Distress tolerance in the eating disorders

OBJECTIVE: It is commonly noted that patients with eating disorders have difficulties in regulating emotional states. This construct is similar to the concept of distress tolerance, which has been identified as a problem in patients with impulsive disorders. However, the elements that make up distress tolerance are not clearly delineated, making it difficult to target treatment in relevant cases. This study aimed to develop a measure of distress tolerance, and to validate it clinically with the eating disorders. METHOD: The sample consisted of 72 women with DSM-IV eating disorder diagnoses, and 62 women with no history of eating disorders. Each completed a newly developed measure of distress tolerance (the Distress Tolerance Scale; DTS) and the Eating Disorders Inventory. RESULTS: The DTS was made up of three scales, each with acceptable psychometric properties. Two of those scales differentiated the groups--the clinical women showed higher levels of 'Avoidance of affect', while the non-clinical women had higher scores in the 'Accept and manage' scale. Avoidance of affect was positively associated with unhealthy eating attitudes. CONCLUSIONS: It is important to examine both maladaptive and adaptive means of coping with affect in the eating disorders. Treatment strategies for modification of distress tolerance should address both the reduction of avoidance and the development of emotional management skills. Further research is needed to determine whether these findings are relevant to the presence of other impulsive behaviours in the eating disorders.     

Confirmatory and exploratory factor analysis of the distress tolerance scale (DTS) in a clinical sample of eating disorder patients

A confirmatory factor analysis of the factor structure of the Distress Tolerance Scale (DTS) created by Corstorphine et al. [Corstorphine, E., Mountford, V., Tomlinson, S., Waller, G., & Meyer, C. (2007). Distress tolerance in the eating disorders. Eating Behaviors, 8, 91–97.] was conducted to assess whether the scale's purported three factors emerged in a clinical sample of patients with a DSM-IV diagnosed eating disorder. The original three-factor model was generally considered to be a poor fit for the data. Subsequent exploratory factor analysis indicated that a better fit emerged using a four-factor structure. Significant associations were observed between behavioral avoidance of positive affect and eating disorder psychopathology. Implications for use of the DTS with eating disorder patients are discussed.     

The Eating Disorder Inventory-2 Perfectionism scale: factor structure and associations with dietary restraint and weight and shape concern in eating disorders

The Eating Disorder Inventory-2 Perfectionism subscale (EDI-P) was originally construed as a unidimensional measure of perfectionism. However, research in non-clinical samples suggests that the EDI-P measures two dimensions of perfectionism: self-oriented and socially prescribed perfectionism. This study aimed to investigate the factor structure of the EDI-P in a transdiagnostic sample of females seeking treatment for an eating disorder, and to determine the unique association between EDI-P dimensions, weight and shape concern, and dietary restraint in anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified. Two hundred and ninety nine females seeking treatment for an eating disorder at an outpatient eating disorder service completed the Eating Disorder Examination and the EDI-P. Confirmatory factor analysis supported a two-factor model of the EDI-P comprising self-oriented and socially prescribed perfectionism. Self-oriented perfectionism, but not socially prescribed perfectionism, accounted for unique variance in weight and shape concern and dietary restraint in both AN and BN. Results highlight the potential importance of self-oriented perfectionism in eating disorders and support the argument that self-imposed standards are central to perfectionism in eating disorders.     

An examination of the food addiction construct in obese patients with binge eating disorder

Objective:

This study examined the psychometric properties of the Yale food addiction scale (YFAS) in obese patients with binge eating disorder (BED) and explored its association with measures of eating disorder and associated psychopathology.

Method:

Eighty‐one obese treatment‐seeking BED patients were given the YFAS, structured interviews to assess psychiatric disorders and eating disorder psychopathology, and other pathology measures.

Results:

Confirmatory factor analysis revealed a one‐factor solution with an excellent fit. Classification of “food addiction” was met by 57% of BED patients. Patients classified as meeting YFAS “food addiction” criteria had significantly higher levels of depression, negative affect, emotion dysregulation, eating disorder psychopathology, and lower self‐esteem. YFAS scores were also significant predictors of binge eating frequency above and beyond other measures.

