Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Relationship between early maladaptive schemas and symptom

dimensions in patients with obsessive-compulsive disorder
Ji Eun Kim a,1, Sang Won Lee b,1, Seung Jae Lee a,n
a
Department of Psychiatry, Kyungpook National University School of Medicine, 680 Gukchaebosang-ro, Jung-gu, Daegu 700-842, South Korea
b
Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), 291 Daehak-ro,
Yuseong-gu, Daegeon 305-701, South Korea

art ic l e i nf o a b s t r a c t

Article history: The aims of this study were to evaluate early maladaptive schemas (EMSs) of patients with obsessive-
Received 14 December 2012 compulsive disorder (OCD) and to clarify relationships between particular EMSs and the five factor-
Received in revised form analyzed symptom dimensions and other clinical variables. Fifty-seven patients with OCD and 70 normal
23 July 2013
controls completed the Young Schema Questionnaire, the Yale–Brown Obsessive Compulsive Scale (Y–
Accepted 28 July 2013
BOCS), the Y–BOCS symptom checklist, and the Beck Depression Inventory. Patients with OCD had
significantly higher scores for schema related to defectiveness/shame, social isolation/alienation, and failure
Keywords: than did normal controls. Among the five OCD symptom dimensions, the sexual/religious dimension was
Obsessive-compulsive disorder only significantly correlated with two schemas of vulnerability to harm or illness and enmeshment/
Symptom dimension
undeveloped self. These two schemas were significant predictors of the sexual/religious dimension,
Maladaptive schema
accounting for 33% of the total variance in this dimension. Any EMSs in patients with OCD were not
Schema therapy
related to clinical variables such as severity of OCD and duration of illness. These findings may constitute
evidence to improve our understandings of OCD from a perspective of schema theory.
& 2013 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Poor response is predicted by early childhood trauma and

Obsessive-compulsive disorder (OCD) is a chronic and severely
disabling anxiety disorder with a fluctuating course and character-
ized by persistent and unwanted thoughts and ritualistic behavior.
OCD was once thought of as relatively treatment resistant (Greist and
Jefferson, 2007). However, with a recent acceleration of progress,
effective treatments including medication and behavior therapy have
emerged. Expert consensus and practice guidelines state that effec-
tive first-line treatments for OCD include behavior therapy including
exposure and response prevention (ERP) and pharmacological ther-
apy (American Psychiatric Association, 2007). Notably, the available
data suggest that ERP is at least as effective as medication, and may
be superior with respect to risks, costs, and enduring benefits (Foa
et al., 2005; Nakatani et al., 2005). However, research indicates that
approximately 50% of patients do not respond satisfactorily (Stanley
and Turner, 1995; Baer and Minichiello, 1998). In many OCD cases
symptoms persist as standard treatment does not lead to full
remission (Pigott and Seay, 1997; Ackerman and Greenland, 2002;
Steketee and Pigott, 2006).
n
Corresponding author. Tel.: +82 53 420 5752; fax: +82 53 426 5361.
E-mail address: jayleemd@knu.ac.kr (S.J. Lee).
1
Two authors contributed equally to this manuscript.
emotional deprivation (Saunders et al., 1992; Lochner et al., 2002),
early onset (AuBuchon and Malatesta, 1994; Abramowitz, 2006),
longer illness duration and greater severity (Goodwin et al., 1969),
and comorbid personality disorder (Jenike et al., 1986; Baer et al.,
1992). In this context, Sookman et al. (1994) already proposed
integrative cognitive therapy for OCD that incorporates the notion
of schemas, developmental theory, attachment experiences, struc-
tural dimension, and emotional as well as interpersonal foci.
Young has extended and modified traditional cognitive therapy
to develop schema therapy (Young and Klosko, 1994). Schema
therapy is an integrative, unifying theory and approach designed
to treat a variety of severe, long-standing psychological problems
such as Axis II disorders. The most basic concept in the schema
approach is the early maladaptive schema (EMS). Young defines an
EMS as a “broad, pervasive theme regarding oneself and one's
relationship with others, developed during childhood and elabo-
rated upon throughout one's lifetime, and dysfunctional to a
significant degree.” Young et al. (2003) discuss each EMS's impact
on the therapeutic process and propose a recommended treatment
approach for each EMS. In their review of preliminary research,
Hawke and Provencher (2011) suggested that given the chronicity
and the developmental risk factors, schema therapy may be
successfully extended beyond the personality disorder to benefit
anxiety disorders patients. In effect, several preliminary studies
reported treatment-resistant OCD cases which showed potential

