Attachment insecurities, maladaptive perfectionism, and eating disorder symptoms: a latent mediated and moderated structural equation modeling analysis across diagnostic groups

Insecure attachment styles in adolescents at risk for eating disorders

The present study examines insecure attachment styles in female adolescents, who are at risk for developing eating disorders. A second goal was to investigate whether attachment styles differentiate between high risk for anorexia and high risk for bulimia. A total of 150 adolescents were divided into four risk groups: High risk for anorexia, high risk for bulimia, medium risk and control group. The attachment styles were assessed using the Experience in Close Relationships Scale and the Relationship Questionnaire. Anxiety Attachment, but not Avoidance Attachment, was found to characterize those adolescents who are at risk for ED (AN + BN), and especially for those at high-risk for BN. The present results do not support the notion of an avoidance of emotional intimacy, characterizing the avoidant attachment style of those presenting with AN. Preoccupied Attachment style was found to characterize high-risk for BN, but not high-risk for AN, while the Insecure, Fearful, and Dismissing Attachment types did not differentiate between these two high-risk groups. This study highlights the dominant attachment style in adolescents at high risk for developing ED: The Anxiety Attachment style for AN and BN, and the Preoccupied Attachment style for BN but not for AN.

Attachment, Mentalization, Emotion Dysregulation, and Empathy in Eating Disorders: Comparing Anorexic and Bulimic Patients

ABSTRACT

Eating disorders (EDs) represent a wide range of clinical symptoms related to food intake, body image, and weight issues, and include anorexia nervosa-restricting type (AN-R), anorexia nervosa-binge-purge type (AN-BP), and bulimia nervosa (BN). The aim was to investigate the characteristics of attachment, mentalization, emotion dysregulation, and empathy in a sample of 102 patients with EDs. A sample of 102 patients and therapists completed a series of measures for the assessment of ED pathology, mentalization, empathy, and emotion dysregulation. Pearson correlations and analysis of variance were used to test the characteristics of the variables among the groups. In relation to attachment and emotion dysregulation, no significant differences were found. In relation to mentalization, significant difference in good mentalization was found in AN-R subtype compared with the BN subtype. In relation to empathy, results showed significantly lower scores in BN subtype on affective empathy compared with the AN-BP subtype, and in AN-R subtype on cognitive empathy. Finally, we used Z -scores for each item ranked by value (higher to lower) to develop different clinical prototypes for each group. Our results point toward the clinical need to address the assessed variables, specifically mentalization, emotion dysregulation, and empathy, in the diagnosis and treatment of EDs.

Attachment, motivational systems and anorexia nervosa: A systematic review and proposed framework for eating disorders

INTRODUCTION

There is a direct association between patients with insecure attachment style (IAS), behavioural inhibition (BIS) and behavioural activation (BAS) motivational systems, and anorexia nervosa (AN). However, the possible direct relationships between these three variables have not been studied.

OBJECTIVE

The main objective of this study is to analyse the relationship between these variables and propose a framework for analysing and understanding these relationships.

METHODOLOGY

A systematic review was carried out following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, searching the following terms: 'anorexia', 'attachment' and those related to motivational systems. The final search was limited to publications in English dated between 2014-2022 for 'anorexia and attachment' and 2010-2022 for 'anorexia and BIS/BAS'.

RESULTS

Of the 587 articles retrieved, 30 were included in this study for the textual data analysis of the relationship between anorexia and attachment (17), anorexia and motivational systems (10) and anorexia, attachment and motivational systems (3). An association between avoidant IAS, AN and hypersensitivity to punishment of the BIS was observed in the analysis. A relationship was also observed with hyperreinforcement sensitivity of the BAS. After reviewing the articles, a possible relationship between the three factors, along with other mediating factors, was found.

DISCUSSION

AN is directly related to the avoidant IAS and to BIS. Similarly, bulimia nervosa (BN) was directly related with anxious IAS and BAS. However, contradictions were found in the BN-BAS relationship. This study proposes a framework for analysing and understanding these relationships.

Neural correlates of Type A personality: Type A personality mediates the association of resting-state brain activity and connectivity with eating disorder symptoms

BACKGROUND

Type A personality (TAP) was characterized by impatience, competitiveness, aggressiveness, and hostility. Higher TAP was proved to be associated with more eating disorder symptoms (EDS). While little is known about the underlying neural substrates of TAP and how TAP is linked to EDS at the neural level.

METHODS

To investigate the neural basis of TAP, we adopted fractional amplitude of low-frequency fluctuations (fALFF) and resting-state functional connectivity (RSFC) via resting-state functional magnetic resonance imaging (rs-fMRI) (N = 1620). Mediation models were examined to explore the relationship between TAP, EDS, and brain activity.

RESULTS

TAP was associated with decreased fALFF in the left middle frontal gyrus (MFG) and increased fALFF in the left precentral gyrus (PreCG). Furthermore, TAP was positively correlated to RSFC between the left MFG and left inferior temporal gyrus (ITG) and between the left PreCG and right middle temporal gyrus (MTG). Mediation analysis showed TAP fully mediated the association of the left MFG activity, MFG-ITG connectivity, and PreCG-MTG connectivity with EDS.

LIMITATIONS

The cross-sectional design of this study precludes us from specifying the causal relationship in the associations we observed.

CONCLUSIONS

Our results suggested spontaneous activity in the left MFG and PreCG is associated with TAP, and even in general sample, people with higher TAP showed more EDS. The present study is the first to investigate the neurobiological underpinnings of TAP in a large sample and further offered new insights into the relation between TAP and EDS from a neural basis perspective.

