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. 2026 Apr 16;65(4):1000–1014. doi: 10.1111/bjc.70052

Do schema modes predict outcome of cognitive behavioural therapy in patients with obsessive–compulsive disorder and anxiety disorders?

Manon Peeters 1, Boris van Passel 1,2, Nancy Peeters 1,2, Julie Krans 1,2,✉
PMCID: PMC13655967  PMID: 41988803

Abstract

Objectives

Cognitive behavioural therapy (CBT) is the psychological treatment of choice for patients with obsessive–compulsive disorder (OCD) or an anxiety disorder. However, a substantial group (30–40%) does not profit sufficiently. Predictors of outcome inform us about how to adapt interventions for this group. Specifically, schema modes might affect CBT outcome; yet, research into the relation between schema modes and CBT outcome for anxiety disorders and OCD is very limited. In this study, it was investigated whether adaptive and maladaptive schema modes predict CBT outcome controlling for symptom levels at the start of treatment.

Methods

Pre‐treatment maladaptive and adaptive schema modes and pre‐ and post‐treatment psychological distress were assessed in 100 patients (60 women and 40 men with a mean age of 32.49 years) diagnosed with OCD (n = 56) or an anxiety disorder (n = 44) receiving CBT. Regression analyses were conducted to assess the unique predictive value of adaptive and maladaptive schema modes in addition to pre‐treatment levels of psychological distress.

Results

Pre‐treatment maladaptive modes (specifically maladaptive child modes) significantly predicted psychological distress after CBT with small effect sizes. Higher pre‐treatment adaptive modes were associated with better CBT response, although this effect was not robust.

Conclusions

Given the small effect size, our study does not yield strong evidence that schema modes influence CBT outcome for patients with OCD or anxiety disorders. Given that this is the first study testing this effect, our findings need to be replicated, preferably in disorder‐specific samples.

Keywords: anxiety disorders, CBT, non‐response, OCD, schema modes, schema therapy

Practitioner points.

  • Maladaptive (child) modes predicted poorer CBT outcome for OCD and anxiety disorders with a small effect size.

  • Adaptive schema modes predicted better CBT outcome, but this finding was not robust.

  • There is as yet no strong evidence that schema modes influence the outcome of CBT for OCD and anxiety disorders.

  • The relation between schema modes and CBT outcome needs to be replicated in disorder‐specific samples.

INTRODUCTION

Obsessive–compulsive disorder (OCD) and anxiety disorders are impairing conditions with a lifetime prevalence ranging between 2 and 12% (Kessler et al., 2010). Cognitive behavioural therapy (CBT) with exposure (and response prevention, or ERP, in case of OCD) is considered the first psychological treatment of choice (National Institute for Health and Care Excellence, 2014; Norton & Price, 2007; Tolin, 2010). The average response rates of CBT for anxiety disorders are 49.5% at post‐treatment and 53.6% in the long term (Loerinc et al., 2015). Gaining knowledge about individual characteristics that may contribute to poorer CBT outcomes may provide valuable insights to optimize treatment for poor responders.

Relevant insights arise from the schema therapy (ST) framework. Although ST has been studied primarily in personality disorders, it was originally developed for both personality pathology and patients showing insufficient response to CBT (Eurelings‐Bontekoe et al., 2010; Young et al., 2003). In the ST model, the chronicity of symptom disorders is attributed to the development of early maladaptive schemas (EMS) arising from childhood adverse events, which are too rigid and entrenched to respond to symptom‐focused interventions such as CBT (Arntz et al., 2021; Young et al., 2003). EMS present broad, inflexible, maladaptive patterns of thoughts, emotions and memories about the self, others and the world, and are proposed to develop in response to chronic or severe violations of basic emotional needs in early childhood. When internal or external cues trigger EMS, this activation in interaction with the individual's coping style results in a schema mode. Schema modes are specific emotional‐cognitive‐behavioural states in response to EMS activation (Arntz et al., 2021), and can be grouped into four categories (Arntz et al., 2021; Lobbestael et al., 2008; Schaap et al., 2016; Yakın et al., 2020; Young et al., 2003): (1) maladaptive child modes: childlike feelings, thoughts and behaviours in which patients experience intense primary emotions like anger, sadness, or fear, (2) critic modes: dysfunctional moral standards and behaviour internalized from attachment figures, such as excessive self‐punishment or overly high standards and extreme demands for achievement, (3) coping modes: dysfunctional coping responses such as shutting down emotions, becoming angry or pleasing to avoid or escape the EMS trigger or activation and (4) adaptive modes: happy child and healthy adult; joy, playfulness, and spontaneity and adequate thoughts, feelings and behaviour with an executive function and reflection attuned with own emotional needs and those of others.

