'Not good enough:' Exploring self-criticism's role as a mediator between childhood emotional abuse & adult binge eating.

Empirical studies have identified emotional abuse in childhood (CEA) as a risk factor with long-term implications for psychological problems. Indeed, recent studies indicate it is more prevalent than behavioral forms of abuse, (i.e. childhood sexual and physical abuse) and the childhood trauma most clearly associated with subsequent eating pathology in adulthood. However, relatively little is understood about the mechanisms linking these distal experiences. This study explores three psychological mechanisms - self-criticism (SC), depression and anxiety symptoms - as plausible mediators that may account for the relationship between CEA and binge eating (BE) among adult women. Detailed telephone interviews conducted with a community-based sample of 498 adult women (mean age 44) assess BE, CEA and SC along with the most frequently researched psychological variables, anxiety and depression. Regression analyses reveal that BE is partially explained by CEA along with the three mediators. Bootstrapping analysis, which compares multiple mediators within a single model using thousands of repeated random sampling observations from the data set, reveals a striking finding: SC is the only psychological variable that makes a significant contribution to explaining BE severity. The unique role of punitive self-evaluations vis-à-vis binge eating warrants additional research and, in the interim, that clinicians consider broadening treatment interventions accordingly.

Binge eating & childhood emotional abuse: The mediating role of anger.

Recent studies reveal that childhood emotional abuse (CEA) is the trauma most clearly associated with adult eating pathology. Yet, relatively little is understood about psychological mechanisms linking these distal experiences. Anger's mediational role in the relationship between CEA and adult binge eating (BE) is explored in a community-based sample of 498 adult women (mean age 44). Detailed telephone interviews assess BE (7 items), CEA (single item), and unresolved anger (single item) along with self-criticism (modified Rosenberg self-esteem scale), depression and anxiety symptoms (BSI sub-scales). Statistical analyses include Pearson correlations, Baron and Kenny's steps for mediation, and Preacher and Hayes bootstrapping method to test proposed multiple mediators simultaneously. Findings reveal significantly more respondents (n = 476 with complete data) with serious BE behaviors report a history of CEA compared to women with considerable and/or minimal BE (53% vs 37%, p = 0.002 respectively). Significant correlations are found among all study variables. Mediation analyses focus on anger together with self-criticism, depression and anxiety. Findings reveal anger and self-criticism fully mediate the CEA-BE relationship. In contrast, depression and anxiety symptoms are not significant mediators in a model that includes anger and self-criticism. Although additional research is warranted to more fully understand complex causal processes, in the interim, treatment interventions should be broadened to include assessments of anger among adult women with BE behaviors, especially those with histories of childhood abuse. Additionally, prevention strategies that incorporate learning how to express anger directly and positively may be particularly effective in reducing various disordered eating behaviors among women and girls.

Does Specializing in Family Medicine Improve the Detection and Diagnosis of Mental Health Problems?

BACKGROUND: Approximately half the patients seeking mental health (MH) treatment consult primary care practitioners (PCPs). Previous research indicates that patients often do not receive correct MH diagnoses or appropriate treatment from PCPs. The present study examines whether a specialization in family medicine compared to other or no PCP residency programs enhances physicians' ability to detect, diagnose and treat MH problems. METHODS: Face-to-face interviews with 49 physicans in eight clinics in Israel. Two case vignettes and questionnaires assess MH awareness and factors influencing treatment. RESULTS: Significantly more family practitioners (FPs) compared to others correctly diagnosed depression and anxiety vignettes were aware of patients' MH problems and prescribed psychotropic drugs. LIMITATIONS: Small sample size, indirect examination of PCPs' skills using vignettes and the absence of psychotherapy options. CONCLUSIONS: FPs are more likely than other PCPs to detect, diagnose and treat MH problems. To improve MH detection among a broad range of PCPs, an expanded MH curriculum should be encouraged. Additional MH training should be available for all PCPs.

Exploring mental health consequences of childhood abuse and the relevance of religiosity.

