Bulimic symptomatology: The role of adaptive perfectionism, shape and weight concern, and self-esteem

The correlates of appearance focused self-concept: personality traits, self-concept, sociocultural, and early life experience factors

BACKGROUND

Theory and research indicate that an appearance focused self-concept (i.e., placing overriding importance on physical appearance for self-definition and self-worth) plays a role in the etiology and maintenance of disordered eating and eating disorders. Although the consequences of an appearance focused self-concept are palpable, less is known about its correlates. Accordingly, we examined a range of factors that may characterize appearance focused people, including personality traits (perfectionism, impulsivity, sensation-seeking, hopelessness, and anxiety sensitivity), self-concept (global self-esteem and self-concept clarity), sociocultural (thin-ideal, muscular-ideal, general attractiveness internalizations, and perceived pressure to be thin), and early life experiences (adverse childhood experiences, attachment styles) factors.

METHODS

Female undergraduate university students (N = 568; Mage = 19.58, SDage = 4.24) completed a questionnaire battery that included the Beliefs About Appearance Scale, Depressive Experiences Questionnaire-Self-Criticism-6 Scale, Frost-Multidimensional Perfectionism Scale, the Revised Almost Perfect Scale, Substance Use Risk Profile Scale, Self-Concept Clarity Scale, Rosenberg Self-Esteem Scale, Sociocultural Attitudes Towards Appearance Questionnaire-4 Scale, Adverse Childhood Experiences Questionnaire, Experiences in Close Relationships Scale Short Form, and the Dietary Restraint subscale of the Eating Disorders Examination Questionnaire.

RESULTS

Multiple regression analyses were conducted for each set of factors separately and together. For personality traits, perfectionism, impulsivity, and anxiety sensitivity were uniquely associated with appearance focused self-concept. For self-concept, global self-esteem and self-concept clarity were uniquely associated with appearance focused self-concept. For sociocultural, general attractiveness internalization, thin-ideal internalization, and perceived pressure to be thin were uniquely associated with appearance focused self-concept. For early life experiences, attachment anxiety and avoidance were uniquely associated with appearance focused self-concept. In the combined analysis, the various factors explained 54% of the variance in appearance focused self-concept. Impulsivity, global self-esteem, general attractiveness internalization, and perceived pressure to be thin were uniquely associated with appearance focused self-concept.

CONCLUSIONS

Results for global self-esteem were consistent with prior research. Findings for evaluative concerns perfectionism were inconsistent with prior research. We discuss future research directions to examine the link between evaluative concerns perfectionism and appearance focused self-concept. We also discuss how sociocultural factors (general attractiveness internalization and perceived pressure to be thin) and impulsivity may help cultivate an appearance focused self-concept, advancing knowledge on the characteristics of appearance-focused people.

Psychotherapies for eating disorders: findings from a rapid review

BACKGROUND

Psychotherapy is considered central to the effective treatment of eating disorders-focusing on behavioural, psychological, and social factors that contribute to the illness. Research indicates psychotherapeutic interventions out-perform placebo, waitlist, and/or other treatments; but, outcomes vary with room for major improvement. Thus, this review aims to (1) establish and consolidate knowledge on efficacious eating disorder psychotherapies; (2) highlight select emerging psychotherapeutic interventions; and (3) identify knowledge gaps to better inform future treatment research and development.

METHODS

The current review forms part of a series of Rapid Reviews published in a special issue in the Journal of Eating Disorders to inform the development of the Australian-government-funded National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2023, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, and population studies). Data pertaining to psychotherapies for eating disorders were synthesised and outlined in the current paper.

RESULTS

281 studies met inclusion criteria. Behavioural therapies were most commonly studied, with cognitive-behavioural and family-based therapies being the most researched; and thus, having the largest evidence-base for treating anorexia nervosa, bulimia nervosa, and binge eating disorder. Other therapies, such as interpersonal and dialectical behaviour therapies also demonstrated positive treatment outcomes. Emerging evidence supports specific use of Acceptance and Commitment; Integrative Cognitive Affective; Exposure; Mindfulness; and Emotionally-Focused therapies; however further research is needed to determine their efficacy. Similarly, growing support for self-help, group, and computer/internet-based therapeutic modalities was noted. Psychotherapies for avoidant/restrictive food intake disorder; other, and unspecified feeding and eating disorders were lacking evidence.

