An examination of the Clinical Impairment Assessment among women at high risk for eating disorder onset

Eating disorder-related functional impairment predicts greater depressive symptoms across one semester of college

Eating disorder (ED) behaviors and depression are associated with numerous negative outcomes, including lower quality of life and functional impairment. College women are at elevated risk for both. Prior research indicates ED behaviors, including binge eating, self-induced vomiting, and fasting, predict increases in future depressive symptoms. However, symptom heterogeneity in EDs is common, and all disordered eating, or its associated distress, cannot be captured by the endorsement of behaviors. Impairment that results from ED behaviors may be a comparable, or stronger, predictor of depressive symptoms. We sought to characterize the longitudinal relationship between ED-related functional impairment, ED behaviors, and depressive symptoms. College-aged women [N = 304; 72 % white, mean (SD) age = 18.45 (0.88)] completed an online survey in August (baseline), and then three months later in November (follow-up). Baseline ED-related functional impairment, but not baseline ED behaviors, significantly predicted depressive symptoms at follow-up, controlling for baseline depressive symptoms, negative affect, and body mass index. Findings indicate ED-related functional impairment is a risk factor for increases in depressive symptoms across one semester of college, irrespective of ED behavior engagement, weight status, and dispositional negative affect. Intervening upon ED-related functional impairment may reduce or prevent future depressive symptoms among college-aged women.

Chinese translation of the Clinical Impairment Assessment (CIA 3.0): Psychometric properties and measurement invariance across sex and age in adolescents, young adults, and adult men

The Clinical Impairment Assessment (CIA) is the most widely used instrument for assessing psychosocial impairment related to eating disorders (EDs). The CIA was translated into Chinese based on standard procedures. The psychometric properties of the Chinese CIA (C-CIA) were assessed among four adolescent and adult samples [i.e., 792 junior high school students (47.0% boys; M_age = 13.09 years), 1324 senior high school students (44.2% boys; M_age = 16.06 years), 812 undergraduate students (36.3% boys; M_age = 18.88 years), and 406 male adults from a general population (M_age = 28.53 years)]. The three-factor structure of the CIA was replicated. Excellent internal consistencies of the C-CIA were revealed, α = 0.93-0.98. The C-CIA showed moderate and good test-retest reliability in a six-month interval for junior high school students (ICC = 0.69) and senior high school students (ICC = 0.76), respectively. The C-CIA had good test-retest reliability in a two-week interval for undergraduate students (ICC = 0.78) and general adult men (ICC = 0.81). Our results supported good construct validity, known-group validity of the C-CIA, and measurement invariance across sex and age. These findings suggest that the C-CIA can be a useful tool assessing psychosocial impairment related to EDs for Chinese adolescents, young adults, and adult men.

The validation of a Farsi version of the Clinical Impairment Assessment (F-CIA) among Iranian adolescent boys and girls

PURPOSE

Although some studies have been conducted to examine general psychosocial impairment in Iran, there is no research to date on clinical impairment secondary to disordered eating in Iranian adolescents. The purpose of this study was to evaluate the Farsi version of the Clinical Impairment Assessment (F-CIA) among Iranian adolescents.

METHODS

A total of 1112 adolescents (age_{M [SD]} = 15.55 [1.59], body mass index [zBMI] _{M [SD]} = - 0.00 [1.0]; 54.6% girls) were recruited from four cities (Tehran [Capital], Tabriz [North-Western], Kurdistan [West], and Rasht [North]) in Iran. After translation and back-translation procedures, the F-CIA, Eating Disorder Examination Questionnaire (EDE-Q), and Beck Depression Inventory-Second Edition (BDI-II) were administered to adolescents. We used confirmatory factor analysis (CFA), measurement invariance, independent samples t tests, Pearson correlation, chi-square tests, and internal consistency to test validity and reliability.

RESULTS

CFA indicated that F-CIA demonstrated good fit to the data and supported a three-factor model. The scale was invariant across gender and zBMI. The F-CIA had good internal consistency (αs = 0.76-0.93) and positive associations (rs = 0.13-0.62; p < 0.001) with zBMI, disordered eating symptoms, and binge/purge symptoms. We found no gender differences across mean scores on the F-CIA, but adolescents with higher zBMI reported higher scores on the F-CIA relative to those with lower zBMIs. Finally, adolescents scoring above CIA cutoffs reported higher zBMI, disordered eating outcomes, and depression.

CONCLUSION

Findings suggested that the F-CIA is a reliable and valid measure of clinical eating disorder-related impairment in Iranian adolescents.

LEVEL OF EVIDENCE

III; Evidence obtained from well-designed observational study, including case-control design for relevant aspects of the study.

'Feeling fat,' eating pathology, and eating pathology-related impairment in young men and women

'Feeling fat' has received little empirical attention despite clinical recognition as an eating disorder maintenance factor. This experience also occurs in non-clinical populations and may relate to elements of subclinical eating pathology. The present study examined whether 'feeling fat' independently contributes to eating pathology and eating pathology-related impairment, over and above over-evaluation of weight and shape and dysphoria. University students (N = 990; 54.3% female) completed questionnaires measuring these constructs. Moderated multiple hierarchical regression analyses evaluated 'feeling fat''s unique contribution to eating pathology and impairment, and the moderating effects of gender and eating disorder symptom severity. 'Feeling fat' accounted for significant unique variance in eating pathology, but not eating pathology-related impairment, over and above over-evaluation of weight and shape and dysphoria. The relationship between 'feeling fat' and eating pathology-related impairment was stronger in women than in men. Symptom severity did not moderate the relationship between 'feeling fat' and either dependent variable. 'Feeling fat' distinctly relates to eating pathology in a sample of young adults, suggesting that 'feeling fat' deserves attention in individuals without eating disorders. Future research should longitudinally investigate the direction of the relationship between 'feeling fat' and eating pathology and examine mechanisms of gender differences in 'feeling fat.'

