Predicting Marital Quality Based on Emotion Regulation, Self-Esteem, and Early Maladaptive Schemas in Women with Cervical Intraepithelial Neoplasia

Introduction

Cancer is the second leading cause of death worldwide, and it is projected to become the leading cause by 2030. Due to its high morbidity and mortality rates, cancer is a critical public health issue (Tewari et al., 2022). Among these, cervical cancer is the second most common cancer among women globally, with approximately 500,000 new cases and 250,000 deaths annually. This type of cancer usually does not cause symptoms; sometimes, abnormal vaginal bleeding following sexual intercourse or pelvic examination occurs, and the patient complains of pain during intercourse (Terasawa et al., 2022).

In women who regularly undergo screening, the first sign of the disease is usually an abnormal Pap smear test. Typically, abnormal cells (precancerous cells) in the cervical tissues are detected by a Pap smear (Shanthi et al., 2022). Cervical intraepithelial neoplasia (CIN) is a precancerous lesion characterized by abnormal proliferation of parabasal cells due to human papillomavirus (HPV) infection (Galati et al., 2022). This infection is a DNA virus that is resistant to heat and drying, and various types can infect the human genital area (Chow et al., 2021).

Chronic diseases, including cervical intraepithelial neoplasia or cancer in women, can cause significant psychological harm due to the conditions and stressors they endure. These include disturbances in family and marital relationships, self-blame, and blame from others, which greatly impact personality, psychological functions, family functions, and individual relationships, ultimately lowering the quality of life in couples. Therefore, one of the issues that arise with advancements in cancer treatment is the quality of marital life. Marital quality represents the balance of deposits such as love, satisfaction with the relationship, care and companionship, and positive marital feelings in the shared life of couples. It can be stated that marital quality is a multidimensional concept that includes various aspects of couple relationships such as satisfaction, happiness, cohesion and commitment, love, stability of the relationship, and the absence of problems (Rasouli et al., 2019).

Apart from the effects of the disease itself, the most important variable that can exacerbate or control the impact of the disease on the marital quality of patients, particularly those with cervical intraepithelial neoplasia, can be the patients' perceptions and their psychological elements (Zheng et al., 2021). One of the psychological constructs that is a significant factor in determining health and successful functioning in interpersonal interactions and marital life is emotion regulation (Frye-Cox et al., 2021). Emotion regulation refers to the reduction and regulation of negative emotions and the positive use of emotions, involving the ability to understand emotions, modify experience, and express emotions (Horwood & Anglim, 2021).

Despite conceptual advances in this area of study, identifying fundamental mechanisms, including the increasing role of emotion regulation in reducing or enhancing marital quality in patients with cervical cancer, requires more comprehensive investigation. Meanwhile, marriage is a complex, delicate, and dynamic human relationship characterized by unique features, where sexual issues, particularly sexual satisfaction, are among the psychological and physiological needs that can lead to mental health, balance, and happiness. Failure to properly satisfy this need within the family environment can result in various physical and psychological consequences, including sexual conflicts, thereby jeopardizing the marital life of couples and even their marriage (Sanjaya & Putra, 2021).

One of the important individual factors influencing the effective relationship and sexual satisfaction of couples is self-esteem (Anzani et al., 2021). Self-esteem, as defined, is the confidence in one's ability to think, trust in one's right to be successful, happy, valuable, and to express needs and desires. With high self-esteem, we are more likely to face life's challenges; however, in situations where self-esteem is low, the likelihood of giving up or not using one's full potential increases (Geukens et al., 2022).

Self-esteem is closely related to one's self-image and adaptation in various dimensions. A positive self-image creates a sense of worthiness, whereas any change in self-image can lead to changes in the sense of worthiness. Disease, treatments, and their side effects can lead to changes in self-image and reduced self-esteem, which is particularly evident in chronic diseases like cervical cancer due to their long-term and unpredictable nature (Adriani et al., 2022).

According to Young et al. (2018), early maladaptive schemas are self-defeating emotional and cognitive patterns formed early in development and repeated throughout life. In women with the disease, these maladaptive schemas may lead to the use of inappropriate strategies for coping with problems arising from the disease, ultimately resulting in the use of ineffective coping styles and avoidant behaviors, which can negatively impact their marital satisfaction. In other words, early maladaptive schemas cause biases in the interpretation of events. These biases in psychopathology manifest as misunderstandings, distorted attitudes, incorrect assumptions, unrealistic goals, and expectations in marital life (Kaya & Aydin, 2021).

