Bulimia nervosa and depression: a theoretical and clinical appraisal in light of the binge-purge cycle

The association between mental health and Bulimia Nervosa among a sample of Lebanese young adults: the indirect effect of difficulties in emotion regulation

BACKGROUND

Bulimia nervosa (BN) is defined as repeated episodes of binge eating, followed by compensatory behaviors such as self-induced vomiting. BN has been shown to be associated with many co-morbidities including depression and anxiety. BN has also been associated with stress, which was shown to trigger binge eating episodes in BN. Furthermore, difficulties in emotion regulation have been seen to play an important role in the psychopathology of eating disorders, including BN. Seeing that BN is the most prevalent eating disorder in Lebanon, which is linked to the stressful events the country has been through, the study aims to examine the indirect effect of emotional dysregulation on this relationship between mental health issues (stress, anxiety and depression) and bulimia nervosa among young adults. We hypothesize that difficulties in emotion regulation would have an indirect effect in the relationship between mental health and BN.

METHODS

This was a cross-sectional observational study, based on an online anonymous survey, which was carried out between September and December of 2020. Participants were all 18 years and above, recruited from all Lebanese governorates (n = 1175).

RESULTS

Difficulties in emotion regulation mediated the association between anxiety/stress/depression and bulimia. Higher mental health issues were significantly associated with more difficulties in emotion regulation; higher difficulties in emotion regulation were significantly associated with more bulimia. Finally, higher anxiety and higher stress, but not depression, were significantly and directly associated with higher bulimia.

CONCLUSION

Results of this study could be used by mental health professional to shed light on the difficulties in emotion regulation in patients with BN and try to use therapeutic strategies to help them better regulate their emotions.

Conceptualising Binge Eating: A Review of the Theoretical and Empirical Literature

Binge eating is a distressing symptom common to bulimia nervosa (BN), anorexia nervosa binge/purge subtype (AN-BP) and binge-eating disorder (BED). Over the last 40 years, many attempts have been made to conceptualise this symptom in terms of its antecedents, function, triggers, consequences, and maintaining factors. Cognitive theories of binge eating have evolved as new evidence has emerged. This literature review summarises the main and most influential cognitive models of binge eating across different eating disorder presentations. Many theories have examined binge eating in the context of restriction or compensatory behaviours, as is often observed in cases of BN. Few theories have examined binge eating as it occurs in BED specifically. The long-term efficacy of cognitive behavioural therapy (CBT) treatment based on these models leaves much to be desired, and indicates that there may be maintaining factors of binge eating not addressed in the typical CBT treatment for eating disorders. More recent cognitive models of binge eating propose possible maintaining beliefs, but further study is required to validate these models. Suggestions for future research are presented.

The Relationship Between Eating Disorder Symptoms and Treatment Rejection among Young Adult Men in Residential Substance Use Treatment

Research has demonstrated that individuals with substance use disorders (SUDs) and comorbid mental health problems evidence heightened negative consequences, including poorer treatment outcomes, a higher risk for relapse, and mortality compared to individuals with a single disorder. In this study, we focus on the comorbidity between SUDs and eating disorder (ED) symptomatology, as EDs are similarly associated with high rates of relapse, morbidity, and mortality. Of particular importance is research examining treatment rejection among individuals in treatment for SUDs with cooccurring ED symptomatology. This study seeks to add to the literature by examining treatment rejection among young adult men in residential treatment for SUDs (N = 68) with cooccurring ED symptomatology. Results from hierarchical regression analyses indicated that ED symptoms were significantly associated with treatment rejection after controlling for alcohol and drug use and problems and depression symptoms. Although this is a preliminary study, the results add to a growing body of research examining the comorbidity between SUDs and ED symptomatology. Future research examining this relationship is needed to further elucidate the treatment patterns among individuals with comorbid ED symptoms and substance use diagnoses.

Eating Disorder Symptoms and Length of Stay in Residential Treatment for Substance Use: A Brief Report

OBJECTIVE

Treatment dropout is common both among people in treatment for eating disorders and for substance use disorders. Because of the high rates of co-occurrence and mortality associated with these disorders, the purpose of the current study was to examine the relationship among eating disorder symptoms, length of stay, and decisions to leave against medical advice among individuals in substance use treatment.

