Nele, Rita en alle verpleegkundigen ben ik bijzonder dankbaar en ik geef met ...... M.P., Mitchell, J.E., Fenna, C.J., Crosby, R,D., Miller, J.P., & Hoberman, H.M. ...
Faculty of Medicine Department of Psychiatry and Medical Psychology
Traits and Eating Disorders:
associations with cognitive and behavioural characteristics
Thesis submitted in fulfilment of the requirements for the degree of Doctor in Medical Sciences Myriam Vervaet
Promotor: Prof. Dr. K. Audenaert
Introduction Part I : ‘Dieting’ and ‘weight concerns’ as risk factors in the development of eating disorders ...................................................................................................................................................... 8 1. Introduction ………………………………………………………………………………………………………....8 2. Binge eating in obese patients five years after treatment
3. Weight concerns and eating patterns in schoolboys and schoolgirls 4. Eating-style and weight-concerns in young females
Part II : The cognitive psychology of eating disorders: personality, ................................................................................................................................ 45 cognitions and behaviour Chapter 1: Theoretical background 1. Definition and epidemiology
2. The complexity of the ED diagnosis 2.1. Categorical classification
.................................................................................................................................. 48 ..................................................................................................................................... 48
2.2. Dimensional classification and co-morbidity
3. Aetiology as a dynamic process: from trait- (vulnerability) to state- (eating disorder category) dependent characteristics ..................................................................................................................................................................................................... 53 3.1. Introduction
3.2. The relationship of low self-esteem and body-dissatisfaction 3.3. Perfectionism as a core trait
3.4. Perception of life events and the coping with life-events by individuals, characterized by low self-esteem and clinical perfectionism .............................................................................................................. 63
4. Information processing in eating-disordered patients ............................................................................................................. 66 4.1. Neuropsychological processes ................................................................................................................................ 66 4.2. Cognitive processes…………………………………………………………………………………… 69 4.3. Information processing and emotional arousal………………………………………………………… 72 4.4. From schemata to behaviour…………………………………………………………………………… 75
5. A hypothetical model for the prediction of eating-disordered behaviour ............................................................................ 80
Chapter 2: Personality characteristics as trait-dependent vulnerability: study results
1. Binge eating disorder and non-purging bulimia: more similar than different?
2. Is ‘drive for thinness’ in anorectic patients associated with personality characteristics?
3. Cognitive and behavioural characteristics are associated with personality dimensions in patients with eating disorders ...........................................................................................................................................138 4. Personality-related characteristics in restricting versus binging and purging eating disordered patients ..............................................................................................................................................................166 5. Attempted suicide and personality in eating disorders. .........................................................................................................174
Chapter 3: Integration of personality characteristics in a psychobiological model of eating disorders ......................................................................................................................................................... 195
Part III : Further study of the psychobiological model of eating ..........................................................................................................................................................................228 disorders 1. Introduction………………………………………………………………………………………………………228 2. Decreased 5-HT2a receptor binding in patients with anorexia nervosa
3. Binding potential of cortical 5-HT2A receptors is not different in bulimia nervosa patients and healthy volunteers .............................................................................................................................................................................236
BIJLAGE: GEBRUIKTE AFKORTINGEN
Ingesloten publicaties: 1. Vervaet M & van Heeringen C (1995). Binge Eating in Obese Patients Five Years after Treatment. Eating Disorders: The Journal of Treatment and Prevention. Vol. 3 : 3, pp. 229-236. 2. Vervaet M, van Heeringen C, & Jannes C (1998). Weight Concerns and Eating Patterns in Schoolboys and -Girls. Eating Disorders: The Journal of Treatment and Prevention, 6, 41-51. 3. Vervaet M & van Heeringen C (2000). Eating-style and weight concerns in young females. Eating Disorders: The Journal of Treatment and Prevention. Vol. 8 : 233-240. 4. Vervaet M, van Heeringen C, & Audenaert K (2004). Psychological differences in Binge Eating Disorder and Bulimia Non-Purging patients. European Eating Disorders Review, 12 (1), 27-33. 5. Vervaet M, van Heeringen C, & Audenaert K (2004). Is Drive for Thinness in Anorectic Patients Associated with Personality Characteristics. European Eating Disorders Review, 12, 6, 375-379. 6. Vervaet M, Audenaert K, & van Heeringen C (2003). Cognitive and behavioural characteristics are associated with personality dimensions in patients with eating disorders. European Eating Disorders Review, 11 (5), 363-379. 7. Vervaet M, van Heeringen C, & Audenaert K (2004). Personality-related characteristics in restricting versus binging and purging eating disordered patients. Comprehensive Psychiatry, 45 (1), 37-43. 8. Vervaet M, van Heeringen C, & Audenaert K (Submitted). Attempted suicide and personality in eating disorders. Journal of Affective Disorders. 9. Audenaert K, Van Laere K, Dumont F, Vervaet M, Goethals I, Slegers G, Mertens J, van Heeringen C, Dierckx R (2003). Decreased 5-HT2a receptor binding in patients with anorexia nervosa. European Journal of Nuclear Medicine, 44, 163-169. 10. Goethals I, Vervaet M, Van De Wiele C, Audenaert K, Slegers G, van Heeringen C, Dierckx R (2004). Binding potential of cortical 5-HT2A receptors is not different in bulimia nervosa patients and healthy volunteers. American Journal of Psychiatry. 161:10, 1916-1918.
Voorwoord Dit wetenschappelijk werk kwam tot stand onder leiding van Prof. van Heeringen wiens professionele onuitputtelijkheid bijzonder stimulerend werkt, niet alleen bij de realisatie van dit werk. Aansluitend wens ik Prof. Audenaert te bedanken voor zijn bereidwilligheid om het promotorschap op zich te nemen. Beiden zijn voor mij meer dan waardevolle collega’s. Bovendien getuigen hun persoonlijkheden van de realiteit dat dwang en impulsiviteit ook heel gezonde kenmerken kunnen zijn en vruchtbare interacties kunnen opleveren. Tevens wil ik alle leden van mijn begeleidings- en examencommissie bedanken voor hun waardevolle vragen en opmerkingen. Speciale dank gaat uit naar Prof. Jansen, die als hoogleraar eetstoornissen mij niet alleen reeds vele jaren boeide maar ook telkens weer verraste met haar originele onderzoeksvragen. Dat uitzonderlijke psychologen ook snel carrière kunnen maken wordt ontegensprekelijk door Prof. De Soete bewezen. Hij was nog student toen hij mij al leerde hoe ik een doctoraat moest schrijven. Blijkbaar met succes, gezien het voor herhaling vatbaar was. Een gezamenlijke schrijfopdracht vijftien jaar geleden en gezamenlijke pogingen om te stoppen met roken eindigden steevast in bijzonder gezellige etentjes met Prof. Kaufman. Met Prof. Thiery ontwikkelde ik in al die jaren een zeer dierbare band, als hoogleraar Medische Psychologie, als excellente deskundige in de Neuropsychologie, als toegewijd en competent behandelaar en tenslotte (hopelijk) ook als vriend. Dat Prof. Colardyn bovenop zijn uitgebreide professionele opdracht deze psychologische brok onderzoekswerk te verwerken kreeg, was het gevolg van zijn, door ons zeer gewaardeerd, voormalig diensthoofdschap. Bovendien was hij als hoofdarts steeds bereid tot luisteren en helpen als wij met onze patiënten weer diep in de moeilijkheden zaten, met de snelheid en de flexibiliteit die hem zo kenmerkt. Ook Prof. Van Cauwenberge heeft vaderlijk de verantwoordelijkheid als onze vakgroepvoorzitter opgenomen in tijden van hoge nood (en die was er meermaals). Van bij mijn start in deze faculteit tot nu heeft hij meermaals zijn psychologische kwaliteiten getoond bij de verzuchtingen van een vreemde eend tussen al die artsen-specialisten. Dat Prof. Kips momenteel mee beleidslijnen uittekent ligt in het verlengde van zijn capaciteiten om zowel structureel als inhoudelijk de puntjes op de i te zetten. Ook hem wil ik bedanken voor de vele gesprekken, de doorverwijzingen van patiënten en zijn toestemming om in de examencommissie te zetelen. En tenslotte mijn dank aan Prof. Debacquer die meermaals mijn obese databank bekeek en probeerde via SPSS het juiste dieet te vinden. In de voorgeschiedenis van dit proefschrift waren Prof. Evrard en Prof. Van Oost de sleutelfiguren bij mijn eerste doctoraat over eetstoornissen. Daarnaast werd ik positief geconditioneerd door Prof. Vandereycken, dé pionier in het onderzoek en behandeling van eetstoornissen in Vlaanderen. Ook hen wil ik nu bedanken. Hun degelijke wetenschappelijke basis gaven mij het vertrouwen om in de faculteit Geneeskunde een plaats te zoeken en te krijgen dank zij Prof. Jannes. Als geboeid wetenschapper kon ik echter niet zonder de kliniek. Het behandelen van eetstoornissen kan enkel door en met een multidisciplinair team dat via een duurzaam en intensief engagement de wondere wereld van deze patiëntengroep probeert te begrijpen. De bouwstenen voor een gespecialiseerde afdeling werden op de dienst Endocrinologie gelegd. Bij deze wens ik Dr. Deslypere en het verpleegkundig team onder leiding van Bea van harte te bedanken voor de vele uren die zij extra spendeerden aan onze probleemmeisjes. Het was de bakermat voor onze huidige 21-bedden tellende eetkliniek. In 1998 verhuisden we naar de afdeling Psychiatrie. Van in het begin was daar een bijzondere grote inzet en zonder deze kon dit werk nooit gemaakt worden. Siska, Tina, Bart, Katrien, Nele, Rita en alle verpleegkundigen ben ik bijzonder dankbaar en ik geef met gerust gemoed het roer door aan Dr. Katrien Bernagie die de hospitalisatie-eenheid in de toekomst zal leiden.
Bijzondere dank gaat uit naar Lieve Rousseau, die haar logistieke, esthetische en psychologische kwaliteiten weet te combineren in een relativerende stijl die mij altijd opfleurt. Ook Betty die ons allen buffert tegen de vaak overspoelende telefoons en afspraken. Samen met Brigitte vormden zij met zijn drieën bovendien de trouwe achterhoede in moeilijke jaren. Tot slot gaat mijn dank naar mijn familie. Ik ben de laatste jaren te veel en zeer belangrijke mensen verloren, waardoor mijn werk vaak mijn troost werd. Mijn moeder wil ik bedanken omdat ze ondanks haar gevleugelde uitspraak “dat ze niet begrijpt waarom ze haar kinderen zo lang heeft laten studeren om daarna zo hard te moeten werken” toch accepteert dat zij ons daardoor minder ziet. Mijn zus No die mij al 40 jaar probeert ‘in balans’ te krijgen: “meer sport, meer natuur, meer buiten”, en Isidoor die steeds geboeid informeert naar de fenomenologie van onze patiënten en ondertussen zelf ‘mindful’ probeert te worden. Ook mijn ongelooflijke kranige en mature nichten Ruth en Karlien, die het wetenschappelijke niveau in de toekomst zullen ondersteunen, wil ik hierbij extra bedanken. En tenslotte Elise: bij de finalisering van mijn eerste doctoraat zat zij op mijn schoot als baby en nu zat zij achter haar computer Spaans te leren of Italiaans te sms-en. Haar doorzettingsvermogen in combinatie met haar grote tolerantie zorgden ervoor dat ik mij als moeder nooit schuldig hoefde te voelen. Gent, 20 juni 2005
Recent models in psychiatry explain psychopathology as the consequence of an interaction between stressors (eliciting factors) and a predisposition or vulnerability (predisposing factors), which is expressed through (problem) behaviour. Due to its reinforcing properties, such behaviour may act as a maintaining factor and may become a symptom. A disorder may thus be constituted of maintaining factors. The vulnerability can be caused by genetic or developmental influences, and modified by environmental and psychosocial variables.
Vulnarability is caused by neurobiological mechanisms, in particular by
neuroanatomical brain circuits with their neurophysiological and neuropsychological characteristics.
This vulnerability, however, becomes not necessarily manifest during all periods of life. Eating disorders occur predominantly during adolescence or early adulthood, probably because this transition period is characterised by biological, psychological and social changes. The experience and necessity of change can be very stressful for an individual, especially for an anxious individual. In addition, ‘differentiating’, in terms of individuality/personality, becomes a very important process during adolescence. Indeed, conformity through following the rules of caregivers, i.e. parents, is predominantly the adaptive behavioural pattern during childhood. However, during adulthood, individuals are expected to formulate their own goals and to direct their own behaviour in relation to chosen values and norms. This demand can elicit dysfunctional coping behaviour, such as ‘creating a perfect body’ with divergent meanings and motives. Thus, an extreme need for control can sustain the self-starvation in anorectic patients, or the fear of rejection can motivate a bulimic girl to strive for ideal body shapes.
Over the past few decades, eating disorders have emerged as clinical problems of growing relevance, due to their increasing prevalence, the substantial somatic and psychiatric co-morbidity, increased mortality, frequent relapse, and common failure of treatment. With regard to treatment, and from a
cognitive-behavioural point of view, maintaining factors were the first target. The over-evaluation of body shape and weight has been described as the ‘core psychopathology’ of clinical eating disorders (Fairburn, Cooper, & Shafran, 2003). Dietary restraint is the most obvious behavioural expression of this over-evaluation. In the nineties, the cultural standard of beauty ideals was assumed to be associated with thinness in Western-societies, thus triggering weight concerns and behaviours such as dieting, particularly among young women and girls. The terms ‘dietary restraint’ and ‘restrained eating’ refer to a tendency to consciously restrict food intake in an effort to maintain weight or produce weight-loss (Herman and Polivy, 1975). Dieters display the tendency to overeat when anxious or stressed, whereas normal, unrestrained individuals tend to eat less when anxious (Rutledge and Linden, 1998).
dieters, overeating can be induced by a dysphoric mood, alcohol consumption, and conditions, in which restrained eaters believe that they have broken their diet-rules by consuming a preload of food. This phenomenon is called ‘disinhibition’ or ‘counterregulation’. Explanations for this effect range from physiological mechanisms, i.e. via a dissociation from conditioned satiety signals, to distraction from distress and learned helplessness (Polivy and Herman, 1999).
Additional psychological features associated with restrained eating include exaggerated responsiveness to nutritional or food-related cues (Tuschl, 1990), increased distractibility and emotionality (Herman and Polivy, 1975; Polivy et al., 1978), and depression and anxiety (French and Jeffery, 1994). Physiological consequences of dieting have also been noted, such as elevated triglyceride levels (Laessle et al., 1989) and weight cycling, which in itself has been associated with a higher risk of morbidity (Lissner et al., 1991). Unsuccessful dieters show poorer impulse regulation and more weight fluctuation, and have higher levels of perfectionism and drive for thinness when compared to successful dieters (Van Strien, 1997). They also are more prone to use dietary practices such as counting calories, eating low-calorie foods, and avoiding certain foods. In contrast, dieters who exert more enduring restraint tend to take smaller portions, and eat more slowly (Westenhoefer, 1991).
The relationship between body dissatisfaction and self-esteem on the one hand and unsuccessful dieting on the other hand is less clear. Appearance-motivated dieters are at particular risk of eating pathology. These dieters mainly are younger women, who are characterized by a low self-esteem, body dissatisfaction, and a strong desire to change their bodies despite their normal weight. However, it remains to be demonstrated whether it is the perception that one is “dieting” (the cognitive aspect), or the actual decrease in caloric consumption and resulting physiological changes that disrupts normal eating (Putterman & Linden, 2004).
The first three papers in Part 1 of this thesis describe aspects of the association between the risk factors ‘weight concerns’ and ‘dieting’ and the development of eating disorders.
Without denying the importance of these eliciting and maintaining factors, the main goal of this thesis was to explore the vulnerability for eating disorders, i.e. to study predisposing factors. Therefore, a major research question for the studies as described in this thesis addressed, first the extent to which a predisposition to eating disorders can be described in terms of personality dimensions, and secondly, the expression of such a predisposition through cognitive and behavioural characteristics and their interactions, which are of particular interest for eating disorders (see figure 1).
- feelings o f uselessness - feelings of loneliness and emptiness
- BMI - eating behaviour
type of eating disorder (DSM-IV)
Figure 1: Model of the development of disturbed eating behaviour
Personality is commonly described as a stable organisation of psychobiological structures reflecting temperamental and character dimensions. Rutter (1987) has defined temperament as “simple, non-motivational, non-cognitive stylistic approaches that are heritable and likely rooted in underlying neurobiological processes”.
Although biologically driven temperamental constructs motivate and
restrain behaviour, the expression of the same temperamental constructs is modified by experiences (Kagan, Arcus, & Snidman, 1993). Temperament refers to automatic emotional responses to experience that are moderately heritable and stable throughout life. In contrast, character refers to self-concepts and individual differences in goals and values, which influence voluntary choices, intentions, and the meaning of what is experienced in life. Dimensions of character are influenced by sociocultural learning, and mature in progressive steps throughout life. Behavioural genetic research has indicated that nonshared environmental effects, i.e. experiences that are not shared by siblings in the same family, have the greatest non-genetic effect on the development of psychopathology (Kendler, Neale, Kessler, Heath, & Eaves, 1992).
These dimensions of personality interact with each other in order to motivate adaptation to life experiences and to influence susceptibility to emotional and behavioural disorders.
processing characteristics are determined by these temperamental and character structures, and result in schemata. A schema is defined as a mental structure that consists of a stored domain of knowledge, which interacts with the processing of new information (Williams, Watts, MacLeod, & Mathews, 1997). It is a mental ‘filter’, which is shaped by previous experiences and which colours subsequent interpretations. A schema is rich in meaning, and represents much more than a single belief. Schemata comprise ‘meaning’, with its physical, emotional, verbal, visual, acoustic, kinetic, olfactory, tactile and kinaesthetic features. A schema contains information about the self, the others and the surrounding world, and directs our perception, interpretation and memory. Daily experiences activate schemata, which elicit corresponding feelings and behaviours. While a behaviour is observable, cognition is the quality of knowing which includes perceiving, judging, sensing, reasoning, and imaging” (Weisenberg, 1994). It should be mentioned that this “knowing” can take place inside or outside the realm of attention.
Research findings regarding the application of this theoretical model to eating disorders are described in Part 2, followed by an elaboration of the research hypothesis.
