The role of mindfulness on the psychological aspects of anorexia nervosa

Abstract

Objective

Emotion regulation, perfectionism, and rumination are perpetuating factors in anorexia nervosa (AN). Mindfulness can be protective and therapeutic. We aimed to understand the relationship between these factors and mindfulness in AN.

Methods

20 adolescent girls in the acute phase of the AN, 16 in remission, and 40 in the control group were evaluated.

Results

Mindfulness was lowest in the acute AN group. The difference in the acute AN group regarding body dissatisfaction, emotion dysregulation, perfectionism, and mindfulness disappeared after controlling for the effects of depression and anxiety. The predictors of disordered eating in the entire study population were body dissatisfaction and depressive symptoms. Emotion regulation and perfectionism were the predictors of mindfulness in the acute AN group and the entire study population. When mindfulness decreased, concerns about body shape increased in both acute AN and remission groups, while dietary restriction and disordered eating behaviors increased only in the remission group.

Discussion

Emotion regulation difficulties in acute AN could be related to depression and anxiety. Mindfulness interventions for emotion regulation could be used for depression during the acute phase while for perfectionism in remission. Early intervention for depression and body dissatisfaction seems protective, and mindfulness could be an appropriate intervention.

Keywords

Anorexia nervosa adolescent mindfulness perfectionism rumination emotion regulation

Introduction

Anorexia nervosa (AN) is a disorder in perceiving the size and shape of the body and is characterized by being under the minimum body weight for age and height, being afraid of getting fat, and wanting to be thin. Body dissatisfaction is the core symptom. Depression (around 35–50%) and anxiety disorders (around 11%) are common comorbidities (Buhren et al., 2014; Puccio et al., 2016). Emotion regulation, stress intolerance, and cognitive/emotional avoidance strategies are etiological factors (Racine and Wildes, 2015). Perfectionism and ruminations related to body shape and weight are perpetuating factors (Donahue et al., 2018). Besides the treatment of medical complications, psychotherapy is needed. Psychotherapy is based on understanding the meaning of these factors and the process of separation-individualization and identity formation. The effectiveness of third-wave behavior therapies has also been investigated. These therapies emphasize the emotion regulation strategies such as acceptance, psychological flexibility, and metacognition that modulate the experience of emotion (Linardo et al., 2017). Mindfulness-based therapies are among them.

Emotions are conditional, almost automatic behaviors, physiological responses, and strategies that occur in the face of important experiences. Emotions become dysfunctional when they are not suitable for the current situation, are too intense, and last too long. Restriction in eating and heavy exercise in patients with AN could be due to avoiding negative emotions (Haynos and Fruzzetti, 2011). Patients with AN have difficulties understanding and describing their internal states, accepting the emotion experienced at that time, and especially reaching the right strategy that mediates emotion regulation (Danner et al., 2014).

Perfectionism describes a trait of setting unrealistic goals and valuing oneself according to whether these goals are achieved (Shafran and Mansell, 2001). In maladaptive perfectionism, the idea that society expects a ‘perfect ideal body’ could result in body dissatisfaction and eating disorder (Donahue et al., 2018). High standards of appearance and weight could lead to AN (Nilsson et al., 2007). Perfectionism may predict adverse outcomes and poor prognosis in AN (Bardone-Cone et al., 2007), especially with difficulties in emotion regulation (Byrne et al., 2016).

Rumination is repetitive, involuntary thoughts on a particular topic in the past. People with ruminative thoughts focus on specific points and feel internal discomfort, but they do not try to overcome them (Watkins and Teasdale, 2001). Rumination related to body shape and weight in AN is a mediator between AN and perfectionism (Halmi et al., 2000) and has an affective component rather than physiologic (Fürtjes et al., 2018). Rumination is an avoidance strategy in emotion regulation, providing distance from the emotional experience itself, but paradoxically, it causes the exacerbation of negative emotions (Roemer et al., 2009). In literature, rumination is associated with depression the most (Watkins and Teasdale, 2001), and depression is the most common comorbidity in AN (Buhren et al., 2014; Puccio et al., 2016).

Mindfulness is defined as directing one’s attention to momentary, internal, and environmental stimuli without judgment, accepting the moment by experiencing instant experiences without being influenced by past experiences, emotions, or the future. Its basic components are present-focused attention, acceptance, non-judgment, and introspection (Kabat‐Zinn, 2003). Mindfulness can protect against repetitive negative thoughts and ruminations associated with perfectionism (Short and Mazmanian, 2013). Mindfulness-based therapies have been recommended recently in AN (Merwin et al., 2010). Mindfulness-based therapies enhance interoceptive awareness, acceptance, and paying attention in the present moment non-judgmentally. Mindfulness could reduce restrained eating, improve body image acceptance, and reduce emotional and impulsive eating in AN (Turgon et al., 2019).

In light of current knowledge, the only study on mindfulness in AN included adult women and was conducted on symptoms directly related to eating (Thompson-Brenner et al., 2019). No study evaluates the interrelationships among perfectionism, rumination, emotion regulation, and mindfulness skills among adolescent girls with AN after controlling for the effects of depression and anxiety symptoms. This cross-sectional, case-control study aimed to evaluate mindfulness skills, perfectionism, rumination, and emotion regulation in adolescent girls with AN and to understand their relationship with symptoms of eating disorders during the acute phase and remission. We also investigated the relationship of these variables with the level of body shape dissatisfaction. The hypotheses of this study were: 1. Even after controlling for the effects of depression and anxiety, high rumination and perfectionism levels and more difficulties in emotion regulation negatively affect mindfulness skills in adolescent girls with AN regardless of whether they were in the acute phase or remission. 2. Disordered eating behaviors are related to high emotion regulation difficulties, low mindfulness, high perfectionism, and high body dissatisfaction, even in the control group. 3. Mindfulness is negatively affected by perfectionism, rumination, and emotion dysregulation among the AN group. 4. Mindfulness is higher in remission than in acute AN.

