International Journal of Psychiatry in Clinical Practice

ISSN: 1365-1501 (Print) 1471-1788 (Online) Journal homepage: http://www.tandfonline.com/loi/ijpc20

Early maladaptive schemas in patients with bipolar and unipolar disorder Selçuk Özdin, Gökhan Sarisoy, Ahmet Rıfat Şahin, Ali Cezmi Arik, Hatice Özyıldız Güz, Ömer Böke & Aytül Karabekiroğlu To cite this article: Selçuk Özdin, Gökhan Sarisoy, Ahmet Rıfat Şahin, Ali Cezmi Arik, Hatice Özyıldız Güz, Ömer Böke & Aytül Karabekiroğlu (2017): Early maladaptive schemas in patients with bipolar and unipolar disorder, International Journal of Psychiatry in Clinical Practice, DOI: 10.1080/13651501.2017.1387268 To link to this article: http://dx.doi.org/10.1080/13651501.2017.1387268

Published online: 10 Oct 2017.

Submit your article to this journal

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijpc20 Download by: [Gothenburg University Library]

Date: 11 October 2017, At: 05:12

INTERNATIONAL JOURNAL OF PSYCHIATRY IN CLINICAL PRACTICE, 2017 https://doi.org/10.1080/13651501.2017.1387268

ORIGINAL ARTICLE

Early maladaptive schemas in patients with bipolar and unipolar disorder a € € € €khan Sarisoyb, Ahmet Rıfat S¸ahinb, Ali Cezmi Arikb, Hatice Ozyıldız €keb and €zb, Omer Selc¸uk Ozdin , Go Gu Bo b  lu €l Karabekirog Aytu

Downloaded by [Gothenburg University Library] at 05:12 11 October 2017

a Department of Psychiatry, Kanuni Education and Research Hospital, Trabzon, Turkey; bDepartment of Psychiatry, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey

ABSTRACT

ARTICLE HISTORY

Objective: The aim of our study is to determine the difference between the bipolar disorder, unipolar disorder and control groups in terms of maladaptive schemes and childhood trauma. Methods: Two groups of patients under monitoring with a diagnosis of bipolar or unipolar disorder and one group of healthy controls were enrolled in this study. Each group consisted of 60 subjects. The Young Mania Rating Scale and Beck Depression Inventory were used to confirm that patients were in remission. The Childhood Trauma Questionnaire and Young Schema Questionnaire-Short Form 3 were used to identify childhood traumas and early maladaptive schemas. Results: In bipolar disorder, a positive, low power correlation was observed between the vulnerability to threats schema and emotional, physical and sexual abuse. In the unipolar disorder group, there was a positive, low power correlation between the emotional inhibition, failure, approval seeking, dependence, abandonment and defectiveness schemas and social isolation, and a positive, moderate correlation between social isolation and emotional abuse. Conclusions: Individuals with bipolar disorder suffered greater childhood trauma compared to subjects with unipolar disorder and healthy individuals. Greater maladaptive schema activation were present in individuals with bipolar disorder compared to those with unipolar disorder and healthy individuals.

Received 29 April 2017 Revised 12 September 2017 Accepted 27 September 2017

Introduction Bipolar disorder is a recurrent disease that can appear with mania, hypomania or depression. Unipolar disorder is a disease that progresses with recurrent depressive attacks (American Psychiatric Association, 2013). Early maladaptive schemas are patterns that generally develop in childhood and adolescence that enable the individual to interpret his life, that affect self-perception and interpersonal relations, that recur constantly during the individual’s life, that are generally quiescent in healthy individuals and that are resistant to change. Traumas experienced in childhood play an important role in the development of early maladaptive schemas (Young, Klosko, & Weishaar, 2003). Higher scores for schema dimensions such as social isolation, failure, dependence, emotional inhibition, pessimism, emotional deprivation, self-sacrifice, punitiveness, unrelenting standards and vulnerability to harm have been determined in patients with bipolar disorder compared to the control group (Ak, Lapsekili, Haciomeroglu, Sutcigil, & Turkcapar,  dac¸ic¸ek, (2011) 2012). In another study, Atalay, Atalay, and Bag reported higher abandonment, mistrust, emotional deprivation, social isolation, vulnerability to harm, failure and submission schema scores in patients with unipolar disorder during the remission period compared to the control group. Higher scores for schemas such as abandonment, dependence, failure, unrelenting standards, submissiveness, abandonment and insufficient self-control have been determined in patients with bipolar disorder compared to unipolar disorder (Nilsson, Nielsen, Straarup, & Halvorsen, 2015). € CONTACT Selc¸uk Ozdin Trabzon, Turkey

[email protected]

