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Hemmati Sabet A, Navabi Nejad S, Khalatbari J. Effectiveness of Schema Therapy and Group Cognitive Therapy on Anxiety in Women with High-Risk Sexual Behavior. J Res Dev Nurs Midw. 2017; 14 (1) :44-51
URL: http://nmj.goums.ac.ir/article-1-911-en.html
1- Department of Counseling, Science and Research Branch, Islamic Azad University, Tehran, Iran.
2- Department of counseling, Kharazmi University, Tehran, Iran. , Navabinejad93@yahoo.com
3- Department of psychology, Tonekabon Branch, Islamic Azad University, Mazandaran, Iran.
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Background and Objective: Due to the effectiveness of psychological interventions on mood and anxiety disorders, the schema therapy interventions and group cognitive therapy were used in this study to reduce anxiety in women with high risk sexual behaviors.

Methods: This was a pilot study using cluster sampling method. The statistical population consisted of 500 women (20-60 years old with diploma degree or higher) with a history of high risk sexual behaviors who had referred to the Shohada Ceneter of Hamedan for HIV test. Concurrently, DASS questionnaire with 21 items and psychiatric interview were performed; 250 of them had symptoms of depression, anxiety and perceived stress and 85 of them had symptoms of anxiety; 45 were randomly selected and were divided into three groups: two intervention groups and one control group. 12 group cognitive therapy sessions and 12 schema therapy sessions were considered; each session was 90 min. At the end of the treatment, all groups were post-tested.

Results: Comparison of the mean difference of the anxiety in three groups of schema therapy, cognitive therapy and control showed that there is a significant difference among these groups; moreover, there is a significant difference between the mean of anxiety in cognitive therapy group and schema therapy (-2.376, p = 0.01).

Conclusion: The results showed that schema therapy is more effective than cognitive therapy on anxiety of the women who referred to Shohada Ceneter of Hamedan.

Keywords: Schema Therapy, Cognitive Therapy, Anxiety, Sexual Risk Behavior


 

Introduction

   The third wave of HIV has just begun in Iran and sexual transmission has preceded any other HIV modes of transmissions with 21.1% of the cases in Iran (1). Therefore, two main general objectives of the WHO is 90% reduction in the number of new HIV infections and 50% reduction in infected women deaths by 2016 (2). Women with high risk sexual behaviors are one of the affected groups in the world that are mostly threatened by HIV (3, 4). HIV and other sexually transmitted diseases are caused by behaviors and according to the numerous studies conducted by experts, understanding the HIV- high risk sexual behaviors plays a key role in preventing the spread of AIDS (5-8).

After injection, high risk sexual behaviors are considered as the major factor that transmits the sexually transmitted diseases and HIV [9]. Results of the studies showed that high risk sexual behaviors is common among the Chinese injecting drug adductors and most of them are vulnerable to infectious disease transmission (10). It has been proved that the most important high risk sexual behaviors that adversely affect the HIV-infected patients and the spread of HIV include:  unprotected sexual relationships, multiple sex partners and drug injection with joint syringe (11).

People with high risk behaviors must be increasingly supported. Although intervention in certain groups cannot prevent the epidemic diseases, implementing the treatment and training plan and concentrating on people with high risk behaviors is vital (12).  High risk sexual behaviors can be associated with psychiatric disorders, including anxiety as one the most common disorders.

Anxiety disorders are one of the most prevalent psychiatric disorders. A national study reported that of one out of every four people has diagnostic criterion for at least one anxiety disorder. Women with 30.5 outbreak compared to the men with 19.2% are more affected by psychiatric disorders. Generalized phobic anxiety is unclear and unpleasant and often it involves automatic system and is characterized by symptoms such as headache, sweating, palpitations, chest tightness, and mild abdominal pain. Anxiety warns the people that they are in danger and help them to take action to cope with danger (13). Anxiety disorders may have negative effects on individual, social and occupational performance of people; therefore, a number of treatment approaches have been proposed in order to improve and reduce the severity of symptoms associated with it by mental health experts. Psychological interventions based on the behavioral, cognitive, and emotional theories and different viewpoints are one of the most important tools for the mental health experts.

