Implementation costs of the appraise alcohol brief intervention (ABI) for male remand prisoners: A micro-costing protocol and preliminary findings

OBJECTIVE

This paper documents the methods used to assess the implementation costs of the APPRAISE alcohol brief intervention (ABI) delivered to male remand prisoners across two study sites in Scotland and North East England.

METHOD

We first developed a comprehensive taxonomy of the activities constituting the APPRIASE ABI. Next, data were collected for each activity about the study staff and the subject time spent, in addition to the other resources used and unit costs.

RESULTS

From the pilot data collection it was possible to construct a narrative, for both study sites, for how the intervention was delivered and the time required for each activity. The ABI was delivered by Change Grow Live and Humankind intervention staff and staff salaries were obtained from both organizations to calculate the staff delivery costs for each site. Other costs, such as the printing of materials, were estimated based on APPRAISE study records. Due to the ongoing Covid-19 restrictions and limited access to prison resources and staff, there were significant deviations from the initial study protocols. As a result, we document the costs of implementing the ABI as delivered rather than as planned.

CONCLUSIONS

This paper provides the first estimates of the implementation costs of an ABI delivered in criminal justice setting in the UK. Although these costs are from a pilot implementation that was heavily impacted by the Covid-19 pandemic, this paper nonetheless provides useful, policy-relevant information on the potential costs of providing ABI to remand prisoners. It also serves as a methodological template, guidance, and proof of concept for future micro-costing studies of ABIs in criminal justice settings.

Working with the police service and homeless services in North West England to reduce alcohol harms: A feasibility study of a tailored Blue Light approach

INTRODUCTION

Deaths caused by alcohol are increasing in England and 80 % of people with alcohol use disorders (AUDs) are not in treatment. The Blue Light approach (Alcohol Change UK) is an initiative to support people with AUDs who are not in treatment. This study aimed to tailor the Blue Light approach (combined with alcohol identification and alcohol brief interventions [ABI] training) for police officers and homeless service staff in North West England, and to qualitatively evaluate the feasibility and acceptability of the training.

METHODS

The Blue Light approach was tailored using co-production activities, based on Transdisciplinary Action Research. Full-day and half-day training sessions were delivered to the police (full-day N = 14, half-day N = 54) and homeless service staff (full-day N = 11, half-day N = 32), in local police stations and online (four half-day sessions). Semi-structured interviews (N = 23) were conducted to evaluate implementation and integration, analysing the qualitative data in line with Normalisation Process Theory.

RESULTS

Four themes were identified, each with two to three sub-themes, reflecting: (i) the importance of training for working practice, (ii) implementation of the interventions, (iii) changes to relationships within and between organizations, and (iv) recommendations for further changes to the training. Differences in findings across the organizations (police versus homeless services) and by training type attended (full-day versus half-day, in-person versus online) are presented.

CONCLUSIONS

There is evidence to suggest that the training has provided worthwhile knowledge and intervention techniques that can become embedded into working practices. Nevertheless, structural barriers were apparent, primarily within the police service, with clear disparities between recognising the value of the training and what is achievable in practice, given the competing demands.

A multicomponent psychosocial intervention to reduce substance use by adolescents involved in the criminal justice system: the RISKIT-CJS RCT

Background

Substance use and offending are related in the context of other disinhibitory behaviours. Adolescents involved in the criminal justice system constitute a particularly vulnerable group, with a propensity to engage in risky behaviour that has long-term impact on their future health and well-being. Previous research of the RISKIT programme provided evidence of a potential effect in reducing substance use and risky behaviour in adolescents.

Objectives

To evaluate the clinical effectiveness and cost-effectiveness of a multicomponent psychosocial intervention compared with treatment as usual in reducing substance use for substance-using adolescents involved in the criminal justice system.

Design

A mixed-methods, prospective, pragmatic, two-arm, randomised controlled trial with follow-up at 6 and 12 months post randomisation.

Setting

The study was conducted across youth offending teams, pupil referral units and substance misuse teams across four areas of England (i.e. South East, London, North West, North East).

Participants

Adolescents aged between 13 and 17 years (inclusive), recruited between September 2017 and June 2020.

Interventions

Participants were randomised to treatment as usual or to treatment as usual in addition to the RISKIT-Criminal Justice System (RISKIT-CJS) programme. The RISKIT-CJS programme was a multicomponent intervention and consisted of two individual motivational interviews with a trained youth worker (lasting 45 minutes each) and two group sessions delivered over half a day on consecutive weeks.

Main outcome measures

At 12 months, we assessed per cent days abstinent from substance use over the previous 28 days. Secondary outcome measures included well-being, motivational state, situational confidence, quality of life, resource use and fidelity of interventions delivered.

Results

A total of 693 adolescents were assessed for eligibility, of whom 505 (73%) consented. Of these, 246 (49%) were allocated to the RISKIT-CJS intervention and 259 (51%) were allocated to treatment as usual only. At month 12, the overall follow-up rate was 57%: 55% in the RISKIT-CJS arm and 59% in the treatment-as-usual arm. At month 12, we observed an increase in per cent days abstinent from substances in both arms of the study, from 61% to 85%, but there was no evidence that the RISKIT-CJS intervention was superior to treatment as usual. A similar pattern was observed for secondary outcomes. The RISKIT-CJS intervention was not found to be any more cost-effective than treatment as usual. The qualitative research indicated that young people were positive about learning new skills and acquiring new knowledge. Although stakeholders considered the intervention worthwhile, they expressed concern that it came too late for the target population.

Limitations

Our original aim to collect data on offences was thwarted by the onset of the COVID-19 pandemic, and this affected both the statistical and economic analyses. Although 214 (87%) of the 246 participants allocated to the RISKIT-CJS intervention attended at least one individual face-to-face session, 98 (40%) attended a group session and only 47 (19%) attended all elements of the intervention.

Conclusions

The RISKIT-CJS intervention was no more clinically effective or cost-effective than treatment as usual in reducing substance use among adolescents involved in the criminal justice system.

Future research

The RISKIT-CJS intervention was considered more acceptable, and adherence was higher, in pupil referral units and substance misuse teams than in youth offending teams. Stakeholders in youth offending teams thought that the intervention was too late in the trajectory for their population.

Trial registration

This trial is registered as ISRCTN77037777.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 11, No. 3. See the NIHR Journals Library website for further project information.

The barriers and facilitators to the reporting and recording of self-harm in young people aged 18 and under: a systematic review

BACKGROUND AND AIMS

This systematic review sought to identify, explain and interpret the prominent or recurring themes relating to the barriers and facilitators of reporting and recording of self-harm in young people across different settings, such as the healthcare setting, schools and the criminal justice setting.

