Also social anxiety is one of the important factors predicting Eating Disorder symptoms which The aim of this study was to determine the relationship between Eating Disorder Eating and body image disturbances across cultures: A review. The relationship of trait anxiety and symptoms/diagnoses of anxiety . The review will not be able to determine whether non-eating/weight. Objective: To investigate the prevalence of comorbid eating and anxiety Bulik, C () Anxiety disorders and eating disorders: a review of their relationship.
Finally, patients were treated with B-APP [ 34 ] which lasted sessions depending on clinical severity. At the end of psychotherapy both psychiatrists re-assessed the patients and evaluated the following steps of the treatment plan.
Eating Disorders | Anxiety and Depression Association of America, ADAA
The therapists usually decided whether the second cycle could have the same focus of the previous one or a different one. Family-based therapy [ 35 ] was not specifically adopted since patients were adults and family autonomy was specifically encouraged [ 36 ]. The treatment period generally lasted from six months to three years depending on the eating and general psychopathology, personality structure and traits, treatment compliance, and response to treatment.
Ethics All participants provided written informed consent. All participants completed the following self-report questionnaires at both time-points: It is divided into 7 independent dimensions, 4 of which assess temperament novelty seeking, harm avoidance, reward dependence and persistence the other 3 assess character self-directedness, cooperativeness, and self-transcendence. A well-known instrument with 11 subscales measuring attitudes, behaviors, and eating traits common to individuals with EDs.
Symptom Checklist 90 SCL90 items [ 41 ]. It assesses general psychopathology. It considers nine dimensions somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism and a total score that indicates global severity of psychopathology is provided.
It is used to assess the severity of depressive symptoms. This tests investigates somatic aspects of depression like fatigue, asthenia, decrease of appetite, weight loss, sleep disturbances, sexual impairment, and psychological aspects like sadness, sense of failure, sense of guilt, self-incrimination. Cut-off for clinical attention is fixed at 16 [ 42 ]. We used the SCL to assess anxiety since two scales phobic anxiety and general anxiety separately assess different forms of anxiety.
The age of onset of the disorder, the age at the intake in the study and the age since the first visit duration of the follow-upand also the performed drug treatment three categories: Multivariate regression analysis was performed to ascertain the relationship of the changes in personality with anxiety and depression scores, and eating psychopathology.
Moreover the delta values e. See table 1 for further details. Discussion With this study we performed an 8-year follow-up that garnered encouraging results overall in line with earlier literature [ 4445 ].
Depressive and anxiety symptoms significantly improved at time of follow-up in both AN and BN subgroups although medications [ 48 ] may have played a relevant role in this regard. Nevertheless, the majority of those who were assessed at follow-up were medication free. Moreover, in line with the body of evidence on the effectiveness of psychotherapy in the outcome of depression and anxiety [ 4950 ] the delivered multimodal treatment addressed not only the ED but also self-esteem, resourcefulness, and relational functioning by means of the B-APP [ 3451 ], eventually improving also some pathogenic features of both depression and anxiety.
The possibility that the decrease of eating symptoms which often causes depression or anxiety or recovery may have positively influenced also depressive and anxious features is possible but it cannot be confirmed by multivariate regression analysis except for body dissatisfaction in bulimic women, potentially suggesting nonlinear mechanisms.
Personality traits showed a long-term improvement characterized by reduction of HA, and increase of SD as well as cooperativeness as already found in other outcome studies [ 46 ].
In particular, HA and SD are the personality core features of EDs and other mental disorders as well, eventually representing risk factors for recurrence, partial remission or treatment resistance [ 3147 ]. In particular, their improvement may have played a relevant role in the evolution of eating psychopathology.
Anxiety and the development and maintenance of anorexia nervosa: protocol for a systematic review
Anorectic individuals Notwithstanding the severity of AN and its high rates of recurrence and partial response to treatment [ 4552 - 54 ], we found encouraging results as regards eating psychopathology which was significantly improved at follow-up. The comparison of AN recovered versus non-recovered individuals highlighted some between-group differences in the improvement of anxiety and depression or eating psychopathology and personality traits.
