Sex- and age-specific incidence of healthcare-register-recorded eating disorders in the complete swedish 1979-2001 birth cohort

Comparing severity and qualitative facets of depression between eating disorders and depressive disorders: Analysis of routine data

BACKGROUND

While it is know that depressive symptoms are common in eating disorders (EDs), it is unclear whether these symptoms differ from those in depressive disorders (DDs) with regard to severity and quality.

METHODS

Beck Depression Inventory II (BDI-II) scores at admission to treatment of 4.895 inpatients with a unipolar DD and 3.302 inpatients with an ED were compared by means of independent t-tests and Cohen's d effect sizes with regard to: (1) overall severity (BDI-II total score), (2) six facets of depression identified by non-metric multidimensional scaling of the German BDI-II validation sample, and (3) individual items.

RESULTS

(1) The two groups did not differ with regard to the BDI-II total score. (2) There was no difference in the facet Depressive Core Symptoms. Patients with DDs had higher scores for Diminished Activation (d = 0.40) and patients with EDs had higher scores for Negative View of Self (d = 0.40). (3) Patients with DDs showed higher score on the item Loss of Energy (d = 0.48), while patients with EDs sored higher on Self-Dislike (d = 0.48) and Changes of Appetite (d = 0.48).

CONCLUSIONS

Depression in EDs seems to be as severe as in DDs and may show similar core aspects (e.g., Sadness, Loss of Pleasure). Qualitative differences suggested that individual additional symptoms of depression need to be differently addressed in therapy. The pronounced Negative View of Self in EDs is in line with the "core low self-esteem", a central component of the prevalent transdiagnostic model of EDs.

QTc Interval and Risk of Cardiac Events in Adults With Anorexia Nervosa: A Long-Term Follow-Up Study

BACKGROUND

The literature contains several cases of anorexia nervosa (AN) patients with prolonged QTc interval. However, the risk of prolonged QTc interval is controversial and the risk of cardiac events in AN patients has yet to be investigated.

METHODS

We estimated the difference in mean QTc interval and relative risk of borderline prolonged QTc (>440 ms) and prolonged QTc (>460 ms) between 430 adult women AN patients and 123 healthy controls using 3 correction formulas. In a follow-up study, we estimated the risk of a primary end point (a composite of ventricular tachycardia, aborted cardiac arrest, and cardiac arrest) in AN patients compared with a population-based cohort derived from the Danish Civil Register.

RESULTS

Mean QTc for AN patients was 408 ms (Hodges), 402 ms (Fridericia), and 399 ms (Bazett). Hodges' found a slightly increased mean QTc (6.8 ms, 95% confidence interval, 1.6-12.0; P=0.01) and percentage with QTc >440 ms in AN patients (relative risk, 3.7, 95% confidence interval, 1.4-10.3; P=0.01), not observed with Fridericia's and Bazett's formulas. There was no difference in the risk of QTc >460 ms between AN patients and healthy controls. During a median follow-up of 10.1 years, AN patients had an increased risk of the primary end point compared with the population-based cohort (hazard ratio, 10.4, 95% confidence interval, 2.6-41.6; P=0.001). However, absolute numbers were small with cumulative incidences of 0.5% and 0.07%, respectively, after 10 years. No events occurred in any AN patient with QTc >440 ms. All-cause mortality was also significantly increased in AN patients compared with the population-based cohort (hazard ratio, 11.2, 95% confidence interval, 5.1-24.5; P<0.001).

CONCLUSIONS

Overall, there was no difference in mean QTc interval or risk of prolonged QTc between AN patients and healthy controls. However, AN patients had a notably increased all-cause mortality, as well as an increased risk of cardiac events, which was not related to the baseline QTc interval.

Alterations in serotonin transporter and body image-related cognition in anorexia nervosa

