ORIGINAL RESEARCH published: 21 January 2020 doi: 10.3389/fpsyg.2019.03022 The Potential Role of the Early Maladaptive Schema in Behavioral Addictions Among Late Adolescents and Young Adults Matteo Aloi 1 , Valeria Verrastro 2 , Marianna Rania 1 , Raffaella Sacco 1 , Fernando Fernández-Aranda 3,4,5 , Susana Jiménez-Murcia 3,4,5 , Pasquale De Fazio 1 and Cristina Segura-Garcia 2* 1 Department of Health Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy, 2 Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy, 3 Department of Psychiatry, Bellvitge University Hospital, IDIBELL, Barcelona, Spain, 4 CIBER Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, Barcelona, Spain, 5 Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain Background: Behavioral addiction (BA) is a recent concept in psychiatry. Few studies have investigated the relationship between BA and early maladaptive schemas (EMSs). Edited by: Adriano Schimmenti, EMS is the core of Schema Therapy (ST). According to the ST model, psychiatric Kore University of Enna, Italy disorders result from the development of EMSs in response to unmet emotional needs in Reviewed by: childhood. Bach et al. (2018) grouped the 18 EMSs into four domains: (1) disconnection Silvia Casale, University of Florence, Italy and rejection; (2) impaired autonomy and performance; (3) excessive responsibility and Marco Di Nicola, standards; and (4) impaired limits. This study aims to assess the possible association of Agostino Gemelli University Policlinic, the most frequent BAs with EMSs in a large group of late adolescents and young adults Italy and to evaluate their self-perceived quality of life (QoL). *Correspondence: Cristina Segura-Garcia Methods: A battery of psychological tests assessing food addiction (FA), gambling segura@unicz.it disorder (GD), internet addiction (IA), and QoL was administered to 1,075 late Specialty section: adolescents and young adults (N = 637; 59.3% women). A forward-stepwise logistic This article was submitted to regression model was run to identify which variables were associated with BAs. Psychopathology, a section of the journal Results: Food addiction was more frequent among women and GD among men, while Frontiers in Psychology IA was equally distributed. Regarding the EMSs, participants with FA or IA showed Received: 11 October 2019 Accepted: 20 December 2019 significantly higher scores on all four-schema domains, whereas those with GD exhibited Published: 21 January 2020 higher scores on impaired autonomy and performance and impaired limits. Besides, Citation: average scores of all domains increased with the association of two or more comorbid Aloi M, Verrastro V, Rania M, BAs. Self-perceived QoL was lower for participants with FA and IA, but not for those Sacco R, Fernández-Aranda F, Jiménez-Murcia S, De Fazio P and with GD; the presence of comorbid BAs was associated with lower Physical Component Segura-Garcia C (2020) The Potential Summary (PCS) and Mental Component Summary (MCS) scores. Finally, specific EMS Role of the Early Maladaptive Schema in Behavioral Addictions Among Late domains and demographic variables were associated with each BA. Adolescents and Young Adults. Front. Psychol. 10:3022. Conclusion: Late adolescents and young adults with FA or IA have a lower perception doi: 10.3389/fpsyg.2019.03022 of their mental and physical health. The most striking result is that FA appears to be Frontiers in Psychology | www.frontiersin.org 1 January 2020 | Volume 10 | Article 3022 Aloi et al. BAs and EMSs Among Young associated with the disconnection and rejection schema domain, IA with all the schema domains (except for impaired autonomy and performance), and GD with impaired autonomy and performance schema domain. In conclusion, our findings suggest that EMS should be systematically assessed during psychotherapy of patients with BAs. Keywords: behavioral addiction, early maladaptive schemas, food addiction, internet addiction, gambling disorder, adolescents INTRODUCTION and isolation (Zeeck et al., 2010). Furthermore, many studies have reported poor quality of life (QoL) among people with The construct of behavioral addictions (BAs) is a recent concept BAs because they are associated with physical comorbidities in psychiatry. In fact, it was first included in 2013 in the (i.e., withdrawal symptoms), social problems (i.e., isolation and fifth edition of the Diagnostic and Statistical Manual of Mental social withdrawal, problems at work or at home), psychiatric Disorders (DSM-5) as an official psychiatric diagnosis. So, in disorders (i.e., depression, anxiety), and lower life satisfaction clinical practice, it is necessary to distinguish between substance (Hoseinifar et al., 2011; Lu et al., 2018; Wang et al., 2019). For and BAs. In