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.     

Establishing appropriate symptomatic control groups for the eating disorders

Two symptomatic control groups for the eating disorders were defined using high and low scores on the Dietary Restraint and Disinhibition scales of the Three Factor Eating Questionnaire. Clinical subjects diagnosed with anorexia and bulimia nervosa were compared with these symptomatic control groups using measures of body weight, bulimic symptoms, and anorexic symptoms. In comparison to the high-Restraint/low-Disinhibition group, anorexic subjects scored higher on measures of eating disorder symptoms but not on Restraint and Disinhibition. The high-Restraint/high-Disinhibition group differed from bulimia nervosa subjects on measures of eating disorder symptoms but did not differ on Restraint and Disinhibition. The results suggested that a control group defined by high Restraint and low Disinhibition formed an appropriate control group for anorexia nervosa. For bulimia nervosa, the most appropriate control group was defined by high Restraint and high Disinhibition.     

Body image, shape, and volumetric assessments using 3D whole body laser scanning and 2D digital photography in females with a diagnosed eating disorder: preliminary novel findings

We piloted three-dimensional (3D) body scanning in eating disorder (ED) patients. Assessments of 22 ED patients (including nine anorexia nervosa (AN) patients, 12 bulimia nervosa (BN) patients, and one patient with eating disorder not otherwise specified) and 22 matched controls are presented. Volunteers underwent visual screening, two-dimensional (2D) digital photography to assess perception and dissatisfaction (via computerized image distortion), and adjunctive 3D full-body scanning. Patients and controls perceived themselves as bigger than their true shape (except in the chest region for controls and anorexia patients). All participants wished to be smaller across all body regions. Patients had poorer veridical perception and greater dissatisfaction than controls. Perception was generally poorer and dissatisfaction greater in bulimia compared with anorexia patients. 3D-volume:2D-area relationships showed that anorexia cases had least tissue on the torso and most on the arms and legs relative to frontal area. The engagement of patients with the scanning process suggests a validation study is viable. This would enable mental constructs of body image to be aligned with segmental volume of body areas, overcoming limitations, and errors associated with 2D instruments restricted to frontal (coronal) shapes. These novel data could inform the design of clinical trials in adjunctive treatments for eating disorders.     

Is body checking in the eating disorders more closely related to diagnosis or to symptom presentation?

Body checking behaviours and cognitions are seen as underlying the core pathology of eating disorders-the over-evaluation of eating, shape and weight. While it has been demonstrated that levels of behaviours and cognitions differentiate eating-disordered women from non-eating-disordered women, little is known with regard to how these findings relate to diagnostic group. This study aimed to determine whether body checking cognitions and behaviours are best understood with regard to diagnostic category or symptom presentation. Eighty-four eating-disordered women (with diagnoses of anorexia nervosa, bulimia nervosa, binge eating disorder or other Eating Disorders Not Otherwise Specified) completed measures of body checking behaviours and cognitions and eating psychopathology. Results showed that different aspects of body checking were more closely associated with diagnosis and with symptom presentation. Anorexia nervosa and binge-eating-disorder patients had particularly low levels of body checking behaviours and some related cognitions. However, the belief that body checking allows one to be accurate in knowing one's weight was associated with binging and vomiting behaviours, rather than diagnosis. Future directions for research include understanding the links between body checking phenomena and neurological features. Clinical implications are discussed.     

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.     

A study of temperament and personality in anorexia and bulimia nervosa

Although temperament and personality traits could influence the development and course of eating disorders, only a few studies examined the similarities and differences in personality between anorexia and bulimia nervosa. We compared 72 patients with DSM-IV eating disorders and 30 healthy controls. Dimensions of personality and personality disorders were evaluated with the Eysenck's EPQ, Cloninger's TCI, and the SCID-II questionnaires. The rates of impulsivity and clinical features were evaluated using specific rating scales. A comorbid personality disorder was found in 61.8% of patients with eating disorder. Avoidant personality disorder appeared was relatively common in anorexia nervosa restricting type; borderline personality disorder was most frequent in bulimia nervosa and the binge eating-purging type of anorexia nervosa. From a dimensional perspective, anorexic patients presented high scores in the dimension of persistence. Higher harm avoidance and impulsivity was found in bulimic patients. The overall eating disorders group presented high scores in neuroticism and low scores in self-directedness. Eating disorder patients have heterogeneous features of temperament and personality traits. Cluster C personality disorders seem more common in anorexia nervosa restricting type and impulsive personality features are associated with bulimic symptoms. Impulsivity seems to be a key aspect of temperament of bulimic patients, whereas anorexic symptoms are linked to persistent temperament traits.     

