Recovery from eating disorder 1 year after start of treatment is related to better mentalization and strong reduction of sensitivity to others

Predictors of relapse in eating disorders: A meta-analysis

INTRODUCTION

Eating disorders (EDs) have high rates of relapse. However, it is still not clear which factors are the strongest predictors of ED relapse, and the extent to which predictors of relapse may vary due to study and individual differences.

OBJECTIVE

We conducted a meta-analysis to quantify and compare which factors predict relapse in EDs and evaluate various potential moderators of these relations (e.g., ED subtype, sample age, length of follow-up, timing of predictor assessment, relapse operationalization).

METHODS

A total of 35 papers (effects = 315) were included. We used a multilevel random-effects model to estimate summary study-level effect sizes, and multilevel mixed-effects models to examine moderator effects.

RESULTS

Higher level of care, having psychiatric comorbidity, and higher severity of ED psychopathology were associated with higher odds of relapse. Higher leptin, higher meal energy density/variety, higher motivation for change, higher body mass index/weight/body fat, better response to treatment, anorexia nervosa-restricting (vs. anorexia nervosa-binge purge) subtype diagnosis, and older age of ED onset were associated with lower odds of relapse. Several moderators were identified.

DISCUSSION

A variety of variables can predict ED relapse. Furthermore, predictors of ED relapse vary among ED subtypes, sample ages, lengths of follow-up, timing of predictor assessments, and relapse operationalization. Future research should identify the mechanisms by which these variables may contribute to relapse.

Eating disorder psychopathology: The role of attachment anxiety, attachment avoidance, and personality functioning

OBJECTIVE

Although the relationship between insecure attachment patterns and eating disorder (ED) psychopathology has repeatedly been demonstrated, the underlying mechanisms of this association are not fully understood. Therefore, the current study aimed to examine personality functioning, defined as an impairment in self and interpersonal functioning, as a mediator between attachment insecurity and ED psychopathology.

METHODS

In a representative population-based sample (N = 2508; age range 14-92 years) ED symptomatology, personality functioning, and attachment insecurity (anxiety and avoidance) were assessed. Besides descriptive uni-/bivariate analysis, path analysis was used to test a mediation model while controlling for the effects of age, gender, mental distress, and BMI.

RESULTS

ED symptomatology was associated with lower levels of personality functioning (r = 0.22) and higher levels of attachment anxiety (r = 0.14) but did not correlate with attachment avoidance (r = 0.02). Path analysis revealed that personality functioning fully mediated the effect of attachment anxiety on ED symptomatology: The indirect effect via personality functioning (β = 0.04, p < .001) accounted for 77% of the total effect. Fit indices were excellent. Sensitivity analyses revealed that the main results were mainly applicable to women and the middle age group.

CONCLUSION

The present findings contribute to the growing body of research using dimensional conceptualizations of personality functioning, suggesting that it provides an informative, overarching framework for understanding and treating ED psychopathology. Findings indicate that underlying individual differences, e.g., with respect to insecure attachment configurations, have relevant implications for symptom manifestations. Potential clinical implications and avenues for future research are discussed.

Three Mediating Pathways of Anxiety and Security in the Relationship between Coping Style and Disordered Eating Behaviors among Chinese Female College Students

Background

According to previous studies, eating disorders and disordered eating behaviors are associated with coping style, anxiety, and sense of security. However, the specific mechanism between them has not been elucidated. The purpose of this study was to explore whether anxiety and sense of security play mediating roles in coping style and disordered eating behaviors among Chinese female college students.

Method

Six hundred and ninety-one female college students (mean age = 19.36; SD = 1.06) completed the Simple Coping Style Questionnaire, the Eating Disorder Inventory, the Security Questionnaire, the Hospital Anxiety and Depression Scale, and a brief demographic survey. The percentage bootstrap method of deviation correction was conducted to determine the mediating effect of anxiety and sense of security on coping style and disordered eating behaviors.

