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Effectiveness of Rhythmic Movement Therapy for Disordered Eating Behaviors and Obesity

Authors:
  • St. Petersburg State Institute of Psychology and Social Work

Abstract

The aims of the present study were: a) to examine associations between pre-treatment BMI, body dissatisfaction, perfectionism, alexithymia, and restraint, emotional and external eating behaviour in obese patients; b) to analyze the impact of the pre-treatment measures in psychological variables on the outcome of cognitive-behavioral therapy (CBT) program; c) to test the effectiveness of rhythmic movement therapy (RMT) in the treatment of disordered eating behaviors and obesity with the CBT non-responders. At the first stage of treatment a total of 104 patients (32 males and 72 females, mean age was 37.6 +/- 6.7 years) self-referred or referred by professionals to CBT weight management program were selected at random. At the second stage 58 obese CBT-non-responders were randomly divided among the continuing CBT individual treatment group and RMT group. Control group was included. Results revealed that: a) significant associations existed between pre-treatment BMI, external eating and two dimensions of perfectionism, as well as between emotional and external eating and all dimensions of perfectionism, alexithymia and body image dissatisfaction; b) pre-treatment means of psychological variables significantly impacted the CBT program outcome; c). the efficacy of RMT approach for weight reduction as well as for the improvement of psychological status for CBT-non-responders was confirmed.
The aims of the present study were: a) to examine associations between pre-treatment BMI, body dissatisfaction,
perfectionism, alexithymia, and restraint, emotional and external eating behaviour in obese patients; b) to analyze
the impact of the pre-treatment measures in psychological variables on the outcome of cognitive-behavioral
therapy (CBT) program; c) to test the effectiveness of rhythmic movement therapy (RMT) in the treatment of
disordered eating behaviors and obesity with the CBT non-responders. At the first stage of treatment a total of
104 patients (32 males and 72 females, mean age was 37.6±6.7 years) self-referred or referred by professionals
to CBT weight management program were selected at random. At the second stage 58 obese CBT-non-responders
were randomly divided among the continuing CBT individual treatment group and RMT group. Control group
was included. Results revealed that: a) significant associations existed between pre-treatment BMI, external
eating and two dimensions of perfectionism, as well as between emotional and external eating and all dimensions
of perfectionism, alexithymia and body image dissatisfaction; b) pre-treatment means of psychological variables
significantly impacted the CBT program outcome; c). the efficacy of RMT approach for weight reduction as well
as for the improvement of psychological status for CBT-non-responders was confirmed.
Keywords: disordered eating behaviors, obesity, personality traits, weight reduction program, rhythmic movement
therapy.
El estudio plantea: a) examinar relaciones entre IMC pretratamiento e insatisfacción corporal, perfeccionismo,
alexitimia, y restricciones; así como patrones de conducta alimentaria emocional y externa en pacientes obesos;
b) analizar la influencia de las medidas pretratamiento sobre estas variables psicológicas después de una
terapia cognitivo-conductual (TCC); c) probar la eficacia de la terapia de movimientos rítmicos (TMR) en el
tratamiento de los desórdenes de conducta alimentaria y obesidad con los participantes que no respondían a
la TCC. En la primera fase del tratamiento, participaron 104 pacientes escogidas al azar (32 hombres y 72
mujeres, con una media de edad de 37, 6 ± 6.7 años) autodiagnosticadas o derivadas por profesionales a TCC
en un programa de manejo del peso. En la segunda fase, 58 participantes obsesos que no habían respondido
a TCC, fueron divididos en dos grupos, unos siguieron TCC individual y otros TMR. Los resultados indicaron:
a) relaciones significativas entre el IMC pretratamiento, alimentación externa y dos dimensiones de perfeccionismo,
así como entre la conducta alimentaria externa e interna y todas las dimensiones de perfeccionismo, alexitimia
e insatisfacción con la imagen corporal; b) modificación significativa de las consecuencias de la TCC en función
de las variables psicológicas pretratamiento; c) confirmación de la eficacia de la TMR tanto en la reducción de
peso como en la mejora del estado psicológico de los participantes que no respondían a TCC.
Palabras clave: trastornos de alimentación,obesidad, rasgos de personalidad, programa de reducción de peso,
terapia de movimiento rítmico.
Effectiveness of Rhythmic Movement Therapy
for Disordered Eating Behaviors and Obesity
Irina G. Malkina-Pykh
Russian Academy of Sciences (Russia)
The Spanish Journal of Psychology Copyright 2012 by The Spanish Journal of Psychology
2012, Vol. 15, No. 3, 1371-1387 ISSN 1138-7416
http://dx.doi.org/10.5209/rev_SJOP.2012.v15.n3.39422
Correspondence concerning this article should be addressed to Irina G. Malkina-Pykh. Research Center for Interdisciplinary
Environmental Cooperation, Russian Academy of Sciences (INENCO RAS). St-Petersburg, 191187, nab. Kutuzova, 14 (Russia). E-
mail: malkina@mail.admiral.ru
1371
MALKINA-PYKH
The prevalence of obesity is currently estimated at about
30% of population in developed and low-mortality countries
and is continuing to rise (Fairburn & Brownell, 2003;
Malkina-Pykh, 2007; WHO, 2000). The major dangers of
obesity on a persons functioning and health include among
other things that increased risk of hypertension, type-2
diabetes mellitus, coronary artery disease, stroke, gall-
bladder disease, osteoarthritis, sleep apnea and respiratory
problems, as well as certain types of cancer. From a societal
perspective, obesity is associated with a decreased quality
of life and increased healthcare costs.
Obesity is commonly defined as having excess body
fat resulting from imbalance between calories ingested
versus calories expanded. In recent years, body mass index
(BMI) by Quetelet (calculated by dividing weight-in
kilograms- by height-in meters-squared) has become the
most commonly used method to determine body weight in
adults and is a reasonable reflection of overall body fat.
The international classification developed by the World
Health Organization (WHO, 2000) defines normal weight
as BMI of 18.5 – 24.99 kg/m2; moderate overweight as
BMI of 25.0 – 29.99 kg/m2; class I obesity as BMI 30.0 –
34.99 kg/m2; class II obesity as BMI of 35.0 – 39.99 kg/m2;
class III or extreme (massive/morbid obesity) obesity as
BMI > 40.0 kg/m2.
Obesity involves complex etiological links between
genetic, metabolic and neural frameworks on one hand and
behaviour, food habits, physical activity and socio-cultural
factors on the other. Several studies have previously reported
that eating behaviour is a very strong predictor of adult weight
gain, in contrast to the controversial predictive value of such
dietary composition variables as percentage of energy derived
from fat, carbohydrate, and protein (Malkina-Pykh, 2007).
The term eating behaviour refers to behavioural
responses or sequences associated with eating including
modes of feeding, rhythmic patterns of eating, and time
intervals. In other words, eating behaviour determines why
and how people eat, which foods they eat, and with whom
they eat, as well as the ways people obtain, store, use, and
discard food (Malkina-Pykh, 2007). Although it may be
increasingly difficult to define a “normal” pattern of eating,
the Diagnostic and Statistical Manual of Mental Disorders-
IV (American Psychiatric Association, 1994) recognises
three eating disorder diagnoses: anorexia nervosa (AN),
bulimia nervosa (BN), and eating disorder not otherwise
specified (EDNOS) which currently includes binge eating
disorder (BED) although it may ultimately become a
separate diagnostic category.
The relationship between obesity and eating disorders
has always attracted interest. At the same time, most of the
researches on food behaviours in psychology have focused
on obesity or eating disorders from DSM-IV. However,
beyond three DSM-IV eating disorders, numerous sub-
clinical manifestations of disordered eating patterns exist
including emotional, external and restrained eating
behaviours. These three types of eating behaviours are
considered etiological factors for binge eating, obesity and
other eating pathology (van Strien, Frijters, Bergers, &
Defares, 1986), and can therefore be designated as disturbed
(disordered) eating behaviours. Only in recent years,
researchers have begun to investigate the etiology of
overeating behaviour in people with sub-clinical disordered
eating practices and their correlates to obesity and
psychological traits. Research suggests considerable overlap
between obesity, eating disorders, and disordered eating
behaviours (Neumark-Sztainer et al., 2006).
Scientific literature affirms that psychological constructs
and processes play a role in influencing the increase in
disordered eating. Perfectionism, body dissatisfaction and
alexithymia are frequently quoted as psychological
predisposing factors for eating disorders and disordered
eating behaviours. Perfectionism is a central psychological
feature of people with disordered eating and obesity
(Fairburn & Brownell, 2003), and is considered to be a
main risk factor (de Sousa, 2008; Hewitt, Flett, & Ediger,
1995; Rosenberger, Henderson, & Grilo, 2006; Wardle,
Waller, & Rapoport, 2001).
Despite body image disturbance is not a diagnostic
feature of obesity, however, there has been speculation that
unrealistically thin body shape ideals could be play an
important initiating role (Cash & Pruzinsky, 2002; Matz,
Foster, Faith, & Wadden, 2002; Rosenberger, et al., 2006;
Schwartz & Brownell, 2004; Wardle, 2005). A variety of
longitudinal studies show that body dissatisfaction or weight
concerns predict eating disorders symptoms, if not eating
disorders per se (Shisslak & Crago, 2001). A clinically
observable sign of all eating disorders according to Bruch
(1973) is a disturbed relationship to the own body.
