Bate 1

Peter Dorian Bate

Dr. Zsolt Unoka

Department of Psychiatry

The Role of EMS in Drug Abuse and Addiction

Abstract:

Early maladaptive schemas (EMSs) are rigid inefficient mechanisms that distort how one

perceives the world and people, often leading to psychological distress, or increased distress (Young et

al. 7). Schemas are formed during our childhood and adolescence, and affect us through our coping

mechanisms that help us to deal with stressors such as neglect, abuse, the lack of love, and verbal or

physical violence in the household, and other unmet core emotional needs (Young et al. 9). A key factor

in their formation are traumatic experiences we repeatedly go through as a child. Thus, schemas begin

as a positive mental construct and help us cope with the situations that a specific schema was formed

for. However, once people become older, these same schemas may decrease our ability to cope with the

various stressors that come with life and become maladaptive and we refer to them as an early

maladaptive schema or EMS (Young et al. 7).

Studies have shown that, people with substance use disorder have specific EMSs that have a

role in the development, prediction and treatment of the substance misuse disorder/addiction

(Predicting the Risk 2). Substance use disorder/substance abuse is a major mental health and social

issue worldwide, often with severe and devastating effects on those with the disorder as well as those

closest to the addict. Significant differences in maladaptive schemas have been shown to be present

between clinical groups and control groups in various studies, some of which are presented and

discussed (Predicting the Risk 1). “The findings [of such research] conclude that the existence of

underlying EMSs may constitute a vulnerability factor for developing ... [substance] use disorders later

in life” (Predicting the Risk 1).

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Provided the vast amount of scientific literature in evidence-based treatments focusing on

EMSs, such as Schema Based Therapy, maladaptive schemas and related core beliefs can be detected

and treated in adolescence and early-adulthood to prevent the enactment of the schemas,” likely to

induce substance use disorder (Zamirinejad et al. 1). The fact that Schema Based Therapy has been

shown to help addicts change their EMSs and schemas hints to the importance of EMSs in the

initiation, development and maintenance of drug abuse, as well as in abstinence and treatment.

EMSs, one’s childhood traumas and environment all play integral roles in the development of

substance misuse disorder later in life. They are also relevant to answering the overly complex question

of why certain individuals get addicted to drugs while others in the same community do not. For it is

well known that some people become addicted to a certain drug, or even poly-substance misuse, after

only a truly short period of usage compared to others who may take more time to become an addict.

The answer to this question is complex and not yet fully understood. However, besides any possible

genetic factors, EMSs seem to be important to answering this question. It is true that both peer-pressure

as well as if a youth has friends who uses drugs or do not are involved in this complex interaction of

stimuli that may lead to addiction, one’s environment and EMSs are behind these factors.

Addiction is a complex issue and major problem worldwide, this paper will show through

various studies that have been done the role of EMS in the initiation, development, and maintenance of

substance misuse disorder in some individuals, while others who have been exposed to the same drug

do not develop substance misuse disorder. This paper will discuss what EMS underlie substance use

disorder to gain a better understanding of the risk factors involved with the development of the

disorder, ultimately with the goals of early identification of high-risk individuals. Using this

information, prevention and or early treatment of those with substance use disorder can be affected by

Schema Therapy. A question explored in this paper is: Do certain EMS predict Addiction Potential, and

can we use Schema Therapy to change EMS to healthy schemas, or lessen the strength of EMS of an
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individual to better treat a patient?

Through the understanding of the EMS of individuals, I propose that we can predict the

Addiction Potential of individuals and groups who are at high-risk for the development of substance

use disorder. Thus, we may be able to use this as a tool for the prevention of the development of

addiction in those who have not yet manifested substance use disorder. Furthermore, use of Schema

Therapy as an early treatment to change one’s schemas and affect lasting recovery and ideally

abstinence.

The defense of this paper will be related to the number of EMS common to substance abuse that

are present only, or to a significantly greater degree and absent or present to a significantly lower

amount in the healthy control-groups. Is this a common and widespread outcome or uncommon and

therefore irrelevant and not a useful model for substance abuse? Also, important is the changing of

EMS in Schema-Based Therapy to healthy adaptive schemas that will assist in coping with the daily

stressors of life and getting rid of the maladaptive schemas.

This paper will attempt to answer the following questions based upon various research that has

already been done:

1. Can early identification of EMSs be used to identify high-risk individuals and groups for

substance use disorder?

2. Can Schema-Based Therapy, such as Dual Focus Schema Therapy be used to change the

maladaptive schemas of those with substance use disorder? If yes, will changing the schemas

influence their disorder, and are these methods superior to treatments such as AA and NA,

MMT and Suboxone use?

Introduction

1.1 Schemas and Maladaptive Schemas

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The concept of a schema in psychology first developed by Dr. Jean Piaget and has since been

developed and expanded upon by Dr. Beck and Dr. Young to include their role in psychological

pathophysiology, as well as schema therapy (Kaplan and Sadock 141). According to previous studies

and research, early maladaptive schemas have been shown to be behind many psychological disorders

from substance misuse, bipolar disorder, and other psychopathologies (EMS in Opiate 11). Young et al.

explains that there are five basic schema domains which are related to these basic child-hood needs,

and that organized within these five schema domains are 18 specific early maladaptive schemas which

are specific self-defeating core relational patterns and themes that were learned in child-hood and

become repeated in adulthood” (12-13). 

These domains include: disconnection and rejection, which is a fear that one’s basic needs for

safety, stability, empathy, acceptance, and warmth will not be met by others (schemas of emotional

deprivation, abandonment, mistrust/abuse, social isolation, and defectiveness); impaired autonomy and

performance, a belief that one cannot survive or function independent of other people (schemas of

failure, dependence, vulnerability, and enmeshment); impaired limits, a lack of long-term goal setting

and belief that one lacks responsibility (schemas of entitlement and insufficient self-control); other

directedness, which is an over focus on meeting the needs of other people, usually at the expense of not

meeting one’s own needs (schemas of subjugation, self-sacrifice, and approval-seeking); and

overvigilence and inhibition, which includes beliefs that one must suppress their own feelings/thoughts

and have excessively high standards of behavior (schemas of emotional inhibition, unrelenting

standards, negativity/pessimism, and punitiveness)” (Young et al., 12-20). Schema Domains are

groupings of EMSs based on what characterizes the schemas in the domain. Due to the number of

schemas and their classification into domains, most adults are likely to have a schema from more than

one domain.

“A schema is considered to be a stable long-standing pattern that develops through early

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childhood experiences and develops into an unquestioned lens through which you view the world as an

adult (Schenck).” Our revised, comprehensive definition of an EMS is: a broad, pervasive theme or

pattern; comprised of memories, emotions, cognitions, and bodily sensations; regarding oneself and

one's relationship with others; developed during childhood or adolescence; elaborated throughout one's

lifetime and; dysfunctional to a significant degree” (Young et al. p 7). EMSs therefore last for many

years after their formation into our adulthood. They are derived from our early experiences in life

through our interaction with our environment and the people we spend the most time and our

relationships with them (11). Their longevity can be attributed to their emotional connection via the

amygdala in our brain's limbic system, which is associated with emotion, behavior, and long-term

memory.

“You view yourself, others, different situations and the world through schemas (Kos).”

Whether or not this view of the world and various experiences is realistic is irrelevant here. This is the

manner through which a schema is adaptive or maladaptive, as a schema may no longer apply to an

individual’s life yet it continues to remain and affect that person’s ability to cope with stress without

them realizing this. Therefore, schemas can be either positive, helpful, or negative, harmful to one’s

coping skills, the amount of distress felt, and therefore one’s mental health and risk for developing

psychopathologies.

“An important concept with relevance for psychotherapy is the notion that schemas, many of

which are formed early in life, continue to be elaborated and then superimposed on later life

experiences, even when they are no longer applicable” (Young et al. 7). Young et al. refers this to a

need for "cognitive consistency", in order to maintain a stability in how one views the world and

oneself, whether this view is accurate and realistic or not (7). Thus, we may need a lasting cognitive

framework from which to interpret the world, whether it is consistent with reality or not. This is behind

the longevity of a specific schema/EMS, hence their longevity and stability throughout our life.
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Young et al. point out the importance of a toxic childhood environment and certain core

emotional needs going unmet to the formation of a schema, although this does not need to be the case

as some schemas are formed later in life (7-9). The family members, or primary caretaker of a person

are encountered daily, usually many times throughout a day, hence the importance of the family and

parents in formation of a schema.

For example, if one had parents who failed to discipline their child, he or she may have

problems with limits and addictions as they get older. This would be the maladaptive schema called

Insufficient Self-Control (Kos). Those with a greater number of EMSs and of greater intensity are at an

increased risk for various psychopathologies. “When the early maladaptive schemas become active, …

depression, anxiety, occupational disability, lack of academic progress, drug abuse, and interpersonal

conflicts (5.7)” (Bojed and Nikmanesh 72).

