Association between social support for mothers of patients with eating disorders and mothers’ active listening attitude: a cohort study

Abstract

Background:
Family members of patients with eating disorders, especially their mothers, experience heavy caregiving burdens associated with supporting the patient. We predict that increasing caregivers' support will have a positive effect on their active listening attitudes, mental health, loneliness, and self-efficacy. This study aimed to investigate differences in mothers' active listening attitudes, mental health, loneliness, and self-efficacy improvements between mothers who did and did not experience increased perceived social support.

Main body:
Participants were mothers of patients with eating disorders. Questionnaires for this cohort study were sent to the participants' homes at three time points (baseline, 9 months, and 18 months). The Japanese version of the Social Provision Scale (SPS-10) was used to evaluate social support, the Active Listening Attitude Scale (ALAS) for listening attitude, the UCLA Loneliness Scale (ULS) for loneliness, the General Self-Efficacy Scale (GSES) for self-efficacy, the Beck Depression Inventory (BDI-II) for depression symptoms, and the K6 for psychological distress. An unpaired t-test was used to determine whether participants' status differed between the groups that did and did not experience increased perceived social support. The mean age of the participants was 55.1 ± 6.7 (mean ± SD) years. The duration of their children's eating disorders was 7.6 ± 5.5 years. The degree of improvement for each variable (active listening attitude, loneliness, self-efficacy, depressive symptoms, and mental health) was the difference in each score (ALAS, ULS, GSES, BDI-II, and K6) from T1 to T3. The degree of improvement in active listening attitude and loneliness was significantly greater in the improved social support group than in the non-improved social support group (p < 0.002 and p < 0.012, respectively).

Conclusions:
Our findings indicate that increasing mothers' perceptions of social support will be associated with improving their active listening attitudes and loneliness.

Full text

Katsukietal. BioPsychoSocial Medicine (2023) 17:4
https://doi.org/10.1186/s13030-023-00262-9
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Open Access
BioPsychoSocial Medicine
Association betweensocial support
formothers ofpatients witheating disorders
andmothers’ active listening attitude: acohort
study
Fujika Katsuki1* , Atsurou Yamada2, Masaki Kondo2, Hanayo Sawada1, Norio Watanabe3 and Tatsuo Akechi2
Abstract
Background Family members of patients with eating disorders, especially their mothers, experience heavy caregiv-
ing burdens associated with supporting the patient. We predict that increasing caregivers’ support will have a positive
effect on their active listening attitudes, mental health, loneliness, and self-efficacy. This study aimed to investigate
differences in mothers’ active listening attitudes, mental health, loneliness, and self-efficacy improvements between
mothers who did and did not experience increased perceived social support.
Main body Participants were mothers of patients with eating disorders. Questionnaires for this cohort study were
sent to the participants’ homes at three time points (baseline, 9 months, and 18 months). The Japanese version of
the Social Provision Scale (SPS-10) was used to evaluate social support, the Active Listening Attitude Scale (ALAS) for
listening attitude, the UCLA Loneliness Scale (ULS) for loneliness, the General Self-Efficacy Scale (GSES) for self-efficacy,
the Beck Depression Inventory (BDI-II) for depression symptoms, and the K6 for psychological distress. An unpaired
t-test was used to determine whether participants’ status differed between the groups that did and did not experi-
ence increased perceived social support. The mean age of the participants was 55.1 ± 6.7 (mean ± SD) years. The
duration of their children’s eating disorders was 7.6 ± 5.5 years. The degree of improvement for each variable (active
listening attitude, loneliness, self-efficacy, depressive symptoms, and mental health) was the difference in each score
(ALAS, ULS, GSES, BDI-II, and K6) from T1 to T3. The degree of improvement in active listening attitude and loneli-
ness was significantly greater in the improved social support group than in the non-improved social support group
(p < 0.002 and p < 0.012, respectively).