Discussion:

The subset of BED patients classified as having YFAS “food addiction” appear to represent a more disturbed variant characterized by greater eating disorder psychopathology and associated pathology. © 2011 by Wiley Periodicals, Inc. (Int J Eat Disord 2011)     

Cognitive content and process in eating-disordered patients with obsessive-compulsive features

OBJECTIVE: This study examined the schema-level cognitive content and processes that might explain the presence of compulsive behaviours among patients with eating disorders. METHOD: Each of 62 eating-disordered women completed standardised measures of schema-level core beliefs and cognitive processes, and was interviewed for diagnosis and obsessive compulsive features. RESULTS: Compulsive behaviours were associated with four core beliefs--'mistrust/abuse', 'defectiveness/shame', 'dependence/incompetence' and 'subjugation'. Higher levels of avoidance of emotional arousal were also associated with compulsivity. DISCUSSION: Schema-level beliefs and processes are associated with the presence of compulsivity. The key cognitions might impact via the activation of negative affect, meaning that the compulsive behaviours serve the function of emotion regulation. Such cognitions are likely to be a necessary target in CBT for those presenting with compulsive behaviours in the eating disorders.     

Cross-cultural measurements of psychological well-being: the psychometric equivalence of Cantonese, Vietnamese, and Laotian translations of the Affect Balance Scale.

OBJECTIVES: This paper evaluates the cultural equivalence of Cantonese, Vietnamese, and Laotian translations of the Affect Balance Scale. METHODS: The scale was completed by 399 Vietnamese, 193 Laotian, 756 Cantonese, and 319 English speakers who were participants in the Clarke Institute-University of Toronto Refugee Resettlement Project (n = 1667). RESULTS: Confirmatory factor analyses indicated a good fit between the hypothesized two-factor model (separate factors for positive and negative affect) across the original English-language version and each of the Asian-language translations. Factorial invariance (numbers and patterns of factor loadings) was evident across all versions of the scale. No evidence of item bias was detected by mixed Language x Item analyses of variance. Acceptable reliability was observed; coefficient alphas ranged from .62 to .72 for positive affect and from .62 to .70 for negative affect items. CONCLUSIONS: These findings substantiate the cultural equivalence of the three translations of the scale for population health research. Important future research directions made possible by the availability of culturally equivalent instruments are discussed.     

Beliefs about the emotional consequences of eating and binge eating frequency

Emotions are implicated in the etiology and maintenance of binge eating (BE). It is largely unknown whether BE is more strongly tied to emotions for certain individuals. This study investigated whether beliefs about the function of eating moderate the relationship between positive and negative affect and the frequency of BE. A mixed eating disorder sample (n = 105) prospectively reported their weekly BE frequency and positive and negative affect for 12 weeks after completing the Eating Expectancy Inventory. Results indicated that holding the expectancy that eating helps to relieve negative affect prospectively predicts higher frequencies of BE, and holding the expectancy that eating is pleasurable and useful as a reward predicts lower frequencies. Further, increases in negative affect were associated with increases in BE, and increases in positive affect were associated with decreases in BE. Neither of the hypothesized relationships between affect and BE was moderated by expectancies. However, an interaction between negative and positive affect was found, indicating that only the combination of high positive and low negative affect is specifically related to reduced BE. Holding specific expectancies about the function of eating and fluctuations in both positive and negative affect appear to be associated with BE among individuals with eating disorders. Cognitive interventions should target eating-related expectancies that may maintain BE behavior.     

The Stice model of overeating: tests in clinical and non-clinical samples

The present study tested the dual pathway model of Stice [. A review of the evidence for a sociocultural model of bulimia nervosa and an exploration of the mechanisms of action. Clinical Psychology Review, 14, 633-661 and . A prospective test of the dual-pathway model of bulimic pathology: mediating effects of dieting and negative affect. Journal of Abnormal Psychology, 110, 124-135.] in a non-clinical sample of female adolescents and a clinical sample of female eating disorder patients. The model assumes that negative affect and restrained eating mediates the link between body dissatisfaction and overeating. We also tested an extended version of the model postulating that negative affect and overeating are not directly related, but indirectly through lack of interoceptive awareness and emotional eating. Structural equation modelling was used to test our models. First, in the two samples, body dissatisfaction and drive for thinness were associated with overeating/binge eating. In both clinical and adolescent sample, we found support for the negative affect pathway and not for the restraint pathway. Lack of interoceptive awareness and emotional eating appear to (partly) explain the association between negative affect and overeating. Emotional eating was much more strongly associated with overeating in the clinical than in the adolescent sample. In sum, we found substantial evidence for the negative affect pathway in the dual pathway model. The link between body dissatisfaction and overeating in this respect might be explained by the fact that negative affect, due to body dissatisfaction, is related to a lack of awareness of personal feelings and to eating when dealing with negative emotions, which on its turn is associated with overeating.     

