Attachment insecurity predicts eating disorder symptoms and treatment outcomes in a clinical sample of women

Attachment, Mentalization, Emotion Dysregulation, and Empathy in Eating Disorders: Comparing Anorexic and Bulimic Patients

ABSTRACT

Eating disorders (EDs) represent a wide range of clinical symptoms related to food intake, body image, and weight issues, and include anorexia nervosa-restricting type (AN-R), anorexia nervosa-binge-purge type (AN-BP), and bulimia nervosa (BN). The aim was to investigate the characteristics of attachment, mentalization, emotion dysregulation, and empathy in a sample of 102 patients with EDs. A sample of 102 patients and therapists completed a series of measures for the assessment of ED pathology, mentalization, empathy, and emotion dysregulation. Pearson correlations and analysis of variance were used to test the characteristics of the variables among the groups. In relation to attachment and emotion dysregulation, no significant differences were found. In relation to mentalization, significant difference in good mentalization was found in AN-R subtype compared with the BN subtype. In relation to empathy, results showed significantly lower scores in BN subtype on affective empathy compared with the AN-BP subtype, and in AN-R subtype on cognitive empathy. Finally, we used Z -scores for each item ranked by value (higher to lower) to develop different clinical prototypes for each group. Our results point toward the clinical need to address the assessed variables, specifically mentalization, emotion dysregulation, and empathy, in the diagnosis and treatment of EDs.

Mediation role of interpersonal problems between insecure attachment and eating disorder psychopathology

PURPOSE

Although insecure attachment and interpersonal problems have been acknowledged as risk and maintaining factors of eating disorders (EDs), the mediating role of interpersonal problems between attachment style and ED psychopathology has been poorly explored. The purpose of this study was to investigate the mediating role of interpersonal problems between insecure attachment and ED psychopathology.

METHODS

One-hundred-nine women with anorexia nervosa and 157 women with bulimia nervosa filled in the Eating Disorder Inventory-2 (EDI-2) and the Experiences in Close Relationships (ECR) revised scale to assess ED core symptoms and attachment styles, respectively. Interpersonal difficulties were evaluated by the Inventory of Interpersonal Problems (IIP-32). A mediator's path model was conducted with anxious and avoidant attachment subscores as independent variables, ED core symptoms as dependent variables and interpersonal difficulties as mediators. The diagnosis was entered in the model as a confounding factor.

RESULTS

The socially inhibited/avoidant interpersonal dimension was a mediator between avoidant attachment and the drive to thinness as well as between avoidant attachment and body dissatisfaction. An indirect connection was found between attachment-related anxiety and bulimic symptoms through the mediation of intrusive/needy score.

CONCLUSIONS

Social avoidance and intrusiveness mediate the relationships between avoidant and anxious attachment styles and ED psychopathology. These interpersonal problems may represent specific targets for psychotherapeutic treatments in individuals with EDs and insecure attachment.

LEVEL OF EVIDENCE

Level III: Evidence obtained from well-designed cohort or case-control analytic studies.

Relation between increasing attachment security and weight gain: a clinical study of adolescents and their parents at an outpatient ward

PURPOSE

We wanted to evaluate the impact of a relational focus in the treatment of adolescent ED-patients and their parents at an intensive outpatient ward, based on attachment theory, combined with a family approach and psychodynamic principles. Our aim was to investigate the distribution of different attachment styles among the adolescent ED-patients and their parents, and to find out if they could change by the treatment.

METHODS

Swedish adolescents (n = 33; 3 boys, 30 girls) and their parents (n = 60; 34 mothers, 26 fathers) participated.

MEASURES

Attachment Style Questionnaire (ASQ), Body Mass Index (BMI) and Children's Global Assessment Scale (CGAS) before and after treatment.

RESULTS

The adolescents were high on Need for Approval (ASQ4) of the Insecure/Anxious scale before treatment (in contrast to the parents). The patients had a significant decrease in ASQ4 after treatment, which correlated inversely to the increase in BMI but not to CGAS. The mothers showed features of the Secure/Confident style, fathers of the Insecure/Avoidant with elevated Relationships as Secondary (ASQ2).

CONCLUSIONS

Treatment with a relational and a family focus has impact on attachment insecurity in adolescent ED-patients and outcomes in terms of BMI. It is important to engage the parents, who need to help the adolescents to separate at that developmental stage. A secure therapeutic context, which enables mentalizations and allows new relational experiences, is essential. The ASQ-instrument is useful in indicating how the treatment of ED-adolescents is proceeding.

LEVEL OF EVIDENCE

Level IV: evidence obtained from multiple time series with the intervention.

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.

Exploring the association between early adaptive schemas and self-reported eating disorder symptomatology

OBJECTIVE

The current study aimed to examine the relationship between early adaptive schemas and eating disorder symptomatology in adults.

METHOD

A cross-sectional, correlational design was used to collect data from 352 females and 36 males aged between 18 and 49 years (M = 25.70, SD = 7.04). Participants completed an online questionnaire, which included The Young Positive Schema Questionnaire (YPSQ), Eating Disorder Examination-Questionnaire (EDE-Q) and demographic measures.

RESULTS

Four separate hierarchical multiple regression analyses showed that high levels of Healthy Boundaries and low levels of Optimism significantly predicted lower Restraint, Eating Concern, Shape Concern and Weight Concern scores. Additionally, higher scores in Emotional Openness and Social Belonging significantly predicted lower Eating Concern, while higher scores in Self-Care significantly predicted lower levels of Shape Concern.

CONCLUSION

The findings highlight the protective function that certain early adaptive schemas may play in mitigating eating disorder symptomatology. Moreover, the findings allude to potential modifiable therapy targets in the treatment of eating disorders. Further research is needed to investigate any differences in early adaptive schemas between eating disorder diagnoses.

Negative childhood events and the development of the anorexic voice: A grounded theory

BACKGROUND

Many individuals diagnosed with anorexia nervosa (AN) describe their disorder as being represented by an internal 'anorexic voice' (AV). Previous studies have identified associations between eating psychopathology and multifarious forms of adverse life experiences.

AIMS

This study explores the relationship between adverse experiences in childhood and the development of the AV.

MATERIALS AND METHODS

Twelve women who had the experience of the AV in the context of a diagnosis of AN took part in semi-structured interviews. The interview data were analysed using a constructivist grounded theory methodology.

