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Objective: The Eating Disorder Examination Questionnaire (EDE-Q) is a widely-used measure of eating-disorder symptoms. However, inconsistent replication of the subscale structure raises concern about validity. To provide a rigorous test of the EDE-Q's dimensionality and item-quality, we applied modern and classical test theory approaches to data obtained from a large, transdiagnostic sample of people with clinical eating disorders., Method: We analyzed data from 1197 individuals (M age  = 27.9 years, SD = 10.08, 95% female) with various eating disorders, who had been assessed for treatment at a specialized program. Exploratory analyses (including Parallel Analyses), Confirmatory Factor Analyses (CFA) and graded-response Item Response Theory (IRT) analyses, were conducted with Mplus., Results: Factor analyses showed inappropriate fit to the original EDE-Q subscales, as well as for alternative 1,2,3, and 4-factor solutions. Parallel analyses suggested a one-dimensional structure as best fit. IRT analyses showed substantial variability in EDE-Q-item quality and indicated that five items (fear of weight gain, feeling fat, desire to lose weight, importance of weight, importance of shape) were most pertinent to determining severity. The construct validity of the five EDE-Q items was confirmed by a CFA, showing excellent fit., Discussion: Our results suggest that EDE-Q scores are best interpreted as spanning a one-factor continuum. IRT results suggest that some items are more pertinent than others for determining eating-disorder severity. Results could be useful for establishing short EDE-Q versions, such as a five-item version, which, in turn, would be helpful for measurement-based clinical practice and for data-collection in epidemiological and experimental studies., (© 2024 The Author(s). International Journal of Eating Disorders published by Wiley Periodicals LLC.)

Objective: Previous studies have indicated that virtual treatments for eating disorders (EDs) are roughly as effective as are in-person treatments; the present nonrandomized study aimed to expand on the current body of evidence by comparing outcomes from a virtual day treatment program with those of an in-person program in an adult ED sample., Method: Participants were 109 patients who completed at least 60% of day treatment sessions (n = 55 in-person and n = 54 virtual). Outcome measures included ED and comorbid symptoms, and motivation., Results: Linear mixed models showed that global EDE-Q scores decreased during treatment (AIC = 376.396, F = 10.94, p = 0.002), irrespective of treatment modality (p = 0.186). BMI significantly increased over time (AIC = 389.029, F = 27.97, p < 0.001), with no effect of treatment modality (p = 0.779)., Discussion: Our findings suggest that the virtual delivery of day treatments produces comparable outcomes to those obtained using in-person formats, and that virtual formats may represent a pragmatic treatment option, especially in situations in which access to in-person care is limited., (© 2024 The Author(s). International Journal of Eating Disorders published by Wiley Periodicals LLC.)

Drawing from literature on measurement-based care and prognostic indices in eating disorder (ED) treatment, Wade et al. offer an algorithm for treating co-occurring mental-health conditions (i.e., psychiatric comorbidity) in people with EDs, and for studying effects of comorbidity-oriented treatments. Advocating session-by-session measurement to inform adaptive treatment, their proposal outlines a process for adjusting conventional ED treatment to situations in which comorbidity impedes treatment progress. The plan is methodical and responsive to evidence suggesting that peoples' early in-treatment change has more power, prognostically, than do indices of comorbidity. In the absence of data to inform practices in some areas, the authors intentionally leave key questions unanswered until future results are in. But this means that they reserve comment on how to determine that comorbidity is interfering with treatment response, or to select the best-fitting of available comorbidity-oriented options. Likewise, the proposal draws most of its inspiration from literature on individual (mainly cognitive-behavioral) psychotherapy and, as a result, does not fully represent biopsychosocial perspectives, or elaborate upon the place in comorbidity management of biological treatments, family, and carer involvement, or more complex integrated approaches. Considerations on how to apply the latter methods would broaden the plan's scope., (© 2023 Wiley Periodicals LLC.)

Objective: To determine the association between adolescent hospitalization for suicide attempts and the subsequent risk of eating disorder hospitalization., Method: This was a cohort study of 162,398 adolescent girls in Quebec, Canada, including 7741 with suicide attempts before 20 years of age, matched to 154,657 adolescents with no attempt between 1989 and 2019. The main exposure measure was suicide attempt hospitalization. The main outcome measure was hospitalization for an eating disorder up to 31 years later, including anorexia nervosa, bulimia nervosa, and other eating disorders. We used adjusted Cox regression models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association between adolescent suicide attempts and eating disorder hospitalization., Results: Adolescent girls admitted for a suicide attempt had 5.55 times the risk of eating disorder hospitalization over time (95% CI 3.74-8.23), compared with matched controls. Suicide attempt was associated with anorexia nervosa (HR 3.57, 95% CI 1.78-7.17) and bulimia nervosa and other eating disorders (HR 8.55, 95% CI 5.48-13.32). Associations were pronounced in girls with repeated suicide attempts. Girls who attempted suicide through self-poisoning had an elevated risk of anorexia nervosa, whereas girls who used violent methods such as cutting or piercing had a greater risk of bulimia nervosa and other eating disorders. Suicide attempt was strongly associated with eating disorder hospitalization in the year following the attempt, but associations persisted throughout follow-up., Discussion: Suicide attempt admission is associated with the long-term risk of eating disorder hospitalization in adolescent girls., Public Significance: This study of adolescent girls suggests that suicide attempt admission is associated with the long-term risk of hospitalization for eating disorders. The risk is greatest in the year after the attempt, but persists over time. Adolescents who present with a suicide attempt may benefit from screening for eating disorders and long-term follow-up to help prevent the exacerbation or development of eating disorders., (© 2023 The Authors. International Journal of Eating Disorders published by Wiley Periodicals LLC.)