Implications for the treatment of such illnesses by decreasing the number or intensity of our

EMSs are clinically relevant, and SBTs attempt to do so. As previously stated, schemas are stable

throughout our lives and provide lasting views of our environment and the people in it, yet they are not

permanent and can be altered. Yet As schemas are subjective constructs that we have created, rather

than objective reality and fact, we can change them over time as, previous research has shown they can

be changed through therapy. Thus, it makes sense that an attempt to alter our EMSs through Schema

Based Therapy (SBT) should be applied as a treatment to chronic mental health diseases/illnesses.

Research done by Shorey et al. showed that SBT in the form of (Dual-Focused Schema Therapy) DFST

changed the EMSs in people in a study who were in an in-patient residential treatment for a minimum

of 4 weeks, during which they were abstinent; these patients were in an in-patient residential treatment

center, which focused on changing one’s EMSs (Changes in EMS 4). As substance use disorder is a

chronic illness, and EMSs are stable and long-lasting throughout one’s life, 3 weeks is a rather brief

period of time period to alter the EMSs compared to a longer treatment, like the protocol for DFST,
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which typically lasts for a minimum of 6 months.

Young hypothesized that some of these schemas - especially schemas that develop primarily as

a result of toxic childhood experiences - might be at the core of … many Axis I disorders (7).

“Once acute symptoms have abated, schema therapy is appropriate for the treatment of

many Axis I and Axis II disorders that have a significant basis in lifelong

characterological themes.... Schema therapy is designed to treat the chronic

characterological aspects of disorders, not acute psychiatric symptoms." (Young et al. 6)

As schemas are stable throughout life and longstanding, they are involved in the psychopathology of

many Axis I disorders, which are chronic themselves. Some of the chronic disorders that schema

therapy has been proven useful in treating include chronic depression and anxiety, eating disorders,

difficult couples problems, long-standing difficulties in maintaining satisfying intimate relationships,

and it has helped criminal offenders and relapse prevention in among substance abusers (Young et al.

6). These chronic conditions are based on EMSs as explained, Young et al. state that the core

psychological themes typical of these patients are addressed by Schema Therapy and that their core

psychological themes are their EMSs (6).

“When schemas are triggered in interaction with the environment, they generate automatic

thoughts, intense feelings, strong effects and behavioral tendencies. When schemas are toxic or when

they lead us in a negative direction, they are called maladaptive schemas (Kos).”

Maladaptive schemas tend to be formed in four main ways:

1.A child’s needs are not met

2.The child is traumatized or victimized.

3.By internalizing the caretaker’s voice.

4.Receiving too much of a good thing. (Kos)

“Through the understanding of the schemas that are maladaptive in our lives and their
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formation, we can attempt to enhance our mental health. These EMSs have been linked to various

unhealthy mental states, such as addiction. Schema-based therapy was developed to deal with a variety

of mental illnesses or disorders based on changing our schemas (Kos).” In fact, research has been done

on the changing of EMSs in those with a substance misuse disorder and it has shown that EMSs can be

altered and they remain this way and lessen in strength the longer one remains sober longer (Changes

in EMS 4).

1.2 EMS and Addiction

Addiction, is defined by the development of tolerance, which is the use of increasingly larger

doses in order to achieve the same effect from the drug as originally achieved, and dependence, the

need to use every so many hour to avoid a withdrawal syndrome, or drug-seeking behavior. is currently

of major medical, as well as socioeconomic importance globally.

Substance addiction is chronic disorder that takes many people anywhere from a year to a

lifetime to treat. Programs such as NA and or AA are two very common treatments and are life-long for

those who stick with it. However, there is not much data that these programs work for most people due

to the anonymous nature of these programs. Brief in-patient residential treatments are also very

common, yet the relapse rate is high for these treatments as well with people constantly going in and

out of such treatment centers, in the United States at least.

As EMSs have been shown to be stable and last throughout life, as well as be related to

substance abuse, SBTs such as DFST are likely to be a better treatment. Changing one’s schemas may

be lead to longer-lasting abstinence:

“Early maladaptive schemas … lead to clinical symptoms such as depression,

personality disorders, and substance abuse. Given the importance of this matter, we

conducted a research on early maladaptive schemas in substance-abusers, to allow more

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appropriate preventive measures to be taken with a better understanding of the issue”.

(Karami et al.10)

Research on changing one’s EMSs through SBT has been done and is reviewed later in this paper and

shows more promising results for treating addiction, while other research that is reviewed here shows

various connections between EMSs and addiction. The author of this paper is convinced that more

research needs to be done on the relationships between EMSs and addition and its treatment, and

believes that SBT is far superior to both of the two treatment styles mentioned above, AA and brief

residential treatments.

Why is it that some people are more easily becoming addicted to a drug, while others who use

the same amount and as often do not develop a drug problem. Myriad factors are involved, of course,

one’s genetics, life experiences and environment, and their early maladaptive schemas seem to be

major factors. Many research papers have shown that, compared to a non-clinical control group, people

with substance abuse disorders score higher for most of the EMS on the YQT-SF and the YQT-LF (long

form version), which affect their ability to cope in a healthy manner with the stressors of everyday life.

Conversely, by definition, adaptive schemas perform opposite to EMSs and therefore decrease psychic

stress and assist one in coping with stressors in our lives, putting them at decreased risk of developing a

substance abuse disorder.

Early maladaptive schemas and EMS-based Therapy has proven that there is a distinct

difference between the EMSs of substance-users and the general population. The author of this paper

suggests that based on the YSQ-SF (Short Form, LF for Long Form) questionnaire, along with other

questionnaires, and previously published research papers has shown an obvious difference in the EMSs

of drug abusers/users vs. non-users. Furthermore, the author of this Analysis Paper sets out to combine

data from various papers to prove this is the same in different nations around the world, so that the

results should be the same regardless of an individual’s specific nation, cultural and religious
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backgrounds. Therefore, EMS’s are integral to identifying users as well as those who are in a high-risk

group for the development of addiction in individuals. The effectiveness of Schema Based Therapy

(SBT) is discussed and gives further proof to the EMS-based theory of a relationship between certain

specific EMS and substance-abuse, correlation and causation. 

Other questions and concepts to be explored include the prediction of both high-risk groups for

substance abuse and prevention of these individuals specifically from abusing substances; the

relationship between substance abuse and the implications from all of this data for directing future

research, and the prevention and treatment of substance/drug and alcohol use/misuse/abuse.

Background
I. Addiction and Substance Use Disorder
Substance addiction was previously defined In addition to any health problems caused by

addiction, there are many social and criminal issues involved in having substance abuse disorder.

“Tolerance is defined as a person’s diminished response to a drug that is the result of repeated use.

People can develop tolerance to both illicit drugs and prescription medications” (Hussar 1). “The

essential feature of a substance use disorder is a cluster of cognitive, behavioral and physiological

symptoms indicating the individual continues using the substance despite significant substance-related

problems” (What is DSM). Addiction usually refers to the above, or a psychological state with drug-

seeking behavior being the main symptom. However, although dependence and drug withdrawal

usually do not occur with some drugs, they can be of the greatest importance with certain specific drugs

such as alcohol and benzodiazepines, in which withdrawal can even be fatal if not treated correctly.

Dependence is a physiological state in which your body now needs the drug in question in order

to refrain from entering a withdrawal state. For example, in the case of opiates, which are exogenous

endorphins, chronic consumption of these drugs results in lower production of endogenous endorphins,

which are produced normally by the body. When an opiate abuser abruptly ceases in the consumption
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of opiates or opioids, the body suddenly has low amounts of endorphins in the body inducing a

withdrawal state will begin. The withdrawal state of opiate cessation is a group of signs and symptoms

that includes: “muscle aches, restlessness, anxiety, lacrimation (eyes tearing up), runny nose, excessive

sweating, inability to sleep, yawning very often, later symptoms, which can be more intense, begin

after the first day or so. They include “diarrhea, abdominal cramping, goose bumps, on the skin, nausea

and vomiting, dilated pupils and possibly blurry vision, rapid heartbeat, high blood pressure, increased

pain and stress, depression, mydriasis, diarrhea, and more (Case-Lo).” Thus, the withdrawal state for

opiate abuse, as well as other drugs is often basically the opposite state achieved by regular

consumption of excess opiates/drugs, though this is not always the case and just the specifics of opiate

withdrawal.