Conclusions Our findings indicate that increasing mothers’ perceptions of social support will be associated with
improving their active listening attitudes and loneliness.
Keywords Caregiver, Eating disorders, Social support, Mother-patient relationship, Symptoms of eating disorders
*Correspondence:
Fujika Katsuki
katsuki@med.nagoya-cu.ac.jp
1 Department of Psychiatric and Mental Health Nursing, Nagoya City
University Graduate School of Nursing, 1 Kawasumi, Mizuho-Cho,
Mizuho-Ku, Nagoya, Japan
2 Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya
City University Graduate School of Medical Sciences, 1 Kawasumi,
Mizuho-Cho, Mizuho-Ku, Nagoya, Japan
3 Department of Psychiatry, Soseikai General Hospital, 101 Shimotoba,
Hiroosa-Machi, Fushimiku, Kyoto, Japan
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Katsukietal. BioPsychoSocial Medicine (2023) 17:4
Background
Eating disorders are serious mental disorders associ-
ated with high levels of mortality and disability, physi-
cal and psychological morbidity, and impaired quality
of life. The estimated standardized mortality ratios
are 5.86 for anorexia nervosa (AN), 1.7 for bulimia
nervosa, and 1.92 for eating disorders not otherwise
specified [1]. Evidence of effective treatments for eat-
ing disorders in children and adolescents has been
established [2]. However, a network meta-analysis of
psychological interventions in adult AN outpatients
reported no strong evidence to support the superior-
ity or inferiority of any of the specific treatments rec-
ommended by clinical guidelines [3]. Even if there are
evidence-based treatments for child and adolescent
eating disorders, it is difficult to provide them to eve-
ryone who needs them.
With few effective treatments available, many fami-
lies live with individuals with eating disorders who
often engage in problematic behaviors such as suicidal
behavior, obsessional thoughts, refusal of treatment,
and behaviors concerning weight, body shape, and food
for extended periods of time [4]. Family members who
spend much of their time with the patient, especially
mothers, suffer a heavy psychological burden. Although
some studies have reported that caregivers do not expe-
rience high levels of distress, many studies have sug-
gested that they experience high levels of depression
and anxiety [5, 6].
Patients with eating disorders have been found to
lack confidence in identifying their thoughts and
feelings [7, 8]. Submissive behavior was signifi-
cantly higher in patients with eating disorders than
in healthy controls [9]. Some studies have identified
a strong relationship between low levels of assertive-
ness and eating disorder psychopathology [10, 11]. It
is believed that patients with eating disorders are una-
ble to recognize and assert their thoughts and desires.
Mothers’ good active listening ability may promote
self-expression in patients with these characteristics.
However, as mentioned above, mothers often experi-
ence high distress owing to the difficulty of respond-
ing to various symptoms and their involvement in
eating disorder behaviors. Such situations make it dif-
ficult for mothers to relax and listen to patients well.
Several studies have reported that caregiver support is
associated with psychosocial stress and coping. Per-
ceived high social support has been significantly asso-
ciated with lower levels of depression among mothers
of patients with eating disorders [12]. Some studies
have reported that social support increases caregivers’
ability to cope [13, 14].
is cohort study aimed to investigate differences in
mothers’ active listening attitudes, mental health, lone-
liness, and self-efficacy improvements between moth-
ers who did and did not experience increased perceived
social support.
Methods
Design
is was a longitudinal survey with assessments at three
time points: baseline (Time 1 [T1]), 9 months (Time 2
[T2]), and 18months (Time 3 [T3]).
Participants
Participants were mothers of patients with eating dis-
orders. Inclusion criteria were age between 30 and
85 years and being the mother of a child who met
the patient inclusion criteria. e inclusion criteria
for patients were age between 16 and 50years and a
clinical diagnosis of an eating disorder from a physi-
cian or psychiatrist in a hospital. Regarding caregiv-
ers, although we understand the fathers’ involvement
is important for the treatment of eating disorders, this
study focuses only mothers to ensure the homogene-
ity of the participants because it has been reported
that mothers have a higher burden than fathers [15].
