Somatoform dissociation in eating-disordered patients

This study investigated the role of somatoform dissociation in eating disorders and pathological eating behaviour, relative to the established association of eating pathology with psychological dissociation. The participants were 131 women with DSM-IV diagnoses of anorexic or bulimic disorders and 75 women who had no such disorder. Each woman completed measures of psychological and somatoform dissociation, as well as a measure of bulimic attitudes. The current presence or absence of specific bulimic behaviours was identified during the clinical interview. Levels of both forms of dissociation were higher in the women who had diagnoses of disorders with a bulimic component (bulimia nervosa; anorexia nervosa of the binge/purge subtype) than in the non-clinical or restrictive anorexic women. Somatoform dissociation showed particularly strong links with the presence of bulimic behavioural features (excessive exercise, laxative abuse, diet pill abuse, diuretic abuse) and with bulimic attitudes. The formulation and treatment of cases where there are bulimic features is likely to be enhanced by the assessment of somatoform dissociation.     

Depression and bulimia: the link between depression and bulimic cognitions

This study assessed the link between bulimic and depressive cognitions. Twenty-nine bulimics and 16 controls from the general population were first assessed on levels of depression using the Schedule for Affective Disorders and Schizophrenia-Change Version and the Beck Depression Inventory (BDI). Bulimics were significantly more depressed than controls. Bulimics differed significantly from controls on all cognitive measures associated with depression (Automatic Thoughts Questionnaire, Dysfunctional Attitude Scale, and Attributional Style Questionnaire), but differences on these measures were nonsignificant when depression, as measured by the BDI, was controlled. Bulimics differed from controls regardless of level of depression on the three scales of the Restraint Inventory, the Rationalization and All-or-None scales of the Thoughts About Eating Inventory, and most of the eight scales of the Eating Disorders Inventory. Bulimics showed more maladaptive thinking associated with depression, but these differences likely reflect the levels of depression for each group. The differences on the measures of cognitive and behavioral symptoms of bulimia remained when the level of depression was controlled statistically. This suggests that although depression can be frequently diagnosed in a bulimic sample, specific maladaptive cognitions and behaviors reflect a distinct disorder (bulimia) and are not simply the expression of an affective disorder.     

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.     

MMPI-A in the inpatient assessment of adolescents with eating disorders.

The MMPI-A (Butcher et al., 1992), like the older MMPI (Hathaway & McKinley, 1983), distinguishes between anorexia and bulimia. In this study, 245 adolescent girls diagnosed with anorexia, bulimia, or eating disorder not otherwise specified completed the MMPI-A. Multivariate analyses revealed significant differences between anorexia and bulimia on the MMPI-A's validity, clinical, content, and supplementary scales, particularly suggesting multiple impulse control problems among bulimic patients. However, profiles were also more homogeneous across eating disorder groups than in studies using the older MMPI, with high points involving some combination of Scales 1, 2, 3, and 0 for two thirds of the patients in this study. Implications are considered for understanding the common and differential psychopathology of eating disorders.     

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.     

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.     

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.     

Gender identity and bulimic eating behavior

From a social-psychological perspective, the disproportionate number of women compared to men affected by bulimia nervosa implies that gender (i.e., the social construction of sex) plays an important part in the etiology of this disorder. From this perspective it was hypothesized that the risk of developing bulimia depends, in part, on the composition of a woman's gender identity. Three questionnaire studies conducted in the United States and former West Germany tested competing hypotheses on the relationship between gender identity and bulimia. Respondents were predominantly middle class and Caucasian. Study 1 was conducted in West Germany and tested the hypothesis that bulimia is related to a hyperfeminine gender identity [M. Boskind-Lodahl (1976) Cinderella's stepsisters: A feminist perspective on anorexia nervosa and bulimia, Signs, Vol. 2, pp. 342–356]. Twenty-six bulimic women were compared to 26 nonbulimic women. Results from Study 1 indicated that bulimic women typically had a gender-typed identity, whereas nonbulimic controls tended to be androgynous. However, between-group differences were based on hypomasculinity rather than hyperfemininity on part of bulimic women. Study 2 and Study 3 explored the idea that masculinity positively contributes to general esteem and reduces the risk of bulimia nervosa. In Study 2, three competing theories of the optimal relationship between mental health and gender identity (congruence, androgyny, and masculinity) were related to bulimia and tested with structural equation modeling in a sample of 301 North American undergraduates. In Study 3, the findings of Study 2 were cross-validated in a sample of 464 West German high school students. The results indicate that masculinity had significant positive effects on eating behavior via esteem, whereas the effects of femininity were negligible.The research and preparation of this article were supported in part by a Fulbright scholarship, a predoctoral stipend from the University of Heidelberg, and a postdoctoral stipend from the Max Planck Institute for Human Development and Education.I thank the women who volunteered to participate in this research project as subjects. I gratefully acknowledge the support of the principals, especially Frau Ute Vater, and teachers of the Bunsen-, Feudenheim-, and Lessing-Gymnasium, who enabled Study 3.Thanks to Michael Marsiske, Ulrich Mayr, John R. Nesselroade, Kai Schnabel, Anna Stetsenko, and two anonymous reviewers for their comments on an earlier draft of this paper, and to Bettina Franzke for technical support. I also extend my thanks to Frank Faulbaum and Norbert Schwarz, without whom this research could not have been completed.     