ß 2017 Informa UK Limited, trading as Taylor & Francis Group

KEYWORDS

Early maladaptive schema; childhood trauma; bipolar disorder; unipolar disorder

Watson and colleagues (2014) found that all types of traumatic experiences but sexual abuse were common in patients with bipolar disorder. It was also found that there was more trauma in patients with unipolar disorder than in the control group (Williams, Debattista, Duchemin, Schatzberg, & Nemeroff, 2016). Our search of the literature revealed no studies examining the relation between childhood traumas and early maladaptive schemas in patients with bipolar and unipolar disorders. The purpose of this study was to reveal possible differences between bipolar and unipolar disorders in terms of early maladaptive schemas and childhood traumas and to determine the relation between early maladaptive schemas and childhood traumas in these disorders. One of our hypotheses in our study might have been the difference between the groups in terms of early maladaptive schemas and childhood traumas. Another hypothesis was that there might be an association between early maladaptive schemas and childhood traumas.

Methods Participants Two groups of patients followed by a diagnosis of bipolar disorder or unipolar disorder at the Samsun Ondokuz Mayıs University Medical Faculty Department of Psychiatry, Turkey, and one group of healthy controls were enrolled in this study. Each group consisted of 60 subjects. The bipolar and unipolar disorder groups consisted of patients aged 18–65 diagnosed with bipolar or unipolar disorder on the basis of DSM V diagnostic criteria, who were

Department of Psychiatry, Kanuni Education and Research Hospital, Inon€u Mah., Maras¸ cad., 61210 Ortahisar/

2

€ _IN ET AL. S. OZD

standards and approval seeking) the impaired boundaries schema domain (insufficient self-control) and the other-directedness schema domain (self-sacrifice and punitiveness).

literate, in remission, with no additional psychiatric or medical disease and who agreed to take part in the study. The control group consisted of healthy individuals matched with the patient groups in terms of age, sex and education levels, with no psychiatric or medical disease and agreeing to participate. The trial was approved by local ethic committee.

Statistical analysis Statistical analyses were performed on SPSS 15.0 software (SPSS Inc., Chicago, IL). Compatibility with normal distribution of data obtained from the scales in the groups was assessed using the Kolmogorov–Smirnov test. Since the data did not exhibit normal distribution, non-parametric analysis techniques were used. The chi square test was used in the comparison of grouped data, the Mann–Whitney U test in the comparison of numerical variables from two groups and the Kruskal–Wallis test in the comparison of numerical variables between more than two groups, Bonferroni correction was used for multiple comparisons. Significance was set at p ¼ .05/3 ¼ .017 in the Bonferroni-corrected Mann–Whitney U test and at p ¼ .05 for other comparisons. In the analysis of effect sizes for correlation coefficients, as recommended by Hinkle, Wiersma, and Jurs (1979), 0.00–0.30 was regarded as very low, 0.30–0.50 as low, 0.50–0.70 as moderate, 0.70–0.90 as high and 0.90–1.00 as very high.

Downloaded by [Gothenburg University Library] at 05:12 11 October 2017

Instruments Participants’ sociodemographic characteristics were evaluated using a questionnaire eliciting information concerning age, sex, educational level, marital status, duration of disease, number of attacks, presence of any psychiatric disease in the family, hospitalization, life events at first attack and attempted suicide. The Young Mania Rating Scale (YMRS) (Young, Bigss, Ziegler, & Meyer, 1978) and Beck Depression Inventory (BDI) (Beck, 1961) were used to confirm that bipolar and unipolar patients were in remission. Cut-off scores of these scales for mania and depression were taken as 7 and 17, respectively. Turkish validity and reliability , Oral, studies of these scales were performed (Hisli, 1989; Karadag Yalc¸ın, & Erten, 2001). The Childhood Trauma Questionnaire (CTQ) was used to identify childhood traumas (Bernstein & Fink, 1998). The validity and reliability study of the scale was performed by € urk, and _Ikikardes¸ (2012). This inventory measures emoS¸ar, Ozt€ tional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect. The Young Schema Questionnaire-Short Form 3 (YSQ) (Young, 1990) is used to identify early maladaptive schemas. The schemas in the YSQ, the original version of which contains 18 schemas, although 14 schema were determined during Turkish  lu, & C¸akır, 2009), are €t, Karaosmanog language validation (Soygu grouped under five schema domains. These, and the schemas they contain, are as follows: the impaired autonomy schema domain (dependence, abandonment, failure, pessimism and vulnerability to harm), disconnection schema domain (emotional inhibition, emotional deprivation, social isolation/mistrust and defectiveness), the high standards schema domain (unrelenting

Results There were no significant differences between the groups in terms of age, sex, marital status or level of education. Onset of disease was earlier, duration of drug use longer and hospitalization more common in patients with bipolar disorder than in those with unipolar disorder. The mean number of manic attacks in the bipolar disorder group was 3.05 ± 2.24 (Table 1). When the groups were compared in terms of YSQ schemas, significant difference was determined on failure, pessimism, social isolation, approval seeking, dependence, abandonment, punitiveness, defectiveness or vulnerability to threats schema activation scores. At two-group comparisons, failure, social isolation,

