The main objective of this paper is to analyse the possible relationship between psychopathological and clinical variables with the neuropsychological characteristics of patients diagnosed with an ED as well as their possible influence on the attitude towards change.
An observational analytical transversal study was done. Patients were outpatients referred from the Eating Disorders Unit of General University Hospital of Ciudad Real, during a 6-month period. Inclusion criteria were: (1) diagnosis of anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) or eating disorder not otherwise specified (EDNOS) according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5); (2) female gender; (3) aged between 18 and 50 years; (4) their current clinical state allows psychometric evaluation. Comorbidity with depression and anxiety was possible. Patients were excluded if they: 1) spoke a native language different from Spanish; (2) did not give written informed consent; (3) male gender; (4) comorbidity with bipolar disorder, psychotic disorder or major depressive disorder, organic mental disorder, attention-deficit hyperactivity disorder, autism spectrum disorder, Tourette syndrome or chronic fatigue syndrome.
Participants
At first, 74 subjects were included. The average age was 28.97 years (standard deviation, SD, 9.30). Upon arrival, participants were instructed about the procedure and signed informed consent. Clinical and neuropsychological tests were administrated and psychopathological self-report questionnaires were given (but 23 participants, 31.08%, did not give them back).
Although the sample was reduced to 51 subjects, relationships between neuropsychological and clinical features and body shape disturbances (measured by Gardner Body Image Scale) could be evaluated in the 74 patients initially included (15).
Procedure
Treatment was conducted on an outpatient basis and followed the protocols of the unit with pharmacotherapy added to psychotherapy if it was needed. Motivational and cognitive- behavioural treatment was conducted individually, in groups and/or with family members.
Daily, selected patients were informed about the study and its procedure and informed consent was signed. After this, self-report questionnaires were given. Data were dissociated, anonymised and stored in a password-protected Excel base. Local Clinical Research Ethics Committee approved the study.
Instruments
Status
The patient’s clinical status was evaluated by the Psychiatric Status Rating Scale. It is based on Herzog’s work (16), updated with DSM-5 criteria for the different disorders. Patients would be divided into several groups according to punctuation: a score of 5-6 points mean patient met criteria of the disorder; 3-4 points mean partial recovery, and 1-2 points mean total recovery.
Body Shape Questionnaire (BSQ)
Validation was carried out in the Spanish population by means of a 34-item self-report questionnaire with a six-point Likert-style rating scale (1= never; 6= always) (17). It measures body weight and shape concern in ED. Its internal consistency using Cronbach was good (0.97) as well as its concurrent validity. It differentiates clinical from nonclinical subjects and persons with predictably more or less weight concern. A score of 105 is the cut-off point in the Spanish population.
Eating Disorders Inventory (2nd edition) (EDI-2)
This is a self-report questionnaire with 91 items (11 scales called: “Drive for the thinness”, “Bulimia”, “Body dissatisfaction”, “Ineffectiveness”, “Perfectionism”, “Interpersonal distrust”, “Interoceptive awareness”, “Maturity fear”, “Ascetism”, “Impulsiveness” and “Social insecurity”). The internal consistency (Cronbach Alpha) is higher than 0.80 in ED samples. Reliability coefficients (alpha) were from 0.83 to 0.93 in samples of patients from the original studies. It is validated in the Spanish population (18,19).
The Bulimic Investigatory Test, Edinburgh (BITE)
This is a self-reported test with 33 items to evaluate bulimic symptoms. There are two scales: “Symptoms” (30 items) and “Severity” (3 items) (20,21). The Alpha coefficient is 0.96 for “Symptoms” and 0.62 for “Severity”. Retest-reliability is also high (0.68-0.86).
Beck’s depression inventory (BDI)
Self-reported questionnaire with 21 items to evaluate existence and severity of depressive symptoms (22,23). Internal consistency is higher than 0.85.
State-Trait Anxiety Inventory (STAI).
This is divided in two independent scales that measure state and trait anxiety (24–26). Cronbach’s Alpha is 0.90 for trait anxiety and 0.94 for state anxiety.
Dissociative Experiences Scale (DES).
This is a self-assessment questionnaire based on a visual analogue scale composed of 28 dissociative experiences and asks how often a subject experiences them (0-100%). An average of 30 or more means that dissociative disorder is expected (27–30). There are 3 scales: “Derealization and depersonalization”, “Absorption” and “Amnesia” (31). The internal reliability (Cronbach’s Alpha) was 0.93 and retest-reliability 0.87.
Attitudes Towards Change in Eating Disorders Scale (ACTA).
Self-reported questionnaire with 59 items validated in the Spanish population (32). There are 6 scales: “Precontemplation”, “Contemplation”, “Decision”, “Action”, “Maintenance” y “Relapse”. The reliability for each scale was from 0.90 to 0.74 and retest-reliability 0.86-0.64.
Neuropsychological variables:
Working memory
This was measured by the test “Letter Number Sequencing” (LNSIII) included in WAIS-IV (“Wechsler Adult Intelligence Scale”) (33). Participants listen to a verbal sequence of letters and numbers which is gradually increased and must be memorized, ordered and repeated back to the tester. Its reliability and validity are high, but data are related to intelligence evaluation.
Inhibition:
“Stroop’s effect” (34), is defined as the difference in the process of naming colours and reading words. It defines Stroop’s test, which measures inhibitory attention. Retest-reliability is high in all studies (0.69-0.89) (35).
Sustained attention:
Symbol and Digit Modalities Test (SDMT) (36,37) mainly evaluates attention (included in the paradigm of sustained attention), optical tracking, speed of mental processing and visuo-motor speed. The test is based on pairing meaningless geometrical paintings with numbers from 1 to 9 following a previous model.
Executive functions:
The Rey-Osterrieth complex figure test (ROCFT) (38,39) consists of copying and then drawing from memory a complicated line drawing. Several indexes are obtained: quantitative and qualitative scores of copying and memory reproduction accuracy, style, order and central coherence (40–42).
Data analysis
Statistical Package for the Social Sciences 19.0 was used for analysing the data obtained.
Firstly, a descriptive analysis was carried out, and after that an inferential one. The statistical level accepted as significant was 5% (p<0.05). Qualitative variables were statistically analysed by means of the Chi-Square test for independence. Normality was analysed for quantitative variables (Kolmogorov-Smirnov Test with more than 50 data and Shapiro-Wilk with less than 50 data). T-Student and U Mann-Whitney were used in dichotomic independent variables, and ANOVA and Kruskal-Wallis with independent variables with more than two categories. Pearson’s and Spearman’s correlations were used with quantitative independent variables.
Multivariate analysis was made by Simple Linear Regression to evaluate models of quantitative dependent variables. Variables included in the models were those which were statistically significant in bivariant analysis in our sample and variables statistically significant in previous studies or were considered of interest for the current study for their transdiagnostic meaning (Body Mass Index (BMI), dichotomic status, age of onset of ED, antidepressants, benzodiazepines, total score of DES, anxiety, depression, “Perfectionism”). Later, models were reduced to improve their alignment.