Anorexia athletica in pre-professional ballet dancers

Development of a revised version of the transdiagnostic skills scale (T2S-R)

Introduction

The transdiagnostic approach has been shown to offer promising prospects in psychopathology, based on the observation that common factors may be involved in different psychiatric disorders. The transdiagnostic skills scale (T2S) was developed recently to assess the skills that are disrupted in these disorders. However, studies have shown that the T2S has lower predictive power for externalizing than internalizing disorders. This may be due to the fact that the skills assessed do not include the control of urges and cravings. The aims of the current study are thus to develop a revised version of the T2S (T2S-R) integrating this dimension, and to assess its factor structure and invariance across employment status (workers vs. students) and the level of psychopathology.

Method

We recruited 1,298 French participants online through social media. They completed the revised version of the T2S and the symptomatic transdiagnostic test (S2T), which evaluates 11 clusters of psychiatric symptoms. We assessed the factor structure, internal consistency, invariance, and predictive validity of the revised T2S.

Results

We found a good fit for a bifactor exploratory structural equation modeling (B-ESEM) approach including a global skills factor and seven specific factors. The results also indicate that the new dimension (i.e., control of urges and cravings) has good predictive value, especially for externalizing problems. We also found total invariance of the scale across employment status and partial invariance across the level of psychopathology.

Conclusion

The revised version of the T2S-R has good psychometric properties. It predicts better externalizing problems than the original version. However, the scale remains more correlated with internalizing than externalizing problems. We discuss the implications of the results on the transdiagnostic conceptualization and the interest of using a mixed approach combining transdiagnostic and diagnostic analyses.

Current trends and perspectives in the exploration of anorexia athletica-clinical challenges and therapeutic considerations

Elite athletes are exposed to a considerable amount of physical and psychological stress throughout their entire professional life, but the exploration of the consequences of this stressful regimen on mental health is still in its early stages. Eating disorders (EDs), substance use disorders, and behavioral addictions represent only several domains that are worth more investigation in this vulnerable population, in order to find preventative and therapeutic strategies. The exploration of EDs in athletes is important because this population is very vulnerable to the impact that weight and body shape may have on their professional performances, and epidemiological studies support this concern, i.e., the prevalence of EDs in athletes is significantly higher than in the general population. This article is dedicated to the synthesis of available data regarding a specific pathology reported in elite athletes, i.e., anorexia athletica (AA), based on a narrative reviewing methodology. The information about risk factors, pathophysiology, positive and differential diagnosis, epidemiology, structured evaluation, and treatment of AA have been summarized and future research directions have been highlighted. While tentative diagnostic criteria for AA and a self-administered questionnaire exist, its pathophysiology is still insufficiently explored, and the treatment is not based on good-quality trials. According to the retrieved data, more research targeting the physical and mental health of elite athletes, especially those practicing esthetic sports, is needed, in order to implement adequate screening and early intervention programs. Future studies targeting various sub-populations of elite athletes, i.e., esthetic vs. non-esthetic sports, individuals presenting a history of ED vs. those without such a history, and those practicing individual sports vs. team sports are needed to reach the objective of improving the quality of life in this population.

An integrative model as a step toward increasing the awareness of eating disorders in the general population

Eating disorders (EDs) represent a contradictory chapter of clinical psychiatry, i.e., although they are associated with significant prevalence and risks in the long term (including vital risk, especially for anorexia nervosa), the therapeutic resources are minimal and based on low-quality data. Another contradiction arose in the last few decades, i.e., a variety of new EDs have been described, either by clinicians or signaled by mass media, but their systematic exploration is progressing very slowly. Entities like "food addiction," "orthorexia nervosa," or "emotional eating disorder" still require intensive exploration in order to find the most accurate diagnostic instruments, diagnosis criteria, prevalence data, vulnerability factors, and therapeutic approaches. This article is focused on integrating into a comprehensive model a variety of EDs not specified or loosely defined by the current international classifications of psychiatric disorders. This framework is intended as an instrument for stimulating clinical and epidemiological research, with potential favorable consequences for therapeutic research. The dimensional model suggested here includes four main categories that accommodate the already recognized EDs (i.e., anorexia nervosa, bulimia nervosa, and binge eating disorder) as well as ten EDs that still need intensive research to find their clinical and pathophysiological characteristics. More good-quality studies are urgently required regarding this topic, based on the mental and physical negative impact these EDs may have in the short and long term, especially in vulnerable populations (e.g., pregnant women, athletes, adolescents, etc.).

