Temperamental factors predict long-term modifications of eating disorders after treatment

Metacognition as a transdiagnostic factor across eating disorders: a latent profile analysis study

Background

Metacognition is a crucial aspect of understanding and attributing mental states, playing a key role in the psychopathology of eating disorders (EDs). This study aims to explore the diverse clinical profiles of metacognition among patients with EDs using latent profile analysis (LPA).

Method

A total of 395 patients with a DSM-5 diagnosis of ED (116 AN-R, 30 AN/BP, 100 BN, 149 BED) participated in this study. They completed self-report measures assessing metacognition, eating psychopathology, depression, emotional dysregulation, personality traits, and childhood adversities. LPA and Welch ANOVAs were conducted to identify profiles based on metacognition scores and examine psychological differences between them. Logistic regression models were employed to explore associations between personal characteristics and different profiles.

Results

A 3-class solution had a good fit to the data, revealing profiles of high functioning (HF), intermediate functioning (IF), and low functioning (LF) based on levels of metacognitive impairments. Participants in the IF group were older and had a higher BMI than those in the HF and LF groups. Individuals with BN were largely categorized into HF and LF profiles, whereas participants with BED were mainly included in the IF profile. Participants in the LF group reported an impaired psychological profile, with high levels of depression, emotional dysregulation, childhood adversity, and personality dysfunction. Multinomial logistic regression analyses showed significant associations between metacognitive profiles and emotional and neglect abuse, emotion dysregulation, and detachment.

Conclusion

This exploratory study unveils distinct metacognitive profiles in EDs, providing a foundation for future research and targeted interventions. In this light, metacognitive interpersonal therapy could be a valid and effective treatment for EDs, as suggested by the initial promising results for these patients.

Therapeutic outcome and long-term naturalistic follow-up of female adolescent outpatients with AN: clinical, personality and psychopathology evolution, process indicators and outcome predictors

BACKGROUND

Anorexia nervosa (AN) is a serious mental illness of growing prevalence in childhood and adolescence. Despite its severity, there are still no completely satisfactory evidence-based treatments. Follow-up studies represent the most effective attempt to enlighten treatment effectiveness, outcome predictors and process indicators.

METHODS

Seventy-three female participants affected with AN were assessed at intake (T0) and at 6 (T1) and 12 (T2) months of an outpatient multimodal treatment program. Nineteen participants were assessed 15 years after discharge (T3). Changes in diagnostic criteria were compared with the chi-square test. Clinical, personality and psychopathology evolution were tested with ANOVA for repeated measures, using the t-test or Wilcoxon test as post-hoc. T0 features among dropout, stable and healed participants were compared. Healed and unhealed groups at long-term follow-up were compared using Mann-Whitney U test. Treatment changes were correlated to each other and with intake features using multivariate regression.

RESULTS

The rate of complete remission was 64.4% at T2, and 73.7% at T3. 22% of participants maintained a full diagnosis at T2, and only 15.8% at T3. BMI significantly increased at each time-point. A significant decrease of persistence and increase in self-directedness were evidenced between T0 and T2. Interoceptive awareness, drive to thinness, impulsivity, parent-rated, and adolescent-rated general psychopathology significantly decreased after treatment. Lower reward dependence and lower cooperativeness characterized the dropout group. The healed group displayed lower adolescent-rated aggressive and externalizing symptoms, and lower parent-rated delinquent behaviors. BMI, personality and psychopathology changes were related with each other and with BMI, personality and psychopathology at intake.

CONCLUSION

A 12-months outpatient multimodal treatment encompassing psychiatric, nutritional and psychological approaches is an effective approach for the treatment of mild to moderate AN in adolescence. Treatment was associated not only with increased BMI but also with positive personality development, and changes in both eating and general psychopathology. Lower relational abilities may be an obstacle to healing. Approaches to treatment resistance should be personalized according to these finding.

Exploring effectiveness of CBT in obese patients with binge eating disorder: personality functioning is associated with clinically significant change

BACKGROUND

Binge eating disorder (BED), as the most prevalent eating disorder, is strongly related to obesity and other somatic and psychiatric morbidity. Despite evidence-based treatments a considerable number of BED patients fail to recover. There is preliminary evidence for the association between psychodynamic personality functioning and personality traits on treatment outcome. However, research is limited and results are still contradictory. Identifying variables associated with treatment outcome could improve treatment programs. The aim of the study was to explore whether personality functioning or personality traits are associated with Cognitive Behavioral Therapy (CBT) outcome in obese female patients with BED or subthreshold BED.