According to Karami et al., opiates/opioids, anxiolytics such as benzodiazepines, sedatives and

hypnotics such as Ambien/zolpidem, alcohol, cannabis, hallucinogens, stimulants such as

(meth)amphetamine and cocaine, and synthetic drugs such as MDMA are among the most commonly

used and abuse drugs (10). The pharmaceutical industry, and the over prescription of especially the

opioid and benzodiazepine class of drugs are now a major health and social problem, especially in the

United States, but in many other countries as well (“Understanding the Epidemic”). Also, in the last

decade or so, cannabis has become a legal drug, whether for recreational usage or medicinal use only in

the United States.

Alcohol and marijuana are the top two most commonly abused drugs, in 2012 17.7 and 4.3

million Americans abuse these two drugs, respectively (Beachesrecovery). Ease of access to a drug, its

social acceptability and a drug’s legal status are among some of the reasons why these two are at the

top of the list. Social acceptability of a substance, as well as a relatively cheap or expensive price, and

legal status are other factors in which drugs are most used.
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Some patients begin their use of narcotic painkillers (opiates/opioids) for legitimate reasons

such as chronic or acute pain-relief. However, too many have not been properly informed of the

consequences of continued usage or are not being correctly managed by their doctor and tolerance,

dependence and addiction may result. Others begin their addictions in order to achieve a high and

continue their usage due to tolerance and/or to avoid drug withdrawal, a major factor for relapse with

some drugs whether illicit or not. Reasons people use drugs for many reasons, many use substances to

reduce psychological pain and decrease stress as well as experience euphoria (Karami et al. 11).

The question of why some individuals become addicted to a drug either at all, or relatively

easier compared to others is a question of vast importance with many implications. Some people can

try even “hard drugs” such as heroin or methamphetamine (crystal meth) once, and either become

addicted very quickly, while others who have also tried these drugs one time to a few times and do not

develop an addiction ever. Due to the cognitive theory of schemas, the author believes that the

environment of a person is highly involved, both one’s early environment, and therefore EMSs, and

one’s present environment when older, which may active an EMS.

The unique “Rat Park” experiments by Bruce Alexander and his colleagues give some important

insight into why this may be the case, at least in some situations, and excluding any genetic related risk

factors. His experiments were done in the 1970's and were at first the results were dismissed before

finally being accepted. Though, as, rats and humans are vastly different, one can still look at his data

through the lens of EMSs and see why it may be that some people are more easily addicted to various

substances than others. Bruce Alexander knew about the “Skinner Box Rat Cage” experiments, in

which a rat was placed alone with no mate into a small cage, with nothing to do press a level for food

or for drugs administered through and indwelling catheter, it may have a running wheel if lucky

(ADDICTION). He created a new environment for the rats in which they had up to 20 mates, various

tubes and tunnels to explore, and other enjoyable activities to partake in, including sex. Also, in
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addition to having up to 19 other rats to have sex with and socialize with, the cage was no longer a tiny

sad affair, having up to 200 times the surface area (ADDICTION). This was “Rat Park”.

II. Schema Therapy

Schema therapy was founded by Dr. Jeffrey Young and represents a development of cognitive

behavioral therapy (CBT) specifically for treating Axis I (chronic) disorders. Young et al. “developed

schema therapy to treat patients with chronic characterological problems who were not being

adequately helped by traditional cognitive-behavioral therapy: the 'treatment failures'” (5). These

patients tended to benefit more from an SBT, which can be of varying length, and has been successful

in treating various chronic Axis disorders once the acute symptoms have abated (Schema Therapy 5).

Young focused on pulling from different therapies equally when developing schema therapy. “It

expands on traditional cognitive-based therapy by placing much greater emphasis on exploring

childhood and adolescent origins of psychological problems, ... and on maladaptive coping styles”

(Schema Therapy 5). There is some emphasis on limited reparenting in order to change one’s EMSs.

Young et al. recommend this therapy for clients with difficult and chronic psychological disorders;

there has been success treating eating disorders, personality disorders, depression and substance abuse

(5).

III. Methodology

The methodology of this paper, as a synthesis paper, was to research schemas and EMS,

Schema Therapy, and study several research papers on the topic with the goal of investigating the role

of EMS in substance misuse disorder. Some of the research papers studied aimed to discover any links

between EMS and addiction by comparing differences in the EMS present in those in clinical groups

who are in treatment for their addiction and the EMS of those in a non-clinical group with similar

demographic data. Others were interested in whether addiction potential could be assessed by the
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presence of specific EMS, and others whether the EMS that are strongly and positively correlated with

substance use disorder that were identified in previous research change over time after brief periods of

abstinence. One well/known and unique paper, called “Rat Park”, aims to answer the question of why

some people become addicted and not others. Taking in this large body of information the writer of this

paper was able to draw conclusions that did agree with the main thesis questions, mainly that those

with substance use disorder do have a larger number of EMS than those who do not have substance use

disorder, such as the control groups, and that specific EMS are stronger predictors of addiction

potential and are more common in the clinical groups of those with addiction disorder. The “Rat Park”

paper goes on to show a deeper truth about animal behavior concerning drug abuse, as rats who are

alone and in a small cage with no other stimuli than the normal water and the drugged water show

remarkably different behavior towards drugs than rats who are in a larger cage with more activities to

do and companions.

As per the literature on EMS, this makes sense as according to Young, EMS increase the stress

on an individual throughout their lives, decrease their coping skills, and increase their perception of the

stressful and negative events in life (Schema Therapy 6). These same individuals also are lacking in the

necessary coping skills to deal with these negative events in a healthy manner. Therefore, based on the

current research literature on Schema Theory as developed by Beck and Young it makes sense that

people with a greater number of EMS, are at higher risk for the initiation and maintenance of substance

use disorder, especially those that have been shown to have a correlation with predicting opioid and

substance use disorder specifically, as the research shows. In the research papers that were reviewed,

the role of EMSs in the prediction, commencement and maintenance of substance use disorder is

identified and explored.

Methodologies of Previous Research

Different studies used various yet similar methods to identify the clinically significant EMS and

gather information on drug and alcohol use of the past year. Tools and methods employed in the various
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research and data collection included the Young Schema Questionnaire (YSQ-L3), both long and short

forms (-LF and -SF), DUDIT, AUDIT, and pre-existing patient medical records. DUDIT and AUDIT

measure the relevant data for drugs and alcohol, respectively.

Drug and alcohol use were examined with use of the Drug Use Disorders Identification Test

(DUDIT), the Alcohol Use Disorders Identification Test (AUDIT), and the The Young Schema

Questionnaire – Long Form, Third Edition was used to examine the early maladaptive schemas of both

groups” (“EMS among Young “ qtd. in Young and Brown).

Early Maladaptive Schemas

Young and Brown explain that, the Young Schema Questionnaire comes in a long form and a

short form having a different number of questions and testing for different numbers of EMSs (EMSs

among Young 5). The YSQ-LF, the long form, assesses 18 EMSs (EMS among Young 5). The YSQ-SF,

the short form, assesses 16 EMSs (Bojed and Nikmanesh 73). Both forms have been instrumental in

identifying the EMSs of both the experimental and the control groups’ EMSs.

The Young Schema Questionnaire – Long Form, Third Edition (“EMS among Young

“qtd. In Young and Brown) was used to examine the early maladaptive schemas of both

groups. This 232-item self-report measure is designed to examine the 18 early

maladaptive schemas identified by Young and colleagues. Both groups answered each

question using a six-point scale (1 = completely untrue of me; 6 = describes me

perfectly) to indicate how much they believe each item described themselves. For each

early maladaptive schema, a score of 4 or greater for each item contributes to the total

score of each specific schema, since a response of 4 or greater is indicative that that

particular item may be representative of a maladaptive belief and/or behavior (Young

and Brown, qtd. in “EMS among Young” 5).

Scores less than 4 were recorded as “0” and marked as not indicative of clinically significant early
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maladaptive schema. The YSQ-SF (Short Form), a 75-item self-report measure designed to examine 16

of the 18 early maladaptive schemas was used in some studies rather than the long form version. Thus,

these questionnaires were used to identify the clinical significance of the 18, or 16, EMSs. Participants

answered each question and the results indicated which EMSs were or were not clinically significant to

them as well as their intensity according to the 6-point scale.

Drug and Alcohol Use

Different studies used various yet similar methods to identify the clinically significant EMSs

and gather information on drug and alcohol use of the past year. The Young Schema Questionnaire

identifies EMSs more prevalent in substance misusers as explained, and Shorey et al. explains how the

AUDIT and DUDIT questionnaires are used to score one’s alcohol and drug use (EMS among Young,

qtd. in. DUDIT: Stuart et al.).