RESULTS

Participants recalled feeling unsafe in a variety of relationships and a theory was constructed in which the AV provides a sense of conditional safety, becoming increasingly hostile and belittling when it is disobeyed, revealing similar characteristics to abusers and bullies in childhood.

DISCUSSION

Findings are related to the broader literature on the link between trauma and eating disorders, and to existing theories of internal voices.

CONCLUSIONS

The findings have implications for a trauma-focused approach when working with the AV.

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.

Attachment insecurity predicts worse outcome in patients with eating disorders treated with enhanced cognitive behavior therapy: A one-year follow-up study

OBJECTIVE

This study aimed to explore the role of attachment insecurity in predicting a worse longitudinal trend of eating disorder (ED) psychopathology and body uneasiness in patients with Anorexia Nervosa (AN) or Bulimia Nervosa (BN) treated with Enhanced Cognitive Behavior Therapy, considering the longitudinal interplay between these dimensions.

METHOD

In total, 185 patients with AN or BN performed the baseline assessment, and 123 were re-evaluated after 1 year of treatment. Participants completed questionnaires evaluating ED psychopathology (Eating Disorders Examination Questionnaire) and body uneasiness (body uneasiness test). For the assessment of adult attachment, the Experiences in Close Relationships-Revised was administered at baseline. Bivariate latent change score analysis within the structural equation modeling framework was performed to investigate the evolution of ED psychopathology and body uneasiness, their longitudinal interplay, and the role of attachment style as an outcome predictor.

RESULTS

After treatment, all psychopathological features showed an overall improvement. Higher baseline levels of body uneasiness predicted a worse course of ED psychopathology. The change in body uneasiness over time depended on changes over time in ED psychopathology, but not vice versa. Insecure attachment predicted a worse longitudinal trend of ED psychopathology, and, through this impairment, it indirectly maintained higher levels of body uneasiness, as confirmed by mediation analyses.

DISCUSSION

The role of attachment insecurity as a predictor of treatment outcome suggests the need for an integration of the cognitive-behavioral conceptualization of EDs with a developmental perspective that considers attachment-related issues.

PUBLIC SIGNIFICANCE STATEMENT

Considering the burden of EDs in terms of public health and the unsatisfactory response to standard treatments, the identification of outcome predictors is of considerable clinical interest. This study demonstrated that attachment insecurity was associated with worse longitudinal trends of ED psychopathology and body uneasiness in patients with AN and BN treated with CBT-E, highlighting the importance of personalizing treatment programs taking into account a developmental perspective on these disorders.

Experiences of mimicry in eating disorders

BACKGROUND

People unknowingly mimic the behaviors of others, a process that results in feelings of affiliation. However, some individuals with eating disorders describe feeling "triggered" when mimicked. This study explores the effects of implicit non-verbal mimicry on individuals with a history of an eating disorder (ED-His) compared to healthy controls (HCs).

METHOD

Women (N = 118, n_ED-His = 31; M_age = 21 years) participated in a laboratory task with a confederate trained to either discreetly mimic (Mimicry condition) or not mimic (No-Mimicry condition) the mannerisms of the participant. Participants rated the likability of the confederate and the smoothness of the interaction.

RESULTS

Participants in the No-Mimicry condition rated the confederate as significantly more likable than in the Mimicry condition, and ED-His rated the confederate as more likable than HCs. ED-His in the Mimicry condition rated the interaction as less smooth than HCs, whereas this pattern was not found in the No-Mimicry condition. Among ED-His, longer disorder duration (≥ 3.87 years) was associated with less liking of a confederate who mimicked and more liking of a confederate who did not mimic.

CONCLUSIONS

We discuss the implications of these findings for interpersonal therapeutic processes and group treatment settings for eating disorders. Our study on subtle, nonverbal mimicry revealed differences in social behavior for women with a history of an eating disorder compared to healthy women. For participants with an eating disorder history, a longer duration of illness was associated with a worse pattern of affiliation, reflected in lower liking of a mimicker. Further research on how diverging processes of affiliation may function to perpetuate the chronicity of eating disorders and implications for treatment is needed.

Common Features in Compulsive Sexual Behavior, Substance Use Disorders, Personality, Temperament, and Attachment-A Narrative Review

Do addictions share common traits of an “addictive personality” or do different addictions have distinct personality profiles? This narrative review examines the differences in the associations between substance use disorder (SUD) and compulsive sexual behavior disorder (CSBD), on the one hand, and personality traits, attachment dispositions, and temperament, on the other hand. We found that both people with a SUD and people with CSBD tended to be more spontaneous, careless, and less reliable, to place self-interest above getting along with others, to show emotional instability and experience negative emotions such as anger, anxiety, and/or depression, to be less able to control their attention and/or behavior, and to be engulfed with a constant sensation of “wanting”. Only people with CSBD, but not SUD, noted concerns with their social ties, fear of losing close others, and/or trusting others around them. Results also suggested that people with a SUD and people with CSBD share high commonalities in personality traits and temperament, yet there are noted differences in their social tendencies, especially with close others. People with CSBD reported more concerns with possible relationship losses compared to people with SUD issues, who may be more worried about losing their source of escapism.

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.

Insecure attachment as a transdiagnostic risk factor for major psychiatric conditions: A meta-analysis in bipolar disorder, depression and schizophrenia spectrum disorder

Insecure attachment has been suggested as a major risk factor for mental health problems as well as a key element for the development and trajectory of psychiatric disorders. The aim of this meta-analysis was to assess whether insecure attachment constitutes a global transdiagnostic risk factor in bipolar disorder, depression, and schizophrenia spectrum disorders. We conducted a PRISMA-based systematic quantitative review to explore the prevalence of insecure attachment among patients of three representative psychiatric disorders - major depression, schizophrenia spectrum disorders and bipolar disorder - in comparison with healthy controls (HC) from a transdiagnostic point of view. Effect sizes on differences of anxious, avoidant and insecure prevalence were calculated based on 40 samples including a total of n = 2927 individuals. Overall, results indicated a large effect on prevalence of insecure attachment across all disorders compared to HC (k = 30, g = 0.88, I² = 71.0%, p < 0.001). In a transdiagnostic comparison, the only difference was found in avoidant attachment, which was significantly lower (p = 0.04) compared to HC in the schizophrenia spectrum disorder subgroup (k = 10, g = 0.31, I² = 76.60%, p < 0.0001) than the depression subgroup subgroup (k = 12, g = 0.83, I² = 46.65%, p < 0.0001). The lack of further transdiagnostic differences between three distinct psychiatric disorders corroborates insecure attachment as a general vulnerability factor to psychopathology. Our findings warrant further investigations, which should explore the pathways from attachment insecurity towards psychopathology. Insecure attachment likely has implications on assessment, prediction and treatment of psychiatric patients.

