Bulimic Behaviors Research Articles

Weight suppression is a robust predictor of outcome in the cognitive-behavioral treatment of bulimia nervosa.

This study examined weight suppression (difference between highest premorbid weight and pretreatment weight) as a predictor of outcome in 188 outpatients with bulimia nervosa enrolled in a cognitive-behavioral therapy intervention. Participants who dropped out of treatment had significantly higher levels of weight suppression than treatment completers. Of participants who completed treatment, those who continued to engage in binge eating or purging had significantly higher levels of weight suppression than those who were abstinent from bingeing and purging. Results did not change when body mass index, dietary restraint, weight and shape concerns, or other relevant variables were controlled. Relinquishing bulimic behaviors and adopting normal eating patterns may be most feasible for patients who are closest to their highest premorbid weights.

Treatment of Eating Disorders in Children, Adolescents, and Young Adults

Treatment of Eating Disorders in Children, Adolescents, and Young Adults

Alcohol use in adolescents with eating disorders

Eating disorders, in particular bulimia nervosa and binge eating disorder are associated with co-morbid alcohol and drug abuse. School-based studies have shown significant associations between bulimic behaviors and various measures of alcohol, cigarette and other drug use and abuse. Amongst bulimic adolescents, substance use is related to an increased likeliness of high risk behaviors such as attempted suicide, stealing and sexual intercourse. In contrast with bulimics and binge eaters, restricting anorexics have low rates of co-morbid substance abuse. It appears that restricting anorexics, binge eaters and bulimics represent distinct subgroups within the eating disordered population and binge eaters and bulimics are more prone to alcohol use. It is possible that individuals with eating disorders turn to alcohol use/abuse as a way of coping with the problems caused by their eating disorder. Researchers have proposed that an addictive personality is an underlying trait, which predisposes individuals to both eating disorders and alcohol abuse. Eating disorders are often conceptualized as an addictive disorder. Opioid antagonists, such as naltrexone, may be useful in treating both eating and alcohol use disorders. There is also evidence that serotonin reuptake inhibitors, which are traditionally used to treat major depression, may be an effective treatment. Cognitive-behavioral therapy has been effective in treating alcohol use and eating disorders individually and may be an effective combined treatment for co-morbid eating disorders and alcohol use. Teaching healthy ways to cope with the stressful situations may also help decrease alcohol use and disordered eating behaviors.

Is multi-impulsive bulimia a distinct type of bulimia nervosa: Psychopathology and EMA findings

To determine if clinically defined multi-impulsive bulimia (MIB) can be validated using an empirical classification approach. One hundred and twenty-five women who met DSM-IV criteria for bulimia nervosa were interviewed and completed a two-week EMA protocol. Participants who reported at least three highly impulsive behaviors were compared to participants who did not report such impulsive behavior. Also, Latent Class Analysis (LCA) was conducted to determine if the MIB classification could be replicated empirically. LCA produced a two-class solution consistent with the traditional clinical approach to MIB classification. In both approaches, MIB was associated with higher levels of anxiety disorders, child abuse, and daily self-damaging behaviors than the non-MIB class. Clinical classification of MIB was empirically supported through LCA. Although the classes failed to differ in bulimic behavior, MIB appears to represent a group of bulimic individuals with significant trauma histories and associated psychopathology.

Polycystic ovary syndrome in bulimic women – an evaluation based on the new diagnostic criteria

An association between bulimia nervosa and polycystic ovary syndrome (PCOS) has been suggested but also questioned. Since there is still a controversy about this issue, we investigated clinical and biochemical symptoms of PCOS according to the new diagnostic criteria in a large group of bulimic women compared with controls. Seventy-seven women with bulimia and 59 matched healthy women were investigated with respect to menstrual status, polycystic ovaries, hirsutism, acne and sex hormone levels. We found increased occurrence of menstrual disturbances, hirsutism and PCOS in bulimic women, whereas ovarian variables and acne did not differ from controls. Hirsutism score and indices of biologically active testosterone were positively correlated in bulimics but not in controls, while there were no major differences in serum androgens. In conclusion, this study supports an increased frequency of PCOS in bulimic women and may also indicate increased androgen sensitivity in these women. PCOS may promote bulimic behavior since androgens have appetite-stimulating effects and could impair impulse control. Menstrual disturbances and clinical signs of hyperandrogenism should be evaluated in bulimics in order to provide adequate medical care and treatment.

