Body image measurement in eating disorders

The current paper reviews the methods used for assessing body image in anorexia nervosa and bulimia nervosa. A major concern in the assessment of body image in the area of eating disorders has been the apparent failure to recognize the complexity of the body image construct. The development of a range of standardized measures of body image has been an important advancement in recent years; however, it would be premature to assume that any of these methods assesses body image in its entirety. Rather, each provides an operational index of one aspect of this multidimensional construct. The relationship between different dimensions of body image and their respective operational measures remains a potentially valuable area for investigation. Few studies have employed multiple measurement techniques and it is recommended that future investigations incorporate convergent measures which tap perceptual, affective and cognitive elements of the broad body image construct. Factors such as reliability and validity of the different measures of body image must be considered in planning studies with eating disorder patients. Reliability is particularly important because it sets an upper limit on validity. Most studies may be criticized for not addressing the validity of measures employed. Concurrent, convergent, discriminant and predictive validity should be demonstrated for existing as well as new methods. The issue of construct validity which remains a more general concern in the area of body image applies to the investigation of eating disorders. There is the danger that 'body image disturbances' become reified based upon group differences on a particular operational measure. Therefore, conclusions must be cautious even when inferences are drawn from measures which appear to have 'face validity'. The literature on body image in eating disorders has expanded rapidly during the past several years. Generally, it has confirmed the clinical impression that these patients display serious distortions in the feelings, attitudes and perceptions related to their bodies. Hopefully, future research will clarify the mechanisms of action of these body image disturbances and provide insights which will lead to improved treatment.

Validating the Body Uneasiness Test (BUT) in obese patients

OBJECTIVE

To investigate the psychometric properties of the Body Uneasiness Test (BUT) in a large sample of subjects with obesity seeking treatment. BUT is a 71-item self-report questionnaire in two parts: BUT-A which measures weight phobia, body image concerns, avoidance, compulsive self-monitoring, detachment and estrangement feelings towards one's own body (depersonalization); and BUT-B, which looks at specific worries about particular body parts or functions.

METHODS

We recruited a clinical sample of 1,812 adult subjects (age range 18-65 years, females 1,411, males 401) with obesity (Body Mass Index, BMI > or = 30 kg/m2) and a normal weight (BMI value between 18.5 and 25 kg/m2) non-clinical sample of 457 adult subjects (females 248, males 209) with an Eating Attitudes Test-26 (EAT-26) score under the cut-off point 20 (scores > or = 20 indicate possible cases of eating disorders).

RESULTS

The exploratory and confirmatory analyses confirmed a structural five-factor model for BUT-A and an eight-factor model for BUT-B. Internal consistency was satisfactory. Concurrent validity with Binge Eating Scale (BES) and Three-Factor Eating Questionnaire (TFEQ) was evaluated. The authors calculated mean values for BUT scores in adult (18-65 years) patients with obesity, and evaluated the influence of gender, age and BMI. Females obtained statistically significant higher scores than males in all age groups and in all classes of obesity; patients with obesity, compared with normal weight subjects, generally obtained statistically significant higher scores, but few differences could be attributed to the influence of BMI.

CONCLUSION

The BUT can be a valuable multidimensional tool for the clinical assessment of body uneasiness in obesity; the scores of its sub-scales do not show a linear correlation with BMI values.

The Body Uneasiness Test (BUT): development and validation of a new body image assessment scale

OBJECTIVE

To investigate the psychometric properties of the Body Uneasiness Test (BUT), a 71-item self-report questionnaire that consists of two parts: BUT*A which measures weight phobia, body image concerns, avoidance, compulsive self-monitoring, detachment and estrangement feelings towards one's own body (depersonalization); and BUT*B which looks at specific worries about particular body parts or functions.

METHODS

We recruited a clinical sample of 531 subjects (491 females) suffering from eating disorders and a general population sample of 3273 subjects (2016 females) with BMI <25 and Eating Attitudes Test-26 scores under the cut-off 20.

RESULTS

The exploratory and confirmatory analyses confirmed a structural five-factor model for BUT*A and an eight-factor model for BUT*B. Internal consistency was satisfactory. The test-retest correlation coefficients were highly significant. Concurrent validity with other tests (Eating Disorder Inventory, EDI-2; Eating Attitudes Test, EAT-26; Symptom Check List, SCL-90R and Coopersmith Self-Esteem Inventory, SEI) was evaluated. Normative values for BUT scores in non-clinical samples of normal-weight non eating disordered subjects, from adolescence to old age, males and females, were calculated. The differences between males and females were highly significant, above all in the 18-39-age range. As for the comparison between women with eating disorders and controls, the results demonstrated a good predictive validity for anorexia nervosa and bulimia nervosa.

CONCLUSIONS

The BUT is psychometrically sound. It can be a valuable tool for the screening and the clinical assessment of abnormal body image attitudes and eating disorders.

