Empirical evidence on the relationship between eating disorders and impaired mentalising is in its early stages. Studies conducted in this field so far have indicated that patients with eating disorders do display deficits in RF. Two studies have
investigated the RF of psychiatric inpatients, including patients with eating disorders. Fonagy et al. (1996) studied 82 psychiatric patients diagnosed with depression, anxiety, substance use, eating disorders, BPD, antisocial or paranoid disorder, and other
personality disorders. Along with the patients diagnosed with BPD, the eating disorder patients scored lowest on RF, which was scored from the AAI. Fourteen eating disorder patients were found to have low mentalising abilities (M = 2.8; SD = 1.7), which was fewer than the other psychiatric patients in the sample with low mentalising abilities. Fonagy et al. suggested that patients with AN have difficulty with interpreting and regulating emotions, as well as discerning the stimuli within their own body. They also suggested that eating disorder patients often experience misunderstandings and
interpersonal conflict, which in turn lead to a further sense of insecurity and reduction in mentalising abilities (Zavattini, n.d.). In this context, AN symptoms are seen to be a means of gaining control and predictability.
In a similar study, Müller, Kaufhold, Overbeck and Grabhorn (2006) investigated RF on 24 psychiatric inpatients (aged 18–55; mean age 28). Of these patients, 16 met DSM-4 criteria for eating disorders (8 AN and 8 BN) and 8 for depressive disorders. The participants mean RF score was low (M = 3.0; SD: none reported). Scores varied between 1 (absent RF) and 5 (ordinary RF); no participants demonstrated scores indicating distinct RF (scores of 6 or above). Separate mean scores for eating disorders and depression were not reported. Neither of these studies utilised a control group, but instead relied on normative data that scores of 3 and below
correspond to questionable or low RF.
One study (Skårderud, 2007a) investigated themes of mentalising and AN via a qualitative study. Skårderud interviewed 10 female patients (aged 16–35) about the nature and history of their eating disorders. He identified examples of psychic
equivalence mode, which he identified as the patients expressing their internal affect as concretised metaphors, that is, expressing internal affect through physical means. In the transcripts, the women used body sensations and qualities such as weight, shape and hunger to represent psychological processes. This tendency represents difficulty
discriminating physical reality from psychological reality and a use of the body or food as symbolic tools for controlling and representing inner experiences.
Examples of pretend mode were also identified, as patients talked about
themselves using words that did not connect with real experiences. Skårderud identified patients operating in teleological mode, as they attempted to change their feelings of ineffectiveness and social acceptance by directing their energy towards altering their physical bodies. Skårderud surmised that the symptoms of an eating disorder help provide a coherent sense of self and a maladaptive mode of communication of a
patient’s inner experiences. Although the study was of a very small sample, it provided qualitative evidence of the concretisation that Skårderud described.
Some studies in the field of eating disorders have investigated the conceptual link between attachment theory and mentalising, taking into account intergenerational transmission of attachment. Evidence for the intergenerational transmission of insecure attachment models and unresolved states of mind was demonstrated by Ward et al. (2001), who investigated RF in the attachment relationship between mothers and their adolescent or adult children (aged 15–46; n = 20) with AN. The study found that inpatients with a diagnosis of AN demonstrated low RF (M = 2.4; SD = 1.6) compared to published norms. This study also undertook a transgenerational perspective on attachment. While no association of attachment classification was found between the women with AN and their mothers, both mothers and their daughters scored low on RF (mean 2.4), and the majority of the mothers were classified as unresolved with respect
to loss using the AAI. This suggests that the mothers’ dysregulated affect, typical of the unresolved state of mind, may have had an impact on their daughters’ psychological functioning, leading them to use minimising and idealising strategies as defences to help them avoid the emotional impact of their mothers’ negative affect. This idealising- dismissing strategy perhaps results in a poorly developed ability to recognise and express emotions that is a typical characteristic of patients with AN (Zavattini, n.d.). A significant limitation of this study is the absence of a comparison group. Further, it is important to note that the groups of eating disorder patients in the Fonagy and Ward studies were suffering from eating disorders significant enough to be treated in an inpatient setting. This limits the generalisability of the findings, considering that most individuals suffering from eating disorders are treated as outpatients (Katzman, Kanbur, & Steinegger, 2010). Another possible limitation of Ward et al.’s study is the question of whether the RF scale on the AAI is a reliable measure of RF in adolescents.
Rothschild-Yakar et al. (2010) also compared RF scores (measured with AAI) across 34 female inpatients with AN-BP, ranging in age from adolescence to adulthood (mean age 18.2 years; SD = 2.7) and 35 non-eating-disordered controls (mean age 17.8 years; SD = 2.31). This study investigated the influence of RF on eating disorder symptoms, and also its interaction with the perceived quality of their relationship with parents. They found that the patients with eating disorders presented with higher RF scores (M = 3.8; SD = 1.8) than those reported in Ward et al. (2001); however, this mean RF of the eating disordered group was significantly lower than that of normal control group (M = 5.77; SD = 1.46; F(1, 67) = 24.48, p < .001). They also found that high RF correlated with lower eating disorder symptomatology as measured by the Eating Disorders Inventory. Higher RF in the patient group correlated positively with bulimic symptoms. When the eating disorder group was split into subcategories
according to ‘drive for thinness’ and ‘bulimia’, the bulimia subscale was significantly correlated to higher RF scores (r = 0.36, p < 0.05). Bulimia symptomatology has been associated with the preoccupied attachment style (Candelori & Ciocca, 1998), which involves a higher awareness of one’s own internal states and therefore increased tendency to reflect on them in the AAI, resulting in a higher RF score. This link could account for Rothschild-Yakar et al.’s finding, though it also needs to be kept in mind that the mean RF for this bulimia group still represented questionable or low RF according to the RF rating scale. In the control group for this study, higher RF score correlated negatively with drive for thinness. A methodological strength of this study is that it included a control group, and the sample consisted only of eating disorder patients. It is important to note that all patients were inpatients at the time of recruitment, and all met full criteria for AN-BP. While all patients were deemed medically stable, they were receiving inpatient treatment and may therefore have been at the severe end of the spectrum for the disease. In addition, 61.8% of the patient group were diagnosed with comorbid depressive disorder, and 26.5% were diagnosed with a comorbid obsessive-compulsive disorder. The researchers did not control for symptoms of anxiety or depression in the analysis.
