خودتصویری منفی و نتیجه در اختلالات تغذیه ای: نتایج در 3 سال پیگیری

Introduction Negative self-image has been hypothesised to be of aetiological significance in eating disorders; however, its relationship to outcome remains unclear. The present study examined the relationship between self-image and follow-up status in a heterogeneous sample of eating disorder patients (N = 246). Methods Patients were assessed at intake and after 36 months. Self-image was measured using SASB, and a general outcome measure was calculated comprising eating disorder symptoms, occupational status, interpersonal relationships and general psychopathology. Results SASB self-hate was the most important variable for predicting poor outcome, followed by occupational status, interpersonal relationships, eating disorder symptoms, SASB self-emancipation and general psychiatric symptoms. Together these variables predicted 23% of the variance in outcome. Discussion High levels of self-hate may increase the risk of poor outcome in eating disorders by adversely affecting interpersonal relationships and making it difficult for patients to engage in treatment.

Negative self-image is a common characteristic of eating disorders that may have important implications for both treatment (Björck et al., 2003 and Keel and Mitchell, 1997) and aetiology (Bruch, 1973, Crisp, 1980, Palazzoli, 1974 and Silverstone, 1992). Empirical work suggests that negative self-image is a significant risk factor in eating disorders (Fairburn et al., 1999, Fairburn et al., 1998 and Fairburn et al., 1997); however, its impact on outcome remains unclear. Since many patients suffer from residual symptoms, such as negative self-image and over-concern about body shape and weight, although they may have recovered in terms of key diagnostic symptoms (Button & Warren, 2002; Sullivan, 2002), more systematic investigation of the relationship between negative self-image and outcome may help to improve treatment. The identification of outcome predictors is important for all forms of treatment, since it may help us to better understand prognosis and ultimately influence the course of illness for individual patients. Research on outcome in eating disorders has been characterised by substantial variability in recovery rates, which may largely be due to methodological problems with different outcome measures (Clausen, 2004, Keel et al., 2000, Quadflieg and Fichter, 2003 and Vaz, 1998). Most outcome measures have been categorical, and based purely on expert ratings of key diagnostic symptoms. Few studies have attempted to include measures of general psychiatric morbidity, psychological symptoms, interpersonal relationships and occupational status in general measures of outcome. This is unfortunate since analysing multiple aspects of outcome may be essential for making relevant predictions in the real world (Fisher, 2003). Another problem has been that research on outcome in eating disorders has also been limited by the overwhelming focus on the two major syndromes of anorexia nervosa (AN) and bulimia nervosa (BN). There has been a dearth of outcome studies on the large groups of eating disorder patients suffering from eating disorders not otherwise specified (EDNOS) and binge eating disorder (BED) (Norring & Palmer, 2005). This is an important point when research suggests that as many as half of all patients seeking help with an eating disorder may be suffering from EDNOS (Fairburn and Harrison). In order to understand why some patients remain ill despite valiant treatment efforts, a clinically meaningful theory is also needed to add perspective on different kinds of outcome processes in eating disorders. The Structural Analysis of Social Behaviour (SASB) developed by Benjamin, 1974 and Benjamin, 2000 is potentially such a theory, which also provides an effective method of examining the role of self-image on outcome. Greater understanding of how self-image impacts on outcome may be instrumental for providing clinicians with interpersonal tools to improve treatment of eating disorders. SASB has the added advantages of being both empirically well grounded, and clinically useful within the context of different forms of psychotherapy. SASB is based around the assessment of interpersonal interactions and self-image. According to the interpersonal theory, which is at the heart of SASB, self-image constitutes a guiding force in a person's perceptions and interpretations of interactions with others (Sullivan, 1953). Another important strength of SASB is that it, unlike methods that focus on a single dimension, is built upon two axes (interdependence and affiliation), which are measured in terms of three aspects (or surfaces as they are termed within the theory). Each surface has a specific interpersonal focus (i.e. other, self and self-image). With regard to self-image (i.e. 3rd surface in SASB theory), the interdependence — affiliation axes can be understood in terms of self-control vs. self-emancipation and self-love vs. self-hate. Although all three SASB surfaces are central components of a person's interpersonal world, investigating self-image is particularly important since it can be seen as forming the cornerstone of a person's ongoing interactions with others. As such, self-image can be used to better understand actions and subsequent reactions in interpersonal situations. For example, negative self-image could imply interpersonal difficulties, such as the inability to perceive positive affirmation or trusting and caring responses from therapists, which may have a negative effect on outcome. In the present study we aimed to explore the importance of SASB self-image at initial presentation for subsequent outcome in a representative sample of patients who had been treated for eating disorders. Outcome was not confined to one particular aspect of functioning. Instead we aimed to use a clinically relevant measure of general outcome based on multiple domains of functioning. This was done since clinically relevant outcome can be considered to be more than just amelioration of eating disorder symptoms. Other important domains of outcome include general psychopathology, such as symptoms of depression or other psychiatric problems that are important for recovery. Interpersonal relationships and occupational status are also important aspects of normal functioning that need to be taken into account. Our aim was to compute a continuous measure of general outcome, based on both standardised self-report measures and structured interviews that reflected the above domains. The use of a continuous (as opposed to categorical) measure allowed for greater consideration of individual differences in outcome. Although emphasis was placed on multidimensional general outcome, specific domains of outcome were also analysed in order to compare domains of outcome and to aid comparisons with previous studies. We included the full range of eating disorder patients, and did not make distinctions between particular diagnoses. This was done since negative self-image has been hypothesised to be im