Does psychological well-being change following treatment? An exploratory study on outpatients with eating disorders
Introduction
Widely used criteria for treatment response in eating disorders are typically focused on the reduction of psychopathological symptomatology as well as modifications of physical and behavioral aspects [1], [2]. Recently, the concept of euthymia, a term used in psychiatry to define when patients no longer meet criteria of a disorder, has been revisited by authors who recommend the inclusion of positive gains as criteria for mental health outcomes [3]. Indeed, gains in positive functioning are frequently not considered, despite findings indicating the persistence of impairment in positive qualities such as psychological well-being in various psychiatric illnesses including eating disorders (EDs) [4]. Such impairments may be associated with increased vulnerability to future adversity [5], [6].
The focus on the improvement of positive characteristics falls within the realm of positive psychology, whose purpose is to broaden definitions of mental health towards the inclusion of optimal functioning and a focus on building the best qualities. Positive psychology represents a clear paradigm shift from the historical negativity bias of the fields of psychiatry and psychology originally based on the disease model [7] and from a preoccupation only with repairing the worst aspects of life [8]. Such a shift has profound clinical implications. Bringing an individual out of negative functioning is one form of success, while facilitating progression towards the restoration of positive functioning is quite another [8], [9]. Indeed, the World Happiness Report 2016 Update [10] found that autonomy, positive affect, generosity and social support were highly associated with quality of life and overall well-being, a correlation which was non-existent with negative affect, commonly the sole target for psychiatric disorder treatment.
Several definitions of well-being in psychology have been attempted, the most widespread being various conceptualizations of subjective well-being, that is an individuals' perceptions and evaluations of their own lives in terms of their psychological and social functioning and affective states. Subjective well-being is frequently limited to and operationalized as the presence of positive emotions and satisfaction [8]. Alternatively, one of the most rigorously tested models of psychological well-being, introduced by Ryff [11], synthesizes clinical and personality theorists' conceptions of positive functioning, constituting a more comprehensive model of well-being. Ryff's model expands subjective well-being definitions towards a broader conceptualization of positive functioning. The author's eudaimonic model [11] derived from Jahoda's mental health criteria [12] considers specific domains that contribute to the development of optimal functioning and the fulfillment of one's potential including six interrelated psychological dimensions: autonomy, self-acceptance, a sense of continued growth and development, the belief that life is purposeful and meaningful, quality relationships with others, and the capacity to master effectively one's environment. A number of clinical studies on psychiatric populations have yielded substantial support to this model, finding that psychological well-being was frequently impaired [9], [13], [14]. Unlike other well-being definitions, this model of psychological well-being has not only been operationalized into an empirically validated instrument, Ryff's Psychological Well-Being Scales [11] but is also the theoretical basis for a specific psychotherapeutic intervention, well-being therapy [5], recently tested in EDs [15].
However, to date when positive mental health has been considered in eating disorders, there has been an exclusive focus on well-being in terms of subjective well-being and quality of life [16], [17], [18], [19]. In our previous controlled study, a paucity of optimal positive functioning, in terms of psychological well-being, correlated with eating disorder symptomatology in ED out-patients. The lack of psychological well-being was independent of the presence of psychological distress and the severity of the disorder [4]. Furthermore, very few studies on EDs have focused on gains in positive functioning following treatment. Recently, a study investigated how a specific cognitive-behavioral intervention (Identity Intervention Program) increased positive self-schemas and psychological well-being in a sample of ED patients [20]. No studies have instead explored if such changes in psychological well-being are observable following first-line standard CBT-based and nutritional rehabilitation treatment for EDs [21], and whether such changes reach healthy levels. Therefore, the aim of this study is to examine whether dimensions of psychological well-being in ED out-patients change after CBT-based and nutritional rehabilitation treatment and whether any observed gains in remitted patients reach optimal levels found in matched healthy controls.
Section snippets
Sample
A convenience sample of consecutively screened female out-patients (n = 195) who met DSM IV-TR diagnostic criteria for EDs [22], began an integrated treatment in an ED specialized out-patient clinic (Bologna, Italy). ED diagnoses were established at intake by the consensus of a psychiatrist and a clinical psychologist independently using the Structured Clinical Interview for DSM-IV (SCID) [23]. Patients who completed treatment were evaluated for remission from EDs status through face-to-face
Results
Out of the 195 consecutively screened patients entering treatment, 76.9% completed treatment (N = 150) while 23.1% (N = 45) dropped out. Ten drop-out patients did not have any baseline data and were excluded from the analyses.
No statistically significant differences emerged in age, illness duration, BMI, and psychometric measures (PWB scale scores, GHQ and EAT total scores) between treatment completers and drop-outs and between the subsample that completed all assessment measures at post-treatment
Discussion
While it is known that CBT reduces symptomatology in EDs [1], less is known about how changes in positive functioning may ensue. Previous studies have investigated well-being impairment among ED patients and compared such scores to general population controls [4], as well as investigated psychological well-being after a psychotherapeutic intervention [20]. However, no studies had yet evaluated psychological well-being changes in ED patients following standard CBT-based treatment.
The current
Conclusions
The assessment of treatment outcome in EDs may benefit from considering changes in positive functioning [2], [34], [40] such as psychological well-being, in addition to the standard measurement of BMI, symptomatology and behavioral parameters. CBT-based treatments for EDs may be strengthened by promoting the development of optimal domains particularly in the interpersonal realm, such as building of quality and warm relationships and focusing on enhancing self-acceptance.
As the development of
Acknowledgment
The authors thank the therapists and the collaborators of the Eating Disorder Clinic “Centro Gruber” and the Fondazione Gruber.
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