Identity Functioning in Patients with an Eating Disorder: Developmental Trajectories throughout Treatment.

Increasing research has indicated a strong association between identity functioning and eating disorder (ED) symptomatology. However, a detailed investigation of identity throughout ED treatment is lacking. The present longitudinal study examined identity in inpatients with an ED and explored its simultaneous change with ED symptomatology throughout treatment. A total of 225 female patients completed questionnaires at admission. From these 225 patients participating at admission (Wave 1), 110 also participated in at least one additional measurement wave, with 43.64% (n = 48) participating at admission and during treatment, 16.36% (n = 18) participating at admission and at discharge, and 40% (n = 44) participating at admission, during treatment and at discharge. Questionnaires on identity synthesis, identity confusion, identity processes, and ED symptomatology were completed. Latent growth curve modeling was used to address the research questions. Throughout treatment, a decrease in identity confusion and an increase in identity synthesis and adaptive identity processes were found. Accordingly, increases in identity synthesis and identification with commitment were related to general decreases in the drive for thinness and body dissatisfaction. Similarly, such decreases in ED symptoms were related to general decreases in identity confusion and ruminative exploration. The present study points to an increase in identity functioning throughout treatment, and longitudinal associations between identity functioning and ED symptomatology were found. Helping patients to decrease their ruminative exploration and to increase their identification with previously made life commitments and treating body/weight concerns could both be helpful in ED treatment.

Are Sensitivity to Punishment, Sensitivity to Reward and Effortful Control Transdiagnostic Mechanisms Underlying the Eating Disorder/Obesity Spectrum?

Although it has been postulated that eating disorders (EDs) and obesity form part of a broad spectrum of eating- and weight-related disorders, this has not yet been tested empirically. In the present study, we investigated interindividual differences in sensitivity to punishment, sensitivity to reward, and effortful control along the ED/obesity spectrum in women. We used data on 286 patients with eating disorders (44.6% AN-R, 24.12% AN-BP, and 31.82% BN), 126 healthy controls, and 640 Class II/III obese bariatric patients (32.81% Class II and 67.19% Class III) with and without binge eating. Participants completed the behavioral inhibition and behavioral activation scales, as well as the effortful control scale, to assess sensitivity to punishment and reward and effortful control. Results showed that patients with EDs scored significantly higher on punishment sensitivity (anxiety) compared to healthy controls and Class II/III obese patients; the different groups did not differ significantly on reward sensitivity. Patients with binge eating or compensatory behaviors scored significantly lower on effortful control than patients without binge eating. Differences in temperamental profiles along the ED/obesity spectrum appear continuous and gradual rather than categorical. This implies that it may be meaningful to include emotion regulation and impulse regulation training in the treatment of both EDs and obesity.

Obsessive-compulsive symptoms in female patients with an eating disorder with or without impulsive non-suicidal self-injury.

BACKGROUND AND AIMS: In the present study, we investigated differences in obsessive-compulsive (OC) symptoms in patients with an eating disorder (ED) with or without recent/lifetime impulsive non-suicidal self-injury (NSSI). We included 429 female inpatients with an ED, of whom 31.9% engaged in recent impulsive NSSI and 56.4% in lifetime impulsive NSSI. MATERIALS: They filled out the Eating Disorder Evaluation Scale, the Self-Injury Questionnaire-Treatment Related and the Padua Inventory-Revised (OC symptoms). METHODS AND RESULTS: Patients with anorexia nervosa, binge-eating/purging type (AN-BP) and bulimia nervosa (BN) engaged more frequently in recent/lifetime impulsive NSSI compared to patients with anorexia nervosa, restrictive-type (AN-R). Two MANCOVAs with OC symptoms as dependent variables, and ED subtypes and recent/lifetime impulsive NSSI as independent variables controlling for age and body mass index showed the main effects of ED subtypes and recent/lifetime impulsive NSSI. Patients with AN-BP reported significantly more impulses (i.e., being afraid of losing control over motor behaviours) compared to patients with AN-R and BN. ED patients with impulsive recent/lifetime NSSI scored significantly higher on all OC scales compared to patients without NSSI. DISCUSSION AND CONCLUSION: In sum, the presence of recent/lifetime impulsive NSSI in patients with an ED seems to be related to more severe OC symptoms. Hence, this comorbidity needs to be addressed in psychotherapy, such as in transdiagnostic cognitive behavioural therapy for EDs.