0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.psychres.2013.07.036

Please cite this article as: Kim, J.E., et al., Relationship between early maladaptive schemas and symptom dimensions in patients with
obsessive-compulsive disorder. Psychiatry Research (2013), http://dx.doi.org/10.1016/j.psychres.2013.07.036i
2 J.E. Kim et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
effectiveness of schema-focused therapy, considering schema
therapy as a more promising approach for severe OCD cases with
weak response to regular CBT, especially patients with chronic
OCD, trauma history, and comorbid personality disorder (Sookman
et al., 1994; Sookman and Pinard, 1999; Gross et al., 2012).
On the other hand, a few studies have been conducted on the
EMSs of patients with OCD to understand this disorder from a
perspective of schema theory. Atalay et al. (2008) reported that
patients with OCD were more likely than healthy participants to
activate EMSs, especially those in the schemas of social isolation/
alienation, vulnerability to harm or illness, and negativity/pessimism.
Another study compared EMSs in OCD with those in trichotillo-
mania (TTM) (Lochner et al., 2005). OCD participants scored
significantly higher than the TTM group in the schemas of
mistrust/abuse, social isolation/alienation, defectiveness/shame, sub-
jugation, and emotional inhibition. Unfortunately, it was not possi-
ble to identify the EMSs that were elevated in both disorders
because no healthy control group was included.
Although previous reports are valuable, these two studies used
simple comparisons without controlling for confounding factors
such as depression. More importantly, it remains unclear whether
the schemas activated in these studies were specific to OCD or
whether their activation resulted from non-specific factors such as
comorbidity, disability, or functional impairment due to living
with a chronic illness. For example, non-psychiatric, chronic pain
patients scored higher on dependence/incompetence, vulnerability
to harm or illness, and negativity/pessimism schemas than did
controls (Saariaho et al., 2009). In fact, Lochner et al. (2005) also
emphasized the need for further studies assessing the relationship
between schema and duration of illness.
In reality, OCD is a clinically heterogeneous disorder with
symptoms that can be summarized in terms of a few dimensions:
symmetry/ordering, hoarding, contamination/cleaning, aggres-
sion/checking, and sexual/religious (Baer 1994; Mataix-Cols
et al., 2005). Each symptom dimension has been associated with
patterns of genetic transmission, neuroimaging data, comorbid
disorders, and treatment responses (Alonso et al., 2001; Leckman
et al., 2003; Mataix-Cols et al., 2005). Thus, analysis of OCD
symptom dimensions in terms of EMSs may reveal OCD-specific
schemas and contribute information on the differential EMS-
related characteristics of each OCD symptom domain.
The aims of this study were (1) to evaluate differences between
the EMSs of OCD patients and those of normal controls using the
Young Schema Questionnaire-short form, (2) to examine relation-
ships between EMSs and OCD symptom dimensions, and (3) to
determine whether EMSs are related to clinical variables such as
severity of OCD, age at onset, and duration of illness.
2. Methods
2.1. Subjects
Seventy-four patients aged between 18 and 65 years at the OCD clinic at
Kyungpook National University Hospital, Daegu, South Korea, who fulfilled Diag-
nostic and Statistical Manual of Mental Disorders, Fourth edition, Text Revision
(DSM-IV-TR; American Psychiatric Association, 2000) criteria for OCD were
enrolled from January 2009 to March 2012. Subjects were excluded if they suffered
from a current comorbid Axis I diagnosis, psychotic symptoms, mental retardation,
neurological disease, or a history of head injury or medical illness with documented
cognitive sequelae. Further, to ascertain OCD and other comorbid diagnoses, the
Structured Clinical Interview for DSM-IV-TR Axis I Disorders, patient version (SCID-
I/P) was carried out (First et al., 2002a). This interview was completed by an
experienced psychiatrist (S.J.L). Of the 74 patients, 17 were ruled out in accordance
with the exclusion criteria and/or the poor quality of self-reports. Overall, data for
57 patients (38 males and 19 females) were finally collected and analyzed. Written
informed consent was obtained from each subject after a complete description of
Please cite this article as: Kim, J.E., et al., Relationship between early maladaptive schemas and symptom dimensions in patients with
obsessive-compulsive disorder. Psychiatry Research (2013), http://dx.doi.org/10.1016/j.psychres.2013.07.036i
the study, which was approved by the Institutional Review Board of Kyungpook
National University Hospital.
Seventy healthy comparison subjects (49 males and 21 females), who were all
first-year graduate students in 2009, were recruited from the graduate school at