To recruit participants, we conducted lectures at four
locations in Japan (i.e., Hokkaido, Chiba, Fukui, and
Nagoya). ese lectures included an introduction to the
study. Participants were recruited between July 2017
and August 2018, with the last follow up in February
2020. Participants were provided with a leaflet explain-
ing the study’s purpose and procedures. After receiving
permission, we mailed the questionnaires to the par-
ticipants’ homes. Participants were formally enrolled in
the study only when their completed baseline question-
naires were returned. e questionnaires were mailed
at three time points (i.e., at baseline, 9 months, and
18months) and returned each time. e scales com-
pleted at each time point were the same. is study was
approved by the Ethics Review Committee of Nagoya
City University Graduate School of Medical Sciences,
Japan (Ref: No 60–17-0001).
Outcome measures
A shortened version of Social Provisions Scale (SPS-10)
by Iapichino etal. was used to evaluate mothers’ per-
ception of social support [16]. We created a Japanese
version of the SPS-10 [17]. e SPS-10 consists of 10
items and retains the following five of the six original
SPS subscales: attachment, social integration, reas-
surance of worth, reliable alliance, and guidance. e
total SPS-10 score ranges from 10 to 40. A higher score
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Katsukietal. BioPsychoSocial Medicine (2023) 17:4
indicates a stronger perception of social support. e
General Self-Efficacy Scale (GSES) developed by Sakano
etal. was used to assess mothers’ self-efficacy [18]. e
higher the score, the higher the general self-efficacy.
e Japanese version [19] of the University of Cali-
fornia, Los Angeles Loneliness Scale (ULS), originally
developed by Russell etal., was used to assess mothers’
loneliness [20]. e higher the score, the stronger the
loneliness. e Active Listening Attitude Scale (ALAS)
developed by Mishima etal. was used to assess moth-
ers’ active listening attitude [21]. e higher the score,
the better the listening attitude or skill. e Japanese
version [22] of the Beck Depression Inventory—Second
Edition (BDI-II), originally developed by Beck et al.,
was used to assess depression within the last two weeks
[23]. e higher the score, the more severe the depres-
sive symptoms. e Japanese version [24] of the Kessler
Psychological Distress Scale (K6), originally developed
by Kessler etal., was used to assess psychological dis-
tress [25]. e higher the score, the more severe the
psychological distress.
Statistical analysis
Descriptive data analysis was conducted by calculating
mean scores, standard deviations, or rates (%). Correla-
tions among the variables at T1 were examined using
Pearson’s correlation coefficient. We examined changes
in status between mothers who did and did not expe-
rience increased perceived social support. Mothers
who experienced increased perceived social support
comprised those whose SPS-10 scores increased from
T1 to T3. Mothers who did not experience increased
perceived social support consisted of participants
whose SPS-10 scores remained the same or decreased
from T1 to T3. We used an unpaired t-test to compare
the two groups, with significance set at p < 0.05. Statis-
tical analyses were performed using SPSS Statistics ver-
sion 22.
Results
Participants’ characteristics
We mailed 85 sets of questionnaires to the partici-
pants’ homes, 72 of which were returned. The mean
age was 55.1 ± 6.7 (mean ± SD) years. The duration
for which their children had suffered from an eating
disorder was 7.6 ± 5.5 years. Half of the participants
cooperated with their partner in caring for the patient,
and 68.4% were currently part of a family self-help
group. Table1 summarizes the participants’ baseline
(T1) characteristics, and Table2 summarizes the par-
ticipants’ scores at all three time points. Correlations
among the variables at T1 are summarized in Table3.
There were moderate or strong significant correlations
between the scales.
