Preliminary evaluation of the online course "I Care" targeting eating disorder knowledge and attitudes among sports coaches and fitness instructors.

BACKGROUND: Fitness instructors, coaches and trainers are often looked up to and seen as role-models within their sporting community. Since problematic exercise is a common symptom of eating disorders, they are also highly likely to meet individuals at risk for developing eating disorders within their profession. Thus, educating coaches about how to promote healthy ideals within their sports/training context and equipping them with knowledge to be able to detect and approach individuals at risk, is of great importance. METHOD: We studied the pre-to-post effects of the I Care online psychoeducational intervention in 150 coaches, trainers, and fitness instructors. Variables included the Compulsive Exercise Test, as well as knowledge of eating disorders, and confidence and awareness regarding approaching, talking to, and referring individuals whose observed behavior raised concerns. RESULTS: Results showed significant and large improvements in coaches' confidence and knowledge regarding warning signs and how to approach an at-risk person, and a decrease in their perceived ability to recognize eating disorders by sight, e.g., insight about EDs not being recognizable just by looking at a person. Also, significant positive change in attitudes about their own rule-driven exercise behavior and lack of enjoyment of exercise was observed. CONCLUSIONS: Although the lack of a control group compels caution, the study suggests that I Care may have positive effects in terms of a "declaration of intent" toward more positive role-modeling and interactions with clients.

Fitness instructors, coaches and trainers are often looked up to within their sporting community. They are also likely to meet individuals at risk for developing eating disorders, since excessive or compulsive exercise is a common symptom of these disorders. Coaches therefore need to know more about how to promote healthy ideals and how to detect and approach individuals at risk of developing an eating disorder.We studied if a brief online education called I Care could improve personal compulsive exercise tendencies, knowledge about eating disorders, and readiness to approach individuals seemingly at risk, in 150 coaches, trainers, and fitness instructors.We found that coaches felt more confident and knowledgeable about warning signs and how to approach a person at risk after completing I Care. They also showed increased insight about EDs not being recognizable just by looking at a person and their attitudes about their own exercise behavior changed in a positive way.Although the lack of a comparison group makes conclusions tentative, I Care may have positive effects in terms of a "declaration of intent" toward more positive role-modeling and interactions with clients.

Validity of eating disorder diagnoses in the Swedish national patient register.

The Swedish National Patient Register (NPR) includes population-level longitudinal data, and determining the validity of NPR diagnoses is critical to undergirding the research and policy recommendations they inform. Sweden also has the integrated "Riksät" and "Stepwise" National Quality Registers (QR), with data from specialized eating disorder (ED) treatment based on structured, valid assessment methods. To validate NPR ED diagnoses, we compared ICD-10-based anorexia nervosa (AN), bulimia nervosa (BN), and unspecified ED in NPR to DSM-IV-based AN, BN, and ED not otherwise specified category (EDNOS) in QR. Patients' first diagnoses registered in QR between February 2008 and August 2013 were compared with NPR diagnoses entered within ±1 month (N = 2074). QR registration includes the semi-structured DSM-IV-based Structured ED Interview. Each ED diagnosis was analyzed separately for degree of match using several indices: overall agreement, sensitivity, positive predictive value, specificity, negative predictive value, area under the curve, and Cohen's kappa. Results showed moderate to excellent agreement depending on estimate (e.g. positive predictive values AN: 0.747; BN:.836; EDNOS: 0.761), except for a somewhat low sensitivity for BN, and EDNOS agreement was overall the lowest. Case prevalence in the NPR and QR was highly similar for AN, and within five percentage points for BN and EDNOS. Generalizability is hampered by limited age range and diagnostic resolution as well as few males. Available data precluded study of presence/absence of ED, and complementary approaches are considered for future research. We conclude that NPR ED diagnoses have acceptable validity and are appropriate for use in research.

Binge Eating and Addictive-Like Behaviours in Males and Females.

INTRODUCTION: Binge eating is a common behaviour that is strongly linked to both obesity and eating disorder. There is evidence that binge eating commonly co-occurs with other problematic and addictive-like behaviours; however, this has not been explored systematically. The present study aimed to examine the relationship between binge eating, body weight, disordered eating behaviours and associated addictive-like behaviours, with particular attention paid to gender differences. METHOD: A community sample (N = 500; 75% female, Mage = 32.5 years) reported disordered eating behaviours (i.e. binge eating, purging, restriction of eating, compulsive exercise), body mass index (BMI), food addiction, starvation addiction, exercise dependence, tobacco use and alcohol consumption. RESULTS: 42% of females and 21% of males reported binge eating during the past four weeks. Binge eating was significantly associated with all investigated behaviours in females, and with purging, compulsive exercise and overweight/obesity in males. Controlling for BMI, self-starvation predicted binge eating in males (OR = 1.07), while food addiction (OR = 1.73) and alcohol dependence (OR = 1.11) predicted binge eating in females. CONCLUSIONS: The multiple associations between binge eating and addictive-like behaviors supports broad screening and generalized prevention efforts. Prevention efforts should reflect gender differences.

