Peter J. Cooper

The development and validation of the body shape questionnaire

Concerns about body shape are common among young women in Western cultures, and, in an extreme form, they constitute a central feature of the eating disorders anorexia nervosa and bulimia nervosa. To date there has been no satisfactory measure of such concerns. A self-report instrument, the Body Shape Questionnaire (BSQ) has therefore been developed. The items that constitute this measure were derived by conducting semistructured interviews with various groups of women including patients with anorexia nervosa and bulimia nervosa. The BSQ has been administered to three samples of young women in the community as well as to a group of patients with bulimia nervosa. The concurrent and discriminant validity of the measure have been shown to be good. The BSQ provides a means of investigating the role of concerns about body shape in the development, maintenance, and treatment of anorexia nervosa and bulimia nervosa.

Confusion over the core psychopathology of bulimia nervosa.

There has been particular confusion concerning two aspects of the psychopathology of bulimia nervosa: dissatisfaction with body shape and overvalued ideas about shape and weight. Whilst these features are closely related, they are nevertheless distinct. Body shape dissatisfaction is commonly found in these patients but is not necessarily present; whilst the over-valued ideas about shape and weight are a necessary diagnostic feature. Analysis of the relationship between these two features and depressed mood and self-esteem showed that, in the course of treatment, change in body shape dissatisfaction was closely associated with change in mood; and change in the overvalued ideas was closely associated with change in self-esteem. This finding supports the distinction between these two facets of the core psychopathology of bulimia nervosa.

Subclinical versus formal eating disorders: Differentiating psychological features

Sixty referrals to a Pediatric Eating Disorder clinic were compared on a number of demographic, clinical, and psychological variables. Twelve patients met definite diagnostic criteria for anorexia nervosa and 14 met criteria for a diagnosis of bulimia nervosa. Twenty-one patients had a subclinical form of anorexia nervosa and eight had subclinical bulimia nervosa. Five patients could not be classified. The subclinical and definite diagnostic groups were compared across a number of demographic, eating pathology, and general psychological variables. The results revealed a clear pattern of difference between the two bulimia nervosa groups on variables related to the regulation of affects and impulses. There was no clear pattern of difference between the definite and subclinical anorexia nervosa groups. The results suggest that the DSM-III-R criteria for anorexia nervosa may substantially underestimate the number of individuals with a psychologically distressing eating disorder, but provide tentative support for the maintenance of strict diagnostic criteria for bulimia nervosa.

Psychosocial factors associated with the early termination of breast-feeding

The relation between a number of psychosocial factors and the early termination of breast-feeding was examined in two large independent samples of puerperal women. The findings were remarkably similar. In both cohorts there was a significant association with depressive disorder which in the great majority preceded the cessation of breast-feeding. Other factors of importance were low social class, being young and lower educational attainment.

An evaluation of the efficacy of supervised cognitive behavioral self-help for bulimia nervosa

Eighty two patients with bulimia nervosa were managed by providing them with supervision in the use of a highly structured cognitive behavioral self-help manual. Their progress was assessed in an open clinical trial. The 67 patients who completed the course of self-help experienced considerable benefit; the frequency of bulimic episodes and self-induced vomiting decreasing by 80% and 79%, respectively. Compared to those who benefited, those who had a poor outcome or dropped out of treatment were more than twice as likely to have had anorexia nervosa in the past and were somewhat more likely to have a personality disorder. Three-quarters of those who persisted with the programme of supervised self-help were followed up a year after commencing treatment. Clinical gains were well maintained: almost two thirds were abstinent with respect to both bulimic episodes and self-induced vomiting. It would seem appropriate that, as part of a stepped care approach to the management of bulimia nervosa, supervised cognitive behavioral self-help should routinely be the first line treatment.

Self-help for bulimia nervosa: a preliminary report.

Eighteen patients with DSM-III-R bulimia nervosa were treated by providing them with supervision in the use of a self-help manual based on the cognitive behavioral treatment for the disorder. The patients were assessed before beginning the self-help program, and again 4 to 6 months later, using standardized measures of psychopathology. The findings were encouraging. At follow-up one half of the patients had ceased bulimic episodes and self-induced vomiting, and most of the remainder had made significant improvements. These preliminary findings, together with related published work, suggest that supervised self-help might be an appropriate first line treatment for patients with bulimia nervosa and that for many patients it could be sufficient.

An experimental study of the effect of mood on body size perception.

The study presented is an experimental investigation of the effect of mood on body size perception. Female students estimated their body size and indicated their degree of dissatisfaction with their body size before and after the induction of a negative or positive mood state. Compared with women who received the positive induced mood, the induction of low mood led to greater disturbances in body size perception in the form of a tendency to overestimate their body size more and significantly greater dissatisfaction with their body size. Furthermore, among the women who received the negative mood condition, compared with those with little or no concern with their body shape, for those with such concerns the induction of low mood led to greater disturbances in body size perception in the form of overestimating their body size significantly more and a tendency towards greater dissatisfaction with their body size. These findings suggest that depressed mood may play an important role in determining the extent of disturbance in body size perception in clinical populations.

A problematic counter-regulation experiment: implications for the link between dietary restraint and overeating

The current study failed to find any evidence of laboratory counter-regulation amongst restrained eaters given a preload, regardless of the measures of dietary restraint used to classify subjects, including dieting status on the day of the study. Furthermore, there was no evidence to suggest that high restrainers characteristically overeat or experience a sense of loss of control over eating in naturalistic settings. These findings indicate that the link between dietary restraint and overeating or bulimic episodes is, at most, a weak one. Future investigations must incorporate more detailed and sensitive measures of both restraint and overeating if analogue studies are to be useful for understanding the process involved in clinically significant episodes of overeating or binge eating.

Cognitive distortions amongst women experiencing bulimic episodes

A self-report questionnaire was devised to assess cognitive distortions of a general depressogenic nature and ones specifically related to concerns about food, eating, shape, and weight. This questionnaire was administered to three groups: those established by interview to experience bulimic episodes, those reporting bulimic episodes on a self-report questionnaire (but not confirmed by interview), and controls. The group definitely experiencing bulimic episodes was found to differ from the others in terms of the extent of personalization, overgeneralization, catastrophization, and selective abstraction in relation to themes concerning food, eating, shape, and weight. This difference remained when the effect of more general depressogenic distortions was removed statistically.

Behavioral treatment of bulimia nervosa

Eight patients with bulimia nervosa were treated using purely behavioral techniques in the absence of explicit cognitive procedures. All were systematically assessed before and after treatment; seven were reassessed at a 1-year follow-up. As a group, they showed substantial improvement in terms of eating habits, a global index of specific psychopathology, and mental state. These changes were comparable to those previously obtained in an Oxford sample of patients using a cognitive behavioral treatment. These findings raise the question as to whether cognitive procedures are necessary to produce change in patients with bulimia nervosa.