Comparison betweentheimproved social support group
andnon‑improved social support group
The groups of mothers who did and did not experience
increased perceived social support consisted of 26 and
38 participants, respectively. The mean age of the par-
ticipants who experienced increased perceived social
support was 54.6 ± 7.2, and their children’s eating
disorder duration was 7.5 ± 6.2 years. The mean age
of the participants who did not experience increased
perceived social support was 55.3 ± 6.0, and their
Table 1 Participants’ baseline characteristics (n = 72)
Age, years, mean (SD) 55.1 (6.7)
Mother’s confirmation of patient being under medical care, years, mean (SD) 7.6 (5.5)
Mother’s experience with counseling, n (%) Currently receiving 12 (15.8%)
Received in the past 28 (36.8%)
No 31 (40.8%)
Mother’s history of eating disorder, n (%) Yes 2 (2.6%)
No 65 (85.5%)
Unknown 4 (5.3%)
Mother’s feeling of cooperation with the father to handle the patient, n (%) Yes 38 (50.0%)
No 8 (10.5%)
Neither agreement nor denial 21 (27.6%)
Not applicable 4 (5.3%)
Mother’s experience with joining a family self-help group, n (%) Yes 52 (68.4%)
Yes, in the past 14 (18.4%)
No 4 (5.3%)
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Katsukietal. BioPsychoSocial Medicine (2023) 17:4
children’s eating disorder duration was 7.6 ± 4.4years .
The degree of improvement for each variable (active
listening attitude, loneliness, self-efficacy, depres-
sive symptoms, and mental health) was the difference
in each score (ALAS, ULS, GSES, BDI-II, and K6)
from T1 to T3. The degree of improvement in active
listening attitude and loneliness was significantly
greater in the improved social support group than in
the non-improved social support group (p < 0.002 and
p < 0.012, respectively; Table 4). No significant dif-
ference was found between the groups regarding the
score differences from T1 to T2 (Table4).
Table 2 Participants’ scores at all three time points and the reliability of each scale in the current study
T1 Baseline, T2 9months, and T3 18months, ALAS Active Listening Attitude Scale, SPS-10 The Social Provision Scale-10 item, ULS University of California, Los Angeles
Loneliness Scale, GSES General Self-Ecacy Scale, BDI-II Beck Depression Inventory, K6 Kessler Psychological Distress Scale
T1 T2 T3
Scale Cronbach’s α Mean (SD) n Mean (SD) n Mean (SD) n
Active listening attitude ALAS 0.86 35.8 (7.1) 71 36.8 (6.6) 65 37.1 (7.3) 63
Social support SPS-10 0.89 31.1 (4.6) 72 31 (5.7) 66 39.5 (10.4) 64
Loneliness ULS 0.90 38.5 (9.2) 69 38.1 (9.6) 58 38.7 (10.0) 63
Self-efficacy GSES 0.80 7.2 (3.8) 72 7.8 (3.7) 65 7.8 (3.9) 65
Depressive symptoms BDI-II 0.92 14.1 (9.7) 72 12 (9.6) 64 11.3 (9.2) 65
Mental health K6 0.86 6.9 (4.2) 71 6.1 (4.3) 66 5.9 (4.5) 64
Table 3 Correlations among variables at T1
SPS-10 The Social Provision Scale-10 item, ALAS Active Listening Attitude Scale, ULS University of California, Los Angeles Loneliness Scale, GSES General Self-Ecacy
Scale, BDI-II Beck Depression Inventory, K6 Kessler Psychological Distress Scale
* P < 0.05, **P < 0.01
SPS‑10 (T1) ALAS (T1) ULS (T1) GSES (T1) BDI‑II (T1) K6 (T1)
SPS-10 (T1) 1
ALAS (T1) .321** 1
ULS (T1) -.794** -.252*1
GSES (T1) .312** .443** -.417** 1
BDI-II (T1) -.443** -.275*.466** -.465** 1
K6 (T1) -.398** -.381** .362** -.468** .753** 1
Table 4 Comparison of groups that did and did not experience increased perceived social support
T1 Baseline, T2 at 9months, T3 at 18months, ALAS Active Listening Attitude Scale, ULS University of California, Los Angeles Loneliness Scale, GSES General Self-Ecacy