Data on 800 eating
disordered patients are reported and compared with previous research findings. Furthermore, particular attention is given to the correlation between personality dimensions and three cognitive characteristics, which are defined as core characteristics in the main trans-diagnostic models of eating disorders (Fairburn, Cooper, & Shafran, 2003; Serpell & Troop, 2003).
These cognitive factors, i.e. body
dissatisfaction, perfectionism and interpersonal distrust, were measured using the Eating Disorder Inventory (EDI; Garner, Olmstead, & Polivy, 1983).
The personality model as used in the studies, which constitute this thesis, is psychobiological in nature, and serves as a basis for the study of the neurobiological correlates of these psychological characteristics. Part 3 describes two such studies.
Conclusions and suggestions for further research are provided in the final chapter.
References Fairburn CG, Cooper Z, & Shafran R (2003). Cognitive behaviour therapy for eating disorders: A ‘transdiagnostic’ theory and treatment. Behaviour Research and Therapy, 41, 509-528. French SA, & Jeffery RW (1994). Consequences of dieting to lose weight: Effects on physical and mental health. Health Psychology, 13: 195-212. Garner DM, Olmstead MP, & Polivy J (1983). Development and validation of a multidimensional Eating Disorder Inventory for anorexia nervosa and bulimia nervosa. International Journal of Eating Disorders, 2, 15-24. Herman CP, & Polivy J.(1975). Anxiety, restraint and eating behaviour. Journal of Abnormal Psychology, 84, 666-672. Kagan J, Arcus D, & Snidman N (1993). The idea of temperament: Where do we go from here? In R.Plomin & G.E. McClearn (Eds.), Nature, nurture and psychology. Washington, DC: American Psychological Association. Kendler KS, Neale MC, Kessler RC, Heath AC, & Eaves LJ (1992). The genetic epidemiology of phobias in women: The interrelationship of agoraphobia, social phobia, situational phobia, and simple phobia. Archives of General Psychiatry, 49, 273-281. Laessle RG, Tushel RJ, Kotthaus BC, & Pirke KM (1989). Behavioral and biological correlated of dietary restraint in normal life. Appetite 12: 83-94. Lissner L, Odell PM, D’Agostino RB, Stokes J, Kreger BE. Belanger AJ & Brownell KD (1991). Variability of body weight and health outcomes in the Framingham population. N. Eng. J. Med. 324-: 1839-1844. Polivy J, & Herman CP (1999). Distress and eating: why do dieters overeat? International Journal of Eating Disorders, 26, 153-164. Polivy J, Herman CP, & Warsh S (1978). Internal and external components of emotionality in restrained and unrestrained eaters. J. Abnorm. Psychol. 87: 497-504. Putterman E, & Linden W (2004). Appearance versus Health: Does the reason for dieting affect dieting behavior? Journal of Behavioral Medicine, Vol. 27, 2, 185-204. Rutledge T, & Linden W (1998). To eat or not to eat: Affective and physiological mechanisms in the stress-eating relationship. J. Behav. Med. 21: 221-240. Rutter M (1987). Temperament, personality, and personality disorder. British Journal of Psychiatry, 150, 443-458. Serpell L, & Troop N (2003). Psychological factors. In : J. Treasure, U. Schmidt & E. van Furth (Eds), Handbook of Eating Disorders. Second Edition, Wiley & Sons, Chichester.
Tuschl RJ, Laessle RG, Platte P, & Pirke KM (1990). Differences in food-choice frequencies between restrained and unrestrained eaters. Appetite 14: 9-13. Van Strien T (1997). The concurrent validity of a classification of dieters with low versus high susceptibility toward failure of restraint. Addictive Behaviors, 22, 587-597. Weisenberg M (1994). Cognitive aspects of pain. In P.D. Wall, & R. Melzack (Eds.), Textbook of pain (pp. 275-289). New York: Churchill Livingstone. Williams JMG, Watts FN, Mac Leod C, & Mathews A (1997). Cognitive psychology and emotional disorders (2nd ed.). Chichester: Wiley.
PART I ‘Dieting’ and ‘weight concerns’ as risk factors in the development of eating disorders
1. Introduction The core psychopathological feature of eating disordered patients is their over-evaluation of shape and weight. In contrast with the probably complex and badly understood cause of the disease, the symptoms are clear forward, measurable and uniting all patients.
Moreover, the physical abnormalities
in these patients appear to be largely secondary to their disturbed eating habits, and the majority of the somatic symptoms are reversed by restoration of healthy eating habits. Consequently, the somatic treatment seems to be easy, and merely a question of willpower and clear indications. At the same time young adolescents grow up, while living in a society with television soaps, commercials and computergames in which thin female bodies are idealized. The consequent pressure of ‘looking good’ often leads to a ‘normative discontent’ (Rodin, Silberstein, & Striegel-Moore, 1985), due to which many girls worry about their body shape and try to induce a negative energy balance. A dramatic consequence is the prevailing view, even among medical professionals, that eating disorders are self-inflicted and that they are an expression of temporary immaturity. Disturbed eating patterns can indeed be placed on a continuum from harmless to pathological, but this unscientific opinion ignores the fact that typical eating disorders are severe and often chronic disorders associated with high levels of physical and psychological co-morbidity and poor quality of life.
For example, the mortality rate in anorectic
inpatients is indeed twice as high as the rate in other psychiatric inpatients. Equally important is the question whether restricting behaviour can induce a psychiatric syndrome.
Bearing in mind the study
of Keys (1946), it was hypothesized that too strict dieting may have iatrogenic effects, such as inducing binge eating and other eating-related pathology.
Following this line of reasoning, the first part of this thesis includes three studies describing the presence of disturbed eating patterns among risk groups such as obese patients (after treatment with strict diets), fashion models and young adolescents. These articles were published between 1995 and 2000 and formed the start for the search to distinguish between dieting as symptom of psychopathology and dieting as a means of reaching a healthy weight.
2. Binge eating in obese patients five years after treatment.1
Five years after treatment for obesity, combining cognitive-behavioral treatment with a very low calorie diet (VLCD) or a low calorie diet (LCD), the eating behavior of 112 female patients was studied. At the time of reassessment most of the women showed a restrained eating style combined with bingeing. Significantly more patients in the VLCD-group than in the LCD-group reported bingeing. More than half of the successfully treated women (BMI ≤ 30) reported binge eating. No association between treatment success and a restrained eating style was found.
Habitual dieters show marked overcompensation in eating behavior in a way that is similar to the bingeing in eating disorders (Polivy & Herman, 1985; Wardle, 1987). But binge eating does not occur in all dieters (Tuschl, 1990). More-over, in some people binge eating is a transitory phenomenon, while for others it progresses to a chronic condition. Nevertheless there is a close connection between dietary restraint and binge eating. Hence it is no surprise that binge eating is a common problem among the obese (Hudson et al., 1988; Kolotkin et al., 1987; Marcus & Wing, 1987). Binge eating may also be a serious complication of treatment.
Marcus and Wing (1987) found
that between 20% and 46% of obese individuals participating in a behavioral weight control program reported binge eating. The quantity of food consumed and the duration of episodes were similar to those in patients with bulimia nervosa. Garner and Wooley (1991) suggest that excessive dieting associated with overweight may induce binge eating, which in turn leads to increased caloric intake and greater adiposity. Since treatment of the obese according to the addiction model includes intensifying restraint rather than just normalizing food intake (Bemis, 1985; Vandereycken, 1990; Wardle, 1987), it may have iatrogenic effects. Of further interest is the finding that both obese and lean dieters eat more when depressed, a pattern which is reversed in non-dieters (Baucom & Aiken, 1981; Polivy & Herman, 1985). Therefore, dieting may cause depression which in turn makes the individual more vulnerable to bouts of overeating. 1
Vervaet, M. & van Heeringen, C. (1995). Binge eating in obese patients five years after treatment. Eating Disorders The Journal of Treatment and Prevention, 3, pp.229-236.
Telch, Agras, and Rossiter (1988) found that binge eating becomes significantly more common when the degree of overweight increases. A significant positive relationship between the degree of overweight and binge severity has also been demonstrated by other researchers (Kolotkin et al. 1987; Marcus et al., 1985). These findings suggests that individuals who binge eat may be at greater risk for overweight. Other studies have indicated that obese binge eaters may have a poorer treatment response in standard behavioral weight loss programs than obese nonbinge eaters (Keefe et al., 1984) because of a higher rate of dropout and a more rapid regain of weight (Marcus, Wing, & Hopkins, 1988). The current study aimed at the assessment of differences in the prevalence of binge eating between obese patients who followed a cognitive-behavioral treatment combined with a low calorie diet and those with a very low calorie diet. The association between binge eating and treatment outcome was also investigated. Methods We studied 260 obese women (definition: Body Mass Index of 30 or more) who followed a multidisciplinary treatment according to two different programs. In the first group, treatment included both a very low calorie diet (VLCD, 400-600 Kcal) and cognitive behavior group therapy for weight loss during one year.
Treatment began with a six-week VLCD fasting program, followed by gradual
refeeding. The second group started with a low calorie diet (LCD, 800-1,200 Kcal) during several months before refeeding, on an individually basis. During the initial three months, sessions occurred weekly, then biweekly for the next six months, and monthly for the final three months of treatment. Group sessions lasted for 60 minutes and individual sessions for 30 minutes. Both kinds of treatment were supplied by a female behavior therapist. The treatment included three basic elements. First, information about medical topics (e.g. the risks of obesity, influence of different diets) was presented by an endocrinologist who also followed the medical evolution of the patients. Fenfluramine was given in case of great carbohydrate cravings. Second, patients were engaged in an exercise program included swimming, jogging, and fitness training on a regular basis (minimally three times a week for one hour). As to the specific diet, patients learned how to purchase, compose, and prepare meals that were different from fat- and carbohydrate-rich ones. Third, we applied a form of cognitive-behavior therapy based on self-monitoring, stimulus control,
stress management, cognitive restructuring, relapse prevention training, enlargement of social support and self-esteem, and amelioration of body image. The final aim of the program was to reach a sense of self-control, especially in eating situations. The patient group consisted of 78 females treated in an outpatient clinic in Antwerp and 182 female patients who were consecutively admitted to the Unit for Eating Disorders of the Department of Endocrinology, University Hospital, Gent. Five years after treatment, a questionnaire was sent to all 110 obese women who had participated in the VLCD treatment and to the 150 in the LCD group.
The following characteristics were
monitored: age, situation of living, activity, weight before treatment and after 1 year and 5 years, body mass index (BMI), highest weight ever, desired weight, use of laxatives and/or anorectic drugs, vomiting, and eating-behavior. Subjects were also asked to fill out the Dutch eating questionnaire (Van Strien et al., 1986). For this questionnaire the results were compared to the norm tables of obese women (Van Strien et al., 1986) and divided in three groups: low (L), mean (M) and high (H) correspondence group, using the cut-off-scores shown in Table 1.
Table 1: Cut-off Scores from the Dutch Eating Questionnaire
Restrained eating External eating Eating with clear emotions Eating with diffuse emotions Totally emotional eating
Results Of the total of 260 women, data on 112 patients (43 %) were available for analysis, including 56 patients of the VLCD group (group 1) and 56 females of the LCD group (group 2). To investigate the relationship between frequency of binge eating and treatment outcome, the latter was dichotomized as successful (BMI ≤ 30) or not successful (BMI > 30).
The following picture of the eating behavior emerged from questionnaires: 74 % ate between the meals, including 49 % in the evening; 14 % skipped breakfast, 5 % lunch, and another 5 % dinner; 11 % ate a lot of sweets, 28 % regularly and 56 % sometimes; most of the women (71 %) preferred sweet to salt; 37 % ate alone regularly, 47 % thought a lot about food during the day, and 26 % counted calories. Loss of control while eating was reported by 74 women (66%), including 12 women (11 %) who binged daily. In order to get information about the difference of 'objective' and 'subjective' binges, patients were asked to quantify their binges: 21 women (19%) reported binges involving the intake of more than 2,000 Kcal, while 31 (28 %) reported the intake of about 1,000 Kcal; 17 (15%) reported binges of less than 500 Kcal, which can therefore be called ‘subjective’ binges. Table 2: Bingeing in VLCD and LCD Bingeing Occurrence
VLCD n % 45
(n = 56) n 30
LCD (n = 56) p* .0026 .0200
*< 500 Kcal
*> 1000 Kcal
*> 2000 Kcal
*Chi-square tests A significant difference in the frequency of bingeing between the VLCD and the LCD group was found. Of the VLCD women, 45 women (80.4%) reported bingeing versus 30 (53.6 %) LCD-women,
as shown in Table 2. No significant difference between the treatment groups could be found for the quantity of binges. No indications for an association between the occurrence or frequency of bingeing and treatment outcome could be found (see Table 3). Table 3: Bingeing in Successful and Unsuccessful Treatment Outcome. Bingeing
BMI≤30 (n = 44)
BMI>30 (n = 68)
< 500 Kcal
> 1000 Kcal
> 2000 Kcal
* Chi-square tests
However, a significant difference between successfully and unsuccessfully treated patients emerged for the kind of binges : objective binges (involving the intake of at least 1,000 Kcal) were reported more often by women in the non-successful group. No significant differences between the successfully and unsuccessfully treated groups could be found for the use of other methods to influence the body weight:
34 patients (30 %) of the total group used appetite suppressing drugs, 9 patients (8 %) reported vomiting, and 35 patients (31 %) used laxatives. Table 4: High scores on the Dutch Eating Questionnaire in VLCD and LCD. H-score
VLCD (n = 56)
LCD (n = 56)
Clear emotional eating
Diffuse emotional eating
Total emotional eating
* Chi-square tests
Of particular interest is the finding of a significant difference between the VLCD and the LCD groups on the indices for Emotional Eating of the Dutch Eating Questionnaire (df = 2; X2 = 10.277; p = 0.005). As shown in Table 4, 32 patients in the VLCD-group (57.1 %) had a high score versus 17 in the LCD-group (30.4 %). Only two VLCD-patients (3.6 %) had a low score on this item, versus nine LCDpatients (16.1 %).
No significant differences between the treatment groups were found for the
proportion of high scores on Restrained Eating, and External Eating. However, high scores on Eating by Clear Emotions and Eating by Diffuse Emotions were found more often in the VLCD group than in the LCD group. With respect to the association between high scores on the questionnaire and treatment outcome, it appeared that high scores on External Eating and Eating by Clear Emotions were more common among unsuccessfully treated patients (see Table 5).
Table 5: High scores on the Dutch Eating Questionnaire in Successful and Unsuccessful Treatment Outcome. H-score
Clear Emotional eating
Diffuse emotional eating
Total emotional eating
*Chi-square tests Discussion Preceding a discussion of the results of this study, some methodological shortcomings should be addressed. First, the results are likely to be biased because follow-up data are known for only 43% of the patients. Second, because of the retrospective nature of the study no base line data on the occurrence and characteristics of bingeing before treatment were available. Thus, it cannot be concluded that bingeing has been induced by the treatment. Nevertheless, the differences between VLCD and LCD outcome seem to support the hypothesis that the degree of dieting determines the degree of loss of control over eating: loss of control was present in 80 % of the VLCD-patients and in 53 % of the LCD-group. Our results also suggest a link between emotional eating and bingeing. VLCD-patients more often reported bingeing, and also more commonly had high scores on items related to eating, because of clear or diffuse emotions. With respect to the association between treatment outcome and binge eating, we found that more than half of the successfully treated subjects reported bingeing, but objective binges occurred significantly less often. Although restrained eating was as common as in unsuccessfully treated women, the results suggest that successfully treated women lose less control in situations where they are externally or emotionally stimulated to eat.
Anyway, the results from this study indicate that bingeing is a serious problem even several years after treatment for obesity. Many women in this study used laxatives and anorectic drugs, vomited, and dieted, without losing weight. One explanation for this failure can be found in their disturbed eating pattern: they skip meals, prefer sweets, eat alone regularly, and think a lot about food, but most of all they regularly lose control over their eating in emotional situations. In view of the finding that better treatment outcome is associated with less external and emotional eating, and with a smaller quantity of food intake in case of bingeing, the results of the current study indicate that the focus of treatment for obesity should be shifted from stimulating dieting to improving self-control. Finally, our follow-up data make the use of very low calorie diets - still very popular in Europe - indicate a rather questionable practice.
References Baucom, D. H., & Aiken, P.A.(1981). Effect of depressed mood on eating among obese and nonobese dieting and nondieting persons. Journal of Personality and Social Psychology, 41, 577-585. Bemis, K.(1985). "Abstinence" and "nonabstinence" models for the treatment of bulimia. International Journal of Eating Disorders, 4, 389-406. Garner, D.W., & Wooley S.C.(1991). Confronting the failure of behavioral and dietary treatments for obesity. Clinical Psychology Review, Vol. 11, PP. 729-780. Hudson, J.I., Pope, H.G., Wurtman, J., Yurgelun-Todd, D., Mark, S., & Rosenthal, N.E.(1988). Bulimia in obese individuals: Relationship to normal-weight bulimia. Journal of Nervous and Mental Disease, 176, 144-152. Keefe, P.H., Wyshogrod, D., Weinberger, E., & Agras, W.S. (1984). Binge eating and outcome of behavioral treatment of obesity: A preliminary report, Behaviour Research and Therapy, 22, 319-321. Kolotkin, R.L., Revis, E.S., Kirkley, B.G., & Janick, L. (1987). Binge eating in obesity: Associated MMPI characteristics. Journal of Consulting and Clinical Psychology, 55, 872-876. Marcus, M.D., & Wing, R.R.(1987). Binge eating among the obese. Annals of Behavioral Medicine, 9, 23-27. Marcus, M.D., Wing, R.R., & Hopkins, J.(1988). Obese binge eaters: Affect, cognitions, and response to behavioral weight control. Journal of Consulting and Clinical Psychology, 56, 433-439. Marcus, M.D., Wing, R.R., & Lamparski, D.M.(1985). Binge eating and dietary restraint in obese patients. Addictive Behaviors, 10, 163-168. Polivy, J., & Herman, C.P.(1985). Dieting and bingeing: A causal analysis. American Psychologist, 40, 193-201. Telch, C.F., Agras, W.S., & Rossiter, E.M.(1988). Binge eating increases with increasing adiposity. International Journal of Eating Disorders, 7, 115-119. Telch, C.F., & Agras, W.S.(1993). The effects of a Very Low Calorie Diet on binge eating. Behavior Therapy, 34, 177-193. Tuschl, R.J.(1990). From dietary restraint to binge eating: Some theoretical considerations. Appetite, 14, 105-109. Van Strien, T., Frijters, J., Roosen, R., Knuiman-Mijl, D., & Defares, P.(1986). Eating behavior, personality traits and body mass in women. Agricultural University, Wageningen, The Netherlands. Vandereycken, W.(1990). The addiction model in eating disorders: Some critical remarks and a selected bibliography. International Journal of Eating Disorders, 9, 95-101. Wardle, J.(1987). Compulsive eating and dietary restraint. British Journal of Clinical Psychology, 26, 47-55.