Materials and Methods

Sample and Design

Data were collected from adolescent girls (aged 12–18) who were outpatients of the Department of Child and Adolescent Psychiatry, Hacettepe University Faculty of Medicine, between March 2020 and July 2020. This study was approved by the Institutional Review Board of Hacettepe University (2020/06-52). Written informed consent was obtained from both participants and their parents. The exclusion criteria were having a chronic medical and/or neurological illness other than psychiatry, being diagnosed with intellectual disability, or any psychotic disorder or bipolar disorder. All participants were evaluated with a semi-structured interview, Schedule for Affective Disorders and Schizophrenia for School-Aged Children, Present and Lifetime Version (K-SADS-PL), to diagnose psychiatric disorders in AN and Remission groups and rule out psychiatric disorders in the control group. The reliability and validity in Turkish were performed (Ünal et al., 2019).

Adolescents aged 12–18 who self-identified as girls and applied to our clinic with complaints such as not eating and/or weight loss were evaluated for the AN group. The adolescent girls with AN who needed hospitalization at the time of the evaluation were included in the study after 1 month of discharge. The Remission group consisted of adolescent girls with a history of AN whose symptoms did not meet the diagnosis of AN according to K-SADS-PL. Although there is no consensus on the remission criteria in the literature, we defined remission as a BMI ≥19 and a decrease in symptoms to at least a sub-threshold level for at least 3 months (Khalsa et al., 2017; De Young et al., 2020). The control group consisted of adolescent girls who applied to our clinic to get a report stating that they have no psychiatric problems or get counseling about a challenge in their lives (e.g., School change). A psychiatric evaluation has been performed for these applications. For this study, K-SADS-PL was applied to be sure they had no psychiatric disorders currently and in the past. One adolescent girl in the AN group was excluded because of her high BMI. Twenty adolescent girls were in the acute phase of the AN group, 16 were in remission, and 40 were in the control group. The groups were matched concerning sociodemographic level.

Measurements

Sociodemographic and Clinical Information Form

This form was developed by researchers. Sociodemographic, developmental, medical, and family histories were asked.

Eating Disorder Examination Questionnaire (EDE-Q)

This 7-point Likert-type scale assesses eating disorders attitudes and behaviors with 28 items. There are four subscales: Dietary restraint, eating concern, shape concern, and weight concern. The total score is calculated by averaging the four subscales, and higher scores indicate severe eating disorders (Fairburn & Beglin, 1994; Yucal et al., 2011).

Five Facets Mindfulness Questionnaire (FFMQ)

The questionnaire has 39 items that assess the tendency to be mindful in daily life (Baer et al., 2006; Kınay, 2013). The five facets are as follows: Observing (the tendency to observe internal and external experiences), Describing (the tendency to describe and label internal experiences in words), Acting with awareness (acting with awareness and undivided attention to the present activity or experience), Nonjudging (take a nonjudgmental stance toward inner experiences), and Nonreactivity (the tendency to allow thoughts and feelings to go without focusing or elaborating on them). Higher scores indicate a tendency to that facet of mindfulness, and the total score is also calculated.

Ruminative Response Scale- Short Version (RRS-SV)

This 4-point Likert-type scale evaluates the tendency to ruminate in response to sadness and depression with 10 items (Treynor et al., 2003). It contains two subscales: Brooding (a maladaptive rumination style that refers to mood pondering) and Reflection (reassessment of past and present events, feeling, and behaviors thoughtfully and unemotionally; it could be adaptive or maladaptive). Higher scores indicate a greater rumination tendency in that way. Turkish reliability and validity were conducted (Erdur-Baker and Bugay, 2010).

Difficulties in Emotion Regulation Scale (DERS)

This 5-point Likert-type scale consists of 36 items that evaluate the difficulties in emotion regulation in six subscales: Goals (difficulty in engaging goal-directed behaviors while experiencing negative emotions), strategies (limited access to emotion regulation strategies), impulse (controlling impulsivity while experiencing negative emotions), awareness (being aware of responses when facing with negative emotions), clarity (lack of emotion clarity), and nonacceptance (nonacceptance of negative emotions). Higher scores indicate the difficulty stated in that subscale, and the total score is also calculated (Gratz and Roemer, 2004; Rugancı and Gencoz, 2010).

Frost Multidimensional Perfectionism Scale (FMPS)

It has 35 items with six subscales: Doubts about actions (feeling unsure of the quality of one’s actions), Concern over mistakes (negative reactions to mistakes, thinking of mistakes as a failure), Parental expectations (thinking of parents’ high standards), Parental criticism (the belief that parents are overly critical), Personal standards (having extremely high standards for performance), and Organization (tendency to be orderly and organized). Each item is answered using a 5-point Likert-type style. Besides the total score, higher scores indicate the severity of perfectionism stated in that subscale. The organization is thought to have a distinct feature that is not calculated with the total score (Frost et al., 1990; Ozbay and Misirli Tasdemir, 2003).

Body Image Satisfaction Questionnaire (BISQ)

It is a 5-point Likert-type scale with 25 items, including general appearance, face, extremities, trunk, chest, upper torso, and sexual organs. The score of each body part is calculated by dividing the sum of points by the number of items in that body part. Higher scores indicate higher body dissatisfaction (Berscheid et al., 1972; Gökdoğan, 1988).

Beck Depression Inventory (BDI)

This inventory measures the severity of depression with 21 items. It is a 4-point Likert-type scale with a cut-off of 17 (Beck and Ward, 1961; Hisli, 1989).

Screen for Child Anxiety and Related Disorders (SCARED)

This 3-point Likert-type scale includes 41 items. A score of ≥25 may indicate the presence of an anxiety disorder (Birmaher et al., 1997; Karaceylan Cakmakci, 2004).

Statistical Analysis

Statistical analysis was performed by Statistical Package for the Social Sciences 22 (SPSS 22). The significance of the difference between the two groups was evaluated with an independent sample t test or Mann-Whitney U test, depending on whether parametric conditions were satisfied. In order to compare the variables between more than two groups, a one-way analysis of variance (ANOVA) or Kruskal-Wallis test was performed. Categorical variables were evaluated with Pearson’s Chi-Square or Fisher’s Exact test. Spearman’s correlation coefficient was used to determine the relationship between two continuous variables. Analysis of covariance (ANCOVA) was performed to determine the main effect of an independent variable on a dependent variable (age, CDI, SCARED). A linear regression analysis with the forward model was used to identify the factors affecting EDE-Q and FFMQ. p < 0.05 was considered statistically significant.

