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.     

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.     

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.     

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.     

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.     

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-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.     

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.     

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.     

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.     

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.     

Overvaluation of shape and weight in binge eating disorder and overweight controls: refinement of a diagnostic construct

Debate continues regarding the nosological status of binge eating disorder (BED) as a diagnosis as opposed to simply reflecting a useful marker for psychopathology. Contention also exists regarding the specific criteria for the BED diagnosis, including whether, like anorexia nervosa and bulimia nervosa, it should be characterized by overvaluation of shape/weight. The authors compared features of eating disorders, psychological distress, and weight among overweight BED participants who overvalue their shape/weight (n=92), BED participants with subclinical levels of overvaluation (n=73), and participants in an overweight comparison group without BED (n=45). BED participants categorized with clinical overvaluation reported greater eating-related psychopathology and depression levels than those with subclinical overvaluation. Both BED groups reported greater overall eating pathology and depression levels than the overweight comparison group. Group differences existed despite similar levels of overweight across the 3 groups, as well as when controlling for group differences in depression levels. These findings provide further support for the research diagnostic construct and make a case for the importance of shape/weight overvaluation as a diagnostic specifier.     

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.     

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.     

Low self-esteem in eating disordered patients in the absence of depression

Both low self-esteem and depression are well recognised as occurring in patients with eating disorders. 43 patients with eating disorders were studied to assess whether this low self-esteem occurred as part of an affective disorder or was independent of this. The patients, 23 with anorexia nervosa and 20 with bulimia nervosa, were assessed for low self-esteem, using the Rosenberg Self-esteem Questionnaire, and for depression, using the Hospital Anxiety and Depression Scale. The patients had low self-esteem, despite only a minority (33%) being depressed. This study demonstrates that low self-esteem occurs in patients with eating disorders in the absence of depression.     

Loneliness and eating disorders

This article examines the link between loneliness and eating disorders. This concept is evaluated through a systematic review of the literature that links loneliness and eating disorders and through a survey of themes connecting the 2 conditions. Eating disorders-including anorexia nervosa, bulimia nervosa, and eating disorders that are not otherwise specified, which include binge eating disorder-are challenging health issues. Each of these diagnoses specifically relates to loneliness. This negative emotion contributes to and fuels eating disorder symptoms. Negative interpersonal relationships, both real experiences and individuals' skewed perceptions, exacerbate eating disorders and feelings of loneliness. Characteristics that have been associated with loneliness clearly relate to eating disorders. Understanding this relationship is vital, so that we can appreciate our patients' struggles and work to target these intense emotions within the treatment setting. We need to be aware of the power of loneliness as it applies to individuals in general and specifically to those struggling with disordered eating.     

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

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

Nachsorge nach station?rer Psychotherapie f��r Essst?rungen

Background

Despite high relapse rates there is a lack of feasible, effective and efficient interventions to provide aftercare support to patients who complete treatment for an eating disorder. A program based on the short message service (SMS) and text messaging has been developed in order to provide such additional support to patients who undergo inpatient treatment for an eating disorder.

Materials and methods

A total of 165 patients with bulimia nervosa or an eating disorder not otherwise specified were randomly assigned either to the intervention group (n?=?82) with access to the text messaging intervention for 4 months following discharge from hospital or to the control group (n?=?83). The efficacy of the intervention was determined via the three eating disorder related subscales of the Eating Disorder Inventory (EDI-2) at 4 and 8 months follow-up and via the frequency of self-reported binge eating and compensatory behaviors (vomiting and abuse of laxatives) in the Short Evaluation of Eating Disorders (SEED) at 8 months follow-up.

Results

Participants in the intervention group reported significantly lower impairment on the EDI scales drive for thinness and body dissatisfaction both at 4 and 8 months follow-up. They also reported significantly fewer episodes of binge eating and vomiting. No differences were found for the EDI subscale bulimia and for the frequency of the use of laxatives.

Conclusion

The intervention based on text messaging proved efficacious in the aftercare treatment of patients with eating disorders. Chances and limitations concerning its use in the clinical routine as part of a stepped care model are discussed.     

Psychological treatment of eating disorders

Significant progress has been achieved in the development and evaluation of evidence-based psychological treatments for eating disorders over the past 25 years. Cognitive behavioral therapy is currently the treatment of choice for bulimia nervosa and binge-eating disorder, and existing evidence supports the use of a specific form of family therapy for adolescents with anorexia nervosa. Important challenges remain. Even the most effective interventions for bulimia nervosa and binge-eating disorder fail to help a substantial number of patients. A priority must be the extension and adaptation of these treatments to a broader range of eating disorders (eating disorder not otherwise specified), to adolescents, who have been largely overlooked in clinical research, and to chronic, treatment-resistant cases of anorexia nervosa. The article highlights current conceptual and clinical innovations designed to improve on existing therapeutic efficacy. The problems of increasing the dissemination of evidence-based treatments that are unavailable in most clinical service settings are discussed.     

Belastungen in der Kindheit und in der Jugend Essgestörter

Depending on definition and sample, a minority of varying size of women with eating disorders report to be victims of sexual and/or physical abuse. These stressful experiences are risk factors for mental disorders in general and not specifically for eating disorders. Parental high expectations and pre-morbid negative self-evaluation seem to be specific risk factors for anorexia nervosa and bulimia nervosa. Probably, patients with bulimia nervosa suffered more childhood adversity than those with restrictive anorexia nervosa. Patients with a history of sexual and/or physical abuse may be more severely ill and more difficult to treat than other patients with eating disorders. Careful questioning about childhood adversity seems advisable. In therapy, maintaining factors—like problems of self-esteem—are more important than predisposing or precipitating factors. For prevention, it is recommended to provide for the safety of children when treating their parents with mental illness—particularly substance use disorders—and to avoid parental high expectations.