Table 1. Clinical characteristics of groups. Bipolar disorder

Unipolar disorder

p Value

Test value

Agea

33.91 (10.67)

32.75 (10.86)

33.56 (6.89)

.595

KW 1.040

Sexb Male Female Education timea

18 (30%) 42 (70%) 11.88 (3.60)

17 (28.3%) 43 (71.7%) 11.88 (3.18)

20 (33.3%) 40 (66.7%) 11.46 (3.55)

.833

v2 0.367 KW 0.660

34 25 1 23.53

32 26 2 26.90

Control group

.719

b

Marital status Married Single Other Age of illness onseta Duration of drug usea Number of depressive epizode Hospital admissionb 1 2 Suicide attemptb 1 2 Mood disorder in familyb 1 2

a

b

(53.3%) (43.3%) (3.4%) (8.50)

41 (68.3%) 17 (28.3%) 2 (3.4%)

.434 .023

10.00 (8.45)

2.95 (3.54)

.000

2.60 (1.85)

2.28 (1.78)

.151

v2 3.799 U 5.168 U 35.00 U 2.067

45 (75%) 15 (25%)

10 (16.6%) 50 (83.4%)

.000

v2 41.119

4 (6.6%) 56 (93.4%)

3 (5%) 57 (95%)

.697

v2 0.152

24 (40%) 36 (60%)

23 (38.3%) 37 (61.7%)

.852

v2 0.035

KW: Kruskal–Wallis. Mean (SD). n (%). Bold values are statistically significant findings. a

(56.6%) (41.7%) (1.7%) (6.58)

INTERNATIONAL JOURNAL OF PSYCHIATRY IN CLINICAL PRACTICE

3

Table 2. The mean scores of the group's Young Schema Scale schema dimensions.

Downloaded by [Gothenburg University Library] at 05:12 11 October 2017

Emotional inhibition Failure Pessimism Social isolation Emotional deprivation Approval-seeking Dependence Insufficient self-control Self-sacrifice Abandonment Punitiveness Defectiveness Vulnerability to harm Unrelenting standards

Bipolar disorder (1) 10.05 (5.25) 14.00 (6.61) 12.53 (5.62) 17.33 (7.07) 11.55 (5.18) 21.31 (6.99) 20.85 (9.39) 21.43 (7.03) 15.18 (5.75) 10.43 (4.78) 21.98 (6.76) 12.00 (5.61) 11.61 (5.22) 9.01 (4.01)

Unipolar disorder (2) 10.48 (5.80) 13.23 (6.17) 13.38 (6.37) 17.41 (6.51) 11.53 (4.53) 18.71 (5.42) 18.15 (7.34) 19.40 (6.27) 14.95 (4.86) 9.95 (4.33) 19.91 (5.12) 10.63 (4.18) 10.25 (4.22) 7.90 (3.76)

Control (3) 8.40 (2.80) 9.78 (3.44) 9.93 (4.08) 13.40 (4.27) 9.65 (3.00) 18.08 (4.54) 15.83 (4.55) 18.28 (4.75) 16.65 (4.71) 7.66 (2.16) 19.38 (5.67) 7.81 (2.11) 8.28 (2.84) 7.83 (3.03)

p Value .411 .000*,1-3,2-3 .005*,1-3,2-3 .000*,1-3,2-3 .070 .004*,1-3,1-2 .011*,1-3 .052 .101 .002*,1-3,2-3 .035*,1-3 .000*,1-3,2-3 .000*,1-3,2-3 .077

KW 1.781 17.203 10.513 16.178 5.330 10.923 8.971 5.909 4.586 12.460 6.690 30.030 16.021 5.129

KW: Kruskal–Wallis. Standard deviations in parentheses. Bonferroni correction was used for multiple comparisons. 1-3 Significant difference between bipolar disorder–control group comparison (p < .017) 2-3 Significant difference between unipolar disorder–control group comparison (p < .017). 1-2 Significant difference between bipolar disorder–unipolar disorder group comparison (p < .017). Bold values are statistically significant findings. Table 3. CTQ average scores of groups. CTQ Emotional abuse Physical abuse Physical neglect Emotional neglect Sexual abuse Total

Bipolar disorder (1) 7.58 6.20 6.41 9.05 5.91 35.16

(3.30) (1.79) (2.05) (4.37) (3.70) (11.01)

Unipolar disorder (2) 7.05 5.73 6.25 9.48 5.15 33.66

(2.94) (1.21) (1.92) (4.18) (0.63) (7.76)