Although childhood abuse is an established risk factor for mental health problems in adulthood, there is relatively little empirical evidence concerning intervening factors that may mitigate the risk. One potentially protective factor is religiosity. A unique opportunity to explore religiosity's relevance exists with a community-based sample of adult Jewish women that includes sizable subsamples of both rigorously devout ultra-Orthodox (Haredi) and nonreligious Secular Jews. A global measure of any childhood abuse (ACA) includes sexual, physical, and/or emotional abuse. Mental health is assessed with the Brief Symptom Inventory (BSI distress) and a single item reflecting unresolved anger about the past. Predictors of distress severity are examined with separate hierarchical regressions for each religious observance (RO) group. Despite being located at opposite ends of the religiosity spectrum, several surprising similarities emerge including no significant RO group differences in distress among abuse survivors. Moreover, ACA emerges as the strongest predictor of BSI distress within both groups and regressions explain similar amounts of variance. In contrast, two important differences emerge regarding unresolved anger and any recent abuse (ARA). Anger makes a strong contribution to explaining Haredi distress severity, less so for Secular respondents (6.1% vs. 2.9% respectively) while ARA is significant only for Haredi respondents. These initial findings suggest that abusive traumas in childhood may seriously compromise religiosity's potentially protective role. Broadening the research agenda to focus on resilient survivors would expand our understanding of healing resources-both within and outside of a religious framework. Moreover, a better understanding of unresolved anger would likely enhance interventions with greater potential for mitigating the suffering of those abused in childhood.

Disordered eating and cultural distinctions: exploring prevalence and predictors among women in Israel.

BACKGROUND: Cultural differences in serious eating problems among adult women have important treatment and prevention implications yet remain relatively unexplored. This is the first study to examine these issues among Israel's multi-cultural adult population. METHOD: Disordered eating behaviors (DEB) are assessed with 14 DSM-related symptoms (including binge eating) in a multi-cultural sample of 485 women. Prevalence rates and clinical predictors of DEB severity are examined for three culturally distinct groups of Jews. RESULTS: Second generation Israeli-born and first generation Israelis of Sephardic and Ashkenazi origins differ significantly in DEB prevalence (19.4%, 11.4%, 13.9%, p<.05). Regarding clinical predictors, self-criticism is strongest predictor for second generation while weight is strongest predictor for both first generation groups. CONCLUSIONS: Prevailing wisdom largely attributes eating disturbances to cultural thinness norms. However, substantial differences between culturally distinct groups of Israeli Jews, similarly exposed to westernized norms, challenge the prevailing wisdom. Culturally sensitive interventions warrant additional research and more illuminating explanatory models than "one size fits all."

Disordered eating & cultural diversity: a focus on Arab Muslim women in Israel.

CONTEXT: A dearth of data concerning eating problems among adult women from minority population groups leaves substantial knowledge gaps and constrains evidence-based interventions. OBJECTIVES: To examine prevalence and predictors of disordered eating behaviors (DEB) among Arab Muslim women in Israel, whose eating behaviors have not been previously examined and to compare with second generation Israeli-born Jews of European heritage. DESIGN: Community-based study includes sub-samples of Arab Muslims and Israeli-born Jews. DEB is assessed with fourteen DSM-IV related symptoms. Hierarchical regressions examine influence of weight, self-criticism and psychological distress on DEB severity. RESULTS: Relatively high prevalence rates emerge for Muslims (27%) and Jews (20%), a nonsignificant difference. In contrast, regressions reveal substantially different predictor patterns. For Arab Muslims, weight has the strongest association; for Jews, weight is not significant while self-criticism is the strongest predictor. Explained variance also differs considerably: 45% for Muslims and 28% for Jews. CONCLUSIONS: Surprising similarities and distinct differences underscore complex patterns of eating disturbances across culturally diverse groups. Culturally sensitive interventions are warranted along with more illuminating explanatory paradigms than 'one size fits all.'

Physicians' influence on primary care patients' reluctance to use mental health treatment.

OBJECTIVES: The study examined attitudes of primary care patients toward mental health treatment and whether ambivalent or negative attitudes change after patients receive recommendations from their primary care physicians to seek treatment from a mental health professional. METHODS: Data were collected in face-to-face interviews with 902 Jewish patients aged 25-75 in eight primary care clinics in Israel. Measures included validated mental health instruments and a vignette eliciting patients' readiness to consider treatment and potential influence of a physician's recommendation. RESULTS: Initially, almost half of patients were reluctant to consider specialized mental health treatment. The probability of having a more positive attitude after the physician's recommendation was significantly higher among patients with more severe clinical diagnoses. CONCLUSIONS: A major finding was the positive impact of primary care physicians' recommendations on reluctant patients. Encouraging physicians to discuss mental health issues would likely promote more positive attitudes and increase patients' willingness to access treatment.

