The Relationship Between Guilt and Self-Blame with Early Maladaptive Schemas in Patients with Cancer: A cross-sectional study

TL;DR

This study shows that early maladaptive schemas are strongly linked to guilt and self-blame in cancer patients, even after considering overall psychological distress.

Contribution

The study reveals the independent role of early maladaptive schemas in guilt and self-blame among cancer patients.

Findings

EMSs are strongly correlated with guilt (r = 0.51) and self-blame (r = 0.314) in cancer patients.

The correlation between EMSs and guilt/self-blame decreases after accounting for psychological distress.

Schema-focused interventions may help reduce emotional distress in cancer patients.

Abstract

Cancer is still one of the leading causes of death worldwide and a high percentage of patients with cancer face emotional challenges such as guilt and self-blame. Early maladaptive schemas (EMSs) can make these feelings even stronger. This study aimed to explore how guilt and self-blame relate to EMSs in individuals with cancer, while taking overall psychological distress into account.

This cross-sectional study was conducted at Rasoul-e-Akram and Firoozgar hospitals in Tehran, Iran, from October 2022 to June 2023. Patients with cancer answered the Early Maladaptive Schema Questionnaire-Short Form, Eysenck's Guilt Questionnaire (2007) and the Cognitive Emotion Regulation Questionnaire. Pearson correlation was used to examine the associations and partial correlation to control for psychological distress (Depression Anxiety-Stress Scale-21 [DASS-21] total score).

A total of 145 patients with cancer were included in this study; 69.7% were female and most were diagnosed with colon or breast cancer. After accounting for psychological distress measured by DASS-21, the analysis showed a clear link between EMSs and feelings of guilt (r = 0.51; P <0.001) and self-blame (r = 0.314; P <0.001). However, after accounting for psychological distress, the connections between EMSs appeared less intense.

These findings suggest that EMSs are closely linked to feelings of guilt and self-blame among patients with cancer, both before and after accounting for psychological distress. The adjustment reduced correlation, which illustrates how EMSs render emotional distress more relatable. These results suggest that schema-focused interventions can reduce these responses, improving psychological well-being and treatment effectiveness.

Tables

Table 1.. Characteristics of the patients with cancer included in this study (N = 145).

Characteristic	n (%)
Gender
Female	101 (69.7)
Male	44 (30.3)
Age in years
≤29	14 (9.7)
30–39	27 (18.6)
40–49	40 (27.6)
≥50	64 (44.1)
Education level
Secondary school	78 (53.8)
High school diploma	39 (26.9)
Associate's degree	7 (4.8)
Bachelor's degree	14 (9.7)
Master's degree	6 (4.1)
PhD	1 (0.7)
Job status
Employed	142 (97.9)
Unemployed	3 (2.1)
Duration of cancer in years
<1	87 (60.0)
1–3	36 (24.8)
4–6	15 (10.4)
>6	7 (4.8)
Type of cancer
Gastric	6 (4.1)
Lymphatic	10 (6.9)
Colon	36 (24.8)
Brain	3 (2.1)
Cervix	6 (4.1)
Breast	28 (19.3)
Liver	17 (11.7)
Lung	4 (2.8)
Ovary	6 (4.1)
Testicle	1 (0.7)
Blood	14 (9.7)
Oesophagus	2 (1.4)
Kidney	2 (1.4)
Thyroid	2 (1.4)
Gall bladder	1 (0.7)
Retina	1 (0.7)
Bone	3 (2.1)
Bladder	1 (0.7)
Skin	1 (0.7)
Prostate	1 (0.7)

Table 2.. Correlations between the Early Maladaptive Schema Questionnaire-Short Form score and guilt score before and after adjusting the Depression Anxiety-Stress Scale-21 score.

