Effects of analytical and experiential self-focus on stress-induced cognitive reactivity in eating disorder psychopathology

Previous research suggests distinct modes of self-focus, each with distinct functional properties: Analytical self-focus appears maladaptive, with experiential self-focus having more adaptive effects on indices of cognitive-affective functioning (e.g., Watkins, Moberly, & Moulds, 2008). The authors applied this framework to eating disorder (ED) psychopathology and manipulated the mode of self-focus prior to exposure to a stressor (imagining eating a large meal; Shafran, Teachman, Kerry, & Rachman, 1999). Study 1 showed that students high in ED psychopathology reported lower post-stressor feelings of weight or shape change and less subsequent attempts to neutralise (e.g., imagining exercising) after experiential relative to analytical self-focus. Study 2 found that partially weight restored patients with anorexia nervosa had lower post-stressor estimates of their own weight and reported lower urge to cancel stressor effects following experiential compared to analytical self-focus. Experiential self-focus was also followed by less neutralisation than analytical self-focus. Results suggest that the mode of self-focus affects cognitive reactivity following a stressor in individuals with ED psychopathology. Examining the mode within which individuals with ED psychopathology focus on self and body may raise important implications for understanding of psychopathology and open new possibilities for augmenting current treatments.     

The relationship between rumination, avoidance and depression in a non-clinical sample

Recent commentaries have proposed conceptualizations of rumination in terms of both cognitive and behavioral avoidance. This study examined the relationship between rumination, avoidance and depression using a newly developed self-report measure of avoidance in depression, the Cognitive-Behavioral Avoidance Scale (CBAS) [Ottenbreit, N.D., & Dobson, K.S. (2004). Avoidance and depression: The construction of the cognitive-behavioral avoidance scale. Behaviour Research and Therapy, 42, 293-313]. A non-clinical sample (N=104) of undergraduate students completed self-report measures of depression, anxiety, rumination and avoidance. Rumination, avoidance and depression were all significantly correlated. Rumination and behavioral avoidance remained intercorrelated when anxiety was controlled, confirming an association that is independent of anxiety. By contrast, the relationship between cognitive avoidance and rumination disappeared when anxiety was partialled out. Notably, avoidance predicted unique variance in depression scores, over and above anxiety and rumination. Consistent with the proposal of Ottenbreit and Dobson [Avoidance and depression: The construction of the cognitive-behavioral avoidance scale. Behaviour Research and Therapy, 42, 293-313], our findings support the value of clinicians and psychopathologists giving consideration to avoidance in their conceptualization of depression.     

Perfectionism in depression, obsessive-compulsive disorder and eating disorders

High levels of perfectionism have been observed in major depression, anxiety disorders and eating disorders. Though few studies have compared levels of perfectionism across these disorders, there is reason to believe that different dimensions of perfectionism may be involved in eating disorders than in depression or anxiety [Bardone-Cone, A. M. et al. (2007). Perfectionism and eating disorders: Current status and future directions. Clinical Psychology Review, 27, 84-405]. The present study compared patients with major depression, obsessive-compulsive disorder, and eating disorders on dimensions of perfectionism. Concern over Mistakes was elevated in each of the patient groups while Pure Personal Standards was only elevated in the eating disorder sample. Doubts about Actions was elevated in both patients with obsessive-compulsive disorder and eating disorders, but not in depressed patients. Analyses of covariance indicated that Concern over Mistakes accounted for most of the variance in the relationship of perfectionism to these forms of psychopathology.     

Personality disorder cognitions in the eating disorders

The eating disorders are frequently found to be comorbid with Axis II cluster B and C personality disorders. It is important to identify the personality-level cognitions that typify these disorders. This study of a clinical group examines the personality disorder cognitions in the eating disorders. The cognitions that were most relevant to the eating disorder pathology were those relating to avoidant and obsessive-compulsive personality disorder. Other personality disorder cognitions were associated with comorbid psychopathology in largely clinically meaningful ways. These findings extend our understanding of the comorbidity of eating disorders and personality pathology, suggesting that some cases need to be assessed and formulated with such cognitions in mind. Treatment strategies are required that address both the eating and the personality pathology, while considering the impact of these cognitions on the therapeutic relationship.     

