Nordic Journal of Psychiatry
ISSN: 0803-9488 (Print) 1502-4725 (Online) Journal homepage: http://www.tandfonline.com/loi/ipsc20
The association between interpersonal problems and treatment outcome in the eating disorders: A systematic review Allan Jones, Nanna Lindekilde, Marlene Lübeck & Loa Clausen To cite this article: Allan Jones, Nanna Lindekilde, Marlene Lübeck & Loa Clausen (2015) The association between interpersonal problems and treatment outcome in the eating disorders: A systematic review, Nordic Journal of Psychiatry, 69:8, 563-573, DOI: 10.3109/08039488.2015.1019924 To link to this article: http://dx.doi.org/10.3109/08039488.2015.1019924
Published online: 13 Mar 2015.
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The association between interpersonal problems and treatment outcome in the eating disorders: A systematic review ALLAN JONES, NANNA LINDEKILDE, MARLENE LÜBECK, LOA CLAUSEN
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Jones A, Lindekilde N, Lübeck M, Clausen L. The association between interpersonal problems and treatment outcome in the eating disorders: A systematic review. Nord J Psychiatry 2015;69:563–573. Objective: To review systematically the eating disorder literature in order to examine the association between pre-treatment interpersonal problems and treatment outcome in people diagnosed with an eating disorder. Methods: Six relevant databases were searched for studies in which interpersonal problems prior to treatment were examined in relation to treatment outcome in patients diagnosed with anorexia nervosa (AN), bulimia nervosa (BN) or eating disorders not otherwise specified (EDNOS). Results: Thirteen studies were identified (containing 764 AN, 707 BN and 48 EDNOS). The majority of studies indicated that interpersonal problems at the start of therapy were associated with a detrimental treatment outcome. Conclusions: Individuals with a binge/purge-type of eating disorder may be particularly vulnerable to interpersonal issues and these issues may lead to poorer treatment recovery by reducing the individual’s ability to engage in the treatment process on a functional level. The clinical and research implications are discussed. • Eating disorders, Interpersonal problems, Treatment outcome. Allan Jones, M.Sc., Ph.D., C.Psychol., A.F.B.Ps.S., Institute of Psychology, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark, Email: [email protected]; Accepted 12 February 2015.
I
nterpersonal problems have been identified as important in the onset, maintenance and remission of eating disorder symptoms (1). Interpersonal problems are characterized by difficulties in social functioning and problems with forming healthy and meaningful relationships with others. Difficulties interacting with others are often associated with negative or distorted evaluations of the self and compensatory behaviour such as dominance, intrusiveness, non-assertiveness, social-avoidance etc. (2, 3). Individuals with an eating disorder have been found to display more interpersonal problems compared with non-clinical samples (4–6). Moreover, associations between interpersonal problems and eating disorder symptoms have been reported, finding the degree of interpersonal problems to be positively associated with more concerns over eating, shape and weight (7), as well as severity of bulimic behaviour (7, 8). A recent review of cross-sectional studies examining interpersonal problems in people with an eating disorder (restrictive and bingeing/purging-type) found interpersonal problems such as social anxiety, interpersonal sensitivity and social inhibition to be associated with eating disorder psychopathology (9).
© 2015 Informa Healthcare
It has recently been suggested that interpersonal problems at the start of therapy could influence treatment outcome (10). Interpersonal barriers such as the inability of the patient to engage with the therapist and others on a meaningful/functional level may interfere with the treatment process (e.g. treatment completion) and inhibit treatment efficacy (e.g. symptom reduction, recovery) (11–15). As such, a better understanding of the relationship between interpersonal problems and treatment outcome may help to guide future research and to inform clinical practice—such as whether or not to screen for interpersonal problems, as well as implications for psychological treatment. The aim of the present study was therefore to review systematically the eating disorder literature for studies that examine the association between pre-treatment interpersonal problems and treatment outcome in people diagnosed with an eating disorder.
Methods Search strategy Six relevant databases, including PubMed, PsychINFO, Embase, Web of Science, CINAHL and SCOPUS, were DOI: 10.3109/08039488.2015.1019924
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searched, using the Keywords: eating problem* OR eating disorder* OR disordered eating OR anorexia nervosa OR bulimia nervosa combined with [AND] interpersonal problem* OR interpersonal function* OR interpersonal deficit* OR social skills deficit* OR social maladjustment OR social anxiety. No restrictions on date of publication were applied, with all studies published up until 24 April 2014 included in the search (no articles published after April 2014 are included in the review). The search was limited to exclude books and dissertations. After removal of duplicate records, 1361 articles were identified and screened using the following inclusion criteria:
change (BMI), total/composite scores of eating disorder symptoms, treatment completion/drop-out, response/nonresponse to treatment and post-treatment relapse/nonrelapse. The sample size of the studies ranged from 29 to 220 with a total combined n ⫽ 1519, of which 764 were diagnosed with AN, 707 were diagnosed with BN and 48 were diagnosed with EDNOS. One study focused on eating disorders in adolescents only (16) and the study by Goddard et al. (17) split the sample into adolescents and adult inpatient groups.
1) Studies were required to be peer reviewed, written in the English language and include patient samples diagnosed with anorexia nervosa (AN), bulimia nervosa (BN) or eating disorders not otherwise specified (EDNOS); 2) Studies had to include a psychological intervention targeting eating disorder pathology (e.g. bingeing behaviour, purging behaviour, low body mass index, BMI) with eating disorder pathology measured at both preand post-treatment, or treatment completion; 3) Studies were required to include a measure of interpersonal problems measured at pre-treatment/ beginning of treatment; 4) Studies were required to report the association between the pre-treatment measure of interpersonal problems and treatment outcome (e.g. eating disorder pathology or treatment completion).
A summary of the main findings is presented in Table 2. Nine of the studies reported significant and detrimental associations between pre-treatment interpersonal problems and treatment outcome (2, 10, 17–23). Interpersonal problems prior to treatment were found to be significantly related to poorer treatment outcome or treatment noncompletion. The study by Ohmann et al. (16) provided descriptive data only, showing the treatment drop-out group scored higher on levels of social phobia (SPS). The remaining three studies found no significant associations between pre-treatment interpersonal problems and treatment outcome (13, 15, 24).
Single case studies were excluded. In addition, reference lists of relevant articles were searched for any articles that may have been missed by the initial search. In accordance with the review by Arcelus and colleagues (9), studies on eating disorders were targeted—including AN, BN and EDNOS. Studies on disordered eating in nonclinical samples, obesity, body dissatisfaction etc. were not included in the review.
Results The search resulted in 13 studies that examined and presented results on the relationship between interpersonal problems and post-treatment eating disorder pathology. Figure 1 shows a flowchart of the process of study selection, and Table 1 provides an overview of treatment type, eating disorder type and care setting across studies. The following information was extracted from the studies meeting the inclusion criteria and is presented in Table 2: sample size/eating disorder diagnosis, mean age, pre-treatment measure of interpersonal problems, eating disorder treatment, treatment outcome measures (eating disorder symptoms/ treatment completion) and main findings. The treatment outcome variables across the thirteen studies included bingeing behaviour, purging behaviour, weight
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Interpersonal problems and treatment outcome
Type of interpersonal problem and treatment outcome Five studies examined general interpersonal problems in relation to treatment outcome using the Inventory of Interpersonal Problems (IIP) (3), with two studies showing significant positive associations between interpersonal problems and poorer treatment outcome (2, 18), one study showing mixed results (19) and two studies finding no significant associations (13, 21). Five studies included measures of social avoidance with four of the studies finding greater pre-treatment levels of social avoidance to be significantly associated with poorer treatment outcome (2, 10, 22, 23), and only one study finding no significant association (24). Two studies examined pre-treatment social phobia and social anxiety in relation to treatment outcome (16, 20), with one study finding severe social phobia to be the most salient characteristic of patients with unchanged diagnostic status following treatment completion (20), and the other study showing higher levels of social phobia in the drop-out group compared with the good treatment outcome group, and higher levels of social anxiety in the good treatment outcome group compared with the poor treatment outcome group (16). Three studies examined the association between pre-treatment social adjustment and treatment outcome, with two studies finding poorer social adjustment to be significantly related to poorer treatment outcome (18, 21) and one study finding no difference on the social adjustment scale between post-treatment relapsed and non-relapsed groups NORD J PSYCHIATRY·VOL 69 NO 8·2015
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EATING DISORDERS
2071 references identified from six electronic databases
710 duplicates removed
1361 articles screened for eligibility
Articles were excluded, if: - Sample not diagnosed with AN, BN or EDNOS (n=589) - The study didnot include a psychological intervention targeting eating disorder (n=387)
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- Eating disorder pathology were not measured pre-and post treatment / treatment completion (n=13) - Interpersonal problems were not measured pretreatment or at the beginning of treatment (n=32) - Association between pre-treatment Interpersonal problems and treatment outcome not measured (n=13) - Not written in English (n=106) - Not a primary research study (n=193) - Case study (n=17)
11 articles included 2 articles included after screening references
A total of 13 articles were included in the review
Fig. 1. Flowchart of the process of study selection.