Kyungpook National University. They had no previous or current history of
psychiatric or neurological diagnoses as determined in a brief interview based on
the Structured Clinical Interview for DSM-IV-TR Axis I Disorders, non-patient
version (SCID-I/NP) (First et al., 2002b).The data were adapted from the annual
mental health assessment of graduate school students with permission from the
ethics committee of Kyungpook National University.
2.2. Clinical measures
2.2.1. Yale–Brown Obsessive Compulsive Symptom Scale
The Yale–Brown Obsessive Compulsive Scale (Y–BOCS) is a 10-item instrument
developed by Goodman et al. (1989) to evaluate symptom severity and treatment
response in OCD patients. This scale is a reliable semi-structured interview, which
is typically administered after identifying the content of particular obsessions and
compulsions using the Y–BOCS Symptom Checklist. The scale is divided into
subscales for obsessions and compulsions. Each of five aspects of obsessive and
compulsive pathology is rated on a scale ranging from 0 (no symptoms) to 4
(extreme symptoms): time spent, degree of interference, distress, resistance
(greater resistance is assigned lower scores), and perceived control over symptoms.
Subscale scores are summed to yield total scores on the Y–BOCS.
2.2.2. Yale–Brown Obsessive Compulsive Symptom Checklist
The Y–BOCS checklist is a 58-item instrument designed to evaluate the
presence (yes/no) of current and past symptoms. Factor-analyzed dimensional
scores for obsessive-compulsive (OC) symptoms were measured using the Y–BOCS
checklist, which includes the 58 items organized into eight categories of obsessions
and seven categories of compulsions. When a patient identified at least one of the
specific symptoms under one of these dimensions as a principal or major problem,
that dimension was given a score of 2. When a patient reported the current or past
presence of a given symptoms but did not consider it to be a major problem, that
dimension was given a score of 1. When a patient reported the absence of
symptoms, that dimension was given a score of 0. We classified OC symptoms
into five factor-analyzed symptom dimensions according to a previous study
conducted by Mataix-Cols et al. (1999). Scores on the five symptom dimensions
were calculated by summing the scores for the symptom categories under each
dimension. The five symptom dimensions were symmetry/ordering, hoarding,
contamination/cleaning, aggression/checking, and sexual/religious.
2.2.3. Young Schema Questionnaire
EMSs were assessed with the short form of the Young Schema Questionnaire,
version 3 (YSQ-S3), which contains 90 items and assesses 18 EMSs (Young et al.,
2003). Each item is rated on a six-point Likert scale. Higher scores are indicative of
a more dysfunctional belief. The 18 subscales are grouped into five broad categories
referred to as schema domains: disconnection and rejection, impaired autonomy
and performance, impaired limits, other-directedness, and overvigilance and
inhibition. The Korean version of this instrument with 13 factors has good
psychometric properties and internal reliability (α ¼0.94) (Baranoff et al., 2006).
According to factor structure and loadings yield in psychometric study of this
Korean version, we calculate and report the results of 13 schema subscales
(abandonment/instability, mistrust/abuse, emotional deprivation, defectiveness/shame,
social isolation/alienation, vulnerability to harm or illness, enmeshment/undeveloped
self, failure, entitlement/grandiosity, insufficient self‐control/self‐discipline, self‐sacri-
fice, emotional inhibition, and unrelenting standards/hypercriticalness) in this study.
2.2.4. Beck Depression Inventory
Current levels of depression were measured with the Korean version of the
Beck Depression Inventory (BDI) (Lee and Song, 1991). The BDI is a 21-item scale
that targets cognitive, behavioral, affective, and somatic components of depression.
The measure was initially designed to be administered by clinicians, but it is now
used primarily as a self-report measure. Each of the 21 items requires respondents
to select which one of four statements most accurately reflects symptom intensity
during the past week (Beck et al., 1961).
2.3. Statistical analysis
The sociodemographic characteristics of OCD patients and healthy subjects
were compared using chi-square and t-tests. Analysis of variance (ANOVA) and
analysis of covariance (ANCOVA) with education and depression scores as covari-
ates were used to compare mean differences in schema scores on the YSQ-S3
between patients with OCD and healthy subjects.
Partial correlation analysis was performed to assess the relationship between
EMSs and the five factor-analyzed symptom dimensions in patients with OCD,
adjusting for the severity of OCD and depressive symptoms. Multiple linear
regression analysis (stepwise method) was also performed to assess whether EMSs
 J.E. Kim et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎ 3

