Differences in Emotion Regulation Difficulties Across Types of Eating Disorders During Adolescence

Emotion regulation appears to play a key role in eating disorders. However, prior attempts to associate specific emotion regulation abilities with specific types of eating disorders resulted in inconsistent findings. Moreover, far less is known about emotion regulation in eating disorders during adolescence, a critical period of emotional development. The current study addresses this gap, comparing emotion regulation characteristics between adolescents with restrictive types of eating disorders and those with binge eating or purging types of eating disorders. Ninety-eight adolescents with eating disorders (49 with restrictive and 49 with binge eating/purging eating disorders) completed a set of questionnaires including the Difficulties in Emotion Regulation Scale (DERS). The results revealed that binge eating/purging types of eating disorders were associated with greater difficulties in a variety of emotion regulation dimensions including impulse control, goal-directed behavior and access to effective emotion regulation strategies. Awareness and clarity of emotions were also worse in the binge eating/purging types of eating disorders, but this difference did not remain when comorbid psychopathology measures were controlled for. Moreover, the emotion regulation profile of adolescents with anorexia nervosa-binging/purging type was more similar to that of adolescents with bulimia nervosa than to that of adolescents with anorexia nervosa-restrictive type. While both restrictive and binge eating/purging eating disorders have been associated with emotion regulation difficulties, the current study shows that the presence of binge eating or purging episodes is linked with greater severity of emotion regulation deficits among adolescents with eating disorders.     

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.     

MMPI-2 profiles of women with eating disorders in a Dutch day treatment sample

In this study, we examined the MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) profiles of 324 Dutch patients with eating disorders at an eating disorder day treatment program. We studied the MMPI-2 profiles in 5 diagnostic eating disorder groups. All diagnostic subgroups showed high mean elevations of the T scores on the same 6 or 7 scales. Remarkable similarities existed between the mean profile configurations. The MMPI-2 distinguished especially in that patients with restricting anorexia nervosa scored lower on one Validity scale (F), two Clinical scales (1 and 2) and several Supplementary and Content scales of the MMPI-2 compared to the other groups. Only on the validity Scale L did they score higher. The MMPI-2 also distinguished patients with the bulimia nervosa purging type who scored higher on Scale 9 and different on several Content and Supplementary scales. We discuss results with regard to other studies of MMPI (Hathaway & McKinley, 1983) and MMPI-2 profiles of women with anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified in inpatient and outpatient settings.     

The Cognitive‐Behavioural Theory and Treatment of Bulimia Nervosa: An Examination of Treatment Mechanisms and Future Directions

Enhanced cognitive‐behavioural therapy (CBT‐E) is the current treatment of choice for bulimia nervosa. While the cognitive‐behavioural theory and treatment of bulimia nervosa have made a substantial contribution to our understanding of the disorder, approximately half of patients treated with CBT‐E fail to achieve remission of binge eating and purging. There is evidence showing that mechanisms proposed by the CBT‐E model are associated with binge eating and purging symptoms, and therefore likely important targets for treatment. To identify future directions in improving the efficacy of this treatment, and informed by a model of the client change process, we review the evidence for the hypothesised treatment mechanisms of CBT‐E. We conclude that while the proposed treatment mechanisms of CBT‐E largely change over the course of treatment, there is limited evidence that the treatment manipulations of CBT‐E are responsible for the specific changes in the proposed treatment mechanisms. In addition, given a lack of research in this area, we could find no evidence that changes in the additional treatment mechanisms outlined in CBT‐E are associated with changes in the core symptomatology of binge eating and purging. Based on these findings, we recommend that future efforts are directed towards understanding the client change process in CBT‐E and outline three clear directions for research.     

Using the PAI with an eating disordered population: scale characteristics,factor structure,and differences among diagnostic groups

Psychometric properties of the Personality Assessment Inventory (PAI; Morey 1991) within an eating disordered sample seeking treatment (N = 238) and differences among eating disorder diagnostic groups on the PAI were examined. The PAI showed acceptable alpha coefficients, item-total correlations, and interitem correlations. The factor structure was similar to that reported by Morey (1991), with the addition of another factor related to interpersonal coolness and distance. Those with binge eating disorder (BED) reported fewer problems and less distress in general compared to other eating disordered groups. The BED and bulimia nervosa groups were different from the anorexia nervosa groups in frequency of matching on two PAI clusters. Use of the PAI with an eating disordered population and its utility in understanding eating disorder diagnostic groups is supported.     

Revisiting the affect regulation model of binge eating: a meta-analysis of studies using ecological momentary assessment

The affect regulation model of binge eating, which posits that patients binge eat to reduce negative affect (NA), has received support from cross-sectional and laboratory-based studies. Ecological momentary assessment (EMA) involves momentary ratings and repeated assessments over time and is ideally suited to identify temporal antecedents and consequences of binge eating. This meta-analytic review includes EMA studies of affect and binge eating. Electronic database and manual searches produced 36 EMA studies with N = 968 participants (89% Caucasian women). Meta-analyses examined changes in affect before and after binge eating using within-subjects standardized mean gain effect sizes (ESs). Results supported greater NA preceding binge eating relative to average affect (ES = 0.63) and affect before regular eating (ES = 0.68). However, NA increased further following binge episodes (ES = 0.50). Preliminary findings suggested that NA decreased following purging in bulimia nervosa (ES = -0.46). Moderators included diagnosis (with significantly greater elevations of NA prior to bingeing in binge eating disorder compared to bulimia nervosa) and binge definition (with significantly smaller elevations of NA before binge vs. regular eating episodes for the Diagnostic and Statistical Manual of Mental Disorders definition compared to lay definitions of binge eating). Overall, results fail to support the affect regulation model of binge eating and challenge reductions in NA as a maintenance factor for binge eating. However, limitations of this literature include unidimensional analyses of NA and inadequate examination of affect during binge eating, as binge eating may regulate only specific facets of affect or may reduce NA only during the episode.     

