**The Quality of Depressive Experience as a Prognostic Factor in Eating Disorders**

Mario Speranza, Anne Revah-Levy, Elisabetta Canetta, Maurice Corcos and Frederic Atger

*Centre Hospitalier de Versailles. Service de Pédopsychiatrie. Le Chesnay INSERM U669, Université Paris-Sud et Université Paris Descartes, France* 

### **1. Introduction**

There is overwhelming evidence that depression is one of the most common experiences of eating disorder patients (Herzog et al., 1992; Touchette et al., 2010). Individuals with anorexia or bulimia nervosa commonly display high levels of dysphoric affects, feelings of emptiness and ineffectiveness and emotions such as loneliness and desperation (Bruch 1973). Self-depreciating emotions associated with pathological eating behaviors may probably trigger depressive episodes (Nolen-Hoesema et al., 2007). However, several authors have suggested that eating behaviors themselves (whether starving, bingeing or purging) may serve as adaptive strategies to regulate negative emotions, such as those associated with identity and interpersonal disturbances, frequently seen in these patients (Heatherton et Baumeister, 1991).

For these reasons, it seems worthwhile, in eating disorders, to look for depression not only in a categorical way but also in a dimensional way and to explore the subjective experience of depression of these patients. This is in line with recent conceptualizations on depression from different theoretical perspectives which converge towards the identification of two types of fundamental depressive experiences framed by personality development: the first one focused on concerns associated with disruption in relationships with others (with feelings of loss, abandonment and loneliness) and the second one centered on problems concerning identity (associated with low self-esteem, feelings of failure, culpability, lack of self-confidence) (Blatt and Zuroff 1992). According to Blatt (Blatt, 2004), maladaptive behaviors would emanate directly from an overemphasis and exaggeration of one of the two essential developmental lines of the personality: the Dependent/Anaclitic line, which concerns the establishment of satisfying interpersonal relationships, and the Selfcritical/Introjective line, which focuses on the achievement of a positive and cohesive sense of self (Blatt and Zuroff 1992).

Blatt and colleagues have initially developed the Depressive Experience Questionnaire (DEQ) to assess these two dimensions which emerge as independent factors in analytic studies (Blatt et al., 1976). However, subsequent theoretical developments have suggested that different levels could be indentified, each following a developmental trajectory from immature to more mature forms of interpersonal relatedness and self-definition.

The Quality of Depressive Experience as a Prognostic Factor in Eating Disorders 115

research centres involved in a prospective follow-up study at 30 months. The recruitment centres were academic psychiatric hospitals specialized in adolescents and young adults (age range for reception: 15–30 years). For this study, only female participants who had requested care for an eating disorder were screened for inclusion. At the first assessment and at outcome, patients included in the sample completed a research protocol that consisted of a clinical interview (for sociodemographic and diagnostic data) and a selfreport questionnaire eliciting psychopathological features. Eating disorder diagnoses, whether of Anorexia Nervosa or Bulimia Nervosa, were made by a psychiatrist or a clinical psychologist specialized in the field of eating disorders using DSM-IV diagnostic criteria (APA 2000). Diagnostic assessment was made using the Mini International Neuropsychiatric Interview (MINI) which is a structured, validated diagnostic instrument that explores each criterion necessary for the establishment of current and lifetime DSM-IV axis I main diagnoses (eating disorders, anxiety and depressive disorders, substance-related disorders)(Sheehan et al., 1998). Patients were invited to participate in the follow-up study 3 years later. At 18 months, a reminder letter was sent to all participants. A second letter was sent just before contacting them by phone to plan the second assessment. Only patients with