Past year drug use was assessed using the Drug Use Disorders Identification Test

(DUDIT). The DUDIT contains 14 questions and is modeled after the AUDIT in that it

assesses the frequency and intensity of drug use and symptoms that may be indicative of

tolerance or dependence. The DUDIT examines the use of 7 different classes of drugs

(cannabis, cocaine, hallucinogens, stimulants, sedatives/hypnotics/anxiolytics, opiates,

and other substances [e.g., steroids, inhalants]). The DUDIT, unlike the AUDIT, does

not have a standardized cutoff score to indicate the presence of hazardous/harmful drug

use. The DUDIT has demonstrated good reliability and validity across multiple samples.

(EMS among Young, qtd. in. Stuart et al., 2004; 2008)

Alcohol Use

Past year alcohol use was assessed using The Alcohol Use Disorders Identification Test

(AUDIT) (EMS among Young, qtd. in. Saunders, Asaland, Babor, de la Fuente, &
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Grant, 1993). The AUDIT consists of 10-items that examine the intensity and frequency

of alcohol use, symptoms that might indicate dependence or tolerance to alcohol, and

negative consequences associated with alcohol use. The AUDIT has demonstrated a

greater capability, when compared to other measures of alcohol use and problems, to

identify individuals with a likely alcohol use problem (EMS among Young, qtd. in.,

Reinhert and Allen, 2002). In addition, the AUDIT has shown good reliability and

validity across multiple populations (EMS among Young, qtd. in., Babor, Higgins-

Biddle, Saunders, & Monteiro, 2001). A score of 8 or greater on the AUDIT is indicative

of hazardous drinking. (EMS among Young, qtd. in., Babor et al., 2001; Saunders et al.,

1993)

The DUDIT and AUDIT both are quite capable of demonstrating the presence of tolerance or

dependence. They have a similar scaling system to indicate the level of use or abuse. The DUDIT

unlike the AUDIT, however, better indicates the presence of hazardous/harmful drug use. 

IV. Previous Research

Those with substance use disorder have shown to have significantly greater EMSs than the non-

clinical control groups in the studies done as explained above. Methodologies have been similar, but

experimental groups, methods of scoring EMSs, and what substances have been focused on in any

given study have differed. Previous research shows that the greater the number and intensity of one’s

EMSs, the greater they are at risk for substance misuse disorder, as well as other psychopathologies.

Both the YSQ-LF and the YSQ-SF have been instrumental in identifying the EMSs of both the

experimental and the control groups’ EMSs. In every study, regardless of who is making up the control

group or the experimental group, those who are either in treatment for substance use or are seeking

treatment, “research has demonstrated that early maladaptive schemas are prevalent among individuals
 Bate 18

seeking substance use treatment (EMS among Young, in. qtd. Brotchie, Meyer, Copello, Kidney, &

Waller, 2004; Shorey, Anderson, & Stuart, 2011; 2012).” 

As stated previously, it was found that those with substance abuse disorders scored significantly

higher on the YSQ short and long form questionnaires for every EMS in comparison to the non-clinical

control groups investigated. However, the results of the studies varied, those with substance use

disorder always scored higher in EMSs, the difference was mostly in the number of EMSs they scored

higher in when compared to the non-clinical groups. In one study reviewed, males in residential

treatment for opioid abuse were found to have significantly higher scores in almost all EMSs, this

group scored lower in only 4 of the 15 EMSs examined (Predicting the Risk 12). In another study, the

clinical group of substance abusers scored higher in 9 of the 18 EMSs, as well as scoring higher on the

DUDIT and AUDIT tests, although both groups reached the score for hazardous drinking (EMS among

young 1, 6). The non-clinical group were made up of college students and this may have increased their

drinking habits, though this is not known whether this is the reason for the AUDIT scores. However, it

does make sense that people who abuse substances also abuse alcohol as well to a higher degree than

the non-clinical control group. From these studies we can see that EMSs play a role in addiction and

substance abuse. More research is needed to fill in any gaps in knowledge of this complicated issue and

is relevant for the successful treatment of those who suffer from substance misuse disorder.

Early Maladaptive Schemas among Young Adult Male Substance Abusers: A Comparison with a Non-
Clinical Group
“Men aged 18–25 have a higher prevalence of substance use than any other age group, making

research on risk and protective factors for substance use among this population extremely important.

Recent research has begun to examine early maladaptive schemas as a possible risk factor for the

initiation and maintenance of substance abuse. Although research has demonstrated that early

maladaptive schemas are prevalent among individuals seeking substance use treatment, we are unaware

of any research that has examined whether young adult male substance abusers report greater early
 Bate 19

maladaptive schema endorsement than a non-clinical comparison group. Knowing whether young adult

male substance abusers score higher on early maladaptive schemas than non-clinical controls could

provide useful information for the treatment of substance use within this vulnerable population, such as

by informing treatment providers on the specific early maladaptive schemas that may underlie or

perpetuate substance abuse” (EMS among Young 1).

Shorey, et al. describes the basic methodology of this study as a comparison between

two groups, a clinical group of young men age 18-25 seeking treatment for substance abuse and a

demographically similar group of non-clinical male college students (EMS among Young 1).

Knowing whether young adult male substance abusers score higher on early maladaptive

schemas than non-clinical controls could provide useful information for the treatment of

substance use within this vulnerable population, such as by informing treatment

providers on the specific early maladaptive schemas that may underlie or perpetuate

substance abuse. Using pre-existing patient records from an inpatient substance use

facility and a comparison group of non-treatment seeking college students, the current

study examined differences in early maladaptive schemas among these two groups of

young men. (EMS among Young 1)

The EMSs of the two involved groups of participants were measured using the YSQ-LF and compared.

“Results demonstrated that the substance abuse group scored higher than the non-clinical comparison

group on 9 of the 18 early maladaptive schemas (EMS among Young 1). Both the clinical and non-

clinical control groups also answered questions in the AUDIT and DUDIT questionnaires in order to

assess alcohol and drug usage during the past year (EMS among Young 5-6).

The non-clinical comparison group of college students was asked to provide their age, gender,

race, and academic level. The college student group was also asked to indicate whether they had ever

received treatment for an alcohol or drug problem in their lifetime. As in other studies, any who have

ever used drugs did not have their data included in the study demographics were tested and controlled
 Bate 20

for.

To summarize the results of the EMSs, DUDIT, AND THE AUDIT tests; the clinical group also

scored much higher on the DUDIT, while both groups scored similarly on the AUDIT, with the clinical

group scoring only slightly higher (EMS among Young 6). The clinical group scored significantly

higher on 9 of the 18 schemas, and the non-clinical group did not score higher on any EMS (EMS

among Young 6). With the AUDIT test, a score of 8 or higher signifies hazardous or harmful drinking;

it could be expected that the clinical group would score at least somewhat higher, as they did, it was not

expected that the non-clinical group had score close to that of the non-clinical group. Demographically,

the only difference was that the clinical group were a couple to a few years older (EMS among Young

6).

Predicting the Risk of Opioid Use Disorder Based on Early Maladaptive Schemas

“The current study aimed to assess the role of EMSs in predicting opioid use disorder,” based

on EMSs (Predicting the Risk 1). According to Young et al., EMSs and the maladaptive ways in which

patients learn to cope with them often underlie chronic Axis I symptoms, such as … [and] substance

abuse disorder (Schema Therapy 9). EMSs have been implicated in many other Axis I disorders, which

are chronic psychological or psychiatric disorders under the DSM IV classification. This fact, and that

EMSs are chronic, stable through life, and when activated decrease our ability to cope with stress make

it no surprise that there may be a correlation between EMSs and substance abuse; this has been

previously noted earlier in this paper.

“Recent research has begun to examine early maladaptive schemas as a possible risk factor for

the initiation and maintenance of substance abuse? (EMS among Young 1; int. qtd. in Ball et al.). What

specific EMSs are most likely linked to substance abuse disorder, opiates in this case, is therefore an

important question; with implications related to early prediction of those who have or are at a higher

risk to developing opioid use disorder.

 Bate 21

This study was a “cross-sectional study [that] was conducted in 2013 in … Iran on 60 male

opioid users who received Methadone Maintenance Treatment (MMT) and 60 control males”

(Predicting the Risk 1). Based upon matching demographic variables the control subjects were chosen,

and all subjects of both the control group and the clinical group took the YSQ-SF questionnaire, which

measured 15 maladaptive schemas (Predicting the Risk 1, 3). Therefore, the EMSs of both the clinical

group and the non-clinical control group can be compared for any outstanding differences of EMSs

between the two groups.

“Means of all 15 EMSs in the opioid user group were higher than those of the control group”

(Predicting the Risk 3). However, 4 of the 15 schemas were not significantly higher. “Except for SS,

EG, US, and FA, the mean of other maladaptive schemas in the opioid user group were significantly

than that of the control group….” (Predicting the Risk 1). SS, EG, US, and FA stand for the EMSs of

self-sacrifice, entitlement/grandiosity, unrelenting standards, and failure to achieve, respectively (Kos).