Bridging cognitive, phenomenological and psychodynamic approaches to eating disorders

Cognitive, psychodynamic, and phenomenological scholars converged their attention on abnormal bodily phenomena as the core psychopathological feature of eating disorders (EDs). While cognitive approaches focus their attention on a need for "objective" (i.e., observable, measurable) variables (including behaviours and distorted cognitions), the phenomenological exploration typically targets descriptions of persons' lived experience. According to a new emerging phenomenological perspective, the classic behavioural and cognitive symptoms of EDs should be considered as epiphenomena of a deeper core represented by a disorder of the embodiment. The cognitive-behavioural model is the most studied and, up till now, clinically efficacious treatment for EDs. However, as any coherent and scientifically grounded model, it presents some limitations in its application. Numerous patients report a chronic course, do not respond to treatment and develop a personality structure based on pathological eating behaviours, since "being anorexic" becomes a new identity for the person. Furthermore, the etiopathogenetic trajectory of EDs influences the treatment response: for example, patients reporting childhood abuse or maltreatment respond differently to cognitive-behavioural therapy. To obtain a deeper comprehension of these disorders, it seems important to shift attention from abnormal eating behaviours to more complex and subtle psycho(patho)logical features, especially experiential ones. This characterisation represents the unavoidable premise for the identification of new therapeutic targets and consequently for an improvement of the outcome of these severe disorders. Thus, the present review aims to provide an integrated view of cognitive, psychodynamic, and phenomenological perspectives on EDs, suggesting new therapeutic targets and intervention strategies based on this integrated model. Level of Evidence: Level V.Level of evidence Level V: Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Eating disorder psychopathology: The role of attachment anxiety, attachment avoidance, and personality functioning

OBJECTIVE

Although the relationship between insecure attachment patterns and eating disorder (ED) psychopathology has repeatedly been demonstrated, the underlying mechanisms of this association are not fully understood. Therefore, the current study aimed to examine personality functioning, defined as an impairment in self and interpersonal functioning, as a mediator between attachment insecurity and ED psychopathology.

METHODS

In a representative population-based sample (N = 2508; age range 14-92 years) ED symptomatology, personality functioning, and attachment insecurity (anxiety and avoidance) were assessed. Besides descriptive uni-/bivariate analysis, path analysis was used to test a mediation model while controlling for the effects of age, gender, mental distress, and BMI.

RESULTS

ED symptomatology was associated with lower levels of personality functioning (r = 0.22) and higher levels of attachment anxiety (r = 0.14) but did not correlate with attachment avoidance (r = 0.02). Path analysis revealed that personality functioning fully mediated the effect of attachment anxiety on ED symptomatology: The indirect effect via personality functioning (β = 0.04, p < .001) accounted for 77% of the total effect. Fit indices were excellent. Sensitivity analyses revealed that the main results were mainly applicable to women and the middle age group.

CONCLUSION

The present findings contribute to the growing body of research using dimensional conceptualizations of personality functioning, suggesting that it provides an informative, overarching framework for understanding and treating ED psychopathology. Findings indicate that underlying individual differences, e.g., with respect to insecure attachment configurations, have relevant implications for symptom manifestations. Potential clinical implications and avenues for future research are discussed.

The downside of managers: The moderator role of political skill & deceptive situation

Relying on the trait activation theory and socioanalytic theory, this study investigate conditions that activate or restrain a manager's dark triad, which can predict exploitative leadership. First, we examine the interacting effect of narcissism, Machiavellianism, and psychopathy with deceptive situation cues at work. Then, we investigated the effect of a manager's political skill - into the emergence of exploitative leadership. A multisource data were collected across two studies administered first to employees then to their corresponding managers (N = 150). Structural equation modeling were used to test hypothesis. The study's findings show that the interaction of deceptive conditions with the dark triad is the most predictive of exploitative leadership, while managers' political skill was found to have a neutralize effect. The present study provides an effort to identify a potential cause and a solution to manager's exploitative behavior at work. Implications for the dark triad literature, theories underlying it, and exploitative leadership are discussed.

Mediational Effect of Fairburn's Transdiagnostic Mechanisms Between Attachment to the Mother and Eating Disorder Symptoms in a Clinical Sample

Objective

Research has supported a link between insecure attachment and eating disorders (EDs); however, little is known about how this influence is exerted in young female EDs patients. This study tested, for the first time, a multiple mediational model, wherein the four Fairburn’s transdiagnostic mechanisms mediated the relationship between attachment to the mother and ED symptoms.

Methods

A total of 101 female young EDs patients aged 15–24 were administered the Inventory of Parent and Peer Attachment, Eating Disorder Inventory-3 and Eating Attitudes Test-26 to assess attachment, the four transdiagnostic maintaining mechanisms and ED symptoms, respectively.

Results

Comparison analyses showed that there were no significant differences between the diagnostic groups in terms of attachment and the transdiagnostic variables. Multiple mediational analyses indicated that low self-esteem and clinical perfectionism were significant mediators between insecure attachment to the mother and ED symptoms, while controlling for depressive symptoms.

Conclusion

These findings suggest that the distal risk influence of insecure attachment to the mother in the development of ED symptoms might be explained by low self-esteem and high clinical perfectionism, controlling for depressive symptoms. Further investigation into the efficacy of cognitive-behavioral treatments targeting insecure attachment representations for young EDs patients is recommended.

Emotion dysregulation moderates the relationship between alcohol use and eating pathology among heavy-drinking college men

OBJECTIVES

There is limited research examining the relationship between alcohol use and eating pathology in men or factors that may moderate this association. The current study investigated the relationship between alcohol use and eating pathology, and examined emotion dysregulation as a moderator of this association, among heavy-drinking college men.

METHOD

Men mandated to receive an alcohol intervention (N = 88; average age = 19 years) completed questionnaires related to alcohol use, emotion dysregulation, and eating pathology.

