Social Cognition in Patients With Anorexia Nervosa- the Study Examines Social Understanding in Patients With AN Via Questionnaire and Computer Tasks
Condition: Anorexia Nervosa
MeSH terms: Anorexia; Anorexia Nervosa
Study type: Observational [Patient Registry]

Summary: 
      The current research has two goals: first to validate the Hebrew version of a new measurement
      for assessing mentalization failures. The second goal is to examine the connection between
      attachment, emotional regulation strategies, mentalization, and specific mentalization
      failures - As they manifested in anorexia nervosa (AN) compared with non-patient controls.
      The study includes computer tasks, questionnaires and two short tasks administrated by the
      examiner.
    

Detailed description: 
      Study goals:

        1. To validate the Hebrew version of the Movie for the Assessment of Social Cognition
           (MASC) which asses mentalization ability and mentalization failures (Dziobek et al.,
           2006). This version of the MASC was recently designed by the study group in Haifa
           University. The validation of this version of the MASC will be done by comparing
           patients with AN to non-patients.

        2. To examine the connection between attachment styles, emotional regulation strategies,
           mentalization, and specific mentalization failures.

      Study Hypotheses:

        1. In respect to the first goal of the study, we hypothesize that a. a significant
           correlation between the MASC and other tools examining different aspects of
           mentalization (RME, CAM, TAS and RFQ) will be fond; b. different patterns of
           mentalization will be found between the clinical group and the control group on the
           MASC. More specifically, patients with AN will show more hypo-mentalization tendencies
           on the MASC then the control group.

        2. regarding the second goal of the study, we hypothesize that the connection between
           attachment and mentalization failures will be mediated via emotional regulation
           strategies. More specifically, we anticipate that the connection between avoidant
           attachment and hypo-mentalization will be mediated via emotional isolation strategy and
           the connection between anxious attachment and hyper-mentalization will be mediated via
           emotional flood.

      Method:

      Participants This study will include 120 participants at the ages of 16-26. The participants
      will be assigned into two groups. The AN group will include 60 women diagnosed according to
      the DSM-5 (APA, 2013) as suffering from AN and are currently hospitalized. The control group
      will include 60 women participants, which will be screened and excluded if found to be
      suffering from any type ED, have a psychiatric background or any chronic disease. The control
      group will be recruited threw Haifa university. The control group session will take place in
      Haifa university.

      Measures

      Measures of mentalization

      The Movie for Assessment of Social Cognition (MASC) (Dziobek et al., 2006) - Hebrew version.
      This task was designed to serve as a refined, easily-administered, ecologically-valid measure
      of ToM and ToM errors. It was originally shown to discriminate between adults with Asperger
      syndrome and healthy controls, and has since been used in studies researching ToM,
      mentalization and mentalization deficits in different psychopathology's, including AN and
      SAD. It was also translated to Spanish and Norwegian, and was found to be valid in these
      languages (Lahera et al., 2014, Fretland et al. 2015). The task consists of a film depicting
      four young adults getting together for dinner. The film stops at various points to pose
      questions regarding the thoughts, intentions and feelings of the characters. Overall, the
      task includes 45 multiple-choice questions; each question has one correct answer and three
      distractors, which can be characterized as reflecting exceeding ToM/hypermentalization,
      insufficient ToM/hypomentalization and concrete answers which involve no ToM. We will use the
      Hebrew version of the task, which was translated and dubbed for the purpose of the current
      research project.

      Reading the Mind in the Eyes (RME)- Revised Version (Baron-Cohen et al., 2001). This task was
      designed to assess the ability to recognize basic and complex emotions and ToM. It has also
      been found to be valid when translated into other languages (Hallerbäck et al., 2009, Prevost
      et al., 2014). In the current study we will use the Hebrew version translated by Milo. During
      the task, participants are presented with 52 photographs of eyes exhibiting basic emotions
      (happy, sad, afraid, surprised, disgusted, angry) (Ekman & Friesen, 1976) as well as complex
      emotions (interested, worried, confident, fantasizing, preoccupied, friendly and suspicious)
      (Baron-Cohen et al., 1997). Each picture is presented twice, and participants are asked to
      make a forced choice between four words naming the emotion, with only one correct answer.