Given the above, the main research question of the present study is whether marital quality can be predicted based on emotion regulation, self-esteem, and early maladaptive schemas in women with cervical intraepithelial neoplasia.

Methods and Materials

Study design and Participant

The present study is descriptive and correlational in nature. The statistical population of this study included all married women with cervical intraepithelial neoplasia residing in Tehran in 2022, who referred to specialized gynecologic oncology surgery centers in the city and had medical records. The sampling method used in this study was purposive sampling. From the married women with cervical intraepithelial neoplasia confirmed by a specialist, the sample size was determined using the Plant formula. According to this formula, the sample size in correlational studies is calculated using the formula (N = 50 + 8M), where N is the sample size and M is the number of predictor variables. In this study, with three predictor variables including emotion regulation, self-esteem, and early maladaptive schemas, the sample size was calculated as 74 (50 + 8×3). However, to ensure greater reliability and generalizability of the results, a sample size of 148 was considered, of which 28 questionnaires were excluded due to being invalid, leaving 120 participants in the final study.

Inclusion Criteria: Confirmed diagnosis of the disease and having a medical record, being married, not having psychiatric disorders and being under treatment, consent to participate in the study.

Exclusion Criteria: Lack of confirmed diagnosis, being under psychiatric treatment during the study, lack of consent to participate in the study, and being single.

Measures

Quality of Life

This self-report instrument was developed by Busby et al. in 1995 and includes 14 questions with three subscales: agreement, satisfaction, and cohesion. The initial form of this tool had 32 questions, which was based on the theory of Levys and Spinner about marital relationship quality. The questionnaire items are scored on a 6-point Likert scale (always disagree with a score of 0 to always agree with a score of 5). The reliability of the questionnaire using Cronbach's alpha coefficient was reported to be 0.80 by the developers. The validity of the instrument was also estimated at 0.79. In Iran, the Cronbach's alpha coefficient for this tool was reported as 0.89 and its validity as appropriate (Rasouli et al., 2019).

Emotion Regulation

This self-report questionnaire was developed by Gross and John in 2003 and includes 10 questions with two subscales: emotional inhibition and cognitive reappraisal. The questionnaire is scored on a 7-point Likert scale (strongly disagree = 1 to strongly agree = 7). The reliability of the questionnaire using Cronbach's alpha coefficient was reported by the developers as 0.79 for the total questionnaire, 0.67 for the emotional inhibition component, and 0.69 for the cognitive reappraisal component. In the study by Karbalai et al., the reliability of the questionnaire was reported as 0.81, with 0.79 for the emotional inhibition component and 0.80 for the cognitive reappraisal component (Terasawa et al., 2022).

Self-Esteem

This self-report tool was developed and validated by Coopersmith in 1967 to measure self-esteem. It consists of 58 questions with four subscales: personal self-esteem, family self-esteem, social self-esteem, and academic self-esteem. The questionnaire items are scored as yes (1 point) or no (0 points). The developer reported a Cronbach's alpha coefficient of 0.88 for the entire tool and a range of 0.76 to 0.88 for the subscales. In Iran, the Cronbach's alpha coefficient for the entire tool was reported as 0.86, with subscales ranging from 0.73 to 0.85 (Adriani et al., 2022).

Early Maladaptive Schema

This self-report tool was developed by Young in 2005 to measure early maladaptive schemas. The questionnaire, available in both long and short forms, has 75 questions in the short form with five schema domains: Disconnection and Rejection (Mistrust/Abuse, Emotional Deprivation, Defectiveness/Shame, Social Isolation), Impaired Autonomy and Performance (Dependence/Incompetence, Vulnerability to Harm, Enmeshment/Undeveloped Self, Failure), Impaired Limits (Entitlement/Grandiosity, Insufficient Self-Control), Other-Directedness (Subjugation, Self-Sacrifice), and Overvigilance and Inhibition (Emotional Inhibition, Unrelenting Standards/Hypercriticalness). The items are scored on a 6-point Likert scale (completely untrue = 1 to completely true = 6). If the average score for any subscale exceeds 2.5, that schema is considered maladaptive. The reliability and validity of this tool have been demonstrated in numerous studies. In Iran, normalization of this questionnaire was conducted by Ahi in 2006 at Tehran universities. The internal consistency using Cronbach's alpha was 0.97 for females and 0.98 for males, and in the study by Shahamat et al. (2010), Cronbach's alpha was 0.96 with the following for specific schemas: Emotional Deprivation (0.86), Abandonment (0.70), Mistrust/Abuse (0.81), Social Isolation (0.79), Defectiveness/Shame (0.89), Failure (0.89), Dependence/Incompetence (0.84), Vulnerability to Harm (0.84), Enmeshment/Undeveloped Self (0.77), Subjugation (0.82), Self-Sacrifice (0.82), Emotional Inhibition (0.78), Unrelenting Standards/Hypercriticalness (0.69), Entitlement/Grandiosity (0.78), and Insufficient Self-Control (0.71) (Young et al., 2018).