Body Composition, Eating Habits, and Disordered Eating Behaviors among Adolescent Classical Ballet Dancers and Controls

Adolescent classical ballet dancers are nutritionally vulnerable, as they try to retain a lean body shape during a life period of high nutritional requirements due to rapid growth. Studies conducted on adult dancers have indicated a high risk for the development of disordered eating behaviors (DEBs), but research on adolescent dancers remains scarce. The aim of the present case-control study was to compare the body composition, dietary habits, and DEBs of female adolescent classical ballet dancers and their non-dancer same-sex peers. Self-reported questionnaires, namely the Eating Attitudes Test-26 (EAT-26) and a 19-item Food Frequency Questionnaire (FFQ), were used for the assessment of habitual diet and DEBs. The assessment of body composition included the measurements of body weight, height, body circumference, and skinfolds and bioelectrical impedance analysis (BIA). The results indicate that the dancers were leaner than the controls, with lower weight, BMIs, and hip and arm circumferences, leaner skinfolds, and less fat mass. No differences were observed between the two groups regarding eating habits and the EAT-26 scores, but almost 1 out of 4 (23.3%) participants scored ≥ 20, indicative of DEBs. Participants with an EAT-26 score ≥ 20 had significantly higher body weight, BMIs, body circumferences, fat mass, and fat-free mass than those with a score < 20. Adolescents must be educated on nutrition and healthy methods to control body weight through evidence-based information and programs, and whenever appropriate, also through individual counseling by the appropriate health professionals.

Eating psychopathology in ballet dancers: a meta-analysis of observational studies

OBJECTIVE

To assess whether ballet dancers have higher eating psychopathology mean scores than the general population.

METHODS

Meta-analysis of cross-sectional observational studies comparing the scores of one or more of the validated eating psychopathological scales between ballet dancers and any control groups.

RESULTS

Twelve studies were included in the metanalysis. Ballet dancers had a significantly higher EAT score (12 studies retrieved, SMD 0.82 [95% CI 0.44-1.19], p < 0.00001, I² = 84)]; subgroup analysis suggested a possible role of control subjects' choice in explaining heterogeneity. Scores on the EDI subscales of Drive for Thinness, Bulimia, and Body dissatisfaction were available from four studies; Drive for Thinness was higher in ballet dancers (SMD 0.62 [0.01, 1.22]), as well as the Bulimia scale (SMD 0.38 [0.02, 0.73], p = 0.04) and the Body Dissatisfaction scale (SMD 0.34 [0.15, 0.53]). Data on Perfectionism, Interpersonal problems, Ineffectiveness, and Maturity fears, were available from three studies. Higher scores in Perfectionism (SMD 0.68 [0.24, 1.12] p = 0.02), Interpersonal problems (SMD 0.24 [0.02, 0.47], in Inefficacy, (SMD 2.18 [1.31, 3.06]) were found for ballet dancers; on the other hand, Maturity fears scores were not significantly different between ballet dancers and controls (IV-MD = 0.15 [- 0.07, 0.36]). Seven studies reported tests not performed elsewhere.

DISCUSSION

Ballet dancers show a higher level of restriction and drive for thinness than controls, and they may be, therefore, at higher risk for the development of eating disorders. Available studies do not allow the discrimination of dysfunctional eating attitudes and behaviors from adaptive responses.

LEVEL OF EVIDENCE

Level I (evidence obtained from systematic reviews and meta-analyses).