The relationships between alexithymia and eating
behaviours in obesity have been sparsely studied and poorly
understood. There is empirical evidence suggesting a
relationship between alexithymia and obesity (Clerici,
Albonetti, Papa, Penati, & Invernizzi, 1992; Legorreta, Bull,
& Kiely, 1988). Although some studies do not support this
hypothesis, positing that alexithymia is present in obese or
eating-disorder subjects with psychopathological
characteristics (de Zwaan et al., 1995; Laquadra & Clopton,
1994; Morosin & Riva, 1997).
Thus, on the base of the presented literature review we
concluded that although disordered eating behaviours,
perfectionism, alexithymia and body dissatisfaction are
often examined in research on obesity, they are usually
studied apart from one another. Researchers have often
stated that when examining the development of eating
disorders, it is fruitful to take a multi-dimensional approach
in order to identify the role of several contributing factors.
Unfortunately, this framework been used all too rarely in
the general research on eating disorders and obesity.
There are three opposing theoretical models and
treatment approaches in the literature regarding obesity: the
1372
medical and medical surgical, the cognitive-behavioural and
the somatic psychodynamic/ psychoanalytic (Weiss, 2004).
Cognitive-behaviour therapy (CBT), generally based on the
cognitive model postulated by Fairburn (1997), demonstrates
impressive outcomes in controlled research of eating disorder
and obesity treatment (Kuller et al., 2001; Latner et al.,
2000; Rapoport, Clark, & Wardle, 2000). At the same time,
cognitive-behavioural programs, developed as adaptations
of those used for the treatment of bulimia nervosa, are more
successfully applied to patients with eating disorders (Ricca,
et al., 2000), but the results of psychotherapy on body weight
are often unsatisfactory (Foreyt, Goodrick, & Gotto, 1981).
Also, while weight loss efforts are very common among
overweight individuals, only a small percentage reach or
maintain a healthy weight (Stotland, Larocque, & Kronick,
2006; Wadden & Stunkard, 2002). It was shown in several
studies that in general weight loss was not achieved despite
the elimination of disordered eating (Ricca et al., 2000).
Prompted by the large heterogeneity of individual results
in obesity and disordered eating treatment, many studies
have attempted to predict weight outcomes from information
collected from participants before they start the program
(Byrne 2002; De Panfilis et al., 2007; Teixeira, Going,
Sardinha, & Lohman, 2005).
According to the studies concerning the impact of
alexithymia on treatment outcome, alexithymia predicts
poorer outcome in eating disorders (Ogrodniczuk, Piper, &
Joyce, 2005; Speranza, Loas, Wallier, & Corcos, 2007).
Freyberger (1977) deemed alexithymic patients unsuitable
for insight-oriented psychotherapy because of their reduced
or failing self-reflection abilities, their diminished tolerance
of frustrations typical of the psychoanalytically orientated
psychotherapeutic situation and their reduced capacity for
learning new emotional behaviour.
Improvement in body image has also been suggested as
a critical intervention goal in the treatment of obesity
(Cooper & Fairburn, 2001). Bruch (1973) indicated that
prognosis for obese patients were guarded unless their body
image disturbance was corrected. Another clinical observation
supports Bruch’s theoretical position that underscores body
image disturbance as the main reason why weight programs
don’t work in the long run (Weiss, 2004).
Perfectionism is identified as one of core features, or
“maintaining mechanisms” of the most chronic and
treatment-resistant eating disorders (Fairburn, Cooper, &
Shafran, 2003). Trait perfectionism is found to persist into
recovery in individuals with eating disorders (Bardone-
Cone, Sturm, Lawson, Robinson, & Smith, 2010; Vitousek
& Manke, 1994) and obesity (Stotland et al., 2006).
Although it is well established that psychopathology
predicts poor obesity treatment outcomes for adults, the
results of studies on the impact of significant psychological
characteristics on the outcome of obesity treatment are
mixed, probably because they are biased due to their
retrospective nature. Thus, it seems evident, that identifying
variables that help explain why some people are successful
in weight reduction program while so many others are not
is a clear research priority (Brownell, 2000; Fairburn 2008;
Foster, Markis, & Bailer, 2005; Franko & Orosan-Weine,
1998; Stice, 2002).
One possible reason why CBT interventions are not
effective in some cases is that they do not sufficiently target
true causal mechanisms of behaviour change. However, weight
loss is only one of the many parameters of treatment success.
It seems evident that weight control programs need to be
evaluated both in terms of their desired effect on body weight
and their impact on psychological outcome variables. These
secondary outcome measures are just as important as the
primary outcome of weight control, because obese people
seeking treatment often experience concomitant psychological
problems that may be alleviated by effective obesity treatment,
resulting in improved psychological or mental health status.
One more shortcoming of CBT for eating disorders and
obesity is the lack of effective available strategies for non-
responders to the conventional treatment. Many researchers
in the field began to stress the need to test the effectiveness
of alternative techniques of psychotherapy. They argued that
a diversity of effective treatment techniques would provide
more opportunity to match patients to appropriate therapy
and that a wider range of psychological functions would be
tapped by different kinds of therapies. Given the evidence
supporting eating disorder and obesity psychotherapies,
treatment innovations are necessary. New treatments should
focus on the hallmark features of eating disorders, such as
body image distortion, drive for thinness, perfectionism and
some others (Raney,Shapiro, & Bulik, 2009).
The interest in body-oriented approaches for treatment
of eating disorders and obesity has been growing
continuously during the last years. Body-, movement- and
breathing therapies become more and more integrated into
the treatment plans (Laumer et al., 2004).
Another promising direction of research that is gaining
increasing empirical support in obesity and disordered eating
treatment is mindfulness-based interventions (Wilson, 1996).
Mindfulness is a way of paying attention that is taught
through the practice of meditation or other exercises, in
which participants learn to regulate their attention by
focusing nonjudgmentally on stimuli such as thoughts,
emotions, and physical sensations (Kabat-Zinn, 1990).
Although the application of mindfulness and acceptance-
based approaches to disordered eating has been investigated
in only a few studies, early results are encouraging (Baer,
Fischer, & Huss, 2005; Kristeller & Hallett, 1999).
Enhancing body awareness may not be the main
objective for all of these approaches, but it has been
described as a key element or a mechanism of action by
which they may provide health benefits (Mehling et al.,
2011). A lack of body awareness is one of several factors
related to the development of body dissatisfaction and eating
disorders (Daubenmier, 2005).
THERAPY FOR DISORDERED EATING BEHAVIOURS AND OBESITY 1373
However, there is little indication in the obesity literature
that body awareness, movement, and body-oriented
techniques are used in the treatment of obese and disordered
eating adults (Gupta, Gupta, Schork, & Watteel, 1995). It
seems that incorporating movement into the therapeutic
work is a natural progression in treatment of obese and
disordered eating individuals. In the present study we
propose the approach of rhythmic movement therapy (RMT)
that explores integration of mind and body through the use
of movement. Also, RMT is innovative and successful way
to apply group techniques to obese disordered eating people.
RMT is a model of psychological intervention that is
philosophically and theoretically rooted in Body-oriented
psychotherapy (Lowen, 1975; Reich, 1949; etc.), Dance-
movement psychotherapy (Chodorow, 1991; Roth, 1997;
Stark, 1987; etc.) and rhythmic gymnastics (aerobics)
(Malkina-Pykh, 2001, 2007).
The detailed description of RMT phases and methods
is out of the scope of the present work (Malkina-Pykh,
2001 for such descriptions). However, we will very briefly
describe them. The therapeutic work in RMT can be
summarized in two main principles: (1) using the diagnostic
system of core personal problems corresponding with
various characters and body types; and (2) using rhythmic
movement as a medium of change.
We have placed together those core problems and
schemas that are most related to each central capacity –
dependency needs, aggression (either overcontrol or
undecontrol) and sexual identity, following Freud’s original
psychoanalytic description of oral, anal, and genital (phallic)
character. Also, RMT diagnostic system includes Ernst
Kretschmer ’s typology and somatotypes proposed by W.
Sheldon that allows associating preliminary the core personal
problems with specific body types (Malkina-Pykh, 2001).
RMT is founded on the principle that a vital connection
exists between personality and the way in which one
moves, and that changes in movement behaviour affect the
emotional, intellectual, and physical health of the individual.
By working with movement patterns, and by focusing on
the interrelationship between psychological and
physiological processes, individuals are helped to reveal,
release, and transform internalized feelings, conflicts, and
desires. Schilder underscores the importance of motility
in his study of body image: “We would not know much
about our bodies unless we moved them. Sensations
stemming from multiple perceptual and muscular feedback
are integrated into a dynamically developing body image,
thus motility plays an essential role, not only in defining
the boundaries of the self, but in differentiating one’s self
from the total perceptual environment“ (Schilder, 1935).
Through special rhythmic movements, the patient in RMT
gains a deeper awareness of and contact with his body.
Through the awareness and acceptance of his body and its
feelings, the individual broadens his contact with all other
aspects of reality.
One of the main reasons for RMT application in obesity
and disordered eating treatment is the high level of
alexithymia in these patients. Alexithymia has often been
deemed immutable and alexithymic people poor candidates
for insight-oriented psychotherapies. In the framework of
our approach body image become the basic mediators in
treatment process with alexithymic patients (Cash &
Pruzinsky, 2002).
The aims of the present study were: a) to examine
associations between pre-treatment BMI, body
dissatisfaction, perfectionism, alexithymia, and restraint,
emotional and external eating behaviour in obese patients,
b) to analyze the impact of the pre-treatment measures in
several psychological variables on the outcome of CBT
weight management program, c) to test the effectiveness
of RMT in the treatment of disordered eating behaviours
and obesity with those subjects for whom the CBT was
ineffective.