METHODS

A search strategy was developed to ensure all relevant literature around the reporting and recording of self-harm in young people was obtained. Literature searches were conducted in six databases and a grey literature search of policy documents and relevant material was also conducted. Due to the range of available literature, both quantitative and qualitative methodologies were considered for inclusion.

RESULTS

Following the completion of the literature searches and sifting, nineteen papers were eligible for inclusion. Facilitators to reporting self-harm across the different settings were found to be recognising self-harm behaviours, using passive screening, training and experience, positive communication, and safe, private information sharing. Barriers to reporting self-harm included confidentiality concerns, negative perceptions of young people, communication difficulties, stigma, staff lacking knowledge around self-harm, and a lack of time, money and resources. Facilitators to recording self-harm across the different settings included being open to discussing what is recorded, services working together and co-ordinated help. Barriers to recording self-harm were mainly around stigma, the information being recorded and the ability of staff being able to do so, and their length of professional experience.

CONCLUSION

Following the review of the current evidence, it was apparent that there was still progress to be made to improve the reporting and recording of self-harm in young people, across the different settings. Future work should concentrate on better understanding the facilitators, whilst aiming to ameliorate the barriers.

What is in a Meter? A Qualitative Exploration into the Implementation of Electricity Metering Across Mumbai Communities Using Normalisation Process Theory

Metering is fundamental in the efficient operation of electricity networks, as meters facilitate controlled usage and improve health and well-being. However, across the Global South, meters have often been found to be lacking or not fit for purpose. Therefore, this study sought to determine residents’ perceptions and access to electricity metering across a community in Mumbai, with the goal of developing recommendations to support the implementation of meters in the future. Fifty semi-structured interviews were conducted by phone, with participants from different areas and socioeconomic classes, within Greater Mumbai. The sample consisted of 20 low-income, 20 middle-income, and 10 high-income participants. The Normalisation Process Theory (NPT) was used to inform the interview schedule and to organise the thematic analysis. Meter accessibility and location was variable across the participant groups, as was the education and awareness of metering technology. Socio-political factors were found to directly affect the use of meters, specifically in the low-income group. The high cost associated with metering was a prominent finding; with a preconception that introducing meters would only increase utility expenditure. Future work should focus around ensuring meters are easy to use, practical and accessible to all residents and supporting education programmes around how to use a meter and how they can reduce utility expenditure. The cost of meters should also be investigated, to establish that the costs, associated with introducing new meters, are not passed disproportionately to consumers.

A Rapid Systematic Review of Worldwide Alcohol Use Disorders and Brief Alcohol Interventions in the Criminal Justice System

Although the relationship is complex, there is an association between alcohol use and offending behavior with an interplay between the amount drank, the pattern of drinking and individual and contextual factors. Alcohol brief interventions have been shown to be effective in primary healthcare, however there is currently a lack of compelling evidence in the criminal justice system. We carried out a rapid systematic review of the literature, which updated our review conducted in 2016. Following systematic searches, we included 36 papers on prevalence and 13 papers on effectiveness. Between 26 and 88% of individuals in the policy custody setting scored positive for an alcohol use disorder. In the magistrates court this was 95%; 31-86% in the probation setting and between 19 and 86% in the prison system. In relation to probable dependence, between 21 and 38% of individuals were shown to have probable alcohol dependence in the police custody suite setting; 39 per cent in the magistrate court system; 17-36% in the probation setting and between 18 and 48% in the prison system. This compares to 6% in the general population. We included 13 studies of effectiveness with differing outcome measures and outcomes. We conclude more studies are needed in the field to develop the current evidence base.

A two-arm parallel-group individually randomised prison pilot study of a male remand alcohol intervention for self-efficacy enhancement: the APPRAISE study protocol

INTRODUCTION

The prevalence of at-risk drinking is far higher among those in contact with the criminal justice system (73%) than the general population (35%). However, there is little evidence on the effectiveness of alcohol brief interventions (ABIs) in reducing risky drinking among those in the criminal justice system, including the prison system and, in particular, those on remand. Building on earlier work, A two-arm parallel group individually randomised Prison Pilot study of a male Remand Alcohol Intervention for Self-efficacy Enhancement (APPRAISE) is a pilot study designed to assess the feasibility and acceptability of an ABI, delivered to male prisoners on remand. The findings of APPRAISE should provide the information required to design a future definitive randomised controlled trial (RCT).

METHODS AND ANALYSIS

APPRAISE will use mixed methods, with two linked phases, across two prisons in the UK, recruiting 180 adult men on remand: 90 from Scotland and 90 from England. Phase I will involve a two-arm, parallel-group, individually randomised pilot study. The pilot evaluation will provide data on the likely impact of A two-arm parallel group individually randomised Prison Pilot study of a male Remand Alcohol Intervention for Self-efficacy Enhancement (APPRAISE), which will be used to inform a future definitive multicentre RCT. Phase II will be a process evaluation assessing how the ABI has been implemented to explore the change mechanisms underpinning the ABI (figure 1) and to assess the context within which the ABI is delivered.

ETHICS AND DISSEMINATION

The APPRAISE protocol has been approved by the East of Scotland Research Ethics Committee (19/ES/0068), National Offender Management System (2019-240), Health Board Research and Development (2019/0268), Scottish Prison Service research and ethics committee, and by the University of Edinburgh's internal ethics department. The findings will be disseminated via peer-reviewed journal publications, presentations at local, national and international conferences, infographics and shared with relevant stakeholders through meetings and events.

TRIAL REGISTRATION NUMBER

ISRCTN27417180.

Intermittent fasting interventions for treatment of overweight and obesity in adults: a systematic review and meta-analysis

OBJECTIVE

To examine the effectiveness of intermittent energy restriction in the treatment for overweight and obesity in adults, when compared to usual care treatment or no treatment.

INTRODUCTION

Intermittent energy restriction encompasses dietary approaches including intermittent fasting, alternate day fasting, and fasting for two days per week. Despite the recent popularity of intermittent energy restriction and associated weight loss claims, the supporting evidence base is limited.

INCLUSION CRITERIA

This review included overweight or obese (BMI ≥25 kg/m) adults (≥18 years). Intermittent energy restriction was defined as consumption of ≤800 kcal on at least one day, but no more than six days per week. Intermittent energy restriction interventions were compared to no treatment (ad libitum diet) or usual care (continuous energy restriction ∼25% of recommended energy intake). Included interventions had a minimum duration of 12 weeks from baseline to post outcome measurements. The types of studies included were randomized and pseudo-randomized controlled trials. The primary outcome of this review was change in body weight. Secondary outcomes included: i) anthropometric outcomes (change in BMI, waist circumference, fat mass, fat free mass); ii) cardio-metabolic outcomes (change in blood glucose and insulin, lipoprotein profiles and blood pressure); and iii) lifestyle outcomes: diet, physical activity, quality of life and adverse events.