METHODS

We analyzed de-identified medical record data for 122 adult women enrolled in residential treatment for substance use disorders over a 12-month period. Routine treatment intake included standardized assessments of eating disorders, depression, and substance use.

RESULTS

Participants averaged 43.1 years of age (SD = 10.7) and were primarily non-Hispanic Caucasian (n = 118, 96.7%). Approximately 8 (6.6%) patients met criteria for a probable eating disorder and 79 (64.8%) for a probable alcohol use disorder. Mean length of stay was 28.1 days (SD = 6.6) and 21 (17%) patients left against medical advice. Logistic regression analysis showed that eating disorder symptoms were significantly associated with decisions to leave treatment against medical advice after controlling for age, years of education, depression symptoms, alcohol problems, and drug problems: χ(2) = 14.88, df = 6, p =.02. This model accounted for 19.1% (Nagelkerke R(2)) of the variance in discharge type. Eating disorder symptoms were not associated with length of treatment.

CONCLUSIONS

Our findings suggest the importance of assessing and monitoring eating disorder symptoms among individuals in treatment for substance use disorders.

Examining the Relationship between Binge Eating and Coping Strategies and the Definition of Binge Eating in a Sample of Spanish Adolescents

The present study had two major goals: to explore the relationship between binge eating and coping strategies in a sample of Spanish adolescents and to examine the adolescents' concept of binge eating. Two hundred and fifty-nine adolescents from a secondary school completed the Adolescent Coping Scale (ACS; Frydenberg & Lewis, 1993) and the Bulimic Investigatory Test, Edinburgh (BITE; Henderson & Freeman, 1987), as well as additional questions regarding the binge-eating episodes. The results show that the adolescents who reported binge eating used more avoidance coping strategies than those who did not engage in this behavior. Adolescents took into account mainly the amount of food eaten when defining a binge with few of them mentioning loss of control in their descriptions. The results of the study have implications for the prevention of this behavior. The development of constructive ways for solving daily problems and coping with stressors may be a possible prevention strategy for this behaviour in adolescence.

The state of nursing science - cultural and lifespan issues in depression: part I: focus on adults

Depression is a devastating disorder, affecting approximately 17 million persons within the United States. The manifestation of depressive phenomena is a complex, dynamic, biopsychosocial process involving lifespan and cultural aspects. Unless appropriately treated, depression persists over time having a significant negative effect on life and increasing the risk of suicide. Psychiatric mental health (PMH) nurses are uniquely positioned to address this epidemic health concern. This manuscript is Part I of the review of current nursing literature on adult depression. This review can be used to enhance PMH nurses' knowledge of current nursing research and their efforts in addressing prevention, early intervention, education and treatment of adults who experience depression.

Shame and severity of bulimic symptoms

Initial research suggests that self-conscious affect such as shame may perpetuate bulimic symptoms among individuals suffering from bulimia nervosa (BN). This investigation reports findings from two studies that examine the relation of shame to bulimic symptoms. In the first study, the relation of shame to bulimic symptoms was examined among 137 female college undergraduates. Shame accounted for a significant portion of variance in bulimic symptoms after controlling for age, weight status, guilt, and depressed mood. A second study examined the severity of shame in 30 bulimic patients compared to 28 eating-disordered patients with subclinical symptoms. Although patients with more severe bulimic symptoms exhibited higher levels of shame, this relation was not independent of the shared relation with depression and guilt. Findings are discussed in terms of the role of shame in bulimic symptoms.

A Biopsychosocial Model of Disordered Eating and the Pursuit of Muscularity in Adolescent Boys

This review provides an evaluation of the correlates and/or risk factors associated with disordered eating and the pursuit of muscularity among adolescent boys. One of the main conclusions is that similar factors and processes are associated with both behavioral problems. Several factors found to be consistently associated with disordered eating among boys are also similar to those found with girls. These include body mass index, negative affect, self-esteem, perfectionism, drug use, perceived pressure to lose weight from parents and peers, and participation in sports that focus on leanness. However, as many of the findings have only been verified using cross-sectional designs, prospective studies are now needed.

Wie spezifisch sind Beeinträchtigungen des Selbstkonzepts bei Essstörungen?