The relationship between binge eating disorder and non-purging bulimia nervosa

AIMS

To further investigate the differentiation between non-purging bulimia nervosa (BN-NP) and binge eating disorder (BED), particularly as concerns weight-shape overconcern affecting self-esteem, a core belief to both anorexia and bulimia nervosa.

METHODS

Twenty-five female subjects with BN-NP and 25 female subjects with BED, consecutively referred to the Eating Disorder Unit of the DPPhNB, were administered the BEDCI, the EDI-2 and the BUT.

RESULTS

BED patients had a higher BMI (35.5 vs. 23.8 kg/m2, p<0.0001) and were slightly older than BN-NP ones. Weight-shape concerns as one of the main/the most important things influencing self-esteem were reported by 68% of BN-NP patients and 62.5% of BED ones. Age at onset of binge-eating, weight-cycling, overall impairment due to the eating behavior, sexual harassment, depressive and substance abuse comorbidity were equally represented in the two groups of patients. BN-NP patients scored higher than BED ones as regards EDI drive for thinness (p<0.05) and BUT weight phobia (p<0.05), with these scores significantly related to differences in BMI (p<0.0005 and p=0.012). Weight-shape overconcern influencing self-esteem was predictive of an earlier onset of binge-eating (p<0.05) and higher scores at the BUT weight phobia, and body image concerns (p<0.05).

CONCLUSIONS

Differences between BED and BN-NP seem to be more of degree than type and there seems little value in the separation between BED and BN-NP based on weight-shape concerns that substantially impair self-esteem. This construct seems core to both disorders and plays a substantial role in triggering and maintaining the binge-eating cycle.

Affective temperament in the eating disorders

BACKGROUND

In this study, we investigate the affective temperamental characteristics in a sample of ED (eating disorder) patients.

METHODS

49 ED patients diagnosed by the SCID (Structured Clinical Interview for DSM-IV), were divided into two groups on the basis of the presence or absence of Binge Eating (restricting-anorexia nervosa [R-AN]= 16; Binge Eaters= 33). All patients were administered the TEMPS-I (Temperament Evaluation Memphis Pisa Semistructured - Interview), to assess affective temperament. A third group of controls (N= 1010), derived from a study with the TEMPS-I on normal subjects, was included for comparison.

RESULTS

A full affective temperament was not found in patients of the restricting group. By contrast 24% of the binge eating group had a full affective temperament of one of three types. Comparing the three temperaments for the three groups, only cyclothymic temperament proved to be significant, with higher levels in the binge eating group (p<0.01).

CONCLUSIONS

In this study, people with R-AN do not show a full affective temperament. However, people with binge eating, had depressive and hyperthymic temperament, and displayed higher level of cyclothymic temperament than the normal population. The findings of this study add to a growing literature on temperament in people with ED; particularly, they add to the view that may be various paths leading to R-AN, and these may differ from those of binge eating.

Predictors of success and satisfaction in the practice of psychiatry: a preliminary follow-up study

BACKGROUND

Few studies have examined the predictors of psychiatrists' perceived success and personal satisfaction with their careers. The present study examines self-reported success and personal satisfaction with their careers in a cohort of psychiatrists followed for more than 20 years.

METHODS

A total of 29 psychiatrists, all of whom had participated in a study during their residency 21 to 24 years earlier, completed a self-report questionnaire. The first set of questions addressed the type and characteristics of their professional practice; the second set assessed aspects of their nonprofessional practice; and the third set assessed aspects of their nonprofessional, personal lifestyles. The personality traits of neuroticism and extraversion were assessed during the residency years and were used as predictors. Composite measures of self-perceived external success and personal satisfaction were computed. Regression models were constructed to determine the best predictors of these composite measures.

RESULTS

Neuroticism proved to be a significant predictor of external success but not of personal satisfaction, with higher scores predicting a lower rating of perceived external success. There were 2 practice characteristics--involvement with research and practising from an orientation other than psychoanalytic--that predicted perception of success. One personal lifestyle characteristic--the perception that one's nonprofessional life sustained professional life--also predicted perception of success. The best predictor of personal satisfaction was overall satisfaction with nonprofessional aspects of life.

CONCLUSIONS

Personality, nonprofessional social support, and engaging in research are associated with greater perceived success and personal satisfaction with a career in psychiatry.

Comparisons of men with full or partial eating disorders, men without eating disorders, and women with eating disorders in the community

OBJECTIVE

The authors compared 62 men who met all or most of the DSM-III-R criteria for eating disorders with 212 women who had similar eating disorders and 3,769 men who had no eating disorders on a wide variety of clinical and historical variables.

METHOD

The groups of subjects were derived from a community epidemiologic survey performed in the province of Ontario that used the World Health Organization's Composite International Diagnostic Interview.