Results

Sociodemographic and Clinical Variables

Among sociodemographic variables, only age was statistically significant; adolescent girls with remission were older than others (mean age was 15.5 ± 1.42 y in the AN group, 15.4 ± 1.38 y in Controls, and 16.7 ± 1.4 y in the Remission group; p:0.001). There were no differences between groups in terms of living place (urban or rural), duration of education, parental education levels, parents’ age, socioeconomic level, occupational status of parents, and the number of siblings. BMI and all EDE-Q scores were significantly lower in the AN group. Also, the AN group had higher body dissatisfaction and depression scores than other groups. Total anxiety score, panic/somatic, and school phobia scores in AN were significantly higher than in the Remission group. The general anxiety score in AN was higher than in the Control group (Table 1).

Table 1.

Clinical Characteristics of Groups.

	AN (n:20 girls)	Remission (n:16 girls)	Controls (n:40 girls)	p-value
BMI (mean ± SD)	17.22 ± 1.76^a	19.78 ± 2.35	20.87 ± 2.41	p < 0.001
(≥17), n (%)	13 (65%)	-	-
(16.0–16.9), n (%)	3 (15%)
(15.0–15.9), n (%)	1 (5%)
(<15), n (%)	3 (15%)
AN subtype
Restrictive, n (%)	16 (80%)	12 (75%)		p:0.82^b
Binge eating/purging, n (%)	4 (20%)	3 (18.8%)
Mix, n (%)	0	1 (6.2%)
Duration of remission, Months (mean ± SD)	-	5.8 ± 2.2	-
Medication
No, n (%)	3 (15%)	4 (25%)		p:0.27^b
Fluoxetine, n (%)	11 (55%)	11 (68.5%)
Fluoxetine + Olanzapine, n (%)	6 (30%)	1 (6.2%)
	Median (lowest-highest)
Age at onset, year	14.5 (12–16)	15 (13–17)	-	p:012^c
Duration of illness, months	10.5 (12–16)	10.5 (13–17)	-	p:0.96^c
EDE-Q (total)	3.19 (1.1–5.7)^a	0.55 (0–5.1)	0.86 (0–3.9)	p < 0.001
Dietary restraint	2.4 (0.2–5.2)^a	0.4 (0–5.6)	0.4 (0–4)	p < 0.001
Eating concern	4.31 (2–5.75)^a	0.81 (0–6)	1.25 (0–5.25)	p < 0.001
Shape concern	3.6 (0.6–6)^a	0.6 (0–4)	0.8 (0–4.6)	p < 0.001
Weight concern	3.19 (1.1–5.7)^a	0.55 (0–5.1)	0.86 (0–3.9)	p < 0.001
BISQ	2.86 (1.64–4.6)^a	4.06 (2.32–4.8)	3.86 (2.4–4.8)	p < 0.001
BDI	23.5 (4–54)^a	8.5 (0–41)	7 (0–22)	p < 0.001
BDI <17, n (%)	12 (60%)^a	5 (31.2%)	8 (20%)	p:0.008
BDI ≥17, n (%)	8 (40%)	11 (68.2%)	32 (80%)
SCARED (total)	37.5 (7–66)	22.5 (4–49)	28.5 (6–55)	p:0.03
Panic/Somatic	11.5 (2–30)	8 (1–21)	10 (1–25)	p:0.16
Social phobia	6 (0–10)	3 (0–10)	6 (1–10)	p:0.04
General anxiety	11 (0–15)	6.5 (1–13)	6.5 (0–14)	p:0.02
School phobia	3 (0–9)	1 (0–4)	2 (0–7)	p:0.04
Separation anxiety	3 (0–7)	2.5 (0–6)	3.5 (0–8)	p:0.24
SCARED
SCARED<25, n (%)	15 (75%)	8 (50%)	26 (65%)	p:0.296
SCARED≥25, n (%)	5 (25%)	8 (50%)	14 (35%)

^aStatistically different group.

^bFisher’s exact test.

^cMann-Whitney U test; AN: Anorexia nervosa; BMI: Body mass index; EDE-Q: Eating disorder questionnaire; BISQ: Body image satisfaction questionnaire; BDI: Beck depression inventory; SCARED: Screen for child anxiety & related disorders.

Table 2 shows the scores of FFMQ, RRS-SV, DERS, and FMPS. The brooding score of RRS-SV, concerns over mistakes score of FMPS, total, strategies, and awareness scores of DERS were significantly higher in the AN group from other groups. Parental criticism, total scores of FMPS, and clarity score of DERS were significantly higher in AN while observing score of FFMQ was significantly lower than in Controls. ‘Parental criticism’ was similar between the AN and Remission groups. The remission group significantly differed from the other groups in terms of the organization score of FMPS, which was the highest in the Remission group. The impulse score of DERS was significantly higher in AN than in the Remission group, while acting with awareness of FFMQ was significantly lower. When comparing the total score of FFMQ in two groups with the Mann-Whitney U test, the score of the AN group was found to be significantly lower than the score of the Control group (p:0.022).

Table 2.

Mindfulness, Rumination, Emotion Regulation, and Perfectionism in Groups.

