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Comprehensive Psychiatry 54 (2013) 933 942
www.elsevier.com/locate/comppsych

Pretreatment outcome indicators in an eating disorder outpatient group:

The effects of self-esteem, personality disorders and dissociation
Carmelo La Mela, MD a , Marzio Maglietta, MD a,, Stefano Lucarelli, MD a ,
Sara Mori, PhD a , Sandra Sassaroli, MD b
a

Cognitive Psychotherapy Clinical Centre, 50144, Florence, Italy

Studi Cognitivi, Post-graduate Cognitive Psychotherapy School, Milan, Italy

Abstract
Objective: The prognosis for eating disorders (ED) is unsatisfactory, and the literature about outcome indicators is controversial. The present
study evaluates the roles of self-esteem, personality disorders (PD), and dissociation as outcome predictors.
Method: Fifty-seven ED outpatients were recruited from a population beginning a Cognitive Behavioral Therapy-Enhanced (CBT-E)
treatment. All patients received the Structured Clinical Interview for DSM-IV Axis I (SCID-I), the Structured Clinical Interview for DSM-IV
Axis II (SCID-II), and completed the Eating Disorder Examination Questionnaire (EDE-Q), the Dissociation Questionnaire (DIS-Q), and the
Rosenberg Self-Esteem Scale (RSES). One month after the end of treatment, recovery was evaluated as meeting the DSM-IV criteria for EDs.
Results: A small group of patients recovered (42.2%). Low self-esteem and dissociation results correlated with a negative outcome.
Discussion: Dissociation may be an important moderator of psychotherapy and treatment success, as already suggested by previous studies
on non-eating-related disorders.
2013 Elsevier Inc. All rights reserved.

1. Introduction
The recovery rates in outcome studies on eating disorders
(EDs) range from 30% to 75% for anorexia nervosa (AN)
and from 50% to 70% for bulimia nervosa (BN) [111]. This
large variability is mainly related to methodological aspects.
Furthermore, diagnostic shifts between the different ED
diagnoses over time are common [12,13], and empirical
support for the current diagnostic division of ED is
controversial. There is an increasing emphasis on common
psychopathological features in various EDs, and a transdiagnostic theory has been proposed [14].
There is evidence that cognitive behavioral therapy
(CBT) is the most effective form of intervention for BN
and binge eating disorder (BED) patients [14], and, despite
less evidence to support the usage of CBT for AN [14,15], it
is one of the most commonly applied treatments. Enhanced
Corresponding author. Cognitive Psychotherapy Clinical Centre, P.
Box: Via Delle Porte Nuove, 10, 50144, Florence, Italy. Tel.: +39 055
3245357; fax: +39 055 3245357.
E-mail address: marzioma@katamail.com (M. Maglietta).
0010-440X/$ see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.comppsych.2013.03.024

Cognitive Behavioral Therapy (CBT-E) is based on the

trans-diagnostic theory. It is designed to treat ED psychopathology rather than an ED diagnosis. It includes modules
to address certain obstacles that are external to the core
eating disorder, namely clinical perfectionism, low selfesteem, and interpersonal difficulties.
In our present study, we have therefore analyzed patients
with AN, BN, and eating disorders not otherwise specified
(EDNOS) in one sample.
Many prognostic factors for EDs regarding the specific
characteristics of the disorders have been evaluated by
previous studies, including the following: severity and
duration of the disorder, body and weight concerns
[2,5,8,16,17] (particularly for AN), higher frequency or
severity of binge eating [1824] and attitude toward weight
and shape (especially for BN), or early abstinence from
binge eating [25] (for BED).
Several studies have evaluated the prognostic influence of
less specific psychopathological variables. ED patients with
lower self-esteem had worse outcomes [18,24,2629].
Alternatively, women who recovered from BN reported an
increase in their self-esteem [30].