All other EMSs, 11 out of 15, were scored via the YSQ-SF and were found to be significantly higher

than the control group.

According to Zamirinejad et al., Emotional Deprivation, Mistrust/Abuse, and Unrelenting

Standards can predict opioid abuse … but, out “of all 15 EMSs, the severity of ED increased the

likelihood of starting opioid use the most (Predicting the Risk 1, 4)”. Thus, 11 of the 15 schema were

present to greater degrees in the opiate user group, and “logistic regression identified that [the schemas

of] Emotional Deprivation, Mistrust/Abuse, and Unrelenting Standards can predict opiate use

(Predicting the Risk 1).” Zamirinejad et al. actually have found these 3 schemas to be the 3 best

predictors of opioid use among all 15 schemas (Predicting the Risk 7). Thus, the risk of opiate-abuse

disorder in those with higher YSQ-SF scores for these specific schemas is higher, and the risk of opioid

use disorder can be predicted based on EMSs.

This study has clear implications for further research to proceed in order to treat opiate use
 Bate 22

disorder at the level of education and early prevention, which would be extremely beneficial as it is

much easier to treat those who have either not yet developed a substance use disorder, or are still in the

initiation stages of this disorder, as opposed to individuals who have been abusing opiates for many

years and longer. Treating the EMSs through an SBT treatment of these individuals would be the

treatment of choice. The conclusion that further research in this area is justified if the results of the

research done by Zamirinejad et al. is found to be correct:

The findings conclude that the existence of underlying EMS may constitute a

vulnerability factor for developing opioid use disorders later on in life. Provided the vast

amount of scientific literature in evidence-based treatments focusing on EMSs,

maladaptive schemas and related core beliefs can be detected and treated in adolescence

to prevent the enactment of the schema and psychological distress likely to induce

opioid use. (Predicting the Risk 1-2)

EMSs in Opiate and Stimulant Users (Karami et al.)

“Given the importance of this matter [drug use], we conducted a research on early maladaptive

schemas in substance-abusers, to allow more appropriate preventive measures to be taken with a better

understanding of the issue (Karami et al. 10).” This research specifically studies the difference in EMSs

between opiate users and stimulant users, mostly methamphetamine.

“For this descriptive -comparative study, 115 patients (91 opiate users and 24 stimulant users)

visiting drug addiction treatment centers were selected through convenience sampling from persons

who were admitted to substance abuse treatment centers (Methadone Maintenance therapy centers),

addiction treatment camps and self-help groups and Narcotics Anonymous (NA) of Yasuj” (Karami et

al. 10). This study was done in Iran, where opiates are abused more than stimulants, but the abuse of

more dangerous drugs such as methamphetamine and synthetic drugs are on the rise (Karami et al. 10).
 Bate 23

The YSQ-SF questionnaire and The Demographic Information Questionnaire were used to identify the

EMSs of the participants,

Karami et al. believe that EMSs can be used by clinicians and researchers as a psychopathology

and treatment method for substance abuse disorder (10). As this paper has previously stated, EMSs are

likely able to identify high-risk groups and preventative or early treatment of substance misuse disorder,

once one’s schemas have been identified. The results of current research and literature shows this is

likely the case, though further research needs to be done. Some of the further research needed has been

done by Karami at al. in their research on the different maladaptive schemas between people who abuse

different classes of drugs, such as opiates and stimulants. However, this is the only research paper

discussed to have researched the EMSs of stimulant users.

The EMSs between the two groups studied showed significant differences, as the author of this

paper expected:

The results showed a significant difference between users of opiates and stimulants in

terms [11 of the 16 EMSs studied] of vulnerability to harm or illness, enmeshment,

subjugation, emotional inhibition, entitlement, insufficient self-control/self-discipline,

emotional deprivation, social isolation, defectiveness, failure/shame, and dependence.

The average score of the stimulant-users was higher than that of opiate-users in all the

schemas except for the dimensions of abandonment, mistrust, and unrelenting

standards. (Karami et al. 10)

The stimulant group scored higher in almost every EMS. Notably, two of the EMSs, mistrust and

unrelenting standards, happen to be two of the three of EMSs identified as the best three EMSs for

predicting opioid abuse (Predicting the Risk 206). Also notable, is the fact that these EMSs are two of

the only three EMSs not having an average score higher than the stimulant using group. “Stimulant

users have more early maladaptive schemas and are at a greater risk of
 Bate 24

psychological vulnerability” (Karami et al. 10). As discussed, those with more EMSs are at a greater

risk for mental health problems, as they eventually “lead to clinical symptoms such as anxiety,

depression, personality disorders, loneliness, … alcohol and substance abuse” (Karami et al.11).

Different EMSs and environmental factors are relevant and important to the treatment of addiction:

Razavi et al.’s study shows that addicts have more maladaptive, disconnection and rejection

schemas as compared to non-addicts. Moreover, schemas of abandonment and instability,

emotional deprivation, punitiveness, social isolation and alienation, insufficient self-control,

entitlement and grandiosity are the more pronounced schemas in individuals dependent on

substances” (Karami et al.11, int. qtd. 22).

We thus can use the differences in EMSs between those who do not use substances, and those who do,

and the EMSs will help predict what substance that individual has a substance misuse problem with.

Those with different addictions, such as those for opiates and stimulants, have different EMSs.

Considering the results of this and other studies, we may conclude that different EMSs are responsible

for addictions to different substances. Therefore, as we identify an individual’s EMSs we may predict

not only if they will be at risk for substance abuse, but even which substances they may be more likely

to abuse, whether alcohol, opiates, stimulants, etc. The implications for identification and treatment as

mentioned in my opening paragraphs, may be groundbreaking.

Changes in Early Maladaptive Schemas After Residential Treatment for Substance Use

The research discussed here, done Shorey et al. with the above title, explores whether it may be

possible to modify the early maladaptive schemas of alcohol- and opiate-dependent individuals after

relatively brief periods of intervention. “Research suggests that early mal-adaptive schemas may

underlie substance abuse and that the intensity of early maladaptive schemas may decrease after brief

periods of abstinence. The current study examined changes in early maladaptive schemas after a 4-
 Bate 25

week residential substance use treatment program” (Changes in EMS 1). “Results have shown this is

possible and findings indicate that early maladaptive schemas can be modified during brief substance

use treatment and may be an important component of substance use intervention programs” (Changes

in EMS 1). Shorey et al. found that 8 EMSs decreased in intensity significantly by the end of treatment,

and that EMSs “can be modified during brief substance use intervention programs” (Changes in EMS

1). Implications for clinical treatment of substance use by decreasing EMS intensity are therefore clear,

as well as for directing future research.

Studies have shown that, people with substance use disorder have specific EMSs that have a

role in the development, prediction and treatment of the substance misuse disorder/addiction (5 role).

Substance use disorder/substance abuse is a major mental health and social issue worldwide, often with

severe and devastating effects on those with the disorder as well as those closest to the addict.

Significant differences in maladaptive schemas have been shown to be present between clinical and

control groups in various studies, furthermore the EMSs are different among those abusing different

substances:

“The findings [of such research] conclude that the existence of underlying EMSs may

constitute a vulnerability factor for developing ... [substance] use disorders later in life.

Provided the vast amount of scientific literature in evidence-based treatments focusing

on EMSs, such as Schema Based Therapy, maladaptive schemas and related core beliefs

can be detected and treated in adolescence and early-adulthood to prevent the

enactment of the schemas,” likely to induce substance use disorder (Predicting the Risk).

The fact that Schema Based Therapy has been shown to help addicts change their EMS and schemas

hints to the importance of EMS in the initiation, development and maintenance of drug abuse.

The length of time a patient remains abstinent and how long one’s EMSs remain modified after

treatment are key factors in clinical application of this research. This research does show that even in
 Bate 26

just 4 weeks, there was a significant decrease in the intensity of many schemas. Further research may

explore whether a longer period spent in therapy while abstinent gives better results, and specifically

what therapies are the most efficient, such as in-patient residential treatment, NA/AA and Schema

Based Therapy, DFST for example. Not all of these treatments focus on EMSs, however, the residential

treatment in this study and specifically SBT, such as DFST.

Therefore, even in brief periods of abstinence while in treatment, one may decrease their early

maladaptive schemas and their strength. Shorey et al. suggest that additional research is needed in this

type of study in which changes in early maladaptive schemas are studied after a brief treatment, this is

the only known study researching alcohol- and opiate-dependent patients, and the second research

paper about changes in early maladaptive schemas in brief periods of treatment (Changes in EMS 2).