Method
Participants
A total of 104 patients who were self-referred or
referred by professionals to weight management program
between September 2006 and September 2010 were
selected at random. All participants were approved by their
general practitioner (primary physician) as being suitable
to take part in a weight-loss program. Demographic items
included age and gender, which were assessed with single
questions. The sample consisted of 32 (31%) males and
72 (69%) females, and mean age in this sample was 37.6
years (SD =6.7).
Participants were weighed and measured, and BMI was
calculated using Quetlet’s index. The sample included 32
(31%) overweight subjects with BMI = 27.8 ± 1.3; 30
(29%) subjects with class I obesity, BMI = 32.7 ± 1.5; 22
(21%) subjects with class II obesity, BMI = 37.6 ± 1.5, and
20 (19%) subject with class III obesity, BMI = 44.5 ± 2.7.
Measures
Patients were assessed with five measures listed below.
Eating behaviours was investigated using the Dutch
Eating Behaviour Questionnaire (33 items) (van Strien et
al., 1986). These self-report contains three scales: “restraint
eating,” “external eating,” and “emotional eating.”
Restraint scale measures intentions to restrict food intake
and actual control of food intake. Emotional eating
corresponds to the tendency toward overeating in response
to negative emotions. External eating corresponds to the
tendency toward overeating in response to food-related
stimuli. A Russian-validated translation was used (Malkina-
Pykh, 2007).
MALKINA-PYKH
1374
THERAPY FOR DISORDERED EATING BEHAVIOURS AND OBESITY
Alexithymia was investigated using the Toronto
Alexithymia Scale-26 (TAS-26) (Taylor, Ryan, & Bagby,
1985). The TAS-26 is a 26-item self-report measure of
alexithymia with a three-factor structure theoretically
congruent with the alexithymia construct. Factor 1: difficulty
in identifying feelings and distinguishing between feelings
and somatic sensations of emotional arousal; Factor 2:
difficulty in describing feelings to others; and Factor 3:
externally-oriented thinking. A cutoff score of 62 was used
to define alexithymia as recommended. A Russian-validated
translation was used (Malkina-Pykh, 2007).
Body image dissatisfaction was investigated using Body
Image Test (Jade, 2002). Participants were asked to answer
how often they felt uncomfortable about their appearance
in different situations. The test includes 20 items, which
are answered based on a 4-point Likert scale. The scale
ranges from 0 of “never” to 3 of “always”. Higher scores
show greater body image dissatisfaction. A Russian-validated
translation was used (Malkina-Pykh, 2007).
Personal Perfectionism Scale (PPS) includes three
subscales from the “Multidimensional Perfectionism Scale”
by (Frost, Marten, Lahart, & Rosenblate., 1990). “Personal
Standards” subscale consists of 7 items relate to setting
high standards and goals for achievement, “Concern over
Mistakes” subscale includes items relating to reacting
negatively to making mistakes and perceiving mistakes as
failures and “Doubts about Action” subscale has items that
measure doubting one’s performance, and not feeling that
things are “quite well”. “Concern over Mistakes” and
“Doubts about Actions” subscales were combined into one
and included 13 items. Thus, PPS includes 20 items, which
are answered based on a 7-point Likert scale. The scale
ranges from 1 of ‘disagree’ to 7 of ‘agree’. Higher scores
show greater chance of perfectionism.
Social Perfectionism Scale (SPS) includes two scales
from “Multidimensional Perfectionism Scale” by (Hewitt,
Flett, & Ediger, 1995): “Other-oriented Perfectionism” -
the individual’s unrealistic standards for others and “Socially
Prescribed Perfectionism” - the individual’s beliefs that
others expect them to achieve unrealistically high standards,
judge them based on the high standards, and require them
to be perfect. The SPS includes 30 items, which are
answered based on a 7-point Likert scale. The scale ranges
from 1 of ‘disagree’ to 7 of ‘agree’. Higher scores show
greater chance of perfectionism. Each of two dimensions
consists of 15 items.
The reliability and validity of the Russian versions of the
Personal Perfectionism Scale (PPS) and Social Perfectionism
Scale (SPS) have been supported by our empirical studies.
The internal consistency of the PPS and SPS in the obese
group and the general population group was determined by
means of the Cronbach’s alpha coefficient. Internal
consistency reliability of the PPS has been demonstrated,
with alphas of 0.88 for the “Personal Standards” subscale,
and 0.85 for the “Concern over mistakes, doubts about
actions” subscale. Internal consistency reliability of the SPS
has been demonstrated, with alphas of 0.86 for the “Other-
oriented perfectionism” subscale, and 0.79 for the “Socially
prescribed perfectionism” subscale. The coefficient alphas
for the overall scales were 0.99 for PPS and 0.94 for SPS.
These coefficient alphas indicate that both scales have very
good internal consistency in both populations.
Procedure
The study was conducted in the framework of weight
management program organized in the “Human Ecology”
department of the Research Center for Interdisciplinary
Environmental Cooperation of Russian Academy of Sciences
and clinic “MEDI”, St-Petersburg, Russia. All the
psychologists are trained in cognitive behaviour theory and
rhythmic movement therapy for eating disorders and obesity
during a one-year course.
In accordance with the aims of the study it was
organised in three phases: pretest assessment phase, Stage
I of CBT treatment and Stage II of RMT treatment. The
essence of the stages is described below. The nature of the
study was explained to prospective participants in an initial
meeting, and written informed consent was obtained.
In the pretest phase participants were given
approximately one hour to complete the scales described
above. In all cases, participants were reminded that the
questionnaires were confidential.
Stage I. At the first stage cognitive-behavioural therapy
(CBT) was proposed to all patients of the weight
management program. The structure of the protocol for
CBT generally followed the manuals described by (Fairburn,
2008; Foster, Markis, & Bailer, 2005), supplemented by
our own adaptation of cognitive-behavioural therapy
principles for obesity. Russian-validated CBT program was
used (Malkina-Pykh, 2007).
The subjects were proposed to attend 24 individual
treatment sessions, each 45-50 minutes in duration, delivered
over 24 weeks. CBT treatment was delivered in an
individual format, on an outpatient basis.
Over the past few years, it has become clear that
moderate weight loss is associated with significant health
benefits. This has prompted a move toward redefining what
constitutes success in the treatment of obesity (Foster,
Wadden, Vogt, & Brewer, 1997; Jeffery, Wing, & Mayer,
1998). We suggested that losing 4 – 5 kg per month is
reasonable for adults.
Weight loss during the 24 weeks of CBT treatment in
kg/month and BMI were expressed as a change scores.
After 24 weeks of CBT treatment program two groups of
patients were formed. Group 1 consisted of 46 persons (20
males, 26 females) who reduced weight significantly (> 1,5
kg/month) and Group 2 included 58 persons (12 males, 46
females) who reduced weight nonsignificantly (< 1,5
kg/month), or even not at all.
1375
Stage II. The second stage of our treatment experiment
investigated effectiveness of rhythmic movement therapy
for those patients, who didn’t show any improvement in
their weight status after 6 months of previous CBT
treatment. This stage of the study used a multi-group design
with repeated pretest-posttest measurements, with one
control group. Two experimental groups (CBT and RMT)
were compared with each other and with the control group,
including pre- and post-intervention measurements.
At the beginning of this stage the CBT non-responded
patients were repeatedly assessed with the same measures
as in the pretest phase of the study.
At this stage 58 CBT-nonresponders were randomly
divided among two groups: the continuing CBT individual
treatment group and rhythmic movement therapy (RMT)
group. RMT group (group A) consisted of 30 patients, 6 (20%)
males, 24 (80%) females, with mean age 39.9 ± 7.45 years.
CBT group (group B) consisted of 28 patients, 6 (26.5%)
males, 22 (73.5%) females, with mean age 36.6 ± 6.58 years.
The design of the present stage of the study included a
control group of obese or overweight subjects, who entered
the weight reduction program, were assessed with the
measures listed above during the first consultation, dropped
out of the program immediately because of various reasons,
but agreed to be assessed repeatedly after 12 weeks of the
first assessment. This group included 18 subjects, 14 females
(78%), 4 males (22%), with mean age 37.6 ± 7.39 years.
Following the proposed diagnosis system the main
objects of work in RMT sessions are core problems of
grounding, boundaries, communication, aggression,
overcontrol, self-image, blockage release and integration
(Malkina-Pykh, 2001; 2007).
Each RMT session consists of three types of exercises:
diagnostic, resource and test. The main object of diagnostic
exercises in the context of theory of rhythmic movement
therapy is the discovering patterns of blocked self-expression
and their corresponding connection to personality type,
allows the emergence of a potential framework for the course
of therapy. By utilizing the rhythmic movement resource
exercises,patients increase their understanding and expression
of feelings, recognize options, develop coping skills, increase
focus and concentration, recognize strengths, and accept
limitations. Test exercises are intended to analyse whether
the increase in a person’s contact with his body is producing
a significant improvement in his self image (body image),
in his interpersonal relationships, in the quality of his
thinking and feeling, and in his enjoyment of life or not.
The duration of each RMT session is 45 - 50 minutes
and it starts with the introduction into the theory of the
problem under consideration given by the psychologist.
Each session is devoted to one selected core problem. Each
RMT session is completing with the closing phase, which
lasts about 10-15 minutes. This phase is devoted to
reflection and discussion about whatever events had
occurred in the session. There are comments regarding the
interactions involved, the conflicts appearing during the
activities and ways to resolve them, the degree of pleasure
induced by the exercises, etc.