Emotion recognition and alexithymia in females with non-clinical disordered eating

ObjectivesThe aims were to determine if emotion recognition deficits observed in eating disorders generalise to non-clinical disordered eating and to establish if other psychopathological and personality factors contributed to, or accounted for, these deficits.DesignFemales with high (n = 23) and low (n = 22) scores on the Eating Disorder Inventory (EDI) were assessed on their ability to recognise emotion from videotaped social interactions. Participants also completed a face memory task, a Stroop task, and self-report measures of alexithymia, depression and anxiety.ResultsRelative to the low EDI group, high EDI participants exhibited a general deficit in recognition of emotion, which was related to their scores on the alexithymia measure and the bulimia subscale of the EDI. They also exhibited a specific deficit in the recognition of anger, which was related to their scores on the body dissatisfaction subscale of the EDI.ConclusionsIn line with clinical eating disorders, non-clinical disordered eating is associated with emotion recognition deficits. However, the nature of these deficits appears to be dependent upon the type of eating psychopathology and the degree of co-morbid alexithymia.     

The relationship between eating self-efficacy and eating disorder symptoms in a non-clinical sample

Most research on eating self-efficacy has focused on its relationship with eating behaviors and weight-loss in clinical populations. The purpose of this study was to investigate the relationship between eating self-efficacy and the behavioral and psychological characteristics associated with eating disorders in a non-clinical sample of adults. A total of 219 men and women aged 18 and older completed questionnaires measuring eating disorder symptoms and eating self-efficacy. The results indicated that low confidence in the ability to control eating while experiencing negative emotions was associated with greater weight preoccupation and bulimic thought and behaviors. In addition, low confidence in ability to control eating when an abundance of food is available was inversely related to feelings of ineffectiveness or general negative self-evaluation. Ultimately, the findings suggest that low eating self-efficacy may also be associated with eating problems within populations not seeking treatment for either eating disorders or weight-loss. The implications of the findings are discussed.     

Linguistic analyses of natural written language: unobtrusive assessment of cognitive style in eating disorders

OBJECTIVE: Linguistic style analysis is introduced as a method of nonreactive measurement of cognitive style in individuals with eating disorders (ED). METHOD: A journaling exercise was implemented on an ED inpatient unit. Thirty-four written essays collected from an unselected sample of 11 patients were analysed with the Linguistic Inquiry and Word Count, with regard to predefined text categories. At each session, self-report of participant well-being and session impact were assessed. RESULTS: Compared to essays from a student control group, and message-board entries of individuals who had recovered from an anorexia nervosa (AN), the inpatient journals displayed the highest rates of self-related words, negative emotion words, and the lowest rate of positive emotion words. Inpatients used more anxiety words and fewer words that refer to social processes and eating concerns than individuals who had recovered from an AN. Associations were found between linguistic categories, prewriting well-being, and postwriting evaluation. CONCLUSION: Linguistic style analysis offers insights into cognitive styles, and provides a promising approach for their unobtrusive measurement in ED.     

An attachment insecurity model of negative affect among women seeking treatment for an eating disorder

The purpose of this study was to propose and test a model of attachment insecurity in a clinical sample of 268 eating disordered women. Structural relationships among attachment insecurity, BMI, perceived pressure to diet, body dissatisfaction, restrained eating, and negative affect were assessed. A heterogeneous sample of treatment seeking women with a diagnosed eating disorder completed psychometric tests prior to receiving treatment. The data were analysed using structural equation modeling. Fit indices indicated that the hypothesized model fit adequately to the data. Although cross-sectional in nature, the data suggested that attachment insecurity may lead to negative affect. As well, attachment insecurity may lead to body dissatisfaction, which in turn may lead to restrained eating among women with eating disorders. Attachment insecurity could be a possible vulnerability factor for the development of eating disorder symptoms among women.     