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C. La Mela et al. / Comprehensive Psychiatry 54 (2013) 933942

Moreover, the reported frequencies of personality disorders (PD) vary from 27% to 93% among clinical and
community samples with EDs [3136]. It is likely that
methodological problems account for this variation, and
personality features are affected by malnutrition [37,38].
Among the pretreatment variables associated with poor
outcomes, the presence of a comorbid PD is considered
relevant in several studies [21,3941]. The presence of
borderline PD (BPD) has been associated with poor
treatment responses in AN bingepurge types, BN
[36,42,43] and BED [44]. These results were not fully
replicated by other studies [4547]. Vrabel et al. [48]
showed a decreasing prevalence of PDs in a 5-year follow-up
of long-standing ED patients, indicating that meaningful
clinical changes in PDs do occur among ED patients,
especially during the period of treatment that focused on ED
symptoms. In the follow-up of the same series done by R
et al. [49], improvements in ED symptoms preceded changes
in PDs.
Several findings support the hypothesis that there is a
relationship between dissociation and EDs [5054]. Furthermore, dissociation has been found to play an important
role in bingeing severity for subjects with bulimic disorders
[5557], and it is probably involved in the most
accomplished theories about binge eating: the mood
modulation theory [5860] and the escape theory [61].
Dissociation has a long tradition in psychodynamic research
in which it is considered a negative prognostic factor [62],
but the body of evidence linking dissociation to a bad
outcome in psychotherapy has begun to grow recently [63].
Michelson et al. [64], in anxiety disorders, observed that
higher levels of dissociation prior to treatment were related
to higher psychopathology assessed after CBT. Likewise,
Rufer et al. [65] found that patients with obsessive
compulsive disorder who experienced higher levels of
dissociation in the beginning of the study experienced
higher symptom severity after CBT. Spitzer et al. [66]
confirmed the negative effect of dissociative experiences on
psychotherapy responses on patients with a broad range of
mental disorders. Many authors consider that the fragmentation of consciousness, memory and identity, which are
characteristics of dissociative experiences, may interfere
with learning processes and therefore negatively influence
the effectiveness of therapies grounded on those, such as
CBT [64,67,68].
The aims of the present study were to assess the roles of
self-esteem, PDs, and dissociative experiences as treatment
outcome predictors for CBT in ED patients.
We hypothesized that, after a minimum follow-up period
of 1 month after the end of a manual-based Cognitive
Behavioral Therapy-Enhanced (CBT-E) treatment for ED
patients, we would find that a negative outcome (not
recovered or dropout), compared to a positive outcome
(recovered), is correlated with lower levels of self-esteem,
the presence of a PD and higher levels of dissociation, as
measured during the assessment phase.

2. Methods
2.1. Participants
From November 2010 to November 2011, 61 Italian
women who suffered from EDs were recruited from a
population admitted consecutively to an outpatient treatment
program for EDs, which was administered in a specialized
unit: the Cognitive Psychotherapy Clinical Centre of
Florence, Italy. All patients were recruited during the initial
assessment phase of treatment, and all participants were
informed about the procedures and aims of the study and
provided written consent. The research was reviewed and
approved by the internal review board of the Cognitive
Psychotherapy Clinical Centre of Florence.
2.2. Procedure
The present study used a longitudinal perspective. A
summary of the flow of participants through each stage of the
study is presented in Fig. 1. To determine the diagnosis, all
patients received the Structured Clinical Interview for DSMIV [69] Axis I (SCID-I) [70,71] and the Structured Clinical
Interview for DSM-IV [69] Axis II (SCID-II) [71,72] during
the assessment phase. Personal data were collected via a
paper questionnaire; psychiatrists measured both height and
weight. Psychologists trained in cognitive therapy (4-years
training, according to the criteria set forth by the Italian
Ministero dell'Istruzione, dell'Universit e della Ricerca,
and by the Societ Italiana di Terapia Comportamentale e
Cognitiva) assessed demographic data. The psychologists
administered the Italian versions of the SCID-I and the
SCID-II, and a battery of self-report questionnaires.
Criteria for inclusion in the study were as follows:
A Diagnostic and Statistical Manual of Mental Disorders
(DSM) diagnosis of an ED or an eating disorder not
otherwise specified (EDNOS) based on the SCID-I
A body mass index (BMI) above 17.5 kg/m 2
No actual or previously reported DSM diagnosis of mood
disorders, schizophrenia, or schizoaffective disorder
A minimum age of 18 years, mental competency, and the
ability to adequately comprehend written Italian.