METHODS

A systematic search was conducted from database inception to November 2015. The following electronic databases were searched: MEDLINE, Embase, CINAHL, Cochrane Library, ClinicalTrials.gov, ISRCTN registry, and anzctr.org.au for English language published studies, protocols and trials. Two independent reviewers evaluated the methodological quality of included studies using the standardized critical appraisal instruments from the Joanna Briggs Institute. Data were extracted from papers included in the review by two independent reviewers using the standardized data extraction tool from the Joanna Briggs Institute. Effect sizes were expressed as weighted mean differences and their 95% confidence intervals were calculated for meta-analyses.

RESULTS

Six studies were included in this review. The intermittent energy restriction regimens varied across studies and included alternate day fasting, fasting for two days, and up to four days per week. The duration of studies ranged from three to 12 months. Four studies included continuous energy restriction as a comparator intervention and two studies included a no treatment control intervention. Meta-analyses showed that intermittent energy restriction was more effective than no treatment for weight loss (-4.14 kg; 95% CI -6.30 kg to -1.99 kg; p ≤ 0.001). Although both treatment interventions achieved similar changes in body weight (approximately 7 kg), the pooled estimate for studies that investigated the effect of intermittent energy restriction in comparison to continuous energy restriction revealed no significant difference in weight loss (-1.03 kg; 95% CI -2.46 kg to 0.40 kg; p = 0.156).

CONCLUSIONS

Intermittent energy restriction may be an effective strategy for the treatment of overweight and obesity. Intermittent energy restriction was comparable to continuous energy restriction for short term weight loss in overweight and obese adults. Intermittent energy restriction was shown to be more effective than no treatment, however, this should be interpreted cautiously due to the small number of studies and future research is warranted to confirm the findings of this review.

Intermittent fasting interventions for the treatment of overweight and obesity in adults aged 18 years and over: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

Are intermittent fasting interventions an effective treatment for overweight and obesity in adults, when compared to usual care treatment (continuous daily energy restriction - reduced calorie diet) or no treatment (ad libitum diet)?

BACKGROUND

Overweight and obesity (classified as Body Mass Index [BMI] of greater than or equal to 25 and 30 respectively) is a global public health concern, with more than 1.9 billion adults worldwide being overweight in 2014 (over 600 million of whom are obese), and resulting in more deaths than underweight. A raised BMI in adulthood is associated with an increased risk of developing a number of chronic diseases which include diabetes, cardiovascular disease, muscular skeletal disorders and some cancers. In addition to this substantial impact on individual health and well being, there are also significant wider costs, for example, in England the annual direct cost to the national health service for treating overweight, obesity and associated morbidity is estimated at over £5 billion pounds, with costs to the wider economy estimated at £27 billion. Therefore effective weight management is essential.As overweight and obesity results from an accumulation of excess body fat arising from an energy imbalance - consuming more energy (kcal) than is expended - the majority of weight management approaches center around behaviors to address this imbalance, i.e. reducing energy intake through caloric restriction and increasing energy expenditure through physical activity. However, the aetiology of overweight and obesity is highly complex, involving an interplay of biological, psychological, societal and environmental drivers. Consequently, effective weight management is challenging, and whilst there exists a plethora of available weight loss programs, not all are comprehensively evaluated and compared, and many weight loss attempts result in weight regain and poor long term results. It is therefore vitally important to review the effectiveness of all new approaches to support an evidence-based approach to weight management.Intermittent fasting (IF), also known as alternate day fasting (ADF), periodic fasting or intermittent energy restriction (IER) is a relatively new dietary approach to weight management that involves interspersing normal daily caloric intake with a short period of severe calorie restriction/fasting. In terms of the possible underlying biological benefits of intermittent fasting, there is some evidence, predominantly from animal studies, to demonstrate beneficial effects on weight loss and cardio-metabolic risk factors. Whilst the underpinning mechanistic evidence is limited, there is some evidence to suggest that the benefits may be explained mechanistically through fat utilization and nutritional stress. However current National Institute for Health and Care Excellence (NICE) guidance on the treatment of adult obesity does not recommend the routine use of very low calorie diets (VLCD) (defined as a hypocaloric diet of 800 or less kcal/day) for the treatment of adult obesity. The National Institute for Health and Care Excellence states that this approach should only be recommended if there is a clinical rationale for rapid weight loss and must be nutritionally complete, part of a multi-component weight management strategy, including ongoing support, and should be undertaken for a maximum of 12 weeks (followed continuously or intermittently). Furthermore, the British Dietetic Association raises concerns that rapid weight loss associated with fasting may largely be due to loss of water and glycogen rather than fat, and may result in fatigue, dizziness and low energy levels. Essentially IF involves the intermittent use of a VLCD, and there remain questions about the side effects of this approach, whether there is an optimal fasting pattern or calorie limit, and how sustainable it is for long term weight management.Intermittent fasting has recently gained much popularity following significant media attention. In the UK this dietary approach reached mainstream after a BBC Horizon documentary aired in August 2012, featured an IF approach called the 5:2 diet, which involves five days of regular eating patterns interchanged with two days of fasting (max 500kcal for women and 600kcal for men). However other IF patterns are used such as alternate day fasting. Despite the recent popularity of intermittent fasting and associated weight loss claims, the supporting evidence base in humans remains small and there is only one published systematic review examining the health benefits of this approach. However the aim of this review was to examine the impact of this intervention on wider health benefits (not specifically as a treatment approach for overweight and obesity), and did not provide a comprehensive methodology or meta-analysis of RCT data. This proposed review will hence address these gaps in the evidence base.

Psychopathology and violent behaviour in psychiatric intensive care

This study considered the use of staff observation and patient's self-ratings of subjective psychopathology on admission to a psychiatric intensive care unit. The aim was to evaluate these measures as a means of predicting subsequent assaults and self-injury during the patients' stay on the ward. Few studies have shown a relationship between subjective experience and observable violent behaviour although some have found a correlation with ‘violence potential’. Eichelman & Hartwig (1990) have suggested the use of the SCL-90 hostility subscale, although doubts have been expressed about the ability of psychotic patients to complete such questionnaires reliably. The usefulness of both patients' self-ratings and staff observation would lie in their ability to help staff predict violence and self-injury and to take appropriate action.

Exploring the factors affecting the implementation of tobacco and substance use interventions within a secondary school setting: a systematic review

BACKGROUND

The aim of this mixed-methods, systematic literature review was to develop an understanding of the factors affecting the implementation of tobacco and substance use intervention programmes in the secondary school setting using NPT as an analytical framework.