Scale, BDI-II Beck Depression Inventory, K6 Kessler Psychological Distress Scale
Mothers who experienced increased perceived social support group Mothers who did not
experience increased
perceived social support
group
Mean SD n Mean SD n t value p value
Improvement of Active listening attitude ALAS (ΔT3-T1) 3.40 5.90 24 -1.00 4.70 37 3.22 0.002
Improvement of Loneliness ULS (ΔT3-T1) -1.60 5.59 25 1.70 4.70 37 -2.59 0.012
Improvement of Self efficacy GSES (ΔT3-T1) 0.84 2.27 26 0.44 1.94 38 0.75 0.455
Improvement of Depressive symptoms BDI-II (ΔT3-T1) -4.50 7.40 26 -1.70 8.00 38 -1.39 0.167
Improvement of Mental health K6 (ΔT3-T1) -1.80 3.40 25 -0.51 4.53 37 -1.20 0.234
Improvement of Active listening attitude ALAS (ΔT2-T1) 1.20 4.60 25 0.45 4.71 35 0.60 0.548
Improvement of Loneliness ULS (ΔT2-T1) 1.90 6.20 21 0.18 5.97 33 1.01 0.314
Improvement of Self efficacy GSES (ΔT2-T1) 0.12 1.87 25 0.83 2.03 36 -1.38 0.170
Improvement of Depressive symptoms BDI-II (ΔT2-T1) -2.64 7.73 25 -0.94 7.80 35 -0.38 0.408
Improvement of Mental health K6 (ΔT2-T1) -0.65 3.05 26 -0.88 4.10 35 0.24 0.810
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Katsukietal. BioPsychoSocial Medicine (2023) 17:4
Discussion
is study investigated differences in active listening
attitude, mental health, loneliness, and self-efficacy after
18-months follow-up among mothers who did and did
not experience increased perceived social support. Our
findings suggest that increasing a mothers’ perceptions
of social support may be associated with improving their
active listening attitudes and loneliness. Because being a
single parent and eating alone have been associated with
the onset of eating disorders [26], the parents’ concern
and listening to them may be important for eating disor-
der prevention and recovery.
Patients with eating disorders have been found to
lack confidence in identifying their own thoughts and
feelings and have low levels of assertiveness [10, 11];
if their mothers consistently listened well, they would
be able to explain themselves without anxiety. Mar-
cos reported significant positive correlations between
informative support for patients with eating disorders,
including listening, encouraging, and advising, and
family self-concept as evaluated by the patient [27].
Family self-concept refers to patient-evaluated feel-
ings such as “I feel more or less happy at home” and
“parents would help with any type of problem.” Results
from the above studies indicate that caregivers who lis-
ten and encourage patients help them feel safe and have
peace of mind at home. If mothers of patients with eat-
ing disorders listen well, patients are able to use verbal
communication more frequently; they may be able to
avoid using eating disorder behaviors. ese findings
revealed that increasing mothers’ perceptions of social
support may be associated with improving their active
listening attitudes.
However, the mothers in this study showed worse
mental health status at T1 (Table2; the average BDI-II
score of 14.1 ± 9.2 for our participants indicated mild
depressive symptoms). Such mental exhaustion situa-
tions make it difficult for mothers to listen to patients.
At T1 (Table 3), there were strong significant correla-
tions between SPS-10 and ULS (r =—0.794) and moder-
ate significant correlations between the SPS-10 and K6
(r = -0.407) and the SPS-10 and BDI-II (r = -0.463). ese
results highlight the importance of continuing support
from professionals and self-help groups for the mothers
of patients with eating disorders.