Dancing in a culture of disordered eating: A feminist poststructural analysis of body and body image among young girls in the world of dance

Eating disorders among adolescent girls are a public health concern. Adolescent girls that participate in aesthetic sport, such as dance, are of particular concern as they experience the highest rates of clinical eating disorders. The purpose of this study is to explore the experiences of young girls in the world of competitive dance and examine how these experiences shape their relationship with the body; feminist poststructural discourse analysis was employed to critically explore this relationship. Interviews were conducted across Canada with twelve young girls in competitive dance (14–18 years of age) to better understand how the dominant discourses in the world of competitive dance constitute the beliefs, values and practices about body and body image. Environment, parents, coaches, and peers emerged as the largest influencers in shaping the young dancers’ relationship with their body. These influencers were found to generate and perpetuate body image discourses that reinforce the ideal dancer’s body and negative body image.

Systematic review of risk factors for eating psychopathology in athletes: A critique of an etiological model

OBJECTIVE

The theoretical model by Petrie and Greenleaf (2007, 2012) is an admirable attempt to collate the causal factors of disordered eating in athletes. The aims of this systematic review are (a) to provide an overview of the findings from the relevant literature, (b) to assess whether the model is supported by the existing research, (c) to evaluate the different designs, methods, and measures used to test the mediators in the model, and (d) to highlight areas for improvements and future research.

METHOD

A systematic review of four major online databases identified 37 relevant papers on risk factors of disordered eating in athletes, which were reviewed and critically compared with the theoretical model.

RESULTS

There is a lack of longitudinal research with the relevant mediators in athlete populations, which makes it difficult to determine whether the potential mediators described by Petrie and Greenleaf are causal risk factors rather than simply correlates of disordered eating for athletes. Findings for all the potential mediators are inconsistent, and the range of measures used makes it problematic to draw conclusions.

CONCLUSIONS

Future research needs to use gold standard measures and longitudinal designs in order to fully test and possibly update the model.

Eating Disorders in Athletes: From Risk Management to Therapy

BACKGROUND

Balanced sporting activity should be considered a resource in the treatment of eating disorders (ED), in particular of the BED and in obesity and, if conducted and guided by expert preparers and rehabilitators, in some forms of anorexia and in bulimia.

OBJECTIVE

To assess the role of excessive physical activity, predominantly interfering with daily activities by ultimately resulting in greater energy consumption leading to weight loss, and study the diagnostic criteria of bulimia and anorexia nervosa.

METHODS

A number of literature studies also report the presence of ED among athletes. A 2004 study reported that the prevalence of eating disorders in sports would be 13.5% compared to 4.5% of the control subjects.

RESULTS

In general, nutrition is used as a tool for improving performance not only of athletes but also of technicians and coaches. But in the presence of factors of vulnerability towards ED, the tendency to manipulate the weight can result in an eating disorder or the so-called athletic anorexia or the RED-S.

CONCLUSION

It is important to emphasize that not only do professional athletes suffer from it, but also good-looking amateurs and laypersons.

Essstörungen: Entwicklungspsychologische und entwicklungspsychopathologische Perspektive

Zusammenfassung. Der vorliegende Beitrag betrachtet Essstörungen unter entwicklungspsychologischer und entwicklungspsychopathologischer Perspektive. Körperbildstörungen, gestörtes Essverhalten und der Einfluss beider Eltern werden in den Kontext der normalen Mädchenentwicklung gestellt und insbesondere der Einfluss der Freundinnen und der neuen Medien herausgearbeitet. Bereits bei nicht essgestörten Jugendlichen fallen extremes Diätieren und ängstliche Körperkontrolle, aber auch elterliche problematische Kommunikationsstile und die oft schädlichen Interaktionen mit Gleichaltrigen auf. Die Grenze zu pathologischen Phänomenen ist entsprechend schwer zu ziehen. Hinzukommen hohe Komorbiditäten zwischen verschiedenen Essstörungen und mit internalisierenden und externalisierenden psychischen Störungen. Zeitgeschichtliche Phänomene wie die „holy anorexia“ der vergangenen Jahrhunderte und die gegenwärtig beobachtbare Zunahme an Essstörungen bei Jungen und der Wunsch, das Geschlecht zu verändern (Transgender) werden ebenso betrachtet wie kulturelle Einflüsse („Is fat beautiful?“). In diesem Zusammenhang wird auch der Frage nachgegangen, ob Essstörungen zugenommen haben und welchen Beitrag die neuen Medien dabei möglicherweise haben.

