herstelde patiënten 12 maanden later lager dan niet-herstelde patiënten op comorbide persoonlijkheidsstoornissen, depressie, angst, psycho-neuroticisme en zelfverwondend gedrag. De herstelde patiënten waren in 1 jaar tijd significant verbeterd qua autonomie, terwijl dit bij niet herstelde patienten niet het geval was: De gevoeligheid voor anderen was verminderd en ze konden beter omgaan met nieuwe situaties. Aanvullend op de tentatieve conclusie in Hoofdstuk 4 dat vergroting van het mentaliserend vermogen bij patiënten de kans op een succesvolle behandeling van eetstoornissen zou kunnen vergroten, stel ik daarnaast vast dat verbetering van de autonomie mogelijk eveneens belangrijk is om herstel van een eetstoornis te bereiken.
Hoofdstuk 6 bestaat uit een algemene discussie van de resultaten en van de beperkingen van mijn onderzoek, uitmondend in conclusies en aanbevelingen voor de klinische praktijk en toekomstig onderzoek. Het testen van de eerste twee hypotheses, zoals beschreven in Hoofdstuk 3, leverde uitkomsten op die de resultaten van andere studies naar gehechtheid en mentaliseren bij patiënten met een eetstoornis in vergelijking tot gezonde controlepersonen bevestigden. Ik vond geen relaties tussen gehechtheid en eetstoornissymptomen, waar dergelijke relaties wel waren gevonden in studies die gehechtheid hadden bepaald middels zelfrapportage instrumenten. Het verschil met mijn studie is het gebruik van het AAI dat minder geschikt zou kunnen zijn voor het onderzoeken van correlaties tussen gehechtheid en psychopathologie. Zowel een comorbide BPS als zelfverwondend gedrag bleken geassocieerd met een laag niveau van mentaliseren; dit suggereert dat de toepassing van MBT bij patiënten met AN en BN en een BPS en/of zelfverwondend gedrag nuttig zou kunnen zijn. Zoals verondersteld werd in de derde hypothese, nam veilige gehechtheid toe in 1 jaar van behandeling; deze verandering was niet gerelateerd aan een verbetering van symptomen (vierde hypothese). Opnieuw zou het gebruik van het AAI de verklaring kunnen zijn voor het niet vinden van dergelijke relaties. Het mentaliserend vermogen verbeterde nauwelijks in 1 jaar tijd bij behandelde eetstoornispatiënten. In een andere studie, bij patiënten met een BPS, verbeterde het mentaliseren wel na 1 jaar psychotherapie (Levy et al., 2006). In mijn steekproef van eetstoornispatiënten kwamen naast de BPS cluster C persoonlijkheidsstoornissen (met name de ontwijkende persoonlijkheidsstoornis en de dwangmatige persoonlijkheidsstoornis) veel voor. Dit zou kunnen verklaren waarom 1 jaar van behandeling in deze studie onvoldoende was om verbetering van mentaliseren te bewerkstelligen. Het niet vinden van een relatie tussen veilige gehechtheid en herstel van een eetstoornis, bij de toetsing van de vijfde en zesde hypotheses zoals beschreven in Hoofdstuk 5, zou het gevolg kunnen zijn van de kleine steekproefgrootte.
Het niveau van mentaliseren echter bleek wel samen te hangen met herstel na 1 jaar van behandeling, en met aanhouden van het herstel tot de follow up na 18 maanden. Bij aanvang van de behandeling bestonden er geen verschillen in comorbiditeit of in ernst van de eetstoornis tussen de herstelde of niet-herstelde patiënten. Een jaar later waren de herstelde patiënten in tegenstelling tot de niet-herstelde vooruitgegaan in het opzicht van autonomie. Dit suggereert dat het bereiken van gezonde niveaus van en het vinden van een goed evenwicht tussen gevoeligheid voor anderen en zelf-bewustzijn – zoals dit bij gezonde autonome personen het geval is –van belang zou kunnen zijn voor het herstel van AN of BN.
Beperkingen van dit dissertatieonderzoek zijn de kleine grootte van de onderzochte groep eetstoornispatiënten, het korte tijdsbestek tot de follow up, het scoren van AAI en RFS door slechts een persoon, en het geringe aantal patiënten met BN dat meedeed aan de studie. Voor toekomstig onderzoek beveel ik, behalve de inclusie van een groter aantal patiënten en een langere periode van follow up, het gebruik aan van instrumenten ter bepaling van gehechtheid en van mentaliseren die zich meer lenen voor herhaalde metingen dan het AAI. De inzet van de ACS-30 voor het beoordelen van autonomie is erg informatief gebleken in mijn onderzoek, en nader longitudinaal onderzoek naar de relaties tussen autonomie en symptomen in de behandeling van eetstoornissen wordt aanbevolen.
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