Objective: Findings show virtual therapy (conducted using internet-based videoconferencing techniques) to be a viable alternative to in-person therapy for a variety of mental-health problems. COVID-19 social-distancing imperatives required us to substitute virtual interventions for in-person sessions routinely offered in our outpatient eating disorder (ED) program-and afforded us an opportunity to compare the two treatment formats for clinical efficacy., Methods: Using self-report assessments, we compared outcomes in a historical sample of 49 adults with heterogeneous EDs (treated in-person over 10-14 weeks in individual and group therapies) to those of 76 patients receiving comparable virtual treatments, at distance, during the COVID-19 outbreak. Linear mixed models were used to study symptom changes over time and to test for differential effects of treatment modality., Results: Participants in both groups showed similar improvements on eating symptoms, levels of weight gain (in individuals in whom gain was indicated), and satisfaction with services., Discussion: Our results suggest that short-term clinical outcomes with virtual and in-person ED therapies are comparable, and point to potentials of virtual therapy for situations in which geographical distance or other barriers impede physical access to trained therapists or specialized treatments., (© 2021 Wiley Periodicals LLC.)

Objective: Identifying modifiable predictors of outcomes following treatment for eating disorders may help to tailor interventions to patients' individual needs, improve treatment efficacy, and develop new interventions. The goal of this meta-analysis was to quantify the association between pretreatment motivation and posttreatment changes in eating disorder symptomology., Method: We reviewed 196 longitudinal studies reporting on change on indices of overall eating-disorder symptomatology, weight gain, binge-eating, vomiting, anxiety/depression, and treatment adherence. Meta-analyses were performed using two complementary approaches: (a) combined probability analysis using the added Z's method; (b) effect size analyses. Using random-effect models, effect sizes were pooled when there were at least three studies with the same type of statistical design and reporting statistics on the same outcome. Heterogeneity in study outcome was evaluated using Q and I 2 statistics. Studies were reviewed qualitatively when the number of studies or reported data were insufficient to perform a meta-analysis., Results: Forty-two articles were included. Although samples and treatments differed substantially across studies, results across studies were remarkably consistent. Both combined-probability and effect-size analyses indicated positive effects of pretreatment motivation on improvement in general eating-disorder symptoms (Cohen's r = .17), and an absence of effects on anxiety/depression symptoms. Remaining outcome indices were subject to selective reporting and/or small sample size bias., Discussion: Our findings underscore the importance of incorporating treatment engagement approaches in the treatment of eating disorders. Optimal reporting of study findings and improving study quality would improve future efforts to obtain an in-depth understanding of the relationship between motivation and eating disorder symptoms., (© 2020 Wiley Periodicals LLC.)

Objective: People who are ill with anorexia nervosa (AN) show altered availability of key plasma nutrients. However, little is known about the patterning of alterations that occurs across diverse nutrients during active phases of illness or about the persistence of any such alterations following remission of illness., Method: We compared plasma levels of one-carbon metabolism nutrients across women with active AN (AN-Active: n = 53), in remission from AN (AN-Remitted: n = 40), or who had no eating-disorder history (NED: n = 36). We also tested associations between body mass index (BMI) changes and changes in pre- to posttreatment nutrient levels, and explored the association between nutrient levels, on the one hand, and BMI and eating symptoms, on the other. Choline, betaine, and methionine were analyzed using mass spectrometry. Folate and B12 were analyzed using the AccuBind® ELISA kit. Eating-disorder symptoms were assessed by interview and self-report., Results: Compared to NED individuals, AN-Active individuals exhibited significantly elevated B12 and (less-reliably) betaine. In AN-Active individuals, lower BMI was associated with higher B12., Discussion: The observed alterations run contrary to the intuition that plasma nutrient levels should be directly responsive to nutritional status and suggest, instead, the existence of compensatory adaptations to malnutrition in individuals with active AN. Further study is required to clarify mechanisms that underlie such effects., (© 2020 Wiley Periodicals, Inc.)

Several objectives underlie the current article. First, to review historical diagnostic issues and clinical strategies for treating SE-AN. Second, to provide an overview of recent evidence informed strategies and clinical innovations for the treatment of SE-AN. Third, based on the authors' collective clinical and research experience, we offer eight observations that we believe capture the current clinical experience of patients with SE-AN. Some of these observations represent empirically testable hypotheses, but all are designed to generate a meaningful discussion about the treatment of this group of individuals with eating disorders. Finally, we hope to call clinicians, scientists, professional organizations, advocates, and policy makers to action to attend to critical issues related to the care of individuals with SE-AN. We believe that an international discussion could clarify areas of need for these patients and identify opportunities for clinical innovation that would enhance the lives of individuals with SE-AN and their families., (© 2020 Wiley Periodicals, Inc.)