There is empirical evidence for the presence of heightened EMS in patients with anxiety disorders and OCD. The systematic review by Bär et al. (2023) presents an overview. The studies included in this review (Atalay et al., 2008; Kwak & Lee, 2015) show that the most frequent EMS in panic disorder are the ‘vulnerability to harm’, ‘self‐sacrifice’, ‘entitlement’, ‘approval seeking’ and ‘insufficient self/control’ schemas. Compared with non‐clinical samples, patients with panic disorder showed elevated levels of ‘vulnerability to harm’, whereas ‘self‐sacrifice’ was higher than in patients with OCD but comparable to patients with major depressive disorder (MDD). Panic disorder patients tended to score lower than patients with OCD and MDD on ‘defectiveness’ and ‘social isolation’. The authors of the review noted that there was insufficient data for other anxiety disorders. A meta‐analysis comprising 15 studies in youth and adolescents with anxiety disorders, on the other hand, reported medium to large correlations between the EMS of ‘disconnection‐rejection’, ‘impaired autonomy‐performance’ and ‘other‐directedness’ and anxiety disorder symptoms (Tariq et al., 2021).

For OCD (Atalay et al., 2008; Basile et al., 2017; Khosravani et al., 2021; Kim et al., 2014; Kizilagac & Cerit, 2019; Kwak & Lee, 2015; Voderholzer et al., 2014), the EMS of ‘unrelenting standards’, ‘approval seeking’, ‘negativism’, ‘punitiveness’ and ‘self‐sacrifice’ were most often endorsed. Compared with non‐clinical control groups, OCD patients showed elevated scores on ‘social isolation’, ‘defectiveness’, ‘dependence’, ‘failure’ and ‘vulnerability to harm’. In comparison to clinical control groups (including panic disorder, eating disorders, chronic pain, bipolar disorder and schizophrenia), OCD patients reported elevated levels of ‘social isolation’, ‘abandonment’ and ‘vulnerability to harm’. Furthermore, a meta‐analysis across 22 studies (Dostal & Pilkington, 2023) reported medium to large correlations between OCD and especially the schema domains of ‘dependence‐incompetence’, ‘vulnerability to harm or illness’ and ‘negativity‐pessimism’. Finally, a cross‐sectional study in 30 patients with OCD showed elevated scores on ‘emotional deprivation’, ‘emotional inhibition’ and ‘failure’, with the latter the only significant but strong correlate of OCD symptom severity (Abdelrazek et al., 2024).

Only very few studies assessed schema modes in anxiety and OCD. These found that, compared with patients with chronic pain disorder and eating disorders, OCD patients showed elevated levels of maladaptive child and critic modes (Basile et al., 2017; Voderholzer et al., 2014), whereas OCD severity was predicted by the level of critic modes (Basile et al., 2017). Only one study directly investigated schema modes in anxiety. This cross‐sectional study in patients with social anxiety disorder found significant correlations between the Vulnerable Child, Punitive Critic, Demanding Critic, Compliant Surrender and Detached Self‐Soother modes and symptom severity (Norton et al., 2023).

Indirect evidence that EMS and schema modes may interfere with CBT treatment comes from a systematic review showing that some comorbid personality disorders were associated with poorer outcome of CBT for OCD patients (Thiel et al., 2013). Furthermore, emerging research suggests that ST, which focuses on EMS and schema modes, may be promising for patients with anxiety disorders or OCD and a poor response to CBT (Peeters et al., 2021, 2022; Remmerswaal et al., 2023; Taylor et al., 2017; Thiel et al., 2016). Only a few studies directly tested the predictive value of EMS on treatment outcome in anxiety disorders and OCD. One study reported on the relation between EMS and CBT outcome in a combined sample of patients with MDD or an anxiety disorder (Halford et al., 2002). The CBT treatment had medium to large effects on levels of depression and anxiety, and small effects on EMS. Overall, EMS (specifically ‘disconnection’, ‘overconnection’ and ‘exaggerated standards’) at pre‐treatment did not predict changes in anxiety levels, but reductions in EMS were associated with greater reductions in levels of depression and anxiety. Three studies were published on patients with OCD. The first Haaland et al. (2011) showed that the ‘abandonment’ schema at pre‐treatment explained poorer CBT (with ERP) treatment, whereas ‘self‐sacrifice’ was in fact related to better outcome. In terms of changes in EMS, reductions in the ‘failure’ schema were the only significant predictor of better outcome. A second study showed that pre‐treatment EMS of ‘failure’ and ‘emotional inhibition’ predicted poorer CBT with ERP outcome in an inpatient setting (Thiel et al., 2014). Finally, one study found that the overall level of EMS was a small predictor of non‐response or relapse over the course of 8 years after group CBT with ERP in OCD patients (Sunde et al., 2019).