Moreover, dietary management was well controlled in
the present study. The nutritional counseling was identical
for the control group and the two psychological treatment
groups.
All patients of groups A and B completed their treatment
programs in accord with preplanned schedules of biweekly
24 sessions. After this stage was completed, patient of
groups A, B and control were repeatedly assessed with the
same measures as at the beginning of the Stage II of the
experiment.
Statistical analysis
Prior to completing analyses all obtained data were
checked for normality (Kolmogorov-Smirnov test),
homogeneity of variances (Levene’s test), sphericity
(Mauchly’s test of sphericity) and equality of the covariance
matrixes across groups (Box’s M-test). After that three sets
of statistical analysis were carried out. Bivariate, two-tailed
correlations were used to investigate the strength of the
associations between variables in the baseline assessment.
A one-way ANOVA and MANOVA were used for between-
group comparisons. Repeated measures ANOVA were used
to compare the pre- and post-treatment means in all groups.
To better control the regression towards the mean of the
data and to eliminate the effects of the pretest scores on
the posttest score, we carried out a pretest-posttest
ANCOVA, using the pretest scores as covariates.
Additionally, effect size of the therapeutic change was
computed to present the RMT effectiveness.
Results
The first set of analysis used data from the baseline
(pretreatment) assessment, examined cross-sectional
associations among baseline BMI, body satisfaction, all
dimensions of perfectionism, alexithymia, restraint,
emotional and external eating behaviours and demonstrated
the following results (Table 1).
Age was significantly positively associated with
alexithymia (r= .43, p< .01) and negatively (r= − .23, p
< 0.05) with baseline BMI. Baseline BMI was associated
with external eating (r= .28, p< .01) and two dimensions
of perfectionism: personal standards (r= .22, p< .05) and
concern over mistakes, doubts about actions (r= .29, p<
.01). BMI showed no significant correlation with any other
variables.
Additionally, alexithymia was positively and significantly
related with emotional (r= .37, p< .01) and external eating
(r= .32, p< .01) as well as with all dimensions of
perfectionism and body dissatisfaction.
MALKINA-PYKH
1376
THERAPY FOR DISORDERED EATING BEHAVIOURS AND OBESITY
For body dissatisfaction, we observed a significant
positive association (p< .01) with emotional and external
eating and all dimensions of perfectionism.
All dimensions of perfectionism are positively and
significantly associated with all types of eating disorders
under study, except for personal standards that is not
associated with the restrained eating.
A one-way ANOVA showed that women had higher
scores on emotional eating than man, F(1, 102 ) = 33.989,
p< .001, as well as on the two dimensions of perfectionism
(«Personal standards», F(1, 102) = 4.089, p= .046, and
«Concern over mistakes, doubts about action», F(1, 102)
= 8.478, p = .004), body dissatisfaction, F(1, 102) = 33.806,
p = .0001,and alexithymia F(1, 102) = 10.156, p = .002.
Stage I. The main objective of the next phase of our
study was to analyse the impact of the pre-treatment
meanings of subjects’ psychological variables on the
outcome of CBT weight management program.
One-way ANOVA was used to examine the
differences on all pre-CBT assessment measures in group
1 of successful completers ( > 1,5 kg/month) and group
2 of those subjects who didn’t reduce weight or reduced
no significantly ( < 1,5 kg/month). No significant
differences between groups were obtained on pre-
treatment BMI and age, but the means of all other pre-
treatment measures were significantly different. Means
and standard deviations of the pre-CDT assessment
measures are shown in Table 2. Although only three
psychological variables were correlated with pre-
treatment BMI, all studied variables have been found to
be important predictors of weight loss after 6 months of
CBT treatment program.
1377
Table 1
Correlation coefficients (Spearman) between study variables
Variables .1.2.3.4.5.6.7.8.9.10 .11
1. Age (years) .
2. Restrained eating −.05 .
3. Emotional eating −.15 .02 .
4. External eating .00 .01 .53** .
5. Personal standards .10 .12 .39** .27** .
6. Concern over mistakes, doubts about action −.14 .25* .56** .40** .48** .
7. Other-oriented perfectionism .15 .22* .45** .39** .49** .49** .
8. Socially prescribed perfectionism .12 .32** .25** .35** .32** .37** .50** .
9. Body dissatisfaction −.15 .14 .63** .52** .41** .45** .38** .43** .
10. Alexithymia .43** .15 .37** .32** .37** .31** .43** .46** .57** .
11. Baseline BMI −.23* −.04 .13 .28** .11 .22* .29** .10 .05 −.08 .16
*p< .05, ** p< .01
Table 2
CBT pretreatment scores in groups 1 and 2
Performance Group 1 n= 46 Group 2 n= 58
Psychological variables M(SD)M(SD)
F(1, 102) p
Age (years) 36.8(6.1) 38.3(7.2) 1.194 .227
Restrained eating 2.8(.8) 3.1(.6) 6.128 .015
Emotional eating 2.5(.9) 3.6(.8) 38.069 < .001
External eating 3.0(.7) 3.8(.7) 39.486 < .001
Personal standards 16.9(3.0) 22.9(6.8) 31.011 < .001
Concern over mistakes, doubts about action 27.7(6.7) 35.2(9.5) 2.351 < .001
Other-oriented perfectionism 49.6(8.3) 62.0(13.8) 28.796 < .001
Socially prescribed perfectionism 52.3(7.0) 58.6(11.1) 11.177 < .001
Body dissatisfaction 18.4(8.2) 28.7(9.4) 34.328 < .001
Alexithymia 60.2(8.0) 69.4(8.5) 31.953 < .001
Weight loss (kg/month) 3.1(1.1) .5(.6) 234.38 < .001
Baseline BMI 34.4(6.6) 34.6(6.1) .022 .881
BMI after 6 month of CBT treatment 28.6(5.3) 33.3(6.2) 17.132 < .001
Pre-treatment measures of restraint, emotional and
external eating behaviours in subjects of group 1 were
similar to those in healthy, nonobese people and differ
significantly from the means in subjects of group 2. Similar
findings were obtained for all other CBT pre-treatment
measures of psychological variables. A look at table 2
reveals that there were significant differences in scores in
subjects successful in weight reduction and in nonsuccessful.
Although body dissatisfaction was not correlated with pre-
treatment BMI, it was significantly associated with less weight
reduction in treatment, when described as either the percentage
of initial weight or BMI reduction, as shown in Table 2.
Thus, the obtained results seem to be clear evidence,
that in our sample the success of CBT weight reduction
program was significantly associated with the pre-treatment
psychological wellness of the participants.
Stage II. Comparison at baseline. At the beginning of
the Stage II of the study we analyzed the equivalence of
two experimental (CBT and RMT) and control groups
regarding all variables under study. The results of the
MANOVA carried out on the set of variables revealed that
in the pretest phase of Stage II of intervention, there were
no statistically significant group differences, Wilks’ Lambda
= .734, F(10, 64) = 1.07, p= .39, η² = .14. The ANOVAs
didn’t yield significant differences in the variables.
Therefore, at the start of this stage of investigation, the
three groups were relatively homogeneous in the criterion
variables to be treated (Tables 4, 5, 6).
MALKINA-PYKH
1378
Table 3
Changes in psychological variables at pre- and post-test for groups A, B and control
Performance Group А (RMT) n= 30 Group B (CBT) n= 28 Control group n= 18
Pre- Post- Pre- Post- Pre- Post-
treatment treatment treatment treatment treatment treatment
Psychological variables MM MM MM
(SD) (SD) (SD) (SD) (SD) (SD)
Restrained eating 3.03 2.79 17.25*** 3.14 3.14 2.08 3.18 3.16 .65
(.53) (.42) * (.62) (.60) .07 (.50) (.50) .04
Emotional eating 3.69 2.98 45.38*** 3.42 3.39 2.40 3.36 3.35 .03
(.79) (.63) .61 (.83) (.79) .08 (.61) (.54) .00
External eating 3.82 3.04 30.76** 3.78 3.77 .39 3.47 3.41 3.54
(.70) (.34) .52 (.62) (.61) .01 (.69) (.62) .17
Personal standards 22.5 20.5 12.82** 23.3 23.4 .18 24.2 24.1 .32
(6.99) (6.08) .31 (6.64) (6.62) .0 (5.62) (5.44) .02
Concern over mistakes, doubts 33.5 28.5 15.81*** 37.0 36.9 .66 35.9 35.7 1.09
about action (8.97) (7.20) .35 (9.86) (9.96) .02 (10.7) (10.2) .06
Other-oriented perfectionism 60.0 49.5 22.78*** 64.0 64.0 .00 61.2 60.8 2.29
(14.9) (8.65) .44 (12.4) (11.6) .00 (12.8) (12.4) .12
Socially prescribed 57.5 53.2 11.76** 59.9 59.7 1.41 59.7 59.9 1.66
perfectionism (12.1) (10.2) .29 (9.93) (9.76) .05 (7.29) (7.24) .09
Body dissatisfaction 28.5 21.6 42.05*** 29.0 28.1 2.96 27.2 27.0 .59
(7.71) (6.42) .59 (11.1) (10.5) .10 (9.32) (8.96) .03
Alexithymia 68.9 62.7 28.91*** 69.9 69.6 1.83 68.4 68.2 .81
(10.3) (7.08) .50 (6.09) (6.09) .06 (7.98) (7.63) .05
BMI 33.2 29.6 208.3*** 33.4 33.4 2.08 36.4 36.4 .06
(6.82) (5.92) .88 (5.39) (5.39) .07 (4.57) (4.46) .00
*p< .05, ** p< .01, *** p< .001
ANOVA
F(1, 17)
Eta (η²)
ANOVA
F(1, 27)
Eta (η²)
ANOVA
F(1, 29)
Eta (η²)
THERAPY FOR DISORDERED EATING BEHAVIOURS AND OBESITY
Comparisons at outcome. Assessment of the treatment
effects of rhythmic-movement therapy demonstrated the
following results. The within-group comparison revealed that
only in the Group A (RMT) the improvement was significant,
but not in the Group B (CBT) or Control Group (Table 3).