Control (3) 6.05 5.48 6.46 7.55 5.03 30.58

(1.77) (0.99) (1.76) (2.82) (0.18) (5.26)

p Value

.007*,1-3 .047*,1-3 .635 .043*,2-3 .179 .041*,X

KW 10.016 6.102 0.907 6.298 3.440 6.364

CTQ: Childhood Trauma Questionnaire; KW: Kruskal–Wallis. Standard deviations in parentheses.Bonferroni correction was used for multiple comparisons. 1-3 Significant difference between bipolar disorder–control group comparison (p < .017). 2-3 Significant difference between unipolar disorder–control group comparison (p < .017). X Binary comparisons of groups did not reveal any differences between the results. Bold values are statistically significant findings.

approval seeking, dependence, abandonment, punitiveness, defectiveness and vulnerability to threats schema activation scores were higher in patients with the bipolar disorder group compared to the control group. Failure, pessimism, social isolation, abandonment, defectiveness and vulnerability to threats schema activation scores were higher in patients with unipolar disorder compared to the control group. The approval seeking schema activation score was higher in patients with bipolar disorder than in patients with unipolar disorder (Table 2). As will be seen in Table 3, the differences in the mean CQT emotional abuse and the mean CQT physical abuse scores observed between the groups derived from the difference between the bipolar disorder and control groups. The difference in the mean CQT emotional neglect derived from the difference between the bipolar disorder and control groups. Although significant difference was determined in terms of total CTQ scores at three-way group analysis, no significant variation was determined at two-way group comparisons (bipolar disorder– control: p value: .023, unipolar disorder–control: p value: .038, bipolar disorder–unipolar disorder: p value: .760) (Table 3). In patients with bipolar disorder, a positive, low power correlation was observed between the vulnerability to threats schema activation score and emotional, physical and sexual abuse. Positive, low power correlation was also present between the social isolation schema activation score and emotional abuse. Positive, low power correlation was also determined between the failure, pessimism and abandonment schemas and physical neglect (Table 4). In patients with unipolar disorder group, there was a positive, low power correlation between the emotional inhibition, failure,

social isolation, approval seeking, dependence, abandonment and defectiveness schema activation scores and emotional abuse, and a positive, moderate correlation between social isolation and emotional abuse. Positive, low power correlation was also determined between emotional inhibition and emotional neglect and between emotional deprivation and physical neglect (Table 5).

Conclusion Age at onset of bipolar disorder is generally 20–25 years (Kawa et al., 2005; Weissman et al., 1996). Unipolar disorder can be seen at any age, but is most common between 25 and 30 (Kessler et al., 2003; Weissman et al., 1996). In agreement with these findings, mean age at onset of bipolar disorder in our study was 23.53, and mean age at onset of unipolar disorder was 26.90. A lower level of hospitalization and a longer duration of drug use have been determined among bipolar disorder patients compared to unipolar disorder. The presence, in addition to depressive attacks in bipolar disorder patients of manic attacks (mean 3.05 manic attacks), a difficult psychiatric period treated with outpatient polyclinic follow-ups, may be responsible for the greater number of hospitalizations in this group. A longer use of drugs is also expected due to the greater duration of disease in patients with bipolar disease. The suicide rates may have been low because our study did not include comorbid patients (Pavlak et al., 2013). And the relatively younger average age (Diler et al., 2017) of the patients enrolled in the study may have caused the suicide rate to be lower. Higher scores have been reported in patients with bipolar disorder compared to a control group on the YSQ in terms of such

4

€ _IN ET AL. S. OZD

Table 4. Correlation between childhood traumas and maladaptive schemas in bipolar disorder patients. Emotional abuse YSQ Emotional inhibition Failure Pessimism Social isolation Emotional deprivation Approval-seeking Dependence Insufficient self-control Self-sacrifice Abandonment Punitiveness Defectiveness Vulnerability to harm Unrelenting standards

Emotional neglect

Physical abuse

Physical neglect

Sexual abuse

R

p

R

p

R

p

R

p

R

p

0.103 0.210 0.252 0.324a 0.065 0.056 0.125 0.165 0.182 0.210 0.107 0.296 0.344a 0.122

.435 .107 .052 .012 .622 .671 .342 .208 .164 .107 .416 .022 .007 .351

0.134 0.203 0.194 0.223 0.101 0.057 0.281 0.168 0.050 0.195 0.179 0.167 0.131 0.116

.309 .120 .247 .087 .441 .663 .030 .200 .703 .356 .172 .202 .318 .379

0.075 0.031 0.251 0.265 0.143 0.093 0.101 0.078 0.226 0.234 0.215 0.191 0.351a 0.141

.571 .813 .046 .041 .276 .478 .442 .556 .083 .071 .099 .143 .006 .282

0.135 0.331a 0.472a 0.228 0.278 0.059 0.221 0.145 0.130 0.304a 0.098 0.229 0.175 0.102

.305 .010 .000 .080 .032 .656 .095 .268 .322 .018 .456 .079 .181 .436

0.048 0.195 0.214 0.227 0.257 0.021 0.060 0.041 0.280 0.226 0.066 0.123 0.373a 0.061

.718 .135 .100 .081 .047 .874 .648 .753 .030 .083 .616 .348 .003 .646

a

Downloaded by [Gothenburg University Library] at 05:12 11 October 2017

Low power correlation. Bold values are statistically significant findings.