Body-image disturbances and bulimia nervosa: An empirical analysis of recent revisions of the DSM-III

In the recent revision of the DSM-III, the diagnosis of bulimia nervosa includes the criterion of persistent overconcern with body shape and weight, which may be conceptualized as a form of body-image disturbance. The new diagnostic criteria for bulimia nervosa include only those who exhibit a binge-purge eating patern, excluding binge-eaters who, in the older DSM-III, receive a diagnosis of bulimia. This study was conducted to investigate body-image disturbances in bulimia nervosa and simple bulimia (i.e., binge-eating without purging). The experimental design included two control groups, obese and normal subjects, in order to determine whether the binge-eater had body-image disturbances different form those of normal and overweight samples. The study evaluated 596 subjects (417 normals, 109 bulimia nervosa subjects, 50 binge-eaters, and 30 obese subjects) in terms of perception of current body size and selection of ideal body size. Results indicated that the bulimia nervosa group selected a current body size larger than that selected by normals and an ideal body size smaller than that chosen by normals. However, bingeeaters did not differ from the obese control group on either current or ideal body size. These results are discussed in terms of the recent debate regarding the diagnosis of bulimia nervosa and sociocultural influences upon body-image disturbances.     

The severity and status of eating disorder NOS: implications for DSM-V

"Eating disorder NOS" is the most common eating disorder encountered in outpatient settings yet it has been neglected. The aim of this study was to describe the characteristics of eating disorder NOS, establish its severity, and determine whether its high relative prevalence might be due to the inclusion of cases closely resembling anorexia nervosa or bulimia nervosa. One hundred and seventy consecutive patients with an eating disorder were assessed using standardised instruments. Operational DSM-IV diagnoses were made and eating disorder NOS cases were compared with bulimia nervosa cases. Diagnostic criteria were then adjusted to determine the impact on the prevalence of eating disorder NOS. Cases of eating disorder NOS comprised 60.0% of the sample. These cases closely resembled the cases of bulimia nervosa in the nature, duration and severity of their psychopathology. Few could be reclassified as cases of anorexia nervosa or bulimia nervosa. The findings indicate that eating disorder NOS is common, severe and persistent. Most cases are "mixed" in character and not subthreshold forms of anorexia nervosa or bulimia nervosa. It is proposed that in DSM-V the clinical state (or states) currently embraced by the diagnosis eating disorder NOS be reclassified as one or more specific forms of eating disorder.     

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.     

Biased perception of overeating in bulimia nervosa and compulsive binge eaters

This study investigated the relationship between caloric intake and perceived overeating in subjects with and without a history of problematic binge eating. Eighty subjects (20 in four groups: bulimia nervosa, compulsive binge eaters, obese, and normal controls) self-monitored eating for 2 weeks. The regression slopes for self-reported overeating as a function of caloric intake were contrasted across the four groups. At higher caloric levels, bulimics and binge eaters reported overeating at a significantly higher rate compared to obese and normal control groups. These data were interpreted as a type of cognitive bias whereby subjects with a history of binge eating distorted their perception of overeating at progressively higher caloric levels. It was proposed that excessive concern about eating and dieting may cause such cognitive biases. A parallel was drawn with body image distortion, which appears to be associated with overconcem with body size and shape.     

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.     

Cognitive Behavior Therapy With Body Image Exposure for Bulimia Nervosa: A Case Example

Cognitive behavior therapy (CBT) is an effective treatment for bulimia nervosa (BN). However, among patients with BN, symptom improvement is more pronounced for behavioral eating symptoms (i.e., bingeing and purging) than for body image disturbance, and the persistence of body image disturbance is associated with relapse. The need for more effective body image interventions led to the development of mirror exposure, which focuses on encouraging patients to view themselves in a holistic, nonjudgmental, mindful fashion. Behavioral manifestations of body image disturbance—body checking and avoidance—are also targeted in order to reduce and eliminate such behaviors and their associated preoccupation and distress. A preliminary trial of Body Image Exposure has shown promise, but it has not yet been tested in the context of CBT for BN. The case of “Sara” illustrates the application of this targeted treatment for body image disturbance. Central clinical issues around the perceptual, cognitive, and behavioral components of body image are delineated as they arose in treatment, as are issues of motivation and compliance. Treatment was associated with improvement in eating symptoms, body image, and mood.     

