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

Irrational beliefs and their role in specific and non-specific eating disorder symptomatology and cognitive reappraisal in eating disorders

Background: Research on which specific maladaptive cognitions characterize eating disorders (ED) is lacking. This study explores irrational beliefs (IBs) in ED patients and controls and the association between IBs and ED-specific and non-specific ED symptomatology and cognitive reappraisal. Methods: 79 ED outpatients with anorexia nervosa, bulimia nervosa, or other specified feeding or eating disorders and 95 controls completed the Attitudes and Beliefs Scale-2 (ABS-2) for IBs. ED outpatients also completed the Eating Disorder Inventory-3 (EDI-3) for ED-specific (EDI-3-ED Risk) and non-specific (EDI-3-General Psychological Maladjustment) symptomatology; General Health Questionnaire (GHQ) for general psychopathology; Emotion Regulation Questionnaire (ERQ) for cognitive reappraisal. Results: Multivariate analysis of variance with post hoc comparisons showed that ED outpatients exhibit greater ABS-2-Awfulizing, ABS-2-Negative Global Evaluations, and ABS-2-Low Frustration Tolerance than controls. No differences emerged between ED diagnoses. According to stepwise linear regression analyses, body mass index (BMI) and ABS-2-Awfulizing predicted greater EDI-3-ED Risk, while ABS-2-Negative Global Evaluations and GHQ predicted greater EDI-3-General Psychological Maladjustment and lower ERQ-Cognitive Reappraisal. Con-clusion: Awfulizing and negative global evaluation contribute to better explaining ED-specific and non-specific ED symptoms and cognitive reappraisal. Therefore, including them, together with BMI and general psychopathology, when assessing ED patients and planning cognitive–behavioral treatment is warranted

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 somaticaffective 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

The relationship between demoralization and depressive symptoms among patients from the general hospital: Network and exploratory graph analysis

Introduction: Depression and demoralization are highly prevalent among individuals with physical illnesses but their relationship is still unclear. Objective: To examine the relationship between clinical features of depression and demoralization with the network approach to psychopathology. Methods: Participants were recruited from the medical wards of a University Hospital in Italy. The Demoralization Scale (DS) was used to assess demoralization, while the Patient Health Questionnaire-9 (PHQ-9) to assess depressive symptoms. The structure of the depression-demoralization symptom network was examined and complemented by the analysis of topological overlap and Exploratory Graph Analysis (EGA) to identify the most relevant groupings (communities) of symptoms and their connections. The stability of network models was estimated with bootstrap procedures and results were compared with factor analysis. Results: Life feeling pointless, low mood/discouragement, hopelessness and feeling trapped were among the most central features of the network. EGA identified four communities: (1) Neurovegetative Depression, (2) Loss of purpose, (3) Frustrated Isolation and (4) Low mood and morale. Loss of purpose and low mood/morale were largely connected with other communities through anhedonia, hopelessness and items related to isolation and lack of emotional control. Results from EGA displayed good stability and were comparable to those from factor analysis. Limitations: Cross-sectional design; sample heterogeneity Conclusions: Among general hospital inpatients, features of depression and demoralization are independent, with the exception of low mood and self-reproach. The identification of symptom groupings around entrapment and helplessness may provide a basis for a dimensional characterization of depressed/demoralized patients, with possible implications for treatment

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

La caratterizzazione della demoralizzazione in un campione di pazienti con disturbi del comportamento alimentare