(15). Finally, in the Hartmann et al. study (2) pre-treatment interpersonal problems with dominant behaviour were found to be significantly associated with less posttreatment weight gain for individuals with AN; the study by Goddard et al. (17) found the quality of social relationships and carer expressed emotion in people with AN significantly predicted eating disorder symptoms at treatment discharge; and the study by Tasca et al. (23) found that people with AN-binge/purge (AN-BP) who scored high on anxious attachment tended to complete treatment, while those with lower anxious attachment tended not to complete treatment.
Study characteristics and treatment outcome Results from each study were entered into a matrix to examine whether significant and null findings were clustered around specific study characteristics available NORD J PSYCHIATRY·VOL 69 NO 8·2015
for extraction across studies, including: age of study participants (adolescent, adult, mixed), type of eating disorder (AN, BN, EDNOS, mixed), type of therapy (cognitive behaviour therapy—CBT, interpersonal therapy—IPT, mixed) and treatment setting (outpatient, inpatient, inpatient and day-care). Six of the studies used treatment dropout as an outcome/categorical variable; as such, treatment duration was not analysed. Significant or null findings were not found to cluster around any specific study characteristic and heterogeneity in outcome could not be explained by these study variables. Associations between interpersonal problems and treatment outcome were observed across the eating disorders. Only four of the studies reviewed examined differences on interpersonal measures and treatment outcome across eating disorder type (2, 10, 23, 24) and eating disorder types were combined in two studies (19, 22) adopting a more transdiagnostic
565
3 1 5 4 ⫹
⫹
CBT, cognitive behaviour therapy; IPT, interpersonal therapy; BT, behaviour therapy; AN, anorexia nervosa; BN, bulimia nervosa.
⫹ ⫹ ⫹ ⫹ ⫹ ⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹ ⫹
⫹ ⫹ ⫹ ⫹
⫹
⫹ ⫹
⫹ ⫹ ⫹ ⫹ ⫹ ⫹
Treatment type CBT IPT Mixed Eating disorder type AN BN Mixed Care setting Inpatient Day-care Outpatient Inpatient & day-care
⫹
⫹
5 5 3 ⫹
⫹ ⫹
Tasca et al., 2004 (23) Rø et al., 2005 (22) Olmsted et al., 1994 (15) Ohmann et al., 2013 (16) Hartmann et al., 2010 (21) Hartmann et al., 2010 (2) Goddard et al., 2013 (17) Ghaderi 2006 (20) Constantino et al., 2005 (13) Carter et al., 2012 (10) Arcelus et al., 2009 (19) Agras et al., 2000 (18)
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Table 1. Overview of treatment type, eating disorder type and care setting across studies.
566
⫹
3 2 8
Zeeck et al., 2005 (24)
Total studies
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approach (25). The study by Zeeck et al. (24) reported no significant associations; however, the combined findings of the remaining three studies suggest that individuals with a restrictive-type eating disorder may be less affected by interpersonal issues, resulting in a better treatment outcome. In the study by Carter et al. (10), individuals with AN-BP reported significantly higher levels of overall interpersonal problems compared with individuals with AN-R, and individuals with AN-R were significantly more likely to complete treatment than individuals with AN-BP. In the Tasca et al. (23) study, individuals with AN-BP displaying high avoidant attachment tended not to complete treatment, whereas individuals with AN-BP and low avoidant attachment tended to remain in treatment. The same was not found for the AN-R group, however. In the study by Hartmann et al. (2), people with AN-BP measured significantly higher on social avoidance and interpersonal distress compared with people with AN-restrictive (AN-R) and BN. Accordingly, binge frequency decreased significantly over the course of treatment for individuals with BN, but not for individuals with AN-BP. Number of participants per group was also examined (below 50 participants, between 50 and 100 participants, over 100 participants). Significant associations were found across all group size categories. Effect sizes were calculated for studies with groups in the under-50participant category that reported non-significant findings and statistical power examined. The Arcelus et al. (19), Ghaderi (20), Hartmann et al. (21) and Olmsted et al. (15) studies were potentially underpowered; unfortunately, there were insufficient data available to calculate effect sizes. The study by Zeeck et al. (24) found no significant differences on the IIP subscales between treatment drop-out (n ⫽ 42) and completer groups (n ⫽ 91). However, when looking at effect sizes for differences on IIP subscale measures between groups, effect sizes in the small to medium range were observed on the subscales domineering (Hedges g ⫽ 0.33; power [1 ⫺ B err prob] ⫽ 0.42), overly-nurturant (Hedges g ⫽ 0.38; power [1 ⫺ B err prob] ⫽ 0.52) and intrusive (Hedges g ⫽ 0.44; power [1 ⫺ B err prob] ⫽ 0.65) with the drop-out group displaying more problems in these areas at pre-treatment. Statistical power calculations indicated risk of type II error over the recommended parameters (power calculated with alpha at 0.05—two tailed). In addition to risk of type II error, the quality of the studies included in the review was assessed using the Downs and Black (26) checklist for the methodological quality of studies of healthcare interventions. Issues in external validity only were observed. This was due to the use of specialized treatment conditions and/or the inclusion of selected study participants making generalization of findings to the wider eating disorder population limited in three of the studies (13, 18, 22). NORD J PSYCHIATRY·VOL 69 NO 8·2015
28.1 years (s ⫽ 7.9); 100% female
28.1 years (s ⫽ 7.0); 100% female
26.0 years (s ⫽ 7.6); 97% female
28.1 (s ⫽ 7.2); 100% female
27.2 years (s ⫽ 7.8); % female—not specified
n ⫽ 59; BN ⫽ 27; EDNOS ⫽ 32
n ⫽ 218; AN-R ⫽ 132; AN-BP ⫽ 86
n ⫽ 220; BN
n ⫽ 50; BN
Arcelus et al., 2009, UK (19)
Carter et al., 2012, Canada (10)
Constantino et al., 2005, USA (13)
Ghaderi, 2006, Sweden (20)
Age in years
n ⫽ 188; BN
Sample size/eating disorder diagnosis
Agras et al., 2000, USA (18)
Study: author, year, country
Table 2. Overview of the studies included in the review.
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Social phobia
IIP- 64; Inventory of Interpersonal Problems
IIP-32—Inventory of Interpersonal Problems (short version)
IIP-32; Inventory of Interpersonal Problems (short version)
IIP -64; Inventory of Interpersonal Problems; SAS-SR Social Adjustment Scale- Self-Report
Pre-treatment measure of interpersonal problems
Outpatient manual based CBT or individualized CBT; 19 weekly individual sessions, of 50 min duration
Outpatient CBT or IPT Individual psychotherapy 19 sessions of 50 min duration conducted over 20 weeks
Inpatient and day care group psycho-therapy with an interpersonal focus; 30–40 h weekly, with an average length of stay of 13.5 weeks
Outpatient IPT; 16 weekly sessions of 45 min duration
Outpatient CBT; 18 individual 50-min sessions over 16 weeks
Eating disorder treatment
Main findings
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(Continued )
Non-completers had higher scores on pre-treatment IIP than completers, ES ⫽ 0.39; non-completers were more likely to have reported poor social adjustment (SAS-SR) than completers, ES ⫽ 0.45; nonrecovered had higher scores on pre-treatment IIP than recovered, ES ⫽ 0.36; non-recovered were more likely to have reported poor social adjustment (SAS-SR) than recovered, ES ⫽ 0.46 Non completers n ⫽ 14; Non-completers had significantly completers n ⫽ 45; non higher levels of interpersonal responders to treatment problems (IIP) than completers n ⫽ 13; responders to Z ⫽ 2.733; P ⫽ 0.006; no significant treatment n ⫽ 32 differences on the IIP were found between non-responders and responders (no data reported) Completers n ⫽ 124 The socially avoidant subscale on the (achieving BMI ⱖ 20 by IIP significantly predicted treatment end of treatment & outcome (as levels of initial social remittance of binge eating avoidance increased, the odds of & purging behaviour successful treatment completion during last 4 weeks of decreased); B ⫽ ⫺ 0.48; SE 0.21; treatment); non completers Wald 5.40; P ⫽ 0.02; OR ⫽ 0.62; n ⫽ 94 (not meeting the 95% CI 0.41 ⫺ 0.93 above criteria) Purge frequency There were no significant correlations between pre-treatment IIP and post-treatment purge frequency r ⫽ 0.00, or change in purge frequency r ⫽ ⫺ 0.06 (change from baseline to session 12) Unchanged diagnosis n ⫽ 2; The most salient characteristic of still symptomatic n ⫽ 8; patients with unchanged diagnostic responders to treatment status (n ⫽ 2) was presence of n ⫽ 40; EDE—Eating severe social phobia disorder examination; EDE-Q –Eating disorder Questionnaire; EDIEating disorder inventory