were related to the presence of specific OC symptom dimensions. In these models,
the patients' scores for each EMS were entered as independent variables, and their
scores on the five previously identified OCD symptom dimensions were entered as
dependent variables. To control for the effects of OC symptom severity and
depression, all analyses were repeated by first entering total Y–BOCS and BDI
scores into the models (enter method).
Pearson's correlation analysis was used to explore relationships between EMSs
and clinical variables such as severity of OCD, age at onset of OCD, and duration of
illness. Due to the influence of level of depression and OC severity on EMSs (Stopa
and Waters, 2005), partial correlation coefficients for EMSs and clinical factors
were then calculated controlling for BDI scores and OC severity.
Data were analyzed using SPSS for Windows, version 11.0.1 (SPSS, Inc., Chicago,
IL). The false discovery rate (FDR) correction was used to control type 1 error
inflation (Narum, 2006). The FDR-corrected alpha coefficient for 18 tests (one per
EMS) was 0.014.
3. Results
3.3. Relationship between OCD subtype and EMS
The sexual/religious dimension was correlated with higher
scores for vulnerability to harm or illness (r ¼ 0.44, P ¼0.001) and
enmeshment/undeveloped self (r ¼0.42, P¼ 0.001). None of the
other OCD symptom dimensions was significantly related to EMSs
(Table 4).
Multiple regression analysis was also performed to examine the
influence of EMSs, as measured by the YSQ-S3, on the sexual/
religious dimension showing significant relationships in the par-
tial correlation analysis. The schemas related to vulnerability to
harm or illness and enmeshment/undeveloped self were significant
predictors of the sexual/religious dimension, accounting for 33%
(ΔR2 ¼ 0.37  0.04 ¼0.33) of the total variance in this dimension
(β¼0.47, t¼3.6, P o0.001 for vulnerability to harm or illness; β¼
0.42, t ¼3.4, Po0.001 for enmeshment/undeveloped self) (Table 5).

