The Interpersonal World of Patients with Eating Disorders: Still a Frontier

Surprisingly little is known about the interpersonal world of a patient with eating disorders, according to a team of Swedish researchers. Better understanding of this world might improve their diagnosis and treatment (Psychology and Psychotherapy Theory: Theory, Research, and Practice 2003; 76:337).

The Swedish researchers defined “interpersonal” not only as interactions between self and others but also included the process of introjection, in which these interactions are internalized. More than 50 years ago, Sullivan (1953) argued that self-image is a guiding force in a person’s perceptions and interpretations of interactions with others; he also reasoned that a person’s self-image is based on how others have treated him or her.

Dr. Caroline Björck and co-workers at the Karolinska Institute in Stockholm used the Structural Analysis of Social Behavior (SASB), a questionnaire developed in 1974 (Psychol Rev 1974; 81:392), to study 830 patients participating in the Co-ordinated Evaluation and Research at Specialized Units for Eating Disorders in Sweden (CO-RED) project. This longitudinal naturalistic study follows patients treated at 15 specialist treatment centers for eating disorders across Sweden. All subjects had completed the SASB at their initial assessment.

Twenty-one percent of the subjects had diagnoses of anorexia nervosa (AN), 39% had bulimia nervosa (BN), 6% had binge eating disorder (BED), and 34% had eating disorders not otherwise specified (EDNOS). Patients ranged in age from 14 to 54 years (mean: 24.9 years), and body mass index ranged from 10.4 to 54.0 (mean was 20.6). Twelve males were included. A group of 104 normal control participants was drawn from a student population in Uppsala, Sweden, and a third comparison group included 26 students with subclinical depression. The researchers compared patients with controls, patients with other patients, and between-group comparisons of self-image, and finally studied the possible confounding influences on general psychopathology on self-image.

Results and implications

When compared with the normal patients, those with eating disorders clearly had more negative self-images. When the different diagnostic groups were compared, anorexics were found to be significantly more self-controlling, self-blaming, and self-hating than were patients with BN, BED, or EDNOS. Patients with BED were significantly more self-affirming than bulimic patients and less self-controlling than patients with EDNOS.

Patients with BED presented with less negative self-images compared to patients in the other groups. They also rated themselves as more self-emancipated, more self-affirming and more self-loving than the other patient groups. However, this doesn’t necessarily mean that patients with positive interpersonal styles are easier to treat than those with negative interpersonal style. Sociable patients may tend to evoke cooperative and trusting responses from the treatment staff, which in turn could reinforce patients’ underlying tendencies toward social conformity and thereby hinder change. When applied to BED patients, this might help explain why some readily comply with treatment but make few changes in behavior.

The negative interpersonal profiles of eating disorder patients in general and anorexics in particular may be a sign of considerable risk for development of negative reaction to psychotherapy. A patient’s subjective sense of suffering and despair over her symptoms from an eating disorder, while at the same time coupled with resistance to treatment, can be puzzling and problematic. This could be a reflection of the patient’s negative self-image, according to the authors. This might be a case where the patient is not being impervious to treatment itself but may be acting to defend and maintain a negative self-image. This may be distressing but also allows her to make sense of the world around her.

Finally, Dr. Björck and colleagues stress that the significant differences reported between diagnostic groups once again underscored the importance of taking into account patients’ interpersonal profiles when planning psychotherapeutic treatment.