fact, even if BAs do not appear in the DSM-5, this reason, behavioral addicts need much help and support. except for gambling disorder (GD) and Internet gaming disorder Besides, gender seem to moderate the link between BAs and (IGD, which is included in Section III among the “Conditions their clinical phenotype. In fact, recent findings showed that for Further Study”), they share the following characteristics while GD was more frequent among males than females with substances addiction: the age of onset in adolescence and (Fröberg et al., 2015; Di Nicola et al., 2017; Carneiro et al., early adulthood, the specific features (i.e., impaired control, 2019), IA did not show a gender-related trend (McNicol and functional impairment, and persisting engagement in the Thorsteinsson, 2017; Li et al., 2019) and FA was more frequent behavior despite negative consequences), and the clinical course among females (Aloi et al., 2017; Borisenkov et al., 2018; (Sussman et al., 2017). Magyar et al., 2018). Other problematic behaviors, such as food addiction (FA) and Perhaps the most relevant point to highlight is that research Internet addiction (IA), have aroused interest in recent years has mainly focused on the presence/absence of symptoms of (Jiménez-Murcia et al., 2017; Romero et al., 2019). Although BAs, whereas the etiological processes and peculiar characteristics there are still insufficient data to allocate these disorders into the of BAs have rarely been investigated. Moreover, some of these diagnostic category of psychiatric disorders, they seem to share symptoms, such as withdrawal and tolerance, are difficult to many clinical characteristics with BAs (Meule and Gearhardt, apply and measure in relation to behaviors (Starcevic, 2016; 2014; Petry et al., 2018). The notion of FA theorizes that Kardefelt-Winther et al., 2017). individuals experience addictive-like symptoms related to the According to the theoretical model of Schema Therapy consumption of high calorie/palatable foods, which leads to (ST), psychiatric disorders might result from the formation clinically significant impairment or distress on several areas of early maladaptive schemas (EMSs) in response to unmet of functioning (Gearhardt et al., 2011). Recently, researchers needs in childhood. EMSs are defined as “extremely stable in the field of eating disorders (EDs) have claimed that FA and enduring themes, comprised of memories, emotions, should be comprised within the spectrum of EDs (Wiss and cognitions, and bodily sensations regarding oneself and one’s Brewerton, 2017; Fernandez-Aranda et al., 2018; Jiménez-Murcia relationship with others, that develop during childhood and et al., 2019); on the contrary, others believe that FA does not are elaborated on throughout the individual’s lifetime, and yet have enough evidence to be an independent nosographic that are dysfunctional to a significant degree” (Young et al., category (Hebebrand et al., 2014). Regarding IA, it may be 2003). The new proposed model (Bach et al., 2018) grouped considered an autonomous nosographic entity from IGD given 18 EMSs into four specific domains: (1) disconnection and that the problematic or excessive use of the Internet is not rejection: All the schemas of this domain are associated necessarily related to gaming for many people (Griffiths and with a lack of security, safety, and stability in interpersonal Pontes, 2014). Recent findings demonstrate that even if IGD relationships; (2) impaired autonomy and performance: People and IA can share online gaming, distinctive characteristics of with schemas of this domain perceive themselves as insecure IA are online chatting and social networking, while male gender and suffer from a lack of autonomy, i.e., they are afraid that is distinctive of IGD (Király et al., 2014). Consequently, data autonomous decisions may damage important relationships, or seem to support the notion that IA and IGD are distinct they expect to fail in situations where they must provide a nosological entities. performance; (3) excessive responsibility and standards: People All of these addictions, however, are associated with a pattern with patterns in this domain typically put the needs, desires of emotional dysregulation and cognitive distortions, which and wishes of others before their own, and, as a result, are typical of behaviors that people use to seek immediate many of their efforts are directed toward satisfying the gratification. It has been hypothesized that dysfunctional wishes of others; and (4) impaired limits: A lack of internal behavior could be a maladaptive strategy for dealing with limits, an inability to form long-term goals, and a lack of negative emotions and feelings, such as frustration, inadequacy, responsibility to others. Frontiers