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

The correlates of appearance focused self-concept: personality traits, self-concept, sociocultural, and early life experience factors

BACKGROUND

Theory and research indicate that an appearance focused self-concept (i.e., placing overriding importance on physical appearance for self-definition and self-worth) plays a role in the etiology and maintenance of disordered eating and eating disorders. Although the consequences of an appearance focused self-concept are palpable, less is known about its correlates. Accordingly, we examined a range of factors that may characterize appearance focused people, including personality traits (perfectionism, impulsivity, sensation-seeking, hopelessness, and anxiety sensitivity), self-concept (global self-esteem and self-concept clarity), sociocultural (thin-ideal, muscular-ideal, general attractiveness internalizations, and perceived pressure to be thin), and early life experiences (adverse childhood experiences, attachment styles) factors.

METHODS

Female undergraduate university students (N = 568; Mage = 19.58, SDage = 4.24) completed a questionnaire battery that included the Beliefs About Appearance Scale, Depressive Experiences Questionnaire-Self-Criticism-6 Scale, Frost-Multidimensional Perfectionism Scale, the Revised Almost Perfect Scale, Substance Use Risk Profile Scale, Self-Concept Clarity Scale, Rosenberg Self-Esteem Scale, Sociocultural Attitudes Towards Appearance Questionnaire-4 Scale, Adverse Childhood Experiences Questionnaire, Experiences in Close Relationships Scale Short Form, and the Dietary Restraint subscale of the Eating Disorders Examination Questionnaire.

RESULTS

Multiple regression analyses were conducted for each set of factors separately and together. For personality traits, perfectionism, impulsivity, and anxiety sensitivity were uniquely associated with appearance focused self-concept. For self-concept, global self-esteem and self-concept clarity were uniquely associated with appearance focused self-concept. For sociocultural, general attractiveness internalization, thin-ideal internalization, and perceived pressure to be thin were uniquely associated with appearance focused self-concept. For early life experiences, attachment anxiety and avoidance were uniquely associated with appearance focused self-concept. In the combined analysis, the various factors explained 54% of the variance in appearance focused self-concept. Impulsivity, global self-esteem, general attractiveness internalization, and perceived pressure to be thin were uniquely associated with appearance focused self-concept.

CONCLUSIONS

Results for global self-esteem were consistent with prior research. Findings for evaluative concerns perfectionism were inconsistent with prior research. We discuss future research directions to examine the link between evaluative concerns perfectionism and appearance focused self-concept. We also discuss how sociocultural factors (general attractiveness internalization and perceived pressure to be thin) and impulsivity may help cultivate an appearance focused self-concept, advancing knowledge on the characteristics of appearance-focused people.

Psychotherapies for eating disorders: findings from a rapid review

BACKGROUND

Psychotherapy is considered central to the effective treatment of eating disorders-focusing on behavioural, psychological, and social factors that contribute to the illness. Research indicates psychotherapeutic interventions out-perform placebo, waitlist, and/or other treatments; but, outcomes vary with room for major improvement. Thus, this review aims to (1) establish and consolidate knowledge on efficacious eating disorder psychotherapies; (2) highlight select emerging psychotherapeutic interventions; and (3) identify knowledge gaps to better inform future treatment research and development.

METHODS

The current review forms part of a series of Rapid Reviews published in a special issue in the Journal of Eating Disorders to inform the development of the Australian-government-funded National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2023, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, and population studies). Data pertaining to psychotherapies for eating disorders were synthesised and outlined in the current paper.

RESULTS

281 studies met inclusion criteria. Behavioural therapies were most commonly studied, with cognitive-behavioural and family-based therapies being the most researched; and thus, having the largest evidence-base for treating anorexia nervosa, bulimia nervosa, and binge eating disorder. Other therapies, such as interpersonal and dialectical behaviour therapies also demonstrated positive treatment outcomes. Emerging evidence supports specific use of Acceptance and Commitment; Integrative Cognitive Affective; Exposure; Mindfulness; and Emotionally-Focused therapies; however further research is needed to determine their efficacy. Similarly, growing support for self-help, group, and computer/internet-based therapeutic modalities was noted. Psychotherapies for avoidant/restrictive food intake disorder; other, and unspecified feeding and eating disorders were lacking evidence.

CONCLUSIONS

Currently, clinical practice is largely supported by research indicating that behavioural and cognitive-behavioural psychotherapies are most effective for the treatment of eating disorders. However, the efficacy of psychotherapeutic interventions varies across studies, highlighting the need for investment and expansion of research into enhanced variants and novel psychotherapies to improve illness outcomes. There is also a pressing need for investigation into the whole range of eating disorder presentations and populations, to determine the most effective interventions.