	AN (n:20 girls)	Remission (n:16 girls)	Controls (n:40 girls)	p
	Median (lowest-highest)
FFMQ (total)	115.5 (79–155)	130.5 (101–155)	128.5 (92–160)	0.05
Observing	29 (16–43)	28.5 (15–39)	30 (17–43)	0.13
Describing	22 (10–38)	29.5 (15–40)	29 (16–40)	0.02
Acting with awareness	24.5 (8–40)	32 (25–40)	29 (19–40)	0.008
Nonjudging	22 (11–38)	25.5 (15–33)	20.5 (9–39)	0.15
Nonreactivity	15.5 (8–20)	15 (10–24)	17 (12–32)	0.13
RRS-SV (total)	23 (12–34)	20 (12–32)	21 (11–35)	0.34
Brooding	13 (5–17)	10 (6–18)	11 (6–16)	0.03
Reflection	10 (6–19)	11 (6–14)	10 (5–19)	0.95
DERS (total)	108.5 (48–172)	79.5 (43–115)	80 (44–141)	0.003
Goals	18 (5–25)	13.5 (7–25)	16 (5–23)	0.39
Strategies	25.5 (8–40)^a	15.5 (8–29)	16.5 (8–38)	0.008
Impulse	16.5 (7–30)	10 (6–25)	12 (6–29)	0.003
Awareness	21 (9–30)	14.5 (7–26)	15 (8–24)	0.006
Clarity	14.5 (5–25)	11.5 (5–17)	11 (5–23)	0.01
Nonacceptance	12.5 (6–27)^a	9.5 (5–21)	10 (6–24)	0.07
FMPS (total)	102.5 (42–135)	89 (46–116)	79 (45–121)	0.005
Concerns over mistakes	35.5 (10–45)^a	27 (9–39)	23 (11–42)	0.001
Doubts about actions	18 (6–25)	12.5 (6–21)	12.5 (5–24)	0.007
Parental expectations	12.5 (5–25)	16.5 (9–25)	15 (5–24)	0.28
Parental criticism	9.5 (5–19)	10 (4–19)	7 (4–15)	0.02
Personal standards	24 (9–30)	23.5 (16–29)	23 (12–30)	0.76
Organization	24.5 (11–30)	28 (16–30)^a	21.5 (6–30)	0.003

^aStatistically different group; AN: Anorexia nervosa; FFMQ: Five facets mindfulness questionnaire; RRS-SV: Ruminative response scale-short version; DERS: Difficulties in emotion regulation scale; FMPS: Frost multidimensional perfectionism scale.

After controlling for the effect of age, EDE-Q, DERS, and BDI were still significantly higher in AN than in the other groups, while BISQ was still significantly lower in AN than in other groups. The SCARED score was still significantly higher in AN (34.98 ± 2.96) than in the Remission group (19.53 ± 3.4) even after controlling for the effect of age (Controls: 29.42 ± 2.11; F: 5.64, p < 0.01). The mindfulness score was significantly lower in AN (Median: 115.5 (70–155)) than in Control (Median: 128.8 (92–160)) group (p:0.022; Remission: 130.5 (101–155)). However, after controlling for the effect of age, the mindfulness score in AN (116.38 ± 3.74) became significantly lower than in both Remission (131.81 ± 4.38) and Control (128.04 ± 2.66) groups (F: 4.18, p < 0.05).

The differences between groups in BISQ, DERS, FMPS, and FFMQ disappeared after controlling for the effects of depression and anxiety, though the EDE-Q score was still significantly higher in the AN group. There was no significant difference in RRS-SV between groups before and after controlling for the effects of depression and anxiety (Table 3).

Table 3.

Corrected Total Scores of Scales According to Depression and Anxiety Symptoms.

	AN (n:20 girls)	Remission (n:16 girls)	Controls (n:40 girls)	F-Statistic
	Mean ± SD			F-value
EDE-Q	2.79 ± 0.24^b	1.35 ± 0.24	1.30 ± 0.16	13.11^a
BISQ	3.36 ± 0.12	3.69 ± 0.12	3.71 ± 0.08	2.79
RRS-SV	20.57 ± 1.28	21.9 ± 1.28	22.05 ± 0.85	0.42
FMPS	86.20 ± 3.61	92.19 ± 3.61	85.15 ± 2.40	1.35
FFMQ	123.96 ± 3.60	125.31 ± 3.60	126.85 ± 2.40	0.20
DERS	91.41 ± 4.03	86.66 ± 4.03	1.30 ± 0.16	0.45

^ap < 0.001.

^bSignificantly different group; AN: Anorexia nervosa; EDE-Q: Eating disorder questionnaire; BISQ: Body image satisfaction questionnaire; RRS-SV: Ruminative response scale-short version; FMPS: Frost multidimensional perfectionism scale; FFMQ: Five facets mindfulness questionnaire; DERS: Difficulties in emotion regulation scale.

The Correlation Analysis

The significant relationships between age and scales were: BDI in the Control group (r: 0.55, p < 0.001), and RRS-SV (r: 0.53, p < 0.05), DERS (r: 0.54, p < 0.05), BDI (r: 0.48, p < 0.05), and SCARED (r: 0.45, p < 0.05) in AN group. The relationship between EDE-Q and BMI was found only in the Control group (r: 0.58, p < 0.001). The correlation of EDE-Q with other scales is shown in Table 4.

Table 4.

Correlations of EDE-Q with Other Scales.

	EDE-Q
	AN		Remission		Controls
	r	p	r	p	r	p
BISQ	−0.66	0.002	−0.76	0.001	−0.35	0.03
BDI	0.57	0.009	0.78	<0.001	0.28	0.08
SCARED	0.57	0.009	0.64	0.008	0.41	0.008
FMPS	0.48	0.03	0.60	0.01	0.10	0.50
FFMQ	−0.20	0.39	−0.59	0.02	−0.26	0.09
RRS-SV	0.56	0.01	0.45	0.08	0.23	0.15
DERS	0.32	0.16	0.69	0.003	0.26	0.10

r: Spearman correlation analysis; AN: Anorexia nervosa; EDE-Q: Eating disorder questionnaire; BISQ: Body image satisfaction questionnaire; BDI: Beck depression inventory; SCARED: Screen for child anxiety & related disorders; FMPS: Frost multidimensional perfectionism scale; FFMQ: Five facets mindfulness questionnaire; RRS-SV: Ruminative response scale-short version; DERS: Difficulties in emotion regulation scale.

In the AN group, concerns about body shape increased when mindfulness decreased in the acute period. In the Remission group, concerns about restriction, eating, and body shape increased as mindfulness decreased (Table 5).

Table 5.

Correlations of EDE-Q Subscales with Mindfulness.

