Demographic and clinical correlates of selective information processing in patients with bulimia nervosa

Demographic and clinical correlates of interference with color-naming words related to eating, weight, and shape were investigated in 75 patients with bulimia nervosa. Interference with color-naming was related to two measures, overall level of psychiatric symptoms and frequency of purging. Multiple regression analysis showed that frequency of purging, and not level of general psychiatric symptoms, was the best predictor of interference. Thus, as would be predicted by cognitive theories, interference appears to be most closely related to features specific to bulimia nervosa rather than to measures of general psychopathology. © 1993 by John Wiley & Sons, Inc.     

Selective processing of linguistic and pictorial food stimuli in females with anorexia and bulimia nervosa

PURPOSE: This study investigated subjects with eating disorders' selective attention to linguistic and pictorial representations of food stimuli in a version of the Stroop color-naming task. If subjects with eating disorders' attention really are biased by food stimuli, one would expect equally delayed color-naming latencies to food pictures as previous studies have found to food words. METHOD: Twenty females with eating disorders (anorexia nervosa, bulimia nervosa, or a combination of both) and 24 female controls identified the color of Stroop versions of linguistic and pictorial representations of color, food, emotional, and neutral stimuli. RESULTS: The eating disorder group was slower than the controls in identifying the color of all words (including the food words) and the pictures depicting food stimuli (but not any of the other pictures). The eating disorder group was also slower in identifying the color of both food and emotional than neutral stimuli, both for the linguistic and pictorial stimuli. CONCLUSION: These findings indicate that females with bulimia and anorexia nervosa's biased attention to food stimuli are not restricted to linguistic representations. The delayed responses to the emotional words and pictures suggest that processing of negative emotional stimuli, in addition to dysfunctional concerns about stimuli related to food and eating, is important in the maintenance of eating disorders.     

Body shape concerns in bulimia nervosa

Overconcern with shape and weight is considered a primary feature of the psychopathology of bulimia nervosa and was included as a diagnostic criterion in DSM- III-R. In order to test the significance of shape and weight concern in bulimia nervosa, we administered the Body Shape Questionnaire (BSQ) to 78 outpatients with bulimia nervosa and three comparison groups: 14 women with seasonal affective disorder (SAD), 10 acquaintances of patients, and 32 normal controls. Women with bulimia nervosa had significantly higher mean BSQ scores than did other subject groups. Other self-report measures of body shape concern, eating attitudes, and depression were correlated with BSQ score. Furthermore, all patients had BSQ scores greater than the average score of the normal control group. These data support the continued inclusion of body shape and weight overconcern as a diagnostic criterion for bulimia nervosa but suggest that “overconcern” should be interpreted as “above average” rather than “outside the normal range”.     

Selective processing of weight- and shape-related words in bulimia nervosa: use of a computerised Stroop test

A computerised Stroop colour-naming task was used to measure concerns about weight, shape, and eating in bulimia nervosa. Two versions of the computerised Stroop were compared, a voice-activated and a button-pressing-activated programme. Bulimia nervosa patients were significantly slower in colour naming shape- and weight-related words than their female age-matched controls. The button-pressing computerised Stroop was both more sensitive and more accurate at measuring colour-naming speeds than the voice-activated version. When the bulimia nervosa group were divided according to their Eating Attitudes Test (EAT) scores, those who showed extreme pathological attitudes to weight and shape were significantly slower in colour naming size words and in food disruption scores than those with a lesser degree of psychopathology. The computerised Stroop might be useful as a diagnostic tool and in the assessment of the effectiveness of therapy for the individual patient.     

Dissimilarities in eating attitudes,body image distortion,depression, and self-esteem between high-intensity male runners and women with bulimia nervosa

It has been suggested that high-intensity exercise regimens in males bear a resemblance to the features of eating disorders and that male runners may resemble women with anorexia nervosa and bulimia nervosa with regard to eating and weight attitudes, negative body image, and negative psychological adjustment. Twenty high-intensity male runners were compared with 20 sedentary-moderate exercising male controls and 20 women with bulimia nervosa. Compared with the bulimia nervosa subjects, the male runners were not anxious about eating, overly preoccupied with food, excessive in binge-eating or purging behavior, negatively preoccupied with their weight, intent on losing weight, high on personality traits presumed to underlie eating disorders, nor depressed or low in self-esteem. The male groups of high-intensity runners and controls were not significantly different on any measure. These results suggest that high-intensity exercising in males is not analogous to anorexia nervosa and bulimia nervosa.     