Les cognitions et leur évaluation dans les troubles des conduites alimentaires

Cognitions are of crucial importance in the -aetiology and the maintenance of eating disorders. Dysfunctional cognitions in eating disorders are related to body image, self-esteem and feeding. The aim of this paper is to review the actual knowledge in this area. First, we will display -cognitive models in eating disorders. Cognitive factors in -eating disorders are logical errors, cognitive slippage and conceptual complexity. Eating disorder patients seem to have a deficient cognitive development. Some cognitive models stipulate that eating disorder patients may develop organised cognitive structures schemas concerning the issues of weight and its implications for the self. These schemas can account for the persistence and for the understanding the "choice of the eating disorder symptomatology. Cognitive pheno-mena of interest are self-schema, weight-related schema and weight-related self-schema. The maintenance model of ano-rexia nervosa argued that, initially there is an extreme need to control eating which is supported by low self-esteem. The maintenance of the disorder is reinforced by three mechanisms: dietary restriction enhances the sense of being in control; aspects of starvation encourage further dietary restriction; concerns about shape and weight encourage restriction. The development and maintenance of bulimic symptomatology are explained by placing a high value on attaining an idealised weight and body shape accompanied by inaccurate beliefs. The cognitive model of specific family of origin experiences puts forward the development of -maladaptative expectancies for eating and thinness. Second, we discuss distortions in information processing. a) In feeding laboratories, bulimics show a wide range of caloric intake and a disruption of circadian feeding patterns. In overeating bulimics, large meals occurred mainly during afternoon and evening with high fat and carbohydrate intake, but the majority of meals were of normal size and frequency. Responsivity to food cues indicates that bulimics were more responsive to sight, smell and taste of their favourite binge food, and a greater responsivity was associated with increasing -cue salience. Eating disorder patients appear to have internalised a mediated social rule concerning "good food" and make drastic selections thus removing the possibility of choice of foodstuffs. b) Experimental processes: temporal factors in the processing of threat seem to be of importance in patients with high levels of eating psychopathology. There is no evidence for preattentive processing biases among anorectics. Changes in information processing speed after treatment were not linked to treatment condition or treatment response. c) Judgement and emotions: in eating disorder patients, distortions of depressogenic nature are found that influence the cognitive style; thoughts about eating, weight and shape are characterised by negative affective tone; negative emotions could account for bulimic behaviour; anxiety and distress are correlated to thought control strategies. Information treating seems to be impaired in a non-homogeneous way. d) Cognitive schemas are seriously maladaptive and not well investigated. In eating disorder patients, core beliefs are absolute, unconditional and dichotomous cognitions about oneself and the world. There are only few studies in this field moreover showing controversial results. Core beliefs can explain links between personality disorders and eating psychopathology. Pathological core beliefs have to be taken in to account because they influence the outcome and the efficacy of cognitive behavioural therapy. Third, the last part of this paper summarises actually available rating scales eva-luating distorted cognitions in eating disorders. There are different methods for evaluation: specific and non-specific self-report questionnaires, thought-sampling procedures, -methods derived from cognitive psychology. The Mizes Anorectic Cognition questionnaire (MAC) is a well-known self-rating scale with good psychometric properties. The revised form of the MAC appears to be an improvement in the area of internal consistency, sensitivity, and reliability. It is obvious that there is no particular rating scale referring to specific cognitions on food. the main result of this literature review reflects that the cognitive treatment in eating disorders is altered in a specific way on an emotional basis and on self-representation.