Reflections on athletes and eating disorders

ObjectivesThe purposes of this paper were to offer reflections, thoughts, and observations on the burgeoning research regarding eating disorders in athletes over the past 25 years, to comment on the findings and clinical implications of the studies contained in this special issue, and to provide suggestions for future research.ResultsDisordered eating and eating disorders are complex, multidimensional, and multiply determined, and can affect the health and performance of athletes in both genders and most sports. Although coaches and teammates can be significant sources of weight and body image pressure, they can also play a positive role in identification and prevention.ConclusionsFurther research is needed in several areas. These include a broader focus that includes athletes believed to be at less risk, most notably males and non-lean sport athletes, and ironically younger athletes, who may be at greatest risk. We also need more research related to treatment of athletes with eating disorders and especially how we might better motivate them for recovery.     

Rumination, distraction, and mindful self-focus in depressed patients

Rumination has been proposed as a cognitive risk factor for the onset and maintenance of depression. In parallel, mindfulness interventions have shown to reduce the risk for recurrence of depressive episodes. This study aimed to investigate effects of short periods of induced rumination, distraction, and mindful self-focus on sad mood in depressed patients and to assess possible moderator effects of habitual variables on respective mood changes. Seventy-six depressed patients 3.5 years after discharge from inpatient treatment were subjected to negative mood induction and subsequently randomly assigned to a rumination, distraction, or mindful self-focus induction. Habitual aspects of rumination, distraction, and mindfulness were assessed by questionnaires. Compared to rumination, the induction of a mindful self-focus and of distraction showed clear beneficial effects on the course of negative mood. While habitual distraction predicted better mood outcomes across all conditions, patients high in habitual mindfulness tended to show stronger negative mood reduction specifically after the induction of a mindful self-focus. This study indicates that - similar to distraction - an experimentally induced mindful self-focus is able to reduce negative mood in depressed patients. Implications regarding possible subgroups of patients who might particularly benefit from mindfulness-based interventions are discussed.     

The role of body image in the prevention of eating disorders

This article reviews theory and research pertaining to prevention of negative body image and eating disorders. Research derived from the social cognitive model (SCM) and non-specific vulnerability-stressor (NSVS) model indicates that sustained prevention effects for attitudes and behaviors are possible, but not easy to achieve or explain. These limitations are considered in the context of promising research derived from a third model, critical social perspectives (CSP). We conclude that (1) research on practice should aim beyond the examination of efficacy in order to clarify the active ingredients contributing to prevention; and (2) research informed by each of the divergent perspectives can be used to enrich theory and practice in the field of eating disorders prevention.     

Body checking and avoidance and the core features of eating disorders among obese men and women seeking bariatric surgery

This study examined two aspects of body checking and avoidance, and their relations to the core psychopathology of eating disorders (EDs), in severely obese men and women seeking bariatric surgery. A consecutive series of 260 (44 male and 216 female) gastric bypass candidates were administered measures to assess body checking and avoidance, binge eating, restraint, and overevaluation of weight and shape. The majority of patients reported regularly pinching areas of their body to check for fatness and avoided wearing clothing that made them particularly aware of their body. Significant associations were observed between checking and restraint, and between avoidance and binge eating. Both checking and avoidance behaviors were significantly associated with overevaluation of weight and shape. The positive associations between each of the two behaviors (body checking and avoidance) with overevaluation of weight/shape remained significant even after controlling for the effects of avoidance on body checking and vice versa. Stepwise multiple regression analyses revealed that binge eating, body checking, and avoidance behaviors made significant unique contributions and jointly accounted for 22-25% of the variance in overevaluation of weight and shape, respectively. This study documents the presence of eating disorder psychopathology among severely obese patients seeking bariatric surgery. The findings support the view that body checking and avoidance behaviors are manifestations of overevaluation of weight and shape and disordered eating.     

