State dissociation in bulimic eating disorders: an experimental study

The treatment of dissociative identity disorder in an eating disorder residential treatment setting

OBJECTIVE

Child maltreatment, dissociation and dissociative disorders have been noted in relationship to eating disorders (EDs) for decades, and their co-occurrence generally is associated with greater morbidity, self-harm and mortality. The concomitant presentation of dissociative identity disorder (DID) with an ED (ED + DID) is especially challenging, and there is limited information on approaches to and the effects of integrated treatment for this serious comorbidity, especially in higher levels of care. There are also limited treatment resources for such patients, since they are often turned away from specialty units due to lack of expertise with or bias toward one or the other disorder.

METHOD

We report our experience with a case series of 18 patients with DSM-5 defined ED + DID (mean age (SD) = 32.6 (11.8) years) admitted to residential treatment (RT) and assessed using validated measures for symptoms of ED, major depression (MD), PTSD, state-trait anxiety, quality of life (QOL), age of ED onset, and family involvement during treatment. All patients received integrated, multimodal, trauma-focused approaches including those based on DID practice guidelines, principles of cognitive processing therapy (CPT), and other evidence-based approaches. Fifteen of 18 patients also completed discharge reassessments, which were compared to admission values using paired t-tests.

RESULTS

Following integrated, trauma-focused RT, patients with ED + DID demonstrated statistically significant improvements in all measures, with medium (anxiety) to high (ED, PTSD, MD, QOL) effect sizes.

DISCUSSION

These results provide positive proof of concept that patients with ED + DID can be effectively treated in a specialty, trauma-focused ED program at higher levels of care.

PUBLIC SIGNIFICANCE

EDs and dissociative identity disorder (DID) are related conditions, but little is known about treating patients with both conditions. We describe the clinical features and integrated treatment of 18 such patients, 15 of whom completed discharge assessments. Significant clinical improvements were found in multiple domains (ED, PTSD, mood, anxiety, quality of life), which demonstrate positive proof of concept that ED + DID can be effectively treated in a specialty, trauma-focused ED program.

Clinical high-risk criteria of psychosis in 8–17-year-old community subjects and inpatients not suspected of developing psychosis

BACKGROUND

In children and adolescents compared to adults, clinical high-risk of psychosis (CHR) criteria and symptoms are more prevalent but less psychosis-predictive and less clinically relevant. Based on high rates of non-converters to psychosis, especially in children and adolescents, it was suggested that CHR criteria were: (1) Pluripotential; (2) A transdiagnostic risk factor; and (3) Simply a severity marker of mental disorders rather than specifically psychosis-predictive. If any of these three alternative explanatory models were true, their prevalence should differ between persons with and without mental disorders, and their severity should be associated with functional impairment as a measure of severity.

AIM

To compare the prevalence and severity of CHR criteria/symptoms in children and adolescents of the community and inpatients.

METHODS

In the mainly cross-sectional examinations, 8–17-year-old community subjects (n = 233) randomly chosen from the population register of the Swiss Canton Bern, and inpatients (n = 306) with primary diagnosis of attention-deficit/hyperactivity disorder (n = 86), eating disorder (n = 97), anxiety including obsessive–compulsive disorder (n = 94), or autism spectrum disorder (n = 29), not clinically suspected to develop psychosis, were examined for CHR symptoms/criteria. Positive items of the Structured Interview for Psychosis-Risk Syndromes (SIPS) were used to assess the symptomatic ultra-high-risk criteria, and the Schizophrenia Proneness Instrument, Child and Youth version (SPI-CY) was used to assess the 14 basic symptoms relevant to basic symptom criteria. We examined group differences in frequency and severity of CHR symptoms/criteria using χ² tests and nonparametric tests with Cramer’s V and Rosenthal’s r as effect sizes, and their association with functioning using correlation analyses.