METHODS

A search strategy was developed that combined implementation, school and intervention search terms. Literature searches were conducted in MEDLINE, Embase, PsycHINFO, Scopus, ERIC, CINAHL, Web of Science and the Cochrane Library. PROSPERO was also searched for similar systematic reviews and a grey literature search of policy documents and relevant material was also conducted. Papers were eligible for inclusion if they were based in a secondary school and focused on the implementation of a tobacco or substance use programme. Both quantitative and qualitative methodologies were considered for inclusion. Normalisation Process Theory (NPT) was used as a conceptual framework to identify facilitators and barriers of implementation and to structure the synthesis.

RESULTS

Inclusion criteria were met by 15 papers. The included papers were both quantitative and qualitative and focused on a range of tobacco and substance use interventions, delivered by differing providers. Key facilitating factors for implementation were positive organisational climate, adequate training and teacher's and pupil's motivation. Barriers to implementation included heavy workloads, budget cuts and lack of resources or support. Quality appraisal identified papers to be of moderate to weak quality, as papers generally lacked detail.

CONCLUSION

NPT highlighted the need for studies to extend their focus to include reflexive monitoring around appraisal and the evaluation processes of implementing new tobacco or substance use programs. Future research should also focus on employing implementation theory as a tool to facilitate bridging the gap between school health research and practice.

Validity of the Eating Disorders Examination-Questionnaire when used with adolescents with bulimia nervosa and atypical bulimia nervosa

OBJECTIVE

To validate the online questionnaire form of the Eating Disorders Examination (EDE-Q) against the interview version (EDE) in a clinic and community sample of adolescents with bulimia nervosa (BN) or atypical BN (eating disorder not otherwise specified with bulimic features - EDNOS-BN).

METHOD

Adolescents with BN (N=58) or EDNOS-BN (N=37) completed the EDE over the telephone and the EDE-Q online.

RESULTS

There were moderate to high correlations between the attitudinal scales. Eating was rated as more pathological on the EDE-Q than the EDE, except dietary restraint. As in research among adults, agreement between the two measures was low regarding binge eating episodes, but better for vomiting episodes. When compared with the EDE, the EDE-Q attitudinal scales were more valid for BN than for EDNOS-BN patients, and more valid for the clinic sample.

CONCLUSION

The online version of the EDE-Q has partial validity for use with adolescents. The EDE-Q might be reporting a more accurate description of current status, as it avoids possible filtering and approval aspects.

Cognitive-behavioural therapy for adolescents with bulimic symptomatology: the acceptability and effectiveness of internet-based delivery

BACKGROUND

The evidence base for the treatment of adolescents with bulimia nervosa (BN) is limited.

AIMS

To assess the feasibility, acceptability, and clinical outcomes of a web-based cognitive-behavioural (CBT) intervention for adolescents with bulimic symptomatology.

METHOD

101 participants were recruited from eating disorders clinics or from beat, a UK-wide eating disorders charity. The programme consisted of online CBT sessions ('Overcoming Bulimia Online'), peer support via message boards, and email support from a clinician. Participants' bulimic symptomatology and service utilisation were assessed by interview at baseline and at three and six months. Participants' views of the treatment package were also determined.

RESULTS

There were significant improvements in eating disorder symptoms and service contacts from baseline to three months, which were maintained at six months. Participants' views of the intervention were positive.

CONCLUSIONS

The intervention has the potential for use as a first step in the treatment of adolescents with bulimic symptomatology.

Core beliefs and social anxiety in the eating disorders

Social anxiety is a common comorbid problem in the eating disorders. The present study investigated whether specific types of core beliefs are common in eating-disordered individuals presenting with high levels of social anxiety. The participants were a group of 191 women meeting Diagnostic and Statistical Manual-IV (DSM-IV) criteria for an eating disorder. Young's Schema Questionnaire (YSQ-S) was used as a measure of core beliefs, while a brief version of the Fear of Negative Evaluation scale (Brief FNE) was used as a measure of social anxiety. The results showed that eating-disordered individuals with high levels of comorbid social anxiety report higher levels of socially-oriented core beliefs (abandonment; defectiveness/shame) than those who experience low levels of social anxiety. The findings highlight the potential importance of addressing core beliefs in specific groups of eating-disordered individuals. Implications for future research and clinical practice are discussed.

Family functioning in adolescent anorexia nervosa: a comparison of family members' perceptions

Abnormal patterns of family functioning have often been reported in anorexia nervosa. Moreover, members of families with an adult with eating disorders have different family functioning perspectives. This study investigated whether differences in family members' perspectives, similar to the ones found in families of adults with eating disorders, can be found in families of adolescents with anorexia nervosa. Perceived family functioning, measured with the Family Assessment Device, was compared between 49 control and 34 clinical families, and across family members. Differences were found between the two groups on a number of aspects of family functioning, with the clinical families showing most disturbances. There was a general agreement across family members in their perceptions of family functioning, with one notable exception. Clinical daughters disagreed with both their parents about the family level of communication, whereas control daughters disagreed only with their fathers. Disagreements between clinical adolescents and their mothers about the family communication style appear to be important in anorexia nervosa in this age group, although it is not possible to reach conclusions about the direction of causality. These findings support the use of family-oriented therapies that aim to identify and work with difficulties in communication within the family.

The prevalence of DSM-IV personality pathology among individuals with bulimia nervosa, binge eating disorder and obesity

BACKGROUND

There are numerous reports of personality disorder pathology in different eating disorders. However, few studies have directly compared personality pathology in bulimia nervosa, binge eating disorder and obesity. The present study examines group differences in DSM-IV personality pathology, considering the potential utility of understanding personality disorders in terms of diagnosis and dimensional scores.

METHOD

Eating disorder diagnoses were established using the Eating Disorder Examination interview. Thirty-five bulimia nervosa patients, 15 binge eating disorder patients and 37 obese patients were assessed and compared on the International Personality Disorder Examination using categorical and dimensional personality disorder scores.

RESULTS

For most personality disorders, there was a dichotomy of binge eaters versus non-binge eaters. In contrast, there was a continuum of severity in borderline personality disorder pathology between the groups. The dimensional system of measurement of personality pathology allowed for clearer differentiation between the groups.

CONCLUSION

The study strongly indicates that personality disorder difficulties are present in patients who binge eat, while obese patients who do not binge eat display significantly less personality disorder pathology. Assessment of bulimia nervosa, binge eating disorder and obesity needs to address personality disorders and pathology. Dimensional markers of personality pathology can be used to supplement categorical diagnoses, providing information about the traits that underlie diagnosis.