3.1. Demographic and clinical characteristics

Demographic and clinical characteristics are presented in 3.4. Relationship between clinical characteristics and EMS
Table 1. We found no significant differences between groups in
sex or age. However, patients with OCD had less education and OCD severity, as assessed by the Y–BOCS, was not significantly
higher scores on the BDI than did normal controls. Mean (7S.D.) correlated with any EMSs after controlling for depressive symp-
age at onset and duration of illness were 18.6 76.8 years and toms. Duration of illness was not also significantly related to any
8.0 76.5 years, respectively. The OC symptom assessment per- EMSs after adjusting for depressive symptoms and OCD severity.
formed at the time of testing revealed moderate to severe Age of OCD onset was correlated with mistrust/abuse (r¼  0.28,
symptom levels in the OC group. Fifty four (95%) patients were P¼0.042), social isolation/alienation (r¼  0.28, P¼ 0.041), and vul-
taking selective serotonin reuptake inhibitors (SSRIs), such as nerability to harm or illness (r¼  0.32, P¼0.018) after adjusting for
escitalopram (62%), paroxetine (19%), sertraline (7%), and fluvox- depressive symptoms and OCD severity. However, these results did
amine (7%). Concomitant medications were anxiolytics (55%) and not reach an experiment-wise p-value of 0.014 in this study.
antipsychotics (14%). Table 2 shows the distribution of frequencies
for the major symptom dimensions on the Y–BOCS checklist
among all patients with OCD.
Table 2
Frequencies of the major symptom dimensions of the Yale–Brown Obsessive-
Compulsive Checklist in patients with obsessive-compulsive disorder.
3.2. Comparison of EMS between patients with OCD and normal
controls Symptom dimension Major Present Absent
symptom symptom symptom
We found significant differences between patients with OCD
n % n % n %
and normal controls with regard to several EMSs (Table 3). OCD
patients had higher scores for all schemas except entitlement and Symmetry/ordering 33 57.9 19 33.3 5 8.8
self-sacrifice. However, patients with OCD reported higher levels of Hoarding 1 1.8 19 38.6 37 64.9
defectiveness/shame (F¼6.6, P ¼0.011), social isolation/alienation Contamination/cleaning 28 49.1 19 33.3 10 17.5
Aggressive/checking 29 50.9 22 38.6 6 10.5
(F¼ 13.3, Po 0.001), and failure (F ¼19.1, P o0.001) after control- Sexual/religious 9 15.8 22 38.6 26 15.8
ling for education and depression (Table 3).

Table 1
Sociodemographic and clinical characteristics of patients with obsessive-compulsive disorder and healthy comparison subjects (mean 7 S.D.).

Characteristics Patients with OCD (N ¼ 57) Normal controls (N ¼70) Statistics

t or χ2 P

Age, years 26.7 76.3 25.5 7 2.3 0.96 0.3

Male/female 38/19 49/21 0.04 0.8

Education, years 13.8 7 3.2 15.8 70.6  5.12 o0.001

Age at onset of OCD, years 18.6 7 6.8 – – –

Duration of illness, years 8.0 76.5 – – –

Y–BOCS score
Obsession 11.9 73.8 – – –
Compulsion 11.5 73.5 – – –
Total 23.5 76.6 – – –

BDI score 21.9 7 11.0 6.0 7 4.7 10.95 o0.001

Y–BOCS: Yale–Brown Obsessive Compulsive Scale, BDI: Beck Depression Inventory.

Please cite this article as: Kim, J.E., et al., Relationship between early maladaptive schemas and symptom dimensions in patients with
obsessive-compulsive disorder. Psychiatry Research (2013), http://dx.doi.org/10.1016/j.psychres.2013.07.036i
4 J.E. Kim et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎

Table 3
Comparison of early maladaptive schemas in patients with obsessive-compulsive disorder and normal controls (mean 7 S.D.)