Predicting probable eating disorder case-status in men using the Clinical Impairment Assessment: Evidence for a gender-specific threshold

The Clinical Impairment Assessment (CIA) is a widely used self-report measure of the psychosocial impairment associated with eating-disorder symptoms. Past studies recommended a global CIA score of 16 to identify clinically significant impairment associated with a probable eating disorder (ED). However, to date, research on the properties of the CIA has been conducted in majority-women samples. Preliminary research on gender differences in CIA scores suggested men with EDs report less impairment on the CIA relative to women with EDs. Thus, the purpose of this study was to test if a different impairment threshold is needed to identify cases of men with EDs. We hypothesized that a lower CIA threshold, relative to that identified in majority-women samples, would most accurately identify men with EDs. Participants (N = 162) were men from our university-based and general community-based ED participant registry who completed the CIA and Eating Disorder Diagnostic Scale. Both precision-recall and receiver operating characteristic curves assessed what CIA global score threshold most accurately identified men with EDs. Both analytic approaches indicated that a CIA global score of 13 best predicted ED case-status in men. Consistent with past research, men with a clinically significant ED appear to report lower impairment on the CIA. Results have implications for screening and assessing for substantial ED-related impairment in men. Additionally, past research using the CIA to identify men with EDs may have under-identified men with clinically significant symptoms.

Factor structure and psychometric properties of the clinical impairment assessment 3.0 (CIA) in a clinical eating disorder sample

PURPOSE

The aim of this study was to investigate the psychometric properties and the factor structure of the Clinical Impairment Assessment 3.0 (CIA) utilizing a confirmatory factor analysis in a large clinical sample of ED patients.

METHODS

A total of 260 patients between the ages of 18 and 45 who completed assessments in a partial hospitalization or residential treatment program at an ED treatment facility between December 2012 and December 2016 were included in the analyses. Assessment measures included the CIA, EDE-Q, BDI-II, WHODAS, and a demographic questionnaire.

RESULTS

Results favored a bifactor model with a strong general factor and three unreliable subfactors. The CIA showed strong construct validity with other measures of ED pathology (EDE-Q) and health-related QoL (WHODAS). Furthermore, admission CIA scores were predictive of treatment outcomes.

CONCLUSIONS

The CIA assesses general psychosocial impairment, supporting the use of a total, but not subscale scores, among symptomatic ED samples in the United States.

Are the Criterion B binge-eating symptoms interchangeable in understanding binge-eating severity? An item response theory analysis

OBJECTIVE

The Criterion B binge-eating symptoms represent five symptoms associated with binge eating. Any three out of five symptoms can be used to meet Criterion B. However, Criterion B symptoms may not be interchangeable in terms of how binge-eating severity is associated with each symptom. Item response theory (IRT) can test how endorsing each symptom relates to the overall level (i.e., severity) of binge-eating measured by Criterion B. We used IRT to identify (a) how each Criterion B symptom corresponded with binge-eating severity in a transdiagnostic binge-eating sample and (b) how well each symptom differentiated individuals with differing levels of severity.

METHOD

Participants (N = 219) were adults (80.8% female) with a current ED that included objective binge-eating episodes assessed via semi-structured interview. A two-parameter logistic IRT model evaluated how endorsement of each Criterion B symptom corresponded with the level of latent binge-eating severity.

RESULTS

"Eating large amounts when not hungry" and "eating alone" reflected the highest binge-eating severity. "Eating alone" was the best discriminator across different binge-eating severity levels, whereas "uncomfortably full" was the poorest discriminator across binge-eating severity levels.

DISCUSSION

Criterion B symptoms were not interchangeable in terms of what level of binge-eating severity corresponded with symptom endorsement. "Eating large amounts when not hungry" or "eating alone" may signify elevated binge-eating severity, whereas "uncomfortably full" and "feeling disgusted/depressed/guilty" were not necessarily indicative of elevated severity. Results suggested that Criterion B may need to be revised to eliminate symptoms that are redundant with other binge-eating diagnostic criteria.

Examining the factor structure, sex invariance, and psychometric properties of the Body Image Acceptance and Action Questionnaire and the Functionality Appreciation Scale

Body image flexibility and functionality appreciation are two facets of positive body image gaining significant research attention. The measures that assess these constructs- the Body Image Acceptance and Action Questionnaire (BI-AAQ) and Functionality Appreciation Scale (FAS), respectively-have produced a unidimensional structure with adequate psychometric properties. However, the cross-sex invariance of the BI-AAQ has yet to be established, and replicating the FAS' one-factor structure is needed. We examined the factor structure, cross-sex invariance, and psychometric properties of the BI-AAQ and FAS. Data were analyzed from 383 men and 631 women who completed questionnaires (participants were not restricted to a specific country). An unacceptable model fit for the BI-AAQ was found for men and women, indicating that the unidimensional structure was not replicated. The unidimensional structure of the FAS and an abbreviated 5-item BI-AAQ was replicated, and tests of measurement invariance between men and women were upheld. Evidence of internal consistency, convergent validity, and incremental validity for the abbreviated BI-AAQ and FAS was found. Overall, the abbreviated BI-AAQ and the FAS appear to be psychometrically sound measures of positive body image. Findings suggest that sex comparisons on the abbreviated BI-AAQ and FAS are permissible.