2.3. Measuring instruments

2.3.1. Structured Clinical Interview DSM-IV-I
We administered the Italian version of the SCID-I
[70,71], a structured interview based on DSM-IV criteria,
to determine a diagnosis of Axis I psychiatric disorders.
2.3.2. Structured Clinical Interview for DSM-IV-II
The DSM-IV Axis II diagnoses were assessed using the
Structured Clinical Interview for DSM-IV Axis II Disorders
(SCID-II) [71,72].

C. La Mela et al. / Comprehensive Psychiatry 54 (2013) 933942

935

Baseline assessment (2-3 sessions):

Personal and clinical data, SCID I,
SCID II, EDE-Q, DIS-Q, RSES
61 subjects eligible for study

Treatment:

Treatment:

57 subjects included in the study

underwent CBT-E ( 20 sessions)

4 subjects refused to participate to

the study

18 AN, 21 BN, 18 EDNOS

End of treatment:

End of treatment:

40 subjects completed the

treatment

17 subjects dropped out from

treatment

12 AN, 15 BN, 13 EDNOS

6 AN, 6 BN, 5 EDNOS

Follow up visit (4 weeks

after the end of treatment):

Follow up visit (4 weeks

after the end of treatment):

24 assessed as recovered

16 assessed as not recovered

6, AN, 9 BN, 9 EDNOS

24 Positive Outcome
6 AN, 9 BN, 9 EDNOS

6 AN, 6 BN, 4 EDNOS

33 Negative Outcome
12 AN, 12 BN, 9 EDNOS

Fig. 1. Consort diagram showing the flow of participants through each stage of the study.

2.3.3. Eating disorder examination questionnaire and

assessment of binge eating episodes
Eating attitudes and behaviors were specifically investigated by means of the Italian version of the Eating
Disorder Examination Questionnaire (EDE-Q). The selfreported EDE-Q consists of 38 items that assess the core
psychopathologic features of EDs and contains four
subscales: eating concern, weight concern, shape concern,
and dietary restraint. The dietary restraint subscale is an
admixture of cognitions and behaviors pertaining to dietary
restriction. The three other subscales evaluate dysfunctional

attitudes regarding eating and overvalued thoughts regarding weight and shape. The global score represents the
mean value of the four subscale scores. Different studies
have shown that the EDE-Q has adequate testretest
reliability [73,74], good convergence with the EDE
interview [7577], and both discriminant and concurrent
validity [78,79]. To assess binge eating episodes, we
considered specific questions from the SCID-I [70,71] that
are relevant to the diagnosis of an ED and that investigate
episodes of uncontrolled overeating with reference to the
past 4 weeks.

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C. La Mela et al. / Comprehensive Psychiatry 54 (2013) 933942

2.3.4. Dissociation questionnaire

To assess dissociative experiences, the participants filled
out a self-report, the Italian version of the Dissociation
Questionnaire (DIS-Q) [80,81]. This 63-item scale is based
on a selection of items from three other questionnaires: the
Dissociative Experiences Scale [82], the Perceptual Alteration Scale [83,84], and the Questionnaire of Experiences of
Dissociation [85]; some new items were added. For this
questionnaire, the subject indicates to what extent each item
is applicable to that particular subject (1 = not at all, 2 = a
little bit, 3 = moderately, 4 = quite a bit, 5 = extremely).
The DIS-Q consists of four factors accounting for 77% of the
common variance [80]: identity confusion and alteration
(referring to experiences of derealization and depersonalization); loss of control over behavior, thoughts, and emotions
(referring to experiences of losing control over behavior,
thoughts, and emotions); amnesia (referring to experiences
of memory lacunas) and absorption (referring to experiences
of enhanced concentration, which are supposed to play an
important role in hypnosis). The reliability coefficient is
0.96 for the total scale and 0.94, 0.93, 0.88, and 0.69 for the
four subscales, respectively. The testretest reliability
coefficient for the total scale is 0.94, which indicates that
the DIS-Q produces scores that are stable over time.
Administered to a group of 752 healthy subjects (matched
for age, sex, education level, and demographic status) and
several subgroups of psychiatric patients, the DIS-Q was
shown to have good discriminant validity and was able to
distinguish between patients with dissociative disorders and
other subjects. A cutoff score of 2.9 yielded a satisfying 85%
sensitivity and 88% specificity [80].
2.3.5. Rosenberg self-esteem scale
Self-esteem was measured using the widely used 10-item
Rosenberg Self-Esteem Scale (RSES) [84]. Items are
answered on a 4-point scale, ranging from 3 (strongly
agree) to 0 (strongly disagree). Scores range from 0 to 40,
and higher scores indicate higher global self-worth. This
measure has good reliability and validity [84,86,87].
Cronbach's was 0.87.
2.4. Treatment
Treatment was conducted on an outpatient basis and
followed the protocols outlined in the detailed CBT-E
treatment guide [88]. All patients attended two to three
assessment sessions followed by 20, on average, 50-min
treatment sessions. The treatment content was the same for
all ED patients. For low-weight patients, the CBT-E
protocols indicate a longer treatment period to allow for
increasing motivation and weight regain, but in this study,
which was only performed on outpatients, we excluded
patients with a BMI under 17.5 kg/m 2. The treatment moved
through four stages. The initial stage focused on engaging
and educating the patient, creating an initial personalized
formulation, and obtaining maximum behavior change. Stage
2 involved a detailed review of progress and identification of

