Subtypes in bulimia nervosa: the role of eating disorder symptomatology, negative affect, and interpersonal functioning

State of Mind Assessment in Relation to Adult Attachment and Text Analysis of Adult Attachment Interviews in a Sample of Patients with Anorexia Nervosa

BACKGROUND

Attachment theory represents one of the most important references for the study of the development of an individual throughout their life cycle and provides the clinician with a profound key for the purposes of understanding the suffering that underlies severe psychopathologies such as eating disorders. As such, we conducted a cross-sectional study with a mixed-methods analysis on a sample of 32 young women with anorexia nervosa (AN); this study was embedded in the utilized theoretical framework with the following aims: 1. to evaluate the state of mind (SoM) in relation to adult attachment, assuming a prevalence of the dismissing (DS) SoM and 2. to analyze the linguistic attachment profile emerging from the transcripts of the AAIs.

METHODS

Interviews were transcribed verbatim, coded, and analyzed using the linguistic inquiry and word count (LIWC) method.

RESULTS

The results were observed to be consistent with the referenced literature. The prevalence of a DS SoM (68.75%) is observed in the study sample, whereas the results of the lexical analysis of the stories deviate from expectations. Notably, the lexical results indicate the coexistence of the dismissing and entangled aspects at the representational level.

CONCLUSIONS

The study results suggest a high level of specificity in the emotional functioning of patients with AN, with a focusing on a pervasive control of emotions that is well illustrated by the avoidant/ambivalent (A/C) strategy described in Crittenden's dynamic-maturational model. These findings and considerations have important implications for clinical work and treatment, which we believe must be structured on the basis of starting from a reappraisal of emotional content.

Narrative and Bodily Identity in Eating Disorders: Toward an Integrated Theoretical-Clinical Approach

Eating disorders (EDs) can be viewed as "embodied acts" that help to cope with internal and external demands that are perceived as overwhelming. The maintenance of EDs affects the entire identity of the person; the lack of a defined; or valid sense of self is expressed in terms of both physical body and personal identity. According to attachment theory, primary relationships characterized by insecurity, traumatic experiences, poor mirroring, and emotional attunement lead to the development of dysfunctional regulatory strategies. Although the literature shows an association between attachment style or states of mind, trauma, behavioral strategies, and various EDs, the debate is still ongoing and the results are still conflicting. Therefore, we believe it is important to examine and treat EDs by understanding which narrative trajectory intercepts distress in relation to narrative and embodied self-concept. Drawing on clinical observation and a narrative review of the literature, we focus on the construction and organization of bodily and narrative identity. Because bodily representations are the primary tools for generating meaning, organizing experience, and shaping social identity from the earliest stages of life, we focus on the role that bodily interactions and sensorimotor and proprioceptive patterns have played in the development of EDs. We consider the role that lack of attunement, insecure attachment, and relational trauma play in mentalizing, affecting self-representation and emotion regulation strategies. The paper also considers a semantic mode of trauma in EDs that involves a top-down pathway through beliefs and narratives about oneself based on lack of amiability, on devaluation, and on humiliation memories. Finally, we would like to highlight the proposal of an integrated model with multiple access model to psychotherapy that takes into account the complexity of ED patients in whom aspects related to dysregulation, body image disintegration, and post-traumatic symptoms are associated with a suffering sense of self and a retraumatizing narrative.

Restrained Eating Is Associated with Lower Cortical Thickness in the Inferior Frontal Gyrus in Adolescents

Some eating patterns, such as restrained eating and uncontrolled eating, are risk factors for eating disorders. However, it is not yet clear whether they are associated with neurocognitive differences. In the current study, we analyzed whether eating patterns can be used to classify participants into meaningful clusters, and we examined whether there are neurocognitive differences between the clusters. Adolescents (n = 108; 12 to 17 years old) and adults (n = 175, 18 to 40 years old) completed the Three Factor Eating Questionnaire, which was used to classify participants according to their eating profile using k means clustering. Participants also completed personality questionnaires and a neuropsychological examination. A subsample of participants underwent a brain MRI acquisition. In both samples, we obtained a cluster characterized by high uncontrolled eating patterns, a cluster with high scores in restrictive eating, and a cluster with low scores in problematic eating behaviors. The clusters were equivalent with regards to personality and performance in executive functions. In adolescents, the cluster with high restrictive eating showed lower cortical thickness in the inferior frontal gyrus compared to the other two clusters. We hypothesize that this difference in cortical thickness represents an adaptive neural mechanism that facilitates inhibition processes.