Over the period of recent four decades, at least two basic mutations in theory and treatment of anxiety; one for use of drugs to relieve the symptoms of anxiety, and the other for cognitive behavioral therapy (14). The main pivot of Rational Emotive Behavior Therapy (REBT) proposed by Ellis is one of these theories, stating that the people develop emotional and stable reactions, and inner speech and these internal phraseology sometimes reflects the unexpressed assumptions or irrational beliefs about the necessities for leading a meaningful life. These kind of treatments aim to remove the self-destructive beliefs by their rational analysis (15). A study conducted on the effectiveness of group cognitive therapy on anxiety symptoms in men with HIV showed that this intervention reduces symptoms of anxiety (16). Nowadays, one of the challenges of cognitive-behavioral therapy is its reduced effectiveness on chronic disorders. On the other hand, the effectiveness of this therapeutic approach on acute disorders such as anxiety disorders is short and is associated with recurrence of symptoms (17).

Although since the emergence of this approach, treatment interventions and techniques were focused in literature, clinical experiences and research evidence showed that underlying factors should be considered in order to solve the patients who requested treatment, notably for those with a long-standing chronic problems. Yang schema therapy approach is one of the approaches that concentrate on this issue and it is based on the discovery of the origins of transformation and psychological problems and primary maladaptive schema. Primary maladaptive schema are self-damaging cognitive and emotional patterns that are formed at the beginning of the evolution of the mind and are repeated during life. Maladaptive schema and solutions through which patients learn cope with others, often underpin the chronic symptoms of anxiety disorders. Changes are important in therapy schema since they lead to change in lifestyle (18). Due to the lack of the studies that concurrently deal with the effectiveness of the schema therapy and cognitive therapy on the anxiety of the people with high risk sexual behaviors, this study considered the parallel studies, too.

The results of numerous studies showed that meta-cognitive therapy has been effective on symptoms of anxiety disorders, including generalized anxiety and obsession (19-22).
On the other hand, the results of some studies on schema therapy showed that this treatment approach is effectiveness in improving anxiety symptoms in patients with generalized anxiety disorder (23-25).

This study aimed to compare the effectiveness of schema therapy and group cognitive therapy on anxiety of the women with high risk sexual behaviors.

Methods

   This single-blind intervention study was conducted in 2006 on women with high risk sexual behaviors who referred to behavioral health clinics of Hamedan for HIV test. Single-stage cluster sampling method was used. At first, one center (Shohad treatment center) was randomly selected out of five behavioral disorders center of Hamedan. Then 250 patients out of 500 ones, who met the inclusion criteria were selected. Inclusion criteria included sex partner, unprotected sexual experience, 20-60 years old with diploma degree or higher. Then, Depression Anxiety Stress Scales (DASS) was administered to the participants and was completed by them; 85 people who obtained at least 16 were selected and of whom, 45 subjects were divided into three groups, each o 15 (two intervention groups and one control).

Twelve group cognitive therapy sessions were hold for the first intervention group and 12 sessions for second intervention. For each intervention, two sessions of 90 min were hold per week. No loss or absence of the subjects was observed except two cases with once absence in the session. They were asked to explain the reason for their absence in individual sessions and the advantages and disadvantages of the participation in the study was again explained; one week after finishing the intervention, all three groups completed the questionnaires again.

 DASS was used as the research tool in this study. This scale has three subscales, each of them with seven questions and their final score is obtained by summing up the scores of the items. Each items is scored from zero (It's not true for me) to three (It's true for me). Since it is the short form of main scale (42 items), final score of each subscale should be doubled. Then the severity of the symptoms should be identified using the table related to the questionnaire. Cut-off point obtained for the anxiety was 16 and higher than it. Research scale is reliable and valid and have been approved in Iran and abroad. The reliability and validity of this questionnaires has been investigated in Iran by Samani and Jokar (2007) and retest reliability for depression, anxiety and stress was respectively 0.80, 0.76, 0.70.  Cronbach's alpha for depression, anxiety and stress was 0.81, 0.74 and 0.78, respectively (26-28).

