Abstract Background: Generalized Anxiety Disorder (GAD) is a chronic and debilitating condition, and a considerable proportion of patients do not achieve adequate improvement following standard treatments. Emerging evidence suggests that early maladaptive schemas (EMSs) may be involved in the development and maintenance of GAD and may have implications for understanding inadequate treatment response. This systematic review aimed to synthesize the available evidence on the relationship between EMSs, the persistence of GAD symptoms, and treatment outcomes, with particular attention to treatment resistance. Methods: Following the PRISMA 2020 guidelines, a systematic search was conducted in international (PubMed, Scopus, Science Direct, Google Scholar) and Persian (SID and Civilica) databases. Quantitative studies examining the relationship between EMSs and GAD, symptom persistence, or treatment outcomes were considered. Methodological quality was assessed using appropriate tools, including the Joanna Briggs Institute (JBI) critical appraisal checklists and the Cochrane Risk of Bias 2 (RoB 2) tool, where applicable. Given the methodological and clinical heterogeneity of the studies, the findings were synthesized narratively. Results: Seventeen studies were included. Overall, the findings indicated associations between GAD symptoms and several EMSs, including emotional deprivation, abandonment, vulnerability to harm, pessimism, and unrelenting standards. However, the specific schema patterns varied across studies. In one regression analysis, intolerance of uncertainty (β = 0.39, p < 0.001) and the vulnerability schema (β = 0.34, p < 0.001) were significant statistical predictors of GAD symptoms. Intervention studies provided preliminary evidence for the potential benefits of schema-focused and integrative approaches. Schema therapy was associated with reductions in EMS scores, while an integrated Emotional Schema Therapy–Metacognitive Therapy approach (EST-MCT) was associated with greater reductions in repetitive negative thinking than conventional cognitive behavioral therapy (CBT) (F = 60.44, p < 0.001). Nevertheless, the latter finding reflects changes in related cognitive-emotional processes rather than direct modification of Young's EMSs. Evidence from treatment-resistant clinical samples also suggested an association between improvements in schema-related measures and reductions in psychological symptoms (r = 0.64, p < 0.01); however, these findings were derived from small and diagnostically heterogeneous samples. Conclusion: EMSs may be relevant to understanding the cognitive and emotional processes involved in the persistence of GAD symptoms. Although preliminary findings suggest that schema-focused interventions may have therapeutic potential, current evidence does not establish EMSs as causal determinants of treatment resistance in GAD. Further longitudinal research and adequately powered randomized controlled trials involving clinically diagnosed and treatment-resistant GAD samples are needed to clarify the role of specific schemas and evaluate the effectiveness of schema-focused interventions.

Generalized Anxiety Disorder Early Maladaptive Schemas Treatment Resistance Schema Therapy