Validation of the Portuguese version of the Clinical Impairment Assessment (CIA) in eating disorders' patients

PURPOSE

The purpose of the study was to assess the psychometric properties of the Portuguese version of the Clinical Impairment Assessment (CIA) in eating disorders (ED) patients.

METHOD

The CIA is a 16-item brief self-reported instrument developed to assess psychosocial impairment secondary to EDs. The CIA was administered to a clinical sample of 237 women with EDs and a college sample of 196 women. The clinical sample completed the Eating Disorders Examination Questionnaire, the Beck Depression Inventory and the Outcome-45 Questionnaire. Reliability, confirmatory factor analysis, validity, and clinically significant change were calculated.

RESULTS

Confirmatory factor analysis validated the original 3-factor structure showing an adequate model fit. CIA showed good psychometric properties with high internal consistency, good convergent validity with the EDE-Q, the OQ-45, and the BDI. For divergent validity, participants CIA scores in the clinical sample were significantly higher than in the non-clinical sample. ROC curve analysis provided a cutoff of 15. For known-groups validity participants' scoring above CIA cutoff reported significantly higher CIA scores. In addition, non-underweight participants and participants reporting the presence of dysfunctional ED behaviors had significantly higher CIA scores. Finally, for clinically significant change, a reliable change index of 5 points was obtained to consider a reliable change in the CIA global score.

CONCLUSIONS

Our findings support the validity and clinical utility of the CIA as a good self-report measure to be used in both clinical and research settings.

LEVEL OF EVIDENCE

Level V. Cross-sectional descriptive study.

Relationship between Psychosocial Impairment, Food Choice Motives, and Orthorexic Behaviors among Polish Adults

Orthorexic behaviors correlate not only with health motives when choosing food but may also coexist with psychosocial impairment. The aim of this study was to assess the motives of food choice and psychosocial impairment among adults with orthorexic behaviors through the use of ORTO-15 and ORTO-7. The data for the study were collected from a sample of 1007 Polish adults through a cross-sectional quantitative survey conducted in 2019. The respondents were asked to complete the ORTO-15 questionnaire, the Food Choice Questionnaire (FCQ), and the Clinical Impairment Assessment (CIA). Orthorexic behaviors were measured using both the 15-item and the shorter 7-item version of the ORTO questionnaire. To determine the factors coexisting with the orthorexic behaviors, linear regression models were developed. The scores of both ORTO-15 and ORTO-7 correlated positively with the global CIA scores and the scores of personal, cognitive, and social impairments, but compared to the ORTO-7 scores, the ORTO-15 scores showed weaker correlations with the global CIA score and individual CIA scales. Orthorexic behaviors measured with ORTO-15 correlated positively with such food choice motives as health, natural content, and weight control; whereas orthorexic behaviors measured with ORTO-7 showed positive bivariate correlations only with two food choice motives: health and weight control. In regression models, sensory appeal, age, and education lower than secondary were associated inversely with orthorexic behaviors measured by both the ORTO-15 and the ORTO-7. In conclusion, the obtained results confirm that orthorexic behaviors are associated with a higher score regarding health motivation and cause an increase in psychosocial impairment. In addition, orthorexic behaviors are associated with greater importance of body weight control, which confirms the relationship between orthorexic behaviors and other eating disorders (ED), such as anorexia nervosa (AN) and bulimia nervosa (BN). However, similar motives for food choice displayed by the groups with higher scores of the ORTO-15 and the ORTO-7 and strong correlation between results obtained from both tools confirmed the similarity between these two questionnaires, thus revealing the weak psychometric properties also of the shorter seven-item version of the ORTO. Future studies on food motives, psychosocial impairment, and orthorexic behaviors should consider using other tools for measuring orthorexic behaviors.

Further development of the 12-item EDE-QS: identifying a cut-off for screening purposes

BACKGROUND

The Eating Disorder Examination - Questionnaire Short (EDE-QS) was developed as a 12-item version of the Eating Disorder Examination Questionnaire (EDE-Q) with a 4-point response scale that assesses eating disorder (ED) symptoms over the preceding 7 days. It has demonstrated good psychometric properties at initial testing. The purpose of this brief report is to determine a threshold score that could be used in screening for probable ED cases in community settings.

METHODS

Data collected from Gideon et al. (2016) were re-analyzed. In their study, 559 participants (80.86% female; 9.66% self-reported ED diagnosis) completed the EDE-Q, EDE-QS, SCOFF, and Clinical Impairment Assessment (CIA). Discriminatory power was compared between ED instruments using receiver operating characteristic (ROC) curve analyses.