In this research, all ethical principles, including satisfaction of all voluntary participants in the study, confidentiality and informing the subjects to get out of the study with no restrictions were observed. Researcher received the Ethics Committee permission for conducting this study from Hamedan University of Medical Sciences. This research was registered in Iranian Registry of Clinical Trials: IRCT. 2012121911782N2

Description of cognitive therapy sessions

   First session: introducing, reviewing the structure of the meetings, the laws and the importance of commitment, raising people's problems and providing information to members about stress, relaxation and cognitive logic, receiving the feedback.

Second session: Training and practicing the progressive relaxation. Training the concepts of reality and perception, consciousness and the difference between feelings and thoughts, the assignment, and receiving the feedback.

Third session: reviewing assignments, training the second stage of progressive relaxation and help the members to think about the reasons that make them upset, training the five cognitive distortions, giving assignments and receiving feedback.

Session Four: Reviewing assignments, training the third stage of progressive relaxation, five other cognitive distortions, giving the assignment, receiving feedback.

Fifth session: Reviewing assignments, training the fourth stage of progressive relaxation, discussion about recent emotional experience and playing a role, receiving feedback.

Sixth Session: Reviewing assignments, discussion about recent emotional experience and learned techniques, training the basic cognition, love, success, perfectionism, giving assignment, receiving feedback.

Seventh session: reviewing assignment, discussion about necessities as one of the techniques for identifying fundamental schemas, investigating the role of cognitive distortions in creating and sustaining stress, giving the assignment, receiving feedback.

Eighth Session: reviewing assignments, helping participants to understand their punishment and rewarding methods. These participants should consider an applicable plan to encourage them practice the method that they learnt during these sessions.

Ninth session: reviewing assignments, investigating the solutions for changing the fundamental ineffective beliefs to the beneficial ones with the help of the consultant.

Session ten: participants were encouraged to review their mental states and moods in recent month, identify and seek to reduce them

Session eleven: reviewing assignments, investigating the participants’ plans for continuing the results they obtained during treatment.

Session twelve: reviewing assignments, summarizing past meetings by members and the therapist, posttest and giving gifts, discussion about how to return to the treatment, generalizing learning to the real world [29].

Description schema therapy sessions

Sessions (1-2): Creating a reciprocal relationship with collaboration, education, schema therapy approach, obtaining informed consent, providing the  research tests, meetings, assessing patient problems, assessing coping styles, classifying the problems using the rules-based structures based on the schema therapy and completing the conceptualization form.

Sessions (3-6): The use of cognitive techniques in order to discredit the dominant schemas of the patients.

Sessions (7-9): using experimental techniques to learn and understand and familiarize the patients with transformational origins of the schema and understanding the maladaptive solutions to satisfy emotional needs.

Sessions (10-12): encouraging authorities to stop using the maladaptive coping styles and practice adaptive coping behaviors to satisfy the basic emotional needs, and forcing the patients to prepare a list of the skills learned in the treatment and prevention of relapse (18).

Data were analyzed using descriptive statistical methods (graphs, mean and standard deviation) and inferential statistics (multivariate analysis of covariance (MANCOVA), post hoc test, Bonferroni alpha and software and SPSS19

Analysis of specific demographic characteristics of the under study population showed that the mean and total standard deviation of the participants was 34.24± 9.88, respectively. Most of them (75.7 %) were 20 to 40 years old. In terms of education level, most of them had diploma degree (86.7%). In terms of marital status, most of them were divorced (51.2%).

