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Samane Ghadampour; Kourosh Amraei; Masoud Sadeghi
Abstract
Objective: Health anxiety, characterized by excessive worry about having a serious illness, leads to significant functional impairment. Its etiology involves complex cognitive-emotional mechanisms. This study proposes and tests a novel integrated mediation model to elucidate these pathways. We posit ...
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Objective: Health anxiety, characterized by excessive worry about having a serious illness, leads to significant functional impairment. Its etiology involves complex cognitive-emotional mechanisms. This study proposes and tests a novel integrated mediation model to elucidate these pathways. We posit that Early Maladaptive Schemas (EMS)-deep-seated cognitive structures-predispose individuals to dysfunctional health interpretations. Building on schema and metacognitive theories, we hypothesize that EMS activate specific health-related metacognitive beliefs. These beliefs, in turn, are central in initiating maladaptive cognitive processes encapsulated by the Cognitive-Attentional Syndrome (CAS), which includes persistent worry, threat monitoring, and counterproductive coping, and its behavioral manifestation in online health-seeking, known as cyberchondria. Concurrently, emotion dysregulation is theorized to interact with and exacerbate these cognitive pathways, creating a vicious cycle that maintains health anxiety. The primary aim is to examine both direct and indirect associations between EMS and health anxiety, with health-related metacognitive beliefs, CAS, cyberchondria, and emotion dysregulation serving as sequential and parallel mediating variables. Testing this comprehensive model provides a holistic etiological framework for health anxiety, integrating predisposing vulnerabilities with maintaining factors. Confirmation of these pathways holds significant clinical implications, suggesting that effective interventions should target not only surface-level worries but also the underlying schemas,metacognitive beliefs, attentional processes, and emotion regulation strategies that perpetuate this debilitating condition. Method: This study employed a cross-sectional correlational design to examine the proposed model. The target population consisted of all single and married women aged 18 to 55 years in Tehran, Iran, with a clinically confirmed diagnosis of health anxiety, who had attended specialized or pain clinics at Shariati and Imam Khomeini Hospitals during the 2024 calendar year. A convenience sampling method was used to recruit an initial pool of 310 eligible participants. Following a comprehensive data screening procedure, which included checks for unengaged responding and multivariate outliers, data from 259 participants were retained for the final analysis, ensuring robust data quality. Participants completed a battery of validated self-report questionnaires, including: the Health Anxiety Inventory (HAI), the Schema Questionnaire—Short Form (YSQ-S3; Young, 2005), the Health-related Metacognitions Questionnaire (H-MCQ; Bailey & Wells, 2015), the Cognitive-Attentional Syndrome Scale (CAS-1; Wells., 2009), the Difficulties in Emotion Regulation Scale (DERS; Bjureberg et al,2016) and the Cyberchondria Severity Scale (McElroy et al., 2019). The hypothesized conceptual model, positing both direct and indirect pathways between early maladaptive schemas and health anxiety via multiple mediators, was tested using structural equation modeling (SEM). The analyses were conducted using two specialized statistical software packages, LISREL (version 8.80) and Mplus (version 7.4), to ensure the reliability and validity of the model fit indices and parameter estimates. Ethical approval for the study was obtained prior to data collection. Results: The structural equation modeling analysis revealed a differentiated pattern of significant and non-significant pathways within the hypothesized model. The following direct paths were not statistically significant: from the Vulnerability to Harm/Illness schema to Health Anxiety; from the Negativity/Pessimism schema to the Cognitive-Attentional Syndrome (CAS), Cyberchondria, and Health Anxiety; from the Insufficient Self-Control/Self-Discipline schema to CAS; and from Emotion Dysregulation to Health Anxiety. All other specified paths demonstrated significant coefficients. Regarding direct effects, the Vulnerability to Harm/Illness schema exerted