Anna C. Ciao

Peer Facilitated Eating Disorder Prevention: A Randomized Effectiveness Trial of Cognitive Dissonance and Media Advocacy

The authors investigated the effectiveness of 2 interventions in reducing eating disorder risk factors under naturalistic conditions in sororities. On the basis of previous research, the campus sororities chose to implement a semimandatory, 2-session eating disorder prevention program to all new sorority members (N = 90) during sorority orientation. To facilitate evaluation, sororities agreed to random assignment of new members to either a cognitive dissonance or a media advocacy intervention. Undergraduate peer facilitators ran the groups. Although both interventions had an effect, cognitive dissonance generally was superior at 8-month follow-up. Results further support the utility of cognitive dissonance in reducing eating disorder risk factors and suggest that nondoctoral-level leaders can deliver the program. Results also indicate that a semimandatory format does not reduce effectiveness.

Reducing eating disorder risk factors in sorority members: A randomized trial

Although sororities are often perceived as contributing to eating-disordered behavior, limited research has investigated eating disorders in sorority members. The purpose of this study was to investigate the utility of a highly interactive cognitive dissonance prevention program in reducing empirically supported risk factors in sorority members. Members (N = 149) were randomized to the highly interactive intervention, a more passive intervention, or wait-list. Results indicated that both interventions reduced dietary restraint, body dissatisfaction, and eating disorder pathology. Only the highly interactive group reduced thin-ideal internalization as compared to wait-list. Exploratory analyses also indicated that interventions were beneficial to both lower- and higher-risk members. Taken together, results suggest that sororities are a viable population to target in the prevention of eating disorders.

Effects of being a peer-leader in an eating disorder prevention program: can we further reduce eating disorder risk factors?

Studies regarding the effect of peer-leadership on peer-leaders in prevention programs remain extremely limited. In this study, 83 undergraduate sorority members, who previously participated in the program, served as peer-leaders for an eating disorder prevention program. Peer-leaders attended 9 hours of training and then led two 2-hour sessions. Leaders showed decreases (beyond participation in earlier studies) in dietary restraint, bulimic pathology, body dissatisfaction, and thin-ideal internalization from pre-training through 7-week follow up. Results from this exploratory study suggest that peer-leaders who participate in a program and subsequently lead it may experience additional benefits compared to participation in the program alone.

Weight bias internalization in treatment-seeking overweight adults: Psychometric validation and associations with self-esteem, body image, and mood symptoms

Internalized weight bias has been previously associated with impairments in eating behaviors, body image, and psychological functioning. The present study explored the psychological correlates and psychometric properties of the Weight Bias Internalization Scale (WBIS) among overweight adults enrolled in a behavioral weight loss program. Questionnaires assessing internalized weight bias, anti-fat attitudes, self-esteem, body image concern, and mood symptoms were administered to 90 obese or overweight men and women between the ages of 21 and 73. Reliability statistics suggested revisions to the WBIS. The resulting 9-item scale was shown to be positively associated with body image concern, depressive symptoms, and stress, and negatively associated with self-esteem. Multiple linear regression models demonstrated that WBIS scores were significant and independent predictors of body image concern, self-esteem, and depressive symptoms. These results support the use of the revised 9-item WBIS in treatment-seeking samples as a reliable and valid measure of internalized weight bias.

Subjective and objective binge eating in relation to eating disorder symptomatology, depressive symptoms, and self-esteem among treatment-seeking adolescents with bulimia nervosa.

This study investigated the importance of the distinction between objective (OBE) and subjective binge eating (SBE) among 80 treatment-seeking adolescents with bulimia nervosa. We explored relationships among OBEs, SBEs, eating disorder (ED) symptomatology, depression, and self-esteem using two approaches. Group comparisons showed that OBE and SBE groups did not differ on ED symptoms or self-esteem; however, the SBE group had significantly greater depression. Examining continuous variables, OBEs (not SBEs) accounted for significant unique variance in global ED pathology, vomiting, and self-esteem. SBEs (not OBEs) accounted for significant unique variance in restraint and depression. Both OBEs and SBEs accounted for significant unique variance in eating concern; neither accounted for unique variance in weight/shape concern, laxative use, diuretic use, or driven exercise. Loss of control, rather than amount of food, may be most important in defining binge eating. Additionally, OBEs may indicate broader ED pathology, while SBEs may indicate restrictive/depressive symptomatology.