FFMQ
EDE-Q	AN		Remission		Controls
EDE-Q	r	p	r	p	r	p
Dietary restraint	0.36	0.12	−0.61	0.01	−0.14	0.36
Eating concern	−0.26	0.27	−0.57	0.02	−0.15	0.36
Shape concern	−0.50	0.02	−0.57	0.02	−0.26	0.13
Weight concern	−0.38	0.09	−0.43	0.09	−0.29	0.09

r: Spearman correlation analysis; AN: Anorexia nervosa; EDE-Q: Eating disorder questionnaire; FFMQ: Five facets mindfulness questionnaire.

Mindfulness correlated negatively with anxiety, body dissatisfaction, and emotion dysregulation in all groups. Depression and perfectionism were correlated negatively with mindfulness in the AN group (Table 6).

Table 6.

Correlations of Mindfulness (FFMQ) with Other Scales.

	FFMQ
	AN		Remission		Controls
	r	p	r	p	r	p
BISQ	0.49	0.03	0.66	0.005	0.35	0.04
BDI	−0.60	0.006	−0.72	0.002	−0.14	0.38
SCARED	−0.45	0.04	−0.77	0.001	−0.50	0.001
FMPS	−0.14	<0.001	−0.42	0.10	−0.47	0.002
EDE-Q	−0.20	0.38	−0.59	0.02	−0.27	0.09
RRS-SV	−0.31	0.18	−0.26	0.33	−0.06	0.70
DERS	−0.77	<0.001	−0.67	0.004	−0.39	0.01

r: Spearman correlation analysis; AN: Anorexia nervosa; FFMQ: Five facets mindfulness questionnaire; BISQ: Body image satisfaction questionnaire; BDI: Beck depression inventory; SCARED: Screen for child anxiety & related disorders; FMPS: Frost multidimensional perfectionism scale; EDE-Q: Eating disorder questionnaire; RRS-SV: Ruminative response scale-short version; DERS: Difficulties in emotion regulation scale.

Regression Analysis

The sample size in the AN group was not sufficient for regression analysis with all scales. Body image satisfaction (BSIQ), rumination (RRS-SV), and perfectionism (FMPS) were entered in linear regression with the forward model because of their high correlation scores with EDE-Q. Only BSIQ stayed in this model and explained 41% of the variance of EDE-Q (R-squared: 0.41, p:0.002). On the other hand, when linear regression analysis with the forward model was performed for mindfulness (FFMQ), perfectionism (FMPS), emotion regulation (DERS), and BISQ were entered. Only DERS stayed in the model and explained 64% of the variance of FFMQ (R-squared: 0.64, p:0.002).

All scales were entered in linear regression analysis to find all participants’ associated factors of eating disorder (EDE-Q) and mindfulness (FFMQ). For EDE-Q, the forward model was used, and in Model 1, BSIQ explained 53% of the variance (R-squared: 0.53, p < 0.001). When depression (BDI) entered Model 2, it explained 61% of the variance (R-squared: 0.61, p < 0.001). Depression and body image dissatisfaction were the predictors of disordered eating in the entire population. When the forward model was used for FFMQ, emotion regulation (DERS) explained 47% of the variance in Model 1 (R-squared: 0.47, p < 0.001), and perfectionism (FMPS) explained 52% of the variance in Model 2 (R-squared: 0.52, p < 0.001). Emotion regulation and perfectionism were the predictors of mindfulness in all participants (Table 7).

Discussion

In this study, many psychological aspects of AN, body satisfaction, symptoms of depression, and anxiety were evaluated and compared. The inclusion of only adolescent girls creates a homogeneous group. In the studies carried out, there is no research examining all these variables together in a clinical sample. Also, studies comparing the acute and remission phase of AN are limited.

Table 7.

Associated Factors of Eating Disorder (EDE-Q) and Mindfulness (FFMQ) in All Groups.

Predictors	Beta	Standardized Beta	T	95% confidence interval	p
EDE-Q
BISQ	−0.974	−0.448	0.219	−3.408/0.075	<0.001
BDI	0.053	0.396	0.014	0.800/1.676	<0.001
FFMQ
DERS	−0.346	−0.481	−4.17	−5.11/−0.181	<0.001
FMPS	−0.271	−0.294	−2.549	−0.482/−0.059	0.013

EDE-Q: Eating disorder questionnaire; BISQ: Body image satisfaction questionnaire; BDI: Beck depression inventory; DERS: Difficulties in emotion regulation scale; FMPS: Frost multidimensional perfectionism scale.

The lower BMI, higher eating disorder score, and lowest body satisfaction in the AN group, even after controlling for the effects of depression and anxiety, are compatible with the literature (Steinglass et al., 2020). The lowest anxiety level in the Remission group may be due to their treatment history.

In the AN group, body dissatisfaction was correlated with emotion regulation difficulties, but emotion dysregulation was not correlated with eating disorder behaviors. Besides, the significance of higher emotion regulation difficulties scores in the AN group than in the other groups disappeared after controlling for the effects of depression and anxiety. On the other hand, in the Remission group, both body dissatisfaction and eating disorder behaviors were correlated with emotion regulation difficulties. Also, body dissatisfaction and depression correlated in the Remission group. We suggest that during the acute phase, difficulties in emotion regulation may be due to comorbid depression and anxiety symptoms, while during the remission phase, emotion regulation strategies may be more related to the psychological aspects of AN. Emotion regulation is not an AN-specific feature but a transdiagnostic feature (Svaldi et al., 2012), so it could be a mediator in the transition from one comorbidity to another during AN. Some studies considered difficulties in emotion regulation as an independent variable not associated with anxiety (Haynos et al., 2015).

Maladaptive perfectionism is associated with AN (Halmi et al., 2000). In follow-up studies, perfectionism persists even after the weight becomes normal (Bastiani et al., 1995; Srinivasagam et al., 1995). This study found a positive relationship between eating disorders, perfectionism, and body dissatisfaction in the AN and Remission groups. Besides, emotion dysregulation was correlated with perfectionism in all groups, and body dissatisfaction and depressive symptoms were found as predictors of eating disorder symptoms in the entire study population. Consistent with past research (Byrne et al., 2016; Donahue et al., 2018), these results suggest that body dissatisfaction in a depressive adolescent girl could trigger eating disorders combined with perfectionism and emotion dysregulation. The current findings revealed that clinicians should target perfectionism as well when treating depressive symptoms in both the acute and remission phase of AN. Depression can increase emotion dysregulation and lead to a decrease in coping with the distress caused by perfectionism.