in Psychology | www.frontiersin.org 2 January 2020 | Volume 10 | Article 3022 Aloi et al. BAs and EMSs Among Young Many studies have found that EMSs are associated with the Measures development of personality disorders (Sempértegui et al., 2013) Young Schema Questionnaire Short Form-3 and other psychopathological conditions (Basile et al., 2017; The Young Schema Questionnaire Short Form-3 (YSQ-S3) is a Aloi et al., 2019; Rania et al., 2019). EMSs have also recently self-report instrument that consists of 90 items rated on a six- been investigated in samples with GD (Shorey et al., 2012) and point scale (from “completely untrue of me” to “describes me substance-use disorders (SUDs) (Shorey et al., 2013, 2014), but perfectly”) that accounts for 18 EMSs (Young, 2005). Different only a few studies have investigated the relationship between validations of YSQ-S3 in various languages suggest that the BAs and EMSs (Elmquist et al., 2016; Shajari et al., 2016; YSQ-S3 is a sound instrument for measuring schemas, including Imperatori et al., 2017). From the literature, it appears that GD factorial validity and test–retest stability as well as convergent and patients are characterized by numerous EMSs, in particular by discriminant validity. the schema domain impaired autonomy and performance (Shorey These EMSs are grouped together into four domains: et al., 2012). IA seems to be associated with all the schema disconnection and rejection, excessive responsibility and standards, domains (Shajari et al., 2016). Finally, researchers found that impaired autonomy and performance, and impaired limits (Bach the disconnection/rejection schema domain was independently et al., 2018). Internal consistency of the four domains were: associated with FA severity, suggesting that this domain may be a disconnection and rejection 0.919, impaired autonomy and crucial factor for the development of FA (Imperatori et al., 2017). performance 0.904, excessive responsibility and standards 0.791, Based on the above, this study has two aims: and impaired limits 0.834, indicating very good reliability. (1) To assess the possible association of specific BAs (i.e., FA, Internet Addiction Test IA, and GD) with EMSs and gender in a large group of late The Internet Addiction Test (IAT) is a self-report test that adolescents and young adults. More in detail, according assesses problematic Internet use and consists of 20 items on to the previous research, we expect to find: FA associated 5-point Likert-type (Young, 1998; Servidio, 2017). The total with the disconnection and rejection schema domain; IA scores range from 20 to 100. According to Young’s criteria, total associated with all the schema domains; and, GD associated IAT scores of from 20 to 49 denote an average internet user, who with impaired autonomy and performance schema domain. can sometimes use the web a little too long without losing control Regarding the possible role of gender in the development of the situation; scores 50–79 denote over-users with frequent of BAs, we suppose to find the male gender associated problems due to their Internet usage; scores 80–100 denote a use with GD, the female gender with FA, and no gender of the Internet that is very intense and causes significant problems difference on IA. for the person. In the current study, we used the cut-off 80–100 (2) To evaluate their self-perceived QoL; in particular, we to diagnose IA. Cronbach’s alpha in this study was 0.879. expect to find a worse QoL among participants with any BAs. South Oaks Gambling Screen South Oaks Gambling Screen (SOGS) is the most widely known and used questionnaire for the screening of GDs and is composed MATERIALS AND METHODS of 16 questions, including 37 items, which ask the subjects about their gambling activity and associated behaviors throughout their Participants and Procedure lifetime. There are 20 scoring items, all equally weighed, requiring First- and third-year university students and senior high school a “yes” or “no” answer, so scores range from 0 to 20 (Lesieur students from the same catchment area in southern Italy and Blume, 1987; Barbaranelli et al., 2013). Scores 3 to 4 indicate participated in the research. at-risk gambling, scores ≥5 indicate problematic gambling and Through an anonymous online survey, the participants ≥9 indicate a serious GD. In this study, we used the cut-off completed an informed consent form and the questionnaires, SOGS ≥9 to diagnose GD. Cronbach’s alpha in the present and they also provided their heights and weights. Answers of research was 0.848. participants who did not complete all items were dropped from the electronic database automatically. Anonymity was guaranteed Yale Food Addiction Scale 2.0 through the use of nicknames (formed by at least eight