This study has several limitations. First, the sam-
ple size is small. This may have resulted in the small
effects we observed, subsequently preventing the
detection of significant differences among the studied
variables. Second, we did not identify or differenti-
ate between subgroups of eating disorders. Thus, we
believe that future studies should distinguish patients
by specific eating disorder; different types may evoke
different outcomes among caregivers. However, the
strength of our study was its cohort study design using
18-month follow-up data.
Conclusion
Our main findings suggest that social support for mothers
of patients with eating disorders is associated with improv-
ing their active listening attitudes. erefore, it is important
that professionals and self-help support groups continu-
ously support not only patients with eating disorders but
also their caregivers.
Abbreviations
ALAS Active Listening Attitude Scale
BDI-II Beck Depression Inventory
CFI Comparative Fit Index
GSES General Self-Efficacy Scale
K6 Kessler Psychological Distress Scale
RMSEA Root Mean Square Error of Approximation
SEM Structural Equation Modeling
SPS The Social Provisions Scale
SPS-10 The Social Provisions Scale-10 item
ULS University of California, Los Angeles Loneliness Scale
Acknowledgements
The authors wish to thank Takao Suzuki of the family support group for eating
disorders (“Pokoapoko”) for his support. We also thank all participants.
Authors’ contributions
FK, AY, HS, and NW designed this study. FK wrote the manuscript. FK and AY
conducted the recruitment and data collection. NW, MK, and AT supervised
the study and edited the various drafts of the manuscript. All the authors have
read and approved the final manuscript.
Funding
This study was supported by a Grant-in-Aid for Scientific Research (KAKENHI
Grant Number 16K12256) from the Japanese Ministry of Education, Science,
and Technology.
Availability of data and materials
The datasets used and/or analyzed in the current study are available from the
corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
This study was approved by the Ethics Review Committee of Nagoya City
University Graduate School of Medical Sciences, Japan (Ref: No 60–17-0001).
All participants provided written informed consent to participate in this study.
Consent for publication
Not applicable.
Competing interests
FK has received speaker fees from Otsuka Pharmaceutical Co., Ltd. AY has
received medical fees from Gifu Hospital, speaker fees from Aichi Education
and Sports Foundation, Kyowa Pharmaceutical Industry Co., Ltd., Meiji Seika
Pharma Co., Ltd, Mental Care Association Japan, Mochida Pharmaceutical
Co., Ltd., Otsuka Pharmaceutical Co., Ltd., Shionogi & Co., Ltd., and other fees
from Nagoya City. HS declares no conflicts of interest. MK reports a grant from
Novartis Pharma K.K., personal fees from Shionogi & Co., Ltd., and personal
fees from Yoshitomiyakuhin Corporation, outside the submitted work. TA
has received lecture fees from Astra Zeneca Co., Ltd., Daiichi Sankyo Co., Ltd.,
Dainippon-Sumitomo Co., Ltd., Eisai Co., Ltd., Janssen Co., Ltd., Kyowa Co.,
Ltd., Eli Lilly Japan K.K., MSD K.K., Meiji -Seika Pharma Co., Ltd., Mochida Co.,
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References
1. Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with
anorexia nervosa and other eating disorders. a meta-analysis of 36 stud-
ies. Arch Gen Psychiatry. 2011;68:724–31. https:// doi. org/ 10. 1001/ archg
enpsy chiat ry. 2011. 74.
2. Couturier J, Isserlin L, Norris M, Spettigue W, Brouwers M, Kimber M,
McVey G, Webb C, Findlay S, Bhatnagar N, Snelgrove N, Ritsma A, Preskow
W, Miller C, Coelho J, Boachie A, Steinegger C, Loewen R, Loewen T, Waite
E, Ford C, Bourret K, Gusella J, Geller J, LaFrance A, LeClerc A, Scarborough
J, Grewal S, Jericho M, Dimitropoulos G, Pilon D. Canadian practice guide-
lines for the treatment of children and adolescents with eating disorders.