Impulsivity and compulsivity as parallel mediators of emotion dysregulation in eating-related addictive-like behaviors, alcohol use, and compulsive exercise.

INTRODUCTION: Transdiagnostically relevant psychological traits associated with psychiatric disorders are increasingly being researched, notably in substance use and addictive behaviors. We investigated whether emotion dysregulation mediated by impulsivity and/or compulsivity could explain variance in binge eating, food addiction, self-starvation, and compulsive exercise, as well as alcohol use (addictive-like behaviors relevant to the obesity and eating disorder fields). METHOD: A general population sample of adults (N = 500, mean age = 32.5 years), females (n = 376) and males (n = 124), completed the Difficulties in Emotion Regulation Scale-16, the Trait Rash Impulsivity Scale, the Obsessive-Compulsive Inventory-Revised, the Eating Disorders Examination Questionnaire, the Self-Starvation Scale, the Exercise Dependence Scale, the Yale Food Addiction Scale, and the Alcohol Use Disorders Identification Test online. Besides gender comparisons and intercorrelations between measures, we used predefined multiple mediation models with emotion dysregulation as independent variable, impulsivity and compulsivity as parallel mediators, to investigate whether these factors contributed explanatory power to each addictive-like behavior as outcome, also using age and body mass index as covariates. RESULTS: Females scored higher than males on emotion dysregulation and the eating-related addictive-like behaviors food addiction, self-starvation, and binge eating. Intercorrelations between measures showed that emotion dysregulation and compulsivity were associated with all outcome variables, impulsivity with all except compulsive exercise, and the eating-related behaviors intercorrelated strongly. Mediation models showed full or partial mediation of emotion dysregulation for all behaviors, especially via compulsivity, suggesting a behavior-specific pattern. Mediation models were not affected by age or gender. DISCUSSION: Addictive-like behaviors seemed to be maintained by trait levels of emotion dysregulation, albeit channeled via trait levels of compulsivity and/or impulsivity. The role of emotion dysregulation may help us to understand why addictive-like behaviors can be difficult to change in both clinical and nonclinical groups, and may be informative for treatment-planning in patients where these behaviors are present. Our findings support adopting a more dimensional approach to psychiatric classification by focusing psychological facets such as those studied.

Taking the LEAP: study protocol for a randomized, multicentre, naturalistic, efficacy trial of the compuLsive Exercise Activity theraPy (LEAP) - a cognitive behavioral program specifically targeting compulsive exercise in patients with eating disorders.

BACKGROUND: About half of Swedish eating disorder patients report exercising compulsively and compulsive exercise (CE) is prevalent in all diagnoses and both genders. Yet there are no systematic treatments targeting CE in specialist care. This study aims to evaluate the effects of The CompuLsive Exercise Activity TheraPy (LEAP) - a promising group treatment targeting compulsive exercise, in Swedish eating disorder patients. METHOD: One hundred twenty-eight adult females and males suffering from anorexia nervosa, bulimia nervosa or other specified feeding and eating disorders (type 1, 2, or 4) with CE will be recruited via four specialist eating disorder treatment units. Participants will be randomized to receive treatment as usual (control group) or treatment as usual plus LEAP (intervention group). The groups will be assessed on key variables (e.g., BMI, eating disorder symptoms, exercise cognitions and behaviors) at three occasions: initially, after 3 months and after 6 months. DISCUSSION: The project takes place in a clinical setting, including both male and female patients with different eating disorder diagnoses with CE, enabling a good indication of the efficacy of LEAP. If our results are positive, LEAP has the potential of benefiting about half of the eating disorder population, with remission and recovery hopefully improving as a result. TRIAL REGISTRATION: The trial is registered with the ISRCTN registry (registration date 2020-03-25), trial ID: ISRCTN80711391 .

Self-image and 12-month outcome in females with eating disorders: extending previous findings.

