Non-suicidal self-injury in patients with eating disorders: prevalence,forms, functions,and body image correlates

IntroductionMore than one third of patients with eating disorders report NSSI. Moreover, negative attitudes and feelings toward the body, body dissatisfaction, and body image disturbances have been linked to NSSI in community and clinical samples. However, there is a lack of studies exploring NSSI frequency and functions and the specific relationship between multidimensional body image dimensions and NSSI in eating disorder patients.ObjectivesFirst, we explored the frequency, types, and functions of NSSI in a sample of 226 Spanish female participants with eating disorders (ED). Second, we explored differences in NSSI and body image depending on the ED restrictive-purgative subtype; and third, we explored differences in body dissatisfaction, body image orientation, and body investment in eating disorder patients without NSSI (n = 144), with NSSI in their lifetime (n = 19), and (b) with NSSI in the previous year (n = 63).ResultsOf the overall sample, 37.1% (n = 89) had a history of self-injury during their lifetime, and 27.1% (n = 65) had self-injured in the previous year. Among the types of ongoing NSSI, the most frequent were banging (64.6%) and cutting (56.9%). Restrictive vs purgative patients differed on NSSI lifetime, Appearance Evaluation, Body Areas Satisfaction, Body Protection and Feelings and Attitudes toward the Body. Moreover, significant differences were found on Appearance Evaluation, Body Areas Satisfaction, Positive Feelings and Attitudes towards the Body, Body Protection, and Comfort with physical contact, between participants without a history of self-injury and both NSSI groups.DiscussionBody dissatisfaction and body investment have been found to be variables related to NSSI. Thus, the present study highlights the importance of working on body image in ED patients to reduce the frequency of NSSI.     

Comparison of internet and face-to-face delivery of a group body image and disordered eating intervention for women: a pilot study

Increased access to therapy for body dissatisfaction and disordered eating is required. This pilot study compared a group intervention delivered face-to-face or synchronously over the Internet. Women with body dissatisfaction and disordered eating were randomly assigned to a face-to-face (N = 19) or Internet (N = 21) group. Body dissatisfaction, disordered eating, and psychological variables were assessed at baseline, post-intervention, and two months follow-up. Significant improvements on all outcome variables were observed and maintained at follow-up in both groups. There were no significant differences between delivery modes. This program shows promise, and the Internet mode of delivery has potential to overcome geographical distance.     

Adding mindfulness to CBT programs for binge eating: a mixed-methods evaluation

The current study investigated the effectiveness of a combined mindfulness-CBT group therapy program for women with binge eating problems. Questionnaires were completed by group participants pre-program (n = 30), post-program (n = 30) and 3 month follow-up (n = 28). Significant reductions between pre- and post-program scores were found on standardised measures assessing binge eating, dieting, and body image dissatisfaction, with all reductions maintained at follow-up. Qualitative interviews with 16 women following completion of the program revealed the value of mindfulness in improving eating behaviour through increased self-awareness. This exploratory study supports the value of adding mindfulness to the more commonly utilised CBT-based programs for binge eating.     

Cost-effectiveness of achieving clinical improvement with a dissonance-based eating disorder prevention program

Using data from an effectiveness trial delivered by college clinicians, we examined the cost-effectiveness of the dissonance-based Body Project program for reducing eating disorder symptoms in women with body dissatisfaction. The outcome of interest was individual-level change; 14.9% of Body Project participants attained clinically meaningful improvement vs. 6.7% of controls. Delivering the intervention costs approximately $70 (2012 U.S. dollars) per person. Incremental cost-effectiveness was $838 for each additional at-risk person reducing eating disorder symptomology to a clinically meaningful degree. These analyses demonstrate the economic value of the Body Project for college-age women with symptoms below the eating disorder diagnosis threshold.     

The Influence of Gender and Age on the Association Between “Fat-Talk” and Disordered Eating: An Examination in Men and Women From Their 20s to Their 50s

Fat-talk is a common experience in college-aged women, yet little is known about fat-talk in men and across the lifespan. Exposure to fat-talk was compared in a large sample of men (n = 819) and women (n = 1,696) across four age cohorts. Greater exposure to fat-talk was associated with increased disordered eating for men and women. Men experienced less fat-talk than women. Age was negatively associated with fat-talk in women but not in men. Weaker associations between fat-talk and disordered eating were found in men compared to women and in older individuals compared to younger individuals. Nonetheless, the positive association between fat-talk and disordered eating in men and women from late adolescence to midlife and beyond indicates a need to extend intervention programs to target fat-talk in men and women across the lifespan.     

