When parenting fails: alexithymia and attachment states of mind in mothers of female patients with eating disorders

The association between deficiencies in paternal and maternal reflective functioning and anorexia nervosa symptomatology

BACKGROUND

A large theoretical body of knowledge exists emphasizing the importance of parental mentalizing in the context of anorexia-nervosa (AN). However, the empirical support to these assumptions is still scarce. The aim of the present study was to examine whether parents of patients with AN are characterized by a lower mentalizing ability, and whether it is associated with impaired mentalizing, AN symptomatology and eating disorder (ED) related psychological traits in the daughters.

METHODS

Thirty-two family triads (fathers, mothers, and daughters) of female adolescent and young adult inpatients with AN were compared with thirty-three non-clinical family triads (N = 195). The mentalizing ability of all the participants was assessed using semi-structured interviews and coded using the Reflective Functioning Scale (RFS). Self-report questionnaires were administered to the daughters to evaluate ED symptomatology and ED related psychological traits (e.g., low self-esteem, interpersonal insecurity, emotional dysregulation).

RESULTS

Decreased reflective functioning (RF) levels were found among mothers and fathers of patients with AN compared to their control peers. Examining the entire sample, clinical and non-clinical groups together, showed that both paternal and maternal RF were associated with the daughters' RF and each were found to have a significant and distinct contribution to the daughters' RF. Significant associations were found between lower levels of maternal and paternal RF and increased ED symptoms and ED related psychological traits. The use of a mediation model suggested a serial relationship in which low maternal and paternal RF contributes to the daughters' low RF, which in turn is associated with higher levels of psychological maladjustment, and ultimately contributes to the increased severity of ED symptoms.

CONCLUSIONS

The present results provide strong empirical support for theoretical models that suggest that deficits in parental mentalizing may represent important correlates of the presence and severity of ED symptoms in AN. Furthermore, the results highlight the relevance of fathers' mentalizing ability in the context of AN. Finally, clinical and research implications are discussed.

Caregivers in anorexia nervosa: is grief underlying parental burden?

ABSTARCT

PURPOSE: Anorexia Nervosa (AN) is a severe chronic disorder and parents' experience of caregiving is usually marked by emotional distress and burden. Severe chronic psychiatric disorders are known to be linked with the concept of grief. Grief has not been investigated in AN. The aim of this study was to explore parents' and adolescents' characteristics that may be related to parental burden and grief in AN, and the link between these two dimensions.

METHODS

Eighty mothers, 55 fathers and their adolescents (N  =  84) hospitalized for AN participated in this study. Evaluations of clinical characteristics of the adolescent's illness were completed, as well as self-evaluations of adolescent and parental emotional distress (anxiety, depression, alexithymia). Levels of parental burden were evaluated with the Experience of Caregiving Inventory and levels of parental grief with the Mental Illness Version of the Texas Revised Inventory of Grief.

RESULTS

Main findings indicated that the burden was higher in parents of adolescents with a more severe AN; fathers' burden was also significantly and positively related to their own level of anxiety. Parental grief was higher when adolescents' clinical state was more severe. Paternal grief was related to higher anxiety and depression, while maternal grief was correlated to higher alexithymia and depression. Paternal burden was explained by the father's anxiety and grief, maternal burden by the mother's grief and her child's clinical state.

CONCLUSION

Parents of adolescents suffering from AN showed high levels of burden, emotional distress and grief. These inter-related experiences should be specific targets for intervention aimed at supporting parents. Our results support the extensive literature on the need to assist fathers and mothers in their caregiving role. This in turn may improve both their mental health and their abilities as caregivers of their suffering child.

LEVEL OF EVIDENCE

Level III: Evidence obtained from cohort or case-control analytic studies.

Parent and Child's Negative Emotions During COVID-19: The Moderating Role of Parental Attachment Style

In February 2020, the coronavirus disease 2019 (COVID-19) appeared and spread rapidly in Italy. With the health emergency and social isolation, parents started spending more time with their children, and they might have experienced greater distress. Attachment style is considered as an effective emotion regulation strategy in the parent-child relationship. However, few empirical studies have addressed this issue. Based on attachment theory, this study aimed to find parental attachment style as a candidate to moderate the relation between parents' negative emotions and their perceptions of their children's negative emotions related to COVID-19. Parents (Mage = 42.55 ± 6.56, 88.2% female) of 838 Italian children and adolescents aged 3 to 18 years participated in an online survey. Results showed that parents with a fearful attachment style had significantly higher negative emotions when facing COVID-19 than those with other attachment styles. Moreover, parents with a dismissing attachment style perceived fewer negative emotions in their children than parents with fearful and preoccupied styles. At last, higher parents' negative emotions were associated with greater perception of children's negative emotions only in parents classified as secure and fearful. These findings suggest that parents with dismissing and fearful attachment styles and their children may be at higher risk during the COVID-19 pandemic and they should be given long-term attention.