Use of unconventional therapies by primary care patients--religious resources vs. complementary or alternative medicine services.

OBJECTIVES: The study examines the difference in characteristics between primary care patients who turn to "religious resources for medical purposes" (RRMP) and those who turn to "complementary or alternative medicine" (CAM) services to cope with a physical or mental health problem. DESIGN AND SETTING: Data were collected from eight primary care clinics in Israel and included 905 Jewish patients aged 25-75. MAIN OUTCOME MEASURE: A self-report questionnaire with a battery of validated mental health assessment instruments and two questionnaires regarding use of unconventional therapies (RRMP and CAM services) were administered to the participants. The association of various variables with type of 'service use' was examined through logistic regression analysis. RESULTS: Primary care patients suffering from emotional problems have a propensity to utilize unconventional therapies in addition to conventional medical treatment. However, differences exist between patients who turn to RRMP and to CAM. The risk factors for turning to RRMP are North African, Middle Eastern or Israeli origin, low SES, religious observance, and high use of primary care clinics. For using CAM services the risk factor is high SES. CONCLUSIONS: In the present study, a quarter of primary care patients also use additional resources for their medical problems. While all segments of the population use unconventional resources, our study reveals that two types of unconventional therapies - RRMP and CAM - tend to be used by two different population sectors. It is noteworthy that those suffering from mental health problems are more likely to utilize unconventional resources.

Disordered eating and complexities of cultural origin: a focus on Jews from Muslim countries.

CONTEXT: A dearth of data concerning eating problems among adult women from diverse cultural origins leaves substantial knowledge gaps and constrains evidence-based interventions. OBJECTIVE: To examine prevalence and predictors of disordered eating behaviors (DEB) among adult Jewish women (21+) from distinct cultural origins. DESIGN: Community-based study includes 175 Israelis born to parents from Muslim countries (aka Sephardic) and 108 second generation Israelis mostly of European ancestry. DEB assessed with DSM-IV related symptoms. Hierarchical regressions examine influence of weight, self-criticism and psychological distress on DEB severity. RESULTS: Despite similar exposure to Israel's westernized norms, substantial group differences emerge. Considerably lower rate of DEB found among respondents of Sephardic origin (11.4%, 19.4%, p<.05); regressions reveal dissimilar patterns of clinical predictors. CONCLUSIONS: Community cohesiveness and deeply-rooted cultural and religious traditions may be protective for Israelis of Sephardic origin. Additional research is needed to clarify cultural influences and enhance culturally sensitive interventions for multicultural populations.

Disordered eating and religious observance: a focus on ultra-Orthodox Jews in an adult community study.

OBJECTIVE: To broaden the socio-cultural context of eating disturbances by exploring religious observance and its presumed protective role for ultra-Orthodox women. METHOD: Detailed telephone interviews with community sample of adult Jewish women in Israel, including 261 ultra-Orthodox. Frequency of 14 symptoms of disordered eating (DEB) assessed. Hierarchical regressions examine predictors of DEB severity within observance categories (ultra-Orthodox, Orthodox, Traditional, and Secular). RESULTS: Contrary to expectations, no significant differences were found in the frequency of serious DEB between the most and least religiously observant, ultra-Orthodox, and Secular women. Regressions reveal similar predictors of DEB severity (obesity followed by self-criticism) as well as substantial variations in amount of variance explained. DISCUSSION: Apparently, rigorous religious adherence does not protect ultra-Orthodox women from serious eating problems. Additional analyses can inform socio-cultural perspectives by examining the connection between body dissatisfaction and disordered eating in this insular and isolated religious community, whose exposure to secular media is prohibited.

Revisiting the relationship between eating disturbances and cultural origin: a focus on adult women in 14 community studies.

Are there differences in prevalence and predictors of eating disturbances among adult women (age 30+) from diverse cultural backgrounds? Most research has explored these issues with young age groups, although the results may also be relevant to adults. Fourteen community-based studies with culturally diverse samples are examined. A majority of studies (70%) reveals no significant group differences in prevalence rates. In contrast, significantly different clinical predictors emerge from multivariate analyses despite groups having similar frequency rates. Collectively, findings offer a complex, sometimes contradictory and inconclusive picture. Additional research is warranted for developing evidence-based interventions sensitive to adults from diverse cultural traditions.