Jennifer E. Wildes

The roles of ethnicity and culture in the development of eating disturbance and body dissatisfaction: A meta-analytic review.

This meta-analysis involved 35 studies examining eating disturbance and body dissatisfaction in white and non-white populations and the role of acculturation in the development of eating-related psychopathology. While the role of acculturation in predisposing non-whites to eating disorders remains to be determined, mean effect sizes indicate that whites report more eating disturbance than non-whites. Differences are greatest when studies compare black and white college samples on measures of subclinical eating pathology, like dietary restraint, ideal body shape, and body dissatisfaction. They are weakest when non-clinic populations and clinical forms of eating disturbance, like bulimia nervosa, are examined. These findings suggest that the current literature may be incorrect in its view that subclinical and clinical forms of eating disturbance represent the poles of a single continuum. In addition, they call into question the belief that SES influences the development of eating pathology.

Emotion Avoidance in Patients with Anorexia Nervosa: Initial Test of a Functional Model

OBJECTIVE This study aimed to evaluate emotion avoidance in patients with anorexia nervosa (AN) and to examine whether emotion avoidance helps to explain (i.e., mediates) the relation between depressive and anxiety symptoms and eating disorder (ED) psychopathology in this group. METHOD Seventy-five patients with AN completed questionnaires to assess study variables. Rates of emotion avoidance were compared to published data, and regression models were used to test the hypothesis that emotion avoidance mediates the relation between depressive and anxiety symptoms and ED psychopathology in AN. RESULTS Patients with AN endorsed levels of emotion avoidance that were comparable to or higher than other psychiatric populations and exceeded community controls. As predicted, emotion avoidance significantly explained the relations of depressive and anxiety symptoms to ED psychopathology. DISCUSSION Findings confirm that emotion avoidance is present in patients with AN and provide initial support for the idea that anorexic symptoms function, in part, to help individuals avoid aversive emotional states.

Development of emotion acceptance behavior therapy for anorexia nervosa: a case series.

This case series describes the development of a novel psychotherapeutic intervention for older adolescents and adults with anorexia nervosa (AN). Emotion acceptance behavior therapy (EABT) is based on a model that emphasizes the role of anorexic symptoms in facilitating avoidance of emotions. EABT combines standard behavioral interventions that are central to the clinical management of AN with psychotherapeutic techniques designed to increase emotion awareness, decrease emotion avoidance, and encourage resumption of valued activities and relationships outside the eating disorder. Five patients with AN aged 17-43 years were offered a 24-session manualized version of EABT. Four patients completed at least 90% of the therapy sessions, and three showed modest weight gains without return to intensive treatment. Improvements in depressive and anxiety symptoms, emotion avoidance, and quality of life also were observed. These results offer preliminary support for the potential utility of EABT in the treatment of older adolescents and adults with AN.

Emotion dysregulation and symptoms of anorexia nervosa: The unique roles of lack of emotional awareness and impulse control difficulties when upset

OBJECTIVE Extant research suggests that individuals with anorexia nervosa (AN) have deficits in emotion regulation across a variety of domains. The current study investigated associations between specific difficulties with emotion regulation and the core symptoms of AN. METHOD Participants were 192 patients with AN presenting to an intensive eating disorder treatment facility. Emotion regulation was assessed using the multidimensional Difficulties in Emotion Regulation Scale, and associations with body mass index (BMI) at admission, eating disorder cognitions, objective binge eating, subjective binge eating, and purging were examined. RESULTS Eating disorder cognitions were significantly associated with multiple forms of emotion dysregulation; however, only lack of emotional awareness was independently related to these symptoms. In contrast, impulse control difficulties when upset was the only emotion regulation impairment associated with the presence of recurrent objective binge eating and recurrent purging in AN. No significant relationships between emotion regulation and BMI or subjective binge eating were detected. DISCUSSION Results point to differential associations between specific emotion regulation deficits and core symptoms of AN. These findings suggest that parsing the construct of emotion regulation as well as the AN phenotype can help to identify the unique ways in which eating disorder symptoms may function to regulate emotions.

Development and validation of the Eating Pathology Symptoms Inventory (EPSI).