significant, strong positive effects on Health-related Metacognitive Beliefs (β=0.59), CAS (β=0.68), Emotion Dysregulation (β=0.43), and Cyberchondria (β=0.72). The Negativity/Pessimism schema had significant, moderate positive effects on Metacognitive Beliefs (β=0.29) and Emotion Dysregulation (β=0.21). Conversely, the Insufficient Self-Control/Self-Discipline schema showed a significant but weak negative direct effect on Health Anxiety (β=-0.14), as well as negative effects on Metacognitive Beliefs (β=-0.14) and Cyberchondria (β=-0.13),alongside a positive effect on Emotion Dysregulation (β=0.21). Crucially, the mediating variables-Health-related Metacognitive Beliefs (β=0.33), CAS (β=0.25), and Cyberchondria (β=0.39)-all had significant positive direct effects on Health Anxiety. Analysis of indirect effects using bootstrapping was pivotal. For the Vulnerability to Harm/Illness schema, all specific indirect pathways to Health Anxiety were significant: via Metacognitive Beliefs (β=.194), via CAS (β=.168), and via Cyberchondria (β=.277), resulting in a significant total indirect effect (β=.640). In stark contrast, for the Negativity/Pessimism schema, none of the specific indirect pathways (via Metacognitive Beliefs: β=.096; via CAS: β=.009; via Cyberchondria: β = .030) nor the total indirect effect (β=.135) reached statistical significance. Similarly, for the Insufficient Self-Control schema, all specific indirect paths and the total indirect effect (β=-.069) were non-significant.Conclusion: This study provides evidence for a model of health anxiety, elucidating the pathways through which early maladaptive schemas contribute to the disorder. The findings demonstrate a direct effect of the insufficient self-control schema and an indirect effect of the vulnerability to harm schema, mediated by metacognitive processes and cyberchondria. These results advance our understanding of the underlying mechanisms of health anxiety.The results indicate that health anxiety is not a linear outcome of schema activation but rather the end product of a complex cognitive chain. Schemas require specific mediating factors namely, dysfunctional metacognitive beliefs and cyberchondric behaviors to manifest as clinical health anxiety symptoms. Consequently, therapeutic interventions for health anxiety, particularly in individuals with these schemas, should prioritize restructuring maladaptive metacognitive beliefs, modifying attentional biases, and reducing excessive online health-seeking behaviors (cyberchondria). Targeting these mediating processes is crucial for mitigating the influence of core cognitive schemas on the development and maintenance of health anxiety.
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Roghayeh Asgarnejad; Atefeh Hojjati
Abstract
Objective: Breast cancer is the most prevalent malignancy among women worldwide, and its experience significantly elevates the likelihood of developing somatization symptoms, thereby imposing substantial healthcare costs (Arnold et al., 2022; Moran et al., 2023). Identifying factors influencing these ...
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Objective: Breast cancer is the most prevalent malignancy among women worldwide, and its experience significantly elevates the likelihood of developing somatization symptoms, thereby imposing substantial healthcare costs (Arnold et al., 2022; Moran et al., 2023). Identifying factors influencing these symptoms is therefore imperative. Personality organization, as a foundational psychological construct, plays a pivotal role in psychosomatic responses to stress, with specific personality traits demonstrably linked to mental health outcomes and adaptation processes in cancer patients (Kovács et al., 2021; Cerezo et al., 2020). Conversely, somatization frequently stems from an inability to directly express negative emotions, a process exacerbated by "entrapment", a psychological state commonly observed in cancer populations and associated with particular personality dimensions such as neuroticism (Çetin & Varma, 2021; Chen et al., 2022). Despite existing evidence, prior research has predominantly focused on direct relationships between Five-Factor Model personality traits and psychosomatic outcomes, exhibiting two critical limitations: first, neglecting the comprehensive theoretical framework of "personality organization," and second, failing to examine the mediating role of entrapment as a key mechanism in chronic cancer-related stress responses. This research