Repeated measures ANOVA were used to compare the pre-
and post-treatment means in all three groups. Another way
to present the effectiveness of psychotherapy is a computation
of effect size of the therapeutic change or proportion of
explained variance for each variable, according to the criterion
proposed by Cohen (1988), who defined effect size as small
(η² = .2), medium (η² = .5), and large (η² = .8).
After the rhythmic movement therapy program in Group
A improvement was indicated in all outcome measures,
including BMI, as displayed in Table 3. Also, the
improvements were statistically significant for alexithymia,
body dissatisfaction, all dimensions of perfectionism and three
types of disordered eating. Effect size in this group is varying
between medium ² = .29, p< .01 in “Socially prescribed
perfectionism”) and large (η² = .88, p< .001 in BMI).
Comparing the means of all outcome measures before
and after CBT treatment in Group B yielded no significant
results, including weight reduction. The effect size values
in CBT group ranged between lowest (η² = .00, p> .05 in
“Other-oriented perfectionism”) and low (η² = .10, p> .05
in body dissatisfaction).
The comparison of the pre-posttest scores of the studied
variables in Control group demonstrated similar results.
1379
Table 4
Means, standard deviations, A OVAs of the CBT and RMT groups, and pretest and posttest A COVAs
Pre-treatment Post-treatment
Performance Group А (RMT) Group B (CBT) Group А (RMT) Group B (CBT)
n = 30 n = 28 n = 30 n = 28
Psychological variables MM MM
(SD) (SD) (SD) (SD)
Restrained eating 3.03 3.14 .52 2.79 3.14 6.07* 21.48***
(.53) (.62) .01 (.42) (.60) .01 .28
Emotional eating 3.69 3.42 1.62 2.98 3.39 4.81* 37.95***
(.79) (.83) .03 (.63) (.79) .03 .41
External eating 3.82 3.78 .06 3.04 3.77 32.36*** 48.88***
(.70) (.62) .00 (.34) (.61) .37 .47
Personal standards 22.5 23.3 .18 20.5 23.4 3.00 14.70***
(6.99) (6.64) .00 (6.08) (6.62) .05 .21
Concern over mistakes, 33.5 37.0 1.97 28.5 36.9 13.67*** 21.68***
doubts about action (8.97) (9.86) .03 (7.20) (9.96) .20 .28
Other-oriented perfectionism 60.0 64.0 1.23 49.5 64.0 29.27*** 49.91***
(14.9) (12.4) .02 (8.65) (11.6) .34 .48
Socially prescribed 57.5 59.9 .75 53.2 59.7 6.13* 14.57***
perfectionism (12.1) (9.93) .01 (10.2) (9.76) .10 .21
Body dissatisfaction 28.5 29.0 .05 21.6 28.1 8.37** 31.51***
(7.71) (11.1) (6.42) (10.5) .13 .36
Alexithymia 68.9 69.9 .20 62.7 69.6 15.76*** 43.84***
(10.3) (6.09) (7.08) (6.09) .22 .44
BMI 33.2 33.4 .01 29.6 33.4 6.52* 278.8***
(6.82) (5.39) (5.92) (5.39) .10 .84
*p< .05, ** p< .01, *** p< .001
ANOVA
F
Eta (η²)
ANOVA
F
Eta (η²)
ANCOVA
Pre-Posttest
F
Eta (η²)
The effect size values in Control group ranged between
lowest (η² = .001, p> .05 in BMI) and low (η² = .17, p>
.05 in external eating).
In between group comparison, the MANOVA carried
out on the posttest scores revealed statistically significant
group differences in all the variables, Wilks’ Lambda =
.436, F(10, 64) = 3.29,p< .001, η² = .34.
To better control the regression towards the mean of the
data and to eliminate the effects of the pretest scores on the
posttest score, we carried out a pretest-posttestANCOVA, using
the pretest scores as covariates, obtaining significant differences
in the studied variables in group A (RMT) and Group B (CBT),
The ANCOVAs confirmed these significant differences, reaching
effect sizes that ranged between low (η². = .21, p< .001 in
personal standards) and high (η² = .84, p< .001 in BMI). The
results of between groups comparison is displayed in table 4.
The comparison of the posttest scores of the studied
variables in Group A (RMT) and Control group
demonstrated similar results (Table 5). The ANCOVAs
confirmed these significant differences, reaching effect sizes
that ranged between low (η² = .21, p< .01 in personal
standards) and medium (η². = .59, p< .001 in BMI).
The comparison of the posttest scores of the studied
variables in Group B (CBT) and Control group demonstrated
no differences, except for external eating behaviour (Table
6). The ANCOVAs confirmed these results, reaching very
low effect sizes ranged between η² = .00, p> .05 in
alexithymia and η² = .14, p< .01 in external eating behaviour.
MALKINA-PYKH
1380
Table 5
Means, standard deviations, A OVAs of the RMT and control groups, and pretest and posttest A COVAs
Pre-treatment Post-treatment
Performance Group А (RMT) Control group Group А (RMT) Control group
n = 30 n = 18 n = 30 n = 18
Psychological variables MM MM
(SD) (SD) (SD) (SD)
Restrained eating 3.03 3.18 .96 2.79 3.16 7.28** 13.58**
(.53) (.50) .02 (.42) (.50) .14 .23
Emotional eating 3.69 3.36 2.41 2.98 3.35 4.27* 24.29***
(.79) (.61) .05 (.63) (.54) .04 .35
External eating 3.82 3.47 2.85 3.04 3.41 7.19** 14.79***
(.70) (.69) .06 (.34) (.62) 14 .25
Personal standards 22.5 24.2 .76 20.5 24.1 4.50* 11.22**
(6.99) (5.62) .02 (6.08) (5.44) .10 .20
Concern over mistakes, 33.5 35.9 .70 28.5 35.7 8.09** 13.87**
doubts about action (8.97) (10.7) .02 (7.20) (10.2) .15 .24
Other-oriented perfectionism 60.0 61.2 .08 49.5 60.8 13.73** 26.11***
(14.9) (12.8) .00 (8.65) (12.4) .23 .37
Socially prescribed 57.5 59.7 .54 53.2 59.9 5.99* 12.51**
perfectionism (12.1) (7.29) .01 (10.2) (7.24) .12 .22
Body dissatisfaction 28.5 27.2 .27 21.6 27.0 5.90* 26.12***
(7.71) (9.32) .01 (6.42) (8.96) .11 .37
Alexithymia 68.9 68.4 .04 62.7 68.2 6.38* 25.76***
(10.3) (7.98) .00 (7.08) (7.63) .12 .36
BMI 33.2 36.4 2.99 29.6 36.4 17.78*** 64.58***
(6.82) (4.57) .06 (5.92) (4.46) .28 .59
*p< .05, ** p< .01, *** p< .001
ANOVA
F
Eta (η²)
ANOVA
F
Eta (η²)
ANCOVA
Pre-Posttest
F
Eta (η²)
Discussion
The findings of the present study showed that pre-
treatment BMI significantly but weakly associated with
external eating and two dimensions of perfectionism –
“concern over mistakes, doubt about actions” and “other
oriented perfectionism” and, correspondently, the lack of
association of pre-treatment BMI with other psychological
variables under study. Also, the obtained results
demonstrated the significant association of the emotional
and external eating with all dimensions of perfectionism,
alexithymia level and body image dissatisfaction. The
comparative analysis of the baseline measures of all
psychological variables of the CBT-responders and non-
responders gave the clear evidence of the significant
association between personal traits of the subjects and CBT
treatment success. The results of RMT treatment in the
group of CBT-non-responders supported the assumption
that it would be necessary to address psychological variables
as a part of obesity treatment program for those patients,
who demonstrated not only disordered eating, but also high
levels of alexithymia, perfectionism and body image
dissatisfaction. Comparison of the values of effect size in
CBT and RMT groups confirmed the efficacy of RMT
approach for weight reduction as well as for improvement
of psychological status of the subjects.