RESULTS

A score of 15 emerged as the threshold that ensured the best trade-off between sensitivity (.83) and specificity (.85), and good positive predictive value (.37) for the EDE-QS, with discriminatory power comparable to other ED instruments.

CONCLUSION

The EDE-QS appears to be an instrument with good discriminatory power that could be used for ED screening purposes.

My fitness pal usage in men: Associations with eating disorder symptoms and psychosocial impairment

My Fitness Pal (MFP) is a calorie-tracking smartphone application that is gaining popularity worldwide. Although MFP has the potential to be a cheap and efficient weight-loss tool, concerns that MFP could trigger, maintain, or exacerbate eating disorder symptoms have been raised. Preliminary research has documented associations between MFP use and eating disorder symptoms in women with eating disorders and in undergraduate students. However, whether these associations exist additionally in a male-only sample has not been tested. Thus, we aimed to estimate MFP usage and examine its association with eating disorder symptoms and psychosocial impairment in a male sample. Cross-sectional data were analysed from 122 male participants (M_age = 28.4, SD = 8.93) recruited primarily through fitness-related social media sites. Around half (56%) of the sample reported having used MFP. Nearly 40% of users perceived MFP as a factor contributing to disorder eating symptoms to some extent. MFP users reported significantly higher levels of attitudinal (dichotomous thinking, shape, weight, and eating concerns) and behavioural (binge eating, dietary restraint) eating disorder symptoms and psychosocial impairment than non-users. Effect sizes were large. MFP use also predicted unique variance in global attitudinal symptoms after controlling for eating disorder behaviours, impairment, and demographics. That nearly one-third of men perceived MFP as a factor contributing to their disordered eating highlights the possible utility of enquiring about the use of calorie-tracking apps when screening and assessing for eating disorder symptoms in men.

Eating Disorders in Sport: Comparing Eating Disorder Symptomatology in Athletes and Non-Athletes During Intensive Eating Disorder Treatment

The current study tested if athlete patients differed from non-athlete patients in measures of eating disorder (ED) and related pathology. Athlete (n = 91 in Study 1; n = 39 in Study 2) and non-athlete (n = 76 in Study 1; n = 26 in Study 2) patients completed self-report measures, and body mass index (BMI) was calculated. Athlete patients had significantly lower ED symptomatology and depression than non-athlete patients (ps < .05). ED impairment, worry, psychosocial functioning, BMI, obsessive-compulsiveness, and compulsive exercise did not significantly differ between groups (ps > .08). Greater ED symptomatology was associated with higher psychosocial functioning among athlete patients and higher obsessive-compulsive symptoms and compulsive exercise among non-athlete patients. This is a novel study comparing ED symptomatology and related measures of mental health in athlete and non-athlete patients engaged in residential or partial hospitalization ED treatment. Future research should further investigate how participation in high-level sport impacts the presentation, treatment, and outcome of individuals with EDs.

The clinical impairment assessment questionnaire: validation in Italian patients with eating disorders

BACKGROUND

The Clinical Impairment Assessment (CIA) is a measure of functional impairment secondary to eating disorder symptoms.

AIM

The aim of this study was to examine the psychometric proprieties of the Italian-language version of the CIA.

METHODS

The tool was translated into Italian and administered to 259 Italian-speaking in- and outpatients with eating disorders and 102 healthy controls. The clinical group also completed the Eating Disorder Examination Questionnaire (EDE-Q) and the Brief Symptom Inventory (BSI).

RESULTS

Confirmatory factor analysis revealed a good fit for the original three-factor structure. Internal consistency was high for both the global CIA and all subscale scores, and test-retest reliability was acceptable. The high correlation between CIA and EDE-Q and BSI confirmed the convergent validity of the instrument. T test indicated higher raw scores on CIA in patients with eating disorders than healthy controls, and a cut-off score of 16 on the CIA discriminated between eating disorder and general psychopathology scores. Finally, global CIA and subscale scores were significantly higher in patients who reported objective bulimic episodes, purging behaviours, and excessive exercising than in those who did not; in underweight than in not-underweight patients, and in inpatients than outpatients, confirming the good known-groups validity of the tool.

CONCLUSIONS

Overall, the study showed the good psychometric properties of the Italian version of the CIA, and validated its use in Italian-speaking eating disorder patients.

LEVEL OF EVIDENCE

Level V, Descriptive study.

Online prevention of disordered eating in at-risk young-adult women: a two-country pragmatic randomized controlled trial

BACKGROUND

Disordered eating (DE) is a widespread, serious problem. Efficacious prevention programs that can be delivered at-scale are needed.

METHODS

A pragmatic randomized controlled trial of two online programs was conducted. Participants were young-adult women from Australia and New Zealand seeking to improve their body image. Media Smart-Targeted (MS-T) and Student Bodies (SB) were both 9-module interventions released weekly, whilst control participants received positive body image information. Primary [Eating Disorder Examination-Questionnaire (EDE-Q) Global], secondary (DE risk factors) and tertiary (DE) outcome measures were completed at baseline, post-program, 6- and 12-month follow-up.