Dropped out n ⫽ 48; completed n ⫽ 140; not recovered n ⫽ 82; recovered n ⫽ 58
Treatment outcome measures (Eating disorder symptoms/ treatment completion)
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568 SAS-SR—Social Adjustment Scale—SelfReport; IIP-64— Inventory of Interpersonal Problems
24.5 years (s ⫽ 7.5), 94% female
25.1 years (s ⫽ 7.4); 93% female
n ⫽ 208; AN-R ⫽ 56; AN–BP ⫽ 57; BN ⫽ 95
n ⫽ 43; BN
Hartmann et al., 2010, Germany (21)
Goddard et al., 2013, UK (17)
Hartmann et al., 2010, Germany (2)
Age in years WHO Social ⫽ quality of social relationships. Levels of Expressed Emotion Scale (LEE) ⫽ carer expressed emotion IIP-64; Inventory of Interpersonal Problems
Sample size/eating disorder diagnosis
Pre-treatment measure of interpersonal problems
n ⫽ 177; inpatient Inpatient adult:26.5 adult: AN ⫽ 150; (s ⫽ 8.9); 95.5% inpatient adolescent: female; inpatient AN ⫽ 11; day adolescent:15.2 patient adult: (s ⫽ 1.6); 91.1% AN ⫽ 16 female; day patient adult:24.7 (s ⫽ 5.3); 100% female
Study: author, year, country
Table 2. (Continued )
Inpatient and day care over 13 weeks. Twice-weekly individual psychodynamic psychotherapy sessions, 6 weekly group sessions (a psychodynamic group twice a week, a body therapy group twice a week, an eating disorder group once a week, and an art therapy group once a week), 1–2 family sessions over the course of therapy and CBT sessions
Inpatient adult: AN ⫽ 150; Inpatient adolescent: AN ⫽ 11; Day care adult: AN ⫽ 16; Guided self-help skills training intervention using a cognitive interpersonal and behavioural maintenance model Inpatient and day care weekly individual and group psycho-dynamic therapy, body therapy, relaxation therapy, art therapy, symptom oriented behavioural therapy and family therapy; Average treatment duration approx. 33 weeks for AN-R, 31 weeks for AN-BP, 21 weeks for BN
Eating disorder treatment
Outcome at 3 months follow-up; treatment failure n ⫽ 18; treatment success (partial or full remission) n ⫽ 22 (3 missing)
Binge severity ⫽ BN and AN-BP; weight gain (BMI) ⫽ AN-R and AN-BP
Eating Disorder Examination— Questionnaire (EDEQ); BMI
Treatment outcome measures (Eating disorder symptoms/ treatment completion)
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Higher total scores on pre-treatment IIP were associated with greater binge severity at the end of treatment, but not weight gain (no data reported); BN, AN-BP: initial problems with social avoidance significantly predicted greater binge severity at end of treatment β ⫽ 0.24, SE ⫽ 0.13, P ⬍ 0.005; AN-R, AN-BP: initial problems with dominance significantly predicted less weight gain over the course of treatment β ⫽ ⫺ 0.22, SE ⫽ 0.07, P ⬍ 0.005 Poor social adjustment at intake (SAS-SR total) significantly predicted treatment failure at 3-months follow-up R2 ⫽ 0.13, P ⫽ 0.006; main factors on the IIP did not predict treatment failure/ success (no data reported)
Significant interpersonal predictors of eating disorder symptoms at discharge included quality of social relationships (WHO Social) β ⫽ 0.178, P ⬍ 0.05 and expressed emotion (LEE) β ⫽ 0.205, P ⬍ 0.05
Main findings
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14.3 (range 13–17); 100% female
25.8 (s ⫽ 7.1); 100% female
30.2 (s ⫽ 7.6); 98.6% female
n ⫽ 29; AN-R ⫽ 22; AN-BP ⫽ 7
n ⫽ 48; BN
n ⫽ 72; AN ⫽ 13; AN-R ⫽ 7; BN ⫽ 36; EDNOS ⫽ 16
Ohmann et al., 2013, Austria (16)
Olmsted et al., 1994, Canada (15)
NORD J PSYCHIATRY·VOL 69 NO 8·2015
Rø et al., 2005, Norway (22)
The avoidant personality index
SAS-SR—Social Adjustment Scale- Self-Report
SPS—Social Phobia Scale; SIAS— Social Interaction Anxiety Scale
Day care group psychotherapy focused on normalizing eating behaviour; 8 h a day 5 days a week, over 8–16 weeks Inpatient CBT, IPT, art therapy or psychoeducation. Daily group meetings over 22–23 weeks for AN and 15 weeks for BN
Outpatient group CBT a maximum of 40 weekly sessions lasting 90 min and family sessions once monthly.
EDE—Eating Disorder Examination; EDI— Eating Disorder Inventory
Good outcome: attaining the 25th age related BMI percentile, absence of restrictive or bulimic eating behaviour and other strategies for losing weight, eating & problem behaviour changed to normal. Poor outcome: very protracted course, small improvements or deterioration in BMI, restrained eating behaviour, no or small changes of other outcome variables. Drop-out: patients discontinued CBT before attaining target therapeutic goals Relapsed group n ⫽ 15; non-relapsed group n ⫽ 33
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(Continued )
Differences between pre-treatment scores on the social adjustment scale between post-treatment relapsed and non-relapsed groups did not reach significance (no data reported) The avoidant personality index significantly predicted the level of eating disorder related distress (global EDE) at follow-up B ⫽ 0.88, SE ⫽ 0.18, df ⫽ 247, t ⫽ 4.9, P ⬍ 0.0001, but did not significantly predict treatment outcome (i.e. improved at the same rate as the others)
Drop-outs (n ⫽ 8) scored higher on pre-treatment levels of social phobia (SPS—social phobia scale) compared with good outcome (n ⫽ 16) and poor outcome (n ⫽ 5) patients; social phobia (SPS): good: 14.2 ⫾ 7.7; poor: 13.6 ⫾ 6.3 (good vs. poor ES ⫽ 0.08); drop-out: 18.8 ⫾ 14.7 (good vs. drop-out ES ⫽ 0.39). The good outcome group scored higher on levels of social anxiety than the poor outcome group. Social anxiety (SIAS): good: 24.6 ⫾ 8.9; poor: 22.0 ⫾ 10.9 (good vs. poor ES ⫽ 0.26); drop-out: 24.5 ⫾ 9.5 (good vs. drop-out ES ⫽ 0.01) (descriptive data only)
INTERPERSONAL PROBLEMS IN THE EATING DISORDERS
569
570 24.8 years (s ⫽ 6.89); 92.5% female
n ⫽ 133; AN-R⫹ ANBP
Zeeck et al., 2005, Germany (24)
IIP-64 Inventory of Interpersonal Problems
ASQ—Attachment Styles Questionnaire; Avoidant attachment Anxious attachment
Pre-treatment measure of interpersonal problems
Inpatient treatment including CBT and psychodynamic therapy with individual and group sessions
Inpatient group psychotherapy with focus on reduced disordered eating behaviour and improved interpersonal relationship; 4 days a week over 8.5–16 weeks
Eating disorder treatment
Drop-out (defined as any one-sided [team or patient] decision for a premature termination of treatment before the planned regular discharge date) n ⫽ 42; completers n ⫽ 91
Completers n ⫽ 33; non-completers n ⫽ 41
Treatment outcome measures (Eating disorder symptoms/ treatment completion)
Those with AN-BP with higher Relationships as Secondary scores (avoidant attachment) tended not to complete treatment, whereas those with AN-BP with lower Relationship as Secondary scores tended to remain in treatment B—2.56, SE ⫽ 1.22, Wald 4.37, P ⫽ 0.037, OR ⫽ 12.89; 95% CI 1.16–140.85. Those with AN-BP with higher Preoccupied attachment scores (anxious attachment) tended to complete treatment, and those with lower Preoccupied attachment scores tended not to complete treatment B ⫽ 3.82, SE ⫽ 1.41, Wald 7.29, P ⫽ 0.007; OR ⫽ 45.44; 95% CI 2.85–725.13 Differences on pre-treatment IIP measures between treatment drop-out and completer groups failed to reach significance. Using logistic regression none of the IIP subscales predicted dropout/ completion (no data reported)
Main findings
BN, bulimia nervosa; s, standard deviation; CBT, cognitive behaviour therapy; ES, effect size; EDNOS, eating disorders not otherwise specified; IPT, interpersonal therapy; AN, anorexia nervosa; AN-R, anorexia nervosa restrictive subtype; AN-BP, anorexia nervosa binge/purge subtype; BMI, body mass index; EDE, Eating Disorder Examination.