Many current measures of eating disorder (ED) symptoms have 1 or more serious limitations, such as inconsistent factor structures or poor discriminant validity. The goal of this study was to overcome these limitations through the development of a comprehensive multidimensional measure of eating pathology. An initial pool of 160 items was developed to assess 20 dimensions of eating pathology. The initial item pool was administered to a student sample (N = 433) and community sample (N = 407) to determine the preliminary structure of the measure using exploratory and confirmatory factor analyses. The revised measure was administered to independent samples of patients recruited from specialty ED treatment centers (N = 158), outpatient psychiatric clinics (N = 303), and students (N = 227). Analyses revealed an 8-factor structure characterized by Body Dissatisfaction, Binge Eating, Cognitive Restraint, Excessive Exercise, Restricting, Purging, Muscle Building, and Negative Attitudes Toward Obesity. Scale scores showed excellent convergent and discriminant validity; other analyses demonstrated that the majority of scales were invariant across sex and weight categories. Eating Pathology Symptoms Inventory scale scores had excellent internal consistency (median coefficient alphas ranged from .84-.89) and reliability over a 2- to 4-week period (mean retest r = .73). The current study represents one of the most comprehensive scale development projects ever conducted in the field of EDs and will enhance future basic and treatment research focused on EDs.

The clinical utility of personality subtypes in patients with anorexia nervosa.

OBJECTIVE Elucidation of clinically relevant subtypes has been proposed as a means of advancing treatment research, but classifying anorexia nervosa (AN) patients into restricting and binge-eating/purging types has demonstrated limited predictive validity. This study aimed to evaluate whether an approach to classifying eating disorder patients on the basis of comorbid personality psychopathology has utility in predicting treatment response and readmission in patients with AN. METHOD Data were collected from 154 AN patients (M [SD] age = 25.6[9.4] years; 95.5% female; 96.8% Caucasian) at admission, discharge, and 3 months postdischarge from intensive treatment. Latent profile analysis of personality traits assessed at admission was performed to classify participants into personality subtypes, which were then used to predict outcomes at discharge and risk of readmission. RESULTS The best fitting model identified 3 personality subtypes (undercontrolled, overcontrolled, low psychopathology) that contributed significantly to multivariate models predicting study outcomes. Undercontrolled patients were more likely to have a poor outcome at discharge than overcontrolled (OR = 3.56, p = .01) and low psychopathology patients (OR = 11.23, p < .001). Undercontrolled patients also had a greater risk of discharge against medical advice (HR = 2.08, p = .02) and readmission than overcontrolled patients (HR = 3.76, p = .009). Binge-eating/purging versus restricting subtypes did not predict discharge against medical advice or readmission in the multivariate models. CONCLUSIONS Findings support the clinical utility of personality subtypes in AN. Future work is needed to identify mechanisms that explain diminished treatment response in undercontrolled patients and to develop interventions for this high-risk group.

Prevalence and correlates of eating disorder co-morbidity in patients with bipolar disorder

This study was designed to document eating disorder symptoms in a well-defined sample of patients with bipolar disorder and to evaluate the relationship of current loss of control over eating (LOC) to demographic and clinical features hypothesized to characterize bipolar patients at risk for disordered eating. Eighty-one patients enrolled in the Bipolar Disorder Center for Pennsylvanians provided demographic information and completed the Structured Clinical Interview for DSM-IV Axis I Disorders. The Eating Disorder Examination was administered by independent clinicians to evaluate current and lifetime eating disorder symptomatology. Twenty-one percent of participants met DSM-IV criteria for a lifetime eating disorder, and 44% reported a history of LOC. Patients who endorsed weekly LOC during the past six months (n=18) were heavier, had more atypical depressive symptoms, and were more likely to have a lifetime substance use disorder compared to patients in the rest of the sample (n=63). These findings indicate that eating disorder symptoms are prevalent in patients with bipolar disorder and are associated with obesity and other psychiatric morbidity. Screening for eating disorders in bipolar patients is warranted, as intervention may minimize distress and improve treatment outcome.