Objective: Although hospitalization is sometimes necessary when treating individuals with anorexia nervosa, the available literature provides limited guidance to inform decisions surrounding optimal components or duration of inpatient treatments. We report observational data comparing outcomes of two inpatient treatments. The first was longer and more strictly structured around a Contingency Management Protocol (CMP) emphasizing external incentives for achieving weight-restoration goals; the second was a shorter Autonomy Support Protocol (ASP) that progressively increased patient autonomy around meal management without external incentives., Method: We compared data from 41 patients who participated in the ASP to a historical sample of 41 patients treated using the CMP. At admission, discharge, and post-treatment follow-up, participants completed the Eating Disorder Examination Questionnaire and the Behavior and Symptom Identification Scale-32, and we measured height and weight to compute body mass index., Results: Multilevel modeling analyses that controlled for time in treatment and time in follow-up indicated the two protocols yielded equivalent in-treatment gains and post-treatment loss of gains., Discussion: Our results indicate that shorter inpatient stays emphasizing autonomous control over eating behavior may yield outcomes that are equivalent to those of lengthier, more stringent, and more costly approaches implicating external incentives and controls., (© 2019 Wiley Periodicals, Inc.)

According to Self-Determination Theory, when motivation to reach an objective is fully internal, it is said to be "autonomous"; when driven by external incentives, it is said to be "controlled". Previous research has indicated that autonomously motivated individuals show better response to treatments for eating disorders., Objective: In individuals undergoing different intensities of outpatient treatment for an eating disorder, we sought to assess associations between autonomous and controlled motivations and response to treatment on the one hand, and likelihood of dropping out of treatment, on the other., Method: Seven hundred seventy adults meeting DSM-5 criteria for an eating disorder (216 with Anorexia Nervosa, 282 with Bulimia Nervosa, and 272 with Other Specified Feeding or Eating Disorder) were included in this study. Before an interval of outpatient treatment, individuals completed the Eating Disorder Examination Questionnaire and the Autonomous and Controlled Motivations for Treatment Questionnaire. Participants completed the Eating Disorder Examination Questionnaire again at one or two subsequent timepoints., Results: After controlling for diagnosis, treatment intensity, and number of previous treatments, analyses showed that higher autonomous motivation was associated with better response on eating-disorder overall symptoms and lower likelihood of dropping out of treatment. In contrast, controlled motivation was not associated with response to treatment., Discussion: Our results suggest that autonomous motivation has trans-diagnostic influence upon response to various intensities of treatment for an eating disorder. In support of an autonomy supportive approach to treatment, findings link autonomous motivation with more favorable outcome., (© 2018 Wiley Periodicals, Inc.)

Objective: Across diverse clinical problems, therapists' autonomy support has been found to increase patients' autonomous motivation for change. Being self-motivated has, in turn, been linked to superior treatment response. In people undergoing outpatient eating disorder (ED) treatment, we examined associations among ratings of autonomy support received from therapists and other carers, self-reported engagement in therapy, and clinical outcomes., Method: Ninety-seven women with anorexia nervosa, bulimia nervosa, or a related ED provided measures of motivational status and clinical symptoms at the beginning and end of time-limited (12-16 weeks) segments of specialized treatment. At mid-treatment, patients also rated the extent to which they perceived their individual therapists, group therapists, group-therapy peers, family members, friends, and romantic partners as being autonomy supportive., Results: Overall, multiple regression analyses indicated autonomy support to moderate (rather than mediate) the link between initial autonomous motivation and later change in autonomous motivation-with results indicating that, independently of ED diagnosis or treatment intensity, greater perceived autonomy support (from therapists and nontherapists alike) coincided with larger increases in autonomous motivation over the course of therapy. In turn, higher autonomous motivation at end-of-therapy coincided with larger reductions in eating symptoms., Discussion: Findings suggest that the experience of autonomy support (from therapists and nontherapists) is associated with increasing motivation in people undergoing ED treatment, and that becoming self-motivated is linked to better outcomes. Such results indicate that support from therapists, relatives, and peers can favorably influence personal engagement in individuals undergoing ED treatment., (© 2017 Wiley Periodicals, Inc.)

Objective: We explored the effect of autonomous and controlled motivation on outcomes for patients undergoing inpatient treatment for Anorexia Nervosa (AN)., Method: Data on 80 patients with AN were available for the start of treatment, and for 49 at end of treatment. Patients completed measures of autonomous and controlled motivation, eating disorder symptoms and attitudes, and comorbid psychopathology at the start and end of treatment., Results: Patients showed significant improvements on eating symptoms and comorbid psychopathology over the course of treatment. Autonomous motivation was a significant predictor of change in severity of eating symptoms and attitudes such that patients with higher pre-treatment levels of autonomous motivation showed larger post-treatment reductions on these indices. No such effects were associated with controlled motivation., Discussion: This study highlights a relationship between autonomous motivation and outcome in an inpatient setting. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:626-629)., (© 2016 Wiley Periodicals, Inc.)

Inspired by an article on 50 terms that, in the interest of clarity in scientific reasoning and communication in psychology, psychiatry, and allied fields, "should be avoided or at most be used sparingly and only with explicit caveats,"(1) we propose a list of terms to avoid or think twice about before using when writing for the International Journal of Eating Disorders (IJED). Drawing upon our experience as reviewers or editors for the IJED, we generated an abridged list of such terms. For each term, we explain why it made our list and what alternatives we recommend. We hope that our list will contribute to improved clarity in scientific thinking about eating disorders, and that it will stimulate discussion of terms that may need to be reconsidered in our field's vocabulary to ensure the use of language that is respectful and sensitive to individuals who experience an eating disorder., (© 2016 Wiley Periodicals, Inc.)