METHODS

Eating disorder symptoms and clinical variables were assessed in 168 obese female patients with DSM-5 BED or subthreshold BED, referred to a 6-month outpatient CBT program in a pre-post measurement design. Personality functioning was assessed by the Developmental Profile Inventory (DPI), personality traits by the Temperament and Character Inventory (TCI). Treatment outcome was assessed by the Eating Disorder Examination-Questionnaire (EDE-Q) global score and self-reported binge eating frequency. According to the criteria of clinical significance, 140 treatment completers were categorized in four outcome groups (recovered, improved, unchanged, deteriorated).

RESULTS

EDE-Q global scores, self-reported binge eating frequency and BMI significantly decreased during CBT, where 44.3% of patients showed clinically significant change in EDE-Q global score. Treatment outcome groups showed significant overall differences on the DPI Resistance and Dependence scales and the aggregated 'neurotic' scale. Significant overall differences were found between groups on TCI Harm avoidance, although post hoc t-tests were non-significant. Furthermore, multiple logistic regression analysis, controlling for mild to moderate depressive disorder and TCI harm avoidance showed that 'neurotic' personality functioning was a significant negative predictor of clinically significant change.

CONCLUSION

Maladaptive ('neurotic') personality functioning is significantly associated with a less favorable outcome after CBT in patients with binge eating. Moreover, 'neurotic' personality functioning is a predictor of clinically significant change. Assessment of personality functioning and personality traits could support indication for more specified or augmented care, tailored towards the patients' individual strengths and vulnerabilities.

TRIAL REGISTRATION

This study protocol was retrospectively evaluated and approved on 16-06-2022 by the Medical Ethical Review Committee (METC) of the Amsterdam Medical Centre (AMC). Reference number W22_219#22.271.

Mediation models of anxiety and depression between temperament and drive for thinness and body dissatisfaction in anorexia nervosa

PURPOSE

Anorexia nervosa (AN) is a life-threatening condition in which temperament, anxiety, depression, and core AN body-related psychopathology (drive for thinness, DT, and body dissatisfaction, BD) are intertwined. This relationship has not been to date disentangled; therefore, we performed a multiple mediation analysis aiming to quantify the effect of each component.

METHODS

An innovative multiple mediation statistical method has been applied to data from 184 inpatients with AN completing: Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire, Eating Disorders Inventory-2, State-Trait Anxiety Inventory, and Beck Depression Inventory.

RESULTS

All affective temperaments but the hyperthymic one were involved in the relationship with DT and BD. Only the anxious temperament had a significant unmediated direct effect on DT after the strictest correction for multiple comparisons, while the depressive temperament had a significant direct effect on DT at a less strict significance level. State anxiety was the strongest mediator of the link between affective temperament and core AN body-related psychopathology. Depression showed intermediate results while trait anxiety was not a significant mediator at all.

CONCLUSION

Affective temperaments had a relevant impact on body-related core components of AN; however, a clear direct effect could be identified only for the anxious and depressive temperaments. Also, state anxiety was the strongest mediator thus entailing interesting implications in clinical practice.

LEVEL OF EVIDENCE

V, cross-sectional study.

Predictors of Stepping Up to Higher Level of Care Among Eating Disorder Patients in a Partial Hospitalization Program

Partial hospitalization programming (PHP) is a treatment option available for individuals with eating disorders (ED) who have made insufficient progress in outpatient settings or are behaviorally or medically unstable. Research demonstrates that this level of care yields efficacy for the majority of patients. However, not all patients achieve recovery in PHP and later admit to a higher level of care (HLOC) including residential treatment or inpatient hospitalization. Although PHP is an increasingly common treatment choice for ED, research concerning outcome predictors in outpatient, stepped levels of care remains limited. Thus, the current study sought to identify the predictors of patients first admitted to PHP that later enter residential or inpatient treatment. Participants were 788 patients (after exclusions) enrolled in adolescent or adult partial hospitalization programs in a specialized ED clinic. When compared to patients who maintained treatment in PHP, a significantly greater proportion of patients who discharged to a HLOC had previously received ED residential treatment. Moreover, patients who discharged to a HLOC were diagnosed with a comorbid anxiety disorder and reported greater anxious and depressive symptomatology. A logistic regression model predicting discharge from PHP to a HLOC was significant, and lower body mass index (BMI) was a significant predictor of necessitating a HLOC. Supplemental programming in partial hospitalization settings might benefit individuals with previous ED residential treatment experience, higher levels of anxiety and depression, and lower BMIs. Specialized intervention for these cases is both practically and economically advantageous, as it might reduce the risk of rehospitalization and at-risk patients needing to step up to a HLOC.