Eating Disorders “Mental Health Literacy” in Low Risk,High Risk and Symptomatic Women: Implications for Health Promotion Programs

Attitudes and beliefs concerning the nature and treatment of bulimia nervosa (BN) were compared among young adult women at low risk of an eating disorder (n = 332), at high risk (n = 83), or already showing symptoms (n = 94). Participants completed a self-report questionnaire that included a measure of eating disorder symptoms. A vignette of a fictional person suffering from BN was presented, followed by a series of questions addressing the nature and treatment of the problem described. High-risk and symptomatic participants were more likely than low-risk participants to report that they would not approach anyone for advice or help, were they to have BN or a similar problem, because they would not want anyone to know. Symptomatic participants were more likely to believe that someone with BN would be discriminated against, more likely to consider bulimic behaviors to be acceptable, and more likely to view BN as being common among women in the community, than low-risk participants, participants in the high-risk group being intermediate on each of these questions. The findings suggest that the attitudes and beliefs of individuals with eating disorder symptoms differ systematically from those of individuals at high risk, but who do not yet have symptoms, and from those at low risk. They also indicate specific attitudes and beliefs that may need to be addressed in prevention and early intervention programs. The potential benefits of assessing individuals' attitudes and beliefs concerning the nature and treatment of eating-disordered behaviour and tailoring program content accordingly may be worthy of investigation.     

Body Dysmorphic Disorder and Other Clinically Significant Body Image Concerns in Adolescent Psychiatric Inpatients: Prevalence and Clinical Characteristics

Background  This study assessed prevalence and clinical correlates of body dysmorphic disorder (BDD), eating disorders (ED), and other clinically significant body image concerns in 208 consecutively admitted adolescent inpatients. It was hypothesized that adolescents with BDD would have higher levels of depression, anxiety, and suicidality. Adolescents with eating disorders were expected to have higher levels of depression, anxiety, and trauma-related symptoms. Trauma-related symptoms were also examined in relation to BDD, in the absence of specific hypotheses. Method  Participants completed the Body Dysmorphic Disorder Questionnaire (BDDQ) and reliable and valid self-report measures of suicidality, depression, anxiety, post-traumatic stress disorder (PTSD), dissociation, and sexual preoccupation/distress. Prevalence of BDD, eating disorders, and other clinically significant body image concerns was determined, and clinical correlates were examined. Results  6.7% (n=14) of participants met DSM-IV criteria for definite (n=10) or probable (n=4) DSM-IV BDD, 3.8% (n=8) met criteria for an eating disorder, and 22.1% (n=46) had clinically significant shape/weight concerns (SWC) that did not clearly meet criteria for BDD or an eating disorder. Both the BDD and SWC groups scored significantly higher than the group with no significant body image concerns (no BDD/ED/SWC group) on measures of anxiety and suicidality. The BDD, SWC, and ED groups all had significantly higher levels of depression than the no BDD/ED/SWC group. Only the SWC group scored significantly higher than the no BDD/ED/SWC group on measures of PTSD, dissociation, and sexual preoccupation/distress. Conclusions  A high proportion of participants had clinically significant body image concerns or a body image disorder. These concerns/disorders were associated with higher levels of depression, anxiety, and suicidality. In addition, the group concerned with body shape or weight had significantly greater symptoms of PTSD, dissociation, and sexual preoccupation/distress. These relatively common body image concerns and disorders deserve further study in adolescents.This research was supported by the Bradley Hospital Adolescent Unit and a Mid-Career Investigator Award in Patient-Oriented Research (1 K24 MH63975) from the National Institute of Mental Health to Dr. Phillips     

Effects of emotional acceptance and rumination on media-induced body dissatisfaction in anorexia and bulimia nervosa

IntroductionBody dissatisfaction is an important risk and maintaining factor for eating disorders. The aim of the present study was to experimentally test the effects of two emotion regulation strategies - acceptance and rumination - on media-induced body dissatisfaction in eating disorders.MethodAfter watching pictures of thin models, women with anorexia nervosa (AN; n = 39) and bulimia nervosa (BN; n = 39) were encouraged to either use emotional acceptance or rumination to cope with their feelings. Body dissatisfaction and mood were repeatedly assessed.ResultsAcceptance significantly improved body dissatisfaction in women with BN. Rumination led to a significant increase of body dissatisfaction in both eating disorder groups. Results were independent from mood changes.DiscussionFindings highlight the importance ruminative thinking may have in the aggravation of dissatisfaction with the own body in AN and BN. Results suggest that emotional acceptance is a useful strategy to regulate body dissatisfaction after exposure to thin-ideal media in BN.     

