Affect regulation and food intake in bulimia nervosa: emotional responding to food cues after deprivation and subsequent eating

Emotional responding to salient food cues and effects of food deprivation and consumption were investigated in 32 women with bulimia and 32 control women. One half of each group was food deprived before viewing unpleasant, neutral, pleasant, and food-related pictures. Then participants could eat from a buffet before viewing a parallel picture set. Women with bulimia showed a substantial potentiation of startle responses during viewing of food cues relative to control women. This startle potentiation was attenuated by food deprivation and augmented by increased food consumption. These data support the affective regulation model suggesting that food cues prompt negative affective states in women with bulimia, who are overwhelmed by fasting. The resulting deprivation increases the incentive value of food cues and may thus trigger binge eating.     

Multifactorial assessment of bulimia nervosa

We investigated a multifactorial approach to the assessment of bulimia nervosa by means of hierarchical factor analysis. Two hundred forty-five bulimia nervosa patients and 68 patients with either anorexia nervosa or eating disorders not otherwise specified were administered a self-report battery that was organized into 21 dimensions relevant to eating disorder patients. When dimensions from this battery were subjected to hierarchical factor analysis, support for bulimia nervosa as a unique diagnostic category was obtained. However, the emergence of 3 secondary factors and 6 primary factors suggests that bulimia nervosa can also be described more complexly. The emergence of a multifactorial model of bulimia nervosa that incorporates several existing undimensional models suggests the potential for both divergent and complicated clinical presentation in bulimia nervosa patients.     

Overvaluation of shape and weight in binge eating disorder, bulimia nervosa, and sub-threshold bulimia nervosa

Increasing empirical evidence supports the validity of binge eating disorder (BED), a research diagnosis in the appendix of DSM-IV, and its inclusion as a distinct and formal diagnosis in the DSM-V. A pressing question regarding the specific criteria for BED diagnosis is whether, like bulimia nervosa (BN), it should be characterized by overvaluation of shape and weight. This study compared features of eating disorders in 436 treatment-seeking women comprising four groups: 195 BED participants who overvalue their shape/weight, 129 BED participants with subclinical levels of overvaluation, 61 BN participants, and 51 participants with sub-threshold BN. The BED clinical overvaluation group had significantly higher levels of specific eating disorder psychopathology than the three other groups which did not differ significantly from each other. Findings suggest that overvaluation of shape and weight should not be considered as a required criterion for BED because this would exclude a substantial proportion of BED patients with clinically significant problems. Rather, overvaluation of shape and weight warrants consideration either as a diagnostic specifier or as a dimensional severity rating as it provides important information about severity within BED.     

Possible differences in family patterns in anorexia nervosa and bulimia nervosa

This paper examines the interactions in three families, one where the daughter had anorexia nervosa and two where the daughters had bulimia nervosa, and proposes some differences in the families’ patterns of enmeshment. It is hypothesized that these may be linked to differences in the development of the mother—child relationship. Implications for the choice of therapeutic strategies are discussed.     

Examining a psychosocial interactive model of binge eating and vomiting in women with bulimia nervosa and subthreshold bulimia nervosa

The current study tested a psychosocial interactive model of perfectionism, self-efficacy, and weight/shape concern within a sample of women with clinically significant bulimic symptoms, examining how different dimensions of perfectionism operated in the model. Individuals with bulimia nervosa (full diagnostic criteria or subthreshold) completed measures of bulimic symptoms, multidimensional perfectionism, self-efficacy, and weight/shape concern. Among those who were actively binge eating (n=180), weight/shape concern was associated with binge eating frequency in the context of high perfectionism (either maladaptive or adaptive) and low self-efficacy. Among those who were actively vomiting (n=169), weight/shape concern was associated with vomiting frequency only in the context of high adaptive perfectionism and low self-efficacy. These findings provide support for the value of this psychosocial interactive model among actively binge eating and purging samples and for the importance of considering different dimensions of perfectionism in research and treatment related to bulimia nervosa.     

Psychological responses to body shape exposure in patients with bulimia nervosa

One of the unresolved issues regarding research on bulimia nervosa concerns the question as to how patients diagnosed with bulimia nervosa respond to body image exposure. In addition, it remains unclear whether there are differential responses associated with different exposure techniques (e.g. in vivo exposure vs. exposure by visualization). The aim of the present study was to investigate psychological responses to body image exposure. Twenty participants diagnosed with bulimia nervosa (DSM IV) and twenty non-eating disordered individuals were exposed to their body image using a video recording (video confrontation). In addition, they were asked to imagine and describe the appearance of their body (imagery task). Results indicate that self-reported negative emotions increased in response to both, video confrontation and imagery task, in the clinical as well as in the control group. Furthermore, video confrontation led to more pronounced group differences than exposure by visualization (imagery task). Participants diagnosed with bulimia nervosa took less time to describe their waist, hips and bottom compared to non-eating disturbed controls. This last result could be interpreted in terms of avoidance behavior and other mechanisms during body image exposure.     

