Attachment and mentalization as predictors of outcome in family therapy for adolescent anorexia nervosa

Effectiveness and predictors of psychotherapy in eating disorders: state-of-the-art and future directions

PURPOSE OF REVIEW

Psychotherapy is the cornerstone of the multidisciplinary treatment approach for eating disorders. This review examines recent evidence regarding effectiveness, predictors, and mechanisms of change of psychotherapy in eating disorders, providing a road map for clinicians and researchers.

RECENT FINDINGS

Family-based treatments (FBT) are effective in adolescents with anorexia nervosa and bulimia nervosa. Evidence-based psychotherapies for anorexia nervosa have no evidence of superiority compared with treatment as usual (TAU) in adults with anorexia nervosa. Cognitive-behavioural therapy (CBT) is the first-choice psychotherapy recommended for adults with bulimia nervosa and binge-eating disorder (BED). Self-help interventions have some evidence of effectiveness in nonunderweight individuals with eating disorders. Early symptom improvement and adolescent age predict more favourable outcomes.

SUMMARY

Evidence-based psychotherapies can be suggested for eating disorders, although follow-up data are needed. Beyond anorexia nervosa, bulimia nervosa, and BED, there is no evidence of psychotherapy effectiveness in other eating disorders. The effectiveness of novel (e.g. 'third-wave') psychotherapies, treatment delivery modality (e.g. internet-delivered), and adjunctive interventions (e.g. virtual reality) needs to be further explored. A broader definition of recovery is recommended, including behavioural, physical, and psychological criteria. Predictors and mechanisms of changes have not been studied enough: quantitative and qualitative studies are needed to promote more tailored and individualized psychotherapy interventions.

Weight gained during treatment predicts 6-month body mass index in a large sample of patients with anorexia nervosa using ensemble machine learning

OBJECTIVE

This study used machine learning methods to analyze data on treatment outcomes from individuals with anorexia nervosa admitted to a specialized eating disorders treatment program.

METHODS

Of 368 individuals with anorexia nervosa (209 adolescents and 159 adults), 160 individuals had data available for a 6-month follow-up analysis. Participants were treated in a 6-day-per-week partial-hospital program. Participants were assessed for eating disorder-specific and non-specific psychopathology. The analyses used established machine learning procedures combined in an ensemble model from support vector machine learning, random forest prediction, and the elastic net regularized regression with an exploration (training; 75%) and confirmation (test; 25%) split of the data.

RESULTS

The models predicting body mass index (BMI) at 6-month follow-up explained a 28.6% variance in the training set (n = 120). The model had good performance in predicting 6-month BMI in the test dataset (n = 40), with predicted BMI significantly correlating with actual BMI (r = .51, p = 0.01). The change in BMI from admission to discharge was the most important predictor, strongly correlating with reported BMI at 6-month follow-up (r = .55). Behavioral variables were much less predictive of BMI outcome. Results were similar for z-transformed BMI in the adolescent-only group. Length of stay was most predictive of weight gain in treatment (r = .56) but did not predict longer-term BMI.

CONCLUSIONS

This study, using an agnostic ensemble machine learning approach in the largest to-date sample of individuals with anorexia nervosa, suggests that achieving weight gain goals in treatment predicts longer-term weight-related outcomes. Other potential predictors, personality, mood, or eating disorder-specific symptoms were relatively much less predictive.

PUBLIC SIGNIFICANCE

The results from this study indicate that the amount of weight gained during treatment predicts BMI 6 months after discharge from a high level of care. This suggests that patients require sufficient time in a higher level of care treatment to meet their specific weight goals and be able to maintain normal weight.