Objective: Evidence associates anorexia nervosa (AN) with epigenetic alterations that could contribute to illness risk or entrenchment. We investigated the extent to which AN is associated with a distinct methylation profile compared to that seen in normal-eater women., Method: Genome-wide methylation profiles, obtained using DNA from whole blood, were determined in 29 women currently ill with AN (10 with AN-restrictive type, 19 with AN-binge/purge type) and 15 normal-weight, normal-eater control women, using 450 K Illumina bead arrays., Results: Regardless of type, AN patients showed higher and less-variable global methylation patterns than controls. False Discovery Rate corrected comparisons identified 14 probes that were hypermethylated in women with AN relative to levels obtained in normal-eater controls, representing genes thought to be associated with histone acetylation, RNA modification, cholesterol storage and lipid transport, and dopamine and glutamate signaling. Age of onset was significantly associated with differential methylation in gene pathways involved in development of the brain and spinal cord, while chronicity of illness was significantly linked to differential methylation in pathways involved with synaptogenesis, neurocognitive deficits, anxiety, altered social functioning, and bowel, kidney, liver and immune function., Discussion: Although pre-existing differences cannot be ruled out, our findings are consistent with the idea of secondary alterations in methylation at genomic regions pertaining to social-emotional impairments and physical sequelae that are commonly seen in AN patients. Further investigation is needed to establish the clinical relevance of the affected genes in AN, and, importantly, reversibility of effects observed with nutritional rehabilitation and treatment., (© 2015 Wiley Periodicals, Inc.)

Background: Research associates maternal stress exposures (especially when occurring late in gestation) with heightened risk of subsequent emotional and behavioral problems in affected offspring. However, as yet, no study has examined the association between prenatal maternal stress (PNMS) and affected children's risk of anorexia- or bulimia-type eating disturbances., Objective: To study the influences of PNMS on later disordered eating in exposed offspring., Method: We used the Eating Attitudes Test (EAT)-26 to measure eating attitudes and behaviors in 54 thirteen-year olds whose mothers had been exposed, while pregnant with these children, to the 1998 Quebec Ice Storm-a natural disaster regarded as a model of exposure to severe environmental stress. Mothers' stress was measured shortly after exposure to the storm using established indices of objective and subjective stress., Results: Hierarchical multiple linear regression analyses indicated that once variance owing to children's body mass index and sex was accounted for, stress exposures during the third trimester of pregnancy predicted elevated EAT-26 scores in affected children-perhaps even more so when levels of objective stress were high., Discussion: Third trimester exposure to PNMS, especially when objectively severe, seems to be associated with increased eating-disorder-linked manifestations in affected early adolescents., (© 2015 Wiley Periodicals, Inc.)

Objective: To depict the processes through which animals and human beings engage their environment in continuously evolving states of conflict and cooperation., Method: Descriptive literature review., Results: Life history outcomes are more relative than they are absolute. Genetic variations play a crucial role, but heavily influencing behavioral outcomes, psychopathology included, are external cues that epigenetically remodel DNA along experience-dependent signaling pathways. The result is phenotypes that either optimize adjustment, or constrain it., Discussion: Knowledge of epigenetic mechanisms may help shed new light on the origin of maturational phenotypes underlying eating disorders and why adjusting treatments to these realities warrants our attention., (© 2014 Wiley Periodicals, Inc.)

Objective: We examined differences in treatment outcome associated with a "self-directed"- versus "external-incentive"-based day treatment protocol for individuals with eating disorders (EDs) with below normal body mass index. The self-directed protocol recommended a weekly 500 g weight gain, but allowed participants freedom to gain weight at their own rate; the "external-incentive" protocol required a minimum weight gain of 500 g/week as a requirement for staying in the program., Method: Weight outcome was available for 49 individuals who were treated with the recommended weight gain protocol, and 40 individuals who were treated with the required weight gain protocol., Results: Post-treatment weight was significantly higher in patients treated in the required weight gain protocol compared to those treated in the recommended weight gain protocol. All patients, regardless of which program they completed, showed improvements in the measures of eating-disorder and comorbid-psychiatric symptoms., Discussion: This study demonstrated the benefits of an alteration in protocol that required no additional financial or human resources. Further studies are needed to validate the effectiveness of various day treatment protocol parameters., (© 2014 Wiley Periodicals, Inc.)

Objective: To compare levels of methylation of the glucocorticoid receptor (GR) gene (NR3C1) promoter between women with bulimia nervosa (BN) and women with no eating disorder (ED), and also to explore, in women with BN, the extent to which methylation of the GR gene promoter corresponds to childhood abuse, suicidality, or borderline personality disorder (BPD)., Method: We measured methylation levels in selected NR3C1 promoter regions using DNA obtained from lymphocytes in 64 women with BN (32 selected as having a history of severe childhood abuse and 32 selected as having no such history) and 32 comparison women with no ED or history of childhood abuse., Results: Compared to noneating disordered women, women with BN and comorbid BPD (or BN with a history of suicidality) showed significantly more methylation of specific exon 1C sites. There was also a (nonsignificant) result indicative of greater methylation in some 1C sites among women with BN, when compared (as a group) to women with no ED. No parallel effects owing to childhood abuse were observed., Discussion: Our findings associate BN (when accompanied by BPD or suicidality) with hypermethylation of certain GR exon 1C promoter sites. We discuss theoretical and clinical implications of our findings., (Copyright © 2013 Wiley Periodicals, Inc.)

