Psychometric properties of the Compulsive Exercise Test in a large sample of female adolescent and adult inpatients with anorexia nervosa and bulimia nervosa

Psychometric properties of the German version of the Eating Pathology Symptoms Inventory

BACKGROUND

The Eating Pathology Symptoms Inventory (EPSI) is a multidimensional self-report measure for the assessment of eating pathology and related aspects: Body Dissatisfaction, Binge Eating, Cognitive Restraint, Purging, Restricting, Excessive Exercise, Negative Attitudes Toward Obesity, and Muscle Building. The aims of the current studies were to provide a German translation of the EPSI and replicate the original EPSI's psychometric properties and correlates.

METHODS

In two cross-sectional surveys using convenience samples (n = 361 and n = 178), participants completed the German EPSI along with other questionnaires.

RESULTS

In both studies, the EPSI's eight-factor structure, high internal consistencies, and differential associations with other instruments assessing eating disorder-specific and general psychopathology as well as gender differences on the EPSI's scales were largely replicated.

CONCLUSIONS

The German EPSI had sound psychometric properties that allow for a reliable and valid, multidimensional assessment of eating-disorder psychopathology.

Purging frequency and number of purging methods as indicators of severity in bulimia nervosa: Interactive effects with binge eating episodes

OBJECTIVE

In the Diagnostic and Statistical Manual of Mental Disorders-5, severity of bulimia nervosa (BN) is defined by the frequency of purging behaviour. Previous research suggests the number of purging methods as an alternative rating. The current analysis investigated characteristics (sociodemographic and treatment-related variables, body mass index [BMI], eating disorder-specific and general psychopathology) of persons with BN as a function of purging frequency and number of purging methods in order to examine which approach might be better suited for indicating severity of BN.

METHOD

Two-hundred and sixty-one persons (98.5% female; mean age 25.2 years, SD = 9.41; mean BMI 22.0 kg/m2, SD = 3.79) with BN completed self-report questionnaires on eating disorder-specific and general psychopathology at admission to inpatient (n = 214) or daypatient (n = 47) treatment.

RESULTS

Higher severity based on either purging frequency or number of purging methods tended to relate to lower BMI and higher eating disorder-specific and general psychopathology. In addition, binge-eating frequency differentially related to eating disorder-specific and general psychopathology as a function of severity groups.

CONCLUSIONS

This study partially supports the utility of both purging frequency and the number of purging methods as indicators of severity in persons with BN. However, focussing only on purging behaviours may be short-sighted as it appears necessary to consider the number of binge-eating episodes as well when evaluating severity of BN.

Disordered Eating in Pediatric Obesity

Children and youth with overweight and obesity are at an increased risk for the development of an eating disorder. Previous research has shown that disordered eating behaviors are prevalent in this population. Screening for disordered eating behaviors in children and youth with overweight and obesity is necessary to determine the course of the treatment. In children and youth with obesity and comorbid disordered eating behaviors, treatment should be multidisciplinary and include psychological, medical, nutrition, and physical activity care.

Comparing family-based treatment with inpatient treatment in youth with anorexia nervosa eligible for hospitalization: A 12-month feasibility study

OBJECTIVE

Family-based treatment (FBT) for youth with anorexia nervosa (AN), has not been compared to inpatient, multimodal treatment (IMT).

METHOD

Prospective, non-randomized pilot feasibility study of adolescents with AN receiving FBT (n = 31), and as a reference point for exploratory outcome comparisons IMT (n = 31), matched for baseline age and percent median BMI (%mBMI). Feasibility of FBT in youth fulfilling criteria for IMT was assessed via study recruitment and retention rates; acceptability via drop-out and caregiver strain; safety via adverse events; preliminary treatment effectiveness between groups was assessed via a change in %mBMI, AN psychopathology (Eating Disorder Examination-Questionnaire, EDE-Q), and hospital days, over 12 months with intent-to-treat, mixed models repeated measures analyses covering post-intervention usual care until 12 months.