RESULTS

Results demonstrated positive relationships between alcohol use and some eating pathology, and a significant interaction between alcohol use and emotion dysregulation. However, results were contrary to hypotheses, such that there was a positive relationship between alcohol use and eating pathology at low levels of emotion dysregulation.

CONCLUSION

Future studies should continue to examine the overall presentation of eating pathology in men and investigate factors that may impact the relationship between alcohol use and eating pathology.

Childhood trauma, life-time self-harm, and suicidal behaviour and ideation are associated with polygenic scores for autism

Autistic individuals experience significantly elevated rates of childhood trauma, self-harm and suicidal behaviour and ideation (SSBI). Is this purely the result of negative environmental experiences, or does this interact with genetic predisposition? In this study we investigated if a genetic predisposition for autism is associated with childhood trauma using polygenic scores (PGS) and genetic correlations in the UK Biobank (105,222 < N < 105,638), and tested potential mediators and moderators of the association between autism, childhood trauma and SSBI. Autism PGS were significantly associated with childhood trauma (max R2 = 0.096%, P < 2 × 10-16), self-harm ideation (max R2 = 0.108%, P < 2 × 10-16), and self-harm (max R2 = 0.13%, P < 2 × 10-16). Supporting this, we identified significant genetic correlations between autism and childhood trauma (rg = 0.36 ± 0.05, P = 8.13 × 10-11), self-harm ideation (rg = 0.49 ± 0.05, P = 4.17 × 10-21) and self-harm (rg = 0.48 ± 0.05, P = 4.58 × 10-21), and an over-transmission of PGS for the two SSBI phenotypes from parents to autistic probands. Male sex negatively moderated the effect of autism PGS on childhood trauma (β = -0.023 ± 0.005, P = 6.74 × 10-5). Further, childhood trauma positively moderated the effect of autism PGS on self-harm score (β = 8.37 × 10-3 ± 2.76 × 10-3, P = 2.42 × 10-3) and self-harm ideation (β = 7.47 × 10-3 ± 2.76 × 10-3, P = 6.71 × 10-3). Finally, depressive symptoms, quality and frequency of social interactions, and educational attainment were significant mediators of the effect of autism PGS on SSBI, with the proportion of effect mediated ranging from 0.23 (95% CI: 0.09-0.32) for depression to 0.008 (95% CI: 0.004-0.01) for educational attainment. Our findings identify that a genetic predisposition for autism is associated with adverse life-time outcomes, which represent complex gene-environment interactions, and prioritizes potential mediators and moderators of this shared biology. It is important to identify sources of trauma for autistic individuals in order to reduce their occurrence and impact.

Associations Between Trauma, Early Maladaptive Schemas, Personality Traits, and Clinical Severity in Eating Disorder Patients: A Clinical Presentation and Mediation Analysis

Background: The literature has shown a significant association between traumatic experiences and eating psychopathology, showing a greater symptomatology in patients with trauma history. Less is known about the associations between trauma and cognitive schemas, and personality traits and the differences between childhood and adulthood trauma experiences. Thus, this paper aims to assess the clinical and psychological characteristics of eating disorder (ED) patients, looking for differences between patients without a history of trauma and patients with trauma experiences, as well as at possible differences between exposure in childhood, adulthood, or repeated events. Another aim of the paper is to evaluate the possible mediation role of cognitive schemas and personality traits in the relationship between early trauma and eating psychopathology.

Methods: From January to November 2020, 115 consecutive inpatients admitted for a specific multidisciplinary ED treatment in a dedicated Unit were evaluated for trauma, differentiating between trauma occurring in childhood and adulthood. The subjects were evaluated for early maladaptive schemas (EMS), personality traits, trauma symptomatology, quality of life, and specific psychopathologies linked to EDs. Mediation analyses between childhood and adulthood trauma and eating psychopathology were performed, with EMS and personality traits as mediators.

Results: Patients with a history of trauma showed higher physical and psychological symptomatology scores, with a more impaired clinical profile in patients with both childhood and adulthood trauma exposure. The mediation analysis showed a specific mediator role for the “disconnection and rejection (DR)” EMS factor in the relationship between childhood trauma (cT) and eating psychopathology.

Conclusion: Trauma experiences are associated with more severe clinical symptomatology in EDs and may need a specific assessment in patients with failed outpatient standard treatments. Specific cognitive schemas linked to DR domain should be evaluated in treatments for ED patients with history of trauma due to the mediation role between trauma and eating psychopathology. The need for outcome studies about treatment approaches for ED patients with history of trauma is discussed.

Confidence in one-self and confidence in one's own body: The revival of an old paradigm for anorexia nervosa

Impaired interoceptive function represents an important variable in the psychopathology of anorexia nervosa (AN) and is thought to be influenced by maladaptive schemas grounded on early intimate interactions. However, the role of the different psychological processes involved in the interoceptive function has been poorly assessed in AN. We aimed to investigate the associations between adult insecure attachment, interoceptive processes, and psychopathology. One hundred and fifty participants with AN completed self-report questionnaires: the Multidimensional Assessment of Interoceptive Awareness, which measures interoception dimensions; the Attachment Style Questionnaire, assessing adult attachment styles, and the Eating Disorder Inventory-2, exploring eating-related core symptoms. Pearson's correlations were employed to assess the relationships between MAIA and EDI-2 subscores. Structural equation models (SEM) were performed to investigate the relationships between insecure attachment dimensions, interoception, and AN core symptoms as latent variables. Body listening, self-regulating, and trusting were interoceptive dimensions associated with eating psychopathology. As confirmed by an exploratory factor analysis, these interoceptive dimensions are included in a latent variable which points to "confidence" in body sensations. SEM showed that insecure, in particular anxious, attachment predicts body "confidence" and, in turn, AN core symptoms. Confidence in body sensations as a trustworthy source of knowledge represents the specific interoceptive dimension associated with psychopathology in AN. In accordance with Bruch's model of AN, insecure attachment patterns may promote a need to validate inner experiences by external sources conferring vulnerability to symptomatology. These psychopathological pathways could be addressed in clinical interventions.

