Elsevier

Clinical Psychology Review

Volume 33, Issue 1, February 2013, Pages 156-167
Clinical Psychology Review

The role of interpersonal functioning in the maintenance of eating psychopathology: A systematic review and testable model

https://doi.org/10.1016/j.cpr.2012.10.009Get rights and content

Abstract

This review aims to systematically evaluate the empirical literature relating to the interpersonal functioning of those with eating disorder psychopathology and presents a preliminary model to help the formulation of patients' problems. Following a thorough literature search, 35 papers were included in this systematic review. The vast majority of studies indicate a strong association between eating psychopathology and certain maladaptive personality traits. The origins of social anxiety and poor social support that have been described as maintaining eating disorders appear to differ according to diagnostic groups. Interpersonal difficulties in people with restrictive behaviors such as anorexia appear to be related to the avoidance of expressing feelings to others and to giving priority to other people's feeling over their own. While interpersonal difficulties in patients with bulimia nervosa appear to be more related to interpersonal distrust and negative interaction and conflict with others. These concepts are presented in a preliminary model of interpersonal functioning in the eating disorders.

Highlights

► Association between eating psychopathology and certain personality traits. ► Restrictive behaviors associated to the avoidance of expressing feelings to others. ► Restrictive disorders linked to giving priority to people's feeling over their own. ► Bulimic behavior associated to interpersonal distrust. ► Bulimic disorders linked to negative interaction with others.

Introduction

The term ‘interpersonal’ encompasses not only the patterns of interaction between the individual and significant others, but also the process by which these interactions are internalized and form part of the self-image (Sullivan, 1953). Interpersonal functioning is considered crucial to good mental health. According to Klinger (1977), when people are asked what makes their lives meaningful, most will mention their close relationships with others. Being involved in secure and fulfilling relationships is perceived by most individuals as critical to wellbeing and happiness (Berscheid & Peplau, 1983).

It is, therefore, not surprising that interpersonal difficulties are strongly associated with many psychiatric disorders; such as depression (Petty, Sachs-Ericsson, & Joiner, 2004), anxiety (Montgomery, Haemmerlie, & Edwards, 1991), schizophrenia (Sullivan & Allen, 1999), autistic spectrum disorders (Travis & Sigman, 1998) and eating disorders (Fairburn, 1997, Hinrichsen and Clougherty, 2006, Hoffart et al., 2007). The important role of interpersonal problems in psychiatric disorders, including eating disorders, has been highlighted by the relative success of treatments, such as Interpersonal Psychotherapy (IPT), which focuses on maladaptive interactional patterns (e.g., Fairburn, 1997, Fairburn et al., 1993, Fairburn et al., 1991, Hinrichsen and Clougherty, 2006, Hoffart et al., 2007, McIntosh et al., 2000, Roth and Ross, 1988, Weissman et al., 2000, Whight et al., 2011, Wilfley et al., 1993, Wilfley et al., 2002). The premise of this treatment is that those who suffer from certain psychiatric disorders do so in response to interpersonal disturbances or that the disorder is maintained by interpersonal problems (Klerman et al., 1984, Markowitz, 1998). Clinicians argue that by improving the individual's ability to utilize social support networks and manage interpersonal deficits, symptomatology will improve (Fairburn, 1997, Weissman et al., 2000).

Despite the growing availability of IPT for the treatment of eating disorders (Roth and Ross, 1988, Whight et al., 2011, Wilfley et al., 1993, Wilfley et al., 2002) there is a lack of research that focuses on how IPT benefits patients and which specific interpersonal problems it targets. With this in mind, the aim of this review is to systematically evaluate the empirical literature that has investigated the relationships between interpersonal functioning and eating psychopathology. First, an outline of the review methodology will be presented. Next, the studies reviewed are described and evaluated methodologically. Finally, a preliminary model within which to conceptualize these associations is presented.

Section snippets

Search method

A comprehensive three-stage literature search was used. First, Web of Science, PubMed, PsycInfo, Science Direct, EBSCO, OVID and SCOPUS electronic search engines were used. Second, key eating disorder journals were subjected to individual on-line searches using the same search terms. Finally, reference lists of relevant review papers, as well as reference lists of identified articles, were systematically explored to ensure that any further articles missed by the database and on-line journal

Study characteristics

The characteristics of the participants from the 35 studies varied considerably. The oldest study included in this review took place in 1980 (Thompson & Schwartz, 1980) and the most recent one was published in 2012 (Levinson & Rodebaugh, 2012). Twenty-four studies included patients with eating disorders: 11 of them included both diagnoses within the same study and compared interpersonal problems between AN and BN; ten described interpersonal problems exclusively in patients with BN and three

Summary according to diagnosis

Many studies in this review have not differentiated between patients with anorexia nervosa and patients with bulimia nervosa and have grouped patients into one category (eating disorders). This could be partly due to the transdiagnostic model that has been proposed by Fairburn et al. (1993), who suggested that current eating disorder classifications should be re-evaluated because they have been divided arbitrarily in a way that does not reflect clinical experience. Patients with anorexia

A preliminary model

This review has described how eating disorder-related attitudes and behaviors are associated with maladaptive interpersonal traits and related social maladjustment which may predict or exacerbate eating disorder psychopathology. The findings support a model whereby those with eating psychopathology are more likely to avoid the expression of emotions, especially when they feel they will be perceived negatively, which may hinder the use of support from their social networks. This appears to be

Discussion

This review aimed to systematically evaluate the empirical literature concerning the interpersonal functioning of those with eating disorder psychopathology, in order to develop an empirically based model to inform clinicians and generate ideas for future research. The literature review is limited by the quality and the amount of studies in the field. In particular, there is a lack of longitudinal studies, which limits interpretations of causality in the associations identified. Most of the

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