The validity of the eating disorder examination and its subscales

The classification of bulimic eating disorders: a community-based cluster analysis study

There is controversy over how best to classify eating disorders in which there is recurrent binge eating. Many patients with recurrent binge eating do not meet diagnostic criteria for other of the two established eating disorders, anorexia nervosa or bulimia nervosa. The present study was designed to derive an empirically based, and clinically meaningful, diagnostic scheme by identifying subgroups from among those with recurrent binge eating, testing the validity of these subgroups and comparing their predictive validity with that of the DSM-IV scheme. A general population sample of 250 young women with recurrent binge eating was recruited using a two-stage design. Four subgroups among the sample were identified using a Ward's cluster analysis. The first subgroup had either objective or subjective bulimic episodes and vomiting or laxative misuse; the second had objective bulimic episodes and low levels of vomiting or laxative misuse; the third had subjective bulimic episodes and low levels of vomiting or laxative misuse; and the fourth was heterogeneous in character. This cluster solution was robust to replication. It had good descriptive and predictive validity and partial construct validity. The results support the concept of bulimia nervosa and its division into purging and non-purging subtypes. They also suggest a possible new binge eating syndrome. Binge eating disorder, listed as an example of Eating Disorder Not Otherwise Specified within DSM-IV, did not emerge from the cluster analysis.

Infant growth in the context of maternal eating disorders and maternal depression: a comparative study

There is evidence of growth faltering in infants of mothers with eating disorders. The aim of the current study was to examine whether this is a specific relationship. Thus, the infants of mothers with eating disorders were compared with infants of mothers with post-natal depression and a large comparison group. This study also aimed to explore possible mechanisms whereby growth disturbance comes about. It was found that the infants of mothers with eating disorders were smaller, both in terms of weight for length and weight for age, than either comparison group infants or infants of mothers with post-natal depression. There was little evidence, however, that mothers with eating disorders preferred smaller children or were dissatisfied with their children's shape or that they misperceived their children's size. On the contrary these mothers seemed highly sensitive to their children's shape and, compared with the other two groups, were more likely to judge their children's size accurately. None of these maternal measures significantly predicted the child's growth. The mechanism whereby growth disturbance arises in the context of eating disorders does not appear to be by means of a direct extension of the maternal psychopathology to the infant.

An evaluation of the efficacy of supervised cognitive behavioral self-help bulimia nervosa

Eighty two patients with bulimia nervosa were managed by providing them with supervision in the use of a highly structured cognitive behavioral self-help manual. Their progress was assessed in an open clinical trial. The 67 patients who completed the course of self-help experienced considerable benefit; the frequency of bulimic episodes and self-induced vomiting decreasing by 80% and 79%, respectively. Compared to those who benefited, those who had a poor outcome or dropped out of treatment were more than twice as likely to have had anorexia nervosa in the past and were somewhat more likely to have a personality disorder. Three-quarters of those who persisted with the programme of supervised self-help were followed up a year after commencing treatment. Clinical gains were well maintained: almost two thirds were abstinent with respect to both bulimic episodes and self-induced vomiting. It would seem appropriate that, as part of a stepped care approach to the management of bulimia nervosa, supervised cognitive behavioral self-help should routinely be the first line treatment.

A comparison of two psychological treatments for bulimia nervosa: implications for models of maintenance

In an effort to elucidate the role of cognitive factors in the maintenance of bulimia nervosa, the efficacy of two psychological treatments was examined in a randomised control trial: cognitive behaviour therapy in the absence of explicit exposure instructions was compared with exposure and response prevention treatment in the absence of cognitive restructuring procedures. In the short term both treatments were successful at effecting substantial improvement in both the specific and the non-specific psychopathology of the disorder. However, at a one year follow up, whilst improvements were well maintained for those who had received the cognitive-behavioural treatment, virtually all of those who had responded to the purely behavioural treatment had relapsed. This provides some support for the cognitive model of the maintenance of bulimia nervosa. Nevertheless, the two treatment groups could not be distinguished on post-treatment measures of cognitive disturbance and neither was it the case that residual levels of cognitive disturbance, as assessed, predicted relapse. This may suggest that the level at which the necessary cognitive change takes place may not be accessible by conventional assessment procedures.

Views on classification and diagnosis of eating disorders

OBJECTIVE

To highlight developments in the taxonomy of eating disorders since Russell's original description of bulimia nervosa (BN) in 1979 and through 3 versions of the Diagnostic and Statistical Manual.