RESULTS

Men with eating disorders were very similar to women with eating disorders on most variables. Men with eating disorders showed higher rates of psychiatric comorbidity and more psychosocial morbidity than men without eating disorders.

CONCLUSIONS

These results confirm the clinical similarities between men with eating disorders and women with eating disorders. They also reveal that both groups suffer similar psychosocial morbidity. Men with eating disorders show a wide range of differences from men without eating disorders; the extent to which these differences are effects of the illness or possible risk factors for the occurrence of these illnesses in men is not clear.

The eating attitudes test: twenty-five years later

This manuscript reviews the literature involved with the Eating Attitudes Test (EAT), first developed in the late 1970s as a self-report, indicative of the symptoms of eating disorders. The EAT has good psychometric properties of reliability and validity, and reasonable sensitivity and specificity for the eating disorders, but very low positive predictive value because eating disorders are relatively uncommon. In addition they exist on a continuum, because of denial and social desirability, the results of a self-report instrument may be affected. A very large literature has documented the use of the EAT in a variety of cultures. It is used to screen eating disturbances in general as the first part of a two-part diagnostic screen, as an ability to compare across groups and to measure change between groups and over time.

Charismatic leadership, boundary issues, and collusion

The authors suggest that a charismatic leadership style has an impact on the maintenance of boundaries and standards of practice within a department of psychiatry. They also underline the need for all members of a self-regulated professional group to assume responsibility for the maintenance of standards within the group. An overview of leadership tasks and styles, with particular emphasis on the qualities of charismatic leadership, is provided, and the impacts of boundary violations committed by members of a psychiatric department or institute on the integrity of the professional group are also elaborated. The authors then develop several hypotheses regarding the phenomenon of emotional collusion that occurs in departments in which a charismatic leader becomes sexually involved with patients. The individual internal psychological mechanisms and companion group dynamics that may allow the leader to be supported at the cost of ethical standards, principles of practice, and the ultimate creativity and viability of the group are then discussed. The authors conclude that the maintenance of standards within a self-regulating professional group must be the shared responsibility of all members. The example of boundary violations by a charismatic leader is used to illustrate the need for open debate regarding fundamental principles required to maintain a healthy functioning of critical checks and balances within the psychiatric profession.

Psychiatry in the new millennium

The field of psychiatry is experiencing great excitement at this time, much as it was 100 years ago. Current excitement is rooted in the greatly strengthened therapeutics, new models for understanding, and an exponential increase in knowledge of brain function as well as in the opportunity to revise health care delivery. While public expectations of professionals have generally fallen, the role of the healer, which is at the heart of psychiatric practice, has remained high in public regard. Psychiatry has also had to develop new relationships with an active consumer movement. Consumers now appropriately expect to be part of the planning, governance, and evaluation of care. Patients are questioning the research agenda and demand a role in determining the conduct of investigations. This active consumer movement is playing an important role in destigmatizing mental illnesses. Newer, nonmoralistic theories about mental illness and the profession's emphasis on the public trust have also played an important role. The increasing closeness of psychiatry to the rest of medicine has had a greatly beneficial impact, not only on stigma but also on diagnosis and treatment. Care must be taken, however, to see that diagnosis does not become a means to avoiding understanding of people. A welcome recent change has been the reunion between psychiatry and the addictions. This reunion has been facilitated by the development of multifactorial models of care in the mental health field and harm-reduction strategies in the addictions. This bodes well for more integrated treatment in the coming years. The strong psychiatric treatments that are now available and those on the horizon also auger well for an exciting period in our field. The excitement is enhanced by recognizing the multiple approaches to care that have been demonstrated to be effective and the need for great investment in research in this country and by developing new partnerships between the profession and public.

Difficulties in treating patients with eating disorders: a review of patient and clinician variables

OBJECTIVE

Patients with eating disorders (EDs) are often difficult to treat. Despite recent advances in treatment, a significant percentage of patients remain treatment refractory. This paper reviews variables that contribute to these difficulties and recent strategies that focus on increasing patient motivation for treatment.

METHOD

The authors relate their clinical experience and synthesize the literature examining aspects of patients with EDs that may contribute to their treatment resistance and therapist variables that may contribute to negative nontherapeutic reactions.

RESULTS

Patient variables include the nature of the symptoms that patients experience, issues of trust, the not uncommon failure of ambulatory treatments, and issues related to comorbidity. Aspects of clinicians include lack of understanding of the biopsychosocial pathophysiology of these conditions and lack of experience and appreciation for the countertransferential reactions that these patients evoke in caregivers.

CONCLUSIONS

Improving understanding of the reasons for treatment refractoriness in patients with EDs is critical to improving their care. New interventions aimed at enhancing motivation may facilitate this process.