The only relationship between rumination and eating disorders was in the AN group. In a study, rumination and perfectionism were predictors of eating disorders (McLaughlin and Nolen-Hoeksema, 2011). Besides, in another study, rumination was considered a mediator between perfectionism and eating disorder symptoms (Halmi et al., 2000). The results of the regression analysis of our study did not support these findings. The small sample size could be the reason. Our study’s highest brooding score in the AN group is consistent with the literature (Rawal et al., 2010). Brooding is thought to be related to depression (Treynor et al., 2003), and in our study, brooding in the AN group may also be associated with depression. However, we found a correlation between the total rumination score and depressive symptoms only in Control and Remission groups. Content in ruminations differentiated into different psychological disorders, and food and weight-related ruminations are the key maintenance factors in AN (Fürtjes et al., 2018). Although RRS-SV does not contain items related to eating disorders, we thought that the rumination of body dissatisfaction and eating in the AN group might lead to pathological eating and body-related preoccupations during the active period of AN.

Mindfulness can protect against eating disorders by reducing ruminations about eating, weight, and body shape (Dunne et al., 2021). People with high mindfulness have significantly lower maladaptive perfectionism, rumination, and mental distress (Short and Mazmanian, 2013). In this study, mindfulness was negatively correlated with body satisfaction in all groups, and emotion dysregulation and perfectionism were the strongest predictors of mindfulness. Mindfulness was the lowest in the AN group and was correlated with perfectionism in AN. When adolescent girls’ mindfulness lowers, they could feel dissatisfied with their appearance and start criticizing themselves for perfectionism. Given this, mindfulness could be a protective factor in AN. In our study, the relationship between depressive symptoms and mindfulness was only present in the AN and Remission.

Additionally, the difference in mindfulness between groups disappeared after controlling for the effects of depression and anxiety. Negative self-evaluation with emotion dysregulation may trigger depressive symptoms, and depression with body dissatisfaction was the predictor of disordered eating. Treatment of depression may increase motivation and decrease body dissatisfaction and emotion dysregulation (Gregertsen et al., 2019; Puccio et al., 2016). We think mindfulness would be effective for depression and anxiety in the acute phase while for emotion regulation and perfectionism in the remission phase.

In summary, when we consider our hypotheses: 1. Mindfulness correlated negatively with depression in both AN and Remission groups, while it correlated negatively with anxiety in all groups. The difference in AN from other groups in terms of lower mindfulness scores disappeared when the effects of depression and anxiety on all these psychological aspects were controlled. Even after controlling for the effects of depression and anxiety, high perfectionism levels and more difficulties in emotion regulation negatively affect mindfulness skills in all participants. 2. Disordered eating behaviors are related to depressive symptoms and high body dissatisfaction in all groups. 3. Mindfulness is negatively correlated with emotion dysregulation in all groups. 4. Mindfulness is higher in remission than in acute AN. However, this difference becomes statistically insignificant after controlling for the effects of depression and anxiety. Depression is one of the poor prognostic factors in AN (Franko et al., 2018), and it persists even after weight gain (De Young et al., 2020). Mindfulness could be effective for the symptoms of AN and depression and psychological aspects of AN like emotion dysregulation and perfectionism, which are important for prevention and recurrence.

This study has some limitations. Although we specified the remission criteria according to the literature, these criteria have not been determined strictly in the literature. Additionally, it is challenging to understand treatment effects in the Remission group because of the absence of assessments during their active period. The control group in our study consisted of individuals who applied to the psychiatry outpatient clinic. While we did apply a psychiatric evaluation to ensure these participants had no psychiatric disorders, we acknowledge that this control sample may have limited generalizability to a larger population. A homogeneous Remission group created with accurate criteria for comparison is recommended. Besides, follow-up studies in which the before and after treatment scores of scales are compared, should be carried out with larger samples.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Burcu Ersöz Alan

Author biographies

Neşe Dikmeer is working as a child and adolescent psychiatrist at Dr. Sami Ulus Training and Research Hospital for Maternity and Child Health.

Burcu Ersöz Alan is an assistant professor at Hacettepe University. She is working in the field of child and adolescent psychopathologies at the Department of Child and Adolescent Psychiatry.

Dilşad Foto Özdemir is a professor at Hacettepe University. She is working in the field of child and adolescent psychopathologies at the Department of Child and Adolescent Psychiatry.

References

Baer

R. A.

Smith

G. T.

Hopkins

Krietemeyer

Toney

(2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13, 27–45. https://doi.org/10.1177/1073191105283504

Bardone-Cone

A. M.

Wonderlich

S. A.

Frost

R. O.

Bulik

C. M.

Mitchell

J. E.

Uppala

Simonich

(2007). Perfectionism and eating disorders: Current status and future directions. Clinical Psychology Review, 27(3), 384–405. https://doi.org/10.1016/j.cpr.2006.12.005

Bastiani

A. M.

Rao

Weltzin

Kaye

W. H.

(1995). Perfectionism in anorexia nervosa. International Journal of Eating Disorders, 17(2), 147–152. https://doi.org/10.1002/1098-108x(199503)17:2<147::aid-eat2260170207>3.0.co;2-x

Beck

A. T.

Ward

Mendelson

Mock

Erbaugh

J. J. A. G. P.

(1961). Beck depression inventory (BDI). Archives of General Psychiatry, 4(6), 561–571.

Berscheid

Bohrnste

Walster

(1972). Body image. Psychology Today, 6(2), 57.