Perfectionism and binge eating association: a systematic review and meta-analysis

BACKGROUND

Perfectionism is considered a vulnerability factor for eating disorders. However, the role of perfectionism in binge eating needs clarification due to notably inconsistencies between studies. The purpose to this study was to conduct a systematic review and meta-analysis to estimate the perfectionism-binge eating association.

METHOD

Systematic review was performed according to the PRISMA 2020 statement. Four databases (Web of Science, Scopus, PsycINFO and Psicodoc) were searched to identify studies published until September 2022. The literature search yielded 30 published articles (N = 9392) that provided 33 independent estimations of the correlation between the two variables.

RESULTS

Random-effects meta-analysis revealed a small-to-moderate positive average effect size between general perfectionism and binge eating (r₊ = .17) with a large heterogeneity. Perfectionistic Concerns showed a significant small-to-moderate relationship with binge eating (r₊ = .27), whereas Perfectionistic Strivings presented a negligible relationship with binge eating (r₊ = .07). Moderator analyses showed that the age, the type of the sample, the study design, and the tools for assessing both variables were statistically associated with the perfectionism-binge eating effect sizes.

CONCLUSIONS

Our findings suggest that Perfectionism Concerns are closely associated with binge eating symptomatology. This relationship might be moderated by certain variables, especially by the clinical or non-clinical nature of the sample and the instrument employed to assess binge eating.

The relationship between individual symptom connectivity and global eating disorder symptom severity

BACKGROUND

The network approach has emerged as a useful framework for conceptualizing and investigating psychopathology, including eating disorders. Network connectivity, that is, the density of the connections among network nodes, has been somewhat neglected despite its theoretical relevance. As predicted by network theory, symptom connectivity would be distinct but related to symptom severity and may be a useful clinical indicator of psychopathology as stronger and/or more diffuse connections among symptoms offer more avenues for symptom activation. This study aimed to investigate the relationship between moment-by-moment individual-level symptom connectivity and global levels of symptom severity in the context of eating disorder symptoms and experiences.

METHODS

A sample of 58 female undergraduate college students, mean (SD) age = 20.5 (3.1) provided data on eating disorder symptoms eight times a day over the course of 10 days. Network analyses were used to calculate the eating disorder symptoms network connectivity for each participant. In addition, participants completed survey of self-report measures of eating disorder symptom severity and trait mindfulness and body image flexibility.

RESULTS

Analyses revealed a moderate, positive relationship between individual network connectivity and eating disorder symptom severity. In addition, symptom connectivity predicted unique variance of symptom severity even after controlling for other clinically-relevant variables.

CONCLUSIONS

Individual-level network connectivity may be an important dimension of psychopathology and further work exploring the role of network connectivity is warranted.

PUBLIC SIGNIFICANCE

These findings suggest that symptom severity and the extent to which different eating disorder symptoms are connected are related but different dimensions. Investigating how these different dimensions play a role in eating disorder pathology could help to better understand and treat these disorders.

Intuitive Eating Scale-2: psychometric properties and clinical norms among individuals seeking treatment for an eating disorder in private practice

PURPOSE

Intuitive Eating (IE) is an approach to eating designed to facilitate a positive relationship with food. Its use in clinical settings and in the community is rapidly growing in popularity. The Intuitive Eating Scale 2 (IES-2) is a widely used measure that indexes intuitive eating motivations and behaviour, however evidence of its validity in populations with clinical eating disorders remains scarce. The objective of the proposed study was thus to evaluate the factor structure of the IES-2 in a large sample of individuals seeking treatment for eating disorders in private practice.

METHODS

Data collected from 569 women and men aged 12-68 years seeking treatment for an eating disorder in one of eight specialist private outpatient eating disorder clinics were examined using confirmatory factor analysis (CFA). Relationships between IES-2 scores and measures of psychopathology were also examined.

RESULTS

Results were relatively consistent with the purported four-factor structure of the IES-2. The measure displayed strong construct validity and good internal consistency. Scores on the IES-2 were inversely associated with scores of depression, anxiety, and disordered eating, providing evidence for divergent validity of the measure. Clinical norms are provided for anorexia nervosa (AN) spectrum disorders and bulimia nervosa (BN) spectrum disorders, as well as for the clinical sample as a whole.

CONCLUSION

Findings suggest that the IES-2 may be an appropriate measure for evaluating behaviours relating to IE in community outpatient eating disorder settings, and provide further evidence for the association between IE and positive health outcomes.