Dual Focused Schema Therapy, or DFST, is a longer therapy for altering one’s schemas, taking

at least 6 months to be effective” (Changes in EMS 4). DFST was developed “specifically for

modifying early maladaptive schemas among substance abusers (Changes in EMS 4).” Shorey et al.

describe DFST, how it draws from various techniques from both schema therapy as well as relapse

prevention, yet takes at least 6 months to be truly affective, which would not work for brief residential

treatment that lasts for weeks (Changes in EMS 4). Further research should be directed to study the

differences between the results of this paper and that of one that studied patients who underwent at least

6 months of DFST treatment.

Possible limitations of this study may be an effect of the different times that the participants

answered the YSQ questionnaire. Patient records from the treatment center were used in this study,

specifically the results of the patients’ YSQ results, in order to follow their EMSs. How the patients felt

when they were admitted and at the end of the treatment of the patients may have had an affect on the

results. Any patients who were feeling effects of detoxification or withdrawal of their substance of

choice may have had such an effect as making the number and intensity of their EMSs greater as they
 Bate 27

would have not been feeling well. Likewise, at the end of the treatment the patients not only just spent

the past 4 weeks in an isolated environment away from the stressors of real life that activate their

specific EMSs. In addition, to this possible insulation effect, the patients may have wanted to please

those running the study or treatment center by wanting them to think that they did indeed heal

psychologically, even if subconsciously this may have had an effect. Together, these details may have

made it appear as if their EMSs had decreased more than they actually did. A follow up YSQ

questionnaire some time after they participants had been back home living their lives with all of the

stressors in it that may activate a particular schema may show whether decreases in schemas were true

and lasting or not, providing that the participant remains abstinent and takes the time to answer the

questions. A Schema Based Therapy is likely still superior to changing one’s schemas than shorter

treatment programs or programs such as AA or NA, even if the patient is not living insulated from the

real world and the stress involved.

Effect of Early and Later Colony Housing on Oral Ingestion of Morphine in Rats

“Rat Cage vs. Rat Park”

Why do some people become addicted to drugs after having used a substance once or a few

times, while others who have tried the same drug a few times if ever never develop a substance use

disorder? As stated before this is a difficult question to attempt to answer of course, and the two major

factors being looked at in this paper are one’s EMSs and environment when young, and stress

encountered later in life as well. While EMSs provide good insight into this question as discussed, a

series of experiments done on rats, which are discussed below, provide some additional insight worth

considering. They also have a factor similar to EMSs involved, the early environment of the rat, which

would be the environment during the weaning phase of its life. Though, of course, rats and humans are

extremely different, the experiments discussed below can be looked at through the lens of EMSs and
 Bate 28

humans for a good thought experiment on addiction, as far as the comparison to rats and human beings

goes. A key factor found in this research is the importance of one’s environment, which has been

overlooked with too much focus being put upon the drug itself and its inherent addictive qualities, or

the moral failings of an individual in the past, when the first rat experiments were done. Another key

factor in human beings are EMSs, and in the rat experiments the equivalent is factor is the environment

of the rat from birth to weaning; as in some of the experiments the rats are switched from being in

isolation to being in the rat colony, or “Rat Park”, cage and vice-versa. The Skinner rat cage

experiments can be summarized by the following:

In the middle and end of the last century various experiments were done to study the addictive

qualities of drugs, specifically cocaine, amphetamine, morphine and heroin on model animals; which

were done by studying rats who had access to both pure water and drugged water (Alexander,

ADDICTION). These initial experiments came to be known as “Rat Cage” to Alexander, and his own

series of experiments became known as “Rat Park” (Alexander, ADDICTION). Alexander describes

the first series of experiments not done by himself as the Skinner rat cage experiments:

When I was an experimental psychologist, between about 1960 and 1980, white

laboratory rats had to live in solitary confinement cellblocks like this… the rats lived in

close proximity, they could neither see nor touch each other, because the sides of their

cages were made of sheet metal. The only visual stimulation they got was seeing the

people who brought food and water and cleaned…. (Alexander, ADDICTION)

Placed into alone into a tiny cage with almost nothing to stimulate it and no opportunities to

engage in the activities of a rat’s normal existence, there environment was analogous to solitary

confinement in a prison. “Because these animals lost control of their behavior to the point of their own

demise, the conclusion was twofold: the drug was irresistible and it was lethal (Dunleavy).” This was

the prevailing attitude at the time before Alexander’s series of experiments. According to Alexander,
 Bate 29

rats in nature are highly social, sexual, and industrious creatures, and solitary confinement is known to

drive people crazy and induce mental health problem (Alexander, ADDICTION). Alexander et al.

describes the individual rat housing:

Individual housing was in standard wire mesh cages (18x25x18 cm). During intake

testing, fluid consumption was monitored by weighing the two drinking bottles affixed

to each cage daily. An approximate correction for leakage and evaporation was made by

subtracting the mean weight loss from two similar bottles mounted on empty cages in

the same rack. (571)

Obviously, rats and human beings are not similar animals yet even still the point of is evident,

especially given the results of the series of second experiments done by Alexander, which addressed

these factors in an experiment known as “Rat Park,” (“Rat Park”).

Alexander describes the results of the individual housing rat experiments:

The drug passed through the tube and the needle into the rats’ bloodstreams almost

instantaneously when they pushed the lever. It reached their brains moments later. Under

appropriate conditions, rats would press the lever often enough to consume large

amounts of heroin, morphine, amphetamine, cocaine, and other drugs in this situation.

(Alexander, ADDICTION)

Such a living condition does not offer much to existence, or life. Is it possible that the environment

experienced throughout the rat’s life since weaning has a great effect on drug usage? The name rat park

alone suggests a contrast to the cages of the original and control experiments, which were just cages

with drugs inside of them, and the lack of mates for sexual activity and socializing; just a tiny

environment with nothing to do except take drugs to help with the purposed psychological pain and

boredom. Alexander’s experiment, “dubbed the Rat Park—provided a large cage to house multiple

rats, along with wheels and tunnels and space to explore”, however the choice for plain or drugged
 Bate 30

water was the same in both housing units (Alexander, ADDICTION). “Colony housing was in a large

(8.8 m2), open-topped plywood enclosure containing cedar shavings, empty cannisters, and small

boxes for hiding and nesting” (Alexander et al. 571). Alexander’s rat park “included lots of rats of both

sexes, and naturally the place soon was teeming with babies (Alexander, ADDICTION)”. “Small doses

of morphine significantly reduce sexual behavior and social cohesion in group caged rats, and that

species-specific behaviors are self-reinforcing (Alexander 1)”, thus is makes sense that these rats did

not develop addiction. Hence, the colony rats had lower drug usage.

These rats had an ideal living quarters, maybe too ideal and not realistic, but neither were the

control experiments or the original experiments that were done in Skinner Boxes. The results were just

as extreme as the conditions and results of the isolated rats as well:

You will see at a glance that the rats in Rat Park, called the “Social Females” and

“Social Males” in this graph [Fig. 1], are consuming hardly any morphine solution, but

the “Caged Females” and “Caged Males” are consuming a lot. In this experiment the

females consumed more than the males, but that gender difference did not hold up in

later experiments. It soon became absolutely clear to us that the earlier Skinner box

experiments did not prove that morphine was irresistible to rats. Rather, most of the

consumption of rats isolated in a Skinner box was likely to be a response to isolation

itself. (Alexander, ADDICTION)

One can clearly see that the rats housed individually used much more drugs than the rats in the colony

housing. Isolation and cramped, unnatural, living conditions no doubt influenced the drug consumption.

Likewise, another limitation, or possible flaw, of this experiment are the housing conditions for those in

the rat colony, which could be described as a rat heaven. However, the original Skinner Box

experiments according to Alexander proved only that, “most of the consumption of rats isolated in a

Skinner box was likely to be a response to isolation itself” (Alexander, ADDICTION).

 Bate 31

Other experiments done by Alexander et al. investigated the effect of the early environment of

the rats, that would be the environment the rat was in from Day 22 to day 65; as from birth to day 21

the rats are still weaning pups (Alexander et al. 572). Some rats are placed in the colony, some in

individual cages, and half of them were later switched to the other environment. Alexander et al.

explains that, complexity of the very early post-weaning environment has major effects on the

development of central nervous system, some of which have been related to drug use (571). This would

lend credence to the fact that as in humans, the early environment has a great effect on substance use.

For example, “early isolation appeared to increase morphine intake in the [later] colony-dwelling

males” (Alexander 572). These males began their lives in isolation, and therefore used more morphine

even after being transferred to the colony, thus the theory of early life conditions may have some

importance in the development of addiction.

