Not all body image constructs are created equal: Predicting eating disorder outcomes from preoccupation, dissatisfaction, and overvaluation

Exploring weight bias and negative self-evaluation in patients with mood disorders: insights from the BodyTalk Project

Background

Negative body image and adverse body self-evaluation represent key psychological constructs within the realm of weight bias (WB), potentially intertwined with the negative self-evaluation characteristic of depressive symptomatology. Although WB encapsulates an implicit form of self-critical assessment, its exploration among people with mood disorders (MD) has been under-investigated. Our primary goal is to comprehensively assess both explicit and implicit WB, seeking to reveal specific dimensions that could interconnect with the symptoms of MDs.

Methods

A cohort comprising 25 MD patients and 35 demographically matched healthy peers (with 83% female representation) participated in a series of tasks designed to evaluate the congruence between various computer-generated body representations and a spectrum of descriptive adjectives. Our analysis delved into multiple facets of body image evaluation, scrutinizing the associations between different body sizes and emotionally charged adjectives (e.g., active, apple-shaped, attractive).

Results

No discernible differences emerged concerning body dissatisfaction or the correspondence of different body sizes with varying adjectives. Interestingly, MD patients exhibited a markedly higher tendency to overestimate their body weight (p = 0.011). Explicit WB did not show significant variance between the two groups, but MD participants demonstrated a notable implicit WB within a specific weight rating task for BMI between 18.5 and 25 kg/m2 (p = 0.012).

Conclusions

Despite the striking similarities in the assessment of participants' body weight, our investigation revealed an implicit WB among individuals grappling with MD. This bias potentially assumes a role in fostering self-directed negative evaluations, shedding light on a previously unexplored facet of the interplay between WB and mood disorders.

Momentary appearance focused self-concept is associated with dietary restraint and binge eating in female university students: An experience sampling study

OBJECTIVE

Appearance focused self-concept (i.e., overvaluing the importance of appearance for self-definition and self-worth) is theorized to predict dietary restraint and binge eating in the short-term (e.g., daily life). Yet, no research has examined whether appearance focused self-concept increases within-persons during a day and if such increases are linked to greater dietary restraint and binge eating for that day. We addressed this gap in knowledge.

METHOD

Sixty-three female university students completed four items from the Beliefs About Appearance Scale as a measure of appearance focused self-concept six times per day (9 am, 11 am, 1 pm, 3 pm, 5 pm, and 7 pm) for 14 days. Daily at 9 pm, they completed measures of dietary restraint and binge eating for that day.

RESULTS

Analyzing data from 555 days, latent growth curve analyses revealed a small-to-moderate linear increase in appearance focused self-concept from 9 am to 3 pm that plateaued from 3 to 7 pm. A more rapid linear increase in appearance focused self-concept from 9 am to 3 pm was associated with greater binge-eating frequency during that day, but not with dietary restraint. The findings were observed when adjusting for between-day appearance focused self-concept at 9 am, which was positively associated with dietary restraint and binge-eating frequency.

DISCUSSION

Findings are discussed in relation to research on appearance focused self-concept as a risk factor for disordered eating. Findings are also discussed in relation to how sociocultural factors may increase appearance focused self-concept over time. Future research should delve into the within-day dynamic interplay between appearance focused self-concept and disordered eating.

PUBLIC SIGNIFICANCE

Our study revealed a noteworthy increase in the importance women attach to their appearance over the course of a day, correlating with increased binge eating during that day. Additionally, heightened appearance importance at the onset of a day was associated with more dietary restraint and binge eating during that day. These findings suggest a shorter timescale for the connection between appearance importance and disordered eating than previously understood.

An examination of adults with atypical anorexia nervosa at admission to treatment at higher levels of care: An attempt to increase diagnostic clarity

OBJECTIVE

Anorexia nervosa (AN) is a serious illness with a high mortality rate and multiple physiological complications. The vague definition of atypical AN allows for subjective interpretation. This retrospective study aimed to focus future research on the operational definition of atypical AN by examining four factors associated with atypical AN at admission to higher level of care treatment.