RESULTS

Baseline was completed by 608 women (M age = 20.71 years); 33 were excluded leaving 575 randomized to: MS-T (N = 191); SB (N = 190) or control (N = 194). Only 66% of those randomized to MS-T or SB accessed the intervention and were included in analyses with controls; 78% of this sample completed measures subsequent to baseline. Primary intent-to-treat (ITT) analyses revealed no differences between groups, while measure completer analyses found MS-T had significantly lower EDE-Q Global than controls at 12-month follow-up. Secondary ITT analyses found MS-T participants reported significantly higher quality of life-mental relative to both SB and controls (6-month follow-up), while MS-T and controls had lower clinical impairment relative to SB (post-program). Amongst measure completers, MS-T scored significantly lower than controls and SB on 5 variables. Of those with baseline DE, MS-T participants were significantly less likely than controls to have DE at 12-month follow-up.

CONCLUSIONS

Given both programs were not therapist-moderated, MS-T has potential to achieve reductions in DE risk at low implementation costs.

Evidence That the Clinical Impairment Assessment (CIA) Subscales Should Not Be Scored: Bifactor Modelling, Reliability, and Validity in Clinical and Community Samples

Aim: The Clinical Impairment Assessment (CIA 3.0) is the most widely used instrument assessing psychosocial impairment secondary to eating disorder symptoms. However, there is conflicting advice regarding the dimensionality and optimal method of scoring the CIA. We sought to resolve this confusion by conducting a comprehensive factor analytic study of the CIA in a community sample ( N = 301) and clinical sample comprising patients with a diagnosed eating disorder ( N = 209). Convergent and discriminant validity were also assessed. Method: The CIA and measures of eating disorder symptoms were administered to both samples. Results: Factor analyses indicated there is a general impairment factor underlying all items on the CIA that is reliably measured by the CIA Global score. CIA Global demonstrated good convergent and discriminant validity. Conclusions: CIA Global is a reliable and valid measure of psychosocial impairment secondary to eating disorder symptoms; however, subscale scores should not be computed.

Depression, worry, and psychosocial functioning predict eating disorder treatment outcomes in a residential and partial hospitalization setting

This retrospective study explores depression, worry, psychosocial functioning, and change in body mass index (BMI) as predictors of eating disorder (ED) symptomatology and BMI at discharge and 1-year follow-up from a residential and partial hospitalization ED treatment center. Participants were 423 male and female patients receiving treatment at an ED treatment center. Results indicate significant improvement in ED symptomatology, psychological impairment, and change in BMI (in patients with anorexia nervosa) at treatment discharge and follow-up compared to treatment admission (ps < 0.001). Depression and worry predicted ED symptomatology and psychological impairment at discharge (ps < 0.05). Depression, worry, and psychosocial functioning predicted ED symptomatology and psychological impairment at 1-year follow-up (ps < 0.001). Change in BMI was not a significant predictor of outcome. Depression, worry, and psychosocial functioning each play a role in treatment outcomes and may help clarify who might benefit from treatment. Clinicians in ED treatment centers should consider these as areas of focus for improved outcomes.

Eating Disorder Examination Questionnaire (EDE-Q) and Clinical Impairment Assessment (CIA): clinical norms and functional impairment in male and female adults with eating disorders

AIM

The aim of the current study was to collect clinical normative data for the Clinical Impairment Assessment questionnaire (CIA) and the Eating Disorder Examination Questionnaire (EDE-Q) from adult patients with eating disorders (EDs). This study also examined unique contributions of eating disorder (ED) symptoms on levels of ED-related impairment.

METHODS

A sample of 667 patients, 620 females and 47 males, was recruited from six specialist centres across Norway. The majority of the sample (40.3%) was diagnosed with eating disorder not otherwise specified (EDNOS), 34.5% had bulimia nervosa (BN), and 25.2% were diagnosed with anorexia nervosa (AN).

RESULTS

There were significant differences for global EDE-Q and CIA scores between females and males. In the female sample, significant differences were found on several EDE-Q sub-scales between the AN and BN group, and between the AN and EDNOS group. No significant differences were found between the diagnostic groups on the CIA. In the male sample, no significant differences were found between diagnostic groups on the EDE-Q or CIA. A multiple regression analysis revealed that 46.8% of the variance in impairment as measured by the CIA was accounted for by ED symptoms.

CONCLUSIONS

Body mass index, Eating Concern, Shape/Weight Concern, and binge eating served as significant, unique predictors of impairment. The results from the present study contribute to the interpretation of EDE-Q and CIA scores in ED samples.

Perfectionism, emotion dysregulation, and affective disturbance in relation to clinical impairment in college-age women at high risk for or with eating disorders

Individuals with eating disorders (EDs) demonstrate impaired quality of life; however, less than one-third report severe clinical impairment. Thus, it is important to determine factors that may identify those who are most likely to report marked impairment. Perfectionism, emotion dysregulation, and aspects of affective disturbance, such as anxiety and depression, are independently associated with eating pathology and clinical impairment in eating and other disorders. However, little research has explored these three factors concurrently in relation to eating pathology. It is possible that the combined interaction effect of these constructs could be especially harmful. The current study examined the influence of these constructs and their interactions on clinical impairment in college-aged women at high risk for or with a DSM-5 clinical or subclinical ED. Although the three-way interaction of perfectionism, emotion dysregulation, and affective disturbance (i.e., anxiety or depression) was not significant, the two-way interaction between perfectionism and emotion dysregulation was significant such that those who were high in both perfectionism and emotion dysregulation reported the highest levels of clinical impairment. This suggests that the combination of perfectionism and emotion dysregulation may be especially problematic for those with or at high risk for EDs. Interestingly, perfectionism alone was not a predictor of clinical impairment when accounting for the other constructs, implying that perfectionism may have a greater impact when in conjunction with emotion dysregulation. Understanding the impact of combined perfectionistic tendencies and emotion dysregulation on clinical impairment may better inform treatment and more directly target contributors to impaired quality of life.