Results

Coping style had direct and indirect effects on disordered eating behaviors. Anxiety and sense of security were not only independent mediators in the relationship between coping style and disordered eating behaviors but also chain mediators.

Conclusions

The results of the current study provide preliminary evidence that preventive interventions targeting anxiety and sense of security may be feasible for young women who develop disordered eating behaviors due to stress in their lives.

Attachment, mentalizing, and eating disorder symptoms in adolescent psychiatric inpatients and healthy controls: a test of a mediational model

OBJECTIVE

Research has supported a link between insecure attachment and eating disorders (EDs) in adolescents; however, mechanisms accounting for this association remain unclear. Growing evidence suggests impaired mentalizing as a potential mechanism. Yet, little is known about the relationship between mentalizing and ED symptoms or how it relates to the link between attachment and EDs in adolescents. This study examined mentalizing deficits in adolescents with ED symptoms relative to psychiatric and healthy controls and tested a mediational model, wherein mentalizing capacity mediates the relationship between attachment and ED symptoms.

METHOD

Inpatient adolescents with EDs and other pathology (n = 568) and healthy controls (n = 184) were administered the child attachment interview, the movie for the assessment of social cognition and the diagnostic interview schedule for children to assess attachment, mentalizing and ED symptoms, respectively.

RESULTS

Inpatients showed lower attachment security and more hypermentalizing than healthy adolescents. Hypermentalizing explained the association between insecure attachment and ED symptoms.

CONCLUSIONS

These findings suggest potential utility of targeting mentalizing in prevention and treatment of EDs in adolescents.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

'Impaired Autonomy and Performance' predicts binge eating disorder among obese patients

PURPOSE

The present study examined the predictive value of early maladaptive schema (EMS) domains on the diagnosis of binge eating disorder (BED).

METHODS

Seventy obese patients seeking treatment for weight loss were recruited and allocated to either group 1 (obese) or group 2 (BED-obese) according to clinical diagnosis. Both groups underwent psychometric assessment for EMS (according to the latest four-factor model), eating and general psychopathologies. Logistic regression analysis was performed on significant variables and BED diagnosis.

RESULTS

In addition to showing higher values on all clinical variables, BED-obese patients exhibited significantly higher scores for all four schema domains. Regression analysis revealed a 12-fold increase in risk of BED with 'Impaired Autonomy and Performance'. Depression did not account for a higher risk.

CONCLUSIONS

Impaired Autonomy and Performance is associated with BED in a sample of obese patients. Schema therapy should be considered a potential psychotherapy strategy in the treatment of BED.

LEVEL OF EVIDENCE

Level III, case-control study.

Comorbid depression as a negative predictor of weight gain during treatment of anorexia nervosa: A systematic scoping review

BACKGROUND

Anorexia nervosa (AN) is a serious mental illness with high rates of relapse and mortality. Psychiatric comorbidities are common but their impact on the prognosis is largely unknown.

OBJECTIVE

The aim was to investigate the influence of psychiatric comorbidity on weight gain during treatment of AN.

METHODS

A systematic search was performed in PubMed/MEDLINE, EMBASE and PsycINFO. Studies evaluating psychiatric comorbidity as a predictor for treatment outcome (weight gain) were included, however, comorbid alcohol/drug addiction was excluded from this review.

RESULTS

Four thousand five hundred and twenty six publications were identified from which 15 were included. The majority of the included studies had a prospective open naturalistic study design, a short-term follow-up period, and were based on small populations of primarily adolescent and adult women. Four studies indicate depression, and two obsessiveness as negative prognostic factors, whilst one study indicated moderate depression and yet another, neuroticism, as positive predictors for weight gain.

DISCUSSION

The systematic scoping review found a large number of publications whereof only a few directly described the influence of psychiatric comorbidity on weight gain in AN. Overall, studies were heterogeneous in design, purpose and outcome making comparisons difficult. Findings were divergent but depression had a negative influence on weight gain in four studies.

