Predicting bulimic symptoms: an interactive model of self-efficacy, perfectionism, and perceived weight status

An interactive model of perfectionism, perceived weight status, and self-efficacy was tested on 406 women to predict the bulimic symptoms of binge eating and inappropriate compensatory behaviors separately. This longitudinal study assessed hypothesized vulnerabilities of high perfectionism and low self-efficacy and the stressor of feeling overweight at Time 1 and then gathered weekly assessments of binge eating, vomiting, laxative use, fasting, and diet pill use for 11 weeks. As predicted, results showed that perfectionism, weight perception, and self-efficacy interacted to prospectively predict binge eating. In particular, women high in perfectionism who felt they were overweight and who had low self-efficacy reported the most number of weeks of binge eating. This interactive model did not predict inappropriate compensatory behaviors. Future directions and clinical implications are discussed.     

Bulimic symptomatology: the role of adaptive perfectionism, shape and weight concern, and self-esteem

An interactive model implicating high perfectionism, high weight and shape concern, and low self-esteem in the onset and maintenance of bulimic symptoms ( [Bardone et?al., 2000] and [Vohs et?al., 1999] ) has received mixed support. This study aimed to replicate the cross-sectional model in a clinical sample of women with eating disorders, and to investigate whether the model could predict changes in binge eating and purging at the end of treatment. Eating disorder outpatients (n = 353) completed measures of perfectionism, weight/shape concern, self-esteem, and bulimic symptoms at pre-treatment and discharge. Contrary to the hypotheses, the three-way interaction did not predict binge eating or purging cross-sectionally or prospectively as a moderator of psychotherapy outcome. It was concluded that the robustness of the interactive model seems questionable and may be impacted by an inadequate conceptualization of the perfectionism construct.     

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.     

Weight suppression is a robust predictor of outcome in the cognitive-behavioral treatment of bulimia nervosa

This study examined weight suppression (difference between highest premorbid weight and pretreatment weight) as a predictor of outcome in 188 outpatients with bulimia nervosa enrolled in a cognitive-behavioral therapy intervention. Participants who dropped out of treatment had significantly higher levels of weight suppression than treatment completers. Of participants who completed treatment, those who continued to engage in binge eating or purging had significantly higher levels of weight suppression than those who were abstinent from bingeing and purging. Results did not change when body mass index, dietary restraint, weight and shape concerns, or other relevant variables were controlled. Relinquishing bulimic behaviors and adopting normal eating patterns may be most feasible for patients who are closest to their highest premorbid weights.     

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.     

An experimental study of the relationship between thoughts and eating behaviour in bulimia nervosa

This study tested the hypothesis that cognitive disturbance has a causal role in the maintenance of disturbed eating in bulimia nervosa. Thoughts about eating, weight and shape were activated in one group of patients with bulimia nervosa (the experimental group) but not in another (the control group). There was an increase in negative self-statements in the experimental group following the experimental manipulation. Food consumption was then measured in a taste test. As predicted, the experimental group ate less in the short term than the control group. Contrary to expectations, they did not subsequently report more objective bulimic episodes as a consequence of this decreased food intake. They did, however, report significantly fewer subjective bulimic episodes.     

An evaluation of the enhanced cognitive-behavioural model of bulimia nervosa

The original cognitive-behavioural model of bulimia nervosa (BN) has been enhanced to include four additional maintaining mechanisms: low self esteem, clinical perfectionism, interpersonal problems, and mood intolerance. These models have been used to guide cognitive-behavioural treatment for BN, but the enhanced model has yet to be directly evaluated as a whole in a clinical sample. This study aimed to compare and evaluate the original and the enhanced cognitive-behavioural models of BN using structural equation modelling. The Eating Disorder Examination and self-report questionnaires were completed by 162 patients seeking treatment for BN (N = 129) or atypical BN (N = 33). Fit indices suggested that both the original and enhanced models provided a good fit to the data, but the enhanced model accounted for more variance in dietary restraint and binge eating. In the enhanced model, low self esteem was associated with greater overevaluation of weight and shape, which, in turn, was associated with increased dietary restraint. Interpersonal problems were also directly associated with dietary restraint, and binge eating was associated with increased purging. While the current study provides support for some aspects of the enhanced cognitive-behavioural model of BN, some key relationships in the model were not supported, including the important conceptual relationship between dietary restraint and binge eating.     