METHODS

Adults with atypical AN (n = 69) were examined within sample analyses among four groups: (1) >10% versus ≤10% weight loss; (2) weight loss within the previous 3 months versus >3 months; (3) engaging in purging behaviors versus absence of purging behaviors; and (4) endorsing versus not endorsing significant cognitive aspects of AN.

RESULTS

Patients with atypical AN endorsed elevated ED cognitions on the Eating Disorder Examination-Questionnaire and depressive symptoms; a lack of association was found between weight loss severity and weight loss time frame with depressive symptoms, eating concern, and restraint. Purging behavior was associated with a higher expected body weight percentage (%EBW) and dietary restraint, while greater AN cognitions were associated with a higher EBW and weight loss percentage. Few patients demonstrated bradycardia, hypophosphatemia, or amenorrhea.

DISCUSSION

This study demonstrated the severity of ED cognitions and depressive symptoms in this atypical AN sample and provided directions for future studies in the nosology of atypical AN. It may be important to distinguish between individuals with atypical AN who are purging and those who are not. Atypical AN was associated with a low frequency of physiological disturbances.

PUBLIC SIGNIFICANCE

This study provides further clarification regarding the operational definition of atypical AN; currently, a constellation of symptoms under Other Specified Feeding or Eating Disorders. This study was consistent with previous research in reporting severe eating disorder cognitions in adults with atypical AN, and noted the potential importance of distinguishing a purging distinction. A minority of patients in this study had physiological impairments.

Body image concerns among individuals with different levels of sporting engagement and exercise: A longitudinal study

This longitudinal study examined whether body image concerns (general; sporting) predicted eating disorder psychopathology, and whether the link differed according to nature of sport engagement. Participants were competitive sports engagers, non-competitive sports engagers, or sports non-engagers. At baseline, 510 adults completed online measures of sports demographics, eating psychopathology and body image. Eating psychopathology and body image measures were taken at follow-up (6 months later). Competitive sports engagers had better body image than the other two groups. Poorer body appreciation and better appearance-related body image predicted higher eating disorder psychopathology. Engaging in sports competitively may be beneficial for body image. However, positive appearance-related sporting body image may pose a risk for later eating psychopathology.

Negative body image mental health literacy in women: Exploring aesthetic and functional concerns and the role of self-objectification

Despite its high prevalence in women, few studies have examined lay knowledge and beliefs about negative body image. Yet, studies applying mental health literacy to body image problems suggest recognition of appearance concerns is poor, which could impede help-seeking. The present study extended previous work by investigating problem recognition, beliefs and help-seeking for aesthetic and functional (physical ability focused) body image concerns in women, and the role of self-objectification in help-seeking. A within-subjects online survey design employing the mental health literacy paradigm was undertaken in a sample of 210 female-identifying adults residing in Australia (Mage = 31.25, SD = 12.76). Overall, results indicated that recognition of body image problems depicted via fictional text vignettes was limited. Moreover, recognition, as well as ratings of perceived prevalence, distress, sympathy, affective reactions, and help-seeking recommendations and intentions, were significantly greater for aesthetic compared to functional body image concerns. Self-objectification displayed significant negative associations with help-seeking recommendations for aesthetic (but not functional) concerns, and was not associated with help-seeking intentions. Findings suggest that negative body image mental health literacy is poor in women, particularly in relation to body functionality. More research is needed to facilitate help-seeking and reduce the impact of body image concerns in women.

Diversity of Binge-Eating Disorder Symptoms Is Associated with Anxiety about Getting Fat Rather Than Body Image: A Clinical Study of Women in Poland

BACKGROUND

Anxiety about gaining weight is strongly related to body image. Evidence indicates that body dissatisfaction is a strong predictor of eating disorder development. Although not included in DSM-V diagnostic criteria, body image dissatisfaction, and concern are clearly relevant also for individuals with binge-eating disorder (BED). Weight gain anxiety is associated with psychopathological behaviors, but existing research in this area is primarily focused on bulimia nervosa and anorexia nervosa. The goal of this present study was to investigate body image and body mass anxiety in people with BED.