METHOD

Criteria for anorexia nervosa (AN), BN and binge eating disorder (BED) are systematically described.

RESULTS

While criteria for AN remain largely unchanged between DSM-III-R and DSM-IV, the subclassification of binge/purge and restricter subgroups endorses previous research findings. For BN, the definition of "binge" has occupied considerable attention both in quantitative and qualitative terms. The arbitrary choice of 2 episodes per week as a minimum frequency is also discussed in light of recent data from the Ontario Health Supplement. A third eating disorder, BED, is now included in the appendix of DSM-IV under Eating Disorders--Not Otherwise Specified category. The potential overlap between this disorder and nonpurging BN is discussed. Finally, the relationship between eating disorders and other psychiatric disorders including depression, schizophrenia, obsessional, and conversion disorders is considered as well as the continuum from preoccupation with weight to eating disorder.

CONCLUSION

While significant advances have been made in understanding and classifying eating disorders during the past 15 years, further empirical work is necessary to clarify areas of uncertainty.

Eating disorders: an Indian perspective

Anorexia nervosa and related eating disorders are rare in non-western cultures. In India the information regarding these disorders is very limited. The authors describe five cases of young women who chiefly presented with refusal to eat, persistent vomiting, marked weight loss, amenorrhea and other somatic symptoms. They did not show overactivity or disturbances in body image seen characteristically in anorexia nervosa. Though finally diagnosed and treated as cases of eating disorder, they presented considerable difficulty in diagnosis. The paper discusses the reasons for the seeming rarity of anorexia nervosa in India and sociocultural reasons for its atypical presentation.

Alexithymia, depression, and treatment outcome in bulimia nervosa

Disturbances in emotional awareness, sometimes referred to as alexithymia, have been hypothesized to contribute to the development of binge/purge symptoms among women with bulimia nervosa (BN) and/or are considered secondary to the state of depression and/or disordered eating. The present study was designed to assess alexithymia among women with BN, to evaluate the interrelationship between alexithymia, depression, and somatic symptoms, and to determine whether an intensive group psychotherapy program contributes to a reduction in the degree of alexithymia. Thirty-one of 50 BN women (62%) who completed The Toronto Hospital Day Hospital Program for Eating Disorders (DHP) were administered pretreatment and posttreatment questionnaires. Findings from this clinical sample were compared with those from 20 non-eating-disordered women who completed the same battery. Using the Toronto Alexithymia Scale (TAS), significantly more BN women were alexithymic at pretreatment (61.3%) and post-treatment (32.3%) than in the comparison group (5.0%), even when depression was controlled for. At discharge, abstinence from binge/purge episodes was associated with a significant reduction in alexithymia, although there was a significant correlation between TAS scores, depression, and vomit frequency. Alexithymia among BN women is not simply a concomitant of disordered eating. Its partial reversibility following an intensive psychotherapy program may be a direct effect of the treatment and/or may be secondary to a reduction in depressive and/or binge/purge symptoms.

Assessment of eating disorders: interview or self-report questionnaire?

A detailed comparison was made of two methods for assessing the features of eating disorders. An investigator-based interview was compared with a self-report questionnaire based directly on that interview. A number of important discrepancies emerged. Although the two measures performed similarly with respect to the assessment of unambiguous behavioral features such as self-induced vomiting and dieting, the self-report questionnaire generated higher scores than the interview when assessing more complex features such as binge eating and concerns about shape. Both methods underestimated body weight.

Self-help for bulimia nervosa: a preliminary report

Eighteen patients with DSM-III-R bulimia nervosa were treated by providing them with supervision in the use of a self-help manual based on the cognitive behavioral treatment for the disorder. The patients were assessed before beginning the self-help program, and again 4 to 6 months later, using standardized measures of psychopathology. The findings were encouraging. At follow-up one half of the patients had ceased bulimic episodes and self-induced vomiting, and most of the remainder had made significant improvements. These preliminary findings, together with related published work, suggest that supervised self-help might be an appropriate first line treatment for patients with bulimia nervosa and that for many patients it could be sufficient.

Signs of subclinical eating disorders in teenage girls

OBJECTIVE

To study possible indicators for subclinical eating disorders among teenage girls.

DESIGN

A descriptive cross-sectional study based on two anonymous self-report questionnaires.

SETTING

Girls aged 15 to 19 years in secondary high school in Bergen, Norway.