Emotion Regulation Factors as Mediators Between Body Dissatisfaction and Bulimic Symptoms in Early Adolescent Girls

Research suggests that negative affect is an important mediator in the relationship between body dissatisfaction and bulimic symptoms. This study examines the mediational role of specific emotion regulation processes (i.e., negative emotionality, poor awareness of emotion, nonconstructive coping with negative emotion) in bulimic symptoms. In addition to these emotion regulation variables, body dissatisfaction and bulimic symptoms were assessed in 234 girls in Grades 6 to 8 (mean age = 12 years, 11 months). The results indicated that negative affect, poor awareness of emotion, and nonconstructive coping with negative emotion partially mediated the relationship between body dissatisfaction and bulimic behaviors. The findings are discussed in light of previous research that suggests emotion regulation needs to be viewed as a multidimensional construct.

Time trends in eating disturbances in young Greek migrants

The study intends to measure time trends in eating disorder psychopathology in Greek adolescents in Veria (Greece) and migrant Greek adolescents in Munich (Germany). For this purpose, large samples of students were assessed at both locations in the 1980s and about two decades later. Our research question was whether the frequency of eating disorder-related psychopathology had changed over time and that there were differences between migrants and nonmigrants. The present-day prevalence of eating disorders in the Greek population was established. Greek adolescents were assessed in Munich and Veria in the 1980s (N = 2,631) and almost two decades later (N = 2,920). At both times, the Anorexia Nervosa Inventory for Self-Rating (ANIS) was used to assess eating disorder pathology and the General Health Questionnaire (GHQ-28) was used to assess mental health status. In the second wave, persons at risk for an eating disorder were interviewed using the Structured Interview for Anorexic and Bulimic Syndromes (SIAB-EX). At both times and both locations, adolescent girls in comparison to boys had higher, more pathologic scores on the GHQ-28 and on all ANIS self-rating subscales. Females in Munich reported an increase over time in figure consciousness and their fear of negative effects of meals. In the 1980s, significantly higher scores of bulimic behavior were found in Veria as compared with Munich. In the second wave, bulimic behavior was considerably decreased in Veria for both girls and boys, and for bulimic behavior no significant differences were found between locations. The percentage of girls with a low body weight (<5th percentile) increased significantly over time in Veria and Munich. In the second wave, the current prevalence for girls with anorexia nervosa was 0.00% in Munich and 0.59% in Veria (lifetime 1.26% and 1.18%, respectively). For bulimia nervosa, current prevalence was 1.89% in Munich and 1.18% in Veria. Differences between locations diminished over time. Bulimic syndromes are prevalent in both locations.

Childhood Sexual Abuse, Disordered Eating, Alexithymia, and General Distress: A Mediation Model.

Drawing from trauma-related theory (e.g., M. F. Schwartz & P. Gay, 1996), this article presents a model of associations among child sexual abuse (CSA), psychological distress, alexithymia, and disordered eating (DE). Structural equation modeling was used to test this conceptual model with a sample of female college students (N = 589). Results indicate that CSA is not directly associated with DE. Instead, CSA is associated with psychological distress, which is further related to alexithymia. Additionally, bootstrapping analyses were used to show that distress and alexithymia mediate the relationship between CSA and DE. Finally, restrictive eating behaviors and attitudes mediate between alexithymia and bulimic behaviors. This latter pathway was shown to be important to the model by the analysis of a 2nd, nested model. Although this model is only one of many possible, these results point to a weak but significant complex relation between CSA and DE.

Prevalence, Characteristics, and Correlates of Teasing Experiences among Overweight Children vs. Non‐overweight Peers