barriers to change, which shaped the remainder of treatment.

In Stage 3, the emphasis was placed on modifying the
processes maintaining the patient's ED psychopathology.
During this stage, additional maintaining mechanisms of
perfectionism, low self-esteem, interpersonal difficulties, and
mood intolerance were also addressed as relevant. During the
final stage, the focus turned to maintenance of gains and
relapse prevention. The treatment guide allows some
flexibility and variability in the number of sessions required
to complete each treatment stage and to progress through the
entire treatment. Treatment completion was defined as
successful transition through the four stages.
The patients were treated by one member of a team of six
clinical psychologists trained in CBT-E for ED after the first
routine visit with one of two psychiatrists expert on EDs (S.
L. and a colleague). The psychiatrists scheduled further visits
with the patients only in cases in which a pharmacological
treatment was considered helpful. The therapists attended
monthly individual supervision meetings with an expert
psychiatrist (S.L.) and two monthly team meetings with two
expert psychiatrists (S.L. and a colleague), to discuss cases
and adherence to treatment protocol.
2.5. Outcome variable
For the purposes of this study, we used a categorical
measure of recovery. We defined a positive outcome (PO)
as not meeting the DSM-IV criteria for an ED, which was
assessed by the treating team based on clinical judgment
during a follow-up visit with a psychiatrist 28 days after
the end of treatment. On the contrary, a negative outcome
(NO) was defined as meeting the DSM-IV criteria for an
eating disorder at the follow-up visit or dropping out
during the treatment period. We defined dropout as a nonconsensual interruption of treatment on the basis of the
patient's decision.
2.6. Statistical analysis
Data are expressed as the mean ( SD) when normally
distributed, as the median when non-normally distributed
and as percentages when categorical. The Kolmogorov
Smirnov test was used to test the parameter distribution.
The 2 and one-way analysis of variance [ANOVA] tests
were used for categorical and continuous variables,
respectively. Correlation coefficients were calculated using
Spearman methods. A value of p b 0.05 was considered
statistically significant.
A logistic regression analysis was performed using the
stepwise forward selection method to assess the association
with the outcome of a list of candidate variables. The
regression was performed by entering the outcome as the
dependent variable (dummy coded: positive outcome = 0,
negative outcome = 1), and the scores of the EDE-Q total,
DIS-Q total, RSES and the presence of BPD (coded as
categorical) as independent variables.

C. La Mela et al. / Comprehensive Psychiatry 54 (2013) 933942

937

All analyses were performed using SPSS for Windows

14.0 (SPSS, Chicago, IL).

recovered. Finally, we considered 24 (42.1%) positive

treatment outcomes and 33 (57.9%) negative outcomes
(Fig. 1).