LEVEL OF EVIDENCE

III, evidence obtained from well-designed cohort or case-control analytic studies.

Distress tolerance across substance use, eating, and borderline personality disorders: A meta-analysis

BACKGROUND

Distress tolerance (DT) has received increased attention in recent years due to its purported role in dysregulated behaviours and their clinical manifestations, such as problematic substance use (PSU), disordered eating behaviours (e.g., binge-eating and purging; DEB), and borderline personality disorder (BPD) symptomatology. Despite the proposed transdiagnostic utility of DT across PSU, DEB, and BPD, there has yet to be a systematic and comprehensive examination characterising and comparing its association with this class of impulsive-type psychopathology.

METHODS

A systematic search was conducted across five electronic databases using search terms designed to capture extant literature on the association between DT and PSU, DEB, and BPD symptomatology. A series of meta-analyses were undertaken on correlation coefficients from 81 studies to examine the association between DT and each psychopathology domain, as well as impulsive-type psychopathology overall. Moderator analyses were conducted to examine whether these relationships were moderated by DT measurement type, sample type, age, and gender.

RESULTS

DT shared significant, negative, medium correlations with PSU (r = -.18,), DEB (r = -.20), and BPD symptomatology (r = -.27). The magnitude of these associations was not significantly different across the three psychopathology domains, supporting transdiagnostic conceptualisation. DT measurement type, age, and sample type moderated several of these indicated relationships.

LIMITATIONS

The majority of studies were conducted in adult samples from Western countries, limiting understanding of these relationships across development and different cultures.

CONCLUSIONS

The present findings support the putative transdiagnostic role of DT across PSU, DEB, and BPD, which may ultimately inform novel, cross-cutting interventions.

Irrational Beliefs and Their Role in Specific and Non-Specific Eating Disorder Symptomatology and Cognitive Reappraisal in Eating Disorders

BACKGROUND

Research on which specific maladaptive cognitions characterize eating disorders (ED) is lacking. This study explores irrational beliefs (IBs) in ED patients and controls and the association between IBs and ED-specific and non-specific ED symptomatology and cognitive reappraisal.

METHODS

79 ED outpatients with anorexia nervosa, bulimia nervosa, or other specified feeding or eating disorders and 95 controls completed the Attitudes and Beliefs Scale-2 (ABS-2) for IBs. ED outpatients also completed the Eating Disorder Inventory-3 (EDI-3) for ED-specific (EDI-3-ED Risk) and non-specific (EDI-3-General Psychological Maladjustment) symptomatology; General Health Questionnaire (GHQ) for general psychopathology; Emotion Regulation Questionnaire (ERQ) for cognitive reappraisal.

RESULTS

Multivariate analysis of variance with post hoc comparisons showed that ED outpatients exhibit greater ABS-2-Awfulizing, ABS-2-Negative Global Evaluations, and ABS-2-Low Frustration Tolerance than controls. No differences emerged between ED diagnoses. According to stepwise linear regression analyses, body mass index (BMI) and ABS-2-Awfulizing predicted greater EDI-3-ED Risk, while ABS-2-Negative Global Evaluations and GHQ predicted greater EDI-3-General Psychological Maladjustment and lower ERQ-Cognitive Reappraisal.

CONCLUSION

Awfulizing and negative global evaluation contribute to better explaining ED-specific and non-specific ED symptoms and cognitive reappraisal. Therefore, including them, together with BMI and general psychopathology, when assessing ED patients and planning cognitive-behavioral treatment is warranted.

Self-compassion as a moderator of the relationships between shape and weight overvaluation and eating disorder psychopathology, psychosocial impairment, and psychological distress

Shape and weight overvaluation is a core component of body image theorized to drive many of the symptoms of eating disorders (ED) and associated distress and impairment. Identifying variables that protect against the negative effects of shape and weight overvaluation is needed for informing primary intervention targets. Self-compassion may be a protective factor given its role as an adaptive affect regulation strategy. We thus examined whether self-compassion would attenuate the relationships between shape and weight overvaluation and ED psychopathology, psychosocial impairment, and psychological distress. Cross-sectional data were analyzed from 992 (619 women and 373 men) participants. Multiple regression analyses revealed that self-compassion moderated the relationship between shape and weight overvaluation and each dependent variable. Specifically, among men and women with lower levels of self-compassion, overvaluation of shape and weight was strongly associated with each of the criterion variables; however, these relationships were either absent or weaker among those with higher levels of self-compassion. Present findings suggest that it may be beneficial for ED prevention and early intervention programs to explicitly incorporate components of compassion-focused interventions to improve mental health outcomes among the general public.