Using the eating disorder examination to identify the specific psychopathology of binge eating disorder

OBJECTIVE: The clinical features of binge eating disorder (BED) are not well established. Therefore, a comprehensive assessment of the specific psychopathology of BED as compared to anorexia nervosa (AN) and bulimia nervosa (BN) is warranted. This comparison was the aim of the present study. METHOD: Detailed ratings from an investigator-based interview, the Eating Disorders Examination (EDE), were compared across three groups of female patients: those with BED, AN, and BN, as well as normal-weight and overweight control subjects. RESULTS: When comparing BED to AN and BN, patients with BED had lower levels of restraint, eating concerns comparable to AN patients but lower than BN patients, and weight and shape concerns comparable to BN patients but higher than AN patients. Significantly more eating disorder psychopathology was found for BED patients as compared to the overweight controls on all bar the EDE restraint subscale. On the majority of individual EDE items, BED patients' scores were similar to those of AN and BN patients, including importance of shape and weight in self-evaluation and preoccupation with shape and weight. No significant relationship was found between BED patients' degree of overweight and eating psychopathology. DISCUSSION: Our findings support the status of BED as an eating disorder and suggest that the elevated EDE scores reflect the combined impact of being objectively overweight and having disordered cognitions and behaviors about eating, shape, and weight.     

Changes on the stroop test following treatment: relation to word type, treatment condition, and treatment outcome among women with bulimia nervosa

OBJECTIVE: To examine changes in speed of information processing on a modification of the Stroop color-naming task following cognitive-behavior therapy (CBT) and to evaluate whether changes are associated with word type, treatment condition, or treatment response. METHOD: Subjects were 98 women aged between 17 and 45 years with a current primary diagnosis of bulimia nervosa who were participating in a randomized clinical trial evaluating CBT. Data were available on all relevant variables for 98 women. Speed of information processing was assessed at pretreatment and posttreatment using a modification of the Stroop color-naming paradigm. RESULTS: Significant main effects were found for the factors time (pretreatment vs. posttreatment) and word type (food/body words vs. color words, food/body words vs. control words). Predicted interactions between time and word type were not identified. DISCUSSION: Changes in information processing speed over treatment were not specifically associated with word type, treatment condition, or treatment response. Consequently, the utility of the modified Stroop paradigm as a measure of change over time for bulimia nervosa is questioned.     

The epidemiology of bulimia nervosa: Two community studies

Recent studies of American college students suggest that the syndrome bulimia is common and that individual elements of the condition are even more widespread. In Britain, two community-based studies of the related syndrome bulimia nervosa have been reported. In the first, 499 women who fulfilled diagnostic criteria for bulimia nervosa were identified with the help of a women's magazine. These women closely resembled bulimia nervosa patients attending psychiatric hospitals. Although more than half reported that they wanted medical help, less than one-third had discussed their eating difficulties with a doctor and only 2.5% were currently receiving treatment. The second study investigated the eating habits and attitudes of 369 attenders at a family planning clinic. Of these, 20.9% reported current episodes of “binge-eating”; 2.9% currently used vomiting as a means of weight control; and 1.9% fulfilled diagnostic criteria for bulimia nervosa. Comparison of the two samples indicates that people with bulimia nervosa are prone to have been both overweight and underweight in the past. They also have more disturbed attitudes toward food, eating, body weight, and body shape and a considerably higher degree of psychological disturbance. These studies suggest that bulimia nervosa constitutes a significant undetected source of psychiatric morbidity. The service implications of these findings have yet to be examined.     