RESULTS

The 7.3% prevalence rate of CHR criteria in community subjects did not differ significantly from the 9.5% rate in inpatients. Frequency and severity of CHR criteria never differed between the community and the four inpatient groups, while the frequency and severity of CHR symptoms differed only minimally. Group differences were found in only four CHR symptoms: suspiciousness/persecutory ideas of the SIPS [χ² (4) = 9.425; P = 0.051, Cramer’s V = 0.132; and Z = -4.281, P < 0.001; Rosenthal’s r = 0.184], and thought pressure [χ² (4) = 11.019; P = 0.026, Cramer’s V = 0.143; and Z = -2.639, P = 0.008; Rosenthal’s r = 0.114], derealization [χ² (4) = 32.380; P < 0.001, Cramer’s V = 0.245; and Z = -3.924, P < 0.001; Rosenthal’s r = 0.169] and visual perception disturbances [χ² (4) = 10.652; P = 0.031, Cramer’s V = 0.141; and Z = -2.822, P = 0.005; Rosenthal’s r = 0.122] of the SPI-CY. These were consistent with a transdiagnostic risk factor or dimension, i.e., displayed higher frequency and severity in inpatients, in particular in those with eating, anxiety/obsessive–compulsive and autism spectrum disorders. Low functioning, however, was at most weakly related to the severity of CHR criteria/symptoms, with the highest correlation yielded for suspiciousness/persecutory ideas (Kendall’s tau = -0.172, P < 0.001).

CONCLUSION

The lack of systematic differences between inpatients and community subjects does not support suggestions that CHR criteria/symptoms are pluripotential or transdiagnostic syndromes, or merely markers of symptom severity.

Feel Good, Eat Better: The Role of Self-Compassion and Body Esteem in Mothers' Healthy Eating Behaviours

Mothers’ eating behaviours are important to ensure the health and well-being of themselves and their families. Recent research has pointed to self-compassion, defined as extending kindness to oneself in times of perceived inadequacy or general suffering, as a trait associated with healthy forms of eating, such as intuitive eating, and reduced maladaptive forms of eating, such as emotional eating. However, little is known about the psychological mechanism through which self-compassion relates to healthy eating behaviours. This study examined 100 mothers’ levels of self-compassion, body esteem and eating behaviours. Structural equation modelling revealed that self-compassion was positively associated with diet quality and intuitive eating, while being negatively associated with emotional eating. Moreover, these links occurred, in part, due to higher body esteem. This points to a mechanism through which self-compassion may positively contribute to mothers’ healthy eating behaviours. The implications for eating outcomes and women’s health are discussed.

Eating for numbing: a community-based study of trauma exposure, emotion dysregulation, dissociation, body dissatisfaction and eating disorder symptoms

Objective

The current study tests the relationship between eating disorder (ED) symptoms and trauma exposure. The mechanisms via which trauma is related to ED symptoms have not been sufficiently examined. This study examines the complex role of dissociation and emotional dysregulation in the context of trauma, BMI, ED symptoms and body dissatisfaction (BD). We hypothesized that dissociation and emotional dysregulation would mediate the relationship between trauma exposure and ED symptoms/BD. We further hypothesized that BMI would play a moderating role in this association.

Method

A community sample of 229 (16.2% male) participants, with a mean age of 29.08 ± 10.68 reported online on traumatic events (Life Events Checklist), dissociation (Dissociative Experiences Scale-II), emotional dysregulation (Difficulties in Emotional Regulation Scale), ED symptoms (Eating Disorders Examination-Questionnaire) and BD (Figure Rating Scale).

Results

Participants reported experiencing a mean of 2.87 ± 2.27 traumatic events, with a relatively high percentage (~86%) reporting at least one. The most commonly reported traumatic events were transportation accidents and physical assault. Although frequency of traumatic events did not directly predict ED symptoms, BMI, dissociation, emotional dysregulation and BD did. An SEM model showed that traumatic events predicted ED symptoms indirectly through dissociation, emotional dysregulation and BMI. Dissociation and emotional dysregulation predicted ED symptoms directly. BMI also moderated the association between traumatic events and both ED symptoms and BD.

Conclusions

Therapists treating patients with high BMI or obesity should be aware of these relationships and investigate the possibility that trauma and/or PTSD may underlie the presenting disordered eating or eating disorder.