Treatment outcome research of enhanced cognitive behaviour therapy for eating disorders: a systematic review with narrative and meta-analytic synthesis

Enhanced cognitive behaviour therapy (CBT-E) has recently generated interest as a potentially useful treatment for eating disorders (ED). In the current study, we conducted a systematic review of the outcome literature on CBT-E, with both narrative and meta-analytic synthesis. We included single-group uncontrolled pre-post design studies and randomised control trials (RCTs) of CBT-E, which allowed us to include a larger number of studies, and also compare the two methodologies in terms of effect size. The primary analysis included 15 CBT-E studies with a total of 948 participants. Narrative synthesis examined bingeing and purging episodes, BMI change, and follow-up results. A large, statistically significant effect supported CBT-E as a treatment for all EDs (g = 1.06). When comparing methodologies, both pre-post design studies (g = 1.26) and RCTs (g = 0.82) yielded large effects. Narrative synthesis outlined reductions in ED behaviours and increases in BMI which were maintained at follow-up. Limitations include that further RCTs of CBT-E are needed to establish clinical effectiveness of this treatment approach for all EDs; however, results from narrative exploration indicate this endeavour would be worthwhile. Despite the limitations, this study provides additional support for CBT-E as a successful treatment across the range of EDs.

Self-image and 12-month outcome in females with eating disorders: extending previous findings

BACKGROUND

The interpersonal Structural Analysis of Social Behavior (SASB) model of self-image has repeatedly proven valuable in relation to eating disorder (ED) symptoms and in predicting ED outcome.

OBJECTIVE

We studied the association between initial self-image according to the SASB and 12-month outcome, in five diagnostic groups of female ED patients. Based on previous findings, we expected autonomy related variables (self-control/autonomy) would strongly predict outcome in anorexia nervosa (AN) groups, whereas variables related to affiliation (self-attack/love) would moderately predict outcome in bulimia nervosa (BN).

METHOD

Participants were adult female patients, of whom 457 had AN restrictive type, 228 AN binge/purge subtype, 861 BN, 505 other specified ED and 170 binge eating disorder. Data came from the Stepwise clinical database in Sweden. Outcomes were presence/absence of ED diagnosis and self-rated ED symptoms, and we controlled for baseline ED pathology, BMI, age and general psychiatric symptoms.

RESULTS

Regression analyses showed that although the pattern differed somewhat between diagnostic groups, high initial self-love and low self-attack/self-blame predicted a more positive 12-month outcome. In some groups (AN/R in particular), these variables remained important even when baseline pathology and age were included in the analyses.

DISCUSSION

Self-image aspects once again display substantial power in predicting outcome in EDs. In AN/R patients, self-love plays an almost as crucial a role as baseline ED pathology in relation to 12-month outcome.

Investigating transdiagnostic factors in eating disorders: Does self-esteem moderate the relationship between perfectionism and eating disorder symptoms?

OBJECTIVE

According to Fairburns transdiagnostic model of eating disorders (EDs), high levels of perfectionism and low self-esteem are two core traits across EDs. This study investigates the role of self-esteem as a transdiagnostic moderator of the relationship between perfectionism and ED symptoms across EDs.

METHOD

A large group of patients (n = 732) completed several questionnaires measuring perfectionism, self-esteem, and disordered eating symptomatology, more specifically, drive for thinness (DFT) and body dissatisfaction (BD).

RESULTS

Across EDs, self-esteem served as a moderator for the association between perfectionism and DFT. However, by testing the model for DFT in each ED separately, the effect only remained in patients with anorexia nervosa and ED not otherwise specified. When testing the model for BD, no moderation effect was found in any of the included EDs.

CONCLUSIONS

This study found that the interaction between perfectionism and self-esteem on DFT can be seen as transdiagnostic, although this effect is not found in each ED separately. These results suggest that ED treatment should consider to not only focus on transdiagnostic factors but also look at the specific impairments of each individual ED.

Looking beyond the mirror: Psychological distress; disordered eating, weight and shape concerns; and maladaptive eating habits in lawyers and law students

Research indicates that, in comparison to professionals and University students in other disciplines, lawyers and law students may be at greater risk of experiencing high levels of psychological distress. There is also a large body of literature supporting an association between stress, anxiety and depression and unhealthy eating. This article reports on the results of a study of Australian legal professionals and law students that evidence a positive association between psychological distress; disordered eating, weight and shape concerns; and maladaptive eating habits in lawyers and law students. Additionally, this study confirms a positive link between frequency of exercise and subjective physical well-being, that in turn is associated with enhanced emotional well-being. Based on the results of this study, we suggest simple yet effective strategies law firms and law schools might adopt to support the mental health of their staff and students.

