Demoralization in Eating Disorders: Its Psychological Characterization and Role in Treatment Response

Aims: The first study investigates the clinical characteristics of demoralization, a syndrome characterized by helplessness, hopelessness and a sense of incompetence, in eating disorder (ED) patients, in addition to examining its distinction from depressive disorders. The second study has the aim of testing the role of demoralization’s hallmark feature, subjective incompetence, in treatment response. Methods: Eighty-three ED outpatients and inpatients, undergoing cognitive-behavioral therapy-based treatment, were recruited and evaluated at baseline and mid-treatment for demoralization, subjective incompetence, depressive and eating-related symptomatology, and psychological well-being (PWB). Chi-squared test was applied to examine overlap of demoralization and depression diagnoses. Multivariate analyses of variance compared ED patients with comorbid demoralization, to those with comorbid depression and no comorbidity. Hierarchical linear regression analyses were conducted to test whether subjective incompetence reductions predicted changes in ED symptoms and psychological well-being dimensions. Logistic regression analysis was conducted to explore whether mood-related variables and psychological well-being domains predicted drop-out. Results: Demoralization was highly prevalent and associated with increased distress and impaired psychological well-being. Although cases of only demoralization in absence of depression were documented, demoralization significantly overlapped with depressive disorders. Compared to depressed ED patients, demoralized patients had less severe eating-related pathology, were impaired in fewer psychological well-being domains, did not necessarily exhibit depressed mood, anxiety, and sleep difficulties. By mid-treatment demoralization diagnoses and subjective incompetence were significantly reduced. Such decreases in subjective incompetence, controlling for depression and illness severity, significantly predicted response in ED symptomatology and positive functioning. Only PWB-autonomy predicted drop-out. Conclusions: Demoralization, unlike depression, was not associated with worse eating-related symptomatology in EDs. It emerges as an indicator of worsening status in terms of specific depressive symptoms which may not reach diagnostic thresholds, and in terms of worse psychological well-being. Subjective incompetence may be an additional therapeutic target to increment treatment response in EDs.