Psychoform and somatoform dissociation in anorexia nervosa: A systematic review

Dissociation is a debilitating condition often present as comorbidity in patients with eating disorders, but to date only sparse findings are available on this topic. Additionally, very little data exist on the classification of dissociation, namely, psychoform and somatoform, in anorexia nervosa (AN). This review aimed to provide an updated view on the literature about dissociation in AN, with a focus on AN subtypes (i.e., restricter and binge-purging) as well as dissociation type (i.e., psychoform and somatoform), when available. We screened 304 studies, and after title and abstract selection and full-text reading, 29 of them were included in this review. Most of the studies investigated psychoform dissociation, whereas just four publications considered somatoform dissociation. Dissociation resulted to be present in AN more than in healthy controls and in individuals with other psychiatric disorders, and it was related mostly to the binge-purging subtype of AN. Moreover, dissociation was linked to traumatic events, self-harm and negative treatment outcomes, especially in patients affected by the binge-purging subtype of AN. However, results on these matters are scarce and partially discordant. The methodological assessment we performed revealed an overall fair quality of the included studies, although several flaws emerged as well. The present review reported on one hand the relevance of dissociation in AN, but on the other hand the need to stimulate the scientific debate on (a) a deeper investigation of somatoform dissociation in AN and (b) the relationship between dissociation and both clinical severity and treatment response/resistance in AN.

Jenkins P, Abu-Abeid S, Goldzweig G. Body Image, Emotional Eating and Psychological Distress among Bariatric Surgery Candidates in Israel and the United States

BACKGROUND

The present study aimed to examine the relations between body image dissatisfaction (BID) and psychological distress variables among bariatric surgery candidates from two distinct cultures in Israel and in the United States.

METHODS

A sample of consecutive pre-surgical bariatric candidates was recruited from a Bariatric Center in Israel (N = 114) and a Bariatric Center in the Unites States (N = 81). Body image dissatisfaction (BID-BSQ8), suicidal ideation (SBQ-R), depressive symptoms (PHQ-9), anxious symptoms (PHQ-7), and emotional eating behaviors (EES), were measured. Mediation models were assessed using path analysis.

RESULTS

BID was positively correlated with suicidality, depression, and anxiety in both samples. The relations between BID depression and anxiety were mediated by emotional eating in both cultures. However, the relation between BID and suicidality that was mediated by emotional eating in the Israeli sample, was reflected in a direct link between BID and suicidality in the US sample.

CONCLUSION

Our findings confirm the adverse effect of BID on psychological distress among surgery candidates in both cultures, emphasizing the intercultural similarities related to emotional eating behavior. Physicians and other health professionals are encouraged to be more attentive to this specific behavior.

Psychoform and somatoform dissociation among individuals with eating disorders

Objective: This study analyzed the prevalence of psychoform and somatoform dissociation among individuals with the whole spectrum of eating disorder diagnoses and compared it with ratings from a non-clinical group. The relationship between dissociation and severity of eating disturbance was examined as well as differences between the eating disorder diagnosis groups in extent of dissociation. The validity of a new structural dissociation interview suitable for eating disorder patients was analyzed.Method: Sixty individuals with eating disorder completed three self-report questionnaires: Dissociation Questionnaire Sweden, Somatoform Dissociation Questionnaire and Eating Disorder Examination Questionnaire. The ratings were compared with the scores in a female non-clinical group (N = 245). Twenty patients with eating disorder diagnoses were interviewed with the Interview for Dissociative Disorders and Trauma Related Symptoms. The validity of the interview was tested by comparing the ratings on the interview subscales with the scores on the Dissociation questionnaires and the Somatoform Dissociation Questionnaire.Results: Participants with eating disorders reported a higher extent of both psychoform and somatoform dissociation compared with the non-clinical individuals. Analyses also showed a correlation between degree of dissociation and severity of eating disorder symptoms. No differences in dissociation were found between the ED subgroups. Participants reporting more dissociation got higher ratings on the interview, indicating convergent validity.Discussion: Eating disorders seem to be associated with presence and severity of dissociative symptoms. The extent of dissociation needs to be assessed for these individuals as treatment may benefit from a focus on such symptoms in order to increase its effect.

Levels of childhood traumatic experiences and dissociative symptoms in extremely obese patients with and without binge eating disorder

Background: It has been suggested that obese patients with binge eating disorder (BED) show higher levels of dissociation and childhood trauma. Aim: This study assesses childhood trauma history and dissociative symptoms in obese patients with BED compared to obese patients without BED. Methods: The 241 patients participating in the study had to meet obesity criteria. These patients were applicants for bariatric surgery and were consulted by a psychiatry service. Patients were separated into two groups that were accompanied by BED diagnoses according to structured clinical interviews administered according to the DSM-IV (SCID-I). Patients were assessed using the Dissociation Questionnaire (DIS-Q) and the Childhood Trauma Questionnaire (CTQ). The two groups of patients were compared. Results: A total of 75 (31.1%) of the 241 obese patients were diagnosed with BED. The study showed that obese patients with BED had higher dissociative scores than those without BED (p < .05). The results showed higher total scores and two different types of childhood trauma (physical abuse and emotional abuse) in BED patients compared to non-BED patients (p < .05). Conclusions: Clinicians should be fully aware of BED, dissociative symptoms and childhood traumatic experiences. These results show that, for at least a sub-group of obese patients, BED is associated with obesity and may be connected with dissociative symptoms and childhood physical abuse and emotional abuse.

