Journal of Behavior Therapy and Experimental Psychiatry
Stability of dysfunctional attitudes and early maladaptive schemas: A 9-year follow-up study of clinically depressed subjects
Introduction
Since major depression is a highly prevalent, recurrent, and often chronic disorder (Andrade et al., 2003, Kessler et al., 2003) it is imperative to increase our knowledge about vulnerability factors in order to prevent and treat depression.
According to Beck, 1967, Beck, 1987 cognitive theory of depression, vulnerability may develop in individuals with a history of loss or adversity in childhood contributing to the formation of negative self-schemas, containing dysfunctional attitudes. Dysfunctional attitudes, frequently assessed with the Dysfunctional Attitude Scale (DAS; Weissman & Beck, 1978), include core beliefs such as that one’s happiness depends on being perfect, being in control, or on other people’s approval (Beck, Hollon, Young, Bedrosian, & Budenz, 1985). Furthermore, the core beliefs are according to Beck’s theory assumed to be relatively stable cognitive characteristics that confer vulnerability to stress which subsequently may lead to the onset of depression.
Numerous studies have examined the stability of negative schemas operationalized by means of the DAS. Fairly consistently, DAS scores have been found to fluctuate with the clinical state, indicating that dysfunctional attitudes may rather be a state than a trait characteristic. State-dependent effects of dysfunctional attitudes have been reported both in cross-sectional (Clark and Beck, 1999, Ingram et al., 1998, Power et al., 1995) and in treatment studies (Beevers and Miller, 2004, Hamilton and Abramson, 1983, Zuroff et al., 1999). However, some studies have found DAS scores of remitted depressed patients still elevated after treatment as compared to non-depressed controls (Beevers & Miller, 2004; Peselow et al., 1990, Zuroff et al., 1999). Moreover, research has consistently shown that vulnerable as compared to less vulnerable individuals, report more dysfunctional attitudes during negative mood-states (Scher, Ingram, & Segal, 2005). Such findings have made several researchers to claim that it is a simplification of a more complex causality to explain elevated DAS scores solely with either state or trait factors. For example, Person and Miranda (1992), in line with Beck et al.’s theory have hypothesized that putative vulnerability factors are present in vulnerable individuals, but are more or less accessible depending on mood-state. Accordingly, Zuroff et al. (1999) proposed a state-trait vulnerability model comprising both stable differences in availability of cognitive-affective structures, and fluctuating differences in accessibility of those structures dependent on current levels of depressive symptoms. In an 18 months follow-up study of depressed patients they found evidence of trait-like properties of DAS scores, although mood-state dependent effects were evident.
More recently, similar findings have been obtained in a treatment study by Beevers and Miller (2004) who assessed cognitive bias, dysfunctional attitudes and depression severity in 121 subjects who were hospitalized for depression and followed-up during a 6-months outpatient treatment and one year after its completion. Mean score change, test–retest correlation, and path analysis both demonstrated relative stability over time, but also that fluctuations in mood-state influenced dysfunctional attitudes and cognitive bias. Otto et al. (2007) as well, found in a three-year prospective study of a large, community-based sample of 750 women, an association between DAS scores and subsyndromal levels of depressive symptoms indicating mood-state effects on dysfunctional attitudes. However, they also found dysfunctional attitudes as predictive of future episodes of depression in women, but only when a history of depression was ignored.
Young, 1990, Young, 1999 has elaborated on the schema concept to reflect themes of adverse relational experiences in childhood. Young (1990) hypothesized that connectedness, autonomy, worthiness, reasonable expectations and realistic limits, are five primary objectives that the child has to fulfill in order to pursue a healthy development. When caregivers make it difficult for the child to achieve one or more of these five objectives, Young proposed that Early Maladaptive Schemas (EMSs) will develop. Young (1990) originally identified sixteen schemas, which are grouped into five domains reflecting the childhood objectives mentioned above: Disconnection, Impaired Autonomy, Undesirability, Restricted Self-Expression, and Impaired Limits. In this way, Young assumed the EMS domains to represent predisposing factors for the development and maintenance of clinical symptom states, and to explain various types of interpersonal and personality related problems. To assess the EMSs, Young (1990) developed the Young Schema Questionnaire (YSQ; Young & Brown, 1990).