	Before adjusting for DASS-21			After adjusting for DASS-21
Variable	Pearson's r	P value	95% CI	Correlation coefficient (Pearson's r)	P value	95% CI
Emotional depriviation	0.29	<0.001	0.135–0.452	0.18	0.030	0.003–0.353
Abandonment	0.38	<0.001	0.226–0.499	0.28	<0.001	0.127–0.421
Mistrust/abuse	0.26	<0.001	0.126–0.422	0.26	0.001	0.100–0.414
Social isolation/alienation	0.37	<0.001	0.217–0.526	0.27	<0.001	0.117–0.453
Defectiveness/shame	0.38	<0.001	0.228–0.501	0.25	0.002	0.106–0.403
Failure	0.43	<0.001	0.257–0.538	0.34	<0.001	0.137–0.448
Dependence/incompetence	0.39	<0.001	0.223–0.483	0.22	0.009	0.074–0.354
Vulnerability to harm or illness	0.37	<0.001	0.224–0.496	0.23	0.006	0.071–0.378
Enmeshment/undeveloped self	0.26	<0.001	0.105–0.408	0.18	0.027	0.039–0.333
Subjugation	0.41	<0.001	0.240–0.524	0.32	<0.001	0.141–0.463
Self-sacrifice	0.30	<0.001	0.118–0.405	0.25	0.009	0.059–0.371
Emotional inhibition	0.39	<0.001	0.225–0.486	0.28	0.001	0.107–0.394
Unrelenting standards	0.20	<0.001	0.070–0.361	0.27	<0.001	0.127–0.409
Entitlement/grandiosity	0.30	<0.001	0.153–0.436	0.30	<0.001	0.153–0.418
Insufficient self-control/self-discipline	0.32	<0.001	0.155–0.424	0.17	0.043	–0.001–0.315
Total score	0.61	<0.001	0.357–0.602	0.51	<0.001	0.256– 0.534

Table 3.. Correlation between the Early Maladaptive Schema Questionnaire-Short Form score and self-blame score before and after adjusting the Depression Anxiety-Stress Scale-21 score.

	Before adjusting for DASS-21			After adjusting for DASS-21
Variable	Pearson's r	P value	95% CI	Correlation coefficient (Pearson's r)	P value	95% CI
Emotional depriviation	0.10	0.21	–0.053–0.276	0.08	0.34	-0.099–0.245
Abandonment	0.24	0.003	0.046–0.419	0.21	0.01	0.034–0.403
Mistrust/abuse	0.28	<0.001	0.125–0.426	0.28	<0.001	0.110–0.410
Social isolation/alienation	0.21	0.01	0.032–0.365	0.18	0.01	0.008–0.339
Defectiveness/shame	0.29	<0.001	0.140–0.418	0.27	<0.001	0.124–0.413
Failure	0.07	0.35	–0.064–0.223	0.04	0.62	–0.116–0.192
Dependence/incompetence	0.05	0.55	-0.097–0.195	-0.004	0.87	-0.151–0.145
Vulnerability to harm or illness	0.002	0.94	–0.157–0.148	–0.06	0.45	–0.230–0.101
Enmeshment/undeveloped self	0.17	0.05	0.002–0.318	0.16	0.08	–0.012–0.307
Subjugation	0.09	0.29	–0.077–0.247	0.06	0.50	–0.106–0.224
Self-sacrifice	0.18	0.04	-0.004–0.342	0.16	0.06	–0.021–0.326
Emotional inhibition	0.13	0.13	-0.042–0.283	0.10	0.26	-0.076–0.257
Unrelenting standards	0.34	<0.001	0.181–0.473	0.35	<0.001	0.185–0.480
Entitlement/grandiosity	0.33	<0.001	0.163–0.479	0.32	<0.001	0.159–0.477
Insufficient self-control/self-discipline	0.06	0.47	-0.096–0.204	0.01	0.9	–0.151–0.167
Total Score	0.33	0.001	0.162–0.471	0.31	0.001	0.143–0.458