Testing the Ideology of Openness: The Comparative Effects of Talking,Writing, and Avoiding a Stressor on Rumination and Health

A persistent assumption across the psychological literature is that talking and writing about one's stress is inherently more beneficial than avoiding it. This study compared the effects of these stress management strategies on personal and relational health. Two hundred and fifty‐one dating individuals focused on a stressor that was a current source of rumination. Writing about one's stressor for 5 consecutive days (without talking about it) decreased anxiety the most. Talking continuously about one's stressor to a dating partner harmed the relationship more than writing about or avoiding it. The effect of talking repeatedly about one's stressor on relationship quality and brooding, however, depended upon the emotional support received from one's dating partner and the ability to reappraise (positively or neutrally) the stressor.     

The role of avoidance of emotional material in the anxiety disorders

Many psychotherapeutic traditions have conceptualized clinical levels of anxiety as resulting from the avoidance of threatening or emotional material. In this paper, we examine behavioral models of avoidance of emotions and emotional material, integrating findings that support established behavioral theories of emotional avoidance and anxiety, and that extend these theories to further explain the intense, intrusive, and interfering nature of clinical anxiety. Research on the suppression and avoidance of emotional material suggests that emotional avoidance and thought suppression may not only hinder the learning process and maintain anxious responding, but may also (a) paradoxically heighten anxious responding to threatening cues and (b) interfere with emotion functionality, thereby further impeding adaptive responding. Findings are discussed in terms of future research and implications for clinical treatment of anxiety disorders.     

Self-induced vomiting in eating disorders: Associated features and treatment outcome

Self-induced vomiting is adopted by people with a variety of eating disorders (ED) to control body shape and weight. We tested the prevalence, the associated features and the role on treatment outcome of self-induced vomiting in 152 ED patients consecutively admitted to an inpatient cognitive-behavioral treatment (CBT), based on the transdiagnostic CBT for ED. The Eating Disorder Examination, together with the Beck Depression Inventory, the State-Trait Anxiety Inventory and the Temperament and Character Inventory were recorded at entry and at end of treatment. Self-induced vomiting was reported in 35.5% of cases, and 21.1% had multiple purging with vomiting. Individuals with vomiting and those with multiple purging had significantly higher BMI and a higher frequency of bulimic episodes, but individuals with multiple purging were also characterized by higher levels of depression, longer ED duration, more severe ED psychopathology and lower self-directness. Individuals with vomiting had higher eating concern and novelty seeking compared with those without purging behaviors. However, the three groups had similar dropout rates and outcomes in response to inpatient CBT, in keeping with the transdiagnostic theory of EDs.     

Changes in alcohol intake in response to transdiagnostic cognitive behaviour therapy for eating disorders

Objective

The aim of this study was to examine how alcohol intake changes during and after transdiagnostic cognitive behaviour therapy for eating disorders (CBT-E). Additionally, the paper considers the relationship between alcohol consumption, eating disorder diagnosis and current major depressive episode at the time of first assessment.

Method

One hundred and forty nine outpatients with an eating disorder (body mass index over 17.5) were divided into high or low alcohol intake groups (HIG and LIG) according to their intake at pre-treatment assessment. Their alcohol intake and eating disorder psychopathology were examined over the course of treatment and follow-up.

Results

There was no difference between the groups on response of the eating disorder to treatment. The HIG significantly reduced their alcohol intake following treatment whilst the intake of the LIG remained stable over the course of treatment and follow-up. There were no group differences in major depression and overall severity of eating disorder at baseline.

Conclusions

The response to CBT-E was not influenced by baseline level of alcohol use. The mean alcohol intake of the heavy drinking subjects decreased without being specifically addressed by the treatment.     

The use of virtual reality in the study, assessment, and treatment of body image in eating disorders and nonclinical samples: a review of the literature

This article reviews research into the use of virtual reality in the study, assessment, and treatment of body image disturbances in eating disorders and nonclinical samples. During the last decade, virtual reality has emerged as a technology that is especially suitable not only for the assessment of body image disturbances but also for its treatment. Indeed, several virtual environment-based software systems have been developed for this purpose. Furthermore, virtual reality seems to be a good alternative to guided imagery and in vivo exposure, and is therefore very useful for studies that require exposure to life-like situations but which are difficult to conduct in the real world. Nevertheless, review highlights the lack of published controlled studies and the presence of methodological drawbacks that should be considered in future studies. This article also discusses the implications of the results obtained and proposes directions for future research.     