THERAPY FOR DISORDERED EATING BEHAVIOURS AND OBESITY 1381
Table 6
Means, standard deviations, A OVAs of the CBT and control groups, and pretest and posttest A COVAs
Pre-treatment Post-treatment
Performance Group B(CBT) Control group Group B(CBT) Control group
n = 28 n = 18 n = 28 n = 18
Psychological variables MM MM
(SD) (SD) (SD) (SD)
Restrained eating 3.14 3.18 .06 3.14 3.16 .14 .91
(.62) (.50) .00 (.60) (.50) .001 .02
Emotional eating 3.42 3.36 .08 3.39 3.35 .04 .38
(.83) (.61) .00 (.79) (.54) .00 .01
External eating 3.78 3.47 2.44 3.77 3.41 3.79 7.21**
(.62) (.69) .05 (.61) (.62) .08 .14
Personal standards 23.3 24.2 .25 23.4 24.1 .19 .23
(6.64) (5.62) .01 (6.62) (5.44) .00 .01
Concern over mistakes, 37.0 35.9 .12 36.9 35.7 .17 .95
doubts about action (9.86) (10.7) .00 (9.96) (10.2) .00 .02
Other-oriented perfectionism 64.0 61.2 .53 64.0 60.8 .80 3.12
(12.4) (12.8) .01 (11.6) (12.4) .02 .07
Socially prescribed 59.9 59.7 0.01 59.7 59.9 .01 2.71
perfectionism (9.93) (7.29) .00 (9.76) (7.24) .00 .06
Bodydissatisfaction 29.0 27.2 .34 28.1 27.0 .15 .82
(11.1) (9.32) .01 (10.5) (8.96) .00 .02
Alexithymia 69.9 68.4 .55 69.6 68.2 .49 .05
(6.09) (7.98) .01 (6.09) (7.63) .01 .00
BMI 33.4 36.4 3.77 33.4 36.4 3.92 .41
(5.39) (4.57) .08 (5.39) (4.46) .08 .0
*p< .05, ** p< .01, *** p< .001
ANOVA
F
Eta (η²)
ANOVA
F
Eta (η²)
ANCOVA
Pre-Posttest
F
Eta (η²)
Our finding of the lack of association between pre-
treatment BMI and body dissatisfaction is consistent with
the results of (de Sousa, 2008; Matz et al., 2002;
Rosenberger, Henderson, & Grilo, 2006; Sarwer &
Thompson, 2002; Teixeira et al., 2005;), but is in
contradiction with other results (Hudson, 2008; Schwartz
& Brownell, 2003; Wadden & Stunkard, 2002) in which
the increasing of body dissatisfaction following the
increasing of BMI was demonstrated.
Our findings are generally consistent with previous
studies investigating the association of disordered eating
with the dimensions of perfectionism, and extending them
significantly. The results of the study (Stotland & Laroque,
2004) demonstrated significant positive correlations between
the main dimensions of perfectionism, external and
emotional eating. The dissertation paper (Sherry, 2006)
proposed and evaluated a model relating dietary restraints
and binge eating to self-oriented and socially prescribed
dimensions of perfectionism. The results of the study (Byrne
et al., 2004) identified such prospective predictors of weight
regain as dichotomous thinking.
We suggest that perfectionism can function in two broad
ways in disordered eating behaviours. First, perfectionism
can influence both the frequency and impact of distressing
environmental events (Hewitt, Flett, & Ediger, 1995). Hewitt
et al. (1995) reported that both self-oriented and socially
prescribed perfectionism are correlated with disordered
eating patterns, which is concordant with the fact that such
individuals suffer from extreme sensitivity to the perceived
demands of others along with the demands they place on
themselves.
The results of our study on the association between
alexithymia and body image in patients with disordered
eating behaviours are consistent with many other results
(de Berardis et al., 2007; Carano et al., 2006). It was shown
(De Panfilis et al., 2003), that body image disturbance in
disordered eaters may be conceptualized as a deficit in self-
development, resulting from failures in parent-child
interactions which impaired the ability to distinguish bodily
needs from emotional experiences.
Our finding on the significant association between body
dissatisfaction and all dimensions of perfectionism expands
the results of the other studies (Hewitt, Flett, & Ediger,
1995), and demonstrates that in our sample of the
overweight and obese people body dissatisfaction correlates
with neurotic (or maladaptive), as well as with normal (or
adaptive) perfectionism. It means that the interpretation of
such dimension of perfectionism as “Personal Standards”
as healthy is limited. Similar results were obtained in the
study by (Davis, 1997) who showed that normal
perfectionism was positively associated with body esteem,
but only when levels of neurotic perfectionism were low.
Conversely, body-image disparagement was most
pronounced when normal and neurotic perfectionisms were
both elevated.
The finding of our study of significant association
between personal traits of the subjects and CBT treatment
success is consistent with the many other results. This
finding is counter to those of prior work on perfectionism
and eating disorder recovery, and shed light on important
issues related to defining recovery and the role of
perfectionism in eating disorders (Bardone-Cone et al.,
2007). Individuals fully recovered from an eating disorder
had perfectionism levels comparable to healthy controls
and generally significantly lower than partially recovered
(physical and behavioural, but not psychological, recovery)
and active eating disorder cases, which were groups with
comparable perfectionism levels. This occurred across all
conceptualizations of perfectionism – that is, trait
perfectionism, perfectionism related to self-presentation,
and frequency of perfectionism-related thoughts (Bardone-
Cone et al., 2010). From this perspective, interventions
and/or experiences that help decrease perfectionism may
be a key to making full recovery attainable.
Our finding is also supported with the results of (Stotland
et al., 2006) that demonstrate high significant correlations
between weight control motivation scales and perfectionism
in subjects participating in weight reduction program.
Our results on association between alexithymia and
CBT outcome are consistent with several other findings.
Alexithymia can cause negative influences on the clinical
expression of the disordered eating and on the response to
therapeutic interventions (Speranza et al., 2007). It was
found that patients with the greatest difficulty in identifying
emotions at baseline are more often symptomatic at follow-
up and show a less favorable clinical improvement. Results
of the study (Ogrodniczuk et al., 2005) demonstrated that
patients with high levels of alexithymia adversely affect
treatment outcome. The results from the study (De Panfilis
et al., 2007) showed that in obese patients poor outcome
of treatment was predicted by alexithymia.
Though, the body images disturbances are not being
frequently investigated in treatment of obesity, several results
support the finding of our study. The theory is that body
dissatisfaction motivates attempts at weight control which
are ultimately counterproductive because they disturb the
appetite control system and increase the reward value of
food. Essentially, this is the “restraints as cause” model
(body dissatisfaction → restraint → overeating → weight
gain) (Wardle, 2005). This model supports the assumption
that body dissatisfaction is the initial element in the process
leading to obesity. The literature claimed that cognitive-
behavioural therapy was the only treatment modality that
has any effect on body image and is empirically tested, but
several studies (Weiss, 2004) as well as our results
demonstrated that perception of one’s body image could
not change from merely talk therapy.
In conclusion, the comparative analysis of the baseline
measures of all psychological variables of responders and
non-responders to CBT treatment allows to propose a
MALKINA-PYKH
1382
hypothesis that CBT treatment for disordered eating and
obesity is effective for patients whose obesity is a result
more likely of psychosocial, but not personal factors, such
as family dysfunctions, for example, parent family eating
style and some others.
The primary purpose of this study was to explore the
efficacy of RMT intervention as a treatment for disordered
eating behaviours and obesity. The effectiveness of RMT
approach was analysed using pre-post treatment data for
three groups. Substantial changes in eating behaviours and
psychological state were observed among the participants
as a result of RMT intervention. The improvements achieved
in RMT were not restricted to the disordered eating
behaviours and obesity, but were found also in psychological
variables. In particular, the all three types of disordered
eating behaviour (emotional, external and restrained)
improved, and alexithymia, body image disturbance and
all dimensions of perfectionism decreased.
With regard to disordered eating behaviours and obesity,
controlled randomized studies investigating the effectiveness
of mindfulness’ body-oriented psychotherapies are very rare.
Nevertheless, our findings of RMT effectiveness are generally
consistent with the results of several other studies in the field.
The study (Baer, Fischer, & Huss, 2005) examined the
application of mindfulness-based cognitive therapy (MBCT)
to binge eating disorder. MBCT includes such techniques
as the body scan, mindful stretching and walking, sitting
meditation and some others, when awareness is focused
sequentially on several targets, including breathing, bodily
sensations, sounds, thoughts, and emotions. It was shown
that at the end of MBCT treatment the frequency of binge
eating was greatly reduced.
Another study (Daubenmier, 2005) found that yoga
exercise as a mind–body practice is associated with greater
body awareness and responsiveness, which, in turn, are
associated with lower levels of trait self objectification,
greater body satisfaction, and lesser disordered eating
attitudes. Mind– body exercises, or exercises that explicitly
encourage body awareness and responsiveness, promote
healthy eating patterns.
By gaining sensitivity and responsiveness to bodily cues,
including those of hunger and satiety, yoga practitioners
may increasingly regulate food intake more based on bodily
needs and less on emotional, situational, or other factors.
In line with this reasoning, Kristeller and Hallett (1999)
found that participation in meditation-based intervention
reduced the number and severity of binges among obese
women diagnosed with binge eating disorder.
Hutchinson (1985) is referring to an evaluation of a
training program consisting of exercises using imagination
and elements of Feldenkrais lessons to change the negative
body and self image of obese women.
The outcome points to the therapeutical effectiveness
of the Feldenkrais Method with eating-disorder patients
within another multimodal treatment program (Laumer et
al., 2004). The participants of the Feldenkrais-course showed
increasing contentment with regard to problematic zones
of their body and their own health as well as concerning
acceptance and familiarity with their own body. Other results
were a more spontaneous, open and self-confident
behaviour, the decrease of feelings of helplessness and
decrease of the wish to return to the security of the early
childhood , which indicates the development of felt sense
of self, self-confidence and a general process of maturation
of the whole personality.
The present study is the first systematic application of
RMT in the treatment of patients with disordered eating
behaviours and obesity. Considering the lack of experience
in the field, the achievement of RMT patients versus CBT
patients can be regarded as encouraging and calls for further
research.
Conclusion
The results of the present study do seem to inform our
understanding of the association between pre-treatment
psychological health and treatment outcome, suggesting
that management of psychological variables might usefully
be considered as part of the process of maximizing the
efficacy of weight-management programs.