3. Weight Concerns and Eating Patterns in Schoolboys and -Girls2
In this study, weight concerns and eating patterns were assessed in a large group of school-aged adolescents by means of questionnaires. Girls far more commonly reported problems related to eating and body weight, restrained eating with counting of calories, and abuse of laxatives. Loss of control over eating was reported by more than half of the girls. The occurrence of eating problems and associated behavioral characteristics among girls clearly increased with age, even though young girls reported problems related to body weight and eating patterns to such an extent that the introduction of prevention programs should be considered in the first years of secondary school.
Outcome studies indicate a substantially increased risk of medical and psychiatric disorders (Fombonne, 1995), and of premature death (Sullivan, 1995), among eating disordered patients. These findings underline the need for more effective preventive measures that should be based on the knowledge of factors that facilitate or predict the development of eating disorders. Longitudinal studies have shown that dissatisfaction with body shape is a major factor contributing to the development of eating disorders (Attie & Brooks-Gunn, 1989; Striegel-Moore, Silberstein, & Rodin, 1989). Therefore, it is alarming that recent surveys consistently demonstrate high levels of body dissatisfaction among adolescent girls despite normal actual weights (Attie & BrooksGunn, 1989; Huenemann, Shapiro, Hampton, & Mitchell, 1966; Paxton et al., 1991; Richards, Boxer, Petersen, & Albrecht, 1990). Consequently, it is not surprising that adolescent girls commonly engage in weight reducing behavior, most often by means of dieting. Weight reduction behavior was already reported to be common by the 1960s (Dwyer, Feldman, Seltzer, & Mayer, 1969; Huenemann et al., 1966; Nylander, 1971). However, the average weight of young women has tended to increase over the last 30 years (Gulliford, Rona, & Chinn, 1992; Shah, Hannan, & Jeffery, 1991), while the ideal body weight has decreased 15 kg over the same period (Kinoy, 1994). The relationship of dieting and development of eating disorders is not clear. Many studies have shown only a limited association between dieting and being overweight. For example, only half of the
Vervaet, M., van Heeringen, C., & Jannes, C. (1998). Eating Disorders. The Journal of Treatment and Prevention, 6,41-51.
girls studied by Dwyer et al. (1969) were actually overweight. Individuals such as ballet dancers, student fashion models, and young athletes had higher scores on self-report measures of eating disturbances than individuals in the general population, and they developed clinically defined eating disorders at much higher frequencies (Attie & Brooks-Gunn, 1989; Garner, Garfinkel, Schwartz, & Thompson, 1980; Garner, Garfinkel, Rockert, & Olmstead, 1987; Hamilton, Brooks-Gunn, & Warren, 1985; Szmukler, Eisloer, Gillies, & Hayward, 1985). However, none of the authors mentioned in the studies cited above have said that dieting per se is a risk factor for eating disorders in these populations. Longitudinal studies of general population samples of school-aged girls also have demonstrated that dieters at the time of the first interview were seven times as likely as nondieters to develop an eating disorder by the time of the second interview 1 year later (Johnson-Sabine, Wood, Patton, Mann, & Wakeling, 1988; Patton, Johnson-Sabine, Wood, Mann, & Wakeling, 1990) . Recent studies indicate a difference in eating styles between men and women (Van Strien, 1994). "Restrained eating" and "emotional eating" are more commonly reported by women. However, in Western societies more men are overweight, and the typical male abdominal fat distribution is associated with a higher risk of coronary diseases than the typical female fat distribution (Van Gaal, Rillaerts, Creten, & De Leeuw, 1988). Therefore, the reported differences in eating styles and weight concerns according to gender appear not to be due to medical reasons. Next to an effect of gender, a limited number of studies have indicated a substantial effect of age on body dissatisfaction and weight concern. At the onset of puberty, girls experience a weight spurt as their body weight increases by 10 kg because of a substantial increase in body fat (Fombonne, 1995). This increase is accompanied by negative psychological states, particularly among early maturers (Dornbusch et al., 1984). On the contrary, during puberty boys experience an increase in weight and muscularity that may enhance their self-esteem. Boys perceive thinness rather negatively, as they generally prefer to be tall and muscular (Paxton et al., 1991). Thus, the currently available data indicate that weight concerns and disturbed eating patterns are common among adolescents and may provide clues to the prevention of eating disorders. However,
when the results of distinct studies are combined it appears that gender and age also have to be taken into account to delineate specific subgroups with particularly increased risks of developing eating disorders. Therefore, this study aimed at the assessment of (a) weight concerns and eating patterns and (b) the effects of age and gender on these characteristics in a large sample of school-aged adolescents.
Subjects and methods The study population consisted of students between 13 and 18 years of age who were attending four secondary schools in Gent, Belgium. Data were collected by means of two anonymous self-report questionnaires. Questionnaires were filled in by the students collectively at the same moment in each class, under the supervision of the first author. Items on the first questionnaire inquired about age, weight, gender, desired weight, use of anorectic drugs and laxatives, weight and eating problems (defined as self-criticism on weight and eating patterns: weight is perceived to be too high or too low and a feeling of lack of control over eating), vomiting, eating patterns, thinking about eating (degree of preoccupation), eating alone (eating in secret), counting calories, preference for sweet or salt, loss of control over eating, and the frequency and severity of this loss. We calculated body mass indexes (BMI = G/LXL) by using reported weights and heights. The ideal BMI was defined as a current BMI between 20 and 25, and we calculated the desired BMI (DBMI) by means of reported desired weights and heights. Subjects were also asked to fill out the Dutch Eating Questionnaire (Van Strien, Frijters, Roosen, Knuiman-i\tlijl, & Defares, 1986), which is based on the Eating Pattern Questionnaire (Wollersheim, 1970), the Questionnaire for Latent Obesity (Pudel, Metzdorff, & Oeting, 1975), and the Eating Behavior Inventory (O'Neil et al., 1979). The following subscales can be identified: Emotional Eating, Restrained Eating, and External Eating. We compared the scores on the questionnaire and on the
subscales with those of nonobese controls after dividing the subjects into three subgroups-low (L), mean (M), and high (H)-using the cutoff scores (Van Strien et al., 1986) . Table 1 Occurrence of assessed characteristics
Variable (total n = 745) BMI < 20 20 2.38 Emotional Eating scores > 2.1 External Eating scores > 3.04
N 454 293 11 423 167 1 130 103 32 68 95 17 12 692 173 250 55 595 390 335 475 285
% 61 39 1 57 22 0.1 17 14 4 9 13 2 2 93 23 33 7 80 52 45 64 38
Note: BMI = body mass index; DBMI = desired body mass index
We examined the effect of age by comparing two subject age groups: 13-15 years versus 16-18 years. We performed statistical analyses using Statistica (Statsoft, 1994). Differences between groups were tested by means of the Mann-Whitney U test for continuous variables and the chi-square test for the comparison of proportions.
Results The questionnaires were filled in by 745 adolescents attending four secondary schools. Two schools were exclusively attended by girls (n = 370), one school was attended exclusively by boys (n = 161), and the fourth school was attended by students of both sexes (n = 214). The frequency distribution of the measured variables is shown in Table 1. Although 16% of the participants indicated weight problems and 13% eating problems, 39% had a current BMI between 20 and 25. In 60% of the participants the BMI was even lower than 20. As indicated by the reported desired BMI, 71 % wanted a BMI under the ideal BMI. Noteworthy was the common occurrence of "eating between meals" (87%), perception of loss of control (49%), restrained eating (42%), and emotional eating (60%). Loss of control was reported as occurring "sometimes" in 61 % of the subjects, "regularly" in 30%, and "frequently" in 8%. Table 2 shows the means of the current and desired BMIs for girls and boys and the scores for restrained, emotional, and external eating as measured by the Dutch Eating Questionnaire. Table 2 COMPARISON BETWEEN GIRLS AND BOYS
BMI DBMI Restrained Eating score External Eating score Emotional Eating score
19,5 18,7 2,5 2,8 2,6
19,2 19,7 1,6 2,9 1,7
Eating problems Weight problems Loss of cntrol Use of laxatives Thinking a lot about food Counting calories Eating alone Vomiting
p .105 .000 .000 .177 .000
87 107 275 59 168 50 97 25
17 21 54 8 22 6 19 5
16 20 109 9 78 5 73 7
6 7 41 1 10 1 27 3
.000 .000 .000 .000 .260 .000 .015 .085
Although no significant difference between girls and boys was found for the current BMI, the desired BMI among girls was significantly lower than among boys and was clearly lower than the ideal BMI. Furthermore, significant differences between boys and girls were found for restrained and emotional eating. Girls reported significantly more eating problems, weight problems, and loss of control over eating. They abused laxatives and counted calories significantly more than boys did; however, boys reported eating alone more than girls. Finally, no significant difference regarding thinking about eating between both groups could be demonstrated. Table 3 shows the mean scores and frequency distributions on the same characteristics for the two age groups among the girls. Older girls restrained significant more commonly and ate more commonly in emotional situations. No difference was found in regard to scores on the External Eating subscale. The mean score for older girls was high when compared to scores among the controls in the Van Strien et al. (1986) study. A significantly higher number of older girls reported eating problems, loss of control, Table 3. COMPARISON BETWEEN YOUNGER (13-15 YEARS) AND OLDER (16-18 YEARS) GIRLS
Characteristic 15 years (n=370)
18,3 17,5 2,1 2,8 2
20 19,1 2,7 2,8 2,9
17 28 45 4 27 8 10 9
12 20 33 3 19 6 7 7
70 79 230 55 141 42 87 16
18 21 62 15 38 11 24 4
.040 .915 .000 .000 .000 .026 .000 .367
abuse of laxatives, thinking about food, counting calories, and eating alone when compared with the younger group. In both groups, 1 in 5 girls indicated a weight problem in spite of a normal mean BMI. There was a nonsignificant trend for a higher frequency of vomiting among younger girls than among older girls. We made a similar comparison for boys and, as shown in Table 4, a totally different picture emerged. First, the desired BMI was higher than the current BMI in both age groups. Younger boys showed a more pronounced restrained eating style than older boys, but these scores were normal for both groups when compared with controls (Van Strien et al., 1986). For emotional eating, scores were higher among older than among younger boys but were equally comparable to scores among controls. A significantly higher number of older boys than younger boys reported that they ate when they were externally or emotionally stimulated. With respect to eating patterns, significant differences between younger and older boys were found for thinking about food, eating alone, and vomiting. Table 5 shows a comparison of the numbers of students with high scores for restrained, external, and emotional eating for the total group and for the different age- and gender-specific groups. High scores for restrained and emotional eating were found more commonly among girls-more specifically, among older girls. Among boys, an effect of age could be
Table 4. COMPARISON BETWEEN YOUNGER (13-15 YEARS) AND OLDER (16-18 YEARS) BOYS
BMI DBMI Restrained Eating score External Eating score Emotional Eating score
15 years (n=127)
18 18,4 1,7 2,8 1,6
20,7 21,2 1,5 3 1,8
11 14 51 6 32 3 28 7
7 10 36 4 22 2 19 5
5 6 58 3 46 2 45 0
4 5 46 2 37 2 36 0
.203 .089 .071 .521 .001 .917 .000 .002
Table 5. COMPARISON BY AGE
n 133 171 288
% 26 35 57
Restrained Eating External Eating Emotional Eating
n 21 49 25
Young Girls % 15 35 18
n 112 122 263
Restrained Eating External Eating Emotional Eating
n 31 50 30
Young boys % 21 34 21
n 13 60 40
Restrained Eating External Eating Emotional Eating
n 44 110 70
p % 16 40 26
.000 .099 .000
% 30 35 71
.000 .999 .000
% 10 47 31
.002 .010 .016
observed on the occurrence of high scores on the Restrained Eating (more common among younger boys) and Emotional Eating (more common among older boys) subscales. Discussion The results of this large-scale survey of weight concerns and eating patterns among adolescents clearly indicate first that current and desired body weights (as measured by means of body mass index) very commonly are lower than ideal from a medical point of view. Therefore, it is not surprising that restrained eating is very commonly reported, and that, to a lesser extent, adolescents additionally report vomiting, laxative abuse, counting of calories, and skipping meals in order to lose weight. However, the results of this study indicate that a restrained eating style commonly occurs in association with emotional eating, because eating between meals, loss of control over eating, and eating under emotional circumstances were commonly reported. Second, the results show a marked effect of gender on these characteristics. Although girls and boys reported current and desired BMIs that are lower than ideal from a medical point of view, the desired BMI was lower than the current BMI among girls. On the contrary, boys indicated a higher desired than current BMI. When compared with boys, girls far more commonly reported problems related to eating and body weight, the occurrence of restrained eating with counting of calories, and abuse of laxatives. Loss of control over eating was reported by more than half of the girls. Third, an effect of age can be recognized. Among girls, the incidence of eating problems and associated behavioral characteristics as described above clearly increased with age. .Among boys the effect of age was less marked. It is noteworthy, however, that in spite of a higher desired than current BMI, restrained eating and vomiting were reported by boys but that the rate of these characteristics decreased with age. The occurrence of externally or emotionally stimulated eating increased with age. Before we discuss these results we should note that the study group is not representative of the general population, because only adolescents at higher educational levels were included. This selection
bias may result in an overestimation of the occurrence of eating problems, as previous research has shown a positive correlation between rates of eating disorders and educational level (Fombonne, 1995). The overall picture emerging from this survey is that girls want to lose weight, whereas boys indicate a desire to gain weight. Current BMI does not differ between boys and girls, but girls show. more concern about their body weight and are at a clearly increased risk of developing behavioral disorders associated with a restrained eating style and loss of control over eating under emotional circumstances. This risk increases with age. The combination of restrained eating styles with eating in emotional circumstances is likely to reflect a vicious circle resulting in persisting high levels of body dissatisfaction. The demonstrated association between female gender and weight related concerns and behaviors indeed indicates the common existence of a dissatisfaction with the body shape among female adolescents. This finding is in keeping with the results from previous studies (Attie & Brooks-Gunn, 1989; Huenemann et al., 1966; Paxton et al., 1991; Richards et al., 1990). As described earlier, this dissatisfaction with body shape does not appear to exist for medical reasons. It is likely to be the result of a perceived pressure exerted by society. The present study adds to our current knowledge a similar difference between current and desired BMIs among boys, albeit in an opposite way. In agreement with a previously demonstrated negative appreciation of thinness among boys (Paxton et al., 1991), the present study shows that adolescent boys actually desire to gain body weight. This may be due to the enhancement of self-esteem associated with an increase in body weight and muscularity among boys. The difference between current and desired BW among boys, however, does not appear to be associated with disturbed eating pat- terns. Therefore, it appears that the desire to increase body weight does not induce disturbed eating patterns. In conclusion, a large proportion of female adolescents shows disturbed eating patterns. For some of these girls these symptoms may be risk factors for the development of eating disorders or symptoms of a current eating disorder. For the other girls, the significant impairment that these
symptoms may bring cannot be underestimated. Therefore, the introduction of curriculum-based programs to prevent eating disorders needs to be considered. The results of this study indicate that the risk of developing eating disorders increases with age. However, young girls already shows disturbances in eating patterns to such an extent that prevention programs should start in the first years of secondary school.
References Attie, I., & Brooks-Gunn, J. (1989). Development of eating problems in adolescent girls: A longitudinal study. Developmental Psychology. 25. 70-79. Dornbusch. S. M., Carlsmith, J. M., Duncan, P. D., Gross, R. T., Martin, J. A., Ritter, P. L., Siegel-Gorelick, B. (1984). Sexual maturation, social class, and the desire to be thin among adolescent females. Developmental and Behavior Pediatrics, 5, 308314. Dwyer, J. T., Feldman, J, J., Seltzer, C. C., & Mayer, J. (1969). Body image in adolescents: Attitudes toward weight and perception of appearance. American Journal of Clinical nutrition. 20, 1045-1056. Fombonne, E. (1995). Eating disorders: Time trends and possible explanatory mechanisms. In M Rutter & D. Smith (Eds.), Psychosocial disorders in young people: Time trends and their causes Gamer, D. M., Garfinkel, P. E., Rockert, W., & Olmsted, M. P. (1987). A prospective study of eating ilisturbances in the ballet. Psychotherapy and Psychosomatics, 48, 170-175. Gamer, D. M., Garfinkel, P. E., Schwartz, D., & Thompson, M. (1980). Cultural expectations of thinness in women. Psychological Reports, 47, 483-491. Gulliford, M. C., Rona, R. J., & Chinn, S. (1992). Trends in body mass index in young adults in England and Scotland from 1973 to 1988. Journal of Epidemiology and Community Health, 46, 187-190. Hamilton, L. H., Brooks-Gunn, J., & Warren, M. P. (1985). Sociocultural influences on eating disorders in female professional dancers. International Journal of Eating Disorders, 4, 465-477. Huenemann, R. 1., Shapiro, L. R., Hampton, M. C., & Mitchell, B. W. (1966). A longitudinal study of gross body composition and body conformation and their association with food and activity in a teenage population. American Journal of Clinical Nutrition, 18, 325-338. Johnson-Sabine, E., Wood, K., Patton, G., Mann, A., & Wakeling, A. (1988). Abnormal eating attitudes in London schoolgirls-A prospective epidemiological study: Factors associated with abnormal response on screening questionnaires. Psychological Medicine, 18, 615-622. Kinoy, B. (1994). Eating Disorders: New Directions in Treatment and Recovery (p. 16). New York: Columbia University Press. Nylander, I. (1971). The feeling of being fat and dieting in a school population: Epidemiologic interview investigation. Acta Sociomedica Scandinavica, 3, 17-26. O'Neil, P. H., Currey, H. S., Hirsch, A. A., Malcolm, R. J., Sexauer, J. D., Riddle, F. E., & Taylor, C. I. (1979). Development and validation of the Eating Behavior Inventory. Journal of Behavioral Assessment, 1, 123-132. Patton, G. C., Johnson-Sabine, E., Wood, K., Mann, A. H., & Wakeling, A. (1990). Abnormal eating attitudes in London schoolgirls-A prospective epidemiological study: Outcome at twelve month follow-up. Psychological medicine, 20, 383-394. Paxton, S. J., Wertheim, E. H., Gibbons, K., Szmukler, G. I., Hillier, 1., & Petrovich, J. (1991). Body image satisfaction, dieting beliefs, and weight loss behaviors in adolescent girls and boys. Journal of Youth and Adolescence, 20, 361-379. Pudel, V., Metzdorff, M., & Oeting, M. (1975). The personality of the obese in psychological texts taking into account the latent obesity. Journal of Psychosomatic Medicine and Psychoanalysis, 21, 345-361. Richards, M. H., Boxer, A. M., Petersen, A. C., & Albrecht, R. (1990). Relation of weights to body image in pubertal girls and boys from two communities. Developmental Psychology, 26, 313-321.