Assessment of Family Functioning and Eating Disorders - The Mediating Role of Self-Esteem

The aim of the study was to measure whether people at increased risk for eating disorders (EDs) and people without an increased risk of EDs differ from each other in the assessment of family functioning (FF) and self-esteem (SE) dimensions. Moreover, the correlations between FF, EDs, and SE were verified, looking for the mediating role of SE in the context of the FF and EDs. The research was conducted on the group of 160 people aged from 18 to 47 years, including 74 people at increased risk for EDs. We used: The Family APGAR (Adaptability, Partnership, Growth, Affection, and Resolve); The SCOFF Questionnaire; The Multidimensional Self-Esteem Inventory, MSEI. Analyses indicate that the compared groups differ significantly in terms of EDs, assessment of FF, and all components of SE, in such a way that people without an increased risk of EDs are characterized by a more positive assessment of FF and higher SE in all its dimensions. All SE dimensions, except defensive high SE, are mediators in the relationship of FF with EDs. In therapeutic interactions, it is worth focusing on the SE dimensions, as they are one of the mediation elements in the relationship between the assessment of FF and EDs.

Anorexia Nervosa and a Lost Emotional Self: A Psychological Formulation of the Development, Maintenance, and Treatment of Anorexia Nervosa

In this paper, we argue that Anorexia Nervosa (AN) can be explained as arising from a 'lost sense of emotional self.' We begin by briefly reviewing evidence accumulated to date supporting the consensus that a complex range of genetic, biological, psychological, and socio-environmental risk and maintenance factors contribute to the development and maintenance of AN. We consider how current interventions seek to tackle these factors in psychotherapy and potential limitations. We then propose our theory that many risk and maintenance factors may be unified by an underpinning explanation of emotional processing difficulties leading to a lost sense of 'emotional self.' Further, we discuss how, once established, AN becomes 'self-perpetuating' and the 'lost sense of emotional self' relentlessly deepens. We outline these arguments in detail, drawing on empirical and neuroscientific data, before discussing the implications of this model for understanding AN and informing clinical intervention. We argue that experiential models of therapy (e.g., emotion-focused therapy; schema therapy) be employed to achieve emergence and integration of an 'emotional self' which can be flexibly and adaptively used to direct an individual's needs and relationships. Furthermore, we assert that this should be a primary goal of therapy for adults with established AN.

Anorexia Nervosa, Theory and Treatment: Where Are We 35 Years on from Hilde Bruch's Foundation Lecture?

Hilde Bruch's foundation lecture in 1982 is a milestone from which to survey current theory and treatment for anorexia nervosa. Bruch described problems in body perception, emotion processing and interpersonal relationships as core theoretical aspects of the illness and built her theory of psychopathology on these aspects, as well as on animal studies on attachment. She also noted that many psychological problems result as consequence of starvation. In the first part of this paper, we parse Bruch's clinical descriptions into elements of psychopathology (disturbances in body perception, attachment, emotion expression, perception and regulation, social comparison, interpersonal, and family and therapeutic relationships), in order to assemble and update the theoretical evidence for a model of the illness. In the second part, we describe and extend her description of three core targets of treatment: family relationships, patient's inner confusion and nutritional restoration. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Recovery from eating disorder 1 year after start of treatment is related to better mentalization and strong reduction of sensitivity to others

PURPOSE

To investigate whether recovery from an eating disorder is related to pre-treatment attachment and mentalization and/or to improvement of attachment and mentalization during treatment.

METHOD

For a sample of 38 anorexia nervosa (AN) and bulimia nervosa (BN) patients receiving treatment the relations between attachment security, mentalization, comorbidity and recovery status after 12 months (not recovered or recovered), and after 18 months (persistently ill, relapsed, newly recovered, or persistently recovered) were investigated. Attachment security and mentalization were assessed by the Adult Attachment Interview at the start of the treatment and after 12 months. Besides assessing co-morbidity-for its effect on treatment outcome-we measured psycho-neuroticism and autonomy because of their established relations to both eating disorder symptoms and to attachment security.

