Cognitive-behavioural therapy for adolescents with bulimic symptomatology: the acceptability and effectiveness of internet-based delivery.

BACKGROUND: The evidence base for the treatment of adolescents with bulimia nervosa (BN) is limited. AIMS: To assess the feasibility, acceptability, and clinical outcomes of a web-based cognitive-behavioural (CBT) intervention for adolescents with bulimic symptomatology. METHOD: 101 participants were recruited from eating disorders clinics or from beat, a UK-wide eating disorders charity. The programme consisted of online CBT sessions ('Overcoming Bulimia Online'), peer support via message boards, and email support from a clinician. Participants' bulimic symptomatology and service utilisation were assessed by interview at baseline and at three and six months. Participants' views of the treatment package were also determined. RESULTS: There were significant improvements in eating disorder symptoms and service contacts from baseline to three months, which were maintained at six months. Participants' views of the intervention were positive. CONCLUSIONS: The intervention has the potential for use as a first step in the treatment of adolescents with bulimic symptomatology.

Causes of injuries resulting in hospitalisation in Australia: assessing coder agreement on external causes.

OBJECTIVE: To assess extent of coder agreement for external causes of injury using ICD-10-AM for injury-related hospitalisations in Australian public hospitals. METHODS: A random sample of 4850 discharges from 2002 to 2004 was obtained from a stratified random sample of 50 hospitals across four states in Australia. On-site medical record reviews were conducted and external cause codes were assigned blinded to the original coded data. Code agreement levels were grouped into the following agreement categories: block level, 3-character level, 4-character level, 5th-character level, and complete code level. RESULTS: At a broad block level, code agreement was found in over 90% of cases for most mechanisms (eg, transport, fall). Percentage disagreement was 26.0% at the 3-character level; agreement for the complete external cause code was 67.6%. For activity codes, the percentage of disagreement at the 3-character level was 7.3% and agreement for the complete activity code was 68.0%. For place of occurrence codes, the percentage of disagreement at the 4-character level was 22.0%; agreement for the complete place code was 75.4%. CONCLUSIONS: With 68% agreement for complete codes and 74% agreement for 3-character codes, as well as variability in agreement levels across different code blocks, place and activity codes, researchers need to be aware of the reliability of their specific data of interest when they wish to undertake trend analyses or case selection for specific causes of interest.

Validity of the Eating Disorders Examination-Questionnaire when used with adolescents with bulimia nervosa and atypical bulimia nervosa.

OBJECTIVE: To validate the online questionnaire form of the Eating Disorders Examination (EDE-Q) against the interview version (EDE) in a clinic and community sample of adolescents with bulimia nervosa (BN) or atypical BN (eating disorder not otherwise specified with bulimic features - EDNOS-BN). METHOD: Adolescents with BN (N=58) or EDNOS-BN (N=37) completed the EDE over the telephone and the EDE-Q online. RESULTS: There were moderate to high correlations between the attitudinal scales. Eating was rated as more pathological on the EDE-Q than the EDE, except dietary restraint. As in research among adults, agreement between the two measures was low regarding binge eating episodes, but better for vomiting episodes. When compared with the EDE, the EDE-Q attitudinal scales were more valid for BN than for EDNOS-BN patients, and more valid for the clinic sample. CONCLUSION: The online version of the EDE-Q has partial validity for use with adolescents. The EDE-Q might be reporting a more accurate description of current status, as it avoids possible filtering and approval aspects.

Core beliefs and social anxiety in the eating disorders.

Social anxiety is a common comorbid problem in the eating disorders. The present study investigated whether specific types of core beliefs are common in eating-disordered individuals presenting with high levels of social anxiety. The participants were a group of 191 women meeting Diagnostic and Statistical Manual-IV (DSM-IV) criteria for an eating disorder. Young's Schema Questionnaire (YSQ-S) was used as a measure of core beliefs, while a brief version of the Fear of Negative Evaluation scale (Brief FNE) was used as a measure of social anxiety. The results showed that eating-disordered individuals with high levels of comorbid social anxiety report higher levels of socially-oriented core beliefs (abandonment; defectiveness/shame) than those who experience low levels of social anxiety. The findings highlight the potential importance of addressing core beliefs in specific groups of eating-disordered individuals. Implications for future research and clinical practice are discussed.