28.42 (s ⫽ 10.64); 100% female
Age in years
n ⫽ 74; AN-R ⫽ 30; AN-BP ⫽ 44
Sample size/eating disorder diagnosis
Tasca et al., 2004, Canada (23)
Study: author, year, country
Table 2. (Continued )
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Discussion The aim of the review was to examine the association between pre-treatment interpersonal problems and treatment outcome in people diagnosed with an eating disorder in an attempt to better understanding the role of interpersonal problems in symptom maintenance and symptom reduction, and to inform clinical practice. The majority of studies reviewed found significant and detrimental associations between pre-treatment interpersonal problems and treatment outcome (e.g. eating disorder pathology or treatment completion). Three of the studies, however, found no significant associations (13, 15, 24). The study characteristics—age of study participants, type of eating disorder, type of therapy or treatment setting could not explain the observed heterogeneity, although it was likely that some of the studies were underpowered due to small sample size. The mechanisms of action are therefore unclear when comparing studies finding an association between interpersonal problems and treatment outcome with studies not finding an association. The model of interpersonal functioning in the eating disorders proposed by Arcelus et al. (9) suggests that individuals with a restrictive-type eating disorder may differ on type and severity of interpersonal problem(s) compared with individuals with a binge/purge-type of eating disorder. Subsequently, such differences may explain variances in treatment outcome. Unfortunately, only four of the studies reviewed examined differences on interpersonal measures and treatment outcome across eating disorder type (2, 10, 23, 24). The combined findings of the studies tentatively suggest that individuals with a binge/purge-type eating disorder may be more affected by interpersonal issues, in particular social avoidance, resulting in higher risk of treatment drop-out and poorer prognosis. Support for this is found in a related study by Eldredge et al. (27), in which good treatment outcome (including reduction in binge frequency) in people enrolled in a weight-loss programme was found to be significantly associated with lower pretreatment scores on the IIP socially avoidant subscale. Thus, when looking at type of interpersonal problem and treatment outcome, social avoidance may be a detrimental characteristic, especially for people with a binge/ purge-type eating disorder. There is related evidence that the client–therapist relationship may mediate the association between interpersonal difficulties and treatment success. Interpersonal problems such as social avoidance at the start of therapy may influence treatment recovery by reducing the individual’s ability to engage in the treatment process on a meaningful/functional level (11–15). For example, Constantino et al. (13) found that pre-treatment interpersonal problems were associated with poorer therapist alliance at mid-treatment for individuals with BN following a programme of interpersonal therapy (IPT). Moreover, the NORD J PSYCHIATRY·VOL 69 NO 8·2015
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model of interpersonal functioning in the eating disorders proposed by Arcelus et al. (9) suggests that individuals with AN-R may be more compliant, may want to avoid conflict with others and may be more worried about negative evaluation (for example from the therapist), which may aid in maintaining the therapeutic relationship and increase the likelihood of treatment completion and reduction in eating disorder pathology. Conversely, individuals with AN-BP and BN may display more interpersonal distrust and hostility toward others including the therapist (9), which may cause barriers to maintaining the therapeutic bond, reduce treatment-effect and increase the likelihood of premature disengagement from treatment (18, 19, 23). Also, Tasca et al. (23) suggest that higher levels of avoidant attachment in individuals with AN-BP may lead to a devaluation of the importance of the therapeutic relationship and a disengagement from the therapeutic process when concerns of weight gain are challenged. Thus, differences in interpersonal profiles between eating disorder types may, via their influence on therapeutic alliance, explain some of the variance in treatment success in individuals being treated for an eating disorder. In addition to the possible disruption to the therapeutic relationship and subsequent treatment effect, interpersonal difficulties have been suggested to disrupt treatment outcome by hampering the potentially positive effect that the family and social network of the individual with an eating disorder may have on recovery (28). The review by Arcelus et al. (9) suggests that individuals with AN-R are more likely to avoid expressing feelings to others compared with individuals with AN-BP and BN. This could result in fewer reported problems in AN-R patients (e.g. Carter et al. (10)) and may explain some of the differences observed between subtypes on measures of psychopathology (23). Future research may wish to explore further the role of willingness to report on self-report measures of psychopathology in people with restrictive and binge/purge-type eating disorders. Finally, while some interpersonal problems may be detrimental to treatment outcome, anxious attachment may be associated with less attrition in individuals with AN-BP (23), and social anxiety may be associated with better treatment outcome in AN patients (16). Individuals with anxious attachment styles and social anxiety may have more concerns about negative peer appraisal, be more prone to worries about losing the client–therapist relationship and have a greater need for positive appraisal from the therapist, resulting in increased likelihood of treatment completion (23).
Study limitations, clinical implications and concluding remarks The review highlights the need for a more detailed analysis of the role specific interpersonal problems play in treatment outcome across the eating disorders. The
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thirteen studies included in the review differed (among other things) in how interpersonal problems were operationalized (with the IIP most commonly used), differed in type of eating disorder examined, differed on whether individuals were grouped by eating disorder diagnosis or transdiagnostically and differed in terms of the type of treatment method applied. While such diversity increases ecological validity, it makes comparative analysis challenging and conclusions tentative. Moreover, the research methodology differed in quality, with methodological issues due to small sample sizes or limited external validity observed in some of the studies. Despite these limitations, it does appear that interpersonal problems may have a detrimental impact on treatment success and is an area that deserves more attention. The first step would be to consider screening people for specific interpersonal problems prior to treatment start or in cases in which treatment does not result in early changes in eating disorder symptoms. The decision to screen must be weighed up against the ability to help the individual facilitate change in interpersonal functioning, or the ability to navigate the challenges that certain interpersonal profiles may pose in the therapeutic process—which is the second step. The first step is relatively straight forward, and measures such as the IIP can be used for this purpose. The second step is much more challenging and requires a far better understanding of the interactions between different types of interpersonal issues and treatment success across the eating disorders, as well as a better knowledge of the comparative efficacy of therapies employing different treatment methods for individuals with co-morbid interpersonal difficulties and disordered eating. In the case of socially avoidant behaviour, the recommendations for psychological intervention include exposure therapy, social skills training, feedback to correct distorted cognitions and training in externally focused attention (29, 30). Future research may wish to address the following questions: to what degree (in magnitude and duration) and when in the treatment process do specific interpersonal problems influence treatment adherence and outcome? Do interpersonal problems impede the process of change by hampering the creation of the therapeutic alliance? When are interpersonal problems a result of the eating disorder itself, especially the often shameful bingeing behaviour, and when are such problems an expression of a more severe co-morbidity and a contributing factor to the eating disorder? Answers to such questions may lead to effective interventions focused on the removal of potential interpersonal barriers to treatment completion and behaviour change in the eating disorders. Declaration of interest: The authors report no conflicts of interest.
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References 1. McIntosh VV, Bulik CM, McKenzie J M, Luty S E, Jordan J. Interpersonal psychotherapy for anorexia nervosa. Int J Eat Disord 2000;27:125–39. 2. Hartmann A, Zeeck A, Barrett MS. Interpersonal problems in eating disorders. Int J Eat Disord 2010;43:619–27. 3. Horowitz L M, Rosenberg S E, Baer BA, Ureno G, Villasenor VS. Inventory of Interpersonal Problems: Psychometric properties and clinical applications. J Consult Clin Psychol 1998;56:885–92. 4. Kernhof K, Kaufhold J, Grabhorn R. Object relations and interpersonal problems in sexually abused female patients: An empirical study with the SCORS and the IIP. J Pers Assess 2008;90:44–51. 5. Connan F, Troop N, Lamdau S, Campbell I C, Treasure J. Poor social comparison and the tendency to submissive behaviour in anorexia nervosa. Int J Eat Disord 2007;40:733–9. 6. Troop N A, Allan S, Treasure J L, Katzman M. Social comparison and submissive behaviour in eating disorder patients. Psychol Psychother Theory Res Pract 2003;76:237–49. 7. Haslam M, Meyer C, Arcelus J. Interpersonal problems in bulimic disorders. Eur Eat Disorders Rev 2010;11. 8. Telch C F, Agras W S. Obesity, binge eating and psychopathology: Are they related? Int J Eat Disord 1994;15:53–61. 9. Arcelus J, Haslam M, Farrow C, Meyer C. The role of interpersonal functioning in the maintenance of eating psychopathology: A systematic review and testable model. Clin Psychol Rev 2013;33:156–67. 10. Carter J C, Kelly A C, Norwood S J. Interpersonal problems in anorexia nervosa: Social inhibition as defining and detrimental. Personal Indiv Diff 2012;53:169–74. 11. Chen E C, Mallinckrodt B. Attachment, group attraction, and selfother agreement in interpersonal circumplex problems and perceptions of group members. Group Dynam 2002;6:311–24. 12. Clinton D, Bjarck C, Sohlberg S, Norring C. Patient satisfaction with treatment in eating disorders: Cause for complacency or concern? Eur Eat Disorders Rev 2004;12:240–6. 13. Constantino MJ, Arnow BA, Blasey C, Agras W S. The association between patient characteristics and the therapeutic alliance in cognitive-behavioural and interpersonal therapy for bulimia nervosa. J Consult Clin Psychol 2005;73:203–11. 14. Hilliard R B, Henry W P, Strupp H H. An interpersonal model of psychotherapy: Linking patient and therapist developmental history, therapeutic process, and types of outcome. J Consult Clin Psychol 2000;68:125–33. 15. Olmsted M P, Kaplan AS, Rockert W. Rate and prediction of relapse in bulimia nervosa. Am J Psychiatry 1994;151:738–43. 16. Ohmann S, Popow C, Wurzer M, Karwautz A, Sackl-Pammer P, Schuch B. Emotional aspects of anorexia nervosa: Results of prospective naturalistic cognitive behavioural group therapy. Neuropsychiatry 2013;27:119–28. 17. Goddard E, Hibbs R, Raenker S, Salerno L, Arcelus J, Boughton N, et al. A multi-centre cohort study of short term outcomes of hospital treatment for anorexia nervosa in the UK. BMC Psychiatry 2013;13:287. 18. Agras WS, Crow SJ, Halmi KA, Mitchell JE, Wilson GT, Kraemer HC. Outcome predictors for the cognitive behaviour treatment of bulimia nervosa: Data from a multisite study. Am J Psychiatry 2000;157:1302–8. 19. Arcelus J, Whight D, Langham C, Baggott J, McGrain L, Meadows L, et al. Case series evaluation of a modified version of interpersonal psychotherapy (IPT) for the treatment of bulimic eating disorders: A pilot study. Eur Eat Disorders Rev 2009;17:260–8. 20. Ghaderi A. Does individualization matter? A randomized trial of standardized (focused) versus individualized (broad) cognitive behaviour therapy for bulimia nervosa. Behav Res Ther 2006;44:273–88. 21. Hartmann A, Orlinsky D, Weber S, Sandholz A, Zeeck A. Session and intersession experience related to treatment outcome in bulimia nervosa. Psychother Theory Res Pract Train 2010;47:355–70. 22. Rø Ø, Martinsen EW, Hoffart A, Sexton H, Rosenvinge J H. Adults with chronic eating disorders. Two-year follow-up after inpatient treatment. Eur Eat Disorders Rev 2005;13:255–63.