Rothschild-Yakar et al. (2013) investigated mentalising and attachment patterns of 71 female adolescent inpatients with eating disorders (AN-R, n = 31; AN-BP, n = 18; and BN, n = 22) and 45 controls without eating disorders (both groups aged 14–19) using the Object Relations Inventory and self-report measures assessing emotional distress and eating disorder symptoms. They found that patients with eating disorders had significantly lower mentalising capacity compared to the non-clinical controls. Higher mentalising abilities were found to indirectly predict lower eating disorder symptoms via lower distress levels. The authors suggested that adequate mentalising
capacity and positive working models of attachment to parents may serve as protective factors against severity of eating disorder symptoms.
These findings were corroborated by Zavattini’s (n.d.) recent study; as previously described, this study focused on attachment style and RF in a group of 31 adolescent girls with AN (aged 13–16; mean age = 14.9) and their parents. All patients met DSM-4 criteria for AN, did not have comorbid mental health disorders, and had not previously engaged in psychotherapy. Parents’ RF was assessed using the RF scale on the AAI, and the adolescents’ RF was coded from the Attachment Interview in
Childhood and Adolescence (Italian Version). The study reported that 54.8% of the daughters with AN scored 3 on the RF scale, as well as 29% of the mothers and 38.7% of the fathers. Of the mothers, 16% scored negatively (-1), indicating rejection of RF, and 51.1% scored equal or less than 2, indicating limited RF. The study found a significant correlation between the mothers’ and daughters’ RF scores (Spearman’s rho = .290, p = .026). No correlation was found between fathers’ and daughters’ RF scores. Zavattini (n.d.) suggested this indicated that a mother’s RF is more central to the development of her daughter’s RF than a father’s.
Zavattini (n.d.) also suggested that these results indicate that a deficit in mentalising capacity is a characteristic of patients with AN. Zavattini argues that this supports the notion of adolescents with AN expressing their psychological needs via their body as a concrete means of communicating their emotional needs. As mentioned previously, a significant limitation of Zavattini’s study is its lack of a control group. Considering the lack of studies published that have used the RF scale on interview measures for adolescents, it is unclear to date what a typical adolescent RF score is. Zavattini’s method assumes that typical RF scores are the same for adolescents and adults.
Only one study to date has focused solely on adult outpatients with BN.
Pedersen et al. (2012) investigated mentalising capacity of adult BN outpatients (mean age = 25.8; SD = 4.8). They rated RF on the AAI and found that BN patients did not have significantly lower RF scores (M = 4.11, n = 70) compared to a group of normal controls (M = 4.25, n = 20). The mean RF in this patient group was higher than in earlier studies on eating disorders (e.g., Fonagy et al., 1996; Müller et al., 2006; Rothschild-Yakar et al., 2010; Ward et al., 2001) and also somewhat higher than in studies of RF in various other clinical samples (e.g., Fonagy et al., 1996; Levy et al., 2006). Finally, in contrast to prior studies on BPD and RF, this study found no
significant difference between the RF scores of patients with a comorbid BPD diagnosis (M = 4.38; SD = 1.85; n = 8) and without a comorbid BPD diagnosis (M = 4.11;
SD = 1.80; n = 61; p = .70). One interesting finding in the clinical group was that,
although on average RF scores were similar to control, they were polarised as either high or low, with fewer patients scoring in the mid-range. This suggests more heterogeneous mentalising abilities in patients with eating disorders; poor reflective abilities appear to be a part of the clinical picture for some patients with BN, but not all. However, for some patients, BN can develop and persist despite good mentalising skills, indicating a complex interaction between symptoms and mentalisation.
4.11 Summary
Mentalising theory offers a means of understanding connections between attachment and development of sense of self, emotion regulation, coping strategies, personality and social-emotional functioning. The development of measures for assessing mentalisation in adults, parents and adolescents has allowed researchers to explore how mentalisation and the intergenerational transmission of RF relate to
associated with mental health outcomes, including depression, personality disorders and self-harm. Mentalising theory offers a contribution to the understanding of risk for eating disorders, and may guide new approaches that take into account the interplay of biopsychosocial factors involved (Skårderud, 2007b; Skårderud & Fonagy, 2012). The few studies that have investigated RF in clinical samples of patients with eating
disorders to date support the presence of impaired mentalising in adults and adolescents with eating disorders. The two studies on parents of patients with eating disorders also indicate that these parents tend to have low RF, indicating a link between parental RF and eating disorders in their children. The following chapter outlines the rationale for the present study, including its aims and an overview of the multi-method research design.