A naturalistic examination of social comparisons and disordered eating thoughts, urges, and behaviors in college women.

OBJECTIVE We examined the effects of body, eating, and exercise social comparisons on prospective disordered eating thoughts and urges (i.e., restriction thoughts, exercise thoughts, vomiting thoughts, binge eating urges) and behaviors (i.e., restriction attempts, exercising for weight/shape reasons, vomiting, binge eating) among college women using ecological momentary assessment (EMA). METHOD Participants were 232 college women who completed a 2-week EMA protocol, in which they used their personal electronic devices to answer questions three times per day. Generalized estimating equation models were used to assess body, eating, and exercise comparisons as predictors of disordered eating thoughts, urges, and behaviors at the next report, adjusting for body dissatisfaction, negative affect, and the disordered eating thought/urge/behavior at the prior report, as well as body mass index. RESULTS Body comparisons prospectively predicted more intense levels of certain disordered eating thoughts (i.e., thoughts about restriction and exercise). Eating comparisons prospectively predicted an increased likelihood of subsequent engagement in all disordered eating behaviors examined except vomiting. Exercise comparisons prospectively predicted less-intense thoughts about exercise and an increased likelihood of subsequent vomiting. DISCUSSION Social comparisons are associated with later disordered eating thoughts and behaviors in the natural environment and may need to be specifically targeted in eating disorder prevention and intervention efforts. Targeting body comparisons may be helpful in terms of reducing disordered eating thoughts, but eating and exercise comparisons are also important and may need to be addressed in order to decrease engagement in actual disordered eating behaviors.

The effects of psychotherapy treatment on outcome in bulimia nervosa: Examining indirect effects through emotion regulation, self‐directed behavior, and self‐discrepancy within the mediation model

OBJECTIVE The purpose of this investigation was to examine the indirect effects of Integrative Cognitive-Affective Therapy (ICAT-BN) and Cognitive-Behavioral Therapy-Enhanced (CBT-E) on bulimia nervosa (BN) treatment outcome through three hypothesized maintenance variables: emotion regulation, self-directed behavior, and self-discrepancy. METHOD Eighty adults with BN were randomized to 21 sessions of ICAT-BN or CBT-E. A regression-based bootstrapping approach was used to test the indirect effects of treatment on outcome at end of treatment through emotion regulation and self-directed behavior measured at mid-treatment, as well as the indirect effects of treatment at follow-up through emotion regulation, self-directed behavior, and self-discrepancy measured at end of treatment. RESULTS No significant differences in outcome between treatment conditions were observed, and no significant direct or indirect effects were found. Examination of the individual paths within the indirect effects models revealed comparable treatment effects. Across treatments, improvements in emotion regulation and self-directed behavior between baseline and mid-treatment predicted improvements in global eating disorder scores but not binge eating and purging frequency at end of treatment. Baseline to end of treatment improvements in emotion regulation and self-directed behavior also predicted improvements in global eating disorder scores at follow-up. Baseline to end of treatment improvements in emotion regulation predicted improvements in binge eating and baseline to end of treatment increases in positive self-directed behavior predicted improvements in purging at follow-up. DISCUSSION These findings suggest that emotion regulation and self-directed behavior are important treatment targets and that ICAT-BN and CBT-E are comparable in modifying these psychological processes among individuals with BN.

