factor Five factors with a global factor

Model χ2 (df)

Robust CFI

SRMR

RMSEA (95% CI)

12,974.1 (2,676) 6,668.2 (2,579)

0.798 0.933

0.310 0.157

0.067 (0.065–0.068) 0.043 (0.041–0.044)

9,419.0 (2,664) 6,580.0 (2,651) 6,609.6 (2,656)

0.876 0.938 0.937

0.278 0.056 0.056

0.054 (0.053–0.055) 0.041 (0.040–0.043) 0.041 (0.040–0.043)

8,028.8 (2,662) 6,447.1 (2,655) 6,465.4 (2,658)

0.907 0.941 0.940

0.240 0.054 0.054

0.048 (0.047–0.049) 0.041 (0.039–0.042) 0.041 (0.039–0.042)

7,180.9 (2,661) 6,557.0 (2,658) 6,557.0 (2,658)

0.925 0.938 0.938

0.140 0.055 0.055

0.044 (0.043–0.045) 0.041 (0.040–0.042) 0.041 (0.040–0.042)

14,511.7 (2,668)

0.773

0.070

0.071 (0.070–0.073)

13,573.7 (2,667)

0.793

0.068

0.069 (0.067–0.070)

14,560.2 (2,676)

0.755

0.142

0.071 (0.070–0.073)

Note. N = 871.

four-factor model, which also required four degrees of freedom less than the fivefactor model (χ2 /d f = 33.3, p < .0001). The four-factor model also fit better than the three-factor model, as indicated by a significant chi-square difference of 110 for three degress of freedom (χ2 /d f = 36.7, p < .0001). The correlated versions of the second-order factor models fit considerably better than the uncorrelated ones. The correlated four-factor model and the four-factor model including a third-order general factor had similar fit levels, but there was a significant increase of model chi-square from the correlated to the third-order model (χ2 /d f = 6.1, p < .01). The correlated version of the four-factor model was therefore chosen as the best one and it is diagrammed in Fig. 1. To examine the structural invariance of the chosen solution, the loadings of the first-order factors on the four second-order factors in Samples 1 and 5 were fixed to be identical, thus allowing a comparison between the general outpatient and the anxious inpatient sample. This model fit the data moderately well: The robust CFI was .926, the SRMR was .060, and the RMSEA was .050 (95% confidence interval: .048–.052). Only the Entitlement schema had different loadings on the Impaired Limits factor (χ2 = 6.9, p < .01). There were no other differences in the factor loadings. Assessing the Unique Variance of Each Scale The second-order four-factor model was used as the basis for assessing the unique variance of each EMS subscale. The Ds are provided to the left in

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0.66

0.75

Emotional Deprivation

0.75

Emotional Inhibition

0.66 0.56

Mistrust /Abuse

0.83 Disconnection

0.89 0.45

Social Isolation

0.87 Defectiveness

0.49

0.49

0.92

Subjugation

0.53

Dependence

0.66

Failure

0.88 0.85 0.76 0.66

Vulnerability

0.70

Abandonment

0.75

0.53

Impaired Autonomy

0.71

0.72 0.69

0.48

Enmeshment

0.51 0.71 0.59

Insuff. Self-control

0.43 0.97 0.23

0.76

Impaired Limits

0.76

Entitlement

Self Sacrifice

0.65 0.46

Unrelenting Standards

0.89

0.47 Exaggerated Standards

Fig. 1. Lee et al.’s second-order factor model of the 15 primary schema factors applied to a sample of 871 psychiatric patients. The standardized parameter estimates are next to the arrows. The disturbance (D) term for the primary schema factors are provided to the left in the figure. All paths were significant (p < .01).

Fig. 1. According to the chosen criteria, Abandonment, Self-Sacrifice, and Emotional Inhibition had a high degree of unique variance, whereas Social Isolation, Defectiveness, Subjugation, Unrelenting Standards, and Entitlement had little unique variance beyond what could attributed to the relevant second-order factor.


