What knowledge do patients have about the physical consequences of their eating disorder?

BACKGROUND: A poor knowledge of the physical consequences or health risks of an eating disorder may be a sign of denial or minimization of the problem linked to a poor willingness to change. AIM: Testing the knowledge of eating disorder patients about the physical consequences of their disorder and whether this can be improved by means of a psychoeducational program. METHOD: Shortly after admission to a specialized inpatient eating disorder unit, a total of 66 female patients filled out a questionnaire with 20 items testing their knowledge about physical aspects of eating disorders. After about one month, 40 patients repeated the assessment. In between, they had received some psychoeducation in the form of an interactive group session and a special brochure. RESULTS: The average knowledge was rather good (14 correct answers on a total of 20 questions), although a considerable number answered "I don't know" on 11 questions. The majority of these switched to correct answers after 1 month leading to a significant improvement of the general knowledge (on average 17/20), independently of the subtype of eating disorder. One question turned out to elicit the greatest number of incorrect answers: 'As long as a woman does not menstruate, she cannot get pregnant in a natural way'. DISCUSSION: Assessing the (insufficient) knowledge about the physical consequences of an eating disorder may serve as the starting point for a specific psychoeducation, which can have an impact on the motivational process in these patients.

Are maladaptive schema domains and perfectionism related to body image concerns in eating disorder patients?

Both maladaptive schemas (MS) and perfectionism have been associated with eating pathology. However, previous research has not examined these variables simultaneously and has not studied possible mediating relationships between MS and multidimensional perfectionism for body image concerns in eating disorder (ED) patients. Eighty-eight female ED patients completed the Young Schema Questionnaire, the Frost Multidimensional Perfectionism Scale, and the Body Attitude Test. Body image concerns were found to be positively related to Personal Standards (PS) and Evaluative Concerns (EC) perfectionism and all five schema domains. PS Perfectionism was positively associated with Disconnection, Other-directedness, and Overvigilance. EC Perfectionism was positively related to Disconnection, Impaired Autonomy, Other-directedness, and Overvigilance. Moreover, EC perfectionism was found to be a significant mediator in the relationship between the schema domains Impaired Autonomy and Overvigilance and body image concerns. These findings denote the importance to address both core beliefs and perfectionism in ED treatment.

Personality subtypes in female pre-bariatric obese patients: do they differ in eating disorder symptoms, psychological complaints and coping behaviour?

In the pre-bariatric psychological assessment of 102 morbidly obese women, two personality subtypes emerged: a resilient/high functioning subtype with a 'normal' personality profile and an emotional dysregulated/ undercontrolled subtype, characterized by high neuroticism and low extraversion/conscientiousness. Emotional dysregulated/ undercontrolled patients showed more concerns about eating/weight/shape, more binge eating driven by emotions and external triggers, more psychological complaints (such as depression and anxiety) and more avoidance and depressive coping reactions than resilient/high functioning patients. Further research should clarify whether these clearly different psychological profiles are related to different outcomes (weight loss or well-being) of bariatric surgery.

Self-change in eating disorders: is "spontaneous recovery" possible?

A limited series of community studies including non-treatment-seekers has shown that a considerable number of eating disorder patients do not enter the health care system but can be considered "clinically recovered" (remission of major symptoms) if followed up long enough. The possibility of "spontaneous recovery" (overcoming an eating disorder without professional treatment or formal help) often faces scepticism on the part of professionals. Clearly, self-change is an underestimated pathway to recovery from an eating disorder, but open-minded clinicians can learn a lot from it. Active coping and making use of one's "recovery capital" are key features of self-change even if maintenance of change is associated with social support and positive life changes.

The scars of the inner critic: perfectionism and nonsuicidal self-injury in eating disorders.

Nonsuicidal self-injury (NSSI) is quite common in eating disorder (ED) patients and we wondered whether this combined self-harming behaviour is related to perfectionism, a feature often found in ED patients. In addition, we examined associations between perfectionism and functions underlying NSSI and the possible mediating role of intrapersonal perfectionism in the association between perceived parental criticism and NSSI. In a sample of 95 ED patients, 38.9% reported at least one type of NSSI, and this subgroup reported significantly higher levels of parental criticism and evaluative concerns perfectionism (ECP) compared with ED patients without NSSI. ECP was positively related to the self-punishment and cry-for-help functions of NSSI. Finally, ECP was found to mediate the association between parental criticism and NSSI symptoms. Directions for future research and practical implications are discussed.