Parental bonding, childhood maltreatment and eating disorder psychopathology: an investigation of their interactions

PURPOSE

Childhood trauma and parental bonding have been widely recognized as risk factors for eating disorders (EDs). However, their interplay in determining ED psychopathology has been poorly investigated. Consequently, we have assessed their interaction with core ED psychopathological symptoms.

METHODS

Fifty-seven patients with anorexia nervosa, 43 with bulimia nervosa and 77 healthy women completed the Childhood Trauma Questionnaire, the Parental Bonding Instrument and the Eating Disorder Inventory-2. Chi square test and regression analyses with a moderation model were performed to investigate the interplay between childhood trauma, parental bonding and ED symptoms such as ineffectiveness, social insecurity, drive to thinness, interoceptive awareness, impulsivity and perfectionism.

RESULTS

Compared to controls, patients with EDs showed higher levels of trauma and parental control perception and lower levels of parental care. Childhood maltreatment was more prevalent in patients with the affectionless control parental style. Moderation analyses revealed that higher maternal control significantly predicted the ED symptom of social insecurity only when participants experienced lower levels of emotional abuse.

CONCLUSIONS

These findings demonstrate an interplay between deranged problematic parental bonding and childhood trauma in promoting a possible vulnerability to social insecurity, one of the most central dimensions of ED psychopathology. This interaction might have psychotherapeutic implications.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

The unsafe haven: Eating disorders as attachment relationships

OBJECTIVES

Some patients with eating disorders (EDs) seem to experience their illness as an entity, a symbolic other to whom they relate, and which may influence both symptom levels and self-image. Extending previous research, this study investigated whether the patient-ED relationship has attachment qualities.

DESIGN

Structural Analysis of Social Behaviour was used to operationalize the patient-ED relationship, and the Attachment Style Questionnaire was used to measure attachment.

METHOD

We examined ED patients' (N = 148) relationship with their ED, attachment behaviour, symptoms, and self-image. Attachment dimensions of Confidence, Anxious/ambivalence, and Avoidance were found to be significantly correlated with aspects of the patient-ED relationship. Introjection (i.e., whether ED actions were incorporated into patients' self-image) was investigated by examining the match between self-image profiles and the actions of patients' EDs. A double mediation model was tested in which ED control/emancipation and patients' Self-blame mediated the effect of attachment security on ED symptoms.

RESULTS

Attachment insecurity was associated with greater ED control and patient submission. In 28.5% of patients, there was a high degree of correlation between self-image and ED action profile. Data supported the mediation model.

CONCLUSIONS

Attachment processes appear to be associated with the manner in which ED patients relate to their disorder, at least in some cases. Attempts to maintain psychological proximity to the ED as an introjected attachment figure may help to explain treatment resistance and ambivalence about change. This perspective may be useful in treatment.

PRACTITIONER POINTS

Attachment behaviours are associated with the patient-ED relationship, in which attachment insecurity is correlated with greater eating disorder control and patient submission. Some patients seem to incorporate the actions of the ED in their self-image, suggesting the presence of introjection. The patient-ED relationship may help explain patients' anxiety and ambivalence about change, seen from an attachment perspective. In treatment, it may be important to explore alternative safe havens and secure bases to the ED, such as interpersonal relationships and activities.

Mediators linking insecure attachment to eating symptoms: A systematic review and meta-analysis

In the last two decades, the number of studies focused on the mediators connecting insecure attachment with Eating Disorders (EDs), at both clinical and sub-clinical level, has considerably increased. However, there has not been a systematic synthesis of this literature to date. To fill this gap, the current meta-analytic review aimed at identifying and quantifying the extent to which mediators contribute to the explanation of this relationship. The present study was registered with PROSPERO (CRD42017076807). A comprehensive search process in seven different electronic databases retrieved 24 studies that examined how insecure attachment leads to ED symptoms through mediation analysis. Standardized regression coefficients of the indirect and total paths of 21 mediation models were pooled. Studies were coded and ranked for quality. We found evidence to show that maladaptive emotion regulation and depressive symptoms had the highest effect size for mediation (mediation ratio [P_M] = 0.71). Further, body dissatisfaction, neuroticism, perfectionism, mindfulness and social comparison had significant, but moderate to low mediating effects (P_M = 0.21–0.58). The methodological quality of these studies was mostly low to moderate and potential areas for development were highlighted. Our findings support the direct targeting of these psychological constructs in prevention programs and treatment of EDs. Future investigations addressing the time sequence between the variables will provide valuable clues to untangle the prospective contribution of each variable on the development and maintenance of eating pathology.

"Partner in Prime"? Effects of repeated mobile security priming on attachment security and perceived stress in daily life

Lacking secure attachment representations is associated with vulnerability to mental and physical health problems, perhaps mediated by increased susceptibility to stress and impaired emotion regulation. Even though cognitive representations of self and others tend to favor confirmation over information, research has shown that adult attachment security can be positively influenced. In a randomized control trial using a mixed between- and within-subjects design, participants (N = 112) were mobile primed with attachment security stimulating visualization tasks, over a 7-day period. Self-reported attachment security was unchanged; however, reduced attachment avoidance and perceived stress and increased resilience and self-compassion scores were obtained up to one week after the last prime. Participants who reported less effort and more pleasure in carrying out the visualization tasks experienced the highest gains. Results highlight the potential of mobile attachment security priming for intervention, but also the differential potential of such intervention for people with different attachment orientations.