Predictors of change in psychosocial impairment secondary to an eating disorder

Eating disorders (ED) can significantly impair psychosocial health in patients. However, no published studies have so far used a standardized and specific instrument to evaluate predictive factors in ED-related psychosocial impairment. This prospective cohort study involved 177 patients receiving outpatient treatment for an ED at baseline and 115 patients at the 1-year follow-up. Patients completed three self-administered questionnaires: the Clinical Impairment Assessment (CIA), the Eating Attitudes Test-12 (EAT-12), and the Health-Related Quality of Life in ED-short form (HeRQoLED-s). Descriptive statistics, ANOVA, chi-square, and Fisher's exact test were applied to examine intervariable relationships. Multivariate linear regression was used to determine predictors of change in CIA scores. An improvement was reported by patients with restrictive anorexia nervosa (AN) compared to those with purgative AN. In the multivariate analysis, employment status, subtype of ED, and the bulimia and food preoccupation factor of the EAT-12 were significant predictors of change in the CIA scores.

Impairment due to eating disorder pathology: Identifying the cut-off score on the Clinical Impairment Assessment in a clinical and community sample

OBJECTIVE

The Clinical Impairment Assessment (CIA) is a self-report measure of impairment secondary to eating disorder (ED) features. The purpose of this study was to identify the global CIA cut-off score that maximized sensitivity and specificity to discriminate impairment due to eating disorder pathology in a community versus clinical ED sample using receiver operating characteristic (ROC) analyses.

METHOD

Participants were 1,468 female community participants and 552 eating disorder patients.

RESULTS

Mean global CIA scores were 5.17 (SD 7.61) and 32.50 (SD 10.20). The ROC analysis demonstrated excellent accuracy of the global CIA score (AUC = 0.97; 95% CI: 0.96-0.98). A cut-off score of 16.0 yielded a sensitivity of 0.91 (95% CI: 0.88-0.93) and a specificity of 0.91 (95% CI: 0.89-0.93).

DISCUSSION

This study is the first to replicate findings from the original development study of the CIA and lends support to initial recommendations. Data provide strong evidence of the discriminant validity of the CIA and suggest the utility of assessing eating-disorder related impairment for classification purposes. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:635-638).

Attention-deficit/hyperactivity disorder-specific stimulant misuse, mood, anxiety, and stress in college-age women at high risk for or with eating disorders

OBJECTIVE

To examine the misuse of attention-deficit/hyperactivity disorder (ADHD)-specific stimulants in a college population at high risk for or with clinical or subclinical eating disorders.

PARTICIPANTS

Four hundred forty-eight college-age women aged 18-25 at high risk for or with a clinical or subclinical eating disorder.

METHODS

Participants completed assessments of stimulant misuse and psychopathology from September 2009 to June 2010.

RESULTS

Greater eating disorder pathology, objective binge eating, purging, eating disorder-related clinical impairment, depressive symptoms, perceived stress, and trait anxiety were associated with an increased likelihood of stimulant misuse. Subjective binge eating, excessive exercise, and dietary restraint were not associated with stimulant misuse.

CONCLUSIONS

ADHD-specific stimulant misuse is associated with eating disorder and comorbid pathology among individuals at high risk for or with clinical or subclinical eating disorders. Screening for stimulant misuse and eating disorder pathology may improve identification of college-age women who may be engaging in maladaptive behaviors and inform prevention efforts.

Loss of control eating in adolescents from the community

OBJECTIVE

Loss of control (LOC) eating is a salient indicator of eating disorder psychopathology in adolescents and is associated with marked distress. While research has focused on the relevance of episode size, clinical significance of LOC eating frequency has rarely been explored. Therefore, this study aimed at identifying LOC eating prevalence with respect to its recurrence and associated variables in a community-based sample.

METHOD

Participants were 1,643 adolescents, aged 12-20 years (62.4% female). Based on EDE-Q self-report, participants were categorized as those reporting recurrent (N = 156; 9.5%), nonrecurrent (N = 226; 13.8%), and no LOC eating (N = 1261; 76.7%).

RESULTS

Adolescents with recurrent LOC eating reported clinically relevant and significantly greater eating disorder psychopathology, functional impairment, and distress because of LOC eating, and a significantly higher body mass index (BMI, kg/m(2) ) than adolescents with nonrecurrent and those without LOC eating.

DISCUSSION

These results underline that LOC eating is a common eating behavior among adolescents in the community associated with clinical characteristics of eating disorders, and could therefore be a risk factor for developing full- or partial-syndrome eating disorders. Further research on the classification of eating disorders in adolescents with LOC eating and severity indicators is warranted.

The Persian Version of Eating Disorder Examination Questionnaire and Clinical Impairment Assessment: Norms and Psychometric Properties for Undergraduate Women

OBJECTIVE

The aim of this study was to provide norms of Eating Disorder Examination Questionnaire (EDE-Q) and Clinical Impairment Assessment (CIA) for undergraduate women in Iran.