The Yale Food Addiction Scale 2.0 (YFAS 2.0) evaluates alphanumeric and symbol characters). No grant or economic addiction-like eating behavior over the preceding 12 months compensation was offered to participants. (Gearhardt et al., 2016; Aloi et al., 2017). It consists of The final sample consisted of 1,075 participants (N = 637; 35 items, which are scored on an eight-point scale ranging 59.3% women) with a mean age of 19.69 ± 1.7 (17–24) years from never (score = 0) to every day (score = 7) to assess old; 810 (80.5%) participants had middle school diplomas while symptoms related to the 11 diagnostic criteria for substance- 210 (19.5%) had high school diplomas. All participants were related and addictive disorders (SRAD) of DSM-5. The 11 Caucasian. The present study was carried out in accordance symptoms of FA following the DSM-5 criteria of SRAD are: with the latest version of the Declaration of Helsinki and overeating (Criterion 1), desire to cut down (Criterion 2), time was approved by the local Ethical Committee. All participants spent (Criterion 3), craving (Criterion 4), related impairment provided informed consent before participating and parental (work/school, family, social relationship) (Criteria 5–7), risky consent was sought for those younger than 18 years of age. use (physically hazardous, detrimental physical/psychological Frontiers in Psychology | www.frontiersin.org 3 January 2020 | Volume 10 | Article 3022 Aloi et al. BAs and EMSs Among Young consequences) (Criteria 8–9), tolerance (Criterion 10), and 184 (17.1%) to IAT, and 73 (6.8%) to SOGS; besides, among withdrawal (Criterion 11). these, 50 participants were positive to two tests (20 IAT/YFAS, Each of the 11 diagnostic criteria was considered present if one 20 IAT/SOGS, 10 SOGS/YFAS) and only 3 participants were or more of the relevant questions for each criterion reached the simultaneously positive to all measures. FA was more frequent threshold. For the specific threshold of each item, it is possible among women, and GD was more frequent among men, while recover them in the validation of the scale1 Two types of scoring IA was equally distributed (Table 1). are possible: (1) a final symptom-count score can be calculated Table 2 summarizes the results of the comparison between by adding up all of the endorsed symptoms; (2) the severity level BAs and YSQ-S3 domains. Participants who had positive scores is described according to the diagnostic thresholds for SRAD in with the YFAS 2.0 and the IAT showed significantly higher DSM-5: mild FA (2–3 symptoms), moderate FA (4–5 symptoms), scores on all four-schema domains, whereas participants who and severe FA (≥6 symptoms). Finally, every FA “diagnosis” were positive on the SOGS exhibited higher scores on the requires the presence of the distress or impairment criteria. In this impaired autonomy and performance and impaired limits schema study, we used the cut-off≥6 symptoms (severe FA) to diagnose domains. As displayed on the last row of the table, average FA. Kuder–Richardson’s alpha for dichotomous variables was run scores of all domains increased with the association of two or and in this study was 0.880. more comorbid BAs. Table 3 displays the findings of the comparison of SF- Short Form-12 Health Survey 12 dimensions between participants with and without each The Short Form-12 Health Survey (SF-12) is a widely used BA. Individuals who were positive to the YFAS 2.0 and the instrument for assessing QoL and consists of 12 items derived IAT showed significantly lower scores on both PCS and MCS. from the SF-36 (Ware et al., 1996; Apolone et al., 2001). These No differences in self-perceived QoL was evident between items are grouped into two domains, named Physical Component participants who were positive and negative to the SOGS. Summary (PCS) and Mental Component Summary (MCS), both The presence of comorbid BAs was associated to lower including six items. Responses to questions are dichotomous PCS and MCS scores. (yes/no), ordinal (excellent to poor), or expressed by a frequency The results of the logistic regression models are shown in (always to never). The total score ranges from 0 to 100, with Table 4. Female gender, higher BMI, and the disconnection and higher scores referring to higher QoL. In this study, Cronbach’s rejection schema domain scores were associated with YFAS 2.0 alpha coefficient for the PCS-12 and MCS-12 scores were 0.84 and positivity. Younger age and higher scores in the disconnection 0.81, respectively. and rejection, excessive responsibility and standards, and impaired limits schema domains were associated with IAT positivity. Statistical Analysis Finally, male gender and impaired autonomy and performance Data analyses were performed using the Statistical Package were