gap is particularly pronounced among Iranian women with breast cancer, who face unique cultural challenges (Hosseini et al., 2023). Consequently, the present study employs structural equation modeling to investigate the relationship between personality organization and somatization symptoms, incorporating entrapment as a mediating variable. The primary objective is to determine whether these variables collectively predict somatization symptoms in this population. Method: This fundamental research utilized a descriptive-correlational design. The statistical population comprised all women diagnosed with breast cancer attending Shahid Tajrish Hospital in Tehran during the Iranian calendar years 1402–1403 (2023–2024). Adhering to structural equation modeling principles (Kline, 2012), a sample size of 200 participants was determined and selected via purposive sampling based on predefined inclusion and exclusion criteria. Assessment instruments included the Stress Symptom Checklist (Cheng & Hamid, 1996) for measuring somatization, the Personality Organization Questionnaire (Kernberg, 2002), and the Entrapment Questionnaire (Gilbert & Allan, 1998). The validity and reliability of these tools have been established in both international and Persian-language studies (Shaker, 2018; Ghamarani et al., 2013; Cheng & Hamid, 1995). Following informed consent acquisition, data were collected through self-report questionnaires. Data analysis employed descriptive and inferential statistical methods, specifically path analysis within a structural equation modeling framework using SPSS and AMOS software. This analytical approach enabled examination of direct and indirect relationships among personality organization, entrapment, and somatization symptoms within a cohesive theoretical model. Results: Personality organization demonstrated a significant positive direct effect on entrapment (standardized coefficient β = 0.593, p <.001). Both entrapment (β=0.264, p=.005) and personality organization (β=0.473, p<.001) exhibited significant direct effects on somatization symptoms. Bootstrap testing (Table 1) revealed a significant indirect effect of personality organization on somatization symptoms through entrapment (β=0.156, p=.014), confirming that diminished personality organization intensifies entrapment, subsequently amplifying somatization symptoms at the 5 percent significance level.Conclusion: This study demonstrates that deficits in personality organization predict somatization symptoms in women with breast cancer both directly and indirectly through the mediating role of entrapment. These findings suggest that individuals with maladaptive personality structures lack effective emotion regulation and stress-processing mechanisms, leading them to suppress psychological distress related to their illness and unconsciously manifest it as physical pain or fatigue (Lipowski, 1988). Within this pathway, entrapment functions as a critical missing link: personality disorganization fosters perceptions of helplessness and being trapped by the disease (O'Connor & Portzky, 2018), thereby intensifying the conversion of psychological suffering into physical symptoms. Consistent with prior research (Hosseini et al., 2023; Kang et al., 2023), these results underscore the necessity of transcending purely biological perspectives on cancer. Practically, therapeutic interventions should extend beyond physical symptom management to address personality structure reconstruction and reduction of entrapment feelings. Approaches such as Emotion-Focused Therapy or Cognitive-Behavioral Therapy may disrupt the vicious cycle of somatization by facilitating direct emotional expression and restoring perceived control (Çetin & Varma, 2021). Although limitations exist, including the cross-sectional design and uncontrolled clinical variables, this model provides a valuable framework for developing integrated psychosomatic care protocols tailored to the Iranian cultural context, where direct expression of psychological distress often encounters social barriers.
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Pourandokht Niroumand; Mahnaz Aliakbari Dehkordi; Nazanin Abed; Ahmad Alipour
Abstract
Objective: Intimacy is conceptualized as the capacity for self-awareness in the presence of others, driven by a motivation to cultivate meaningful social integration. Given its pivotal role in psychological well-being, this study aims to elucidate the lived experiences of intimacy among resilient ...