Patients with OCD Normal controls Fa Fb

Disconnection and rejection

Abandonment/instability 12.0 7 5.1 9.3 7 3.7 14.3nn 1.2
Mistrust/abuse 12.3 7 5.8 7.17 2.9 42.2nn 1.7
Emotional deprivation 13.2 7 5.7 6.6 7 2.3 77.8nn 2.8
Defectiveness/Shame 14.9 7 6.5 6.6 7 2.4 97.1nn 6.6n
Social isolation/alienation 16.0 7 6.1 7.7 72.7 101.3nn 13.3nn
Impaired Autonomy and performance
Vulnerability to harm or illness 13.2 7 5.0 7.7 72.9 57.9nn 0.6
Enmeshment/undeveloped self 13.5 7 5.0 8.8 7 3.4 38.1nn 1.2
Failure 14.2 7 6.0 7.2 72.5 78.4nn 19.1nn
Impaired Limit
Entitlement/grandiosity 11.7 7 3.1 10.7 7 3.1 3.5 0.01
Insufficient self control/Self discipline 15.4 7 5.0 9.8 7 3.3 57.7nn 2.5
Other directedness
Self-sacrifice 12.2 7 4.1 12.2 7 3.5 0.0 5.7
Overvigilance and inhibition
nn
Emotional inhibition 14.6 7 5.2 9.5 7 3.7 41.5 1.2
Unrelenting standards/hypercriticalness 15.8 7 5.5 12.7 7 4.3 12.7n 0.2

All degrees of freedom ¼ 1,125

a
Analysis of variance (ANOVA)
b
Analysis of covariance (ANCOVA) adjusted for education and depression score as covariates
n
Po 0.014.
nn
Po 0.001

Table 4
Partial correlations between OC symptom dimensions and EMS in patients with obsessive-compulsive disorder.

Symmetry/ordering Hoarding Contamination/cleaning Aggression/checking Sexual/religious

Disconnection and Rejection

Abandonment/instability 0.168  0.085 0.083 0.030 0.209
Mistrust/abuse 0.220 0.121  0.050 0.142 0.256
Emotional deprivation 0.173  0.018 0.047 0.193 0.170
Defectiveness/shame 0.239  0.079 0.160 0.145 0.147
Social isolation/alienation 0.245 0.193 0.164 0.171 0.284

Impaired Autonomy and Performance

Vulnerability to harm or illness 0.148 0.137  0.129 0.284 0.443n
Enmeshment/undeveloped self 0.013 0.024 0.131 0.046 0.423n
Failure 0.025  0.028  0.085  0.102 0.160

Impaired limit
Entitlement/Grandiosity 0.067 0.135  0.062 0.088 0.195
Insufficient self control/Self discipline 0.119 0.015  0.095  0.044 0.178

Other directedness
Self-sacrifice 0.108  0.022  0.063 0.052 0.201

Overvigilance and inhibition

Emotional inhibition 0.137 0.132 0.070 0.295 0.252
Unrelenting standards/hypercriticalness 0.201 0.039 0.021 0.157 0.198

Partial correlations controlling for total Y–BOCS and BDI scores.

n
Po 0.014.

4. Discussion
The aims of this study were to evaluate EMS patterns of
patients with OCD and to clarify relationships between these
patterns and factor-analyzed symptom dimensions and other
clinical variables. Patients with OCD had significantly higher scores
for schemas related to defectiveness/shame, social isolation/aliena-
tion, and failure than did normal controls. Of the five OCD
symptom dimensions, the sexual/religious dimension was only
significantly correlated with schemas such as vulnerability to harm
or illness and enmeshment/undeveloped self.
4.1. Characteristic EMSs in patients with OCD compared with normal
controls
We found higher scores for defectiveness/shame, social isolation/
alienation, and failure in those with OCD than in controls. These
results are in close agreement with previous reports on EMSs in
OCD subjects, which found that this group was characterized by
high scores for defectiveness/shame (Lee et al., 2010) and social
isolation/alienation (Atalay et al., 2008).
A defectiveness/shame schema involves the feeling that one is
defective, bad, unwanted, inferior, or invalid in important ways

Please cite this article as: Kim, J.E., et al., Relationship between early maladaptive schemas and symptom dimensions in patients with
obsessive-compulsive disorder. Psychiatry Research (2013), http://dx.doi.org/10.1016/j.psychres.2013.07.036i
 J.E. Kim et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎ 5

Table 5
Regression analysis for sexual/religious dimension of obsessive-compulsive disorder.