Transdiagnostic vs. disorder-focused perspective in children and adolescents with eating disorders: Findings from a large multisite exploratory study

BACKGROUND

The transdiagnostic model of eating disorders (ED) proposes common cognitive mechanisms in patients with ED psychopathology. Little is known about their role in the maintenance of ED in children and adolescents. This study aimed to determine whether the relationships between key factors (low self-esteem, weight and shape control, clinical perfectionism, interpersonal problems, distress and mood instability) and core maintaining mechanisms (binge-eating and restraint) would support a transdiagnostic theory in young patients.

METHODS

A total of 419 patients (mean age 14.7 ± 2.14 years; age range: 7-18 years; males 13.8%) diagnosed with an ED were assessed in six Italian clinical centers in 2013. Multiple comparisons between ED diagnosis, correlation analysis and principal component analysis (PCA) were performed.

RESULTS

Of the entire collective, 51.5% of patients were diagnosed with Anorexia Nervosa (AN), 12.3% were diagnosed with Bulimia Nervosa (BN) and 36.2% with Eating Disorder Not Otherwise Specified (EDNOS). In PCA, the core ED mechanisms, dietary restraint and binge eating, acted as poles of attraction of the other variables. The AN group was particularly linked to restraint and the BN group was particularly related to "Bulimia". Considering the diagnostic subtypes, there were no significant differences between the anorexic binge-purging group, bulimic purging group and bulimic non-purging group, which constituted a unique cluster related to affective, interpersonal problems and to perfectionism, indicating a very homogeneous subgroup. Restricting anorexic group (AN-R), related to shape concern and anxious-depressed mood, was not linked to the other subtypes. EDNOS appeared to be opposed to the AN-R group; the binge eating disorder group appeared to be independent from others.

CONCLUSION

Our results suggest the presence of both specific and transdiagnostic mechanisms in ED subtypes, whose knowledge is of relevance for clinical practice.

Evaluation of the DSM-5 Severity Specifier for Bulimia Nervosa in Treatment-Seeking Youth

A new severity specifier for bulimia nervosa (BN), based on the frequency of inappropriate weight compensatory behaviours (e.g., laxative misuse, self-induced vomiting, fasting, diuretic misuse, and excessive exercise), has been added to the most recent (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a means of addressing variability and heterogeneity in the severity of the disorder. While existing research provides support for the DSM-5 severity specifier for BN in adult patients, evidence for its validity and clinical utility in youth is currently lacking. To address this gap, data from 272 treatment-seeking adolescents with DSM-5 BN (94.2% female, M _age = 15.3 years, SD 1.7) were analysed to examine whether these patients, sub-grouped based on the DSM-5 severity definitions, would show meaningful differences in a broad range of clinical variables and demographic and physical characteristics. Analyses revealed that participants categorized with mild, moderate, severe, and extreme severity of BN significantly differed from each other in 15 variables regarding eating disorder pathological features and putative maintenance factors (i.e., core low self-esteem, perfectionism, social appearance anxiety, body surveillance, and mood intolerance), health-related quality of life and comorbid psychiatric (i.e., affective and anxiety) disorders (large effect sizes). Between-group differences in demographics, body mass index, or age-of-BN onset were not observed. Collectively, our findings provide support for the utility of the frequency of inappropriate weight compensatory behaviours as a severity indicator for BN and suggest that age-at-onset of BN is probably more disorder- than severity-dependent. Implications for future research are outlined.

Conceptualising Binge Eating: A Review of the Theoretical and Empirical Literature

Binge eating is a distressing symptom common to bulimia nervosa (BN), anorexia nervosa binge/purge subtype (AN-BP) and binge-eating disorder (BED). Over the last 40 years, many attempts have been made to conceptualise this symptom in terms of its antecedents, function, triggers, consequences, and maintaining factors. Cognitive theories of binge eating have evolved as new evidence has emerged. This literature review summarises the main and most influential cognitive models of binge eating across different eating disorder presentations. Many theories have examined binge eating in the context of restriction or compensatory behaviours, as is often observed in cases of BN. Few theories have examined binge eating as it occurs in BED specifically. The long-term efficacy of cognitive behavioural therapy (CBT) treatment based on these models leaves much to be desired, and indicates that there may be maintaining factors of binge eating not addressed in the typical CBT treatment for eating disorders. More recent cognitive models of binge eating propose possible maintaining beliefs, but further study is required to validate these models. Suggestions for future research are presented.