Personal recovery of young adults with severe anorexia nervosa during adolescence: a case series

PURPOSE

Despite the emergence of a growing qualitative literature about the personal recovery process in mental disorders, this topic remains little understood in anorexia nervosa (AN), especially severe AN during adolescence. This cases series is a first step that aims to understand recovery after severe AN among adolescents in France, from a first-person perspective.

METHODS

This cases series applied the interpretative phenomenological analysis (IPA) method to data collected in semi-structured face-to-face interviews about the recovery process of five young women who had been hospitalized with severe AN 10 years earlier during adolescence.

RESULTS

A model of recovery in four stages (corseted, vulnerable, plastic, and playful) crossing seven dimensions (struggle and path of initiation; work on oneself; self-determination and help; body; family; connectedness; and timeline) emerged from the analysis. New features of the AN personal recovery process were characterized: bodily well-being and pleasure of body; stigmatization; the role of the group; relation to time; and importance of narratives. We suggest a new shape to model the AN recovery process, one that suggests several tipping points. Recruitment must now be widened to different AN contexts.

CONCLUSIONS

The personal recovery paradigm may provide a new approach to care, complementary to medical paradigm.

REGISTRATION OF CLINICAL TRIAL

No. NCT03712384. Our study was purely observational, without assignment of medical intervention. As a consequence, this clinical trial was registered retrospectively.

LEVEL OF EVIDENCE

Level V, descriptive study.

Early changes in depression predict outcomes of inpatient adolescent anorexia nervosa

PURPOSE

The aim of this study was to investigate the predictive value of early changes in depression levels during inpatient treatment of adolescent anorexia nervosa (AN).

METHODS

Fifty-six adolescents (88% girls) aged 10-18 years (M = 15.35, SD = 2.23) diagnosed with AN were assessed at admission and 1 month following admission to an inpatient setting. Depression levels and eating disorder symptoms were reported at both assessments. Re-hospitalization within 12 months of discharge was documented using official national records.

RESULTS

Whereas depression levels at baseline were found equivalent between subsequently re-hospitalized and non-re-hospitalized patients, at 1 month after admission patients who were later re-hospitalized had higher levels of depression compared to those who were not re-hospitalized. These differences remained significant after controlling for weight gain and anti-depressant medication intake. We additionally found that the proportion of boys in the non-re-hospitalized group was substantially larger than their proportion in the re-hospitalized group.

CONCLUSIONS

Our results suggest that depression at the point of hospital admission may not be a reliable predictor of treatment outcomes, and highlight the risk of relapse in AN patients whose depression levels do not alleviate after a month of inpatient treatment. Clinicians should consider providing more adjusted and intensive attention to such patients in their efforts to facilitate remission.

LEVEL OF EVIDENCE III

Well-designed cohort study.

Eating disorder recovery is associated with absence of major depressive disorder and substance use disorders at 22-year longitudinal follow-up

BACKGROUND

Psychiatric comorbidity is common in eating disorders (EDs) and associated with poor outcomes, including increased risk for relapse and premature death. Yet little is known about comorbidity following ED recovery.

METHODS

We examined two common comorbidities, major depressive disorder (MDD) and substance use disorder (SUD), in adult women with intake diagnoses of anorexia nervosa and bulimia nervosa who participated in a 22-year longitudinal study. One hundred and seventy-six of 228 surviving participants (77.2%) were interviewed 22 years after study entry using the Eating Disorders Longitudinal Interval Follow-up Evaluation to assess ED recovery status. Sixty-four percent (n = 113) were recovered from their ED. The Structured Clinical Interview for DSM-IV was used to assess MDD and SUD at 22 years.