Thoughts about eating, weight and shape in anorexia nervosa and bulimia nervosa.

Concurrent verbalisation and a self-report questionnaire were used to investigate self-statements in patients with anorexia nervosa, patients with bulimia nervosa, two groups of dieters and non-dieting controls. Thoughts were collected while subjects performed three behavioural tasks, looking at themselves in a full-length mirror, weighing themselves and eating a chocolate covered mint. Both groups of patients had more negative thoughts related to eating, weight and shape than those in the three control groups. In addition, patients with anorexia nervosa showed a greater concern with eating while patients with bulimia nervosa showed a greater concern with weight and appearance. Differences were found between the patients and non-dieting controls using both methods but the self-report questionnaire was less sensitive than concurrent verbalisation to differences between the patients and dieters. Implications of the findings for cognitive-behavioural treatments of the two disorders are discussed.     

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.     

The interaction of perfectionism, perceived weight status, and self-esteem to predict bulimic symptoms: the role of 'benign' perfectionism

The present study sought to replicate an interactive model of global perfectionism, perceived weight status, and self-esteem in predicting bulimic symptom development in a sample of young women [Bardone-Cone, et al. (2006). Predicting bulimic symptoms: An interactive model of self-efficacy, perfectionism, and perceived weight status. Behaviour Research and Therapy, 44, 27-42; Vohs, K. D., et al. (1999). Perfectionism, perceived weight status, and self-esteem interact to predict bulimic symptoms: A model of bulimic symptom development. Journal of Abnormal Psychology, 108, 695-700; Vohs, K. D., et al. (2001). Perfectionism, body dissatisfaction, and self-esteem: An interactive model of bulimic symptom development. Journal of Social and Clinical Psychology, 20, 476-497]. The aim was to investigate the role of 'problematic' and 'benign' perfectionism within this model, using data from 95 female university students over a 3-month period. Contrary to hypotheses, multivariate analyses revealed a significant three-way interaction only between 'benign' perfectionism, perceived weight status and self-esteem in predicting change in bulimic symptoms over a 3-month period. The predictive effect of the interaction between 'benign' perfectionism and perceived weight status on bulimic symptoms was strongest for women with high self-esteem, for whom feeling overweight and having perfectionistic attitudes preceded increased bulimic symptoms. These findings suggest that high self-esteem is insufficient to protect against the development of bulimic symptoms when both the perception of oneself as being overweight, and high levels of perfectionistic standards, are present. It would appear that the role of perfectionism within the context of disordered eating is complex.     

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.     

Overvaluation of shape and weight in binge eating disorder, bulimia nervosa, and sub-threshold bulimia nervosa

Increasing empirical evidence supports the validity of binge eating disorder (BED), a research diagnosis in the appendix of DSM-IV, and its inclusion as a distinct and formal diagnosis in the DSM-V. A pressing question regarding the specific criteria for BED diagnosis is whether, like bulimia nervosa (BN), it should be characterized by overvaluation of shape and weight. This study compared features of eating disorders in 436 treatment-seeking women comprising four groups: 195 BED participants who overvalue their shape/weight, 129 BED participants with subclinical levels of overvaluation, 61 BN participants, and 51 participants with sub-threshold BN. The BED clinical overvaluation group had significantly higher levels of specific eating disorder psychopathology than the three other groups which did not differ significantly from each other. Findings suggest that overvaluation of shape and weight should not be considered as a required criterion for BED because this would exclude a substantial proportion of BED patients with clinically significant problems. Rather, overvaluation of shape and weight warrants consideration either as a diagnostic specifier or as a dimensional severity rating as it provides important information about severity within BED.     