Objective: We sought to estimate prevalences of childhood emotional abuse (CEA) in bulimic and normal-eater control groups, and to replicate previous findings linking CEA to severity of eating symptoms in BN. We also examined potential mediators of the link between CEA and disordered eating., Method: Women diagnosed with a bulimic disorder (n = 176) and normal-eater women (n = 139) were assessed for childhood traumata, eating-disorder (ED) symptoms and psychopathological characteristics (ineffectiveness, perfectionism, depression, and affective instability) thought to be potential mediators of interest., Results: CEA was more prevalent in the bulimic than in the nonbulimic group, and predicted severity of some eating-symptom indices. Ineffectiveness and affective instability both mediated relationships between CEA and selected ED symptoms., Discussion: We found CEA to predict eating pathology through mediating effects of ineffectiveness and affective instability. CEA might influence severity of ED symptoms by impacting an individual's self-esteem and capacity for affect regulation., (Copyright © 2011 Wiley Periodicals, Inc.)

Objective: To investigate the effects of acute alcohol intoxication on eating-related urges among women with bulimia nervosa (BN)., Method: Participants included women with BN or normal-weight eating disorder NOS with regular binge/purge symptoms (N = 13), and normal-eater control women (N = 17). Tested individually, the women reported on their mood state as well as on urges to binge eat and engage in various compensatory behaviors, prior to consuming alcohol, and again at 60 and 180 min following the consumption of 1.0 ml kg(-1) alcohol., Results: Both groups reported feeling less clearheaded after drinking, as well as initial subjective mood stimulation followed by subsequent mood lowering. In addition, BN participants reported reductions in their urges to binge eat, exercise compulsively, and restrict food intake following alcohol consumption-the urge to purge was not significantly affected., Discussion: Among women with BN, alcohol consumption appeared to reduce select eating-related urges with concomitant reductions in attention or concentration., (Copyright © 2010 Wiley Periodicals, Inc.)

Objective: In participants with eating disorders (EDs), prior physical or sexual abuse has been associated with increased likelihood of impulsivity and affective instability. However, previous studies among participants with eating disorders have not systematically explored relationships between empirically derived, personality-trait-based classes, on the one hand, and likelihood of exposure to either childhood sexual or physical abuse, on the other., Method: We assessed multiple psychopathological traits, eating symptoms, and history of abuse in 185 women with an ED and 93 with no ED., Results: A latent class analysis, conducted using psychopathological-trait measures, yielded latent classes of participants with eating disorders fitting the descriptors "dissocial/impulsive," "inhibited/compulsive," and "low psychopathology." ED was generally associated with increased risk of childhood sexual abuse, but the dissocial/impulsive characteristic corresponded with a unique likelihood of physical abuse and especially high rates of sexual abuse., Discussion: Observed associations between different forms of childhood abuse and trait-defined ED variants help inform models on the development of eating disorders and of psychopathological traits that often accompany them., (2009 by Wiley Periodicals, Inc.)

Objective: To investigate behavior-outcome expectancies relating to thinness, dietary restriction, eating, and alcohol consumption in women with bulimia nervosa (BN)., Method: Women with BN (N = 29), women with BN and a co-morbid lifetime alcohol use disorder (AUD; N = 18), and control women (N = 24), completed interviews and questionnaires assessing eating- and alcohol-related symptoms, as well as questionnaires measuring expectancies relating to thinness, dietary restriction, eating, and alcohol consumption., Results: Compared with the control group, both bulimic groups reported greater positive expectancies relating to thinness, dietary restriction and eating; expectancy endorsements were also predictive of the severity of eating-related symptoms. Compared with the other groups, the bulimic group with comorbid lifetime AUD had elevated positive alcohol-related expectancies, and alcohol expectancy endorsements predicted severity of alcohol-related symptoms., Discussion: Women with BN endorsed more positive expectancies relating to thinness, dietary restriction, and eating, whereas women with BN and a lifetime comorbid AUD endorsed more positive alcohol expectancies. The results are consistent with expectancy theory in that positive expectancy endorsements were associated with symptom severity in a syndrome-specific manner. Expectancies related to thinness, dietary restriction, eating, and alcohol consumption in women with BN., ((c) 2008 by Wiley Periodicals, Inc.)

Objective: We estimated the prevalence of eating disorders and maladaptive eating behaviors in a population-based sample and examined the association of maladaptive eating with self-rated physical and mental health., Method: A sample of 1,501 women (mean age = 31.2 years, SD = 6.2) were recruited using random-digit dialing to participate in a 20-min telephone interview about eating behaviors., Results: Weighted frequency analysis showed the prevalence of frequent binge-eating to be 4.1%, that of regular purging to be 1.1%, and that of frequent compensation to be 8.7%. Although we found none of the women to meet full criteria for anorexia nervosa, 0.6% met criteria for bulimia nervosa, 3.8% provisional criteria for binge eating disorder, and 0.6% criteria for a newly proposed entity, purging disorder. As many as 14.9% fell into a residual category representing subthreshold, but potentially problematic variants of eating disturbances. Logistic regression analyses showed that clinical-level maladaptive eating attitudes and behaviors predicted self-rated physical- and mental-health problems after sociodemographic factors were controlled., Discussion: This population-based survey provides prevalence estimates of BN, BED, and purging disorder that are compatible with those of recent epidemiological studies and shows that maladaptive eating attitudes and behaviors represent a substantial population burden.

