Depressive psychopathology and adverse childhood experiences in eating disorders

European Psychiatry 18 (2003) 377–383 www.elsevier.com/locate/eurpsy

Original article

Depressive psychopathology and adverse childhood experiences in eating disorders Mario Speranza a,b,*, Frederic Atger b, Maurice Corcos b, Gwenolé Loas b,c, Olivier Guilbaud b, Philippe Stéphan d, Fernando Perez-Diaz e, Olivier Halfon d, Jean Luc Venisse f, Paul Bizouard g, François Lang h, Martine Flament b,e, Philippe Jeammet b a

Centre Hospitalier de Versailles, Service de Pédo-Psychiatrie, 177, rue de Versailles, 78157 Le Chesnay, France b Département de Psychiatrie de l’Adolescent, Institut Mutualiste Montsouris, 42 Bd Jourdan, 75014 Paris, France c Service Hospitalo-Universitaire de Psychiatrie, Hôpital Pinel, 80044 Amiens cedex 1, France d Service de Psychiatrie de l’Enfant et de l’Adolescent, rue du Bugno 23 A, 1005 Lausanne, Switzerland e CNRS, UMR 7593, Hôpital de la Salpétrière, 47, bd de l’Hôpital, 75013 Paris, France f Unité des Addictions, Hôpital Saint-Jacques, BP 1005, 44035 Nantes, France g Service de Psychiatrie, CHU de Besançon, 2, place Saint-Jacques, 25000 Besançon, France h Service de Psychiatrie, CHU de Saint-Etienne, 23, boulevard Pasteur, 42055 Saint-Etienne, France Received 18 August 2002; received in revised form 22 April 2003; accepted 25 April 2003

Abstract Purpose. – The aim of this paper was to investigate the diagnostic specificity of the self-critical and dependent depressive experiences in a clinical sample of eating disorder patients and to explore the impact of adverse childhood experiences on these dimensions of personality. Method. – A sample of 94 anorexic and 61 bulimic patients meeting DSM-IV criteria and 236 matched controls were assessed with the Depressive Experience Questionnaire (DEQ), the abridged version of the Beck Depression Inventory (BDI) and the AMDP Life Events Inventory. Subjects presenting a major depression or a comorbid addictive disorder were excluded from the sample using the Mini International Neuropsychiatric Interview (MINI). Results. – Anorexic and bulimic patients showed higher scores than controls on both self-criticism and dependency sub-scales of the DEQ. Bulimic patients scored significantly higher than anorexic patients on self-criticism and reported more adverse childhood experiences. Finally, negative life events correlated only with self-criticism in the whole sample. Discussion. – Differences in the DEQ Self-Criticism between anorexics and bulimics could not be accounted for by depression since bulimic patients did not show higher BDI levels compared to anorexic patients and depressive symptoms measured with the BDI were not found to be significant predictors of diagnostic grouping in a logistic multiple regression. Conclusion. – This study supports the diagnostic specificity of the dependent and self-critical depressive dimensions in eating disorders and strengthens previous research on the role of early experiences in the development of these disorders. © 2003 Éditions scientifiques et médicales Elsevier SAS. All rights reserved. Keywords: Self-criticism; Dependency; Depression; Eating disorders; Life events

1. Introduction There is overwhelming evidence that depression is one of the most common experiences of eating disorder patients. Several studies indicate that depressive states of varying

* Corresponding author. E-mail address: [email protected] (M. Speranza). © 2003 Éditions scientifiques et médicales Elsevier SAS. All rights reserved. doi:10.1016/j.eurpsy.2003.04.001

intensities foreshadow the development of anorexia nervosa and bulimia nervosa. The lifetime prevalence of affective disorders in eating disorders ranges between 25% and 80% across different samples and concerns mainly dysthymic rather than classical unipolar or bipolar disorders [24,27]. Eating disorder patients, moreover, commonly display high levels of dysphoric affects, feelings of emptiness and ineffectiveness and emotions such as loneliness and desperation. These symptoms are closely related to the hypothesised core