Screening for eating disorders in primary care: EDE-Q versus SCOFF

OBJECTIVE AND METHODS: The comparative validity of the Eating Disorder Examination Questionnaire (EDE-Q) (22 items) and SCOFF (five items) in screening for cases of the more commonly occurring eating disorders was examined in a primary care sample of young adult women (n=257). Diagnoses were confirmed in a sub-group of interviewed participants (n=147). RESULTS: Twenty-five cases, primarily variants of bulimia nervosa (BN) not meeting formal diagnostic criteria, were identified in the interviewed sample. An EDE-Q global score of >or= 2.80 yielded the optimal trade-off between sensitivity (Se) (0.80) and specificity (Sp) (0.80) (positive predictive value (PPV)=0.44), whereas a score of two or more positive responses on the SCOFF was optimal (Se=0.72, Sp=0.73, PPV=0.35). Validity coefficients for both measures varied as a function of participants' age and body weight, although these effects were more pronounced for the SCOFF. CONCLUSIONS: Both measures performed well in terms of their ability to detect cases and to exclude non-cases of the more commonly occurring eating disorders in a primary care setting. The EDE-Q performed somewhat better than the SCOFF and was more robust to effects on validity of age and weight. These findings need to be weighed against the advantage of the SCOFF in terms of its brevity.     

Just world beliefs, causal beliefs, and acquaintance: Associations with stigma toward eating disorders and obesity

The current study investigated the relationship between just world beliefs and stigmatizing attitudes toward eating disorders and obesity. Further, the associations between stigma and causal beliefs, and between stigma and acquaintance with these conditions, were examined. Participants (n = 447) read four vignettes describing an individual with anorexia nervosa, bulimia nervosa, binge eating disorder, or obesity. After each vignette, participants completed questionnaires assessing stigmatizing attitudes, just world beliefs, causal beliefs, and acquaintance with the condition depicted in the vignette. Stronger just world beliefs were associated with greater stigma toward all three eating disorders, as well as obesity (rs ranging from −.11 to −.18). More stigmatizing attitudes were associated with greater attribution of individual responsibility for the development of the disorder. However, participants with personal experience or who knew someone with the depicted problem did not have lower stigma scores than those who did not. The current study suggests that justification ideologies such as just world beliefs and controllability beliefs may underlie the stigmatization of eating disorders and obesity. These findings provide support for stigma reduction efforts aimed at targeting justification ideologies and altering causal beliefs.     

Comparison of dysfunctional attitudes and social adjustment among infertile employed and unemployed women in Iran

This study aims to compare dysfunctional attitudes and social adjustment in infertile employed and unemployed females. Due to the stresses of infertility, infertile females are faced with a variety of sexual and psychological problems, as well as dysfunctional attitudes that can lead to depression. Moreover, infertility problems provoke women into maladjustment and inadvertent corruption of relationships. In this regard, our goal is to consider the effects of employment in conjunction with education on dysfunctional attitudes and social adjustment among infertile women in Iran. In this work, we employed the survey method. We recruited 240 infertile women, utilizing the cluster random sampling method. These women filled out the Dysfunctional Attitudes Scale and the social adjustment part of the California Test of Personality. Next, multivariate analysis of variance was performed to test the relationship of employment status and education with dysfunctional attitudes and social adjustment. Our results indicated that dysfunctional attitudes were far more prevalent in infertile unemployed women than in infertile employed women. Also, social adjustment was better in infertile employed women than in infertile unemployed women. It was shown that education level alone does not have significant effect on dysfunctional attitudes and social adjustment. However, we demonstrated that the employment status of infertile women in conjunction with their education level significantly affects the two dimensions of dysfunctional attitudes (relationships, entitlements) and has insignificant effects on social adjustment. It was revealed that in employed infertile women in Iran, the higher education level, the less dysfunctional were attitudes in relationships and entitlements, whereas in unemployed infertile women, those with a college degree had the least and those with master's or higher degrees had the most dysfunctional attitudes in terms of relationships and entitlements.     