Somatoform dissociation in eating-disordered patients

This study investigated the role of somatoform dissociation in eating disorders and pathological eating behaviour, relative to the established association of eating pathology with psychological dissociation. The participants were 131 women with DSM-IV diagnoses of anorexic or bulimic disorders and 75 women who had no such disorder. Each woman completed measures of psychological and somatoform dissociation, as well as a measure of bulimic attitudes. The current presence or absence of specific bulimic behaviours was identified during the clinical interview. Levels of both forms of dissociation were higher in the women who had diagnoses of disorders with a bulimic component (bulimia nervosa; anorexia nervosa of the binge/purge subtype) than in the non-clinical or restrictive anorexic women. Somatoform dissociation showed particularly strong links with the presence of bulimic behavioural features (excessive exercise, laxative abuse, diet pill abuse, diuretic abuse) and with bulimic attitudes. The formulation and treatment of cases where there are bulimic features is likely to be enhanced by the assessment of somatoform dissociation.

Environmental temperature during gestation and body mass index in adolescence: new etiologic clues?

OBJECTIVE

Being born during certain parts of the year is linked to the presence of obesity in later years. Animal studies suggest that environmental temperature during fetal development may be one aspect of the link to later weight status, but this relationship has not been extensively studied in humans. The present study investigates whether environmental temperature during different stages of human gestation is associated with body mass index (BMI) during late adolescence.

METHODS

Questionnaire data were collected from adolescents (n=578; ages 15-19 y) attending public schools in a mid-Atlantic US city. Pearson correlations were used to assess association of BMI with mean environmental temperature (from meteorological records) during trimesters of intrauterine development and at birth.

RESULTS

BMI was significantly correlated with environmental temperatures in the second and third trimester, but only among female African Americans. Among females, those 'at risk for overweight' or overweight (BMI >85th percentile) tended to be born during periods of warmer average environmental temperatures (>13.2 degrees C). However, this effect was reliable only among African American females (relative risk=2.51, CI 1.07-5.91). A similar, non-significant tendency emerged among Caucasian females, but there was no such effect in males.

CONCLUSIONS

Environmental temperatures during pregnancy and at birth are associated with the likelihood that African American females become overweight as adolescents. Possible biological and dietary mechanisms for this finding are discussed.

Influence of environmental temperatures during gestation and at birth on eating characteristics in adolescence: a replication and extension study

Past research has shown a season of birth effect in clinical subjects with eating disorders. Studies also indicate a similar effect of environmental temperatures in non-clinical subjects, as well as effects of environmental temperatures during the three trimesters of gestation. These two studies aimed to replicate and extend those findings. The participants were adolescents (ages 15-19 years) who attended public schools in a mid-Atlantic US city. They completed the relevant scales of the Eating Disorder Inventory (N=578) and the Three Factor Eating Questionnaire (N=191). Correlational analyses were employed to study the relationship of environmental temperatures during pregnancy (the three trimesters of intrauterine development and at birth) with eating characteristics. The results of the previous studies were broadly replicated in Study 1, but Study 2 revealed a difference in the pattern of associations according to the measure used. This contrast indicates that the way in which one conceptualizes eating pathology is of critical importance in understanding the long-term impact upon eating patterns of environmental temperature during the intrauterine period. Possible theoretical bases for these findings are discussed.

Environmental temperature during pregnancy and eating attitudes during teenage years: a replication and extension study

OBJECTIVE

Among nonclinical adolescents, restrictive eating attitudes are more likely to occur among females born during warmer months. The present study aimed to replicate this finding and to extend it, considering whether such an effect is found in males and across the teenage years. In addition, the influence of temperature across the intrauterine period was considered.

METHOD

The participants consisted of younger and older teenagers, all born in England. Each completed the relevant scales of the Eating Disorders Inventory and provided demographic information. Temperature across fetal development was determined using national meteorological records.

RESULTS

There was a positive link between restrictive attitudes and temperature at birth among the older female group, although this replication effect did not reach significance. The same association among the older males was highly significant. The range of temperatures during fetal development also predicted later restrictive attitudes. In contrast, these effects were not replicated among the younger group, where a different pattern of effect was found (among the females only).

CONCLUSION

Environmental temperature seems to have an important influence on later eating attitudes, but the pattern of influence appears to vary across development. Therefore, studies of the mechanisms behind this effect need to consider the role of gender and development, as well as the role of temperature across the period of intrauterine development.

The utility of dimensional and categorical approaches to understanding dissociation in the eating disorders

OBJECTIVE

The present study compared levels of dissociation across groups of eating-disordered women, investigating the utility of dimensional and categorical measures of dissociation in understanding diagnoses and behaviours in the eating disorders.

METHODS

The Dissociative Experiences Scale (DES-II) was completed by 170 eating-disordered women (drawn from out-patient assessment clinics) and 203 nonclinical women. The clinical group also supplied information regarding eating behaviours and related features (alcohol abuse, reported history of sexual abuse). The DES-II and a subset of its items (DES-Taxon) were used as dimensional and categorical discriminators of the groups and of the presence/absence of specific features and symptoms.

RESULTS

When treated as dimensional measures, the DES-II and DES-Taxon had similar levels of clinical utility (particularly discriminating the binge-purge anorexics from the other clinical groups). However, the DES-Taxon was a superior categorical measure, discriminating groups more clearly and predicting the presence of many symptoms and features much more powerfully.

CONCLUSIONS

The DES-Taxon is a potentially valuable self-report measure for indicating the level and presence of dissociative psychopathology in the eating disorders. As well as being convenient to administer and score, it has the clinical and research value of indicating those patients in whom treatment might need to include addressing pathological dissociation.

The psychopathology of bulimic women who report childhood sexual abuse: the mediating role of core beliefs

Although reported sexual abuse in childhood is associated with bulimic behaviors, less is known about the cognitive factors that explain this association. This study examined the potential role of core beliefs as a mediator in the abuse-bulimia link. Sixty-one bulimic women were interviewed regarding any history of childhood sexual abuse and completed measures of bulimic behaviors, dissociation, depression, and core beliefs. The 21 women who reported a history of childhood sexual abuse had significantly higher levels of several core beliefs and greater levels of psychopathology. Different core beliefs acted as mediators in the relationships between sexual abuse and individual symptoms. The findings support the suggestion that schema-focused cognitive therapy may be useful in working with bulimics, particularly if they have been sexually abused in childhood. Further research is needed to determine the role of core beliefs in mediating the impact of other forms of trauma and how traumas relate to other "escape" behaviors.