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psychopathological features of these patients centred on identity and interpersonal disturbances [14]. For several authors these dimensions are correlated dynamically and all the eating behaviours (whether starving, bingeing or purging) represent adaptive strategies to regulate the emotional distress generated by the dysphoric affects associated with these personality features [21]. For these reasons it seems worthwhile in eating disorders to look for depression not only in a categorical way but also in a dimensional way in the context of personality features and to explore the subjective experience of psychological distress of these patients. This approach is in line with recent conceptualisations on depression from different theoretical perspectives which converge towards the identification of two types of fundamental depressive experiences: the first one focuses on concerns associated with disruption in relationships with others (with feelings of loss, abandonment and loneliness) and the second one centres on problems concerning identity (associated with low self-esteem, feelings of failure, culpability, lack of self-confidence) [8,10]. According to Blatt and Zuroff [10] these two depressive experiences correspond to different personality configurations derived from distinct developmental lines which are thought to be in synergistic interaction throughout development: the anaclitic (or dependent) line which concerns the establishment of satisfying interpersonal relationships and the introjective (self-critical) line which focuses on the achievement of a positive and cohesive sense of self. Blatt et al. [11] have developed the Depressive Experiences Questionnaire (DEQ) to assess these two depressive dimensions. Although Blatt has emphasised the link between selfcriticism and clinical depression, he hypothesised the existence of several forms of introjective and anaclitic psychopathology, not just limited to depression. Several authors since have reported high levels of both self-criticism and anaclitic dimensions in other pathologies such as depression [5], panic disorder [6] or social phobia [15]. Current theorisation on eating behaviours considers these disorders as a reflection of a developmental arrest in the separation–individuation process due to the primary caregiver’s failure to provide essential functions during development. The eating disorder symptoms could be an attempt to cope with needs stemming from this incomplete self-development or to an interruption of the separation–individuation process [19]. Although the clinical features of eating disorders may imply a specific psychopathology of the self-critical and dependent developmental processes, no study up to now has explored these two dimensions in samples of eating patients. Moreover, if several factors may have an impact on these developmental processes, we can suppose that adverse childhood experiences, through their disorganising effect on primary relationships, can affect these two dimensions and create an imbalance, which may imply psychopathology [18]. The aim of this paper was to explore the diagnostic specificity of the depressive experiences in a clinical sample of eating disorder patients and to investigate the relationships

between adverse childhood experiences and the selfcriticism and dependency dimensions of personality. According to the developmental hypothesis of eating disorders, we predicted that eating disorder patients would present high levels of psychopathology in both dependency and selfcriticism lines of development and that these dimensions would correlate positively with adverse childhood experiences. 2. Methodology 2.1. Subjects The clinical sample of this study was derived from a large multi-centre research project investigating the psychopathological features of addictive disorders (Dependence Network 1994–2000, Inserm 494013). For this study, only female subjects aged between 15 and 45 years who had requested care in hospital or consulting facilities for a disorder of eating behaviour were included in the sample. Eating disorder diagnoses, whether of Anorexia Nervosa (restricting or bulimic/purging subtype) or Bulimia Nervosa (bulimic/purging or non-purging subtype), were made by a psychiatrist or a clinical psychologist expert in the field of eating disorders applying individually all DSM-IV diagnostic criteria [1]. Moreover, considering the strength of the association between self-criticism and depression and to create a homogeneous group of eating pathologies, patients presenting a comorbid diagnosis of major depression and of alcohol or drug disorder were excluded from the sample using the Mini International Neuropsychiatric Interview (MINI) which is a structured, validated diagnostic instrument, jointly designed by French and American teams to explore in a standardised fashion each criterion necessary for the establishment of current and lifetime DSM-IV axis I main diagnoses [29]. Patients meeting DSM-IV criteria for a psychotic disorder and patients unable to answer questionnaires correctly were also excluded from the study. A sample of healthy subjects matched individually by sex, age and socio-economic status was recruited by announcement in nursing schools and in medical facilities. Control subjects were screened with the same diagnostic assessment of the patients to eliminate current and lifetime diagnosis of eating disorders, current major depression and substance abuse disorders. All investigators participated in training sessions prior to completing the diagnostic evaluation, including training by an official trainer for use of the MINI (Emmanuelle Weiller, Inserm U 302). The protocol was approved by the local ethics committee. After full information was provided, all subjects gave written consent for participation in the study. 2.2. Assessment procedure For both patients and controls, the diagnostic assessment was completed by a self-questionnaire eliciting socio-

