The structure relationship of body dysmorphic disorder (BDD) with early maladaptive schema and perceived emotional invalidation: the mediating Role of metacognition, body image and distress tolerance

Document Type : Original Article

Authors

1 .Master student of Clinical Psychology, Kharazmi University, Tehran, Iran

2 Associate Professor, Department of Clinical Psychology, Kharazmi University, Tehran, Iran

Abstract

Introductoin: The growing importance of physical attractiveness has led to the fact that sometimes social acceptance and interpersonal success depend on perfect and ideal appearance. Also, the decline in the quality of physical and psychological health due to concerns about body shape and fear of physical appearance led to a to investigate the structural relationship between body dysmorphic disorder and early maladaptive schemas and perceived emotional invalidation with emphasis on the mediating role of metacognition, body image, and distress tolerance.
Method: The present research is descriptive-applied. The statistical population of this study consisted of all students studying in the country's universities at all levels of education. Among them, 297 people participated in the study as a sample using purposive sampling and through the website, of course, after informed consent. They completed the Yale-Brown Obsessive-Compulsive Scale for -BDD (Phillips et al., 1997), the Young Schema Questionnaire – Short Form (Welburn et al., 2002), the Distress Tolerance Scale (Simons and Gaher, 2005), the Perceived Invalidation of Emotion Scale (Zielinski,2016), the Body Dysmorphic Metacognitive Questionnaire (Rabiei et al.,2011), and the Body Image Concern Inventory (Littleton, Axsom, and Pury, 2005) were completed. The research data were analyzed by the structural equation modeling method and SPSS-15 and LISREL-8.5 software.
Results: The results of modeling the structural equations of the research showed that the conceptual model of the research had a good fit with the experimental data. The present model can explain 68% of the symptoms of body dysmorphic disorder. The results of the Bootstrap test also showed that the disturbed body image variable is a mediating variable in the relationship between early maladaptive schemas and perceived emotional discrediting with symptoms of body dysmorphic disorder. In addition, the distress tolerance variable has a mediating role concerning early maladaptive schemas and body deformity disorder, so the direct relationship between early maladaptive schemas and perceived emotional invalidation with body dysmorphic disorder was not significant considering the mediating role of these variables.
Discussion and Conclusion: The results of this study support the full mediating role of distress tolerance and deformity body image in the relationship between early maladaptive schemas and perceived emotional discrediting with body deformity disorder, and may have practical clinical implications for evidence-based interventions for deformity

Keywords


 1-سادوک، بنجامین جیمز؛ سادوک، ویرجینا آلکوت و روئیز ، پدرو. خلاصه روانپزشکی : علوم رفتاری/روانپزشکی بالینی.جلد اول، ترجمه رضائی ، فرزین .تهران: انتشارات ارجمند .1394.
2- American Psychiatric Association. Depressive Disorders: DSM-5® Selections. American Psychiatric Pub; 2015 Jul 8.
3- Buhlmann U, Glaesmer H, Mewes R, Fama JM, Wilhelm S, Brähler E, Rief W. Updates on the prevalence of body dysmorphic disorder: a population-based survey. Psychiatry research. 2010 Jun 30;178(1):171-5.
4- احسانی، امیرهوشنگ؛ فکوری، یوسف؛ غلامعلی، فاطمه؛ مختاری، لیلا؛ سادات حسینی، محبوبه؛ خسروانمهر، نجمه و نورمحمدی، پدرام. شیوع اختلال بدریخت انگاری بدن در بیماران مراجعه کننده با شکایت زیبایی به بیمارستان پوست. مجله دانشکده پزشکی، دانشگاه علوم پزشکی تهران. دوره71،شماره3، 1392: 164-170.
5- موسوی­­­ ،سیده حکیمه. رستمی ،رضا. غلامعلی لواسانی، مسعود.اثر بخشی مداخله فراشناختی براضطراب، تصویر بدن و سایرعلائم مبتلایان به بدشکلی بدن (BDD).فصلنامه علمی پژوهشی، روانشناسی بالینی، شخصیت.14(1)، 1394: 81-88.
6- Calvete E, Orue I, Hankin BL. Early maladaptive schemas and social anxiety in adolescents: The mediating role of anxious automatic thoughts. Journal of anxiety disorders. 2013 Apr 1;27(3):278-88.
