Eating Behaviors 10 (2009) 228–231
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Eating Behaviors
Bulimic symptoms in undergraduate men and women: Contributions of mindfulness and thought suppression Jason M. Lavender ⁎, Bianca F. Jardin, Drew A. Anderson Department of Psychology, University at Albany, State University of New York, Albany, NY, USA
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Article history: Received 8 May 2009 Received revised form 19 June 2009 Accepted 6 July 2009 Keywords: Bulimic symptoms Disordered eating Mindfulness Thought suppression Experiential avoidance Emotion regulation
a b s t r a c t Experiential avoidance, the refusal to accept contact with unpleasant private experiences, is believed to play a role in the onset and maintenance of eating disorders. Preliminary evidence suggests that mindfulness- and acceptance-based interventions that reduce avoidance may be effective in treating disordered eating behaviors. The purpose of the current investigation was to examine whether one form of experiential avoidance (thought suppression) and the theoretically opposing construct of dispositional mindfulness are associated with bulimic symptoms. Undergraduate men (n = 219) and women (n = 187) completed questionnaires assessing mindful attention and awareness, chronic thought suppression, and bulimic symptoms. A series of hierarchical regression analyses revealed that thought suppression and mindfulness accounted for unique variance in bulimic symptoms among men and women after accounting for BMI. Results are discussed in terms of the role of dispositional mindfulness and thought suppression in disordered eating. © 2009 Elsevier Ltd. All rights reserved.
1. Introduction A substantial body of research has provided evidence for an association between negative affect and eating disorders (see Stice, 2002 for a review) and negative affect has been conceptualized as a risk factor for disordered eating among males and females (Ricciardelli & McCabe, 2004; Stice, 2001). The recognition of negative affect as a risk factor for eating disorders has promoted the development of affect regulation models that conceptualize disordered eating behaviors as maladaptive strategies to reduce or avoid unpleasant emotional states (Heatherton & Baumeister, 1991; Polivy & Herman, 1993; Stice, Nemeroff, & Shaw, 1996; Wiser & Telch, 1999). Consistent with these models, recent studies have provided evidence that emotion regulation difficulties contribute to disordered eating behaviors. For instance, Whiteside and colleagues (2007) found that undergraduate men and women who reported binge eating reported experiencing greater difficulties in emotion regulation than their nonbinge eating peers. Specifically, binge eaters reported less emotional clarity and access to fewer adaptive affect regulation strategies than non-binge eaters. Similarly, Lavender and Anderson (in press) found that limited access to adaptive regulation strategies and nonacceptance of emotional experiences were difficulties that contributed to
⁎ Corresponding author. Department of Psychology, University at Albany, State University of New York, 1400 Washington Avenue, Albany, NY, 12222, USA. Tel.: +1 518 442 4851; fax: +1 518 442 4867. E-mail address:
[email protected] (J.M. Lavender). 1471-0153/$ – see front matter © 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.eatbeh.2009.07.002
disordered eating in undergraduate men. Research therefore supports the conceptualization of behaviors such as binge eating, purging, and excessive exercise as efforts to avoid unpleasant affective states, particularly among individuals who have a limited repertoire of adaptive emotion regulation skills. 1.1. Thought suppression A tendency to engage in maladaptive avoidance behaviors in response to distressing or unwanted thoughts and emotions may reflect a broader pattern of experiential avoidance, defined as the refusal to accept contact with unpleasant emotional, physical, and cognitive experiences (Chawla & Ostafin, 2007; Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). One form of experiential avoidance is thought suppression, which has been shown to be associated with a variety of affective disorders (Purdon, 1999). Efforts to suppress unpleasant cognitions frequently can be maladaptive and ultimately ineffective due to a paradoxical increase or rebound in the unwanted thoughts that often occur when suppression attempts fail (O'Connell, Larkin, Mizes, & Fremouw, 2005; Soetens, Braet, Dejonckheere, & Roets, 2006; Wegner, Schneider, Carter, & White, 1987). In an effort to further clarify the role of avoidance in disordered eating, studies have examined the effects of suppressing eating- and weight-related thoughts among individuals high and low in dietary restraint and disinhibition. The results of these studies have been mixed, with some suggesting that restrained eaters and disinhibited eaters are able to successfully suppress eating- and weight-related cognitions (Harnden, McNally, & Jimerson, 1997; Oliver & Huon, 2001)
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and others supporting the idea that suppression efforts result in a rebound effect among restrained eaters and individuals high in both restraint and disinhibition (O'Connell et al., 2005; Soetens et al., 2006). Research also suggests that individuals high in dietary restraint and disinhibition exhibit a greater tendency to engage in generalized thought suppression than unrestrained eaters and individuals who are high in dietary restraint, but low in disinhibition (Soetens, Braet, & Moens, 2008). In sum, preliminary evidence suggests that rejection and avoidance of aversive affective states and cognitions may be associated with disordered eating behaviors. Although the mechanisms underlying this association require further elaboration, some individuals may be more likely to engage in disordered eating behaviors in response to the increased distress that results from failed suppression attempts.