Table 5. Correlation between childhood traumas and maladaptive schemas in unipolar disorder patients. Emotional abuse YSQ Emotional inhibition Failure Pessimism Social isolation Emotional deprivation Approval-seeking Dependence Insufficient self-control Self-sacrifice Abandonment Punitiveness Defectiveness Vulnerability to harm Unrelenting standards

Emotional neglect

Physical abuse

Physical neglect

Sexual abuse

R

p

R

p

R

p

R

p

R

p

0.492a 0.442a 0.191 0.541b 0.290 0.300a 0.370a 0.198 0.270 0.343a 0.007 0.384a 0.171 0.191

.000 .000 .144 .000 .024 .020 .004 .129 .037 .007 .955 .002 .191 .143

0.387a 0.212 0.138 0.296 0.261 0.167 0.175 0.115 0.181 0.096 0.097 0.129 0.145 0.052

.002 .104 .293 .021 .044 .202 .180 .180 .167 .466 .459 .327 .268 .695

0.179 0.023 0.029 0.134 0.064 0.021 0.062 0.048 0.064 0.098 0.290 0.113 0.065 0.045

.172 .861 .827 .306 .628 .874 .640 .715 .627 .457 .025 .390 .624 .734

0.254 0.076 0.056 0.218 0.221 0.077 0.072 0.049 0.160 0.171 0.083 0.176 0.149 0.205

.050 .565 .671 .094 .192 .559 .585 .713 .221 .191 .526 .178 .257 .116

0.000 0.050 0.093 0.080 0.044 0.113 0.094 0.014 0.164 0.017 0.029 0.049 0.056 0.114

.999 .702 .479 .543 .739 .392 .475 .918 .212 .896 .828 .710 .670 .386

a

Low power correlation. Moderate power correlation. Bold values are statistically significant findings.

b

schemas as social isolation, failure, dependence, emotional inhibition, pessimism, emotional deprivation, self-sacrifice, punitiveness, high standards and vulnerability to threats (Lapsekili & Ak, 2012). Ak et al. (2012) reported higher social isolation, dependence, undeveloped identity, failure, entıtlement, insufficient self-control, self-sacrifice, emotional inhibition, high standards and punitiveness schema activation scores in patients with the bipolar disorder group compared to a control group. In our study, too, failure, pessimism, social isolation, approval seeking, dependence, abandonment, punitiveness, defectiveness and vulnerability to threats schema activation scores were higher in patients with the bipolar disorder group compared to the control group. This finding is similar to those of previous studies and contributes to the cognitive model of bipolar disorder. In other words, there may be schemas capable of causing the development of symptoms stimulated by events in the individual’s life in the passive state and that may be associated with development of disease attacks even if bipolar disease is in remission. According to Garno, Goldberg, Ramirez, and Ritzler, (2005) the most common traumas in bipolar disorder are emotional abuse and physical abuse. In our study, too, levels of emotional abuse and physical abuse were higher in patients with the bipolar disorder group compared to the control group. One possible reason for the greater incidence of trauma in patients with bipolar disorder may be that this condition has a high genetic association. In our study, 40% of patients with bipolar disorder had family history of mood disorder. The increased

violent behaviour of patients with mood disorder (Narayan, Chen, Martinez, Gold, & Klimes-Dougan, 2015; Volavka, 2013) compared to the general population may have resulted in increased childhood trauma in the patient groups. Affective liability (Aas et al., €tc¸u € Yildirim, Celik, 2015), a greater history of psychiatric disease (Su Kabakc¸i, & Ulus¸ahin, 2005) and hyperthymic temperament, the probability of which increases in first-degree relatives of patients with bipolar disorder can result in increased traumatization. Another possible cause is that parents may resort to greater violence in association with the emergence of sub-threshold symptoms such as sleeplessness, aggression, mood volatility and anger episodes before the appearance of bipolar disorder (Etain, Henry, Bellivier, Mathieu, & Leboyer, 2008; Hernandez, Marangoni, Grant, Estrada, & Faedda, 2017). Atalay et al. (2011) reported higher abandonment, mistrust, emotional deprivation, social isolation, failure and submission schema activation scores in patients with unipolar disorder during the remission period compared to a control group. In our study, too, failure, pessimism, social isolation, abandonment, defectiveness and vulnerability to threat schema activation scores were higher in patients with the unipolar disorder group than in the control group. These findings show that early maladaptive schemas may occur in patients with unipolar disorder despite being in remission. The presence in a patient with unipolar disorder in remission of such schemas (failure, pessimism, social isolation, abandonment, defectiveness and vulnerability to threats) may