RESULTS

Recovery both at 12 months and at 18 months was related to higher levels of mentalization; for attachment, no significant differences were found between recovered and unrecovered patients. Patients who recovered from AN or BN also improved on co-morbid symptoms: whereas pre-treatment symptom severity was similar, at 12 months recovered patients scored lower on co-morbid personality disorders, anxiety, depression, self-injurious behaviour and psycho-neuroticism than unrecovered patients. Improvement on autonomy (reduced sensitivity to others; greater capacity to manage new situations) in 1 year of treatment was significantly higher in recovered than in unrecovered patients.

CONCLUSION

A focus on enhancing mentalization in eating disorder treatment might be useful to increase the chances of successful treatment. Improvement of autonomy might be the mechanism of change in recovering from AN or BN.

LEVEL OF EVIDENCE

Level III cohort study.

The parental bonding in families of adolescents with anorexia: attachment representations between parents and offspring

INTRODUCTION

The attachment theory is widely used in order to explain anorexia nervosa origin, course and treatment response. Nevertheless, very little literature specifically investigated parental bonding in adolescents with anorexia, as well as the parents' own bonding and intergenerational transmission within the family.

PURPOSE

This study aims to identify any specific pattern of parental bonding in families of adolescents newly diagnosed with restricting-type anorexia, comparing them to the families of the control group.

PATIENTS AND METHODS

A total of 168 participants, adolescents and parents (78 belonging to the anorexia group and 90 to the control one), rated the perceived parental styles on the parental bonding instrument. The latent class analysis allowed the exploration of a maternal bonding latent variable and a paternal one.

RESULTS

The main findings showed that a careless and overcontrolling parental style was recalled by the patients' parents, and in particular by the fathers. As far as the adolescents' responses were concerned, patients with anorexia did not seem to express differently their parental bonding perception from participants of the control group.

CONCLUSION

Clinical implications driven from the results suggest that a therapeutic intervention working on how the parents' own attachment representations influence current relationships may help to modify the actual family functioning and thus the outcome of patients with anorexia.

Attachment in eating-disordered outpatients with and without borderline personality disorder

This study aims at examining the attachment states of mind in 50 female outpatients with eating disorders compared with 50 matched control participants using the Adult Attachment Interview. Moreover, the differences in attachment states of mind among eating-disordered women with and without borderline personality disorders’ diagnosis were explored. The results showed an over-representation of insecure-dismissing and unresolved states of mind in clinical group compared to controls. Patients with both diagnosis showed higher scores on involving anger and unresolved loss compared with those with only eating disorder. Implications for further research and clinical practice are discussed.

Alexithymic characteristics in pediatric patients with primary headache: a comparison between migraine and tension-type headache

Background

Alexithymia is a personality construct characterized by difficulties in verbal emotional expression and a limited ability to use one’s imagination. Evidence of alexithymic characteristics was found in adults suffering from headache, while little is known about children. The aim of this study was to establish the prevalence of alexithymia in two different subgroups of children and adolescents suffering from primary headache. We also looked for correlation between alexithymia in children and in their mothers.

Methods

This study involved 89 participants: 47 (11 males, 36 females, aged 8 to 17 years) suffering from tension-type headache (TTH), and 42 (18 males, 24 females, aged 8 to 17 years) suffering from migraine (M), based on the International Classification of Headache Disorders (ICHD 2013). A control group of 32 headache-free subjects (26 females and 6 males, aged 8 to17 years) was also considered. Two questionnaires were administered to measure alexithymia: the Alexithymia Questionnaire for Children to young patients and controls, and the Toronto Alexithymia Scale (TAS-20) to the mothers.

Results

Higher rates of alexithymia emerged in the TTH group compared to the M group. In particular, TTH sufferers had difficulty identifying their feelings. The mothers of children with headaches didn’t score higher in alexithymia compared to other mothers. In the M and in the control group, there was a significant correlation between the rates of alexithymia in young people and in their mothers.

Conclusions

To date no other study has investigated alexithymia in subgroups of primary headaches in developmental age. Our results suggest that patients suffering from TTH are more alexithymic than M patients. This pave the way to etiopathogenetic and clinical considerations, calling for a comprehensive and multidisciplinary approach to tackle the problem of headache.