Studies directly testing the predictive value of schema modes on treatment outcome for anxiety disorders are lacking. One study was published about patients with OCD. This study (Thiel et al., 2014) found that non‐responders of an inpatient treatment of CBT with ERP had higher ‘vulnerable child’, ‘detached protector’, ‘bully and attack’ modes, a lower ‘happy child’ mode and a higher overall schema mode score than responders, with similar levels of OCD symptoms at pre‐treatment between responders and non‐responders. The ‘vulnerable child’ mode and an exploratory ‘perfectionistic overcompensator’ were the only significant schema modes that had unique predictive value of post‐treatment OCD symptom levels when controlling for levels of EMS. However, these schema modes were not significant anymore when pooled with several covariates, including depression levels, which was the only significant predictor.

In sum, there is cross‐sectional evidence for a relation between EMS and schema modes and symptom severity in anxiety disorders and OCD, and some preliminary evidence of the predictive value of EMS for treatment outcome in these populations. However, with no studies on the predictive value of schema modes in anxiety disorders, and only one study in inpatients with a chronic course of OCD (Thiel et al., 2014), there is a clear gap in the current literature. Hypothetically, schema modes may hamper effective CBT in several ways. For example, difficulties in regulating intense emotions in elevated maladaptive child modes and coping modes could lower commitment for exposure exercises and reduce the corrective experiences for harm expectancies. Safety behaviours might be reinforced by maladaptive coping modes such as dissociation or taking anxiety medication to reduce overwhelming emotions during exposure (Farrell & Shaw, 2012). Extremely high standards in a critic mode may interfere with the patient's willingness to take risks and face uncertainties (Kyrios et al., 2015). Maladaptive modes may also hinder the therapeutic relationship, which is in turn predictive of CBT success (Keeley et al., 2008; Keijsers et al., 2000). Conversely, a sufficiently strong healthy adult mode may be required to adopt beliefs beneficial for exposure outcome, such as understanding that absolute certainty is not realistic, mistakes are part of life, and negative emotions can be tolerated (Kyrios et al., 2015).

In the present study we tested the predictive value of schema modes on treatment outcome in 100 patients with an anxiety disorder or OCD receiving CBT with exposure (and response prevention). We hypothesized that (1) a higher level of pre‐treatment maladaptive modes (i.e., maladaptive child modes, critic modes and coping modes) would predict poorer CBT outcome and that (2) a higher level of pre‐treatment adaptive modes (i.e., healthy adult and happy child) would predict better CBT outcome. Relationships between the four schema mode categories (i.e., maladaptive child modes, critic modes, coping modes and adaptive modes) and CBT outcome were analysed exploratively.

METHODS

Participants

Participants were recruited from a specialized outpatient mental healthcare setting in the Netherlands. Inclusion criteria were: age between 18 and 65 years and a current primary classification of panic disorder, social anxiety disorder (SAD), generalized anxiety disorder (GAD) or OCD according to the DSM‐5 (American Psychiatric Association, 2013), determined through the Mini International Neuropsychiatric Interview (Overbeek et al., 1999) administered by a trained clinician as part of routine care. Patients were excluded for treatment if they had a current psychotic episode, substance abuse disorder, intellectual disability, insufficient Dutch language skills or if their upcoming CBT treatment included (elements of) ST or another psychotherapy focused on personality disorders.

An a priori sample size calculation was performed with G*power for F‐tests for linear multiple regression analysis (Faul et al., 2009) with seven predictors: four categories of schema modes (maladaptive child modes, critic modes, coping modes and adaptive modes), pre‐treatment psychological distress and treatment intensity (standard or intensive; see Treatment description below). The effect size was set to medium (Cohen's f 2 of 0.15; Faul et al. (2009)), alpha to 0.05, with a power of 0.80. The required sample size was estimated at N = 103.

In total, 141 participants were recruited, of which 41 were excluded from the analyses: 31 due to missing values on either the post‐treatment OQ‐45 or the Schema Mode Inventory (SMI), and 10 due to treatment dropout. The final dataset contained 100 participants including 60 women and 40 men, with a mean age of M = 32.49 years (SD = 11.28). Most participants had either a medium (43%) or high (43%) level of education, with 14% having a low educational level. OCD (56%) and panic disorder (30%) were the most prevalent primary diagnoses. GAD and SAD were less frequent (respectively 8% and 6%). Most participants (64%) received the intensive treatment form. The privacy rights of our participants have been observed and informed consent was obtained.