Addictive personality traits in bulimic patients

Forty-five female patients attending for treatment for bulimia nervosa completed the EPQ and an Impulsiveness Inventory (I₇). An Addiction score, derived from items on the EPQ, was obtained confirming that this group of bulimic patients score almost as high as drug addicts and certainly well above the normal range. On individual personality scales, the bulimic Ss scored higher than normals on N, P, Imp and Emp, but lower on E, Vent and Social Desirability.     

Family therapy for bulimia nervosa in adolescents: an exploratory study

Family therapy has only rarely been reported as a treatment for bulimia nervosa and not specifically’for adolescents. This account describes family therapy with eight adolescents who suffered from bulimia nervosa. Change was measured by assessing symptomatic behaviours and global measures of family and social function prior to treatment and again one year later. At reassessment there was a significant reduction in bulimic behaviours although many had some continuing symptoms. Some aspects of the therapy are described and implications for further study of treatment for adolescent bulimia are discussed.     

Desire for thinness among high school cheerleaders: relationship to disordered eating and weight control behaviors

The eating disorders of anorexia nervosa and bulimia are increasing in frequency among adolescent females. These increases have been linked to the cultural ideal in American society of thinness. Attempting to control weight is one behavioral manifestation of the desire for thinness. One particular group of adolescents, female cheerleaders, often experience pressure to attain and maintain weight that is lower than other adolescents of the same height. This study examined cheerleaders' desire for thinness in relationship to disordered eating and weight control behaviors. A Desire for Thinness Scale and selected scales from three eating disorders instruments were administered to 751 high school cheerleaders from the Midwest. Cheerleaders who scored in the upper third on the Desire for Thinness Scale were compared with those who scored in the lower third. Cheerleaders who expressed a strong desire for thinness had significantly higher scores (p less than .0001) on 7 of 8 eating disorders scales. The greater the desire for thinness, the more likely the tendency to report disordered eating and weight control behaviors associated with bulimia. Implications from this study include an awareness of how a cultural ideal of thinness may indirectly increase disordered eating and weight control behaviors by making weight loss a salient goal. A proactive approach to modifying negative aspects of the cultural emphasis on thinness is proposed.     

Mediators in the dissonance eating disorder prevention program

Previous research has supported thin-ideal internalization as a partial mediator of the effects of the dissonance eating disorder prevention program. The current study replicated previous findings and examined an additional mediator, body dissatisfaction, hypothesized to account for partial intervention effects. As a secondary goal, we developed a more rigorous and accurate test of mediation that accounted for the temporal, causal interplay between mediator and outcome, and controlled for “reverse mediation”. Results from a sample of 71 high-risk females (M age = 19.8, SD = 1.3) who participated in a four-week dissonance intervention supported thin-ideal internalization as a partial mediator of the effects of the dissonance intervention on bulimic symptoms, even after controlling for body dissatisfaction as a second mediator. Furthermore, results supported body dissatisfaction as a partial mediator for bulimic symptoms after controlling for thin-ideal internalization. Significant “reverse mediation” effects suggested the reciprocal influence of some risk factors for bulimia nervosa and bulimic symptoms. These results contribute to our understanding of the mediators in the dissonance intervention, which can help refine eating disorder prevention programs.     

tolerance of nonconformity and its effect on attitudes toward the legalization of prostitution: a multivariate analysis

An increasingly popular clinical impression is that physical victimization plays an important role in the etiology of bulimia. There are few data based studies, however, which have tested this belief. Therefore, data were collected to determine if those who have been victimized are more apt to be bulimic than those who have not been victimized. The four forms of victimization explored were rape, sexual molestation, child abuse and partner abuse. Only child abuse was statistically significantly related to bulimia in the bivariate analyses, although all relationships were in the predicted direction. In the multivariate analysis, severity of bulimic‐like symptoms was regressed on the four forms of victimization and on nine demographic characteristics. Child abuse was the only form of victimization related to the severity of symptoms, when controlling for the effects of the other variables. Contrary to clinical impressions, the effect of sexual molestation on severity of bulimic symptoms was negative, but not statistically significant. Among the demographic characteristics, only the number of sisters had a significant effect. The combined effect of being both bulimic as well as a victim did not increase the likelihood of seeking therapy for an eating disorder. The need for empirical evidence to verify clinical impressions is stressed.     

General and specific self-esteem in late adolescent students: race x gender x SES effects

This study assessed the effects of gender, race, and social class on the general and area-specific self-esteem of high school students. One hundred and ninety-five high school students served as subjects in a 2 (gender: male, female) X 2 (race: black, white) X 3 (social class: low, middle and high) factorial design. The Rosenberg General Self-Esteem, the Piers-Harris Children's Self-Concept, and the Brookover Self-Concept of Ability and School Achievement scales were the measures of either general or specific self-esteem. Females, whites, and lower social class adolescents were consistently lower in their self-esteem scores than were males, blacks, and upper social class teenagers, respectively. White females were found to be lower in general and happiness self-esteem than all other gender by race subgroups. High SES white students were lower on the happiness and behavior self-esteem measures than black students and white middle-class students. Black males and white females were less confident in their school ability than were black females and white males.     