Anticipatory effects of food exposure in women diagnosed with bulimia nervosa

OBJECTIVE: To investigate cephalic phase responses (CPRs) in women diagnosed with bulimia nervosa and to test the assumption that eating disordered individuals respond with more marked CPRs and higher increases in psychophysiological arousal to the presentation of food cues. METHOD: Thirteen female inpatients diagnosed with bulimia nervosa were compared to 15 non-eating disordered female volunteers. Participants were exposed to their preferred binge food in a single laboratory session with the possibility to eat immediately after the exposure trial. RESULTS: The results show greater salivation responses to food exposure and lower sympathetic arousal in patients diagnosed with bulimia nervosa than in non-eating-disordered participants. Distress and feelings of tension and insecurity during food exposure were higher in patients compared to controls. DISCUSSION: These results support the hypothesis that anticipatory cephalic phase responses are more marked in eating disordered individuals and may therefore play a role in the maintenance of binge eating behavior.     

Binge eating before the onset of dieting: a distinct subgroup of bulimia nervosa?

OBJECTIVE: While most individuals with bulimia nervosa begin dieting prior to the onset of binge eating, some individuals begin binge eating prior to dieting. The purpose of this study was to assess the differences between these two groups. METHODS: Participants (N = 120) in a treatment study for bulimia nervosa were separated into two groups (Binge First vs. Diet First) based on the ages they reported for the onset of binge eating and of dieting and then compared across a number of variables. RESULTS: Individuals in the Binge First group reported higher weight, higher shape and weight concern, lower age of onset of eating disorder symptoms, and an altered relationship of binge eating to vomiting when compared to individuals in the Diet First group. DISCUSSION: The differences between the two groups suggest that there may be subgroups of individuals with purging bulimia nervosa and that individuals in the Binge First group more closely resemble individuals with binge eating disorder than do those in the Diet First group.     

An ongoing cross-sectional study of the prevalence of eating disorders in freshman college students

Our third cross-sectional survey designed to elicit DSM-III inclusion criteria for bulimia was completed by 1836 students, 97.2% of those surveyed. Based on operationalized criteria, 4.7% of females reported a current eating disorder diagnosis. These included bulimia (4.3%), bulimia nervosa (2.2%), bulimia with weekly binge/purging behavior (1.1%), and anorexia nervosa (0.1%). Current bulimia was reported by 0.1% of males and current bulimia nervosa by 0.3%. Those women with current bulimia were more likely to report a history of treatment for alcoholism and drug abuse than those bulimic women in remission. The data suggest that fear of loss of control over eating is an important part of the diagnostic criteria for bulimia nervosa, while fear of being fat is less apt to differentiate between bulimic and nonbulimic women. The desire for low weight was more pronounced in bulimic female students in the current survey than in previous surveys. The percentage of women who reported a history of bulimia with weekly binge eating and purging went from 1% in 1980 to 3.2% in 1983 and to 2.2% in the current survey indicating that the prevalence for this disorder may have peaked and may be declining.     

Eating Disorder Examination-Questionnaire as a measure of change in patients with bulimia nervosa

OBJECTIVE: The current study evaluated the agreement between the Eating Disorder Examination and the Eating Disorder Examination-Questionnaire in assessing eating disorder pathology in a sample of women with bulimia nervosa. METHOD: Patients with broadly defined bulimia nervosa were enrolled in a double-blind, placebo-controlled treatment study of fluoxetine, with and without guided self-help. The current study presents information from 50 patients with data from both the EDE and EDE-Q at study entry and treatment termination. RESULTS: The EDE and EDE-Q produced more similar scores for compensatory behaviors (vomiting/laxative use) than complex eating-disordered features (binge eating/importance of shape and weight) at the pretreatment and posttreatment assessments, and for change during the study. DISCUSSION: The EDE and EDE-Q are highly correlated for many of the behavioral and attitudinal features of bulimia nervosa. There is substantial variability in agreement for individual patients, but on average, the EDE and EDE-Q will yield similar assessments of eating disorder symptoms and change in symptoms over time.     

