Mentalization in patients with anorexia and bulimia nervosa

Patients suffering from anorexia or bulimia nervosa display restrictive or
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 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 relation with attachment figures. Individuals
with an anxious attachment style often have by poor mentalizing ability.
Anxious attachment is believed to be a risk factor for the development of
psychopathology. Research shows that patients with anorexia or bulimia nervosa
often have anxious attachment styles.
Mentalization Based Treatment is a form of psychotherapeutic day treatment that
for some years is used by patients with borderline personality disorder and
shows to be more effective in reducing symptoms like depressed mood,
automutilation, suicidality and disordered eating behaviour.
Research on attachment and mentalizing capacity in patients with eating
disorders together with the nature of their symptoms make it plausible that
Mentalization Based Treatment would also be effective in reducing eating
disordered behaviour and accompanying symptoms in patients with anorexia or
bulimia nervosa.

To show patients with anorexia or bulimia nervosa more often than healthy
controls display an anxious attachment style and poor mentalizing capacity.
To investigateif there are correlations between mentalizing capacity and
severity of specific symptoms.
To show Mentalization Based Treatment is effective in reducing core and
co-morbid symptoms in patients suffering from anorexia or bulimia nervosa.

Patients suffering from anorexia or bulimia nervosa treated in the clinic for
eating disorders of the GGZ Midden-Brabant are compared to healthy controls on
attachment style, mentalizing capacity, general and specific psychopathology,
by several diagnostic instruments:
- Dutch version of the Ádult Attachment Interview (attachment style and
mentalizing capacity),
- Dutch version of the Structured Interview for DSM- axis II disorders
(personality disorders),
- Dutch version of the Symptom Check List (SCL-90) (general psychopathology),
- Dutch version of Beck's Depression Inventory (depression)
- Dutch version of State Trait Anxiety Inventory (anxiety)
- Dutch version of Eating Disorder Inventory (eating behaviour and body
dissatisfaction)
- Ducth version of Self Injurious Questionnaire (automutilation)
- Dutch scale on interpersonal behaviour: Autonomy-Connectedness Scale.

Correlations between attachment style, mentalizing capacity, and the outcome on
above mentioned instruments will be investigated. The presence of personality
disorders is checked, because this could be a mediating factor.

In an open quasi-experimental design patients with anorexia or bulimia nervosa
treated with Mentalization Based Treatment in the (day)clinic of the GGZ
MIdden-Brabant will be compared with patients with anorexia or bulimia nervosa
treated in the cognitive-behavioral day treatment of the GGZ Oost-Brabant on
outcome. Therefore AAI, SCID-II, SCL-90, BDI, STAI, EDI-2, SIQ and ACS will be
assessed in both groups at the start and after one year of treatment.

The intervention that is done consists in Mentalization Based Treatment. MBT is
a five-day group treatment, with the elements sociotherapy, psychotherapy
(individual and in a group) and non-verbal therapies. Attitude and
interventions of the treating staff aim at the enhancement of the mentalizing
capacity of patients. Treatment staff (incl. sociotherapists) are educated in
this way of intervening. Team intervision on method and patients' problems is
an essential part of the method. The principles of Mentalization Based
Treatment are thoroughly outlined by Fonagy and Bateman.
MBT is effective in reducing symptoms in borderline patients, such as
affectdysregulation, depression, selfdestructive behavior, abuse of alcohol and
drugs, and eating disordered behavior. There are no adverse side-effects known
of MBT.

The burden for participants in this study consists in the undergoing of two
diagnostic interviews and filling in six selfrating questionnaires. Total time:
4 to 5 hours.
People will have to travel to the institution for being interviewed.