7- Rafaeli E, Bernstein DP, Young J. Schema therapy: Distinctive features. Routledge; 2010 Sep 13.
8- Hrabosky JI, Cash TF, Veale D, Neziroglu F, Soll EA, Garner DM, Strachan-Kinser M, Bakke B, Clauss LJ, Phillips KA. Multidimensional body image comparisons among patients with eating disorders, body dysmorphic disorder, and clinical controls: a multisite study. Body image. 2009 Jun 1;6(3):155-63.
9- Van den Berg P, Thompson JK, Obremski-Brandon K, Coovert M. The tripartite influence model of body image and eating disturbance: A covariance structure modeling investigation testing the mediational role of appearance comparison. Journal of psychosomatic research. 2002 Nov 1;53(5):1007-20.
10- Mancuso SG. Body image inflexibility mediates the relationship between body image evaluation and maladaptive body image coping strategies. Body Image. 2016 Mar 1;16:28-31.
11- Bailey KA, Lamarch L, Gammage KL, Sullivan PJ. Self-objectification and the use of body image coping strategies: The role of shame in highly physically active women. The American journal of psychology. 2016 Feb 15;129(1):81-90.
12- Donyavi V, Rabiei R, Nikfarjam M, Mohmmad Nezhady B. Body image and meta-worry as mediators of body dysmorphic disorder. International Journal of Clinical Medicine. 2015;6(3).
13- Linehan M. Skills training manual for treating borderline personality disorder. New York: Guilford press; 1993 May 21.
14- Westphal M, Leahy RL, Pala AN, Wupperman P. Self-compassion and emotional invalidation mediate the effects of parental indifference on psychopathology. Psychiatry research. 2016 Aug 30;242:186-91.
15- Buckholdt KE, Parra GR, Jobe-Shields L. Intergenerational transmission of emotion dysregulation through parental invalidation of emotions: Implications for adolescent internalizing and externalizing behaviors. Journal of child and family studies. 2014 Feb 1;23(2):324-32.
16- Khanjani S, Haghayegh SA. A path analysis of clinical and demographic variables in body dysmorphic disorder in a student sample. Journal of Fundamentals of Mental Health. 2018;20(2):148-58.
17- Gill D, Warburton W. An investigation of the biosocial model of borderline personality disorder. Journal of clinical psychology. 2014 Sep;70(9):866-73.
18- Robertson CD, Kimbrel NA, Nelson-Gray RO. The Invalidating Childhood Environment Scale (ICES): psychometric properties and relationship to borderline personality symptomatology. Journal of personality disorders. 2013 Jun;27(3):402-10.
19-Haslam M, Arcelus J, Farrow C, Meyer C. Attitudes towards emotional expression mediate the relationship between childhood invalidation and adult eating concern. European Eating Disorders Review. 2012 Nov;20(6):510-4.
20- Mountford V, Corstorphine E, Tomlinson S, Waller G. Development of a measure to assess invalidating childhood environments in the eating disorders. Eating behaviors. 2007 Jan 1;8(1):48-58.
21- Katz LF, Shortt JW, Allen NB, Davis B, Hunter E, Leve C, Sheeber L. Parental emotion socialization in clinically depressed adolescents: Enhancing and dampening positive affect. Journal of abnormal child psychology. 2014 Feb;42(2):205-15.
22- Shortt JW, Katz LF, Allen NB, Leve C, Davis B, Sheeber LB. Emotion socialization in the context of risk and psychopathology: Mother and father socialization of anger and sadness in adolescents with depressive disorder. Social Development. 2016 Feb;25(1):27-46.
23- Thomas R, DiLillo D, Walsh K, Polusny MA. Pathways from child sexual abuse to adult depression: The role of parental socialization of emotions and alexithymia. Psychology of Violence. 2011 Apr;1(2):121.
24- Luebbe AM, Bump KA, Fussner LM, Rulon KJ. Perceived maternal and paternal psychological control: Relations to adolescent anxiety through deficits in emotion regulation. Child Psychiatry & Human Development. 2014 Oct;45(5):565-76.
25- Wijsbroek SA, Hale III WW, Raaijmakers QA, Meeus WH. The direction of effects between perceived parental behavioral control and psychological control and adolescents’ self-reported GAD and SAD symptoms. European child & adolescent psychiatry. 2011 Jul;20(7):361-71.