Complexity of mentalization

The ability to understand other people’s emotions, thoughts, and behaviors is associated with an individual’s ability and his attitude in the context of relationships. The development of this process is associated with different psychosocial factors: parental competence, building a secure attachment and reduced risk of violence in the family as well as the future intrapersonal relationships and social reality of one person Mentalization is empirically associated with resolving psychological tasks in normative dilemmas and also, can influence on the outcome of personal and situational crises. And so forth, passing through the different stages of life and prevention of dysfunctional patterns in the family is facilitated. This text aims to investigate the main characteristics of mentalization, its connection with the etiopathogenesis of some main mental disorders, their course and prognosis. Several studies in recent years confirmed that these connections can enroll mentalization to prevention and psychological therapy in some mental disorders and dysfunctional thinking patterns. On the other hand, it serves as a basis for psychotherapeutic competence expressed in the ability to connect, differentiate, and separate, as the main interactional stages of the psychotherapeutic process.

How young people perceive change to occur in family therapy for anorexia nervosa: a qualitative study

BACKGROUND

Family therapy for anorexia nervosa (FT-AN) is the first line recommended treatment for child and adolescent anorexia nervosa. Despite evidence of its efficacy, little is understood about the treatment mechanisms. This study aimed to understand how young people who have received FT-AN perceive change to occur across treatment.

METHOD

Fifteen adolescents (age 12-18 years) completed individual semi-structured interviews online. Recordings were transcribed verbatim and analysed using reflexive thematic analysis.

RESULTS

Four inter-connected themes describing the process of change during treatment were generated; (1) relationships as the vehicle for change, (2) an awakening, (3) through, not around - no way out, (4) the life beyond.

CONCLUSIONS

Current data match relatively closely with theoretical models of FT-AN and emphasise the importance of building trust with all family members, including the young person. Additionally, supporting the family to create a trusting context in which there is a sense that the only way out of the illness is by going through it (rather than avoiding it) is critical. Empirical investigation of each of the described mechanisms is needed.

Impact of the Mediational Intervention for Sensitizing Caregivers on Mentalizing in Orphans and Vulnerable Children in South Africa

The Mediational Intervention for Sensitizing Caregivers (MISC) is a mentalization-based intervention which aims to enhance caregiver sensitivity and responsiveness. MISC has demonstrated treatment effects on mental health problems of Orphans and Vulnerable Children (OVC) in South Africa working with Community-Based Organization (CBO) careworkers as the point of intervention. Recent elaboration of mentalization-based theory points to alternate figures in a child's early environment as critical resources for enhancing children's mentalizing capacity. In this study we evaluated the treatment effect of MISC on children's mentalizing capacity at baseline and following 12-months of the intervention, controlling for the effects of age, gender, orphan status, socioeconomic status, quality of the home environment, and mental health difficulties at baseline. MISC and Treatment as Usual (TAU) groups were compared using a mixed model linear regression. Results demonstrated significant effects of MISC, time, and mental health difficulties on mentalizing capacity. To our knowledge, this study is the first mentalization-based caregiver intervention to demonstrate treatment effects on child mentalizing capacity, and MISC is the first mentalization-based caregiver intervention to focus on paraprofessionals as the point of intervention.

The association between deficiencies in paternal and maternal reflective functioning and anorexia nervosa symptomatology

BACKGROUND

A large theoretical body of knowledge exists emphasizing the importance of parental mentalizing in the context of anorexia-nervosa (AN). However, the empirical support to these assumptions is still scarce. The aim of the present study was to examine whether parents of patients with AN are characterized by a lower mentalizing ability, and whether it is associated with impaired mentalizing, AN symptomatology and eating disorder (ED) related psychological traits in the daughters.

METHODS

Thirty-two family triads (fathers, mothers, and daughters) of female adolescent and young adult inpatients with AN were compared with thirty-three non-clinical family triads (N = 195). The mentalizing ability of all the participants was assessed using semi-structured interviews and coded using the Reflective Functioning Scale (RFS). Self-report questionnaires were administered to the daughters to evaluate ED symptomatology and ED related psychological traits (e.g., low self-esteem, interpersonal insecurity, emotional dysregulation).

RESULTS

Decreased reflective functioning (RF) levels were found among mothers and fathers of patients with AN compared to their control peers. Examining the entire sample, clinical and non-clinical groups together, showed that both paternal and maternal RF were associated with the daughters' RF and each were found to have a significant and distinct contribution to the daughters' RF. Significant associations were found between lower levels of maternal and paternal RF and increased ED symptoms and ED related psychological traits. The use of a mediation model suggested a serial relationship in which low maternal and paternal RF contributes to the daughters' low RF, which in turn is associated with higher levels of psychological maladjustment, and ultimately contributes to the increased severity of ED symptoms.