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Objective: Intimacy is conceptualized as the capacity for self-awareness in the presence of others, driven by a motivation to cultivate meaningful social integration. Given its pivotal role in psychological well-being, this study aims to elucidate the lived experiences of intimacy among resilient Iranian women who have recovered from COVID-19. Method: Employing a descriptive phenomenological approach, Data were collected through semi-structured interviews with 12 Iranian women after reaching theoretical saturation. The purposive sampling method is criterion-based to select individuals who have real-life experience with the phenomenon in question. Participants were women who had recovered from COVID-19 and scored above 85 on the SPF-24 resilience scale. Interview transcripts were analyzed using Colaizzi’s seven-step method include Familiarization, identifying significant statements, formulating meanings, clustering themes, Developing an Exhaustive description, Producing the fundamental structure, and Seeking verification of the fundamental structure. Results: The participants conceptualized intimacy through three main themes—deep emotional connection, intimate physical and sexual interaction, and mutual understanding and coordination in daily matters—along with nine subthemes and 95 initial codes. They employed strategies such as conflict management and problem-solving, maintaining individual autonomy within the relationship, adaptability to change, balancing work and life, social support, strengthening spirituality and shared values, humor, and recreational activities. These
strategies contributed to outcomes including marital satisfaction, trust and empathy, personal autonomy and empowerment, high-quality sexual relations, effective conflict resolution, joint decision-making, psychological security, a positive environment for children's development, happiness, and overall life satisfaction. To verify the reliability of the analysis process, the Holst reliability coefficient, which is a formula for determining the reliability of nominal data in terms of the percentage of agreement observed between the main researcher and another coding researcher, was used. PAO (Percentage Agreement over Observations) For the first theme (deep emotional connection), it is 0.864, for the second theme (intimate physical and sexual interaction), it is 0.883, and for the third theme (mutual understanding and coordination in daily), it is 0.865 and for all three themes of this study, it is 0.870, which confirmed the reliability of the analysis process.
Conclusion: The results of the lived experiences of the meaning of intimacy of resilient Iranian women recovered from Corona in three subjects: 1) Deep Emotional Connection, comprising subthemes of emotional security, empathy and mutual understanding, and trust and honesty;2) intimate physical and sexual interaction comprising subthemes of satisfying and reciprocal sexual relations, affectionate and non-sexual touches, and maintaining personal and physical dignity and boundaries and 3) mutual understanding and coordination in daily matters including three sub-themes: cooperation in home and family affairs, effective interaction in decision-making, and effective conflict resolution indicative three type of intimacy is their emotional, sexual, understanding, and empathy. These findings can be used to empower therapists and couples therapy researchers and teaching marital relationship strategies used by these women, including constructive problem-oriented and emotion-oriented strategies such as "conflict management and problem solving" and "maintaining individual independence in the relationship", marital satisfaction, trust and empathy, personal independence and empowerment, quality sexual relationships, and a positive environment for children to grow.
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MohammadReza Tamannaeifar; Mahboobe Esmikhani
Abstract
Objective: Body dysmorphic disorder is a perceptual disorder in which a person is preoccupied with one or more parts of their body that they perceive as particularly ugly or misshapen. Women with body dysmorphic disorder are intensely concerned with their breasts, buttocks, thighs, and overall weight. ...