Factors Dancers Associate with their Body Dissatisfaction

Body dissatisfaction constitutes an important factor in the development of eating pathologies, particularly among dancers. The aim of this research was to test the factors that dancers identified as relevant to their body dissatisfaction using an exploratory mixed method design. Participants were 369 dancers from two Spanish dance conservatories. Questionnaires assessed body dissatisfaction, abnormal eating attitudes and behaviors, and risk factors to eating disorders in the dance domain. Nine factors were found; the "teacher", the "uniform", and the "mirrors" were the most common. Individuals with a greater likelihood of developing an eating disorder identified teacherś influence as a key factor in their body dissatisfaction. Specifically, ballet dancers were more likely to indicate that teachers were a negative influence compared to students in other dance genres (contemporary, flamenco, and Spanish dance). Programs to reduce negative body image and improve positive body image in dance conservatories are needed, specifically focusing on teachers.

The Effects of 17 Weeks of Ballet Training on the Autonomic Modulation, Hormonal and General Biochemical Profile of Female Adolescents

This study aimed to examine the alterations in physiological and biochemical markers, after 17 weeks of ballet training in high level ballet dancers. Twenty four female ballet dancers from 12 to 15 years old took part in the study. The study followed 17 weeks of ballet training and analyzed changes in body composition, the autonomic nervous system and biochemical variables before and after (post) training. The internal training load was obtained using the session rating of perceived exertion (session-RPE) method, calculated as the mean weekly session-RPE, monotony and strain. After 17 weeks of training there were significant increases in body mass, height, lean body mass, total protein, urea, hemoglobin concentration, testosterone and thyroxine. During this period, decreases in relative body fat, uric acid, red blood cells, C-reactive protein, and ferritin were also found. After the training period, the autonomic modulation demonstrated significant positive alterations, such as increases in parasympathetic related indices. Based on the results obtained we concluded that ballet training led to improvements in body composition and autonomic modulation. In general hematological and biochemical variables demonstrated that the training did not have adverse effects on the health state of the adolescents.

Comorbid psychiatric diagnosis and psychological correlates of eating disorders in dance students

BACKGROUND/PURPOSE

Although dancers are at risk for eating disorders (EDs), little is known about the features of EDs among the dance population. This study explores the prevalence of EDs, and their psychiatric comorbidities and correlates in dance students.

METHODS

In total, 442 female high-school dance students participated in a two-phase survey. All participants completed screening questionnaires as well as measures assessing teasing, self-esteem, perfectionism, body dissatisfaction, and personality. Of the participating students, 311 underwent the Structured Clinical Interview for DSM-IV-TR Axis I Disorders.

RESULTS

Sixty-eight individuals (15.4%) had an ED by DSM-IV diagnosis. The prevalence of any co-occurring mood (47.1%) and anxiety disorders (30.9%) was high. Although low self-esteem, high neuroticism, and high psychological distress were associated with EDs in univariate analysis, only teasing for overweight and body image dissatisfaction were significantly associated with EDs by multivariate analysis.

CONCLUSION

Prevention and intervention programs for dance students should include recognition and management of emotional disorders and strategies promoting positive body image and reducing the incidence of negative weight-related comments.

[A pilot study on the specificity of body image disturbance in anorexia nervosa]

OBJECTIVE

Body image disturbance (BID) is a central feature of anorexia nervosa (AN), but evidence for bodily-related disorders also exists for patients with cystic fibrosis (CF), who are frequently underweight. A comparison of BID in patients with AN, CF and controls serves to clarify the specificity of BID for AN.