The adolescent dissociative experiences scale: psychometric properties and difference in scores across age groups

Adolescence is thought to be a key developmental period for dissociative processes. However, there has been little empirical investigation of dissociation in adolescence. This paper reports the results of a study (N = 768) that investigated the psychometric properties of the Adolescent Dissociative Experiences Scale (A-DES) and compares dissociation scores across the adolescent age range (11 to 16 years). The A-DES had good internal reliability and a one-factor solution. No significant age or gender differences in A-DES scores were found. The implications of these findings for future research and theory are outlined.

Early environmental influences on restrictive eating pathology among nonclinical females: the role of temperature at birth

OBJECTIVE

In eating-disordered populations, restrictive pathologies are associated with a higher rate of births in the spring and early summer. The reasons for this relationship are not understood. The present study of a nonclinical group aimed to determine whether there is a link between being born in warmer months and the level of restrictive pathology in later years.

METHODS

The participants (N = 117) were all young adult females who were conceived and born in England. Each completed the relevant scales of the Eating Disorders Inventory and provided demographic information. Temperature at birth was determined using national meteorological records.

RESULTS

Restrictive attitudes were stronger among women born during the warmer part of the year (May-August), and those attitudes were dimensionally associated with temperature at birth. Body dissatisfaction showed some of the same relationships. Neither period of birth nor temperature at birth was related to bulimic attitudes or body mass index.

CONCLUSIONS

Being born during warmer months is significantly associated with restrictive eating attitudes among nonclinical females, although the link is relatively weak. Potential causal mechanisms are outlined, but further research is needed to explain this link in clinical and nonclinical groups.

Relationships between objective physical characteristics and the use of weight control methods in adolescence: a mediating role for eating attitudes?

This study of non-clinical adolescent males and females examined associations of objectively measured physical characteristics with greater use of methods of weight control and considered whether the relationships between these variables might be explained by a mediating effect of a subjective characteristic--unhealthy eating attitudes. Non-clinical male and female adolescents completed measures of weight control and eating attitudes, and their physical characteristics were measured using a range of standardized anthropometry techniques. Regression analyses were used to test the role of eating attitudes as mediators in the relationship between physical characteristics and the use of weight control methods. The data were compatible with a partial mediator model, where physical characteristics influence eating attitudes, and those where attitudes drive the use of methods to control weight. However, not all of the relationship was explained by this mediator. In addition, there were different patterns of association for men and women, consistent with different patterns of bodily focus between the genders. These findings stress the importance of understanding objective physical characteristics as well as subjective eating attitudes to find out why people use different levels of weight control behaviours. Limitations, further research and potential implications for clinical and preventative programmes are discussed.

Bulimics' responses to food cravings: is binge-eating a product of hunger or emotional state?

This study examined the roles of hunger, food craving and mood in the binge-eating episodes of bulimic patients, and identified the critical factors involved in the processes surrounding binge-eating episodes that follow cravings. This was a prospective study of the binge-eating behaviour of 15 women with bulimia nervosa. The participants used food intake diaries and Craving Records to self-monitor their nutritional behaviour, hunger levels and affective state. Cravings leading to a binge were associated with higher tension, lower mood and lower hunger than those cravings not leading to a binge. Levels of tension and hunger were the critical discriminating variables. The findings of the study support empirical evidence and models of emotional blocking in binge-eating behaviour and challenge the current cognitive starve-binge models of bulimia. The role of food cravings in the emotional blocking model is discussed in terms of a classically conditioned motivational state. Implications for treatment are addressed.

Schema avoidance in bulimic and non-eating-disordered women

OBJECTIVE

Models of bulimia lack a clear conceptualization of avoidance. This study considers the role of different domains of schema avoidance in bulimic disorders and examines the association of scores on the Young-Rygh Avoidance Inventory (YRAI) with bulimic pathology.

METHODS

A total of 19 bulimic and 74 comparison women completed the YRAI and a measure of bulimic psychopathology.

RESULTS

Bulimics scored significantly higher than the nonclinical women did on all YRAI scales. Greater reported use of avoidance was positively associated with bulimic attitudes, but only among the comparison group. At a dimensional level, behavioral/somatic avoidance was more strongly associated with bulimic pathology than cognitive/emotional avoidance, but the same was not true when differentiating groups.

CONCLUSIONS

The YRAI is a robust measure of different domains of schema avoidance in understanding bulimic psychopathology. Clinically, the YRAI might be used to guide treatment for bulimic disorders.

Treating personality fragmentation and dissociation in borderline personality disorder: a pilot study of the impact of cognitive analytic therapy

Recent findings suggest that personality fragmentation may be a core component of borderline personality disorder (BPD) and that successful treatment of BPD may depend on the extent to which this is addressed. Cognitive analytic therapy (CAT) can increase integration by strengthening awareness, and hence control, of the dissociative processes maintaining fragmentation. This pilot study aimed to conduct a systematic evaluation of the impact of CAT on BPD severity and personality integration. A patient series within-subject design was used. Five BPD participants completed a series of assessments to evaluate the impact of therapy on BPD severity, fragmentation, dissociation, symptomatology and interpersonal adjustment before, during and following 16-session CAT. By follow-up, CAT had produced reductions in the severity of BPD for all five participants, and three participants showed significant changes in their levels of personality fragmentation. Improvements in comorbid disturbance were less consistent, however. Although the small number of participants involved limits these findings, they have theoretical and clinical interest. They generally support the suggestion that integration should be enhanced with BPD patients, and suggest that CAT may be a useful method to achieve this goal.

Social convergence of disturbed eating attitudes in young adult women

It has been suggested that a broad range of social factors influence disturbed eating attitudes, but there has been relatively little investigation of the role of peer influence. Drawing from social identity theory, this longitudinal study of a nonclinical group of women examined whether social proximity results in a convergence of eating psychopathology over time. Forty-one nonclinical women (living in 11 communal apartments) completed the Eating Disorders Inventory (EDI) at three time points (1 week after moving in, 10 weeks later, and a further 14 weeks later). The women's eating and related attitudes were compared across the three time points. Then divergence scores were calculated (showing the spread of EDI scores within each apartment) and compared across the three time points. The spread of scores within the apartments changed significantly, indicating some convergence in those attitudes that are socially valued (restrictive attitudes; body concerns) and divergence in those attitudes that are not socially valued (bulimia). There was also an increase in convergence of levels of perfectionism. The findings support the suggestion that social proximity promotes convergence of socially valued eating characteristics but divergence of socially stigmatised characteristics. Further research is suggested to establish the generalizability of these findings and to identify those who are most at risk of such social effects on eating disturbance.

Bulimic psychopathology and impulsive behaviors among nonclinical women

OBJECTIVE

There is evidence that bulimic diagnoses are associated with other impulsive behaviors. This study examines whether bulimic attitudes and behaviors show similar links to impulsive behaviors among nonclinical women.