Shah, M., Hannan, P. J., & Jeffery, R. W. (1991). Secular trend in body mass index in the adult population of three communities from the upper mid-western part of the USA. The Minnesota Heart Health Program. International Journal of Obesity, 15, 499-503. StatSoft. (1994). Statistica for the Macintosh [Computer software] Tulsa: StatSoft, Inc. Striegel-Moore, R. H., Silberstein, L. R., & Rodin, J. (1989). A prospective study of disordered eating among college students. International Journal of Eating Disorders, 8, 499-509. Sullivan, P. F. (1995). Mortality in anorexia nervosa. American Journal of Psychiatry, 152, 1073-1074. Szmukler, G. I., Eisloer, I., Gillies, C., & Hayward, M. E. (1985). The implications of anorexia nervosa in a ballet school. Journal of Psychiatric Research, 19, 177-181. Van Gaal, 1., Rillaerts, E., Creten, W., & De Leeuw, I. (1988). Relationship of body fat distribution pattern to atherogenic risk factors in NIDDM. Preliminary results. Diabetes Care, 11(2) 103-106. Van Strien, T. (1994). The increase in occurence of anorexia nervosa. Journal of ,Wental Health, 6, 647-652. Van Strien, T., Frijters, J., Roosen, R., Knuiman-Mijl, D., & Defares, P. (1986). Eating behavior, personality traits and body mass in women. Agricultural University, Wageningen, The Netherlands. Wollersheim, J. P. (1970). Effectiveness of group therapy based upon learning principles in the treatment of overweight women. Journal of Abnormal Psychology, 76, 462-474.
4. Eating-style and weight-concerns in young females3
In this study, attitudes towards eating among adolescent school-girls were compared to those among fashion models and eating disorder patients. The results clearly demonstrate a preoccupation with body weight, even in school-girls. A majority of the girls indicated a wish to lose weight, even when the current Body Mass Index was between 20 and 25. Eating disorder patients more commonly reported premorbid overweight. Furthermore, fashion models tended to have an eating-style that was comparable to that of patients with eating disorders. The finding that the mean current body weight of all girls was lower than before suggests that many girls developed a restrained eating style. Vomiting, the use of anorectic drugs and laxatives, eating alone, and counting calories were reported by a substantial proportion of the adolescent girls. Moreover, a substantial proportion of the girls experienced a loss of control over eating. The combination of this eating-style and being overweight, can be considered as risk factor for the development of eating disorders. The culture of slimming in Western societies creates an important and increasing discrepancy between the real shape and the ideal shape (Garner, Garfinkel, Schwartz, & Thompson, 1980). Preoccupation with body weight and excessive concerns about body shape may induce eating patterns that are similar to those of patients with eating disorders. It remains to be demonstrated under which conditions such eating patterns develop into eating disorders. Dissatisfaction with body weight and shape are very common among preadolescent and adolescent girls.
It is particularly concerning that girls who show relatively unhealthy baseline eating
attitudes are more likely to fit in the category of the partial syndrome of eating disorders (PSED) at follow-up (Button & Whitehouse, 1981). While PSED is not inevitably associated with the development of anorexia or bulimia nervosa, it can, at the least, be regarded as similar to the first stage of Slade's (1987) developmental model of eating disorders. The danger exists that any girl who has reached this stage is prone to see low body weight and control as rewarding, and that she will then go on to develop a more robust disorder as a consequence. Thus, cultural factors may be a necessary condition in the development of eating disorders, or at least act as a facilitating factor, especially as Western cultures also suggest that success and the approval of others are solutions for problems (Wooley & Wooley, 1985). To be slim is a symbol of beauty, sexual 3
Vervaet, M., & van Heeringen, C. (2000). Eating Style and Weight Concerns in Young Females. Eating Disorders: The Journal of Treatment and Prevention, 8: 233-240.
attractiveness, and success. Weight control is considered synonymous with discipline, personal strength and willpower (Noordenbos, 1990).
Contemporary values such as perfectionism and control and
pressure on females to enhance their appearance induce social stresses. The question remains: To what extent does such an internalisation process remain adaptive, or proceed beyond a certain limit and develop into psychopathology? Knowledge of psychological factors contributing to the development of pathological eating behaviors is indispensable for the identification of diagnostic criteria of the eating disorders. This study compared eating styles and weight concerns among schoolgirls, fashion models, and patients diagnosed as suffering from eating disorders. The groups were chosen in order to assess the association between eating behaviour, weight concerns, and eating disorders.
Method Girls attending the fifth year of two large secondary schools participated in this study (n=333). Questionnaires were filled in collectively. The questionnaire was also sent to 20 fashion models of a national agency and to 40 patients with eating disorders (ED) admitted to the Department of Eating Disorders (University Hospital Gent) in 1993 (31.0% anorectics in treatment, n = 10; 62.5% bulimics of normal weight, n = 20; 6.3% overweight (BMI > 25) bulimics, n = 2). Items in the questionnaire covered age, weight, desired weight, educational level, presence of a boyfriend, use of anorectic drugs and laxatives, weight and eating problems (defined as self-criticism on weight and eating patterns, perceived excessive bodyweight, or lack of control over eating), vomiting, eating-patterns, thinking about eating (i.e. extent of preoccupation), eating alone (eating in secret), counting calories, preference for sweet or salty foods, loss of control, and the frequency (exceptional, sometimes, daily) and severity (2000 Kcal) of this loss of control. Moreover, the participants were asked to fill in the Dutch Eating Behaviour Questionnaire (DEBQ; Van Strien, 1986) which consists of the
following subscales: emotional eating (eating elicited by emotional stimuli), restrained eating (the tendency to eat to lose weight), and external eating (eating elicited by external stimuli). Statistical analysis was performed using SPSS 9.0, and included a comparison of the characteristics between the schoolgirls, models and ED patients, by means of chi-square analysis for nominal variables and non-parametric tests for continuous variables.
Results Questionnaires were returned by 333 schoolgirls (100 %), 11 fashion models (55 %), and 32 ED-patients (80%). Table 1 shows mean values for age, weight, and body mass index (BMI= weight/length x length) in the three groups. Table 1: A Comparison of the Mean Values and Standard Deviation for Age, Weight and BMI Among Schoolgirls, Fashion Models, and ED-patients.
Schoolgirls Models ED n = 333 n = 11 n = 32 Mean (SD) Mean (SD) Mean (SD) _____________________________________________________________ Age (years)1
24 (5.2)bc 54 (12.6) 19 (4.1)
One-way ANOVA, F = 262.8; (df = 2); p < .0001 post-hoc comparison (Bonferroni) a p < .000; b p < .000; c p < .000 2 One-way ANOVA, F = .765; (df = 2); p = .466 3 One-way ANOVA, F = 1.5444; (df = 2); p = .215 There was a significant difference between the three groups in mean age, but not in mean weight and BMI. Mean reported former weight was higher than mean current weight in all three groups (Table 2).
Table 2: A comparison of the Mean and Standard Deviation in Highest Weight, Desired Weight, and Desired BMI among Schoolgirls, Models and ED-patients. ------------------------------------------------------------------------------------------------------------------------Schoolgirls Models ED n = 333 n = 11 n = 32 _____________________________________________________________ Highest weight1
One-way ANOVA, F = 12.9; (df = 2); p < .000 post-hoc comparison (Bonferroni) a p = .445; b p = .000 c p = .528 2 One-way ANOVA, F = .1.2; (df = 2); p = .297 3 One-way ANOVA, F = 2.5; (df = 2); p = .083 On the contrary, girls in the three groups indicated a desired weight that was lower than the ideal BMI (63,5% of the schoolgirls want to lose weight, n = 212 versus 8,1% who want to gain weight, n = 27; 81,8% of the fashion models want to lose weight, n = 9 versus 9,1% who want to gain weight, n = 1; 62,5% of the eating disorder group want to lose weight, n = 20 versus 21,9% who want to gain weight, n = 7). Mean reported highest weight was significantly higher in ED patients than for the other groups. In the eating disorder group 40.6% (n = 13) reported a premorbid overweight, in contrast to 1,2% (n = 4) among the schoolgirls and 0% among the fashion models. Significant differences between the three groups were found for educational level and for reported weight and eating-problems (Table 3).
Table 3: A comparison of the frequency (%) of the Highest School Level, Relationship, Weight Problems, and Eating Problems Among Schoolgirls, Models and ED Patients. Models
Highest school level 74.4
Fashion models had a lower educational level when compared to the other two groups. Although the mean weight of attending schoolgirls was ideal, nearly one in four indicated problems with their body weight. One in two fashion models and one in five schoolgirls experienced eating problems. No significant association was found between having a boyfriend and belonging to one of the study groups. It is noteworthy that approximately 10% of the ED patients denied having eating problems. Table 4 shows the results regarding the use of more drastic methods to reduce body weight, i.e. anorectic drugs, vomiting, or laxatives. It was found that 16 % of the schoolgirls used laxatives, compared to 36 % of the models. Five percent of the schoolgirls used anorectic drugs, while 4 % reported vomiting. Table 4: A comparison of the Use of Anorectic Drugs, Vomiting and Laxatives Among Schoolgirls, Models, and ED patients.
X2 p-value Schoolgirls Models ED % % % ___________________________________________________________ Drugs
Eating patterns also were compared between the three groups. As shown in Table 5, no significant differences in 'skipping breakfast' and 'experienced loss of control over eating' were found. Table 5: Comparison of Eating Pattern Among Schoolgirls, Models and, ED Patients
Skipping breakfast Skipping lunch Skipping dinner Never eating between meals Eating alone Thinking about food Counting calories Loss of control once a day (frequency) >2000Kcal (amount)
school-girls % 10.2
Models % 18.2
ED % 21.9
However, the severity and especially the frequency of loss of control differed significantly between the groups. ED patients showed more frequent loss of control over eating and reported the ingestion of larger amounts of food (in terms of Kcal). The significant character of the differences regarding the other items was mainly due to a lower frequency of disturbed eating patterns among the schoolgirls. However, even 12% of the schoolgirls counted calories, 40% thought about food during the day, and 23 % reported frequent eating while being alone. Mean scores on the items of the Dutch Eating Questionnaire are shown in Table 6.
Table 6: Comparison of the Mean Scores and Their Standard Deviation on the Dutch Eating Questionnaire Among Schoolgirls, Models, and eating ED Patients. School-girls Models ED _____________________________________________________________ Restrained eating1
3.4 (1.0) ac
3.6 (0.9) bc
2.8 (0.8) ab
3.4 (0.7) ac
3.3 (1.2) bc
2.1 (0.7) ab
2.1 (0.7) ac
2.7 (1.2) bc
2.3 (0.7) ab
2.5 (0.4) ac
2.8 (1.1) bc
2.9 (0.5) ab
2.9 (0.5) ac
2.5 (0.7) bc
One-way ANOVA, F = 16,1; (df = 2); p = .000 post-hoc comparison (Bonferroni) a p = .028; b p =.000; c p =1.000
F = .7,8; (df = 2); p = .000 p = .058; b p =.003 c p =1.000 F = 8,7; (df = 2); p = .000 p = 1.000; b p =.000; c p =.101 F = 16,1; (df = 2); p = .001 p = 1.000; b p =.001; c p =.595
F = 16,1; (df = 2); p = .001 p = 1.000; b p =.001; c p =.265 Significant differences (p = 0.001) in the occurrence of ‘restrained eating’, ‘emotional eating’ and
‘external eating’ were found between schoolgirls and ED patients, but no significant differences were found between models and ED patients. The mean score for ‘restrained eating’ was significant lower for schoolgirls than that of the fashion models.
Discussion and conclusion
This study in a large group of young women suggests a substantial preoccupation with body weight, not only in patients diagnosed with eating disorders, but also in fashion models and in schoolgirls. The means of desired weight are lower in all three groups so we may hypothesize that a
majority of girls in this study wanted to lose weight, even when their current BMI could be regarded as ideal. The eating pattern of fashion models appears to resemble that of eating disordered patients. Schoolgirls express severe concerns about their body weight, and one in four indicates problems related to their body weight, although this apparently is not the case in view of girls’ normal BMIs. The perceived problems induce counting calories and a restrained eating style, albeit to a lesser extent than in fashion models and eating disordered patients. The results also show that fashion models do not report to suffer from an eating disorder in spite of the fact that their eating patterns closely resemble those of eating disordered patients. However, even one in ten ED patients does not report to suffer from a disorder although she is currently being treated. In order to lose weight models commonly report the use of laxatives while patients additionally report vomiting. Finally, the results indicate that the highest ever mean body weight was reported by the patients suffering from an eating disorder. The finding of a premorbid overweight in eating disordered patients is in keeping with the results from previous studies. Two methodological aspects of this study should be addressed. First, the schools were not randomly selected. Therefore, participating subjects cannot be considered to be representative of the general population, and may actually have an increased risk of developing an eating disorder as the schools were only attended by girls who belonged to higher social classes, who were obliged to wear uniforms, and who were confronted with a very competitive spirit. Second, some questionnaires were not returned by the fashion models and the patients, so some results may be due to a selection bias. The low response rate in the model group may be due to distrust or lack of interest. The higher weight in models in comparison with the schoolgirls may be due to the significant difference in mean age between schoolgirls and fashion models. Finally, a number of schoolgirls and models may have actually been suffering from an eating disorder. Keeping these methodological limitations in mind, the findings from this study indicate that the mean body weight in schoolgirls can be regarded as ideal, as far as the body mass index is a correct index of body weight in this age group. In any case, the results demonstrate that there are no severe problems regarding body weight in this group of young females. However, restrained eating, vomiting, and the use
of anorectic drugs or laxatives appear to be known as weight reducing strategies even among schoolgirls and nearly one in five schoolgirls reports subjective problems with their body weight and eating. Moreover, eating alone, thinking about food during the day, counting calories and experiencing of a loss of control over eating are commonly experienced. In view of a demonstrated association between binge eating and psychopathology (Telch and Agras, 1994), the finding that almost two-thirds of the schoolgirls report a loss of control over eating is important. Six percent of the schoolgirls even report loss of control to occur once a day, involving the ingestion of more than 2000 Kcal in more than 20%. Equally important are the demonstrated similarities between patients and fashion models, suggesting that the stronger the perceived pressure on body weight, the higher the risk of developing an eating disorder might be. The fact that the models do not consider themselves as suffering from a disorder may reflect the appreciation associated with their appearance, but might also be due to a denial of the negative consequences of their job. In view of the strong impact of pictures of models in fashion magazines (Field et al., 1999) our current findings indicate the necessity of providing information about potential negative consequences of a restrained eating style to become underweight in terms of developing psychopathology. As a conclusion, the results of this study suggest that being overweight during adolescence is a risk factor for developing identity related problems in a Western society with a slimming culture. During the months following this study, 10 of the participating schoolgirls attended the outpatient Department of Eating Disorders. Their symptoms fitted the criteria for an eating disorder according to DSM-IV. Thus, this study not only resulted in the detection of potential risk factors for eating disorders among schoolgirls, but also may have lowered the threshold for seeking treatment.
References American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: APA. Button, E.J., Withouse, A.(1981). Subclinical anorexia nervosa. Psychological Medicine, 11, 509-516. Field, A.E., Cheung, L., Wolf, A.M., Herzog, D.B., Gortmaker, S.L., Colditz, G.A.(1999). Exposure to the Mass Media and Weight Concerns Among Girls. Pediatrics, Vol. 103, (3), 36-45. Garner, D.M., Garfinkel, P.E., & Olmsted, M.P.(1983). An overview of sociocultural factors in the development of anorexia nervosa. In: Darby, P.L., Garfinkel, P.E., Garner, D.M., & Coscina, D.V.(Eds.). Anorexia Nervosa. Recent Developments in Research (pp. 65-82). New York: Alan R. Liss. Garner, D.M., Garfinkel, P.E., Schwartz, D., Thompson, M. (1980). Cultural expectations of thinness in women. Psychological Reports, 47, 483-491. Noordenbos, G. (1990). Looking for the hidden identity behind a secret disorder. The recovery process of anorexia and bulimia nervosa. In: Petherson, G., Essed, Ph., & Richardson, D. (Eds.), Between Selfhelp and Professionalism ( pp.197-212). Amsterdam: The Moon Foundation The International Congress on Menthal Health Care for Women. Slade, P.D.(1987). Early recognition and prevention: Is it possible to screen people at risk of developing an eating disorder? In: D.Hardoff & E.Chigier (Eds). Eating Disorders in Adolescents and Young Adults. London: Freund. Telch, C.F., Agras, W.S.(1994). Obesity, Binge Eating and Psychopathology: Are They Related? International Journal of Eating Disorders, 15(1), 53-61. Van Strien, T., Frijters, J., Roosen, R., Knuiman-Mijl D., Defares, P.(1986). Eating behavior, personality traits and body mass in women. Wageningen, The Netherlands: Agricultural University . Wooley, S.C., & Wooley, O.W.(1985). Intensive outpatient and residential treatment for bulimia. In: Garner D.M. & Garfinkel P.E.(Eds.). Handbook of psychotherapy for anorexia nervosa and bulimia (p. 391). New York/London: Guilford Press.
PART II The cognitive psychology of eating disorders: personality, cognitions and behaviour.
Chapter 1: Theoretical background
1. Definition and epidemiology
An eating disorder (ED) can be defined as a syndrome, in which disturbed eating behaviour is the central and meaningful characteristic (Vandereycken & Noordenbos, 2002). An ED thus can be differentiated from disturbed eating behaviour as a symptom of other psychiatric disorders, such as a mood disorder, schizophrenia, or obsessive compulsive disorder, or as a symptom of somatic disturbances, including infectious, neoplastic and endocrine disorders or malabsorption. The central characteristic of disturbed eating behaviour in syndromal eating disorders is associated with an extreme worry about or preoccupation with body size and body weight. Disturbed eating behaviour may include fasting, dieting and/or binge eating, and/or inappropriate compensating behaviour, including selfinduced vomiting or misuse of laxatives, diuretics, or enemas, and excessive exercise. Binge eating is defined as eating, in a limited period of time (e.g., within a two-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances, combined with a sense of lack of control over this eating behaviour. More than half of the patients suffering from eating disorders have concomitant and secondary problems of anxiety and disturbed mood.