Out of control? Inhibition processes in eating disorders from a personality and cognitive perspective.

OBJECTIVE: The present study examined the role of "a breakdown in inhibition" as a mechanism to explain differences in impulsivity between restrictive and bingeing/purging eating disorders (ED). Two types of inhibition (i.e., executive and reactive inhibition) were assessed by means of personality and neuropsychological tests. METHOD: Forty-eight female in patients with ED completed the Effortful Control Scale, the BISBAS scales, and a set of neuropsychological tests. RESULTS: The results showed that executive inhibition measures were able to differentiate restrictive from bingeing/purging ED subtypes. Patients with ED and bingeing/purging behavior scored significantly lower on the Effortful Control Scale, needed more time to finish the Trail Making Test/STROOP, and showed more reaction time variability on the Go No-Go task. We did not find significant associations between personality and neuropsychological measures of executive/reactive inhibition. DISCUSSION: Insight in the breakdown of inhibition in bingeing/purging patients can increase our understanding of impulse-control disorders and guide the development of tools to improve effortful control.

Can eating disorders become 'contagious' in group therapy and specialized inpatient care?

Eating disorders belong to the broad category of self-harming behaviours which may be acquired in a social learning process of imitation, identification and competition. Hence, we should question the possible dangers or unwanted side-effects in treating patients together within a common therapeutic setting. But little is known about the frequency and extent of possibly negative influences of treatment in a group format, the so-called risk of 'peer contagion' in group therapy and/or inpatient treatment. We review in this paper the rather scarce literature on this subject in order to stimulate more critical thinking and systematic research.

Media hype, diagnostic fad or genuine disorder? Professionals' opinions about night eating syndrome, orthorexia, muscle dysmorphia, and emetophobia.

Many "new" syndromes have been proposed for inclusion in the DSM-V. Some disorders acquired popularity through the Internet, but will they be taken seriously and get accepted by the scientific community? We organized an opinion poll among professionals in the field of eating disorders by presenting them a provisional set of diagnostic criteria of four "new" disorders: Night Eating Syndrome, Orthorexia, Muscle Dysmorphia, and Emetophobia. In general, the opinions did not differ much according to the characteristics of the 111 respondents. Among these professionals, Orthorexia is the best known and Night Eating Syndrome the least. Although the majority is familiar with the concept of Muscle Dysmorphia, it is most often viewed as a creation of the popular media and rarely observed in daily practice. In contrast, the other three disorders seem to be taken more seriously in the sense of "genuine" syndromes, which should receive more attention in research and clinical practice. Emetophobia appears to be the least "fashionable" of the four. The findings are discussed in the light of medialization and medicalization.

Non-suicidal self-injury in eating disordered patients: a test of a conceptual model.

A theoretical model explaining the high co-occurrence of non-suicidal self-injury (NSSI) in eating disordered populations as resulting from childhood traumatic experiences, low self-esteem, psychopathology, dissociation, and body dissatisfaction was previously proposed but not empirically tested. The current study empirically evaluated the fit of this proposed model within a sample of 422 young adult females (mean age=21.60; S.D.=6.27) consecutively admitted to an inpatient treatment unit for eating disorders. Participants completed a packet of questionnaires within a week of admission. Structural equation modeling procedures showed the model provided a good fit to the data, accounting for 15% of the variance in NSSI. Childhood trauma appears to have an indirect relationship to NSSI that is likely to be expressed via relationships to low self-esteem, psychopathology, body dissatisfaction, and dissociation. It appears that dissociation and body dissatisfaction may be particularly salient factors to consider in both understanding and treating NSSI within an eating disordered population.

The affect-regulation function of nonsuicidal self-injury in eating-disordered patients: which affect states are regulated?