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Table III. The Items, the Corrected Item-Total Correlations and the Alphas of the Schema Domain Scales in Sample Varying in Depression Status (n = 149) Disconnection (α = .92) si 45 (0.76) si 47 (0.71) si 48 (0.78) si 50 (0.81) ds 55 (0.64) ds 56 (0.65) ds 60 (0.74) ds 61 (0.75)

Impaired autonomy (α = .92)

Exaggerated standards (α = .85)

Impaired limits (α = .77)

fa 80 (0.64) fa 81 (0.73) fa 83 (0.73) di 99 (0.68) sb 129 (0.75) sb 130 (0.86) sb 131 (0.77) sb 135 (0.74)

ss 141 (0.67) ss 148 (0.48) ss 151 (0.49) us 164 (0.52) us 167 (0.56) us 170 (0.65) us 171 (0.74) us 176 (0.53)

et 180 (0.41) et 182 (0.62) et 183 (0.57) et 184 (0.55) et 185 (0.47) is 194 (0.33) is 195 (0.43) is 203 (0.46)

Note. si: social isolation; ds: defectiveness shame; fa: failure; di: dependence/incompetence; sb: subjugation; ss: self-sacrifice; us: unrelenting standards; et: entitlement; is: insufficient self-control. The prefix and the number refer to the primary subscale and the item number, respectively, in the original 205-item Young Schema Questionnaire. The corrected item-total correlations are provided in the parentheses.

Reliability and Validity Analysis of the Schema Domain Scales Our procedure for constructing schema domain scales gave a scale length of eight items (see listed items in Table III), with Cronbach’s alphas ranging from .82 to .93 across the four scales. Sample of Inpatients with Panic, Agoraphobia, and Cluster C Traits Among the 45 patients in Sample 5 who completed the SQ both at the precare evaluation interview and at the start of treatment, the test–retest correlations of the four schema domain scales ranged from .63 to .87. We examined the relationship between the schema domain scales and agoraphobic symptomatology. Among the 118 patients in Sample 5, who were administered formal diagnostic interviews, a stepwise regression analysis was conducted, using the MI-AAL as a dependent variable and the four schema domain scales at pretreatment as independent variables. Only Impaired Autonomy scores predicted MI-AAL. (B = .35, SE = .06, t = 5.67, p < .0001, R2 = .50, R2 change = .50). We examined the relationships between the schema domain scales at pretreatment and level of personality disorder traits among the 118 inpatients. Separate stepwise regression analyses were conducted using the pretreatment indices for avoidant, dependent, and obsessive-compulsive personality disorder as dependent variables. The four schema domain scales were the independent variables. With the avoidant and the dependent index as the dependent variable, only the Impaired Autonomy scale (B = .21, SE = .04, t = 5.68, p < .0001, R2 = .23, R2 change = .23; and B = .15, SE = .03, t = 5.00, p < .0001, R2 = .19, R2 change = .19, respectively) was a significant predictor. With the obsessive-compulsive index as dependent variable, only the Exaggerated Standards scale (B = .21, SE = .03, t = 6.50, p < .0001, R2 = .28, R2 change = .28) was a significant predictor. When controlling for pretreatment BDI scores, all the obtained relationships remained significant.