Zusammenfassung. Theoretischer Hintergrund: Selbstkonzeptbeeinträchtigungen gelten als zentrales Merkmal anorektischer und bulimischer Patientinnen. Untersuchungen an Patienten mit Binge Eating Störungen fehlen weitgehend. Fragestellung: Überprüfung der Spezifität von Selbstkonzeptbeeinträchtigungen bei drei diagnostischen Gruppen essgestörter Patientinnen und gesunden sowie weiteren klinischen Kontrollgruppen. Methode: Selbstkonzeptbeeinträchtigungen wurden bei essgestörten Patientinnen, parallelisierten gesunden Kontrollgruppen sowie Patientinnen mit Angststörungen und depressiven Störungen unter Berücksichtigung der Rolle der Depressivität untersucht. Ergebnisse: Alle drei Gruppen essgestörter Patientinnen wiesen ein schlechteres Selbstkonzept im Vergleich zu gesunden Kontrollpersonen auf, unabhängig vom Ausmaß ihrer Depressivität. Unterschiede zu den klinischen Kontrollgruppen bestanden v.a. hinsichtlich des globalen Selbstwertgefühls und waren im Vergleich zu Patientinnen mit Angststörungen ausgeprägter als gegenüber Depressiven. Schlussfolgerung: Selbstkonzeptdefizite können nicht als besonders spezifische Beeinträchtigungen essgestörter Patientinnen angesehen werden.

Threat processing in women with bulimia

Cognitive-behavioral treatments are the most commonly used approaches for bulimia nervosa. However, these treatments tend to produce only moderate remission rates. Therefore, it is useful to consider how experimental cognitive approaches can help to revise current cognitive-behavioral models of bulimia. Information processing models highlight the role of attentional biases and schema avoidance in the etiology and maintenance of pathology. This review considers how these processes relate to bulimia. In particular, a growing body of evidence suggests that bulimic behaviors may function to "block" aversive self-awareness. Blocking behaviors also feature strongly in other impulsive disorders. This review considers the relationship between bulimia and impulsivity, and discusses whether the functions of the two behaviors are the same. The clinical implications and future research needs that arise from this literature are discussed.

Dietary restraint and negative affect as mediators of body dissatisfaction and bulimic behavior in adolescent girls and boys

Stice's dual pathway model of dietary restraint and negative affect was examined in both adolescent girls and boys. Self-report measures assessing body dissatisfaction, dietary restraint, negative affect and bulimic behavior were administered to 267 girls and 199 boys aged between 12 and 16 years. The findings for the girls were consistent with Stice's model, in that they indicated that both dietary restraint and negative affect mediated the relationship between body dissatisfaction and bulimic behavior. For the boys who desired a thinner body size, only negative affect was found to mediate the relationship between body dissatisfaction and bulimic behavior. On the other hand, for boys who desired a larger body size, both body dissatisfaction and dietary restraint were found to exert an independent effect on bulimic behavior. As boys can aspire to two contrasting and seemingly opposite body size ideals, the findings highlight that the relationship between body dissatisfaction, dietary restraint, negative affect and bulimic behavior are more complex in males than in females. Further research using longitudinal designs is needed in order to test the directional and bidirectional nature of the observed interrelationships.

Restraint as misregulation in drinking and eating

The present study was designed to increase our understanding of the co-morbidity between problem drinking and binge eating. The study investigated both consummatory behaviors in relation to restrained drinking, restrained eating, and a general measure of self-control. The participants were a sample of 658 boys and 414 girls aged between 14 and 17 years. The dimension of restraint, which best predicted the two problem behaviors when examined separately for both boys and girls, was cognitive and emotional preoccupation (CEP) about controlling one's consummatory intake. In addition, evidence was found linking both problem drinking and binge eating to restraint and poor general self-control. The struggle with self-control and the high emphasis on CEP about controlling one's consummatory intake, which characterise restrained drinking and restrained eating, closely resembles Baumeister and Heatherton's notion of misregulation [Psychol. Inquiry 7 (1996) 1.]. Discussed are the similarities between restraint and misregulation, and the kinds of strategies that can be used to improve self-control.

Decreases in blood perfusion of the anterior cingulate gyri in Anorexia Nervosa Restricters assessed by SPECT image analysis

BACKGROUND

It is possible that psychopathological differences exist between the restricting and bulimic forms of anorexia nervosa. We investigated localized differences of brain blood flow of anorexia nervosa patients using SPECT image analysis with statistic parametric mapping (SPM) in an attempt to link brain blood flow patterns to neurophysiologic characteristics.