The serotonin system has been implicated in the pathophysiology of anorexia nervosa (AN). A recent report proposed that body image distortion (BID), a core symptom of AN, may relate to abnormalities of the serotonin system, especially the serotonin transporter (5HTT). Positron emission tomography (PET) studies of underweight patients with active AN reported alterations in serotonin receptors, but not 5HTT. Here, we aimed to disclose the clinicopathophysiology of AN by focusing on 5HTT and cognitive functions, including BID, in groups with active AN. Twenty-two underweight female patients with AN (12 restricting-type AN (ANR); 10 binge-eating/purging-type AN (ANBP)) and 20 age-matched healthy female subjects underwent PET with a 5HTT radioligand [¹¹C]DASB. The binding potential (BP_ND) of [¹¹C]DASB was estimated semiquantitatively, and clinical data from Raven's colored progressive matrices for general intelligence, the Stroop test for focused attention, the Iowa gambling task for decision making and a dot-probe task designed for BID were compared with the levels of BP_ND in different groups. [¹¹C]DASB BP_ND was significantly decreased in the medial parietal cortex in patients with AN and in the dorsal raphe in patients with ANR compared with healthy subjects (p < .05 corrected). Patients with ANR showed a significantly negative correlation between [¹¹C]DASB BP_ND in the dorsal raphe and performance on the dot-probe task (p < .05 corrected). While reduced 5HTT in the medial parietal cortex (the somatosensory association area) is pathophysiologically important in AN in general, additional 5HTT reduction in the dorsal raphe as seen in ANR is implicated for the clinicopathophysiological relevance.

•

5HTT decreased in the parietal cortex in patients with AN.

•

5HTT decreased in the parietal cortex in patients with ANBP.

•

5HTT decreased in the parietal cortex and the dorsal raphe in patients with ANR.

•

Patients with AN were poor at responding to the test for body image distortion (BID).

•

5HTT in the dorsal raphe was associated with cognitive performance of BID.

Bidirectional relationship between eating disorders and autoimmune diseases

BACKGROUND

Immune system dysfunction may be associated with eating disorders (ED) and could have implications for detection, risk assessment, and treatment of both autoimmune diseases and EDs. However, questions regarding the nature of the relationship between these two disease entities remain. We evaluated the strength of associations for the bidirectional relationships between EDs and autoimmune diseases.

METHODS

In this nationwide population-based study, Swedish registers were linked to establish a cohort of more than 2.5 million individuals born in Sweden between January 1, 1979 and December 31, 2005 and followed up until December 2013. Cox proportional hazard regression models were used to investigate: (a) subsequent risk of EDs in individuals with autoimmune diseases; and (b) subsequent risk of autoimmune diseases in individuals with EDs.

RESULTS

We observed a strong, bidirectional relationship between the two illness classes indicating that diagnosis in one illness class increased the risk of the other. In women, the diagnoses of autoimmune disease increased subsequent hazards of anorexia nervosa (AN), bulimia nervosa (BN), and other eating disorders (OED). Similarly, AN, BN, and OED increased subsequent hazards of autoimmune diseases.Gastrointestinal-related autoimmune diseases such as, celiac disease and Crohn's disease showed a bidirectional relationship with AN and OED. Psoriasis showed a bidirectional relationship with OED. The previous occurence of type 1 diabetes increased the risk for AN, BN, and OED. In men, we did not observe a bidirectional pattern, but prior autoimmune arthritis increased the risk for OED.

CONCLUSIONS

The interactions between EDs and autoimmune diseases support the previously reported associations. The bidirectional risk pattern observed in women suggests either a shared mechanism or a third mediating variable contributing to the association of these illnesses.

Prevalence of eating disorders over the 2000-2018 period: a systematic literature review

BACKGROUND

Eating disorders (EDs) lead to multiple psychiatric and somatic complications and thus constitute a major public health concern.

OBJECTIVES

The aim of this study was to give an exhaustive view of the studies reporting the prevalence of the different EDs or total EDs and to study their evolution.

METHODS

A literature search following PRISMA Guidelines and limited to studies in English or French published between 2000 and 2018 was performed and relevant studies were included in this systematic review on the prevalence of EDs. The literature search revealed 94 studies with accurate ED diagnosis and 27 with broad ED diagnosis.

RESULTS

In 94 studies with accurate ED diagnosis, the weighted means (ranges) of lifetime ED were 8.4% (3.3-18.6%) for women and 2.2% (0.8-6.5%) for men. The weighted means (ranges) of 12-month ED prevalence were 2.2% (0.8-13.1%) for women and 0.7% (0.3-0.9%) for men. The weighted means (ranges) of point prevalence were 5.7% (0.9-13.5%) for women and 2.2% (0.2-7.3%) for men. According to continents, the weighted means (ranges) of point prevalence were 4.6% (2.0-13.5%) in America, 2.2% (0.2-13.1%) in Europe, and 3.5% (0.6-7.8%) in Asia.In addition to the former, 27 other studies reported the prevalence of EDs as broad categories resulting in weighted means (ranges) of total point prevalence of any EDs of 19.4% (6.5-36.0%) for women and 13.8% (3.6-27.1%) for men.