RESULTS

Taking into account that 8 FBT patients (25.8%) crossed over to IMT due to lack of weight gain or psychiatric concerns, FBT and IMT were similarly feasible, acceptable, and safe, apart from more physical antagonism toward others in FBT (p = .010). FBT lasted longer (median [interquartile range, IQR]; 33.6 [17.4, 49.9] vs. 17.3 [14.4, 24] weeks, p < .001), but required fewer hospital days than IMT (median, [IQR], FBT = 1 [0, 16] vs. IMT = 123 [101, 180], p < .001). Baseline comorbidity-adjusted changes over 12 months did not differ between groups in %mBMI (FBT = 12.6 ± 11.9 vs. IMT = 13.7 ± 9.1; p = .702) and EDE-Q global score (median, [IQR]; FBT = -1.2 [-2.3, 0.2] vs. IMT = -1.3 [-2.8, -0.4]; p = .733).

DISCUSSION

Implementing FBT in this pilot study was feasible, acceptable, and safe for youth eligible for IMT according to German S3 guidelines. Non-inferiority of FBT versus IMT requires confirmation in a sufficiently large multicenter RCT.

PUBLIC SIGNIFICANCE

This pilot study with 62 adolescent patients with anorexia nervosa demonstrated that for 2/3rd of patients eligible for a long hospitalization in the German health care system, outpatient, Family-based treatment (FBT) was a safe and feasible treatment alternative. Over 12 months, FBT lead to similar weight gain and reduction in eating disorder cognitions as inpatient treatment with fewer hospital days. This pilot study needs to be followed up by a larger, multicenter trial.

Validation and measurement invariance of the Compulsive Exercise Test among Brazilian and American young adults

PURPOSE

To evaluate compulsive exercise, researchers often rely on the widely used Compulsive Exercise Test (CET). However, the measure has shown unstable factor structure in several validation studies and is not available in Portuguese for use in Brazil. We aimed to describe the translation and cultural adaptation of the CET to Brazilian Portuguese, to test several factor structures among Brazilian and US samples of men and women, to test measurement invariance across countries, and to evaluate its internal consistency. Furthermore, we sought to evaluate convergent validity, correlating the CET with a measure of eating disorder symptoms, and to compare compulsive exercise symptoms between countries.

METHODS

Four models of the latent structure of the CET were tested using confirmatory factor analyses (CFAs), three-factor structure with 15 items, three-factor structure with 18 items, four-factor structure with 21 items, and the original five-factor structure with 24 items, in a sample of 1,531 young adults (601 Brazilians and 930 Americans), aged 18-35 years.

RESULTS

A series of CFAs demonstrated that the three-factor structure with 15 items showed a better fit to the data. This model demonstrated good convergent validity and internal consistency. Results from the CET multigroup CFA showed evidence for the invariance at the configural, metric, and scalar levels across Brazilians and Americans. Furthermore, significant differences were found between Brazilians and Americans, with Brazilians demonstrating higher scores on the Avoidance and rule-driven behavior and Mood improvement subscales, whereas US participants scored higher on the Weight control exercise subscale.

CONCLUSIONS

Results support the three-factor structure with 15 items to be used as a measure of compulsive exercise among Brazilians and Americans, allowing cross-cultural comparisons between these countries.

LEVEL OF EVIDENCE

Level V, Cross-sectional, Psychometric study.

Assessment and treatment of compulsive exercise in anorexia nervosa - A combined investigation of Compulsive Exercise Activity Therapy (LEAP) and Compulsive Exercise Test subscales

INTRODUCTION

Compulsive exercise is a transdiagnostic feature of eating disorders which adversely affects aspects of recovery, such as length of hospitalisation, risk of a chronic outcome, and risk of relapse. CompuLsive Exercise Activity TheraPy (LEAP) aims to reduce compulsive exercise through a cognitive behavioural approach. This study aims to investigate the effect of LEAP on compulsive exercise behaviour using subscales of the Compulsive Exercise Test (CET), a measure of exercise in individuals with eating disorders. Predictive validity of the CET's subscales and its ability to predict eating psychopathology are investigated.

METHOD

This study used data from a randomized controlled trial of LEAP (1). Linear mixed modelling was used to investigate the effect of LEAP on compulsive exercise behaviour, and the predictive ability of CET subscales on various outcomes. The CET was compared to other exercise measures to assess its superiority in predicting eating psychopathology.

RESULTS

LEAP was superior in reducing the scores of the CET's Avoidance and Rule Driven Behaviour and Exercise Rigidity subscales. All subscales made a contribution to the respective models. The CET was superior to other measures in predicting eating pathology.

