Eating Disorders
The Journal of Treatment & Prevention
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Mindfulness in persons with anorexia nervosa
and the relationships between eating disorder
symptomology, anxiety and pain
Julie P. Dunne, Judith Shindul-Rothschild, Laura White, Christopher S. Lee &
Barbara E. Wolfe
To cite this article: Julie P. Dunne, Judith Shindul-Rothschild, Laura White, Christopher S. Lee
& Barbara E. Wolfe (2021) Mindfulness in persons with anorexia nervosa and the relationships
between eating disorder symptomology, anxiety and pain, Eating Disorders, 29:5, 497-508,
DOI: 10.1080/10640266.2019.1688009
To link to this article: https://doi.org/10.1080/10640266.2019.1688009
Published online: 03 Dec 2019.
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EATING DISORDERS
2021, VOL. 29, NO. 5, 497–508
https://doi.org/10.1080/10640266.2019.1688009
Mindfulness in persons with anorexia nervosa and the
relationships between eating disorder symptomology,
anxiety and pain
Julie P. Dunne a,b, Judith Shindul-Rothschilda, Laura Whitea,
Christopher S. Lee a, and Barbara E. Wolfe c
a
W. F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts, USA; bCambridge
Eating Disorder Center, Cambridge, Massachusetts, USA; cCollege of Nursing, University of Rhode
Island, Kingston, Rhode Island, USA
ABSTRACT
Mindfulness is useful for some psychiatric illnesses, but
limited research exists among persons with anorexia nervosa
(AN). This study aimed to determine the relationship between
mindfulness, eating disorder symptomology and indicators of
health in women with AN (n = 59) entering residential treatment.
Participants completed a self-administered survey, including the
Cognitive Affective Mindfulness Scale and other measures.
Additional data from medical records were collected. Greater
mindfulness was associated with less eating disorder symptoms
(p = .049). This relationship was most profound in individuals with
AN, including restrictive and binge-purge subtypes compared to
individuals with atypical AN (interaction p-value = 0.044). Greater
mindfulness was significantly associated with less shape (p = .023)
and weight concern (p = .047). Expectedly, anxiety was inversely
associated with eating disorder symptoms (p = .001). Greater
pain was associated with less eating disorder symptoms (p =
.024). Overall, mindfulness may be a protective factor against
some eating disorder symptomology.
Clinical Implications
● There is limited research on mindfulness in persons with anorexia nervosa.
● Greater mindfulness was associated with less eating disorder symptoms.
● Mindfulness was inversely related to symptoms, especially shape and
weight concern.
Introduction
Anorexia nervosa (AN) is a serious, psychiatric illness associated with
numerous medical and psychological comorbidities, and negative impacts
CONTACT Julie P. Dunne
julie.dunne@bc.edu
W. F. Connell School of Nursing, Boston College, 140
Commonwealth Ave. Chestnut Hill, Massachusetts 02467, USA
Color versions of one or more of the figures in the article can be found online at https://www.tandfonline.com/uedi.
© 2019 Taylor & Francis
498
J. P. DUNNE ET AL.
on cognitive, emotional, social and physical functioning (Arcelus, Mitchell,
Wales, & Nielsen, 2011; Smink, van Hoeken, Oldehinkel, & Hoek, 2014;
Ulfvebrand, Birgegård, Norring, Högdahl, & von Hausswolff-juhlin, 2015).
Treatment of AN is challenging as there are few pharmacological options,
and none approved by the United States Food and Drug Administration
(FDA) (Mitchell, Roerig, & Steffen, 2013). Family-based treatment is effective
for children and adolescents with AN (Loeb & le Grange, 2009), but there are
limited empirically based options available for adults (Herpertz et al., 2011).
Alternative therapies, such as mindfulness, are now starting to be examined.