associated with being positive to the SOGS. for the Social Sciences (SPSS) version 21.0 (SPSS 21.0; SPSS Inc., Chicago, IL, United States). Descriptive statistics included frequencies and percentages, and means and standard deviations, DISCUSSION as appropriate. Differences between groups were assessed with chi-squared for categorical variables and t-tests or ANOVA for The study aimed to assess the possible association of some BAs continuous data, as appropriate. Additionally, Cohen’s d or η2 (i.e., FA, IA, and GD) with EMS and at evaluating their self- were, respectively, calculated for significant results in t-tests or perceived QoL. To the best of our knowledge, this is the first study ANOVA as measures of effect size (ES). Values of 0.2, 0.6, 1.2, and regarding the investigation of EMSs on BA in a very large sample >1.2 can be, respectively, categorized into slight, small, moderate, of young people (n = 1075) according to the new four schema and large ES for Cohen’s d (Cohen, 1988). In the case of η2 domains model proposed by Bach et al. (2018). values of 0.01, 0.06, and 0.14 indicate small, medium, and large ES Thirty-two percent of participants had positive results to at (Levine and Hullett, 2002). A forward-stepwise logistic regression least one BA. IA was the most frequent (17.1%), followed by FA model was run to identify which variables were associated with (8.1%), and then GD (6.8%). BAs. In all cases, differences were considered to be significant Regarding gender distribution, in our study we found a when p < 0.05. different distribution between participants who scored positively to BAs. GD was more likely to occur among males, as previous reports have indicated (Kristiansen and Jensen, 2011; Fröberg RESULTS et al., 2015). The present results are in line with another Italian study that assessed GD together with other addictions among Table 1 describes the differences between males and females. adolescents (Di Nicola et al., 2017). FA was more frequent Average scores of questionnaires assessing dysfunctional among females. Other authors have previously found the same behaviors are as follows: YFAS total present criteria = 1.25 ± 2.3 trend at a lower rate (5.5% for females versus 0.8% for males) (0–11); SOGS = 0.6 ± 1.7 (0–16); IAT = 40.1 ± 11.4 (20–85). in young adults without obesity or other comorbidities (Aloi Overall, 88 (8.2%) participants were positive to YFAS 2.0, et al., 2017), which agrees with most recent investigations 1 https://static-content.springer.com/esm/art%3A10.1007%2Fs40519-017-0421- (Pursey et al., 2014; Mies et al., 2017; Borisenkov et al., 2018; x/MediaObjects/40519_2017_421_MOESM1_ESM.docx Magyar et al., 2018). On the other hand, IA did not show a Frontiers in Psychology | www.frontiersin.org 4 January 2020 | Volume 10 | Article 3022 Aloi et al. BAs and EMSs Among Young TABLE 1 | Sample demographics and distribution of behavioral addictions. Females Males Statistics p d/ϕc Agea 18.8 (1.7) 18.6 (1.7) t = 1.491 0.136 BMIa 21.6 (3.6) 23.2 (3.7) t = −7.389 < 0.001 0.44 YFAS 2.0b Negative 576 (90.4) 411 (93.8) χ2 = 4.020 0.045 0.06 Positive 61 (9.6) 27 (6.2) SOGSb Negative 625 (98.2) 377 (86.1) χ2 = 59.471 < 0.001 0.24 Positive 12 (1.8) 61 (13.9) IATb Negative 533 (83.7) 358 (81.7) χ2 = 0.687 0.407 Positive 104 (16.3) 80 (18.3) a Results are presented as means (SD). b Results are presented as frequencies (%). BMI, Body Mass Index; YFAS 2.0, Yale Food Addiction Scale 2.0; SOGS, South Oaks Gambling Screen; IAT, Internet Addiction Test. c Only effect sizes of significant differences are displayed. Cohen’s d for continuous variables and ϕ for categorical variables. TABLE 2 | Comparison between behavioral addictions and YSQ-S3 domains. Disconnection and Impaired autonomy Excessive responsibility Impaired Rejection and performance and standards limits YFAS 2.0a Negative 2.1 (0.9) 1.8 (0.7) 2.8 (0.9) 2.4 (0.9) Positive 3.3 (1.1) 2.7 (1.0) 3.5 (0.9) 3.1 (0.9) t −11.414 −9.933 −6.743 −6.866 p <0.001 <0.001 <0.001 <0.001 db 1.19 1.04 0.78 0.78 SOGSa Negative 2.2 (1.0) 1.9 (0.8) 2.8 (0.9) 2.4 (0.9) Positive 2.4 (1.2) 2.2 (1.1) 2.9 (1.2) 2.8 (1.1) t −1.806 −3.491 −0.547 −3.258 p 0.071 0.001 0.584 0.001 db 0.31 0.40 IATa Negative 2.1 (0.9) 1.8 (0.8) 2.8 (0.9) 2.3 (0.9) Positive 2.7 (1.1) 2.3 (0.9) 3.0 (1.0) 2.9 (1.0) t −7.786 −8.142 −2.836 −7.172 p <0.001 <0.001 0.005 0.001 db 0.60 0.59 0.21 0.63 BA comorbidity Negative 2.1 (0.9) 1.8 (0.7) 2.8 (0.9) 2.3 (0.9) Positive 1 BA 2.6 (1.1) 2.3 (0.9) 3.0 (1.0) 2.8 (1.0) Positive >1 BA 3.2 (1.2) 2.7 (1.0) 3.2 (1.1) 3.1 (1.1) F 64.539 68.984 13.466 46.332 p <0.001 <0.001 <0.001 <0.001 η2 0.107 0.114 0.025 0.080 a Results are presented as means (SD). b Only effect sizes of significant differences are displayed. YSQ-S3, Young Schema Questionnaire Short Form 