undergraduate men and women. These constructs are in theoretical opposition because mindfulness is characterized by acceptance and awareness of private experiences, whereas thought suppression is characterized by nonacceptance and efforts to reduce unwanted cognitions. It was hypothesized that both of these variables would account for unique variance in bulimic symptoms. Specifically, it was hypothesized that higher levels of dispositional mindfulness would be associated with less bulimic symptomatology, while higher levels of thought suppression would be associated with greater bulimic symptomatology.
1.2. Mindfulness
A total of 187 undergraduate women and 219 undergraduate men from a large Northeastern university participated in the current research for either $10 or credit in an introductory-level psychology course. The mean (SD) age for participants was 19.1 (1.5) years and the mean body mass index (BMI) of the sample was 24.0 (4.5) kg/m2. The ethnic composition of the sample was as follows: 71.9% Caucasian, 9.9% Latino/a American, 7.6% African American, 5.4% Asian American, and 3.7% other. The remaining 1.5% of participants did not report their ethnicity.
Consistent with the recognition that certain forms of experimental avoidance such as thought suppression may contribute to disordered eating, several therapies recently applied to the treatment of eating disorders include components designed to reduce experiential avoidance and increase awareness and acceptance, including Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999) and Dialectical Behavior Therapy (DBT; Linehan, 1993a,b). Although the role of acceptance in DBT and ACT is conceptualized somewhat differently, the therapies include similar strategies to promote awareness and acceptance. For instance, these interventions utilize mindfulness skills training as a method of promoting acceptance and awareness of private experiences in the present moment (i.e., thoughts, emotions, memories). Numerous case reports and treatment studies have provided preliminary evidence for the efficacy of these newer therapies in treating binge eating disorder, bulimia nervosa, and anorexia nervosa (see Baer, Fischer, & Huss, 2005 for a review). Although the exact mechanisms underlying the positive effects of mindfulness practice on disordered eating symptoms require further elaboration, Baer et al. (2005) have proposed several possibilities that are consistent with both cognitive–behavioral and affect regulation models of eating disorders. For example, the authors suggest that adopting a mindful outlook may promote the understanding that distressing cognitions (e.g., irrational thoughts about the consequences of breaking a dietary rule) are only temporary and do not require a particular behavioral response (e.g., purging). Researchers also have suggested that mindfulness functions via exposure and thus reduces the likelihood that an individual will engage in impulsive and maladaptive behaviors in response to aversive private experiences (Baer et al., 2005; Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006). 1.3. Current study Although newer mindfulness- and acceptance-based therapies have shown promise in treating individuals with eating disorders, little research has been conducted on the relationship between disordered eating behaviors and dispositional mindfulness, a trait characterized by attention to and acceptance of one's experiences. Given preliminary research suggesting that increasing mindfulness is associated with reductions in eating disorder symptoms, individuals who exhibit higher levels of dispositional mindfulness may be less likely to engage in disordered eating behaviors. Furthermore, although several studies have assessed the ability of individuals high and low in dietary restraint and disinhibition to suppress food-and weight-related thoughts, few studies have assessed the contribution of generalized thought suppression to the broad array of eating disorder symptoms. The purpose of the present investigation was to determine the extent to which chronic thought suppression and mindful attention and awareness contribute to bulimic symptoms in
2. Method 2.1. Participants