M. Speranza et al. / European Psychiatry 18 (2003) 377–383

demographic data and psychopathological features, namely the abridged version of the Beck Depression Inventory (BDI13) and the DEQ. The BDI-13 [9] is a well-known instrument for measuring depression in clinical and normal samples. Like the complete version, the metrological parameters of the abridged form of the BDI have been repeatedly studied in French samples [13]. The DEQ [11] is a 66-item self-report scale, which was designed to assess the introjective and anaclitic personality dimensions hypothesised by Blatt and Zuroff [10]. Factor analyses have identified two principal depressive factors. The first factor involves items that are internally directed and reflects concerns about self-identity (self-criticism); the second factor consists of items that are more externally directed and refers to a disturbance of interpersonal relationships (dependency). A third factor has emerged, assessing the good functioning of the subject and the confidence in his/her resources and capacities (efficacy). Scales derived from these factors have shown high internal consistency and substantial test–retest reliability [36]. In the present study we used a French factor analysis showing the same three factors as the original study [3]. To assess the impact of adverse life events on depressive experiences we used the AMDP Life Events Inventory (AMDP-LEI) [23]. The AMDP-LEI is a self-rated questionnaire developed by the Association of Methodology and Documentation in Psychiatry to assess the main life events that are thought to influence the onset and course of psychiatric disorders. This instrument was adapted for the purposes of this study. All events related to separation experiences and traumas having a serious impact on primary relationships were selected (parental divorce; long separations from the family; adoption; severe medical or psychiatric illness, death of a parent (mother or father) or of a close family member; physical or sexual abuse). The age of occurrence of each event was specified. For the present study, events were rated as present if they happened during the first 15 years of life. A dimensional score for each respondent was obtained by adding all items positively scored (range: 0–8). Subjects with incomplete information were considered not to have had that experience, thus likely resulting in more conservative estimates. 2.3. Statistical analysis Comparisons between patients and controls were made with the v2-test for categorical variables and with an analysis of variance (ANOVA) test for continuous variables, as appropriate. Following these tests, a priori pairwise contrasts were performed with alpha level adjusted using the Bonferroni procedure. Spearman’s rank order correlations were computed to evaluate the relationships between depression, depressive experiences and life events. Moreover, to determine which variables among the DEQ sub-scales and the BDI were the most predictive of the score of the AMDP-LEI, we conducted a stepwise multiple regression on the whole sample.

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Finally, to determine whether the variance in the difference between the eating disorder groups could be accounted for by the scores of the different variables (depressive experiences, levels of Beck depression and life events), a logistic hierarchical regression was performed only on the clinical sample. Results are presented as mean ± standard deviation. Statistical analyses were performed with the 10.1 version of the Statistical Package for Social Sciences. 3. Results The final sample comprised 391 subjects (94 anorexics, 61 bulimics and 236 controls). Patients and controls were matched by age and socio-economic status. Sixty-eight percent of anorexic patients were of the restrictive type, 22% of the purging type. Eighty-five percent of bulimic patients were of the purging type, 15% of the non-purging type. Anorexics were more often inpatients than bulimics. Anorexic and bulimic patients showed higher scores than controls on the BDI, on the DEQ Self-Criticism and on the DEQ Dependency. However, no differences between patients and controls were found on the DEQ Efficacy. Bulimic patients had higher scores than anorexic patients on the DEQ Self-Criticism, t (144) = –2.84, P < 0.01. Although the sample of our study was large enough to test the differences between restricting and purging sub-types of anorexic patients, we did not observe any significant trend in the selfcritical and dependent depressive experiences between these sub-types. This was the main reason for reporting comparison between anorexic and bulimic groups only. Concerning the Life Events Inventory, over half of the sample experienced at least one adverse childhood event before the age of 15. The most frequent events were the death of a family member, the divorce of the parents and a serious medical or psychiatric disorder affecting a member of the family. The two samples of patients and the controls showed similar profiles of adverse events. However, bulimic patients showed higher rates than the other groups on almost every event. The global AMDP-LEI score was significantly higher in bulimics compared to anorexics (z = –2.42, P = 0.02) and controls (z = –2.32, P = 0.015). Anorexics and controls did not show any difference in this measure (Table 1). We found low but significant correlations between the AMDP-LEI and the DEQ Self-Criticism (r = 0.11, P < 0.05) and the BDI (r = 0.12, P < 0.05), but no correlations between the AMDP-LEI and the DEQ sub-scales Dependency and Efficacy. Self-criticism and dependency were strongly correlated but they were not correlated with efficacy. BDI was strongly correlated with self-criticism, moderately with dependency and weakly with efficacy (Table 2). A stepwise multiple regression conducted including the three sub-scales of the DEQ and the BDI showed that only the DEQ Self-Criticism was a significant predictor of the score of the AMDP-LEI (adjusted R2 = 0.147, F (1, 295) = 6.55, P = 0.011).