Syndromal eating disorders can be ‘typical’, i.e. anorexia nervosa (AN) and bulimia nervosa (BN), or ‘atypical’, i.e. eating disorders not otherwise specified (EDNOS). The latter do not meet all criteria for a typical ED. For example, body weight may not have diminished to less than 85% of the expected body weight in spite of restricting behaviour, so that a diagnosis of AN can not be made, even if patients may not menstruate regularly. Bulimic women who binge and vomit weekly, but less than two times per week, are also diagnosed with EDNOS. Within the group of EDNOS patients, there is a subgroup of binge eaters who do not show compensating behaviour, and who are diagnosed with binge eating disorder (BED). BED will probably be described as a separate diagnostic category in the following edition of the DSM classification system of psychiatric disorders.
Estimated prevalence rates among young females aged 18-30 years are 0.3% and up to 3 % for AN and BN, respectively, and ED are approximately 10 times more common in females than in males (APA, 2000). EDNOS appears to be much more prevalent, and it is estimated that up to 4% of the general population suffers from BED, but accurate epidemiological data are lacking. Assuming that even studies with the most complete case finding methods yield an underestimate of the true prevalence, the overall annual incidence of AN and BN can be estimated to be, at the least, 8 and 12 per 100 000 inhabitants, respectively. In 2000, primary care incidence rates were 4.7 and 6.6 per 100 000 population for anorexia and bulimia nervosa (Currin, Schmidt, Treasure, & Jick, 2005). The incidence rate of AN has a small global increase throughout the 20th century (Keel & Klump, 2003), particularly in females aged 10-24 years, with a stable European incidence since the 1970s (Hoek & van Hoeken, 2003; Currin et al., 2005). Overall there was an increase in the incidence of bulimia, at the least during the first five years after BN was added to the DSM classification system, but rates declined after a peak in 1996 (Currin et al., 2005). For EDNOS, including BED, information regarding incidence rates is insufficient (van Hoeken, Seidell, & Hoek, 2003).
Although the occurrence of ED is not associated with socio-economic status, individuals with particular professions, including dancers, fashion models, actors or athletes, carry an increased risk of ED. Possibly the choice of profession is related to a predisposition to ED.
It can be questioned whether anorexia nervosa is a culture-bound disorder, which is elicited by a pervasive pressure to diet and which is rare or absent in non-Western cultures. First, there are historical descriptions of cases of self-starvation without weight concern in cultures in which there was no emphasis on slimness (Bemporad, 1996). Secondly, cross-cultural comparison has suggested that body shape indeed is not the primary motivation in AN (Lee, 1996). Recent studies in South Africa (La Grange, Telch & Tibbs, 1998; Wassenaar le Grange Winship, et al, 2000), Nigeria (Oyewumi & Kazarian, 1992a, 1992b), Gana (Bennett, Sharpe, Freeman, & Carson, 2004), and Asia (Bhadrinath, 1990; Khandelwal & Saxena, 1990; Lee, Ho & Hsu, 1993), suggest that AN may take different forms in different cultures. The morbid self-starvation may have many motives, such as to atone for sins, to achieve better results, or for religious reasons.
2. The complexity of the ED diagnosis
2.1. Categorical classification
As described above, eating disorders are classified in three categories, i.e. AN, BN and EDNOS (DSM-IV; APA, 1994). Subgroups within the AN and BN have been defined on the basis of variations in eating and compensatory behaviours. Thus, the AN category is subdivided in a restricting (RAN) and binge-purging (BPAN) type. Individuals with BN are classified as a purging type (BP) when they show binge eating and abuse laxatives, self-induce vomiting and/or use enemas, or as a non-purging type (BNP) when they combine binge eating with fasting or extreme exercise. Although, by definition,
EDNOS means a failure to meet all criteria for a formal ED category, a diagnosis of EDNOS does not necessarily reflect a lack of clinical significance (Anderson, Bowers, & Watson, 2001). This categorical classification, predominantly based on descriptive behavioural and weight-related characteristics, has a number of limitations. First, ED categories are heterogeneously composed, and some but not all patients may shift from one category or type (e.g. restricting) to another (e.g. purging and binging) in the course of their illness (Löwe et al., 2001; Wentz, Gillberg, Gillberg & Rastam, 2001). Secondly, personality traits (Bulik, Sullivan, Weltzin, & Kay, 1995b; Bulik, Sullivan, Joyce, Carter, & McIntosh, 1998; Podar, Hannus, & Allik, 1999; Rosenvinge, Martinussen, & Ostensen, 2000) or personality disorders (Bulik, Sullivan, Joyce, & Carter, 1995a; Matsunaga et al., 2000; Muller et al., 2000) may play a particular role in the emergence (Kay et al., 2000a) and maintenance of eating disorder symptomatology (van Hanswijck de Jonge P, van Furth, EF, Lacey JH, & Waller G, 2003). ICD-10 (WHO, 1992) defines a personality disorder (Axis II) as a severe, long-term disorder in an individual’s characterological constitution and behavioural tendencies, which usually extends to various aspects of the personality and is nearly always associated with or results in serious personal and social disturbance. As a consequence, the boundaries between Axis I and Axis II disorders are blurred in ED patients (Webber, 1994). Data suggest a greater incidence of Cluster B personality disorders, e.g. in particular borderline personality disorder (Carroll et al., 1996; Wonderlich & Mitchell, 1997; Matsunaga et al., 2000) in bulimic patients (compared to other ED) associated with behaviours such as self-harm, shoplifting and other impulsive behaviours (Welch & Fairburn, 1996; Wiederman & Pryor, 1996). In that case, some authors have suggested that a diagnosis of ‘multi-impulsive bulimia’ may be appropriate (Lacy, 1993; Lacy & Read, 1993). Cluster C personality disorders, e.g. the avoidant personality disorders (Gillberg et al., 1995; Roosenvinge e.a., 2000) were found more in anorectic individuals.
There is some evidence that
those with BPAN show higher rates of personality disorders than either RAN or BN patients (Piran et al., 1988; Herzog et al., 1992). However, recent studies (Grilo, Sanislow, Shea, Skodo, Stout et al., 2003a; Grilo, Sanislow, Skodel, Gunderson, Stout et al., 2003b) showed that patients with PD do not have
significantly more ED than patients with major depressive disorder but without PD. In addition, patients with specific forms of PD do not differ in their frequencies of ED (Ilkjaer, Kortegaard, Hoerder, Joergensen, Kyvik, & Gillberg, 2004). Nevertheless, rates of co-occurrence of ED and PD are sufficiently high, especially for cluster C, to warrant careful consideration during routine assessment and treatment planning stage, since diagnosable personality disorders occur, and they appear to be associated with greater chronicity and poorer functioning (Skodol et al., 1993; Inceoglu et al., 2000; Johnson et al., 1990). Moreover, it could be taken to mean that the PD, which is considered a more stable “trait” than ED, which is usually regarded as a “state”, is heritable and precedes the onset of ED (Ilkjaer et al., 2004).
2.2. Dimensional classification and comorbidity
While the presence or absence of a personality disorder diagnosis reflects a categorical approach, a dimensional model focuses on the extent to which personality traits are present, assessing the number of personality disorder criteria that are present to an accentuated and/or pathological degree, regardless of whether the patients has a full diagnosis. Nevertheless, it should be noted, that also the distinction between EDs based on personality traits is by no means perfect, as studies have shown particular traits to be present in AN and BN (Carroll et al., 1996; Inceoglu et al., 2000). Three personality clusters have been identified in ED patients: a high functioning, self-critical, perfectionist group, which was mainly associated with BN; a constricted, over-controlled group restricting pleasure, needs, emotions, relationships and self-knowledge, which was associated with RAN; and an impulsive, under-controlled and emotionally dysregulated group also associated with BN and with BED (Fahy & Eisler, 1993; Goldner et al., 1999). A useful and interesting dimensional approach differentiates the compulsive (or restrictive type, RAN) and the impulsive type (or the bulimic, binging and purging patients, BPAN & BP) of ED patients (Claes, Vandereycken & Vertommen, 2002; Polivy & Herman, 2002; Steiger & Seguin, 1999). With regard to impulsivity, many components have been described (Whiteside and Lynam, 2001), but
two have been particularly studied in ED, i.e. urgency and lack of planning (Fischer, Smith, Anderson, 2003). Individuals high in urgency are likely to act rashly in order to cope with distress. Several studies found that the bulimic symptoms ‘binge eating’ and ‘purging’ are related to urgency, since these symptoms can be seen as reflecting mechanisms to cope with negative affect, which is relatively more common in BN patients (Pryor & Wiederman, 1996; Stice, Killen, Hayward, & Taylor, 1998; Telch & Stice, 1998; Tylka & Subich, 1999). Emotional states such as anxiety and depression have indeed been shown to predict binge episodes (Arnow, Kenardy, & Agras, 1995). In contrast, several researchers have found lack of planning to be within the normal range in bulimics (Bushnell, Wells, & Oakley Brown, 1996; Fahy & Eisler, 1993; Newton, Freeman, & Munro, 1993; Fischer et al., 2003). Bulimic behaviour is thus associated with impulsivity, but obsessional features such as rigidity, neatness, conscientiousness and preoccupation with rules and ethics characterize the restrictive anorexic type. This pattern of responding was shown even at a basic perceptual level, with a rigid pattern of responding in AN and an unstable or fluctuating style in BN patients (Tchanturia, Serpell, Troop, & Treasure, 2002). If the latter characteristics are present to such an extent that they result in marked impairment of social or occupational functioning over a considerable period of time, a diagnosis of obsessive-compulsive personality disorder (OCPD) may be warranted (Serpell et al., 2002). A wealth of clinical literature describes the cluster of rigidity, perfectionism and inflexible thinking, that is characteristic of OCPD, in AN (Casper et al., 1992; Karwautz, Troop, Rabe-Hesketh, Collier, & Treasure, 2003; Rosenvinge, Martinussen, & Ostensen, 2000; Strober, 1980; Vitousek & Hollon, 1990). Estimates of the comorbidity of OCPD and ED vary from 3% (Piran et al., 1988) to 60% (Wonderlich et al., 1990). Childhood OCPD personality traits also showed a high predictive value for the development of ED (Brecelj et al., in press). Preliminary data from family studies indicate an increased risk of OCPD in relatives of AN probands compared to controls (Lilenfeld et al., 1998). These findings suggest the existence of a phenotype with core features of rigid perfectionism and propensity for extreme behavioural constraint. Sohlberg and Strober (1994) have suggested that obsessional symptoms are related to the state of starvation, while obsessional traits are stable personality features, which are
maintained after weight gain. Although phobic thoughts of food and weight repeatedly enter the mind of AN patients, they are not regarded as senseless or unwanted (Mazure, Halmi, Sunday, Romano, and Einhorn, 1994), which is in contrast to the typical obsessions and compulsions unrelated to eating that also may occur in AN patients (Bastiani et al., 1996). Obsessions involving symmetry, such as ordering and arranging, were found to be the most common obsessions in AN patients (Bastiani et al., 1996; Matsunaga et al., 1999). The results of the most recent study of this type (Halmi, Sunday, Klump, Strober, Leckman et al., 2003) with larger patient groups at all stages of illness, were remarkably similar to those of the Bastiani study, with no significant difference between the RAN and BPAN women.
The neurobiological basis of the relationship between obsessive-compulsive disorder OCD and ED remains unclear. Data from twin studies suggest that genetic vulnerability factors contribute to both AN (Bulik, Sullivan, Wade, & Kendler, 2000; Klump, Miller, Keel, McGue, & Jacono, 2001; Kortegaard, Hoerder, Joergensen, Gillberg, & Kybik, 2001; Wade et al., 2000) and OCD (Leckman, Zhang, Asobrook, & Paus, in press). The few family aggregation studies suggest that these disorders may be independently transmitted in families (Lilenfeld et al., 1998). Neuroimaging studies suggest that both disorders are associated with alterations in the frontal cortex and in the subcortical and limbic regions (Kaye et al., 2001; Saxena, Brody, Schwartz, & Baxter, 1998). This frontal-subcortical circuitry contains complex direct and indirect pathways that are modulated by serotonin and dopamine. Pharmacologic (DeVeaugh-Geiss, 1991; Halmi, 1999) and physiological (Lilenfeld et al., 1998) studies also indicate that alterations in functional serotonin activity are present in both OCD and AN subjects. The common nature of these phenotypical characteristics of AN and OCD patients may indicate that these disorders share common brain behavioural pathways. However, the incomplete nature of the overlap between these disorders suggests that they have different loci of pathology within these pathways (Halmi et al., 2003).
Describing the restricting versus the bulimic group provides a good example of the overlap between Axis-I ED diagnostic categories and between Axis-I ED diagnoses and Axis-II PD categories. A dimensional approach may thus add information about traits and clinical phenomena to a categorical diagnosis, offering the possibility of a more accurate and effective patient assessment and treatment planning (Van Hanswijck, De Jonge et al., 2003).
3. Aetiology as a dynamic process: from trait- (vulnerability) to state- (eating disorder category) dependent characteristics 3.1. Introduction
Although the aetiology of AN and BN is incompletely understood, a comprehensive aetiological model is likely to include a combination of genetic and familial (Bulik et al., 2000; Treasure & Holland, 1995), personality and psychological (Vitousek & Manke, 1994), environmental and neurobiological elements (Nasser, Katzman, & Gordon, 2001). A role of these factors in the development of ED can be described in terms of their predisposing, precipitating (or eliciting: such as death of a loved one, transition into puberty, dieting) and sustaining effect.
Genetic factors most probably contribute to the predisposition to ED. Twin and family studies indeed suggest a substantial heritability for AN (Collier & Treasure, 2004; Lilenfeld LR, Kaye WH, Greeno CG, Merikangas KR, Plotnicov K, Pollice C, et al., 1998). Also in BN, family and twin studies point at a role of genetic factors in the predisposition (Collier & Treasure, 2004; Hsu, 1990; Walters, Neale, Eaves, Lindon, & Heath, 1992), in addition to -
biological factors such as reduced levels of beta-endorphin (Brewerton, Lydiard, Laraia, Shook, & Ballenger, 1992), norepinephrine (Goldbloom, Garfinkel, & Shaw, 1991), and/or serotonin (Jimmerson, Lesen, Kate, & Brewerton, 1992);
family factors such as poor communication (Hsu, 1990) and high expectations (Pike & Rodin, 1991);
individual factors such as perfectionism, maturity fears (Garner, Olmsted, Polivy, Garfinkel, 1984) and low self-esteem (Katzman & Wolchik, 1984);
sociocultural factors such as preoccupation with thinness and dieting at a societal level (Brownell, 1991; Garner & Garfinkel, 1980).
More recently, a first study reported heritability of the core BED syndrome (Reichborn-Kjennerud, Budlike, Tambs, & Harris, 2004), although the estimates of heritability are somewhat lower than those reported for AN and BN (Budlike et al., 2000).
The focus of the studies as described in this thesis was on psychological factors as the link between neurobiological characteristics and the overt behaviour of eating-disordered patients. Core psychological traits and personality characteristics of ED patients were described as, among others, temperamental and character dimensions which develop as the result of an interaction between genetic and learning processes. In addition to these dimensions, three psychological characteristics were studied as they were identified as core characteristics of ED patients in two recent transdiagnostic models of eating disorders, i.e. negative self-esteem (inextricably related to body dissatisfaction) perfectionism/rigidity and interpersonal difficulties (Fairburn, Cooper & Shafran, 2003; Serpell & Troop, 2003). These three characteristics possibly reflect a premorbid vulnerability, and appear to be necessary (though possibly not sufficient) conditions for the development of ED.
3.2. Low self-esteem and body dissatisfaction
Since the start of the systematic study of ED, the failure to develop a separate and integrated sense of self, as the capacity for self-regulation, was found to be an important psychological factor in the
development of eating disorders (Bruch, 1973). Since then it has become clear that deficits in the self also may become manifest as •
disturbances in the ability to identify and modulate bodily cues and emotional experiences (de Groot & Rodin, 1998; Bydlowski, Corcos, Jeammet, et al., 2005),
low self-esteem and pervasive feelings of ineffectiveness (Rosen, 1990), and
increased sensitivity to external evaluation, or fears of negative evaluation (Gilbert & Meyer, 2005).
ED patients thus lack positive self-schemata by means of which they organize information about the self. In cognitive psychology, self-esteem refers to a cognitive evaluation of one’s competencies. Longitudinal studies have suggested a relationship between low self-esteem and the subsequent development of ED symptoms (e.g. Button et al., 1996; Wood et al., 1994). Retrospective reporting suggests that negative self-evaluation during childhood may be more common among women with AN or BN than among women in a non-psychiatric comparison group or among women with other psychiatric disorders (Fairburn et al., 1997, 1999). However, follow-up studies suggest that self-esteem improves with recovery of BN, but that it remains low in patients whose ED symptoms persist (e.g. Troop et al., 2000).
Clinical observations appear to confirm theoretical considerations of an association between eating disorders and disturbances in the mother-child relationship. These disturbances may include maternal empathic failure and unresponsiveness to child-initiated cues that are thought to interfere with the emerging sense of self. More specifically, studies have identified lower perceived maternal care (Calam, Waller, Slade, & Newton, 1990; Haudek, Rorty, & Henker, 1999), greater maternal criticism (Dare, LeGrange Eisler, & Rutherford, 1994), hostile maternal over-involvement (Humphrey, 1989; Rorty, Yager, Rossotto, & Buckwalter, 2000), and a diminished sense of psychological separateness (Ogden & Steward, 2000) as characteristics of the relationship between AN patients and their mothers. In addition,
dieting and body dissatisfaction have been found in girls whose mothers perceive their own autonomy as low (Ogden & Steward, 2000). Self-esteem may thus be associated with a negative self-evaluation in which environmental effects may be influential. It is not clear, however, to what extent this association can be explained by genetic factors. Indeed, a significant proportion of the variance in self-esteem in the population is due to genetic factors, which, in turn, may become manifest through temperamental characteristics (Kendler, Gardner, & Prescott, 1998). Since personality has an effect on how the environment is experienced, interpreted, and reacted to, children and adolescents with particular temperaments, such as negative emotionality and low sociability, possibly interpret and experience life events in a more negative way (see e.g. the social-information processing model of Crick & Dodge, 1994).
