Diane L. Spangler

Risk factors for binge eating onset in adolescent girls: a 2-year prospective investigation.

Because little is known about the predictors of binge eating (a risk factor for obesity), a set of putative risk factors for binge eating was investigated in a longitudinal study of adolescent girls. Results verified that binge eating predicted obesity onset. Elevated dieting, pressure to be thin, modeling of eating disturbances, appearance overvaluation, body dissatisfaction, depressive symptoms, emotional eating, body mass, and low self-esteem and social support predicted binge eating onset with 92% accuracy. Classification tree analysis revealed an interaction between appearance overvaluation, body mass, dieting, and depressive symptoms, suggesting qualitatively different pathways to binge eating and identifying subgroups at extreme risk for this outcome. Results support the assertion that these psychosocial and biological factors increase risk for binge eating.

Do changes in dysfunctional attitudes mediate changes in depression and anxiety in cognitive behavioral therapy

Using structural equation modeling (SEM), four hypotheses about the causal linkages between dysfunctional attitudes (DAs), anxiety, and depression were tested in a group of 521 outpatients treated with cognitive behavioral therapy (CBT) over a 12-week period. The four hypotheses were as follows: (1) changes in DAs lead to changes in depression and anxiety during treatment (the cognitive mediation hypothesis); (2) changes in depression and/or anxiety lead to changes in DAs (the mood activation hypothesis); (3) DAs and negative emotions have reciprocal causal effects on each other (the circular causality hypothesis); and (4) there are no causal links between DAs and emotions—instead, a third variable simultaneously activates DAs, depression and anxiety (the “common cause” hypothesis). Consistent with previous reports, DAs were significantly correlated with levels of depression and anxiety at intake and at 12 weeks; in addition, changes in DAs were significantly correlated with changes in depression and anxiety during treatment. However, the results were inconsistent with the first three hypotheses. There did not appear to be any causal effects linking the DAs with depression or anxiety at intake or at 12 weeks. Instead, the analyses suggested the existence of an unknown variable with simultaneous causal effects on dysfunctional attitudes, depression, and anxiety. This common cause accounted for all the correlations between the attitude and mood variables, and also appeared to mediate the effects of psychotherapy and medication on dysfunctional attitudes, depression, and anxiety.

Testing the cognitive model of eating disorders: The role of dysfunctional beliefs about appearance

The cognitive theory of eating disorders posits that dysfunctional attitudes about physical appearance give rise to eating disorder risk factors such as dietary restriction, body dissatisfaction, and valuing of thinness. To test this hypothesis, the relationships between appearance beliefs and dietary restriction, body dissatisfaction, self-esteem, and thin-ideal internalization were examined using structural equation modeling. Beliefs about appearance were concurrently associated with dietary restriction, body dissatisfaction, self-esteem, and thin-ideal internalization, and predicted these variables within each time point and across time points. In contrast, none of the eating disorder risk factors predicted beliefs about appearance either within or across time points. Implications of these results for cognitive theory of eating disorders and eating disorder prevention are discussed.

Rumination and Distraction Among Chronic Depressives in Treatment: A Structural Equation Analysis

Response Styles Theory hypothesizes that rumination about ones symptoms amplifies and prolongs depressed mood, whereas distraction has the opposite effect. Response styles are also hypothesized to be trait-like dispositions. The generalizability of Response Styles Theory, as well as the linkages that may account for correlations between rumination, distraction, and depression, were explored with structural equation modeling in a sample of chronically depressed individuals undergoing treatment with psychotherapy, medication, or combination treatment. Results were not consistent with the hypotheses that rumination or distraction have causal effects on recovery from depression or that depression causes rumination or distraction. Rather a common cause or causes appeared to account for the correlations between these variables. Stability of rumination and distraction was low over a 12-week period. Implications of the findings are discussed.

Evaluating the effectiveness of cognitive-behavioral teletherapy in depressed adults.

Telephone psychotherapy is an emerging form of delivery of care that has recently demonstrated utility and efficacy for adult depression when provided as an adjunct to antidepressant treatment in primary care trials. This study constitutes one of the initial evaluations of cognitive behavioral therapy-telephone treatment (CBT-TT) as a stand-alone treatment for adult depression in specialty care. Thirty adults initiating psychotherapy for depression at a mental health clinic participated in the trial. The majority of participants (69%) were very satisfied with the 8-session CBT-TT, reduction in depression severity was significant over 3 and 6 months, and 42% of participants were considered recovered at termination. These outcomes closely parallel the findings from an earlier primary care trial, despite specialty care participants beginning treatment with more severe depression and without adjunctive antidepressant medication. These findings suggest that CBT-TT for adult depression is feasible and has potential as a stand-alone treatment. Implementation of this telephone-based delivery approach in primary and specialty care settings is discussed.