Sociodemographic and clinical characteristics of eating disorder patients treated in the specialized residential settings in Belgium.

INTRODUCTION: Epidemiologic information on sociodemographic and clinical characteristics in eating disorders in Western European countries are scarce. PURPOSE: In this study, we report demographic and clinical characteristics of eating disorder (ED) patients undergoing treatment in five specialized ED centers in Flanders (Belgium). METHOD: Data from 642 ED patients were collected by means of a structured questionnaire. RESULTS: Data show that 93.8% of patients are female, with an average age of 22.6 years. The largest subgroup in our sample suffers from anorexia nervosa, namely 52.8%. Bulimia nervosa (BN), binge eating disorder (BED) and eating disorder not otherwise specified (EDNOS) account for 17.7%, 10.7% and 18.8% of the sample, respectively. Mean age of onset was 17 years. Mean duration of illness was 5.6 years, but 20.2% of patients had their illness for over 8 years. Anorexia nervosa patients of the restricting type (AN-R) have the shortest duration of illness. BED patients stood out because they were older on average, more often in a relationship and more often in ambulatory treatment. 70% of patients over 20 years old completed higher education, but one-third of this group was unemployed and/or disabled. Remarkably, ED patients grow more up in intact families compared to the general population. CONCLUSIONS: Epidemiology of ED patients in treatment in Flanders (Belgium) seems to resemble worldwide findings. The long duration of illness, the common evolution towards chronicity and the early work impairment underline the severe personal and societal impact of ED and call to the need for early detection and treatment of these patients. LEVEL OF EVIDENCE: Level V: cross-sectional descriptive study.

Temperament and Character Traits of Female Eating Disorder Patients with(out) Non-Suicidal Self-Injury.

Eating disorder (ED) patients show alarmingly high prevalence rates of Non-Suicidal Self-Injury (NSSI). Adolescents seem to be particularly at risk, as EDs and NSSI both have their onset in mid-adolescence. It has been suggested that personality could be a transdiagnostic mechanism underlying both EDs and NSSI. However, little attention has been given to adolescent clinical samples compared to adult and/or community samples. Therefore, the current study investigated the role of personality in a sample of 189 female inpatients with an ED (M = 15.93, SD = 0.98). Our results confirmed the high prevalence of NSSI in EDs, specifically in patients with bingeing/purging behaviours (ED-BP). Temperamental differences were found between ED-BP and the restrictive ED subtype (ED-R). Namely, ED-BP patients showed more harm avoidance and less self-directedness compared to ED-R. Temperamental differences were found in NSSI as well, regardless of ED subtype: ED patients who had engaged in NSSI during their lifetime reported less self-directedness and more harm avoidance. Interestingly, only ED patients who recently engaged in NSSI showed less novelty seeking. These temperamental profiles should be recognised as key mechanisms in the treatment of adolescent ED patients with and without NSSI.

Different Clinical Presentations in Eating Disorder Patients with Non-Suicidal Self-Injury Based on the Co-Occurrence of Borderline Personality Disorder.

Non-suicidal self-injury (NSSI) and borderline personality disorder (BPD) features are common in patients with eating disorders (ED), yet little is known regarding the clinical presentation of ED patients who present with NSSI with and without BPD. The current study compared self-injurious, female ED inpatients with (n = 98; NSSI+BPD) and without BPD (n = 45; NSSI-only) on different self-reported clinical features. Results suggest that ED patients with NSSI+BPD differ from those with NSSI-only with regard to frequency of suicidal ideation, alcohol, drug or medication abuse, internalizing/externalizing psychopathology, interpersonal problems, and coping strategies, with the NSSI+BPD group demonstrating more impairment in each of these domains. Despite these differences in clinical presentation, however, groups did not differ in NSSI features. In sum, while self-injurious ED patients may present with similar NSSI behavior regardless of BPD diagnosis, those with NSS+BPD represent a group with much higher clinical complexity and greater treatment needs.

Early maladaptive schemas: Similarities and differences between female patients with eating versus substance use disorders.

