مشکلات بین فردی در بی اشتهایی عصبی: مهار اجتماعی به عنوان تعیین کننده و زیانبار

Interpersonal difficulties are thought to play a central role in both the development and maintenance of anorexia nervosa (AN). The primary aims of this study were to examine the nature of interpersonal problems in AN and to determine whether interpersonal problems are related to AN psychopathology and treatment outcome. The participants were 218 individuals with AN admitted to a specialized treatment program. Overall, in comparison with a normative community sample, a pattern of difficulties with submissiveness, nonassertiveness and social inhibition emerged among patients with AN. Results indicated a positive association between interpersonal problems and eating disorder psychopathology at baseline. The overall level of interpersonal problems decreased from baseline to post-treatment and higher levels of social inhibition at baseline predicted treatment noncompletion. Our findings suggest that AN is associated with a pattern of submissive and socially inhibited interpersonal behavior which contributes to the maintenance of eating disorder pathology and interferes with treatment completion. The theoretical and clinical implications of the findings are discussed.

Anorexia nervosa (AN) is a serious psychiatric disorder characterized by extreme food restriction, maintenance of an abnormally low body weight, intense fear of weight gain, and body image disturbance (American Psychiatric Association, 2000). The focal importance of interpersonal problems in AN has long been recognized in the clinical literature (e.g., Bruch, 1973 and Selvini-Palazzoli, 1974). Disturbances in family functioning have been highlighted in models of both the etiology and maintenance of the disorder (e.g., Lock, Le Grange, Agras, & Dare, 2001), and there is a growing evidence base for the effectiveness of family therapy for children and adolescents with AN (e.g., Le Grange, Binford, & Loeb, 2005). Recently, researchers have begun to focus on the role of marital functioning in the maintenance of AN in adults, and the use of couple therapy in the treatment of the disorder (Bulik, Baucom, Kirby, & Pisetsky, 2011). AN is also associated with significant interpersonal dysfunction outside of the family (Schmidt, Tiller, & Morgan, 1995). A number of studies have found high rates of social anxiety disorder (Godart, Flament, Lecrubier, & Jeammet, 2000) and avoidant personality traits (Díaz-Marsá et al., 2000 and Skodol et al., 1993) among individuals with AN, as well as difficulties with social withdrawal and social isolation (e.g., Beaumont, 2002). To some extent, these interpersonal problems may be a consequence of the illness and, at the same time, they may contribute to the maintenance of the disorder. A growing interest in the role of interpersonal difficulties in the maintenance of AN is reflected by recent research on interpersonal treatment approaches for the disorder. Interpersonal models of AN view eating disorder symptoms as “inextricably intertwined within interpersonal relationships” and contend that interpersonal difficulties are often the trigger for symptoms (McIntosh, Bulik, McKenzie, Luty, & Jordan, 2000). Thus, interpersonal treatments for AN aim to reduce eating disorder pathology by improving interpersonal functioning. Very little research has been conducted on the effectiveness of interpersonal treatments for AN and the results are mixed. McIntosh et al. (2000) adapted interpersonal psychotherapy (IPT), originally developed as a treatment for depression (Klerman, Weissman, Rounseville, & Chevron, 1984), for the treatment of AN. They found that IPT was less effective than cognitive behavior therapy (CBT) and “specific supportive clinical management” (SSCM) as a first-line intervention for acute AN in a randomized controlled study. SSCM was designed to mimic outpatient care for AN in usual clinical practice and involved a combination of clinical management and supportive psychotherapy. However, the sample size in this study was small and the effect sizes in all three conditions were relatively trivial. Schmidt et al. (2011) recently evaluated an interpersonal treatment approach for AN (i.e., MANTRA). MANTRA is based on the idea that AN symptoms facilitate the avoidance of emotions, and that individuals with AN tend to be socially avoidant because close interpersonal relationships may trigger the experience and expression of emotions. No difference was found between MANTRA and SSCM for acute AN (Schmidt et al., 2011). However, the sample size in this study was also small and the effect sizes obtained in both conditions were fairly minor. In addition to being a potential mechanism through which AN symptoms can change, there is preliminary evidence that interpersonal problems at the start of therapy might moderate response to treatment. Tasca, Taylor, Bissada, Ritchie, and Balfour (2004) found that attachment avoidance predicted attrition while attachment anxiety predicted treatment completion among patients with the binge–purge subtype of AN (AN-BP), but not among patients with the restricting subtype (AN-R) (Tasca et al., 2004). Thus, AN-BP patients high in attachment avoidance may find it difficult to maintain therapeutic bonds and may be more likely to disengage from helping relationships, while those who worry about losing close relationships may be more likely to remain in treatment. According to Horowitz, Rosenberg, and Bartholomew (1993), specific attachment styles are associated with particular patterns of interpersonal problems. The Inventory of Interpersonal Problems (IIP) was developed to measure distress arising from interpersonal difficulties (Horowitz, Alden, Wiggins, & Pincus, 2000). The IIP is based on a two-dimensional circumplex model that views every interpersonal behavior along two dimensions—an affiliation dimension ranging from cold (hostile) behavior to overly nurturant (warm) behavior; and a dominance dimension that ranges from nonassertive (submissive) to domineering (controlling) behavior (see Fig. 1). According to this model, interpersonal problems can be defined in terms of different combinations of affiliation or dominance. For example, social avoidance is viewed as a combination of cold and nonassertive, whereas intrusiveness is seen as a combination of overly nurturant and domineering. Full-size image (14 K) Fig. 1. Diagram of the interpersonal circumplex from Horowitz et al. (2000). Figure options The IIP appears to be a useful tool for measuring interpersonal problems in AN since, clinically, individuals with AN tend to report difficulties along these two dimensions—assertiveness and social avoidance. To date, only one study has examined interpersonal problems in AN using the IIP. Hartmann, Zeeck, and Barrett (2010) found that patients with eating disorders report particularly pronounced interpersonal difficulties with nonassertiveness and with putting others’ needs before one’s own. Patients with AN-BP reported more difficulties with social avoidance and lack of closeness to others than patients with AN-R, and these difficulties did not improve with inpatient or day hospital treatment (Hartmann et al., 2010). Taken together, preliminary studies suggest that interpersonal problems may vary according to AN subtype and may affect treatment outcome. The overall goals of the current study were to characterize interpersonal difficulties in AN and to determine whether certain interpersonal problems are associated with AN psychopathology and treatment outcome. In order to address these goals, the current study had five specific aims. The first aim was to examine whether patients with AN-R and AN-BP differ on IIP subscales. The second aim was to compare the IIP profiles of AN patients to a normative community sample as described in Horowitz et al. (2000). The third aim was to examine the association between interpersonal functioning and eating disorder psychopathology. The fourth aim was to examine whether interpersonal problems in AN would improve with remission of the eating disorder. The final aim was to examine whether interpersonal problems at baseline would predict treatment noncompletion.