METHODS

The participants were 53 women with no history of psychological treatment. Each completed two questionnaire measures: the Bulimic Investigatory Test and the Impulsive Behaviors Scale.

RESULTS

Bulimic attitudes and behaviors among this nonclinical group were associated with impulsive behaviors overall. This link was principally with self-harming behaviors, although there was some association with alcohol/drug use.

CONCLUSIONS

Bulimic psychopathology seems to be associated principally with behaviors that share functional similarity on some level (e.g., availability; immediacy of action). These findings need to be replicated in a clinical sample, but suggest a need for clear assessment of the full range of impulsive behaviors in bulimic women.

Internal and external antecedents of binge eating episodes in a group of women with bulimia nervosa

OBJECTIVE

This research examined the internal and external factors that predict whether a food craving develops into a binge in bulimia nervosa.

METHOD

Fifteen bulimic women kept diary records of food cravings over the course of a week, noting their internal state, environmental triggers, and whether the craving developed into a binge. Eighty cravings were examined, of which approximately one half developed into binges.

RESULTS

At the bivariate level, binge eating resulted from cravings more often if the women were alone, in the morning, and following eating the craved food. These factors interacted, so that binges were more likely if the women avoided a craved food in the morning, but not later in the day.

CONCLUSIONS

These findings support a model of binge eating for which both internal states (craving, eating the craved food) and external factors (time of day, social circumstances) need to be taken into account. Relevant models of craving are discussed, along with their implications for clinical practice.

Anger and bulimic psychopathology among nonclinical women

OBJECTIVE

Although there are well-established links between bulimic psychopathology and some affective states, the role of anger is not clearly understood. This is likely to be a product of the diverse nature of anger. The present study examines the association of different components of anger with bulimic attitudes and behaviors among a nonclinical group of women.

METHODS

Eighty-three nonclinical women completed standardized measures of anger and bulimic attitudes/behaviors.

RESULTS

Bulimic attitudes and behaviors were correlated specifically with state anger and anger suppression, rather than with trait anger. The pattern of results suggests that binging and vomiting behaviors may serve different functions with regard to anger.

CONCLUSIONS

Bulimic attitudes and behaviors appear to reduce immediate anger states, particularly when the individual has a strong tendency to avoid expressing that emotion. Potential therapeutic implications are considered.

Emotional processing and bulimic psychopathology: age as a factor among nonclinical women

OBJECTIVES

This study tested the hypothesis that bulimic attitudes are associated with both attentional bias toward and cognitive avoidance of emotion cues among nonclinical women, considering whether the same pattern was found across early adulthood.

METHOD

Eighty nonclinical women were divided into younger (< or =21 years) and older (> or =22 years) age groups. Each completed the Bulimic Investigatory Test and a Stroop task, designed to determine biases in the processing of negative and positive emotional information.

RESULTS

Among the older women, more bulimic attitudes were associated with a specific attentional bias toward negatively valenced emotional material. In contrast, the younger women with more severe bulimic attitudes showed greater cognitive avoidance of both positive and negative emotion cues.

DISCUSSION

These findings suggest that women with bulimic attitudes differ with age in their processing of emotional information. Potential implications are considered for clinical work with bulimic women of different ages.

Psychiatric symptomatology in borderline and other personality disorders: dissociation and fragmentation as mediators

This study considered the role of dissociation and personality fragmentation as psychological factors that might distinguish borderline and personality disorder (BPD) patients, and that might explain why BPD patients have higher levels of other psychiatric symptomatology than those with other personality disorders. Two groups of personality-disordered patients (personality disorders including BPD; personality disorders other than BPD) completed measures of dissociation, personality fragmentation, and psychiatric disturbance. The BPD group had higher levels of a number of aspects of psychiatric symptomatology. Those differences were mediated by aspects of dissociation. Personality fragmentation differentiated the two groups but was not related to the higher levels of other aspects of psychiatric disturbance. Treating the syndrome of BPD may depend on addressing both dissociation and personality fragmentation. In contrast, reducing the level of comorbid psychiatric disturbance in BPD is likely to be more strongly dependent on reducing levels of different aspects of dissociation. Psychotherapeutic techniques and targets for achieving such change are discussed.

Childhood emotional abuse and eating psychopathology

The potential role of childhood emotional abuse (CEA) in the etiology and maintenance of eating psychopathology is reviewed. While childhood sexual and physical abuse have been hypothesized as risk factors in multifactorial models of eating disorders, a role for CEA has only recently been considered. Initial findings demonstrate a phenomenological link between CEA and eating psychopathology, and suggest that this association might be different to the links for other forms of trauma (i.e., CEA may have a relationship with a broader range of eating symptoms than sexual and physical abuse). However, the psychological processes that might account for such a link are not yet well understood. Potential cognitive and affective mediators are considered, with a particular emphasis upon low self-esteem and anxiety. A model is proposed, to act as a framework for further research into this field. The clinical implications of the research to date and of the proposed model are discussed.

Cognitive content among bulimic women: the role of core beliefs

OBJECTIVE

Most cognitive analyses of bulimic disorders have stressed the role of negative automatic thoughts or dysfunctional assumptions regarding weight, shape, and food. This study considered the role of more general core beliefs in the cognitive content of bulimic disorders.

METHODS

Fifty bulimic and 50 comparison women completed the Schema Questionnaire (YSQ) and a diary measure of bulimic behaviors.

RESULTS

The groups could be differentiated using just three of the beliefs: perceived Defectiveness/Shame, Insufficient Self-Control, and Failure to Achieve. This discrimination included differences between bulimic subgroups. At the symptomatic level, the bulimic women's Emotional Inhibition beliefs predicted their severity of binging, whereas their Defectiveness/Shame beliefs predicted severity of vomiting.

CONCLUSIONS

The findings support a model of bulimic psychopathology where the central cognitions encompass more than beliefs about food, shape, and weight. Clinical implications are considered.

Family dysfunction and bulimic psychopathology: the mediating role of shame

OBJECTIVE

Although disturbed family function has some association with bulimic psychopathology, the psychological mechanisms that account for that link are not clear. This study explores the hypothesis that shame acts as a mediator in that relationship, whereas shame-proneness is a moderator variable.

METHOD

The participants were 139 nonclinical women. Each completed measures of perceived family function, shame-proneness, internalized shame, and bulimic psychopathology. Regression analyses were used to test for the mediating and moderating effects of shame.

RESULTS

The findings were compatible with a model where shame-proneness acts as a moderator and internalized shame is a perfect mediator in the link between paternal overprotection and bulimic attitudes.