Evaluation of the DSM-5 severity ratings for anorexia nervosa in a clinical sample

We examined the validity and utility of the DSM-5 severity ratings for anorexia nervosa (AN) in a clinical (treatment-seeking) sample (N = 273; 95.6% women). Participants classified with mild, moderate, severe, and extreme severity of AN based on their measured body mass index, differed significantly from each other in eating disorder features, putative maintenance factors, and illness-specific functional impairment (medium effect sizes). However, they were statistically indistinguishable in psychiatric-disorder comorbidity and distress, demographics, and age-of-AN onset. The implications of our findings, providing limited support for the DSM-5 severity ratings for AN, and directions for future research are outlined.

Attachment and motivational systems: Relevance of sensitivity to punishment for eating disorder psychopathology

An altered balance of reward and inhibition systems may explain Eating Disorder (ED) behaviors and could be related to difficulties in socio-emotional processing. According to attachment theory, early interaction with caregivers affects the ability to regulate emotion in adult interpersonal situation. The aim of our study was to investigate if insecure attachment may be related to ED symptomatology through changes in reward and inhibition systems. Seventy-eight people affected by EDs and 45 healthy controls (HC) filled in the Attachment Style Questionnaire (ASQ), the Behavioral Inhibition System-Behavioral Activation System Scale (BIS-BAS) and the Eating Disorders Inventory-2 (EDI-2) questionnaire. ED people reported significantly higher scores than HC in EDI-2 scores, all dimensions of insecure attachment style and sensitivity to punishment (BIS score). In ED patients, ASQ anxiety scores correlated with almost all EDI-2 subscores and sensitivity to punishment. The association between anxious attachment style and ED symptomatology (drive to thinness and body dissatisfaction) was totally mediated by an indirect effect of sensitivity to punishment. These findings suggest, for the first time, increased sensitivity to punishment as a pathway that may explain the relationship between anxious attachment and ED symptomatology highlighting the relevance to target social experiences as an important psychotherapeutic focus.

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.

Can a Mediator Moderate? Considering the Role of Time and Change in the Mediator-Moderator Distinction

The concepts of mediation and moderation are important for specifying ways in which psychological treatments work and for whom they are most beneficial. Historically, the terms were confused and used interchangeably, so a rich body of scholarly literature makes clear their distinction. Researchers are also becoming increasingly aware that mediation and moderation can be integrated and that such integration can advance theory development and testing. One question that has not received sufficient attention is whether a mediator can simultaneously moderate. We tackle this question in this paper, and in doing so we expand on the MacArthur conceptualizations of mediation and moderation. The result is a presentation of a meta-theoretical model that illustrates how a construct that is initially a mediator can, not simultaneously but over time, evolve into a construct that moderates. When this occurs, a construct that changed for the better as a result of an intervention can later promote more positive change during a later intervention. Various implications of this novel paradigm for future research are discussed, including the importance of this model in the emerging context of managed health care.

Predicting intolerance of uncertainty in individuals with eating disorder symptoms

BACKGROUND

Intolerance of Uncertainty (IU) is recognized for its contribution to various psychopathologies, in particular anxiety and depression. Studies highlight the relevance of IU for Eating Disorders (EDs) however, potential factors contributing to IU in EDs remain unstudied.

METHODS

Three hundred and forty-nine women with ED symptoms and 214 individuals without ED symptoms were recruited and compared on levels of IU, insecure (anxious and avoidant) attachment styles, extraversion and openness. Secondly, the contribution of these factors to IU were tested.

RESULTS

Compared to the non-ED group, the ED group scored higher on IU, insecure attachment, and lower on extraversion and openness. Regression analyses confirmed that higher insecure attachment, and lower extraversion predicted higher IU scores in the ED group, and that insecure attachment predicted higher IU scores in the non-ED group.

CONCLUSIONS

Results confirm the relevance of IU to ED, and demonstrate that personality traits and insecure attachment styles contribute to IU in ED. Findings add to the growing literature on IU in ED and suggest that people with EDs may benefit from clinical interventions targeting IU.

Recovery from eating disorder 1 year after start of treatment is related to better mentalization and strong reduction of sensitivity to others

PURPOSE

To investigate whether recovery from an eating disorder is related to pre-treatment attachment and mentalization and/or to improvement of attachment and mentalization during treatment.

METHOD

For a sample of 38 anorexia nervosa (AN) and bulimia nervosa (BN) patients receiving treatment the relations between attachment security, mentalization, comorbidity and recovery status after 12 months (not recovered or recovered), and after 18 months (persistently ill, relapsed, newly recovered, or persistently recovered) were investigated. Attachment security and mentalization were assessed by the Adult Attachment Interview at the start of the treatment and after 12 months. Besides assessing co-morbidity-for its effect on treatment outcome-we measured psycho-neuroticism and autonomy because of their established relations to both eating disorder symptoms and to attachment security.

RESULTS

Recovery both at 12 months and at 18 months was related to higher levels of mentalization; for attachment, no significant differences were found between recovered and unrecovered patients. Patients who recovered from AN or BN also improved on co-morbid symptoms: whereas pre-treatment symptom severity was similar, at 12 months recovered patients scored lower on co-morbid personality disorders, anxiety, depression, self-injurious behaviour and psycho-neuroticism than unrecovered patients. Improvement on autonomy (reduced sensitivity to others; greater capacity to manage new situations) in 1 year of treatment was significantly higher in recovered than in unrecovered patients.

CONCLUSION

A focus on enhancing mentalization in eating disorder treatment might be useful to increase the chances of successful treatment. Improvement of autonomy might be the mechanism of change in recovering from AN or BN.