There is some evidence that particularly the strength of the association between self-esteem and self-evaluation of weight and shape differentiates between individuals with ED and non-ED young women (and those with other psychiatric disorders) (Serpell et al., submitted; Vitousek and Hollon, 1990). There is thus no doubt that the association between self-esteem and self-evaluation of the weight and shape of the body is typical for eating disorders. It is not clear, however, when this association between self-esteem and self-evaluation of weight and shape emerges in relation to the onset of ED. Girls with a vulnerable sense of self may be at greater risk of linking their self-concept to the weight and shape of their body if they live in familial environments that emphasize the importance of appearance, and associate thinness with femininity, beauty and competence (Levine & Smolak, 1992). Self-concepts and self-esteem emerge in a relational context in which the sense of self may be defined by relationships with others and through evaluation by others, and this contextual effect appears to be more influential among girls than among boys (Gilligan, 1993). This focus on external evaluation may place girls at greater risk of adopting weight and shape as a gauge of their self-worth, especially in such families. Negative self-evaluation may thus develop during the onset or after the onset of ED, and become a symptomatic manifestation of low self-esteem.
On the other hand, body weight- and shape-related self-evaluation was the concept used to refer to the process whereby an individual determines her self-worth based on an evaluation of her body weight and shape (McFarlane, McCabe, Jarry, Olmsted, & Polivy, 2001).
The social comparison theory
(Festinger, 1954) suggested that individuals’ drive for self-evaluation can be met by comparison with similar others. An upward social comparison can have negative effects on mood and self-esteem (Major, Testa, & Bylsma, 1991). Exposure to images of thinness, which are idealized by mass media, can thus have a consistent negative effect on body satisfaction, particularly among certain individuals (Groesz, Levine, & Murnen, 2002), possibly more important among girls. A recent 16-month follow-up study among adolescent boys and girls (McCabe & Ricciardelli, 2005) indeed showed an increase of perceived messages to lose weight over time among the girls, whereas the boys perceived the messages as related to increasing muscles. Among the girls, the strongest influences were mothers and best female friends, while among the boys fathers play the most important role. Trait-dependent psychological features (i.e. low self-esteem and perfectionism) and dysfunctional information processes, which will be described later, may also lead to a disturbed body-image. This disturbance can be viewed as a predisposing factor and as a maintaining factor of the disorder (Cooley & Toray, 2001; Rosen, 1990; Tuschen-Caffier, Vögele, Bracht, & Hilbert, 2003; Stice, 2002; Wilson, Fairburn, & Agras, 1997). Patients with a body-image disturbance are preoccupied with the appearance of their body and show compulsive behaviours such as mirror checking and body measuring. Cognitive models of eating disorders propose that this selective attention to appearance cues is due to underlying knowledge structures (schemas) that filter information and direct attention. These schemata guide the attention to stimuli, the memory for stimuli, and the interpretation of stimuli in ways that serve to maintain the disorder (Ainsworth, Waller, & Kennedy, 2002; Hargreaves and Tiggemann, 2002; Viken, Treat, Nosofsky, McFall, & Palmeri, 2002). It should be noted that many studies have used self-reports to assess attentional processing, which may well reduce the reliability of findings. However, more direct measures of attentional processing show that eating-disordered subjects allocate their attention more
towards a self-identified ugly body part, contrary to the focus of attention when looking at another body, which is a beautiful body part. Normal controls do exactly the opposite (Jansen, Nederkoorn, & Mulkens, 2005). These authors found an increase of attention in the eating-disordered patients when they looked at their own body with activating negative appearance-related schemata as a consequence, instead of the usually found avoidance behaviour.
3.3. Perfectionism as core trait
Perfectionists are anxious subjects with a strong tendency to overestimate the probabilities of negative events and to over-predict threatening events, dangers, and damages (MacLeod, 1999; Rachman, 1998). Anxious subjects spend much time worrying intensively about their fears (Borkovec, Ray, & Stöber, 1998). Among perfectionists, the over-prediction of threatening events is associated with an intensive fear of failure after important performances. In turn, this type of over-feared failure leads to further damage in terms of decreased self-esteem and impaired social, familial and interpersonal wellbeing. Perfectionists have an increased probability of experiencing failure in a stress situation, because even minor shortfalls are tantamount to significant failures. Stress situations and major life events negatively affect eating habits in human and animal models (Connan & Treasure, 1998). In turn, perfectionism may facilitate the development of ED by increasing the impact of distressing environmental events (Hewitt & Flett, 1993a; Hewitt et al., 1995). Therefore, perfectionists have a tendency to worry about and to feel dissatisfied with perceived mistakes (e.g. regarding eating) and imperfections (e.g. regarding body shape and weight) (Ruggiero et al., 2003).
Perfectionism is a salient trait in women with AN and BN during acute illness (Cockell, Hewitt, Seal, Sherry, Goldner, Flett, & Remick, 2002; Fairburn, Cooper, Doll, & Welch, 1999; Goldner et al., 2002; Halmi, Sunday, Strober, Kaplan, Woodside et al., 2000; Lilenfeld, Stein, Bulik, Strober, Plotnicov et al., 2000; Stice & Shaw, 2002) and after recovery (Bastiani, Rao, Weltzin, Kaye, 1995; Bulik, Sullivan, Fear,
& Pickering, 2000; Halmi et al., 2000; Pia & Toro, 1999; Srinivasagam, Kaye, Plotnicov, Greeno, Weltzin, Rao, 1995; Sutandar-Pinnock, Woodside, Carter, Olmsted, & Kaplan, 2003). Clinical (or ‘neurotic’) perfectionism, in which there is an inability to derive pleasure from one’s successes because the performance is never good enough, (e.g. Kiemle et al., 1987; Ruggiero, Levi, Ciuna, Sassaroli, 2003; Slade et al., 1990, 1991) is in particular accompanied by a tendency to evaluate one’s own behaviour in an overly critical way (Frost, Marten, Lahart, & Rosenblate, 1990). “Clinical perfectionism” was defined as “the overdependence of self-evaluation on the determined pursuit of personally demanding, selfimposed, standards in at least one highly salient domain, despite adverse consequences” (p. 778, Shafran, Cooper, & Fairburn, 2002). In addition, the term perfectionism refers to -
selective attention to and over-generalization of failure
a tendency to engage in ‘all or none’ thinking, whereby total success or total failure exist as outcomes (Hewitt & Flett, 1991)
cognitive rumination over mistakes and imperfections
frequent automatic thoughts about attaining perfection (Hewett, Flett, Besser, Sherry, & McGee, 2002).
It should be noted, however, that studies are characterized by poor operational definitions and assessments of perfectionism. As in the current studies, perfectionism is commonly measured using a subscale of the Eating Disorder Inventory (EDI; Garner, Olmstead & Polivy, 1983), a 64-item, selfreport questionnaire that measures cognitive and behavioural characteristics of ED. The Perfectionism subscale (EDI-P) consists of six items that emphasize personal standard setting and parental expectations. Although performance on this subscale is expressed by means of one score, this subscale measures both self-directed (3 items) and socially based (3 items) dimensions of perfectionism (Frost, Marten, Lahart, Rosenblate, 1990; Hewitt & Flett, 1991; Wyatt & Gilbert; 1998; Sherry, Hewitt, Besser, McGee, & Flett, 2004). Recent research (Sherry et al., 2004) emphasized that both the intrapersonal (self-oriented) and interpersonal (other-oriented and socially prescribed) aspects of perfectionism are
independently implicated in the emergence and continuance of eating disorder symptoms.
conclusion is consistent with theoretical considerations (Bruch, 1981) and findings from some (Hewitt, Flett & Edinger, 1995) but not all studies.
Self-oriented perfectionism with a tendency to interpret mistakes as failures is significantly associated with the presence of AN and BN (Bulik, Tozzi, Anderson, Mazzeo, Aggen, & Sullivan, 2003; Cooper, Cooper, & Fairburn, 1985). Socially prescribed perfectionism is positively associated with higher levels of hopelessness and suicidal ideation and negatively associated with positive future thinking (Hewitt, Flett & Turnbull-Donovan, 1992; Hewitt, Newton, Flett, & Callander, 1997, Hunter & O’Connor, 2003). This is not surprising, as socially prescribed perfectionism has been characterized as being driven by the fear of failure or by the avoidance of punishment.
ED patients share high scores on the subscale for doubts about actions (describing the reduced ability to accomplish tasks and obsessional aspects of perfectionism, as assessed by means of the ‘Frost Multidimensional Perfectionism Scale’; Purdon, Antony & Swinson, 1999) with patients suffering from anxiety disorders, possibly due to shared genetic factors. Although truly prospective studies have not been conducted, retrospective clinical reports have frequently described premorbid perfectionism as a risk factor for AN (Bruch, 1978; Halmi et al., 1977; Fairburn, Cooper, Doll, Welch, 1999; Rastam, 1992; Slade, 1982; Srinivasagam et al., 1995). These studies have also provided evidence for a trait-dependent nature of this characteristic, which is thus not simply due to the effects of the illness (e.g. starvation) but which may reflect an underlying, whether or not genetically determined, vulnerability factor.
Few studies have assessed dimensions of temperament or cognitive/psychological domains, which are believed to be important in the development of ED, among parents of ED patients. However, elevated rates of perfectionism have been found in the mothers (and to a lesser extent fathers) of individuals with AN (Woodside, Bulik, Halmi, Fichter, Kaplan et al., 2002), and in the first-degree
relatives of BN patients (Lilenfeld et al., 2000). Possibly, the trait perfectionism will be transmitted through families and represent a vulnerability factor for the development of AN (Woodside et al., 2002). Indeed, twin studies have provided preliminary evidence for the heritability of AN (Holland, Hall, Murray, Russell, & Crisp, 1984; Holland, Sicotte, Treasure, 1988; Klump, Miller, Keel, McGue, & Iacono, 2000). These findings support Strober’s (1991) genotypic foundation hypothesis of AN, with harm avoidance, obsessiveness and self-doubting perfectionism as predisposing traits. Underweight and weight-restored AN patients did not differ from normal controls regarding scores on ‘Parental Expectations’ or ‘Other-Oriented Perfectionism’, while they showed only a trend in differing significantly from normal controls on the ‘Doubt about Action’ and ‘Socially Prescribed Perfectionism’ dimensions (Bastiani et al., 1995). These results suggest that perfectionism in AN is particularly of a selfimposed nature.
Perfectionism could thus well be the behavioural expression of a biologically determined vulnerability. Kaye and colleagues (1991) have provided evidence for such vulnerability by describing an increased neuronal serotonin activity, which persists after long-term recovery of AN patients. The related trait rigidity (related to obsessiveness) is also of interest (Goldner et al., 1999), functioning in various neuropsychological domains, including perception, among AN patients (Tchanturia et al., 2002). This perceptual rigidity appears to be also a stable trait, which persists after recovery from AN (Tchanturia et al., in press). Rigidity may be specifically related to AN, since women with BN typically show a fluctuation rather than rigidity in their perceptual processes (Tchanturia et al., 2002). Reduced serotonergic activity has been associated with impulsive and aggressive behaviour (Coccaro, Kavoussi, & Lesser, 1992; Spoont, 1992), that is opposite in character to the behavioural pattern of AN patients. Indeed, in these patients control, or the absolute certainty of avoiding all the threatening events predicted by perfectionists (Sassaroli & Ruggiero, 2002), is an important behavioural feature. This sense of control often is obtained by monitoring continuously a particular parameter, such as body perception in panic, or intrusive thoughts in obsessionality. For subjects suffering from ED, the parameters may be
related to eating and/or body weight and shape (Fairburn, Shafran, & Cooper, 1998). Therefore, ED’s could be described as disorders of the sense of self-esteem and self-worth, which are without remedy pervasively negative, if not lacking in such subjects. Achieving self-control is the ultimate goal of ED individuals, who fear that they are not sufficiently worthy (Bruch, 1973; Button, 1985; Katzman & Lee, 1997). This general self-schema, a core cognitive characteristic of ED, is called “long-standing negative self evaluation” (Vitousek & Hollon, 1990). Moreover, perfectionist subjects perceive their parents’ love as being connected to parental expectations and critical evaluations (Patch, 1984). Subsequently, the familial form of failure intensively feared by the perfectionist subject is the loss of parental love (Ruggiero et al., 2003).
3.4. Perception of life events and the coping with life-events by individuals, characterized by low self-esteem and clinical perfectionism Serpell and Troop (2003) have recently discussed the presence of stressors and suboptimal coping prior to the onset of eating disorders, while distinguishing between stressors that were temporally distant from onset (i.e. occurring in childhood) and those occurring immediately prior to onset. In general, ED patients appear to report trauma, including sexual abuse and parental antipathy, indifference and over-control, more frequently than women without eating disorders. Within the group of patients with ED, binging and purging patients (BPAN and BP) show the highest levels of childhood adversity (Schmidt et al., 1997a). Based on retrospective reporting and thus subject to recall biases, Schmidt’s (1993a, 1999) and Strober’s (1984) studies suggest that sufferers of the RAN subtype report relatively little childhood adversity, but they report severe events and difficulties prior to onset. Women with BPAN report high levels of childhood adversity, but low rates of events and difficulties prior to onset. Relationship problems with a meaning of loss most commonly provoke the onset of eating disorders (Schmidt et al., 1997b). Events related to pudicity, i.e. crises of a sexual nature that were perceived as shameful, embarrassing or disgusting, were in particular significantly more common in patients
developing AN than in those developing BN and in non-psychiatric controls (24%, 3% and 8%, respectively).
The coping response is important in determining the impact of life events and difficulties, i.e. whether the life event or difficulty will result in high levels of stress. Research shows, in general, that women with AN and BN display high levels of coping through avoidance when compared to non-ED woman. Moreover, women with BN, but not AN, seek less support and are less confident (Bloks, Spinhoven, Calewaert, Willems-Koning, & Turksma, 2001; Neckowitz & Morrison, 1990; Soukup et al., 1991; Troop et al., 1994, 1998, Yager et al., 1995). Using a retrospective semi-structured interview, Troop and Treasure (1997a) found that cognitive avoidance was associated with the onset of AN, while cognitive rumination was associated with the onset of BN. In addition, the onset of an ED was related to higher levels of helplessness in response to the provoking event/difficulty. These authors also found higher levels of helplessness in girls who subsequently developed an ED, suggesting that helplessness is related to the vulnerability for developing an ED. Overall, women with RAN reported lower levels of helplessness than the other ED groups BN and BPAN. However, this may be due in part to the lower levels of severe adversity in childhood in RAN women, since when only those women with two or more adverse childhood experiences were included (e.g. sexual abuse, parental antipathy, parental indifference, etc.) the levels of helplessness were rather similar for the ED subgroups, all of which were higher than the levels found in non-ED women. Interestingly, Tiller and colleagues (1997) found differences in structural and functional aspects of social support between ED subtypes. For example, women with AN reported fewer support figures than non-ED women, but they were equally satisfied with the support they received. BN women, however, reported a network of potential support figures of a similar size as that of non-ED women, but they were considerably more dissatisfied. However, AN and BN women reported fewer friends and more loneliness during their childhood than non-ED women (Fairburn et al., 1997, 1999; Karwautz et al., 2001; Troop & Bifulco, 2002). Two-thirds of AN patients reported social isolation, poor social interpersonal relationships and difficulties with relatives and therapists (Flament,
Godart, Fermanian & Jeammet, 2001). Bulik and colleagues (2000) reported significantly lower maternal and paternal care scores in AN patients who were chronically ill. These associations can be interpreted in different ways. While poor social support may indeed reflect the use of particular coping strategies that may act as a vulnerability factor for ED, the long-standing presence of an ED may affect the family system in an adverse way and/or may bias an individual’s perception of her parents. However, it appears that the absence of adequate maternal and paternal care may contribute directly or indirectly to the chronicity of an ED.
Based on these findings, it can be hypothesized that vulnerable individuals due to a low self-esteem, associated with body dissatisfaction and perfectionism, cope with perceived threatening life-events by avoidance or escape behaviour.
The perception and interpretation of those events is based on
neuropsychological and cognitive processes, which elicited those behaviours.
4. Information processing in eating disordered patients
4.1. Neuropsychological processes
When compared to healthy controls, AN patients show deficits in various neuropsychological domains including verbal and visual memory, visuospatial ability, attentional skills (with a bias toward an analytic and controlled information-processing mode) and executive functioning (Bowers, 1994; FrantzFox, 1981; Green, Elliman, Wakeling, & Rogers, 1996; Kaye, Bastiani, & Moss, 1995; Lauer, Gorzewski, Gerlinghoff, Backmund, & Zihl, 1999; Mathias & Kent, 1998; Pendleton-Jones, Duncan, Brouwers, & Mirsky, 1991; Strauss & Ryan, 1988; Szmukler et al., 1992; Thompson, 1993). Some (Kingston et al., 1996; Lauer et al., 1999; Moser, Benjamin, Bayless et al., 2003; Szmukler et al., 1992), but not all (Green et al., 1996) studies indicate that these neuropsychological deficits recover with treatment.
Among AN patients the attentional and perceptual deficits may be stimulus-specific with specific difficulties in inhibiting irrelevant information, while perceiving stimuli related to body images, food and weight (Cooper and Todd, 1997; Long, Hinton, & Gillespie, 1994; Perpina, Himsley, Treasure, & De Silva, 1993; Rieger, Schotte, Touyz et al., 1998; Smeets, Smit, Panhuysen, & Ingelby, 1998; Smeets, Ingelby, Hoek, & Panhuysen, 1999). The pathological preoccupation with body shape leads to an intensive focus on the body and the search for perfection, which is typical of rigid personalities (Fassino, Piero, Abbate Daga et al., 2002). Performance appears to be affected more when the situation or task is relevant to the individual’s specific concern (Williams et al., 1997). However, methodological flaws associated with the use of particular tasks (such as a modified Stroop colour-naming task) and validity problems of the used questionnaires, hamper the interpretation of the results of studies in ED patients (Mogg & Bradley, 1998).
Using an electrophysiological technique Dodin and Nandrino (2003) showed, that these deficits extend to generic stimuli, irrespective of the task-complexity or to the task-specificity (e.g. requiring attentional, perceptual or motor resources). Logically, it was hypothesized that food deprivation and/or low BMI or the comorbid presence of depression were responsible, but this explanation was not sufficient (Hamsher et al., 1981; Lauer et al., 1999; Kingston et al., 1996; Mathias & Kent, 1998; Moser et al., 2003; Pendleton-Jones et al., 1991; Szmukler et al., 1992).