      The Cambridge Mindreading (CAM) Face-Voice Battery - (Golan et al., 2006). This battery
      examines complex emotion and mental-state recognition in both visual and auditory format. In
      the current study we will use only the visual task, which is comprised of silent clips of
      adult actors, both male and female, of different ethnicities, expressing emotions facially.
      Fifty faces examine recognition of 20 different complex emotions and mental states (e.g.,
      intimate, insincere). During each trial, a clip is presented and the participants are asked
      which of four words best describes the emotions being displayed. There is no time limit for
      answering. The battery provides an overall facial emotion recognition score (max =50) as well
      as individual scores for each of the 20 emotions assessed (pass/fail, i.e., recognized above
      chance or not) and an overall number of the emotions correctly recognized (max=20). The
      current study will use a Hebrew version of this task which was developed by Prof. Ofer Golan,
      one of the designers of the original English version, alongside Prof. Lily Rothschild-Yakar.

      The Toronto Alexithymia Scale (TAS-20) - (Griffith, 1998). The TAS is a 20-item self-report
      measure, which was developed for the assessment of alexithymia, yet can also be used to
      measure mentalization in relation to the self (Luyten et al., 2012). The scale has 3 factors
      which were confirmed in several studies (Parker, Taylor, & Bagby, 2003): (a) difficulty in
      identifying feelings, (b) difficulty in describing feelings to others; and (c) externally
      oriented thinking. The scale's internal consistency (α =.81(, and test-retest reliability (r
      = .77) have been established (Bagby, Taylor, & Parker, 1994), and its Hebrew version showed
      good internal consistency (α = 0.89; Rozenstein et al. 2011) The Reflective Functioning
      Questionnaire (RFQ), (Fonagy et al, 2016). The RFQ is a relatively new instrument, developed
      as a brief, easy-to-administer, self-report screening measure of mentalization. It originally
      included 46 items which the participant responded to on a 6-point scale. Factor analysis
      yielded two main factors, assessing Certainty (RFQ_C) and Uncertainty (RFQ_U) about the
      mental states of self and others. These two factors allow distinguishing between the two the
      main mentalization impairments, hyper-mentalization and hypo-mentalization, with high scores
      of certainty indicating hyper-mentalization and high scores of uncertainty reflecting
      hypo-mentalization; low scores on both scales indicate more genuine mentalizing. The factors
      were relatively distinct, invariant across clinical and non-clinical samples, had
      satisfactory internal consistency and test-retest stability, and were largely unrelated to
      demographic features. The questionnaire's developers have since designed a short, 8-item
      version, consisting of the highest loading items on their respective factor as seen in
      exploratory and confirmatory factor analyses. We will use the short Hebrew version supplied
      by the questionnaire's authors.

      Measure of attachment

      Experiences in Close Relationships Scale (ECR), (Brennan et al., 1998). This measure examines
      patterns of attachment through a self-report questionnaire containing 36 items. The
      participants are required to rate to what extent each item describes his attitude toward
      close relationships, from (1) - strongly disagree, to (7) - strongly agree. 18 items relate
      to an insecure/anxious attachment pattern, and another 18 items relate to an
      insecure/avoidant attachment pattern. The original study reported Cronbach's alpha as .91 and
      .94 for the Anxiety and Avoidance subscales, respectively, and similar results have been
      found since (Vogel & Wei, 2005). Test-retest reliability has been shown to be around 0.7
      (Lopez & Gormley, 2002). The Hebrew version of the questionnaire will be used in this study,
      translated by Mikulincer & Florian (2000). They also validated its two-factor structure on an
      Israeli sample, with high internal reliability (Cronbach's alpha .92 for anxious attachment
      and .93 for avoidant attachment).

      Measure of emotion regulation The Differentiation of Self Inventory (DSI), (Skowron &
      Friedlander, 1998; Skowron & Schmitt, 2003). The DSI is a self-report questionnaire that
      measures self-other differentiation as well as adaptive emotional regulation, which are vital
      for the development of mentalizing ability. This is a self-report instrument for adults (age
      ≥25 years), that was modification translated to Hebrew and validated for adolescents and
      young adults (Rothschild-Yakar et al., 2016). We will use the Hebrew version of Skowron and
      Schmitt's (2003) revised edition comprising 46 items in four subscales (Emotional Reactivity,
      I Position, Emotional Cutoff and Fusion with Others). Participants rated items on a 6-point
      Likert-type response scale ranging from Not at all (1) to Very true (6). Higher scores
      indicate a greater level of differentiation. The DSI showed external validity, with elevated
      DSI scores predicting lower chronic anxiety and better psychological adjustment (Skowron &
      Friedlander, 1998). Internal consistency reliabilities of the DSI and its subscale calculated
      with Cronbach's alpha were reported as follows: DSI full scale=.88, Emotional Reactivity=.84,
      I Position=.83, Emotional Cutoff=.82, and Fusion with Others=.74 (Skowron & Friedlander,
      1998).