Social anxiety and disordered eating: The influence of stress reactivity and self-esteem

While previous research indicates a strong link between social anxiety and disordered eating, more research is needed in order to understand the mechanisms that underlie this relationship. Given that stress is often implicated in disordered eating, it was hypothesised that ones reaction to stress (i.e. stress reactivity) would mediate the relationship between social anxiety and disordered eating. Similarly, given that low self-esteem is commonly reported in both those with social anxiety and eating disorders, it was hypothesised that self-esteem would also mediate the relationship between social anxiety and disordered eating. In order to test this, an online survey measuring social anxiety, disordered eating, stress reactivity and self-esteem, was administered to 282 participants in the community, aged between 18 and 35years. Results showed that self-esteem and a reactivity to stress during social conflict - but not during negative social evaluations - partially mediated the relationship between social anxiety and disordered eating. These findings demonstrate that low self-esteem and interpersonal conflict are powerful mechanisms that can maintain eating disorder psychopathology in those who are socially anxious. This highlights the importance of ensuring that these mechanisms are sufficiently addressed in eating disorder prevention and treatment programs.

Correlates of the over-evaluation of weight and shape in binge eating disorder and mixed eating disorder samples: A meta-analytic review

This meta-analysis assessed the strength of the association between correlates of shape and weight over-evaluation across binge eating disorder and mixed eating disorder samples. Across 32 studies, over-evaluation correlates were divided into demographic, eating pathology, or psychosocial. Shape and weight over-evaluation was associated with higher eating pathology and psychosocial impairment. The method of assessment (interview versus self-report questionnaire) moderated some of the relationships. Over-evaluation was unrelated to demographics and treatment outcome. These findings highlight the importance of addressing shape and weight over-evaluation during treatment, and support the idea of using shape and weight over-evaluation as a severity specifier for binge eating disorder.

Testing the DSM-5 severity indicator for bulimia nervosa in a treatment-seeking sample

PURPOSE

This study tested the new DSM-5 severity criterion for bulimia nervosa (BN) based on the frequency of inappropriate weight compensatory behaviors in a treatment-seeking sample.

METHODS

Participants were 345 adults with DSM-5 BN presenting for treatment. They were sub-grouped based on DSM-5 severity levels and compared on a range of variables of clinical interest and demographics.

RESULTS

Based on DSM-5 severity definitions, 27.2 % of the sample was categorized with mild, 26.1 % with moderate, 24.9 % with severe, and 21.8 % with extreme severity of BN. Analyses revealed that the four (mild, moderate, severe, and extreme) severity groups of BN significantly differed from each other in eating disordered and body-related attitudes and behaviors, factors involved in the maintenance process of the disorder, comorbid psychiatric disorders, psychological distress, and psychosocial impairment (medium-to-large effect sizes). No significant between-group differences were observed in demographics, body mass index, or at the age when BN first occurred, lending some credence to recent suggestions that age-at-onset of BN may be more a disorder- than a severity-dependent variable.

CONCLUSIONS

Collectively, our findings provide support for the severity indicator for BN introduced in the DSM-5 as a means of addressing heterogeneity and variability in the severity of the disorder.

A systematic review of the existing models of disordered eating: Do they inform the development of effective interventions?

Despite significant advances in the development of prevention and treatment interventions for eating disorders and disordered eating over the last decade, there still remains a pressing need to develop more effective interventions. In line with the 2008 Medical Research Council (MRC) evaluation framework from the United Kingdom for the development and evaluation of complex interventions to improve health, the development of sound theory is a necessary precursor to the development of effective interventions. The aim of the current review was to identify the existing models for disordered eating and to identify those models which have helped inform the development of interventions for disordered eating. In addition, we examine the variables that most commonly appear across these models, in terms of future implications for the development of interventions for disordered eating. While an extensive range of theoretical models for the development of disordered eating were identified (N=54), only ten (18.5%) had progressed beyond mere description and to the development of interventions that have been evaluated. It is recommended that future work examines whether interventions in eating disorders increase in efficacy when developed in line with theoretical considerations, that initiation of new models gives way to further development of existing models, and that there be greater utilisation of intervention studies to inform the development of theory.