MATERIALS AND METHODS

Undergraduate women (N = 516) completed the EDE-Q, CIA, and the Binge Eating Scale (BES).

RESULTS

Average score, standard deviation, and percentile rank of EDE-Q and its subscale as well as CIA were reported. In addition, the frequency of key eating disordered behaviors was presented. Both EDE-Q and CIA demonstrated strong internal consistency. In addition to the significant correlation between the EDE-Q and CIA (0.59), they both showed a moderate to strong correlation with the BES (r = 0.33 to 0.61). The EDE-Q and CIA successfully differentiated underweight, normal weight, and overweight women. Moreover, women who reported higher level of restraint or regular binge eating episodes obtained higher score on the CIA than women who did not have such behaviors across the same period.

CONCLUSION

This study provided preliminary support for the reliability and validity of the Persian version of the EDE-Q and CIA. The obtained norms for the EDE-Q and the CIA are helpful in clinical practice and intercultural studies of eating disorders.

Reducing eating disorder onset in a very high risk sample with significant comorbid depression: A randomized controlled trial

OBJECTIVE

Eating disorders (EDs) are serious problems among college-age women and may be preventable. An indicated online eating disorder (ED) intervention, designed to reduce ED and comorbid pathology, was evaluated.

METHOD

206 women (M age = 20 ± 1.8 years; 51% White/Caucasian, 11% African American, 10% Hispanic, 21% Asian/Asian American, 7% other) at very high risk for ED onset (i.e., with high weight/shape concerns plus a history of being teased, current or lifetime depression, and/or nonclinical levels of compensatory behaviors) were randomized to a 10-week, Internet-based, cognitive-behavioral intervention or waitlist control. Assessments included the Eating Disorder Examination (EDE, to assess ED onset), EDE-Questionnaire, Structured Clinical Interview for DSM Disorders, and Beck Depression Inventory-II.

RESULTS

ED attitudes and behaviors improved more in the intervention than control group (p = .02, d = 0.31); although ED onset rate was 27% lower, this difference was not significant (p = .28, NNT = 15). In the subgroup with highest shape concerns, ED onset rate was significantly lower in the intervention than control group (20% vs. 42%, p = .025, NNT = 5). For the 27 individuals with depression at baseline, depressive symptomatology improved more in the intervention than control group (p = .016, d = 0.96); although ED onset rate was lower in the intervention than control group, this difference was not significant (25% vs. 57%, NNT = 4).

CONCLUSIONS

An inexpensive, easily disseminated intervention might reduce ED onset among those at highest risk. Low adoption rates need to be addressed in future research.

Negative affect, interpersonal perception, and binge eating behavior: An experience sampling study

OBJECTIVE

Etiological and maintenance models for disordered eating highlight the salience of negative affect and interpersonal dysfunction. This study employed a 14-day experience sampling procedure to assess the impact of negative affect and interpersonal perceptions on binge eating behavior.

METHOD

Young adult women (N = 40) with recurrent binge eating and significant clinical impairment recorded their mood, interpersonal behavior, and eating behaviors at six stratified semirandom intervals daily through the use of personal digital assistants.

RESULTS

Although momentary negative affect was associated with binge eating behavior, average levels of negative affect over the experience sampling period were not, and interpersonal problems moderated the relationship between negative affect and binge eating. Interpersonal problems also intensified the association between momentary interpersonal perceptions and binge eating behavior. Lagged analyses indicated that previous levels of negative affect and interpersonal style also influence binge eating.

DISCUSSION

The study findings suggest there may be important differences in how dispositional versus momentary experiences of negative affect are associated with binge eating. Results also highlight the importance of interpersonal problems for understanding relationships among negative affect, interpersonal perception, and binge eating behavior. These results offer several possibilities for attending to affective and interpersonal functioning in clinical practice.

The self-rating of the effects of alcohol questionnaire predicts heavy episodic drinking in a high-risk eating disorder population

OBJECTIVE

Heavy episodic drinking (HED) is a serious problem among college women at high-risk for developing eating disorders (EDs). The main objectives of this study are to determine the relationship of the self-rating of the effects of alcohol (SRE) questionnaire and HED over time, and to determine the effects of relationship breakups on HED among college-aged women at high-risk for EDs.

METHOD

Data collected from 163 participants in a randomized controlled trial evaluating the effectiveness of an ED prevention program were used in the analyses. Measures included the SRE, obtained at baseline, and self-reports of the number of HED episodes and relationship breakups each month for the past 12 months.

RESULTS

Generalized linear mixed-effect regression models with Poisson distribution were conducted to test the effects of several variables on reported HED episodes over 12 months. Analyses demonstrated that SRE scores and the presence of a breakup predicted increased HED over time.

DISCUSSION

The SRE may be useful in identifying individuals at risk of or with EDs who are at increased risk of HED. Furthermore, relationship breakups predict HED. Findings from the current study could be used to inform clinical interventions for this population.