CONCLUSIONS

The present results provide strong empirical support for theoretical models that suggest that deficits in parental mentalizing may represent important correlates of the presence and severity of ED symptoms in AN. Furthermore, the results highlight the relevance of fathers' mentalizing ability in the context of AN. Finally, clinical and research implications are discussed.

Attachment in individuals with eating disorders compared to community controls: A systematic review and meta-analysis

OBJECTIVE

Individuals with eating disorders are known to have higher rates of insecure attachment compared to community controls, but the factors underlying this finding are poorly understood. We conducted the first meta-analysis comparing attachment in eating disorder samples compared to community controls that included quality assessment, publication bias and moderation analysis.

METHOD

We pre-registered our meta-analysis (CRD42019146799) and followed PRISMA guidelines. We searched PsychINFO, Embase, Medline, CINAHL, and Scopus for publications. Attachment scores were extracted, and Cohen's d calculated for each study using a random effects model.

RESULTS

In total, 35 studies were included in the meta-analysis and six studies were summarized in a narrative review. Eating disorder samples showed higher rates of insecure attachment compared to community controls, with a large effect size, across measurement methods and different attachment dimensions. Blinding of assessors moderated effect sizes for attachment interview studies, but no other moderators were significant.

DISCUSSION

Risk of insecure attachment is elevated in individuals with eating disorders, albeit heterogeneity is high and largely unexplained. Clinicians may need to take this into account in their work, particularly given the association between attachment insecurity and challenges to therapeutic alliance. Future studies comparing eating disorder samples with community samples should control for general psychopathology.

PUBLIC SIGNIFICANCE

Attachment is a broad concept referring to a person's thoughts, feelings and behaviors in relation to close others. This systematic review and meta-analysis found that individuals with eating disorders are lower in attachment security than community controls, regardless of attachment construct or measurement approach. Attachment may be relevant in influencing eating disorder recovery, the development of therapeutic alliance, and potentially clinical outcomes, although more research is needed.

Weight restoration in adolescent anorexia: parents' goal-directed processes

BACKGROUND

Parent-led weight restoration is a key intervention of family-based treatment, an empirically supported treatment for adolescent anorexia. Successful outcomes in family-based treatment depend almost entirely on parental action, yet current understandings of this intervention are primarily informed by professional theory and expert perspectives. Comparatively little is known about parents' goals and actions while implementing the treatment, despite goal-directed action being an explicit framework of family-based treatment. This study seeks to investigate parents' involvement in weight restoration from the perspective of the goal-directed actions they construct and engage in themselves and with others. This study focuses on the phenomenon of parent-led weight restoration as a project and addresses the following research question: "How do parents participate in the weight restoration of their adolescent as the adolescent recovers from anorexia nervosa?".

METHOD

This multicase study used the action project method and conceptual framework of contextual action theory to examine four cases of five parents engaged in actions to help their adolescent regain weight and recover from anorexia. Data were collected using multi-part interviews and analyzed according to the action project method and the multicase approach.

RESULTS

Parents' weight restoration projects were identified and grouped based on three common a themes. The primary theme, progressing toward health and well-being, was supported by three key processes: maintaining a holistic focus, trusting, and monitoring progress. Two secondary themes captured actions that were integral to the parents' projects, but with less prominence. Secondary themes were creating capacity, which was supported by three processes (managing emotions to maintain a helpful focus, personal work, and resourcing time and finances), and coordinating and negotiating partnerships. The socio-cultural valuing of the thin ideal emerged as a unique process salient in one case. This study presents a goal-directed and contextual perspective on how parents translated the principles of family-based treatment into their daily lives. It joins a small but growing body of work concerned with generating new understandings and frameworks for practitioners and researchers to enhance the effectiveness of family-based treatment in community settings.