Binge eating disorder: Its further validation in a multisite study

Binge eating disorder (BED) is a new eating disorder that describes the eating disturbance of a large number of individuals who suffer from recurrent binge eating but who do not regularly engage in the compensatory behaviors to avoid weight gain seen in bulimia nervosa. This multisite study of BED involved 1,785 subjects drawn from 18 weight control programs, 942 subjects from five nonpatient community samples, and 75 patients with bulimia nervosa. Approximately 29% of subjects in weight control programs met the criteria for BED. In the nonpatient community samples BED was more common than purging bulimia nervosa. The validity of BED was supported by its strong association with (1) impairment in work and social functioning, (2) overconcern with body/shape and weight, (3) general psychopathology, (4) significant amount of time in adult life on diets, (5) a history of depression, alcohol/drug abuse, and treatment for emotional problems. © 1993 by John Wiley & Sons, Inc.     

Maladaptive core beliefs and eating disorder symptoms

This study compared maladaptive core beliefs of eating-disordered groups (full and subthreshold syndrome) and healthy controls and investigated the association between eating disorder symptoms and core beliefs. Participants were compared on self-report measures of core beliefs (YSQ) and eating disorder psychopathology (BITE). Anorexia nervosa (AN; both subtypes) and bulimia nervosa (BN) patients had significantly more core beliefs than healthy controls. Binge eating disorder (BED) patients had intermediate scores between AN and BN on the one hand and healthy controls on the other hand. No correlation was found between core beliefs and frequency of binge eating. Frequency of vomiting, laxative misuse and fasting was positively associated with all domains of core beliefs. Patients with eating disorders have some core beliefs which are not directly related to eating, weight or shape. Frequency of purging and fasting behaviors is associated with more severe maladaptive core beliefs. Our data demonstrate the importance of identifying purging and fasting as significant clinical markers.     

Standardized test meals in assessment of eating behavior in bulimia nervosa: Consumption of feared foods when vomiting is prevented

This study contrasted the amount of food eaten in the absence of vomiting by normal-weight bulimia nervosa patients and matched normal controls. Subjects were instructed to eat as much food as they comfortably could without vomiting afterwards in three standardized test meals: a complete dinner eaten in a laboratory situation, and spaghetti and candy eaten at home. Bulimia nervosa subjects ate a very small amount of food in each test meal when compared with control subjects. Bulimia nervosa subjects also reported greater anxiety and urge to vomit after eating. A content analysis of tape-recorded thoughts showed that bulimia nervosa subjects were more preoccupied with eating and expressed more negative food-related thoughts. The results support the hypothesis that women with bulimia nervosa are unable to eat normal amounts of “frightening” foods when they do not plan to vomit. This behavioral test of eating behavior appears to be useful for the assessment of bulimia nervosa.     

The cognitive behavioural model for eating disorders: a direct evaluation in children and adolescents with obesity

OBJECTIVE: The cognitive behavioural model of bulimia nervosa [Fairburn, C.G., Cooper, Z., & Cooper, P.J. (1986). The clinical features and maintenance of bulimia nervosa. In K.D. Brownell, and J.P. Foreyt (Eds.), Handbook of eating disorders: physiology, psychology and treatment of obesity, anorexia and bulimia (pp. 389-404). New York: Basic Books.] provides the theoretical framework for cognitive behaviour therapy of Bulimia Nervosa. For a long time it was assumed that the model can also be used to understand the mechanism of binge eating among obese individuals. The present study aimed to test whether the specific hypotheses derived from the cognitive behavioural theory of bulimia nervosa are also valid for children and adolescents with obesity. METHOD: The prediction of the model was tested using structural equation modeling. Data were collected from 196 children and adolescents. RESULTS: In line with the model, the results suggest that a lower self-esteem predicts concerns about eating, weight and shape, which in turn predict dietary restraint, which then further is predictive of binge eating. DISCUSSION: The findings suggest that the mechanisms specified in the model of bulimia nervosa is also operational among obese youngsters.     