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28. Tozzi F, Sullivan P F, Fear J L, McKenzie J, Bulik C M. Causes and recovery in anorexia nervosa: The patient’s perspective. Int J Eat Disord 2003;33:143–54. 29. Alden LE, Laposa J M, Taylor CT, Ryder AG. Avoidant personality disorder: Current status and future directions. J Pers Disord 2002;16:1–29. 30. National Institute for Health and Care Excellence (NICE) Guidelines; 2013. Retrieved 6 August 2014, from http://www.nice.org.uk/ guidance/CG159/chapter/1-Recommendations Allan Jones, Institute of Psychology, University of Southern Denmark, Denmark. Nanna Lindekilde, Institute of Psychology, University of Southern Denmark, Denmark. Marlene Lübeck, Institute of Psychology, University of Southern Denmark, Denmark. Loa Clausen, Centre of Child- and Adolescent Psychiatry, Aarhus University Hospital, Risskov, Denmark.
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23. Tasca GA, Taylor D, Bissada H, Ritchie K, Balfour L. Attachment predicts treatment completion in an eating disorders partial hospital program among women with anorexia nervosa. J Pers Assess 2004;83:201–12. 24. Zeeck A, Hartmann A, Buchholz C, Herzog T. Drop outs from in-patient treatment of anorexia nervosa. Acta Psychiatr Scand 2005;111:29–37. 25. Fairburn CG, Cooper Z, Shafran R. Cognitive behaviour therapy for eating disorders: A “transdiagnostic” theory and treatment. Behav Res Ther 2003;41:509–28. 26. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52: 377–84. 27. Eldredge K L, Locke K D, Horowitz L M. Patterns of interpersonal problems associated with binge eating disorder. Int J Eat Disord 1998;23:383–9.
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ISSN: 0803-9488 (Print) 1502-4725 (Online) Journal homepage: http://www.tandfonline.com/loi/ipsc20
The association between interpersonal problems and treatment outcome in the eating disorders: A systematic review Allan Jones, Nanna Lindekilde, Marlene Lübeck & Loa Clausen To cite this article: Allan Jones, Nanna Lindekilde, Marlene Lübeck & Loa Clausen (2015) The association between interpersonal problems and treatment outcome in the eating disorders: A systematic review, Nordic Journal of Psychiatry, 69:8, 563-573, DOI: 10.3109/08039488.2015.1019924 To link to this article: http://dx.doi.org/10.3109/08039488.2015.1019924
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The association between interpersonal problems and treatment outcome in the eating disorders: A systematic review ALLAN JONES, NANNA LINDEKILDE, MARLENE LÜBECK, LOA CLAUSEN
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Jones A, Lindekilde N, Lübeck M, Clausen L. The association between interpersonal problems and treatment outcome in the eating disorders: A systematic review. Nord J Psychiatry 2015;69:563–573. Objective: To review systematically the eating disorder literature in order to examine the association between pre-treatment interpersonal problems and treatment outcome in people diagnosed with an eating disorder. Methods: Six relevant databases were searched for studies in which interpersonal problems prior to treatment were examined in relation to treatment outcome in patients diagnosed with anorexia nervosa (AN), bulimia nervosa (BN) or eating disorders not otherwise specified (EDNOS). Results: Thirteen studies were identified (containing 764 AN, 707 BN and 48 EDNOS). The majority of studies indicated that interpersonal problems at the start of therapy were associated with a detrimental treatment outcome. Conclusions: Individuals with a binge/purge-type of eating disorder may be particularly vulnerable to interpersonal issues and these issues may lead to poorer treatment recovery by reducing the individual’s ability to engage in the treatment process on a functional level. The clinical and research implications are discussed. • Eating disorders, Interpersonal problems, Treatment outcome. Allan Jones, M.Sc., Ph.D., C.Psychol., A.F.B.Ps.S., Institute of Psychology, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark, Email: [email protected]; Accepted 12 February 2015.
I
nterpersonal problems have been identified as important in the onset, maintenance and remission of eating disorder symptoms (1). Interpersonal problems are characterized by difficulties in social functioning and problems with forming healthy and meaningful relationships with others. Difficulties interacting with others are often associated with negative or distorted evaluations of the self and compensatory behaviour such as dominance, intrusiveness, non-assertiveness, social-avoidance etc. (2, 3). Individuals with an eating disorder have been found to display more interpersonal problems compared with non-clinical samples (4–6). Moreover, associations between interpersonal problems and eating disorder symptoms have been reported, finding the degree of interpersonal problems to be positively associated with more concerns over eating, shape and weight (7), as well as severity of bulimic behaviour (7, 8). A recent review of cross-sectional studies examining interpersonal problems in people with an eating disorder (restrictive and bingeing/purging-type) found interpersonal problems such as social anxiety, interpersonal sensitivity and social inhibition to be associated with eating disorder psychopathology (9).
© 2015 Informa Healthcare
It has recently been suggested that interpersonal problems at the start of therapy could influence treatment outcome (10). Interpersonal barriers such as the inability of the patient to engage with the therapist and others on a meaningful/functional level may interfere with the treatment process (e.g. treatment completion) and inhibit treatment efficacy (e.g. symptom reduction, recovery) (11–15). As such, a better understanding of the relationship between interpersonal problems and treatment outcome may help to guide future research and to inform clinical practice—such as whether or not to screen for interpersonal problems, as well as implications for psychological treatment. The aim of the present study was therefore to review systematically the eating disorder literature for studies that examine the association between pre-treatment interpersonal problems and treatment outcome in people diagnosed with an eating disorder.
Methods Search strategy Six relevant databases, including PubMed, PsychINFO, Embase, Web of Science, CINAHL and SCOPUS, were DOI: 10.3109/08039488.2015.1019924
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searched, using the Keywords: eating problem* OR eating disorder* OR disordered eating OR anorexia nervosa OR bulimia nervosa combined with [AND] interpersonal problem* OR interpersonal function* OR interpersonal deficit* OR social skills deficit* OR social maladjustment OR social anxiety. No restrictions on date of publication were applied, with all studies published up until 24 April 2014 included in the search (no articles published after April 2014 are included in the review). The search was limited to exclude books and dissertations. After removal of duplicate records, 1361 articles were identified and screened using the following inclusion criteria:
change (BMI), total/composite scores of eating disorder symptoms, treatment completion/drop-out, response/nonresponse to treatment and post-treatment relapse/nonrelapse. The sample size of the studies ranged from 29 to 220 with a total combined n ⫽ 1519, of which 764 were diagnosed with AN, 707 were diagnosed with BN and 48 were diagnosed with EDNOS. One study focused on eating disorders in adolescents only (16) and the study by Goddard et al. (17) split the sample into adolescents and adult inpatient groups.
1) Studies were required to be peer reviewed, written in the English language and include patient samples diagnosed with anorexia nervosa (AN), bulimia nervosa (BN) or eating disorders not otherwise specified (EDNOS); 2) Studies had to include a psychological intervention targeting eating disorder pathology (e.g. bingeing behaviour, purging behaviour, low body mass index, BMI) with eating disorder pathology measured at both preand post-treatment, or treatment completion; 3) Studies were required to include a measure of interpersonal problems measured at pre-treatment/ beginning of treatment; 4) Studies were required to report the association between the pre-treatment measure of interpersonal problems and treatment outcome (e.g. eating disorder pathology or treatment completion).