CONCLUSIONS

Despite the complexity of integrating all ED prevalence data, the most recent studies confirm that EDs are highly prevalent worldwide, especially in women. Moreover, the weighted means of point ED prevalence increased over the study period from 3.5% for the 2000-2006 period to 7.8% for the 2013-2018 period. This highlights a real challenge for public health and healthcare providers.

Sex Differences in Comorbidity Patterns of Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

To investigate sex differences in associations between attention-deficit/hyperactivity disorder (ADHD) and a spectrum of comorbid disorders.

METHOD

The study population included all children born in Denmark from 1981 through 2013 (N = 1,665,729). Data were merged from Danish registers and information was obtained on birth characteristics, socioeconomic status, familial psychiatric history, and diagnoses of ADHD (n = 32,308) and comorbid disorders. To estimate absolute and relative risks of comorbid disorders, incidence rates and adjusted hazard ratios (HRs) with 95% CIs were calculated for female and male individuals. In addition, interactions between ADHD and sex in association with comorbid disorders were estimated as HR ratios (HRRs) in female and male individuals (95% CIs).

RESULTS

Individuals diagnosed with ADHD had significantly increased absolute and relative risks of all 12 comorbid psychiatric disorders investigated. ADHD-sex interactions were found for some comorbid disorders. Compared with male individuals, ADHD in female individuals showed a stronger association with autism spectrum disorder (HRR 1.86, 95% CI 1.62-2.14), oppositional defiant/conduct disorder (HRR 1.97, 95% CI 1.68-2.30), intellectual disability (HRR 1.79, 95% CI 1.54-2.09), personality disorders (HRR 1.23, 95% CI 1.06-1.43), schizophrenia (HRR 1.21, 95% CI 1.02-1.43), substance use disorders (HRR 1.21, 95% CI 1.07-1.38), and suicidal behavior (1.28, 95% CI 1.12-1.47). The remaining disorders showed no significant sex differences in association with ADHD.

CONCLUSION

This study indicates that the association between ADHD and several comorbid disorders is stronger in female than in male individuals. These important findings add to the literature on sex differences in ADHD and suggest that female individuals diagnosed with ADHD are a more vulnerable group of patients.

Psychiatric comorbidity as a risk factor for mortality in people with anorexia nervosa

Anorexia nervosa (AN) is found associated with increased mortality. Frequent comorbidities of AN include substance use disorders (SUD), affective disorders (AD) and personality disorders (PD). We investigated the influence of these psychiatric comorbidities on all-cause mortality with demographic and socioeconomic factors considered as confounders in the observation window between January 2007 and March 2016 for 1970 people with AN, using data from the case register of the South London and Maudsley (SLaM) NHS Foundation Trust, an almost monopoly-secondary mental healthcare service provider in southeast London. We retrieved data from its Clinical Records Interactive Search (CRIS) system as data source. Mortality was ascertained through nationwide tracing by the UK Office for National Statistics (ONS) linked to CRIS database on a monthly basis. A total of 43 people with AN died during the observation period. Standardized Mortality Ratio (SMR) with England and Wales population in 2012 as standard population for our study cohort was 5.21 (95% CI 3.77, 7.02). In univariate analyses, the comorbidity of SUD or PD was found to significantly increase the relative risks of mortality (HRs = 3.10, 95% CI 1.21, 7.92; and 2.58, 95% CI 1.23, 5.40, respectively). After adjustment for demographic and socioeconomic covariates as confounders, moderately but not significantly elevated risks were identified for SUD (adjusted HR = 1.39, 95% CI 0.53, 3.65) and PD (adjusted HR = 1.58, 95% CI 0.70, 3.56). These results suggest an elevated mortality in people with AN, which might be, at least partially, explained by the existence of the comorbidities SUD or PD.