Downloaded by [Gothenburg University Library] at 05:12 11 October 2017

INTERNATIONAL JOURNAL OF PSYCHIATRY IN CLINICAL PRACTICE

lead to the emergence of several symptoms seen in patients with unipolar disorder as a result of the stimulation of these schemas. Higher emotional abuse, emotional neglect and physical neglect scores have been reported in recurring unipolar disease patients and first attack unipolar disease patients compared to a control group (B€ ulb€ ul et al., 2013). According to Mandelli, Petrelli, and Serretti, (2015) emotional abuse and emotional neglect were identified as possible markers in predicting unipolar disorder. Emotional neglect was significantly greater in patients with unipolar disorder in our study than in the control group. Higher trauma scores in the unipolar group compared to the controls may be associated with a common etiological factor. On the other hand, high mood disorder family history (38.3%) in the unipolar disorder group may have caused childhood trauma to be higher than the control group. Lapsekili and Ak (2012) reported a higher mistrust schema in patients with bipolar disorder than in patients with unipolar disorder. In another study, Hawke, Provencher, and Arntz (2011) reported higher approval seeking and entitlement schemas in patients with bipolar disorder. A higher approval seeking schema activation score was determined in patients with bipolar disorder compared to in patients with unipolar disorder in our study. Looking at various questions assessing the approval-seeking schema (such as ‘Having money and knowing important people make me valuable’ or ‘Successes that other people are aware of are the most valuable successes for me.’), high approval seeking schema activation score in patients with bipolar disorder are not an unexpected finding. Reward sensitivity (Depue, Krauss, & Spoont, 1987), a greater need for recognition (Alatiq, Crane, Williams, & Goodwin, 2010) and increased goal-directed activity (Nusslock, Abramson, Harmon-Jones, Alloy, & Hogan, 2007) in patients with bipolar disorder patients may account for the elevation in the approval seeking schema in these patients. On the other hand, the combination of two opposite concepts such as approval seeking and higher feelings of superiority to others (Gilbert, McEwan, Hay, Irons, & Cheung, 2007) can be explained by the psychoanalytic model of bipolar disorder. According to psychoanalytic viewpoint, mania is a defence against depression. Correlation was determined in our study between the vulnerability to threats schema activation score and trauma such as physical, emotional and sexual abuse in patients with bipolar disorder. Individuals who experience abuse-type trauma begin to perceive the world in an insecure manner. This may give rise to a vulnerability to threats schema. Significant correlation was determined between failure, pessimism and abandonment schema activation scores and physical neglect. Mistrust concerning individuals looked to for security and attachment, an abandonment schema in other words, may be expected in subjects who are physically neglected. In addition, correlation between physical neglect and the failure schema domain, characterized by inevitable inability to succeed, and the pessimism schema characterized by widespread focus on negative aspects of life associated with needs not being met, are expected findings. In addition, significant correlation was found between social isolation and emotional abuse. Fear of the same things occurring in the future in children exposed to emotional abuse may lead to a high social isolation schema in these individuals. Emotional abuse was significantly correlated with failure, social isolation, approval-seeking, dependence, abandonment and defectiveness schema activation scores in patients with unipolar disorder. Emotional abuse refers to extreme verbal threats, mockery and humiliating criticisms and comments on the part of care givers capable of endangering the child’s emotional and psychological health. Subsequent schemas may develop in subjects

5

exposed to such experiences in childhood. Mandelli et al. (2015) reported that emotional abuse was more successful than other traumas in predicting disease in unipolar disorder. Our finding may support this. Early maladaptive schemas must therefore be investigated in patients with unipolar disorder who are known to have been subjected to emotional abuse. One limitation of this study is its cross-sectional nature. The fact that patients were in remission may have affected the inventory scores. Inventory scores may vary in the attack period. The fact that the CTQ assesses traumas experienced in childhood retrospectively may have caused the trauma scores obtained to be lower or less identified. One of the limitations of the study is that the sample size is small. Another limitation of this study is that other variables that may be expected to affect early maladaptive schemas (such as emotional temperament, parental attitudes, chronic diseases, low socioeconomic status and cultural factors such as physical defects being mocked by friends) were not evaluated.

Key points   

In patients with bipolar disorder suffered greater childhood trauma compared to in patients with unipolar disorder and healthy individuals. Greater maladaptive schemas were present in patients with bipolar disorder compared to those with unipolar disorder and healthy individuals. There is a correlation between childhood trauma and early maladaptive schemas in patients with bipolar and unipolar disorder groups.

Acknowledgements The authors thank Carl Nino Rossini for his linguistic consultation of the paper.

Disclosure statement The authors declare no conflicts of interest.