CONCLUSIONS

Currently, clinical practice is largely supported by research indicating that behavioural and cognitive-behavioural psychotherapies are most effective for the treatment of eating disorders. However, the efficacy of psychotherapeutic interventions varies across studies, highlighting the need for investment and expansion of research into enhanced variants and novel psychotherapies to improve illness outcomes. There is also a pressing need for investigation into the whole range of eating disorder presentations and populations, to determine the most effective interventions.

Perfectionism and binge eating association: a systematic review and meta-analysis

BACKGROUND

Perfectionism is considered a vulnerability factor for eating disorders. However, the role of perfectionism in binge eating needs clarification due to notably inconsistencies between studies. The purpose to this study was to conduct a systematic review and meta-analysis to estimate the perfectionism-binge eating association.

METHOD

Systematic review was performed according to the PRISMA 2020 statement. Four databases (Web of Science, Scopus, PsycINFO and Psicodoc) were searched to identify studies published until September 2022. The literature search yielded 30 published articles (N = 9392) that provided 33 independent estimations of the correlation between the two variables.

RESULTS

Random-effects meta-analysis revealed a small-to-moderate positive average effect size between general perfectionism and binge eating (r₊ = .17) with a large heterogeneity. Perfectionistic Concerns showed a significant small-to-moderate relationship with binge eating (r₊ = .27), whereas Perfectionistic Strivings presented a negligible relationship with binge eating (r₊ = .07). Moderator analyses showed that the age, the type of the sample, the study design, and the tools for assessing both variables were statistically associated with the perfectionism-binge eating effect sizes.

CONCLUSIONS

Our findings suggest that Perfectionism Concerns are closely associated with binge eating symptomatology. This relationship might be moderated by certain variables, especially by the clinical or non-clinical nature of the sample and the instrument employed to assess binge eating.

A review of risk factors associated with insulin omission for weight loss in type 1 diabetes

Research suggests that as many as 60% of people with type 1 diabetes (T1D) admit to misusing insulin. Insulin omission (IO) for the purpose of weight loss, often referred to as diabulimia, is a behaviour becoming increasingly recognised, not least since prolonged engagement can lead to serious vascular complications and mortality. Several risk factors appear to be relevant to the development of IO, most notably gender, anxiety and depression and increased weight concerns and body dissatisfaction. Evidence suggests that women, especially young girls, are more likely to omit insulin as a method of weight loss compared to men. Mental health conditions such as anxiety and depression are increasingly prevalent in people with T1D compared to their peers, and appear to contribute to the risk of IO. Increased weight concerns and body dissatisfaction are further prominent risk factors, especially given increases in weight which often occur following diagnosis and the monitoring of weight by diabetes teams. This review presents evidence examining these risk factors which increase the likelihood of a person with T1D engaging in IO and highlights the complications associated with prolongment of the behaviour. Further research looking at the comorbidities of these risk factors, alongside other factors, would provide greater insight into understanding IO in people with T1D.

Examining the effectiveness of cognitive bias modification for perfectionism in exploration of the mediating and moderating effects of body dissatisfaction and self-efficacy