Mindfulness, an enhanced awareness of present experience, is one novel,
therapeutic approach to promote wellness that has been increasingly studied
in medical and psychiatric conditions and linked to positive physical and
psychological health benefits (Brown & Ryan, 2003; Grecucci, Pappaianni,
Siugzdaite, Theuninck, & Job, 2015; Hölzel et al., 2011; Russel & Siegmund,
2016). Although some research is beginning to explore the role of mindfulness in AN, there remains a paucity of data (Dunne, 2018). Limited data
suggest that higher levels of mindfulness are associated with lower levels of
some eating disorder symptomology in persons with eating disorders (e.g.,
Butryn et al., 2013; Lattimore et al., 2017; Sala, Vanzhula, & Levinson, 2019;
Thompson-Brenner, Boswell, Espel-Huynh, Brooks, & Lowe, 2018), but the
relationship exclusively among individuals with a diagnosis of AN has not
been explored. Furthermore, measures of mindfulness vary across studies.
Certain measures do not allow for an assessment of overall mindfulness and
there is a need to understand how, as a unidimensional construct, it relates to
eating disorder symptoms (Sala et al., 2019). Other mindfulness questionnaires contain items about eating, possibly skewing results in persons with
AN (Dunne, 2018). Studies in persons with AN, using unidimensional
measures of mindfulness that are specific to persons with mental illness are
needed to further the field.
In addition to understanding the relationship between mindfulness and
eating disorder symptoms in persons with AN, it is imperative to gain
knowledge about this relationship in the context of other indicators of health
status. For example, persons with AN report psychosocial, functional (e.g.,
pain) and health impairment (Mond, Owen, Hay, Rodgers, & Beumont,
2005; Strigo et al., 2013). In addition, there is a high co-occurrence of anxiety
(Cederlöf et al., 2015; Keski-Rahkonen & Mustelin, 2016) and depression
(Ulfvebrand et al., 2015). Assessing mindfulness and eating disorder symptomology, while controlling for highly correlated clinical indicators of health
will provide a more robust understanding of the relationships between these
variables. Controlling for illness-related factors (e.g., duration of illness, years
in therapy), which may impact eating disorder symptoms, is essential, as well.
Research is needed to assess the level of unidimensional mindfulness in
persons with AN using measures tailored to persons with psychiatric
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disorders, and to examine these relationships in the context of clinical
indicators of health and illness. Therefore, the purpose of this study was to
determine the degree to which unidimensional mindfulness is associated with
eating disorder symptomology in persons with AN entering residential treatment. A secondary aim of this study was to explore the relationships between
mindfulness, eating disorder symptomology and highly correlated indicators
of health (e.g., pain, anxiety), separate from illness-related factors of duration
of illness and years in therapy.
Methods
This study used a survey method and cross-sectional, descriptive design to
assess the relationship between mindfulness and eating disorder symptomology in individuals with AN.
Participants
The study included a convenience sample of adult women with AN (N = 59)
entering residential treatment at a facility in the Greater Boston area. In
addition to limiting participation to female adults entering treatment with
a diagnoses of AN, individuals met inclusion criteria of sufficient cognitive
capacity to complete the survey. The vast majority (93.75%) of eligible
persons admitted to treatment during the period of data collection agreed
to take part in the study.
Procedures
Participants were recruited upon admission to a residential facility. Eligible
consenting individuals completed the web-based survey consisting of 87
questions. Additional information was gathered from participant’s medical
records at the time of admission. This study was approved by an Institutional
Review Board and the treatment center where data were collected.
Measures
Clinical characteristics (e.g., BMI, diagnostic specifiers, year of birth) were
obtained from participant’s official hospital records. Demographic, illnessrelated information (e.g., duration of illness, years in therapy) and questionnaires measuring mindfulness, eating disorder symptoms, clinical indicators of health, anxiety, and depression were collected via the 87-question
survey.
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J. P. DUNNE ET AL.
Cognitive affective mindfulness scale—revised (CAMS-R)
The CAMS-R (Feldman, Hayes, Kumar, Greeson, & Laurenceau, 2007) was used
to assess dispositional (e.g., trait) mindfulness as a unidimensional construct in
lay terms. The CAMS-R is a validated tool, that has demonstrated reliability in
diverse samples, including those with mental illness (Feldman et al., 2007).
Importantly, the CAMS-R does not contain items regarding food intake or
eating behavior. The CAMS-R has not previously been studied in persons with
AN. In the present study, the Cronbach’s alpha was 0.71.
