Reflective functioning and attachment in adolescent eating disorders
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Introduction: A systematic review was undertaken to identify any psychological predictors of treatment dropout for individuals diagnosed with an eating disorder, to help inform psychological therapy and reduce attrition. An empirical study was conducted to understand developmental psychological mechanisms at play in the aetiology and maintenance of eating disordered symptomology by assessing reflective functioning and attachment from a trans-diagnostic perspective. Methods: Twenty-one papers were identified through a systematic search of databases using predefined extraction criteria, identifying psychological predictors of treatment dropout in eating disorders. Fourteen female adolescents with a diagnosis of an eating disorder were recruited to the empirical study from CAMHS inpatient and outpatient departments in NHS Scotland, as well as eighteen same age controls from local secondary schools. Participants completed questionnaires regarding eating behaviour, difficulties in emotion regulation, reflective functioning and were interviewed using the Adult Attachment Projective. Results: The systematic review revealed varied psychological predictors of dropout falling onto a continuum ranging from maturity fears to interpersonal difficulties. Results did not significantly differ for inpatient or outpatient treatment or diagnosis. The empirical study found adolescents with an eating disorder to have significantly more difficulties with their emotion regulation and reflective functioning as well as a more insecure attachment style when compared to controls, none of which were weight dependent. Conclusion: Further research is required to operationalise a definition of dropout. Although eating disorders can be seen as a defence mechanism to control and avoid emotional distress, this actually exacerbates them and causes disengagement from treatment. Clinical interventions need to focus on therapeutic rapport from the outset of treatment in order to reduce interpersonal difficulties leading to attrition. The results of the empirical study support the use of early intervention and person centred therapies for adolescents with an eating disorder, even when acutely starved. Specifically therapies that target reflective functioning and take insecure attachment styles into account may improve psychological efficacy and engagement.