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Table 1 Scores of the clinical and control samples in socio-demographic data and psychopathological measures

S.D. 4.7 1.9 5.6

Bulimic patients (N = 61) Mean 22.5 21.0 10.8

S.D. 4.3 3.6 6.6

Mean 21.8 21.1 3.0

S.D. 5.4 2.7 3.4

f 3.3 189.2 112.5

P n.s. <0.001 <0.001

1.2 0.6 –0.1 0.7

1.1 0.8 0.8 0.8

1.7 0.7 –0.1 1.0

0.8 0.9 0.8 0.9

0.2 0.1 –0.03 0.7

0.9 0.8 0.8 0.9

71.7 20.7 0.5 6.20 a

<0.001 <0.001 n.s. <0.05

N

%

N

%

N

%

AMDP-LEI b Parental divorce Long separation Adoption Serious illness in the family Death of the father Death of the mother Death of a family member Physical or sexual abuse

10 3 0 11 6 3 34 1

10.6 3.2 – 12.1 6.6 3.3 37 1.1

14 5 2 12 6 1 23 2

23 8.2 3.3 20.3 10.2 1.6 37.7 3.3

42 16 4 32 21 6 73 3

17.9 6.8 1.7 13.7 9 2.6 32 1.3

Number of AMDP-LEI b 0 At least one event

48 45

52 48

21 39

35 65

110 125

47 53

Age BMI *,** BDI *** DEQ Self-Criticism ***,** Dependency *** Efficacy AMDP-LEI ****

Anorexic patients (N = 94) Mean 20.5 14.9 10.0

Controls (N = 236)

ANOVA

ANOVA with Bonferroni post-hoc tests. * Significant difference (P < 0.01) between AN and controls. ** Significant difference (P < 0.01) between AN and BN. *** Significant difference (P < 0.01) between AN/BN and controls. **** Significant difference (P < 0.05) between BN and controls. a Kruskal–Wallis test. v2-value, df = 2. b No differences between groups.

Finally, a logistic multiple regression showed that only the DEQ Self-Criticism and the AMDP-LEI scores were significant predictors of diagnostic grouping, whereas BDI, DEQ Dependency and DEQ Efficacy were not. The model with AMDP-LEI and DEQ Self-Criticism showed a good fit with the data, –2 log L = 173.522 (df = 2), P = 0.002 and a good prediction of the specific diagnostic group to which the patients belonged. The DEQ Self-Criticism and the AMDPLEI had almost the same predictive capacity (DEQ1: B = 0.45, Wald = 5.22, P = 0.02 and AMDP-LEI: B = 0.45, Wald = 4.64, P = 0.03).

4. Discussion This is the first published study investigating depressive psychopathology and adverse childhood experiences in patients presenting an eating disorder. The results of this study confirm our prediction concerning the relevance of the DEQ Self-Criticism and Dependency personality dimensions in eating disorders. Both anorexic and bulimic patients showed higher scores than controls in these two dimensions. In contrast, the efficacy dimension of the DEQ did not differentiate patients from controls. Moreover, this study provides some

Table 2 Correlation coefficients between the variables r AMDP-LEI BDI Self-criticism Dependency Efficacy *

AMDP-LEI

BDI

Self-criticism

Dependency

Efficacy

1 0.12 * 0.11 * 0.05 –0.09

1 0.69 ** 0.44 ** –0.17 **

1 0.64 ** –0.02

1 –0.03

1

Correlation is significant at <0.05. ** Correlation is significant at <0.01.

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positive arguments in favour of the diagnostic specificity of the DEQ Self-Criticism in bulimia compared to anorexia. It is worth noting that, although self-criticism was more correlated with BDI scores than dependency, the differences in this dimension between eating disorder sub-types could not be accounted for by depression since major depressed patients were excluded from the study, bulimic patients did not show higher BDI levels than anorexic patients and, finally, depressive symptoms measured with the BDI were not found to be significant predictors of diagnostic grouping in a logistic multiple regression. The negative result of the DEQ Efficacy is concordant with other literature data suggesting that this factor does not represent a specific dimension of the depressive experience and could correspond to a denying attitude towards emotional suffering through cognitive dismissing [7,34]. From our study it appears that dependency and selfcriticism are common dimensions shared by anorexics and bulimic patients. This is not surprising since one of the major problems of eating disorder patients is a constant struggle for autonomy and self-definition which is supposed to arise from an incomplete development of separation–individuation processes during infancy. There is growing empirical evidence to support the clinical view that intense separation distress is common among eating disorders and that many patients demonstrate marked separation anxiety in response to real or imagined abandonment [2]. This is also in line with the high rates of dependent personality disorders observed among restricting anorexic patients [4]. Self-critical depression, on the contrary, seems a more specific feature of bulimic patients and could reflect their identity fragility and their difficulties in regulating self-esteem, which is reflected in the high rates of borderline personality disorders found among bulimic patients [35]. As Heatherton and Baumeister [22] has emphasised, the motivation for binge eating could be an attempt to escape negative aspects of self-awareness and to control the dysphoric states associated with these personality disorders. Our exploration of the relationships between depressive experiences and adverse childhood events is also in line with the developmental hypothesis of eating disorders. Several studies have suggested that environmental factors and stressful life events may account for the development of eating pathology [25]. The most common serious life stresses reported concern close family relationships (family discord, physical or sexual abuse), with bulimics being significantly more often than anorexics directly involved in these interpersonal events [17,28]. In our study, only bulimic patients reported more adverse life events compared to anorexics and controls. It is possible that anorexia stems more from specific interactive failures of intimate primary relationships than from specific negative life-events. An intriguing finding of our study was the positive correlation observed only between adverse childhood life events and self-criticism but not dependency. This result was con-