Full text

1. Introduction

Despite extensive advances in the treatment of incurable diseases, cancer remains a major health challenge worldwide. It ranks as the second leading cause of death globally and the third leading cause in Iran.^1^ The progression of the disease, along with the side effects of the treatments used, is often accompanied by feelings of stress, anxiety and depression.^2^ These emotional struggles can have profound effects on many aspects of patients' lives, such as how they interact socially, how they cope with problems, their overall quality of life, their mental health, their commitment to treatment as well as their feelings of guilt and self-blame.^3^

Most patients with cancer experience feelings of guilt and self-blame, particularly in lifestyle-related situations over which they believe they had some control.^4^ The experience of self-blame and guilt in patients with cancer has been widely documented in numerous studies.^45^ These feelings can be associated with a variety of consequences, including increased disease burden, psychological distress, treatment difficulties and impairment of physical function and overall well-being.^67^

The intensity of these emotions experienced by individuals varies significantly, indicating the greater vulnerability of some patients. The observed difference could also be rooted in internal psychological factors. Understanding the mental framework in patients with cancer who are more vulnerable to guilt and self-blame might help to explain the challenges they encounter.^8910^

One way to understand these emotional reactions is through the theory of early maladaptive schema (EMS). EMSs are deep-seated, unhealthy beliefs that develop during childhood and adolescence, negatively affecting a person's interpersonal and intrapersonal relationships. In patients with cancer, these maladaptive schemas can combine with feelings of guilt and self-blame, potentially worsening emotional distress and psychological disorders.^1112^ Understanding these connections is essential for creating compassionate psychological interventions that enhance mental health outcomes in this vulnerable population.

Research has shown a relationship between some maladaptive schemas, such as feelings of abandonment, dependency, negativity/pessimism and psychological distress.^13^ According to the results of a study on patients with lung cancer, shame and guilt are recognised as predictors of depression and anxiety as well as social stigma acts as a mediating factor.^14^ Also, in another study, “survivor guilt” has been reported among cancer survivors.^15^

Although guilt and self-blame among patients with cancer have been widely researched, the role of EMSs in these feelings has not yet been fully elucidated. Early identification and addressing negative emotions early in the disease process can help healthcare providers improve patients' mental health. Therefore, this study aimed to examine the relationship between EMSs, guilt and self-blame with regard to psychological distress in patients with cancer.

2. Methods

This cross-sectional study was conducted at the Rasoul-e-Akram and Firoozgar hospitals affiliated with the Iran University of Medical Sciences in Tehran, Iran, between October 2022 and June 2023. Patients were recruited consecutively from the oncology departments. Patients with a cancer diagnosis confirmed by an oncologist, living in Tehran, had the ability to read and write simple Persian sentences and were willing to participate were included in this study. Exclusion criteria included not having cancer, not wanting to participate and having severe mental health issues. Participants with serious psychiatric conditions such as psychotic disorders or severe mood disorders, confirmed by their doctor, were not included. This recruitment approach helped ensure a fair and unbiased selection process. Participants were stratified based on cancer type, gender and age group. This stratification allows for the description of the sample's demographic and clinical characteristics, although the study was not powered for formal subgroup analyses.

The 75-item Early Maladaptive Schema Questionnaire-Short Form (EMSQ-SF) questionnaire, developed by Young in 1994, is a short form assessing 15 EMSs. The schemas are as follows: emotional deprivation, abandonment, mistrust/abuse, social isolation/alienation, defectiveness/shame, failure, dependence/incompetence, vulnerability to harm or illness, enmeshment/undeveloped self, subjugation, self-sacrifice, emotional inhibition, unrelenting standards, entitlement/grandiosity and insufficient self-control/self-discipline.^16^ The Persian version of EMSQ-SF has been validated by Khosravani et al., demonstrating Cronbach's alpha values >0.70 for all domains.^17^