Rhythmic movement therapy (RMT) was found to have
positive outcomes in the treatment of disordered eating and
obesity. This conclusion is based on a randomized, controlled
study comparing RMT with another psychological treatment,
cognitive-behavioural therapy (CBT), and a controlled group.
The improvement achieved in RMT was not restricted
to the disordered eating symptomatology and obesity, but
was found also in as well as in several associated personal
traits (body dissatisfaction, alexithymia and perfectionism).
The inclusion of a measurement of such an intrapsychic
theoretical construct is of special significance. This is
because researchers comparing the effectiveness of various
therapeutic techniques do not usually include measures that
will tap areas theoretically supposed to be improved by
these techniques. These findings may support the assumption
that solving underlying problems can reduce overt
behavioural symptoms, even if the latter are not directly
focused on in the session.
The application of RMT to the treatment of disordered
eating behaviours and obesity can enrich the current
repertoire of therapy techniques in the field, which has thus
far been dominated by CBT technique.
Clinical implications
Psychological variables and disordered eating were
identified as predictors of unfavorable treatment outcome
in obese adults. Identification of reliable predictors of
success in obesity treatment could help future programs in
THERAPY FOR DISORDERED EATING BEHAVIOURS AND OBESITY 1383
several ways. For example, an increased focus could be
placed on those intervention components more likely to
produce desired outcomes while discarding redundant ones.
Although most of the current treatment programs for
obese people contain some training in decreasing body
image dissatisfaction, such an intervention element may be
too unspecific and does not necessarily enhance body
awareness as a key mediator in modifying disordered eating
behaviours. Concluding from our present data we
recommend a specific mindfulness exercises as a core
feature of overweight people’s treatment. By utilizing the
rhythmic movement, patients increase their understanding
and expression of feelings, recognize options, develop
coping skills, increase focus and concentration, increase
self-esteem, recognize strengths, accept limitations, learn
to relax and hence work towards maximum integration. It
helps the conscious mind to integrate preverbal ideas,
emotions, and conflicts into its understanding of self.
Also, understanding the time course of individual
changes (e.g., psychological variables) during treatment
and how they relate to outcomes would allow programs to
target critical specific processes at the times when they are
most important. With a description of critical mechanisms
of change, researchers and clinicians may not only improve
treatment efficacy and cost-effectiveness, but also gain
insight into aspects that contribute to the persistence of the
disorder in the first place.
Study limitations and future research directions
The study limitations highlight the need for future
research in this area. First, the study sample is small,
limiting interpretation of comparative results and
generalization of study findings. Future research calls for
a larger sample, randomly assigned to multiple treatment
arms (including an absolute control condition). The obese
participants in this study were not an unselected group from
the community, but men and women who had been referred
or had referred themselves for treatment, and, consequently,
it would not be appropriate to extrapolate these results to
all obese population. Participants from two different
treatment groups were combined for the analyses, although
this may have had the advantage of giving more variation
in the dependent variables.
Second, because lack of self-regulation is a common
and primary issue among disordered eaters and obese in
psychotherapeutic recovery, it is important to measure loci
of control and self-regulation in future RMT research with
this population.
Third, the conclusions regarding the efficacy of the
RMT evaluated in this trial are limited by the absence of
follow-up data. While most previous research on
psychological treatment of disordered eating and obesity
has indicated that improvements at the end of treatment are
maintained on augmented during the first year of follow-
up, there is no assurance that this pattern would extend to
the group evaluated in the current study. Though we are
currently gathering follow-up data on the proposed
treatment, longer studies with follow-ups are needed to
better assess the overall effectiveness of RMT approach.
Further studies investigating the complex relationships
between psychosocial factors, stress responses and affective
states will probably be able to provide the basis for rhythmic
movement protocols tailored to the individual eating-
disordered psychopathology.
RMT can be performed in individual as well as in group
settings; however, the efficacy of individual and group RMT
has not been adequately compared so far. Furthermore, self-
help manuals based on the rhythmic movement approach
can provide interesting results in eating-disordered and
obese patients.
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THERAPY FOR DISORDERED EATING BEHAVIOURS AND OBESITY 1387
... A full breakdown of ethnicity and gender can be found in Supporting Information S1: Tables S4 and S5. Twenty-one studies were conducted in America [37, 39-48, 50, 53, 56, 59, 61, 63, 67, 71, 80, 82], 10 studies were conducted in high-income European countries (Netherlands, Finland, Italy, Portugal, Belgium, Spain, Switzerland) [51, 60, 65, 66, 68, 72-74, 76, 83], seven in middleincome countries (Brazil, Turkey, Russia) [52,57,64,69,[77][78][79], five studies were conducted in the UK [38,54,55,58,70] and four studies conducted in non-European high-income countries (Taiwan, Korea, Australia) [49,62,75,81]. ...
... Most interventions (n = 35, 74.5%) were group-based and delivered in-person [37, 39-44, 47, 48, 50-56, 59-63, 65, 66, 68, 69, 71-73, 75-77, 79-82], four studies (8.5%) were one to one and in-person [45,64,74,83], seven studies (14.9%) were one to one and remote [38,46,49,57,58,67,70] and one study (2.1%) [77] was a group-based remotely delivered intervention. ...
... , 9 were some concern[40,43,48,49,57,62,64,78,83] and 4 were high risk of bias[42,60,66,69]. Of the non-randomised studies, 15 were assessed as having a moderate risk of bias[39,44,47,51,52,56,58,59,61,68,71,76,81] and three serious risk of bias.[54,65,77]. ...
Article
Full-text available
Background Emotional eating (EE) is a barrier to the long-term success of weight loss interventions. Psychological interventions targeting EE have been shown to reduce EE scores and weight (kg), though the mechanisms remain unclear. This review and meta-analysis aimed to identify the specific behaviour change techniques (BCTs) associated with improved outcomes. Methods This is a review update and extension, with new studies extracted from searches of CINAHL, PsycINFO, MEDLINE and EMBASE 1 January 2022 to 31 April 2023. EE interventions for adults with BMI > 25 kg/m2 were considered for inclusion. Paper screening, extraction, BCT-coding and risk of bias were completed using the Template for Intervention Description and Replication (TIDieR) checklist, Behaviour Change Taxonomy v1 (BCTTv1) and Risk of Bias2 (RoB2)/Risk of Bias In Non-randomised Studies (ROBINS-I) tool. Narrative syntheses and random effects multi-level meta-analyses were conducted. Results In total, 6729 participants were included across 47 studies (13 identified in the update). Forty-two studies contributed to the pooled estimate for the impact of interventions on EE (SMD = −0.99 [95% CI: −0.73 to −1.25], p < 0.001). Thirty-two studies contributed to the pooled estimate for the impact of interventions on weight (−4.09 kg [95% CI: −2.76 to −5.43 kg], p < 0.001). Five BCTs related to identity, values and self-regulation were associated with notable improvements to both weight and EE (‘incompatible beliefs’, ‘goal setting outcome’. ‘review outcome goals’, ‘feedback on behaviour’ and ‘pros/cons’). Conclusion Implementation and evaluation of the highlighted BCTs are required. Weight management services should consider screening patients for EE to tailor interventions to individual needs.
... Where data were missing, the authors were emailed to request this data [21,23,32,38,42,46,48,54,57,64]. The Meta-Essentials Workbooks for Meta-analysis version 1.5 were used for the meta-analysis [65]. ...
... Thirty-four studies were included in this review from database inception up to February 2022 [21,23,24, Fifty-nine percent were published from 2017 onwards (n = 20) [23,30,32,34,35,[39][40][41][42]46,50,51,[53][54][55][56][57][58][59][60] and 21% were published from 2021 onwards (n = 7) [34,40,42,46,51,56,57]. The remaining studies (41%) were published before 2017 [21,24,31,33,[36][37][38][43][44][45][47][48][49]52]. Fifty-three percent were published in the USA (n = 18) [24,[30][31][32][33][34][35][36][37][38]40,43,45,47,50,52,58,60] with the remainder being published in Brazil (n = 3) [51,56,57]; Australia (n = 2) [55,59]; the Netherlands (n = 2) [21,53]; the United Kingdom (n = 2) [39,42]; Finland (n = 1) [44]; Italy (n = 1) [49]; Korea (n = 1) [46]; Portugal (n = 1) [54]; Russia (n = 1) [48]; Switzerland (n = 1) [23]; and Turkey (n = 1) [41]. ...
... The remaining studies (41%) were published before 2017 [21,24,31,33,[36][37][38][43][44][45][47][48][49]52]. Fifty-three percent were published in the USA (n = 18) [24,[30][31][32][33][34][35][36][37][38]40,43,45,47,50,52,58,60] with the remainder being published in Brazil (n = 3) [51,56,57]; Australia (n = 2) [55,59]; the Netherlands (n = 2) [21,53]; the United Kingdom (n = 2) [39,42]; Finland (n = 1) [44]; Italy (n = 1) [49]; Korea (n = 1) [46]; Portugal (n = 1) [54]; Russia (n = 1) [48]; Switzerland (n = 1) [23]; and Turkey (n = 1) [41]. Forty-three percent were RCTs (n = 15) [30,34,37,38,[46][47][48][49]51,[53][54][55]57,58,60]; 34% were single group designs (n = 12) [21,23,36,39,40,42,43,45,50,52,56,59]; and 20% were individually randomised group treatment trials comparing two or more EE interventions (n = 7) [24,[31][32][33]35,41,44]. ...