Nevertheless, in both ED groups the recovered group was more likely to report a less relevant improvement then the non-recovered one. This finding could be explained by baseline measures; in fact, the recovered group scored lower at T0.
Psychopathology may have had an effect on recovery in a threshold-related manner: Similar findings in those affected by BN confirm the relevance of general and eating psychopathology traits in the course of EDs, independently from diagnostic subgroup. All in all, our findings confirm that, even though medications in AN are, at-best, poorly effective [ 55 - 58 ] and psychotherapy requires specific focus also on psychopathology features which are not strictly ED-related [ 3759 ], the multimodal treatment facilitated the improvement of eating psychopathology and symptoms, even though not achieving full recovery [ 57 ].
Bulimic individuals The treatment of patients with BN resulted more favorable than that of AN, substantially confirming existing data in literature [ 60 ].
In particular, as specific focus of the present research, we found that anxiety and depressive symptoms were significantly improved at follow-up. The changes in personality, particularly SD which is related to the overall character development, seem to play a heavier role in the BN group than in the AN group and this, along with the higher response to drug treatments [ 61 ], may explain the greater response to psychological treatments of those with BN [ 6263 ]. These results provide support to the long-lasting response to treatment of BN individuals; relatedly, the multimodal treatment was found to be helpful in changing the course of the eating symptoms.
Also in the BN group the non-recovered individuals sometimes reported larger improvements than the recovered ones, highlighting that, regardless of the complete symptom remission, the treatment was effective in reducing distress and psychopathology in all participants.
Relationship between improvement of anxiety and depression symptoms, personality, and eating psychopathology The relationship between changes in HA and SD and also in cooperativeness with many eating psychopathology traits in both ED groups is consistent with previous literature supporting EDs to be entrenched with these personality features [ 31 ].
On the other hand, the weak correlation we found between personality changes and general psychopathology is somehow in contrast with the aforementioned hypothesis. However, the psychopathology process based on the liability of personality traits [ 3147 ] seemed more directly related to eating psychopathology than to anxiety and depressive symptoms.
Even though anxiety and depression levels decreased along with personality traits evolution, they were less linearly related to personality evolution than expected.
In fact, anxiety and depression could fluctuate more e. The relationship of anxiety and depression with eating psychopathology resulted to be less relevant than hypothesized. The direction of the relationship was statistically stronger from general to eating psychopathology, with the only exception of body dissatisfaction eventually producing a sort of relief on depressive feelings in BN women.
Anxiety and the development and maintenance of anorexia nervosa: protocol for a systematic review
This supports that anxiety and depression tend to evolve in a rather similar way during treatment, even though they represent a relevant complication to be treated to favor the recovery process. As concerns the relationship between anxiety and depression the relatedness of the SCL scales suggests that the use of another instrument such as the BDI-II for the assessment of depression is worth of interest in the ED field.
Conclusion The present study supports the effectiveness of the multimodal integrated treatment in the improvement of mood and anxiety features, eating symptoms and psychopathology [ 5766 ]. It could be the result of the combination of both medications and psychodynamic psychotherapy which has been demonstrated to be effective in depression and anxiety disorders [ 67 - 69 ].
Changes in anxiety and depressive symptoms are accompanied by the improvement of those personality traits which are mostly related to general and eating psychopathology [ 13147 ]. We hypothesized that such changes in personality may be partly responsible for the stabilization of the improvements in anxiety and depression.
Nevertheless, we could not demonstrate a linear correlation between the improvement of depression and anxiety, personality, and eating psychopathology. The substantial independence between the improvement in anxiety and depressive features with eating symptoms and psychopathology, and personality traits suggests that multimodal approach does not act hierarchically from personality to general psychopathology to eating symptoms but it could be rather underpinned by complex dynamics which future exploration may want to examine [ 3457 ].