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Sample of Persons Varying in Depression Status To avoid the influence of sample variation, the internal consistency of the scales was examined in Sample 6, which had not been included in the CFA. The items, the corrected item-total correlations, and the alphas of the scales are provided in Table III. The alphas were satisfactory in this independent sample. In a stepwise regression with the BDI as the dependent variable and the four schema domain scales as independent variables, Impaired Autonomy (B = 6.50, SE = 0.54, t = 12.10, p < .0001, R2 = .50; R2 change = .50) and then Disconnection (B = 2.59, SE = .83, t = 3.11, p < .001, R2 = .53; R2 change = .03) were significant predictors. Comparing the asymptomatic previously depressed (n = 32) and the asymptomatic never depressed (n = 46) participants with the Mann–Whitney test indicated that the previously depressed had higher Disconnection scores (z = −5.09; p < .0001) and Impaired Autonomy scores (z = −4.24, p < .0001). There was a tendency towards significance for Exaggerated Standards scores (z = −2.04, p = .04), whereas Impaired Limits scores were not different in the two groups (z = −1.70, p = .090). DISCUSSION In a large sample of psychiatric patients, a confirmatory factor analysis of the 75-item YSQ-S clearly supported the 15 EMS factors rationally developed by Young (1990) and empirically reproduced in a small clinical sample by Schmidt et al. (1995) and in a large clinical sample by Lee et al. (1999). A correlated version of the model proved to have much better fit than an uncorrelated one. The scales corresponding to the 15 factors had satisfactory internal consistencies in this sample. Consistent with the results of Lee et al., adding the nine items of the Social Undesirability subscale of the 205-item YSQ yielded a 16th factor consisting of three items related to bodily unattractiveness. Models that included second-order factors fitted the data better than those that included only correlated first-order factors. Among the second-order factor models we tested, the four second-order factor model appeared to fit the data better than Young’s (1990) five second-order factor model and also better than a three secondorder factor model. The model is parsimonious in that only one EMS—Insufficient Self-Control—is influenced by two second-order factors (Impaired autonomy and Impaired Limits). All other first-order factors (scales) were only influenced by one of the second-order factors (Fig. 1). The four second-order factors were highly intercorrelated, suggesting the possible existence of a third-order factor. However, when a third-order global factor was included in the four-factor CFA, there was a significant increase in model chi-square. Thus, the results were slightly in favor of an oblique four second-order factor model over a four second-order factor model including a third-order global factor. The elimination of the first-order factors in the second-order factor models led to large reductions of fit, supporting the existence of the first-order factors. The conceptual structure of each EMS was investigated by assessing the unique variance of each first-order factor, while taking the second-order relationships


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between the EMSs (using the oblique four-factor model) and measurement error into account. Abandonment, Self-Sacrifice, and Emotional Inhibition had a high degree of unique variance (D > .71; D2 > .50), indicating that these EMSs have much specific informative value, in addition to being an indicator of a higher-order factor. Social Isolation, Defectiveness, Subjugation, Unrelenting Standards, and Entitlement had little unique variance, and their informative value appear to reside in being good indicators of their higher-order factors. Insufficient Self-Control loaded fairly evenly on two higher-order factors, was a moderate indicator of these factors, and had modest unique variance. Thus, Insufficient Self-Control appear to have less informative value than the other EMSs, at least within the range of schemas and second-order factors examined in the present study. Comparing the chosen four-factor model to Young’s (1990) original formulation (Table I), Young’s Restricted Self-Experience factor loses the Emotional Inhibition schema and becomes an Exaggerated Standards factor. Emotional Inhibition loads on the Disconnection factor and the Undesirability factor is no longer present. Further, the Social Undesirability schema was not confirmed as a separate first-order factor in this and two other empirical studies. Nonetheless, both Lee et al. (1999) and this study suggest that bodily unattractiveness may be an independent component. In addition, the Defectiveness/Shame schema moves to the Disconnection factor, whereas the Failure schema moves to the Impaired Autonomy factor. The Abandonment schema moves from the Disconnection factor to the Impaired Autonomy factor. The Abandonment schema has shown a variable affinity across the empirical studies. It loaded on the Disconnection factor among the students of Schmidt et al. (1995), it loaded on both the Disconnection and the Impaired Autonomy factors among Lee et al.’s (1999) patients, and it loaded exclusively on the Impaired Autonomy factor among our patients. Thus, its affinity to Impaired Autonomy seems to increase in patient samples. This may be due to the marked fear of abandonment and of being alone that is evident among patients with dependency, whose core issues are helplessness and despair about being left on their own. Insufficient SelfControl spread on the three second-order factors in Schmidt et al.’s student sample, while it loaded on both Impaired Limits and Impaired Autonomy in Lee et al.’s (1999) and in our patient samples. The responses to the Self-Control items may not only reflect the values that self-disipline and emotional restraint are unimportant, but also that the person experiences low actual self-control. Persons experiencing impaired autonomy may score high on these items because of the anxiety and sense of low self-control that often is associated with impaired autonomy. The four eight-item scales were constructed to allow direct measurement of the higher-order factors. These proved to have satisfactory internal consistency in an independent sample and satisfactory test–retest stability. The predictive capacity of the scales was investigated both in a sample of inpatients with panic disorder with agoraphobia and DSM-IV Cluster C personality disorder traits, and in a sample of persons varying in clinical depression status. Among the patients with panic, agoraphobia, and Cluster C traits, and in line with our hypothesis, Impaired Autonomy was positively related to agoraphobic avoidance. The expected relationships between the schema domain scales and Cluster C personality indices were for the