Family functioning in adolescent anorexia nervosa: a comparison of family members' perceptions.

Abnormal patterns of family functioning have often been reported in anorexia nervosa. Moreover, members of families with an adult with eating disorders have different family functioning perspectives. This study investigated whether differences in family members' perspectives, similar to the ones found in families of adults with eating disorders, can be found in families of adolescents with anorexia nervosa. Perceived family functioning, measured with the Family Assessment Device, was compared between 49 control and 34 clinical families, and across family members. Differences were found between the two groups on a number of aspects of family functioning, with the clinical families showing most disturbances. There was a general agreement across family members in their perceptions of family functioning, with one notable exception. Clinical daughters disagreed with both their parents about the family level of communication, whereas control daughters disagreed only with their fathers. Disagreements between clinical adolescents and their mothers about the family communication style appear to be important in anorexia nervosa in this age group, although it is not possible to reach conclusions about the direction of causality. These findings support the use of family-oriented therapies that aim to identify and work with difficulties in communication within the family.

The prevalence of DSM-IV personality pathology among individuals with bulimia nervosa, binge eating disorder and obesity.

BACKGROUND: There are numerous reports of personality disorder pathology in different eating disorders. However, few studies have directly compared personality pathology in bulimia nervosa, binge eating disorder and obesity. The present study examines group differences in DSM-IV personality pathology, considering the potential utility of understanding personality disorders in terms of diagnosis and dimensional scores. METHOD: Eating disorder diagnoses were established using the Eating Disorder Examination interview. Thirty-five bulimia nervosa patients, 15 binge eating disorder patients and 37 obese patients were assessed and compared on the International Personality Disorder Examination using categorical and dimensional personality disorder scores. RESULTS: For most personality disorders, there was a dichotomy of binge eaters versus non-binge eaters. In contrast, there was a continuum of severity in borderline personality disorder pathology between the groups. The dimensional system of measurement of personality pathology allowed for clearer differentiation between the groups. CONCLUSION: The study strongly indicates that personality disorder difficulties are present in patients who binge eat, while obese patients who do not binge eat display significantly less personality disorder pathology. Assessment of bulimia nervosa, binge eating disorder and obesity needs to address personality disorders and pathology. Dimensional markers of personality pathology can be used to supplement categorical diagnoses, providing information about the traits that underlie diagnosis.

Somatoform dissociation in eating-disordered patients.

This study investigated the role of somatoform dissociation in eating disorders and pathological eating behaviour, relative to the established association of eating pathology with psychological dissociation. The participants were 131 women with DSM-IV diagnoses of anorexic or bulimic disorders and 75 women who had no such disorder. Each woman completed measures of psychological and somatoform dissociation, as well as a measure of bulimic attitudes. The current presence or absence of specific bulimic behaviours was identified during the clinical interview. Levels of both forms of dissociation were higher in the women who had diagnoses of disorders with a bulimic component (bulimia nervosa; anorexia nervosa of the binge/purge subtype) than in the non-clinical or restrictive anorexic women. Somatoform dissociation showed particularly strong links with the presence of bulimic behavioural features (excessive exercise, laxative abuse, diet pill abuse, diuretic abuse) and with bulimic attitudes. The formulation and treatment of cases where there are bulimic features is likely to be enhanced by the assessment of somatoform dissociation.

Influence of environmental temperatures during gestation and at birth on eating characteristics in adolescence: a replication and extension study.