This study examines the affect regulation function of different types of nonsuicidal self-injury (NSSI) in 177 female eating-disordered inpatients. Almost 45% of the eating-disordered patients displayed at least 1 type of NSSI. Cutting and scratching were the most common forms of NSSI followed by bruising and burning oneself. For all types of NSSI except bruising, the affect regulation function was most strongly endorsed. Affect states reported to precede and follow NSSI were also examined to determine the particular affect states regulated by NSSI. In general, positively valenced low-arousal affect states increased and negatively valenced high-arousal affect states decreased from before to after NSSI. Finally, affective changes associated with NSSI were related to different NSSI characteristics, indicating that the increase in positive affect after NSSI is significantly related to the frequency of NSSI and the numbers of functions reported for NSSI. Theoretical and treatment implications are discussed.

Dropping out from a specialized inpatient treatment for eating disorders: the perception of patients and staff.

Most studies of treatment drop-outs have focused on demographic and clinical patient characteristics as possible predictors. To get a better insight in the meaning of dropping-out from therapy, during 1 year the viewpoints of patients and staff were compared in each case (N = 21 or 15.2%) of premature termination of an inpatient treatment program for eating disorders. Both patients and staff were reporting as important reasons of drop-out: not enough freedom, treatment being too difficult, and lack of trust. Contrary to the staff, patients were more often satisfied with the therapy and therefore did not expect further benefit in continuing the inpatient treatment. The findings are discussed mainly within the context of patient-staff interaction. The authors propose to abandon the term "drop-out" because of its negative connotation.

Brief report: the association between non-suicidal self-injury, self-concept and acquaintance with self-injurious peers in a sample of adolescents.

The current study investigated the association between non-suicidal self-injury (NSSI), self-concept and acquaintance with NSSI peers in a sample of 150 high school students (60% female) with a mean age of 15.56 (SD=2.00) years. Analyses showed that students with NSSI rated themselves lower on academic intelligence, physical attractiveness, social skills and emotional stability than their non-NSSI peers. The self-injurers also had more friends who engaged in NSSI, and having more NSSI acquaintances was negatively related to self-esteem. It could be that adolescents with lower self-esteem are more attracted to self-injuring peers, or that adolescents with low self-esteem are more vulnerable to copy NSSI to deal with their problems or to gain a certain identity in their peer group. Future studies must test these possible NSSI pathways.

Gray's Reinforcement Sensitivity Theory as a framework for research on personality-psychopathology associations.

Gray's Reinforcement Sensitivity Theory (RST) presupposes individual differences in the sensitivity of basic brain systems that respond to punishing and reinforcing stimuli. These differences are thought to underlie the personality dimensions of anxiety and impulsivity, and to have relevance for psychopathology. The present article aims at reviewing RST-based research on personality-psychopathology associations. First, RST and its revisions are described and the link between RST systems and personality dimensions is discussed. Second, studies investigating associations between RST systems and specific types of psychopathology are summarized. Although the available research yields a rather consistent picture with respect to constellations of BIS/BAS sensitivity that are associated with specific types of psychopathology, it also provides a clear indication that much work remains to be done. The discussion section highlights several topics that deserve future research attention.

Let eating disorder patients decide: Providing choice may reduce early drop-out from inpatient treatment.

Premature drop-out from treatment is a highly prevalent phenomenon among eating disorder (ED) patients. In a specialized inpatient treatment unit a major change was made in the admission strategy in 2001, giving a maximum of personal choice to the patients. A quasi-experimental research was carried out comparing 87 patients treated till 2000 ('old' strategy) with 87 patients treated from 2001 on ('new' strategy). The results indicate that the provision of choice at the beginning of treatment significantly reduced drop-out during the first weeks of inpatient treatment. No differences between both strategies on later drop-out and weight change (in anorexia nervosa patients) during inpatient treatment were found. The results are discussed in the light of the importance placed on dynamics of personal choice, autonomy and volition within the framework of the self-determination theory (SDT).

The German version of the Anorectic Behavior Observation Scale (ABOS).

OBJECTIVE: To assess the performance of the German version of the Anorectic Behavior Observation Scale (ABOS) as a parent-report screening instrument for eating disorders (ED) in their children. METHODS: Parents of 101 ED female patients (80 with Anorexia Nervosa; 21 with Bulimia Nervosa) and of 121 age- and socioeconomic status (SES)-matched female controls completed the ABOS. RESULTS: Confirmatory factor analysis supported the original three-factor structure model of the ABOS. Cronbach's alpha coefficients indicated good internal consistency for the three factors and the total score in the total sample. The best cut-off point (100% sensitivity and specificity) in the German version was >or=23. CONCLUSION: The ABOS may be a useful additional instrument for assessing ED.