3; YFAS 2.0, Yale Food Addiction Scale 2.0; IAT, Internet Addiction Test; SOGS, South Oaks Gambling Screen; BA, Behavioral Addiction. TABLE 3 | Comparison between behavioral addictions and SF-12 dimensions. SF-12 PCS Statistics p ESb SF-12 MCS Statistics p ESb YFAS 2.0a Negative 52.5 (6.4) t = 3.246 0.001 d = 0.34 43.2 (10.8) t = 7.823 <0.001 d = 0.87 Positive 50.1 (7.5) 33.8 (10.9) SOGSa Negative 52.3 (6.4) t = 0.960 0.337 42.3 (11.1) t = −1.098 0.272 Positive 51.6 (7.7) 43.8 (10.1) IATa Negative 52.5 (6.3) t = 2.597 0.010 d = 0.21 43.1 (11.0) t = 4.859 <0.001 d = 0.39 Positive 51.1 (7.2) 38.8 (10.8) BA comorbidity Negative 52.7 (6.2) F = 7.023 0.001 η2 = 0.013 43.9 (10.7) F = 27.504 <0.001 η2 = 0.049 Positive 1 BA 51.6 (6.9) 38.1 (11.2) Positive >1 BA 49.6 (8.2) 37.7 (11.3) a Results are presented as means (SD). b Only effect sizes of significant differences are displayed. SF-12 PCS, Short Form-12 Health Survey Physical Component Summary; SF-12 MCS, Short Form-12 Health Survey Mental Component Summary; YFAS 2.0, Yale Food Addiction Scale 2.0; SOGS, South Oaks Gambling Screen; IAT, Internet Addiction Test; ES, Effect size; BA, Behavioral Addiction. Frontiers in Psychology | www.frontiersin.org 5 January 2020 | Volume 10 | Article 3022 Aloi et al. BAs and EMSs Among Young TABLE 4 | Results of logistic regression analysis. Dependent variable Independent variables B Standard Error Wald p Exp(B) YFAS 2.0a Categorical BMI 0.118 0.026 19.898 < 0.001 1.125 YSQ-S3 Disconnection and Rejection 0.986 0.110 79.960 < 0.001 2.680 Gender −0.668 0.268 6.218 0.013 0.513 IATb YSQ-S3 Disconnection and Rejection 0.445 1.270 7.270 0.007 1.560 YSQ-S3 Excessive responsibility and standards −0.698 0.154 20.441 < 0.001 0.498 YSQ-S3 Impaired limits 0.492 0.150 10.743 0.001 1.635 Age −0.166 0.068 5.936 0.015 0.847 SOGSc YSQ-S3 Impaired autonomy and performance 0.484 0.127 14.460 < 0.001 1.623 Gender 2.199 0.325 45.724 < 0.001 9.016 YFAS 2.0, Yale Food Addiction Scale 2.0; IAT, Internet Addiction Test; SOGS, South Oaks Gambling Screen; BMI, Body Mass Index; YSQ-S3, Young Schema Questionnaire Short Form 3. a Model 1. Dependent variable: YFAS 2.0; −2log Likelihood = 487.566, Nagelkerke R2 = 0.246. b Model 2. Dependent variable: IAT; −2log Likelihood = 890,515; Nagelkerke R2 = 0.138. c Model 3. Dependent variable: SOGS; −2log Likelihood = 458,896; Nagelkerke R2 = 0.171. gender-related trend, with similar frequency results among males (Tompkins et al., 2017; Nunes-Neto et al., 2018; Wiedemann and females. Another recent cross-cultural study of problematic et al., 2018; Zhao et al., 2018). There is no controversy in Internet usage in Europe described significantly higher scores the association between FA and the impaired physical and in women (26%) than among men (22%). This higher trend psychological domains, even if previous studies used different for women was explained with the assumption that women are instruments to assess QoL dimensions, reporting much more more prone to use online activities and social networks (Laconi discriminant subdimensions, such as emotional, school, and et al., 2018). Nevertheless, data regarding the Italian sample social functioning (Nunes-Neto et al., 2018; Zhao et al., 2018). We showed similar rates of IA between males and females as in only took into consideration the dimensions of PCS and MCS, so the present study. we can only confirm poorer levels in these dimensions. Participants who were screened positive to BAs expressed Quality of life was not found to be impaired among significantly higher values in their schema-domain scores. All pathological gamblers. On the contrary, other studies found a four schema-domains results were more expressed in participants stronger association with poorer mental health among gamblers who were positive to FA and IA. Instead, a more specific pattern than among non-gamblers (Castrén et al., 2013; Ekholm et al., in maladaptive schemas emerged in people who were affected by 2018). Our explanation could be the different age among GD. Impaired autonomy and performance and impaired limits gambling addicts, in fact, somehow, younger gamblers tend to were the schemas that had significantly higher scores among still be in the honeymoon phase of this addiction, while older adolescents and young adults with gambling addictions. gamblers have already developed the long-lasting side-effects According to previous studies that have investigated the with the negative physical and psychological consequences. association between EMSs and eating psychopathology (Pugh, Another explanation of this result could be found in Jiménez- 2015; Imperatori et al., 2017), our findings showed that Murcia et al. (2013) study. These authors clustered young participants with FA had higher scores in all four