METHODS

Women diagnosed with BED (n = 105) aged 18 to 66 were surveyed using the questionnaire developed by the authors evaluating the presence of BED symptoms based on DSM-V criteria, and two other instruments: the Body Esteem Scale (BES), and the Body Mass Anxiety Scale (BMAS-20). Statistical analyses were conducted to examine the correlations of BED with body image and body mass anxiety (Pearson's r), to test differences between groups with greater and lesser BED symptom diversity (Student's t-test or the Mann-Whitney U test), and to assess differences among mild-, moderate- and severe-BED groups (ANOVA with a post-hoc test).

RESULTS

A medium positive relationship was found between anxiety about getting fat (AGF) and the diversity of BED, measured as the number of BED symptoms. A larger number of BED symptoms was shown to be associated with a higher level of AGF. However, no significant differences in AGF levels were observed among BED-severity groups, specified with the frequency of binge eating episodes. No correlations were found between BED and body image. There were also no significant differences in body image between groups with a larger and a smaller number of BED symptoms. The only significant difference in body image observed among BED-severity groups was the level of weight concern. People with mild BED displayed a higher level of weight concern than those with severe BED.

CONCLUSIONS

Women who binge eat experience high levels of AGF. In the present study, AGF was primarily associated with the number of BED symptoms and not the rate of recurrence of binge-eating episodes. The frequency of BED episodes, however, was linked with weight concern. On the other hand, the hypothesized relationship between disturbed body image and BED was not confirmed. The findings indicate that anxiety about getting fat should be viewed as one of the psychological costs incurred by women experiencing BED symptoms, and it should be mentioned in the next DSM version.

Predictors of Treatment Outcome in Eating Disorders: A Roadmap to Inform Future Research Efforts

PURPOSE OF REVIEW

With the current review, we provide a brief summary of recent literature that tests clinically observable characteristics at baseline that may impact treatment response, across eating disorder diagnoses. We then provide a critical discussion regarding how researchers may shift their approach to this research to improve treatment implications and generalizability of these findings.

RECENT FINDINGS

Recent work has broadly replicated prior findings suggesting a negative impact of lower weight status, poor emotion regulation, and early-life trauma on eating disorder treatment outcomes. Findings are more mixed for the relative contributions of illness duration, psychiatric comorbidity, and baseline symptom severity. Recent studies have begun to explore more specific domains of previously tested predictors (e.g., specific comorbidities) as well as previously neglected identity-related and systemic factors. However, recent research continues to use similar sampling techniques and approaches to analysis used in prior work. We propose that resolving remaining questions and illuminating predictors of treatment outcome in eating disorders requires a new approach to research sampling and study design. Suggested changes that can be applied within a traditional clinical trial framework may yield new insights with relevance across transdiagnostic eating disorder presentations.

Body image as a multidimensional concept: A systematic review of body image facets in eating disorders and muscle dysmorphia

Body image disturbance is core to the psychopathology of eating disorders (EDs), and related disorders such as muscle dysmorphia (MD). Global measures of body image fail to quantify specific aspects of body image disturbance that characterizes EDs, and may be differentially associated to outcomes. The aim of this systematic review was to provide an overview of specific body image facets and synthesize findings from controlled studies that compared clinical ED/MD and control-comparison groups in body image disturbance. One-hundred sixty-seven studies met inclusion criteria, and reported on comparisons among 30,584 individuals in 28 body image facets, which were more broadly grouped into evaluative, perceptual, cognitive-affective and motivational categories for the purpose of the present review. Effect sizes were calculated as Cohen's d for every comparison between ED and control groups. Body dissatisfaction (evaluative category) was the most prevalent facet assessed across studies (62 %), and differences between clinical and control groups were the largest in this category, especially for bulimia nervosa (d = 1.37). Scarcity of studies with male and MD clinical samples, and use of single-item and non-validated measures, should encourage development of instruments for body image facets pertinent to EDs and MD that can be validly applied across gender.