26- Hersh MA, Hussong AM. The association between observed parental emotion socialization and adolescent self-medication. Journal of Abnormal Child Psychology. 2009 May;37(4):493-506.
27-مهدی­نژاد، سیدابوالقاسم؛ فرح­بیجاری، اعظم؛ نوروزی­نرگسی، مهسا.مقایسه سوگیری توجه و سبک­های پردازش هیجانی در دانشجویان مبتلا به اختلال اضطراب فراگیر، مبتلا به بدریخت‌انگاری و غیر مبتلا. فصلنامه روانشناسی بالینی. سال ششم، شماره 24 ،1396: 114-99.
28- دوازده­امامی، محمدحسن؛ تاشکه، مجتبی. بختیاری؛ مریم. جعفری، مهدی.مقایسه عدم تحمل بلاتکلیفی در تنظیم هیجان در افراد مبتلا به بدریخت­انگاری بدن و اضطراب اجتماعی. فصلنامه علمی- پژوهشی روانشناسی سلامت،3(27) ،113-130:1397
29- Pecorari G, Gramaglia C, Garzaro M, Abbate-Daga G, Cavallo GP, Giordano C, Fassino S. Self-esteem and personality in subjects with and without body dysmorphic disorder traits undergoing cosmetic rhinoplasty: preliminary data. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2010 Mar 1;63(3):493-8.
30- ربیعی، مهدی؛ صلاحیان، افشین؛ کجباف، محمدباقر؛ پالاهنگ، حسن. اثر بخشی مداخله فراشناختی بر علائم درآمیختگی افکار در بیماران مبتلا به اختلال بدشکلی بدن. مجله افق دانش 18 (1)،1391: 59-53.
31- رشیدی­پور، فاطمه .رابطه سبک دلبستگی و تصویر بدنی با اضطراب اجتماعی دانش آموزان دخترانه منطقه 20 آموزشی. پایان نامه کارشناسی ارشد . دانشگاه علامه طباطبایی.1391.
32- Hartmann AS, Thomas JJ, Greenberg JL, Elliott CM, Matheny NL, Wilhelm S. Anorexia nervosa and body dysmorphic disorder: A comparison of body image concerns and explicit and implicit attractiveness beliefs. Body Image. 2015 Jun 1;14:77-84.
33- Wells A. Metacognitive therapy for anxiety and depression. Guilford press; 2011 Mar 14.
34- Flavell JH. Metacognition and cognitive monitoring: A new area of cognitive–developmental inquiry. American psychologist. 1979 Oct;34(10):906.
35-Spada MM, Caselli G. The metacognitions about online gaming scale: Development and psychometric properties. Addictive Behaviors. 2017 Jan 1;64:281-6.
36- Smith-Jackson T, Reel JJ, Thackeray R. Coping with “bad body image days”: Strategies from first-year young adult college women. Body Image. 2011 Sep 1;8(4):335-42.
37- Cooper M, Osman S. Metacognition in body dysmorphic disorder—A preliminary exploration. Journal of Cognitive Psychotherapy. 2007 Jun 1;21(2):148-55.
38- Donyavi V, Rabiei M, Nikfarjam M, Rahnejat AM. Develop and Validate a Metacognitive-Cognitive-Behavioral Model for Body Dysmorphic Disorder. Open Journal of Medical Psychology. 2015;4.
39- Daig I, Burkert S, Albani C, Martin A, Brähler E. Associations between body dysmorphic symptoms, body image and self-consciousness in a representative population sample. Psychotherapie, Psychosomatik, medizinische Psychologie. 2007 Jul 23;58(1):16-22.
40- Veale D, Gledhill LJ, Christodoulou P, Hodsoll J. Body dysmorphic disorder in different settings: A systematic review and estimated weighted prevalence. Body Image. 2016 Sep 1;18:168-86.
41- Simons JS, Gaher RM. The Distress Tolerance Scale: Development and validation of a self-report measure. Motivation and emotion. 2005 Jun;29(2):83-102.
42- Leyro TM, Zvolensky MJ, Bernstein A. Distress tolerance and psychopathological symptoms and disorders: a review of the empirical literature among adults. Psychological bulletin. 2010 Jul;136(4):576.