schema pathological gamblers and concluded that three different clusters domains of the YSQ-S3. Additionally, in our sample, the scores exist, with differences in terms of gambling severity, and of the impaired limits domain were higher in the group of personality and psychopathological measures. According to this participants who were positive to all three of the investigated BAs. clustering, it is possible that the present sample fits with the “High This is consistent with Young and Klosko’s (1993) study, which General Functioning (Type I)” phenotype that is characterized considered the impaired limits domain to be the most closely by a lower severity of the disorder, general psychopathology, related to externalizing behavioral problems, such as BAs. We and healthier personality traits. On the other hand, Blaszczynski found an association between IA and all EMS domains, as did and Nower (2002) described a subtype of pathological gamblers Shajari et al. (2016). All the above mention gains of interest as the with an earlier age of onset and lower insight of illness. association of more than one BA resulted in higher EMS domains. A final explanation is that adolescents seem to be less able to Regarding QoL, we found that participants with IAs and FAs perceive gambling as a problem, with a discrepancy between self- had low scores in physical and mental health, which was unlike perception and the objective problematic behaviors of gambling those with high GD scores. (Cronce et al., 2007). Our data corroborate the results of previous research about Interestingly, QoL resulted is affected by the comorbidity impaired QoL among IA subjects (Fatehi et al., 2016; Karacic between two or more BAs, especially the mental component. In and Oreskovic, 2017). IA impairs physical functions as it implies other words, there is a summative effect of behavioral additions neglecting usual, daily life functioning and the acquisition of on the mental and physical health of young people. some other behaviors that can lead to physical consequences. Logistic regression was performed to ascertain if demographic Literature on QoL reports poorer values in all dimensions variables or schema domains were candidates for predicting the both among normal-weight and obese adolescents with FA occurrence of BAs. Frontiers in Psychology | www.frontiersin.org 6 January 2020 | Volume 10 | Article 3022 Aloi et al. BAs and EMSs Among Young Internet addiction was associated with younger people and Limitations almost all EMS domains (with the exception of impaired Although this study has many strengths (i.e., large sample size, autonomy and performance). Many studies have demonstrated assessment of EMSs in a young population with and without its increasingly young age of onset (Durkee et al., 2012; El Bas, according to the new model proposed by Bach et al., 2018), Asam et al., 2019). This association could be explained by the some limitations must be acknowledged. First, some BAs, such self-determination theory where people apply some behaviors as compulsive buying or compulsive sexual behavior, were not in order to satisfy three core needs: competence, autonomy, investigated in our research. Second, this is a cross-sectional and relatedness (Deci and Ryan, 2000). In fact, children and study, so our conclusions could just infer an association and adolescents could use the Internet as a coping strategy for not causation. Third, the results cannot be generalized to clinical depressive feelings (Horwitz et al., 2011) resulting from few samples because ours was a sample from the general population. physical social interactions, which lead them not to feel emotions Fourth, the presence or absence of BAs was carried out on the and mental states such as shame, shyness, inadequacy, and failure basis of self-reported questionnaires, but these data were not (Chak and Leung, 2004). For this reason, it is not surprising that, confirmed with face-to-face interviews; nevertheless, in order to in our study, almost all the EMS domains were associated with reduce the possible high rate of false positive participants, we have IA. To our knowledge, our results are in line with the only study used the extreme cut-off values of measures to diagnose each BA. that investigated the relationship between EMS and IA (Shajari Finally, the participants’ personality features were not evaluated et al., 2016). It found a significant relationship between the five and it is known that addictive disorders are often comorbid domains of EMS and IA in students. with personality disorders (i.e., borderline personality disorders) Food addiction correlated with the female gender, higher (Brown et al., 2015). BMI, and the disconnection and rejection schema domain. This is in line with the only