Demoralization in Eating Disorders: Its Psychological Characterization and Role in Treatment Response

Aims: The first study investigates the clinical characteristics of demoralization, a syndrome characterized by helplessness, hopelessness and a sense of incompetence, in eating disorder (ED) patients, in addition to examining its distinction from depressive disorders. The second study has the aim of testing the role of demoralization’s hallmark feature, subjective incompetence, in treatment response. Methods: Eighty-three ED outpatients and inpatients, undergoing cognitive-behavioral therapy-based treatment, were recruited and evaluated at baseline and mid-treatment for demoralization, subjective incompetence, depressive and eating-related symptomatology, and psychological well-being (PWB). Chi-squared test was applied to examine overlap of demoralization and depression diagnoses. Multivariate analyses of variance compared ED patients with comorbid demoralization, to those with comorbid depression and no comorbidity. Hierarchical linear regression analyses were conducted to test whether subjective incompetence reductions predicted changes in ED symptoms and psychological well-being dimensions. Logistic regression analysis was conducted to explore whether mood-related variables and psychological well-being domains predicted drop-out. Results: Demoralization was highly prevalent and associated with increased distress and impaired psychological well-being. Although cases of only demoralization in absence of depression were documented, demoralization significantly overlapped with depressive disorders. Compared to depressed ED patients, demoralized patients had less severe eating-related pathology, were impaired in fewer psychological well-being domains, did not necessarily exhibit depressed mood, anxiety, and sleep difficulties. By mid-treatment demoralization diagnoses and subjective incompetence were significantly reduced. Such decreases in subjective incompetence, controlling for depression and illness severity, significantly predicted response in ED symptomatology and positive functioning. Only PWB-autonomy predicted drop-out. Conclusions: Demoralization, unlike depression, was not associated with worse eating-related symptomatology in EDs. It emerges as an indicator of worsening status in terms of specific depressive symptoms which may not reach diagnostic thresholds, and in terms of worse psychological well-being. Subjective incompetence may be an additional therapeutic target to increment treatment response in EDs

Well-Being Therapy in a Patient with Anorexia Nervosa

While cognitive-behavioral therapy (CBT) is considered a first- line intervention for eating disorders (ED), the development of novel strategies to improve recovery rates is needed. Following standard treatment, ED patients also frequently report persistence of psychological symptoms. Well-Being Therapy was tested in a Patient with Anorexia Nervosa for the first time.Therefore, effective treatment may benefit from promoting positive functioning in ED patients

Subjective incompetence as a predictor of treatment outcomes in eating disorder outpatients

Eating disorder (ED) patients are frequently characterized by feelings of inefficacy. The aims of the present study were to investigate subjective incompetence and whether its early modification in therapy is associated with treatment response in terms of both psychological distress and well-being. Sixty female ED outpatients undergoing cognitive-behaviorally-based treatment integrated with nutritional rehabilitation were evaluated using: Subjective Incompetence Scale (SIS), Eating Attitudes Test (EAT), Beck Depression Inventory (BDI-II), and Psychological Well-being Scales (PWB). Repeated measures analysis of variance to test changes in variables and hierarchical regression analyses to test the predictive role of SIS were conducted. Significant improvements in SIS, and in distress measures (EAT, BDI-II) and well-being (PWB) were observed by mid-treatment. Early SIS reductions in patients significantly predicted reductions in EAT-food and bulimic preoccupations, EAT-oral control and EAT-dietary restraint scores, independently of initial depressive symptomatology and illness severity. Gains in three PWB dimensions (environmental mastery, purpose in life, self-acceptance) were also predicted by changes in subjective incompetence. Treatment response might be enhanced by targeting more specifically persistent feelings of incompetence associated with ED symptomatology and compromised psychological well-being dimensions. Such paucities in positive functioning are central themes in EDs and if left untreated might represent obstacles to recovery

Pride in eating disorders: a scoping systematic Review

Purpose: Pride might play an important role in eating disorders (EDs) and eating disorder symptomatology. The present scoping PRISMA systematic review explores the emotion of pride in EDs and general populations specifically its association with ED-related symptomatology and aspects. Methods: Four databases (PubMed, PsycInfo, Web of Science, Scopus) were searched for studies assessing pride in ED patients or in association with ED-related symptoms. The systematic scoping review followed PRISMA guidelines and PICOS procedure. Results: Fifteen studies were selected including ten quantitative (mostly cross-sectional) and five qualitative studies. Most studies (n=9) were on general population samples assessed for pride in association with ED-related symptoms and behaviors, six were on clinical samples mostly focused on AN (n=5) and one a mixed EDs. Pride was evaluated in various forms including ED-related pride, appearance-related pride, body pride, pro-anorectic pride, and cultural pride. In general populations, high levels of maladaptive pride and low levels of adaptive body pride were related to greater ED-associated behaviors and symptomatology. In qualitative studies on AN patients, pride was associated with themes of control and with illness identification and as one factor that contributed to illness onset, maintenance and recovery. Conclusion: The review supports that integrating assessment of pride experiences in AN patients may be clinically useful for initial assessment, treatment planning and definitions of remission. Gaps in the literature and methodological limitations of studies are discussed. In particular, a lack of quantitative and longitudinal data and inconsistency in pride constructs emerged

The Need to Control Thoughts in Eating Disorder Outpatients: A Longitudinal Study on Its Modification and Association with Eating Disorder Symptom Improvement