Integrative Behavioral Health (IBH) Model at the Intersections of the Philippine Mental Health Law, Education, and Policy: For COVID-19 Recovery and Beyond

The COVID-19 pandemic has impacted the mental health of Philippine citizens. The authors propose the Integrative Behavioral Health (IBH) model to help facilitate the country’s eventual recovery from a health psychology perspective. Findings were integrated from a faculty consultation from a private university’s psychology department, a literature review, and a survey of students who are learning online. The survey results revealed that living with family members negatively correlated with readiness to learn online, r = −.37, p < .05. Further research is needed. Furthermore, combining themes gathered from the consultation, literature review, and variables used from the survey served as anchor words for the IBH model: 1. Emancipatory Education; 2) Filipino Psychology; 3) Contextualization; 4.) Philippine Mental Health Law; 5). Symptom Science; and 6) Social Determinants of Health (SDH). The constructs were implemented into an online health psychology course. The proposed curriculum design provides for an effective mental health response towards post-pandemic recovery.

Link between History of Childhood Maltreatment and Emotion Dysregulation in Adults Suffering from Attention Deficit/Hyperactivity Disorder or Borderline Personality Disorder

Childhood maltreatment (CM) may have a long-term effect on emotion regulation. This study aimed to explore the relationship between CM and emotion dysregulation (ED) in a heterogeneous population. Four hundred seventy French-speaking outpatients (N = 279 ADHD, N = 70 BPD, N = 60 ADHD + BPD, N = 61 clinical controls) completed the Emotion Reactivity Scale (ERS), the Cognitive Emotional Regulation Questionnaire (CERQ), the Childhood Trauma Questionnaire (CTQ), and the Relationship Scales Questionnaire (RSQ). Reports of childhood maltreatment experiences were significantly associated with increased levels of emotion reactivity in all our groups and in the whole population, with a greater use of non-adaptive cognitive emotion regulation strategies and insecure attachment patterns. Emotional abuse showed the strongest effect. Further analysis indicated that an anxious attachment style significantly mediated the relationship between CM and the use of non-adaptive cognitive emotion regulation strategies and emotion reactivity. The results of our study suggest an impact of CM on ED and a potentially marked effect of emotional abuse. They also indicate a potentially mediating role of insecure attachment in the relationship between a history of childhood abuse and emotion reactivity and a higher use of non-adaptive cognitive emotion regulation strategies in adulthood.

Reduced emotion recognition from nonverbal cues in anorexia nervosa

OBJECTIVE

Recent models of anorexia nervosa (AN) emphasise the role of reduced emotion recognition ability (ERA) in the development and maintenance of the disorder. However, methodological limitations impede conclusions from prior research. The current study tries to overcome these limitations by examining ERA with an audio-visual measure that focuses strictly on multimodal nonverbal cues and allows to differentiate between ERA for different emotion categories.

METHOD

Forty women with AN and 40 healthy women completed the Geneva Emotion Recognition Test. This test includes 83 video clips in which 10 actors express 14 different emotions while saying a pseudo-linguistic sentence without semantic meaning. All clips contain multimodal nonverbal cues (i.e., prosody, facial expression, gestures, and posture).

RESULTS

Patients with AN showed poorer ERA than the healthy control group (d = 0.71), particularly regarding emotions of negative valence (d = 0.26). Furthermore, a lower body weight (r = 0.41) and longer illness duration (ρ = -0.32) were associated with poorer ERA in the AN group.

CONCLUSIONS

Using an ecologically valid instrument, the findings of the study support illness models emphasising poor ERA in AN. Directly addressing ERA in the treatment of AN with targeted interventions may be promising.

Childhood Memories in Eating Disorders: An Explorative Study Using Diagnostic Imagery

Together with socio-cultural components, the family environment and early parent-child interactions play a role in the development of eating disorders. The aim of this study was to explore the nature of early parent-daughter relationships in a sample of 49 female inpatients with an eating disorder. To acquire a detailed image description of the childhood experiences of the patient, we used diagnostic imagery, a schema therapy-derived experiential technique. This procedure allows exploring specific contents within the childhood memory (i.e., emotions and unmet core needs), bypassing rational control, commonly active during direct verbal questioning. Additionally, patients completed self-report measures to assess for eating disorder severity, general psychopathology, and individual and parental schemas pervasiveness. Finally, we explored possible differences in the diagnostic imagery content and self-report measures in two subgroups of patients with anorexia nervosa and bulimia nervosa. The results showed that the most frequently reported unmet needs within the childhood memories of patients were those of safety/protection, care/nurturance, and emotional expression, referred specifically to the maternal figure. Overall, mothers were described as more abandoning, but at the same time particularly enmeshed in the relationship with their daughters. Conversely, patients perceived their fathers as more emotionally inhibited and neglecting. Imagery-based techniques might represent a powerful tool to explore the nature of early life experiences in eating disorders, allowing a more detailed case conceptualization and addressing intervention on early-life vulnerability aspects in disorder treatment.

Reconsidering a role for attachment in eating disorder management in the context of paediatric diabetes

We suggest a reconsideration of the role of 'attachment orientation' in the context of eating disorders and paediatric diabetes. Attachment orientation is a psychological construct that describes a relatively stable set of expectations and behaviours an individual relies upon in managing relationships. There is considerable evidence of an association between attachment orientation and the development and maintenance of disordered eating in individuals without diabetes, though evidence is more scant in populations with diabetes. We discuss the underpinning theory and critically examine the existing literature for the relationship between attachment orientation and disordered eating in paediatric diabetes. Finally, we draw on adjacent literatures to highlight potential future directions for research should this area be revisited. Overall, we contextualise our discussion in terms of patient-centred, holistic care that addresses the mind and body (i.e., our discussion of attachment orientation assumes a psycho-biological approach).

Effectiveness of interpersonal psychotherapy for community living depressed women involved with the justice system

BACKGROUND

Despite the prevalence of depression among women in the justice system, and its potentially significant consequences, there is a dearth of studies investigating psychological treatments for depression in this context, especially outside prison.