3. Results

3.1. Differentiation between positive and negative outcomes

Of the 61 ED patients, 4 (6.6%) individuals were

excluded from the analysis because they refused to
participate. The final sample consisted of 57 ED patients,
with a mean age at admission of 32.4 9.9 years. The mean
level of education was 13.2 2.7 years; 23 (40.3%) patients
were married or married through common law, and 33
(57.9%) were employed either full or part-time during the 6month period before the beginning of the study. Illness
duration was 11.5 7.4 years. Before admission, 12
(21.0%) patients had received psychiatric inpatient treatment
elsewhere. Patients who were excluded did not differ
significantly from participants with regard to these variables
(data not shown). Eighteen patients (31.6%) were classified
as having a diagnosis of AN, 21 (36.8%) with BN, and 18
(31.6%) with EDNOS (14, 24.6%, BED, 3, 5.3%, subthreshold BN, 1, 1.7% atypical AN). Thirty-three (58.9%)
subjects suffered from one PD, and 11 (19.3%) were affected
by two PDs.
Regarding the levels of eating psychopathology in our
sample, the EDE-Q global score was 3.21 [2.17; 4.68], the
eating concern subscale score was 3.80 [1.70; 4.40] the
weight concern score was 3.00 [2.15; 4.80], the shape
concern score was 3.75 [2.56; 5.25], and the restraint score
was 3.20 [1.20; 5.00]. About dissociative experiences, we
found that the DIS-Q total score was 1.98 [1.00; 6.00], the
identity confusion subscale score was 1.84 [1.42; 2.28], the
loss of control score was 2.33 [1.69; 2.80], the amnesia score
was 1.36 [1.14; 2.07], and the absorption score was 2.50
[2.00; 3.10]. Finally, regarding self-esteem, the RSES score
was 14.00 [9.25; 19.00]. We found significant correlations
among eating psychopathology, dissociation and self-esteem
(Table 1).
Seventeen participants (29.8%) (6 [10.5%] with AN and 6
[10.5%] with BN and 5 [8.8%] with EDNOS) dropped out of
treatment. Dropped out patients did not differ significantly
from patients who completed the treatment with regard to
demographic variables, illness duration, and previous
treatments (data not shown). During the follow-up visit, we
found that of the 40 (70.2%) patients who completed the
treatment, 24 (42.1%) had recovered, and 16 (24.1%) had not

The PO group of patients did not differ from the NO

group regarding demographic variables (Table 2).
We did not find significant differences between the two
groups regarding diagnostic categories. We diagnosed 6
(25.0%) AN patients in the PO group compared to 12
(36.4%) in the NO group, 9 (37.5%) BN in the PO group
compared to 12 (36.4%) in the NO group, and 9 (37.5%)
EDNOS in the PO group compared to 9 (27.3%) in the NO
group ( 2 = 1.033; p = 0.60).
Regarding eating psychopathology, the NO group had
significantly higher scores on the EDE-Q global, and on the
EDE-Q subscales of weight concern and shape concern, in
comparison to the PO group, but not on the other subscales
(Table 3). The two groups presented a similar frequency of
binge episodes. The number of objective binge eating
episodes was 7.46 ( 9.04) in the PO group, and 12.3 (
14.05) in the NO group (F = 2.19; p = 0.14), while the
number of subjective binge eating episodes was 4.00 (
7.98) in the PO group, and 9.00 ( 12.48) in the NO group
(F = 2.96, p = 0.91).
Regarding the other psychopathological variables, we
found a significantly higher reported self-esteem in the PO
group compared to the NO group, as measured by the RSES
(Table 3). Furthermore, the NO group showed significantly
higher levels of dissociative experiences, as measured by the
DIS-Q total score and with all the subscales of the DIS-Q,
except for absorption (Table 3).
We found no differences regarding the presence of a PD
in the two groups. Twelve (50.0%) subjects in the PO group
presented at least one PD diagnosis, compared to 21 patients
(63.6%) in the NO group, as measured by the SCID-II ( 2 =
1.060, p = 0.42). Regarding specific PD diagnosis, we
found a significant difference between the two groups only
regarding BPD. Three (12.5%) patients in the PO group were
affected by BPD, compared to 14 (42.4%) in the NO group
( 2 = 5.945, p b 0.05). We had no patients with paranoid
personality disorder in the PO group and 1 (3.0%) in the NO
group ( 2 = 0.740); 1 (4.2%) patient with antisocial
personality disorder in the PO group and no patients in the
NO group ( 2 = 0.740); 1 (4.2%) patient with histrionic