A summary of the main findings is presented in Table 2. Nine of the studies reported significant and detrimental associations between pre-treatment interpersonal problems and treatment outcome (2, 10, 17–23). Interpersonal problems prior to treatment were found to be significantly related to poorer treatment outcome or treatment noncompletion. The study by Ohmann et al. (16) provided descriptive data only, showing the treatment drop-out group scored higher on levels of social phobia (SPS). The remaining three studies found no significant associations between pre-treatment interpersonal problems and treatment outcome (13, 15, 24).
Single case studies were excluded. In addition, reference lists of relevant articles were searched for any articles that may have been missed by the initial search. In accordance with the review by Arcelus and colleagues (9), studies on eating disorders were targeted—including AN, BN and EDNOS. Studies on disordered eating in nonclinical samples, obesity, body dissatisfaction etc. were not included in the review.
Results The search resulted in 13 studies that examined and presented results on the relationship between interpersonal problems and post-treatment eating disorder pathology. Figure 1 shows a flowchart of the process of study selection, and Table 1 provides an overview of treatment type, eating disorder type and care setting across studies. The following information was extracted from the studies meeting the inclusion criteria and is presented in Table 2: sample size/eating disorder diagnosis, mean age, pre-treatment measure of interpersonal problems, eating disorder treatment, treatment outcome measures (eating disorder symptoms/ treatment completion) and main findings. The treatment outcome variables across the thirteen studies included bingeing behaviour, purging behaviour, weight
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Interpersonal problems and treatment outcome
Type of interpersonal problem and treatment outcome Five studies examined general interpersonal problems in relation to treatment outcome using the Inventory of Interpersonal Problems (IIP) (3), with two studies showing significant positive associations between interpersonal problems and poorer treatment outcome (2, 18), one study showing mixed results (19) and two studies finding no significant associations (13, 21). Five studies included measures of social avoidance with four of the studies finding greater pre-treatment levels of social avoidance to be significantly associated with poorer treatment outcome (2, 10, 22, 23), and only one study finding no significant association (24). Two studies examined pre-treatment social phobia and social anxiety in relation to treatment outcome (16, 20), with one study finding severe social phobia to be the most salient characteristic of patients with unchanged diagnostic status following treatment completion (20), and the other study showing higher levels of social phobia in the drop-out group compared with the good treatment outcome group, and higher levels of social anxiety in the good treatment outcome group compared with the poor treatment outcome group (16). Three studies examined the association between pre-treatment social adjustment and treatment outcome, with two studies finding poorer social adjustment to be significantly related to poorer treatment outcome (18, 21) and one study finding no difference on the social adjustment scale between post-treatment relapsed and non-relapsed groups NORD J PSYCHIATRY·VOL 69 NO 8·2015
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2071 references identified from six electronic databases
710 duplicates removed
1361 articles screened for eligibility
Articles were excluded, if: - Sample not diagnosed with AN, BN or EDNOS (n=589) - The study didnot include a psychological intervention targeting eating disorder (n=387)
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- Eating disorder pathology were not measured pre-and post treatment / treatment completion (n=13) - Interpersonal problems were not measured pretreatment or at the beginning of treatment (n=32) - Association between pre-treatment Interpersonal problems and treatment outcome not measured (n=13) - Not written in English (n=106) - Not a primary research study (n=193) - Case study (n=17)
11 articles included 2 articles included after screening references
A total of 13 articles were included in the review
Fig. 1. Flowchart of the process of study selection.
(15). Finally, in the Hartmann et al. study (2) pre-treatment interpersonal problems with dominant behaviour were found to be significantly associated with less posttreatment weight gain for individuals with AN; the study by Goddard et al. (17) found the quality of social relationships and carer expressed emotion in people with AN significantly predicted eating disorder symptoms at treatment discharge; and the study by Tasca et al. (23) found that people with AN-binge/purge (AN-BP) who scored high on anxious attachment tended to complete treatment, while those with lower anxious attachment tended not to complete treatment.
Study characteristics and treatment outcome Results from each study were entered into a matrix to examine whether significant and null findings were clustered around specific study characteristics available NORD J PSYCHIATRY·VOL 69 NO 8·2015
for extraction across studies, including: age of study participants (adolescent, adult, mixed), type of eating disorder (AN, BN, EDNOS, mixed), type of therapy (cognitive behaviour therapy—CBT, interpersonal therapy—IPT, mixed) and treatment setting (outpatient, inpatient, inpatient and day-care). Six of the studies used treatment dropout as an outcome/categorical variable; as such, treatment duration was not analysed. Significant or null findings were not found to cluster around any specific study characteristic and heterogeneity in outcome could not be explained by these study variables. Associations between interpersonal problems and treatment outcome were observed across the eating disorders. Only four of the studies reviewed examined differences on interpersonal measures and treatment outcome across eating disorder type (2, 10, 23, 24) and eating disorder types were combined in two studies (19, 22) adopting a more transdiagnostic
565
3 1 5 4 ⫹
⫹
CBT, cognitive behaviour therapy; IPT, interpersonal therapy; BT, behaviour therapy; AN, anorexia nervosa; BN, bulimia nervosa.
⫹ ⫹ ⫹ ⫹ ⫹ ⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹ ⫹
⫹ ⫹ ⫹ ⫹
⫹
⫹ ⫹
⫹ ⫹ ⫹ ⫹ ⫹ ⫹
Treatment type CBT IPT Mixed Eating disorder type AN BN Mixed Care setting Inpatient Day-care Outpatient Inpatient & day-care
⫹
⫹
5 5 3 ⫹
⫹ ⫹
Tasca et al., 2004 (23) Rø et al., 2005 (22) Olmsted et al., 1994 (15) Ohmann et al., 2013 (16) Hartmann et al., 2010 (21) Hartmann et al., 2010 (2) Goddard et al., 2013 (17) Ghaderi 2006 (20) Constantino et al., 2005 (13) Carter et al., 2012 (10) Arcelus et al., 2009 (19) Agras et al., 2000 (18)
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Table 1. Overview of treatment type, eating disorder type and care setting across studies.
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⫹
3 2 8
Zeeck et al., 2005 (24)
Total studies
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approach (25). The study by Zeeck et al. (24) reported no significant associations; however, the combined findings of the remaining three studies suggest that individuals with a restrictive-type eating disorder may be less affected by interpersonal issues, resulting in a better treatment outcome. In the study by Carter et al. (10), individuals with AN-BP reported significantly higher levels of overall interpersonal problems compared with individuals with AN-R, and individuals with AN-R were significantly more likely to complete treatment than individuals with AN-BP. In the Tasca et al. (23) study, individuals with AN-BP displaying high avoidant attachment tended not to complete treatment, whereas individuals with AN-BP and low avoidant attachment tended to remain in treatment. The same was not found for the AN-R group, however. In the study by Hartmann et al. (2), people with AN-BP measured significantly higher on social avoidance and interpersonal distress compared with people with AN-restrictive (AN-R) and BN. Accordingly, binge frequency decreased significantly over the course of treatment for individuals with BN, but not for individuals with AN-BP. Number of participants per group was also examined (below 50 participants, between 50 and 100 participants, over 100 participants). Significant associations were found across all group size categories. Effect sizes were calculated for studies with groups in the under-50participant category that reported non-significant findings and statistical power examined. The Arcelus et al. (19), Ghaderi (20), Hartmann et al. (21) and Olmsted et al. (15) studies were potentially underpowered; unfortunately, there were insufficient data available to calculate effect sizes. The study by Zeeck et al. (24) found no significant differences on the IIP subscales between treatment drop-out (n ⫽ 42) and completer groups (n ⫽ 91). However, when looking at effect sizes for differences on IIP subscale measures between groups, effect sizes in the small to medium range were observed on the subscales domineering (Hedges g ⫽ 0.33; power [1 ⫺ B err prob] ⫽ 0.42), overly-nurturant (Hedges g ⫽ 0.38; power [1 ⫺ B err prob] ⫽ 0.52) and intrusive (Hedges g ⫽ 0.44; power [1 ⫺ B err prob] ⫽ 0.65) with the drop-out group displaying more problems in these areas at pre-treatment. Statistical power calculations indicated risk of type II error over the recommended parameters (power calculated with alpha at 0.05—two tailed). In addition to risk of type II error, the quality of the studies included in the review was assessed using the Downs and Black (26) checklist for the methodological quality of studies of healthcare interventions. Issues in external validity only were observed. This was due to the use of specialized treatment conditions and/or the inclusion of selected study participants making generalization of findings to the wider eating disorder population limited in three of the studies (13, 18, 22). NORD J PSYCHIATRY·VOL 69 NO 8·2015
28.1 years (s ⫽ 7.9); 100% female
28.1 years (s ⫽ 7.0); 100% female
26.0 years (s ⫽ 7.6); 97% female
28.1 (s ⫽ 7.2); 100% female
27.2 years (s ⫽ 7.8); % female—not specified
n ⫽ 59; BN ⫽ 27; EDNOS ⫽ 32
n ⫽ 218; AN-R ⫽ 132; AN-BP ⫽ 86
n ⫽ 220; BN
n ⫽ 50; BN
Arcelus et al., 2009, UK (19)
Carter et al., 2012, Canada (10)
Constantino et al., 2005, USA (13)
Ghaderi, 2006, Sweden (20)
Age in years
n ⫽ 188; BN
Sample size/eating disorder diagnosis
Agras et al., 2000, USA (18)
Study: author, year, country
Table 2. Overview of the studies included in the review.
