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.     

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.     

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.     

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.     

Bulimia nervosa and dietary restraint

Patients with bulimia nervosa were compared with non-bulimic restrained and unrestrained eaters on several questionnaire and interview measures related to eating patterns, preoccupation with dieting and food, and general psychopathology. Bulimic subjects did not differ significantly from non-bulimic restrained eaters on measures of fear of weight gain, dietary restraint, and the Eating Disorders Inventory (EDI) subscales of Drive for Thinness and Body Dissatisfaction, although both groups scored significantly higher on these measures than unrestrained eaters. Subjects with bulimia nervosa differed significantly from both restrained and unrestrained eaters on the Eating Habits Checklist, the Beck Depression Inventory, the EDI total score and Interoceptive Awareness, Introversion and Bulimia subscales, the Three Factor Eating Questionnaire (TFEQ), Disinhibition subscale and the Symptom Checklist 90-revised version. These findings show that bulimic patients may be quite similar to their restrained, non-bulimic counterparts on dietary concern and ideals of slenderness and suggest the importance of including a restrained control group in attempts to isolate the variables that differentiate individuals with the clinical eating disorder from their peers who demonstrate normative discontent about body weight and shape.     

The Continuum Versus Categorical Debate on Eating Disorders: Implications for Counselors

The authors summarize a study by D. A. Williamson et al. (2002) in which clinical groups with anorexia nervosa, bulimia nervosa, eating disorder not otherwise specified, and binge eating disorder were contrasted with nonclinical groups of participants (i.e., obese and normal weight). The eating disorder groups were qualitatively different. Also, bulimia nervosa, purging and nonpurging types, may fall on a continuum of pathology with the binge‐eating, purging type of anorexia. Anorexia nervosa, restricting type, may be distinct from bulimia nervosa, purging and nonpurging types, and the binge‐eating, purging type of anorexia.     

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.     

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.     

Bulimia,dietary restraint,and concern for dieting

The concept of dietary restraint has recently been used to explain binge-eating in dieters. It has been proposed that the violation of various restraint rules typically leads to hinging in individuals exhibiting high dietary restraint. This study examined the role of dietary restraint in a clinical sample of bulimics. After eating a preload to break dietary restraint, bulimic binge-eaters (those who binge but do not purge) were found to eat significantly more than bulimics who binged and purged (bulimia nervosa) and significantly more than normals. In addition, purging bulimics were found to have more concern about dieting than binge-eaters, while normals were found to have less concern about dieting and less anxiety about eating than both bulimic groups. These data suggest that the psychopathology of bulimia nervosa and bulimia (binge-eating) may be substantially different. It was proposed that the most distinguishing characteristic may be the preoccupation with dieting, weight, and body size, which is more extreme in bulimia nervosa.     

The Struggle Continues: Addressing Concerns About Eating and Weight for Older Women’s Well-Being

Eating disorders and concern about weight are generally associated with younger women. This article first reviews the limited literature addressing the prevalence of disordered eating concerns in older women, both related to and independent of weight issues. Excessive concern about weight, body image and restricted eating/fasting appears to continue into the 60s and even 70s. Although bulimia nervosa and anorexia drop markedly in prevalence among older women, binge eating disorder continues to be evident. The article then provides an overview of Kristeller’s Mindfulness-Based Eating Awareness Training (MB-EAT) with particular focus on how the program appears well-matched to the concerns of many older women, including those with binge eating disorder. MB-EAT is a non-dieting approach that emphasizes heightened engagement with mind–body awareness, including hunger and satiety cues, and non-judgmental approaches to food choices and weight management. Evidence from an NIH-funded clinical trial shows that women above age 50 (45% of participants) responded significantly more strongly to the intervention on measures of self-acceptance and non-restrictive aspects of eating behavior and attitudes. Overall, the evidence suggests that further attention needs to be given to these issues in helping older women cultivate an optimally healthy and fulfilling lifestyle.     

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.     

The Sociocultural Attitudes Toward Appearance Questionnaire (SATAQ-3): reliability and normative comparisons of eating disordered patients

The Sociocultural Attitudes Toward Appearance Questionnaire-3 (SATAQ-3) is a measure of one’s endorsement of societal appearance ideals. The measure has received extensive evaluation in normative samples, but only minimal evaluation in clinical groups. In this study, 440 patients with eating disorders completed the SATAQ-3. Internal consistencies were excellent for the four SATAQ-3 subscales. Groups did not differ by diagnosis on the Information subscale, however, individuals with bulimia nervosa scored higher than individuals with both subtypes of anorexia nervosa (restricting and binge eating/purging) on levels of Internalization-General and Internalization-Athlete. The findings provide informative normative data, along with preliminary results indicative of the potentially greater role of media messages and images in the formation and/or maintenance of bulimia nervosa than anorexia nervosa.     