Psychological distress among bariatric surgery candidates: The roles of body image and emotional eating

The increased risk of psychological distress among bariatric surgery candidates may be attributed, at least in part, to body image dissatisfaction (BID). The aim of the present study was to test the hypotheses that body image could be correlated with the psychological distress variables, and that emotional eating behaviours could mediate the relationship between body image and psychological distress. A sample of consecutive participants seeking bariatric surgery (N = 169, 67% females, mean age, 41.8 years [SD = 11.46], mean body mass index 42.0 kg/m² [SD = 11.0]) was recruited from a university-based bariatric centre, a week prior to scheduled surgery. Results showed that BID was positively correlated with suicidality (r = 0.18, P < 0.05), depression (r = 0.39, P < 0.01) and anxiety (r = 0.20, P < 0.05). The relation between BID and depression was partially mediated by emotional eating, whereas the relation between BID and suicidality was fully mediated by emotional eating. Physicians and other health professionals who treat bariatric surgery patients should be encouraged to detect behaviours indicating emotional eating, as these could be an indicator of psychological distress resulting from poor body image.

Comfortably Numb: The Role of Momentary Dissociation in the Experience of Negative Affect Around Binge Eating

Evidence suggests that both dissociation and negative affect (NA) may precipitate binge eating. The extent to which dissociation may impact the experience of NA around binge eating is unclear. Women with bulimia nervosa completed a 2-week ecological momentary assessment protocol of dissociation, NA, and binge eating. Multilevel modeling was used to examine dissociation as a moderator of NA before and after binge eating. NA was greater at the time of binge eating for participants higher in average dissociation (between subjects) and when momentary dissociation was greater than one's average (within subjects). The trajectory of NA was characterized by a sharper increase before binge eating for participants higher in average dissociation; the NA trajectories were characterized by sharper increases before and decreases after binge eating when momentary dissociation was greater than one's average. Results support the salience of both dissociation and NA in relation to the occurrence of binge eating.

Association between depression and eating behaviors among bariatric surgery candidates in a Turkish sample

PURPOSE

The purpose of this study was to explore further whether depression is associated with problematic eating behaviors in a sample of Turkish bariatric surgery candidates.

METHODS

This descriptive study included 168 consecutively seen bariatric surgery candidates in a university bariatric surgery outpatient. Participants were asked to complete the Dutch Eating Behavior Questionnaire (DEBQ), the Beck Depression Inventory (BDI) and surveys assessing sociodemographic and clinical variables. Correlations and linear regression analyses were performed to evaluate the relationship between clinical and demographic variables.

RESULTS

Participants had a mean age 37.7 ± 11.3 years and BMI of 46.4 ± 6.7 kg/m² (SD = 6.7). According to BDI scores, 75.5 % of the patients had mild, moderate, or severe depressive symptomatology. Lower levels of depressive symptoms were associated with higher levels of restrictive eating (r = -0.17; p = 0.04), whereas higher levels of depressive symptoms were associated with more frequent eating in response to both internal (r = 0.3; p = 0.002) and external (r = 0.2; p = 0.04) cues. The BDI scores were significantly associated with increased external eating (ß = 0.03, p < 0.02) and emotional eating (ß = 0.03, p < 0.002) scores. BMI (β = -0.02, p = 0.02 > 0.1) was not associated with DEBQ total scores.

CONCLUSIONS

This research suggests that mild, moderate or severe depressive symptoms are observed in most of the bariatric surgical candidate patients. There is a positive correlation between severity of depression and emotional/external eating behaviors, and a negative correlation between severity of depression and restrictive eating behavior. Additional research is needed to determine whether treating depression preoperatively can assist with alleviating problematic eating behaviors.