Past research has shown a season of birth effect in clinical subjects with eating disorders. Studies also indicate a similar effect of environmental temperatures in non-clinical subjects, as well as effects of environmental temperatures during the three trimesters of gestation. These two studies aimed to replicate and extend those findings. The participants were adolescents (ages 15-19 years) who attended public schools in a mid-Atlantic US city. They completed the relevant scales of the Eating Disorder Inventory (N=578) and the Three Factor Eating Questionnaire (N=191). Correlational analyses were employed to study the relationship of environmental temperatures during pregnancy (the three trimesters of intrauterine development and at birth) with eating characteristics. The results of the previous studies were broadly replicated in Study 1, but Study 2 revealed a difference in the pattern of associations according to the measure used. This contrast indicates that the way in which one conceptualizes eating pathology is of critical importance in understanding the long-term impact upon eating patterns of environmental temperature during the intrauterine period. Possible theoretical bases for these findings are discussed.

Environmental temperature during gestation and body mass index in adolescence: new etiologic clues?

OBJECTIVE: Being born during certain parts of the year is linked to the presence of obesity in later years. Animal studies suggest that environmental temperature during fetal development may be one aspect of the link to later weight status, but this relationship has not been extensively studied in humans. The present study investigates whether environmental temperature during different stages of human gestation is associated with body mass index (BMI) during late adolescence. METHODS: Questionnaire data were collected from adolescents (n=578; ages 15-19 y) attending public schools in a mid-Atlantic US city. Pearson correlations were used to assess association of BMI with mean environmental temperature (from meteorological records) during trimesters of intrauterine development and at birth. RESULTS: BMI was significantly correlated with environmental temperatures in the second and third trimester, but only among female African Americans. Among females, those 'at risk for overweight' or overweight (BMI >85th percentile) tended to be born during periods of warmer average environmental temperatures (>13.2 degrees C). However, this effect was reliable only among African American females (relative risk=2.51, CI 1.07-5.91). A similar, non-significant tendency emerged among Caucasian females, but there was no such effect in males. CONCLUSIONS: Environmental temperatures during pregnancy and at birth are associated with the likelihood that African American females become overweight as adolescents. Possible biological and dietary mechanisms for this finding are discussed.

Environmental temperature during pregnancy and eating attitudes during teenage years: a replication and extension study.

OBJECTIVE: Among nonclinical adolescents, restrictive eating attitudes are more likely to occur among females born during warmer months. The present study aimed to replicate this finding and to extend it, considering whether such an effect is found in males and across the teenage years. In addition, the influence of temperature across the intrauterine period was considered. METHOD: The participants consisted of younger and older teenagers, all born in England. Each completed the relevant scales of the Eating Disorders Inventory and provided demographic information. Temperature across fetal development was determined using national meteorological records. RESULTS: There was a positive link between restrictive attitudes and temperature at birth among the older female group, although this replication effect did not reach significance. The same association among the older males was highly significant. The range of temperatures during fetal development also predicted later restrictive attitudes. In contrast, these effects were not replicated among the younger group, where a different pattern of effect was found (among the females only). CONCLUSION: Environmental temperature seems to have an important influence on later eating attitudes, but the pattern of influence appears to vary across development. Therefore, studies of the mechanisms behind this effect need to consider the role of gender and development, as well as the role of temperature across the period of intrauterine development.

The psychopathology of bulimic women who report childhood sexual abuse: the mediating role of core beliefs.

Although reported sexual abuse in childhood is associated with bulimic behaviors, less is known about the cognitive factors that explain this association. This study examined the potential role of core beliefs as a mediator in the abuse-bulimia link. Sixty-one bulimic women were interviewed regarding any history of childhood sexual abuse and completed measures of bulimic behaviors, dissociation, depression, and core beliefs. The 21 women who reported a history of childhood sexual abuse had significantly higher levels of several core beliefs and greater levels of psychopathology. Different core beliefs acted as mediators in the relationships between sexual abuse and individual symptoms. The findings support the suggestion that schema-focused cognitive therapy may be useful in working with bulimics, particularly if they have been sexually abused in childhood. Further research is needed to determine the role of core beliefs in mediating the impact of other forms of trauma and how traumas relate to other "escape" behaviors.

The adolescent dissociative experiences scale: psychometric properties and difference in scores across age groups.