Data Analysis

Data analysis was performed using SPSS-27 software. The primary statistical method employed was Analysis of Variance (ANOVA) with repeated measurements to compare the changes in Co-Parenting Quality and Interpersonal Obsessive-Compulsive Symptoms between the intervention and control groups over time. This analysis allowed for the examination of within-subjects effects (changes over time), between-subjects effects (differences between the groups), and interaction effects (differences in changes over time between the groups). To further analyze significant findings, Bonferroni post-hoc tests were conducted, which helped in identifying specific time points where differences between the groups were statistically significant. The level of significance was set at p < 0.05 for all tests.

Findings and Results

The results in Table 1 show that the mean total emotion regulation score among the participants was 73.90 (8.58). The results also show that the mean total self-esteem score among the participants was 68.27 (12.75). The results also show that the mean total score of early maladaptive schemas among the participants was 228.39 (46.02). The results show that the mean total marital quality score among the participants was 47.96 (9.26).

Based on the adjusted coefficient of determination, 32% of the variance in marital quality in the sample individuals was explained by emotion regulation. Additionally, the results of the one-way ANOVA showed that the obtained F value was 74.189, which was significant at the alpha level of less than 0.05, indicating that the dimensions of emotion regulation can well explain the changes related to marital quality in the sample individuals, and this shows the suitability of the proposed regression model. Finally, Table 2 shows the standardized and unstandardized coefficients of multiple regression using the simultaneous entry method, indicating that emotional inhibition (P<0.05, B=-0.158) and cognitive reappraisal (P<0.05, B=0.172) can negatively and positively predict marital quality in the sample individuals, respectively. Therefore, the first hypothesis of the study is confirmed.

Additionally, regarding the variable of self-esteem, based on the adjusted coefficient of determination, 23% of the variance in marital quality in the sample individuals was explained by self-esteem. The results of the one-way ANOVA showed that the obtained F value was 56.337, which was significant at the alpha level of less than 0.05, indicating that the dimensions of self-esteem can well explain the changes related to marital quality in the sample individuals, showing the suitability of the proposed regression model. The standardized and unstandardized coefficients of multiple regression using the simultaneous entry method showed that personal self-esteem (P<0.05, β=0.131), family self-esteem (P<0.05, β=0.128), social self-esteem (P<0.05, β=0.096), and academic self-esteem (P<0.05, β=0.053) can predict marital quality in the sample individuals. Therefore, the second hypothesis of the study is confirmed.

Finally, based on the adjusted coefficient of determination, 24% of the variance in marital quality in the sample individuals was explained by early maladaptive schemas. The results of the one-way ANOVA showed that the obtained F value was 81.504, which was significant at the alpha level of less than 0.05, indicating that the dimensions of early maladaptive schemas can well explain the changes related to marital quality in the sample individuals, showing the suitability of the proposed regression model. The standardized and unstandardized coefficients of multiple regression using the simultaneous entry method showed that the dimensions of early maladaptive schemas can predict marital quality in the sample individuals. Therefore, the third hypothesis of the study is confirmed.

Discussion and Conclusion

The results of the study, using Pearson correlation coefficient, showed that there is a negative and significant correlation between the emotional inhibition dimension of emotion regulation and marital quality and a positive and significant correlation between the cognitive reappraisal dimension of emotion regulation and marital quality.

Regression analysis also showed that the dimensions of emotion regulation have the ability to explain marital quality. Therefore, the first hypothesis of the present study is confirmed. This result is consistent with the findings of some previous studies, such as Zheng et al. (2021), Saadati Rad (2020), and Mafakheri and Mehrvarzan (2017).