Implementation of transdiagnostic treatment for emotional disorders in residential eating disorder programs: A preliminary pre-post evaluation

Abstract

Objective: Data are lacking from empirically supported therapies implemented in residential programs for eating disorders (EDs). Common elements treatments may be well-suited to address the complex implementation and treatment challenges that characterize these settings. This study assessed the preliminary effect of implementing a common elements therapy on clinician treatment delivery and patient (N?=?616) symptom outcomes in two residential ED programs. Method: The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders was adapted to address ED and co-occurring psychopathology and implemented across sites. Therapists’ treatment fidelity was rated independently to assess implementation success. Additionally, longitudinal (pre-post) design compared treatment outcomes among patients treated before and after implementation. Patient outcomes included ED and depressive symptoms, experiential avoidance, anxiety sensitivity, and mindfulness. Results: Following training and implementation, clinicians demonstrated adequate to good fidelity. Relative to pre-implementation, post-implementation patients showed significantly greater improvements in experiential avoidance, anxiety sensitivity, and mindfulness at discharge (ps?≤?.04) Relative to patients who were treated during the pre-implementation phase, patients in the post-implementation phase experienced more favorable outcomes on ED symptom severity, depression, mindfulness, and anxiety sensitivity at 6-month-follow-up (ps ≤ .001). A similar result was observed for experiential avoidance, yet this interaction effect was no longer statistically significant (p = .10) when the time x length of stay effect/covariate was added to the model. Conclusions: Preliminary pilot data support the feasibility of implementing transdiagnostic common elements therapy in residential ED treatment, and suggest that implementation may benefit transdiagnostic outcomes for patients.

Clinical or methodological significance of this article: Limited data are available to guide evidence-based residential treatment for eating disorders. This study represents a unique effort to adapt, implement, and test an evidence-based therapy protocol across a large private network of intensive eating disorder treatment programs.     

Parental bonding in patients with eating disorders and self-injurious behavior

Aim: The goal of the study was to investigate the correlations among parental bonding patterns, eating disorders (ED) and self‐injurious behavior (SIB). Methods: The subjects were 80 patients with ED who were divided into two groups based on those that had (n = 25) and had not engaged in SIB at least once in the last month. The patients and 120 healthy control subjects were evaluated using the Eating Disorder Inventory and the Parental Bonding Instrument. Results: On the Parental Bonding Instrument, the ED + SIB group showed significantly lower paternal care compared with the ED/no SIB and control groups. On the Eating Disorder Inventory, the ED + SIB group showed higher body dissatisfaction, and increased maturity fear compared with the other two groups. The total scores and perfectionism and interoceptive awareness differed significantly among the three groups. Conclusion: ED + SIB patients had a more severe ED pathology than ED/no SIB patients, and also felt that they had received low paternal care during childhood. Therefore, paternal care may be linked to severe ED pathology.     

Validation of the Inventory of Interpersonal Problems (IIP-64): a comparison of Swedish female outpatients with anorexia nervosa or bulimia nervosa and controls

Aim: The aim of the study was to explore the psychometric properties of the Inventory of Interpersonal Problems (IIP-64) and to compare levels of interpersonal distress in Swedish female outpatients with anorexia nervosa or bulimia nervosa with age- and gender-matched controls.

Methods: Totally, 401 participants were included; anorexia nervosa (n?=?74), bulimia nervosa (n?=?85) and controls (n?=?242). All participants completed the IIP-64. The eating disorder (ED) patients also filled out the Eating Disorder Inventory-2/3 (EDI).

Results: Internal consistency of IIP-64 was acceptable to high. Principal component analyses with varimax rotation of the IIP-64 subscales confirmed the circumplex structure with two underlying orthogonal dimensions; affiliation and dominance. Significant correlations between EDI-3 composite scales ineffectiveness and interpersonal problems and IIP-64 were found. ED patients reported higher levels of interpersonal distress than controls on all but one subscale (intrusive/needy).

Conclusions: IIP-64 can be considered to have acceptable to good reliability and validity in a Swedish ED sample. IIP-64 can be a useful complement in assessment of interpersonal problems in ED.     

Does shape matter? preferences for a female therapist's figure among patients with eating disorders

Abstract

Although the female therapist's figure has been a topic of discussion with regard to psychotherapy for eating disorders, it has not yet been addressed empirically. In this study, participants with eating disorders (n =34) and a control group of participants with anxiety disorders (n =30) were asked to indicate how important the therapist's figure is to them and what shape they would prefer a therapist to have. The therapist's figure was more important among participants with eating disorders than among those with anxiety disorders. Participants in both groups favored a therapist with an average figure. Within both groups, participants preferred their therapist to have a shape similar to their own. Clinical implications are discussed.     