Development and testing of a new hostility scale

Evidence suggests that assessment of global type A behaviour as a coronary risk factor may not be the most fruitful strategy because some components, particularly hostility, may be more harmful than others. Measurement of hostility has been primarily through two types of instrumentation: the Type A Structured Interview (SI) and the Cook-Medley (Ho) scale. Deficiencies in the measurement of hostility have resulted from a lack of conceptual clarity because definitions of hostility have been blurred by overlap with the concepts of anger and aggression. The main objective of this study was to develop and test an instrument that focuses hostility on attitude rather than emotion or behaviour. Psychometric properties of the Hostile Attitude Scale (HAS) were Cronbach's alpha, 0.80, and correlation of 0.56 with the Ho scale and 0.43 with the SI. In a clinical investigation that used the HAS, SI and Ho scale, all measures were significantly correlated with angiogram outcome, although the strongest relationship was with the HAS. Hostile attitude alone (HAS) accounted for 6% of explained variance in angiogram outcome based on regression analysis. The HAS is offered as a short, easily administered measure of hostility, with particular emphasis on cognitive aspects of the construct.

The effects of the ideal of female beauty on mood and body satisfaction

OBJECTIVE

The present study examined changes in women's mood states resulting from their viewing pictures in fashion magazines of models who represent a thin ideal.

METHOD

Female university students completed the Profile of Mood States (POMS), the Body Parts Satisfaction Scale (BPSS), and the Eating Disorder Inventory (EDI). They were then exposed to 20 slides; the experimental group (N = 51) viewed images of female fashion models and a control group (N = 67) viewed slides containing no human figures. All subjects then completed the POMS and the BPSS again.

RESULTS

Women were more depressed (R2 = 0.745, p < .05) and more angry (R2 = 0.73, p < .01) following exposure to slides of female fashion models.

DISCUSSION

Viewing images of female fashion models had an immediate negative effect on women's mood. This study, therefore, supports the hypothesis that media images do play a role in disordered eating.

A randomized controlled trial of guided imagery in bulimia nervosa

BACKGROUND

The objective of this study was to test a guided imagery therapy designed to enhance self-comforting in bulimia nervosa.

METHODS

A randomized controlled trial compared 6 weeks of individual guided imagery therapy with a control group. Fifty participants who met DSM-III-R criteria for bulimia nervosa completed the study. Measures of eating disorder symptoms, psychological functioning and the experience of guided imagery therapy were administered.

RESULTS

The guided imagery treatment had substantial effects on the reduction of bingeing and purging episodes; the imagery group had a mean reduction of binges of 74% and of vomiting of 73%. The imagery treatment also demonstrated improvement on measures of attitudes concerning eating, dieting and body weight in comparison to the control group. In addition, the guided imagery demonstrated improvement on psychological measures of aloneness and the ability for self-comforting.

CONCLUSIONS

Evidence from this study suggests that guided imagery was an effective treatment for bulimia nervosa, at least in the short-term.

Specificity of eating disorders diagnoses in families of probands with anorexia nervosa and bulimia nervosa

This study examines the prevalence of anorexia nervosa and bulimia nervosa in relatives of probands, and examines the probandwise specificity of any familial clustering. Data were collected from probands using the family history method. Probands were recruited in a sequential cohort fashion. Information collected from probands was rated semiblindly by two of the authors, and a diagnostic hierarchy applied to arrive at a diagnosis for each of the relatives assessed. Data are reported on 2,125 family members, collected from 93 probands. Diagnostic agreement between raters was high, with serious disagreement present in three of 167 possible cases of an eating disorder. Rates of anorexia nervosa, bulimia nervosa, major depression, and substance abuse declined from first- to third-degree relatives, which is consistent with genetic clustering, and there was evidence of a cohort effect operating for anorexia nervosa and bulimia nervosa. The rates of anorexia nervosa and bulimia nervosa in all family members were 5.1%, and 4.3% respectively. An analysis of maternal and paternal descent showed no evidence for X-linked dominant transmission in these families. Preliminary analysis of the clustering of diagnoses in relatives showed a tendency (chi 2 = 14.47, P = .006) for family members to be affected by the same diagnosis as was the proband. This trend was strongest for anorexia nervosa, but there was overlap when the proband had a lifetime diagnosis of bulimia nervosa, with or without anorexia nervosa. These results are compatible with the existence of genetic factors influencing predisposition to eating disorders, but do not prove such.

Guided imagery treatment to promote self-soothing in bulimia nervosa. A theoretical rationale

Bulimia nervosa (BN) has been described as involving impairment in affect regulation and in self-soothing. Such a conceptualization suggests the need to design treatments that specifically target these problems in order to assist individuals with BN in comforting themselves. A model of guided imagery therapy suggests that imagery therapy has multiple levels of action and can assist these individuals in the regulation of affect by providing an external source of soothing and also by enhancing self-soothing. The authors illustrate the model with a case example and report the results of a study in a clinical sample of BN.