Sociocultural influences on eating disorders in professional female ballet dancers

Fifty-five white and eleven black female dancers in nine regional and national ballet companies in America and Europe (mean age 24.9) were surveyed for eating disorders. The dancers, as a whole, weighed 12% below their ideal weight for height. None of the black American dancers reported anorexia nervosa or bulimia, while 15% of the white American dancers reported anorexia nervosa and 19% reported bulimia. All instances of anorexia nervosa were in national rather than regional companies, making the incidence among whites in the former 22%. Self-reported anorectics scored higher on the EAT-26, had lower weights, exhibited more psychopathology, and a poorer body image than the nonanorectics. In addition, all but one of the self-reported anorectics weighed, or had weighed, less than 20% of ideal weight for height. The bulimics valued their careers less, dieted more, and exercised less frequently than the nonbulimics. Weight did not differ for these two groups. The data suggest that the anorectic dancers differ from dancers with no eating disorders and that sociocultural factors are related to the report of eating disorders. Specifically, level of competition is related to reported anorexia nervosa and ethnicity to anorexia nervosa and bulimia.     

Binge eating disorder in females: a population-based investigation

OBJECTIVE: The authors investigated the prevalence of binge eating behavior in a general female Austrian population. METHOD: A random sample of 1,000 women (age range 15a to 85a) was interviewed by dieticians over the phone. Some screening instruments were used to detect binge eating behavior. RESULTS: Of the entire sample, 122 met the diagnostic criteria for binge eating, 84 for binge eating syndrome, and 33 for binge eating disorder (BED). The point prevalence of bulimia nervosa was 1.5%. Women with binge eating episodes carried out more frequently one or more diets within the previous year, and more frequently exhibited a restrained eating behavior than did women without binge eating behavior. Underweight women more often met the diagnostic criteria for bulimia nervosa nonpurging type than did normal weight, overweight, and obese women, while overweight and obese women more frequently met the diagnostic criteria for BED. DISCUSSION: Our findings indicate that binge eating appears to be a fairly common behavior in women. Dieting, chronic restrained eating, and excessive exercise may be important triggers for BED and bulimia nervosa.     

Total energy expenditure as measured by doubly-labeled water in outpatients with bulimia nervosa

OBJECTIVE: This study measured total energy expenditure (TEE) in symptomatic outpatient women with bulimia nervosa and normal controls. The study aimed to test the conceptual model of bulimia nervosa as an illness characterized by a physiological state of starvation, despite normal weight. METHOD: Total fat and fat-free mass were measured using hydrodensitometry and total energy expenditure was assessed via the doubly-labeled water method, in nine normal weight outpatient females with DSM-III-R bulimia nervosa and ten healthy female controls. RESULTS: Patients and controls were similar in age, body mass index, weight, lean body mass, and levels of exercise and general activity. Patients had an average baseline binge frequency of 14.7 episodes per week and purge frequency of 16.8 times per week, and had been ill for an average of 11.9 years. Group mean TEE did not differ between patients and controls (patients 2380 +/- 482 kcal/day, controls 2368 +/- 515 kcal day). Observed TEE in the bulimic subjects did not differ significantly from TEE predicted on the basis of data from the controls. DISCUSSION: This finding of normal TEE in symptomatic outpatients with bulimia nervosa is consistent with a previous study that found no difference in TEE in a sample of symptomatic inpatients with bulimia nervosa. These data suggest that the energy conserving metabolic adaptations characteristic of semi-starvation do not occur in patients with bulimia nervosa.     

Knowledge about eating disorders in the community

One-hundred and forty-nine subjects (80 females and 69 males) were asked about their knowledge of anorexia and bulimia nervosa, the source of their knowledge, and the ways in which their knowledge of these disorders may have affected their attitudes towards eating, dieting, and related behaviors. Almost all subjects had heard of anorexia nervosa, whereas bulimia nervosa was less well known, particularly among males. Knowledge of anorexia nervosa was more detailed than that for bulimia nervosa. The mass media were the major sources of subjects' information about these disorders. Over one-third of females reported that their knowledge concerning anorexia and bulimia nervosa had affected their own eating or related attitudes in some way. The importance of the media in both promoting and preventing eating disorders is discussed.