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.     

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.     

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.     

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.     

MCMI-II borderline personality disorder in anorexia and bulimia nervosa

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

Eating disorder diagnostic scale: additional evidence of reliability and validity

The authors conducted 4 studies investigating the reliability and validity of the Eating Disorder Diagnostic Scale (HDDS; E. Stice, C. F. Telch, & S. L. Rizvi, 2000), a brief self-report measure for diagnosing anorexia nervosa, bulimia nervosa, and binge eating disorder. Study 1 found that the HDDS showed criterion validity with interview-based diagnoses, convergent validity with risk factors for eating pathology, and internal consistency. Studies 2 and 3 found that the EDDS was sufficiently sensitive to detect the effects of eating disorder prevention programs. Regarding predictive validity, Studies 3 and 4 found that the EDDS predicted response to a prevention program and future onset of eating pathology and depression. Results provide additional evidence of the reliability and validity of this scale and suggest it may be useful in clinical and research applications.     

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.     

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.     

Dialectical Behavior Therapy: Does It Bring About Improvements in Affect Regulation in Individuals with Eating Disorders?

The current investigation sought to determine whether a standard outpatient dose of dialectical behavior therapy (DBT) skills training (2 h per week) coupled with standard CBT treatment would be sufficient to produce changes in affect regulation over the course of day hospitalization treatment. In an uncontrolled pre-post treatment design, 65 women diagnosed with anorexia nervosa or bulimia nervosa were assessed at the beginning of treatment and at the end of treatment on affect regulation. Findings indicated that participants demonstrated a significant improvement in their ability to regulate affect, suggesting that weekly DBT treatment may play an important role in producing changes in affect regulation. Secondary analyses on eating disorder outcomes revealed a significant increase in weight gain as well as a significant reduction in restriction, bingeing, purging and eating disordered cognitions. Findings are discussed in the context of clinical and treatment implications for those with severe eating disorders.     

Relation of early menarche to depression, eating disorders, substance abuse, and comorbid psychopathology among adolescent girls

This prospective study tested whether early menarche partially accounts for the increases in depression, eating pathology, substance abuse, and comorbid psychopathology that occur among adolescent girls, with structured interview data from a community sample (N = 496). Early menarche (prior to 11.6 years) was associated with elevated depression, substance abuse, and "any" disorder but did not confer increased risk for anorexia nervosa, bulimia nervosa, or binge eating disorder. Although there was significant comorbidity across all three classes of pathology, early menarche was associated only with comorbid depression and substance abuse. Results provide partial support for the assertion that early menarche is a general risk factor for psychopathology among adolescent girls but suggest that this risk may not apply to certain disorders and that the effects are modest in size.     

Remote treatment of bulimia nervosa and binge eating disorder: a randomized trial of Internet-assisted cognitive behavioural therapy

The present study investigated the efficacy of self-help based on cognitive behaviour therapy in combination with Internet support in the treatment of bulimia nervosa and binge eating disorder. After confirming the diagnosis with an in-person interview, 73 patients were randomly allocated to treatment or a waiting list control group. Treated individuals showed marked improvement after 12 weeks of self-help compared to the control group on both primary and secondary outcome measures. Intent-to-treat analyses revealed that 37% (46% among completers) had no binge eating or purging at the end of the treatment and a considerable number of patients achieved clinically significant improvement on most of the other measures as well. The results were maintained at the 6-month follow-up, and provide evidence to support the continued use and development of self-help programmes.     

A review of eating disorders research in Mexico

The objective of this paper is to summarize research findings on eating disorders and the current state of the field in Mexico. Papers published in indexed journals and graduate dissertations were retrieved, using “eating disorders,” “anorexia nervosa,” “bulimia nervosa,” “body image,” “binge eating,” “restrained eating,” “weight and shape concern,” and “dieting” as keywords. These were combined with the Boolean operator “AND” with “Mexico” and “Latin America.” Findings are presented for epidemiology, the validity of assessment instruments, comorbidity, and risk factors. A national representative survey found a prevalence of 1.8% for bulimia nervosa, and no cases of anorexia nervosa. However, the lack of studies with confirmatory clinical interview and other national or regional representative samples makes it difficult to reach conclusions about the actual prevalence. A number of instruments for the detection of eating disorders and disordered eating have been validated for the Mexican population. The comorbidity of eating disorders in Mexico includes drug and alcohol abuse, obesity, and borderline personality disorder. Risk factors found included body weight and cultural pressure to be thin. Future lines of research should include epidemiological studies with representative samples and diagnosis confirmation, longitudinal studies, and the exploration of protective and risk factors specific to this population.