Boundary violations and personality traits among psychiatrists

OBJECTIVE

To demonstrate that sexual abuse of patients by psychiatrists can be due to a variety of contributors, which may include therapists' psychopathic and narcissistic personality styles.

METHOD

Data from a prospective cohort of residents training in psychiatry were examined to evaluate the personality traits of 2 psychiatrists subsequently convicted of boundary violations.

RESULTS

The 2 psychiatrists who lost their licenses were identifiable at the beginning of their residency training as individuals with significant character pathology.

CONCLUSIONS

For some psychiatrists, repetitive sexual abuse of patients represents one aspect of an ongoing pattern of exploitative relationships. The professional and ethical implications of these findings as they relate to early identification for those at risk are considered.

Boundary violations and departments of psychiatry

OBJECTIVE

To explore a number of issues related to boundary violations in psychiatry, including the relationship between the individual physician and his or her patient and broader issues related to various dilemmas arising in academic departments of psychiatry.

METHOD

Several potentially troublesome scenarios are presented and discussed in the contexts of 1) the doctor-patient relationship, 2) sexual boundary violations, and 3) nonsexual forms of exploitation, such as finances, confidentiality, dual relationships, and relationships with industry.

CONCLUSIONS

A number of examples of boundary problems involving psychiatrists have been explored, and although some of these behaviours are clearly forbidden and harmful, others are less clear and require careful consideration if the profession is to arrive at a thoughtful consensus.

Factors that may influence future approaches to the eating disorders

The past thirty years have seen dramatic changes in our approach to the eating disorders. These include marked improvements in the recognition and understanding of the disorders, and the reduction of the morbidity and mortality of anorexia and bulimia nervosa. Bulimia nervosa itself, now the focus of so much attention, was described less than twenty years ago. While these gains, including those in the level of knowledge and appreciation by the public, have been transmitted to the benefit of patients, there remain significant difficulties in treating people with eating disorders. Critical research may address gaps in knowledge and lead to more efficacious treatments. At the same time, however, changes in the health care system are occurring rapidly and these will have an effect on both research and treatment. The purpose of the present article is to highlight scientific and systemic factors that the authors feel will play an important role in how people with eating disorders are responded to in the coming years. In addressing the eating disorders we are confining our remarks to anorexia and bulimia nervosa, and not to obesity; the latter would require consideration of many other issues, beyond the scope of this review.

Purging and nonpurging forms of bulimia nervosa in a community sample

OBJECTIVE

Recent consensus on the subclassification of the eating disorder bulimia nervosa into purging and nonpurging forms is examined in the context of a large psychiatric epidemiological survey in Ontario, Canada.

METHOD

Among a sample of 8,116 individuals, 62 met criteria for bulimia nervosa. Of these, the 17 who were of the purging subtype could be distinguished from the nonpurging group on a variety of parameters of comorbidity, family history, and childhood environment.

RESULTS

The purging subtype was distinguishable on the basis of early age of onset, and high rates of affective disorders and anxiety and alcoholism, sexual abuse, and parental discord.

DISCUSSION

The data support the taxonomy and point to the need for better understanding of the meaning of purging behavior.

Should amenorrhoea be necessary for the diagnosis of anorexia nervosa? Evidence from a Canadian community sample

BACKGROUND

This study compares the characteristics of women with anorexia nervosa with those of women who have all the diagnostic features of that disorder except amenorrhoea.

METHOD

The study uses data from a large community epidemiological survey of the mental health status of household residents in Ontario, Canada. A multi-stage stratified sampling design generated a sample of 4285 females aged 15-64. DSM-III-R diagnoses were made using the Composite International Diagnostic interview.

RESULTS

Eighty-four out of 4285 female respondents met full or partial-syndrome criteria for anorexia nervosa. Comparison of these two groups revealed few statistically significant differences in terms of demographics, psychiatric comorbidity, family history or early experiences.

CONCLUSIONS

Amenorrhoea did not discriminate between women with anorexia nervosa and women with all the features except amenorrhoea across a number of relevant variables. The authors question the utility of amenorrhoea as a diagnostic criterion.

Psychiatric practice for the coming decade

OBJECTIVE

To identify important trends and themes that will affect psychiatric training and practice.

METHOD

Selective literature review and reflections by the authors.

RESULTS

Three principal themes are elucidated relating to empiricism and integration, accountability and collaboration, and training and the public trust.

CONCLUSIONS

There must be debate and action on these and other themes to maintain the relevance of psychiatry to its changing context.

The hormonal response to intravenous 5-hydroxytryptophan in bulimia nervosa

In recent years evidence has accumulated to implicate a disturbance in serotonin function in the eating disorder bulimia nervosa. This study employs a neuroendocrine technique to assess the effect of intravenous 5-hydroxytryptophan, the immediate precursor to serotonin, on peripheral hormones in bulimia nervosa subjects and controls. Blunted prolactin and growth hormone responses were observed among bulimia nervosa subjects; the possible pathophysiology and implications of the findings are discussed.