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Background: Emotional eating (EE) may be defined as a tendency to eat in response to negative emotions and energy-dense and palatable foods, and is common amongst adults with overweight or obesity. There is limited evidence regarding the effectiveness of interventions that address EE. Objectives: To synthesize evidence on the effectiveness of EE interventions for weight loss and EE in adults living with overweight or obesity. Methods: This is a systematic review and meta-analysis. Adhering to the PRISMA guidance, a comprehensive electronic search was completed up to February 2022. Random effects meta-analysis was carried out to determine the percentage change in weight and EE scores. Results: Thirty-four studies were included. The combined effect size for percentage weight change was -1.08% (95% CI: -1.66 to -0.49, I2 = 64.65%, n = 37), once adjusted for publication bias. Similarly, the combined effect size for percentage change in EE was -2.37%, (95% CI: -3.76 to -0.99, I2 = 87.77%, n = 46). Cognitive Behavioural Therapy showed the most promise for reducing weight and improving EE. Conclusions: Interventions to address EE showed promise in reducing EE and promoted a small amount of weight loss in adults living with overweight or obesity.
... In a prior transversal study we compared patients suffering from obesity and binge eating tendencies with patients suffering from anorexia and bulimia nervosa and with a control group of healthy women without obesity [3]. According to the findings of the study, an adapted psychotherapeutic treatment was proposed to the former, combining techniques of cognitive restructuring with the use of appropriate artistic mediations, especially primitive expression [4,5], rhythmical improvisation and role playing. A longitudinal study aimed at evaluating the efficiency of this integrated therapeutic approach. ...
... Let us stress, that the combination of cognitive restructuring, primitive expression and role playing contributed to the positive results and that no single determinants were isolated in an experimental manner. We can assume that cognitive restructuring allowed addressing the problems of cognitive restriction [42], respectively of shame linked to social stigmatisation [10,12], whereas primitive expression and role playing address more directly the disturbances of the body image [24], as the physical body becomes a source of vitality and as it interacts directly with other persons [5,43,44]. The neuropsychological effects of rapid rhythms and strong movements have recently been documented [25,37]. ...
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Background and Objectives We present a pilot study of arts psychotherapy proposed in combination with cognitive restructuring techniques to N=13 adult women affected by a disturbed body image, low self-esteem and depressive tendencies in relationship with obesity. Methods The methodology of evaluation is based on a psychometric scale (SVF 78), projective tests (Rotter’s Sentences Blank and TAT), a semi-structured self-evaluation form for the patients and an evaluation questionnaire (FBB) for the therapist. Original rating scales were constructed for the projective tests. Results The results of the study show a positive evolution on coping strategies with stress and anxiety, self-esteem, emotional stability and autonomy in social relations. With the help of the Non Linear Principal Components Analysis (PRINCALS) applied on the Delta values of different tests, the latent dimensions of change could be explored. Limitations This exploratory study does not aim at statistical generalization but at demonstrating new treatment and evaluation options, opening tracks for future research Conclusions In the context of a sequential design, the application of Optimal Scaling procedures on Delta values seems very promising for the evaluation of psychotherapies in general.
... These studies appear to focus upon one of three observed elements: body posture, dynamic or changing movement, or localized corporeal expressions (for example, postures, gestures, and subtle expressions). Some studies have investigated the influence of static, or postural, movement on autobiographical memory and goal planning(Dijkstra, Kaschak, & Zwaan, 2007; Zimmermann, Toni, & de Lange, 2013), while others have examined dynamic movement and affect change(Malkina-Pykh, 2012). ...
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This research examined the different psychological effects specific types of rhythmic movements might elicit. These rhythmic movements are derived from the Kestenberg Movement Profile (KMP) system of movement observation and developmental psychology framework.
... In recent literature in the field, attempts have been made to establish this occupational focus as a culture, describing what therapists do, how they think and feel, how they relate, and what they (Kessel, 2013;Koch et al., 2007;Malkina-Pykh, 2012;Schasseur, 2013;Weston, 2012). Although these studies created practice knowledge, they often neglected the inner processes, which combine intuition with sensory knowledge, as well as experience-based intervention, which therapists do, but cannot always verbalize or formulate in any formal way. ...
... Lifestyle interventions were evaluated in 2 SRs [32,33] and 11 RCTs [34][35][36][37][38][39][40][41][42][43][44] and were found to be largely effective at improving body weight and related measures in overweight and obese individuals. Specifically, interventions that included diet plus exercise or diet plus exercise plus behavioural/psychological components had consistently positive outcomes. ...
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Objective Most weight loss research focuses on weight as the primary outcome, often to the exclusion of other physiological or psychological measures. This study aims to provide a holistic evaluation of the effects from weight loss interventions for individuals with obesity by examining the physiological, psychological and eating disorders outcomes from these interventions. Methods Databases Medline, PsycInfo and Cochrane Library (2011–2016) were searched for randomised controlled trials and systematic reviews of obesity treatments (dietary, exercise, behavioural, psychological, pharmacological or surgical). Data extracted included study features, risk of bias, study outcomes, and an assessment of treatment impacts on physical, psychological or eating disorder outcomes. ResultsFrom 3628 novel records, 134 studies met all inclusion criteria and were evaluated in this review. Lifestyle interventions had the strongest evidence base as a first-line approach, with escalation to pharmacotherapy and bariatric surgery in more severe or complicated cases. Quality of life was the most common psychological outcome measure, and improved in all cases where it was assessed, across all intervention types. Behavioural, psychological and lifestyle interventions for weight loss led to improvements in cognitive restraint, control over eating and binge eating, while bariatric surgery led to improvements in eating behaviour and body image that were not sustained over the long-term. DiscussionNumerous treatment strategies have been trialled to assist people to lose weight and many of these are effective over the short-term. Quality of life, and to a lesser degree depression, anxiety and psychosocial function, often improve alongside weight loss. Weight loss is also associated with improvements in eating disorder psychopathology and related measures, although overall, eating disorder outcomes are rarely assessed. Further research and between-sector collaboration is required to address the significant overlap in risk factors, diagnoses and treatment outcomes between obesity and eating disorders.
Article
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Background Cognitive behavioral therapy (CBT) has become one of the most commonly used psychotherapeutic treatments for obesity. It stems from CBT for bulimia nervosa and binge eating disorder, which focuses on amelioration of the eating behavior and body image dissatisfaction (BID), but usually does not focus on weight loss. In contrast, CBT for obesity focuses on weight loss, as well as eating behavior and BID. It is at present unclear whether the improvement of BID during CBT for obesity is associated with improvement of factors other than weight loss. Objective The purpose of this study was to determine whether improvement of BID during CBT for obesity was associated with improvement of factors other than weight loss. Methods One hundred and sixty-five women (BMI 31.8 ± 5.2 kg/m², age 49.3 ± 10.5 years) with overweight or obesity completed a 7-month CBT-based weight loss intervention. BID, depression, anxiety, binge eating, and perfectionism were assessed at both baseline and the end of the intervention through the use of psychological questionnaires. Results Percent total weight loss, baseline BID, baseline binge eating disorder (BED), change in depression (Δdepression), Δstate anxiety, Δtrait anxiety, Δbinge eating, and Δperfectionism were significantly correlated with ΔBID. Multiple regression analysis showed that baseline BID, baseline BED, percent total weight loss, Δbinge eating, and Δdepression were independently associated with ΔBID. Conclusion Improvement of binge eating, and improvement of depression, as well as weight loss, were independently associated with amelioration of BID. Clinical trial registration [https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000008052], identifier [UMIN000006803] and [https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R0000 55850], identifier [UMIN000049041].
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Presentation
At the moment several groups of mathematical methods are used for explaining and predicting the behavior of psychological and/or sociological systems. Frequently a dichotomy is made between complex (knowledge-based) and empirical (“black-box”) models. Unfortunately, the high accuracy of complex models comes at the expense of interpretability; e.g., even the contributions of individual features to the predictions of a complex model are often difficult to understand. In opposite, empirical models usually include statistical analysis procedures based on the general linear model or one of its multivariate generalizations (structural equation models (SEM), generalized linear models (GLM), etc.). Although the different types of linear models are most frequently used approaches in psychology and life sciences, there is a widespread consensus that linear models and the conceptual strategies behind them are inadequate for explaining and predicting psychological and many other types of events. However, when there are physical reasons for believing that the relationship between the response and the predictors follows a particular functional form not only knowledge-based model can be applied but nonlinear regression models as well. To our surprise the application of nonlinear regression models in psychology and life sciences are very rare. Decades of our experience in mathematics/psychology sciences reveal that nonlinear semi-empirical approach be may be regarded as a method that provides the explanation power of knowledge-based models without their insufficient interpretability. Semi-empirical is defined as “a model in which calculations are based on a combination of observed associations between variables and theoretical considerations relating variables through fundamental principles (e.g., conservation of energy)” (IPCC-2013). This approach is able to take into account the most essential features of complex social systems. Although there are a number of characteristics of complex systems, such as uncertainty, interactions among processes deployed at different scale, self-organization and emergence, the nonlinearity of their behavior poses most of the challenges for scientists. Previously we studied the performance of “generalized multiplicative models (GMultMs)” which are based on the method of response functions (MRF) and can be used to identify, explain and predict nonlinear synergistic effect of potential prognostic factors on the processes under study. Short presentation of several constructed GMultMs will be provided. Although, no one linear model is able to provide the information needed for understanding the behavior of complex system as the GMultMs are able, the reviewers usually strictly request the comparison of the results of conventional linear models and GMultMs. Arguments with subsequent examples will be presented that such comparison has no any scientific sense.
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