Predictors of illness course and health maintenance following inpatient treatment among patients with anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is a life-threatening psychiatric disorder associated with significant medical and psychosocial impairment. Hospital-based behavioral treatment is an effective intervention in the short-term. However, relapse rates following discharge are high and thus, there is a need to identify predictors of longitudinal outcome. The current study provides information regarding illness course and health maintenance among patients with AN over 5 years following discharge from an eating disorder inpatient unit.

METHODS

Participants were individuals with AN who were discharged from a specialized, inpatient behaviorally-based unit. Prior to discharge, height and weight were measured and participants completed self-report measures of eating disorder severity and general psychopathology (depression, anxiety, harm avoidance). Participants were contacted annually for self-report measures of weight, eating disorder severity and clinical impairment. Outcome was defined by illness course (body mass index (BMI) and clinical impairment during the 5 years) and health maintenance (categories of weight and eating disorder symptom severity) across follow-up, using all available data. Linear mixed models were used to examine whether demographic and clinical parameters at discharge predicted BMI and clinical impairment over time. Additional analyses examined whether these variables significantly influenced an individual's likelihood of maintaining inpatient treatment gains.

RESULTS

One-hundred and sixty-eight individuals contributed data. Higher trait anxiety at discharge was associated with a lower BMI during follow-up (p = 0.012). There was a significant interaction between duration of illness and time, whereby duration of illness was associated with a faster rate of weight loss (p = 0.003) during follow-up. As duration of illness increased, there was a greater increase in self-reported clinical impairment (p = 0.011). Increased eating disorder severity at discharge was also associated with greater clinical impairment at follow-up (p = 0.004). Higher BMI at discharge was significantly associated with maintaining healthy weight across a priori BMI-based definitions of health maintenance.

CONCLUSIONS

Weight status (higher BMI) and duration of illness are key factors in the prognosis of AN. Higher weight targets in intensive treatments may be of value in improving outcomes.

Affective temperaments and eating psychopathology in anorexia nervosa: Which role for anxious and depressive traits?

BACKGROUND

Anorexia nervosa (AN) is a severe mental illness. Personality traits and comorbidity with affective and anxiety disorders are key-aspects of its pathogenesis but little attention has been paid so far to affective temperaments in AN. Also, childhood anxiety is proposed to impact on AN clinical severity. Therefore, we aimed to investigate if affective temperaments could be related to AN eating psychopathology also clarifying if those with low versus high scores on depressive and anxious temperaments could differ in AN clinical current and lifetime severity.

METHODS

One-hundred and forty-seven inpatients with AN were consecutively recruited. All participants completed: Temperament Evaluation of Memphis, Pisa, Paris and San Diego-Autoquestionnaire, Eating Disorder Examination Questionnaire, State Trait Anxiety Inventory, Beck Depression Inventory. Clinical data were collected upon admission.

RESULTS

Regression models showed that all affective temperaments were associated with eating psychopathology (eating restraint and eating, shape, and weight concerns); however, when controlling for confounders, only the anxious temperament remained significant. Also, those patients with higher scores on depressive and anxious temperaments reported higher current and lowest lifetime body mass index (BMI).

LIMITATIONS

Only inpatients were recruited; self-report assessments were used and follow-up data are lacking.

CONCLUSIONS

Results from this study support the association between affective (anxious in particular) temperament traits and the presence of altered eating psychopathology in AN. Also, higher traits of depressive and anxious temperaments reported higher current and lowest lifetime BMI. Should these findings be confirmed, the assessment of the anxious temperament could fruitfully inform prevention and treatment interventions for AN.

Naturalistic follow-up of subjects affected with anorexia nervosa 8 years after multimodal treatment: Personality and psychopathology changes and predictors of outcome

Background:

Eating disorders (EDs) are serious mental illnesses of growing clinical and social impact. Despite their severity, there is still no satisfactory evidence-based treatment. Follow-up investigations are the most reliable studies to enlighten long-term outcome predictors and modifiers.