Parallel with the findings of
preoccupying cognitions in emotional disorders (Williams, Watts, MacLeod, & Mathews, 1997), the bias towards a controlled processing mode could be related to anxiety with a systematically allocating high level of attentional resources, impeding appropriate selective processing of relevant information (Green, Elliman, & Rogers, 1997; Green & Rogers, 1995, 1998; Green, Rogers, Elliman, & Gatenby; 1994; Jones & Rogers, 2003; Rogers & Green, 1993). Thus, Dodin and Nandrino (2003) explained this phenomenon by the hyperarousal state of AN patients, characterized by a constant need to reassess new incoming stimuli using their working memory. Working memory saturation would then be faster than normally expected, reducing in this way the ability to learn in anorexic subjects. This failure to inhibit frequent
stimuli may correspond to an impaired learning process in association with a working memory deficit, as suggested by Green and co-workers (1996). Even in simple tasks that could be carried out in a more automatic fashion, patients may favour a controlled information-processing mode causing longer perceptual decision times. Dieters and restrained eaters indeed displayed slower reaction times than non-restrained eaters in the presence of a food-related cue reactivity manipulation (Green, Rogers, Elliman, & Gatenby, 1994) and this effect was stronger during the earlier parts of the cognitive processing measure (Green, Rogers, & Elliman, 2000). Non-clinical subjects scoring high on trait anxiety measures showed interference during the automatic but not the controlled processing of emotional material (MacLeod & Hagan, 1992).
Non-ED restrained eaters did not show distortions in the
processing of body shape and weights stimuli, nor an early automatic processing priority or a pattern of strategic processing selectivity in Stroop studies (Jansen, Huygens, & Tenney, 1998). This finding might point at a qualitative difference between normal restrained eaters and subjects with eating disorders of clinical severity.
Slower information processing and deficiencies in the initiation of an adequate problem-solving strategy appear to be present also in BN patients ((Black, Wilson, Labouvie, & Hefferman, 1997; Carter, Bulik, McIntosh, & Joyce, 2000; Cooper & Fairburn, 1994; Hsu, Kaye, & Weltzin, 1993; Ferraro, Wonderlich, & Jocic, 1997). Moreover, unsuccessful dieters, when compared to successful dieters, show increased appetitive physiological responses to food stimuli and a greater vulnerability to disinhibition of restraint and thus to overeating (Jones & Rogers, 2003). They also have more inflexible attitudes towards food and eating (see review by Mela & Rogers, 1998). As a consequence, they may feel the adverse effects of dietary violation more intensely, leading to a marked increase in preoccupation and further impairment of task performance.
4.2 Cognitive processes Cognitive-behavioural research has addressed cognitions that are relatively available to conscious report (i.e., negative automatic thoughts and conditional assumptions, principally regarding food, shape, and weight). However, there may also be a particular role for schema-level cognitive representations, or core beliefs, which are not related to food, shape or weight, but which reflect unconditional negative beliefs about the self, others, or the world. Indeed, the schematic level of cognitive representation (unconditional core beliefs) may well be responsible for phenomena such as rapid mood swings (a result of the triggering of unconditional core beliefs) and mood suppression (caused by the activation of emotional inhibition beliefs) (see e.g., Young, 1994).
Although schema-level representations have
received attention particularly in terms of their capacity to explain personality disorder-related pathology, they may also play a specific role in disorders with an impulsive component, such as bulimia, or with a compulsive element, such as restriction (see e.g., Leung, Waller, & Thomas, 1999).
The cognitive model suggests that schemata relating to threat, particularly threats to self-esteem are associated with bulimic attitudes and behaviours (Everill & Waller, 1995; Waller et al., 1996; Van Strien, 2000a; Vervaet, van Heeringen, & Audenaert, 2004; Gilbert & Meyer, 2005). These schemata are activated prior to (or even without) conscious awareness of the threat and associated with an attentional bias. Binge eating appears to be one way of reducing the activation or dominance of such threat-related schemata. This phenomenon has been studied using a modified Stroop task, but the results of these studies may have been biased as performance on this task may reflect a number of processes in addition to attention (Foa, Feske, Murdock, Kozak, & McCarthy, 1991), and may be under some degree of conscious control. Therefore, researchers such as Waller & Mijatovich (1998) have used subliminal visual presentation of a threatening stimulus (Patton, 1992). The results from studies using both methods confirm earlier conclusions of other models, i.e. that (1) binging serves the function of reducing awareness of negative affect and cognitions (Lacey, 1986; Root and Fallon, 1989) or that (2) attention is
narrowed as a means of reducing awareness of threat, and that eating is disinhibited as a result of this narrowing of attention (Heatherthon and Baumeister, 1991). Clinical experience suggests that both mechanisms take place in the same individual at different times and to different degrees during the development of bulimic disorder (McManus & Waller, 1995). There is evidence that the processes of attentional bias and cognitive avoidance are not independent (de Ruiter & Brosschot, 1994). This hypothesized process is similar to a recent model of anxiety. Beck and Clarke (1997) suggest that information processing is initially automatic, but that it becomes a more strategic, purposeful responding over time. When information is aversive, the initial automatic response (due to an attentional bias to material that is strongly represented cortically) will be followed by a more purposeful form of processing (avoidance of the aversive material). Bulimic psychopathology thus appears to be a cognitive “escape” mechanism (Meyer, Waller, & Watson, 2000).
Using a semi-structured interview, it was found that the self-beliefs of ED patients, unlike those of non-ED women, are negative, unconditional and concerned with themes such as abandonment and uselessness (Cooper, Todd, & Wells, 1998). They were also invariably associated with negative early experiences. Underlying assumptions were of two kinds, i.e. (1) weight and shape as a means to selfacceptance, and (2) weight and shape as a means to achieve acceptance from others. There were also assumptions about eating. The interview also indicated that underlying assumptions provide a link between negative self-beliefs and dieting behaviour. Assumptions appeared to be compensatory beliefs, providing a way for the individual to overcome negative self-beliefs (Young, 1994). However, the conclusions from this study were purely qualitative, and no information was provided regarding the validity and reliability of the interview. Results of the study using a revised version of the interview (Turner & Cooper, 2002) with a good inter-rater and test re-test reliability and promising concurrent validity, in AN patients, non-symptomatic dieters and female controls were however comparable. Patients experienced more eating-related negative automatic thoughts than dieters and controls, with similar differences for duration, degree of belief and associated distress. Patients also reported more
eating-, weight- and shape-related thoughts than controls and had more underlying assumptions related to eating, and weight and shape as a means to acceptance by self and others. Cooper and colleagues (1998) have recently argued that both negative self-beliefs and underlying assumptions about weight, shape and eating need to be present for the development of an ED. Successful dieting may reduce the distress caused by negative self-beliefs and enhance self-esteem and the feeling of success. These beliefs may thus function as ‘schema compensation beliefs’ (Young, 1990). The enhanced self-esteem is however quickly negated by thoughts of inadequate dieting, which in turn reinforce negative self-beliefs. This process may be similar to the ‘schema maintenance processes’ as identified by Young (1990).
The more common use of cognitive strategies involving punishment and worry among individuals, who show a strong tendency of disinhibition, in order to control their thoughts parallels the increased prevalence of these strategies in other clinical domains, such as the anxiety disorders (Wells & Davies, 1994). Furthermore, a rigid and punitive cognitive style is characteristic of dieters and may serve to control food intake as it was shown that the use of punishment correlates positively with ratings of anxiety, distress, perceived thought frequency, and actual number of thoughts about food (Garner & Bemis, 1982). It is unknown however, to what extent these strategies are adopted in response to upsetting intrusive thoughts (Oliver & Huon, 2001).
Patients suffering from Binge Eating Disorder (BED) are characterized by substantially more pathological core beliefs than normal controls. A recent study (Waller, 2003) revealed differences between BED and BN for the nature of these core beliefs, but not for the extent of these beliefs, as in previous research (e.g., Ardovini et al., 1999; Wilfley et al., 2000). In this study, patients with BED showed particularly negative beliefs about their ability to experience or express emotions, their ability to function independently, and their need to sacrifice their own needs for those of others. When compared to the BN patients, BED patients reported however less pathological beliefs regarding the likelihood that they would be abandoned. The absence of purging may thus be related to the lower level of
abandonment beliefs, and the presence rather than the extent of relatively negative abandonment beliefs drives purging behaviours in BN (Patton, 1992).
4.3. Information processing and emotional arousal
In cognitive theories, emotion is a multifaceted phenomenon with cognitive processing of stimuli, motivation, physiological activation, motor behaviour and subjective feeling state (Williams, Watts, MacLeod, & Mathews, 1997).
Emotional disorders involve acute reactions with a strong
autonomic component but also long-term emotional disturbance and cognitive preoccupations. Some individuals may adopt perfectionist standards as compensation for an underlying inferior sense of self and shame-proneness (Miller, 1996), with early infantile narcissistic origins related to the fear of showing one’s physical, intellectual or emotional defects to others (Jacobson, 1964). Shame is a complex emotion in which the self is judged to have fallen short of an internalised set of standards. Even if experienced in private it is as if the self is being judged by some external other. Shame can be considered as the experience that the self is defective (see e.g. Tangney, 1993), while others conceptualise shame as a psychological consequence of being judged to be low in social rank (see e.g. Gilbert, 1997). Implicit in both these conceptualisations is the notion of social comparison (Lazarus, 1999). Shame, unfavourable social comparison and submissive behaviour are associated with socially prescribed perfectionism, suggesting that these individuals see themselves as rather lacking in status, and it may be this that is particularly pathogenic (Wyatt & Gilbert, 1998).
In non-clinical samples shame-proneness is related to eating pathology (Sanftner et al., 1995). In a diary study, Sanftner and Crowther (1998) showed that shame, in general, was more markedly present in women who reported binge eating, but fluctuations in shame were not related to the occurrence of binge episodes.
Interestingly, Waller and colleagues (2000) found that a core belief of
Defectiveness/Shame was related to the frequency of vomiting. At a group level, Defectiveness/Shame
was one of three core beliefs that differentiated between bulimic subgroups (BN, BPAN and BED) and a non-ED comparison group, the other two core beliefs being Insufficient Self-Control and Failure to Achieve.
Andrews (1997) found that bodily shame was a better predictor of BN than body
dissatisfaction and that bodily shame mediated the relationship between childhood physical or sexual abuse and subsequent BN.
Similar to shame, jealousy is a complex emotion involving social comparison (Lazarus, 1999). Two studies have used a sibling-comparison design to assess non-shared childhood environmental effects on the development of AN (Murphy et al., 2000; Karwautz et al., 2001). Both studies found that affected sisters reported having been more jealous of their unaffected sisters in childhood than the unaffected sisters were of them. Women with BN, on the other hand, report their mothers to have been jealous and competitive during their childhoods (Rorty et al., 2000a, 2000b). Thus, while the perception of others being jealous of oneself may be a risk factor for AN and the jealousy of others may be a risk factor in BN, these results suggest that the development of both disorders probably involves competition in the context of social comparison.
The role of anger and hostility in ED has received less attention than other emotions. However, these emotions occur more frequently among patients with ED than among non-ED comparison women (e.g. Tiller et al., 1995). Milligan and Waller (2000) found that state anger, but not trait anger, and anger suppression were related to bulimic pathology. Anger suppression was uniquely related to the presence of binge eating, whereas state anger was uniquely related to the presence of vomiting. The authors suggest that their findings support the functional role of bulimia in blocking unpleasant affective states and, in particular, that different symptoms of bulimia may serve different functions. When compared to normal controls, ED women had higher levels of state anger and anger suppression, especially when they displayed bulimic symptoms (Waller, Babbs, Milligan, Meyer, Ohanian, & Leung, 2003). Considering specific symptoms, bingeing and vomiting were associated with trait anger, while
excessive exercise was associated with state anger, and laxative abuse was linked to anger suppression. It can thus be hypothesized that bulimic behaviours serve different emotional functions, with a particular contrast between the facets of anger that are influenced by “fast-acting” behaviours (bingeing, vomiting, exercise) and those that are influenced by “slow-acting” behaviours (laxative abuse). When considering the role of cognitions, unhealthy core beliefs were associated with higher levels of trait anger in both groups but were relevant to anger suppression only in the ED patients.
Finally, but very interestingly, a specific impairment in the recognition of facial and vocal expressions of emotion was found in ED patients (Kucharska-Pietura, Nikolaou, Masiak, & Treasure, 2004), which was possibly associated with their deficit in social functioning. This impairment may be due to a disturbed emotional processing, which is common to people within the internalizing spectrum of psychopathology (Uher, Murphy, Phillips & Dalgleish, 2001). Another possibility is that people with emotional and interpersonal difficulties have an attention problem in social situations, comparable to the attention deficit in people with social phobia (Chen, Ehlers, Clark, & Mansell, 2002).
4.4. From schemata to behaviour
Clinical investigators have described difficulties in identifying, verbally expressing, and regulating a variety of physical tensions among ED patients (Bruch, 1973; Esplen, Garfinkel, & Gallop, 2000; Troop, Schmidt, & Treasure, 1995).
According to Bruch, the confusion and apprehension in
recognizing and accurately responding to emotional states and the uncertainty in the identification of certain visceral sensations related to hunger and satiety, tapped by the Interoceptive Awareness subscale of the EDI, may result in a pattern of responding to negative mood by food intake, or ‘emotional eating’. Interoceptive awareness is strongly associated with alexithymia (Taylor, Parker, Badbey, & Bourke, 1996). Social self-doubt and unhappiness have been suggested as central elements in inducing the eating pattern of emotional eaters. The escape theory of eating, as formulated by Heatherton and
Baumeister (1991), which incorporates elements of externality and psychosomatic theory, stated that a shift to low levels of thinking would result in a reliance on immediate stimuli and in a dampening of affect. Reduced affect and eating would then occur following escape from self-awareness. As described by Van Strien (2000b), Slochower (1983) has also suggested that emotions and environment may operate conjointly to produce overeating. The restraint theory is not valid for all dieters, but mainly for a subpopulation with a strong tendency towards overeating (van Strien, Cleven & Schippers, 2000). Thus, overeating following a preload occurred only in subjects with high scores on both restraint and disinhibition, as measured by the ‘emotional eating’ and ‘external eating’ scales of the Dutch Eating Behaviour Questionnaire (DEBQ; Van Strien, 1986) and the ‘bulimia’ subscale of the Eating Disorder Inventory (EDI; Garner et al., 1983). A possible explanation is that anything that depletes restrained eaters’ self-regulatory strength (as many everyday self-regulatory tasks) may disinhibit subsequent eating (by undermining the ability to maintain cognitive regulation of the intake in the period following other self-regulatory tasks) and disrupt attempts to diet (Kahan, Polivy, Herman, 2003). The false hope of dieting may deplete the dieter’s resources due to the vicious circle of ill-advised attempts followed by failure and self-recrimination (Polivy & Herman, 2000).
As described above, perfectionism/rigidity (as a particular risk for the restrictive disorders with overevaluation of achieving) and low self-esteem reflect a specific way of information processing, which may make individuals vulnerable to develop an ED. Exposure to severe interpersonal life events (possibly at least in part due to particular traits such as low sensitivity for social cues or impaired recognition of facial and vocal expression of emotion) or to difficulties in combination with helplessness or inadequate coping (another possible trait), in the presence of this predisposition or vulnerability, may precipitate the development of specific core beliefs, such as negative self beliefs. These cognitions can be expressed by a dysfunctional schema of body shape and weight-based self-esteem resulting in strict dieting, excessive exercise and other weight-control behaviour such as purging (Fairburn et al., 2003). Binge eating can
then be a consequence of these restricting behaviours, or, as described above, it can be an escape mechanism in the context of inevitable conflict situations. Consistent with Stice’s (1994, 2001) dual pathway model of eating disorders, dieting and negative affect independently predict the subsequent onset of binge eating (Shepherd & Ricciardelli, 1998; Stice et al., 2000), though only in females. In contrast, experimental studies suggest an interactive effect, the socalled disinhibition of dietary restraint (Ruderman, 1986). Recently, cluster-analytic studies have yielded two subtypes of eating disorders: pure dietary and mixed dietary-negative affect (Grilo, 2004). This last type was characterized by a greater likelihood of binge eating, greater eating-related psychopathology, greater body image dissatisfaction, greater personality disturbance and more commonly reported concerns in clinical areas, including suicidality and childhood abuse. Polivy and Herman’s (1999) study of the disinhibiting effects of emotion on dietary restraint provided no support for the “comfort hypothesis”, which suggests that eating makes people feel better. However, strong support was found for the “masking hypothesis” in which the dieter, by over-eating, misattributes her distress to the problem of over-eating rather than to her real problems. In addition, the findings partially supported the “learned helplessness hypothesis”, in which the experience of stress/distress generalises to all areas in life including the ability to maintain a diet, and the “distraction hypothesis” in which restrained eaters over-eat in order to distract themselves from feeling distressed.
Within a cognitive model, it has been proposed that overeating can serve the function of reducing the awareness of threatening information and intolerable emotions (McManus & Waller, 1995). Such a reduction in awareness corresponds with a lowering of activation of relevant cognitive representations (schemata) through distraction or activation of other structures. At a preconscious level, and thus automatic in nature, associations between abandonment and eating-related cognitions were found (Meyer and Waller, 1999, 2000). At a conscious level, women with BN often report a significant event involving the loss of a significant relationship prior to the onset of their disorder. These observations
may be causally associated through an outspoken need for approval and feelings of social isolation, which are characteristic of bulimic psychopathology (Tiller et al., 1997). Based on their findings, Meyer and Waller (2000) hypothesized that the core beliefs are more likely to focus on abandonment, whereas negative automatic thoughts and dysfunctional assumptions are more likely to center on issues reflecting food, shape, and weight. This leads to states experienced as a non-specific ‘extreme state of tension’, or to feelings of emptiness and aloneness (Cross, 1993) combined with a lower level of soothing receptivity (Glassman, 1988) and poorer capacity for evocative memory, and finally to a sense of loneliness and to difficulties in the regulation of affect. This may offer an explanation for the limited effects of some current therapies, i.e. those that only address the cognitive elements related to body distortion and dieting behaviours, in treating disturbed regulation of affect (Arntz, 1994).