LEVEL OF EVIDENCE

Level III cohort study.

Embodiment Mediates the Relationship between Avoidant Attachment and Eating Disorder Psychopathology

OBJECTIVE

The overvaluation of body shape and weight of persons with eating disorders (EDs) is putatively explained by a disturbance in the way they experience their own body (embodiment). Moreover, attachment disorders seem to promote the use of body as source for self-definition. Therefore, we assessed the role of embodiment in the connection between attachment styles and ED psychopathology.

METHOD

One-hundred and thirteen ED patients and 117 healthy subjects completed the Identity and Eating Disorders (IDEA) Questionnaire, the Eating Disorder Inventory-2 (EDI-2) and the Experiences in Close Relationships Scale.

RESULTS

Eating disorder patients displayed IDEA, EDI-2 and Experiences in Close Relationships scores significantly higher than controls. IDEA total and subtotal scores mediated entirely the influence of avoidant attachment on EDI-2 interoceptive awareness and impulsivity.

DISCUSSION

These findings demonstrate a relationship between insecure attachment and disorders of identity and embodiment and point to embodiment as a possible mediator between avoidant attachment and specific ED psychopathological traits. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Social Rank and Rejection Sensitivity as Mediators of the Relationship between Insecure Attachment and Disordered Eating

AIM

The current study assessed a new interpersonal model for eating disorders (EDs), in which interpersonal rejection sensitivity (RS), appearance-based RS and social rank were hypothesised to mediate the relationship between insecure attachment and disordered eating.

METHOD

The sample comprised a clinical ED group (N = 122) and a control group (N = 622). Participants were asked to complete a number of self-report measures related to the variables of interest.

RESULTS

Invariance testing indicated that the model was structurally non-invariant (different across groups). For the ED group, appearance-based RS and social rank were significant mediators of the relationship between insecure attachment and disordered eating. For the controls, the relationship between insecure attachment and disordered eating was mediated through multiple pathways involving interpersonal RS, appearance-based RS and social rank.

CONCLUSION

These findings may inform existing therapies such as interpersonal psychotherapy for EDs, by emphasising the role of sensitivity to rejection in the development and maintenance of disordered eating. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

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.

Objectified Body Consciousness (OBC) in Eating Psychopathology

Objectified body consciousness (OBC) appears to play a crucial role in eating and body-related disturbances, which typically emerge during adolescence. The 24-item OBC Scale (OBCS) has been employed in eating disorder (ED) research and school-based adolescent samples, but evidence for its psychometric proprieties exists only in adult (nonclinical) populations. We evaluated (a) the construct validity and reliability of the 24-item OBCS with data collected from 1,259 adolescent girls and boys from the community (Study 1) and 643 adolescents of both genders with an ED (Study 2) and (b) whether the instrument functions similarly and equivalently measures the underlying construct(s) across gender and samples (i.e., test of measurement equivalence/invariance; Study 3). Results upheld the three-factor structure and measurement equivalence/invariance of the 24-item OBCS across gender and samples. OBCS subscale scores were internally consistent and stable over a 4-week period. OBCS subscales discriminated community participants with high and low ED symptom levels with fair accuracy, as well as community participants from those with an ED. They were also associated with five constructs closely related to both OBC and ED psychopathology. Latent mean comparisons across samples and gender were performed and discussed. Implications and directions for future research are also outlined.

Respiratory sinus arrhythmia as a predictor of eating disorder symptoms in college students: Moderation by responses to stress and parent psychological control

This longitudinal study examined the prospective contribution of respiratory sinus arrhythmia (RSA), a key physiological indicator of self-regulation, to eating disorder symptoms in college students, and whether this link was moderated by maladaptive responses to stress and parent psychological control. At Wave 1, college students' RSA was measured at rest. At Waves 1 and 2 (six-month follow-up), students reported on their eating disorder symptoms, coping and involuntary responses to stress, and perceptions of their parents' use of psychological control. Significant three-way interactions indicated that the link between RSA and subsequent eating disorder symptoms was contingent on responses to stress and parent psychological control. In the context of maladaptive responses to stress and high psychological control, RSA predicted increased eating disorder symptoms over time. In the absence of parent psychological control, high RSA was beneficial in most cases, even when individuals reported maladaptive responses to stress. This study presents novel evidence that high RSA contributes to risk for or resilience to eating disorder symptoms over time. RSA can be protective against eating disorder symptoms, but in some contexts, the self-regulation resources that high RSA provides may be inappropriately applied to eating cognitions and behaviors. This research highlights the importance of examining physiological functioning conjointly with other risk factors as precursors to eating disorder symptoms over time.

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.

The Social Appearance Anxiety Scale in Italian Adolescent Populations: Construct Validation and Group Discrimination in Community and Clinical Eating Disorders Samples

Anxiety in situations where one's overall appearance (including body shape) may be negatively evaluated is hypothesized to play a central role in Eating Disorders (EDs) and in their co-occurrence with Social Anxiety Disorder (SAD). Three studies were conducted among community (N = 1995) and clinical (N = 703) ED samples of 11- to 18-year-old Italian girls and boys to (a) evaluate the psychometric qualities and measurement equivalence/invariance (ME/I) of the Social Appearance Anxiety (SAA) Scale (SAAS) and (b) determine to what extent SAA or other situational domains of social anxiety related to EDs distinguish adolescents with an ED only from those with SAD. Results upheld the one-factor structure and ME/I of the SAAS across samples, gender, age categories, and diagnostic status (i.e., ED participants with and without comorbid SAD). The SAAS demonstrated high internal consistency and 3-week test-retest reliability. The strength of the inter-relationships between SAAS and measures of body image, teasing about appearance, ED symptoms, depression, social anxiety, avoidance, and distress, as well as the ability of SAAS to discriminate community adolescents with high and low levels of ED symptoms and community participants from ED participants provided construct validity evidence. Only SAA strongly differentiated adolescents with any ED from those with comorbid SAD (23.2 %). Latent mean comparisons across all study groups were performed and discussed.