Daily mood patterns and bulimic behaviors in the natural environment

Objective

Negative affect has been purported to play an important role in the etiology and maintenance of bulimic behaviors. The objective of this study was to identify daily mood patterns in the natural environment exhibited by individuals with bulimia nervosa and to examine the relationship between these patterns and bulimic behaviors.

Method

One hundred thirty-three women aged 18-55 meeting DSM-IV criteria for bulimia nervosa were recruited through clinical referrals and community advertisements. Ecological momentary assessment was used to collect multiple ratings of negative affect, binge eating and purging each day for a two-week period using palmtop computers. Latent growth mixture modeling was used to identify daily mood patterns.

Results

Nine distinct daily mood patterns were identified. The highest rates of binge eating and purging episodes occurred on days characterized by stable high negative affect or increasing negative affect over the course of the day.

Conclusions

These findings support the conclusion that negative mood states are intimately tied to bulimic behaviors and may in fact precipitate such behavior.     

MCMI characteristics of DSM-III-R bulimics

The literature on bulimia has suggested that bulimic women exhibit a number of pathological personality characteristics. However, the Millon Clinical Multiaxial Inventory (MCMI), an objective measure of personality functioning, has not previously been utilized to assess the personality characteristics of a bulimic population. The MCMI was administered to 37 female bulimics, 32 female general psychiatric outpatients, and 30 normal female controls in order to assess the relationship between bulimia and pathological personality traits. Bulimic women were found to score higher than the other groups on MCMI Scales 1 (Schizoid), 2 (Avoidant), and 3 (Dependent). They also scored lower than the other two groups on Scale 6 (Antisocial). Results are discussed within the framework of parallels between the MCMI profiles of bulimics and the existing literature on bulimics' personality characteristics.     

MCMI Characteristics of DSM-II-R Bulimics

The literature on bulimia has suggested that bulimic women exhibit a number of pathological personality characteristics. However, the Millon Clinical Multiaxial Inventory (MCMI), an objective measure of personality functioning, has not previously been utilized to assess the personality characteristics of a bulimic population. The MCMI was administered to 37 female bulimics, 32 female general psychiatric outpatients, and 30 normal female controls in order to assess the relationship between bulimia and pathological personality traits. Bulimic women were found to score higher than the other groups on MCMI Scales 1 (Schizoid), 2 (Avoidant), and 3 (Dependent). They also scored lower than the other two groups on Scale 6 (Antisocial). Results are discussed within the framework of parallels between the MCMI profiles of bulimics and the existing literature on bulimics' personality characteristics.     

Evaluation of a healthy-weight treatment program for bulimia nervosa: a preliminary randomized trial

Objective: Conduct a randomized treatment trial to test whether healthy dieting maintains bulimic symptoms or effectively reduces this eating disturbance.

Methods: Female participants (n=85) with full- and sub-threshold bulimia nervosa were randomly assigned to a 6-session healthy dieting intervention or waitlist condition and assessed through 3-month follow-up.

Results: Relative to control participants, intervention participants showed modest weight loss during treatment and demonstrated significant improvements in bulimic symptoms that persisted through follow-up.

Discussion: These preliminary results suggest that this intervention shows potential for the treatment of bulimia nervosa and may be worthy of future refinement and evaluation. Results also provide experimental evidence that dieting behaviors do not maintain bulimia nervosa, suggesting the need to reconsider maintenance models for this eating disorder.     

School counselors' knowledge of eating disorders

The purpose of this study was to examine school counselors' knowledge of adolescent eating disorders, specifically anorexia and bulimia nervosa. Participants were drawn from the national membership of the American Association of School Counselors; they were requested to complete a 43-item questionnaire on eating disorders. Of the 500 participants randomly selected, 337 (67%) returned usable questionnaires. There were 220 female and 117 male counselors; the mean age was 45.2 years. The majority held a master's degree and counseled high school students; the mean number of years they had been school counselors was 12.2. When asked how competent they were in helping students with eating disorders, 11% rated themselves as very competent, 49% believed they were moderately competent, and 40% believed they were not very competent. The majority (75%) did not believe it was their role to treat students with eating disorders; they were instead referred to an eating disorders program (40%), their parents (34%), or a psychiatrist or other physician (34%). The majority of counselors (72%) had encountered anorexic or bulimic students; the most common method of discovering students with a problem was by being informed by fellow students (35%). The majority of respondents were very knowledgeable regarding the signs and symptoms of anorexia and bulimia nervosa. Examination of their general knowledge of eating disorders revealed that they knew more about anorexia than bulimia. The two sources of eating disorders information utilized by at least half of the respondents were professional journals (70%) and workshops/professional conferences (56%).