**4. Discussion**

At our knowledge, this is the first research investigating the relationships between the development levels of interpersonal relatedness and self-definition and the clinical outcome of adolescents and young adults with an eating disorder. Two main findings should be highlighted: first, a less mature level of interpersonal relatedness at inclusion (as assessed by the Neediness sub-factor of the DEQ) was a significant predictor of the persistence of an eating disorder diagnosis at 3-year follow-up, independently from the severity of the eating disorder, which also appeared as a significant predictor. Second, a more mature level of interpersonal relatedness (as assessed by the Relatedness sub-factor of the DEQ) appeared as a protective factor of a poor social outcome three years later. On the contrary, the severity of depression was a negative predictor of the social outcome, result that agrees with other studies from the literature (Godart et al., 2004). The other variables, such as the BMI, the presence of binge eating behaviors or the other sub-factors of the DEQ at inclusion, had no direct influence over the clinical and social outcome of eating disorders.

Personality factors have already been identified as significant predictors of diagnostic status and social outcome in eating disorders. For example, obsessive-compulsive personality traits have been repeatedly associated with poor diagnostic outcome in anorexia nervosa (Crane et al., 2007; Steinhausen 2009). Furthermore, impulsivity (Fichter et al., 2006) and low selfdirectedness (Rowe et al., 2011) have been related to poor outcome in bulimia nervosa. Results from our study add some interesting data from a developmental perspective showing that personality features reflecting the maturational level of interpersonal relationships may play a significant role in the outcome of eating disorders.

There are several ways in which the developmental level of interpersonal relationships can negatively impact the clinical outcome of eating disorders: via the influence it exerts on the clinical expression of the disorders and via the reduced efficacy of the therapeutic interventions. As Blatt and coworkers have largely described (Blatt 2004; Zuroff et al., 1999b), the establishment of increasingly mature and satisfying interpersonal relationships is an essential component of personality development. Interpersonal relationships are dynamic systems that change continuously throughout development following a trajectory ranging from dependency to more mature expressions of mutuality and reciprocity, including intimacy. Flourishing relationships also allow a dynamic balance between focus on intimate relationships and focus on other social relationships (Fincham and Beach 2010). Subjects with an immature development of interpersonal relationships may feel less competent in social interactions and may experience them as unpleasent and distressing. Investigations in samples of normal adolescents have shown that the Neediness sub-factor of the DEQ correlates negatively with measures of interpersonal competence (Henrich et al., 2001) and is associated to dysphoria, anxiety over loss, introversion, and discomfort with depending on others (Zuroff et al., 2004). Intense separation distress is a common feature among eating disorders (Touchette et al., 2010) and many patients demonstrate marked separation anxiety when confronted to real or imagined abandonments. High scores on the Neediness sub-factor of the DEQ in eating disorders may reflect the disconfort of these patients in social relationships (Zuroff et al., 1999a; Zuroff et al., 2004).

A personality profile characterized by high dependency may have direct implications for therapeutic relationships in eating disorders. As pointed by Zuroff and colleagues (Zuroff et al., 2004), dependent people expect to be hurt in relationships and adopt submissive interpersonal style to forestall conflict and to elicit protection and support (Zuroff et al.,

At our knowledge, this is the first research investigating the relationships between the development levels of interpersonal relatedness and self-definition and the clinical outcome of adolescents and young adults with an eating disorder. Two main findings should be highlighted: first, a less mature level of interpersonal relatedness at inclusion (as assessed by the Neediness sub-factor of the DEQ) was a significant predictor of the persistence of an eating disorder diagnosis at 3-year follow-up, independently from the severity of the eating disorder, which also appeared as a significant predictor. Second, a more mature level of interpersonal relatedness (as assessed by the Relatedness sub-factor of the DEQ) appeared as a protective factor of a poor social outcome three years later. On the contrary, the severity of depression was a negative predictor of the social outcome, result that agrees with other studies from the literature (Godart et al., 2004). The other variables, such as the BMI, the presence of binge eating behaviors or the other sub-factors of the DEQ at inclusion, had no

Personality factors have already been identified as significant predictors of diagnostic status and social outcome in eating disorders. For example, obsessive-compulsive personality traits have been repeatedly associated with poor diagnostic outcome in anorexia nervosa (Crane et al., 2007; Steinhausen 2009). Furthermore, impulsivity (Fichter et al., 2006) and low selfdirectedness (Rowe et al., 2011) have been related to poor outcome in bulimia nervosa. Results from our study add some interesting data from a developmental perspective showing that personality features reflecting the maturational level of interpersonal