Cognitive-behavioral therapy for bulimia nervosa: an illustration.

Cognitive-behavioral therapy for bulimia nervosa (BN) is a well-developed, theoretically grounded treatment for BN with the strongest empirical support for its efficacy of any form of treatment for BN. The treatment package comprises three distinct phases typically delivered over 20 weeks. Incorporating a variety of specific interventions, these three phases of treatment focus systematically on (i) dietary restraint, (ii) dysfunctional beliefs about body weight and shape, and (iii) reactions to recurrence of symptoms, which are thought to be the primary operative mechanisms that cause and maintain BN symptoms. Case material is presented to illustrate cognitive-behavioral treatment principles.

An fMRI investigation of emotional processing of body shape in bulimia nervosa

OBJECTIVE Cognitive-behavioral theories of eating disorder etiology emphasize the role of body-oriented self-schemas. Examination of brain regions associated with self-referencing, such as medial prefrontal cortex (mPFC), during processing of body-related stimuli can thus be utilized to evaluate such theories. METHOD Twelve women with bulima nervosa (BN) and 12 comparison women underwent functional brain imaging while viewing images of women with either thin or overweight bodies in a self-referencing context. RESULTS For thin bodies, there was no significant mPFC activation for either group. For overweight bodies, mPFC activation was significantly greater for BN patients, with a focus in subregions associated with emotional processing. DISCUSSION These findings are consistent with cognitive models of eating disorders which posit that negative body-related stimuli are more central to self-schemas and more emotionally provocative in persons with eating disorders, lending support to treatment and prevention interventions that emphasize body overvaluation as a primary target of change.

An examination of the mechanisms of action in cognitive behavioral therapy for bulimia nervosa

Cognitive-behavioral therapy (CBT) for bulimia nervosa (BN) has received considerable empirical support for its efficacy. However, few investigators have examined the mechanisms proposed to account for the reduction of BN symptoms during CBT. The current study examined the associations between therapist interventions, client mechanisms, and symptoms during treatment in a sample of 56 clients undergoing CBT for BN. Results suggested that behavioral interventions were most associated with symptom change during treatment whereas relational interventions were most associated with change in client mechanisms such as client engagement. Additionally, some changes in BN symptoms were mediated by changes in proposed client mechanisms whereas others were directly associated with therapist interventions. Implications of these findings for CBT theory of BN treatment and CBT treatment process research methodology are discussed.

The Change in Eating Disorder Symptoms scale: scale development and psychometric properties.

Although several instruments provide reliable and valid diagnoses for eating disorders or measure specific features of eating disorders, existing instruments are limited in their ability to comprehensively assess session-by-session change in eating disorder symptoms during treatment. This study describes the initial development and psychometric properties of a scale designed to assess change in eating disorder symptoms during treatment, namely the Change in Eating Disorder Symptoms (CHEDS) scale. Two hundred and sixty-seven eating disordered and non-eating disordered participants completed the CHEDS and related measures. Item and factor analyses were conducted to select optimal items. Correlational analyses, group mean comparisons, and discriminant function analyses were conducted to examine the validity of the CHEDS. The CHEDS consisted of seven distinct symptom factors. The CHEDS total and subscale scores were significantly higher in eating disordered groups compared to non-eating disordered groups, and also differentiated eating disorder subtypes. Overall, results indicated that the CHEDS is a reliable and valid instrument. Studies addressing sensitivity to change and change indices for the CHEDS are forthcoming.

Is it true that men are from Mars and women are from Venus? A test of gender differences in dependency and perfectionism.

Several theorists have proposed that dependency and perfectionism differentially characterize depression in women and men. Structural equation modeling was conducted on a sample of 427 patients with mood disorders to test the hypotheses that: (1) depressed women exhibit greater dependency than depressed men, (2) depressed men exhibit greater perfectionism than depressed women, (3) dependency is more related to depression in women, (4) perfectionism is more related to depression in men, (5) reductions in dependency during treatment are more associated with recovery in women, and (6) reductions in perfectionism during treatment are more associated with recovery in men. No support was found for any of the hypothesized gender differences. Women and men did not differ in the level of dependency or perfectionism, or in the correlation between these variables and depression. In addition, changes in dependency and perfectionism during treatment were not differentially associated with changes in depression in women and men.