Views on classification and diagnosis of eating disorders

OBJECTIVE

To highlight developments in the taxonomy of eating disorders since Russell's original description of bulimia nervosa (BN) in 1979 and through 3 versions of the Diagnostic and Statistical Manual.

METHOD

Criteria for anorexia nervosa (AN), BN and binge eating disorder (BED) are systematically described.

RESULTS

While criteria for AN remain largely unchanged between DSM-III-R and DSM-IV, the subclassification of binge/purge and restricter subgroups endorses previous research findings. For BN, the definition of "binge" has occupied considerable attention both in quantitative and qualitative terms. The arbitrary choice of 2 episodes per week as a minimum frequency is also discussed in light of recent data from the Ontario Health Supplement. A third eating disorder, BED, is now included in the appendix of DSM-IV under Eating Disorders--Not Otherwise Specified category. The potential overlap between this disorder and nonpurging BN is discussed. Finally, the relationship between eating disorders and other psychiatric disorders including depression, schizophrenia, obsessional, and conversion disorders is considered as well as the continuum from preoccupation with weight to eating disorder.

CONCLUSION

While significant advances have been made in understanding and classifying eating disorders during the past 15 years, further empirical work is necessary to clarify areas of uncertainty.

The relationship of partial syndrome eating disorders to anorexia nervosa and bulimia nervosa

A variety of sociocultural, familial and individual features associated with the eating disorders were examined in subjects with full syndrome (FS) and partial syndrome (PS) eating disorders and in normal high school students. The EAT-26 was administered to 995 high school students. This was followed by individual interviews with those who scored in the symptomatic range. Fifty-one students with PS eating disorders, 57 students without eating disorders (normal controls) and 30 hospital patients with FS, anorexia nervosa or bulimia nervosa were compared on subscales of the Eating Disorder Inventory, the Diagnostic Survey for Eating Disorders and the Beck Depression Inventory. The three groups displayed statistically significant differences on dimensions of EDI subscales Ineffectiveness and Interoceptive Awareness and also with respect to depression, history of being overweight and past history of emotional problems, as well as having mothers with medical illnesses. On these characteristics, the FS subjects displayed higher levels than the PS subjects, who in turn were higher than the NC subjects. The PS subjects displayed elevations on Body Dissatisfaction (EDI subscale), past medical illnesses, and mother's over-concern with eating and weight. These data support a continuum model of the eating disorders, but a continuum of multiple associated features rather than of dieting.

Bulimia nervosa in a Canadian community sample: prevalence and comparison of subgroups

OBJECTIVE

Previous epidemiological studies of bulimia nervosa have generated differing estimates of the incidence and prevalence of the disorder. These differences are attributable, in part, to varying definitions of the illness and a range of methodologies. The authors sought to define the prevalence of bulimia nervosa in a nonclinical community sample, examine the clinical significance of DSM-III-R threshold criteria, and examine comorbidity.

METHOD

Subjects across Ontario (N = 8,116) were assessed with a structured interview, the World Health Organization Composite International Diagnostic Interview, with specific questions added for bulimia nervosa. Subjects who met DSM-III-R criteria for bulimia nervosa were compared with those who were missing only the frequency criterion (two or more binge-eating episodes per week for 3 months).

RESULTS

In this sample, the lifetime prevalence of bulimia nervosa was 1.1% for female subjects and 0.1% for male subjects. The subjects with full- and partial-syndrome bulimia nervosa showed significant vulnerability for mood and anxiety disorders. Lifetime rates of alcohol dependence were high in the full-syndrome group. Rates of parental psychopathologies were high in both bulimic groups but tended to be higher in the subjects with full-syndrome bulimia nervosa. Both bulimic groups were significantly more likely to experience childhood sexual abuse than a normal female comparison group.

CONCLUSIONS

This study confirms other prevalence estimates of bulimia nervosa and its comorbid diagnoses from studies that were based on sound methodologies. It also points to the arbitrary aspects of the frequency of binge eating as a diagnostic threshold criterion for the disorder.

Family interactions in bulimia nervosa. II: Complex intrafamily comparisons and clinical significance

This paper extends the analyses performed in part one to the area of complex intrafamily comparisons. Ratings by patients are consistently elevated compared to ratings by parents on all scales of the Family Assessment Measure (FAM), and there are significant interaction effects, which, when examined, suggest that patient scores improve while parental scores are relatively unchanged over the course of treatment in a day hospital. The clinical implications of these findings are discussed, and we attempt to clarify the role of the family therapist in the treatment of bulimia nervosa.