J Eat Disord. 2020;8:4. https:// doi. org/ 10. 1186/ s40337- 020- 0277-8.
3. Solmi M, Wade TD, Byrne S, Del Giovane C, Fairburn CG, Ostinelli EG, De
Crescenzo F, Johnson C, Schmidt U, Treasure J, Favaro A, Zipfel S, Cipriani
A. Comparative efficacy and acceptability of psychological interventions
for the treatment of adult outpatients with anorexia nervosa: a systematic
review and network meta-analysis. Lancet Psychiatry. 2021;8:215–24.
https:// doi. org/ 10. 1016/ s2215- 0366(20) 30566-6.
4. Kostro K, Lerman JB, Attia E. The current status of suicide and self-injury
in eating disorders: a narrative review. J Eat Disord. 2014;2:19. https:// doi.
org/ 10. 1186/ s40337- 014- 0019-x.
5. Treasure J, Murphy T, Szmukler G, Todd G, Gavan K, Joyce J. The experi-
ence of caregiving for severe mental illness: a comparison between
anorexia nervosa and psychosis. Soc Psychiatry Psychiatr Epidemiol.
2001;36:343–7. https:// doi. org/ 10. 1007/ s0012 70170 039.
6. Gonzalez N, Padierna A, Martin J, Aguirre U, Quintana JM. Predictors of
change in perceived burden among caregivers of patients with eating
disorders. J Affect Disord. 2012;139:273–82. https:// doi. org/ 10. 1016/j. jad.
2012. 02. 013S0 165- 0327(12) 00109- 7[pii].
7. Wollast R, Fossion P, Kotsou I, Rebrassé A, Leys C. interoceptive awareness
and anorexia nervosa: when emotions influence the perception of physi-
ological sensations. J Nerv Ment Dis. 2022;210:390–3. https:// doi. org/ 10.
1097/ nmd. 00000 00000 001458.
8. Leppanen J, Brown D, McLinden H, Williams S, Tchanturia K. The Role
of Emotion Regulation in Eating Disorders: A Network Meta-Analysis
Approach. Front Psychiatry. 2022;13:793094. https:// doi. org/ 10. 3389/
fpsyt. 2022. 793094.
9. Troop NA, Allan S, Treasure JL, Katzman M. Social comparison and
submissive behaviour in eating disorder patients. Psychol Psychother.
2003;76:237–49. https:// doi. org/ 10. 1348/ 14760 83033 22362 479.
10. Hartmann A, Zeeck A, Barrett MS. Interpersonal problems in eating disor-
ders. Int J Eat Disord. 2010;43:619–27. https:// doi. org/ 10. 1002/ eat. 20747.
11. Williams GJ, Power KG, Millar HR, Freeman CP, Yellowlees A, Dowds T,
Walker M, Campsie L, MacPherson F, Jackson MA. Comparison of eating
disorders and other dietary/weight groups on measures of perceived
control, assertiveness, self-esteem, and self-directed hostility. Int J Eat
Disord. 1993;14:27–32. https:// doi. org/ 10. 1002/ 1098- 108x(199307) 14:1%
3c27:: aid- eat22 60140 104% 3e3.0. co;2-f.
12. Yamada A, Katsuki F, Kondo M, Sawada H, Watanabe N, Akechi T. Associa-
tion between the social support for mothers of patients with eating
disorders, maternal mental health, and patient symptomatic severity:
a cross-sectional study. J Eat Disord. 2021;9:8. https:// doi. org/ 10. 1186/
s40337- 020- 00361-w.
13. Coomber K, King RM. Coping strategies and social support as predictors
and mediators of eating disorder carer burden and psychological distress.
Soc Psychiatry Psychiatr Epidemiol. 2012;47:789–96. https:// doi. org/ 10.
1007/ s00127- 011- 0384-6.