Engagement and outcome in the treatment of bulimia nervosa: first phase of a sequential design comparing motivation enhancement therapy and cognitive behavioural therapy

Despite the major advances in the development of treatments for bulimia nervosa, drop-outs and a lack of engagement in treatment, continue to be problems. Recent studies suggest that the transtheoretical model of change may be applicable to bulimia nervosa. The aim of this study was to examine the roles of readiness to change and therapeutic alliance in determining engagement and outcome in the first phase of treatment. One hundred and twenty five consecutive female patients meeting DSM-IV criteria for bulimia nervosa took part in a randomised controlled treatment trial. The first phase of the sequential treatment compared four sessions of either cognitive behavioural therapy (CBT) or motivational enhancement therapy (MET) in engaging patients in treatment and reducing symptoms. Patients in the action stage showed greater improvement in symptoms of binge eating than did patients in the contemplation stage. Higher pretreatment scores on action were also related to the development of a better therapeutic alliance (as perceived by patients) after four weeks. However, pretreatment stage of change did not predict who dropped out of treatment. There were no differences between MET and CBT in terms of reducing bulimic symptoms or in terms of developing a therapeutic alliance or increasing readiness to change. The results suggest that the transtheoretical model of change may have some validity in the treatment of bulimia nervosa although current measures of readiness to change may require modification. Overall, readiness to change is more strongly related to improvement and the development of a therapeutic alliance than the specific type of treatment.     

Biased perception of overeating in bulimia nervosa and compulsive binge eaters

This study investigated the relationship between caloric intake and perceived overeating in subjects with and without a history of problematic binge eating. Eighty subjects (20 in four groups: bulimia nervosa, compulsive binge eaters, obese, and normal controls) self-monitored eating for 2 weeks. The regression slopes for self-reported overeating as a function of caloric intake were contrasted across the four groups. At higher caloric levels, bulimics and binge eaters reported overeating at a significantly higher rate compared to obese and normal control groups. These data were interpreted as a type of cognitive bias whereby subjects with a history of binge eating distorted their perception of overeating at progressively higher caloric levels. It was proposed that excessive concern about eating and dieting may cause such cognitive biases. A parallel was drawn with body image distortion, which appears to be associated with overconcem with body size and shape.     

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.     

Bulimia nervosa and dietary restraint

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

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.     

Subtyping adolescents with bulimia nervosa

Cluster analyses of eating disorder patients have yielded a "dietary-depressive" subtype, typified by greater negative affect, and a "dietary" subtype, typified by dietary restraint. This study aimed to replicate these findings in an adolescent sample with bulimia nervosa (BN) from a randomized controlled trial and to examine the validity and reliability of this methodology. In the sample of BN adolescents (N=80), cluster analysis revealed a "dietary-depressive" subtype (37.5%) and a "dietary" subtype (62.5%) using the Beck Depression Inventory, Rosenberg Self-Esteem Scale and Eating Disorder Examination Restraint subscale. The "dietary-depressive" subtype compared to the "dietary" subtype was significantly more likely to: (1) report co-occurring disorders, (2) greater eating and weight concerns, and (3) less vomiting abstinence at post-treatment (all p's<.05). The cluster analysis based on "dietary" and "dietary-depressive" subtypes appeared to have concurrent validity, yielding more distinct groups than subtyping by vomiting frequency. In order to assess the reliability of the subtyping scheme, a larger sample of adolescents with mixed eating and weight disorders in an outpatient eating disorder clinic (N=149) was subtyped, yielding similar subtypes. These results support the validity and reliability of the subtyping strategy in two adolescent samples.     

Predicting eating disorder group membership: an examination and extension of the sociocultural model

The purpose of this research was to examine and extend portions of the sociocultural model of bulimia nervosa (Stice, E. (1994). Review of the evidence for a sociocultural model of bulimia nervosa and an exploration of the mechanisms of action. Clinical Psychology Review, 14, 633-661; Stice, E., & Agras, W. S. (1998). Predicting onset and cessation of bulimic behaviors during adolescence: A longitudinal grouping analysis. Behavior Therapy, 29, 257-276). Participants were women who reported engaging in binge eating at baseline and the 1-year follow-up (n = 26), women who began binge eating between these 2 points (n = 25), and women who did not report binge eating during the course of the study (n = 199). Results of the first discriminant function analysis provided support for the sociocultural model. However, the results of subsequent analyses suggest that additional variables, including stress, escape-avoidance coping, and interoceptive awareness, emerged as important. Implications of these findings for our understanding of the development and maintenance of binge eating are discussed.