Birmaher

Khetarpal

Brent

Cully

Balach

Kaufman

Neer

S. M.

(1997). The screen for child anxiety related emotional disorders (SCARED): Scale construction and psychometric characteristics. Journal of the American Academy of Child & Adolescent Psychiatry, 36(4), 545–553. https://doi.org/10.1097/00004583-199704000-00018

Bühren

Schwarte

Fluck

Timmesfeld

Krei

Egberts

Herpertz-Dahlmann

(2014). Comorbid psychiatric disorders in female adolescents with first-onset anorexia nervosa. European Eating Disorders Review, 22(1), 39–44. https://doi.org/10.1002/erv.2254

Byrne

M. E.

Eichen

D. M.

Fitzsimmons-Craft

E. E.

Taylor

C. B.

Wilfley

D. E.

(2016). Perfectionism, emotion dysregulation, and affective disturbance in relation to clinical impairment in college-age women at high risk for or with eating disorders. Eating Behaviors, 23, 131–136. https://doi.org/10.1016/j.eatbeh.2016.09.004

Danner

U. N.

Sternheim

Evers

(2014). The importance of distinguishing between the different eating disorders (sub) types when assessing emotion regulation strategies. Psychiatry Research, 215(3), 727–732. https://doi.org/10.1016/j.psychres.2014.01.005

10.

De Young

K. P.

Kambanis

P. E.

Bottera

A. R.

Mancuso

Thomas

J. J.

Franko

D. L.

Eddy

K. T.

(2020). Identifying duration criteria for eating-disorder remission and recovery through intensive modeling of longitudinal data. International Journal of Eating Disorders, 53(8), 1224–1233. https://doi.org/10.1002/eat.23249

11.

Donahue

J. M.

Reilly

E. E.

Anderson

L. M.

Scharmer

Anderson

D. A.

(2018). Evaluating associations between perfectionism, emotion regulation, and eating disorder symptoms in a mixed gender sample. The Journal of Nervous and Mental Disease, 206(11), 900–904. https://doi.org/10.1097/NMD.0000000000000895

12.

Dunne

J. P.

Shindul-Rothschild

White

Lee

C. S.

Wolfe

B. E.

(2021). Mindfulness in persons with anorexia nervosa and the relationships between eating disorder symptomology, anxiety, and pain. Eating Disorders, 29(5), 497–508. https://doi.org/10.1080/10640266.2019.1688009

13.

Erdur-Baker

Ö.

Bugay

(2010). The short version of ruminative response scale: Reliability, validity, and its relation to psychological symptoms. Procedia-Social and Behavioral Sciences, 5, 2178–2181. https://doi.org/10.1016/j.sbspro.2010.07.433

14.

Fairburn

C. G.

Beglin

S. J.

(1994). Assessment of eating disorders: Interview or self-report questionnaire? International Journal of Eating Disorders, 16(4), 363–370. https://doi.org/10.1002/1098-108X(199412)16:4<363::AID-EAT2260160405>3.0.CO;2-%23

15.

Franko

D. L.

Tabri

Keshaviah

Murray

H. B.

Herzog

D. B.

Thomas

J. J.

Eddy

K. T.

(2018). Predictors of long-term recovery in anorexia nervosa and bulimia nervosa: Data from a 22-year longitudinal study. Journal of Psychiatric Research, 96, 183–188. https://doi.org/10.1016/j.jpsychires.2017.10.008

16.

Frost

R. O.

Marten

Lahart

Rosenblate

(1990). The dimensions of perfectionism. Cognitive Therapy and Research, 14(5), 449–468. https://doi.org/10.1007/BF01172967

17.

Fürtjes

Seidel

King

J. A.

Biemann

Roessner

Ehrlich

(2018). Rumination in anorexia nervosa: Cognitive-affective and neuroendocrinological aspects. Behaviour Research and Therapy, 111, 92–98. https://doi.org/10.1016/j.brat.2018.10.001

18.

Gökdoğan

(1988). Orta Öğretime Devam Eden Ergenlerde Beden İmajından Hoşnut Olma Düzeyi [Unpublished master’s thesis, Ankara University].

19.

Gratz

K. L.

Roemer

(2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41–54. https://doi.org/10.1023/B:JOBA.0000007455.08539.94

20.

Gregertsen

E. C.

Mandy

Kanakam

Armstrong

Serpell

(2019). Pre-treatment patient characteristics as predictors of drop-out and treatment outcome in individual and family therapy for adolescents and adults with anorexia nervosa: A systematic review and meta-analysis. Psychiatry Research, 271, 484–501. https://doi.org/10.1016/j.psychres.2018.11.068

21.

Halmi

K. A.

Sunday

S. R.

Strober

Kaplan

Woodside

D. B.

Fichter

Kaye

W. H.

(2000). Perfectionism in anorexia nervosa: Variation by clinical subtype, obsessionality, and pathological eating behavior. American Journal of Psychiatry, 157(11), 1799–1805. https://doi.org/10.1176/appi.ajp.157.11.1799

22.

Haynos

A. F.

Fruzzetti

A. E.

(2011). Anorexia nervosa as a disorder of emotion dysregulation: Evidence and treatment implications. Clinical Psychology: Science and Practice, 18(3), 183. https://doi.org/10.1111/j.1468-2850.2011.01250.x

23.

Haynos

A. F.

Roberto

C. A.

Attia

(2015). Examining the associations between emotion regulation difficulties, anxiety, and eating disorder severity among inpatients with anorexia nervosa. Comprehensive Psychiatry, 60, 93–98. https://doi.org/10.1016/j.comppsych.2015.03.004

24.

Hisli

(1989). Beck depresyon envanterinin universite ogrencileri icin gecerliligi, guvenilirligi. (A reliability and validity study of Beck Depression Inventory in a university student sample). J. Psychol, 7, 3–13.

25.

Kabat-Zinn

(2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10(2):144–156. https://doi.org/10.1093/clipsy/bpg016

26.

Karaceylan Cakmakci

(2004). Çocuklarda Anksiyete Bozukluklarını Tarama Ölçeği geçerlik ve güvenirlik çalışması [Unpublished master’s thesis, Kocaeli University].

27.

Khalsa

S. S.

Portnoff

L. C.

McCurdy-McKinnon

Feusner

J. D.

(2017). What happens after treatment? A systematic review of relapse, remission, and recovery in anorexia nervosa. Journal of Eating Disorders, 5(1), 1–12. https://doi.org/10.1186/s40337-017-0145-3

28.

Kınay

(2013). Beş boyutlu bilinçli farkındalık ölçeği‘ni Türkçe‘ye uyarlama, geçerlik ve güvenirlik çalışması [Unpublished master’s thesis, İstanbul Bilim University].