References Aas, M., Pedersen, G., Henry, C., Bjella, T., Bellivier, F., & Leboyer, M. (2015). Psychometric properties of the Affective Lability Scale (54 and 18-item version) in patients with bipolar disorder, first-degree relatives, and healthy controls. Journal of Affective Disorders, 172, 375–380. doi: 10.1016/j.jad.2014.10.028 Ak, M., Lapsekili, N., Haciomeroglu, B., Sutcigil, L., & Turkcapar, H. (2012). Early maladaptive schemas in bipolar disorder. Psychology and Psychotherapy, 85 (3), 260–267. doi: 10.1111/ j.2044-8341.2011.02037.x Alatiq, Y., Crane, C., Williams, J. M., Goodwin, G. M. (2010). Dysfunctional beliefs in bipolar disorder: Hypomanic vs. depressive attitudes. Journal of Affective Disorders, 122 (3):294–300. doi: 10.1016/j.jad.2009.08.021 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association. dac¸ic¸ek, S. (2011). Effect of short-term Atalay, H., Atalay, F., & Bag antidepressant treatment on early maladaptive schemas in patients with major depressive and panic disorder. International Journal of Psychiatry in Clinical Practice, 15 (2), 97–105. doi: 10.3109/13651501.2010.549234

Downloaded by [Gothenburg University Library] at 05:12 11 October 2017

6

€ _IN ET AL. S. OZD

Beck, A. T. (1961). An inventory for measuring depression. Archives of General Psychiatry, 1, 561–571. Bernstein, D., & Fink, L. (1998). Childhood trauma questionnaire: A retrospective self-report questionnaire and manual. San Antonio, TX: Psychological Corp. B€ ulb€ ul, F., Cakir, U., Ulku, C., Ure, I., Karabatak, O., & Alpak, G. (2013). Childhood trauma in recurrent and first episode depression. Anadolu Psikiyatri Dergisi, 14 (2), 93–99. doi: 10.5455/ apd.34484 Depue, R. A., Krauss, S., & Spoont, M. R. A. (1987). Two-dimensional threshold model of seasonal bipolar affective disorder. In A. Magnusson D ve Ohman (Ed.), Psychopathology: An interactional perspective. New York: Academic Press. Diler, R. S., Goldstein, T. R., Hafeman, D., Merranko, J., Liao, F., Goldstein, B. I., … Birmaher, B. (2017). Distinguishing bipolar depression from unipolar depression in Youth: Preliminary findings. Journal of Child and Adolescent Psychopharmacology, 27 (4), 310–319. doi: 10.1089/cap.2016.0154 Etain, B., Henry, C., Bellivier, F., Mathieu, F., & Leboyer, M. (2008). Beyond genetics: Childhood affective trauma in bipolar disorder. Bipolar Disorders, 10 (8), 867–876. doi: 10.1111/j.13995618.2008.00635.x Garno, J. L., Goldberg, J. F., Ramirez, P. M., Ritzler, B. A. (2005). Impact of childhood abuse on the clinical course of bipolar disorder. The British Journal of Psychiatry, 186, 121–125. doi: 10.1192/bjp.186.2.121 Gilbert, P., McEwan, K., Hay, J., Irons, C., & Cheung, M. (2007). Social rank and attachment in people with a bipolar disorder. Clinical Psychology & Psychotherapy, 14, 48–53. doi: 10.1002/ cpp.508 Hawke, L. D., Provencher, M. D., & Arntz, A. (2011). Early Maladaptive Schemas in the risk for bipolar spectrum disorders. Journal of Affective Disorders, 133 (3), 428–436. doi: 10.1016/ j.jad.2011.04.040 Hernandez, M., Marangoni, C., Grant, M. C., Estrada, J., Faedda, G. L. (2017). Parental reports of prodromal psychopathology in pediatric bipolar disorder. Current Neuropharmacology, 15(3), 380–385. doi: 10.2174/1570159X1466160801162046 Hinkle, D. E., Wiersma, W., & Jurs, G. S. (1979). Applied statistics for the behavioral sciences. Chicago: Rand McNally. €g rencileri €niversite o Hisli, N. (1989). Beck Depresyon Envanteri'nin u i, g€  i. Psikoloji Dergisi, 7 (23), 3–13. ic¸in gec¸erlig uvenirlig , F., Oral, E. T., Yalc¸ın, F. A., & Erten, E. (2001). Young Mani Karadag €lc¸eg  inin T€ i. Derecelendirme o urkiye’de gec¸erlik ve g€ uvenilirlig Turk Psikiyatri Dergisi, 13 (2), 107–114. Kawa, I., Carter, J. D., Joyce, P. R., Doughty, C. J., Frampton, C. M., Elisabeth Wells, J., … Olds, R. J. (2005). Gender differences in bipolar disorder: Age of onset, course, comorbidity, and symptom presentation. Bipolar Disorders, 7, 119–125. doi: 10.1111/ j.1399-5618.2004.00180.x Kessler, R. C., Berglund, P., Demler, O., Jin, R., Koretz, D., & Merikangas, K. R. (2003). The epidemiology of major depressive disorder: Results from the National Comorbidity Survey Replication (NCS-R)). The Journal of the American Medical Association, 289 (23), 3095–3105. doi: 10.1001/jama.289.23.3095 Lapsekili, N., & Ak, M. (2012). Early maladaptive schemas related to unipolar and bipolar depression: Similarities and difference. Journal of Cognitive-Behavioral Psychotherapy and Research, 1 (3), 145–151. Mandelli, L., Petrelli, C., & Serretti, A. (2015). The role of specific early trauma in adult depression: A meta-analysis of published