Obiettivi: La demoralizzazione risulta poco studiata nei disturbi del comportamento alimentare (DCA). La presente ricerca ha l\u2019obiettivo di caratterizzare la demoralizzazione ed esplorare la possibilit\ue0 di differenziala dalla depressione in pazienti con DCA. Inoltre la ricerca mira a valutare se la demoralizzazione subisce riduzioni nel corso del trattamento cognitivo-comportamentale integrato con riabilitazione nutrizionale. Metodi: Il campione \ue8 composto da 83 pazienti femminili con DCA. Le pazienti sono state valutate al baseline tramite: Eating Attitude Test-40 per sintomi DCA, Beck Depression Inventory-II e Clinical Interview for Depression per sintomi depressivi, Diagnostic Criteria for Psychosomatic Research per la demoralizzazione, e le Psychological Well-being Scales per il benessere psicologico. Le sole pazienti ambulatoriali sono state rivalutate a met\ue0 trattamento. Dalle cartelle cliniche sono stati rilevate le diagnosi DCA e di disturbi dell\u2019umore. Risultati e Conclusioni: Al baseline si riscontra un\u2019alta prevalenza di demoralizzazione (65%) e disturbo depressivo (47.7%), un\u2019elevata sovrapposizione tra le sindromi pari al 40% (X2= 11.741, p<0.001), ma la possibilit\ue0 di differenziarle: 25% di pazienti demoralizzati non presentano disturbi depressivi e 7.5% di pazienti con disturbo depressivo non risultano demoralizzati. La demoralizzazione si contraddistingue per specifici sintomi depressivi e compromissione nel benessere psicologico. A met\ue0 trattamento si evidenzia una diminuzione significativa (p<0.001) di prevalenza di depressione e demoralizzazione. Il costrutto di demoralizzazione risulta clinicamente utile per cogliere sintomatologia sottosoglia nei DCA non necessariamente ascrivibile ad un quadro depressivo conclamato

Do metacognitions mediate the relationship between irrational beliefs, eating disorder symptoms and cognitive reappraisal?

Objective: Cognitively oriented therapies, first-line treatment for eating disorders (EDs), still show room for improvement in treatment retention and outcomes. Despite the development of additional cognitive models and therapies, few studies examine the relationship between traditional and third-wave cognitive targets in EDs. The study explores the relationship between irrational beliefs (IBs) and metacognitions and their relationship with ED psychopathology and cognitive reappraisal in ED outpatients. Method: Seventy-seven patients (mean age 27.49 \ub1 12.28 years) were assessed with The Attitudes and Beliefs Scale-ABS-2, Meta-cognitions Questionnaire-MCQ-65, Eating Disorder Inventory 3-EDI-3, Eating Attitudes Test-EAT-40, Emotion Regulation Questionnaire-ERQ. Results: Correlational analyses showed that IBs and metacognitions significantly correlated with each other. Metacognitions partially mediated the relationship between IBs and ED-related general psychological maladjustment and completely mediated the relationship between IBs and ED symptom severity. Cognitive reappraisal was predicted only by IBs and metacognitions were not significant mediators. Conclusions: While IBs are sufficient in explaining ED-related psychopathology and reduced use of cognitive reappraisal, a potential integration of metacognitions about need to control thoughts in CBT models for EDs may offer incremental validity given their contribution to ED severity. Treatment implications include targeting metacognitions concerning need to control thoughts, as a potential maintenance mechanism of ED symptomatology through cognitive restructuring

Irrational Beliefs, Cognitive Distortions, and Depressive Symptomatology in a College-Age Sample: A Mediational Analysis

Dysfunctional cognitions such as irrational beliefs (IBs) of Ellis' rational emotive behavior therapy (REBT) model and cognitive distortions (CDs) or cognitive errors from Beck's cognitive behavioral therapy (CBT) model are known to correlate with depressive symptomatology. However, most studies focus on one cognitive theoretical model in predicting psychopathology. The current study examined the relationship between both IBs and CDs in predicting depression. A college-age sample of 507 participants completed the Attitudes and Beliefs Scale-2, the Cognitive Distortions Scale, and the Beck Depression Inventory-II. Half of the sample showed minimal depression, while the remaining sample exhibited mild-moderate (37.4%) to severe (11.1%) depression symptomatology. Through regression analyses, the study aimed to examine whether IBs accounted for more of the variance in depression symptomatology after the effects of CDs were considered. Moreover, it tested whether CDs served as a moderator or mediator between IBs and depression. Each of Ellis' IBs (demandingness, awfulizing, self-downing, and low frustration tolerance) accounted for significantly more variance in depression after the variance of CDs was entered with the IB of self-downing explaining the most variance in depression severity. Moreover, while no moderation effect was found, CDs partially mediated the effect of IBs on depression. Both IBs and CDs contributed unique variance in predicting depression. Findings support the clinical notion that IBs and CDs are associated as well as highlight the clinical utility of both conceptualizations of dysfunctional cognitions in explaining depressive symptomatology. Clinicians might consider that each dysfunctional cognition might not be subject to change if not directly targeted. Rather than choosing to focus exclusively on IBs or CDs underlying negative automatic thoughts, psychotherapeutic efforts might benefit from identifying and challenging both types of dysfunctional cognitions