Depression Anxiety-Stress Scale-21 (DASS-21), developed by Lovibond and Lovibond consists of 21 questions across three subscales: depression, anxiety and stress (7 items each). It uses a Likert scale from 0 (“Did not apply to me at all”) to 3 (“Applied to me very much or most of the time”). Scores of ≥21 on the depression subscale, ≥15 on the anxiety subscale and ≥26 on the stress subscale are considered abnormal. The subscales' Cronbach's alphas are 0.91 (depression), 0.84 (anxiety) and 0.90 (stress).^18^ For the Persian version, the alphas are 0.85, 0.85 and 0.87 for the respective subscales.^19^

Guilt was measured via Eysenck's 2007 guilt questionnaire, a 30-item questionnaire derived from previous research, with a scoring range of 0–30. Reliability, as reported by Razavi et al., had a Cronbach's alpha of 0.67 and a split-half reliability of 0.68.^20^

Self-blame was measured using the Self-Blame subscale of the Cognitive Emotion Regulation Questionnaire (CERQ), a 36-item questionnaire assessing cognitive responses to stress. The full CERQ was administered, but only the Self-Blame subscale (4 items, score range: 4–20) was used in the analyses. Higher scores indicate greater use of this cognitive strategy.^21^ The Cronbach's alpha for the Persian version ranges from 0.68–0.82.^22^

The sample size was determined using G*Power software, Version 3.1.9.2 (Heinrich Heine University Düsseldorf, Düsseldorf, Germany) with a 95% confidence level, a 0.3 effect size and a 10% attrition rate. Categorical variables are presented as frequencies and percentages. The Pearson correlation coefficient was used to assess associations between continuous variables.

DASS-21, measuring general psychological distress, was considered a potential confounder because it could influence both EMSs and feelings of guilt or self-blame. Confounding was assessed by comparing Pearson correlation coefficients between EMSQ-SF scores and guilt/self-blame before and after adjusting for DASS-21. If the correlation changed by more than 10%, DASS-21 was considered a confounder. Accordingly, Pearson's partial correlation coefficients adjusting for DASS-21 were reported.

Correlation coefficients were interpreted as follows: r values between 0.1–0.29, 0.3–0.49 and ≥0.5 indicated weak, moderate and strong correlations, respectively. A significance level of P <0.05 was considered for all statistical tests. Data were analyzed using Statistical Package for Social Sciences (SPSS) software, Version 26 (IBM Corp., Armonk, New York, USA). All questionnaires were examined for completeness before data entry. No missing data were identified for the main study variables; thus, data imputation or adjustment procedures were unnecessary.

3. Results

A total of 145 cancer patients (with lung, larynx, oropharynx, esophagus, bladder, stomach, kidney, pancreas and uterine cancers) were included in this study. The majority of patients were female (69.7%) and the most prevalent type of cancer was colon cancer (24.8%), followed by breast cancer (19.3%). Regarding cancer duration, 60.0% of participants had been diagnosed for less than 1 year, 24.8% for 1–3 years, 10.4% for 4–6 years and 4.8% for more than 6 years [Table 1]. The mean scores for guilt, self-blame, EMS and DASS-21 were 10.81 ± 4.57, 35.30 ± 11.42, 84.86 ± 38.79 and 18.94 ± 11.72, respectively.

A significant positive correlation was observed between the total EMSQ-SF score and guilt, both in the bivariate analysis (r = 0.61; P <0.001) and after controlling for psyCERQ logical distress using partial correlation (r = 0.51; P <0.001). All individual schema domains were significantly correlated with guilt in bivariate analyses (P <0.05). After adjusting for DASS-21 scores, all schemas remained statistically significant (P <0.05), though the magnitude of the correlations varied. The adjusted correlations for specific schemas were as follows: emotional deprivation (r = 0.18; P = 0.030), mistrust/abuse (r = 0.26; P <0.001), social isolation/alienation (r = 0.27; P <0.001), failure (r = 0.34; P <0.001), subjugation (r = 0.32; P <0.001) and entitlement/grandiosity (r = 0.30; P <0.001) [Table 2].