2.2. Measures 2.2.1. Bulimia Test-Revised (BULIT-R; Thelen, Farmer, Wonderlich, & Smith, 1991) The BULIT-R is a 28-item self-report measure of bulimic symptoms. Each item is rated on a 5-point scale and possible scores range from 28 to 140, with higher scores reflecting greater bulimic symptomatology. Sample items include “I am afraid to eat anything for fear that I won't be able to stop” and “I hate the way my body looks after I eat too much.” The measure assesses a broad range of disordered eating attitudes and behaviors including body dissatisfaction, binge eating, purging, and other compensatory behaviors. The measure has been widely used in the eating disorder literature and has been shown to discriminate individuals with bulimia nervosa from controls (Thelen et al., 1991; Thelen, Mintz, & Vander Wal, 1996). Cronbach's alpha was 0.93 in the present investigation. 2.2.2. White Bear Suppression Inventory (WBSI; Wegner & Zanakos, 1994) The 15-item WBSI assesses the tendency to suppress unpleasant or unwanted thoughts. Each item is rated on a 5-point scale from “strongly disagree” to “strongly agree.” Possible scores range from 15 to 75 and higher scores reflect a greater tendency to engage in thought suppression. Example items include “There are things that I try not to think about” and “I have thoughts that I try to avoid.” The measure has exhibited adequate internal consistency and test–retest reliability (Wegner & Zanakos, 1994). In the current study, Cronbach's alpha was 0.94. 2.2.3. Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003) The 15-item MAAS assesses the tendency to be aware of and attentive to present moment experiences in day-to-day life. Participants rate how often they find themselves being preoccupied, not paying attention to the present moment, and completing tasks or engaging in behaviors with little awareness. Each item is rated on a 6-point scale from “almost always” to “almost never.” Items are averaged to calculate the overall score and higher scores are indicative of greater dispositional mindfulness. Example items include “I rush through activities without being really attentive to them” and “I could be experiencing some emotion and not be conscious of it until sometime later.” The measure has evidenced good internal consistency and test–retest reliability
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(Brown & Ryan, 2003; MacKillop & Anderson, 2007). Cronbach's alpha was 0.90 in the present investigation. 2.3. Procedure This research protocol was reviewed and approved by the University at Albany Institutional Review Board. Participants completed a series of self-report questionnaires assessing disordered eating, demographic variables, and several dispositional characteristics. Participants completed the measures in a laboratory setting either individually or in groups. 2.4. Statistical analyses A series of hierarchical regression analyses were conducted in SPSS 13.0 to assess whether thought suppression and mindfulness contributed to bulimic symptoms after accounting for the variance associated with BMI. Separate analyses were conducted for men and women. 3. Results Table 1 presents the means and standard deviations of each variable included in the primary analyses for men and women. These scores are consistent with those obtained in previous studies with male and female undergraduates (Hayaki, in press; MacKillop & Anderson, 2007; Mitchell & Mazzeo, 2005; Wegner & Zanakos, 1994). Independent samples t-tests revealed a significant gender difference in bulimic symptoms [t(336.02) = 5.18, p b .001], but no gender differences were found for BMI, thought suppression, or mindfulness. 3.1. Contributions to bulimic symptoms in women In the first analysis, the BULIT-R score was regressed on BMI at step 1. Thought suppression (WBSI score) and mindfulness (MAAS score) were added at step 2. Results revealed that participant BMI (β = .21, p b .01) at step 1 uniquely explained 4.4% of the variance in bulimic symptoms. At step 2, mindfulness (β = −.20, p b .05) and thought suppression (β = .22, p b .01) were found to account for an additional 13.7% of the variance in bulimic symptoms. Together, the full model explained a total of 18.1% of the variance in bulimic symptoms among women. 3.2. Contributions to bulimic symptoms in men The second analysis followed the same steps: the BULIT-R score was regressed on BMI at step 1, and the WBSI and MAAS scores were added at step 2. Participant BMI (β = .29, p b .01) at step 1 uniquely explained 8.2% of the variance in bulimic symptoms. At step 2, mindfulness (β = −.16, p b .05) and thought suppression (β = .23, p b .01) were found to account for an additional 9.8% of the variance in bulimic symptoms. Together, the full model explained a total of 17.9% of the variance in bulimic symptoms among men.
Table 1 Means and standard deviations for variables among men and women. Variable/Measure Body Mass Index (kg/m2) BULIT-R WBSI MAAS
Men (N = 219)
Women (N = 187)
M
SD
M
SD
24.27 45.54 44.31 3.77
4.40 14.42 12.55 0.92
23.68 54.53⁎ 45.57 3.90
4.52 19.63 13.73 0.90
Note. BULIT-R = Bulimia Test-Revised; WBSI = White Bear Suppression Inventory; MAAS = Mindful Attention Awareness Scale. ⁎ p b .001.