There are several ways in which the developmental level of interpersonal relationships can negatively impact the clinical outcome of eating disorders: via the influence it exerts on the clinical expression of the disorders and via the reduced efficacy of the therapeutic interventions. As Blatt and coworkers have largely described (Blatt 2004; Zuroff et al., 1999b), the establishment of increasingly mature and satisfying interpersonal relationships is an essential component of personality development. Interpersonal relationships are dynamic systems that change continuously throughout development following a trajectory ranging from dependency to more mature expressions of mutuality and reciprocity, including intimacy. Flourishing relationships also allow a dynamic balance between focus on intimate relationships and focus on other social relationships (Fincham and Beach 2010). Subjects with an immature development of interpersonal relationships may feel less competent in social interactions and may experience them as unpleasent and distressing. Investigations in samples of normal adolescents have shown that the Neediness sub-factor of the DEQ correlates negatively with measures of interpersonal competence (Henrich et al., 2001) and is associated to dysphoria, anxiety over loss, introversion, and discomfort with depending on others (Zuroff et al., 2004). Intense separation distress is a common feature among eating disorders (Touchette et al., 2010) and many patients demonstrate marked separation anxiety when confronted to real or imagined abandonments. High scores on the Neediness sub-factor of the DEQ in eating disorders may reflect the disconfort of these

A personality profile characterized by high dependency may have direct implications for therapeutic relationships in eating disorders. As pointed by Zuroff and colleagues (Zuroff et al., 2004), dependent people expect to be hurt in relationships and adopt submissive interpersonal style to forestall conflict and to elicit protection and support (Zuroff et al.,

direct influence over the clinical and social outcome of eating disorders.

relationships may play a significant role in the outcome of eating disorders.

patients in social relationships (Zuroff et al., 1999a; Zuroff et al., 2004).

**4. Discussion** 

2004). This interpersonal style may foster ambivalent feelings toward the therapeutic situation perceived as dangerous and may interfere with the subject's ability to engage in psychotherapy. On the contrary, as witnessed in our study by the protecting value of high levels of Relatedness, valuing intimate relationships and being able of positively use interpersonal and social resources are essential factors that can positively promote the development of therapeutic relationships. Relatedness seems to capture personality features that correspond to a greater level of psychological maturity, indicating a sensitivity to the feelings and need of others and a regard for a symmetrical relationships rather than need gratification only (Zuroff et al., 1999b). As pointed by Greenberg and Bornstein, relational trust, insight and psychological mindedness are tightly related to interpersonal development (Greenberg and Bornstein 1988) as it is the case for therapeutic change. As Blatt and colleagues have highlighted, depressed patients can differently react to treatments (whether psychotherapy or pharmacotherapy) according to the quality and development of interpersonal relatedness and self-definition dimensions (Blatt et al., 1995). Using data from the National Institute of Mental Health Treatment for Depression Collaborative Research Program, Zuroff and Blatt (Zuroff and Blatt 2006) have shown that, independent of type of treatment, a perceived positive therapeutic relationship early in treatment predicts a better adjustment as well a greater enhanced adaptive capacities throughout the 18-month followup. If therapeutic relationships contribute directly to positive therapeutic outcome, it should deserve special attention as a specific mechanism involved in change. As pointed by Fonagy and Target (Fonagy and Target 2002), treatment research should begin with the identification of key dysfunctions associated with a particular disorder and by establishing a conceptual link between the method of treatment and the dysfunctional mechanism identified in connection with the disorder.

According to our results, relational and interpersonal issues should be considered as key dysfunctions in eating disorders and should deserve specific attention. In fact, if symptom control is often a vital aim at the beginning of the therapy, elaborating relational experiences and family dynamics seem essential for the long term care of eating disorders. It is not surprising that interest in family interventions in eating disorders has increased over the past 5 years. A recent metanalysis of RCT studies has shown that systemic family therapy appears efficacious for the treatment of adult eating disorders (von Sydow et al., 2010). Family interventions are the current first-line treatment for adolescent anorexia nervosa and promising for adolescent bulimia nervosa (Le Grange and Eisler 2009; Lock 2011). Familiy treatment would be effective not only for weight restoration, but also in improving some psychological symptoms including dietary restraint, interoceptive deficits, and maturity fears (Couturier et al., 2010). Although encouraging, however these conclusions are based on few trials that included only small numbers of participants with several issues regarding potential bias. The field would benefit from large, well-conducted trials (Fisher et al., 2010).

There are several limitations to this study that must be acknowledged. First, the sample was composed of young women with medium to high levels of education recruited from university hospitals specialized in adolescents and young adults with severe disorders. It is possible that the sample contained patients with specific clinical and socio-demographic profiles that may reduce the generalisability of the results. Second, the study had a naturalistic design, with therapeutic interventions freely chosen on the basis of usual practices. Although we controlled treatments in all statistical analyses, differences in treatments received may have influenced the evolution of patients over time. A final limitation is the middling rate of follow-up. A certain number of refusals can be explained

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