According to the results, the total EMSQ-SF score was significantly correlated with self-blame in both the bivariate (r = 0.31; P <0.001) and partial correlation analyses, controlling for DASS-21 (r = 0.31; P = 0.001). While the total score remained significant, not all individual schemas were significantly associated with self-blame after adjustment for psychological distress. Schemas that maintained a considerable correlation included abandonment (r = 0.21; P = 0.01), mistrust/abuse (r = 0.28; P <0.001), social isolation/alienation (r = 0.21; P <0.01), defectiveness/shame (r = 0.29; P <0.001), unrelenting standards (r = 0.34; P <0.001) and entitlement/grandiosity (r = 0.33; P <0.001). Other schemas, such as failure, dependence/incompetence and vulnerability to harm, were no longer significantly associated with each other [Table 3].

4. Discussion

This study offers evidence on the connection between EMSs and emotional distress in patients with cancer. Initially, there is a clear positive link between EMS total scores and feelings of guilt and this connection stayed strong even after accounting for psychological distress. Additionally, there was a noticeable connection between EMS total scores and self-blame, which remained even after accounting for distress levels. Some schemas, such as emotional deprivation and abandonment, had weaker links with guilt, while others, such as unrelenting standards and entitlement/grandiosity, showed stronger ties to self-blame. Together, these findings offer valuable insights into how EMSs relate to emotional distress in patients with cancer.

The connection between the total EMS score and feelings of guilt in the current study indicated that patients with cancer with dysfunctional core beliefs might see their illness as a result of personal responsibility or moral failure. This pattern is especially noticeable in people who hold beliefs such as defectiveness, shame or self-sacrifice including those who may see themselves as fundamentally flawed or feel that their suffering is necessary to keep their relationships alive.^1415^ As a result, these patients might internalise their illness as something they caused or deserved, which can worsen feelings of guilt. These findings are consistent with earlier studies that connect maladaptive schemas to strong emotions such as anger, anxiety, depression and guilt.^141523^

The attenuation of specific schema relationships, after accounting for DASS-21 scores, highlights that although schemas such as emotional deprivation, abandonment and defectiveness/shame play a role in feelings of guilt, their impact seems to be partly influenced by overall psychological distress. This indicates that feelings of guilt in patients with cancer may stem from deeply ingrained thought-patterns as well as heightened emotional suffering, highlighting a complex and multifaceted origin of guilt in this group.^3^ Being diagnosed with cancer can elicit feelings of fear, despair, guilt, helplessness and abandonment, and can throw a person's psychological balance into turmoil.^24^

This study showed a clear link between EMSs and self-blame, highlighting schemas such as abandonment, mistrust or abuse, social isolation or alienation and unrelenting standards as especially important. Patients with cancer who feel that others will inevitably abandon them or that they are unworthy of support may be more likely to blame themselves, seeing their illness as a reflection of their own inadequacy. Likewise, patients with extremely high standards for themselves might feel guilty for not doing enough to stop or fight the illness, which can make their emotional pain even worse. Following the adjustment for DASS-21 scores, the correlation coefficients for schemas such as emotional deprivation, abandonment, failure and dependence remained significant which highlights how intertwined self-blame and schema-related beliefs are when considering psychological distress. For example, the link between self-blame and the failure schema may partly stem from underlying depressive tendencies that make individuals more likely to self-criticise.

The current study's findings align with previous research by Özer on women with breast cancer, revealing that they often struggle with feelings such as fear, hopelessness, guilt, concerns about treatment and fears of abandonment. The study also indicates that these emotional states might be connected to certain unhealthy patterns such as feelings of failure, pessimism, social withdrawal, self-sacrifice, fear of abandonment or instability, trauma and shame as well as concerns about being harmed or falling ill.^24^

Dozois and Beck describe schemas as patterns consisting of mental images of life experiences, along with their meanings, strategies and physical and emotional symptoms. When faced with stress, these schemas influence how a person reacts to difficult situations.^25^ When faced with negative events, some people develop maladaptive schemas that lead to negative judgments of events and surroundings, resulting in a variety of distressing emotions. EMSs, by disrupting regulation processes, can lead to feelings such as self-blame and guilt, making these emotions more persistent and difficult to manage.^26^

