Mentalization in patients with anorexia or bulimia nervosa

Patients suffering from anorexia of bulimia nervosa display restrictive of
impulsive eating behaviour, sometimes together with purging, as a result of a
poor capacity to deal with negative affects. Affectregulation in patients with
anorexia or bulimia nervosa is either under-or overcontrolled. Underneath the
eating disorder symptoms patients suffer from low self-esteem, uncertainty
about their appraisal by others and difficulties in dealing with interpersonal
events.
Recent theory stresses the importance of mentalizing capacity for
affectregulation and coping with interpersonal experiences. Mentalizing is
defined as the capacity to see self and others as mental beings, as individuals
with feelings, thoughts, expectations and fears, an inner life that influences
behaviour. Mentalizing capacity develops in the relations with attachment
figures. Individuals with an insecure attachment style often have a poor
mentalizing ability. Insecure attachment is believed to be a risk factor for
developing psychopathology.
Research shows that patients with anorexia or bulimia nervosa often have
insecure attachment styles.
For some years a form of psychotherapeutic day treatment that explicitly
intends to enhance mentalizing capacity is used for patients with borderline
personality disorder. It shows to be more effective in reducing symptoms as
depressed mood, automutilation, suicidality and disordered eating behaviour in
this group of patients.
This raises the question if reduction of anorexic or bulimic symptoms, together
with co-morbid symptoms as depression, automutilation by specialist treatment
for eating disorders in patients with anorexia or bulimia nervosa is due to
enhancement of their mentalizing capacity.

To show that patients with anorexia of bulimia nervosa more often than healthy
controls display insecure attachment styles and poor mentalizing capacity.
To investigate if there are correlations between mentalizing capacity and
severity of specific symptoms.
To investigate if poor mentalizing capacity, after one year of treatment,
predicts the persistence of eating disorder symptoms.

Patients suffering from anorexia of bulimia nervosa indicated for (day)
clinical treatment at the unit for eating disorders ot the GGZ Midden-Brabant
or the dayclinic for eating disorders of the GGZ Oost-Brabant are compared to
healthy controls on attachment style, mentalizing capacity, general and
specific psychopathology, and interpersonal functioning, by several diagnostic
instruments:
- Dutch version of the Adult Attachment Interview (attachment style,
mentalizing capacity)
- Dutch version of the Structured Clinical Interview for DSM axis-I disorders
(depression, eating disorder)
- Dutch version of the Structured Clinical Interview for DSM axis-II disorders
(personality disorder)
- Dutch version of the Symptom Check List, SCL-90 (general psychopathology)
- Dutch version of the State Trait Anxiety List (anxiety)
- Dutch version of the Eating Disorder Inventory, EDI-2 (eating behaviour and
body dissatisfaction)
- Dutch version of the Self Injurious Questionnaire (automutilation)
- the Autonomy-Connectedness Scale, ACS-30 (Dutch scale) (interpersonal
functioning)

Correlations between attachment style, mentalizing capacity and the outcome on
the above mentioned, five selfreport scales will be analysed. Eating disorder
and personality disorder are seen as independent variables.

After one year of treatment the same instruments will be applied to the
patients with anorexia of bulimia nervosa to look for changes in attachment
style and mentalizing capacity on the one hand and symptomatology on the other.

Half a year later the SCID-I section on eating disorders will be applied to
them to assess remission or persistence of the eating disorder.

The intervention consists in (day) clinical treatment on the unit for eating
disorders of the GGZ Midden-Brabant or day treatment on the dayclinic for
eating disorders of the GGZ Oost-Brabant.
The GGZ Midden-Brabant offers a five-day group treatment program, including
sociotherapy, psychotherapy (individual and in a group) and non-verbal
therapies. Having been trained in Mentalization Based Treatment, attitude and
interventions of the treatment staff aim at the enhancement of mentalizing
capacity in patients.
The GGZ Oost-Brabant treats patients with anorexia or bulimia nervosa in a
four-day group program, including sociotherapy, psychotherapy and non-verbal
therapies, according to cognitive-behavioural principles. Individual therapy is
offered, temporarily, in crisis.
In both treatment programs systemic therapy is given when needed.

Two diagnostic interviews, AAI and SCID-II, time burden: one hour each, seldom
one hour and a half
Part of SCID-I: one hour
Fillling in five selfreport lists: two hours

Total time required: 5 hours (max. 6)

People will have to travel to the institution for being interviewed. The AAI
will be applied to patients at the location where they are being treated.