Iranian Journal of Psychiatry

Early Maladaptive Schemas, Emotion Regulation, and Forgiveness Across the Narcissism Spectrum: A Dimensional Comparative Study

Reyhaneh Miralikhani — 2026-08-18

Objective: This cross-sectional study compared early maladaptive schemas, emotion regulation, and forgiveness across healthy, narcissistic traits, and narcissistic personality disorder (NPD) groups.

Method: Convenience sampling yielded 492 adults: healthy individuals (n=205), individuals with narcissistic traits (n=196), and NPD (n=91). NPD classification required meeting the Structured Clinical Interview for DSM-5 Screening Personality Questionnaire (SCID-5-SPQ) threshold and telephone-based diagnostic confirmation. The traits group scored ≥8 on the Narcissistic Personality Inventory-16 (NPI-16) but did not meet the SCID-5-SPQ threshold; healthy participants scored below both thresholds. Participants completed Persian versions of the Young Schema Questionnaire-Short Form 3, Emotion Regulation Questionnaire, Interpersonal Emotion Regulation Questionnaire, and Heartland Forgiveness Scale. Multivariate analysis of covariance controlled for age, education, and marital status.

Results: Both narcissistic groups scored higher than healthy participants on emotional deprivation, F (2, 486) = 6.65, P = 0.001, η²_p = 0.027; defectiveness/shame, F (2, 486) = 7.00, P = 0.001, η²_p = 0.028; and entitlement/grandiosity, F (2, 486) = 28.52, P < 0.001, η²_p = 0.105. NPD participants reported higher perspective-taking than both groups, F (2, 486) = 10.57, P < 0.001, η²p = 0.042, and higher soothing than healthy participants, F (2, 486) = 6.87, P = 0.001, η²_p = 0.027. Healthy participants reported higher self-forgiveness than NPD participants, F (2, 486) = 5.14, P = 0.006, η²_p = 0.021, and higher forgiveness of others than both narcissistic groups, F (2, 486) = 13.33, P < 0.001, η²_p = 0.052. Situational forgiveness differed, F (2, 486) = 11.07, P < 0.001, η²_p = 0.044, with healthy > traits > NPD. No differences emerged in enhancing positive affect, social modeling, suppression, or cognitive reappraisal.

Conclusion: schema vulnerabilities and forgiveness difficulties may be associated with narcissistic traits and NPD, while perspective-taking and situational forgiveness may differentiate NPD from trait-level narcissism. Findings are associative, not causal.

Maternal Self-Efficacy, Social Support, and Adaptation to Motherhood in Mothers of Preterm Infants in Neonatal Intensive Care Units

Wafaa Ahmed Ameen — 2026-08-15

Objective: This cross-sectional study examined maternal role adaptation among mothers of preterm infants in Neonatal Intensive Care Units (NICUs), and assessed whether self-efficacy and social support explain additional variance in adaptation beyond global self-esteem.

Method: A cross-sectional correlational design was employed with a convenience sample of 350 mothers of preterm infants (gestational age < 37 weeks) admitted to the NICU at Imam Al-Sadiq Teaching Hospital in Hilla city, Iraq. Participants completed validated Arabic versions of the Rosenberg Self-Esteem Scale, the Arabic Parental Self-Efficacy Scale (APSES), the Multidimensional Scale of Perceived Social Support (MSPSS), and a Maternal Role Adaptation Questionnaire. Data were analyzed using descriptive statistics, Pearson correlations, and hierarchical linear regression.

Results: Overall maternal role adaptation was poor in 61.4% of mothers (mean score 23.72 ± 5.31). Self-efficacy showed the strongest correlation with adaptation (r = 0.56, P < 0.001), followed by social support (r = 0.51, P < 0.001) and self-esteem (r = 0.44, P < 0.001). Hierarchical regression revealed that after controlling for demographic covariates, self-efficacy (β = 0.41, 95% CI: 0.31-0.50, P < 0.001) and social support (β = 0.33, 95% CI: 0.23-0.42 P < 0.001) were independently associated with adaptation, while self-esteem was not significant in the final model (β = 0.08, 95% CI: -0.03-0.19, P = 0.14). The full model explained 44% of the variance in adaptation scores (R² = 0.44).