Denial and concealment of eating disorders: a retrospective survey.

OBJECTIVE: To get an idea of how (ex-)patients deal with the recognition of an emergent eating disorder. METHOD: A retrospective survey was carried out via the websites of two organizations for (ex-)patients with an eating disorder. RESULTS: The respondents (N = 401) reported a variety of attempts to conceal their eating disorder: excuses to avoid eating together, methods to give the false impression of having eaten, avoidance of being weighed and falsifying weight. Often these methods were described as a deliberate strategy. Information about possible health risks had little or no impact on most respondents, who were familiar with the notion of eating disorder but did not apply it to themselves. Many believed they would have recognized their eating disorder earlier if they had met a clinician who was familiar with this disorder. CONCLUSION: Denial of illness together with concealment often reflects a deliberate refusal of self-disclosure within a specific interpersonal context.

Perceived parental psychological control and eating-disordered symptoms: maladaptive perfectionism as a possible intervening variable.

Recent developmental theorizing conceptualizes perfectionism as a mediator of the relation between intrusive parenting and psychopathology. Research addressing this hypothesis in relation to eating disorders (EDs), however, is lacking. This case-control study (a) examined mean-level differences between ED patients and normal controls in psychologically controlling parenting and perfectionism and (b) addressed the intervening role of perfectionism in associations between psychological control and ED symptoms, distinguishing between maladaptive and relatively more adaptive types of perfectionism. Hypotheses were examined in a sample of normal controls (N = 85) and a sample of ED patients (N = 60). Findings indicate that ED patients and bulimics in particular show elevated levels of paternal (but not maternal) psychological control and elevated levels of maladaptive perfectionism compared with normal controls. Mediation analyses show that maladaptive perfectionism is a significant intervening variable between parental psychological control and ED symptoms. Directions for future research on controlling parenting, perfectionism, and ED are outlined.

Body composition in girls and young women with anorexia nervosa: comparison of different equations.

OBJECTIVE: The weight percentage of body fat in anorexic adolescents on the basis of four distinct formulas (Siri; Lohman; Westrate and Deurenberg; Heyward and Stolarczyk) is compared. METHOD: The body composition of 238 anorexia nervosa (AN) patients, divided into four age categories (13-15, 15-17, 17-19, and 19-22 years), was measured by means of densitometry (underwater weighing). RESULTS: Depending on the formula, the results calculated by the formulas differ significantly in each age category. The Siri formula generally results in the highest mean fat percentage (12.76%-13.39%) whereas the Heyward and Stolarczyck formula shows the lowest figures (8.77%-9.31%). Applying the Lohman and the Heyward and Stolarczyck formulas to the 19-22 years category, results in negative fat percentages. CONCLUSION: A clinically useful formula is important for the estimation of body composition in specific age categories. We recommend with some restrictions, to apply the Siri formula in AN patients.

Is there a link between traumatic experiences and self-injurious behaviors in eating-disordered patients?

To find out more about the relationship between the presence of self-injurious behavior (SIB) and a history of traumatic experiences, we studied this link in 70 patients with an eating disorder (ED). The sample showed a high frequency of SIB (38.6%), particularly in patients with bulimia nervosa. We also found high percentages of self-reported experiences of physical (32.3%) and sexual abuse (47.7%). The presence of SIB turned out to be associated with a history of physical and/or sexual abuse. Patients who had suffered interpersonal abuse before the age of 15 were more likely to develop self-destructive behaviors. In line with other investigations, we found that high levels of dissociation and self-criticism differentiated sexually abused ED patients with SIB from those without SIB. We discuss some clinical implications of our findings, with suggestions for treatment.

Self-injurious behavior: differential diagnosis and functional differentiation.

Although often used as synonyms, "self-injury" and "self-harm" may refer to different behaviors with different meanings. Because the literature is quite confusing in this respect, we propose a more specific delineation of the notion of self-injurious behavior (SIB), differentiated from other self-harming behaviors. For this purpose, we present a flowchart for differential diagnosis. This brings us to the question: are we dealing here with a sign of pathology or a meaningful behavior? We compare the structuralist approach, in which SIB is viewed as either a syndrome or a symptom, with the functionalist approach, focusing on the psychosocial functions of SIB.