Obsessive-compulsive symptoms in eating disorders

Obsessive-compulsive symptoms were measured in a consecutive series of new referrals with anorexia nervosa (n = 29) and bulimia nervosa (n = 77). In contrast with previous reports, there was no significant difference on MOCI scores between eating disorder groups and normal controls. A consecutive series of 38 patients with bulimia nervosa then entered a structured treatment programme. Poor outcome cases had a higher score on the MOCI-doubting sub-scale. However, there was no significant difference in obsessive-compulsive scores between those who were binge-free and those who were bingeing daily at the end of treatment and there was no significant in outcome between high and low-scorers on the MOCI. This study fails to support the view that the eating disorders are a subtype of OCD. Previous conflicting results are attributed to selection bias and the effects of low body weight.     

Action monitoring and perfectionism in anorexia nervosa

To study action monitoring in anorexia nervosa, behavioral and EEG measures were obtained in underweight anorexia nervosa patients (n=17) and matched healthy controls (n=19) while performing a speeded choice-reaction task. Our main measures of interest were questionnaire outcomes, reaction times, error rates, and the error-related negativity ERP component. Questionnaire and behavioral results indicated increased perfectionism in patients with anorexia nervosa. In line with their perfectionism and controlled response style patients made significantly less errors than controls. However, when controlling for this difference in error rates, the EEG results demonstrated a reduced error-related negativity in the patient group. These seemingly contradictory outcomes of improved performance and reduced error monitoring are discussed in relation with indications of anterior cingulate cortex hypoactivity in anorexia nervosa patients.     

Exploring experience of family relations by patients with anorexia nervosa and bulimia nervosa using a projective family test

Elements of family dynamics have been shown to be related to onset, course, as well as prognosis of anorexia nervosa and bulimia nervosa. The goal was to explore the experience of family relations in a group of patients with eating disorders using a projective family test. The Patient group (anorexia=21, bulimia=16), as well as a healthy Control group, were given a projective family test, the Eating Disorder Inventory-2, as well as Karolinska Scales of Personality. The Patient group expressed more discord within the family picture than the Control group, such as cold and loveless relationships and not feeling validated. The group of patients reporting the most family discord did not show more eating disorder pathology or general psychopathology. They did, however, have higher scores on the Eating Disorder Inventory-2 subscale Maturity Fears, as well as higher values on the Karolinska Scales of Personality subscale Socialization. These results are interpreted within the background of methodological challenges in this area of research.     

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.     

Body checking and associated cognitions among Brazilian outpatients with eating disorders and nonpsychiatric controls

This work aims to compare in patients with anorexia nervosa, bulimia nervosa, and control subjects: (a) body checking types, frequency, and parts; (b) prevalence of body avoidance and the most checked body parts; (c) body checking cognitions. Eighty-five outpatients with eating disorders (ED) and 40 controls filled out validated body checking and cognition questionnaires. ED patients, especially bulimia nervosa, check their bodies more than do the control subjects. The most checked area was the belly. The most frequent means of body checking was mirror checking, while the most avoided was weighing. The reasons that participants in the various study groups check their bodies seem to differ. Given the importance of body checking in the etiology and maintenance of EDs, it is important that clinicians consider this behavior, as well as the factors that lead to checking/avoidance in the different eating disorder subtypes, so that treatment may be more specific.     

Psychological characteristics of dieters and bulimics.

Two studies examined the continuum and discontinuity models of the relation between dieting and bulimia nervosa. In Study 1, 21 dieters, 19 bulimics, and 33 nondieting controls were compared on 24 measures. Multivariate analyses revealed that each of the groups differed significantly from the other two. Univariate analyses found 18 significant differences between bulimics and dieters and 1 significant difference between dieters and controls. In Study 2, 86 subjects completed measures of psychological functioning, dieting, and bulimia nervosa. On the basis of regression analyses using factor scores from the psychological variables as predictors, high scores on a psychopathology factor and low scores on a defensiveness factor predicted both bulimia and dieting. Low self-concept scores also predicted bulimia. These data indicate that both continuity and discontinuity characterize the relation between dieting and bulimia.     

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.