The frequent feelings of guilt and self-blame linked to EMS highlight the vital need to incorporate psychological support into cancer treatment. Supporting this approach, cognitive regulation strategies have been recognised as an essential factor influencing self-blame in patients with advanced cancer receiving palliative care.^27^ Therapeutic approaches that address these core beliefs can help patients reframe negative thoughts, ease feelings of guilt and reduce self-blame, ultimately supporting emotional healing, strengthening social connections, encouraging commitment to treatment and improving overall recovery.^28^

This study was subject to some limitations that should be acknowledged. First, due to the cross-sectional design, it was not possible to establish a cause-and-effect connection between EMSs, guilt and self-blame. Although significant associations were observed, the direction remains unclear, calling for longitudinal studies to determine whether EMSs lead to these emotional responses or if these responses strengthen maladaptive schemas over time. Second, recruiting participants from two hospitals in Tehran and cultural factors unique to Iranian society—such as attitudes toward illness, emotional expression and help-seeking behaviours—may limit how well these findings apply to wider cancer populations, especially in different cultural or socioeconomic settings. Future research should include a more diverse sample to explore these issues across cultures. Third, excluding patients with severe mental disorders or substance use issues, while it is methodologically sound to concentrate on specific relationships, might have led to underrepresenting individuals experiencing higher levels of guilt and self-blame influenced by EMSs. Fourth, the sample's demographic makeup had limitations; most participants were female which led to gender bias, especially given research indicating differences in how genders express schemas and process emotions. Additionally, because this study included many different types of cancer, it can be useful for understanding general trends across populations. However, this diversity might also make it harder to identify patterns that are specific to individual diagnoses. Different types of cancer can differ in their outlook, treatment approaches and emotional effects, which can influence how patients think and feel. Fifth, it's important to note that the Guilt Questionnaire used in this study had a somewhat low Cronbach's alpha (0.67); this suggests the measure might not be highly reliable in this context. Finally, relying on self-reported measures can lead to response bias, since patients might underreport or overreport symptoms due to feelings of shame, social pressure or personal distress. It's advisable to conduct further validation with larger and more diverse groups to ensure the findings are reliable.

5. Conclusion

This study's findings suggest that EMSs are linked to feelings of guilt and self-blame in patients with cancer. This indicates the potential importance of personalised therapeutic approaches. The lengthy process of diagnosing and treating cancer, along with the disease's aggressiveness and the side effects from surgeries, chemotherapy and radiation, can deepen feelings of guilt. EMSs are an essential psychological factor contributing to this distress, suggesting that schema-focused approaches could meaningfully address these challenging emotions in cancer care.

Authors' Contribution

Mohadeseh Nikandish: Data curation, Project administration, Writing – original draft preparation. Seyede Salehe Mortazavi: Conceptualization, Supervision. Shahrbanoo Ghahari: Conceptualization, Supervision. Mahdiyeh Salehi: Formal analysis, Writing – original draft preparation. Roghie Bagheri: Writing – original draft preparation, Writing – review & editing.

Ethics Statement

The study protocol was approved by the Institutional Review Board of Iran University of Medical Sciences (IR.IUMS.REC.1041.198). The study was performed in accordance with the ethical standards of the Helsinki Declaration. All methods were carried out in accordance with relevant guidelines and regulations. After explaining the research procedures, design and objectives, participants signed a written informed consent and the questionnaires were distributed while ensuring patient confidentiality through anonymous data analysis. Participants could join voluntarily and leave anytime without penalties. After completing the questionnaires, participants were debriefed about the study's purpose and were allowed to ask any questions.

Generative AI Declaration

DeepSeek artificial intelligence software, Version 3.2., was used to improve the translation and rewriting of sentences for improved grammar and sentence structure.

Conflict of Interest

The authors declare no conflicts of interest.

Funding

No funding was received for this study.

Data Availability

Data are available upon reasonable request from the corresponding author.