Adolescence is thought to be a key developmental period for dissociative processes. However, there has been little empirical investigation of dissociation in adolescence. This paper reports the results of a study (N = 768) that investigated the psychometric properties of the Adolescent Dissociative Experiences Scale (A-DES) and compares dissociation scores across the adolescent age range (11 to 16 years). The A-DES had good internal reliability and a one-factor solution. No significant age or gender differences in A-DES scores were found. The implications of these findings for future research and theory are outlined.

Relationships between objective physical characteristics and the use of weight control methods in adolescence: a mediating role for eating attitudes?

This study of non-clinical adolescent males and females examined associations of objectively measured physical characteristics with greater use of methods of weight control and considered whether the relationships between these variables might be explained by a mediating effect of a subjective characteristic--unhealthy eating attitudes. Non-clinical male and female adolescents completed measures of weight control and eating attitudes, and their physical characteristics were measured using a range of standardized anthropometry techniques. Regression analyses were used to test the role of eating attitudes as mediators in the relationship between physical characteristics and the use of weight control methods. The data were compatible with a partial mediator model, where physical characteristics influence eating attitudes, and those where attitudes drive the use of methods to control weight. However, not all of the relationship was explained by this mediator. In addition, there were different patterns of association for men and women, consistent with different patterns of bodily focus between the genders. These findings stress the importance of understanding objective physical characteristics as well as subjective eating attitudes to find out why people use different levels of weight control behaviours. Limitations, further research and potential implications for clinical and preventative programmes are discussed.

Bulimics' responses to food cravings: is binge-eating a product of hunger or emotional state?

This study examined the roles of hunger, food craving and mood in the binge-eating episodes of bulimic patients, and identified the critical factors involved in the processes surrounding binge-eating episodes that follow cravings. This was a prospective study of the binge-eating behaviour of 15 women with bulimia nervosa. The participants used food intake diaries and Craving Records to self-monitor their nutritional behaviour, hunger levels and affective state. Cravings leading to a binge were associated with higher tension, lower mood and lower hunger than those cravings not leading to a binge. Levels of tension and hunger were the critical discriminating variables. The findings of the study support empirical evidence and models of emotional blocking in binge-eating behaviour and challenge the current cognitive starve-binge models of bulimia. The role of food cravings in the emotional blocking model is discussed in terms of a classically conditioned motivational state. Implications for treatment are addressed.

Early environmental influences on restrictive eating pathology among nonclinical females: the role of temperature at birth.

OBJECTIVE: In eating-disordered populations, restrictive pathologies are associated with a higher rate of births in the spring and early summer. The reasons for this relationship are not understood. The present study of a nonclinical group aimed to determine whether there is a link between being born in warmer months and the level of restrictive pathology in later years. METHODS: The participants (N = 117) were all young adult females who were conceived and born in England. Each completed the relevant scales of the Eating Disorders Inventory and provided demographic information. Temperature at birth was determined using national meteorological records. RESULTS: Restrictive attitudes were stronger among women born during the warmer part of the year (May-August), and those attitudes were dimensionally associated with temperature at birth. Body dissatisfaction showed some of the same relationships. Neither period of birth nor temperature at birth was related to bulimic attitudes or body mass index. CONCLUSIONS: Being born during warmer months is significantly associated with restrictive eating attitudes among nonclinical females, although the link is relatively weak. Potential causal mechanisms are outlined, but further research is needed to explain this link in clinical and nonclinical groups.

Treating personality fragmentation and dissociation in borderline personality disorder: a pilot study of the impact of cognitive analytic therapy.

Recent findings suggest that personality fragmentation may be a core component of borderline personality disorder (BPD) and that successful treatment of BPD may depend on the extent to which this is addressed. Cognitive analytic therapy (CAT) can increase integration by strengthening awareness, and hence control, of the dissociative processes maintaining fragmentation. This pilot study aimed to conduct a systematic evaluation of the impact of CAT on BPD severity and personality integration. A patient series within-subject design was used. Five BPD participants completed a series of assessments to evaluate the impact of therapy on BPD severity, fragmentation, dissociation, symptomatology and interpersonal adjustment before, during and following 16-session CAT. By follow-up, CAT had produced reductions in the severity of BPD for all five participants, and three participants showed significant changes in their levels of personality fragmentation. Improvements in comorbid disturbance were less consistent, however. Although the small number of participants involved limits these findings, they have theoretical and clinical interest. They generally support the suggestion that integration should be enhanced with BPD patients, and suggest that CAT may be a useful method to achieve this goal.