43- اکبری. بررسی سهم نسبی سازه‌های فراتشخیصی در پیش‌بینی اختلال وسواسی-اجباری در یک جمعیت بالینی: عدم تحمل بلاتکلیفی، همجوشی شناختی، عدم تحمل آشقتگی. روانشناسی بالینی و شخصیت. (2)15، 1396: 177-167.
43- Zvolensky MJ, Bernstein A, Vujanovic AA, editors. Distress tolerance: Theory, research, and clinical applications. Guilford Press; 2011 Mar 14.
44- Matheny NL, Summers BJ, Macatee RJ, Harvey AM, Okey SA, Cougle JR. A multi-method analysis of distress tolerance in body dysmorphic disorder. Body image. 2017 Dec 1;23:50-60.
45- Buhr K, Dugas MJ. Investigating the construct validity of intolerance of uncertainty and its unique relationship with worry. Journal of anxiety disorders. 2006 Jan 1;20(2):222-36.
46- Summers BJ, Matheny NL, Sarawgi S, Cougle JR. Intolerance of uncertainty in body dysmorphic disorder. Body image. 2016 Mar 1;16:45-53.
47- Robinson LJ, Freeston MH. Emotion and internal experience in obsessive compulsive disorder: reviewing the role of alexithymia, anxiety sensitivity and distress tolerance. Clinical Psychology Review. 2014 Apr 1;34(3):256-71.
48- Oakes A, Collison J, Milne‐Home J. Repetitive, safe, and automatic: The experience of appearance‐related behaviours in body dysmorphic disorder. Australian Psychologist. 2017 Dec 1;52(6):433-41.
49- Krause ED, Mendelson T, Lynch TR. Childhood emotional invalidation and adult psychological distress: The mediating role of emotional inhibition. Child abuse & neglect. 2003 Feb 1;27(2):199-213.
50- Silva E, Pascoal PM, Nobre P. Beliefs about appearance, cognitive distraction and sexual functioning in men and women: A mediation model based on cognitive theory. The journal of sexual medicine. 2016 Sep 1;13(9):1387-94.
51- Tomas-Aragones L, Marron SE. Body image and body dysmorphic concerns. Acta dermato-venereologica. 2016 Jul 1;96(217):47-50.
52-‏‏ Simons RM, Sistad RE, Simons JS, Hansen J. The role of distress tolerance in the relationship between cognitive schemas and alcohol problems among college students. Addictive behaviors. 2018 Mar 1;78:1-8.
53- Batmaz S, Kaymak SU, Kocbiyik S, Turkcapar MH. Metacognitions and emotional schemas: a new cognitive perspective for the distinction between unipolar and bipolar depression. Comprehensive psychiatry. 2014 Oct 1;55(7):1546-55.
54- Irvine KR, McCarty K, McKenzie KJ, Pollet TV, Cornelissen KK, Toveé MJ, Cornelissen PL. Distorted body image influences body schema in individuals with negative bodily attitudes. Neuropsychologia. 2019 Jan 1;122:38-50.
55- Cormier A, Jourda B, Laros C, Walburg V, Callahan S. Influence between early maladaptive schemas and depression. L'encephale. 2011 Mar 26;37(4):293-8.
56- Dykas MJ, Cassidy J. Attachment and the processing of social information across the life span: theory and evidence. Psychological bulletin. 2011 Jan;137(1):19.
57- Didie ER, Kuniega-Pietrzak T, Phillips KA. Body image in patients with body dysmorphic disorder: Evaluations of and investment in appearance, health/illness, and fitness. Body image. 2010 Jan 1;7(1):66-9.
58- Steward T, Pico-Perez M, Mata F, Martinez-Zalacain I, Cano M, Contreras-Rodriguez O, Fernandez-Aranda F, Yucel M, Soriano-Mas C, Verdejo-Garcia A. Emotion regulation and excess weight: impaired affective processing characterized by dysfunctional insula activation and connectivity. PLoS One. 2016 Mar 22;11(3):e0152150.
59- Phillips KA, Hollander E, Rasmussen SA, Aronowitz BR. A severity rating scale for body dysmorphic disorder: development, reliability, and validity of a modified version of the Yale-Brown Obsessive Compulsive Scale. Psychopharmacology bulletin. 1997;33(1):17.