Quantitative evidence for distinct cognitive impairment in anorexia nervosa and bulimia nervosa

It is generally agreed that at least some aspects of abnormal eating behaviour is indeed due in part to disordered cognition. The accumulated literature illustrates cognitive impairment in patients with anorexia nervosa (AN) and bulimia nervosa (BN). Yet beyond being inconsistent, these independent studies also do not reveal the magnitude of impairment within and across studies and fail to give due consideration to the magnitude of impairment so as to understand the severity and breadth of impairment and/or differences in cognitive profiles between patients with AN and BN. Hence, the present review on the subject sought to articulate the magnitude of cognitive impairment in patients with AN and BN by quantitatively synthesizing the existing literature using meta-analytic methodology. The results demonstrate modest evidence of cognitive impairment specific to AN and BN that is related to body mass index in AN in terms of its severity, and is differentially impaired between disorders. Together, these results suggest that disturbed cognition is figural in the presentation of eating disorders and may serve to play an integral role in its cause and maintenance. Implications of these findings with respects to future research are discussed.     

Body images of patients with anorexia nervosa, bulimia nervosa and female control subjects: a comparison with male ideals of female attractiveness

Body images of female patients with anorexia nervosa and bulimia nervosa were assessed against females without eating disorders and compared with male ideals of female attractiveness. A computer program was applied to examine body images of 62 patients with anorexia nervosa, 45 patients with bulimia nervosa, and 40 female and 39 male control subjects. Body size overestimation was most distinct in the two patient groups. Self-ideal discrepancy was highest in bulimia nervosa. Estimation of the society's ideal female body in all three female groups did not differ from men's perception of the most attractive female body. Congruence of ideals of female attractiveness in patients, female, and male control subjects and described differences between patients and female controls support the theory that body image disturbance is a problem of processing self-referential information regarding body image rather than a problem of processing body image related information per se.     

Cognitive behaviour therapy to treating bulimia nervosa: A case study

The general cognitive behaviour therapy postulates that bulimic symptoms are maintained by a characteristic set of overvalued thoughts about the personal implications of body shape and weight. Research shows that there is both a close relationship and specific interaction between thoughts and behaviours that help to maintain the overvalued thoughts. This theoretical proposition concerning the role of behaviours in the maintenance of psychological problems is commonly accepted and empirically validated. To ensure a sustainable therapeutic change in the treatment of bulimia nervosa, therapists may need to initially target these overvalued thoughts about the personal implications of body shape and weight; and then to work on the behaviours that help to maintain the bulimic symptoms. The purpose of the present paper is to discuss the conceptual and practical issues underpinning a therapeutic focus that reflects an integrated clinical approach in the treatment of bulimia nervosa. This integrated approach includes the assessment and disputation of the overvalued thoughts that are causal to bulimia nervosa, and various strategies that facilitate the change in those behaviours that help to maintain the bulimic conditions. Using a case example, this paper also discusses the cognitive behaviour conceptualization in the maintenance of bulimia nervosa.     

Assessment of emotional reactivity produced by exposure to virtual environments in patients with eating disorders.

The aim of this study was to assess the usefulness of virtual environments representing situations that are emotionally significant to subjects with eating disorders (ED). These environments may be applied with both evaluative and therapeutic aims and in simulation procedures to carry out a range of experimental studies. This paper is part of a wider research project analyzing the influence of the situation to which subjects are exposed on their performance on body image estimation tasks. Thirty female patients with eating disorders were exposed to six virtual environments: a living-room (neutral situation), a kitchen with high-calorie food, a kitchen with low-calorie food, a restaurant with high-calorie food, a restaurant with low-calorie food, and a swimming-pool. After exposure to each environment the STAI-S (a measurement of state anxiety) and the CDB (a measurement of depression) were administered to all subjects. The results show that virtual reality instruments are particularly useful for simulating everyday situations that may provoke emotional reactions such as anxiety and depression, in patients with ED. Virtual environments in which subjects are obliged to ingest high-calorie food provoke the highest levels of state anxiety and depression.     

MCMI-II borderline personality disorder in anorexia and bulimia nervosa

The aim of the present study is to explore the MCMI-II personality style and MCMI-II possible disorder of borderline personality (BPD) in various groups of women. 93 patients-31 anorexia nervosa restricting subtype (ANr), 31 anorexia nervosa binge-eating/purging subtype (ANp), and 31 bulimia nervosa purging subtype (BNp); 31 women at high risk for eating disorder or symptomatic control group (S-CG) and 31 without known pathology or not symptomatic control group (NS-CG)-completed the Spanish version of the MCMI-II. The results revealed: (1) clinically significant borderline personality traits [74>Base Rate (BR) <85]: 16.1% ANr, 12.9% ANp, and 45.2% BNp versus 3.2% of the S-CG and none of the NS-CG; (2) possible disorder (BR>84): 29% ANr, 41.9% ANp and 29% BNp. According to the MCM-II, women with BNp displayed more BPD traits than possible disorder (though these were more severe). However, the probability of a possible disorder was higher in ANp (more disorders than traits).     