SUBJECTS

100 girls, mean age 16.6 years, were included. One girl fulfilled DSM-III-R criteria for bulimia nervosa, and was therefore excluded from analysis. Ten girls fulfilled criteria for subclinical eating disorders.

MAIN OUTCOME MEASURES

The Eating Disorder Examination Questionnaire and a 48-item questionnaire designed for the study were used. Attitudes towards own body size/weight, food habits, and somatic symptoms were studied.

RESULTS

Girls with subclinical eating disorders experienced their own body as fatter and were more unhappy with their weight than girls without eating problems. They more often skipped breakfast or lunch, reported more dyspeptic problems and regurgitation, and had a larger weight fluctuation than girls without eating problems.

CONCLUSION

Questions about main meals may serve as neutral opening questions for the general practitioner when case finding in eating disorders. Obviously unrealistic feelings about body size/weight indicate the need to enquire more closely about symptoms of eating disorders.

Assessment of diagnostic features of bulimia nervosa: interview versus self-report format

In order to determine the clinical severity of bulimia nervosa and to measure symptomatic improvement during treatment, the behavioral and psychological features of the syndrome must be assessed. Focused semistructured interviews have recently been designed for this purpose, but such instruments can be time-consuming and costly. The present study compared the assessment of the key symptoms of bulimia nervosa using the Eating Disorder Examination with data obtained in self-report inventories and in patients' diaries of binge eating and purging. Results suggest that once the diagnosis has been established and patients have been instructed in the construct of a binge, the essential features of bulimia nervosa (frequency of binge eating and purging, and overconcern with body shape and weight) can be evaluated with self-report measures. These findings may be useful for the purposes of repeated assessment of progress and measurement of outcome in treatment studies.

The relationship between psychopathology, eating disorder diagnosis, and clinical outcome at 10-year follow-up in anorexia nervosa

General psychopathology as measured by the Minnesota Multiphasic Personality Inventory (MMPI), eating disorder diagnostic status (DSM-III-R), and clinical outcome were compared in a sample of 59 women 10 years after their hospital treatment for anorexia nervosa. There was a substantial and orderly relationship between severity of eating disorder symptomatology and severity of comorbid general psychopathology at follow-up evaluation. Those who had no eating disorder at follow-up displayed essentially no general psychopathology on the MMPI. Persons still suffering from a severe eating disorder (anorexia or bulimia nervosa) showed clinically significant levels of comorbid general psychopathology, and had significantly higher mean scores than the no eating disorder diagnosis group on seven MMPI clinical scales. Little general psychopathology was displayed by persons receiving a NOS eating disorder diagnosis at follow-up. Their mean MMPI profile was intermediate between those for the no diagnosis and severe eating disorder groups, but closer to that for the no diagnosis group. Rank order correlations were significant between levels of eating disorder symptom severity and all relevant MMPI clinical scales. Severity of psychopathology on the MMPI was also related to ratings of global outcome assessed by two approaches to categorizing outcome in anorexia nervosa.

Weight concern should not be a necessary criterion for the eating disorders: a polemic

Problems associated with the inclusion of weight concern as a necessary and defining criterion for the diagnosis of the eating disorders are reviewed. It is proposed that the substitution of the criterion of eating restraint that is overinvested by the subject might have advantages for both clinical classification and for research.

Problem drinking and symptoms of disordered eating in female high school students

Research on the relationship between problem drinking and disordered eating in adolescent girls has produced conflicting results. This study examines this relationship using a state-of-the-art inventory for measuring eating disorder symptoms and a standardized inventory for detecting problem drinking among adolescents. Two hundred thirty-four female high school students (mean age = 15.5 years) completed the Adolescent Drinking Index and the Eating Disorder Examination Questionnaire. Girls diagnosed with an eating disorder were twice as likely to be problem drinkers than girls who were not diagnosed with an eating disorder. Regression analysis and comparisons of problem drinkers and non-problem drinkers point to the central role of body image concerns and dieting in the association of alcoholism and disordered eating among adolescent girls. Prospective studies are needed to explore the mechanisms underlying the links between drive for thinness and problem drinking.