Setting We impose no restrictions pertaining to study setting. Language Only studies reported in English will be included. Eligible studies will have been published in a peer-reviewed journal and in the year or subsequently.
Reference lists of eligible studies identified from database searches will be scanned to ensure we capture all relevant research articles. Data collection and analysis Study selection Following removal of duplicates, the titles and abstracts of studies retrieved using the database searches will be screened by two reviewers.
The full text of potentially eligible studies will be retrieved and assessed for inclusion in the review by two reviewers. Should the full text of a study not be accessible through institutional memberships study authors will be contacted in order to retrieve the manuscript. The decision to include studies will be based on criteria outlined in the preceding section, and a third reviewer will resolve any discrepancies between the screeners at both stages.
Two reviewers must also approve the inclusion of further studies identified from reference lists of the eligible articles found using database searches.
The reason for exclusion of any study will be recorded, and the study selection process presented in a PRISMA flow diagram. Data extraction Using a tailored data collection form, the following information will be extracted from each study: Where data are missing, we will attempt to contact study authors to obtain this.
The checklist considers selection bias, blinding of outcome assessors researcher biaswithdrawal attrition biasand selective reporting reporting bias. Other aspects of study quality are also considered: Regarding the validity of exposure measures, we are particularly concerned with evaluating the potential for these to capture anxiety that reflects the AN i.
For example, social phobia assessments may capture fears of eating in public, which could be symptomatic of the AN rather than of social phobia.
Risk of bias and quality for all studies will be assessed by two reviewers, with discrepancies resolved by a third reviewer, to ensure reliability of the review. If eligible review studies are identified, the outcomes of these review studies will be compared to the outcomes reported by articles included in the present review, to detect systematic reporting biases.
The strength of the body of evidence collected in the course of the review will be assessed using the Grading of Recommendations Assessment, Development and Evaluation GRADE system [ 19 ].
Depressive and Anxiety Symptoms in the Outcome of Eating Disorders: 8-Year Follow-Up
Data synthesis Studies will be categorised according to whether they assess the relationship of anxiety with the development or the maintenance of AN. Within these two categories, studies will be grouped further, according to the type of anxiety considered for its influence on AN i. Ideally, meta-analyses would be conducted to determine the pooled effect size pertaining to the longitudinal relationship of each type of anxiety with both AN onset and AN maintenance.
However, preliminary investigations suggest that the number of eligible studies within each category, and the heterogeneity of these studies, will mean meta-analyses are not feasible. A systematic narrative review will describe findings of the included studies, and the similarities and differences between studies, for studies grouped by outcome AN onset or maintenance and type of anxiety measured.
A table outlining findings of each study will also be provided. Discussion With the inclusion of anxiety in aetiological models of AN, it is important that the relevance of anxiety to AN development and maintenance is clarified.
This study will provide the first, much needed, systematic synthesis of longitudinal studies that investigate the relationship between anxiety and AN. By considering a range of anxiety exposures i. The planned quality assessment is extensive, to enable a comprehensive evaluation of the risk of bias within and across included studies, promoting the validity of conclusions arising from the review. The extent of the data extracted from studies will allow for the identification of differences in findings that may arise from participant and study characteristics.
Most importantly, our method is transparent and explicitly outlined in detail, allowing its replication, as well as assessment of its quality, by others. Interpreting the body of evidence surrounding AN maintenance may also be problematic given the definitions of recovery are not standardised in the field of eating disorders [ 21 ].
We consider the outcome of AN recovery, as opposed to remission or relapse, in an attempt to focus the research question. However, understanding the relationship of anxiety with both remission and relapse in AN would further inform knowledge of the factors associated with AN maintenance.
Because of their longitudinal nature, studies of the review are likely to be subject to high levels of attrition, which is an issue that has implications on the validity of conclusions that may be drawn from the review.