Eating disorders examination questionnaire (EDE-Q)
The EDE-Q (Fairburn & Beglin, 2008) was used to assess overall eating
disorder symptomology (e.g., EDE-Q global score) over the last 28 days,
due to its well-established validity, internal consistency and test–retest reliability (Luce & Crowther, 1999; Peterson et al., 2007). The EDE-Q subscales of
shape concern, weight concern, eating concern and restraint were also used
to understand the relationships between specific eating disorder symptoms
and mindfulness. In this study, the Cronbach’s alpha was 0.92 and, although
responses were, expectedly, negatively skewed, all assumptions for regression
(e.g., normality of the residuals, homoscedasticity, etc.) were met.
MOS 36-item short-form health survey (RAND-36)
To measure clinical indicators of health across eight domains (physical functioning, role limitation due to physical functioning, bodily pain, general health
perceptions, energy, social functioning, role limitations due to emotional problems and mental health) the RAND-36 (Ware & Sherbourne, 1992) was used.
The RAND-36 has been widely administered in psychiatric research, including
among persons with AN (Peterson & Mitchell,). The Cronbach’s alpha for the
RAND-36 (α = .54) in this study was low, but is aligned with findings from
a meta-analysis of articles using this scale in individuals with AN indicating that
the lack of consistency may be related to the disconnect between an individuals’
assessment of their own functioning and wellness compared with their actual
health status (Winkler et al., 2014).
Patient health questionnaire 4 (PHQ-4)
In order to assess severity of anxiety and depressive symptoms, the subscales of
the PHQ-4 (Kroenke, Spitzer, Williams, & Löwe, 2010) were used. The PHQ-4
consists of two, two-item subscales of anxiety and depression (PHQ-4 anxiety
and PHQ-4 depression). The subscales, but not the total score, were used in this
study. Each subscale is independently valid and reliable and both have been
widely used in research and clinical settings, including among persons with AN
(Kroenke et al., 2010; McHorney, Ware, Lu, & Sherbourne, 1994; Peterson &
Mitchell,). The Cronbach’s alpha for the PHQ-4 was 0.89.
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Data analysis
Multiple power analyses were conducted. The estimated sample size for multiple
linear regression with alpha of 0.05, preserving power of 0.80, and assuming
a partial correlation of 0.125 or greater, and three control variables was 57. Data
were analyzed using Stata v16 (College Station, Texas). The relationships
between the CAMS-R and the EDE-Q global score, as well as each subscale,
were examined using simple linear regression. The interaction p-value was
examined to compare the relationship between CAMS-R and EDE-Q between
individuals with AN and those with OSFED AN. Backwards stepwise regression
was used to assess the unique variance accounted for by CAMS-R scores,
separate from the effect of clinical indicators of health (e.g., RAND-36), depression and anxiety (PHQ-4). Best-fit models were identified to explain EDE-Q
scores from the CAMS-R scores and highly correlated clinical indicators of
health. Analyses were one-tailed and directional. A relationship between the
variables was indicated at a significance level of .05.
Results
Sample characteristics
All participants met the Diagnostic and Statistical Manual for Mental Disorders
(5th ed. DSM-5; American Psychiatric Association [APA], 2013) criteria for AN
(N = 59) including restrictive type (AN R) (n = 29, mean BMI = 15.7 kg/m2)
and binge-purge type (AN BP) (n = 13, mean BMI = 17.5 kg/m2) or atypical
AN (OSFED AN) (n = 17, 28.8%, mean BMI = 23.7 kg/m2) based on an
unstructured clinical interview. Clinical diagnoses were made by licensed
clinicians at the time of intake. The median time since onset diagnosis was 8
years (interquartile range = 3–15 years) and individuals reported spending
a median of 1.25 years in therapy (interquartile range = 0.17–5.0 years),
including all levels of care (e.g., inpatient, outpatient, etc.). All participants
were female. The mean age was 25.7 (SD = 8.75) years old. The group was
predominantly white (n = 45, 76.3%), followed by Asian (15.3%, n= 9) and
Hispanic (6.8%, n = 4) backgrounds. In terms of education, 40.7% of participants completed a bachelor’s degree or higher.
CAMS-R and EDE-Q
In unadjusted linear regression models, greater mindfulness was associated with
less global eating disorder symptoms (β = −.061, t = −2.01, p = .049, βs = −.257,
R2 = .066). The inverse relationship between mindfulness and eating disorder
symptoms was most profound in combined group of individuals with AN R and
AN BP (n = 42), compared to individuals with OSFED AN (n = 17) in whom the
relationship was relatively constant across all levels of mindfulness (interaction
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J. P. DUNNE ET AL.