Testing the cognitive-behavioural maintenance models across DSM-5 bulimic-type eating disorder diagnostic groups: a multi-centre study

The original cognitive-behavioural (CB) model of bulimia nervosa, which provided the basis for the widely used CB therapy, proposed that specific dysfunctional cognitions and behaviours maintain the disorder. However, amongst treatment completers, only 40-50 % have a full and lasting response. The enhanced CB model (CB-E), upon which the enhanced version of the CB treatment was based, extended the original approach by including four additional maintenance factors. This study evaluated and compared both CB models in a large clinical treatment seeking sample (N = 679), applying both DSM-IV and DSM-5 criteria for bulimic-type eating disorders. Application of the DSM-5 criteria reduced the number of cases of DSM-IV bulimic-type eating disorders not otherwise specified to 29.6 %. Structural equation modelling analysis indicated that (a) although both models provided a good fit to the data, the CB-E model accounted for a greater proportion of variance in eating-disordered behaviours than the original one, (b) interpersonal problems, clinical perfectionism and low self-esteem were indirectly associated with dietary restraint through over-evaluation of shape and weight, (c) interpersonal problems and mood intolerance were directly linked to binge eating, whereas restraint only indirectly affected binge eating through mood intolerance, suggesting that factors other than restraint may play a more critical role in the maintenance of binge eating. In terms of strength of the associations, differences across DSM-5 bulimic-type eating disorder diagnostic groups were not observed. The results are discussed with reference to theory and research, including neurobiological findings and recent hypotheses.

Body Dissatisfaction and Eating Disorder Symptomatology: A Latent Structural Equation Modeling Analysis of Moderating Variables in 18-to-28-Year-Old Males

Although body dissatisfaction is recognized as the strongest risk factor for eating disturbances, a majority of young males are body dissatisfied, but do not concomitantly report severe levels of eating disorder symptomatology. The present investigation was designed to examine five theoretically relevant variables (i.e., body checking, emotional dysregulation, perfectionism, insecure-anxious attachment, and self-esteem) as potential moderators of the relationship between body dissatisfaction and two critical components of male eating disorder symptomatology: drive for muscularity and bulimic behaviors. Data collected from 551 Italian males between 18 and 28 years old were analyzed using latent structural equation modeling. The authors found that emotional dysregulation, body checking, insecure-anxious attachment and perfectionism intensified the relationship between body dissatisfaction and each criterion variable representing male eating disorder symptomatology; the interactions accounted respectively for an additional 2%, 7%, 4% and 5% of variance in drive for muscularity and for an additional 6%, 4%, 5%, and 2% of the variance in bulimic behaviors. By contrast self-esteem weakened this relationship and the interactions accounted for an additional 3% of the variance in both drive for muscularity and bulimic behaviors. Implications of these findings for prevention and treatment of male eating disturbances are discussed.

The relationship between interpersonal problems, therapeutic alliance, and outcomes following group and individual cognitive behaviour therapy

BACKGROUND

Cognitive behavioural therapy (CBT) is efficacious, but there remains individual variability in outcomes. Patient's interpersonal problems may affect treatment outcomes, either directly or through a relationship mediated by helping alliance. Interpersonal problems may affect alliance and outcomes differentially in individual and group (CBGT) treatments. The main aim of this study was to investigate the relationship between interpersonal problems, alliance, dropout and outcomes for a clinical sample receiving either individual or group CBT for anxiety or depression in a community clinic.

METHODS

Patients receiving individual CBT (N=84) or CBGT (N=115) completed measures of interpersonal problems, alliance, and disorder specific symptoms at the commencement and completion of CBT.

RESULTS

In CBGT higher pre-treatment interpersonal problems were associated with increased risk of dropout and poorer outcomes. This relationship was not mediated by alliance. In individual CBT those who reported higher alliance were more likely to complete treatment, although alliance was not associated with symptom change, and interpersonal problems were not related to attrition or outcome.

LIMITATIONS

Allocation to group and individual therapy was non-random, so selection bias may have influenced these results. Some analyses were only powered to detect large effects. Helping alliance ratings were high, so range restriction may have obscured the relationship between helping alliance, attrition and outcomes.

CONCLUSIONS

Pre-treatment interpersonal problems increase risk of dropout and predict poorer outcomes in CBGT, but not in individual CBT, and this relationship is not mediated by helping alliance. Stronger alliance is associated with treatment completion in individual, but not group CBT.