In the above experiments on caged and isolated rats’ various EMSs that can exist in humans

with substance use disorder can be extrapolated to these rats. For example, these isolated rats stuck in a

tiny cage with nothing to stimulate them, except for drug usage, and with no other rats, if human, it

may very well be said that various EMSs may exist: emotional deprivation, abuse, abandonment, social

isolation, failure to achieve, subjugation of needs, emotional inhibition, etc., which are all significant

EMSs in predicting the risk of opioid use disorder in humans. As well as the possible importance of the

early environment of the rats and the relationship that humans have with EMSs. Just as likely, these

rats are likely to exist in a manner such that “the enactment of the schema and psychological distress

likely to induce opioid use [are present] (Predicting the Risk 1).”

The results of the first rat cage experiments were thought to be proof that addiction was inherent

to the drug itself alone. In his “Rat Park” experiments, Alexander's hypothesis was that drugs alone are

not the major cause of addiction, it is not their inherent addictive qualities but the living conditions and

environment of rats in this case that was (Alexander 3-4).” However, these new experiments and results
 Bate 32

were initially rejected, only to be accepted later.

Under appropriate conditions, laboratory animals drink opiate drug solutions in

preference to water and self-inject opiates through indwelling catheters. These findings

are sometimes taken to suggest that mammals, in general, have a natural affinity for

opiates. However, recent data indicate that laboratory housing may itself increase opiate

intake. Rats housed in a quasi-natural colony drank much less morphine hydrochloride

(MHCI) solution than rats isolated in standard laboratory cages. This was found both in

rats which had been pretreated with morphine and in untreated rats. (Alexander 1)

Alexander’s experiments showed that drug use was significantly different for the rats placed in isolated

cages versus those placed in the colony, moreover, differences in drug intake followed moving the rats

between the two conditions (Alexander 2-3). There were four groups of rats, experimental and controls,

rats that remained in the colony (Rat Park) (CC), isolated rats (II), and rats moved from the isolated

cage to the colony (IC) and those moved from the colony to the isolated cages (CI). (Alexander 2-3).

Rats who remained in the isolated cage used significantly more drugs and became addicted, some even

died (Alexander 2). Rats who remained in the colony used significantly less drugs and did not become

addicted:

Rats living in a colony at the time of testing consumed less MHCI than isolated rats,

whatever their early housing condition, even though they had been exposed to the early

environment for 44 days and to the contemporaneous environment for only 15 days prior

to the start of the experiment. Early isolation appeared to increase morphine

consumption. (Alexander 4)

The more interesting data comes from when the rats were moved between the two conditions. Rats that

were in the isolated cages for several days before being moved to the colony decreased their drug usage

and showed minimal signs of drug withdrawal. Likewise, the rats who started off the experiment in the
 Bate 33

colony and later moved to an isolated cage increased the drug intake:

The present experiment is designed to analyse this housing effect more fully by

separating the effect of early housing from that of housing contemporaneous with intake

testing. We have proposed that colony housed rats avoid morphine because its ingestion

interferes with species-specific behaviors which can occur only in a colony, such as nest

building, mating, and fighting. This speculation implicates housing contemporaneous

with testing as the cause of the housing effect, and is comparable with recent

demonstrations that relatively small doses of morphine significantly reduce sexual

behavior and "social cohesion" in rats , and with the evidence that species-specific

behaviors are self-reinforcing. Another plausible explanation for the housing effect, that

morphine reinforces isolated rats because it relieves the stress of isolation, also would

implicate the contemporaneous environment. … Male and female rats were raised from

weaning either in isolation or in a large colony. At 65 days of age, half the rats in each

environment were moved to the other. At 80 days, the animals were given continuous

access to water and to a sequence of 7 solutions: 3 sweet or bitter-sweet control solutions

and 4 different concentrations of morphine hydrochloride (MHCI) in 10% sucrose

solution. Rats housed in the colony at the time of testing drank less MHC1 solution than

isolated rats, but no less of the control solutions. Colony-dwelling rats previously housed

in isolation tended to drink more MHCI solution than those housed in the colony since

weaning, but this effect reached statistical significance only at the lowest concentration

of MHCI. These data were related to the hypothesis that colony rats avoid morphine

because it interferes with complex, species-specific behavior. (Alexander 1)

“The caged rats (Groups CC and PC) took to the morphine instantly, even with relatively little

sweetener, with the caged males drinking 19 times more morphine than the Rat Park males in one of
 Bate 34

the experimental conditions. The rats in Rat Park resisted the morphine water. Group CP, the rats who

were brought up in cages but moved to Rat Park before the experiment began (” Rat Park”)”. The

sweetness of the morphine solution affected how these animals accepted or rejected it as when it was

sweet it was accepted yet rejected as its strength and flavor increased. It was hypothesized that the rats

wanted the sweet water, so long as it did not disrupt or interfere with their normal social behavior.

Significantly, “when he added a drug called Naloxone, which negates the effects of opioids, to the

morphine-laced water, the Rat Park rats began to drink it” (”Rat Park”). Thus, the rats were basically

consuming this water only due to the sweetness, as the morphine had no effect:

In another experiment, he forced rats in ordinary lab cages to consume the morphine-

laced solution for 57 days without other liquid available to drink. When they moved into

Rat Park, they were allowed to choose between the morphine solution and plain water.

They drank the plain water. He writes that they did show some signs of dependence.

There were "some minor withdrawal signs, twitching, what have you, but there were

none of the mythic seizures and sweats you so often hear about ...". (” Rat Park”)

The effect of the environment on the rats is of major importance in understanding addiction according

to the results of this research. Rats and humans are, of course, hugely different, but this research can be

applied to addiction in humans. The environment is key. People who are in isolation, not having their

social and emotional needs met, etc., tend to have a greater number of mental health issues, such as a

prisoner in an isolated cell. In the treatment and understanding of drug addiction, altering the

environment of the addict is apparently of the utmost importance. In concordance with schemas, drug

use becomes more attractive when an individual fails to have a psychologically healthy early

environment and a normal social existence.

V. Results
 Bate 35

Results of the Presence/Absence of EMSs in the Predicting the Risk of Opioid Use Disorder:

Specifically, the EMSs of Emotional Deprivation, Mistrust/Abuse, and Unrelenting Standards can

predict opioid use. Except for SS (self-sacrifice), EG (entitlement/grandiosity), US (unrelenting

standards), and FA (Failure to Achieve), the mean of other maladaptive schemas in the opioid user

group were significantly higher than that of the control group, adjusted for multiple comparisons.

findings conclude that the existence of underlying EMS may constitute a vulnerability factor for

developing opioid use disorders later in life. Provided the vast amount of scientific literature in

evidence-based Predicting the Risk of Opioid Use Disorder Based on Early Maladaptive Schemas

Somayeh Zamirinejad, Seyed Kaveh Hojjat, [...], and Arash Akaberi Additional article information

“Substance use is a globally devastating social problem. Early maladaptive schemas (EMSs) are

inefficient mechanisms leading directly or indirectly to psychological distress. The current study aimed

to assess the role of EMSs in predicting opioid use disorder. The cross-sectional study was conducted

in 2013 in Bojnurd at northeast of Iran on 60 male opioid users who received Methadone Maintenance

Treatment (MMT) and 60 control males. The opioid users were selected randomly from MMT clinics

and control subjects were selected and matched with opioid users using demographic variables. The

subjects completed the Young Schema Questionnaire-Short Form (YSQ-SF). Except for SS (self-

sacrifice), EG (entitlement/grandiosity), US (unrelenting standards), and FA (Failure to Achieve), the

mean of other maladaptive schemas in the opioid user group were significantly higher than that of the

control group, adjusted for multiple comparisons. Multivariate analysis of variance (MANOVA)

indicated significant differences in maladaptive schemas between the two groups. Logistic regression

identified that Emotional Deprivation, Mistrust/Abuse, and Unrelenting Standards can predict opioid

use. As a result, the risk of opioid-related disorders in people with higher YSQ-SF scores in these

schemas is higher. The findings conclude that the existence of underlying EMS may constitute a

vulnerability factor for developing opioid use disorders later in life. Provided the vast amount of
 Bate 36

scientific literature in evidence-based treatments focusing on EMSs, maladaptive schemas and related

core beliefs can be detected and treated in adolescence to prevent the enactment of the schema and

psychological distress likely to induce opioid use (Predicting the Risk 1).”

VI. Discussion

The research previously done by Zamirinejad (Predicting the Risk 7) shows a relationship

between EMSs and substance use disorder, which may be used for the early identification of those who

are at a higher risk than average, which may be important information for the prevention of and early

treatment of substance use disorder.