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firmed by stepwise multiple regression, which confirmed that only the DEQ Self-Criticism, was a significant predictor of the AMDP-LEI score. As Cox et al. [15] have suggested, however, a research dichotomy that posits, on the one hand self-criticism and negative, achievement-related life events, and on the other hand dependency and adverse, interpersonal life events, could be misleading since self-criticism may be equally affected by interpersonal negative childhood experiences. This is not surprising considering, as Blatt and Zuroff [10] has suggested, that the development of increasingly mature and satisfying interpersonal relationships and the development of a mature sense of self are closely intertwined. Moreover, as attachment theorists have demonstrated, there is a close relationship between caregiver sensitivity to emotional states in children and long-lasting patterns of affective regulation [26]. Early interactions with primary caregivers are transformed into cognitive–affective schemes of self and other which regulate and direct subsequent behaviours. Individuals with early adversity, process their experiences differently and proactively create experiences compatible with past interactions to which they are more vulnerable [31]. Insecure children, for example, interacting with nonsensitive mothers, learn to ward off negative emotions and to replace comfort coming from intimate relationships with self-soothing strategies [16]. These strategies could be considered as precursors of other self-regulating behaviours, as starving or bingeing, observed in patients with eating disorders to control disruptive emotions [20,30]. This proposal is also concordant with recent observations of high levels of alexithymia in eating disorders, which have been reconceptualised as disorders of affect regulation [32]. This person-centred approach emphasises the importance of assessing the subjective experience of depression, which can deepen our understanding of psychiatric disturbances as categorised by the DSM-IV. As Fonagy and Target [18] have outlined, the majority of studies neither explore nor differentiate between these two types of depressive feelings, although the experience of psychological distress can be critically different. Westen et al. [33], for example, have shown that the severity of depression in individuals with borderline personality disorders correlates highly with symptoms like emptiness, loneliness, desperation and diffuse affectivity, but correlates negatively with severity in non-borderline individuals with major depression. This has important therapeutic consequences since response to treatment is powerfully predicted by this distinction. In a collaborative research program on depression conducted at the National Institute of Mental Health, Blatt et al. [12] have observed a significantly different relationship between dependent and self-critical personality dimensions and outcome measures according to the type and length of treatment provided, whether psychotherapy or pharmacotherapy. Blatt considers that introjectives/self-critical patients are more sensitive to interpretations while anaclitic/dependent patients are more sensitive to the holding function of the therapeutic relation. Bulimic patients who show a more self-critical personality

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could profit from a psychodynamic approach, whereas anorexic patients with a strong anaclitic depression would be more suitable for a cognitive-behavioural intervention. Our study complements a growing body of research on depressive experiences, but some methodological limitations must be considered. Although we excluded from the sample all patients presenting a major depression, this is not equivalent to assessing these personality dimensions in different phases of the illness. A longitudinal approach measuring changes in these dimensions in relation to depression and to clinical symptoms of eating disorders could tell us more about the diagnostic specificity of self-criticism and dependency in eating disorders. Moreover, we excluded from our sample all comorbid addicted patients. Whereas this research approach is methodologically sound, pure cases are clinically less common. Moreover, our sample was composed only of women. Even if eating disorders interest mainly female subjects, we know that some differences exist between men and women in the expression of depressive symptoms. Thus, generalisation to other eating disorder samples must be undertaken with caution. Finally, collection of data on childhood adverse events was based on a retrospective self-rating basis, which is open to memory bias, denial or social desirability. Further investigations conducted by clinicians using more specific instruments would refine our results.

[6]

Acknowledgements

[17]

This work was conducted within the clinical research project called “Dependence Network 1994–2000”, which is supported by the Institut National de la Santé et de la Recherche Médicale (Réseau Inserm no. 494013) and the Fondation de France. The sponsor of the project is the Institut Mutualiste Montsouris.

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