AIMS

Our aim was to gather preliminary data on whether individual interpersonal psychotherapy (IPT) is an acceptable and effective treatment for depression in women at an early stage in the justice system.

METHOD

In this pilot study, IPT was offered to 24 depressed women following their first or second contact with the justice system. The women were assessed using a range of scales to quantify depression, anxiety, post-traumatic stress disorder (PTSD) and social support. Multilevel models were used to explore interactions between change in depression and other features given the multiplicity and complexity of problems. Details on engagement and attrition were also collected.

RESULTS

Therapy attrition was low, despite challenging life-circumstances and depression scores followed a linear trajectory with scores significantly decreasing over the time (β = -0.59, SE = 0.07, p < 0.001). Participants with more adverse life events, attachment related anxiety and lower social support had poorer outcomes.

CONCLUSIONS AND IMPLICATIONS

Results are encouraging. More than half of the hard-to-reach women who were eligible did engage, and retention rates suggest the therapy was acceptable to them. Depression scores improved, and potential factors affecting treatment outcome were identified. A randomised controlled trial is now warranted, ensuring adequate supplementary support for women with dependants living on their own and without employment.

Attachment Insecurity in Rats Subjected to Maternal Separation and Early Weaning: Sex Differences

Attachment insecurity in the forms of attachment anxiety and avoidance is associated with mental disorders in humans. In this research field, rodents, especially mice and rats, are commonly used to study social behaviors and underlying biological mechanisms due to their pronounced sociability. However, quantitative assessment of attachment security/insecurity in rodents has been a major challenge. The present study identified attachment insecurity behaviors in rats subjected to maternal separation (MS) during postnatal days (PD) 2-16 and early weaning (EW) during PD 17-21. This MSEW procedure has been used to mimic early life neglect in humans. After MSEW, rats continued to survive until early adulthood when they were subjected to open-field, social interaction, and elevated-plus maze tests. Compared to CNT rats in either gender, MSEW rats moved longer distances at higher velocities in the open-field. The MSEW rats also showed lower ratios of travel distance at central zone over that on whole arena of the open-field compared to CNT rats. In social interaction test, male CNT rats preferred to investigate an empty cage than females; whereas female CNT rats spent more time with a partner-containing cage as compared to males. This gender-specific difference was reversed in MSEW rats. On elevated-plus maze female CNT rats exhibited more risk-taking behaviors as compared to male counterparts. Moreover, female MSEW rats experienced a greater difficulty in making a decision on whether approaching to or averting from which arms of elevated-plus maze. Taken together, male MSEW rats behaved like attachment anxiety while females' phenotype is alike to attachment avoidance described in humans. These results shall prompt further application of MSEW rat in abnormal psychology and biological psychiatry research.

Food Addiction and Tobacco Use Disorder: Common Liability and Shared Mechanisms

As food addiction is being more commonly recognized within the scientific community, parallels can be drawn between it and other addictive substance use disorders, including tobacco use disorder. Given that both unhealthy diets and smoking are leading risk factors for disability and death, a greater understanding of how food addiction and tobacco use disorder overlap with one another is necessary. This narrative review aimed to highlight literature that investigated prevalence, biology, psychology, and treatment options of food addiction and tobacco use disorder. Published studies up to August 2020 and written in English were included. Using a biopsychosocial lens, each disorder was assessed together and separately, as there is emerging evidence that the two disorders can develop concurrently or sequentially within individuals. Commonalities include but are not limited to the dopaminergic neurocircuitry, gut microbiota, childhood adversity, and attachment insecurity. In addition, the authors conducted a feasibility study with the purpose of examining the association between food addiction symptoms and tobacco use disorder among individuals seeking tobacco use disorder treatment. To inform future treatment approaches, more research is necessary to identify and understand the overlap between the two disorders.

Autism spectrum disorder traits are associated with empathic abilities in adults with anorexia nervosa

BACKGROUND

Social and emotional difficulties have been identified as key factors in the development and maintenance of anorexia nervosa (AN). However, few studies have investigated the influence of comorbid psychopathology on social cognition. The aim of the current study was to examine perception of nonverbal communication and empathy in AN using ecologically valid, performance-based measures, and to explore associations with comorbid psychopathology (anxiety, depression, autism spectrum disorder (ASD) traits, alexithymia, and social anxiety).

METHODS

In this cross-sectional study, the Multifaceted Empathy Test (MET) and the Mini Profile of Nonverbal Sensitivity (MiniPONS) were administered to 51 adults with AN, 51 recovered AN (REC), and 51 healthy controls (HCs). Comorbid psychopathological traits were assessed using self-report questionnaires and the Autism Diagnostic Observation Schedule - 2nd edition (ADOS-2).

RESULTS

Individuals with AN showed reduced affective empathy to positive stimuli compared to HCs, and a trend towards lower vocal prosody recognition scores relative to REC. Around a quarter of AN and REC scored above the clinical cut-off for ASD on the ADOS-2, and high ASD symptoms predicted lower cognitive and affective empathy scores.

LIMITATIONS

The study is cross-sectional, future research would benefit from examining social-cognition performance and comorbid psychopathology longitudinally.

CONCLUSIONS

The findings highlight the importance of ASD symptoms in empathy dysfunction in those with a lifetime history of AN. Future research should explore whether treatment adaptations to accommodate for differences in social-cognitive abilities may be helpful in the treatment of AN.

Development of the Modified Yale Food Addiction Scale Version 2.0 summary version in a representative sample of Czech population

BACKGROUND

Food addiction receives attention because of its participation in the rising obesity prevalence that affects the quality of life. The Czech Republic's prevalence of obesity belongs to the highest in Europe.

METHODS

We used the nationally representative non-clinical sample of 1841 respondents (N = 1841; 48,8% of men and 51.2% of women). Participants filled the sociodemographic questionnaire, Czech version of mYFAS 2.0 and the Relationship Questionnaire (RQ) to test the hypothesis.