Predictors of weight loss after bariatric surgery-a cross-disciplinary approach combining physiological, social, and psychological measures

BACKGROUND

Bariatric surgery leads to a substantial weight loss (WL), however, a subset of patients undergoing surgery fails to achieve adequate WL. The reason for the individual variation in WL remains unexplained. Using an exploratory cross-disciplinary approach, we aimed to identify preoperative and early postoperative factors explaining the variation in WL after bariatric surgery.

METHODS

Sixty-one subjects were recruited. Eighteen subjects did not receive surgery and three subjects dropped out, leaving a total sample of 40 subjects. Physiological, social, and psychological data were collected before and 6 months after surgery. All variables were analyzed in combination using a least absolute shrinkage and selection operator (LASSO) regression to explain the variation in WL 18 months after Roux-en-Y gastric bypass (n = 30) and sleeve gastrectomy (n = 10).

RESULTS

Mean WL was 31% (range: 10-52%). The following preoperative factors predicted 59% of the variation in WL: type of surgery (14%), diabetes status (12%), economic resources (9%), sex (7%), binge eating disorder (7%), degree of depression (5%), household type (3%), and physical activity (1%). Including information on early responses after surgery increased the ability to predict WL to 78% and was explained by early WL (47%), changes in energy density of food consumed from a buffet meal (9%), changes in glicentin (5%), degree of depression (5%), sex (5%), type of surgery (2%), economic resources (2%), and changes in drive for thinness (1%).

CONCLUSIONS

Using a cross-disciplinary approach, a substantial part of the individual variation in WL was explained by a combination of basic patient characteristics, psychological profile, and social conditions as well as physiological, psychological and behavioral responses to surgery. These results suggest that patient characteristics collected in a cross-disciplinary approach may help determine predictors for less successful WL after bariatric surgery. If verified in larger cohorts this may form the basis for individualized postoperative support to optimize WL outcome.

Social anxiety disorder and avoidant personality disorder from an interpersonal perspective

OBJECTIVES

The general objective of this article is to study the unclear and overlapping relationship between social anxiety disorder (SAD) and avoidant personality disorder (AvPD) from an interpersonal perspective. The first specific objective is to compare the disorders with regard to interpersonal problems and general symptom distress. The second specific objective is to examine interpersonal subgroups and pathoplasticity.

DESIGN

In a cross-sectional design, patients from an outpatient psychotherapy clinic diagnosed with social anxiety disorder (SAD, n = 299), avoidant personality disorder (AvPD, n = 180), or the comorbid condition of both disorders (AvPD + SAD, n = 29) were assessed before treatment.

METHODS

Patients filled out the Inventory of Interpersonal Problems (IIP-64) and the Symptom Checklist-Revised (SCL-R-90) before treatment.

RESULTS AND CONCLUSIONS

From an interpersonal perspective, the relationship between the diagnostic groups is well described by the severity continuum hypothesis, with similar interpersonal problems related to Nonassertiveness and lower levels of general interpersonal stress in the SAD group compared to the two AvPD groups. However, other differences in severity do not fit the severity continuum hypothesis, as there are no differences in severity on the global severity index, and, moreover, the SAD group has the most severe problems on the SCL-90 phobic anxiety scale. Interpersonal pathoplasticity is not found in the diagnostic groups or in the full sample. However, three interpersonal subgroups are identified in the full sample, designated as Nonassertive, Friendly-submissive, and Cold-submissive. Implications for treatment are discussed.

PRACTITIONER POINTS

SAD is characterized by a lower level of interpersonal distress compared to AvPD, but the two disorders are similar in having Nonassertiveness as their general interpersonal problem. Contrary to expectation, SAD and AvPD did not differ in general level of symptom severity, and patients with SAD reported more problems with phobic anxiety than AvPD patients did. When understanding SAD and AvPD as different conceptualizations of the same disorder and analysing all patients together, three distinct interpersonal subgroups emerge, which can be identified as Nonassertive, Friendly-submissive, and Cold-submissive.