The metacognition of needing to control thoughts has been implicated in eating disorders (EDs)—specifically, in association with the drive for thinness and over-control. To date, it has yet to be investigated longitudinally in ED outpatients undergoing CBT-based treatment. The current study aims to examine whether endorsing a need to control thoughts undergoes modifications during CBT-based treatment for EDs and whether its modification correlates with treatment response in terms of reduced ED symptomatology. Seventy female ED outpatients (34 with AN, 29 with BN, 7 with OSFED) were assessed at baseline and at the end of treatment with the Metacognitions Questionnaire (MCQ), the Eating Attitudes Test (EAT-40), and the General Health Questionnaire (GHQ). Post-treatment, significant reductions were observed in MCQ-need to control thoughts. Using hierarchical linear regression analyses such decreases significantly explained the variance in observed reductions in EAT-oral control and to a lesser extent, reductions in EAT-bulimia and food preoccupation and EAT-dieting. These results underscore the importance of metacognitive change in EDs and the potential utility of CBT-based treatment in its modification. Improving ED outcomes may warrant broadening the therapeutic target of over-control and a sense of loss of control beyond dysfunctional eating behaviors to include maladaptive metacognitions that concern the need to control thoughts

Does psychological well-being change following treatment? An exploratory study on outpatients with eating disorders

Psychological well-being changes following cognitive-behavioral therapy-based treatment were investigated in outpatients with eating disorders (ED). While it is known that CBT reduces symptomatology in EDs, less is known about how changes in positive functioning may ensue. One-hundred and eighty five ED outpatients were analyzed for pre-treatment and post-treatment changes in psychological well-being (PWB) by last observation carried forward \u2013 Wilcoxon signed rank tests. Significant gains in all PWB dimensions were found, with moderate effect size correlations in environmental mastery (r\ua0=\ua0 12.418), personal growth (r\ua0=\ua0 12.351) and self-acceptance (r\ua0=\ua0 12.341). A subsample of patients in remission (n\ua0=\ua051) was selected and compared to healthy controls in PWB post-treatment scores through Mann\u2013Whitney U tests. Remitted patients showed significantly lower psychological well-being in two dimensions compared to controls: PWB-positive relations (r\ua0=\ua0 12.360) and PWB-self-acceptance (r\ua0=\ua0 12.288). However, more than 50% of ED outpatients in remission had PWB scores that fell below the 50th percentile of healthy controls in all psychological well-being dimensions, despite significant treatment response. Several mechanisms of psychological well-being change following CBT-based treatment are discussed. The assessment of treatment outcome in EDs may benefit from considering changes in positive functioning such as psychological well-being, in addition to the standard measurement of BMI, symptomatology and behavioral parameters. CBT-based treatment outcomes may be strengthened by promoting the development of optimal domains particularly in the interpersonal realm, such as building of quality and warm relationships and focusing on enhancing self-acceptance

Mental Pain in Eating Disorders: An Exploratory Controlled Study

Mental pain (MP) is a transdiagnostic feature characterized by depression, suicidal ideation, emotion dysregulation, and associated with worse levels of distress. The study explores the presence and the discriminating role of MP in EDs in detecting patients with higher depressive and ED-related symptoms. Seventy-one ED patients and 90 matched controls completed a Clinical Assessment Scale for MP (CASMP) and the Mental Pain Questionnaire (MPQ). ED patients also completed the Beck Depression Inventory-II (BDI-II), Clinical Interview for Depression (CID-20), and Eating Attitudes Test (EAT-40). ED patients exhibited significantly greater severity and higher number of cases of MP than controls. Moreover, MP resulted the most important cluster predictor followed by BDI-II, CID-20, and EAT-40 in discriminating between patients with different ED and depression severity in a two-step cluster analysis encompassing 87.3% (n = 62) of the total ED sample. Significant positive associations have been found between MP and bulimic symptoms, cognitive and somatic-affective depressive symptoms, suicidal tendencies, and anxiety-related symptoms. In particular, those presenting MP reported significantly higher levels of depressive and anxiety-related symptoms than those without. MP represents a clinical aspect that can help to detect more severe cases of EDs and to better understand the complex interplay between ED and mood symptomatology

Demoralization as a distinct clinical phenomenon from major depressive disorder: a systematic review

Introduction: Demoralization constitutes a cluster of psychological symptoms particularly prevalent in the medical context. We conducted a systematic review with the aim of supporting the evidence for a differentiation of demoralization from major depressive disorder (MDD). Methods: A qualitative systematic review following PRISMA criteria was conducted. Utilizing the keyword \u201cdemoralization\u201d in databases PubMed, PsycINFO, Web of Knowledge, an electronic search was performed, supplemented by a manual search. 60 studies were selected. Study selection criteria included the use of medical samples and of instruments validated to assess demoralization. Four instruments were identified. Three are self-report, the Demoralization Scale (DS), the Psychiatric Epidemiological Research Interview-Demoralization Scale (PERI-D), and the Subjective Incompetence Scale (SIS) and one is a structured interview for the Diagnostic Criteria for Psychosomatic Research (DCPR) (Mangelli et al., 2003). Results: Only the DCPR interview and the DS have been used to detect demoralized cases in absence of MDD. The DCPR interview was applied to assess demoralization across various medical conditions, finding a prevalence ranging from 7% in coronary heart disease to 40% in endocrine diseases. The DS has been administered mostly in cancer patients showing a prevalence of 5-27.4%. To date, no studies using the PERI-D and the SIS have focused on such a differentiation. Discussion/Conclusions: Using validated instruments, demoralization appears to entail specific clinical features and emerges as a distinct condition from MDD. However, the reported prevalence rates may vary due to the characteristics of the assessment instruments