The Impact of Starvation on the Microbiome and Gut-Brain Interaction in Anorexia Nervosa

Interactions between the gut microbiome and the brain are of increasing interest to both researchers and clinicians. Evidence is mounting on the causal role of an altered gut microbiome in inflammatory diseases such as arthritis, inflammatory bowel disease, obesity and diabetes, and psychiatric diseases like anxiety and depression. Mechanisms include altered energy harvest from food, hormonal changes, increased gut permeability, inflammation, immune response, and a direct influence on the brain and behavior. Anorexia nervosa (AN) is the third most common disease in adolescence and exacts a high burden on patients and caregivers. It often becomes chronic and has the highest mortality of all psychiatric diseases. As AN is characterized by nutritional restrictions, weight loss, and severe behavioral symptoms including weight phobia, comorbid anxiety and depression, accompanied by endocrine alterations, increased inflammation, and immune response, exploring the role of the gut microbiome is crucial. Here, we present an overview of the potential mechanisms of interaction between the gut microbiome, the host and particularly the brain in AN and summarize the initial findings of microbiome research on AN. We conclude by identifying future research directions and potential therapeutic approaches, including nutritional interventions, probiotics, prebiotics and food supplements, that could become important additions to current AN therapy.

Time trends in healthcare-detected incidence of anorexia nervosa and bulimia nervosa in the Norwegian National Patient Register (2010-2016)

OBJECTIVE

Few studies have investigated temporal trends in the incidence of eating disorders (EDs). This study investigated time trends in the age- and sex-specific incidence of healthcare-detected anorexia nervosa (AN) and bulimia nervosa (BN) from 2010 to 2016.

METHODS

Data were retrieved from the Norwegian National Patient Register as defined by the International Classification of Diseases (ICD-10): narrowly defined AN (F50.0), broadly defined AN (F50.0 + 50.1), narrowly defined BN (F50.2), and broadly defined BN (F50.2 + 50.3). The average annual percent changes (AAPCs) in incidence rates (IRs) were examined by Joinpoint regression analyses.

RESULTS

The overall (i.e., both genders, ages 10-49) rates of AN were stable across the 7-year period, with IRs ranging from 18.8 to 20.4 per 100,000 for narrowly defined AN and 33.2 to 39.5 per 100,000 for broadly defined AN, whereas overall rates of BN declined. Age- and gender-stratification revealed a significant average annual increase in AN (narrow and broad) among 10- to 14-year-old girls. The incidence of broadly defined AN also increased significantly among females aged 15-19 years between 2010 and 2012, before leveling off. Nearly universal declines in the incidence of narrowly and broadly defined BN among females occurred. IRs among males were stable and comparatively low, with no significant trends toward increasing or decreasing rates of AN or BN over time.

DISCUSSION

Although register-based studies provide an underestimate of the true incidence and may not accurately reflect population-level changes in true ED occurrence, this study extends our knowledge regarding trends in the detected incidence of EDs into the second decade of the 21st century.

Are there differences between men and women in outcome of intensive inpatient treatment for anorexia nervosa? An analysis of routine data

OBJECTIVE

Anorexia nervosa (AN) in men is rare and understudied. We compared admission characteristics and response to specialized inpatient treatment between men and women with AN.

METHOD

One hundred sixteen consecutive male patients with AN were matched to 116 female patients. Patients completed the self-rating Structured Inventory for Anorexic and Bulimic Syndromes (SIAB-S) at admission and discharge. Differences at admission and in treatment response were examined with independent samples t-tests and ANOVA for repeated measures, respectively.

RESULTS

Men had lower body mass index (BMI)-percentiles (Cohen's d = -0.55), higher levels of weight suppression (d = 0.65), and higher scores in the SIAB-S general psychopathology and social integration scale (d = 0.47) at admission. There were no differences in response to treatment except for changes in BMI-percentile (F = 4.49, p = 0.035).

CONCLUSIONS

There were more similarities than differences between genders in AN. Because this similarity might be confounded with traditionally "feminine" conceptualizations of AN, further studies of male AN are needed.

[Anorexia nervosa in males]

Anorexia nervosa in males Abstract. Anorexia nervosa (AN) is a rare disorder in boys and men with limited data and studies available. The recent update of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) will in all likelihood lead to an increase in the prevalence of AN in boys and men. This study aims to give an overview of the existing data in regards to gender differences in epidemiology, etiology, and symptoms of AN. We aim to highlight the differences in AN between the sexes, from a clinical point of view, and underline the need for further research on AN in boys.