Objective: We conducted a naturalistic study to examine negative affect and dissociative experiences as antecedents to binge episodes., Method: Using handheld computers, 33 women with bulimic syndromes provided ongoing self-reports on eating behaviors, affects, and dissociative experiences over 7- to 29-day intervals., Results: Multilevel modeling analyses indicated that negative affect and dissociation were elevated prior to binge episodes. In addition, antecedent effects of dissociation on bingeing were independent of those attributable to negative affect., Conclusion: Our results are consistent with models of binge eating that assign a causal role to negative mood and altered self-awareness. As such, our findings imply that binge eating is a multiply determined behavior linked to diverse cognitive and affective processes., ((c) 2007 by Wiley Periodicals, Inc.)

Objective: Impulsivity is generally believed to be more characteristic of individuals with bulimic than with restrictive eating disorders (EDs). However, studies have not exhaustively explored the association between EDs and various component dimensions of the impulsivity construct., Method: We conducted a multidimensional assessment of impulsivity in 84 women with bulimia nervosa (BN), 37 with anorexia nervosa (AN: 19 restricters and 18 bingers-purgers), and 61 normal-control participants. To assess multiple components of impulsivity, participants completed a battery of self-report questionnaires and a performance test., Results: Compared with normal-control participants, all ED groups showed attentional problems. However, only women suffering BN or AN-binge purge subtype showed elevations on motoric forms of impulsivity, whereas women with BN were the only group to report tendencies toward reckless behavior., Conclusion: These findings suggest that binge-eating behavior coincides with problems of response inhibition, whereas a risk-taking attitude may be a unique characteristic of individuals with BN., ((c) 2006 by Wiley Periodicals, Inc.)

Objective: The current study attempted to characterize the natural course of events linking dietary restraint to urges to binge and actual binge episodes., Method: Using preprogrammed, hand-held computers, 39 women with bulimia-spectrum eating disorders monitored ongoing eating episodes, dietary restraint, and binge cravings over a 7-29-day interval., Results: Multilevel modeling analyses indicated that restraint was not systematically elevated before binging. However, elevated restraint preceded strong binge cravings., Conclusion: Results suggest that dietary restraint may contribute to binge cravings, but may not be a direct antecedent to binge episodes. Such findings are consistent with restraint theory, which suggests that dietary restraint potentiates binging, but does not necessarily trigger its occurrence., (Copyright 2005 by Wiley Periodicals, Inc.)

Objective: A primary objective of the current article is to investigate the relationship between impulsivity and compulsivity in patients with bulimia nervosa (BN). A second goal is to explore the relationship between impulsivity and compulsivity and related psychiatric problems., Method: Two-hundred four females with BN completed several measures of impulsivity and compulsivity as well as measures of personality, substance use, eating pathology, and depression., Results: Participants reported considerable variability on measures of impulsivity and compulsivity and these scores were positively correlated with each other. Impulsive-compulsive groups differed in personality, substance use, eating, and depression., Conclusion: These findings suggest that impulsivity and compulsivity can coexist in BN patients and that both traits may provide useful information about comorbid problems in women with BN.

Background: A short (s) allele in the promoter region of the 5-hydroxytryptamine (5-HT) transporter gene (5HTTLPR) has been associated with low transcription of the 5-HT transporter protein, and with clinical manifestations including impulsivity, affective disorder, and bulimia nervosa., Methods: We studied implications of the 5HTTLPR s allele for eating symptoms, psychopathologic traits, and platelet [3H-] paroxetine binding in 59 women with bulimia spectrum syndromes., Results: Compared with those without it, carriers of the s allele of 5HTTLPR showed significantly more affective instability, behavioral impulsivity, interpersonal insecurity, comorbid borderline personality disorder (BPD), and lower density (Bmax) of paroxetine-binding sites., Conclusions: Our results suggest that proneness to impulsivity, affective dysregulation, and reduced central 5-HT reuptake may (in part) be codetermined by the 5HTTLPR polymorphism. However, given inconsistent 5HTTLPR expression in different populations, we speculate that we may be observing a phenotype (i.e., eating disorder)-dependent manifestation., (2004 by Wiley Periodicals, Inc.)

Objective: We evaluated associations between childhood physical and sexual abuse in bulimic women and eating disturbances, psychiatric symptoms, and likelihood of later abuse in adulthood., Method: Fifty-one bulimics and 25 normal eaters participated in this study. Semistructured interviews and self-report measures were used to assess eating symptoms, comorbid psychiatric disturbances, personality pathology, and childhood and adulthood abuse., Results: Compared with the normal eaters, bulimic women reported higher levels of childhood abuse. Although bulimic women showed more psychopathology than nonbulimic women, there was a correspondence between the presence and severity of abuse and the severity of concurrent psychopathologic symptoms. Results linked dissociation and submissiveness to most severe forms of abuse. Abuse in adulthood was almost always preceded by earlier abuse during childhood., Discussion: Our findings suggest an association between certain psychopathologic traits and the likelihood of abuse (especially when occurring both in childhood and adulthood). Observed associations could implicate causal effects of childhood abuse on personality development, influences of personality traits in heightening the risk of abuse, or both., (Copyright 2003 by Wiley Periodicals, Inc.)