Since the assumptions of linear relationship, homogeneity of the variances and homogeneity of slope of the regression line was observed, researcher can use the analysis of covariance (ANCOVA). Based on the results of Table 5, F is calculated statistically significant. By comparison of the schema of anxiety and cognitive therapy groups showed that the level of anxiety in two groups, there is a significant difference. As a result of schema therapy more effective in reducing anxiety in the cognitive therapy group.

Results

As shown in Table 4, calculated F is statistically significant. As a result, schema therapy and group cognitive therapy are effective on anxiety.

Table 1: Demographic characteristics of participants

levels

frequency

percentage

variable

levels

20-30 years old

20

44.5

Agegroups

20-30 years old

30-41 years old

14

31.2

30-41 years old

41-50 years old

8

17.8

41-50 years old

51-60 years old

3

6.7

51-60 years old

diploma

39

86.7

Education level

diploma

Table 2: Mean and standard deviation of women's anxiety level before and after intervention for each group

Pretest

Posttest

Group

Mean±SD

Mean±SD

Schema therapy

16.73±1.223

11.27±1.387

Cognition therapy

15.87±0.834

13.20±1.521

Control

17.07±1.387

16.07±1.387

Table 3: Mean and modified standard deviation of anxiety in women before the interventio.

SD Error

M

N

Group

0.347

0.371

0.369

11.191

13.546

15.796

15

15

15

Schema therapy

Cognition therapy

Control

Table 4: Analysis of covariance (ANCOVA) the effectiveness of schema therapy, cognitive therapy on anxiety in women after intervention

ƞ2

effect size

Sig

F

ms

df

ss

variable

0.0005

45.761

79.535

2

159.070

0.0005

Inter group anxiety

1.738

41

71.260

Intra group anxiety

Table 5: Analysis of covariance (ANCOVA) the effectiveness of schema therapy, group cognitive therapy on anxiety in women

MD

sig

F

md

df

ss

variable

-2.376

0.01

22.185

38.558

1

38.558

Inter group anxiety

1.738

41

71.260

Intra group anxiety


 

Based on the results of Table 5, calculated F is statistically significant. Comparison of the mean difference between anxiety of two groups of the schema therapy of and cognitive therapy showed that there is a significant difference between the mean of anxiety in two groups. As a result, schema therapy was more effectiveness in reducing anxiety compared to the group cognitive therapy.

Discussion

   This study aimed to compare the schema therapy and cognitive therapy on the anxiety of the women with high risk sexual behaviors. Due to the lack of the studies that concurrently deal with the effectiveness of the schema therapy and cognitive therapy on the anxiety of the people with high risk sexual behaviors, this study considered the parallel and consistent studies, too.

It seems that schema therapy benefits from the applied techniques and resources compared to the cognition therapy. This approach is a multidimensional treatment model that can include all factors affecting the change of the behaviors and at the same time, affects the intra personal and interpersonal aspects. It also can cover the emotional, cognitive and behavioral aspects. Consistent studies show that schema therapy is an efficient method for treating the patients with anxiety disorders and personality disorders [30, 33]. Capron et al. [24] also conducted a study on effectiveness of schema therapy and concluded that it can reduce anxiety sensitivity [24]. Cognitive approach focuses on cognitive aspects and dysfunctional beliefs and this approach aims to reduce the negative belief about themselves, the world and others. Different studies indicated that schema therapy significantly reduces symptoms of anxiety. However, there is no significant difference between the two schema therapy and cognitive therapy in reducing anxiety. These studies are inconsistent with this study [23, 25, 31, and 32].