Taken together, theoretical considerations and empirical findings have suggested a variety of reinforcing consequences that may shape and maintain disordered eating behaviours.
individuals may be more inclined to (1) respond to aversive internal and external events through engagement in disordered eating behaviours that are, in turn, subsequently negatively reinforced as they function to reduce or terminate these aversive events, and (2) engage in disordered eating as to experience immediate gratification of needs or the attainment of immediate reinforcers, or to increase the likelihood of attaining anticipated distal reinforcers (e.g. social approval for a slim appearance). Possibly, reward sensitivity and responsiveness to reward and relief from aversion, and/or insensitivity to signals of threat or punishment are important individual variables associated with the same underlying trait, temperament dimension or brain system (Cloninger, 1987; Gray, 1987). Recently, an association between reward sensitivity and purging behaviours has indeed been reported (Farmer, Nash, & Field, 2002).
Through their association with core psychopathological characteristics of ED patients, traitdependent measures may thus be useful for our understanding of the development and maintenance of
ED-related symptoms and for the prediction of eating-disordered behaviour. The following section will describe a hypothetical dimensional trait model of ED-related characteristics based on Cloninger’s psychobiological model of personality (Cloninger et al., 1993).
Cloninger proposes that specific
dimensions of temperament and character interact with one another to influence susceptibility to emotional and behavioural disorders. Cloninger refers to temperament as emotional responses that are moderately heritable, stable throughout life, and mediated by neurotransmitter functioning in the central nervous system. Cloninger’s four proposed temperament dimensions include: novelty seeking (NS), which reflects behavioural activation to pursue rewards and is posited to be related to decreased dopaminergic activity; harm avoidance (HA), which is the tendency to inhibit behavior to avoid punishment and is purported to be related to increased serotonergic activity; reward dependence (RD), which reflects the maintenance of rewarded behaviour and is hypothesized to be mediated by decreased noradrenergic activity; and persistence (P), which is perseverance without intermittent reinforcement that is also purported to be related to decreased noradrenergic activity. Character, in contrast, refers to self-concepts and individual differences in goals and values that develop through experience. The character dimensions are: self-directedness (SD), which is the degree to which the self is viewed as autonomous and integrated; cooperativeness (C), which reflects the degree to which the self is viewed as a part of society; and self-transcendence (ST), which reflects the degree to which the self is viewed as an integral part of the universe.
4. A hypothetical model for the prediction of eating-disordered behaviour
Although significant advances regarding the identification of individual risk factors have been made, few prospective studies have tested a multivariate etiologic model that details how these individual risk factors work in concert to promote the development of anorectic and bulimic symptoms. Two prospective studies have provided support for a three-factor interactive model for bulimic symptoms in which the confluence of perfectionism, body dissatisfaction and low self-esteem promotes the
development of bulimic symptoms (Vohs, Bardone, Joiner, Abramson, & Heatherton, 1999; Vohs, Voelz, Pettit, Bardone, Katz, Abramson, Heatherthon, & Joiner, 2001). Although a replication study did not support this model, the results confirmed those from previous prospective studies of the importance and significant effect of body dissatisfaction (Shaw, Stice, & Springer, 2004).
According to the cognitive model of the maintenance of eating disorders (Fairburn, 1997), the core psychopathology, even among anorectic patients (Carter, Blackmore, Sutandar-Pinnock, & Woodside, 2004) is the over concern with body shape and weight. Due to this over concern, self-worth is judged largely or even exclusively in terms of satisfaction with weight and shape.
The function of this
overconcern is probably problem-avoidance. Taking into account the need for absolute self-control in AN patients (Fairburn et al., 1999), food restriction in combination with excessive physical activity was found to be highly reinforcing. This reinforcing effect is most probably related to the fact that these behaviours increase circulating levels of endogenous opiates that activate dopamine in the brain’s mesolimbic reward centres (Carter et al., 2004; Davis, Katzman, Kaptein, Kirsh, Brewer, Kalmbach, Olmsted, Woodside, & Kaplan, 1997; Strober, Freeman, Morrell, 1997).
Many studies provide evidence for a strong relationship between impulsivity and eating-disordered behaviour. A higher score on measures of impulsive behaviour has been described in eating disordered individuals, especially in adolescents (Wonderlich, Connolly, & Stice, 2004). There is, however, a difference between trait-oriented impulsivity and behavioural measures of impulsivity. It can be hypothesized that the more outspoken behavioural impulsivity in behaviour among ED patients, particularly in those showing binging-purging behaviours, is the expression of the temperament dimension ‘Novelty Seeking’, whether or not in combination with a poorer character development as measured by ‘Self-directedness’.
Based on a similar line of reasoning, it can be hypothesized that ED patients are characterised by a high score on ‘Harm Avoidance’, expressed by their ‘Perfectionism’ and ‘restricting behaviour’ as a need for control, and a low score on ‘Reward Dependence’, reflecting their rigidity or inability to cope with (social) situations. A higher ‘Persistence’ among ED patients, when compared to normal controls, could explain the persistent nature of avoidance behaviours, in spite of their adverse effects in the long run after the short-term reinforcing effects. With regard to ‘Novelty Seeking’ especially differences between the restricting type (RAN) and the binge-purging type (BPAN and BP) can be expected, expressed by means of a more outspoken ‘body dissatisfaction’ and more frequent ‘emotional and external eating’, combined with more ‘purging’ in the latter type. In view of the common high levels of helplessness, ED patients can be expected to have lower scores on the character dimensions, in particular the ‘Selfdirectedness’ dimension, possibly reflecting low self-esteem. Scores on the self-directedness dimension may even be lower among BN patients, as these individuals do not succeed in restricting and avoiding and are conditioned with regard to their escape behaviours by binging or/and purging.
The following part of this thesis is constituted by studies of these hypothetical associations in the context of the proposed dimensional trait model of factors predisposing to ED.
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PART II The cognitive psychology of eating disorders: personality, cognitions and behaviour.
Chapter 2: Personality characteristics as trait-dependent vulnerability: study results
1. Binge Eating Disorder and Non Purging Bulimia: more similar than different?4
There is evidence of an overlap of symptoms in binge-eating disordered (BED) and bulimia nervosa non-purging (BN-NP) patients. In addition, indications of an evolution from bulimia nervosa to BED along a continuum of vulnerability have been found. However, DSM-IV categorizes BED and BN-NP as distinct disorders based on clinical characteristics. In this study weight history and personality-related characteristics (TCI; Cloninger, Svrakic, & Przybeck, 1993) were studied in 30 BED and 17 BN-NP patients. BED patients were older, and had a longer duration of illness, a larger weight cycling, a higher current and previous BMI and a lower score for the temperament dimension ‘Persistence’ than BN-NP patients. After correcting for age, differences between weight variables remained, including comparatively higher BMIs and larger weight fluctuations among the BED patients. A possible explanation is that this difference is due to a genetic effect of the propensity to be overweight and the temperamental characteristic of Persistence. This ‘morbid’ starting position and the lack of controlling mechanisms are associated with a more trait- than state-dependent condition. Thus, restrained eating is not to be regarded as eliciting bingeing in BED patients. Due to personality characteristics these patients are not able to restrain, which clearly differentiates them from BN-NP patients. Keywords: binge eating disorder, personality, bulimia nervosa non-purging type Introduction Patients diagnosed with Eating Disorders Not Otherwise Specified (EDNOS) are defined as individuals who have an eating disorder of clinical severity but who do not meet diagnostic criteria for anorexia nervosa or bulimia nervosa. Several studies (Mitchell, Pyle, Hatsukami, & Eckert, 1986; Mitrany, 1992; Norvell & Cooley, 1986-1987, Mizes & Sloan, 1998; Spitzer et al., 1992; Williamson, Gleaves, & Savin, 1992), which were mostly descriptive and based on relatively small sample sizes, have suggested that patients suffering from binge eating disorder (BED) form a subgroup within this EDNOS group. An important issue in the discussion of whether BED should be regarded as a diagnostic entity, is the question whether patients with bulimia nervosa without purging (BN-NP) differ from BED patients.
Based on results from a community sample, Striegel-Moore and collegues
suggested that BED does not represent a burned out form of BN (any type; Striegel-Moore et al., 2001).
Vervaet, M., van Heeringen, C., Audenaert, K. (2004). European Eating Disorders Review, 12, 27-33
DSM-IV criteria for BED imply the absence of inappropriate compensatory behaviours in BED patients. BN-NP patients binge at least twice a week without compensatory behaviours, except for fasting and excessive exercise. They appear to form a homogeneous group sharing however some clinical characteristics with purging (BN-P) bulimics (Garfinkel et al., 1995; Kinzl, Traweger, Trefalt, Mangweth, & Biebl, 1999) including age, gender, a similar determination to compensate for their bingeing, and similar pathways to binge-eating. The main behavioural difference between non-purging and purging bulimics is the frequently self-induced vomiting and/or misuse of laxatives and other drugs to counteract the effects of binge-eating among the latter (Kinzl et al., 1999). In BN, the onset of binge eating is very often preceded by dieting and weight loss (Mussell et al., 1997), whereas among patients with BED, binge eating may be the cause, and not the consequence, of dieting behaviour (Marcus, 1995).
However, some cases of bulimia nervosa may evolve into BED, and accumulating evidence
indicates the existence of a continuum of vulnerability with a higher frequency of binge-eating reflecting greater clinical severity among obese and bulimia nervosa patients (de Zwaan et al., 1994; Garfinkel et al., 1995; Kendler et al., 1991; Striegel-Moore, Wilson, Wilfley, Elder, & Brownell, 1998). There is, however, less evidence of an association between BMI and severity of binge-eating. Some studies, but not all (Brody, Walsh, & Devlin, 1995; de Zwaan, Nutzinger, & Schoenbeck, 1992; Goldfein, Walsh, LaChausse, Kissileff, & Devlin, 1993; Wilson, Nonas, & Rosenblum, 1993), have reported an association (de Zwaan et al., 1994; Lowe & Caputo, 1991; Spitzer et al., 1993; Telch, Agras, & Rossiter, 1988). Clinical observation and studies of personality characteristics and comorbidity indicate that BED patients show more severe psychopathology than pure restricting anorexics. Moreover, their family environment appears to be more similar to that of bulimic and anorectic purger/binger patients in terms of conflict and chaos (Kanter, Williams, & Cummings, 1992; Marcus et al., 1990). Thus, there is evidence of an overlap of symptoms in BED and BN-NP patients, and, in addition, indications of an evolution from BN to BED along a continuum of vulnerability have been found.
However, DSM-IV categorizes BED and BN-NP as distinct disorders based on clinical
This study aimed at investigating differences in personality-related characteristics
between BED and BN-NP patients. Methods Sample A total of 409 patients who were consecutively referred to the in- and out-patient units of the Centre for Eating Disorders at the Department of Psychiatry of the University Hospital Gent between December 1998 and April 2002 and who met the DSM-IV criteria for eating disorders, were enrolled in the study. The study was compliant with the Code of Ethics of the World Medical Association (Declaration of Helsinki) and carried out following the guidelines of the local ethics committee. The referred group included 17 patients (4 per cent) with BN-NP, while 75 patients (18 per cent) were diagnosed with EDNOS. In the BN-NP group, which consisted of 16 females and 1 male, the mean age was 23.8 years (SD=7.2 years) and the mean BMI was 24.5 (SD=4.2). Among the EDNOS patients, the mean age was 26.2 years (SD = 10.9 years) and the mean BMI was 26.7 (SD = 10.1). Ninety-eight per cent (n = 72) of the EDNOS patients were female. Thirty-one patients of the EDNOS group met the criteria for BED (female: 28; male: three). The data on one female of the BED group were excluded from statistical analysis because of mental retardation which could have influenced the reliability of the assessment. The mean age of BED patients was 33.1 years (SD = 10.7 years) with a mean BMI of 37.7 (SD = 6.7).
Measures Weight and height, highest and lowest adult weight ever and duration of illness were assessed carefully. The body mass index (BMI) was calculated, as well the highest and lowest BMI (HBMI, LBMI), based on the highest and lowest adult weight ever. Weight fluctuation was defined by the difference between highest and lowest adult weight ever. Patients were asked to describe the frequency of their binging, purging and restricting behaviours according to three categories: never, less than twice per week
(‘sometimes’), or more than twice per week (‘frequent’). Bingeing was described as the loss of control over eating, not including any measurement of calories.
The Dutch version of the SCAN (Schedules
for Clinical Assessment in Neuropsychiatry) was used to assign diagnoses according to DSM-IV criteria (Giel & Nienhuis, 1996). The validated Dutch version of the TCI (Duijsens, Spinhoven, Goekoop, Spermon, & Eurelings-Bontekoe, 2000) was used to assess temperament and character characteristics. The TCI is based on a psychobiological model of personality and assesses both temperament and character. Temperamental aspects of personality are (at least partially) heritable, manifest early in life, and involve preconceptual or unconscious biases in learning (Cloninger et al., 1993). The temperament dimensions include novelty seeking (NS) reflecting behavioural activation, harm avoidance (HA), a tendency toward behavioural inhibition, reward dependence (RD) reflecting behavioural attachment, and persistence (PS), a measure of behavioural maintenance. Character aspects of personality are denoted by individual differences in self-concepts, goals, and values.
The character dimensions include self-
directedness (SD), referring to a self-accepting, purposeful nature, cooperativeness (CO), a trait associated with acceptance of other people and compassion, and self-transcendence (ST) reflecting spirituality and an acceptance, identification, or spiritual union with nature and its source. Individuals with the same temperament may behave differently as a result of differences in character development (Cloninger et al., 1993). In addition to the self-report measurements, eating behaviours were assessed by means of the Dutch Eating Behaviour Questionnaire (DEBQ; Van Strien, 1986). This questionnaire measures the behavioural characteristics emotional eating (eating elicited by diffuse and clear emotional stimuli), restrained eating (the tendency to diet in order to lose weight), and external eating (eating elicited by external stimuli). Finally, patients were asked for feelings of sadness, sleeping disturbances (without drugs), feelings of anxiety or phobia or panic attacks, feelings of depression, a history of deliberate self-harm, and drug abuse.
Obesity or overweight in first degree family members was
assessed. Statistical analysis was performed using SPSS 10.0. t-Tests were used to compare BN-NP with BED patients with regard to demographic, clinical and behavioural (DEBQ) and personality (TCI)
Since a significant difference for age between the two patient groups was found, a
correction for age was applied in further statistical analysis.
Results The study group included 17 BN-NP and 30 BED patients who all binged at least twice per week. Since purging is an exclusion criteria for the BN-NP and BED diagnoses, patients were included only if they vomited or used laxatives less than twice per week. The BN-NP group included one vomiting patient, and one patient who used laxatives, while in the BED group eight patients reported vomiting and four used laxatives, all less than twice a week. BN-NP patients reported food restriction very commonly (more than twice per week, n=13), while BED patients tried to restrict, but failed (five patients reported restricting more than twice per week). Since excessive exercise was assessed only in the last 14 patients, only differences in restricting were calculated. As shown in Table 1 there are thus small numbers in some cells. Consequently, data on excessive exercise were not included in further analysis.
Table 1: Significant differences for age, duration of illness, BMI, HBMI, LBMI and weightfluctuation characteristics between BN-NP and BED patients BN-NP n=17
Never Sometimes Frequently
0 3 14
10 15 5
10 18 19
Excessive exercise Missing Never 1 1 3 Frequently
Sometimes, < twice a week; Frequently, >twice a week, Pearson chi-square = 0.000 As shown in Table 2, BN-NP subjects were younger, and had a shorter duration of illness, when compared to BED patients.
Table 2: Table 2: Significant differences for age, duration of illness, BMI, HBMI, LBMI, weight-fluctuation, behavioural (DEBQ) and personality characteristics (TCI) characteristics between BN-NP and BED patients
Age Duration of illness BMI HBMI LBMI Weight fluctuation Restrained Eating Persistence
BN-NP n=17 m sd 23.8 7.2 4.1 3.5 24.5 4.2 27.1 5.5 19.3 4.1 21.7 12.6 4.0 0.8 5.4 2.1
BED n=30 m sd 33.1 10.7 11.4 7.5 37.7 6.7 39.7 7.6 25.4 3.7 40.6 22.1 2.9 0.6 3.4 2.1
The group of BN-NP patients had a mean lower BMI, adult HBMI and LBMI than BED patients. BED patients showed significantly larger fluctuations in their body weight than patients of the BN-NP group. Patients in the BN-NP group also had a higher score on ‘restrained eating’, than patients in the BED group. With regard to personality dimensions, BN-NP patients scored higher on persistence than BED patients. After correction for age (Table 3), the described differences remained significant.
Table 3: Differences between BN-NP and BED after correction for age
BMI HBM LBMI Weight fluctuation Restrained eating persistence
BN-NP M SE 26.2 1.4 29.1 1.6 19.1 1.0 27.6 4.4
BED M SE 36.7 1.0 38.5 1.2 25.5 0.7 37.1 3.2
3.9 0.2 5.0 0.5
2.9 0.1 3.7 0.4
ANOVA with Bonferroni post hoc comparison; corrected for age, evaluated at covariates appeared in the model: AGE = 29.72
There was a significant difference (Pearson chi-square = 0.007) in overweight or obesity in first degree family members. Twenty-two of the BED patients (76 per cent) and seven of the 17 BN-NP patients (47 per cent) reported that their mother or father was overweight. No differences were found with regard to feelings of sadness, anxiety, depression, or the presence of sleep disturbances, deliberate self-harm or drug abuse (Table 4).
Table 4: Clinical differences between BN-NP and BED patients -------------------------------------------------------------------------------------------------------------------------
Sensitivity, SleepFeelings Feelings of Deliberate Drug Overweight tension, disturbances of Depression Self-harm abuse or obesity sadness anxiety in family 14 7 5 13 3 0 7
N=17 BED N=30 MannWhitney U Asymp.Sig. (twotailed)
Finally, three different groups were compared according to the frequency of restricting food (Table 5).
Table 5. frequency of non-purging compensating behaviour in BN-NP and BED patients
Age BMI HBM LBMI Duration of illness Restrained eating persistence
Never Restricting M (SD) (1) 35.5 (9.9)
Sometimes Restricting M (SD) (2) 27.8 (9.9)
Frequently Restricting M (SD) (3)
38.3 (5.1) 39.8 (6.1) 25.7 (3.6) 13.2 (8.0)
33.5 (8.0) 34.9 (8.6) 23.4 (7.1) 8.3 (5.9)
29.3 (9.7) 32.5 (10.6) 20.2 (4.5) 7.4 (7.5)
4.0 2.1 3.3 2.0
0.026 0.137 0.048 0.148