Beck, 1967, Beck, 1987 and Young (1990) both suggested that the most important etiological pathways of developing dysfunctional attitudes and EMSs are related to adverse experiences during childhood. Young also, influenced by the work of Ainsworth and Bowlby (1991) on attachment theory, emphasized that EMSs refer to the deepest level of cognitive structures representing the self in relation to other persons and the environment. Accordingly, EMSs are suggested to be more persistently activated compared to dysfunctional attitudes, which require the presence of certain stressors or conditions (Schmidt & Joiner, 2004). Because Young (1999) explicitly emphasized the highly stable and enduring themes of the EMSs, the issue of stability is probably even more crucial to Young’s theory. Few studies have investigated the long-term stability of EMSs. However, Riso et al. (2006) examined 55 depressed outpatients over a 2.5–5-years interval and found moderate to good levels of relative stability also after controlling for severity of depression at both assessments. Further, they found that the mean-scores of the majority of the EMSs did not drop significantly in spite of a significant decrease in depression severity at follow-up.
The clinical relevance of demonstrating the relative stability of dysfunctional attitudes and EMSs is essential due to the assumption raised by Beck and Young that dysfunctional attitudes and EMSs may predict the development and maintenance of clinical symptom states including depression. Accordingly, to be regarded as clinically meaningful predictors of vulnerability, also some relative stability is warranted. Several studies have found dysfunctional attitudes as predictive of depression severity, first-onset, relapse and recurrence of major depression (e.g., Alloy et al., 2006, Hankin et al., 2004, Iacoviello et al., 2006, Segal et al., 1999, Segal et al., 2006, Zuroff et al., 1990). Comparably fewer studies have investigated EMSs as predictors of depression severity (Harris and Curtin, 2002, Hoffart et al., 2005, Schmidt et al., 1995). More recently, however, the authors of the present paper found that YSQ scales emerged as significant predictors of concurrent depression severity and depression severity and episodes of Major Depression nine years later in a sample of 149 currently and previously depressed individuals, and never-depressed controls (Halvorsen, Wang, Eisemann, & Waterloo, 2009).
Previous work on the stability of dysfunctional attitudes has illustrated the importance of both examining changes in mean scores, i.e., absolute stability and examining relative stability by using correlational analyses (Santor, Bagby, & Joffe, 1997). Zuroff et al. (1999), when investigating the stability of DAS scores, argued that “It is possible for a group to show large, significant changes in mean scores on a trait in the presence of perfect stability in the participants’ relative standing on the trait” (p. 77). However, research on the stability of schemas has primarily been carried out with cross-sectional and treatment designs. Accordingly, little knowledge exists concerning the stability of both schemas and depressive symptoms in a natural course of major depression. The present study attempts to replicate and extend previous findings by including the YSQ as a second measure of schemas in addition to the DAS in a sample of clinically depressed (CDs), previously depressed (PDs) and never-depressed subjects (NDs), who were followed-up after nine years without any treatment intervention.
Four aims were addressed: (1) to compare groups of CDs, PDs, and NDs on dysfunctional attitudes and EMSs, (2) to investigate the conceptual overlap between dysfunctional attitudes and EMSs in a cross-sectional design, and (3) to examine the relative and (4) absolute stability of dysfunctional attitudes, EMSs, and depressive symptoms after nine years.
Section snippets
Participants and procedure
The analysis is based on a sample of 149 subjects taking part in a study on depression and cognitive vulnerability in the years 1997–1999, i.e., the index study (T1) (Wang, Brennen, & Holte, 2005). In the years 2006–2007 (T2) totally 115 participants from the index study were followed-up. Among the 34 participants who were not part of the follow-up study, one had died, 15 were untraceable and 18 were not willing to take part due to various reasons. The mean period of time from the T1 to T2 was
Response patterns of DAS, YSQ and BDI-I
To address the first aim of the study, i.e., to compare groups of CDs, PDs, and NDs on the DAS and YSQ domains and subscales, Multivariate analysis of covariance (MANCOVA), with age as covariate, were calculated followed by univariate post hoc analyses when an overall difference between groups occurred (Bonferroni adjustment: P < .006 – .05/3 comparisons/3 scales for the DAS scales and P < .001 – .05/3 comparisons/21 scales for the YSQ scales). Because the YSQ scales of the three groups were
Discussion
The present study sought to increase our knowledge about cognitive characteristics that may predispose to depression by examining the relative and absolute stability and conceptual overlap between dysfunctional attitudes and early maladaptive schemas (EMSs).
First, to begin with the stability of depressive symptoms, a significant relative and absolute stability was found over the time span of nine years, but the test–retest correlation decreased in addition to a significant reduction in
Acknowledgements
The authors would like to thank the participants and the research assistants who contributed in the data collection and Professor Mick Power for his valuable comments on the statistical analyses and on an early draft of the paper. The project has been financially supported by the Norwegian Research Council, the Norwegian Foundation for Health and Rehabilitation, the Norwegian Council for Mental Health, and the Psychiatric Research Centre of Northern Norway.
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