Conclusion

   It can be argued that one of the reasons for efficiency of the schema therapy compared to the cognition therapy is investigating the hot cognitions with positive and negative emotions that are of great importance in schema therapy. Inefficient cognition should be first considered in schema therapy, however, treatment is not finished, since many inefficient cognitions of the patients have positive and negative emotional loads and patients have been informed only about their beliefs but they have not basically changed them. Next stages in schema therapy approach that may be the most sensitive ones and the most distinguished aspects compared to the cognition approach is experimental treatment that investigates the emotional beliefs and is a kind of modified emotional experience. Also, emphasizing on the behavioral techniques such as assertiveness training, anger control and communication skills training in the schema therapy approach increase its efficiency, too. Ultimately, another key and effective factor in the treatments that schema therapy is a part of it, is treatment relationship as one of the major factors for measurement and change in the approach. However, in cognition therapy approach, treatment relationship is important however, it is not considered as the major factor of the change. In general, factors affecting schema therapy compared with cognitive therapy include the emphasis on emotions, simultaneous emphasis on the present and past time, and a more active role of the therapist during the schema therapy, creating the modified emotional experience, treatment relationship as the element for measurement and change

Acknowledgement:

   This study is extracted from the PhD thesis; I would appreciate all authorities in Deputy Head of Health and Treatment of Hamedan and triangular clinic of Shohada who helped me in this study. This study was registered in December 30, 2015 in Ethics Committee of the Medical University in Hamedan province with number 11047/32/16 / P, IranDoc with tracking code 1212578 and Iranian Registry of Clinical Trials: IRCT

References

1. The fourth seminar was held in AIDS: HIV transmission through sexual contact First Place in the world, Journal of Laboratory diagnosis 2012; 15(83-84):41-42. [In Persian]

2. Global Monitoring framework and strategy for the global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive (EMTCT), 2012; Available at: http://www.who.int. Accessed Jun 29, 2013.

3 Nasirian M, Doroudi F. Gouya MM, Sedaghat A, Haghdoost AA, Modeling of Human Immunodeficiency Virus Modes of Transmission in Iran, Journal of Research in Health Sciences 2012; 12(2): 81-87.[In Persian]

4. Goldenberg S M, Engstrom D, Rolon M L,Silverman J G. Strathdee SA, Sex Workers Perspectives on Strategies to Reduce Sexual Exploitation and HIV Risk: A Qualitative Study in Tijuana, Mexico, PLoS ONE 2013; 8(8): 1-10.

5. Collins SP, Goldenberg SM, Burke NJ, Bojorquez-Chapela I, Silverman JG, "et al", Situating HIV risk in the lives of formerly trafficked female sex workers on the Mexico-US border, Journal The AIDS Care 2013; 25: 459-465.

6. Goldenberg SM, Rangel G. Vera A, Patterson TL, Abramovitz D, Exploring the impact of underage sex work among female sex workers in two Mexico-US border cities, AIDS Behav 2012; 16: 969-981.

7. Decker M, McCauley H. Phuengsamran D, Janyam S. Silverman J ,Sex trafficking, sexual risk, sexually transmitted infection and reproductive health among female sex workers in Thailand, Journal of epidemiology and community health 2011; 65: 334-339.

8. Devine A, Bowen K, Dzuvichu B. Rungsung R. Kermode MPathways to sex-work in Nagaland, India: implications for HIV prevention and community mobilization, Journal AIDS Care, 2010; 22: 228-237.

9. Strathdee SA, Galai N, Safaiean M, Celentano DD, Vlahov D, Johnson L, et al. Sex differences in risk factors for hiv seroconversion among injection drug users: a 10-year perspective. Arch Intern Med 2001; 161(10): 128-8.

10. Zhao M, Du J, Lu GH, Wang QY, Xu H, Zhu M, rt al. HIV sexual risk behaviors among injection drug users in Shanghai. Drug Alcohol Depend 2006; 82 (1): 43-S47.

11. Zamani S, Kihara M, Gouya MM, Vazirian M, Ono-Kihara M, Razzaghi EM, et al. Prevalence of and factors associated with HIV-1 infection among drug users visiting treatment centers in Tehran, Iran. AIDS 2005; 19(7): 709-16.

12. WHO. AIDS epidemic update. [Online]. 2002 [cited December 2002]; Available from: URL: http://www.who.int/hiv/pub/epidemiology/epi2002/en.