Dysfunction of response inhibition in eating disorders

Introduction: Response inhibition in eating disorders (ED) has been studied using methods such as Go/No-go tasks and cognitive conflict tasks, but the results have been inconsistent with regard to the presence or absence of impaired response inhibition in ED. This may be due to variation across the studies in the characteristics of the tasks and in the degree of underweight of ED participants. Method: We investigated the presence or absence of impaired response inhibition in an ED patient group, including many severe cases (body mass index <15 kg/m²), by comparing the interference effect of ED patients and healthy participants with an arrow–space interference task as the cognitive conflict task. Results: There was a significant interference effect on response time in healthy participants and ED patients, with no significant intergroup difference in response times. However, the interference effect on error rate was significantly greater in ED patients than healthy participants. There was no significant difference in this trend across different ED subtypes (restricting type anorexia nervosa, binge-eating/purging type anorexia nervosa, and eating disorder not otherwise specified). Conclusions: Attentional control such as focused attention and sustained attention are preserved in ED patients, but there appears to be dysfunction of response inhibition. This might be the basis of poor impulse control in the eating behavior of ED patients.     

The impact of an implicit manipulation of self-esteem on body dissatisfaction

Background and objectivesGiven the theoretically postulated causal pathway from low self-esteem on body dissatisfaction, the aim of the present study was to experimentally test this linkage before and after a mirror exposure in body dissatisfied females.MethodThirty-six women with high body dissatisfaction (HBD) and 39 women with low body dissatisfaction (LBD) received either a positive or a negative implicit manipulation of self-esteem and participants’ actual body dissatisfaction and negative emotions were assessed (T1). Following that, they underwent a one minute mirror exposure and actual body dissatisfaction and emotions were assessed once more (T2).ResultsIn the HBD group no effects of the self-esteem manipulation were found prior to the mirror exposure. However, the negative manipulation of self-esteem led to a significant increase of body dissatisfaction over the course of the mirror exposure. The positive manipulation of self-esteem did not decrease body dissatisfaction over the course of the mirror exposure. No effects of self-esteem on body dissatisfaction were found in the LBD group.LimitationsFormal eating disorder diagnosis in study participants was not established. Therefore, the extension of the results to an eating disordered population is recommended.ConclusionsThe results yield evidence of a close linkage between negative self-esteem and body dissatisfaction in individuals high on body dissatisfaction. Consistent with cognitive theories, this link is only apparent when shape and weight schemas are activated, e.g. by the confrontation with one’s own body.     

Affective predictors of the severity and change in eating psychopathology in residential eating disorder treatment: The role of social anxiety

ABSTRACT

Despite evidence documenting relationships between eating disorder (ED) psychopathology, depression, and anxiety, little is known regarding how social anxiety is related to ED symptoms in treatment. Therefore this study examined associations between depression, general anxiety, social anxiety, and ED psychopathology at the beginning and end of treatment (EOT) among patients (N = 380) treated in a residential ED program. Participants completed measures of ED psychopathology and affective variables. Higher depression and general anxiety, but not social anxiety, were related to higher ED psychopathology at baseline. However, social anxiety emerged as a unique predictor of ED psychopathology at EOT such that participants with higher social anxiety evidenced less improvement in ED psychopathology. Findings suggest that social anxiety has specific relevance to treatment in EDs, which may reflect shared mechanisms and underlying deficits in emotion regulation.     

Empirically derived classes of eating pathology in male and female college students

Background: The empirical structure of eating disorder (ED) pathology has often been studied in female, clinical samples, leaving questions about the structure of ED pathology in males and nonclinical samples. Method: A latent class analysis was performed on data combined from two different studies (N = 1,751) using the behavioral items in the Eating Disorder Examination Questionnaire (EDE-Q; binge eating, self-induced vomiting, laxative use, and excessive exercise), with the addition of an item representing restraint. Validation analyses examined weight, shape, and eating concern among the classes. Results: Three similar classes emerged for both the men and women’s models: very low ED behaviors, binge eating, and high ED behaviors. Discussion: These results suggest that binge eating occurs within the context of lower symptom and higher symptom presentations, and that the empirical structure of ED symptoms does not differ in men and women in the nonclinical population. Further research is needed to clarify whether ED phenotypes differ in men and women.     