Conclusion: Maternal self-efficacy and perceived social support demonstrate stronger associations with adaptation to motherhood than global self-esteem among mothers of preterm infants in NICUs. Interventions to enhance NICU mothers' adaptation should prioritize skill-based self-efficacy building and social support mobilization.

Clinical Predictors of Discontinuation of Adapted Intensive Applied Behavior Analysis in Children with Autism: A 10 Year Retrospective Study

Hamidreza Pouretemad — 2026-08-15

Objective: Applied Behavior Analysis (ABA) is an evidence-based intervention for autism spectrum disorder (ASD), but treatment discontinuation remains common. Adapted Intensive Applied Behavior Analysis (AIABA) is a culturally modified version of ABA developed for Iranian families, that integrates cultural and family values into daily routines. This study examined clinical and contextual predictors of AIABA discontinuation.

Method: We reviewed clinical files of 529 children with ASD (mean age = 41.7 months, SD = 13.8) who received AIABA at the Tehran Autism Center (2011 2021). Predictors included parental engagement, programming mode (in person vs. semi online), medication use, age at diagnosis, comorbidity, motor development, additional therapies, and symptom severity. Logistic regression identified predictors of discontinuation.

Results: Discontinuation occurred in 66.7% of children. Mean treatment duration was shorter in the discontinuation group (11.4 months) than the planned termination group (19.1 months). Significant predictors included lower parental engagement (OR = 0.03, 95% CI [0.01 0.07]), concurrent medication use (OR = 3.22, 95% CI [1.89 5.49]), semi online supervision (OR = 3.01, 95% CI [1.61 5.63]), higher pre cessation symptom severity (OR = 1.04, 95% CI [1.01 1.06]), and younger age at diagnosis (OR = 0.97, 95% CI [0.95 0.98]). The model explained 38.8% 53.9% of variance and correctly classified 83.4% of cases.

Conclusion: Lower parental engagement, concurrent medication use, semi online supervision, higher pre cessation symptom severity, and younger age at diagnosis significantly predicted AIABA discontinuation. Targeting parental engagement, monitoring intensity, and coordinated care may reduce dropout risk. Given the retrospective, single center design and reliance on record-based measures, results require cautious interpretation. Prospective multi-site studies are needed to translate these predictors into retention focused planning.

Factors Influencing Suicide Attempts in Patients Hospitalized in Psychiatric Wards from the Perspective of Nurses: A Content Analysis Study

Reza Abdollahi — 2026-08-03

Objective: Suicide is a critical public health issue, with heightened risks among psychiatric inpatients. In Iran, sociocultural and systemic factors uniquely shape suicide attempts in psychiatric wards, yet nurses’ perspectives on these factors remain underexplored. This study aims to identify the factors influencing suicide attempts among hospitalized psychiatric patients in Iran, as perceived by nurses, using a qualitative content analysis approach.

Method: A qualitative study was conducted from June 2024 to June 2025 in the psychiatric wards of two university-affiliated hospitals in Urmia, Iran. Using purposive and subsequent theoretical sampling, 18 registered nurses (12 females, 6 males; mean age 42.3 years; mean experience 12.5 years) were recruited. Sample adequacy was established through data saturation, which was confirmed after 15 interviews with three additional interviews yielding no new themes. Semi-structured interviews explored nurses’ perceptions of factors influencing suicide attempts. Data were analyzed using Graneheim and Lundman’s conventional content analysis, involving iterative coding, condensation of meaning units, development of subcategories, and abstraction into main categories and an overarching theme. Rigor was ensured via Lincoln and Guba’s trustworthiness criteria.