Family interactions in bulimia nervosa. I: Study design, comparisons to established population norms, and changes over the course of an intensive day hospital treatment program

This paper presents the results of a study examining self-reported family functioning by patients with bulimia nervosa (BN) and their parents before and after treatment for the eating symptoms of BN. Ratings of family functioning improved significantly over the course of treatment. There was no evidence of excessive denial or social desirability in the families.

Depression in anorexia nervosa and bulimia nervosa: discriminating depressive symptoms and episodes

In a clinical sample of 198 female patients with anorexia nervosa (N = 83) and bulimia nervosa (N = 115), 43% met criteria for major depression using the Structured Clinical Interview for DSMIII-R. This group had a mean score of 30.9 +/- 8.7 on the Beck Depression Inventory (BDI) which was significantly higher than the BDI mean score of 20.5 +/- 8.9 among the remainder of the sample (p < 0.0001). A score of 26 yielded the highest levels of sensitivity and specificity, while five items from the BDI (loss of satisfaction, discouragement, weight loss, suicidal ideation and decision-making) correctly classified approximately 80% of subjects into "depression-positive" or "depression-negative" categories. Detection of co-morbid depression in patients with eating disorders may have practical implications for treatment.

Bulimia nervosa : a review of therapy research

Since the delineation of bulimia nervosa as a distinct syndrome in 1979, a variety of etiological models and related treatments have evolved. Methodological advances in evaluation have been reflected in recent outcome studies. There is now extensive evidence for the effectiveness of various short-term psychotherapies for bulimia nervosa. However, there is no convincing support for the specificity of any one form; all have a salubrious effect. Cognitive-behavioral therapy has been the most extensively researched. A parallel literature examines antidepressant pharmacotherapy for this disorder, and there are recent studies of comparative and integrative aspects of drug therapy and psychotherapy. Issues related to the long-term outcome of short-term interventions, predictors of response, and mechanisms of change await elucidation.

Advances in diagnosis and treatment of anorexia nervosa and bulimia nervosa

This paper reviews four areas of research into anorexia nervosa (AN) and bulimia nervosa (BN). First, in terms of diagnosis, the psychological concerns about weight and shape are now addressed in BN, bringing it more in line with the related disorder, anorexia nervosa. Second, studies of psychiatric comorbidity confirm the overlap between eating disorders and depression, obsessive compulsive disorder, substance abuse, and personality disorder. Nevertheless, there are reasons to accept the distinct qualities of each syndrome, and eating disorders are not merely a variant of these other conditions. Third, treatment advances in BN involve mainly cognitive-behavioural or interpersonal psychotherapies and pharmacotherapies primarily with antidepressants. The effect of combining more than one approach is beginning to be addressed. Finally, outcome studies involving people with both AN and BN have shown that the disorders "cross over" and that both conditions have a high rate of relapse. A renewed interest in the treatment of AN is needed.

Social desirability and irritable bowel syndrome

The Marlowe-Crowne Social Desirability Scale, a 33-item self-report questionnaire, was administered to an age-matched sample of twenty-five irritable bowel syndrome (IBS) patients, twenty-four psychiatric patients meeting a diagnosis of major depression, and nineteen controls. As predicted, planned comparisons analysis showed a significant group effect: IBS group scores were significantly higher than both depressed and control group scores (p less than .05). Implications of this social desirability response set for the psychological assessment and treatment of IBS are discussed.

Neurasthenia and chronic fatigue syndrome: the role of culture in the making of a diagnosis

Chronic fatigue syndrome is an increasingly popular diagnosis consisting of multiple psychiatric and somatic symptoms. It bears a striking resemblance to the nineteenth-century diagnosis of neurasthenia. Both disorders arose during periods characterized by a preoccupation with commerce and material success and major changes in the role of women. They illustrate the role of culture in the development of a new diagnosis that emphasizes a "medical" rather than "psychiatric" etiology. The authors argue that chronic fatigue syndrome will meet the same fate as neurasthenia--a decline in social value as it is demonstrated that the majority of its sufferers are experiencing primary psychiatric disorders or psychophysiological reactions and that the disorder is often a culturally sanctioned form of illness behavior.

Pineal and adrenal function before and after refeeding in anorexia nervosa

Nine female subjects with anorexia nervosa (AN) were studied when emaciated (mean 72% of average body weight), and after refeeding (mean 85% of average body weight). They were compared to 9 individually age-matched female control subjects. On each occasion blood was sampled for serum melatonin and plasma cortisol through the night, and urine was collected over 24 hr to measure sulfatoxy melatonin levels. The AN group did not differ in their level of depression before and after weight gain. There were no significant differences in serum melatonin values among the patient group before or after weight gain and the control group. Levels of urinary sulfatoxy melatonin were also significantly higher in nighttime compared to daytime samples both before and after weight gain. Plasma cortisol values were significantly elevated in the emaciated state and this was accounted for by higher cortisol levels at 9, 10, 11, and 12 PM and at 6 AM compared with the weight restored state and to controls. This study suggests that pineal activity in patients with AN is not altered by chronic changes in weight, and is not closely associated with changes in cortisol.