Temperament and personality in eating disorders

PURPOSE OF REVIEW

In the last decades, three main different personality domains have been investigated in the field of eating disorders: personality traits, temperament, and personality disorders. The use of a wide range of instruments and the presence of many different approaches in the definition of personality dimensions make it difficult to summarize the emerging results from different studies. The aim of this narrative review is to critically highlight and discuss all interesting developments in this field, as reflected in the recent literature.

RECENT FINDINGS

The study of personality and temperament in eating disorders seems to be in line with the recently suggested dimensional approach, which highlights the importance of symptoms aggregation, rather than the categorical diagnoses. Recent literature seems to confirm that specific personality and temperamental profiles can be drawn for patients with eating disorders, which can discriminate different eating disorders' diagnoses/symptoms.

SUMMARY

These observations have relevant clinical implications as treatment of eating disorders is largely based on psychotherapeutic interventions. However, large longitudinal studies are needed to better clarify the suggested relationships and to identify more defined therapeutic strategies.

Disentangling the Association Between Child Abuse and Eating Disorders: A Systematic Review and Meta-Analysis

OBJECTIVES

The aim of this systematic review and meta-analysis was to estimate the association between distinct types of child abuse--sexual (CSA), physical (CPA), and emotional (CEA)--and different eating disorders (EDs).

METHODS

Electronic databases were searched through January 2014. Studies reporting rates of CSA, CPA, and CEA in people with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED), as compared with individuals without EDs, were included. Pooled analyses were based on odds ratios (ORs), with relevant 95% confidence intervals (CIs), weighting each study with inverse variance models with random effects. Risk of publication bias was estimated.

RESULTS

Thirty-two of 1714 studies assessed for eligibility met the inclusion criteria, involving more than 14,000 individuals. The association between EDs and any child abuse showed a random-effects pooled OR of 3.21 (95% CI = 2.29-4.51, p < .001) with moderate heterogeneity (I2 = 57.2%, p = .005), whereas for CSA, this was 1.92 (95% CI = 1.13-3.28, p = .017), 2.73 (95% CI = 1.96-3.79, p < .001), and 2.31 (95% CI = 1.66-3.20, p < .001), for AN, BN, and BED, respectively. However, adjusting for publication bias, the estimate for CSA and AN was not significant (OR = 1.06, 95% CI = 0.59-1.88, p = .85). Although CPA was associated with AN, BN, and BED, CEA was associated just with BN and BED.

CONCLUSIONS

BN and BED are associated with childhood abuse, whereas AN shows mixed results. Individuals with similar trauma should be monitored for early recognition of EDs.

TRIAL REGISTRATION

The protocol was registered in PROSPERO (an international prospective register of systematic reviews) with the reference number CRD42014007360.

Out of body, out of space: Impaired reference frame processing in eating disorders

A distorted body representation is a core symptom in eating disorders (EDs), though its mechanism is unclear. Allocentric lock theory, emphasising the role of reference frame processing in body image, suggests that ED patients may be (b)locked to an (allocentric) representation of their own body stored in long-term memory (e.g., my body is fat) that is not updated (modified) by the (real-time egocentric) perception-driven experience of the physical body. Employing a well-validated virtual reality-based procedure, relative to healthy controls, ED patients showed deficits in the ability to refer to and update a long-term stored (allocentric) representation with (egocentric) perceptual-driven inputs.

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.

Narcissistic Vulnerability and Grandiosity as Mediators Between Insecure Attachment and Future Eating Disordered Behaviors: A Prospective Analysis of Over 2,000 Freshmen

OBJECTIVE

This study aimed to build on existing literature by examining the potential mediating role of two variants of narcissism (grandiosity and vulnerability) in explaining part of the underlying mechanism by which insecure (avoidant and anxiety) attachment affects behavioral elements of eating pathology (dieting and bulimic behaviors).

METHOD

Longitudinal data collected from 2,055 freshman college students (52.2% women; mean age 18.34 years) were analysed using a latent variable structural equation modelling approach, controlling for initial levels of the endogenous (i.e., dependent) latent variables and holding body mass index, anxiety, stress, depression, and self-esteem levels as time-varying covariates.

RESULTS

The effect of attachment anxiety on future bulimic behaviors was fully mediated through vulnerable narcissism (i.e., no significant direct link between attachment anxiety and bulimic behaviors), whereas grandiose narcissism fully mediated the association between attachment avoidance and future dieting behaviors. Dieting also predicted future bulimic behaviors and served as an additional (full) mediator between grandiose narcissism and bulimic behaviors. Differences in the strength of these associations across gender were not observed, and all indirect effects were statistically significant.

CONCLUSION

Overall, the findings (a) seem to support the theoretical postulations linking different insecure attachment experiences to different narcissistic tendencies, (b) imply that specific insecure attachment patterns may pass through different mediating pathways (narcissistic grandiosity and vulnerability) to specific behavioral elements of eating pathology (dieting and bulimic behaviors) regardless of gender, and (c) suggest that individuals with high grandiose narcissistic levels may not be protected from bulimic behaviors as previously indicated.