Treatment

All participants received outpatient manualized disorder‐specific CBT in standard or intensive form by licensed and CBT‐trained psychologists. The standard CBT consisted of 12 sessions either provided in one‐hour weekly sessions for 12 weeks, or twice weekly 1‐hour sessions for 6 weeks (Keijsers et al., 2017). The intensive CBT program (only available for panic disorder and OCD) consisted of either four intensive days in 1 week, or eight intensive days in 2 weeks with three or four 90‐min sessions per day, followed by 4 weeks of 90‐min weekly booster sessions. All treatments were administered by licensed CBT‐trained psychologists in an outpatient mental healthcare facility specialized in the treatment of anxiety disorders, OCD and PTSD. Disorder‐specific evidence‐based CBT manuals were provided according to guidelines for anxiety disorders and OCD (Balkom et al., 2024; National Institute for Health and Care Excellence, 2014). Patients with panic disorder received interoceptive exposure, exposure in vivo and cognitive restructuring according to the CBT manual of Kampman et al. (2017). For patients with OCD, the CBT manual consisted of exposure with response prevention and cognitive interventions (Verbraak et al., 2017). Patients with SAD were treated according to the CBT manual of Voncken and Allart (2017), which based on a combination of treatment models (Clark, 2001; Clark & Wells, 1995; Hofmann & Otto, 2008). This CBT manual contains experiential exercises to demonstrate the adverse effects of self‐focused attention and safety‐seeking behaviours, video feedback, systematic training in externally focused attention, modification of problematic pre‐ and post‐event processing, exposure, behavioural experiments and imagery rescripting. Patients with GAD received the metacognitive treatment manual (van der Heiden et al., 2009) based the cognitive model of GAD (Wells, 1995, 2013) and consisted of Socratic dialogue, cognitive techniques, behavioural experiments and exposure. Psychoeducation and relapse prevention were provided in all treatments (Keijsers et al., 2017). The intensive CBT programme includes exposure as the main intervention (i.e., interoceptive exposure, exposure in vivo and/or ERP), with added psychoeducation, case conceptualization, targeting family accommodation by increasing the quality of social support, and relapse prevention (Mobach et al., 2025).

Measures

Sample characteristics

Information on demographic variables (sex, age, level of education) and treatment intensity (standard, intensive) was collected from the patient files.

Disorder‐specific symptoms were assessed within the relevant subgroups of our sample. The Panic Disorder Severity Scale (PDSS; Shear et al., 1997; Houck et al., 2002) was used to assess the severity of the core symptoms of panic disorder. The PDSS is a 7‐item questionnaire and items are scored on a 5‐point Likert scale ranging from 0 (no/none) to 4 (extreme/extremely) with a maximum score of 28. Reference scores for PDSS severity are as follows: 0–3 = ‘Normal’; 4–5 = ‘Borderline ill’; 6–9 = ‘Mildly ill’; 10–16 = ‘Moderately ill’; 17–21 = ‘Markedly ill’ and 22–28 = ‘Severely ill’ (Keough et al., 2012). The clinician‐rated version of the PDSS was used in the intensive CBT programme, whereas the self‐report version was used in the standard CBT programme. Both versions of the PDSS demonstrate good reliability and validity (Houck et al., 2002; Shear et al., 2001), with Cronbach's alpha in the current study between .703 and .849.

Social anxiety symptoms were assessed with the Liebowitz Social Anxiety Scale (LSAS; Liebowitz, 1987). This questionnaire consists of 24 descriptions of social situations for which the degree of anxiety and avoidance is self‐rated on a 4‐point Likert scale ranging from 0 (none/never) to 3 (severe/usually), with sum scores ranging between 0 and 144. A total score above 50 is considered a clinical level of symptom severity (Balkom et al., 2004). The LSAS is a reliable and valid instrument for measuring social anxiety symptoms (Fresco et al., 2001; Heimberg et al., 1999). Cronbach's alpha in the current study was .93.

GAD severity was measured with the Penn State Worry Questionnaire (PSWQ; Meyer et al., 1990; van Rijsoort et al., 1997). The PSWQ is a 16‐item questionnaire designed to assess worry severity independent of worry content. Items refer to the frequency, intensity and perceived uncontrollability of worrying on a 5‐point Likert scale from 1 (not at all typical of me) to 5 (very typical of me) with a sum score range of 16–80. Higher scores represent a greater tendency to worry with the following reference scores: <29 = ‘Very low’; 29–38 = ‘Low’; 39–48 = ‘Average’; 49–59 = ‘High’; >59 = ‘Very high’ (van der Heiden et al., 2009). The PSWQ has good psychometric properties (Kerkhof et al., 2000; van der Heiden et al., 2009). For reasons we could not ascertain, but likely due to chance given the small subsample (n = 8), the Cronbach's alpha in the current study was unexpectedly low (.26). The PSWQ was included as a descriptive measure only; therefore this did not impact the analyses.

