Schema Theory proposes that some individuals can develop dysfunctional patterns of beliefs and unhelpful perceptions of the world and themselves [1
]. These beliefs and perceptions usually develop during childhood or adolescence as a result of psychologically harmful experiences involving family members or other significant individuals, and for this reason are referred to as early maladaptive schemas. According to this theory, early maladaptive schemas develop in response to unmet core emotional needs, namely: secure attachment to others, autonomy/competence, freedom to express emotions, spontaneity, and realistic limits/self-control. It was previously suggested that as a result of this process, people can develop different types of psychological disorders and engage in a continuum of dysfunctional behaviors [1
There is some evidence that early maladaptive schemas can relate to dysfunctional eating behaviors. For example, the unhealthy eating behaviors seen in patients with eating disorders were found to be associated with the presence of early maladaptive schemas [2
]. One study [3
] evaluated the presence of early maladaptive schemas in participants with obesity and found that they showed more severe early maladaptive schemas than participants of normal weight, notably the early maladaptive schemas of social isolation/alienation and defectiveness/shame. Another study [4
] found that the early maladaptive schemas of isolation/alienation, emotional inhibition, abandonment/instability and unrelenting standards/hypercriticalness negatively influenced aspects of identity amongst individuals with obesity. Additionally, a higher presence of the following early maladaptive schemas were found amongst adolescents with overweight or obesity in comparison to adolescents of normal weight: social isolation/alienation, defectiveness/shame, emotional deprivation, failure to achieve, dependence/incompetence, and subjugation [5
], as well as emotional deprivation, abandonment/instability, subjugation and insufficient self-control/self-discipline [6
]. Additionally, another study [7
] involving adolescents with overweight found that those who experienced a loss of control over eating had a greater severity of the early maladaptive schemas of social isolation/alienation, abandonment/instability, unrelenting standards/hypercriticalness, mistrust/abuse, failure to achieve and subjugation, in contrast with those that did not experience loss of control over eating.
Another set of dysfunctional cognitive processes, named cognitive distortions, plays an important role in maintaining the negative core beliefs that form early maladaptive schemas, through the perceptual distortion of facts [1
]. Cognitive distortions are common thoughts that happen quickly, involuntarily, and in a distorted manner [8
]. Some specific types of cognitive distortions have been suggested to be experienced by individuals with obesity [9
]. These distorted thoughts occur, for example, when someone thinks that the desire to eat is irresistible (“magnification”), that they are “losers” because they are obese (“labeling”) or that people reject them because they are overweight (“mind reading”). One study found that dichotomous thinking (a type of cognitive distortion) about food, weight and eating was predictive of weight regain, and that a general dichotomous thinking pattern (not necessarily related to food, weight or eating) was an even better predictor of weight regain [10
]. Two other studies [11
] assessed vulnerability to a specific cognitive distortion, namely thought-shape fusion, in participants with obesity and participants of normal weight. This type of cognitive distortion occurs when the imagination of the consumption of high-energy food generates the feeling of being fat and negative moral judgment. In these studies, individuals with obesity were less vulnerable to thought-shape fusion than individuals of normal weight, thus revealing differences in cognitive processes between groups. Studies have further examined the correlation of cognitive distortions with binge eating disorder. A small (n
= 42) exploratory study [13
] reported that participants with obesity, whether or not they had binge eating disorder, showed more cognitive distortions than participants of normal weight. In contrast, another study [14
] found that individuals with obesity and comorbid binge eating disorder were more affected by dichotomous thinking than individuals with obesity but without binge eating disorder. The studies above suggest that individuals with obesity, especially those with comorbid binge eating disorder, experience more of some types of cognitive distortions than individuals of normal weight.
Other studies, however, emphasize the relationship between dysfunctional cognitions and mental health status independently of the occurrence of eating or weight disorders. For example, there is evidence that early maladaptive schemas predict depression [15
], are associated with complex cases of mood and anxiety disorders [16
], and are vulnerability factors for the development of symptoms of depression and anxiety amongst individuals experiencing stressful situations [17
]. There are also indications that early maladaptive schemas predict occupational stress [18
]. Both early maladaptive schemas and cognitive distortions were found to be significantly associated with emotional problems, namely depression and anxiety [19
]. In regards to cognitive distortions specifically, a study found that participants with depression showed strong negative interpretations of metaphors [20
]. Cognitive distortions also predict depression and anxiety amongst children and adolescents [21
]. Additionally, the cognitive model proposes that cognitive distortions, together with neurobiological correlates, influence how people cope with stressful situations and develop depression [22
]. All of the studies discussed in this paragraph show a clear association of the occurrence of dysfunctional cognitions and mental health problems, irrespective of the weight of the participants. Therefore, it is possible that the observation that individuals with obesity experience more early maladaptive schemas or cognitive distortions than individuals of normal weight could be mediated by the fact that participants with obesity frequently experience symptoms of mental illness [23
], and not because of their elevated weight.