Subliminal food images compromise superior working memory performance in women with restricting anorexia nervosa

Prefrontal cortex (PFC) is dysregulated in women with restricting anorexia nervosa (RAN). It is not known whether appetitive non-conscious stimuli bias cognitive responses in those with RAN. Thirteen women with RAN and 20 healthy controls (HC) completed a dorsolateral PFC (DLPFC) working memory task and an anterior cingulate cortex (ACC) conflict task, while masked subliminal food, aversive and neutral images were presented. During the DLPFC task, accuracy was higher in the RAN compared to the HC group, but superior performance was compromised when subliminal food stimuli were presented: errors positively correlated with self-reported trait anxiety in the RAN group. These effects were not observed in the ACC task. Appetitive activation is intact and anxiogenic in women with RAN, and non-consciously interacts with working memory processes associated with the DLPFC. This interaction mechanism may underlie cognitive inhibition of appetitive processes that are anxiety inducing, in people with AN.     

Psychophysiological mechanisms involved in the affective regulation and food restriction of women at risk of suffering from bulimia nervosa

The aim of the study was to explore the effect of visualizing food images under different mood states and food restriction conditions on the emotional modulation of two defense reflexes (startle reflex and cardiac defense). 72 women at risk of suffering from bulimia nervosa were assigned to two groups: 1) a group under induced positive, neutral, or negative mood state and, 2) a 6-hour-food-deprived group or a non-deprived group. Second-by-second heart rate and electromyogram activity from the orbiculari oculi region were recorded after the auditory stimulus. The results showed that, while viewing food images, non-deprived women under negative mood state potentiated the cardiac defense response and the startle motor reflex. Results are discussed in the context of emotional eating theories and Peter Lang's motivational priming model.     

Thoughts about eating, weight and shape in anorexia nervosa and bulimia nervosa.

Concurrent verbalisation and a self-report questionnaire were used to investigate self-statements in patients with anorexia nervosa, patients with bulimia nervosa, two groups of dieters and non-dieting controls. Thoughts were collected while subjects performed three behavioural tasks, looking at themselves in a full-length mirror, weighing themselves and eating a chocolate covered mint. Both groups of patients had more negative thoughts related to eating, weight and shape than those in the three control groups. In addition, patients with anorexia nervosa showed a greater concern with eating while patients with bulimia nervosa showed a greater concern with weight and appearance. Differences were found between the patients and non-dieting controls using both methods but the self-report questionnaire was less sensitive than concurrent verbalisation to differences between the patients and dieters. Implications of the findings for cognitive-behavioural treatments of the two disorders are discussed.     

Predictors of short-term treatment outcome in bulimia nervosa inpatients.

Recent studies, mostly performed on bulimic outpatients, did not find consistent predictors of treatment outcome in bulimia nervosa. This is the first study to investigate anamnestic and clinical factors predictive of the short-term outcome of hospital treatment in 31 female bulimia nervosa patients with a mean age of 22.9 yr. Treatment outcome was assessed by several self-rating instruments measuring different features of the specific and unspecific psychopathology of bulimia nervosa. The most relevant predictors of the outcome of the 8-week hospital treatment were duration of previous inpatient treatments for bulimia, the intensity of anorexic tendency and the pretreatment level of depression. The majority of predictors tested did not show a strong relationship to treatment outcome. The findings are discussed in relation to results of other studies as well as to possible implications for treatment and research.     

Treatment manuals: use in the treatment of bulimia nervosa

As psychology has moved toward emphasizing evidence-based practice, use of treatment manuals has extended from research trials into clinical practice. Minimal research has directly evaluated use of manuals in clinical practice. This survey of international eating disorder professionals examined use of manuals with 259 clinicians’ most recent client with bulimia nervosa. Although evidence-based manuals for bulimia nervosa exist, only 35.9% of clinicians reported using a manual. Clinicians were more likely to use a manual if they were younger; were treating an adult client; were clinical psychologists; were involved in research related to eating disorders; and endorsed a cognitive-behavioral orientation. Clinicians were less likely to use a manual if they provided eclectic psychotherapy that incorporated multiple psychotherapeutic approaches. We conclude that psychotherapy provided in clinical practice often does not align with the specific form validated in research trials, and “eclecticism” is at odds with efforts to disseminate manuals into clinical practice.