Schema avoidance in bulimic and non-eating-disordered women.

OBJECTIVE: Models of bulimia lack a clear conceptualization of avoidance. This study considers the role of different domains of schema avoidance in bulimic disorders and examines the association of scores on the Young-Rygh Avoidance Inventory (YRAI) with bulimic pathology. METHODS: A total of 19 bulimic and 74 comparison women completed the YRAI and a measure of bulimic psychopathology. RESULTS: Bulimics scored significantly higher than the nonclinical women did on all YRAI scales. Greater reported use of avoidance was positively associated with bulimic attitudes, but only among the comparison group. At a dimensional level, behavioral/somatic avoidance was more strongly associated with bulimic pathology than cognitive/emotional avoidance, but the same was not true when differentiating groups. CONCLUSIONS: The YRAI is a robust measure of different domains of schema avoidance in understanding bulimic psychopathology. Clinically, the YRAI might be used to guide treatment for bulimic disorders.

Social convergence of disturbed eating attitudes in young adult women.

It has been suggested that a broad range of social factors influence disturbed eating attitudes, but there has been relatively little investigation of the role of peer influence. Drawing from social identity theory, this longitudinal study of a nonclinical group of women examined whether social proximity results in a convergence of eating psychopathology over time. Forty-one nonclinical women (living in 11 communal apartments) completed the Eating Disorders Inventory (EDI) at three time points (1 week after moving in, 10 weeks later, and a further 14 weeks later). The women's eating and related attitudes were compared across the three time points. Then divergence scores were calculated (showing the spread of EDI scores within each apartment) and compared across the three time points. The spread of scores within the apartments changed significantly, indicating some convergence in those attitudes that are socially valued (restrictive attitudes; body concerns) and divergence in those attitudes that are not socially valued (bulimia). There was also an increase in convergence of levels of perfectionism. The findings support the suggestion that social proximity promotes convergence of socially valued eating characteristics but divergence of socially stigmatised characteristics. Further research is suggested to establish the generalizability of these findings and to identify those who are most at risk of such social effects on eating disturbance.

Internal and external antecedents of binge eating episodes in a group of women with bulimia nervosa.

OBJECTIVE: This research examined the internal and external factors that predict whether a food craving develops into a binge in bulimia nervosa. METHOD: Fifteen bulimic women kept diary records of food cravings over the course of a week, noting their internal state, environmental triggers, and whether the craving developed into a binge. Eighty cravings were examined, of which approximately one half developed into binges. RESULTS: At the bivariate level, binge eating resulted from cravings more often if the women were alone, in the morning, and following eating the craved food. These factors interacted, so that binges were more likely if the women avoided a craved food in the morning, but not later in the day. CONCLUSIONS: These findings support a model of binge eating for which both internal states (craving, eating the craved food) and external factors (time of day, social circumstances) need to be taken into account. Relevant models of craving are discussed, along with their implications for clinical practice.

Bulimic psychopathology and impulsive behaviors among nonclinical women.

OBJECTIVE: There is evidence that bulimic diagnoses are associated with other impulsive behaviors. This study examines whether bulimic attitudes and behaviors show similar links to impulsive behaviors among nonclinical women. METHODS: The participants were 53 women with no history of psychological treatment. Each completed two questionnaire measures: the Bulimic Investigatory Test and the Impulsive Behaviors Scale. RESULTS: Bulimic attitudes and behaviors among this nonclinical group were associated with impulsive behaviors overall. This link was principally with self-harming behaviors, although there was some association with alcohol/drug use. CONCLUSIONS: Bulimic psychopathology seems to be associated principally with behaviors that share functional similarity on some level (e.g., availability; immediacy of action). These findings need to be replicated in a clinical sample, but suggest a need for clear assessment of the full range of impulsive behaviors in bulimic women.