The Yale‐Brown Obsessive–Compulsive Scale (Y‐BOCS; Arrindell & de Vlaming, 1999; Goodman, Price, Rasmussen, Mazure, Fleischmann, et al., 1989) was used to assess OCD severity. The Y‐BOCS is a semi‐structured interview with 10 items on obsessions and compulsions. It was administered by a trained clinician. All items are rated on a 5‐point Likert scale ranging from 0 (no symptoms) to 4 (extreme symptoms) with sum scores ranging between 0–40. Higher scores reflect higher OCD symptom severity, with the reference scores: 0–7 = ‘No OCD’; 8–15 = ‘Mild OCD’; 15–25= ‘Moderate to severe OCD’ and 25–40 = ‘severe OCD’ (Balkom et al., 2004). The Y‐BOCS has good psychometric properties (Goodman, Price, Rasmussen, Mazure, Delgado, et al., 1989; Goodman, Price, Rasmussen, Mazure, Fleischmann, et al., 1989). Cronbach's alpha in this study was acceptable (.73).

Schema modes

The Schema Mode Inventory (SMI; Lobbestael et al., 2010; Young, 2007) was used to assess the presence of schema modes. The SMI consists of 118 items rated on a 6‐point Likert scale ranging from 1 (never or hardly ever) to 6 (always). The number of items per schema mode subscale range from 4 to 10. For our hypotheses, scores were clustered into adaptive modes (Happy Child and Healthy Adult) and maladaptive modes (the remaining 12 modes) in line with previous research (Peeters et al., 2021; Schaap et al., 2016). For the exploratory analyses, we calculated four schema mode categories (Lobbestael et al., 2008; Young et al., 2003): maladaptive child modes (Vulnerable Child, Angry Child, Enraged Child, Impulsive Child and Undisciplined Child), critic modes (Punitive Parent and Demanding Parent), coping modes (Compliant Surrender, Detached Protector, Detached Self‐Soother, Self‐Aggrandizer and Bully & Attack) and adaptive modes (Happy Child and Healthy Adult). The SMI shows good reliability and validity (Lobbestael et al., 2010). Cronbach's alphas in the current sample were .89 (adaptive modes), .94 (maladaptive modes), .91 (maladaptive child modes), .90 (critic modes) and .86 (coping modes).

Psychological distress

The Outcome Questionnaire‐45 (OQ‐45; (de Jong & Nugter, 2004; Lambert et al., 1996)) is a widely used transdiagnostic treatment outcome questionnaire (de Jong et al., 2007; Hatfield & Ogles, 2004). The 45 items assess symptom distress, problems in interpersonal relations, and problems in social role performance. Items are rated on a 5‐point Likert scale with a range from 0 (never) to 4 (always) with a range of 0–180. The OQ‐45 has good psychometric properties (de Jong et al., 2007). Cronbach's alpha was .92 at pre‐treatment and .95 at post‐treatment.

Procedure

Except for the SMI, all measures were part of the Routine Outcome Monitoring (ROM) in standard care. All measures were collected pre‐treatment. The OQ‐45 was additionally administered post‐treatment. For pragmatic reasons related to the reality of collecting data in a clinical setting, pre‐treatment assessments were allowed up to 2 weeks after weekly standard treatment started (n = 6), or up to 1 week after twice‐weekly standard treatment started (n = 4). Pre‐treatment assessments were not eligible for inclusion if active interventions (i.e., exposure, response prevention or cognitive interventions) had already taken place. This was verified by the therapist providing the treatment. Participants in the intensive treatment completed pre‐treatment assessments 1–2 weeks before treatment started. One participant completed the assessment on the first day of treatment.

The OQ‐45 post‐treatment assessment was completed with a leniency of 2 weeks before and 2 weeks after end of treatment for the weekly standard treatment, and a leniency of 1 week before and after treatment completion for the twice‐weekly standard treatment and intensive treatment.

Statistical analyses

All analyses were performed using IBM SPSS Statistics 25 (IBM Corp, 2019) and Python Anaconda Spyder version 2.7 (Raybaut, 2009). Assumptions were verified prior to analyses. Pre‐treatment Y‐BOCS scores were missing for three participants with an OCD diagnosis. There were no other missing data. Multivariate outliers were identified with Mahalanobis distances. Univariate outliers were determined using standard residuals (Field, 2013). The reported analyses include all observations. When excluding outliers changed the significance of the respective analysis, this is reported explicitly.

To test our main hypothesis, a multiple regression analysis with OQ‐45 post‐treatment scores as the dependent variable was run (alpha = .05). Pre‐treatment OQ‐45 scores and treatment intensity (standard, intensive) were entered as predictors in the first model to control for pre‐treatment symptom severity (Eskildsen et al., 2010; Haby et al., 2006) and treatment intensity (Tiemens et al., 2019). SMI maladaptive modes and SMI adaptive modes were added as predictors in the second model. For our exploratory analyses, the regression analysis was repeated with the four SMI mode categories (maladaptive child modes, critic modes, coping modes, adaptive modes) as predictors in the second step.