14. Sepúlveda AR, Graell M, Berbel E, Anastasiadou D, Botella J, Carrobles JA,
Morandé G. Factors associated with emotional well-being in primary and
secondary caregivers of patients with eating disorders. Eur Eat Disord Rev.
2012;20:e78-84. https:// doi. org/ 10. 1002/ erv. 1118.
15. Martin J, Padierna A, Aguirre U, Gonzalez N, Munoz P, Quintana JM.
Predictors of quality of life and caregiver burden among maternal and
paternal caregivers of patients with eating disorders. Psychiatry Res.
2013;210:1107–15. https:// doi. org/ 10. 1016/j. psych res. 2013. 07. 039.
16. Iapichino E, Rucci P, Corbani IE, Apter G, Quartieri Bollani M, Cauli G, Gala
C, Bassi M. Development and validation of an abridged version of the
Social Provisions Scale (SPS-10) in Italian. Journal of Psychopathology.
2016;22:157–63.
17. Katsuki F, Yamada A, Kondo M, Sawada H, Watanabe N, Akechi T, Rucci P.
Development and validation of the 10-item Social Provisions Scale (SPS-
10) Japanese version. Nagoya Med J. 2020;56:229–39.
18. Sakano Y, Tohjoh M. The General Self/Efficay Scale (GSES): Scale develop-
ment and validation. J Assoc Behav Cognitive Ther. 1986;12:73–82.
19. Moroi K. Dimensions of the revised UCLA Loneliness Scale. Ann Rep Dep
Soc Hum Stud Lang Lit. 1992;42:23–51.
20. Russell DW. UCLA Loneliness Scale (Version 3): reliability, validity, and fac-
tor structure. J Pers Assess. 1996;66:20–40. https:// doi. org/ 10. 1207/ s1532
7752j pa6601_2.
21. Mishima N, Kubota S, Nagata S. The development of a questionnaire to
assess the attitude of active listening. J Occup Health. 2000;42:111–8.
22. Kojima M, Furukawa TA, Takahashi H, Kawai M, Nagaya T, Tokudome S.
Cross-cultural validation of the Beck Depression Inventory-II in Japan.
Psychiatry Res. 2002;110:291–9. https:// doi. org/ 10. 1016/ s0165- 1781(02)
00106-3.
23. Beck AT, Steer RA, Brown GK. Manual for the Beck Depression Inventory
Second edition(BDI-II). San Antonia, TX: The Psychological corporation;
1996.
24. Furukawa TA, Kawakami N, Saitoh M, Ono Y, Nakane Y, Nakamura Y,
Tachimori H, Iwata N, Uda H, Nakane H, Watanabe M, Naganuma Y, Hata
Y, Kobayashi M, Miyake Y, Takeshima T, Kikkawa T. The performance of the
Japanese version of the K6 and K10 in the World Mental Health Survey
Japan. Int J Methods Psychiatr Res. 2008;17:152–8. https:// doi. org/ 10.
1002/ mpr. 257.
25. Kessler RC, Barker PR, Colpe LJ, Epstein JF, Gfroerer JC, Hiripi E, Howes MJ,
Normand SL, Manderscheid RW, Walters EE, Zaslavsky AM. Screening for
serious mental illness in the general population. Arch Gen Psychiatry.
2003;60:184–9. https:// doi. org/ 10. 1001/ archp syc. 60.2. 184.
26. Martínez-González MA, Gual P, Lahortiga F, Alonso Y, de Irala-Estévez
J, Cervera S. Parental factors, mass media influences, and the onset of
eating disorders in a prospective population-based cohort. Pediatrics.
2003;111:315–20. https:// doi. org/ 10. 1542/ peds. 111.2. 315.
27. Quiles Marcos Y, Terol Cantero MC. Assesment of social support dimen-
sions in patients with eating disorders. Span J Psychol. 2009;12:226–35.
https:// doi. org/ 10. 1017/ s1138 74160 00016 33.
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