Cosmetic surgery in inpatients with eating disorders: attitudes and experience

Body image disturbance is frequent among individuals undergoing cosmetic surgery and core to the pathology of eating disorders (ED); however, there is little research examining cosmetic surgery in ED. This study examined body image related measures, ED behaviors, and depression as predictors of attitudes toward cosmetic surgery in 129 women with ED. Patients who had undergone surgery (n = 16, 12%) were compared to those who had not. Having a purging diagnosis, linking success to appearance, and making physical appearance comparisons were predictive of more favorable cosmetic surgery attitudes. All of those who had undergone surgery had purging diagnoses and, on average, were older, had higher BMIs, and were more likely to make physical appearance comparisons and know someone who had undergone surgery. In ED, acceptance and pursuit of cosmetic surgery appears to be related to social group influences more than weight and shape disturbance, media influences, or mood.     

Selective visual attention for ugly and beautiful body parts in eating disorders

Body image disturbance is characteristic of eating disorders, and current treatments use body exposure to reduce bad body feelings. There is however little known about the cognitive effects of body exposure. In the present study, eye movement registration (electroculography) as a direct index of selective visual attention was used while eating symptomatic and normal control participants were exposed to digitalized pictures of their own body and control bodies. The data showed a decreased focus on their own 'beautiful' body parts in the high symptomatic participants, whereas inspection of their own 'ugly' body parts was given priority. In the normal control group a self-serving cognitive bias was found: they focused more on their own 'beautiful' body parts and less on their own 'ugly' body parts. When viewing other bodies the pattern was reversed: high symptom participants allocated their attention to the beautiful parts of other bodies, whereas normal controls concentrated on the ugly parts of the other bodies. From the present findings the hypothesis follows that a change in the processing of information might be needed for body exposure to be successful.     

The effect of inpatient cognitive-behavioral therapy for eating disorders on temperament and character

Personality traits seem to have an important role in the development, clinical expression, course, and treatment response in eating disorders (EDs). We investigated the effects of an inpatient cognitive-behavioral treatment (CBT) on the measures of temperament and character (Temperament and Character Inventory (TCI)) in 149 consecutive patients with EDs. Baseline assessment included anthropometry, the Eating Disorder Examination (EDE), the Beck Depression Inventory (BDI), and the TCI. Treatment was based on the transdiagnostic cognitive behavior theory and treatment of ED, adapted for an inpatient setting. Treatment effects were tested by paired ANOVA, adjusted for covariates. No effects were found on Novelty Seeking, Reward Dependence, and Cooperativeness. Harm Avoidance (F=18.17, p<0.001), Persistence (F=7.71, p=0.006), Self-Directedness (F=27.55, p<0.001), and Self Transcendence (F=16.38, p<0.001) significantly changed after treatment. Changes in TCI scores were wholly dependent on the changes in BDI and EDE, and independent of ED diagnosis and behavior and of BMI changes. We conclude that in ED, a few scales of both temperament and character are significantly modified by CBT, in relation to changes in psychopathology and depression, independently of nutrition. These results are relevant for future studies based on TCI.     

Drive for thinness, affect regulation and physical activity in eating disorders: a daily life study

Using Ecological Momentary Assessment, the within patient associations between drive for thinness, emotional states, momentary urge to be physically active and physical activity were studied in 32 inpatients with an eating disorder. Participants received an electronic device and had to indicate at nine random times a day during 1 week their momentary drive for thinness, positive and negative emotional states and their urge to be physically active and physical activity. Multilevel analyses indicated that patients with higher mean levels for urge to be physically active were characterized by lower body mass index (BMI) and chronically negative affect whereas patients with higher mean levels for physical activity were characterized by lower BMI and higher dispositions for drive for thinness. In addition, within patient relations between drive for thinness and urge to be physically active were moderated by BMI and chronically negative affect whereas within patient relations between drive for thinness and physical activity were moderated by BMI. Finally, also positive emotional states were significantly associated with physical activity within patients. By using a daily process design, characteristics of physical activity were revealed that have not been identified with assessment methods that have a lower time resolution.