Information regarding the prevalence, nature, sources, and psychosocial correlates of teasing was obtained for overweight (OV) children (10 to 14 years of age) vs. non-overweight (non-OV) peers. It was hypothesized that weight-related teasing would be negatively correlated with self-esteem in specific domains and with enjoyment of physical/social activities and positively correlated with loneliness, bulimic behaviors, body dissatisfaction, and enjoyment of sedentary/isolative activities. Teasing experiences and psychosocial correlates were assessed among OV children from a fitness camp and a demographically similar school sample of non-OV children. Among the OV children, appearance-related teasing was more prevalent, frequent, and upsetting, involved disparaging nicknames focusing more on weight rather than less stigmatized aspects of appearance, and more often perpetrated by peers in general rather than a specific peer. Degree of teasing within the full sample was significantly associated with higher weight concerns, more loneliness, poorer self-perception of one's physical appearance, higher preference for sedentary/isolative activities, and lower preference for active/social activities, all but the latter association holding up above and beyond actual weight status and demographics. Among OV children, teasing was associated with bulimic behaviors. Associations with type of teasing showed specificity, with weight-related teasing predicting weight and appearance variables and competency-related teasing related to social domain factors. When frequency, intensity, emotional impact, and stigmatized content are examined, findings indicate that teasing is more severe for OV children. Effective interventions are needed to help victims cope with and prevent further weight-related teasing, which may improve peer functioning, enhance weight control efforts, and reduce risk for future eating disturbance.

The impact of appearance-related teasing by family members

Purpose This study evaluated the prevalence and effects of teasing by family members on body dissatisfaction, eating disturbance, and psychological functioning. Methods Self-report data were collected from 372 middle school girls who were part of a larger study in a Tampa Bay, Florida area middle school (mean age: 12.6 years; 85% Caucasian). Results Twenty-three percent of participants reported appearance-related teasing by a parent, and 12% were teased by a parent about being heavy. Nineteen percent of the girls reported appearance-related teasing by fathers, 13% reported appearance-related teasing by mothers, and 29% reported appearance-related teasing by siblings. After controlling for body mass index (BMI) and maternal teasing, paternal teasing was a significant predictor of body dissatisfaction, comparison, thin-ideal internalization, restriction, bulimic behaviors, self-esteem, and depression. After controlling for BMI and paternal teasing, maternal teasing was a significant predictor of depression. After controlling for BMI and maternal teasing, paternal teasing significantly increased the odds of having a sibling who teases. Girls who reported being teased by at least one sibling demonstrated significantly higher levels of body dissatisfaction, comparison, thin-ideal internalization, restriction, bulimic behaviors, depression, and significantly lower levels of self-esteem than those girls who reported they were not teased by their siblings. Frequency of teasing was associated with higher levels of negative outcomes. Conclusions This study has implications for treatment and prevention of eating disorders. The results suggest that health care providers should assess appearance-related teasing in their patients’ lives to identify girls who may be at risk for body image and eating disturbance and poor psychological functioning.

Childhood Beauty Pageant Contestants: Associations with Adult Disordered Eating and Mental Health

This study evaluated the association between childhood beauty pageants and adult disordered eating, body dissatisfaction, depression, and self-esteem. Eleven women who participated in childhood beauty pageants were matched on age and BMI with 11 non-participating women. Childhood pageant participants scored higher on body dissatisfaction, interpersonal distrust, and impulse dysregulation than non-participants, and showed a trend toward greater ineffectiveness. There were no significant differences between groups on measures of bulimia, body perception, depression, and self-esteem. These findings suggest childhood beauty pageant participation may influence adult body dissatisfaction, interpersonal distrust, and impulse dysregulation, but not bulimic behaviors, body perception, depression, and self-esteem. Parts of this article were presented as an oral paper presentation at the Academy for Eating Disorder’s International Conference on Eating Disorders, April 2004, Orlando, Florida.

Reported childhood sexual abuse and eating-disordered cognitions and behaviors

Links have been proposed between childhood sexual abuse and the development of eating disorders (e.g., Fallon & Wonderlich, 1997; Root & Fallon, 1989). However, the reported prevalence of such trauma in the eating-disordered population varies widely across studies, due to differences in definitions, methodologies and tools used (Welch & Fairburn, 1994). Given the similar prevalences of reported sexual abuse in eating-disordered patients, female psychiatric controls, and non-psychiatric controls, some researchers have concluded that there is no specific relationship between sexual abuse and the eating disorders (Pope & Hudson, 1992; Welch & Fairburn, 1994). However, while there appears to be no straightforward causal link between childhood sexual abuse and the simple presence of an eating disorder, there does appear to be evidence for more complex relationships between abuse and specific bulimic behaviors and eating attitudes. For example, when one compares diagnostic subgroups of eatingdisordered patients, the prevalence of childhood sexual abuse is unusually low among restrictive anorexics, but high among women with disorders involving bulimic behaviors (e.g., Steiger & Zanko, 1990; Waller, Halek, & Crisp, 1993). Bingeing and purging behaviors appear to regulate disturbing cognitions and emotions, which can arise from an abuse history (e.g., Root and Fallon, 1989). Similar links appear to be found with other behaviors that can be characterized as assisting in the blocking of intolerable emotional