Bi-directional associations between depressive symptoms and eating disorder symptoms in early adolescence

Despite frequently co-occurring, the temporal relationship between depression and eating disorder symptoms remains poorly understood. This exploratory study sought to investigate the reciprocal relationship between depressive symptoms and (1) shape and weight dissatisfaction, (2) shape and weight overvaluation, (3) preoccupation with shape or weight, (4) preoccupation with food, (5) dietary restraint and (6) binge eating in early adolescence. Adolescents (N = 1393) aged between 11.4 and 13.9 years (M = 12.50, SD = 0.38) completed the Centre for Epidemiological Depression Scale-Revised and Eating Disorder Examination Questionnaire-Adolescent version at the beginning of secondary school (T1) and 12-months later (T2). Cross-lagged models were created to assess the reciprocal relationship between depressive symptoms and ED symptoms. Depressive symptoms at T1 predicted shape and weight dissatisfaction, shape and weight overvaluation, preoccupation with shape or weight, preoccupation with food, dietary restraint and binge eating at T2. Shape and weight dissatisfaction and binge eating were the only ED symptoms at T1 to predict depressive symptoms at T2. Findings suggest young adolescents who experience depressive symptoms in their first year of secondary school are at-risk of developing ED symptoms over the subsequent 12-month period.

Negative body image components as risk factors for orthorexia nervosa: Prospective findings

Emerging theoretical and empirical evidence indicates that negative body image might be implicated in the onset or maintenance of ON symptoms. However, existing research investigating associations between negative body image and ON is limited to cross-sectional designs and has failed to consider the independent role of distinct components of body image. To overcome these limitations, the present study examined the prospective associations between five components of body image (i.e., overvaluation, dissatisfaction, preoccupation, body checking, and body image avoidance) and ON symptoms in community-based adult women. Participants were assessed at baseline and at a three-month follow-up, with 558 women included in the final analyses. After adjusting for baseline ON symptoms, higher scores on each of the five body image components at baseline significantly predicted greater increases in ON symptoms in univariate analyses. However, in multivariate analyses, overvaluation with weight and shape was the only component of body image to uniquely predict ON symptoms. Findings suggest that certain components of negative body image may increase the risk for ON symptoms. Findings also lend support to recent proposals that ON may be better viewed as a variant of an existing eating disorder, given that both appear to share similar underlying risk factors.

Body Checking and Body Image Avoidance as Partial Mediators of the Relationship between Internalized Weight Bias and Body Dissatisfaction

Internalized weight bias is associated with body image disturbances and the development of disordered eating. The association between weight bias internalization and body dissatisfaction has proven difficult to disrupt. In order to develop more effective interventions, we must identify the behavioral targets which account for this robust association. The present study sought to examine whether body checking and body image avoidance mediate the relationship between weight bias internalization and body dissatisfaction. In total, 279 female undergraduates (Mage = 20.13, SD = 4.10) were administered a battery of survey measures. Results demonstrated that body checking partially mediates the relationship between weight bias internalization and body dissatisfaction, Z = 7.42, p < 0.001. Body image avoidance was also found to partially mediate the relationship between weight bias internalization and body dissatisfaction, Z = 70.03, p < 0.001. These findings suggest that body checking and body image avoidance may both partially account for the association between weight bias internalization and body dissatisfaction. These findings extend the existing literature on weight bias internalization by highlighting two behavioral targets for prevention and intervention efforts. Understanding these relationships has important implications for both reducing weight bias internalization and improving body dissatisfaction.

Beyond Description and Deficits: How Computational Psychiatry Can Enhance an Understanding of Decision-Making in Anorexia Nervosa

PURPOSE OF REVIEW

Despite decades of research, knowledge of the mechanisms maintaining anorexia nervosa (AN) remains incomplete and clearly effective treatments elusive. Novel theoretical frameworks are needed to advance mechanistic and treatment research for this disorder. Here, we argue the utility of engaging a novel lens that differs from existing perspectives in psychiatry. Specifically, we argue the necessity of expanding beyond two historically common perspectives: (1) the descriptive perspective: the tendency to define mechanisms on the basis of surface characteristics and (2) the deficit perspective: the tendency to search for mechanisms associated with under-functioning of decision-making abilities and related circuity, rather than problems of over-functioning, in psychiatric disorders.