CONCLUSIONS

The experience of shame appears to be a critical element in understanding the relationship between perceived family dysfunction and bulimic psychopathology. Where individuals perceive their families as problematic, it may be clinically valuable to focus on shame as a psychological consequence of that experience.

The relationship between parental bonding and core beliefs in anorexic and bulimic women

OBJECTIVE

The role of core beliefs in the psychopathology of eating disorders has been considered in recent years. Young (1994) hypothesized that unhealthy core beliefs originate from the experience from the first few years of life. The aim of the present study was to consider whether perceived parental bonding might explain the development of such beliefs in eating disordered women.

METHOD

The participants were 30 anorexics, 27 bulimics and 23 comparison women who completed measures of core beliefs and perceived parental bonding.

RESULTS

There were significant differences in perceived parental bonding behaviours across groups. The association between parental bonding and core beliefs were much stronger in the anorexic group than that in either the bulimic or the control group. In particular, a perceived low level of parental care was predictive of the presence of some unhealthy core beliefs in anorexic women.

CONCLUSION

Longitudinal research is needed to confirm these findings among anorexic and bulimic women. Clinically, these findings provide insight into the possible origins or core beliefs, and hence might aid their challenge in schema-focused cognitive therapy.

Cognitive avoidance and bulimic psychopathology: the relevance of temporal factors in a nonclinical population

OBJECTIVE

Previous research has provided evidence of both an attentional bias towards, and a cognitive avoidance of threat cues, by individuals with unhealthy eating attitudes and disorders. It has been suggested that an initial attentional bias might be followed by a later avoidance process. The present study assessed the speed of processing of self-directed ego threat words following different interstimulus intervals (500, 1,000, 1,500, and 2,000 ms).

METHOD

Fifty female students completed a computer-driven threat processing task and the Eating Disorders Inventory.

RESULTS

Women were significantly slower to process ego-self threat cues following the 2, 000-ms interval than following the other intervals (500, 1,000, and 1,500 ms). Those women with increased levels of bulimic attitudes were slower to process threats following the 1,500-ms interval, but not after the longer or shorter intervals.

CONCLUSIONS

The results stress the importance of temporal factors in the processing of threat by individuals with high levels of eating psychopathology. The findings are discussed in terms of an appropriate cognitive model.

Subliminal activation of abandonment- and eating-related schemata: relationship with eating disordered attitudes in a nonclinical population

OBJECTIVE

Previous research has demonstrated that subliminal abandonment cues can facilitate eating behavior. It is believed that such eating is a response to the activation of specific core schemata. However, the precise nature of those schemata has not been established. This study examined whether the presentation of subliminal abandonment and food/shape cues results in the activation of abandonment-related or food-related schemata.

METHOD

Eighty-two women were exposed to one of three subliminal cues- an abandonment cue ("lonely"), an appetitive cue ("hungry"), and a neutral cue ("gallery"). They subsequently completed Stroop tasks to measure activation of relevant schemata.

RESULTS

Subliminal presentation of abandonment cues led to the activation of food- and shape-related schemata. In contrast, subliminal appetitive cues resulted in an activation of abandonment-related schemata.

CONCLUSIONS

The results show preliminary support for a multilevel cognitive model, involving indirect links between subliminal cue type and the activation of eating-related cognitions.

Outcome of group cognitive-behavior therapy for bulimia nervosa: the role of core beliefs

It is hypothesized that individuals who benefit less from CBT will be those who have more pathological core beliefs (unconditional beliefs, unrelated to food, shape and weight). Twenty bulimic women were treated using 12 sessions of conventional group CBT. Eating behavior and attitudes were assessed pre- and posttreatment. Core beliefs were assessed at the beginning of the programme, and were used as predictors of change across treatment (once any effect of pretreatment psychopathology was taken into account). Group CBT was effective, with reductions of over 50% in bulimic symptoms. Outcome on most indices was associated with pretreatment levels of pathological core beliefs. Possible reasons for these findings are discussed.

Parental style and vulnerability to depression: the role of core beliefs

This study considers the potential role of core beliefs (unconditional schema-level representations) in the relationship between recalled parenting in childhood and major depression in adulthood, comparing a group of depressed outpatients (N = 60) with a healthy community sample (N = 67). The depressed group were differentiated by poorer perceived parenting (low care and high overprotection) and by three unhealthy core beliefs (defectiveness/shame, self-sacrifice, and insufficient self-control). Among nonclinical participants, it appears that vulnerability to harm beliefs act as a partial mediator of the relationship between poor paternal care and the development of depressive features. In contrast, a broader set of core beliefs appears to mediate the relationship of maternal bonding and paternal overprotection with depressive symptoms among the depressed group. The findings suggest that clinical work with adults with major depression might need to take account of parental style. Where parents are reported to be uncaring or overprotective, cognitive-behavioral therapy might need to include a schema-focused component.

Core beliefs in anorexic and bulimic women

There is research evidence to suggest the presence of dysfunctional cognitions in anorexia nervosa and bulimia nervosa that are not related to food, weight, or shape. These maladaptive cognitions have not been addressed by the conventional cognitive behavioral models of etiology or therapy. This study aimed to assess the impact of unhealthy core beliefs on eating disorders and their symptoms. Twenty restricting anorexics, 10 bulimic anorexics, 27 bulimics, and 23 normal controls completed Young's Schema Questionnaire. Eating behaviors and attitudes were also measured. The results indicate that both anorexic and bulimic women had significantly higher levels of unhealthy core beliefs than comparison women, but the clinical groups only differed on one individual core belief (entitlement). However, there were different patterns of association between core beliefs and eating psychopathology in anorexic and bulimic women. It is suggested that future clinical practice should incorporate core beliefs as a potential element in the assessment and treatment of eating disorders.

Emotional eating and eating psychopathology in nonclinical groups: a cross-cultural comparison of women in Japan and the United Kingdom

OBJECTIVE

Emotional eating is associated with eating psychopathology among Western populations. It is not known whether the same conclusions hold in non-Western cultures, where norms for emotional expression differ. This study examined whether emotional eating has the same eating psychopathology correlates in different cultures.

METHOD

Three groups of nonclinical women were compared-Japanese living in Japan; Japanese living in the United Kingdom; and British living in the United Kingdom. They completed an Emotional Eating Scale and the Eating Disorders Inventory.

RESULTS

There were different patterns of association between emotional eating and eating attitudes in the three groups. British women showed a strong linkage, Japanese women living in Japan showed no association, and Japanese women in the United Kingdom showed an intermediate pattern.

CONCLUSIONS

Emotional eating may be less of an index of eating psychopathology in non-Western cultures. However, there appears to be an acculturative process, linking the two when one enters a Western culture. This cross-cultural difference may have implications for the targeting of therapies, although this conclusion requires support from further research.