Objective: Various reports suggest that purging with laxatives is associated with greater behavioral impulsivity in bulimia nervosa (BN) patients. We investigated the extent to which laxative misuse corresponds to specific impulse-control problems., Method: Participants included bulimic women who misuse laxatives (BNL+; n = 12), bulimic women who do not misuse laxatives (BNL-; n = 33), and healthy normal eaters (NE; n = 26). Participants completed the Go/No-Go discrimination task (a well-validated computerized measure of response disinhibition), as well as self-report questionnaires of impulsivity, eating symptoms, and general psychopathology., Results: Compared with the other groups, the BNL+ group made more commission errors on the Go/No-Go under cues for punishment, indicating they were more disinhibited when faced with possible negative outcomes. Compared with the BNL- group, the BNL+ group was also more likely to differ from the NE group on self-reported impulsivity. There were no differences between the two bulimic groups on eating symptoms and the three groups did not differ in terms of general psychopathology., Discussion: Findings suggest that, controlling for eating symptoms and psychopathology, laxative misuse among BN patients is associated with difficulty inhibiting incorrect responses in the face of perceived threats., (Copyright 2002 by Wiley Periodicals, Inc.)

Objective: We investigated the predictive utility of three dimensions of body esteem in explaining self-esteem in samples of eating-disordered (ED) and nonclinical women., Method: Participants comprised 74 ED women and 103 female university students. All women completed questionnaires measuring body esteem and self-esteem and all provided information on height and weight. We ran hierarchical multiple regression analyses with self-esteem as the outcome variable and participant status (clinical or non), body mass index (BMI), body esteem, and interaction terms as predictors., Results: The main finding was a Body Esteem x Participant Status interaction involving the attribution dimension of body esteem. Specifically, among ED women, the higher their body esteem attribution (i.e., the more they endorsed items such as "I think my appearance would help me get dates"), the higher their self-esteem; whereas this relationship was not found among the students., Discussion: Our results contribute to an emerging profile of ED patients as highly socially sensitive., (Copyright 2002 by Wiley Periodicals, Inc.)

Objective: This study compared 55 women with active bulimic symptoms, 18 in remission from a bulimic eating disorder, and 31 who showed no evidence of a past or present eating disorder, on selected personality and psychiatric features., Method: Discriminant function analyses were used to isolate dimensions that differentiated active patients from patients in remission, and controls (i.e., that would logically constitute "state"-related disturbances), and then dimensions that differentiated clinical cases (whether active or in remission) from non-eating-disordered controls (i.e., that might reflect stable trait pathology associated with bulimic syndromes, whether active or not)., Results: Measures of depression, suicidality, and anxiety loaded significantly on the first function (differentiating active bingers from all other cases), whereas narcissism differentiated both clinical groups from non-eating-disordered controls., Discussion: In light of theoretical and empirical evidence stressing the etiological role of narcissistic disturbances in bulimic syndromes, we interpret our findings as suggesting that narcissim may be a common trait characteristic (persisting even after remission of bulimic symptoms) in those who develop bulimic eating syndromes. Alternatively, depression, suicidality, and anxiety appear to be state-dependent features that resolve in many cases, along with remission of bulimic symptoms. We discuss various clinical and theoretical implications of our findings., (Copyright 2000 by John Wiley & Sons, Inc.)

Objective: Naturalistic studies on sufferers of bulimic syndromes suggest that binge episodes are often precipitated by episodes of dietary restraint. However, evidence also implies that binge eating may, in certain psychopathological contexts, have less direct connection with dietary control factors. Applying an 8- to 22-day experience-sampling procedure in individuals with bulimic syndromes, we explored possible moderating effects of trait impulsivity upon the ongoing association between cognitive dietary control and binge eating., Method: Fifty-one women with bulimia spectrum eating disorders provided periodic daily observations on cognitive control over eating, urges to binge, and binge episodes. Impulsivity was assessed by self-report questionnaire. Hierarchical linear modeling techniques were used to assess relationships of interest., Results: Urge to Binge was higher (on average) prior to eating binges than at comparable times on binge-free days, and thus seemed to signal the potential for binge eating. More importantly, scores on Urge to Binge and Dietary Control covaried systematically over time in most participants, but were desynchronous in highly impulsive individuals., Conclusions: Binge eating is closely linked to dietary control in most bulimic individuals, but this may be less typical of individuals showing marked impulsivity. We discuss factors that may explain the disconnection between Dietary Control and Urge to Binge in impulsive binge eaters as well as the implications of such factors for the management of bulimic patients with marked impulsivity., (Copyright 1999 by John Wiley & Sons, Inc.)

Introduction: Many theories attribute anorexia and bulimia nervosa to "pathological narcissism," but this conception has not been adequately evaluated., Method: We compared the scores of 90 eating disorder (ED) sufferers (23 anorexic restricters, 14 anorexic bingers, and 53 bulimics) with those of 36 psychiatric-control (PC) and 54 normal-control (NC) females on validated self-report scales measuring Narcissism, Affective Instability, Stimulus Seeking, Compulsivity, and Restricted Expression., Results: Narcissism scores of ED patients (whether restricters or bingers/purgers) consistently exceeded those of the PC and NC cases, suggesting that Narcissism does indeed load more heavily in the EDs than in other psychiatric disturbances. Conversely, Affective Instability was characteristic of all clinical cases (i.e., of EDs and PCs), Restricted Expression and Compulsivity were characteristic of restricters, and Stimulus Seeking was characteristic of bingers/purgers., Discussion: Results are consistent with the notion that different ED variants may reflect subtype-specific temperaments and/or adaptive styles acting-upon shared underlying narcissistic disturbances.