Development and preliminary validation of a Finnish version of the Eating Disorder Examination Questionnaire (EDE-Q)

Background: Eating behaviour can be viewed as a continuum, ranging from extremely restrictive to extremely disinhibited eating. Valid and reliable instruments are needed to ensure detection of individuals with risk for eating disorders (ED). Self-report methods are the most feasible, cost, and time efficient. One of the most widely used self-reports is the Eating Disorder Examination Questionnaire (EDE-Q).

Aim: The aim of this study was to develop a Finnish version of the EDE-Q version 6.0 and to assess its psychometric properties in adolescents, adults, and ED patients.

Methods: The present study utilized data from three different samples: adolescents (n?=?242), adults (n?=?133), and ED patients (n?=?52). The patient group comprised different EDs, but individual ED diagnoses were not studied separately. Data was collected January 2014 through June 2015.

Results: The Finnish version of the EDE-Q showed acceptable-to-excellent internal consistency on all sub-scales in all three samples and discriminated patients from healthy individuals. Female participants generally scored higher than male and sex differences were more pronounced among the younger age group.

Conclusions: The Finnish version of the EDE-Q can, based on this study, be regarded as reliable, valid, and functional. Further studies are needed to evaluate the population norms and to test the validity in individual ED diagnoses.     

Epidemiology of eating disorders

Objective The aims of this study were to determine the prevalence of eating disorders (ED) in a representative school population of early adolescents of both sexes and to evaluate persistence and incidence after two years. Method An initial sample of 1336 (mean age = 11.37) was assessed in a two-phase design. The Children Eating Attitudes Test was used to select 258 participants (T1) from the initial sample who were followed-up two years later (T2; n = 200). Diagnoses of ED were obtained using the Diagnostic Interview for Children and Adolescents- Children and Parent Version (DICA-C and DICA-P) at T1, and Adolescent Version (DICA-A) at T2. At T2, participants were also assessed with the Eating Attitudes Test, the Bulimic Investigatory Test, and the Eating Disorders Inventory. The Body mass index (BMI) was obtained for all participants. Results The estimated prevalence of any ED according to DICA-C (T1) and DICA-A was 3.44% and 3.81%, respectively. The most frequent diagnoses were syndromes that were not full-blown. Biannual incidence of any ED was 2.02%. Amongst those with an ED, 52.17% persisted. Females showed a higher incidence and persistence of any ED than males. Participants who had the highest BMI were those who had a persistent diagnosis of ED. Conclusion ED that began at early ages in less severe forms and in females often persisted with increasing severity.     

Body dissatisfaction and socio-cultural factors in women with and without BED: Their relation with eating psychopathology

The goal of the present study was to assess the role of body dissatisfaction and socio-cultural factors on eating psychopathology in women with Binge Eating Disorder (BED) and women without BED. Seventy obese women consecutively evaluated participated: 35 with BED and 35 without BED who attended for the first time in a weight loss program. All participants completed a battery of questionnaires, including: Body Shape Questionnaire, Questionnaire of Influences on the Aesthetic Body Shape Model, Questionnaire on Eating and Weight Patterns, Three Factor Eating Questionnaire, and they were interviewed with the Interview for the Diagnosis of Eating Disorder-IV. The Body Mass Index, Waist-to-Hip Ratio and Body Fat were calculated. The results showed that 21% of obese women who participated in a weight reduction program met BED criteria. The scores of body dissatisfaction, influences of socio-cultural factors and eating psychopathology were higher in women with BED compared with women without BED. In the same way, significantly stronger correlations were found among influences of socio-cultural factors, specifically, influence of advertisement, social relations and eating psychopathology in women with BED than women without BED. It is concluded that the high body dissatisfaction as well as stronger associations among influence of socio-cultural factors and eating psychopathology could play an important role in women with BED.     

The Eye of the Beholder: Youths and Parents Differ on What Matters in Mental Health Services

The goal of this study was to examine the degree to which youths and caregivers attend to different factors in evaluating their experiences with mental health programs. Youth (n = 251) receiving mental health services at community agencies and their caregivers (n = 275) were asked open-ended questions regarding the positive and negative aspects of the services. Qualitative analyses revealed some agreement but also divergence between youth and caregivers regarding the criteria by which services were evaluated and aspects of services that were valued most highly. Youths’ positive comments primarily focused on treatment outcomes while caregivers focused more on characteristics of the program and provider. Youths’ negative comments reflected dissatisfaction with the program, provider, and types of services offered while caregivers expressed dissatisfaction mainly with program characteristics. Results support the importance of assessing both youth and caregivers in attempts to understand the factors used by consumers to evaluate youth mental health services.