Eating disorders in adolescence: attachment issues from a developmental perspective

In the present article we review findings from an emerging body of research on attachment issues in adolescents with eating disorders from a developmental perspective. Articles for inclusion in this review were identified from PsychINFO (1966-2013), Sciencedirect (1970-2013), Psychindex (1980-2013), and Pubmed (1980-2013). First, we will outline the crucial developmental changes in the attachment system and discuss how they might be related to the early onset of the disease. Then we will report on the major results from attachment studies using self-report and narrative instruments in that age group. Studies with a developmental approach on attachment will be analyzed in more detail. The high incidence of the unresolved attachment pattern in eating disorder samples is striking, especially for patients with anorexia nervosa. Interestingly, this predominance of the unresolved category was also found in their mothers. To date, these transgenerational aspects are still poorly understood and therefore represent an exciting research frontier. Future studies that include larger adolescent samples and provide a more detailed description including symptom severity and comorbidity would contribute to a better understanding of this complex and painful condition.

Recent Advances in Developmental and Risk Factor Research on Eating Disorders

The Diagnostic and Statistical Manual of Mental Disorders (i.e., DSM-5) currently recognizes three primary eating disorders: anorexia nervosa, bulimia nervosa, and binge eating disorder. The origins of eating disorders are complex and remain poorly understood. However, emerging research highlights a dimensional approach to understanding the multifactorial etiology of eating disorders as a means to inform assessment, prevention, and treatment efforts. Guided by research published since 2011, this review summarizes recent findings elucidating risk factors for the development of eating disorders across the lifespan in three primary domains: (1) genetic/biological, (2) psychological, and (3) socio-environmental. Prospective empirical research in clinical samples with full-syndrome eating disorders is emphasized with added support from cross-sectional studies, where relevant. The developmental stages of puberty and the transition from adolescence to young adulthood are discussed as crucial periods for the identification and prevention of eating disorders. The importance of continuing to elucidate the mechanisms underlying gene by environmental interactions in eating disorder risk is also discussed. Finally, controversial topics in the field of eating disorder research and the clinical implications of this research are summarized.

Mechanisms of influence of body checking on binge eating

Despite the theorized role of body checking behaviours in the maintenance process of binge eating, the mechanisms by which they may impact binge eating remain unclear. Using objectification model of eating pathology as a theoretical framework, the authors examined the potential intervening roles of body shame, appearance anxiety, and dietary restraint in the pathway between body checking and binge eating. Data collected from a large sample of treatment-seeking people with Bulimic-type Eating Disorders (N = 801) were analysed trough structural equation modelling. Results showed that, regardless of specific DSM-5 diagnostic categories, body checking behaviours were indirectly associated with binge eating and dietary restraint through body shame and appearance anxiety, whereas dietary restraint was directly linked to binge eating. The findings have clinical utility as they contribute to gaining insight into how critical scrutiny of one's body may act in several indirect ways to affect binge eating. We discuss practical implications of the findings.

Attachment and eating disorders: a review of current research

OBJECTIVE

Attachment insecurity may confer risk for developing an eating disorder. We describe domains of attachment functioning that are relevant to eating disorders including: affect regulation, interpersonal style, coherence of mind, and reflective functioning. Research since 2000 on attachment and eating disorders related to these domains is reviewed.

METHOD

We searched MedLine/Pubmed and PsycINFO from January 2000 to February 2014 and kept articles that: were empirical, included adults with a diagnosed eating disorder, and used a standard attachment measure. We retained 50 relevant studies.

RESULTS

Compared to controls, those with eating disorders had higher levels of attachment insecurity and disorganized mental states. Lower reflective functioning was specifically associated with anorexia nervosa. Attachment anxiety was associated with eating disorder symptom severity, and this relationship may be mediated by perfectionism and affect regulation strategies. Type of attachment insecurity had specific negative impacts on psychotherapy processes and outcomes, such that higher attachment avoidance may lead to dropping out and higher attachment anxiety may lead to poorer treatment outcomes.

DISCUSSION

Research to date suggests a possible relationship between attachment insecurity and risk for an eating disorder. More research is needed that uses attachment interviews, and longitudinal and case control designs. Clinicians can assess attachment insecurity to help inform therapeutic stances and interventions.

Testing the original and the extended dual-pathway model of lack of control over eating in adolescent girls. A two-year longitudinal study

Stice's (1994, 2001) dual pathway model proposed a mediational sequence that links body dissatisfaction to lack of control over eating through dieting and negative affect. Van Strien et al. (2005) extended the negative affect pathway of the original dual pathway model by adding two additional intervening variables: interoceptive deficits and emotional eating. The purpose of this study was to test and compare the original and extended model using prospective data. Both types of loss of control over eating (i.e., subjective and objective binge eating) were evaluated. Data collected from 361 adolescent girls, who were interviewed and completed self-report measures annually over a 2-year period, were analysed using structural equation modeling. Although both models provided a good fit to the data, the extended model fit the adolescent girls' sample data better and accounted for a greater proportion of variance in binge eating than the original model. All proposed mediational pathways of both models were supported and all indirect effects examined through bootstrap procedure were significant. Although our results confirmed the validity of both models and extended previous findings to an early- to middle adolescent group, the bi-directional relationship between dietary restriction and negative affect suggests that the association between these key risk factors for binge eating are more complex than outlined in both the original and extended dual-pathway models.

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.

Why do only a minority of men report severe levels of eating disorder symptomatology, when so many report substantial body dissatisfaction? Examination of exacerbating factors

In recent years research employing female samples has indicated that although body dissatisfaction may be necessary for the onset of an eating disorder, it is not sufficient. This study examined body surveillance and difficulties in interpersonal domains (attachment anxiety and social anxiety) as potential moderators of the body dissatisfaction-eating disorder symptomatology relationship amongst Italian college men (N = 359). As expected, all examined variables were found to intensify this relationship such that body dissatisfaction was strongly related to men's eating disorder symptomatology when each moderator was at its highest level (i.e., 1 SD above the mean). Practical implications are discussed.