60- ربیعی،مهدی؛ خرم­دل،کاظم؛ کلانتری، مهرداد؛ مولوی،حسین.(1388).ساختار عاملی، پایایی و روایی مقیاس اصلاح شده وسواس فکری- عملی ییل- براون برای اختلال بدشکلی بدن در میان دانشجویان .مجله روانپزشکی و روانشناسی بالینی ایران. 15(4)،1388: 350 -343.
61- Young JE, Questionnaire BG. Special Edition. New York: Schema Therapy Institute. 2001.
62- Welburn K, Coristine M, Dagg P, Pontefract A, Jordan S. The Schema Questionnaire—Short Form: Factor analysis and relationship between schemas and symptoms. Cognitive therapy and research. 2002 Aug;26(4):519-30.
63- آهی، قاسم؛ محمدی فر، محمد علی؛ بشارت، محمد علی. پایایی و اعتبار فرم کوتاه پرسشنامه طرحواره های یانگ. مجله روانشناسی و علوم تربیتی، سال 37، شماره 3، 1386: 5-20.
64- Khosravani V, Najafi M, Mohammadzadeh A. The Young Schema questionnaire-short form: A Persian version among a large sample of psychiatric patients. International journal of mental health and addiction. 2020 Aug;18(4):949-67.
65- Silverman MJ. Therapeutic songwriting to address distress tolerance for adults on an acute care mental health unit: A pilot study. The Arts in Psychotherapy. 2020 Sep 25:101716.
66- عزیزی، علیرضا؛ میرزائی، آزاده؛ شمس، جمال . بررسی رابطه تحمل پریشانی و نتظیم هیجانی با میزان وابستگی دنشجویان به سیگار.مجله پژوهشی حکیم.(1)13 ،1389: 18-11.
67- Zielinski MJ. The Perceived Invalidation of Emotion Scale (PIES): Development and Psychometric Properties. University of Arkansas; 2016.
68- عطار، فراز . مدل فراتشخیصی افسردگی و اضطراب: نقش عاطفه مندی منفی، دشواری در تنظیمی هیجان، افکار تکرارشونده منفی و بی‌اعتبارسازی هیجانی. پایان­نامه کارشناسی ارشد. دانشگاه خوارزمی.1398.
69- Rabiei M, Salahian A, Bahrami F, Palahang H. Construction and standardization of the body dysmorphic metacognition questionnaire. Journal of Mazandaran University of Medical Sciences. 2011 Jul 10;21(83):43-52.
70- Littleton HL, Axsom D, Pury CL. Development of the body image concern inventory. Behaviour Research and therapy. 2005 Feb 1;43(2):229-41.
71- بساک نژاد، سودابه و غفاری، مجید. (1386). رابطه بین ترس از بدر یختی بدنی و اختلال‏های روانشناختی دانشجویان دانشگاه. مجله علوم رفتاری، دوره اول، شماره 2، 1386: 179-187.
72- Ghadakzadeh S, Ghazipour A, Khajeddin N, Karimian N, Borhani M. Body Image Concern Inventory (BICI) for identifying patients with BDD seeking rhinoplasty: using a Persian (Farsi) version. Aesthetic plastic surgery. 2011 Dec 1;35(6):989-94.
73- Cecero JJ, Marmon TS, Beitel M, Hutz A, Jones C. Images of mother, self, and God as predictors of dysphoria in non-clinical samples. Personality and individual differences. 2004 May 1;36(7):1669-80.
74- یدالهی باستانی ، سوگل؛ نشاط دوست، حمیدطاهر؛ عابدی ، محمدرضا؛ عابدی ، احمد.اثر بخشی طرحواره درمانی برکاهش علائم اختلال بدشکلی بدنی در مبتلایان به بدشکلی بدنی : پژوهش مورد منفرد ، چعارمین کنگره بین المللی روان تنی (سایکوسوماتیک)، اصفهان، دانشگاه آزاداسلامی واحد خوراسگان.1391.
75- Makinson JE. Early maladaptive schemas and their relationship to psychopathology in adolescence. (2013)
76- خوش­اقبال ، مرجان .مقایسه طرحواره های ناسازگار اولیه ، کمال گرایی و نارضایتی از تصویر بدن در افرادی که برای جراحی زیبایی بینی و غیر متقاضیان در ارومیه متقاضی هستند ، پایان نامه کارشناسی ارشد ، روانشناسی عمومی ، دانشگاه ارومیه.1393.