RESULTS

Confirmatory Factor Analysis showed that the single-factor model of Czech version of mYFAS 2.0 had adequate fit indices (χ² (55) = 9670.8, p <  0.001; CFI, TLI > 0.95; SRMR < 0.07; and RMSEA < 0.08). The sample reliability in our research corresponded to Cronbach's α = 0.89 (95% CI 0.88-0.90). The youngest population (aged 15-19) had a significantly higher score of mYFAS 2.0, than the older age groups. People living alone scored significantly higher than the married respondents. The middle-income groups scored significantly lower in mYFAS 2.0 than the lowest income group. Occasional (social) smokers showed a higher mYFAS 2.0 score in comparison with non-smokers. A difference regarding attachment styles has also been revealed, respondents characterized by insecure attachment styles showed a higher YFAS score.

CONCLUSION

The findings reinforce future work on the Czech version of mYFAS 2.0, including validation and using mYFAS 2.0 to explore food addiction and its related variables and attachment styles in the Czech environment.

Effect of intrapersonal emotional competences on the relationship between attachment insecurity and severity of eating disorder symptoms in patients with restrictive anorexia

OBJECTIVE

Attachment insecurity and emotional competences (EC) form a key part of conceptual models of anorexia nervosa (AN). We explored the relationship between attachment dimensions and EC on the severity of eating disorders in patients diagnosed with restrictive AN.

METHOD

Sixty-three female patients with restrictive AN and 63 healthy participants completed self-report measures (eating symptoms, EC, attachment, depression, and anxiety).

RESULT

Patients with restrictive AN used fewer adaptive and more maladaptive regulation strategies and showed low levels of intrapersonal EC. The partial least squares path modeling analysis showed that high levels of attachment anxiety or avoidance lead to a decrease in intrapersonal EC, which in turn contributes to greater severity of eating symptoms in anorexic patients.

CONCLUSIONS

Lower intrapersonal EC played an important mediating role in the effects of attachment insecurity on the severity of eating disorders. The joint use of therapeutic programs that target both EC and attachment processes constitutes a promising approach.

Attachment disorder and attachment theory - Two sides of one medal or two different coins?

INTRODUCTION

Currently, attachment quality and attachment disorder exist in parallel, but the mutual association is still insufficiently clarified. For policy makers and clinical experts, it can be difficult to differentiate between these constructs, but the distinction is crucial to develop mental-health services and effective treatment concepts. We aimed to investigate the association between attachment representations (AR) and attachment disorders (AD), including Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) in children aged between 5 and 9.

METHODS

A total of 135 children aged between 5 and 9 years (M=7.17 years, SD=1.40, 63% male) and their primary caregivers participated in the study. Children were interviewed with the story stem method to assess AR, and the primary caregiver completed diagnostic interviews and questionnaires on mental disorders, AD, emotional and behavioral problems, and intelligence and development.

RESULTS

The prevalence of AR in children with AD was 28.6% for the 'secure' form of AR, 17.1% for the 'insecure-avoidant' form, 25.7% for the 'insecure-ambivalent' form, and 28.6% for the 'disorganized' form. Prevalences of the various AR forms did not differ statistically significantly, indicating that AR is conceptionally distinct from AD. Children with disorganized attachment scored significantly lower on language and intelligence skills than children with secure attachment. AD was significantly associated with a higher number of comorbidities, emotional and behavioral problems, and lower language skills.

CONCLUSIONS

Longitudinal studies using standardized assessment instruments are needed to systematically provide comparable and reliable empirical findings to improve current understanding of AR and AD as well as their etiological models.

Self-Injurious Behaviors and Adult Attachment: A Review of the Literature

Self-injurious behaviors (SIB) continue to afflict a significant segment of the clinical and general population, sometimes with fatal consequences. The development of SIB seems to share developmental pathways and mechanisms similar to attachment insecurity. To date, no reviews have explored their relationship. A search of publication databases PubMed and PsychInfo from 1969 through April 2018 was conducted and 17 papers met inclusion criteria. Of the 17 articles identified, 13 reported a positive relationship and 1 reported a negative relationship between attachment insecurity and SIB. Both attachment anxiety and avoidance seem to play a role in the risk for SIB, possibly through different mechanisms and likely with different impacts on the choice for either self-harm or suicide attempts.

Mediators linking insecure attachment to eating symptoms: A systematic review and meta-analysis

In the last two decades, the number of studies focused on the mediators connecting insecure attachment with Eating Disorders (EDs), at both clinical and sub-clinical level, has considerably increased. However, there has not been a systematic synthesis of this literature to date. To fill this gap, the current meta-analytic review aimed at identifying and quantifying the extent to which mediators contribute to the explanation of this relationship. The present study was registered with PROSPERO (CRD42017076807). A comprehensive search process in seven different electronic databases retrieved 24 studies that examined how insecure attachment leads to ED symptoms through mediation analysis. Standardized regression coefficients of the indirect and total paths of 21 mediation models were pooled. Studies were coded and ranked for quality. We found evidence to show that maladaptive emotion regulation and depressive symptoms had the highest effect size for mediation (mediation ratio [P_M] = 0.71). Further, body dissatisfaction, neuroticism, perfectionism, mindfulness and social comparison had significant, but moderate to low mediating effects (P_M = 0.21–0.58). The methodological quality of these studies was mostly low to moderate and potential areas for development were highlighted. Our findings support the direct targeting of these psychological constructs in prevention programs and treatment of EDs. Future investigations addressing the time sequence between the variables will provide valuable clues to untangle the prospective contribution of each variable on the development and maintenance of eating pathology.

Anorexia Nervosa and a Lost Emotional Self: A Psychological Formulation of the Development, Maintenance, and Treatment of Anorexia Nervosa

In this paper, we argue that Anorexia Nervosa (AN) can be explained as arising from a 'lost sense of emotional self.' We begin by briefly reviewing evidence accumulated to date supporting the consensus that a complex range of genetic, biological, psychological, and socio-environmental risk and maintenance factors contribute to the development and maintenance of AN. We consider how current interventions seek to tackle these factors in psychotherapy and potential limitations. We then propose our theory that many risk and maintenance factors may be unified by an underpinning explanation of emotional processing difficulties leading to a lost sense of 'emotional self.' Further, we discuss how, once established, AN becomes 'self-perpetuating' and the 'lost sense of emotional self' relentlessly deepens. We outline these arguments in detail, drawing on empirical and neuroscientific data, before discussing the implications of this model for understanding AN and informing clinical intervention. We argue that experiential models of therapy (e.g., emotion-focused therapy; schema therapy) be employed to achieve emergence and integration of an 'emotional self' which can be flexibly and adaptively used to direct an individual's needs and relationships. Furthermore, we assert that this should be a primary goal of therapy for adults with established AN.