Psychopharmacological advances in eating disorders

INTRODUCTION

Anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED) are the primary eating disorders (EDs). The only psychopharmacological treatment options for EDs with approval in some countries include fluoxetine for BN and lisdexamfetamine for BED. Given the high comorbidity and genetic correlations with other psychiatric disorders, it seems possible that novel medications for these conditions might also be effective in EDs. Areas covered: The current scientific literature has increased our understanding of how medication could be beneficial for patients with EDs on a molecular, functional and behavioral level. On the basis of theoretical considerations about neurotransmitters, hormones and neural circuits, possible drug targets for the treatment of EDs may include signal molecules and receptors of the self-regulatory system such as serotonin, norepinephrine and glutamate, the hedonic system including opioids, cannabinoids and dopamine and the hypothalamic homeostatic system including histamine, ghrelin, leptin, insulin, and glucagon-like peptide-1. Expert commentary: The latest research points to an involvement of both the immune and the metabolic systems in the pathophysiology of EDs and highlights the importance of the microbiome. Therefore, the next few years may unveil drug targets for EDs not just inside and outside of the brain, but possibly even outside of the human body.

Risk of being convicted of theft and other crimes in anorexia nervosa and bulimia nervosa: A prospective cohort study in a Swedish female population

OBJECTIVE

We examined epidemiological associations between anorexia nervosa (AN) and bulimia nervosa (BN) and risks of committing theft and other crimes in a nationwide female population.

METHOD

Females born in Sweden during 1979-1998 (N = 957,106) were followed from age 15 for up to 20 years using information on clinically diagnosed AN and BN (exposures), convictions of theft and other crimes (outcomes), psychiatric comorbidities, and familial relatedness from Swedish national registers. We estimated hazard ratios (HRs) of criminality in exposed versus unexposed females using Cox proportional hazards regressions and explored how comorbidities and unmeasured familial factors explained the associations.

RESULTS

The cumulative incidence of convictions of theft (primarily petty theft) and other crimes was higher in exposed females (AN: 11.60% theft, 7.39% other convictions; BN: 17.97% theft, 13.17% other convictions) than in unexposed females (∼5% theft, ∼6% other convictions). The significantly increased risk of being convicted of theft in exposed females (AN: HR = 2.51, 95% confidence interval = [2.29, 2.74], BN: 4.31 [3.68, 5.05]) was partially explained by comorbidities; unmeasured familial factors partially explained the association with convictions of theft in BN but not in AN. Females with BN had a doubled risk of convictions of other crimes, which was partially explained by comorbidities.

DISCUSSION

Individuals with eating disorders had increased risk for convictions of theft and potentially other crimes. Results underscore the importance of regular forensic screening and encourage research on mechanisms underlying the relation between crime and eating disorder psychopathology and efforts to determine how best to address such relation in treatment.

Paternal age at childbirth and eating disorders in offspring

BACKGROUND

Advanced paternal age at childbirth is associated with psychiatric disorders in offspring, including schizophrenia, bipolar disorder and autism. However, few studies have investigated paternal age's relationship with eating disorders in offspring. In a large, population-based cohort, we examined the association between paternal age and offspring eating disorders, and whether that association remains after adjustment for potential confounders (e.g. parental education level) that may be related to late/early selection into fatherhood and to eating disorder incidence.

METHOD

Data for 2 276 809 individuals born in Sweden 1979-2001 were extracted from Swedish population and healthcare registers. The authors used Cox proportional hazards models to examine the effect of paternal age on the first incidence of healthcare-recorded anorexia nervosa (AN) and all eating disorders (AED) occurring 1987-2009. Models were adjusted for sex, birth order, maternal age at childbirth, and maternal and paternal covariates including country of birth, highest education level, and lifetime psychiatric and criminal history.

RESULTS

Even after adjustment for covariates including maternal age, advanced paternal age was associated with increased risk, and younger paternal age with decreased risk, of AN and AED. For example, the fully adjusted hazard ratio for the 45+ years (v. the 25-29 years) paternal age category was 1.32 [95% confidence interval (CI) 1.14-1.53] for AN and 1.26 (95% CI 1.13-1.40) for AED.

CONCLUSIONS

In this large, population-based cohort, paternal age at childbirth was positively associated with eating disorders in offspring, even after adjustment for potential confounders. Future research should further explore potential explanations for the association, including de novo mutations in the paternal germline.

Toward a new generation of quality registries for neurodevelopmental disorders: the example of NEUROPSYK

Swedish healthcare quality registries are tools for the evaluation and improvement of clinical services and population-based research. There are presently 11 national quality registries that focus on psychiatric disorders; but none cover all neurodevelopmental disorders (NDDs) as defined by the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Health care professionals have called for more user-friendly; time-saving; and clinically informative registers.