Associations of borderline personality disorder traits with stressful events and emotional reactivity in women with bulimia nervosa

Borderline personality disorder (BPD) traits are common among those with bulimia nervosa (BN). However, how these traits impact the state experience of precipitants of BN behavior, such as stressful events and emotional reactivity, has not been determined. Thus, the purpose of this naturalistic study was to examine this trait-state association in BN. Women with DSM-IV BN (N = 133) completed a baseline measure of personality pathology traits, and subsequently recorded their affective state and the frequency and perception of 3 types of stressful events (interpersonal, work/environment, and daily hassles) several times per day for 2 weeks using ecological momentary assessment (EMA). Pearson correlations assessed the associations between BPD traits (affective lability, identity problems, insecure attachment, and cognitive dysregulation) and (a) frequency of stressful events and (b) perception of stressful events. Generalized linear models (GLM) were used to evaluate the relationship between BPD traits and changes in negative affect following stressful events. Results revealed that while all traits were significantly associated with perceived stressfulness, certain BPD traits were significantly associated with the frequency of stressful events. Individuals with higher trait insecure attachment experienced larger increases in negative affect following interpersonal stressful events. These findings suggest that interventions focused on addressing stressful events and enhancing adaptive emotional responses to interpersonal events may be particularly useful for a subset of individuals with BN with BPD-related personality characteristics, including insecure attachment, affective lability, and identity problems. (PsycINFO Database Record

Mind the gap: In-session silences are associated with client attachment insecurity, therapeutic alliance, and treatment outcome

OBJECTIVE

The association between in-session silences and client attachment, therapeutic alliance, and treatment outcome was investigated in two treatments for bulimia nervosa.

METHOD

69 women and one man were randomized to two years of psychoanalytic psychotherapy (PPT) or 20 sessions of cognitive behavioral therapy (CBT). Client attachment was assessed using the Adult Attachment Interview. Early, middle and late sessions (N = 175) were evaluated with the Vanderbilt Therapeutic Alliance Scales, and quality of in-session silences was coded with the Pausing Inventory Categorization System (PICS). Multilevel Poisson and linear regression analyses were performed.

RESULTS

Coders identified 6236 pauses, which were more frequent in PPT than in CBT. Higher pausing frequency and higher relative frequency of obstructive pauses were associated with client insecure attachment as well as with poorer treatment alliance, and accounted for part of the relation between client attachment and therapeutic alliance. Good outcome clients had higher relative frequency of productive pauses, especially in mid-treatment, and lower relative frequency of obstructive pauses, especially in late treatment.

CONCLUSION

The study further validates the PICS. Findings indicate that therapists may be able to use in-session silences as an indicator of client attachment insecurity and as a prognostic sign of eventual treatment outcome.

Personality prototype as a risk factor for eating disorders

OBJECTIVE

To establish whether the risk of suffering from an eating disorder (ED) is associated with the high-functioning, undercontrolled, or overcontrolled personality prototype groups.

METHOD

The Revised NEO Personality Inventory (NEO-PI-R) and the Eating Disorder Inventory 2 (EDI-2) were administered to 69 patients diagnosed as suffering from EDs (cases) and 89 people free of any ED symptoms (control group). A cluster analysis was carried out to divide the participants into three groups based on their scores in the Big Five personality dimensions. A logistic regression model was then created.

RESULTS

Participants in the undercontrolled group had a risk of suffering from an ED 6.517 times higher than those in the high-functioning group (p = 0.019; odds ratio [OR] = 6.517), while those in the overcontrolled subgroup had a risk of ED 15.972 times higher than those in the high-functioning group.

CONCLUSIONS

Two personality subtypes were identified in which the risk of EDs was six times higher (the undercontrolled group) and almost 16 times higher (the overcontrolled group). Prevention and treatment programs for ED could benefit from focusing on the abovementioned personality profiles.

Psychodynamic profile and reflective functioning in patients with bulimia nervosa

OBJECTIVE

The aim of this study was to examine the general psychological functioning of patients suffering from bulimia nervosa (BN) using the Karolinska Psychodynamic Profile (KAPP). Furthermore, KAPP data and data from the Reflective Functioning scale (RF), measuring the ability to mentalize, were combined in order to examine differences in alexithymia, impulse control and affect regulation in patients with high or low RF.

METHOD

Seventy patients with BN were interviewed with both the KAPP and the Adult Attachment Interview (AAI) from which RF is coded. Differences in KAPP scores of patients with high or low RF were analyzed.

RESULTS

Most of the patients with BN were found to have a personality structure within the normal or neurotic range (n=50 of 70). BN patients with a high RF had significantly lower scores on KAPP's alexithymia scale than patients with a low RF score, demonstrating that poor mentalizing is related to alexithymia. Concurrently, patients with high RF showed problems with impulse control and coping with aggressive affects according to KAPP scores.

CONCLUSION

Although BN patients with high RF showed good capacities for describing their mental states, they still had difficulties regulating the emotions and impulses related to these states.

SIGNIFICANT OUTCOME

Among patients suffering from BN, patients with high RF were significantly less alexithymic than low RF patients.

LIMITATIONS

The findings of this study are limited by the relatively small numbers of participants especially in the RF subgroups, posing a danger of not finding as significant existing differences in character pathology between high and low RF groups.