Cognitive and Affective Empathy in Eating Disorders: A Systematic Review and Meta-Analysis

Background: Recent models of eating disorders (EDs) have proposed social and emotional difficulties as key factors in the development and maintenance of the illness. While a number of studies have demonstrated difficulties in theory of mind and emotion recognition, little is known about empathic abilities in those with EDs. Further, few studies have examined the cognitive-affective empathy profile in EDs. The aim of this systematic review and meta-analysis was to provide a synthesis of empathy studies in EDs, and examine whether those with EDs differ from healthy controls (HC) on self-reported total, cognitive, and affective empathy. Methods: Electronic databases were systematically searched for studies using self-report measures of empathy in ED populations. In total, 17 studies were identified, 14 of which could be included in the total empathy meta-analysis. Eight of the 14 studies were included in the cognitive and affective empathy meta-analyses. Results: Meta-analyses showed that while total empathy and affective empathy scores did not differ between those with anorexia nervosa (AN) and HC, those with AN had significantly lower cognitive empathy scores compared to HCs (small effect size). Meta-analyses of Interpersonal Reactivity Index sub-scores revealed that AN had significantly lower Fantasy scores than HC (small effect size), indicating that those with AN have more difficulty in identifying themselves with fictional characters. Only 3 studies examined empathy in those with bulimia nervosa (BN) or binge eating disorder (BED). Conclusions: The lowered cognitive empathy and intact affective empathy profile found in AN is similar to that found in other psychiatric and neurodevelopmental conditions, such as autism spectrum disorder (ASD). These findings add to the literature characterizing the socio-emotional phenotype in EDs. Future research should examine the influence of comorbid psychopathology on empathy in EDs.

The Relationship between Adult Attachment and Mental Health Care Utilization: A Systematic Review

OBJECTIVE

Several studies have shown a relationship between individual attachment and various aspects of treatment utilization in individuals with medical problems as well as mental health disorders. This review systematically evaluates existing literature targeting the relationship between attachment and all aspects of treatment utilization, such as engagement, participation, and completion, in adults with mental health problems.

METHOD

A computerized search of PsycINFO, Medline, Embase, PubMed, and Healthstar and a manual search were employed. Of 5733 titles, 105 abstracts were selected. Of these, 18 studies met full inclusion criteria. The quality of studies was evaluated and scored according to 9 characteristics.

RESULTS

Most studies supported an association between attachment and treatment engagement and participation. In general, attachment anxiety was associated with higher engagement and participation in services while attachment avoidance was associated with less. Data regarding attachment dimensions and treatment completion were less conclusive.

CONCLUSIONS

The review suggests a clear relationship between attachment and stages of treatment engagement and participation in a variety of psychiatric populations and treatments. The 2 attachment dimensions appear to have opposite effects, with possible risks for either treatment over- or underutilization. Clinical implications are discussed.

Can adults with Asperger's syndrome learn about positive attachment behaviors between parents and young babies through the use of a skill-training DVD?

OBJECTIVES

To explore how much people with Asperger's syndrome know and understand about early attachment behaviors and whether this knowledge can be increased through a DVD.

METHODS

Adults with Asperger's syndrome who were not parents (N = 28) took part in four experimental conditions: Baseline, pre-intervention, post-intervention, and follow-up. Participants watched a DVD and received a booklet summarizing its contents. Participants were asked seven questions about attachment in all four conditions. Measures of trait emotional intelligence, IQ and autistic symptomatology were explored as possible predicting factors.

RESULTS

A significant increase in knowledge of early attachment behaviors was observed at post-intervention for the total knowledge score and four out of the seven attachment questions. This was maintained at follow-up. Trait emotional intelligence, IQ and autistic symptomology did not predict pre-intervention or increase in knowledge.

CONCLUSIONS

Knowledge and understanding of early attachment behaviors can be improved through the use of a DVD.

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.

Contextual determinants of psychopathology. The singularity of attachment as a predictor of mental dysfunction

The general aim of this research is to evaluate the singular weight of attachment relationships in psychopathology, to determine the point to which these relationships cannot be subsumed by other variables that are famously related to attachment, such as experience of stressful life events, social support, and coping styles. 172 people treated in mental health centers provided data related to these four aspects and about manifestations of psychopathology. Multiple linear regression analyses determined that 51% of the variance in the level of symptomatology is explained with six variables: two related to adult attachment (fear of rejection and abandonment in romantic relationships, and the degree of similarity to the fearful prototype), one related to social support (family appreciation), one to life events (overall perceived stress), and two to coping style (cognitive restructuring and social withdrawal). Fear of rejection was the variable accounting for the most variance. The findings suggest that adult attachment is a non-redundant individual factor associated with manifestations of psychological dysfunction and highlight the desirability of taking attachment history into account in clinical practice.

Examining the role of attachment in the relationship between childhood adversity, psychological distress and subjective well-being

Childhood adversity is associated with a wide range of detrimental psychological consequences. This study examined the mediating role of relationship-specific attachment (avoidance and anxiety) in the associations between childhood adversity and both psychological distress and subjective well-being. University students (N=190) across the Republic of Ireland completed self-report measures including the Adverse Childhood Experiences scale, Experiences in Close Relationships - Relationship Structures scale, Depression Anxiety and Stress scales and measures of subjective well-being. One hundred and twenty-eight participants (67.4%) reported experiencing at least one adverse childhood experience. Childhood adversity was associated with symptoms of psychological distress and subjective well-being. All such associations were mediated by certain relationship-specific attachment dimensions. Of these, attachment anxiety in general relationships was the most prominent mediator for both psychological distress and subjective well-being. Attachment to one's father and to one's romantic partner did not mediate any association. These findings indicate that attachment, in particular relationships, is an important factor in the associations between childhood adversity and both psychological distress and subjective well-being as an adult. One's attachment anxiety in general relationships is particularly important in these associations. Therapeutic interventions addressing these attachment domains may offset the detrimental effects of childhood adversity. Future research is required using a longitudinal design.