13. .Sadock, B. J., & Sadock, V. A.. Kaplan and Sadock's synopsis of psychiatry: Behavioral sciences/clinical psychiatry. Lippincott Williams & Wilkins. translated by Rezai ,F . Arjmand  publication.2011. [In Persian]

14.Oei .T.  Bullbeck ,K.  Campbell, JM. Cognitive change process during group cognitive behaviour therapy for depression. Journal of Affective Disorders2006; 92(2-3):231-241.

15. Nik khoo ,M therapeutic approach in psychology and psychiatry , Tehran, Sokhan pulication.2005. [In Persian]

16. Hemmati Sabet, A.Khalat bari ,JGroup training of stress management vs. Group conitive _behavioral therapy in reducing depression ,anxiety and perceived stress among Hiv - positive Men.2012, 7(1): 4-8.

17. Young, j.E.Reinventing your life .how to break free from negative life patterns .New York :plume book.1994.

18. Young, J., Klosko, J., Weishaar, M. Schema Therapy A Practitioners Guide (3rd ed.).2003.

19. Janeck AS, Calamari JE, Riemann BC, Heffelfinger SK. Too much thinking about thinking: metacognitive differences in obsessive-compulsive disorder. Journal of Anxiety Disorders. 2003; 17(2): 181-95.

20. Fisher PL, Wells A. Metacognitive therapy for obsessive-compulsive disorder: A case series. Journal of Behavior Therapy and Experimental Psychiatry. 2008; 39(2): 117-32.

21. Khorramdel K, Neshatdoost HT, Molavi H, Amiri SH, Bahrami F. The effect of metacognitive therapy of wells in patient with anxiety J Funda Men Heal 2010; 12(1): 400-409. [In Persian].

22. Sadock BJ, Sadock VA. Kaplan and Sadock’s Synopsis of Psychiatry. 9th Ed. New York: Williams & Wilkins; 2003. Therapy in Treating Women’s Generalized Anxiety Disorder. J Psych Clin Psycho 2011; 16(4): 420-31.[In Persian]

23.Hamidpoor H. Comparison the effectiveness of cognitive behavior therapy and schema therapy in treatment women who suffer from generalized anxiety disorder (dissertation ).Tehran university of Behzisti science and rehabilitation :2009. .[In Persian]

24.Capron DW,Kotov R, Schmidt NB. A cross culture replication of an interactive model of anxiety sensitivity relevant to suicide. Psychiatry research .2013;205(1)74-80.

25.Hamidpoor H,Dolatshahi B, pour Shahbaz A, The efficacy of schema therapy in training women generalized Anxiety disorder. J psych clin psycho 2011;16(4):420-431.[In Persian]

26. Lovibond, P.F. Lovibond, S.H. The structure of negative emotional states: Comparison of  the Depression Anxiety Strees Scale (DASS) with the beck Depression  and Anxiety Inventories. Behavior Research and Therapy. 1995,33(3):335-343.

27. Antony,M.M, Bieling,PJ, COX ,Enns,M,W ,Swinson R.P. Psychometric  properties of the 42- item  and 21- item version  of  the  depression  anxiety stress scale  in clinical group  and a community sample. Psychological Assessment. 1998 .

28.Samani .F, Joukar. B, Study of validity and reliability of depression, anxiety and stress scale.2007, 26(3)65-76. .[In Persian]

29. Free ,Michal L Cognitive therapy in group :guideline and resources for practice, 1999.

30. Hawke L. D., Provencher,  M, DSchema theory and schema therapy in mood and anxiety disorders: a review. Journal of Cognitive Psychotherapy. 2011,257-276

31. Carter JD, McIntosh VV, Jordan J, et al. Psychotherapy for depression: A randomized clinical trial compariang schema therapy and cognitive behavior therapy. Journal of Affective Disorders. 2013; 151(2): 500-5.

