Early maladaptive schemas from child maltreatment in depression and psychotherapeutic remediation: a predictive coding framework

Abstract

Schemas are affective-cognitive conceptual models of self, others and the world, derived from life experience. Predictive Coding theory proposes schema are created from perceptual input as follows: Based on previous similar experiences, the brain generates schema, with "predictions," expectations of future sensory experiences. Discrepancy between predicted versus actual experience produces a "prediction error." Exposure to prediction errors considered more certain than the predictions of a schema prompts the hippocampus to update and revise the schema. Hypothesized underlying mechanisms include memory reconsolidation, extinction and pattern separation. Depression is characterized by negative schemas predicting helplessness, hopelessness and worthlessness. Early maladaptive schemas, from childhood, are implicated in mediating the greater risk of depression from childhood maltreatment. Prominent examples include the Defectiveness/Shame self-schema, predicting a flawed, unlovable self and the Social Isolation/Alienation schema, predicting isolation. Predictive Coding offers the following biopsychosocial hypothesis explaining how childhood maltreatment promotes depressogenic early maladaptive schema, and how psychotherapy can help: Schema can be difficult to change because of an attention/memory bias away from schema-incongruent information that generate prediction errors prompting schema revision. Childhood maltreatment exacerbates this learning bias. Maladaptive coping styles associated with childhood maltreatment, decrease exposure to experiences contradicting depressogenic schema. Biological changes from childhood maltreatment, including inflammation, interfere with hippocampal updating of schema. Finally, impaired socio-occupational function, associated with childhood maltreatment, reinforces depressogenic schema. By targeting factors associated with childhood maltreatment, which reinforce depressogenic early maladaptive schema or diminish prediction errors, psychotherapy can facilitate revision of depressogenic schema.

Keywords: child maltreatment (CM); depression; early maladaptive schemas (EMS); predictive coding; psychotherapy.

Figure 1

The self-sustaining feedback loops underlying depression. CM exacerbates all the elements driving the loops. In one loop, psychological sequelae of CM, including shame, maladaptive shame-coping, mentalization difficulties, social withdrawal, and a motivation, all impair socio-occupational function (–41). In turn, repeated socio-occupational disappointments can confirm EMS of Defectiveness/Shame and Social Isolation/Alienation, reinforcing their certainty and resistance to schema-incongruent information (53, 54). In another interlocked recursive loop, CM sequelae diminish exposure to and learning from reward prediction errors, which could have revised depressogenic EMS: For example, avoidant coping decreases social/occupational engagement, thus reducing opportunities for reward prediction errors. When rewarding experiences do arise, their impact is decreased by biological sequelae of CM: amygdala hyperactivity, HPA axis dysfunction, and inflammation promote preferential learning of negative information (–59), through attenuated reward prediction error, negative overgeneralized memory, and negative memory/attention biases socio-occupational stress further exacerbates the biological sequelae (–62), completing the loop.

Figure 2

Psychotherapy targets elements promoting EMS and boosts factors supporting revision of depressogenic early maladaptive schema. The figure illustrates hypothetical pathways explaining how psychotherapy targets vulnerability factors (in black) promoting depression/depressogenic and boosts factors (in blue) supporting EMS revision. (1) Verbalizing implicit schema supports memory reconsolidation. (2) Psychotherapy (security priming & CBT) improves CM biological sequelae that would otherwise attenuate prediction error. (3) Prediction error prompting EMS revision is boosted by directing attention and improving cognitive receptivity to schema-incongruent information. Security priming also promotes self-compassion, which is incongruent with the Defectiveness/Shame EMS, and thus generates a prediction error. (4) Self-compassion, emotion approach coping, and Mentalization skills counteract harsh self-criticism and avoidant coping, support emotional fluency, and facilitate socio-occupational engagement.