Self-reported binge eating in severe pediatric obesity: impact on weight change in a randomized controlled trial of family-based treatment

Objective:This study sought to document self-reported binge eating in a large sample of severely obese children and to examine the impact of binge eating on changes in percent overweight among children randomized to family-based behavioral treatment (intervention) versus control (usual care).Participants and methods:As part of a larger randomized controlled trial, 192 children aged 8–12 years (M=10.2, s.d.=1.2) with a mean body mass index (BMI) percentile of 99.2 (s.d.=0.7) completed assessments at baseline and 6-, 12-, and 18 months post-randomization. A parent or guardian also participated. Child psychological symptoms, including binge eating, were measured before randomization using self-report questionnaires. Child height and weight were measured at baseline, 6-, 12-, and 18 months. The primary study outcome was percent overweight (that is, percent over median BMI for age and sex).Results:Twenty-two children (11.5%) endorsed binge eating at baseline (Binge Eating Group). Children in the Binge Eating Group were younger and had more depressive, anxiety, and eating disorder symptoms, and lower self-esteem than children in the rest of the sample (No Binge Eating Group). There also were differences between the Binge Eating and No Binge Eating groups with respect to the short-term effects of treatment group assignment on change in percent overweight during the study. Specifically, improvements in percent overweight in the intervention condition relative to usual care were documented in the No Binge Eating Group only. Among children in the Binge Eating Group, those assigned to intervention showed a 2.6% increase in percent overweight, on average, at the completion of acute treatment as compared to an 8.5% decrease among children without binge eating. However, these effects were not maintained during follow-up.Conclusion:Results of this study suggest the importance of considering binge eating in the development of weight management programs for severely obese youth.

Childhood Maltreatment and Psychiatric Morbidity in Bariatric Surgery Candidates

BackgroundThis study used standardized assessments to evaluate the association between childhood maltreatment (i.e., emotional, physical, and sexual abuse and emotional and physical neglect) and Axis I and II psychiatric disorders in patients presenting for bariatric surgery.MethodsParticipants (N = 230) provided demographic information and completed the Childhood Trauma Questionnaire, short form. The Structured Clinical Interview for the DSM-IV was used to assess Axis I clinical disorders and Axis II personality disorders.ResultsApproximately 66% of participants had a history of childhood maltreatment. Individuals reporting childhood maltreatment had a greater number of lifetime Axis I diagnoses than did those without, although the effect for physical neglect was no longer significant after controlling for multiple comparisons. With respect to specific Axis I diagnoses, a history of emotional or sexual abuse was associated with increased rates of lifetime mood and anxiety disorder diagnoses. Emotional neglect also was associated with increased rates of mood disorder diagnoses, and physical abuse was associated with increased rates of substance use disorders. There was no significant association between childhood maltreatment and personality psychopathology.ConclusionThis study confirms high rates of childhood maltreatment in patients presenting for bariatric surgery that are associated with increased prevalence of lifetime mood, anxiety, and substance use disorders. Future prospective studies should include evaluation of a broad range of mental health and childhood experiences to tease apart the nature of the relationships between these factors and their potential impact on post-surgical outcomes.

Childhood adversity and anxiety versus dysthymia co-morbidity in major depression

BACKGROUND Childhood adversity places individuals with major depression at risk for anxiety and dysthymia co-morbidity. The goal of the present paper is to broaden this area of research by examining specificity between the type of adversity (e.g. abuse versus neglect/indifference) and the resulting co-morbid disorder (e.g. anxiety versus dysthymia co-morbidity). METHOD The volunteer sample consisted of 76 women meeting Diagnostic and Statistical Manual (DSM-IV) criteria for major depression. Of these, 28 were diagnosed with a co-morbid anxiety disorder and 21 were diagnosed with co-morbid dysthymia. Childhood physical abuse, sexual abuse, psychological abuse, antipathy and indifference were assessed using a contextual interview and rating system. RESULTS Severe sexual abuse and psychological abuse were significantly and preferentially associated with co-morbid anxiety, while severe physical abuse was significantly and preferentially associated with co-morbid dysthymia. Indifference and antipathy were significantly associated with both co-morbid anxiety and dysthymia. Multivariate analyses revealed that severe sexual abuse was the adverse childhood experience most strongly associated with co-morbid anxiety. CONCLUSIONS These results suggest that particular adverse experiences in childhood do set up specific vulnerabilities to the expression of anxiety versus dysthymia co-morbidity in adulthood major depression. Cognitive mediators of these associations are discussed as avenues of future research.