32.Ashori J .Compare of meta cognitive therapy and schema therapy to reduce of anxiety and depression among midwifery and nurse student 2015, 18; (2)50-61. .[In Persian]

33.Khorshid poor M, Effectiveness of schema therapy on women with social anxiety. Phd dissertation. allameh tabatabai university.2011.[In Persian]

Type of Study: Original Article |

References
1. The fourth seminar was held in AIDS: HIV transmission through sexual contact First Place in the world, Journal of Laboratory diagnosis 2012; 15(83-84):41-42. [In Persian]
2. Global Monitoring framework and strategy for the global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive (EMTCT), 2012; Available at: http://www.who.int. Accessed Jun 29, 2013.
3. 3 Nasirian M, Doroudi F. Gouya MM, Sedaghat A, Haghdoost AA, Modeling of Human Immunodeficiency Virus Modes of Transmission in Iran, Journal of Research in Health Sciences 2012; 12(2): 81-87.[In Persian]
4. Goldenberg S M, Engstrom D, Rolon M L,Silverman J G. Strathdee SA, Sex Workers Perspectives on Strategies to Reduce Sexual Exploitation and HIV Risk: A Qualitative Study in Tijuana, Mexico, PLoS ONE 2013; 8(8): 1-10. [DOI:10.1371/journal.pone.0072982]
5. Collins SP, Goldenberg SM, Burke NJ, Bojorquez-Chapela I, Silverman JG, "et al", Situating HIV risk in the lives of formerly trafficked female sex workers on the Mexico-US border, Journal The AIDS Care 2013; 25: 459-465.
6. Goldenberg SM, Rangel G. Vera A, Patterson TL, Abramovitz D, Exploring the impact of underage sex work among female sex workers in two Mexico-US border cities, AIDS Behav 2012; 16: 969-981. [DOI:10.1007/s10461-011-0063-3]
7. Decker M, McCauley H. Phuengsamran D, Janyam S. Silverman J, Sex trafficking, sexual risk, sexually transmitted infection and reproductive health among female sex workers in Thailand, Journal of epidemiology and community health 2011; 65: 334-339. [DOI:10.1136/jech.2009.096834]
8. Devine A, Bowen K, Dzuvichu B. Rungsung R. Kermode MPathways to sex-work in Nagaland, India: implications for HIV prevention and community mobilization, Journal AIDS Care, 2010; 22: 228-237. [DOI:10.1080/09540120903039869]
9. Strathdee SA, Galai N, Safaiean M, Celentano DD, Vlahov D, Johnson L, et al. Sex differences in risk factors for hiv seroconversion among injection drug users: a 10-year perspective. Arch Intern Med 2001; 161(10): 128-8. [DOI:10.1001/archinte.161.10.1281]
10. Zhao M, Du J, Lu GH, Wang QY, Xu H, Zhu M, rt al. HIV sexual risk behaviors among injection drug users in Shanghai. Drug Alcohol Depend 2006; 82 (1): 43-S47. [DOI:10.1016/S0376-8716(06)80008-6]
11. Zamani S, Kihara M, Gouya MM, Vazirian M, Ono-Kihara M, Razzaghi EM, et al. Prevalence of and factors associated with HIV-1 infection among drug users visiting treatment centers in Tehran, Iran. AIDS 2005; 19(7): 709-16. [DOI:10.1097/01.aids.0000166094.24069.72]
12. WHO. AIDS epidemic update. [Online]. 2002 [cited December 2002]; Available from: URL: http://www.who.int/hiv/pub/epidemiology/epi2002/en.
13. .Sadock, B. J., & Sadock, V. A.. Kaplan and Sadock's synopsis of psychiatry: Behavioral sciences/clinical psychiatry. Lippincott Williams & Wilkins. translated by Rezai ,F . Arjmand publication.2011. [In Persian]
14. Oei. T. Bullbeck, K. Campbell, JM. Cognitive change process during group cognitive behaviour therapy for depression. Journal of Affective Disorders2006; 92(2-3):231-241. [DOI:10.1016/j.jad.2006.02.004]
15. Nik khoo ,M therapeutic approach in psychology and psychiatry , Tehran, Sokhan pulication.2005. [In Persian]