The relationship between perfectionism, body dissatisfaction, and self-efficacy is unclear. This study attempted to distinguish the relationship between different dimensions of perfectionism and to examine how they relate to body dissatisfaction and self-efficacy. Experiment 1 examined the effectiveness of two types of Cognitive Bias Modification for Interpretation (CBM-I) techniques in the induction of perfectionism. Experiment 2 explored the mediation and moderation effects of perfectionism facets, body dissatisfaction, and self-efficacy in the induction of perfectionism. Participants were randomly assigned to one of the four CBM-I conditions and completed self-report measures of trait and state perfectionism, body dissatisfaction, self-efficacy, as well as a behavioural task that assessed perfectionistic behaviours before and after the CBM-I induction. The results indicated no significant differences in perfectionism between the experimental groups and the control groups following the perfectionism induction. Using baseline participant characteristics, body dissatisfaction was found to mediate socially-prescribed perfectionism and self-efficacy. Self-oriented perfectionism moderated the association between body dissatisfaction and self-efficacy. State perfectionism may not be influenced by a single session (30 trials) of CBM-I training. Treatment targeting body dissatisfaction may enhance self-efficacy in socially-prescribed perfectionists. Further, interventions that decrease self-oriented perfectionism may reduce body dissatisfaction while increasing self-efficacy.

The relationship between perfectionism and eating-related symptoms in adolescents: A systematic review

The clinical significance of two major aspects of perfectionism, perfectionistic strivings (PS) and perfectionistic concerns (PC), in eating disorders (EDs) symptoms was well-established among adults. However, no systematic review has assessed evidence examining associations between both unidimensional and multidimensional perfectionism and EDs in early and middle adolescence. For this aim, three online databases (PsycINFO, Medline and PsycArticle) were searched for articles published until January 2019, and observational studies were considered. Study quality was systematically appraised, and results were summarized using a narrative synthesis approach. Fifty-one cross-sectional and 28 longitudinal studies were included. Most studies supported the relationship between perfectionism and EDs, with the majority adopting a unidimensional approach for assessing perfectionism. Among studies that employed multidimensional measures of perfectionism, the majority (n = 11) of evidence supported the relationship between eating symptoms and PC, while fewer (n = 5) studies provided significant unique associations with PS. These findings are consistent with the body of research suggesting the strength of the relationship between PC and EDs was greater than between PS and EDs. It was recommended that preventive interventions should be primarily focused on reducing self-critical perfectionism, since it resulted to be the most relevant perfectionistic dimension in the development of eating symptoms in adolescents.

Investigating transdiagnostic factors in eating disorders: Does self-esteem moderate the relationship between perfectionism and eating disorder symptoms?

OBJECTIVE

According to Fairburns transdiagnostic model of eating disorders (EDs), high levels of perfectionism and low self-esteem are two core traits across EDs. This study investigates the role of self-esteem as a transdiagnostic moderator of the relationship between perfectionism and ED symptoms across EDs.

METHOD

A large group of patients (n = 732) completed several questionnaires measuring perfectionism, self-esteem, and disordered eating symptomatology, more specifically, drive for thinness (DFT) and body dissatisfaction (BD).

RESULTS

Across EDs, self-esteem served as a moderator for the association between perfectionism and DFT. However, by testing the model for DFT in each ED separately, the effect only remained in patients with anorexia nervosa and ED not otherwise specified. When testing the model for BD, no moderation effect was found in any of the included EDs.

CONCLUSIONS

This study found that the interaction between perfectionism and self-esteem on DFT can be seen as transdiagnostic, although this effect is not found in each ED separately. These results suggest that ED treatment should consider to not only focus on transdiagnostic factors but also look at the specific impairments of each individual ED.

The self and eating disorders

In our review, we focus on self-related constructs in the context of eating disorders with four aims. First, we examine a variety of self-related constructs that have been theoretically and empirically linked to the development and course of eating disorders. In addition to the more well-researched constructs of self-esteem and self-efficacy, we also report on findings related to selflessness, contingent self-worth, self-objectification, ego-syntonicity, self-concept clarity, self-compassion, social comparison, self-oriented perfectionism/self-criticism, and narcissism. Second, we discuss self-related constructs that may be especially relevant to comorbidities common among those with eating disorders. Third, we review intervention and prevention programs where self-related constructs play a prominent role. Lastly, we share future research directions regarding self-related constructs and eating disorders that we believe will advance a deeper understanding of the role of the self in the eating disorders.