Table 1
Correlations among eating psychopathology, dissociation and self-esteem in the whole sample (n = 57).
Variables rho; (p)

DIS-Q Total

DIS-Q Identity Confusion

DIS-Q Loss of Control

DIS-Q Amnesia

DIS-Q Absorption

RSES

EDE-Q Total
EDE-Q Eating Concern
EDE-Q Weight Concern
EDE-Q Shape Concern
EDE-Q Restraint

0.556 (b
0.444 (b
0.464 (b
0.454 (b
0.363 (b

0.495 (b 0.01)
0.334 (b 0.05)
0.462 (b 0.01)
0.480 (b 0.01)
0.236 (0.08)

0.637 (b
0.467 (b
0.602 (b
0.590 (b
0.347 (b

0.527 (b
0.322 (b
0.484 (b
0.512 (b
0.335 (b

0.234 (0.08)
0.027 (0.84)
0.225 (0.09)
0.240 (0.07)
0.196 (0.14)

0.522 (b 0.01)
0.489 (b 0.01)
0.414 (b 0.01)
0.520 (b 0.01)
0.163 (0.23)

Statistics: Spearman's rho.

0.01)
0.01)
0.01)
0.01)
0.01)

0.01)
0.01)
0.01)
0.01)
0.01)

0.01)
0.05)
0.01)
0.01)
0.05)

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C. La Mela et al. / Comprehensive Psychiatry 54 (2013) 933942

Table 2
Demographic variables.
Variables

PO (n = 24)

NO (n = 33)

2/F

Age (y)
Education (y)
Employed
Married
BMI

35.1 10.7
13.8 2.5
14 (58.3%)
10 (43.5%)
25.4 9.0

30.5 9.0
12.8 2.8
19 (57.6%)
13 (41.9%)
23.6 9.3

3.01
1.65
0.01
0.01
0.47

0.09
0.21
0.98
0.91
0.49

Abbreviations: PO: positive outcome group, NO: negative outcome group.

Statistics: mean SD for age, education, and BMI; number and percentage
within the group for other variables; 2 for employment and marital status;
ANOVA for other variables.

personality disorder in the PO group and 1 (3.0%) in the

NO group ( 2 = 0.530); 1 (4.2%) patient with paranoid
personality disorder in the PO group and 3 (9.1%) in the
NO group ( 2 = 1.515); 3 (12.5%) patients with avoidant
personality disorder in the PO group and 4 (12.1%) in the
NO group ( 2 = 0.002); 2 (8.3%) patients with dependent
personality disorder in the PO group and 2 (6.1%) in the
NO group ( 2 = 0.110); and 1 (4.2%) patient with
obsessivecompulsive personality disorder in the PO
group and 4 (12.1%) in the NO group ( 2 = 1.099)
(p N 0.05 for all comparisons).
A stepwise logistic regression analysis model was
performed to assess the relationship between the outcome
and the variables that were correlated with it in preliminary
analysis. The regression was performed by entering the
outcome as the dependent variable (dummy coded: positive
outcome = 0, negative outcome = 1), and by using a
forward selection method, the scores of the EDE-Q total,
DIS-Q total, RSES, and the presence of BPD (coded as
categorical) as independent variables. In this model, DIS-Q
total score was inversely related to PO, while the RSES score
was directly related to it (Table 4).

4. Discussion
The results of our study indicate a generally poor outcome
for the treatment of ED patients, especially considering a