Reorganization of the brain and heart rhythm during autogenic meditation

The underlying changes in heart coherence that are associated with reported EEG changes in response to meditation have been explored. We measured EEG and heart rate variability (HRV) before and during autogenic meditation. Fourteen subjects participated in the study. Heart coherence scores were significantly increased during meditation compared to the baseline. We found near significant decrease in high beta absolute power, increase in alpha relative power and significant increases in lower (alpha) and higher (above beta) band coherence during 3~min epochs of heart coherent meditation compared to 3~min epochs of heart non-coherence at baseline. The coherence and relative power increase in alpha band and absolute power decrease in high beta band could reflect relaxation state during the heart coherent meditation. The coherence increase in the higher (above beta) band could reflect cortico-cortical local integration and thereby affect cognitive reorganization, simultaneously with relaxation. Further research is still needed for a confirmation of heart coherence as a simple window for the meditative state.

Dissociation in the binge-purge cycle of bulimia nervosa

OBJECTIVE

This study focused on whether those suffering from bulimia nervosa may experience dissociative symptoms in relation to bulimic behavior rather than as a general pattern.

METHOD

In this study, which used an experience sampling methodology, 12 adult women who met Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for bulimia nervosa completed questionnaires measuring state levels of dissociation during 5 sequential binge-purge cycles and at a random time not associated with bingeing or purging.

RESULTS

Participants did experience dissociative symptoms, which were higher during bingeing and purging. Dissociation varied within the binge-purge cycle, rising throughout the cycle until after the purge, then declining slightly.

CONCLUSION

Women with bulimia nervosa reported experiencing higher levels of dissociative symptoms during binge-purge episodes, and dissociative symptoms returned to normal levels after completion of the purge. These data support the idea that bulimia nervosa is associated with dissociation, but that the dissociative symptoms are expressed most dramatically during binges. They are also supportive of models of bingeing as an escape.

The relationship between dissociation and binge eating

Despite research findings demonstrating a relationship between dissociation and binge eating, the psychological processes that may underlie this association remain unclear. The present study examined 2 potential explanations: (a) that dissociation disinhibits behavioral control over eating and (b) that dissociation interferes with self-awareness and undermines body image. A total of 151 female university students completed measures of dissociation, body dissatisfaction, impulsivity, internalization of the thin ideal, body comparison, and binge eating. Correlations confirmed the presence of a relationship between dissociation and binge eating, and regression analyses revealed that this relationship is limited to body-specific (somatic) symptoms of dissociation. Path analyses identified body dissatisfaction, comparison, and impulsivity as significant mediators of this relationship. However, inclusion of all 3 mediated paths in a full model revealed that only body dissatisfaction is a unique mediator. The relevance of somatic symptoms, and the unique contribution of body dissatisfaction as a mediator, are consistent with an explanation of the relationship between dissociation and binge eating that is based on a vulnerability of body image. The results emphasize the need for future research to consider the relation of dissociation to a broader range of disordered eating symptoms than simply binge eating.

The Body Uneasiness Test (BUT): development and validation of a new body image assessment scale

OBJECTIVE

To investigate the psychometric properties of the Body Uneasiness Test (BUT), a 71-item self-report questionnaire that consists of two parts: BUT*A which measures weight phobia, body image concerns, avoidance, compulsive self-monitoring, detachment and estrangement feelings towards one's own body (depersonalization); and BUT*B which looks at specific worries about particular body parts or functions.

METHODS

We recruited a clinical sample of 531 subjects (491 females) suffering from eating disorders and a general population sample of 3273 subjects (2016 females) with BMI <25 and Eating Attitudes Test-26 scores under the cut-off 20.

RESULTS

The exploratory and confirmatory analyses confirmed a structural five-factor model for BUT*A and an eight-factor model for BUT*B. Internal consistency was satisfactory. The test-retest correlation coefficients were highly significant. Concurrent validity with other tests (Eating Disorder Inventory, EDI-2; Eating Attitudes Test, EAT-26; Symptom Check List, SCL-90R and Coopersmith Self-Esteem Inventory, SEI) was evaluated. Normative values for BUT scores in non-clinical samples of normal-weight non eating disordered subjects, from adolescence to old age, males and females, were calculated. The differences between males and females were highly significant, above all in the 18-39-age range. As for the comparison between women with eating disorders and controls, the results demonstrated a good predictive validity for anorexia nervosa and bulimia nervosa.

CONCLUSIONS

The BUT is psychometrically sound. It can be a valuable tool for the screening and the clinical assessment of abnormal body image attitudes and eating disorders.