Identifying Predictors Associated with the Severity of Eating Concerns in Females with Eating Disorders

Considering how to improve efficacy of therapeutic strategies, the overall objective of the present study was to investigate the extent of eating concerns and to identify predictors associated with the severity of disordered eating symptomatology among people with eating pathologies. We screened 80 female eating disordered patients, ranging from 13 to 40 years, by means of self-report measures of parental behavior as perceived by the offspring, self-esteem, perfectionism, body shame and eating disorder severity. Self-reported weight and height were obtained. The diagnosis of bulimia nervosa resulted to be associated with a greater severity of the eating symptomatology. Maladaptive perfectionism, body shame and self-esteem, significantly predicted the level of eating concerns. The recognition of potential maintaining factors may support the choice of particular therapeutic strategies to improve the treatment of eating pathologies and their outcomes.

A systematic review of the existing models of disordered eating: Do they inform the development of effective interventions?

Despite significant advances in the development of prevention and treatment interventions for eating disorders and disordered eating over the last decade, there still remains a pressing need to develop more effective interventions. In line with the 2008 Medical Research Council (MRC) evaluation framework from the United Kingdom for the development and evaluation of complex interventions to improve health, the development of sound theory is a necessary precursor to the development of effective interventions. The aim of the current review was to identify the existing models for disordered eating and to identify those models which have helped inform the development of interventions for disordered eating. In addition, we examine the variables that most commonly appear across these models, in terms of future implications for the development of interventions for disordered eating. While an extensive range of theoretical models for the development of disordered eating were identified (N=54), only ten (18.5%) had progressed beyond mere description and to the development of interventions that have been evaluated. It is recommended that future work examines whether interventions in eating disorders increase in efficacy when developed in line with theoretical considerations, that initiation of new models gives way to further development of existing models, and that there be greater utilisation of intervention studies to inform the development of theory.

Perfectionism, weight and shape concerns, and low self-esteem: Testing a model to predict bulimic symptoms

Previous studies have tested multivariate models of bulimia pathology development, documenting that a confluence of perfectionism, body dissatisfaction, and low self-esteem is predictive of disordered eating. However, attempts to replicate these results have yielded controversial findings. The objective of the present study was to test an interactive model of perfectionism, weight and shape concerns, and self-esteem in a sample of patients affected by Eating Disorder (ED). One-hundred-sixty-seven ED patients received the Structured Clinical Interview for DSM-IV Axis I (SCID-I), and they completed the Eating Disorder Examination Questionnaire (EDE-Q), the Rosenberg Self-Esteem Scale (RSES), and the Multidimensional Perfectionism Scale (MPS-F). Several mediation analysis models were fit to test whether causal effects of concern over weight and shape on the frequency of bulimic episodes were mediated by perfectionism and moderated by low levels of self-esteem. Contrary to our hypotheses, we found no evidence that the causal relationship investigated was mediated by any of the dimensions of perfectionism. As a secondary finding, the dimensions of perfectionism, perceived criticism and parental expectations, were significantly correlated with the presence of bulimic symptoms. The validity of the interactive model remains controversial, and may be limited by an inadequate conceptualization of the perfectionism construct.

Predictors of treatment outcome in individuals with eating disorders: A systematic review and meta-analysis

OBJECTIVE

Understanding the factors that predict a favourable outcome following specialist treatment for an eating disorder may assist in improving treatment efficacy, and in developing novel interventions. This review and meta-analysis examined predictors of treatment outcome and drop-out.

METHOD

A literature search was conducted to identify research investigating predictors of outcome in individuals treated for an eating disorder. We organized predictors first by statistical type (simple, meditational, and moderational), and then by category. Average weighted mean effect sizes (r) were calculated for each category of predictor.

RESULTS

The most robust predictor of outcome at both end of treatment (EoT) and follow-up was the meditational mechanism of greater symptom change early during treatment. Simple baseline predictors associated with better outcomes at both EoT and follow-up included higher BMI, fewer binge/purge behaviors, greater motivation to recover, lower depression, lower shape/weight concern, fewer comorbidities, better interpersonal functioning and fewer familial problems. Drop-out was predicted by more binge/purge behaviors and lower motivation to recover. For most predictors, there was large interstudy variability in effect sizes, and outcomes were operationalized in different ways. There were generally insufficient studies to allow analysis of predictors by eating disorder subtype or treatment type.