Rumination, experiential avoidance, and dysfunctional thinking in eating disorders

The majority of research in eating disorders (ED) has investigated the content of disorder-specific thoughts, while few studies have addressed underlying cognitive-affective processes. A better understanding of processes underpinning ED may have important implications for treatment development. Two studies were conducted that investigated levels of rumination, beliefs about rumination, experiential avoidance, and aspects of schematic thinking in individuals with eating pathology. The latter was assessed with a newly designed ED-Sentence Completion Task (ED-SCT). Study 1 (N = 177) examined relations between ED psychopathology and these variables in a student population. Extending this, Study 2 (N = 26) assessed differences between patients with anorexia nervosa and healthy control participants. The results showed that ED psychopathology was related to disorder-specific cognitions, experiential avoidance as well as ruminative brooding but not reflection. A follow-up of anorexia nervosa patients indicated that changes in ED psychopathology were associated with changes in dysfunctional attitudes and maladaptive cognitive-affective processes. These findings highlight cognitive processes that may play an important role in the maintenance of eating pathology.     

The impact of exposure to images of ideally thin models in TV commercials on eating behavior: an experimental study with women diagnosed with bulimia nervosa

This study investigates whether eating behavior in women with diagnosed bulimia nervosa is influenced by prior exposure to images of ideally thin models. Twenty-six participants diagnosed with bulimia nervosa (BN) and 30 normal controls (NC) were exposed to body-related and neutral TV commercials; then food that typically triggers binge eating was provided, and the amount of food eaten was measured. No significant difference for food intake between NC and BN could be found, but food intake for BN was predicted by the degree of thoughts related to eating behaviors during exposure to the thin ideal. No impact of general body image or eating pathology on food intake could be found. The results emphasize the importance of action-relevance of dysfunctional cognitions for the maintenance of eating-disordered behaviors in women with bulimia nervosa, when exposed to eating-disorder-specific triggers.     

The relation between risk factors for binge eating and bulimia nervosa: a population-based female twin study.

This study investigated the differential risk factors for the initiation of binge eating and the transition from binge eating to bulimia nervosa. Women from a population-based twin registry (850 complete pairs) were assessed with respect to specific measured variables (including demographics, religiosity, lifetime psychopathology, current symptomatology, and personality) and latent genetic and environmental variables. Because of the relative rarity of bulimia nervosa, statistical power was low, but findings suggested considerable overlap between the genetic risk factors for the development of binge eating and the genetic risk factors for the transition from binge eating to bulimia nervosa. Genetic risk factors for binge eating and bulimia nervosa may be largely similar, whereas nonshared environment may be important in influencing the risk for bulimia nervosa once binge eating is initiated.     

Selective processing of eating-, shape-, and weight-related words in persons with bulimia nervosa.

The Stroop color-naming task was used to investigate selective information processing in people with bulimia nervosa. Three cards were used: a target card consisting of words related to eating, weight, and shape; a control word card; and the standard conflicting-color card. Thirty-six patients with bulimia nervosa were compared with a group of age-matched female controls. It was found that the amount of disruption caused to color naming by the target card was significantly greater in the bulimia nervosa group than in the female control group, whereas that caused by the color card was similar in the two groups. The Stroop color-naming task may be a useful objective measure of one aspect of the cognitive disturbance of patients with bulimia nervosa.     

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.     

An analysis of social anxiety in anorexic,bulimic, social phobic,and control women

Responses to the Social Phobia and Anxiety Inventory (SPAI) were examined in 23 women with anorexia nervosa, 54 women with bulimia nervosa, 50 female college undergraduates, and 43 social phobic women. Results indicated that women with anorexia nervosa and bulimia nervosa scored comparably high to social phobic women on measures of social anxiety and that these fears were not limited to fears of eating or drinking in public. This study suggests that fears of negative evaluation in women with eating disorders may generalize beyond the fears of scrutiny of body shape and size to more traditional social situations.     

Health-Related Quality of Life in Women with Eating Disorders: Association with Subjective and Objective Binge Eating

This study examined health-related quality of life (QOL) and its association with different forms of binge eating in 53 women with eating disorders. Participants had enrolled in treatment for anorexia nervosa, bulimia nervosa, binge eating disorder, or other eating disorders not otherwise specified and completed measures of QOL, eating-related psychopathology, and mood disturbance. Eating- and mood-related psychopathology, and to a lesser extent, mental-component QOL scores, were severely impaired in this sample relative to population norms. QOL was significantly and independently predicted by subjective bulimic episodes and compensatory behaviors, including food avoidance, laxative abuse, and self-induced vomiting, accounting for 32% of the variance. Subjective bulimic episodes and food avoidance also independently predicted the physical-component QOL, accounting for 27% of the variance. These findings suggest that subjective bulimic episodes may be independently associated with impairment in QOL and may require specific attention as targets of treatment.