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most part, supported by the results. As expected, Impaired Autonomy was related to higher levels of avoidant and dependent traits. Also as expected, Exaggerated Standards was related to higher levels of obsessive-compulsive traits. The obtained relationships largely remained significant when controlling for depressive symptom level, suggesting that the presence of depressive symptoms could not explain these relationships. Among depressed, previously depressed, and never depressed persons, and in line with our hypotheses, Impaired Autonomy and Disconnection were related to depressive symptomatology. Asymptomatic previously depressed scored higher on Impaired Autonomy and Disconnection than asymptomatic never depressed individuals. There was a statistical tendency for a difference between these two groups on Exaggerated Standards. These findings are interesting in the context of the literature on dysfunctional thinking and depression, especially in that cognitive selfreport measures such as the Dysfunctional Attitudes Scale have not uncovered differences between previously depressed but currently asymptomatic and never depressed individuals (Miranda & Gross, 1997). Thus, the schema domain scales of the YSQ may prove to be sensitive to cognitive vulnerabilities, even when the vulnerable individuals are not currently depressed. The overall sample of psychiatric patients consisted of five samples of consecutive patients representing the three most common levels of care: Outpatient, daypatient, and inpatient. The overall sample should therefore be representative of the spectrum of non-psychotic patients. However, the inpatient subsample was rather homogenous in that it consisted for the most part of agoraphobic patients with chronic and severe problems. On the other hand, this subsample was rather heterogenous with regard to the presence of DSM-IV personality disorders. Comparing the two largest subsamples—one general outpatient and one anxious inpatient— with regard to the chosen four second-order factor structure supported that the structure was essentially the same in the two samples. This suggests that the results may be valid for psychiatric patients in general, despite that some of the studied subsamples were not well-described. A limitation of this study was the sole use of self-report for the assessment of schemas. Schmidt et al. (1995) refer to preliminary evidence that the YSQ factors may also be assessed by behavioral information processing tasks, supporting the construct validity of the YSQ. Fifteen of Young’s 16 rationally derived primary schemas were validated by the present results, supporting the utility of the YSQ-S in clinical assessment, case formulation, and treament planning. Furthermore, the obtained four second-order factor structure of the EMSs has theoretical implications, in particular for theories of ontogenetic development. The four scales constructed on the basis of the higherorder factor structure proved to have sound psychometric properties. However, the Impaired Limits scale could not be fully evaluated in this sample, as it would be expected to be related more to Cluster B than to Cluster C personality traits, and Cluster B traits were underrepresented in the sample we examined. The YSQ-S probably overlaps with constructs such as current symptomatology and life stress. To determine the extent to which this is the case, the YSQ-S would need to be related to other, more established measures of psychopathology and personality styles, such


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as the big five (Costa & Widiger, 1994) and the Structural Analysis of Social Behavior (Benjamin, 1974). To test the hypothesized relationships between the schema domains and childhood experiences, the YSQ-S should be related to measures of attachment and parental bonding. It is conceivable that some of the schemas may be more primary and may even give rise to other schemas. That is, change in one schema may effect change in another. Exploring this would require that the YSQ-S is repeatedly administered to individuals undergoing change. These issues will need to be addressed in future studies. ACKNOWLEDGMENTS Part of the project has been financially supported by the Norwegian Research Council, the National Council for Mental Health, Norway, and the NorthNorwegian Psychiatric Research Center.

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