Attachment insecurity predicts worse outcome in patients with eating disorders treated with enhanced cognitive behavior therapy: A one‐year follow‐up study

Abstract

Objective: This study aimed to explore the role of attachment insecurity in predicting a worse longitudinal trend of eating disorder (ED) psychopathology and body uneasiness in patients with Anorexia Nervosa (AN) or Bulimia Nervosa (BN) treated with Enhanced Cognitive Behavior Therapy, considering the longitudinal interplay between these dimensions. Method: In total, 185 patients with AN or BN performed the baseline assessment, and 123 were re-evaluated after 1 year of treatment. Participants completed questionnaires evaluating ED psychopathology (Eating Disorders Examination Questionnaire) and body uneasiness (body uneasiness test). For the assessment of adult attachment, the Experiences in Close Relationships-Revised was administered at baseline. Bivariate latent change score analysis within the structural equation modeling framework was performed to investigate the evolution of ED psychopathology and body uneasiness, their longitudinal interplay, and the role of attachment style as an outcome predictor. Results: After treatment, all psychopathological features showed an overall improvement. Higher baseline levels of body uneasiness predicted a worse course of ED psychopathology. The change in body uneasiness over time depended on changes over time in ED psychopathology, but not vice versa. Insecure attachment predicted a worse longitudinal trend of ED psychopathology, and, through this impairment, it indirectly maintained higher levels of body uneasiness, as confirmed by mediation analyses.Discussion: The role of attachment insecurity as a predictor of treatment outcome suggests the need for an integration of the cognitive-behavioral conceptualization of EDs with a developmental perspective that considers attachment-related issues.Public significance statement: Considering the burden of EDs in terms of public health and the unsatisfactory response to standard treatments, the identification of

Emotional non‐acceptance mediates the relationship between insecure attachment and specific psychopathology in women with eating disorders

“…Preliminary data suggest that EABT may have utility for a subset of adults with AN (Wildes et al., 2014). Moreover, the evidence of a worse longitudinal trend of ED psychopathology in individuals with EDs and insecure attachment treated with CBT‐E (Rossi et al., 2022) could be explained considering that CBT‐E does not address attachment issues as specific targets of intervention. A recent longitudinal study demonstrated that emotion dysregulation was the nexus linking early traumatic experiences and worse response to CBT‐E in patients with AN (Cassioli et al., 2022), suggesting that persistence of difficulties in emotion regulation might maintain ED psychopathology in insecurely attached patients treated with CBT‐E (Cortés‐García et al., 2019).…”

Attachment in individuals with eating disorders compared to community controls: A systematic review and meta‐analysis

“…Emerging evidence suggests that secure attachment predicts positive alliance in eating disorder treatment (Folke et al, 2016; Jewell et al, 2021). There have been few adequately‐powered studies of attachment as a predictor of outcome in eating disorders: Jewell et al (2021) reported null findings in relation to family therapy for adolescent AN, but Rossi et al (2022) and Illing et al (2010) both found attachment insecurity to predict higher ED psychopathology in adults with AN and BN receiving cognitive behavior therapy and day‐hospital group therapy, respectively. Finally, attachment could be relevant to eating disorder recovery, even in the absence of psychological treatment, since social connection to close others is a consistent theme in qualitative studies of recovery (Bardone‐Cone et al, 2018; Bohrer et al, 2020).…”

Eye movement desensitisation and reprocessing as add‐on treatment to enhanced cognitive behaviour therapy for patients with anorexia nervosa reporting childhood maltreatment: A quasi‐experimental multicenter study

“…However, increasing evidence showed that treatment response is far from satisfactory, as remission rates are about 50% (Atwood & Friedman, 2020), with a consequent risk of chronicity, disability, and mortality (Steinhausen, 2009; Fichter & Quadflieg, 2016; van et al., 2020). Thus, scholars are investigating reasons for lack of response, including psychopathological features not adequately challenged by CBT‐E, and possibly linked to different developmental trajectories (Cassioli, Rossi, D’Anna, et al., 2022; Halmi, 2013; Longo et al., 2023; Rossi et al., 2022).…”