To fill this gap, the NEUROPSYK Quality Register was established in 2014 by the Center of Neurodevelopmental Disorders at Karolinska Institutet. Initially, this was a clinical register of child and adolescent psychiatry for the Stockholm County Council.

The main objectives of NEUROPSYK are to improve the assessment of and interventions used for individuals with NDDs by doing the following: 1) supporting adequate follow-up related to the implementation of existing regional and national guidelines for assessment and treatment; 2) providing clinical decision-making aids; and 3) conducting large-scale clinical epidemiological research. The registry incorporates all legal requirements for quality registries in Sweden.

NEUROPSYK includes patients of all ages diagnosed with NDDs per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. These diagnoses include autism spectrum disorder, attention-deficit/hyperactivity disorder, intellectual disabilities, communication disorders, specific learning disorders, and motor disorders. Medication and behavioral interventions are recorded and patient outcomes over time are measured with the economical and user-friendly Clinical Global Impression tool, the Global Assessment of Functioning instrument, and patient-reported health-related quality of life.

NEUROPSYK minimizes administrative work for health care professionals because it is integrated with structured digital patient records, thereby increasing the likelihood of high coverage and data quality. NEUROPSYK combines several strengths to exemplify a new generation of quality research registers for use in psychiatry and other areas of health care.

Read more about NEUROPSYK: http://ki.se/en/kind/neuropsyk-quality-registry-for-neurodevelopmental-disorders

Epidemiology of eating disorders in Europe: prevalence, incidence, comorbidity, course, consequences, and risk factors

PURPOSE OF REVIEW

Eating disorders - anorexia nervosa, bulimia nervosa, and binge eating disorder - affect numerous Europeans. This narrative review summarizes European studies on their prevalence, incidence, comorbidity, course, consequences, and risk factors published in 2015 and the first half of 2016.

RECENT FINDINGS

Anorexia nervosa is reported by <1-4%, bulimia nervosa <1-2%, binge eating disorder <1-4%, and subthreshold eating disorders by 2-3% of women in Europe. Of men, 0.3-0.7% report eating disorders. Incidences of anorexia appear stable, whereas bulimia may be declining. Although the numbers of individuals receiving treatment have increased, only about one-third is detected by healthcare. Over 70% of individuals with eating disorders report comorbid disorders: anxiety disorders (>50%), mood disorders (>40%), self-harm (>20%), and substance use (>10%) are common. The long-term course of anorexia nervosa is favorable for most, but a substantial minority of eating disorder patients experience longstanding symptoms and somatic problems. The risk of suicide is elevated. Parental psychiatric disorders, prenatal maternal stress, various family factors, childhood overweight, and body dissatisfaction in adolescence increase the risk of eating disorders.

SUMMARY

Eating disorders are relatively common disorders that are often overlooked, although they are associated with high comorbidity and serious health consequences.

Emotion dysregulation, self-image and eating disorder symptoms in University Women

BACKGROUND

We studied associations between emotion dysregulation, self-image and eating disorder (ED) symptoms in university women, and contrasted two indirect effect models to examine possible intervening mechanisms to produce ED symptoms.

METHODS

252 female Swedish university students completed the Difficulties in Emotion Regulation Scale (DERS), the Structural Analysis of Social Behavior (SASB) self-image measure, and the Eating Disorder Examination Questionnaire (EDE-Q). Correlations between scales were followed by five simple mediation analysis pairs with two possible pathways using five ED symptom variables as outcome. The models posited either self-image or emotion dysregulation as mediator or independent variable, respectively. ED symptoms were EDE-Q Global score, objective binge eating episodes (OBE), subjective binge eating episodes (SBE), and two variants of EDE-Q excessive exercise.

RESULTS

Emotion dysregulation and self-image were strongly correlated, and both correlated moderately with EDE-Q Global score. There were distinct indirect effects through self-image on the relationship between emotion dysregulation and ED symptoms, but not vice versa. These indirect effects were evident in relation to cognitive ED symptoms and both OBE and SBE, but not in relation to excessive exercise.

CONCLUSIONS

Results suggest that even if closely related, emotion dysregulation and self-image both contribute unique knowledge in relation to ED symptoms. Self-image as an intervening mechanism between emotion dysregulation and ED symptoms is relevant for models of the development, maintenance and treatment of ED, as well as treatment focus.