RECENT FINDINGS

Computational psychiatry can provide a novel framework for understanding AN because this approach emphasizes the role of computational misalignments (rather than absolute deficits or excesses) between decision-making strategies and environmental demands as the key factors promoting psychiatric illnesses. Informed by this approach, we argue that AN can be understood as a disorder of excess goal pursuit, maintained by over-engagement, rather than disengagement, of executive functioning strategies and circuits. Emerging evidence suggests that this same computational imbalance may constitute an under-investigated phenotype presenting transdiagnostically across psychiatric disorders. A variety of computational models can be used to further elucidate excess goal pursuit in AN. Most traditional psychiatric treatments do not target excess goal pursuit or associated neurocognitive mechanisms. Thus, targeting at the level of computational dysfunction may provide a new avenue for enhancing treatment for AN and related disorders.

Preoccupation in bulimia nervosa, binge-eating disorder, anorexia nervosa, and higher weight

OBJECTIVE

Preoccupation (excessive and constant thoughts) about shape/weight and food/eating is thought to be prominent in individuals with eating disorders but has received much less research than overt behavioral features. This study examined the significance and distinctiveness of different foci of preoccupation in individuals categorized with different forms of eating disorders and in individuals with higher weight.

METHOD

Participants (N = 1,363) completed a web-based survey with established measures of eating-disorder psychopathology and depression. The current study compared preoccupation among individuals with core features of bulimia nervosa (BN; n = 144), binge-eating disorder (BED; n = 576), anorexia nervosa (AN; n = 48), and higher body weight (body mass index [BMI] ≥ 25) without eating-disorder features (higher weight [HW]; n = 595). Associations of each type of preoccupation with other eating-disorder psychopathology and depression were examined both between and within study groups.

RESULTS

Preoccupation with shape/weight and with food/eating showed a graded pattern of statistically significant differences: AN and BN had higher preoccupation than BED, which was higher than HW. Within BN, BED, and AN study groups, correlation magnitudes of shape/weight and food/eating preoccupation with eating-disorder psychopathology and depression did not differ significantly. Within the HW group, shape/weight preoccupation was significantly more strongly correlated than food/eating preoccupation with overvaluation, body dissatisfaction, and depression.

DISCUSSION

The preoccupation cognitive style, as well as focus, appears associated with other facets of eating-disorder psychopathology and depression. If results are confirmed among individuals with formal diagnoses, clinicians addressing maladaptive cognitions in cognitive-behavioral therapy should consider the role of preoccupation. Future research should investigate whether preoccupation predicts or moderates eating disorder treatment outcomes.

Bidirectional relationships between intuitive eating and shape and weight overvaluation, dissatisfaction, preoccupation, and fear of weight gain: A prospective study

Using a prospective design, we investigated possible bi-directional relationships between intuitive eating and four empirically distinct components of negative body image: overvaluation (judgements of self-worth contingent upon weight/shape), dissatisfaction (general discontent with weight/shape), preoccupation (ruminative thinking about weight/shape), and fear of weight gain. We assessed adult women at baseline (T1) and four-month follow-up (T2), as prior work has demonstrated that this time lag is sufficient to detect change in intuitive eating scores. After adjusting for T1 intuitive eating scores and demographic confounds, higher T1 dissatisfaction was the only body image component to significantly predict lower T2 intuitive eating scores in both univariate and multivariate models. Higher T1 intuitive eating scores also significantly predicted lower scores on each of the four negative body image components at T2. Findings suggest that general body discontent may be one of the more important body image variables that lead to decreases in intuitive eating principles. Present findings also add to a growing body of evidence demonstrating the potentially adaptive role of intuitive eating on psychological health indices.