      Measures of background variables, comorbidity, and estimation of intellectual ability

      Personal details questionnaire. This questionnaire covers basic personal details such as age,
      country of origin, formal education, past or present emotional difficulties, past or present
      symptoms of EDs and the height and weight of the participants, as well as family details such
      as parental marital status, socioeconomic status, and parental education.

      The short Depression, Anxiety and Stress Scale (DASS)-21 - (Lovibond & Lovibond, 1995). The
      DASS-21 is a 21-item self-report measure designed to assess and discriminate between symptoms
      of depression, anxiety, and stress. It consists of 21 items, which participants rate on a
      scale of 0 to 3 about how accurately statements regarding depression, anxiety, and stress
      applied to them over the past week. The DASS-21 has demonstrated acceptable psychometric
      properties in clinical and nonclinical populations, with high internal consistency for each
      sub-scale ranging from α = .82 to .94 (Antony, Bieling, Cox, Enns, & Swinson, 1998; Henry &
      Crawford, 2005).

      The Eating Attitudes Test (EAT-26): (Garner et al, 1982). The EAT-26 will be used to measure
      the presence and severity of EDs. This is a self-report questionnaire that examines the level
      of pathological eating-related preoccupations and behaviours. The EAT-26 includes three main
      subscales: (a) dieting, refraining from fatty food, and physical appearance; (b) bulimic
      symptomatology and preoccupation with food; and (c) personal control over eating habits.
      Participants rate the 26 items on a 6-point scale ranging from Never (1) to Always (6). High
      reliability and validity of the EAT-26 were found across different cultures (Garfinkel &
      Newman, 2001; Garner et al 1982), including in Israeli patients with EDs (Koslowsky et. al.,
      1992, Niv-Nadler, 1997).

      The SCOFF- questionnaire for the assessment of eating disorders (Morgan et al., 1999). The
      SCOFF questionnaire is a simple 5- yes/no question tool, developed to screen for eating
      disorders in the general population. For every positive answer one point is given. A total
      score of two and above has been found to be 100% sensitive and 87.5% specific for the
      presence of any ED.

      An estimated IQ: Similarities and block design subtests (Wechsler, 2008). Similarities and
      Block Design will be used as an estimate for IQ. The Similarities and Block Design subtests
      will be used from the Hebrew version of WAIS IIIHeb (Wechsler, 1997) for Adults. The two
      subtests were found to possess high loading on the factors to which they belong (Watkins et
      al, 2006).

      Study procedure All tasks will be administrated individually by a master or doctoral student
      in a single two hours session. After receiving an information regarding the purpose of the
      study and its procedure the participants will sign a consent form. For participants under the
      age of 18, parental consent will be obtained as well. During the session the participants
      will complete online self-report questionnaires (personal details questionnaire, experiences
      in close relationships scale and the differentiation of self inventory) followed by the
      Hebrew version of the movie for assessment of social cognition (MASC-heb). Then the
      participants will complete an online self report questionnaire ( the Toronto alexithymia
      scale) followed by two computer tasks (the Cambridge mindreading face-voice battery and the
      reading the mind in the eyes),the Wechsler's Similarities and Block design and more online
      self- report questionnaires (the short depression, anxiety and stress scale, the reflective
      functioning questionnaire and the eating attitudes test 26).

      To ascertain that the participants of the control group will not include participants
      suffering from EDs, they will pass the SCOFF questionnaire which is a common screening tool
      for Eds.

      Control participants will be compensated for their participation by 80 NIS for their
      participation in the study. Control group sessions will take place in Haifa university.

      20 participants (10 from the AN group and 10 from the control group) will be invited to a
      second half hour session, 2-6 month after the first session. The session will be
      administrated by a master or doctoral student. After receiving an information regarding the
      purpose of the study and its procedure the participants will sign a consent form. For
      participants under the age of 18, parental consent will be obtained as well. During the
      session the participant will complete the MASC-heb. Control participants will be compensated
      for their participation by 40 NIS for their participation in the study.
    

Intervention name(s): The study do not include an intervention
Intervention type(s): Other
Intervention description(s): The study do not include an intervention
Observational model: Other
Time perspective: Other
Sampling method: Probability Sample
Study population: 
        Women hospitalized with AN at the ages 16-28.