sample of patients with a long-term ED, a relative high

prevalence of an AN diagnosis, and relatively high levels of
dissociative experiences. Otherwise, our percentage of fully
recovered patients is in accordance with previous literature
[115]. The number of patients who dropped out of
treatment is similarly high, as in the case in the majority of
literature on this subject [5,24,46].
We found no differences for the rate of positive treatment
outcomes among the three principal diagnostic categories of
EDs. This result supports the trans-diagnostic model of EDs
[14], even though our study is based on a specific population
of patients and very underweight subjects were not included.
In our analysis, we found a relationship between negative
outcomes and higher levels of eating psychopathology, but
we did not find a correlation regarding the frequency of
binge eating episodes. Only two studies among the studies
selected by Steinhausen and Weber [46] found that frequent
binge eating episodes were related to poor outcomes for BN.
Although our results may be influenced by the BMI range of
our sample (above 17.5 kg/m 2), our data seem to suggest a
relationship between weight and shape concerns and
prognosis, rather than the dimension of eating concerns
and restricting behaviors. Furthermore, our results underline
the importance of self-esteem on outcomes, according to
part of the literature on ED [1826]. Despite the specific
module of CBT-E used to treat subjects with low levels of
self-esteem, low self-esteem seems to maintain a relevant
influence on outcomes.
In our sample BPD was the most frequently reported
personality disorder, and we found a specific relationship
between this feature and negative outcomes. This result is
not surprising considering the literature about this subject
[36,42]. It is possible that these data, and the general
inconsistencies in the literature about this subject [3138],
partially depend on the categorical nature of classifying
personality features. It is interesting to look at our results in
light of studies by Vrabel et al. [48,49] and R et al. [48,49],
which indicate that PDs are less stable and more modifiable
than we once believed, and may be at least partially a
consequence of general symptomatology and ED symptoms.

Table 3
Psychometric scores.
Variables

PO (n = 24)

NO (n = 33)

EDE-Q Total
EDE-Q Eating Concern
EDE-Q Weight Concern
EDE-Q Shape Concern
EDE-Q Restraint
DIS-Q Total
DIS-Q Identity Confusion
DIS-Q Loss of Control
DIS-Q Amnesia
DIS-Q Absorption
RSES

2.61 [1.92; 3.37]

2.40 [1.60; 3.50]
2.60 [1.80; 3.75]
3.31 [2.19; 4.07]
2.60 [0.65; 3.60]
1.00 [1.00; 1.95]
1.58 [1.34; 1.89]
2.03 [1.56; 2.43]
1.29 [1.09; 1.36]
2.00 [2.40; 3.00]
18.50 [12.25; 21.75]

3.85 [2.62; 4.86]

3.20 [2.10; 4.60]
4.40 [2.40; 5.10]
4.75 [2.75; 5.50]
3.60 [1.50; 5.30]
3.76 [1.17; 6.00]
2.16 [1.44; 3.06]
2.56 [1.89; 3.16]
1.86 [1.29; 2.46]
2.80 [2.00; 3.20]
11.00 [3.75; 16.00]

1.624
1.059
1.680
1.454
1.002
2.174
1.793
1.680
1.906
0.734
1.582

b0.01
b0.22
b0.01
b0.05
b0.27
b0.01
b0.01
b0.01
b0.01
b0.66
b0.05

Abbreviations: PO: positive outcome group, NO: negative outcome group. Statistics: median [quartiles], KolmogorovSmirnov test.

C. La Mela et al. / Comprehensive Psychiatry 54 (2013) 933942

939

Table 4
Stepwise logistic regression analysis predicting positive outcome (dependent variable); n = 57.
Step models

Nagelkerke R 2

Step 1
Step 2

13.328
5.002

b0.01
b0.03

0.284
0.375

Variables in the equations

Standard error

Exp (B)