RESULTS

Descriptive statistics

Clinical characteristics are reported in Table 1. On average, the sample showed high levels of pre‐treatment psychological malfunctioning and moderate to severe levels of disorder‐specific symptoms. A paired sample t‐test indicated a significant overall reduction of 16% in OQ‐45 scores from pre‐treatment to post‐treatment, t(99) = 6.27, p < .001, d = .63.

TABLE 1.

Clinical characteristics of the sample (N = 100).

Measure M SD Range (min – Max)
Y‐BOCS (n = 53) 25.68 5.20 10–37
PDSS (n = 30) 14.53 5.21 4–28
PSWQ (n = 8) 67.25 3.65 61–71
LSAS (n = 6) 67.17 22.33 39–98
SMI maladaptive modes 2.23 0.44 1.14–3.50
SMI maladaptive child modes 2.10 0.48 1.02–3.52
SMI critic modes 2.59 0.81 1.06–5.29
SMI coping modes 2.20 0.45 1.13–3.38
SMI adaptive modes 3.70 0.69 1.85–5.70
OQ‐45 pre‐treatment 75.09 20.76 11–117
OQ‐45 post‐treatment 62.65 24.10 15–112
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Abbreviations: LSAS, Liebowitz Social Anxiety Scale; OQ‐45, Outcome Questionnaire‐45; PDSS, Panic Disorder Severity Scale; PSWQ, Penn State Worry Questionnaire; SMI, Schema Mode Inventory; Y‐BOCS, Yale‐Brown Obsessive–Compulsive Scale.

Predicting CBT outcome with maladaptive and adaptive schema modes

Results of the regression analysis are displayed in Table 2. The first model, including pre‐treatment OQ‐45 scores and treatment intensity, explained a significant 39% of the variance in post‐treatment OQ‐45 scores. Only pre‐treatment OQ‐45 scores was a significant predictor. The second model added another 7% of explained variance uniquely attributed to the SMI maladaptive and SMI adaptive modes. SMI maladaptive modes and SMI adaptive modes were both significant predictors, and the influence of pre‐treatment OQ‐45 scores became non‐significant. Maladaptive modes were associated with higher OQ‐45 scores at post‐treatment, whereas adaptive modes were associated with lower OQ‐45 scores post‐treatment.

TABLE 2.

Results of the multiple regression analysis testing the predictive value of maladaptive and adaptive schema modes on post‐treatment psychological distress (n = 100).

Predictors R 2 β (95% CI) Standardized β p‐value sr 2
Model 1. 0.390 <.001***
OQ‐45 pre‐treatment .695 [0.508, 0.882] 0.599 <.001*** .585
Treatment intensity 4.590 [−3.454, 12.634] 0.092 .260 .090
Model 2. 0.458 .004**
OQ‐45 pre‐treatment .282 [−0.016, 0.579] 0.242 .063 .142
Treatment intensity 4.447 [−3.220, 12.113] 0.089 .252 .087
SMI maladaptive mode 12.941 [1.816, 24.065] 0.235 .023* .174
SMI adaptive mode −9.71 [−17.207, −2.209] −0.278 .012* −.194
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Abbreviations: OQ‐45, Outcome Questionnaire‐45; SMI, Schema Mode Inventory.

*p < .05, **p < .01, ***p < .001.

Exploratory analysis: Predicting CBT outcome by four schema mode categories

Results are displayed in Table 3. The four schema mode categories uniquely explained an additional 9% in variance. Only SMI maladaptive child modes and adaptive modes significantly predicted post‐treatment OQ‐45 scores. Maladaptive child modes were associated with higher OQ‐45 scores at post‐treatment, whereas adaptive modes were associated with lower OQ‐45 scores post‐treatment. Pre‐treatment OQ‐45 scores became non‐significant. Inspection of the z‐scores, however, revealed one univariate outlier in post‐treatment OQ‐45 scores (z = −3.34) in this second regression analysis. Although the case had no undue influence on the model according to Cook's distance (<1), adaptive modes were no longer a significant predictor when this outlier was excluded (β = −0.18, p = .10, 95% CI [−13.48, 1.12]).

TABLE 3.

Results of the multiple regression analysis exploring the predictive value of four schema mode categories (Maladaptive Child Modes, Critic Modes, Coping Modes and Adaptive Modes) on post‐treatment psychological distress assessed with the OQ‐45 (N = 100).

Predictors R 2 β (95% CI) Standardized β p‐value sr 2
Model 1. 0.390 <.001***
OQ‐45 pre‐treatment .695 [0.508, 0.882] 0.599 <.001*** .585
Treatment intensity 4.590 [−3.454, 12.634] 0.092 .260 .090
Model 2. 0.478 .006**
OQ‐45 pre‐treatment .231 [−0.076, 0.539] 0.199 .139 .112
Treatment intensity 5.614 [−2.098, 13.326] 0.112 .152 .108
SMI maladaptive child modes 15.449 [3.296, 27.602] 0.308 .013* .189
SMI critic modes 2.641 [−2.859, 8.141] 0.089 .343 .071
SMI coping modes −4.260 [−15.496, 6.976] −0.079 .453 −0.56
SMI adaptive modes −8.922 [−16.610, −1.233] −0.256 .023* −.173
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Abbreviations: OQ‐45, Outcome Questionnaire‐45; SMI, Schema Mode Inventory.