Relations between negative affect, coping, and emotional eating

The study was designed to examine the relations between negative affect, coping, and emotional eating. It was tested whether emotion-oriented coping and avoidance distraction, alone or in interaction with negative affect, were related to increased levels of emotional eating. Participants were 125 eating-disordered women and 132 women representing a community population. Measures included the Positive and Negative Affectivity Schedule (PANAS), the Coping Inventory for Stressful Situations (CISS), and the Dutch Eating Behavior Questionnaire (DEBQ). Both emotion-oriented coping and avoidance distraction were related to emotional eating, while controlling for levels of negative affect. Negative affect did not have a unique contribution to emotional eating over and above emotion-oriented coping or avoidance distraction. The findings suggest that emotional eating is related to reliance on emotion-oriented coping and avoidance distraction in eating-disordered women as well as in relatively healthy women.     

The measurement of “eating-disorder-thoughts” and “eating-disorder-behaviors”: Implications for assessment and detection of eating disorders in epidemiological studies

To test a theoretically driven second-order factor model of eating disorders, with eating-disordered thoughts and eating-disordered behaviors representing the higher order factors, we conducted a confirmatory factor analysis using a female university student sample (N = 1816). The ‘Thought’ latent construct was comprised of indicators representing fear of fat and dissatisfaction with body shape/weight and the latent construct ‘Behavior’ was comprised of indicators representing binging, purging and restricting. From the thought and behavior latent factors, composite groups were created by varying the level of thoughts and behaviors (high, moderate, and few/or none). We examined the independent contributions of thoughts and behaviors on a measure of psychopathology (depression). A second-order model of “eating disorder thoughts” and “eating disorder behaviors” was supported by the data, based on model fit, factor loadings, and model parsimony. Mean scores on depression were clinically significant for groups engaged in any level of eating disorder behavior whereas thoughts contributed to risk for depression only at the extreme end. Because of the disproportionate representation of eating disorder thoughts (high) and eating disorder behaviors (low) in non-clinical populations, the measurement and detection of eating disorders may be enhanced by measuring thoughts separate from behaviors.     

Anger and core beliefs in the eating disorders

OBJECTIVE: The link between emotion and eating pathology has long been established, but relatively little is known about the role of anger, partly because the existing literature has tended to concentrate on anger as a unitary construct. Nor is there any understanding of the cognitive factors that drive this affect in the eating disorders. This study had two aims: to determine levels of different facets of anger across eating disorder diagnoses and behaviors; and to investigate whether facets of anger are related to the individual's negative core beliefs. METHOD: The sample consisted of 140 women who met DSM-IV criteria for eating disorders, and 50 female control participants (university undergraduates). The women completed self-report questionnaires of anger levels and unhealthy core beliefs, and the presence of bulimic behaviors was recorded at assessment. RESULTS: The eating-disordered women had higher levels of state anger and anger suppression, particularly if the diagnosis included bulimic symptoms. Different aspects of anger were associated with specific bulimic behaviors. Unhealthy core beliefs were associated with higher levels of trait anger in both groups but with anger suppression in the clinical women only. DISCUSSION: Suggestions are made regarding ways in which state anger and anger suppression might be understood and treated in women with eating disorders.     

Perfectionism traits and perfectionistic self-presentation in eating disorder attitudes,characteristics, and symptoms

Objective: The purpose of this study was to assess the association between several dimensions of perfectionism and measures of eating disorder symptoms, body image, and appearance self-esteem in college students. Method: A sample of 81 female university students completed the Multidimensional Perfectionism Scale, the Perfectionistic Self-Presentation Scale, the Eating Attitudes Test, the Bulimia Test, the Body Image Avoidance Questionnaire, and two measures of self-esteem. Results: It was found that whereas self-oriented perfectionism was related only to anorexic symptoms, the social facets of perfectionism, especially socially prescribed perfectionism and the perfectionistic self-presentation dimensions, were related to eating disorder symptoms as well as body image avoidance and self-esteem. Discussion: The findings support the usefulness of differentiating personal and interpersonal dimensions of perfectionism as well as trait versus self-presentational aspects of perfectionism in investigating personality and attitudes and behaviors related to eating disorders. © 1995 by John Wiley & Sons, Inc.     