Chance in 2-log likelihood

Step 1

0.583
1.135
0.509
0.103
0.489

b0.193
b0.501
b0.190
b0.049
b0.892

0.01
0.02
0.01
0.05
0.58

0.558
3.112
0.601
1.108
0.614

13.328

Step 2

DIS-Q
Constant
DIS-Q
RSES
Constant

Variables not in the equations

Score

Step 1

b1.469
b4.806
b1.872
b0.108
b0.271

0.23
0.03
0.17
0.74
0.60

Step 2

EDE-Q Total
RSES
BPD
EDE-Q Total
BPD

In conclusion, the literature examining the effect of

personality on ED treatment response and prognosis is
quite limited and controversial, and this subject needs to be
explored in further detail.
In our preliminary analysis, eating psychopathology was
correlated with dissociation. Furthermore, a negative
outcome was significantly associated with the dissociative
dimensions of identity confusion, loss of control, and
amnesia, but not with absorption. This finding is consistent
with the widespread view that absorption is a common and
non-pathological phenomenon experienced by most people
to varying degrees, unlike pathological forms of dissociation. Absorption is defined a characteristic of the
individual that involves an openness to emotional experience and cognitive alterations across a variety of situations
[89]. Our data are consistent with those represented in a
study by Vanderlinden et al. [56], which did not attribute
the association with eating symptoms to a specific
dissociative style.
The multivariate analysis confirmed the importance of
low self-esteem and dissociation over other variables,
including the presence of a BPD, that, by definition,
encompass dissociative experiences. We can argue that
dissociation may be an important moderator of psychotherapy and treatment success, as already suggested by previous
studies on non-eating disorders [6266]. We can also
hypothesize that the possible role of dissociative experiences
on loss of control and binge eating episodes could influence
the outcome of CBTs specifically on EDs. The mood
modulation theory postulates that individuals engage in
bingeing to alleviate negative emotional states and predicts
that bulimic episodes are more likely to follow periods of
intense negative affect [5860]. Several authors, in fact,
have suggested that dissociation may serve as a psychological defense against intolerable emotional states and it is
likely that patients with higher levels of bulimic psychopathology have a greater need for coping strategies, such as

9.359
5.002

dissociation [57]. According to the escape theory proposed

by Heatherton and Baumeister [61], by narrowing awareness, dissociation may enable patients to initiate bingeing
behavior without having to deal with the long-term
consequences of their actions such as weight gain, guilt,
and self-dislike. By considering both of these theories and
underlining the importance of interventions aimed either at
helping patients tolerate negative affect or increasing their
level of awareness, our data seem to showcase the need for
dealing with dissociation directly during treatment to obtain
a better outcome.
Moreover, it is possible that disturbed consciousness and
memory interfere with learning and thereby hinder the
effectiveness of therapies that rely on learning [64]. Recent
studies performed on BPD with high levels of dissociation
offer evidence for this hypothesis [67]. Because basic
learning processes are the foundations of CBT treatment
and because various brain areas underlying conditioning
processes are influenced by dissociative experiences, it
seems likely that learning processes in psychotherapy
treatment are influenced by dissociation [68].
Finally, psychiatric treatment and psychotherapy for ED
patients frequently raise powerful emotions. For subjects
who respond to these emotions with detachment and a shift
to lower levels of awareness, it is likely that these elements
may interfere with treatment response.
Our study has important clinical implications. Our results
indicate an elevated rate of negative outcomes for CBT
treatment of ED and suggest a need to improve our clinical
interventions. Despite the presence of a specific module of
CBT-E that is directed against low self-esteem, self-esteem
seems to maintain a relevant role as a negative prognostic
factor. Moreover, by identifying the role of dissociation as a
predictor of bad outcomes, our data point to the importance
of interventions aimed either at helping patients tolerate
negative affect or increasing their level of awareness to
prevent dissociation.

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C. La Mela et al. / Comprehensive Psychiatry 54 (2013) 933942

Our results must be evaluated in light of several

limitations. First, a dichotomous measure of outcomes is
applied based on the diagnostic criteria of the DSM-IV for
EDs. This option, which is useful for research purposes,
could lead to underestimating the presence of partially
favorable outcomes that are probably the most frequent in
clinical practice. Second, we did not repeat the battery of
psychometric tests at the end of treatments, resulting in a lack
of information about eating features and other variable
changes at the end of the treatment. Third, when enrolling the
sample, by considering outpatient management and maintaining a low risk of hospitalization, we chose to exclude
cases with a BMI value under 17.5 kg/m 2. This choice
reduces the possibility of generalizing our results for the
entire ED population. Fourth, the exclusion of comorbidity
during sample enrollment to improve the specificity of the
results on EDs has similar consequences. In fact, as is widely
known, most individuals with EDs have an Axis I diagnosis
in addition to ED [31]. Fifth, we did not provide diagnoses
for dissociative disorders, because of the choice to measure
dissociative experiences as a continuous variable. Sixth, the
assessments of the patients before and after treatment have
been made by the psychiatrists partaking of the team
delivering the treatment.
Further studies should overcome these limitations by
trying to evaluate the different roles of the variables
identified for outcomes. Future research should especially
take note of dissociation, which is not presently a direct
target of CBT-E, so that psychotherapist may plan the best
individual treatment for each patient.

[10]
[11]
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[21]

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