study that investigated the relationship between EMSs and FAs (Imperatori et al., 2017). The authors CONCLUSION found that the disconnection and rejection schema was associated with FA, suggesting that this domain may play a key role for the Our findings partially confirmed our hypotheses. In fact, mental development of FA. Additionally, several studies have highlighted and physical health perceptions were impaired in IAs and FAs, how FA positively correlated with the female gender (Aloi et al., but not in GDs. Nevertheless, the most striking result is that 2017; Carr et al., 2017; Rogers, 2017) and BMI (Aloi et al., 2017; FA appears to be associated with the disconnection and rejection Granero et al., 2018). In fact, a higher prevalence of FA was found schema domain, IA with all the schema domains (except for among obese patients (Gearhardt et al., 2014). impaired autonomy and performance), and GD with impaired The occurrence of GD was associated with the male gender autonomy and performance schema domain. For this reason, and with the impaired autonomy and performance domain. To EMSs should be systematically assessed within psychotherapy of our knowledge, only one study has investigated the relationship patients with BAs. between potential GD and EMSs in a sample of alcohol- A priori, in line with the concept of personalized and precision dependent men (Shorey et al., 2012). Shorey et al. (2012) medicine, ST could provide a real tailor-made therapy addressing found that many EMSs were associated with gambling – more the EMSs that seem to underpin the addictive behavior. specifically, the insufficient self-control schema was one of the most significant schema among gamblers. This is in line with our results. In fact, the insufficient self-control schema falls within the DATA AVAILABILITY STATEMENT domain of impaired autonomy and performance. Concerning the association between the male gender and pathological gambling, The datasets generated for this study are available on request to several studies have yielded solid results showing how the male the corresponding author. gender was more likely to be associated with GD (Potenza et al., 2002; Villella et al., 2011; Di Nicola et al., 2017). From the results of the regression analysis, we might think that ETHICS STATEMENT EMSs could play an important role not only in the development, but also in the maintenance, of BAs. In fact, if by definition, the The studies involving human participants were reviewed and EMSs are stable and perpetuated over time, when patients with approved by the Ethical Committee of Azienda Ospedaliera BAs experience emotional triggers, they will reactivate specific Universitaria Mater Domini. Written informed consent to EMSs, and this will continue the vicious circle. Just as we said participate in this study was provided by the participants’ legal in the introduction, the EMSs are “comprised of memories, guardian/next of kin. emotions, cognitions and bodily sensations regarding oneself and one’s relationship with others,” it could be assumed that many alterations in cognition, in self-perceptions of emotions (i.e., AUTHOR CONTRIBUTIONS alexithymia), and in the experience of pleasure (i.e., anhedonia), repeatedly reported in the literature among patients with BAs CS-G and PD contributed to the conception and design of the (Guillot et al., 2016; Moccia et al., 2017, 2018), may be associated study. MA, MR, and RS organized the database. MA and CS-G with the development and perpetuation of EMSs. performed the statistical analysis. MA wrote the first draft of the Frontiers in Psychology | www.frontiersin.org 7 January 2020 | Volume 10 | Article 3022 Aloi et al. BAs and EMSs Among Young manuscript. MR and VV wrote sections of the manuscript. CS-G, funded by Delegación del Gobierno para el Plan Nacional sobre PD, SJ-M, and FF-A critically revised the manuscript. All authors Drogas (2017/I067) and co-funded by FEDER Funds/European contributed to manuscript revision, and read and approved the Regional Development Fund (ERDF), a way to build Europe. submitted version. CIBERobn is an initiative of ISCIII. FUNDING ACKNOWLEDGMENTS This manuscript and research was supported by grants from the The authors are grateful to all partakers who accepted to Ministerio de Economía y Competitividad (PSI2015-68701-R), participate in this research. FF-A and SJ-M thank CERCA Instituto de Salud Carlos III (ISCIII) (FIS PI14/00290) and Programme/Generalitat de Catalunya for institutional support. REFERENCES Di Nicola, M., Ferri, V. R., Moccia, L., Panaccione, I., Strangio, A. M., Tedeschi, D., et al. (2017). Gender differences and psychopathological features associated Aloi, M., Rania, M., Caroleo, M., Carbone, E. 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