Figure 1. AN (R and BP) = Anorexia nervosa (restricting and binge-purge subtype)OSFED = Other
specified feeding and eating disorder, atypical anorexia nervosa.
Table 1. Relationship between CAMS-R and EDE-Q subscales.
EDE-Q subscale
Shape Concern
Weight Concern
Eating Concern
Restraint
Standardized regression coefficient
−.296
–.260
–.221
–.124
P value
.023*
.047*
.095
.352
n
59
59
58
58
*significant at p < .05
p-value = 0.044; Figure 1). Greater mindfulness was significantly associated
with less eating disorder symptoms in the EDE-Q subscales of shape concern
(p = .023) and weight concern (p = .047). No relationship was observed between
mindfulness and the EDE-Q subscales of restraint and eating concern (Table 1).
Of note, the personal characteristics of age, race, and education level were not
associated with CAMS-R scores.
EDE-Q and clinical indicators of health
Multicollinearity among the predictor variables, duration of illness and years
in therapy, was ruled out by examination of the variance inflation factor.
P-value removal during backwards stepwise regression was 0.10 (Table 2).
Mindfulness and illness-related variables of duration of eating disorder and
prior treatment (e.g., lifetime years in therapy) were forced to be retained in
the model. This analysis resulted in a final model for explaining EDE-Q
global score that was significantly associated with only PHQ-4 anxiety subscale score (e.g., “Feeling nervous, anxious or on edge” and “Not being able
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503
Table 2. Correlations with EDE-Q Global.
Independent Variables
CAMS-R
RAND-36
Physical Functioning
Pain
General Health
Energy/Fatigue
Emotional Wellbeing
Health Change
Role Limitations due to Physical Health
Social Functioning
Role Limit due to Emotional Problems
PHQ-4
Anxietya
Depression
Duration of Illness
Years in therapy
a
r
−.243
P value
.341
.015
–.441
–.317
.336
.441
–.317
–.217
–.324
–.188
.754
.122
.258
.323
.247
.349
.816
.644
.448
.537
.383
.145
.021
.015
.660
.540
.717
n = 58
Table 3. Stepwise linear regression of EDE-Q global scores with predictor variables.
Variables
Mindfulness
Duration of illness
Lifetime years in therapy
Anxiety
Pain
B
.001
.001
−.023
.310
−.013
SE (B)
.031
.020
.036
.090
.005
t
0.04
0.03
−0.67
3.44
−2.33
P value
.967
.977
.509
.001
.024
95% CI
−.062 .0642
−.040 .041
−.093 .045
.129 .490
−.024 − .002
R2 = .374; adjusted R2 = .313; Standard error of estimate = 1.051; SS = 34.280
to stop of control worrying” over the last 2 weeks) and RAND-36 pain
subscale score (e.g., “How much bodily pain have you had during the past
4 weeks?” and “During the past 4 weeks, how much did bodily pain interfere
with your work … including housework?”) (R2 = .374; adjusted R2 = .313;
Table 3). When repeating this analysis for the EDE-Q subscales of shape and
weight concern, only anxiety and pain met p-value removal criteria and the
same relationships as above were noted (data not shown for economy of
presentation). Mindfulness did not account for unique variance in any of
the models.
Discussion
To our knowledge, this is the first study to use the CAMS-R in a sample of
individuals with AN. This study provides a unique assessment of the relationship
between overall eating disorder symptoms and mindfulness, as a unidimensional
construct and measured on a scale pertinent to persons with mental illness. Results
from the present study are similar to findings showing an inverse correlation
between mindfulness and eating disorder symptoms in individuals with mixed
types of eating disorders (Butryn et al., 2013; Lattimore et al., 2017; Sala et al., 2019;
504
J. P. DUNNE ET AL.
Thompson-Brenner et al., 2018) and persons with an eating disorder history
(Cowdrey & Park, 2012). Considering existing data and that, in this study, the
relationship was strongest for persons with AN R and AN BP, mindfulness may
play a protective role against some eating disorder symptomology (e.g., low
weight, preoccupation with eating, weight or body shape).