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Social phobia
IIP- 64; Inventory of Interpersonal Problems
IIP-32—Inventory of Interpersonal Problems (short version)
IIP-32; Inventory of Interpersonal Problems (short version)
IIP -64; Inventory of Interpersonal Problems; SAS-SR Social Adjustment Scale- Self-Report
Pre-treatment measure of interpersonal problems
Outpatient manual based CBT or individualized CBT; 19 weekly individual sessions, of 50 min duration
Outpatient CBT or IPT Individual psychotherapy 19 sessions of 50 min duration conducted over 20 weeks
Inpatient and day care group psycho-therapy with an interpersonal focus; 30–40 h weekly, with an average length of stay of 13.5 weeks
Outpatient IPT; 16 weekly sessions of 45 min duration
Outpatient CBT; 18 individual 50-min sessions over 16 weeks
Eating disorder treatment
Main findings
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(Continued )
Non-completers had higher scores on pre-treatment IIP than completers, ES ⫽ 0.39; non-completers were more likely to have reported poor social adjustment (SAS-SR) than completers, ES ⫽ 0.45; nonrecovered had higher scores on pre-treatment IIP than recovered, ES ⫽ 0.36; non-recovered were more likely to have reported poor social adjustment (SAS-SR) than recovered, ES ⫽ 0.46 Non completers n ⫽ 14; Non-completers had significantly completers n ⫽ 45; non higher levels of interpersonal responders to treatment problems (IIP) than completers n ⫽ 13; responders to Z ⫽ 2.733; P ⫽ 0.006; no significant treatment n ⫽ 32 differences on the IIP were found between non-responders and responders (no data reported) Completers n ⫽ 124 The socially avoidant subscale on the (achieving BMI ⱖ 20 by IIP significantly predicted treatment end of treatment & outcome (as levels of initial social remittance of binge eating avoidance increased, the odds of & purging behaviour successful treatment completion during last 4 weeks of decreased); B ⫽ ⫺ 0.48; SE 0.21; treatment); non completers Wald 5.40; P ⫽ 0.02; OR ⫽ 0.62; n ⫽ 94 (not meeting the 95% CI 0.41 ⫺ 0.93 above criteria) Purge frequency There were no significant correlations between pre-treatment IIP and post-treatment purge frequency r ⫽ 0.00, or change in purge frequency r ⫽ ⫺ 0.06 (change from baseline to session 12) Unchanged diagnosis n ⫽ 2; The most salient characteristic of still symptomatic n ⫽ 8; patients with unchanged diagnostic responders to treatment status (n ⫽ 2) was presence of n ⫽ 40; EDE—Eating severe social phobia disorder examination; EDE-Q –Eating disorder Questionnaire; EDIEating disorder inventory
Dropped out n ⫽ 48; completed n ⫽ 140; not recovered n ⫽ 82; recovered n ⫽ 58
Treatment outcome measures (Eating disorder symptoms/ treatment completion)
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568 SAS-SR—Social Adjustment Scale—SelfReport; IIP-64— Inventory of Interpersonal Problems
24.5 years (s ⫽ 7.5), 94% female
25.1 years (s ⫽ 7.4); 93% female
n ⫽ 208; AN-R ⫽ 56; AN–BP ⫽ 57; BN ⫽ 95
n ⫽ 43; BN
Hartmann et al., 2010, Germany (21)
Goddard et al., 2013, UK (17)
Hartmann et al., 2010, Germany (2)
Age in years WHO Social ⫽ quality of social relationships. Levels of Expressed Emotion Scale (LEE) ⫽ carer expressed emotion IIP-64; Inventory of Interpersonal Problems
Sample size/eating disorder diagnosis
Pre-treatment measure of interpersonal problems
n ⫽ 177; inpatient Inpatient adult:26.5 adult: AN ⫽ 150; (s ⫽ 8.9); 95.5% inpatient adolescent: female; inpatient AN ⫽ 11; day adolescent:15.2 patient adult: (s ⫽ 1.6); 91.1% AN ⫽ 16 female; day patient adult:24.7 (s ⫽ 5.3); 100% female
Study: author, year, country
Table 2. (Continued )
Inpatient and day care over 13 weeks. Twice-weekly individual psychodynamic psychotherapy sessions, 6 weekly group sessions (a psychodynamic group twice a week, a body therapy group twice a week, an eating disorder group once a week, and an art therapy group once a week), 1–2 family sessions over the course of therapy and CBT sessions
Inpatient adult: AN ⫽ 150; Inpatient adolescent: AN ⫽ 11; Day care adult: AN ⫽ 16; Guided self-help skills training intervention using a cognitive interpersonal and behavioural maintenance model Inpatient and day care weekly individual and group psycho-dynamic therapy, body therapy, relaxation therapy, art therapy, symptom oriented behavioural therapy and family therapy; Average treatment duration approx. 33 weeks for AN-R, 31 weeks for AN-BP, 21 weeks for BN
Eating disorder treatment
Outcome at 3 months follow-up; treatment failure n ⫽ 18; treatment success (partial or full remission) n ⫽ 22 (3 missing)
Binge severity ⫽ BN and AN-BP; weight gain (BMI) ⫽ AN-R and AN-BP
Eating Disorder Examination— Questionnaire (EDEQ); BMI
Treatment outcome measures (Eating disorder symptoms/ treatment completion)
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Higher total scores on pre-treatment IIP were associated with greater binge severity at the end of treatment, but not weight gain (no data reported); BN, AN-BP: initial problems with social avoidance significantly predicted greater binge severity at end of treatment β ⫽ 0.24, SE ⫽ 0.13, P ⬍ 0.005; AN-R, AN-BP: initial problems with dominance significantly predicted less weight gain over the course of treatment β ⫽ ⫺ 0.22, SE ⫽ 0.07, P ⬍ 0.005 Poor social adjustment at intake (SAS-SR total) significantly predicted treatment failure at 3-months follow-up R2 ⫽ 0.13, P ⫽ 0.006; main factors on the IIP did not predict treatment failure/ success (no data reported)
Significant interpersonal predictors of eating disorder symptoms at discharge included quality of social relationships (WHO Social) β ⫽ 0.178, P ⬍ 0.05 and expressed emotion (LEE) β ⫽ 0.205, P ⬍ 0.05
Main findings
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14.3 (range 13–17); 100% female
25.8 (s ⫽ 7.1); 100% female
30.2 (s ⫽ 7.6); 98.6% female
n ⫽ 29; AN-R ⫽ 22; AN-BP ⫽ 7
n ⫽ 48; BN
n ⫽ 72; AN ⫽ 13; AN-R ⫽ 7; BN ⫽ 36; EDNOS ⫽ 16
Ohmann et al., 2013, Austria (16)
Olmsted et al., 1994, Canada (15)
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Rø et al., 2005, Norway (22)
The avoidant personality index
SAS-SR—Social Adjustment Scale- Self-Report
SPS—Social Phobia Scale; SIAS— Social Interaction Anxiety Scale
Day care group psychotherapy focused on normalizing eating behaviour; 8 h a day 5 days a week, over 8–16 weeks Inpatient CBT, IPT, art therapy or psychoeducation. Daily group meetings over 22–23 weeks for AN and 15 weeks for BN
Outpatient group CBT a maximum of 40 weekly sessions lasting 90 min and family sessions once monthly.