16. Hemmati Sabet, A.Khalat bari ,JGroup training of stress management vs. Group conitive _behavioral therapy in reducing depression ,anxiety and perceived stress among Hiv - positive Men.2012, 7(1): 4-8.
17. Young, j.E.Reinventing your life .how to break free from negative life patterns .New York :plume book.1994.
18. Young, J., Klosko, J., Weishaar, M. Schema Therapy A Practitioners Guide (3rd ed.).2003.
19. Janeck AS, Calamari JE, Riemann BC, Heffelfinger SK. Too much thinking about thinking: metacognitive differences in obsessive-compulsive disorder. Journal of Anxiety Disorders. 2003; 17(2): 181-95. [DOI:10.1016/S0887-6185(02)00198-6]
20. Fisher PL, Wells A. Metacognitive therapy for obsessive-compulsive disorder: A case series. Journal of Behavior Therapy and Experimental Psychiatry. 2008; 39(2): 117-32. [DOI:10.1016/j.jbtep.2006.12.001]
21. Khorramdel K, Neshatdoost HT, Molavi H, Amiri SH, Bahrami F. The effect of metacognitive therapy of wells in patient with anxiety J Funda Men Heal 2010; 12(1): 400-409. [In Persian].
22. Sadock BJ, Sadock VA. Kaplan and Sadock's Synopsis of Psychiatry. 9th Ed. New York: Williams & Wilkins; 2003. Therapy in Treating Women's Generalized Anxiety Disorder. J Psych Clin Psycho 2011; 16(4): 420-31.[In Persian]
23. Hamidpoor H. Comparison the effectiveness of cognitive behavior therapy and schema therapy in treatment women who suffer from generalized anxiety disorder (dissertation ).Tehran university of Behzisti science and rehabilitation :2009. .[In Persian]
24. Capron DW,Kotov R, Schmidt NB. A cross culture replication of an interactive model of anxiety sensitivity relevant to suicide. Psychiatry research .2013;205(1)74-80. [DOI:10.1016/j.psychres.2012.08.006]
25. Hamidpoor H,Dolatshahi B, pour Shahbaz A, The efficacy of schema therapy in training women generalized Anxiety disorder. J psych clin psycho 2011;16(4):420-431.[In Persian]
26. Lovibond, P.F. Lovibond, S.H. The structure of negative emotional states: Comparison of the Depression Anxiety Strees Scale (DASS) with the beck Depression and Anxiety Inventories. Behavior Research and Therapy. 1995,33(3):335-343. [DOI:10.1016/0005-7967(94)00075-U]
27. Antony,M.M, Bieling,PJ, COX, Enns,M,W, Swinson R.P. Psychometric properties of the 42- item and 21- item version of the depression anxiety stress scale in clinical group and a community sample. Psychological Assessment. 1998 . [DOI:10.1037/1040-3590.10.2.176]
28. Samani .F, Joukar. B, Study of validity and reliability of depression, anxiety and stress scale.2007, 26(3)65-76. .[In Persian]
29. Free ,Michal L Cognitive therapy in group :guideline and resources for practice, 1999.
30. Hawke L. D., Provencher, M, DSchema theory and schema therapy in mood and anxiety disorders: a review. Journal of Cognitive Psychotherapy. 2011,257-276 [DOI:10.1891/0889-8391.25.4.257]
31. Carter JD, McIntosh VV, Jordan J, et al. Psychotherapy for depression: A randomized clinical trial compariang schema therapy and cognitive behavior therapy. Journal of Affective Disorders. 2013; 151(2): 500-5. [DOI:10.1016/j.jad.2013.06.034]
32. Ashori J .Compare of meta cognitive therapy and schema therapy to reduce of anxiety and depression among midwifery and nurse student 2015, 18; (2)50-61. .[In Persian]
33. Khorshid poor M, Effectiveness of schema therapy on women with social anxiety. Phd dissertation. allameh tabatabai university.2011.[In Persian]

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