Personality features are considered to be important factors in the pathogenesis of both eating disorder (ED) and substance use disorder (SUD). This study investigates similarities and differences between these early maladaptive schemas (EMSs) (a) between female patients with ED (N = 179) or SUD (N = 169) and (b) between ED subtypes of the restrictive (N = 52), bulimic type (N = 127), or SUD. In total, 348 female patients (Mage  = 29.95; SDage  = 8.40) completed the Young Schema Questionnaire. Multivariate analyses of covariance with EMS scales as dependent variables and (a) ED versus SUD and (b) ED subtypes versus SUD as independent variables and age and psychopathology as control variables revealed that ED patients scored significantly higher on Unrelenting Standards, Defectiveness, Social Undesirability, and Failure than did SUD patients. Additionally, when comparing ED subtypes and SUD, bulimic and SUD patients scored significantly higher on Insufficient Self-Control than did restrictive patients. These results confirm the role of EMSs in ED (subtypes) and SUD.

An Adjunctive Multi-family Group Intervention with or without Patient Participation during an Inpatient Treatment for Adolescents with an Eating Disorder: A Pilot Study.

This study reports on a pilot study of a family group intervention with or without patient participation adjunctive to a specialized inpatient treatment for eating disorders (EDs). Participants were 112 female adolescent ED inpatients and one or both of their parents. The parents were invited to participate in an adjunctive multi-family group with patient (MFT) or in a similar multi-parent group without patient participation (MPT). Questionnaires assessing ED symptoms, family functioning and caregiving experiences were administered before and after intervention. Post-intervention results obtained from both patient and parent(s) indicated that improvement in ED symptoms and parental burden occurred after both types of interventions. Family functioning improved differently according to the informant: fathers reported an improvement of general family functioning, patients reported an improvement of problem solving and mothers reported a decrease in problem solving across both formats. This study emphasized the importance of including a multi-informant approach in family interventions. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Identity Processes and Statuses in Patients with and without Eating Disorders.

Problems with identity formation are associated with a range of psychiatric disorders. Yet, the mechanisms underlying such problems and how they are refined into specific diagnostic presentations require further investigation. The present study investigated identity processes among 123 women with eating disorders (ED) and age-matched community controls via a newly developed identity model. Several clinical outcome variables were assessed. Patients with ED scored lower on committing to and identifying with identity-related choices and scored higher on maladaptive or ruminative exploration, identity diffusion and identity disorder. They also experienced less identity achievement as compared with controls. The identity disorder status was associated with the highest scores on anxiety, depression, borderline personality disorder symptoms, and non-suicidal self-injury and the lowest scores on need satisfaction. Results indicate that patients with ED experience more identity problems than community controls and those captured by an identity disorder status experience the most problematic psychosocial functioning. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

Early Maladaptive Schemas in Eating Disordered Patients With or Without Non-Suicidal Self-Injury.

This study investigates early maladaptive schemas (EMSs) in function of eating disorder (ED) subtypes (restrictive/bulimic) and the presence/absence of non-suicidal self-injury (NSSI). Female inpatients (N = 491) completed the Young Schema Questionnaire and the Self-Injury Questionnaire. The influence of ED subtype and the presence/absence of NSSI and their interaction on the EMS were investigated by means of a MANCOVA. The results showed main effects of ED subtype and the presence of NSSI on EMS. Patients with bulimia scored significantly higher on insufficient self-control and emotional deprivation, which are more related to cluster B compared with restrictive patients, whereas restrictive patients scored significantly higher on social undesirability, failure to achieve, subjugation and unrelenting standards compared with patients with bulimia that are more related to cluster C. Patients with ED with NSSI reported significantly higher EMS levels compared with patients without NSSI, suggesting that they could be of particular interest to benefit from schema therapy. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

The Role of Non-suicidal Self-Injury and Binge-Eating/Purging Behaviours in the Caregiving Experience Among Mothers and Fathers of Adolescents with Eating Disorders.

This study investigated the caregiving experiences of mothers and fathers of restrictive and binge-eating/purging eating disordered (ED) inpatients with and without non-suicidal self-injury (NSSI). Sixty-five mothers and 65 fathers completed the Experience of Caregiving Inventory. All inpatients completed the Self-Injury Questionnaire-Treatment Related to assess NSSI and the Eating Disorder Evaluation Scale to assess eating disorder symptoms. Mothers reported significant more negative and more positive caregiving experiences compared with fathers. Mothers (but not fathers) of restrictive ED patients reported more positive caregiving experiences compared with mothers of binge-eating/purging patients. The presence of NSSI in ED patients was associated with more negative caregiving experiences of both parents. Mothers and fathers of ED inpatients differ in caregiving experiences, and both binge-eating behaviours and NSSI negatively affect their caregiving experience. Therefore, supportive interventions for parents of ED patients are necessary, especially of those patients who engage in NSSI.