DISCUSSION

To ensure that this area continues to develop with robust and clinically relevant findings, future studies should adopt a consistent definition of outcome and continue to examine complex multivariate predictor models. Growth in this area will allow for stronger conclusions to be drawn about the prediction of outcome for specific diagnoses and treatment types.

In double trouble for eating pathology? An experimental study on the combined role of perfectionism and body dissatisfaction

BACKGROUND AND OBJECTIVES

A number of correlational studies suggest that the combined presence of perfectionism and body dissatisfaction creates elevated risk for the development of eating disorder pathology. The aim of this study was to examine the causal role of this combination of risk factors for eating pathology.

METHOD

We conducted an experimental study in a sample of female college students (N = 47). Specifically, we performed an experimental manipulation of perfectionism and examined whether this manipulation would interact with body dissatisfaction to predict eating disorder symptoms.

RESULTS

We found that the effect of the experimental manipulation was moderated by body dissatisfaction, such that women in the perfectionism condition and scoring high on body dissatisfaction exhibited the highest levels of eating disorder symptoms.

LIMITATIONS

The sample was rather small (resulting in limited statistical power) and the participants were predominantly healthy and well-adjusted women, which may limit the generalizability and interpretation of our findings.

CONCLUSIONS

The results suggest that the combination of perfectionism and body dissatisfaction is particularly detrimental and predictive of risk for eating disorder symptoms.

How perfectionism and ineffectiveness influence growth of eating disorder risk in young adolescent girls

While perfectionism is widely considered to influence risk for eating disorders, results of longitudinal studies are mixed. The goal of the current study was to investigate a more complex model of how baseline perfectionism (both high personal standards and self-critical evaluative concerns) might influence change in risk status for eating disorders in young adolescent girls, through its influence on ineffectiveness. The study was conducted with 926 girls (mean age of 13 years), and involved three waves of data (baseline, 6- and 12-month follow-up). Latent growth curve modelling, incorporating the average rate at which risk changed over time, the intercept (initial status) of ineffectiveness, and baseline perfectionism, was used to explore longitudinal mediation. Personal standards was not supported as contributing to risk but results indicated that the higher mean scores on ineffectiveness over the three waves mediated the relationship between higher baseline self-critical evaluative concerns and both measures of eating disorder risk. The relationship between concern over mistakes and change in risk was small and negative. These results suggest the usefulness of interventions related to self-criticism and ineffectiveness for decreasing risk for developing an eating disorder in young adolescent girls.

An exploratory assessment of theory of mind and psychological impairment in patients with bulimia nervosa

This study aimed to investigate psychosocial functioning and different dimensions of theory of mind (ToM) in people with bulimia nervosa (BN) and Eating Disorder Not Otherwise Specified-BN type (EDNOS-BN). Psychosocial functioning and ToM were assessed in a sample of young adult females, 16 BN and 16 EDNOS-BN outpatients and 16 healthy controls (HCs). They were assessed using the Eating Disorder Inventory-Symptom Checklist-2 (EDI-2 SC) for evaluating psychological traits associated with eating disorders; the Symptom Checklist-90-Revised (SCL-90-R) for evaluating psychopathological status; and the Theory of Mind Assessment Scale (Th.o.m.a.s.), a semi-structured interview aimed at assessing a person's different dimensions of ToM. The BN and EDNOS-BN groups exhibited worse performance than the control group on all dimensions of the SCL-90-R, and on all dimensions of the EDI-2 SC. The only difference for perfectionism was that BN obtained higher scores than EDNOS-BN group. Our results also revealed an impairment of third-person and second-order ToM in patients with bulimia (BN and EDNOS-BN) with respect to control subjects. These preliminary data have important implications for future empirical work, in that they provide valuable information regarding the importance of investigating the various facets of ToM ability separately, in order to provide a more detailed profile of ToM functioning in the clinical samples.