literature. Childhood trauma and adult depression. European Psychiatry, 30 (6), 665–680. doi: 10.1016/j.eurpsy.2015.04.007 Narayan, A. J., Chen, M., Martinez, P. P., Gold, P. W., & KlimesDougan, B. (2015). Interparental violence and maternal mood disorders as predictors of adolescent physical aggression within the family. Aggressive Behavior, 41(3), 253–266. doi: 10.1002/ AB.21569 Nilsson, K., Nielsen, K., Straarup, K., & Halvorsen, M. (2015). Early maladaptive schemas: A comparison between bipolar disorder and major depressive disorder. Clinical Psychology & Psychotherapy, 22 (5), 387–391. doi: 10.1002/cpp.1896 Nusslock, R., Abramson, L. Y., Harmon-Jones, E., Alloy, L. B., & Hogan, M. E. 2007. A goal-striving life event and the onset of hypomanic and depressive episodes and symptoms: Perspective from the behavioral approach system (BAS) dysregulation theory. Journal of Abnormal Psychology, 116, 105–115. doi: 10.1037/0021-843X.116.1.105 Pavlak, J., Dmitrzak-Weglarz, M., Skibinska, M., Szczepankiewicz, A., Leszczynska-Rodziewicz, A., Rajewska-Rager, A., … Hauser, J. (2013). Suicide attempts and clinical risk factors in patients with bipolar and unipolar affective disorders. General Hospital Psychiatry, 35 (4), 427–432. doi: 10.1016/ j.genhosppsych.2013.03.014 lu, A., & C¸akır, Z. (2009). Erken do €nem Soyg€ ut, G., Karaosmanog erlendirilmesi: young s¸ema o €lc¸eg i kisa uyumsuz s¸emalarin deg €zelliklerine ilis¸kin bir inceleme. Turk form-3’€ un psikometrik o Psikiyatri Dergisi, 20 (1), 75–84. S€ utc¸€ u Yildirim, A., Celik, M., Kabakc¸i, E., & Ulus¸ahin, A. (2005). Psychopathology and personality patterns in the first-degree relatives of bipolar patients. Turk Psikiyatri Dergisi, 16 (4), 229–236. € urk, E., & _Ikikardes¸, E. (2012). C¸ocukluk C¸ag ı Ruhsal S¸ar, V., Ozt€ € ¸eg inin T€ Travma Olc urkc¸e uyarlamasının gec¸erlilik ve i. Turkiye Klinikleri Journal of Medical Sciences, 32, €venilirlig gu 1054–1063. doi: 10.5336/medsci.2011-26947 Volavka, J. (2013). Violence in schizophrenia and bipolar disorder. Psychiatria Danubina, 25 (1), 24–33. Watson, S., Gallagher, P., Dougall, D., Porter, R., Moncrieff, J., Ferrier, I., & Young, A. H. (2014). Childhood trauma in bipolar disorder. Australian & New Zealand Journal of Psychiatry, 48 (6), 564–570. doi: 10.1177/0004867413516681 Weissman, M. M., Bland, R. C., Canino, G. J., Faravelli, C., Greenwald, S., & Hwu, H. G. (1996). Cross-national epidemiology of major depression and bipolar disorder. The Journal of the American Medical Association, 276 (4), 293–299. doi: 10.1001/ jama.1996.03540040037030 Williams, L. M., Debattista, C., Duchemin, A. M., Schatzberg, A. F., & Nemeroff, C. B. (2016). Childhood trauma predicts antidepressant response in adults with major depression: Data from the randomized international study to predict optimized treatment for depression. Translational Psychiatry, 6, e799. doi: 10.1038/ tp.2016.61 Young, R. C., Bigss, T., Ziegler, V. E., & Meyer, D. A. (1978). A rating scale for mania: Reliability, validity and sensitivity. The British Journal of Psychiatry, 133, 429–435. Young, J. E. (1990). Cognitive therapy for personality disorders: A schema-focused approach. Sarasota FL. Professional Resource Press. Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guide. New York, NY: Guilford Press.

Early maladaptive schemas in patients with bipolar and unipolar disorder.

The aim of our study is to determine the difference between the bipolar disorder, unipolar disorder and control groups in terms of maladaptive schemes...
799KB Sizes 0 Downloads 13 Views