The Rat Park experiments done by Alexander et al. (572) have suggested that the environment

of an individual is critical in the initiation, maintenance and relapse in those with a higher vulnerability

to developing substance use disorder, or those already diagnosed. Those with the EMSs that suggest a

higher risk of the development of substance use disorder may be able to avoid the development of this

disorder via Dual Focused Schema Therapy (DFST) (“Substance Abuse Prediction” ?). Certain

schemas can predict the vulnerability to development of the use of various substances, specifically

opiates, stimulants and alcohol according to research done by Karami et al. (EMS in Opiate and

Stimulant 13-14).

Early treatment via SBT with the goal of educating one on their own schemas and changing

their maladaptive schemas before they have become addicted to a substance can help to halt

initiation of substance use disorder. Also, education about and access to prescription drugs,

especially in the United States would be of paramount importance in prevention, as in America

the CDC has declared there to be a state of an “Opioid Epidemic” due to over-prescription of

narcotic pain killers and rising heroin use (“Understanding the Epidemic”). The research done suggests
 Bate 37

that the identification of an individual's schemas, and changing them through SBT/DFST, as well as

being mindful of one's environment may be of great importance in the prevention and treatment

of substance use disorder and preventing relapse.

The EMSs of those who abuse certain drugs such as opiates/opioids, stimulants, and alcohol all

have different EMSs and score higher than the control groups in these studies in almost every

schema in the YSQ questionnaire (EMS in Opiate 10-13). Karami et al. further state that those who

abuse stimulants score higher in almost every EMS compared to those addicted to opiates or opioids

(10), and Shorey et al. state that alcoholics scored higher than opiate abusers, with female alcoholics

scoring higher than alcoholic males in most EMSs (Differences in EMSs 3).

Substance use and abuse is a prevalent problem among young adult men, with a

number of associated personal and societal consequences. Men aged 18–25 have a

higher prevalence of substance use than any other age group (Johnston, O’Malley,

Bachman, & Schlenberg, 2011; SAMSHA, 2010), making research on risk and

protective factors for substance use among this population extremely important.

Recent research has begun to examine early maladaptive schemas as a possible

risk factor for the initiation and maintenance of substance abuse (Ball, 1998;

2007; Roper, Dickson, Tinwell, Booth, & McGuire, 2010; Young, Klosko, &

Weishaar, 2003) (“Substance Abuse Prediction”).

Treating such groups that are a relatively high-risk for the development of substance abuse

disorder with Schema-Based-Therapy, specifically a “therapy that combines aspects of relapse

prevention (Marlatt & Gordon, 1985) and schema therapy (Young et al., 2003), which he [Ball]

termed Dual Focused Schema Therapy (DFST) (“Substance Abuse Prediction”). Dr. Young and Dr.

Beck founded CBT and developed SBT. and Ball further developed this process into DFST, which

“focuses on targeting and modifying early maladaptive schemas, [and] results in improved substance
 Bate 38

use outcomes when compared with traditional 12-step therapy” (Ball, 2007) (“Substance Abuse

Prediction”). The first step is identification of the EMSs, then improving coping strategies, and

eventually replacing maladaptive schemas with healthy schemas and modes (Kos).

Changing the EMSs and or decreasing their intensity of one diagnosed with substance use

disorder will help the patient deal with stress better and acquire better coping skills, thus

reducing some of the pressure on them to want to escape feeling. If a patient focuses and alters

his or her schemas, specifically the ones associated with substance use, they will be able to

remain substance free longer, ideally with no relapses if they get the proper treatment.

Addiction is seen by some as a moral failure and by others a disease. Either way a number of

factors are involved in the addiction of one person. Changing one’s environment is extremely helpful

for those who are serious about their treatment. For example, the rat park studies show that a rat

who is alone, in a small cage with nothing to do will consume drugs until they are dead. While

the rats in the large, stimulating cages with other rats of both sexes will rarely become addicted

to the drug-laced water. Comparing this to a human, one can think and see how being socially

isolated, not having a relationship, nor being stimulated is much more likely to turn to drugs for

self-medication. A prisoner in isolation for a long time will end up with negative mental effects.

The rat cage and rat park studies, even though rats are vastly different than humans, show the

effects of some possible schemas that are related to substance abuse such as: emotional

inhibition, abandonment, abuse, emotional deprivation, social isolation, etc.

Possibly unique to America where several various opiates/opioids were and still are, though

to a lesser degree, prescribed to people who neither needed the drug, would have been better

off without it and given much too large of a supply of the drug (Prescription Drugs). Fig. 4 shows a rise

in overdoses from opiates and opioids from 1999 to 2017, and a sudden rise in heroin overdoses as

the government began to slowly stop the overprescribing prescription narcotics and people then
 Bate 39

began to turn to the cheaper opioid alternatives, heroin, fentanyl, etc and overdoses increased

dramatically (U.S. Department of Health-web, quotes, italics?).

Early identification of those who have the EMSs that may predict opioid abuse, or other

substances, can be prevented from developing substance use disorder by not being allowed to

be prescribed certain drugs, with serious exceptions only withstanding. If an individual who is at

risk for substance use disorder due to the EMSs he or she may have, doctors should not be

prescribing them drugs that are commonly abused to get high; benzo’s, opiates/opioids,

amphetamines, etc. If we could get this information about patients who may be prescribed these

drugs, a lot of addictions could be stopped.

Possible ways of getting the information on a patient's EMSs exist. For example: kids who get

in trouble with the school can take a test such as the YSYSQ-L/SF in place of other forms of

punishment, it could be made mandatory for anyone arrested for drug-use related crimes, those

who either want to get into MMT or Suboxone maintenance or a fast detox of withdrawal

symptoms, and those beginning to see pain management Dr.s all could help to gather much

more data on the EMSs of individuals and in some of the cases help prevent people from

developing substance use disorder at all.

One limitation of the studies I have seen is in the size of the experimental groups, and possible

future research could use much larger number of clinical groups in the research. By collecting

more schema data from experimental groups such as those in rehab, AA & NA, who could be

followed over longer periods of time, which would give us data on how EMSs change over time

in treatment, and time spent sober.

VII. Limitations
Bate 40

Tables and Figures to be used:
Domain
1. Disconnection or Rejection
2. Impaired Autonomy or
Performance
3. Impaired Limits
4. Other-Directedness
5. Over vigilance and inhibition
Table 1. The 18 Early Maladaptive Schemas and their 5 Domains
Bate 41
Schema
1. Abandonment/Instability
2. Mistrust/Abuse
3. Emotional Deprivation
4. Defectiveness/Shame
5. Social Isolation/Alienation
6. Dependence/Incompetence
7. Vulnerability to Harm or Illness
8. Enmeshment/Undeveloped Self
9. Failure
10. Entitlement/Grandiosity
11. Insufficient Self-Control and/or Self-Discipline
12. Subjugation
13. Self-Sacrifice
14. Approval-Seeking/Recognition-Seeking
15. Negativity/Pessimism
16. Emotional Inhibition
17. Unrelenting Standards/Hypercriticalness
18. Punitiveness
 Bate 42

• Validated, self-confident and accepted

• Competent, autonomous, self-reliant
1. Happy Child
• Strong, in-control, resilient
• Optimistic, spontaneous

  Appropriate adult functions, such as:

• Comfortable making decisions

• Problem-solver
• Thinks before acting
• Sets limits and boundaries
• Forms healthy relationships
2. Healthy Adult
• Takes care of health
• Does enjoyable activities
• Values himself/herself
• Expresses emotions in a healthy way
• etc.

Table 2: Healthy Schema Modes

 Bate 43

Mean and standard deviation early Maladaptive Schemas (N = 260)

Early Maladaptive Schemas Mean ± SD

Disconnection/rejection 64.72 ± 22.83

Impaired autonomy and

45.28 ± 17.46
performance

Impaired limits 32.66 ± 9.37

Other-directedness 28.81 ± 8.84

Over vigilance/inhibition 37.21 ± 10.85

Table 3 -from substance abuse

 Bate 44

Figure 1
 Bate 45

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O’Malley, Bachman, & Schlenberg, 2011; SAMSHA, 2010), making research on risk and protective
factors for substance use among this population extremely important. OR: Recent research has begun
to examine early maladaptive schemas as a possible risk factor for the initiation and maintenance of
substance abuse (Ball, 1998; 2007; Roper, Dickson, Tinwell, Booth, & McGuire, 2010; Young, Klosko,
& Weishaar, 2003).

Primary Sources, quoted as sources in my sources…

 Bate 48

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Young JE, Brown G. Young schema questionnaire. Sarasota, FL: Professional Resource Exchange;

2003. *from biblio. 7, pg. 5; pg. 20 of my work

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Guide. New York: Guilford Press, 2003. Print. *young & colleagues

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 Bate 49

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 Bate 50

'
Bate 51