Emotions and eating in everyday life

This field study assessed emotional states experienced in everyday life and examined the subjective motivation to eat associated with these emotional states. Twenty-three female subjects rated their momentary emotional state and motivation to eat on 6 consecutive days at 11:00a.m., 2:00p.m., 5:00p.m., 8:00p.m. and 11:00p.m. A cluster analysis of the resulting 634 emotion profiles revealed three types of emotional states characterized by the labels "Anger-dominance", "Tension/Fear" and "Relaxation/Joy". A fourth cluster showing generally low levels of emotions was labelled "Unemotional state". Most of the self-rated motivations to eat were increased during periods of negative emotions. During negative emotions a heightened tendency to cope with these emotions through eating and more intense bodily symptoms of hunger were also reported. No differences in motivations to eat were found between the two negative emotion clusters or between relaxation/joy and the unemotional state. Results indicate the presence of "emotionally instrumental eating" in a non-clinical population under real life conditions. Physiological correlates of negative emotional states may be involved in emotionally instrumental eating.     

Neuroticism and introversion: a risky combination for disordered eating among a non-clinical sample of undergraduate women

Recent evidence suggests that people who score low on measures of sociability may be at risk for certain types of psychopathology, including mood and anxiety disorders. In an attempt to extend these findings to other forms of psychopathology, we examined levels of neuroticism and extraversion in relation to eating problems in a non-clinical sample of undergraduate women. The Eysenck Personality Questionnaire (EPQ), Eating Disorders Inventory (EDI), and the Eating Attitudes Test (EAT-26) were completed by 196 first-year undergraduate females. We found that high neuroticism was related to high scores on both of the EDI subscales (Bulimia and Drive for Thinness) as well as high scores on the EAT-26 measure, replicating previous work. In addition, neuroticism served as a moderator such that lower extraversion (i.e., introversion) was related to greater disordered eating, but only for those women who scored high on neuroticism. Thus, a combination of neuroticism and introversion may be a risk-factor for symptoms of eating disorders in a non-clinical sample of university women.     

Evaluation of the French version of the Orientation Towards Chocolate Questionnaire: chocolate-related guilt and ambivalence are associated with overweight and disordered eating

The aims of this study were firstly to evaluate the psychometric properties of the French version of the Orientation towards Chocolate Questionnaire (OCQ), secondly to examine differences in chocolate craving as a function of weight status, and thirdly to examine the OCQ craving dimensions as predictors of body dissatisfaction and disordered eating. Participants included 247 female students from the University of Toulouse, France, who completed measures of chocolate craving, body dissatisfaction, bulimia, drive for thinness, and emotional eating, and for whom body mass index (BMI) was available. Confirmatory factor analysis supported the three-factor model of the OCQ, with guilt, approach, and avoidance subscales. Patterns of endorsement of chocolate craving dimensions differed according to weight status, with ambivalence present only amongst overweight participants. Guilt and approach were positively associated with disordered eating, whereas avoidance was negatively associated with bulimia. These results confirm the validity and reliability of the French version of the OCQ and highlight strong associations between chocolate craving dimensions and disordered eating patterns.     

The role of experiential avoidance, rumination and mindfulness in eating disorders

Anorexia nervosa has been associated with high levels of ruminative thoughts about eating, shape and weight as well as avoidance of emotion and experience. This study examined the associations between disorder-specific rumination, mindfulness, experiential avoidance and eating disorder symptoms. A sample of healthy females (n=228) completed a battery of on-line self-report measures. A hierarchical regression analysis revealed that ruminative brooding on eating, weight and shape concerns was uniquely associated with eating disorder symptoms, above and beyond anxiety and depression symptoms. In a small group (n=42) of individuals with a history of anorexia nervosa, only reflection on eating weight and shape was able to predict eating disorder symptoms when controlling for depression and anxiety. The results suggest that rumination (both brooding and reflection) on eating, weight and shape concerns may be a process which exacerbates eating disorder symptoms. Examining rumination may improve understanding of the cognitive processes which underpin anorexia nervosa and this may in turn aid the development of novel strategies to augment existing interventions. Replication in a larger clinical sample is warranted.