CONCLUSION

The results lend credibility to LEAP's ability to reduce core parts of compulsive exercise. The CET has been found to target important aspects of compulsive exercise behaviour, and has was superior to other exercise measures in predicting eating psychopathology.

Impact of LEAP and CBT-AN Therapy on Improving Outcomes in Women with Anorexia Nervosa

Anorexia nervosa (AN) is a mental health disorder that has serious physical, emotional and social consequences. Whilst cognitive behavioural therapy for AN (CBT-AN) has demonstrated efficacy, there remains a global need to improve AN treatment. Compulsive exercise activity therapy (LEAP) is an active therapy consisting of the addition to CBT-AN of eight specific sessions that focus on exercise and motivation for behavioural change. This paper presents a secondary analysis of 74 female participants in a randomised control trial of LEAP plus CBT-AN versus CBT-AN alone. The main aim of this study was to explore putative predictors and to estimate the magnitude of changes due to LEAP for specific outcome measures. Participants (LEAP: n = 36; CBT-AN: n = 38) were assessed at three successive surveys: baseline, end of therapy, and 6 months post-therapy. The overall effect sizes for changes between baseline to end of therapy and baseline to 6-month follow-up assessment showed large effect sizes (Cohen's d > = 0.80) for mental-health-related quality of life (MHRQoL), weight concern, dietary restraint, eating concern, AN stage change, and psychological distress (all p < 0.05). The results also indicated that several pre-treatment characteristics, including body mass index (BMI), level of eating disorder (ED) symptoms, and MHRQoL are important for identifying whether a treatment is likely to be effective. Future treatment programs should aim to optimise early improvements in BMI, ED symptoms, and MHRQoL.

Compulsive Exercise, Exercise Identity, and Coping Styles

Abstract. Compulsive exercise occurs among the general exercise population and is associated with adverse mental and physical health outcomes. The current study explored compulsive exercise behavior regarding coping styles and its relationship to identity to improve our understanding of compulsive exercise among the general exercise population. A community sample of 1,209 adults (aged 18 – 89) with varied exercise levels completed an online survey. We examined the relationships between engagement and disengagement coping styles (as assessed by the Coping Strategy Inventory) and exercise identity (Exercise Identity Scale) with compulsive exercise (Compulsive Exercise Test) using correlation, regression, and moderation analyses. Emotion-focused engagement (β = .075, p < .01) and emotion-focused disengagement (β = .212, p < .001) coping styles significantly predicted compulsive exercise, as did exercise identity (β = .514, p < .001). Coping styles did not moderate the relationship between exercise identity and compulsive exercise behaviors. The results indicate that both adaptive and maladaptive emotion-based coping styles are associated with greater compulsive exercise behavior.

Measuring exercise in eating disorder patients: a Delphi study to aggregate clinical and research knowledge

BACKGROUND

Exercise is a prominent feature of most eating disorders, and has been shown to have a number of detrimental effects on treatment outcome. There is some disagreement in the literature regarding the construct of compulsive exercise, and assessment and treatment varies significantly. This study therefore aimed to aggregate expert clinicians' and researchers' views on how to define and measure compulsive exercise in eating disorder patients. The expert panel was also asked about questionnaire design, and possible problems when measuring compulsive exercise.

METHOD

This study used the Delphi method to establish consensus amongst an expert panel. Three successive rounds of questionnaires were distributed to the panel over a period of six months. The first round consisted of four open-ended questions regarding the definition and measurement of compulsive exercise in eating disorder patients. For Round 2, 70 statements were derived from the answers, and panelists were asked to rate each item on a Likert-based scale. An 85% consensus level was chosen. In Round 3, 44 statements were re-rated by the panel.

RESULTS

Seventeen of 24 participants completed all three rounds of the study. Consensus was achieved for 63% of the items, while 18.5% reached near consensus, and 18.5% did not reach consensus after Round 3. The panel agreed on a number of important aspects of compulsive exercise. Several suggestions regarding the format of a questionnaire assessing this behavior were also endorsed. The panel further identified common difficulties when assessing compulsive exercise in eating disorder patients, notably a lack of consensus still apparent in the literature.

CONCLUSION

The current findings constitute a further step towards a unified definition of compulsive exercise, and contribute important suggestions to the measurement of this behavior.