R R2 F P B SE B β t P

Step 1
Constant 0.80 0.50 1.61 0.11
BDI 0.21 0.04 1.22 0.30 0.02 0.01 0.21 1.54 0.13
YBOCS  0.01 0.02  0.09  0.63 0.53

Step 2
Constant 0.04 0.50 0.08 0.94
BDI  0.01 0.01  0.07  0.46 0.64
0.48 0.23 5.32 o0.001
YBOCS  0.01 0.02  0.09  0.74 0.46
Vulnerability 0.10 0.03 0.52 3.60 o 0.001

Step 3
Constant  0.70 0.50  1.39 0.17
BDI  0.02 0.01  0.23  1.62 0.11
YBOCS 0.69 0.37 7.66 o0.001  0.01 0.02  0.07  0.63 0.53
Vulnerability 0.09 0.03 0.47 3.59 o 0.001
Enmeshment 0.08 0.02 0.42 3.39 o 0.001

BDI: Beck Depression Inventory, Y–BOCS: Yale–Brown Obsessive Compulsive Scale, Vulnerability: Vulnerability to harm or illness schema, Enmeshment: Enmeshment/
undeveloped self schema.

and may include hypersensitivity to criticism and rejection or a
sense of shame regarding perceived flaws. People with this
schema fear relationships with others because they dread the
inevitable moment when their defectiveness will be exposed.
Therefore, this schema may cause difficulties in the ability to
maintain healthy social relationships and may even lead to the
emergence of social isolation/alienation schema during social
development. One study showed that patients with OCD perceived
more rejection and less emotional warmth from their fathers or
from both parents (Hoekstra et al., 1989; Alonso et al., 2004).
Moreover, individuals with these schemas tend to be self-
conscious around others and preoccupied with their own
thoughts. These schemas seem to be a basis for the development
of obsessive thoughts. On the other hand, OC symptoms may
perpetuate or aggravate these schemas. Patients with OCD are
typically secretive and ashamed about their obsessive thoughts
and compulsive behaviors (Hyman and Pedrick, 2010). Their
typical coping strategy is to hide their illness, which, in turn,
may lead to so called “schema perpetuation.”
Patients with OCD also scored higher than normal controls in
the failure schema. A failure schema is the belief that one has failed
relative to one's peers in areas of achievement such as career,
money, status, school, or sports (Honjo et al., 1989; Adams et al.,
1994). Obsessive rumination and compulsive activities often take
up so much time that students with OCD cannot concentrate on
their schoolwork, leading to poor or incomplete work and even
academic failure. In addition to the diagnostic criterion regarding
symptoms' significant interference with school, social activities,
and important relationships (American Psychiatric Association,
2000), OCD is thought to be severely disruptive to academic life
(Adams et al., 1994).
In terms of cross-cultural differences of EMSs, the only cross-
cultural research rather reported that the Korean version of the
YSQ-SF has a similar factor structure and internal reliability to that
of the Western version (Baranoff et al., 2006). Thus, in light of the
limited empirical information available regarding this issue, a
further study will be needed to clarify the differences and
specificity of EMSs and the associated effects on OC symptoms
across cultures.
4.2. EMSs specific to OC symptom dimensions
The aforementioned EMSs in patients with OCD were general
schemas that were affected by complex factors and that differed
from those of normal controls, irrespective of whether they were
specific to OCD. The EMSs in this section were specific to OC
symptoms in contrast to the results of simple group comparisons
between patients with OCD and normal controls.
First, of the five OC symptom dimensions, sexual/religious
dimension was only significantly correlated with several schemas.
These findings suggest that this symptom dimension may be more
related to EMSs than are the other dimensions, and corroborates
the results of previous studies reporting that the sexual/religious
dimension is correlated with most comorbid personality disorders
(Ha et al., 2004).
Second, over 30% of the variance in the sexual/religious
dimension was accounted for by two schemas: vulnerability to
harm or illness and enmeshment/undeveloped self. Young et al.
(2003) suggested that persons with vulnerability to harm or illness
are afraid of catastrophic events and rely on avoidance or over-
compensation to cope with this. Thus, they become phobic, restrict
their lives, engage in magical thinking, or perform compulsive
rituals. Young et al. (2003) also noted that persons characterized
by enmeshment/undeveloped self have blurred boundaries in rela-
tion to a parental figure; they think about the parental figure and
suppress all thoughts, feelings, and behaviors that would lead to
differentiation from him or her. They may even feel that they can
sense what that other person wants without the other asking.
Taken together, these schemas may render individuals hyper-
moral and hyper-responsible in response to sexual or religious
content. Indeed, these traits frequently characterize patients with
the sexual/religious OC symptom dimension (Hyman and Pedrick,
2010), the so-called pure type of obsessions.
4.3. Relationship between EMSs and clinical variables in patients
with OCD
One previous study using the same schema questionnaire as
that used in the present study showed no correlation between the
severity of OCD symptoms and individual schema except depen-
dence/incompetence (Atalay, et al., 2008). In general, consistent
with our result, EMSs may be less likely to be associated with the
severity of OCD symptoms. Any EMSs in patients with OCD were
not related to clinical variables such as duration of illness.
This study has several limitations. First, comorbid Axis II
disorder which is the one of important aspects of applying schema
therapy to Axis I disorders was not assessed in the present study.
Further studies are needed to find any differences in schemas
between OCD patients with and without personality disorders.
Second, because of the lack of the use of instruments about