METHODS

The subjects enrolled in this study included the following three groups: pure restrictor anorexics (AN-R), anorexic bulimics (AN-BP), and healthy volunteers (HV). All images were transformed into the standard anatomical space of the stereotactic brain atlas, then smoothed. After statistical analysis of each brain image, the relationships among images were evaluated.

RESULTS

SPM analysis of the SPECT images revealed that the blood flow of frontal area mainly containing bilateral anterior cingulate gyri (ACC) was significantly decreased in the AN-R group compared to the AN-BP and HV groups.

CONCLUSIONS

These findings suggest that some localized functions of the ACCare possibly relevant to the psychopathological aspects of AN-R.

Beeinträchtigungen des Selbstkonzepts bei Eßstörungen

Zusammenfassung. Die vorliegende Arbeit gibt einen Überblick über Selbstkonzeptbeeinträchtigungen bei Patientinnen mit Eßstörungen (Anorexia nervosa und Bulimia nervosa). Aus theoretischer Sicht werden Selbstkonzeptbeeinträchtigungen 1. als charakteristisches beschreibendes oder diagnostisches Merkmal sowie 2. als ätiologisches Merkmal im Rahmen verschiedener theoretischer Modelle beschrieben. Auf dem Hintergrund dieser Modelle werden anschließend die prospektiven empirischen Befunde zur Rolle von Selbstkonzeptbeeinträchtigungen als Risikofaktor sowie Querschnittsbefunde bei Anorexia und Bulimia nervosa im Vergleich zu Gesunden und anderen klinischen Kontrollgruppen zusammengefaßt. Die Befunde bestätigen die theoretisch postulierten Beeinträchtigungen des Selbstkonzepts der Eßgestörten nur gegenüber gesunden Kontrollgruppen eindeutig und sind unabhängig von der Art der Operationalisierung.

Test of Stice's dual pathway model: dietary restraint and negative affect as mediators of bulimic behavior

The present study was designed to test whether dietary restraint and negative affect mediate the relationship between body dissatisfaction and bulimic behavior. Four hundred and twelve female students completed questionnaires which measured body dissatisfaction, restrained eating, negative affect and bulimic behavior. The results indicated that dietary restraint and negative affect partially mediated the relationship between body dissatisfaction and bulimic behaviors. The findings are discussed in light of previous research which suggests that restraint needs to be viewed as a multidimensional construct. Longitudinal studies are now needed to investigate the causal and possible bidirectional nature of the interrelationships in the model tested here.

Combined naloxone and fluoxetine on deprivation-induced binge eating of palatable foods in rats

Opioid antagonism and serotonergic stimulation is associated with macronutrient-specific hypophagia in animals. In the present study we evaluated their systemic effect alone, and in combination, at various doses, on the intake of sweet carbohydrate-rich and sweet fat-rich foods, tastes, and nutrients that are typical of binge-food items. Low-dose (1 mg/kg) naloxone, alone, preferentially suppressed fat-rich intake while low-dose (2.5 mg/kg) fluoxetine, alone, preferentially suppressed carbohydrate-rich intake. Each drug at these doses, combined with various doses of the other (2.5-10 mg/kg fluoxetine; 0.01-1 mg/kg naloxone) additively suppressed both kinds of the sweet foods. Naloxone and fluoxetine have therapeutic potential in treating binge-eating disorders. This animal study suggests what shortcomings and benefits might be expected when combining these two agents.

Biases in the processing of different forms of threat in bulimic and comparison women

This study uses Stroop methodology to investigate cognitive biases in the processing of five different forms of threat in bulimic and comparison women. The processing of different forms of threat was found to be relatively independent, which suggests that the measures do not tap a unitary threat construct. As predicted, the bulimic women showed a greater general attentional bias (interference effect) than the comparison women in color-naming threatening words. In the bulimic women, an attentional bias for specific forms of threat was positively correlated with bulimic psychopathology. A strong association was found between bulimic characteristics and sensitivity to self-directed ego-threats and a less robust association with sensitivity to autonomy threats (threats to personal control). The clinical implications of these findings are discussed in light of recent formulations of bulimia, which suggest that a function of binging and vomiting is to reduce the individual's awareness of threat (e.g., aversive emotional states).