Reliability and validity of the Experiences in Close Relationships Scale-12: Attachment dimensions in a clinical sample with eating disorders

OBJECTIVE

Attachment insecurity is a potential risk factor for the development and maintenance of eating disorders (EDs). To date, there are multiple psychometrically sound questionnaires for the evaluation of attachment in both clinical and healthy populations, such as the Experience in Close Relationships (ECR) scale. Composed by two subscales (i.e., attachment anxiety and avoidance), the ECR scale was recently adapted to a shorter, 12-item version (ECR-12). However, a validation of the ECR-12 among patients with EDs is still lacking. The present study sought to investigate the psychometric properties of the ECR-12, when used in a treatment-seeking sample with EDs.

METHOD

A total of 1,262 treatment-seeking patients with various ED diagnoses completed the ECR-12, together with a commonly used measure of ED psychopathology (Eating Disorder Inventory-2). Subsamples also completed the Attachment Style Questionnaire (n = 66) or underwent a Day Hospital Program (n = 128).

RESULTS

A multigroup confirmatory factor analysis indicated that the ECR-12 maintained its two-factor structure across the ED diagnostic groups. In addition, the scale demonstrated good convergent validity, internal consistency, concurrent, and incremental validity. Finally, both ECR-12 subscales demonstrated adequate test-retest reliability.

DISCUSSION

Our results provide preliminary evidence of the psychometric properties of ECR-12 in assessing attachment anxiety and avoidance among patients with EDs. This short scale could help clinicians tailor interventions for EDs that take into account attachment dimensions.

Anorexia Nervosa, Theory and Treatment: Where Are We 35 Years on from Hilde Bruch's Foundation Lecture?

Hilde Bruch's foundation lecture in 1982 is a milestone from which to survey current theory and treatment for anorexia nervosa. Bruch described problems in body perception, emotion processing and interpersonal relationships as core theoretical aspects of the illness and built her theory of psychopathology on these aspects, as well as on animal studies on attachment. She also noted that many psychological problems result as consequence of starvation. In the first part of this paper, we parse Bruch's clinical descriptions into elements of psychopathology (disturbances in body perception, attachment, emotion expression, perception and regulation, social comparison, interpersonal, and family and therapeutic relationships), in order to assemble and update the theoretical evidence for a model of the illness. In the second part, we describe and extend her description of three core targets of treatment: family relationships, patient's inner confusion and nutritional restoration. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Relationships between patients' attachment characteristics and views and use of psychiatric treatment

This study explored the influence of attachment on psychiatric treatment by considering attitudes towards and the use of psychotropic medication and psychotherapy in patients with depressive and anxiety disorders. Adults referred to a psychiatrist completed self-report measures and participated in a diagnostic interview based on DSM-IV criteria. Those with depressive, anxiety or adjustment disorders were included (n = 124). Patients reported the types and dosage of current psychotropic medication as well as number of different psychiatrists and psychologists/counselors they had seen in the past 10 years. Multiple regression analyses were used to examine relationships between attachment anxiety and avoidance and the variables capturing treatment use and attitudes towards treatments. Attachment anxiety was positively associated with the number of current psychiatric medications and with both the number of psychiatrists and the number of psychologists/counselors seen. Attachment avoidance was negatively associated with the number of current psychotropic medications and beliefs about the efficacy of psychotherapy. The findings suggest that patients' attachment characteristics play a role in their views and choices regarding treatments. Developing treatments sensitive to the needs of insecurely attached individuals may lead to improved treatment outcomes.

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

PURPOSE

To investigate whether recovery from an eating disorder is related to pre-treatment attachment and mentalization and/or to improvement of attachment and mentalization during treatment.

METHOD

For a sample of 38 anorexia nervosa (AN) and bulimia nervosa (BN) patients receiving treatment the relations between attachment security, mentalization, comorbidity and recovery status after 12 months (not recovered or recovered), and after 18 months (persistently ill, relapsed, newly recovered, or persistently recovered) were investigated. Attachment security and mentalization were assessed by the Adult Attachment Interview at the start of the treatment and after 12 months. Besides assessing co-morbidity-for its effect on treatment outcome-we measured psycho-neuroticism and autonomy because of their established relations to both eating disorder symptoms and to attachment security.

RESULTS

Recovery both at 12 months and at 18 months was related to higher levels of mentalization; for attachment, no significant differences were found between recovered and unrecovered patients. Patients who recovered from AN or BN also improved on co-morbid symptoms: whereas pre-treatment symptom severity was similar, at 12 months recovered patients scored lower on co-morbid personality disorders, anxiety, depression, self-injurious behaviour and psycho-neuroticism than unrecovered patients. Improvement on autonomy (reduced sensitivity to others; greater capacity to manage new situations) in 1 year of treatment was significantly higher in recovered than in unrecovered patients.

CONCLUSION

A focus on enhancing mentalization in eating disorder treatment might be useful to increase the chances of successful treatment. Improvement of autonomy might be the mechanism of change in recovering from AN or BN.

LEVEL OF EVIDENCE

Level III cohort study.

Embodiment Mediates the Relationship between Avoidant Attachment and Eating Disorder Psychopathology

OBJECTIVE

The overvaluation of body shape and weight of persons with eating disorders (EDs) is putatively explained by a disturbance in the way they experience their own body (embodiment). Moreover, attachment disorders seem to promote the use of body as source for self-definition. Therefore, we assessed the role of embodiment in the connection between attachment styles and ED psychopathology.

METHOD

One-hundred and thirteen ED patients and 117 healthy subjects completed the Identity and Eating Disorders (IDEA) Questionnaire, the Eating Disorder Inventory-2 (EDI-2) and the Experiences in Close Relationships Scale.

RESULTS

Eating disorder patients displayed IDEA, EDI-2 and Experiences in Close Relationships scores significantly higher than controls. IDEA total and subtotal scores mediated entirely the influence of avoidant attachment on EDI-2 interoceptive awareness and impulsivity.

DISCUSSION

These findings demonstrate a relationship between insecure attachment and disorders of identity and embodiment and point to embodiment as a possible mediator between avoidant attachment and specific ED psychopathological traits. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Social Rank and Rejection Sensitivity as Mediators of the Relationship between Insecure Attachment and Disordered Eating

AIM

The current study assessed a new interpersonal model for eating disorders (EDs), in which interpersonal rejection sensitivity (RS), appearance-based RS and social rank were hypothesised to mediate the relationship between insecure attachment and disordered eating.

METHOD

The sample comprised a clinical ED group (N = 122) and a control group (N = 622). Participants were asked to complete a number of self-report measures related to the variables of interest.