This study also examined the relationship between mindfulness and EDEQ subscales, extending previous findings using global scores. Mindfulness
was inversely correlated with shape and weight concern, the subscales of the
EDE-Q that are primarily focused on the perception of self and body (e.g.,
dissatisfaction and preoccupation with the importance of shape or weight,
fear of weight gain or being weighed, and/or a desire for flat stomach or
desire to lose weight; Fairburn & Beglin, 2008). This finding may be related
to altered interoceptive awareness (Khalsa et al., 2018) and distorted body
image (Dakanalis et al., 2016; Gaudio & Quattrocchi, 2012) among persons
with AN. For example, abnormal interoceptive processes (e.g., internal physical or somatic cues including hunger, satiety, heartbeat detection, and
anxiety), especially in response to anticipated food intake (Khalsa et al.,
2018), may distort one’s sense of body and self (Herbert & Pollatos, 2012).
This lack of awareness, distortion or ‘lack of mindfulness of the body,’
especially related to shape and weight concern, may account for the inverse
relationship observed in this study. Mind-body interventions may be particularly useful for persons with AN and should be explored further.
Although mindfulness did not correlate with eating disorder symptoms
when also considering clinical indicators of health, anxiety and pain did
show a relationship. Interestingly, anxiety and pain are interoceptive stimuli.
Anxiety disorders are common among persons with AN (Cederlöf et al., 2015;
Keski-Rahkonen & Mustelin, 2016) likely explaining the relationship noted. In
terms of the unanticipated inverse relationship between bodily pain and eating
disorder symptoms, symptomology may serve to mitigate pain, preceding the
development of an eating disorder, for some people with AN (Sim, Lebow,
Weiss, Harrison, & Bruce, 2017). Another possible explanation for this finding
could be linked to aberrant pain processing in individuals with AN and higher
levels of body dissatisfaction related to reduced gray matter volume and lack of
activation after painful thermal stimuli in the right and left posterior cingulate
cortex (Bär, de la Cruz, Berger, Schultz, & Wagner, 2015; Yamamotova, Bulant,
Bocek, & Papezova, 2017).
These findings further suggest a lack of present-moment, bodily and interoceptive awareness in persons with AN (Hölzel et al., 2011). Research supports the
usefulness of mindfulness-based interventions to reduce or manage anxiety
symptoms (Bluett, Homan, Morrison, Levin, & Twohig, 2014; Hofmann,
Sawyer, Witt, & Oh, 2010; Spijkerman, Pots, & Bohlmeijer, 2016) and pain
(Hilton et al., 2017; Veehof, Trompetter, Bohlmeijer, & Schreurs, 2016).
Targeting anxiety, pain and interoceptive processing in individuals with AN
EATING DISORDERS
505
through mindfulness-based interventions may be beneficial via enhanced bodyand self-awareness.
While a novel study, there are a few limitations that should be considered.
First, the cross-sectional, descriptive design was non-experimental and cannot
establish causality. Second, a convenience sample was used and inferences
about the findings may not be generalizable. Diagnostic information, despite
being assessed by trained clinicians, was based on unstructured interviews and
may have varied between different providers. In addition, subjective responses
may have contributed to under or over-reporting on certain measures. Lastly,
although not unlike previous research, the Cronbach’s alpha for the RAND-36
was low, possibly attenuating reliability of results.
Overall, this study uniquely examined the inverse relationship between levels
of overall mindfulness and eating disorder symptoms in a sample of individuals
with acute AN. The results enhance existing knowledge and support continued
exploration of mindfulness-based interventions in practice. Additional research
is warranted to further detail the relationship between mindfulness and eating
disorder symptoms over the course of treatment and examine the efficacy of
mindfulness enhancing interventions in persons with AN.
Acknowledgments
The authors would like to thank 10% Happier for providing free subscriptions as a participant
incentive.
Data Sharing Statement
The data that support the findings of this study are available from the corresponding author
upon reasonable request.
ORCID
Julie P. Dunne
http://orcid.org/0000-0001-8594-0971
Christopher S. Lee
http://orcid.org/0000-0002-2510-4071
Barbara E. Wolfe
http://orcid.org/0000-0002-9465-320X
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