In summary, dysfunctional thinking styles, known as early maladaptive schemas and cognitive distortions, have been found in individuals with eating disorders, overweight or obesity. However, it is possible that these findings are associated with the mental health status of the participants and not necessarily with their obesity. Our study thus aimed to further examine this issue. Therefore, we sought to clarify whether individuals with morbid obesity show higher levels of dysfunctional cognitions than individuals of normal weight, and if so, if this is related to their individual mental health condition. Ultimately, this understanding could aid in the development of effective psychological and behavioral assessments and subsequent interventions, tailored specifically for individuals with morbid obesity.
The main aim of this study was to compare the occurrence of early maladaptive schemas and cognitive distortions in participants with morbid obesity versus those of normal weight, and to examine if mental health status could influence potential differences between groups in the occurrence of these dysfunctional cognitions. Higher occurrences of the early maladaptive schema of insufficient self-control/self-discipline and a statistical trend towards higher occurrence of the cognitive distortion of labeling were found in participants with morbid obesity compared to participants of normal weight. However, after controlling for symptoms of depression, of anxiety, and stress, participants with morbid obesity and participants of normal weight did not differ statistically in regards to scores on early maladaptive schemas. These findings support a previous study that found that an individual’s responses in the YSQ-S are influenced by their emotional state while completing the questionnaire [35
]. Furthermore, even before controlling for mental health status, the statistical differences of early maladaptive schemas and cognitive distortions found amongst participants with morbid obesity compared to participants of normal weight were small (1 out of 15 types of early maladaptive schemas and 1 out of 15 types of cognitive distortions). These are slight differences that may have been found due to chance. These findings do not indicate significant clinical differences in the occurrence of dysfunctional cognitions between those with morbid obesity and those of a normal weight.
We did not find statistically significant differences between participants with morbid obesity and participants of normal weight in regards to symptoms of depression and stress. However, significant differences were found in the presence of anxiety symptoms between groups. These findings contradict a systematic review and meta-analysis that found an association between obesity and depression, particularly amongst women [36
]. The levels of depression symptoms in the participants with morbid obesity in our sample were possibly low since more than half (54%) of our participants with morbid obesity were being treated with psychiatric medication at the time of the assessment. Although stress-induced eating habits seem to have an important role in the development of obesity [37
], in our study, no differences in the level of stress symptoms were found between groups. Our findings regarding the higher anxiety symptoms amongst participants with morbid obesity are consistent with the outcomes from a systematic review and meta-analysis that found a positive association between anxiety disorders and obesity [38
]. A previous study found that individuals with obesity, especially those with comorbid binge eating disorders, tend to eat in response to unpleasant emotional states [39
An additional finding of our study is that the participants with morbid obesity used significantly more psychiatric medication than the participants of normal weight. This may have been influenced by the fact that the participants with morbid obesity were patients of the bariatric surgery clinic and therefore were regularly seen by the medical team, and such medical attention did not necessarily occur for participants of normal weight. This finding is compatible with a previous study [40
] that found high psychiatric medication use amongst individuals with morbid obesity (40.7% of their sample). A controversial issue regarding the prescription of psychiatric medication for individuals with morbid obesity is the effect of these medicines on weight. A recent systematic review reported that body fat accumulation is a common side effect of psychotropic medication [41
]. Therefore, it is possible that the higher use of psychiatric medication contributed to the excess weight of the participants with morbid obesity, albeit this was not the focus of the current study.
The current findings have relevance to clinical practice. Lifestyle interventions aimed at promoting healthy eating habits and appropriate levels of physical activity are routinely recommended for people with morbid obesity, due to their role in reducing the medical complications related to morbid obesity and in improving psychological health [42
]. However, further psychological therapy may be required for some individuals with morbid obesity. Their mental health status should be assessed, and those with depression, anxiety and/or psychological distress may be considered for further assessment of early maladaptive schemas and cognitive distortions and these (if present) may need to be addressed with specific psychotherapy, such as cognitive and/or schema therapy [1
Limitations of this study include the use of self-report assessment of early maladaptive schemas and cognitive distortions, as some people may have difficulty identifying their own dysfunctional thoughts [43
]. A second limitation is that participants with morbid obesity may have tried to express socially desirable responses in an attempt to allay social stigma [44
], or for fear of a psychological evaluation that could deny or delay their referral for bariatric surgery [45
] (although they were told that their responses would be confidential). A third limitation of this study is that types of psychiatric medication used by the participants, psychotherapeutic treatment and psychiatric diagnosis were not assessed. Future research in this field should include participants with obesity that are not seeking treatment, and examine causal effects of anxiety symptoms and use of psychiatric drugs amongst individuals with morbid obesity.