29.

Linardon

Fairburn

C. G.

Fitzsimmons-Craft

E. E.

Wilfley

D. E.

Brennan

(2017). The empirical status of the third-wave behaviour therapies for the treatment of eating disorders: A systematic review. Clinical Psychology Review, 58, 125–140. https://doi.org/10.1016/j.cpr.2017.10.005

30.

McLaughlin

K. A.

Nolen-Hoeksema

(2011). Rumination as a transdiagnostic factor in depression and anxiety. Behaviour Research and Therapy, 49(3), 186–193. https://doi.org/10.1016/j.brat.2010.12.006

31.

Merwin

R. M.

Timko

C. A.

Moskovich

A. A.

Ingle

K. K.

Bulik

C. M.

Zucker

N. L.

(2010). Psychological inflexibility and symptom expression in anorexia nervosa. Eating Disorders, 19(1), 62–82. https://doi.org/10.1080/10640266.2011.533606

32.

Nilsson

Abrahamsson

Torbiornsson

Hägglöf

(2007). Causes of adolescent onset anorexia nervosa: Patient perspectives. Eating Disorders, 15(2), 125–133. https://doi.org/10.1080/10640260701190642

33.

Ozbay

Misirli Tasdemir

(2003). Çok Boyutlu Mükemmeliyetçilik Ölçeği: Geçerlik ve Güvenirlik Çalışması. In: VII Ulusal Psikolojik Danışma ve Rehberlik Kongresi, Malatya, 9–11 Temmuz, 2023.

34.

Puccio

Fuller-Tyszkiewicz

Ong

Krug

(2016). A systematic review and meta-analysis on the longitudinal relationship between eating pathology and depression. International Journal of Eating Disorders, 49(5), 439–454. https://doi.org/10.1002/eat.22506

35.

Racine

S. E.

Wildes

J. E.

(2015). Dynamic longitudinal relations between emotion regulation difficulties and anorexia nervosa symptoms over the year following intensive treatment. Journal of Consulting and Clinical Psychology, 83(4), 785. https://doi.org/10.1037/ccp0000011

36.

Rawal

Park

R. J.

Williams

J. M. G.

(2010). Rumination, experiential avoidance, and dysfunctional thinking in eating disorders. Behaviour Research and Therapy, 48(9), 851–859. https://doi.org/10.1016/j.brat.2010.05.009

37.

Roemer

Lee

J. K.

Salters-Pedneault

Erisman

S. M.

Orsillo

S. M.

Mennin

D. S.

(2009). Mindfulness and emotion regulation difficulties in generalized anxiety disorder: Preliminary evidence for independent and overlapping contributions. Behavior Therapy, 40(2), 142–154. https://doi.org/10.1016/j.beth.2008.04.001

38.

Rugancı

R. N.

Gençöz

(2010). Psychometric properties of a Turkish version of the difficulties in emotion regulation scale. Journal of Clinical Psychology, 66(4), 442–455. https://doi.org/10.1002/jclp.20665

39.

Shafran

Mansell

(2001). Perfectionism and psychopathology: A review of research and treatment. Clinical Psychology Review, 21(6), 879–906. https://doi.org/10.1016/S0272-7358(00)00072-6

40.

Short

M. M.

Mazmanian

(2013). Perfectionism and negative repetitive thoughts: Examining a multiple mediator model in relation to mindfulness. Personality and Individual Differences, 55(6), 716–721. https://doi.org/10.1016/j.paid.2013.05.026

41.

Srinivasagam

N. M.

Kaye

W. H.

Plotnicov

K. H.

Greeno

Weltzin

T. E.

Rao

(1995). Persistent perfectionism, symmetry, and exactness after long-term recovery from anorexia nervosa. American Journal of Psychiatry, 152(11), 1630–1634. https://doi.org/10.1176/ajp.152.11.1630

42.

Steinglass

J. E.

Glasofer

D. R.

Dalack

Attia

(2020). Between wellness, relapse, and remission: Stages of illness in anorexia nervosa. International Journal of Eating Disorders, 53(7), 1088–1096. https://doi.org/10.1002/eat.23237

43.

Svaldi

Griepenstroh

Tuschen-Caffier

Ehring

(2012). Emotion regulation deficits in eating disorders: A marker of eating pathology or general psychopathology? Psychiatry Research, 197(1-2), 103–111. https://doi.org/10.1016/j.psychres.2011.11.009

44.

Thompson-Brenner

Boswell

J. F.

Espel-Huynh

Brooks

Lowe

M. R.

(2019). Implementation of transdiagnostic treatment for emotional disorders in residential eating disorder programs: A preliminary pre-post evaluation. Psychotherapy Research, 29(8), 1045–1061. https://doi.org/10.1080/10503307.2018.1446563

45.

Treynor

Gonzalez

Nolen-Hoeksema

(2003). Rumination reconsidered: A psychometric analysis. Cognitive Therapy and Research, 27(3), 247–259.

46.

Turgon

Ruffault

Juneau

Blatier

Shankland

R. J. M.

(2019). Eating disorder treatment: A systematic review and meta-analysis of the efficacy of mindfulness-based programs (pp. 1–20).

47.

Ünal

Öktem

Çetin Çuhadaroğlu

Çengel Kültür

S. E.

Akdemir

Foto Ödemir

et al. (2019). Reliability and Validity of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version, DSM-5 November 2016-Turkish Adaptation (K-SADS-PL-DSM-5-T). Turkish Journal of Psychiatry,, 30(1), 42–50. https://doi.org/10.5080/u23408.

48.

Watkins

E. D.

Teasdale

J. D.

(2001). Rumination and overgeneral memory in depression: Effects of self-focus and analytic thinking. Journal of Abnormal Psychology, 110(2), 353. https://doi.org/10.1037/0021-843x.110.2.333

49.

Yucel

Polat

Ikiz

Dusgor

B. P.

Elif Yavuz

Sertel Berk

(2011). The Turkish version of the eating disorder examination questionnaire: Reliability and validity in adolescents. European Eating Disorders Review, 19(6), 509–511. https://doi.org/10.1002/erv.1104