The Role of Non-Suicidal Self-Injury and Binge-Eating/Purging Behaviours in Family Functioning in Eating Disorders.

This study aimed to investigate family functioning of restrictive and binge-eating/purging eating disordered adolescents with or without non-suicidal self-injury (NSSI), as perceived by the patients and their parents (mothers and fathers). In total, 123 patients (between 14 and 24 years), 98 mothers and 79 fathers completed the Family Assessment Device. Patients completed the Self-Injury Questionnaire-Treatment Related and the Symptom Checklist 90-Revised. No main effects were found of restrictive versus binge-eating/purging behaviour nor of presence/absence of NSSI. For the parents, a significant interaction between binge-eating/purging behaviour and NSSI emerged: Mothers and fathers reported worse family functioning in the binge-eating/purging group in presence of NSSI, whereas mothers reported worse family functioning in the restrictive group without NSSI. Parental perception of family functioning is affected by the combined presence of binge-eating/purging behaviour and NSSI. This finding should be taken into account when treating families living with eating disorders.

Non-suicidal self-injury in patients with eating disorder: associations with identity formation above and beyond anxiety and depression.

In the present study, we investigated the association between non-suicidal self-injury (NSSI) and problems in identity formation among patients with eating disorder (ED). NSSI is highly prevalent in ED, and problems with identity formation are characteristic of both NSSI and ED. Few studies, however, have investigated identity formation in patients with ED with and without NSSI while taking into account comorbid psychopathology (e.g. anxiety and depression). Therefore, we investigated the relationships between NSSI characteristics, identity confusion/synthesis, and anxiety/depression in 99 female patients with ED by means of self-report questionnaires. The results showed that 58.6% of the patients with ED engaged in at least one type of NSSI (most frequently cutting), with no significant differences in rates of NSSI or identity problems among ED subtypes. Presence, versatility and automatic negative reinforcement functions of NSSI were each significantly and positively related to identity confusion and negatively related to identity synthesis. Even after controlling for age, anxiety, and depression, lack of identity synthesis remained a significant predictor of NSSI in patients with ED. Given that NSSI may constitute an effort to deal with identity confusion/synthesis in patients with ED, therapists should take this developmental task into account while treating patients with ED with NSSI.

Personality profiles in Eating Disorders: further evidence of the clinical utility of examining subtypes based on temperament.

Despite recent modifications to the DSM-V diagnostic criteria for Eating Disorders (ED; American Psychiatric Association, 2013), sources of variability in the clinical presentation of ED patients remain poorly understood. Consistent with previous research that has used underlying personality dimensions to identify distinct subgroups of ED patients, the present study examined (1) whether we could identify clinically meaningful subgroups of patients based on temperamental factors including Behavioral Inhibition (BIS), Behavioral Activation (BAS) and Effortful Control (EC), and (2) whether the identified subgroups would also differ with respect to ED, Axis-I and Axis-II psychopathology. One hundred and forty five ED inpatients participated in this study. Results of a k-means analysis identified three distinct groups of patients: an Overcontrolled/Inhibited group (n=53), an Undercontrolled/Dysregulated group (n=58) and a Resilient group (n=34). Further, group comparisons revealed that patients in the Undercontrolled/Dysregulated group demonstrated more severe symptoms of bulimia, hostility and Cluster B Personality Disorders compared to the other groups, while patients in the Resilient group demonstrated the least severe psychopathology. These findings have important implications for understanding how individual differences in personality may impact patterns of ED symptoms and co-occurring psychopathology in patients with ED.

Reflections of older adults on the process preceding their suicide attempt: a qualitative approach.

The study explores the reflections of older adults on the process preceding their suicide attempt. Data were gathered using in-depth interviews with eight older inpatients who had attempted suicide. Grounded theory methodology was used for data analysis. They described their life and the self as disrupted after experiencing a loss, loneliness, loss of control, and unwillingness to continue living the current life. The findings suggest that the concurrence of these constructs precedes a suicide attempt in later life.