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Objective: Body dysmorphic disorder is a perceptual disorder in which a person is preoccupied with one or more parts of their body that they perceive as particularly ugly or misshapen. Women with body dysmorphic disorder are intensely concerned with their breasts, buttocks, thighs, and overall weight. The obsessive nature of body dysmorphic disorder can cause a person to experience repeated negative feelings and discomfort about their appearance and how others perceive them, and an overall decrease in psychological and social functioning. For example, people with body dysmorphic disorder may engage in self-checking activities, such as repeatedly looking at themselves in the mirror to assess the area(s) of concern and comparing their appearance to that of others. Body dysmorphic disorder concerns (or symptoms related to body dysmorphic disorder) are distressing and can cause significant suffering and are influenced by various factors, one of which is primary maladaptive schemas. Early maladaptive schemas serve as a framework for interpreting reality that provides a stable and coherent sense of self and the world. It is clear that early maladaptive schemas are associated with body dysmorphic disorder, but what could be important is to discover and examine the role of mediating variables in the relationship between early maladaptive schemas and body dysmorphic disorder, which in this study examined the mediating role of self-esteem, because self-esteem, in addition to being affected by the antecedents of this study, namely early maladaptive schemas, can affect dysmorphic disorder. For this reason, and based on research precedents, self-esteem can be an appropriate mediating variable in the relationshis between the variables in this study. The purpose of the present study was to investigate structural equation modeling of the body dysmorphic disorder based on early maladaptive schemas with mediating role of self-esteem in women with breast cancer. Method: The method of the present research is applied in terms of its purpose and descriptive in terms of survey type, which is considered quantitative research. The statistical population of the study was women with breast cancer referral to the oncology center of Imam Khomeini and Imam Hussein Hospital of Tehran city in autumn year 2024. The sample size was selected based on Klein's model (2023) and with subjectivw sampling of 300 women. Data collection tools include the body dysmorphic disorder scale (BDDS) of Hanley and et al (2020), Young schema questionnaire – short form version 3 (YSQ-S3) of Young (2005) and self-esteem scale (RSEs) of Rosenberg (1989). The inclusion criteria for the study were diagnosis of breast cancer, being in the radiotherapy treatment phase, having a minimum level of literacy, full consent to participate in the study, the right to withdraw from the study, having sufficient time to answer the questionnaires, and not receiving psychiatric treatment. Failure to fully answer the questionnaire questions and not having the necessary cooperation to participate in the study were exclusion criteria. For descriptive data analysis, mean and standard deviation were used; for inferential data analysis, Pearson correlation coefficient and structural equation modeling were used. Data analysis software was SPSS and AMOS version 28. Results: The number of respondents was 300, and no outliers or outliers were identified in this study. The mean age and standard deviation were 37.33 and 2.92, respectively. The results showed direct effect of early maladaptive schemas and self-esteem on body dysmorphic disorder is significant. The results also showed that self-esteem has a significant mediating role in the relationship between early maladaptive schemas with body dysmorphic disorder. Also, the final research model had a good fit (RMSEA=0.07, SRMR=0.05, p<0.05) and 84% of the variance of body dysmorphic disorder is explained. Conclusion: In explaining the mediating role of self-esteem in the relationship between early maladaptive schemas and dysmorphic disorder, it can be said that when a person experiences changes in their appearance and body due to illness and considers these changes to be a kind of defect in them, they judge their body and appearance based on this perceived defect. Therefore, it is possible that the emotions and cognitions present in the schemas of self-regulation and impaired functioning react to signs of defect and show sensitivity to appearance. Given that the activity of self-regulation and impaired functioning schemas is, to some extent, accompanied by negative judgments about themselves and the experience of feelings of failure and helplessness, this feeling of failure and helplessness can lower the self-esteem of women with breast cancer, leading them to exhibit weaker self-esteem than other women. Consequently, when women with breast cancer do not have sufficient self-esteem, they feel inadequate due to the removal of the breast and the defect in the breast area, and they believe that they have a serious and major defect in their body. In such cases, they are more likely to experience body dysmorphic disorder. It can be concluded that body dysmorphic disorder in women with breast cancer can be improved with schema therapy and self-esteem training. The present study had several limitations. First, this study was a cross-sectional design. Therefore, future studies could adopt experimental or longitudinal designs to explore the relationship between variables. Data were collected using self-report questionnaires only. Although the validity and reliability of these questionnaires have been well established, response bias or socially desirable responses may have existed in the present study. The participants in this study were a sample from Tehran, so the cross-cultural applicability of the results is limited. Given that this study was conducted among women with breast cancer, future studies could also collect data from different groups of women with other chronic physical illnesses to gain more insight into the factors affecting dysmorphic disorder. The results of the present study have theoretical and practical implications. Theoretically, this study using a mediation model may help to understand the mechanisms involved and affecting dysmorphic disorder. Also, the results of the present study showed that early maladaptive schemas and self-esteem are key factors for predicting body dysmorphic disorder. Therefore, it can be concluded that body dysmorphic disorder can be improved in women with breast cancer with schema therapy and self-esteem training.