Psychopharmacology training in psychiatric residency programs: the Canadian scene

A survey among psychiatric residents about their satisfaction with and concerns about their training in psychopharmacology was conducted. One hundred and seventy responders (61%) from ten post-graduate psychiatric programs in Canada completed the questionnaire. The questionnaire assessed the residents' satisfaction with the training they had received over the previous six months as well as over their entire residency period. The questionnaire inquired specifically about the quantity and quality of supervision in the use of different medications for different therapeutic purposes. It also looked at the quality of supervision of drug therapies within hospital services, inpatient, outpatient, consultation and emergency services. Residents also were asked about coverage of specific topics and ranked different methods of learning. The survey uncovered a number of deficiencies mostly related to the teaching of basic psychopharmacology, integration of psychopharmacological and psychosocial issues and the lack of teaching of clinical appraisal of recent advances. Factors that may have contributed to the development of such deficiencies as well as specific recommendations are discussed.

Chronic fatigue syndrome and depression: cause, effect, or covariate

Depressed mood and the psychiatric diagnosis of major depressive episode (MDE) are common findings in patients with chronic fatigue syndrome (CFS). The relationship between depression and CFS is unclear and may be explained by one of four models: (1) CFS is an atypical manifestation of MDE; (2) depression is the result of CFS as either an organic mood syndrome or an adjustment reaction; (3) CFS and MDE are covariates; and (4) the diagnosis of MDE is artifactual. The evidence for these models is discussed. The potentially confounding effect of depression on tests of immune function and neuropsychological testing is described. The implications of these different models for the design of studies of CFS are examined.

The serotonin hypothesis of bulimia nervosa: theory and evidence

Bulimia nervosa is an eating disorder with multiple causes that has been the object of extensive research since it was first described in 1979. This review evaluates both the theoretical rationale and empirical evidence for a model which suggests that disturbed serotonin activity is involved in the development of this disorder. Limitations of the hypothesis and prospects for the future are considered.

Chronic fatigue syndrome and the psychiatrist

The number of patients who are identified as having chronic fatigue syndrome (CFS) has increased, and as a result, chronic fatigue syndrome has received widespread attention. Research has demonstrated that cognitive, affective and behavioural symptoms are prominent in CFS. Psychiatrists are therefore being asked to participate in the assessment and management of patients with this syndrome. This paper will provide an overview of the clinical characteristics of CFS and the current empirical findings related to its pathology, and will conclude with a discussion of the management of these patients.

The empathic process and its mediators. A heuristic model

Clinical empathy research has been plagued with conceptual and methodological difficulties. This paper describes a model of the empathic process that enables clinicians, teachers, and researchers to examine specific components of the model and to determine the influence of particular mediators on the empathic process. Empathy is conceptualized as a three-phase time-sequenced process rather than as a multidimensional or multicomponent phenomenon. Stripped of detail, the empathic process reveals an inducement phase, a matching phase, and a participatory-helping phase. By examining these phases, it becomes possible to distinguish empathy from closely related concepts such as sympathy. Each of the phases reveals numerous mediating variables that influence the outcome of the phase, i.e., whether the process of empathy continues or an alternate terminal point is reached. Many of these mediators are derived from existing conceptual and empirical work on empathy. Particular attention is paid to situational or contextual mediators of empathy. Contextual mediators have only recently been acknowledged as an important variable in the empathic process. For clinicians, identification of contextual variables that may be responsive to intervention is a critical step in the modification of the clinical environment. We would suggest that clinical empathy research is largely the study of these mediating influences and should be recognized as such.

Sulphatoxy melatonin: an index of depression in anorexia nervosa and bulimia nervosa

Urinary excretion of the principal melatonin metabolite, sulphatoxy melatonin (aMT6s), was assessed both during the day and during the night in 38 female eating disorder patients (anorexia nervosa, n = 17; bulimia nervosa, n = 12; anorexia nervosa + bulimia nervosa, n = 9) and 14 female control subjects. Correlations between nocturnal serum melatonin and urinary aMT6s were also obtained. All patient groups and the controls showed a preservation of diurnal rhythm with elevated nocturnal urinary aMT6s values and no significant difference in amplitude between groups. However, patients with concurrent major depression had significantly lower levels of daytime and nighttime urinary aMT6s than the nondepressed group. Weight did not influence these findings. Correlations between nocturnal serum melatonin levels and urinary aMT6s were high for control subjects (r = 0.77) and moderate for the patient groups (r = 0.31). This may reflect differences in the rate of excretion of melatonin between patients and controls.