Comprehensive examination of the trans-diagnostic cognitive behavioral model of eating disorders in males

The Trans-diagnostic Model (TM) of eating pathology describes how one or more of four hypothesized mechanisms (i.e., mood intolerance, core low self-esteem, clinical perfectionism and interpersonal difficulties) may interrelate with each other and with the core psychopathology of eating disorders (i.e., over-evaluation of weight and shape) to maintain the disordered behaviors. Although a cognitive behavioral treatment based on the TM has shown to be effective in treating eating disorders, the model itself has undergone only limited testing. This is the first study to both elaborate and test the validity of the TM in a large sample (N=605) of undergraduate men. Body mass index was controlled within structural equation modeling analyses. Although not all expected associations for the maintenance variables were significant, overall the validity of the model was supported. Concern about shape and weight directly led to exercise behaviors. There was a direct path from binge eating to exercise and other forms of compensatory behaviors (i.e., purging); but no significant path from restriction to binge eating. Of the maintaining factors, mood intolerance was the only maintaining variable directly linked to men's eating disorder symptoms. The other three maintaining factors of the TM indirectly impacted restriction through concerns about shape and weight, whereas only interpersonal difficulties predicted low self-esteem and binge eating. Potential implications for understanding and targeting eating disturbances in men are discussed.

Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample: a structural equation model

OBJECTIVES

Childhood maltreatment occurs often among those with an eating disorder and is considered a nonspecific risk factor. However, the mechanisms by which childhood maltreatment may lead to an eating disorder are not well understood. The current study tests a model in which attachment insecurity is hypothesized to mediate the relationship between childhood maltreatment and eating disorder psychopathology.

METHOD

Treatment seeking adults with eating disorders (N=308) completed questionnaires about childhood maltreatment, eating disorder psychopathology, and adult attachment.

RESULTS

Structural equation models indicated that childhood trauma had a direct effect on eating disorder symptoms. Also, attachment anxiety and avoidance each equally mediated the childhood maltreatment to eating disorder psychopathology relationship.

CONCLUSIONS

Attachment insecurity, characterized by affect dysregulation and interpersonal sensitivities may help to explain why eating disorder symptoms may be one consequence of childhood maltreatment in a clinical sample. Clinicians treating primarily those with trauma might assess for disordered eating as a potential manifestation of the sequelae of trauma and attachment insecurity.

The relationship between interpersonal problems, negative cognitions, and outcomes from cognitive behavioral group therapy for depression

BACKGROUND

Interpersonal functioning is a key determinant of psychological well-being, and interpersonal problems (IPs) are common among individuals with psychiatric disorders. However, IPs are rarely formally assessed in clinical practice or within cognitive behavior therapy research trials as predictors of treatment attrition and outcome. The main aim of this study was to investigate the relationship between IPs, depressogenic cognitions, and treatment outcome in a large clinical sample receiving cognitive behavioral group therapy (CBGT) for depression in a community clinic.

METHODS

Patients (N=144) referred for treatment completed measures of IPs, negative cognitions, depression symptoms, and quality of life (QoL) before and at the completion of a 12-week manualized CBGT protocol.

RESULTS

Two IPs at pre-treatment, 'finding it hard to be supportive of others' and 'not being open about problems,' were associated with higher attrition. Pre-treatment IPs also predicted higher post-treatment depression symptoms (but not QoL) after controlling for pre-treatment symptoms, negative cognitions, demographics, and comorbidity. In particular, 'difficulty being assertive' and a 'tendency to subjugate one's needs' were associated with higher post-treatment depression symptoms. Changes in IPs did not predict post-treatment depression symptoms or QoL when controlling for changes in negative cognitions, pre-treatment symptoms, demographics, and comorbidity. In contrast, changes in negative cognitions predicted both post-treatment depression and QoL, even after controlling for changes in IPs and the other covariates.

LIMITATIONS

Correlational design, potential attrition bias, generalizability to other disorders and treatments needs to be evaluated.

CONCLUSIONS

Pre-treatment IPs may increase risk of dropout and predict poorer outcomes, but changes in negative cognitions during treatment were most strongly associated with improvement in symptoms and QoL during CBGT.

Adding thin-ideal internalization and impulsiveness to the cognitive-behavioral model of bulimic symptoms

This study evaluated the cognitive-behavioral (CB) model of bulimia nervosa and an extension that included two additional maintaining factors - thin-ideal internalization and impulsiveness - in 327 undergraduate women. Participants completed measures of demographics, self-esteem, concern about shape and weight, dieting, bulimic symptoms, thin-ideal internalization, and impulsiveness. Both the original CB model and the extended model provided good fits to the data. Although structural equation modeling analyses suggested that the original CB model was most parsimonious, hierarchical regression analyses indicated that the additional variables accounted for significantly more variance. Additional analyses showed that the model fit could be improved by adding a path from concern about shape and weight, and deleting the path from dieting, to bulimic symptoms. Expanding upon the factors considered in the model may better capture the scope of variables maintaining bulimic symptoms in young women with a range of severity of bulimic symptoms.