4. Discussion The primary aim of the current investigation was to determine whether dispositional mindfulness and chronic thought suppression account for unique variance in bulimic symptoms among undergraduate men and women. The predictor variables in each of the hierarchical regression analyses were found to significantly contribute to the overall models predicting bulimic symptoms, accounting for approximately 18% of the variance among both men and women. As hypothesized, both mindfulness and thought suppression contributed unique variance in predicting bulimic symptoms after accounting for BMI. Additionally, thought suppression was found to account for a greater percentage of the variance than mindfulness among men and a greater percentage of the variance than mindfulness and BMI among women. Given research findings suggesting that unsuccessful suppression efforts may result in a rebound in the frequency of unwanted thoughts, individuals who engage in thought suppression may be at risk for turning to maladaptive strategies such as disordered eating behaviors to cope if their initial suppression efforts fail. This is consistent with prior research that also has shown nonacceptance of emotional experiences to be associated with disordered eating (Lavender & Anderson, in press). Nonacceptance of affective and cognitive experiences are forms of experiential avoidance and the current results therefore support the hypothesis that avoidance is associated with disordered eating. In contrast, the finding that MAAS scores were negatively associated with bulimic symptoms suggests that men and women who are higher in mindful attention and awareness are less likely to experience disordered eating attitudes and behaviors. Individuals who exhibit higher levels of dispositional mindfulness are more attentive to their cognitive and affective experiences, and Brown and Ryan (2004) propose that higher levels of attention and awareness promote acceptance of private experiences. Highly mindful individuals theoretically experience less distress in response to unwanted thoughts and emotions and may therefore be less likely to rely on disordered eating behaviors as maladaptive coping strategies. These findings are consistent with an affect regulation model of disordered eating and with prior research suggesting that difficulties in emotion regulation are associated with eating disorder symptoms (Lavender & Anderson, in press; Whiteside et al., 2007). There were several limitations in the present investigation. First, participants were non-treatment-seeking undergraduate men and women. Although eating disordered behaviors are a significant problem for undergraduate populations (Luce, Crowther, & Pole, 2008; O'Dea & Abraham, 2002), future studies will need to replicate the current findings in clinical samples. A second limitation is that the cross-sectional nature of this study precludes any causal inferences. For instance, although chronic thought suppression may theoretically function as a risk factor for eating disordered behaviors, it is possible that the tendency to engage in thought suppression develops in response to the unpleasant cognitions associated with disordered eating. Prospective studies are necessary to elucidate the nature and direction of the relationship between these dispositional factors and disordered eating. A further limitation was the reliance on self-report questionnaires. Although some authors have suggested that the greater anonymity associated with self-report measures of disordered eating may produce more honest responding than face-to-face interviews (Anderson, Simmons, Milnes, & Earleywine, 2007; French et al., 1998; Lavender & Anderson, 2008; Keel, Crow, Davis, & Mitchell, 2002), future studies may want to include interview-based assessments in conjunction with paper-based measures. Additionally, the assessment of mindfulness via self-report measures remains a contentious issue, with various authors conceptualizing the nature and measurement of mindfulness in different ways (Baer, Smith, &
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Allen, 2004; Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006; Brown & Ryan, 2004; Cardaciotto, Herbert, Forman, Moitra, & Farrow, 2008). Further research with other mindfulness measures is recommended. Finally, although the purpose of the current study was to examine whether mindfulness and thought suppression are associated with bulimic symptoms, these dispositional factors are likely implicated in a broad array of psychopathologies and are therefore not unique to disordered eating. For example, thought suppression has been shown to be associated with a variety of affective disorders (Purdon, 1999), and studies have revealed that lower levels of dispositional mindful attention and awareness are associated with disorders including pathological gambling and borderline personality (Lakey, Campbell, Brown, & Goodie, 2007; Wupperman, Neumann, Axelrod, 2008). Although newer mindfulness- and acceptance-based therapies such as ACT and DBT have been adapted for use in the treatment of eating disorders, there have been relatively few basic research studies on the role of experiential avoidance and dispositional mindfulness among individuals who engage in disordered eating behaviors. The results of the present research contribute to the literature suggesting that a tendency to engage in experiential avoidance is associated with disordered eating. Specifically, the tendency to suppress unwanted or unpleasant thoughts is associated with greater disordered eating pathology. These findings also provide evidence for a negative association between eating disordered behaviors and dispositional mindful attention and awareness. Role of funding sources Partial funding for this study was provided by the University at Albany Department of Psychology. The Department had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. Contributors Jason Lavender participated in developing the study design, collecting and analyzing the data, and preparing the manuscript. Bianca Jardin contributed to developing the study, collecting the data, and preparing the manuscript. Drew Anderson contributed to the conceptualization and design of the study and provided assistance in preparing the manuscript. All authors contributed to and have approved the final manuscript. Conflict of interest All authors declare that they have no conflicts of interest.
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