A community study of depression in adolescent girls. II: The clinical features of identified disorder

The clinical characteristics of two subsamples of 11-16-year-old girls were determined from direct interview: those who met DSM-III-R criteria for an episode of major depressive disorder within the past month (n = 28); and those who did not currently meet these criteria but had done so at some time in the previous 12 months (n = 13). The symptom profiles of these cases were compared with a subsample of girls who reported depressive symptoms but did not meet DSM-III-R criteria and were designated as having a 'partial syndrome' (n = 93), and a sample of non-depressed controls (n = 129). Phobias and worry about peer acceptance were common in controls suggesting that these symptoms constitute normal adolescent concerns. The symptom profile of depressed cases altered across three age bands (11-12, 13-14, and 15-16 years), suggesting developmental influences on clinical presentation. Comorbidity for anxiety, behavioural, and obsessional disorders was found in 40% of the depressed cases. None of the cases of major depressive disorder was known to the clinical services.

A comparison of body image perception in bulimics, restrainers, and normal women: an extension of previous findings

Figure drawings ranging from very thin to heavy (Stunkard, Sorenson, & Schulsinger, 1980) were utilized to assess body-image perception in a group of women with bulimia nervosa, a group classified as restrained eaters, and a non-eating-disordered group of women. Participants were asked to choose the figures that most resembled their current figure, their ideal figure, and the figure they believed was most attractive to men. All women chose an ideal figure that was thinner than their current figure. However, the size of the discrepancy between their current and ideal figure was significantly larger for the bulimic group compared with the non-eating-disordered women. Furthermore, while the non-eating-disordered women rated their current figure similar to the size that they believed men would find most attractive, both the bulimic group and the restrained eaters rated their current figure larger than what they believed men would find most attractive. Finally, although it was hypothesized that the bulimic group would desire a figure even thinner than what they believed men would find most attractive, this hypothesis was not supported, as all three groups of women chose an ideal figure similar to the figure that they believed men would find most attractive. These present results are compared with previous investigations which utilized similar methodologies.

Measuring the specific psychopathology of eating disorder patients

Cooper and Fairburn's Eating Disorder Examination (EDE) is a semi-structured interview designed to assess the specific psychopathology of eating disorder subjects. It was employed in a study of 116 Sydney patients for 2 purposes: first, to determine its usefulness in an Australian context; and second, to compare patients with anorexia nervosa, bulimia and atypical eating disorder. The instrument appears to be quite appropriate for studies in Australia. With respect to the second aim, the results emphasize the essential similarity in psychopathology between the three diagnostic groups. The relevance of this latter finding to the categorisation of eating disorders in the DSM-IV proposals is discussed.

How well are 'cured' anorexia nervosa patients? An investigation of 16 weight-recovered anorexic patients

Eating behaviour, nutritional intake and psychopathology were examined in 16 weight-recovered anorexia nervosa patients. The Eating Disorders Examination (EDE) and a food diary were the main outcome measures, but body fat content and psychosocial adjustment were also assessed. Although body fat and overall psychosocial adjustment had returned to normal in most patients, 12 still had a restricted eating pattern with nutritional intake below 90% of their energy requirements. These results suggest that weight, menstruation, and psychosocial criteria are not sufficient to determine full recovery from anorexia nervosa, and that attention should be given also to measures of the specific behavioural and attitudinal disturbance.

Confusion over the core psychopathology of bulimia nervosa

There has been particular confusion concerning two aspects of the psychopathology of bulimia nervosa: dissatisfaction with body shape and overvalued ideas about shape and weight. Whilst these features are closely related, they are nevertheless distinct. Body shape dissatisfaction is commonly found in these patients but is not necessarily present; whilst the over-valued ideas about shape and weight are a necessary diagnostic feature. Analysis of the relationship between these two features and depressed mood and self-esteem showed that, in the course of treatment, change in body shape dissatisfaction was closely associated with change in mood; and change in the overvalued ideas was closely associated with change in self-esteem. This finding supports the distinction between these two facets of the core psychopathology of bulimia nervosa.

A problematic counter-regulation experiment: implications for the link between dietary restraint and overeating

The current study failed to find any evidence of laboratory counter-regulation amongst restrained eaters given a preload, regardless of the measures of dietary restraint used to classify subjects, including dieting status on the day of the study. Furthermore, there was no evidence to suggest that high restrainers characteristically overeat or experience a sense of loss of control over eating in naturalistic settings. These findings indicate that the link between dietary restraint and overeating or bulimic episodes is, at most, a weak one. Future investigations must incorporate more detailed and sensitive measures of both restraint and overeating if analogue studies are to be useful for understanding the process involved in clinically significant episodes of overeating or binge eating.