Objective: The present study tested a dual-process family model in understanding the relationships among dysfunctional family relationships, family preoccupation with weight and appearance, and body- and self-esteem problems in the development of eating and psychiatric symptoms., Method: Subjects, 918 adolescent girls from eight high schools, completed measures assessing familial factors, body- and self-esteem problems, and eating and general psychiatric symptoms., Results: Structural equation analyses suggested that family environment contributed to the development of eating and psychiatric symptoms through two interrelated pathways. On one hand, family preoccupation with weight and appearance had direct effects on body dissatisfaction and eating symptoms. Body dissatisfaction had direct effects on self-esteem deficit and eating symptoms, and indirect effects mediated by self-esteem deficit on eating and psychiatric symptoms. On the other hand, general family dysfunction had direct effect on negative self-esteem, and indirect effects through negative self-esteem on eating and psychiatric symptoms., Discussion: Findings are discussed in relation to the possible mechanisms by which dysfunctional family relationships and family preoccupation with weight may predispose girls to eating pathology.

We assessed prognostic implications of categorical personality disorder (PD) diagnoses at selected points during and following treatment for bulimic syndromes. Seventy-six bulimic cases were organized into Borderline PD, Other PD, or No PD groups, and then assessed at pretreatment, after 3 months of therapy, and at termination (after a modal 8 months). Results at 3- and 12-month posttreatment follow-ups (available in 43 and 38 cases, respectively) provided a reflection of status after therapy termination. On comorbid symptoms, borderline/ nonborderline differences were very striking: Borderlines showed more initial psychiatric symptoms than did nonborderlines, and despite improvements, retained disturbances of clinical magnitude to completion of therapy and into follow-up. On eating symptoms, borderline/ nonborderline differences were less dramatic, the overall pattern implying that borderlines showed only marginally poorer response in selected areas of disturbance. Results corroborate others linking Axis-II comorbidity to unfavorable outcome in the eating disorders, but suggest that character disturbance is more strongly linked to course of general psychiatric symptoms than it is to course of eating disturbances. We discuss clinical implications of differing strengths of association observed between eating and psychiatric symptoms, on the one hand, and Axis-II pathology, on the other.

Objective: This study extends an earlier investigation on the link between familial traits and eating disorders (EDs), and examines the extent to which selected eating attitudes and psychopathological traits are (a) familial in nature and (b) specific to anorexia- and bulimia-spectrum disorders., Methods: We measured various ED-relevant dimensions (eating and body image attitudes) and psychopathological traits (e.g., affective instability, narcissism, compulsivity, restricted expression) in the mothers, fathers, and sisters of probands displaying an ED (n = 88), another psychiatric disturbance (n = 42), or neither disturbance (n = 59). Total sample, including relatives, was 553., Results: A principal components analysis (PCA), used to reduce variables and to characterize main sources of variation, yielded three interpretable factors: eating concerns and symptoms (grouping all eating-related dimensions), dramatic-erratic traits (grouping affective instability, narcissism, and conceptually related dimensions), and obsessive-compulsive traits (grouping compulsivity and restricted expression). Correlations among subjects' factor scores (derived from the PCA) showed two types of transgenerational effects: correspondences between daughters' and parents' psychopathological traits, and between daughters' and mothers' eating concerns. Despite these, relatives of ED probands were not discriminable on any factor score from relatives of controls., Discussion: These results imply that transgenerational effects exist on eating attitudes and psychopathological traits, but do not uniquely identify families in which clinical ED syndromes occur.

To examine the extent to which first-degree relatives of eating-disordered (ED) probands endorse maladaptive eating attitudes and personality/affective traits, we compared self-reported eating concerns (Restraint, Emotional Eating, Body Dissatisfaction, and maladaptive eating attitudes) and psychopathological traits (Affective Instability, Anxiousness, Compulsivity, and Narcissism) across groups of restricter (n = 19), binger (n = 56), psychiatric control (PC, n = 38), normal dieter (ND, n = 29), and nondieter control (NC, n = 28) probands, and then across participating nuclear family members. Results among probands were as anticipated: ED probands showed expected elevations in both areas, and predicted restricter/binger differences were obtained. However, corresponding differences were not obtained on measures of mothers', fathers', or siblings' eating concerns and traits. Our findings corroborate the notion that EDs represent a convergence of eating, affective, and personality disturbances, but not that such a clustering of features exists as a familial trait. We discuss normal trait and attitudinal variations observed in ED probands' relatives in light of findings showing EDs and other psychiatric syndromes to aggregate within families.

We evaluated several indices of pretreatment social adaptation (social and vocational adjustment, DSM-III-R Axis-V ratings, and "object-relations" capacities) as predictors of the response of 44 completers of a multimodal therapy for bulimia nervosa. Response was assessed using standard measures of eating and psychiatric symptoms. Hierarchical regressions revealed that pretreatment social adjustment explained substantial (and significant) proportions of variance in posttreatment binge/purge symptoms, after variance associated with (a) initial severity of eating symptoms and (b) concurrent psychiatric symptoms (at posttreatment) was accounted for. Hence, social adjustment emerged as a somewhat specific predictor of response of bulimic behaviors. Possible clinical implications of this apparent predictive effect are discussed.