Methods:

In total, 59 subjects affected with anorexia nervosa were assessed 8 years after their admission into an outpatient multimodal treatment program for eating disorders. The follow-up changes in diagnostic criteria were compared with Chi-square test. Improved and not-improved subjects were compared. Clinical, personality and psychopathology features between T0 and T1 were compared with t-test for repeated measures. Correlation between T0 features and changes at T1 in personality and psychopathology features were assessed.

Results:

The rate of complete remission was 42%, an overall rate of 67.8% improved, a rate of 18.6% worsened. Concerning personality, a significant decrease of harm avoidance and increase in self-directedness were evidenced. Interoceptive awareness, drive for thinness, bulimia were significantly reduced at follow-up. Many T0 personality facets were related to personality and psychopathology improvement at follow-up.

Conclusion:

Multimodal treatment encompassing psychiatric, nutritional and psychological approaches is at the moment the most reliable approach for the treatment of moderate to severe anorexia nervosa with a discrete rate of improvement. Some personality and psychopathology characteristics may represent specific factors which favor resistance and impair improvement. Future approaches should consider the personalization of therapeutic approach according to these features.

Personality as predictor of outcome in internet-based treatment of bulimic eating disorders

Internet-based cognitive behavioral therapy (ICBT) for bulimic eating disorders has demonstrated clinical utility and cost efficiency, but is associated with low patient preference, low credibility, sizeable dropout and only moderate symptom reduction. To improve outcome it is imperative to learn more about who might benefit from internet-based interventions. To do this, the current study investigated the Five Factor Model of personality as predictor of outcome in patients with full or sub-threshold bulimia nervosa (n = 109). Patients in a randomized controlled trial of ICBT were assessed prior to and at the end of treatment. Patients showed significant symptom reduction over time (Cohen's d = 1.0, p < .001). Remission as well as overall symptom reduction was positively predicted by Openness to Experience and Conscientiousness. Binge eating cessation specifically, was positively predicted by Extraversion. The study supports the use of personality assessment for patient selection and outcome optimization in internet-based treatment of bulimic eating disorders.

Affective temperaments in anorexia nervosa: The relevance of depressive and anxious traits

BACKGROUND

Affective temperaments have been so far understudied in anorexia nervosa (AN) despite the relevance of personality and both affective and anxious comorbidity with regard to vulnerability, course, and outcome of this deadly disorder.

METHODS

Ninety-eight female inpatients diagnosed with AN and 131 healthy controls (HCs) were enrolled in this study and completed the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A) in addition to assessments of eating psychopathology, depression, and anxiety.

RESULTS

AN patients and HCs differed in all affective temperaments. The diagnostic subtypes of AN differed as well with binge-purging individuals being more cyclothymic and anxious than those with restricting-type AN. TEMPS-A scores correlated with body mass index and eating psychopathology but not with duration of illness. Concerning comorbidity, grater scores on the depressive and lower scores on the hyperthymic temperaments were found in depressed patients. Those who had either an anxious or irritable temperament were significantly more diagnosed with an anxious disorder than those who did not show this temperament. When logistic regression was performed, high depressive/low hyperthymic and high irritable/anxious traits resulted to be associated with depressive and anxious comorbidity, respectively, independently of confounding factors.

LIMITATIONS

Cross-sectional design, some patients on medications, few baseline clinical differences between diagnostic subtypes, no other personality assessments.

CONCLUSIONS

An affective continuum strongly associated with mood and anxious comorbidity emerged in AN. Such an evaluation could have several research and clinical implications given the need of improving treatment individualization and early interventions for such a complex disorder.

A comprehensive review of psychodynamic treatments for eating disorders

PURPOSE

To comprehensively review the existing literature on the effectiveness of psychodynamic psychotherapies in eating disorders (EDs) and to stimulate both debate and research on this topic.

METHODS

Online and hand searches were conducted to identify papers published between 1980 and 2015 on psychodynamic treatments delivered to adults with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED).

RESULTS

A total of 47 studies were finally included in this review. Fifteen studies were available for AN, 9 for BN, 12 for BED, and 11 for samples with mixed diagnoses. Several methodological flaws emerged, but overall psychodynamic interventions showed promising results at the end of treatment and follow-up, when available.

CONCLUSIONS

The body of literature on psychodynamic treatments is sparse and sometimes methodologically questionable; nevertheless, current data provide support to the effectiveness of these interventions, particularly for AN. However, both a defined approach (focus, themes, and techniques) and randomized controlled trials (RCTs) are warranted to clarify the effectiveness of psychodynamic psychotherapies.