In explaining this finding, it can be said that emotion regulation skill is the most effective individual factor in mental health and the level of perceived control over the inner and outer world. As the level of perceived control decreases, the individual moves away from complete health and towards more emotional and psychological problems. Nonadaptive or maladaptive cognitive emotion regulation strategies weaken the ability to manage and control emotions. This weakness in managing and controlling emotions in the realm of interpersonal relationships, especially marital relationships, can lead to marital problems. The use of negative and maladaptive emotion regulation strategies can cause individuals to feel less in control of their inner and outer worlds. Negative cognitive coping strategies are positively correlated with depression, anxiety, and stress. Therefore, it can be concluded that the use of negative and maladaptive emotion regulation strategies, such as emotional inhibition, can cause individuals to feel less in control of their inner and outer worlds. This means that individuals with marital discord and problems may come to the conclusion that they have no control over their marital tensions and problems, which in turn can increase emotional problems such as mood and anxiety symptoms, thereby exacerbating their marital problems.

Inability to regulate emotions also leads to emotional and cognitive distress and disrupts the organization of an individual's emotions and cognitions. This disruption in social interactions leads to interpersonal problems, as emotions play a crucial role in forming, maintaining, and ending interpersonal relationships by regulating the distance between individuals (drawing them closer or pushing them apart). Furthermore, individuals with ineffective emotional styles such as emotional inhibition cannot manage their emotional situations effectively and are less able to maintain their relationships with their spouses, feeling trapped in negative interaction patterns with their partners. They feel out of control, which prevents them from achieving satisfaction and tranquility in marital life and being content with the process of life. Due to negative skills in establishing appropriate communication with their partners, these individuals face problems, making it unsurprising that they experience marital conflicts and disagreements, thus affecting their marital quality.

Moreover, it can be explained that individuals who engage in positive reappraisal tend to interpret stressful events like illness in an optimistic manner and actively try to improve their negative moods. These individuals, compared to those who use this strategy less frequently, experience and express more positive and fewer negative emotions. Individuals who can recognize and effectively express their emotional states are better able to face life’s problems and are more successful in adapting to their environment and others. These individuals not only enjoy better mental health but also perceive negative and challenging events as opportunities rather than threats. They also have closer social relationships, higher self-esteem, greater life satisfaction, and fewer mood and anxiety symptoms, thereby maintaining their marital quality.

The results of the study, using Pearson correlation coefficient, showed that there is a positive and significant correlation between self-esteem and marital quality. Regression analysis also showed that the dimensions of self-esteem have the ability to explain marital quality. Therefore, the second hypothesis of the study is confirmed. This result is consistent with the findings of some previous studies, such as Diarian and Nik Nihad (2016).

Self-esteem is a fundamental need that plays a crucial role in the processes of life because it aids in individual growth and health. Without positive self-esteem, psychological growth halts. In reality, self-esteem acts like a conscious immune system, providing the necessary resistance and capacity for life. Conversely, low self-esteem reduces an individual's resilience against problems. The presence of maladaptive schemas in individuals involved in emotional relationships and emotional failures weakens their self-esteem and self-worth, disrupting their social, interpersonal, and familial functions. An individual with an early maladaptive schema (impaired performance and self-regulation) holds beliefs about themselves that make them feel weak, ineffective, and helpless. This schema significantly impacts self-esteem in various areas of life. Additionally, individuals with the defectiveness/shame schema feel flawed, bad, inferior, and worthless, and if they expose themselves to others, they expect to be rejected. Consequently, their interpersonal relationships and, ultimately, their marital quality are affected.

Furthermore, in explaining the above finding, it can be said that interpersonal relationships are essential methods for a healthy and constructive life. These skills are a set of abilities that facilitate adaptation to others and the formation of positive and beneficial behaviors. These abilities enable individuals to play their appropriate roles in society and the family environment without causing harm to themselves or others. Therefore, a person with communication skills should be able to establish relationships with others in a way that flexibly considers the rights, obligations, satisfaction, or assigned duties. This characteristic leads to increased self-esteem in individuals.