The quality of the depressive experience was assessed with the Depressive Experience Questionnaire (Blatt et al., 1976). The DEQ is a 66-item self-report scale rated on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). This questionnaire was designed to assess the personality dimensions hypothesized by Blatt and Zuroff (Blatt and Zuroff 1992) to underlie different forms of depression. The instrument was developed by assembling a pool of items describing experiences frequently reported by depressed individuals. Factor analyses of the 66 items in normal and clinical samples have yielded three orthogonal factors matching the constructs of Interpersonal Concerns, Self-Criticism, and Efficacy (Blatt et al., 1976; Kuperminc et al., 1997). Subsequent factor analyses have identified two sub-factors within the Interpersonal Concerns factor, namely Neediness and Relatedness corresponding to different levels of maturation of interpersonal relatedness (Blatt et al., 1995; Rude and Burnham 1995). The DEQ has been shown to have high internal consistency and test-retest reliability (Mongrain and Zuroff 1994), high convergent and discriminant validity (Blaney and Kutcher 1991), as well as a high level of construct validity (Blatt and Zuroff 1992; Mongrain and Zuroff 1994). For the present study, we calculated the factor scores for Self-Criticism and Efficacy using the factor-weighting procedure provided by Blatt and colleagues (Blatt et al., 1976) and adapted in French by Atger and colleagues (Atger et al., 2003). We also calculated the sub-factor scores for the Neediness and Relatedness subscales of the Interpersonal Concerns factor using the scoring program for

Depression severity was measured with the French translation of the abridged version of the Beck Depression Inventory (BDI-13). The BDI is a self-report inventory measuring characteristic attitudes and symptoms of depression (Beck 1961). An abridged version with 13 items selected within all the items showing a high correlation (≥.90) with the total score of the BDI-21 has been developed as a specific tool for epidemiological studies including clinical and non-clinical subjects (Beck and Beck 1972). The 21-item and the 13-item forms have shown correlations ranging from 0.89 to 0.97 and a similar factor structure indicating that the short form is an acceptable substitute for the long form (Beck et al., 1974). Both the

complete files at follow-up were included in the study.

SPSS developed by Besser & Babchoock (Besser and Babchoock 2001).

**2.2 Measures at baseline** 

Investigations using the Depressive Experience Questionnaire (DEQ) have thus identified two levels within the Dependency factor (relabeled more appropriately, Interpersonal Concerns): a first sub-factor, labeled *Neediness,* assesses feelings of loneliness and insecurity as well as a marked vulnerability to nonspecific experiences of loss, rejection, and abandonment. The second sub-factor, labeled *Relatedness,* appears to assess a more mature level of interpersonal relatedness, including valuing intimate relationships and being concerned about disruptions of particularly meaningful, specific, interpersonal relationships (Blatt 2004). In a similar way, the development of a sense of self seems to follow an analogous progression. Research conducted with the DEQ has identified two levels within the development of self-definition: a first level, which corresponds to the Self-critical factor of the DEQ, assesses concerns about self-worth and failure to meet self and externally imposed standards. The second level contains more positive, proactive expressions of competence and confidence in one's self and in the future. Items corresponding to this more mature level of self-definition load mostly on the Efficacy factor already identified within the DEQ. Thus, the DEQ appears to measure adaptive and maladaptive dimensions of interpersonal relatedness (Neediness and Relatedness)(McBride et al., 2006), as well as adaptive and maladaptive dimension of selfdefinition (Self-Criticism and Efficacy)(Blatt 2004).

Blatt and colleagues in their initial conceptualization largely emphasized the link between the personality dimension of self-criticism and the clinical expression of depression. However, they hypothesized the existence of several forms of introjective and anaclitic psychopathology, not just limited to depression. Several authors since have reported high levels of both selfcriticism and dependency in disorders such as depression (Bagby et al., 1994), panic disorder (Bagby et al., 1992) or social phobia (Cox et al., 2000). The exploration of the depressive experience of eating disorder patients has only recently brought attention (Speranza et al., 2003), notwithstanding the fact that the clinical features of these disorders may imply a specific psychopathology of the developmental processes involving interpersonal relatedness and selfdefinition. In fact, current theorization on eating behaviors considers these disorders as a reflection of a specific developmental arrest in the separation–individuation process due to the primary caregiver's failure to provide essential functions during development (Corcos and Jeammet 2001). The eating disorder symptoms could be an attempt to cope with needs stemming from this incomplete self-development or to an interruption of the separation– individuation process (Goodsit 1997). Moreover, it can be hypothesized that the level of maturation of interpersonal relationships and/or identity could differentially characterize and influence the outcome of eating disorders according to the different subtypes.

The aim of this paper was to reach a better understanding of the impact of personality development on the clinical outcome of patients with eating disorders. We specifically sought to explore if anorexic or bulimic patients presenting more immature forms of interpersonal relatedness and/or self-definition would present a worst outcome. As relational maturation and identity formation are special duties of adolescence, we focused our investigation on a sample of adolescents and young female with eating disorders.