Anxiety and depression mediate the role of low self-esteem and low self-directedness in the development of eating disorders

OBJECTIVE

Low self-esteem and low self-directedness (SD) are considered a risk factor for the development of eating disorders (EDs). The aim of this study was to test the hypothesis that low self-esteem and low SD lead to a higher risk for EDs through the mediation of anxiety and depression.

METHODS

Seventy-seven female teenagers answered the Eating Disorder Inventory 3 (EDI-3), the Intolerance of Uncertainty Scale (IUS), the Temperament and Character Inventory-Revised (TCI-R), the Rosenberg Self-Esteem Scale (RSES), and the State and Trait Anxiety Inventory (STAI), and the Symptom Checklist-90-Revised (SCL-90-R). To test the hypothesis, a structural equation model (SEM) was used.

RESULTS

According to the EDI3-EDRC scores, 23/77 (29.9%) participants demonstrated positive results in the screening. Participants who had positive results in the screening had significantly higher scores on trait and state anxiety, depression, and IU, and lower means of self-esteem and SD. The SEM demonstrated good fit indices and all paths were significant in the predicted directions, confirming the hypothesized model.

CONCLUSIONS

The current results confirm the role of self-esteem and SD in the development of an ED among adolescent females through the mediating action of IU, anxiety, and depression.

Temperament and personality in eating disorders

PURPOSE OF REVIEW

In the last decades, three main different personality domains have been investigated in the field of eating disorders: personality traits, temperament, and personality disorders. The use of a wide range of instruments and the presence of many different approaches in the definition of personality dimensions make it difficult to summarize the emerging results from different studies. The aim of this narrative review is to critically highlight and discuss all interesting developments in this field, as reflected in the recent literature.

RECENT FINDINGS

The study of personality and temperament in eating disorders seems to be in line with the recently suggested dimensional approach, which highlights the importance of symptoms aggregation, rather than the categorical diagnoses. Recent literature seems to confirm that specific personality and temperamental profiles can be drawn for patients with eating disorders, which can discriminate different eating disorders' diagnoses/symptoms.

SUMMARY

These observations have relevant clinical implications as treatment of eating disorders is largely based on psychotherapeutic interventions. However, large longitudinal studies are needed to better clarify the suggested relationships and to identify more defined therapeutic strategies.

The prevalence of orthorexia nervosa among eating disorder patients after treatment

BACKGROUND

The pursuit for healthy food consumption is considered a laudable habit. This attitude can turn into pathological when cognitions and worries about healthy nutrition lead to such an accurate food selection that correct diet becomes the most important part of one's own life leading to important dietary restrictions, stereotyped eating or impairment in important areas of functioning. This behaviour is coined orthorexia nervosa (ON) and can share common characteristics with anorexia nervosa (AN) and bulimia nervosa (BN). The purpose of the present study was to examine the frequency of ON among women with eating disorders (EDs) and to evaluate if it changed after treating the ED.

METHODS

Thirty-two patients with AN or BN were evaluated by means of the ORTO-15, the Yale-Brown-Cornell Eating Disorder Scale (YBC-EDS) and the Eating Attitude Test (EAT-26) before (t0) and 3 years after the treatment of their ED (t1), and compared to 32 female healthy controls (HC) matched by gender, age, and BMI at t1.

RESULTS

A significantly higher percentage of patients either at t0 (28 %) or t1 (58 %) resulted positive to ORTO-15 compared to controls (6 %). YBC-EDS and EAT-26 scores were higher among ED patients than in HC, but they decreased from t0 to t1.

CONCLUSIONS

Orthorexia nervosa symptoms are highly prevalent among patients with AN and BN, and tend to increase after treatment. ON seems associated both with the clinical improvement of AN and BN and the migration towards less severe forms of EDs. It is necessary to clarify if ON residual symptomatology can be responsible for a greater number of relapses and recurrences of EDs.

Resistance to treatment in eating disorders: a critical challenge

The Special Issue "Treatment resistance in Eating Disorders" gathers together the contributions provided by several experienced groups of researchers in the field of Eating Disorders (EDs). The main topic is addressed from multiple perspectives ranging from pathogenesis (including developmental and maintaining factors) to treatment. An explicative model of resistance in EDs is also proposed.