Please cite this article as: Kim, J.E., et al., Relationship between early maladaptive schemas and symptom dimensions in patients with
obsessive-compulsive disorder. Psychiatry Research (2013), http://dx.doi.org/10.1016/j.psychres.2013.07.036i
6 J.E. Kim et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
parenting and coping styles related with EMSs, the whole picture
as to OCD specific formulation of schema theory seems to be
overlooked. Third, patients with OCD in our study had a relatively
high mean BDI score although some were excluded from the
sample due to a diagnosis of major depressive disorder. Even
though we attempted to statistically control for the effects of
depressive symptoms, some bias associated with depression may
have remained. Fourth, since mood and anxiety disorders fre-
quently co-occur with one another (Brown et al., 2001), the
exclusion of a current comorbid Axis I diagnosis may be stringent.
Thus, our subjects may not be a sufficient representative of the
general population of patients with OCD. Also, the use of doctoral
students as controls is a further limiting factor. Lastly, previous
studies reported that hoarding was the OC symptom dimension
most strongly correlated with personality. However, too few
respondents in our sample experienced hoarding as a major
symptom to confirm previous results. Indeed, it has been sug-
gested that hoarding is not a specific symptom subtype of OCD
(Wu and Watson, 2005).
Regardless of these limitations, our study with a relatively large
sample size demonstrated the existence of schemas that are
specific to OC symptom dimensions in addition to non-specific
schemas related to defectiveness/shame, social isolation/alienation,
and failure schemas. Of the five OCD symptom dimensions, sexual/
religious dimension was only significantly correlated with sche-
mas such as vulnerability to harm or illness and enmeshment/
undeveloped self. These findings may constitute evidence to
improve our understandings of OCD from a perspective of schema
theory.
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Please cite this article as: Kim, J.E., et al., Relationship between early maladaptive schemas and symptom dimensions in patients with
obsessive-compulsive disorder. Psychiatry Research (2013), http://dx.doi.org/10.1016/j.psychres.2013.07.036i