RESULTS

Invariance testing indicated that the model was structurally non-invariant (different across groups). For the ED group, appearance-based RS and social rank were significant mediators of the relationship between insecure attachment and disordered eating. For the controls, the relationship between insecure attachment and disordered eating was mediated through multiple pathways involving interpersonal RS, appearance-based RS and social rank.

CONCLUSION

These findings may inform existing therapies such as interpersonal psychotherapy for EDs, by emphasising the role of sensitivity to rejection in the development and maintenance of disordered eating. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Allostatic load and comorbidities: A mitochondrial, epigenetic, and evolutionary perspective

Stress-related pathophysiology drives comorbid trajectories that elude precise prediction. Allostatic load algorithms that quantify biological "wear and tear" represent a comprehensive approach to detect multisystemic disease processes of the mind and body. However, the multiple morbidities directly or indirectly related to stress physiology remain enigmatic. Our aim in this article is to propose that biological comorbidities represent discrete pathophysiological processes captured by measuring allostatic load. This has applications in research and clinical settings to predict physical and psychiatric comorbidities alike. The reader will be introduced to the concepts of allostasis, allostasic states, allostatic load, and allostatic overload as they relate to stress-related diseases and the proposed prediction of biological comorbidities that extend rather to understanding psychopathologies. In our transdisciplinary discussion, we will integrate perspectives related to (a) mitochondrial biology as a key player in the allostatic load time course toward diseases that "get under the skin and skull"; (b) epigenetics related to child maltreatment and biological embedding that shapes stress perception throughout lifespan development; and

Emotional Eating, Binge Eating and Animal Models of Binge-Type Eating Disorders

PURPOSE OF REVIEW

The objective of this paper is to review the role that hedonic factors, emotions and self-regulation systems have over eating behaviours from animal models to humans.

RECENT FINDINGS

Evidence has been found to suggest that for some high-risk individuals, obesity/binge eating may develop as an impulsive reaction to negative emotions that over time becomes a compulsive habit. Animal models highlight the neural mechanisms that might underlie this process and suggest similarities with substance use disorders. Emotional difficulties and neurobiological factors have a role in the aetiology of eating and weight disorders. Precise treatments targeted at these mechanisms may be of help for people who have difficulties with compulsive overeating.

Relational containment: exploring the effect of family-based treatment for anorexia on familial relationships

BACKGROUND

The aim of this research was to investigate the process of familial relationship change for adolescents with anorexia nervosa and their parents, who participated in Family-Based Treatment (FBT).

METHOD

A Constructionist grounded theory design was employed with purposive sampling. Sixteen young people between 12 and 18 years with a good outcome in FBT and twenty-eight of their parents participated. Young people and their parents took part in separate interviews at the end of treatment. Each interview was transcribed and analysed to identify a unifying phenomenon across the data to elicit a theory that explained the data and then integrated into existing theory.

RESULTS

Prior to treatment families' experienced significant conflict, disconnection and isolation. The FBT structure, therapist direction, and the specialist medical setting created a process of relational containment. This enabled parents to trust the process of FBT and develop confidence in their executive role in the family. In turn this allowed the adolescent with anorexia nervosa to trust their parents, feel more secure and gradually engage in the treatment process themselves. Improvements in closeness, communication and adolescent sense of self were reported after FBT.

CONCLUSIONS

These findings illuminate a possible mechanism of change in FBT. It underscores the importance of parental management of eating disorder symptoms at the commencement of treatment to enable increased parental confidence. Meaningful changes occurred for the adolescents' that aided normal developmental and relational processes, an important aspect of recovery.

TRIAL REGISTRATION

Australian Clinical Trials Register number: ACTRN012607000009415.

Attachment Insecurity Predicts Punishment Sensitivity in Anorexia Nervosa

Individuals with anorexia nervosa (AN) experience insecure attachment. We investigated whether insecure attachment is associated with punishment and reward sensitivity in women with AN. Women with AN (n = 24) and comparison women (n = 26) (CW) completed The Eating Disorder Examination Questionnaire, Depression Anxiety Stress Scale, The Attachment Style Questionnaire, and Sensitivity to Punishment/Sensitivity to Reward Questionnaire. Participants with AN returned higher ratings for insecure attachment (anxious and avoidant) experiences and greater sensitivity to punishment (p = 0.001) than CW. In AN, sensitivity to punishment was positively correlated with anxious attachment and negative emotionality but not eating disorder symptoms. Regression analysis revealed that anxious attachment independently predicted punishment sensitivity in AN. Anxious attachment experiences are related to punishment sensitivity in AN, independent of negative emotionality and eating disorder symptoms. Results support ongoing investigation of the contribution of attachment experiences in treatment and recovery.

Attachment-Based Family Therapy: A Review of the Empirical Support

Attachment-based family therapy (ABFT) is an empirically supported treatment designed to capitalize on the innate, biological desire for meaningful and secure relationships. The therapy is grounded in attachment theory and provides an interpersonal, process-oriented, trauma-focused approach to treating adolescent depression, suicidality, and trauma. Although a process-oriented therapy, ABFT offers a clear structure and road map to help therapists quickly address attachment ruptures that lie at the core of family conflict. Several clinical trials and process studies have demonstrated empirical support for the model and its proposed mechanism of change. This article provides an overview of the clinical model and the existing empirical support for ABFT.

The role of interpersonal personality traits and reassurance seeking in eating disorder symptoms and depressive symptoms among women with bulimia nervosa

INTRODUCTION

The role of interpersonal factors has been proposed in various models of eating disorder (ED) psychopathology and treatment. We examined the independent and interactive contributions of two interpersonal-focused personality traits (i.e., social avoidance and insecure attachment) and reassurance seeking in relation to global ED psychopathology and depressive symptoms among women with bulimia nervosa (BN).

METHOD

Participants were 204 adult women with full or subclinical BN who completed a battery of self-report questionnaires. Hierarchical multiple OLS regressions including main effects and interaction terms were used to analyze the data.

RESULTS

Main effects were found for social avoidance and insecure attachment in association with global ED psychopathology and depressive symptoms. In addition, two-way interactions between social avoidance and reassurance seeking were observed for both global ED psychopathology and depressive symptoms. In general, reassurance seeking strengthened the association between social avoidance and global ED psychopathology and depressive symptoms.

CONCLUSION

These results demonstrate the importance of reassurance seeking in psychopathology among women with BN who display personality features characterized by social avoidance.