Self-care behaviour and blood glucose control in young adults with type 1 diabetes mellitus

Self-care behaviour, knowledge about diabetes, and blood glucose control were studied in 113 young adults with Type 1 diabetes using a semi-structured interview, self-report questionnaires, and a biochemical measure (glycated haemoglobin). The majority of subjects followed their prescribed regimen reasonably accurately, but individuals followed different aspects of the regimen to different degrees. Subjects were more concerned with the avoidance of hypoglycaemia than with attainment of 'tight' blood glucose control. The blood glucose test level at which subjects took remedial action was the best single predictor of symptomatic control. Frequency of nocturnal polyuria appeared to be a reliable indicator of impaired metabolic control. Insulin omission or dose reduction for the purpose of body weight reduction was common among women, who also had worse blood glucose control than men. Elevated glycated haemoglobin levels were associated with higher alcohol consumption in men. Theoretical knowledge about diabetes management was only weakly associated with self-care behaviour and blood glucose control in this population. The blood glucose test result at which subjects take remedial action appears to be the most appropriate behavioural target for intervention to improve control in such subjects.

Demographic and clinical correlates of selective information processing in patients with bulimia nervosa

Demographic and clinical correlates of interference with color-naming words related to eating, weight, and shape were investigated in 75 patients with bulimia nervosa. Interference with color-naming was related to two measures, overall level of psychiatric symptoms and frequency of purging. Multiple regression analysis showed that frequency of purging, and not level of general psychiatric symptoms, was the best predictor of interference. Thus, as would be predicted by cognitive theories, interference appears to be most closely related to features specific to bulimia nervosa rather than to measures of general psychopathology.

Evaluation of a new instrument for the detection of eating disorders in community samples

The aim of this study was to develop and evaluate an instrument to detect the various forms of clinical eating disorder that exist among young women in the community. A subsidiary aim was to test an alternative instrument based directly on the DSM-III-R criteria for eating disorders. Participants were 285 young adult women listed in the case registers of two general practices. Receiver operating characteristic analysis showed that the new (statistically derived) instrument performed well and was better at case identification than the only other instrument currently available. In contrast, the instrument based directly on the DSM-III-R criteria performed poorly. It was not possible to assess the ability of the new instrument to detect cases of anorexia nervosa since there were no cases in the sample.

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.

Advances in diagnosis and treatment of anorexia nervosa and bulimia nervosa

This paper reviews four areas of research into anorexia nervosa (AN) and bulimia nervosa (BN). First, in terms of diagnosis, the psychological concerns about weight and shape are now addressed in BN, bringing it more in line with the related disorder, anorexia nervosa. Second, studies of psychiatric comorbidity confirm the overlap between eating disorders and depression, obsessive compulsive disorder, substance abuse, and personality disorder. Nevertheless, there are reasons to accept the distinct qualities of each syndrome, and eating disorders are not merely a variant of these other conditions. Third, treatment advances in BN involve mainly cognitive-behavioural or interpersonal psychotherapies and pharmacotherapies primarily with antidepressants. The effect of combining more than one approach is beginning to be addressed. Finally, outcome studies involving people with both AN and BN have shown that the disorders "cross over" and that both conditions have a high rate of relapse. A renewed interest in the treatment of AN is needed.

Eating disorders in women who abuse alcohol

It has been suggested that various forms of addictive behaviour and substance abuse co-exist more frequently than would be expected by chance. Such co-morbidity may lessen the effectiveness of treatment, and may not be recognized by clinicians who specialize in one particular form of addiction. This study addresses one aspect of this issue: the co-existence of eating disorders and alcohol abuse. Women attending an alcohol treatment unit completed a self-report measure of the clinical features of eating disorders. Thirty-six per cent of the sample reported the symptom of binge-eating, 26% fulfilled diagnostic criteria for a probable current clinical eating disorder, and 19% had a history of probable anorexia nervosa. The findings suggest that the behaviour and attitudes characteristic of clinical eating disorders are over-represented in women receiving treatment for an alcohol problem, and further study of such co-morbidity is merited.

The validity of the eating disorder examination and its subscales

The EDE is a semistructured interview which has been developed as a measure of the specific psychopathology of anorexia nervosa and bulimia nervosa. To establish its discriminant validity it was administered to 100 patients with anorexia nervosa or bulimia nervosa and to 42 controls. The two groups differed significantly on all items. Five subscales were derived on rational grounds and evaluated on the two populations. The alpha coefficients for each subscale indicated a satisfactory degree of internal consistency. The EDE provides clinicians and research workers with a detailed and comprehensive profile of the psychopathological features of patients with eating disorders.