BACKGROUND: The interpersonal Structural Analysis of Social Behavior (SASB) model of self-image has repeatedly proven valuable in relation to eating disorder (ED) symptoms and in predicting ED outcome. OBJECTIVE: We studied the association between initial self-image according to the SASB and 12-month outcome, in five diagnostic groups of female ED patients. Based on previous findings, we expected autonomy related variables (self-control/autonomy) would strongly predict outcome in anorexia nervosa (AN) groups, whereas variables related to affiliation (self-attack/love) would moderately predict outcome in bulimia nervosa (BN). METHOD: Participants were adult female patients, of whom 457 had AN restrictive type, 228 AN binge/purge subtype, 861 BN, 505 other specified ED and 170 binge eating disorder. Data came from the Stepwise clinical database in Sweden. Outcomes were presence/absence of ED diagnosis and self-rated ED symptoms, and we controlled for baseline ED pathology, BMI, age and general psychiatric symptoms. RESULTS: Regression analyses showed that although the pattern differed somewhat between diagnostic groups, high initial self-love and low self-attack/self-blame predicted a more positive 12-month outcome. In some groups (AN/R in particular), these variables remained important even when baseline pathology and age were included in the analyses. DISCUSSION: Self-image aspects once again display substantial power in predicting outcome in EDs. In AN/R patients, self-love plays an almost as crucial a role as baseline ED pathology in relation to 12-month outcome.

The unsafe haven: Eating disorders as attachment relationships.

OBJECTIVES: Some patients with eating disorders (EDs) seem to experience their illness as an entity, a symbolic other to whom they relate, and which may influence both symptom levels and self-image. Extending previous research, this study investigated whether the patient-ED relationship has attachment qualities. DESIGN: Structural Analysis of Social Behaviour was used to operationalize the patient-ED relationship, and the Attachment Style Questionnaire was used to measure attachment. METHOD: We examined ED patients' (N = 148) relationship with their ED, attachment behaviour, symptoms, and self-image. Attachment dimensions of Confidence, Anxious/ambivalence, and Avoidance were found to be significantly correlated with aspects of the patient-ED relationship. Introjection (i.e., whether ED actions were incorporated into patients' self-image) was investigated by examining the match between self-image profiles and the actions of patients' EDs. A double mediation model was tested in which ED control/emancipation and patients' Self-blame mediated the effect of attachment security on ED symptoms. RESULTS: Attachment insecurity was associated with greater ED control and patient submission. In 28.5% of patients, there was a high degree of correlation between self-image and ED action profile. Data supported the mediation model. CONCLUSIONS: Attachment processes appear to be associated with the manner in which ED patients relate to their disorder, at least in some cases. Attempts to maintain psychological proximity to the ED as an introjected attachment figure may help to explain treatment resistance and ambivalence about change. This perspective may be useful in treatment. PRACTITIONER POINTS: Attachment behaviours are associated with the patient-ED relationship, in which attachment insecurity is correlated with greater eating disorder control and patient submission. Some patients seem to incorporate the actions of the ED in their self-image, suggesting the presence of introjection. The patient-ED relationship may help explain patients' anxiety and ambivalence about change, seen from an attachment perspective. In treatment, it may be important to explore alternative safe havens and secure bases to the ED, such as interpersonal relationships and activities.

Running on empty - a nationwide large-scale examination of compulsive exercise in eating disorders.

BACKGROUND: Compulsive exercise (CE) has been the neglected "Cinderella" among eating disorder (ED) symptoms, even though it seems to impact severity, treatment and outcome. This prompted a large-scale and systematic examination of the impact of CE in a representative ED sample. METHODS: CE was examined in over 9000 female and male patients from a clinical ED database (covering out-patient, day and/or residential treatment) with respect to prevalence, ED diagnosis, ED symptoms, clinical features, patient characteristics, and outcome at 1-year follow-up. Relationships between changes in CE behavior and remission were also examined. RESULTS: CE was a transdiagnostic symptom, present in nearly half of all patients (48%). It was associated with greater overall ED pathology, particularly dietary restraint, and negative perfectionism. Initial CE did not impact remission rate, but patients continuing or starting CE during treatment had considerably lower remission rates compared to patients who never engaged in, or ceased with, CE. Results were comparable for females and males. CONCLUSIONS: At baseline, there were few differences between patients with and without CE, except a somewhat higher symptom load for patients with CE, and CE did not predict ED outcome. However, how CE developed during treatment to 1-year follow-up considerably impacted remission rates. We strongly recommend CE to be systematically assessed, addressed, and continuously evaluated in all ED patients seeking treatment.

Exercise Caution: Questions to Ask Adolescents Who May Exercise Too Hard.

When the primary goal of exercise is to compensate for food intake and to alter body shape and weight, it is considered compulsive and may be harmful. Compulsive exercise (CE) is important in the pathogenesis of eating disorders (EDs). Many healthy adolescents engage in CE too, and this may indicate a risk for EDs. Our aim was to learn more about ED risk factors tied to CE and to try to isolate questions to ask in order to probe for high ED risk in adolescents engaging in CE. Using two well-established instruments (the Structural Analysis of Social Behavior and the Eating Disorders Examination Questionnaire), we studied associations between ED variables and CE in healthy adolescent boys and girls. We examined gender-specific items to generate the best possible fit for each gender. Individuals with CE displayed significantly greater ED pathology and more self-criticism, and this pattern was stronger in girls than in boys. Risk factors for ED among individuals with CE differed slightly for boys and girls. We put forward a set of gender-specific questions that may be helpful when probing for ED risk among adolescents engaging in CE.

