Early Maladaptive Schemas in Patients with Panic Disorder with Agoraphobia

By Hedley, Liv Margaret; Hoffart, Asle et al. | Journal of Cognitive Psychotherapy, January 1, 2001 | Go to article overview

Early Maladaptive Schemas in Patients with Panic Disorder with Agoraphobia


Hedley, Liv Margaret, Hoffart, Asle, Sexton, Harold, Journal of Cognitive Psychotherapy


The present study explored the relationships among Early Maladaptive Schemas (EMS), beliefs about loss of control, a fear of bodily sensations, and avoidance in patients undergoing cognitive therapy. Fifty-nine patients (43 women and 16 men) being treated for panic disorder with agoraphobia (PDA) participated in the study. Two EMS that are seen as being central in PDA [vulnerability to harm (VH) and functional incompetence/dependency (DI)], beliefs about loss of control, a fear of bodily sensations, and avoidance were measured at treatment start and at six months follow-up. The data were analyzed using structural modeling techniques. The VH schema influenced beliefs about loss of control, a fear of bodily sensations, and avoidance. Beliefs about loss of control, in turn, predicted a fear of bodily sensations. DI was predicted by VH and did not influence other aspects of PDA. The results were largely in consort with the theoretical suppositions of schema theory and indicated that the VH schema may contribute to the maintenance of PDA.

According to cognitive theory as described by Beck, Freeman, and associates (1990), personality may be conceptualized as a relatively stable organization composed of schemas. Schemas are viewed as rather enduring structures, which embody various sets of rules, beliefs, assumptions and formulas that influence the person's perceptions, interpretations, emotions and behavior (Beck & Emery, with Greenberg, 1985). Thus, schemas can be seen as basic units of personality. According to this theory, personality disorders, such as "avoidant" and "dependent," are viewed as the overt expressions of underlying dysfunctional schemas (Beck, Freeman, & associates, 1990). Presumably, also, at the core of the Axis I disorders, such as depression and anxiety, lie the activation of dysfunctional schemas (Beck, Freeman, & associates, 1990; Young, 1990). Thus, schemas may be viewed as the inferred underlying structures that could account for manifest psychological problems.

Although, as noted in several review articles (Brooks, Baltazar, & Munjack, 1989; Ruegg & Frances, 1995; Tyrer, Gunderson, Lyons, & Tohen, 1997), panic disorder with agoraphobia (PDA) has most commonly been associated with dependent and avoidant behavior, little is known about the mechanisms by which schemas may influence the presentation of PDA (Taylor & Livesly, 1995). Our aim has been to explore this issue by utilizing the concept of "Early Maladaptive Schemas" (EMS, Young, 1991)using 'causal' or directional modeling techniques.

EMS are viewed as a subset of schemas which are: "extremely broad and pervasive themes regarding oneself and one's relationships with others, developed during childhood and elaborated throughout one's life" (Young & Lindemann, 1992). EMS might serve as templates for the processing of later experience and presumptively develop as a result of cumulative dysfunctional experiences in childhood, rather than from isolated traumatic events. They are seen as being influential upon the individual's self-concept and serve to shape the individual's perception of the environment. According to Young (1990) EMS are perceived as unconditional, a priori truths about the individual in relation to the environment. Whereas they may have had a functional purpose in childhood, EMS are supposed to be highly dysfunctional in adulthood. Presumably, the psychological disposition for anxiety disorders, developed in childhood, is embodied in the EMS.

Triggering of the EMS can be extremely disruptive and painful. Therefore the individual is seen to engage in a variety of maneuvers to prevent schema activation. One of the processes by which the individual prevents schema activation is avoidance. The avoidance can be cognitive, affective, or behavioral. Behavioral avoidance refers to the tendency of many patients to avoid real-life situations or circumstances that might trigger painful schemas (Young, 1990).

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