RESULTS

At 22-year follow-up, 28% (n = 49) met criteria for MDD, and 6% (n = 11) met criteria for SUD. Those who recovered from their ED were 2.17 times more likely not to have MDD at 22-year follow-up (95% CI [1.10, 4.26], p = .023) and 5.33 times more likely not to have a SUD at 22-year follow-up than those who had not recovered from their ED (95% CI [1.36, 20.90], p = .008).

CONCLUSION

Compared to those who had not fully recovered from their ED, those who had recovered were twice as likely not to be diagnosed with MDD in the past year and five times as likely not to be diagnosed with SUDs in the past year. These findings provide evidence that long-term recovery from EDs is associated with recovery from or absence of these common major comorbidities. Because comorbidity in EDs can predict poor outcomes, including greater risk for relapse and premature death, our findings of reduced risk for psychiatric comorbidity following recovery at long-term follow-up is cause for optimism.

Autonomy–Connectedness, Self-Construal, and Acculturation: Associations With Mental Health in a Multicultural Society

The present study investigated the associations between self-construal, acculturation, and autonomy–connectedness, as well as the relations between autonomy–connectedness and psychopathological symptoms, controlling for self-construal and acculturation. Participants were 1,209 Dutch individuals, of whom 693 (57.3%) were immigrants with a non-Western background. Results showed that an independent self-construal was positively associated with self-awareness and capacity for managing new situations, and was negatively associated with sensitivity to others (which are the three components of autonomy–connectedness). Moreover, an interdependent self-construal was negatively associated with self-awareness and capacity for managing new situations, and was positively associated with sensitivity to others. Importantly, the latter associations were similar for both Dutch natives and immigrants, and the associations between acculturation and autonomy–connectedness were small and nonsignificant. Autonomy–connectedness, after controlling for self-construal and acculturation, explained a large amount of additional variance in anxiety (12.7%) and depression (14.1), and a medium amount of additional variance in drive for thinness (3.7%) and bulimia (4.8%). Autonomy–connectedness, thus, seems to be an important construct for people with a Western background, as well as for immigrants with a non-Western background.

An Overview of Conceptualizations of Eating Disorder Recovery, Recent Findings, and Future Directions

PURPOSE OF REVIEW

This review delineates issues in the conceptualization and operationalization of eating disorder recovery, highlights recent findings about recovery (since 2016), and proposes future directions.

RECENT FINDINGS

A longstanding problem in the field is that there are almost as many different definitions of recovery in eating disorders as there are studies on the topic. Yet, there has been a general shift to accepting that psychological/cognitive symptoms are important to recovery in addition to physical and behavioral indices. Further, several operationalizations of recovery have been proposed over the past two decades, and some efforts to validate operationalizations exist. However, this work has had limited impact and uptake, such that the field is suffering from "broken record syndrome," where calls are made for universal definitions time and time again. It is critical that proposed operationalizations be compared empirically to help arrive at a consensus definition and that institutional/organizational support help facilitate this. Themes in recent recovery research include identifying predictors, examining biological/neuropsychological factors, and considering severe and enduring anorexia nervosa. From qualitative research, those who have experienced eating disorders highlight recovery as a journey, as well as factors such as hope, self-acceptance, and benefiting from support from others as integral to the process of recovery. The field urgently needs to implement a universal definition of recovery that is backed by evidence, that can parsimoniously be implemented in clinical practice, and that will lead to greater harmonization of scientific findings.

Is reduction of symptoms in eating disorder patients after 1 year of treatment related to attachment security and mentalization?

In a sample of 38 eating disorder (ED) patients who received psychotherapeutic treatment, changes in attachment security, and mentalization in relation to symptoms reduction were investigated. Attachment security improved in 1 year but was unrelated to improvement of ED or comorbid symptoms. Mentalization did not change significantly in 1 year. Pretreatment mentalization was negatively related to the severity of ED symptoms, trait anxiety, psycho-neuroticism, and self-injurious behavior after 1 year of treatment. We conclude that for ED patients, improving mentalization might increase the effect of treatment on core and comorbid symptoms.