Using individual networks to identify treatment targets for eating disorder treatment: a proof-of-concept study and initial data

BACKGROUND

Eating disorders (EDs) are severe mental illnesses, with high morbidity, mortality, and societal burden. EDs are extremely heterogenous, and only 50% of patients currently respond to first-line treatments. Personalized and effective treatments for EDs are drastically needed.

METHODS

The current study (N = 34 participants with an ED diagnosis collected throughout the United States) aimed to investigate best methods informing how to select personalized treatment targets utilizing idiographic network analysis, which could then be used for evidence based personalized treatment development. We present initial data collected via experience sampling (i.e., ecological momentary assessment) over the course of 15 days, 5 times a day (75 total measurement points) that were used to select treatment targets for a personalized treatment for EDs.

RESULTS

Overall, we found that treatment targets were highly variable, with less than 50% of individuals endorsing central symptoms related to weight and shape, consistent with current treatment response rates for treatments designed to target those symptoms. We also found that different aspects of selection methods (e.g., number of items, type of centrality measure) impacted treatment target selection.

CONCLUSIONS

We discuss implications of these data, how to use idiographic network analysis to personalize treatment, and identify areas that need future research.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04183894. Registered 3 December 2019-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04183894 . NCT04183894 (ClinicalTrials.gov identifier).

Associations among weight suppression, self-acceptance, negative body image, and eating disorder behaviors among women with eating disorder symptoms

The present study aimed to clarify existing research that has inconsistently shown that weight suppression (differences between individuals' highest and current body weights) is associated with worse eating disorder (ED) behaviors and negative body image among women with lifetime EDs, by examining whether an understudied client-supported protective factor for ED pathology - self-acceptance - moderates these associations. Currently symptomatic women with lifetime EDs (N = 108) completed measures assessing self-acceptance and ED symptoms via an online survey. Moderated regressions examined whether self-acceptance moderated associations between weight suppression and both body image (weight/shape preoccupation, overvaluation, dissatisfaction) and ED behavior (dietary restraint, compensatory behaviors, binge eating) outcomes. Results indicated that weight suppression was associated with more severe negative body image and dietary restraint, but not compensatory behaviors or binge eating. In contrast, self-acceptance consistently emerged as a protective factor relative to all negative body image and ED behavior indices. This protective effect did not offset apparent risk factor associations between weight suppression, and negative body image and ED behavior outcomes. These results support further assessment of self-acceptance as an understudied protective factor for women's ED symptoms and as a mechanism of change in EDs intervention research. Women's weight suppression should be assessed during ED prevention initiatives.

Distinctiveness and significance of body dissatisfaction and overvaluation among Latinx/Hispanic and White men and women

OBJECTIVE

To examine the distinctiveness and significance of two body image constructs, dissatisfaction with weight and shape and overvaluation of weight and shape, with respect to eating disorder psychopathology, weight, and depression in White and Latinx/Hispanic men and women.

METHODS

Participants were White (n = 1,941) and Latinx/Hispanic (n = 568) adults living in the United States who completed an online battery of established measures of body image, eating disorder psychopathology and behaviors, and depression.

RESULTS

Two body image constructs, dissatisfaction with weight and shape and overvaluation of weight and shape, were related to each other but showed some important distinctions in their associations with eating- and weight-related variables. Significantly greater proportions of White than Latinx/Hispanic individuals reported co-occurring dissatisfaction and overvaluation, and significantly greater proportions of Latinx/Hispanic than White individuals reported dissatisfaction alone. Ethnicity moderated the association of dissatisfaction and overvaluation with body mass index (BMI), and the association of overvaluation with depression. Ethnicity also had a main effect on binge-eating frequency.

CONCLUSIONS

Dissatisfaction and overvaluation were distinct among both Latinx/Hispanic and White individuals. However, associations with eating- and weight-related variables varied between ethnicities, suggesting a need for further research on the influence of cultural variables on body image and eating disorder psychopathology.