Results: One overarching theme emerged: "Interwoven Threads of Vulnerability and Resilience in Psychiatric Care." Four main categories were identified: (1) Individual Patient Vulnerabilities (unresolved trauma, impulsivity, substance use); (2) Relational and Familial Dynamics (familial stigma, interpersonal conflicts, and, specifically within Iran’s collectivist culture, expectations of emotional stoicism linked to historical narratives of martyrdom); (3) Ward Environment and Systemic Barriers (inadequate staffing, disruptive interactions, inconsistent protocols); and (4) Neglected Protective Factors (undervalued therapeutic alliances, culturally resonant but overlooked spiritual coping such as Quranic recitation, and missed empowerment opportunities). These themes were deeply shaped by Iran-specific conditions, including the legacy of war-related trauma, family honor–based stigma, chronic overcrowding with nurse-to-patient ratios reaching 1:20, and underutilized Islamic faith practices.

Conclusion: Nurses’ insights reveal that suicide attempts in Iranian psychiatric wards stem from a complex interplay of vulnerabilities, relational strains, and systemic deficiencies. Accordingly, culturally tailored interventions should directly target each finding: trauma-informed care (addressing individual vulnerabilities), family education programs to reduce honor-based stigma (addressing relational dynamics), staffing ratio enforcement and protocol standardization (addressing systemic barriers), and the integration of spiritual coping and skill-building groups (activating neglected protective factors). These evidence-grounded recommendations offer a roadmap for suicide prevention in resource-constrained Iranian psychiatric settings.

Effect of Play Therapy versus Virtual Reality on Reducing Anxiety in Children Pre-Cardiac Catheterization: A randomized Single-Blind Trial

Sabreen Kareem Flayh — 2026-08-02

Objective: This study aimed to compare the effectiveness of virtual reality (VR) versus play therapy in reducing pre-procedural anxiety among children scheduled for cardiac catheterization, and to evaluate parental satisfaction with these interventions.

Method: A randomized, assessor-blinded, pretest-posttest comparative trial was conducted at Al-Nasiriyah Heart Hospital between December 2025 and February 2026. A total of 75 children aged 3-7 years with congenital heart defects were randomly allocated into three equal groups (n = 25 each): VR (15 minutes of immersive 3D video), play therapy (15 minutes of coloring activity), and control (standard care). Anxiety was assessed using the Modified Yale Preoperative Anxiety Scale (mYPAS) at four time points (two pre-intervention and two post-intervention measurements). The outcome assessor was blinded to group allocation. Data were analyzed using analysis of covariance (ANCOVA) with Bonferroni-adjusted post-hoc comparisons to control for baseline age and anxiety differences.

Results: The VR group demonstrated the lowest mean anxiety score post-intervention (mean = 5.04 ± 0.20), followed by the play therapy group (mean = 5.88 ± 1.33), while the control group maintained consistently higher anxiety levels (mean = 12.24 ± 1.39). ANCOVA, controlling for baseline anxiety and age, revealed a statistically significant main effect of intervention group on post-intervention anxiety scores [F 2, 70) = 38.24, P < 0.001, η² = 0.52]. Post-hoc pairwise comparisons with Bonferroni correction showed that, compared with the control group, both VR (P < 0.001) and play therapy (P < 0.001) significantly reduced anxiety. Furthermore, VR produced significantly greater anxiety reduction than play therapy (P = 0.03, Cohen's d = 0.83). Parental satisfaction was uniformly high across both intervention groups, with no significant difference between them (P = 0.568).

Conclusion: Both VR and play therapy are effective non-pharmacological interventions for reducing pre-catheterization anxiety in children. VR demonstrated superior anxiolytic effects compared to play therapy, with a large effect size. Integrating VR-based distraction into routine pre-procedural nursing care may enhance pediatric procedural experiences

and improve clinical outcomes.