METHOD

22 patients with AN, 10 patients with CF, and 23 controls were tested with regard to perceptual and cognitive-affective components of BID. Further data concerning eating-disorder-related psychopathology were assessed.

RESULTS

BID occurred in all patients with AN. Patients with CF perceived themselves as thinner than the controls did, and three of them exhibited BID. Patients with AN and CF did not differ regarding body satisfaction, and only controls showed higher satisfaction than patients with CF. Patients with AN and CF differed on desire for thinness, dissatisfaction with their body, and interoceptive awareness, with higher scores occurring in patients with AN.

CONCLUSIONS

Our pilot study reveals no severe psychopathology concerning body image in patients with CF. However, we did observe a general body dissatisfaction among these patients, probably associated with their being underweight. BID still seems to be a central diagnostic criterion for AN and should be carefully considered during therapeutic interventions.

Transtornos alimentares e insatisfação com a imagem corporal em bailarinos

INTRODUÇÃO: Os transtornos alimentares (TA) tornaram-se um problema relevante de saúde pública. Paralelamente a esse fato, observa-se aumento na frequência de problemas associados à percepção da imagem corporal. Esses transtornos alimentares são mais incidentes em praticantes de esportes que preconizam o baixo peso corporal, como o balé clássico.OBJETIVO: Determinar a prevalência de comportamentos de risco de transtornos alimentares e insatisfação com a imagem corporal em bailarinos adolescentes na cidade de São Luís, MA, Brasil.MÉTODOS: Realizou-se estudo transversal com 30 bailarinos clássicos, não profissionais de ambos os sexos, com idade de 15 a 19 anos. Para avaliação do comportamento de risco de anorexia nervosa, utilizou-se o teste de atitudes alimentares (EAT-26), e para o comportamento de risco de bulimia nervosa, o teste de investigação bulímica de Edimburgo (BITE). A imagem corporal foi avaliada por meio do questionário de imagem corporal (BSQ).RESULTADOS: A prevalência de comportamentos de risco de TA foi de 30,0% para anorexia nervosa, de acordo com o EAT-26 e, segundo a escala de sintomas do BITE, 40,0% apresentaram comportamento de risco de bulimia nervosa. Além disso, o BSQ identificou que 26,7% dos bailarinos estavam insatisfeitos com sua imagem. Analisando o comportamento de risco de TA e a insatisfação com a imagem corporal, por sexo, não houve diferença estatisticamente significante (p > 0,05).CONCLUSÃO: A alta incidência de insatisfação com a imagem corporal associada à grande prevalência de comportamentos de risco de TA encontrada neste estudo ratifica que a prática do balé parece ser um fator primordial para o aumento da suscetibilidade desses bailarinos desenvolverem TA.

Prevalence of eating disorders amongst dancers: a systemic review and meta-analysis

Eating disorders in dancers are thought to be common, but the exact rates remain to be clarified. The aim of this study is to systematically compile and analyse the rates of eating disorders in dancers. A literature search, appraisal and meta-analysis were conducted. Thirty-three relevant studies were published between 1966 and 2013 with sufficient data for extraction. Primary data were extracted as raw numbers or confidence intervals. Risk ratios and 95% confidence intervals were calculated for controlled studies. The overall prevalence of eating disorders was 12.0% (16.4% for ballet dancers), 2.0% (4% for ballet dancers) for anorexia, 4.4% (2% for ballet dancers) for bulimia and 9.5% (14.9% for ballet dancers) for eating disorders not otherwise specified (EDNOS). The dancer group had higher mean scores on the EAT-26 and the Eating Disorder Inventory subscales. Dancers, in general, had a higher risk of suffering from eating disorders in general, anorexia nervosa and EDNOS, but no higher risk of suffering from bulimia nervosa. The study concluded that as dancers had a three times higher risk of suffering from eating disorders, particularly anorexia nervosa and EDNOS, specifically designed services for this population should be considered.