*p < .05, **p < .01, ***p < .001.

DISCUSSION

We tested the added predictive value of schema modes on CBT outcome in a transdiagnostic sample consisting of patients with a primary diagnosis of OCD or an anxiety disorder. We controlled for pre‐treatment levels of psychological distress and treatment intensity. Consistent with our hypotheses, higher pre‐treatment maladaptive schema modes predicted poorer psychological distress at post‐treatment, whereas higher pre‐treatment adaptive schema modes predicted less psychological distress at post‐treatment. Exploratory analyses showed that maladaptive child modes specifically were associated with poorer response, although the effect was small. Adaptive modes were associated with slightly better response, but this effect became non‐significant after removing an outlier.

To our knowledge, this is the first study on the predictive value of schema modes in CBT treatment outcome for anxiety disorders, and the second for OCD. Compared with the earlier study in OCD (Thiel et al., 2014), our findings converge on maladaptive child modes being predictive of poorer CBT (with ERP) outcomes. In the Thiel et al. study, the vulnerable child mode specifically was elevated in inpatient treatment non‐responders compared with responders. It was a significant predictor of change in OCD symptoms. The vulnerable child is generally considered the central child mode in ST and involves experiencing high levels of fear/sadness and helplessness (Bär et al., 2023), which fits with the symptoms of anxiety disorders and OCD. The limited research on the presence of schema modes in anxiety disorders and OCD suggests that the vulnerable child mode is elevated in panic disorder and OCD compared with non‐clinical populations. Still, it does not clearly discriminate panic disorder and OCD from other clinical disorders (Bär et al., 2023). Together, this gives rise to the question whether the vulnerable child mode may be a general risk factor for poorer (CBT) treatment outcomes. However, given the small effect sizes in both our study and the Thiel et al. study, this finding needs to be replicated first to test its robustness.

Contrary to the Thiel et al. (2014) study, we did not find a significant effect for coping modes. In their study, non‐responders showed a higher detached protector and bully and attack mode than responders, and an exploratory ‘perfectionistic overcompensator’ mode was a significant predictor of CBT outcome after controlling for EMS effects (although this became non‐significant after controlling for other covariates, such as depression). Furthermore, studies on the presence of schema modes in OCD showed that stronger critic modes appear to be related to higher symptom severity (Basile et al., 2017) and to discriminate OCD from other clinical disorders (specifically chronic pain and eating disorders) (Basile et al., 2017; Voderholzer et al., 2014). Similar results were found in the one study on schema modes in (social) anxiety disorder where correlations between several coping and critical modes and symptom severity were reported (Norton et al., 2023). Overall, there is preliminary evidence for the presence of child, critic and coping schema modes in OCD (but a lack of research in anxiety disorders) that are more and less disorder‐specific. The findings of the Thiel et al. (2014) study and our findings suggest that the vulnerable/maladaptive child modes are specifically related to CBT treatment outcome in OCD and anxiety disorders. However, their impact on treatment outcome in these populations is very modest, suggesting that the presence of schema modes is unlikely to interfere with treatment. Yet, these findings must be replicated in future studies given the limited data available.

In terms of adaptive modes (i.e., healthy adult and happy child), our results were inconclusive. Initially, a significant positive relation between the adaptive modes and treatment outcome emerged, but this appeared to be driven by a single score that barely met our threshold of statistical outliers. In the Thiel et al. (2014) study, non‐responders had a lower happy child mode than responders, although this mode was not associated with treatment outcome. Research on the presence of schema modes in OCD suggests that adaptive modes may be stronger in OCD than in chronic pain and eating disorders (Voderholzer et al., 2014), and lower in OCD than in non‐clinical groups (Basile et al., 2017), but this does not provide further insight into the relation between adaptive modes and treatment outcome. For anxiety disorders, there is, so far, no information on the presence of adaptive modes (Bär et al., 2023; Norton et al., 2023) or their relation to treatment outcome.