Factors related to severity of vomiting behaviors in bulimia nervosa

Assessments of the severity of vomiting (weekly frequency), depressive and eating-related psychopathology, anger level and management, and personality dimensions were used to characterize patients with bulimia nervosa binge purging type (BN-BP). The sample comprised 130 outpatients with BN and 130 control women. The Eating Disorder Inventory-2 (EDI-2), the State-Trait Anger Expression Inventory, the Beck Depression Inventory, and the Temperament and Character Inventory (TCI) were administered to all patients. The Self-Directedness dimension of the TCI and the Bulimia subscale of the EDI-2 were the strongest predictors of the severity of bulimic behavior; anger levels and anger expression were not so strongly related to illness severity. A more severe form of bulimic symptomatology probably has substrata in specific character deficits (low Self-Directedness on the TCI) and particular psychopathological features (high bulimia on the EDI-2). Patients with a high frequency of vomiting need specific therapeutic interventions to enhance the character dimension of Self-Directedness.

The impact of subliminal abandonment and unification cues on eating behavior

Subliminal presentation of visual abandonment cues leads to greater levels of eating, despite a lack of conscious awareness of the information involved. The current study examined whether this behavioral impact can be countered by the subliminal presentation of contradictory, counterschematic information (unification cues). Ninety-six nonclinical women were presented with subliminal abandonment cues, either preceded or followed by neutral or unification cues. The dependent variable was the amount eaten after the task. Presenting subliminal unification information before or after the subliminal abandonment cue significantly reduced the amount eaten (relative to the impact of neutral cues). These findings are consistent with a model where preconscious processing of unification cues has the effect deactivating abandonment schemas, either through inoculation or restoration. Preconscious presentation of unification cues might play a role in the broader cognitive-behavioral treatment of bulimic behaviors.

State dissociation in bulimic Eating Disorders: An experimental study

Dissociation and binge eating appear to have equivalent functions, lowering awareness of generalized threat and negative self-esteem. Dissociation can be a general characteristic of the individual, present in all situations (i.e., a trait), or it can be a time-limited reaction to a specific situation (i.e., a state). Previous studies have shown that the subliminal presentation of threat cues leads to increased bulimic behaviors. This experimental study examines whether dissociation is activated under similar conditions, thus testing whether dissociation is a reactive state in bulimic women, as well as a trait. The participants were 24 bulimic and 26 nonclinical women, each of whom completed the Eating Disorders Inventory and the Dissociative Experiences Scale. Each woman was exposed to subliminal neutral and threat cues, before completing the subjective component of the Clinician-Administered Dissociation Scale and a measure of anxiety and mood (the Hospital Anxiety and Depression Scale). The subliminal threat cue significantly increased state dissociation (particularly derealization levels) in the bulimic women but had no effect on the nonclinical group. There was no impact on mood. State dissociation appears to play an integral role in the bulimic process, but further studies are needed to determine the causal structure in that relationship and whether it applies in other disorders. Future clinical practice should be directed towards the identification and treatment of state dissociation in therapy.

Cognitive avoidance in the strategic processing of ego threats among eating-disordered patients

This study of strategic processing examined whether it is possible to demonstrate cognitive avoidance of ego threats in women with eating disorders, using a task that involves less automatic identification of threat cues. Fifty eating-disordered (anorexic and bulimic) and 50 comparison women completed a task of strategic processing, assessing their speed of solving neutral, food-related, and ego threat-related anagrams. Cognitive avoidance of threat-related information was shown, but only among women with bulimic characteristics. The presence of bulimic behaviors (binging and vomiting) was the clearest factor associated with such avoidance. There was no evidence of avoidance of disorder-related (food) cues. Research and therapeutic implications are discussed, including the potential utility of therapies that directly or indirectly address the schema-level representation of ego threats when working with eating pathology.