EDE—Eating Disorder Examination; EDI— Eating Disorder Inventory
Good outcome: attaining the 25th age related BMI percentile, absence of restrictive or bulimic eating behaviour and other strategies for losing weight, eating & problem behaviour changed to normal. Poor outcome: very protracted course, small improvements or deterioration in BMI, restrained eating behaviour, no or small changes of other outcome variables. Drop-out: patients discontinued CBT before attaining target therapeutic goals Relapsed group n ⫽ 15; non-relapsed group n ⫽ 33
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(Continued )
Differences between pre-treatment scores on the social adjustment scale between post-treatment relapsed and non-relapsed groups did not reach significance (no data reported) The avoidant personality index significantly predicted the level of eating disorder related distress (global EDE) at follow-up B ⫽ 0.88, SE ⫽ 0.18, df ⫽ 247, t ⫽ 4.9, P ⬍ 0.0001, but did not significantly predict treatment outcome (i.e. improved at the same rate as the others)
Drop-outs (n ⫽ 8) scored higher on pre-treatment levels of social phobia (SPS—social phobia scale) compared with good outcome (n ⫽ 16) and poor outcome (n ⫽ 5) patients; social phobia (SPS): good: 14.2 ⫾ 7.7; poor: 13.6 ⫾ 6.3 (good vs. poor ES ⫽ 0.08); drop-out: 18.8 ⫾ 14.7 (good vs. drop-out ES ⫽ 0.39). The good outcome group scored higher on levels of social anxiety than the poor outcome group. Social anxiety (SIAS): good: 24.6 ⫾ 8.9; poor: 22.0 ⫾ 10.9 (good vs. poor ES ⫽ 0.26); drop-out: 24.5 ⫾ 9.5 (good vs. drop-out ES ⫽ 0.01) (descriptive data only)
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570 24.8 years (s ⫽ 6.89); 92.5% female
n ⫽ 133; AN-R⫹ ANBP
Zeeck et al., 2005, Germany (24)
IIP-64 Inventory of Interpersonal Problems
ASQ—Attachment Styles Questionnaire; Avoidant attachment Anxious attachment
Pre-treatment measure of interpersonal problems
Inpatient treatment including CBT and psychodynamic therapy with individual and group sessions
Inpatient group psychotherapy with focus on reduced disordered eating behaviour and improved interpersonal relationship; 4 days a week over 8.5–16 weeks
Eating disorder treatment
Drop-out (defined as any one-sided [team or patient] decision for a premature termination of treatment before the planned regular discharge date) n ⫽ 42; completers n ⫽ 91
Completers n ⫽ 33; non-completers n ⫽ 41
Treatment outcome measures (Eating disorder symptoms/ treatment completion)
Those with AN-BP with higher Relationships as Secondary scores (avoidant attachment) tended not to complete treatment, whereas those with AN-BP with lower Relationship as Secondary scores tended to remain in treatment B—2.56, SE ⫽ 1.22, Wald 4.37, P ⫽ 0.037, OR ⫽ 12.89; 95% CI 1.16–140.85. Those with AN-BP with higher Preoccupied attachment scores (anxious attachment) tended to complete treatment, and those with lower Preoccupied attachment scores tended not to complete treatment B ⫽ 3.82, SE ⫽ 1.41, Wald 7.29, P ⫽ 0.007; OR ⫽ 45.44; 95% CI 2.85–725.13 Differences on pre-treatment IIP measures between treatment drop-out and completer groups failed to reach significance. Using logistic regression none of the IIP subscales predicted dropout/ completion (no data reported)
Main findings
BN, bulimia nervosa; s, standard deviation; CBT, cognitive behaviour therapy; ES, effect size; EDNOS, eating disorders not otherwise specified; IPT, interpersonal therapy; AN, anorexia nervosa; AN-R, anorexia nervosa restrictive subtype; AN-BP, anorexia nervosa binge/purge subtype; BMI, body mass index; EDE, Eating Disorder Examination.
28.42 (s ⫽ 10.64); 100% female
Age in years
n ⫽ 74; AN-R ⫽ 30; AN-BP ⫽ 44
Sample size/eating disorder diagnosis
Tasca et al., 2004, Canada (23)
Study: author, year, country
Table 2. (Continued )
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Discussion The aim of the review was to examine the association between pre-treatment interpersonal problems and treatment outcome in people diagnosed with an eating disorder in an attempt to better understanding the role of interpersonal problems in symptom maintenance and symptom reduction, and to inform clinical practice. The majority of studies reviewed found significant and detrimental associations between pre-treatment interpersonal problems and treatment outcome (e.g. eating disorder pathology or treatment completion). Three of the studies, however, found no significant associations (13, 15, 24). The study characteristics—age of study participants, type of eating disorder, type of therapy or treatment setting could not explain the observed heterogeneity, although it was likely that some of the studies were underpowered due to small sample size. The mechanisms of action are therefore unclear when comparing studies finding an association between interpersonal problems and treatment outcome with studies not finding an association. The model of interpersonal functioning in the eating disorders proposed by Arcelus et al. (9) suggests that individuals with a restrictive-type eating disorder may differ on type and severity of interpersonal problem(s) compared with individuals with a binge/purge-type of eating disorder. Subsequently, such differences may explain variances in treatment outcome. Unfortunately, only four of the studies reviewed examined differences on interpersonal measures and treatment outcome across eating disorder type (2, 10, 23, 24). The combined findings of the studies tentatively suggest that individuals with a binge/purge-type eating disorder may be more affected by interpersonal issues, in particular social avoidance, resulting in higher risk of treatment drop-out and poorer prognosis. Support for this is found in a related study by Eldredge et al. (27), in which good treatment outcome (including reduction in binge frequency) in people enrolled in a weight-loss programme was found to be significantly associated with lower pretreatment scores on the IIP socially avoidant subscale. Thus, when looking at type of interpersonal problem and treatment outcome, social avoidance may be a detrimental characteristic, especially for people with a binge/ purge-type eating disorder. There is related evidence that the client–therapist relationship may mediate the association between interpersonal difficulties and treatment success. Interpersonal problems such as social avoidance at the start of therapy may influence treatment recovery by reducing the individual’s ability to engage in the treatment process on a meaningful/functional level (11–15). For example, Constantino et al. (13) found that pre-treatment interpersonal problems were associated with poorer therapist alliance at mid-treatment for individuals with BN following a programme of interpersonal therapy (IPT). Moreover, the NORD J PSYCHIATRY·VOL 69 NO 8·2015
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model of interpersonal functioning in the eating disorders proposed by Arcelus et al. (9) suggests that individuals with AN-R may be more compliant, may want to avoid conflict with others and may be more worried about negative evaluation (for example from the therapist), which may aid in maintaining the therapeutic relationship and increase the likelihood of treatment completion and reduction in eating disorder pathology. Conversely, individuals with AN-BP and BN may display more interpersonal distrust and hostility toward others including the therapist (9), which may cause barriers to maintaining the therapeutic bond, reduce treatment-effect and increase the likelihood of premature disengagement from treatment (18, 19, 23). Also, Tasca et al. (23) suggest that higher levels of avoidant attachment in individuals with AN-BP may lead to a devaluation of the importance of the therapeutic relationship and a disengagement from the therapeutic process when concerns of weight gain are challenged. Thus, differences in interpersonal profiles between eating disorder types may, via their influence on therapeutic alliance, explain some of the variance in treatment success in individuals being treated for an eating disorder. In addition to the possible disruption to the therapeutic relationship and subsequent treatment effect, interpersonal difficulties have been suggested to disrupt treatment outcome by hampering the potentially positive effect that the family and social network of the individual with an eating disorder may have on recovery (28). The review by Arcelus et al. (9) suggests that individuals with AN-R are more likely to avoid expressing feelings to others compared with individuals with AN-BP and BN. This could result in fewer reported problems in AN-R patients (e.g. Carter et al. (10)) and may explain some of the differences observed between subtypes on measures of psychopathology (23). Future research may wish to explore further the role of willingness to report on self-report measures of psychopathology in people with restrictive and binge/purge-type eating disorders. Finally, while some interpersonal problems may be detrimental to treatment outcome, anxious attachment may be associated with less attrition in individuals with AN-BP (23), and social anxiety may be associated with better treatment outcome in AN patients (16). Individuals with anxious attachment styles and social anxiety may have more concerns about negative peer appraisal, be more prone to worries about losing the client–therapist relationship and have a greater need for positive appraisal from the therapist, resulting in increased likelihood of treatment completion (23).
Study limitations, clinical implications and concluding remarks The review highlights the need for a more detailed analysis of the role specific interpersonal problems play in treatment outcome across the eating disorders. The
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thirteen studies included in the review differed (among other things) in how interpersonal problems were operationalized (with the IIP most commonly used), differed in type of eating disorder examined, differed on whether individuals were grouped by eating disorder diagnosis or transdiagnostically and differed in terms of the type of treatment method applied. While such diversity increases ecological validity, it makes comparative analysis challenging and conclusions tentative. Moreover, the research methodology differed in quality, with methodological issues due to small sample sizes or limited external validity observed in some of the studies. Despite these limitations, it does appear that interpersonal problems may have a detrimental impact on treatment success and is an area that deserves more attention. The first step would be to consider screening people for specific interpersonal problems prior to treatment start or in cases in which treatment does not result in early changes in eating disorder symptoms. The decision to screen must be weighed up against the ability to help the individual facilitate change in interpersonal functioning, or the ability to navigate the challenges that certain interpersonal profiles may pose in the therapeutic process—which is the second step. The first step is relatively straight forward, and measures such as the IIP can be used for this purpose. The second step is much more challenging and requires a far better understanding of the interactions between different types of interpersonal issues and treatment success across the eating disorders, as well as a better knowledge of the comparative efficacy of therapies employing different treatment methods for individuals with co-morbid interpersonal difficulties and disordered eating. In the case of socially avoidant behaviour, the recommendations for psychological intervention include exposure therapy, social skills training, feedback to correct distorted cognitions and training in externally focused attention (29, 30). Future research may wish to address the following questions: to what degree (in magnitude and duration) and when in the treatment process do specific interpersonal problems influence treatment adherence and outcome? Do interpersonal problems impede the process of change by hampering the creation of the therapeutic alliance? When are interpersonal problems a result of the eating disorder itself, especially the often shameful bingeing behaviour, and when are such problems an expression of a more severe co-morbidity and a contributing factor to the eating disorder? Answers to such questions may lead to effective interventions focused on the removal of potential interpersonal barriers to treatment completion and behaviour change in the eating disorders. Declaration of interest: The authors report no conflicts of interest.
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