Insidious: The relationship patients have with their eating disorders and its impact on symptoms, duration of illness, and self-image.

OBJECTIVES: In published clinical and autobiographical accounts of eating disorders, patients often describe their disorder in personified ways, that is, relating to the disorder as if it were an entity, and treatment often involves techniques of externalization. By encouraging patients to think about their eating disorder as a relationship, this study aimed to examine how young female patients experience their eating disorder as acting towards them, how they react in response, and whether these interactions are associated with symptoms, illness duration, and self-image. DESIGN: Structural Analysis of Social Behavior (SASB) was used to operationalize how patients experience the actions of their eating disorder and their own reactions to the disorder. METHOD: The relationship between patients (N = 150) and their eating disorders was examined with respect to symptoms, duration of illness, and self-image. Patients were also compared on their tendency to react with affiliation in relation to their disorder. RESULTS: Patients' responses on the SASB indicated that they tended to conceptualize their eating disorders as blaming and controlling, and they themselves as sulking and submitting in response. Greater experience of the eating disorder as being controlling was associated with higher levels of symptomatology. Patients reacting with more negative affiliation towards their disorder were less symptomatic. CONCLUSIONS: When encouraging patients to think about their eating disorder as a relationship, comprehensible relationship patterns between patients and their eating disorders emerged. The idea that this alleged relationship may resemble a real-life relationship could have theoretical implications, and its exploration may be of interest in treatment. PRACTITIONER POINTS: Patients were able to conceptualize their eating disorder as a significant other to whom they relate when encouraged to do so. Patients tended to experience their disorder as controlling and domineering. Exploring the hypothetical patient-eating disorder relationship may prove helpful in understanding dysfunctional relational patterns. Helping patients to rebel against their eating disorder could potentially aid in symptom reduction.

Factor analysis of the adolescent version of the Eating Disorders Examination Questionnaire (EDE-Q): results from Swedish general population and clinical samples.

BACKGROUND: Although the Eating Disorder Examination Questionnaire (EDE-Q) is perhaps the single most widely used self-report measure of eating disorder (ED) symptoms, important questions remain about its validity and applicability in relation to particular groups of individuals, especially adolescents of both genders. METHODS: The present study investigated the factor structure of the adolescent version of the Eating Disorder Examination Questionnaire (EDE-Q) in samples of Swedish girls and boys from the general population and girls with a diagnosed eating disorder. Girls (N = 239) and boys (N = 248) aged between 13 and 15 years who were attending school, and girls (N = 570) aged between 12 and 14 years who were in treatment for an eating disorder at a specialist eating disorder clinic were assessed on the adolescent version of the EDE-Q. RESULTS: The adolescent version of the EDE-Q demonstrated satisfactory levels of internal consistency. However, confirmatory factor analysis (CFA) failed to support the four-factor model of the EDE-Q. Parallel analysis (PA) and subsequent exploratory factor analysis (EFA) suggested that the adolescent version of the EDE-Q comprises one underlying factor in young adolescent girls (both clinical and general population), centred on Dissatisfaction with Shape and Weight. In boys three factors were found: Weight-related Concerns, Body Discomfort and Restraint. CONCLUSIONS: The EDE-Q appears to measure different underlying aspects of eating disorder psychopathology in young teenagers compared to adults. The dimensions underlying disordered eating in young girls may become increasingly differentiated with time. There appear to be important gender-based differences in the dimensions underlying the EDE-Q in young teenagers. Therapists should be alert to beliefs that girls have about the importance of shape and weight, while in boys it may be more important to be attentive to how they feel about their bodies in relation to weight.

Self-image and eating disorder symptoms in normal and clinical adolescents.

Eating disorders (ED) are psychiatric disorders of multifactorial origin, predominantly appearing in adolescence. Negative self-image is identified as risk factor, but the association between self-image and ED in adolescents or sex differences regarding such associations remains unclear. The study aimed to investigate the relationship between specific self-image aspects and ED symptoms in normal and clinical adolescents, including sex differences. Participants included 855 ED patients (girls=813, boys=42) and 482 normal adolescents (girls=238, boys=244), 13-15 years. Stepwise regression demonstrated strong associations between self-image and ED in normal adolescents (girls: R(2)=.31, boys: R(2)=.08), and stronger associations in patients (girls: R(2)=.64, boys: R(2)=.69). Qualitative sex differences were observed in patients. Connections between specific self-image aspects and ED have implications for clinical management of ED. The strong link between self-image variables and ED symptoms in normal girls, but not boys, is discussed in terms of the continuity-discontinuity hypothesis.