77- Dehbaneh MA, Bahrainian SA. The comparison between early maladaptive schemas and dysfunctional attitudes and coping strategies in people with Body Dysmorphic Disorder and healthy people in a study population in Tehran. Middle East Journal of Family Medicine. 2018 Jan 1;16(1)1-11.
78- Esmaeilnia M, Dousti Y, Mirzaian B. The Role of Early Maladaptive Schema and Perfectionism on Body Dysmorphic Disorder Mediating Through Thought Fusion, Meta-worry, Anxiety, and Attributional Style: A Structural Model. Avicenna Journal of Neuro Psycho Physiology. 2018 Nov 10;5(4):169-78.
79- Contreras GA, Sabiston CM, O'Loughlin EK, Bélanger M, O'Loughlin J. Body image emotions, perceptions, and cognitions distinguish physically active and inactive smokers. Preventive medicine reports. 2015 Jan 1;2:141-5.
80- Mor N, Winquist J. Self-focused attention and negative affect: a meta-analysis. Psychological bulletin. 2002 Jul;128(4):638.
81- Veale D. Advances in a cognitive behavioural model of body dysmorphic disorder. Body image. 2004 Jan 1;1(1):113-25.
82- Rabiei M, Mulkens S, Kalantari M, Molavi H, Bahrami F. Metacognitive therapy for body dysmorphic disorder patients in Iran: acceptability and proof of concept. Journal of behavior therapy and experimental psychiatry. 2012 Jun 1;43(2):724-9.
83- Nikfarjam M, Rabiei M, Donyavi V, Mahmoodabadi HZ. Development and Validation of a Measure for Metacognitive Factors in Body Dysmorphic Disorder Patients. International Journal of Clinical Medicine. 2015 May 18;6(05):334.
84- Skeen M. A Schema-focused Analysis of Philip Carey in W. Somerset Maugham's" Of Human Bondage". ProQuest; 2007.
85- Ledoux T, Winterowd C, Richardson T, Clark JD. Relationship of negative self-schemas and attachment styles with appearance schemas. Body Image. 2010 Jun 1;7(3):213-7.
86- Mojallal M, Khosrojavid M, Pakzad F, Ghanbari M. Early maladaptive schemas, body image, and self-esteem in iranian patients undergone cosmetic surgery compared with normal individuals. Practice in Clinical Psychology. 2014 Jul 10;2(3):201-10.
87- Rosen JC, Ramirez E. A comparison of eating disorders and body dysmorphic disorder on body image and psychological adjustment. Journal of Psychosomatic Research. 1998 Mar 1;44(3-4):441-9.
88- Jarry JL, Ip K. The effectiveness of stand-alone cognitive-behavioural therapy for body image: A meta-analysis. Body image. 2005 Dec 1;2(4):317-31.
89- Cash TF, Smolak L, editors. Body image: A handbook of science, practice, and prevention. Guilford press; 2011 Jul 19.
90- Neziroglu F, Khemlani-Patel S, Veale D. Social learning theory and cognitive behavioral models of body dysmorphic disorder. Body image. 2008 Mar 1;5(1):28-38.
91- Kollei I, Brunhoeber S, Rauh E, de Zwaan M, Martin A. Body image, emotions and thought control strategies in body dysmorphic disorder compared to eating disorders and healthy controls. Journal of Psychosomatic Research. 2012 Apr 1;72(4):321-7.
92- Kollei I, Martin A. Body-related cognitions, affect and post-event processing in body dysmorphic disorder. Journal of behavior therapy and experimental psychiatry. 2014 Mar 1;45(1):144-51.
93- Hambrook D, Oldershaw A, Rimes K, Schmidt U, Tchanturia K, Treasure J, Richards S, Chalder T. Emotional expression, self‐silencing, and distress tolerance in anorexia nervosa and chronic fatigue syndrome. British Journal of Clinical Psychology. 2011 Sep;50(3):310-25.
94- Summers BJ, Matheny NL, Cougle JR. ‘Not just right’experiences and incompleteness in body dysmorphic disorder. Psychiatry research. 2017 Jan 1;247:200-7.
95- Simons RM, Sistad RE, Simons JS, Hansen J. The role of distress tolerance in the relationship between cognitive schemas and alcohol problems among college students. Addictive behaviors. 2018 Mar 1;78:1-8.