Adaptation and validation of the Spanish version of the Clinical Impairment Assessment Questionnaire

The Clinical Impairment Assessment (CIA) assesses psychosocial impairment secondary to an eating disorder. The aim of this study was to create and validate a Spanish-language version of the CIA. Using a forward-backward translation methodology, we translated the CIA into Spanish and evaluated its psychometric characteristics in a clinical sample of 178 ED patients. Cronbach's alpha values, confirmatory factor analysis (CFA), and correlations between the CIA and the Eating Attitudes Test-12 and the Health-Related Quality of Life in ED-short form questionnaires evaluated the reliability, construct validity, and convergent validity, respectively. Known-groups validity was also studied comparing the CIA according to different groups; responsiveness was assessed by means of effect sizes. Data revealed a three-factor structure similar to that of the original CIA. Cronbach alpha coefficient of 0.91 for the total CIA score supported its internal consistency and correlations with other instruments demonstrated convergent validity. The total CIA score and factor scores also significantly discriminated between employment status, evidencing known-groups validity. Responsiveness parameters showed moderate changes for patients with restrictive eating disorders. These findings suggest that the CIA can be reliably and validly used in Spain in a number of different clinical contexts, by researchers and clinicians alike.

Evaluating reliable and clinically significant change in eating disorders: comparisons to changes in DSM-IV diagnoses

Assessing clinically meaningful change is valuable for treatment planning, monitoring course of illness and evaluating outcome. Although DSM eating disorder (ED) diagnoses have been criticized for poor clinical utility, instability, and uncertainty, remission/change of diagnosis is often the standard for evaluating outcome. We tested the validity of the clinically significant reliable change index (CS/RCI) compared to change in DSM-IV ED-diagnoses. We investigated if CS/RCI was concordant to diagnostic change and compared explained variance on measures at follow-up. Using a database for specialized ED treatment in Sweden the sample contained 1042 female patients (246 adolescents/796 adults). CS/RCI was calculated for the Clinical Impairment Assessment (CIA) and the Eating Disorder Examination Questionnaire (EDE-Q). CS/RCI explained more variance in gain scores for psychopathology measures than diagnostic change (DSM-IV). Average agreement between diagnostic change and CS/RCI was 62% and 60% for CIA and EDE-Q, respectively. Diagnostic change always resulted in more positive outcome than CS/RCI. Together with clinical judgment, CS/RCI is a valuable method for determining clinically significant changes in clinical practice and research. It is economically sound and results are easily interpreted and communicated to patients.

Psychometric validation of the Clinical Impairment Assessment in a UK eating disorder service

A number of studies have provided data on young women for the Clinical Impairment Assessment (CIA, v. 3.0), a measure of psychosocial impairment in eating disorders. However, little data exists on eating disorder samples. The aim of the current study was to investigate psychometric properties of the CIA in a clinical sample, using confirmatory factor analysis based on the originally-proposed model. The CIA was administered alongside with the Eating Disorder Examination (EDE) to 190 individuals referred to an eating disorder service. Psychometric properties of the CIA were acceptable, based on model fit and factor loadings. The CIA appears to be a useful and valid measure for the assessment of impairment in eating disorders.

What constitutes clinically significant binge eating? Association between binge features and clinical validators in college-age women

OBJECTIVE

To investigate the association between binge features and clinical validators.

METHOD

The Eating Disorder Examination assessed binge features in a sample of 549 college-age women: loss of control (LOC) presence, binge frequency, binge size, indicators of impaired control, and LOC severity. Clinical validators were self-reported clinical impairment and current psychiatric comorbidity, as determined via a semistructured interview.

RESULTS

Compared with women without LOC, those with LOC had significantly greater odds of reporting clinical impairment and comorbidity (ps < 0.001). Among women with LOC (n = 252), the indicators of impaired control and LOC severity, but not binge size or frequency, were associated with greater odds of reporting clinical impairment and/or comorbidity (ps < 0.05). DICUSSION: Findings confirm that the presence of LOC may be the hallmark feature of binge eating. Further, dimensional ratings about the LOC experience--and possibly the indicators of impaired control--may improve reliable identification of clinically significant binge eating.

Clinical characteristics and distinctiveness of DSM-5 eating disorder diagnoses: findings from a large naturalistic clinical database

BACKGROUND

DSM-IV eating disorder (ED) diagnoses have been criticized for lack of clinical utility, diagnostic instability, and over-inclusiveness of the residual category "ED not otherwise specified" (EDNOS). Revisions made in DSM-5 attempt to generate a more scientifically valid and clinically relevant system of ED classification. The aim with the present study was to examine clinical characteristics and distinctiveness of the new DSM-5 ED diagnoses, especially concerning purging disorder (PD).

METHODS

Using a large naturalistic Swedish ED database, 2233 adult women were diagnosed using DSM-5. Initial and 1-year follow-up psychopathology data were analyzed. Measures included the Eating Disorder Examination Questionnaire, Structural Eating Disorder Interview, Clinical Impairment Assessment, Structural Analysis of Social Behavior, Comprehensive Psychiatric Rating Scale, and Structured Clinical Interview for DSM-IV Axis I Disorders.

RESULTS

Few meaningful differences emerged between anorexia nervosa binge/purge subtype (ANB/P), PD, and bulimia nervosa (BN). Unspecified Feeding and Eating Disorders (UFED) showed significantly less severity compared to other groups.

CONCLUSIONS

PD does not appear to constitute a distinct diagnosis, the distinction between atypical AN and PD requires clarification, and minimum inclusion criteria for UFED are needed. Further sub-classification is unlikely to improve clinical utility. Instead, better delineation of commonalities is important.