Group cognitive‐behavior therapy for bulimia nervosa: Statistical versus clinical significance of changes in symptoms across treatment

Cognitive-behavior therapy (CBT) is the most effective treatment to date for bulimia nervosa. The current study investigated the effects of group CBT treatment (including some interpersonal elements) for bulimic clients. Twenty-nine patients completed the Stirling Eating Disorder Scales, the Beck Depression Inventory, and the Beck Anxiety Inventory at assessment, pretreatment, end of treatment, and at 6 months follow-up. Symptom change was explored in two ways. Statistically significant change was determined using repeated-measures analyses of variance and clinically significant change was determined using criteria proposed by Jacobson & Truax (1991, Journal of Consulting and Clinical Psychology, 59, 12-19). There was an overall improvement in dimensional measures of bulimic and restrictive attitudes and behaviors (maintained at the 6-month follow-up), which was most closely matched by clinically significant changes in bulimic behaviors. Depression (but not anxiety) was also targeted effectively. Statistically significant improvements in psychological functioning were evident only for assertiveness, but the analysis of clinical significance showed improvement for some participants in self-evaluation (self-directed hostility). Group CBT (including interpersonal elements) is broadly effective when treating bulimia nervosa, but it does not work in all cases (and may lead to enhancement of restrictive characteristics in some cases). Tests of statistical and clinical significance provide different information, which can inform practice and aid in the development of treatments for patients who respond less well to current best practice.

Child sexual abuse in China: a study of adolescents in four provinces

Objective: Little is known about Child Sexual Abuse (CSA) in Chinese societies. This study examined CSA experiences and associations with demographic factors, self-reported health and risky behaviors among senior high school students in four provinces in central and northern China. Method: Students in four schools in Hubei, Henan, Hebei, and Beijing provinces participated in an anonymous, self-completed questionnaire survey. From a total enrolment of 3,261 students in the target classes in years 11 and 12, 2,300 (70.5%) returned valid questionnaires. Mean age was 17.2 years. The questionnaire was adapted from prior CSA research in Australia and utilized standard scales for depression, self-esteem, and youth risk behavior. Results: Prevalence of any unwanted sexual experience before the age of 16 years was higher among females (16.7%) than males (10.5%). Sexual penetration was rarely reported (1%), while 7% reported at least one type of physical contact abuse (female 8.9%, male 5.0%). Risk of any CSA was not associated with the existence of siblings (one-child vs. two- or more child families), rural/urban residence during childhood, or parental education. Males and females with CSA were more depressed and suicidal, and drank alcohol more often, than unaffected adolescents. Contact CSA was strongly associated with sexual intercourse (ever) for both males and females. Females with CSA were more likely than others to engage in anorexic and bulimic behaviors, while males with CSA were often involved in violence. Conclusion: Social norms for consensual sexual experiences differ between Eastern and Western societies. CSA experiences also differ, with substantially less penetrative and physical contact abuse in China. However, the psychological and behavioral profile of abused, young Chinese people, including the additional burden associated with contact abuse, is similar to that found in other cultures.

The associations between childhood dance participation and adult disordered eating and related psychopathology

Objective To examine the relationship between childhood dance participation and adult eating behavior and psychological health. Methods A total of 546 undergraduate females at a large Midwestern university completed questionnaires regarding eating behavior and associated features, depression, self-esteem, and body image. Results Women who participated in childhood dance are more likely to score higher on measures of bulimic behaviors than nondancers. In addition, childhood dancers indicated greater drive for thinness and poorer impulse control compared to nondancers. Furthermore, there was a statistical trend for childhood dancers to report greater perfectionism and a smaller ideal body mass than nondancers. There were no significant differences between dance groups on measures of depression and self-esteem. Conclusion These findings suggest that participating in dance as a child may influence one's eating behavior as an adult, including associated factors such as drive for thinness and impulse control and potentially perfectionism and preferred body size.