Predictors and moderators of psychological changes during the treatment of adolescent bulimia nervosa

This study examined predictors of psychological change among 80 adolescents with bulimia nervosa (BN) participating in a randomized-controlled trial comparing family-based treatment (FBT) to supportive psychotherapy (SPT). Psychological outcomes (cognitive eating disorder pathology, depression, and self-esteem) were explored at baseline, post-treatment, and 6-month follow-up. Multi-level growth models examined predictors of rate of change in psychological outcomes and moderators of treatment effects. All psychological outcomes improved through 6-month follow-up (moderate to large effect sizes) across both treatments. Overall, few significant predictors were identified. Older adolescents had faster change in self-esteem relative to younger adolescents (p = 0.03). Adolescents taking psychotropic medication at baseline had faster change in eating concerns relative to adolescents not taking medication (p = 0.02). Age (p = 0.02) and baseline purging severity (p = 0.03) moderated the relationship between treatment condition and change in eating concerns, where younger adolescents and individuals with high baseline purging had greater change when treated with FBT relative to SPT. Age and purging did not significantly moderate change in other psychological outcomes. Bulimic symptom improvement did not predict change in psychological symptoms. Generally, FBT and SPT were equally efficacious with respect to psychological improvement, although FBT may be more efficacious in younger adolescents and those with more frequent purging.

Restrictive eating in anorexia nervosa

OBJECTIVE This study examined negative and positive affect in relation to restrictive eating episodes (i.e., meals/snacks perceived as restrictive) and whether restrictive eating was associated with likelihood of subsequent eating disorder behaviors (i.e., additional restrictive eating, binge eating, vomiting, laxative use, weighing, exercising, meal skipping, drinking fluids to curb appetite, body checking). METHOD Women with anorexia nervosa (N = 118) completed a 2-week ecological momentary assessment protocol. RESULTS For both restrictive and nonrestrictive eating, negative affect significantly increased from prebehavior to the time of the behavior but remained stable thereafter, while positive affect remained stable from prebehavior to the time of the behavior but decreased significantly thereafter. Across time, negative affect was significantly lower and positive affect was significantly greater in restrictive than nonrestrictive episodes. Engagement in restrictive eating was associated with an increased likelihood of subsequent restrictive eating, laxative use, and body checking, but not other behaviors. Engagement in nonrestrictive eating was associated with a decreased likelihood of subsequent restrictive eating, binge eating, vomiting, laxative use, weighing, meal skipping, drinking fluids to curb appetite, and body checking. DISCUSSION Despite similar patterns of affect across eating episodes over time, results suggest affect may be involved in the maintenance of restrictive eating in anorexia nervosa since restrictive episodes were associated with lower negative and greater positive affect across time compared to nonrestrictive episodes. Further, while restrictive episodes increased the likelihood of only three subsequent eating disorder behaviors, nonrestrictive episodes were protective since they decreased likelihood of all but one behavior.

Restrictive Eating in Anorexia Nervosa: Examining Maintenance and Consequences in the Natural Environment

OBJECTIVE This study examined negative and positive affect in relation to restrictive eating episodes (i.e., meals/snacks perceived as restrictive) and whether restrictive eating was associated with likelihood of subsequent eating disorder behaviors (i.e., additional restrictive eating, binge eating, vomiting, laxative use, weighing, exercising, meal skipping, drinking fluids to curb appetite, body checking). METHOD Women with anorexia nervosa (N = 118) completed a 2-week ecological momentary assessment protocol. RESULTS For both restrictive and nonrestrictive eating, negative affect significantly increased from prebehavior to the time of the behavior but remained stable thereafter, while positive affect remained stable from prebehavior to the time of the behavior but decreased significantly thereafter. Across time, negative affect was significantly lower and positive affect was significantly greater in restrictive than nonrestrictive episodes. Engagement in restrictive eating was associated with an increased likelihood of subsequent restrictive eating, laxative use, and body checking, but not other behaviors. Engagement in nonrestrictive eating was associated with a decreased likelihood of subsequent restrictive eating, binge eating, vomiting, laxative use, weighing, meal skipping, drinking fluids to curb appetite, and body checking. DISCUSSION Despite similar patterns of affect across eating episodes over time, results suggest affect may be involved in the maintenance of restrictive eating in anorexia nervosa since restrictive episodes were associated with lower negative and greater positive affect across time compared to nonrestrictive episodes. Further, while restrictive episodes increased the likelihood of only three subsequent eating disorder behaviors, nonrestrictive episodes were protective since they decreased likelihood of all but one behavior.