The literature on EMS as a predictor of treatment outcome similarly shows inconsistent findings and small effects or null findings (see Halford et al. (2002) for a mixed MDD and anxiety disorders sample, and Haaland et al. (2011); Sunde et al. (2019); Thiel et al. (2014) for OCD samples). A preliminary impression of the literature is that there is yet no convincing data showing that EMS and schema modes are strong or consistent predictors of (CBT) treatment outcome for patients with anxiety disorders or OCD. However, the number of studies is still very limited, and it is premature to draw a definitive conclusion. Furthermore, there is emerging evidence that ST can be effective for patients with anxiety disorders and OCD who did not benefit from CBT, and for those patients with comorbid personality disorders (Peeters et al., 2021, 2022; Remmerswaal et al., 2023; Taylor et al., 2017; Thiel et al., 2016). Additionally, several studies (but not all) showed poorer CBT outcome for patients with comorbid personality disorders (Keeley et al., 2008; Porter & Chambless, 2015; Reich, 2003; Thiel et al., 2013); but see Dreessen and Arntz (1999); Olatunji et al. (2013); Ramnerö and Öst (2004). Perhaps EMS and schema modes predict CBT outcome only when they exceed a specific (clinical) threshold. If so, it remains an empirical question whether schema modes actively interfere with CBT or whether higher levels of EMS and schema modes merely indicate greater symptom severity or comorbidity.

Several limitations of this study require mentioning. First, although ecological validity is a strength of this naturalistic observational study, no causal conclusions can be drawn about the association between schema modes and treatment outcome due to its correlational design. Furthermore, our data included only pre‐ and post‐treatment assessments, so it is not possible to test whether changes in schema modes preceded symptom change, as would be expected if we reason that schema modes interfere with CBT delivery. Second, our clinical sample was skewed towards a relatively large proportion of participants with an OCD diagnosis (56%). We therefore conducted a post‐hoc analysis to test whether the findings were comparable for patients with OCD and patients with anxiety disorders in our sample. The primary regression analysis was repeated with additional predictors representing the interaction terms of diagnostic group (OCD versus anxiety disorder [i.e., SAD, GAD and panic disorder]) and maladaptive schema modes, adaptive schema modes and CBT intensity, respectively. The diagnostic group interaction terms did not significantly improve model fit (ΔR 2 = .007, ns) and were all non‐significant (all p > .05). This suggests that the pattern of findings was comparable for the OCD and anxiety disorders group. Nevertheless, there may be relevant differences between the different anxiety disorders which could not be detected in the current study. Finally, the OQ‐45, which we used as a transdiagnostic symptom measure, may be less sensitive than disorder‐specific symptom measures, which could have possibly overshadowed significant relations with schema modes.

CONCLUSIONS

To conclude, our study contributes to the literature as the first empirical study testing the added predictive value of schema modes on CBT treatment outcome for patients with OCD or anxiety disorders. Our results indicate that higher levels of maladaptive child modes at the start of treatment may predict poorer CBT outcomes, but only to a small degree. Adaptive schema modes predicted better CBT outcomes, yet this finding was not robust as it depended on one outlier. Given the small effect sizes, there is yet no substantial evidence that elevated schema modes are predictive of a poorer CBT outcome in this population. However, our findings are preliminary and need to be replicated before drawing firm conclusions.

Should schema modes prove to be a robust (albeit small) predictor, further research is needed to disentangle what role schema modes play in attenuating treatment effects. In light of the limitations of our study, further research is needed for (1) specific (anxiety) disorders, (2) using disorder‐specific symptom measures, (3) preferably with a longitudinal mediational design and (4) including sufficiently large subgroups of patients with low and high levels of schema modes.

AUTHOR CONTRIBUTIONS

Manon Peeters: Conceptualization; data curation; formal analysis; investigation; methodology; project administration; writing – original draft; writing – review and editing. Boris van Passel: Conceptualization; data curation; methodology; resources; supervision; writing – original draft; writing – review and editing. Nancy Peeters: Data curation; formal analysis; investigation; project administration; software; writing – original draft; writing – review and editing. Julie Krans: Conceptualization; data curation; formal analysis; methodology; project administration; resources; supervision; writing – original draft; writing – review and editing.

FUNDING INFORMATION

This research did not receive any specific grant from funding agencies in the public, commercial or not‐for‐profit sectors.

CONFLICT OF INTEREST STATEMENT

The authors declare that they have no known competing financial interests or personal relationships that could have influenced the work reported in this paper.

ETHICS STATEMENT

All procedures were performed in compliance with the World Medical Association Declaration of Helsinki and all relevant laws and institutional guidelines. The study was approved by the Radboud University ethics committee (ECSW‐2019‐123) on 9 January 2020.

ACKNOWLEDGEMENTS

We would like to thank all the participants of this study, and Laura Wesseldijk for her help with the statistical analyses and providing feedback to the manuscript. We are also grateful to Jan Spijker, MD, for acting as our independent physician.

DATA AVAILABILITY STATEMENT

The study was pre‐registered (As predicted #98979), and the anonymized data are publicly available at https://osf.io/zwvde/.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The study was pre‐registered (As predicted #98979), and the anonymized data are publicly available at https://osf.io/zwvde/.

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