Self-esteem can be the outcome of successfully performing an act and, overall, successful functioning in various domains. Self-esteem is the central core of an individual's psychological structures, protecting them against anxiety. Self-esteem plays a protective role in coping with psychological pressures, supporting individuals against negative life stressors. A person with high self-worth can easily confront external threats and stressors without experiencing negative arousal and psychological breakdown. Therefore, it can be said that self-esteem is also evident in marital success. On the other hand, self-esteem is a critical factor in growth and maintaining mental health. Negative life experiences, such as dealing with illness, can lead to a negative belief in individuals, reflecting a sense of worthiness. Self-esteem can affect both psychological and physical processes and potentially be a risk factor for various maladaptive behaviors and negative outcomes.

The results of the study, using Pearson correlation coefficient, showed that there is a negative and significant correlation between early maladaptive schemas and marital quality. Regression analysis also showed that the dimensions of early maladaptive schemas have the ability to explain marital quality. Therefore, the third hypothesis of the study is confirmed. This result is consistent with the findings of some previous studies, such as Pilkington et al. (2021) and Sharifian Safariniam and Alizadeh Fard (2017).

Given that each spouse creates not only their own schemas but also schemas specific to their marital relationship, they try to act in a way that validates their schemas in the course of life and interaction with their partner. However, these schemas are maladaptive, leading to dissatisfaction and dissatisfaction in the couple's relationship. Furthermore, early maladaptive schemas result in the use of inappropriate strategies and ineffective coping styles in dealing with marital problems, resulting in incompatibility and dissatisfaction with the marital relationship. Additionally, early maladaptive schemas affect the way spouses interact and perceive each other, increasing tension and conflicts. Therefore, the more individuals use maladaptive schemas, the lower their marital satisfaction, which is a factor in the stability of a marital relationship, and the higher the tendency toward divorce. According to Young (2003), each new developmental stage requires roles, responsibilities, cognitive expectations, and behavioral adaptations, challenging previous schemas and coping strategies. Individuals with maladaptive schemas, such as abandonment, cannot form secure and satisfying attachments with others, and their relationships lack stability throughout their marital life. Individuals with active emotional inhibition schemas suppress spontaneous feelings and impulses, refraining from expressing emotions toward themselves or their spouse, hindering intimate and satisfying marital relationships. Individuals with emotional deprivation schemas always feel misunderstood by their spouse, appearing sad and depressed. Individuals with dependency schemas, who feel incapable of taking on daily responsibilities without help from others, are unlikely to perform effectively in marital relationships. These factors collectively lead to reduced marital satisfaction and, ultimately, a lower quality of married life.

Young believes that schemas are formed due to unmet basic emotional needs for secure attachment to others, such as the need for security, expressing needs and healthy emotions, spontaneity, fun, realistic limits, and self-control during childhood (Young et al., 2018). Hazen (1994) suggests that childhood attachment types influence the nature of romantic relationships in adulthood and the quality of communication. Each spouse with an insecure attachment style shows low levels of trust towards their partner, demonstrating low levels of cohesion and mutual reliance, having difficulty with commitment and intimacy, reporting low levels of relationship satisfaction, and high levels of conflict.

Limitations and Suggestions

Therefore, early maladaptive schemas and attachment styles overlap and interact. Individuals with maladaptive schemas, growing up in cold, isolated, unpredictable, and abusive families, expect their needs for security, stability, affection, empathy, acceptance, and respect to be unmet predictably. This process creates and maintains an insecure attachment style, shown in multiple studies to be associated with marital conflicts. Individuals with maladaptive schemas and insecure attachment styles constantly seek to confirm these schemas and attachment styles in their relationship with their spouse and close ones, selecting behaviors that activate or confirm their schemas. This style of living, where individuals selectively choose behaviors from their partner, leads to conflict. As a result, these individuals avoid intimate relationships and, due to fear of separation, are less likely to express their love and affection. Additionally, the fear of conflict and tension with their spouse plays a crucial role in maintaining negative relationships, significantly influenced by early maladaptive schemas. Therefore, early maladaptive schemas can be continuously activated, making marital relationships highly vulnerable and naturally reducing the quality of the marital relationship.

Authors’ Contributions

Authors contributed equally to this article.

Declaration

In order to correct and improve the academic writing of our paper, we have used the language model ChatGPT.

Transparency Statement

Data are available for research purposes upon reasonable request to the corresponding author.

Acknowledgments

We would like to express our gratitude to all individuals helped us to do the project.

Declaration of Interest

The authors report no conflict of interest.

Funding

According to the authors, this article has no financial support.

Ethical Considerations

The study protocol adhered to the principles outlined in the Helsinki Declaration, which provides guidelines for ethical research involving human participants.