Eating disorders in adolescence: attachment issues from a developmental perspective

In the present article we review findings from an emerging body of research on attachment issues in adolescents with eating disorders from a developmental perspective. Articles for inclusion in this review were identified from PsychINFO (1966-2013), Sciencedirect (1970-2013), Psychindex (1980-2013), and Pubmed (1980-2013). First, we will outline the crucial developmental changes in the attachment system and discuss how they might be related to the early onset of the disease. Then we will report on the major results from attachment studies using self-report and narrative instruments in that age group. Studies with a developmental approach on attachment will be analyzed in more detail. The high incidence of the unresolved attachment pattern in eating disorder samples is striking, especially for patients with anorexia nervosa. Interestingly, this predominance of the unresolved category was also found in their mothers. To date, these transgenerational aspects are still poorly understood and therefore represent an exciting research frontier. Future studies that include larger adolescent samples and provide a more detailed description including symptom severity and comorbidity would contribute to a better understanding of this complex and painful condition.

Client attachment security predicts alliance in a randomized controlled trial of two psychotherapies for bulimia nervosa

OBJECTIVE

This study investigated the relation between clients' attachment patterns and the therapeutic alliance in two psychotherapies for bulimia nervosa.

METHOD

Data derive from a randomized clinical trial comparing cognitive-behavioral therapy (CBT) and psychoanalytic psychotherapy (PPT) for bulimia nervosa. Client attachment patterns were assessed with the Adult Attachment Interview. Independent raters scored audiotapes of early, middle, and late therapy sessions for 68 clients (175 sessions) using the Vanderbilt Therapeutic Alliance Scale.

RESULTS

Client attachment security was found to be a significant (p = .007) predictor of alliance levels at the three measured time points, with clients higher on attachment security developing stronger alliances with their therapists in both treatments as compared to clients higher on attachment insecurity. No evidence was found to support a hypothesized interaction whereby dismissing clients would develop weaker alliances in PPT and preoccupied clients would develop weaker alliances in CBT.

CONCLUSIONS

As the first study to examine client attachment and therapeutic alliance using observer-based instruments, this study supports the theoretical assumption that clients with secure attachment patterns are likely to develop stronger alliances with their therapist across different treatment settings.

Attachment and eating disorders: a review of current research

OBJECTIVE

Attachment insecurity may confer risk for developing an eating disorder. We describe domains of attachment functioning that are relevant to eating disorders including: affect regulation, interpersonal style, coherence of mind, and reflective functioning. Research since 2000 on attachment and eating disorders related to these domains is reviewed.

METHOD

We searched MedLine/Pubmed and PsycINFO from January 2000 to February 2014 and kept articles that: were empirical, included adults with a diagnosed eating disorder, and used a standard attachment measure. We retained 50 relevant studies.

RESULTS

Compared to controls, those with eating disorders had higher levels of attachment insecurity and disorganized mental states. Lower reflective functioning was specifically associated with anorexia nervosa. Attachment anxiety was associated with eating disorder symptom severity, and this relationship may be mediated by perfectionism and affect regulation strategies. Type of attachment insecurity had specific negative impacts on psychotherapy processes and outcomes, such that higher attachment avoidance may lead to dropping out and higher attachment anxiety may lead to poorer treatment outcomes.

DISCUSSION

Research to date suggests a possible relationship between attachment insecurity and risk for an eating disorder. More research is needed that uses attachment interviews, and longitudinal and case control designs. Clinicians can assess attachment insecurity to help inform therapeutic stances and interventions.

Inhibitory control and decision making under risk in bulimia nervosa and binge-eating disorder

OBJECTIVE

To investigate neuropsychological mechanisms of impulsivity in patients with bulimia nervosa (BN) and binge-eating disorder (BED).

METHOD

Nineteen BN patients and 31 age- and body-mass-index (BMI)-matched healthy controls (c-BN) as well as 54 overweight and obese BED patients and 43 age- and BMI-matched healthy controls (c-BED) were investigated using an inhibitory control task (stop signal task, SST) and a decision-making under risk task (game of dice task, GDT).

RESULTS

Compared to c-BN, BN patients demonstrated significant greater stop signal reaction times in the SST, but no differences for the frequency of risky decisions in the GDT. BED patients did not differ from c-BED in the SST or the GDT.

DISCUSSION

BN but not BED patients differed from their respective control groups concerning the "stopping" component of impulsivity. These differences in motor inhibition may contribute to the behavioral distinctions in binge-eating behavior between BN and BED.