Eating patterns and disorders in a college population: Are college women's eating problems a new phenomenon?

This paper examines the relationship between gender differences in eating patterns among college students and the disorders as clinically defined. A considerable number of college women but few men in our sample show behavioral patterns associated with an eating disorder (anorexia or bulimia). Our findings for women are in the moderate to high range for these symptoms, compared with other university populations. Results indicate that the eating difficulties of college women may be an eating problem, which only partially resembles clinical eating disorders. Although our female college sample displays the behavioral symptoms associated with anorexia and bulimia, they exhibit few of the constellation of psychological traits associated with these disorders. Some evidence suggests that the etiology of eating problems may be partly related to women wanting to be thinner than is medically desirable and may represent a response of normal women to the new, more demanding cultural and supercultural standards for thinness. Diagnosis and treatment issues as well as sociocultural implications of these results are discussed.The author wishes to thank Alan Clayton-Matthews, Larry Zaborski, John Downey, Larry Ludlow, the Editor, and an anonymous reviewer for their helpful comments. This research was supported, in part, from a grant from the Office of Research Administration, Boston College.     

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.     

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.     

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.     

Three boys and their stories: Atypical eating and primitive relations1

Eating disorders of whatever category, especially the most severe ones such as anorexia or bulimia, are often considered typical of the female sex. While this is correct concerning these two disorders, I suggest that there are other eating disorders that are more frequent among boys, especially the ones concerning atypical relations to food, notwithstanding the evidence that the already very well‐known syndromes of bulimia and anorexia are also gaining ground among males. However, similar, unspecified eating disorders do not seem to occur so often among girls. Clinical data from my private practice should be taken for granted considering these matters, since I do not yet have statistical data to back up my thesis. In examples from three clinical cases involving boys and one female vignette, I shall attempt to establish a relation between eating disorders and primitive relations with men and women. This relation goes well beyond the oft‐cited ‘contemporary’ causes of eating disorders. In addition, I shall situate these differences among symptoms of both sexes and relate them to impasses in different stages of emotional development, as well as to the extent to which girls’ identification with their mother’s sex can influence their acquisition of eating disorders.     

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.     

Cognitive behaviour therapy for eating disorders: a "transdiagnostic" theory and treatment

This paper is concerned with the psychopathological processes that account for the persistence of severe eating disorders. Two separate but interrelated lines of argument are developed. One is that the leading evidence-based theory of the maintenance of eating disorders, the cognitive behavioural theory of bulimia nervosa, should be extended in its focus to embrace four additional maintaining mechanisms. Specifically, we propose that in certain patients one or more of four additional maintaining processes interact with the core eating disorder maintaining mechanisms and that when this occurs it is an obstacle to change. The additional maintaining processes concern the influence of clinical perfectionism, core low self-esteem, mood intolerance and interpersonal difficulties. The second line of argument is that in the case of eating disorders shared, but distinctive, clinical features tend to be maintained by similar psychopathological processes. Accordingly, we suggest that common mechanisms are involved in the persistence of bulimia nervosa, anorexia nervosa and the atypical eating disorders. Together, these two lines of argument lead us to propose a new transdiagnostic theory of the maintenance of the full range of eating disorders, a theory which embraces a broader range of maintaining mechanisms than the current theory concerning bulimia nervosa. In the final sections of the paper we describe a transdiagnostic treatment derived from the new theory, and we consider in principle the broader relevance of transdiagnostic theories of maintenance.     

A study of temperament and personality in anorexia and bulimia nervosa

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

Body image, 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.     

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.     

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.     

Case Conceptualization and Treatment of Comorbid Body Dysmorphic Disorder and Bulimia Nervosa

Body dysmorphic disorder (BDD) and eating disorders often co-occur and share some clinical features. In addition, the co-occurrence of BDD and an eating disorder may be associated with greater impairment in functioning. Furthermore, clinical impressions suggest that this comorbidity may be more treatment resistant than either disorder alone. The current article discusses the treatment of a 48-year-old female diagnosed with BDD and comorbid bulimia. We attempted to address these co-occurring disorders in a strategic, formulation-based manner using a variety of cognitive-behavioral strategies such as cognitive restructuring, rational disputation, exposure with response prevention, and mirror retraining. Despite the complexity of this case, results suggest that comorbid BDD and bulimia nervosa can be effectively managed with cognitive behavioral therapy.     

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%).     

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 “Perseverant” Personality: A Preattachment Perspective on the Etiology and Evolution of Binge/Purge Eating Disorders

The author integrates “psycho-digestive” metaphor with contemporary relational perspectives and developmental research to propose a way of thinking about the etiology and evolution of binge/purge eating disorders—including “purging anorexia,” bulimia, and “yo-yo” binge/dieting—and the personality organization that may underlie them. Focusing on the unifying, cyclical nature of these disorders, the author hypothesizes that an early-developing, fear-based form of somatopsychic perseveration may be set in motion from the beginning of life when a nursing infant is unable to achieve a psychic connection with a physically present and feeding (m)other. Without intervention, such a preattachment failure in (m)other/infant synchrony would inevitably impact all subsequent development. The author proposes that it may also lay the foundation for a uniquely intertwined somatopsychic personality organization—what she calls a “perseverant” personality—that fosters the development of binge/purge eating disorders. A perseverant personality is defined as a solitary and circular mode of being, thinking, and relating that is organized around a sustained physiological and psychological reliance on the feeding as a mode of thought-processing and affect regulation.     

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.     

Zahnhartsubstanzschäden bei Essstörungen

Eating disorders such as anorexia nervosa and bulimia nervosa lead to several serious physical problems. One possible consequence is acid-related dental erosion. Dental erosion can be identified early and is caused by exogenic (selection of food) and / or endogenic (gastric acid) factors. That is why dentists play an important role in the early identification of eating disorders as well as in the prevention and therapy of dental erosion. They should be important collaborators of psychotherapists. We review characteristic damages to the teeth that are seen in eating disorders as well as preventive and therapeutic interventions. Psychotherapists should be informed about dental problems and preventive strategies to educate their patients.     

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.     

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.