Number of Different Purging Behaviors Used Among Women With Eating Disorders: Psychological, Behavioral, Self-Efficacy and Quality of Life Outcomes

Park Nicollet Melrose Institute, St Louis Park, Minnesota, USA.
Eating disorders (Impact Factor: 1.48). 03/2011; 19(2):156-74. DOI: 10.1080/10640266.2010.511909
Source: PubMed
ABSTRACT
The objective of this study was to examine differences between a number of different purging behaviors used and outcome measures among eating disorder patients. Among 211 females who received inpatient or partial hospitalization eating disorder treatment, analyses of covariance and cross-tabulations identified associations among a number of different purging behaviors (vomiting, laxative use, diuretic use) used and psychological, behavioral, self-efficacy and quality of life measures at follow-up. Most patients (80.1%) reported purging for weight control. Use of different purging behaviors was significantly associated at follow-up with lower self-esteem, greater depression, higher state and trait anxiety, higher BMI, poorer self-efficacy for normative eating and body image, compromised quality of life, greater dietary restraint, and eating, shape and weight concerns. Furthermore, a higher percentage of those who used purging behaviors met criteria for a subthreshold or threshold eating disorder at follow-up compared to their non-purging peers. Eating disorder patients who use different purging behaviors are more compromised at follow-up than patients who do not purge. Due to the severe medical complications associated with different purging behaviors, future research should address best practices for clinical intervention and prevention.

Full-text

Available from: Diann M Ackard, Nov 28, 2014
P LE AS E S C R O LL D O W N F O R AR T IC LE
!"#$%&'(#)*+%,&$%-.,/*.&-+-%012%
345(#6#$+-2%7/#8+'$#(1%.9%:#//+$.(&%;#0'&'#+$<%!,#/%=#(#+$>
4/2%
?@%A5'#*%?@BB
A))+$$%-+(&#*$2%
A))+$$%C+(&#*$2%3$D0$)'#5(#./%/D60+'%EF?FG?@?F>
HD0*#$"+'%
I.D(*+-J+
K/9.'6&%;(-%I+J#$(+'+-%#/%L/J*&/-%&/-%M&*+$%I+J#$(+'+-%ND60+'2%B@O?EPQ%I+J#$(+'+-%.99#)+2%:.'(#6+'%R.D$+<%FOS
QB%:.'(#6+'%T('++(<%;./-./%MB!%FUR<%7V
L&(#/J%C#$.'-+'$
HD0*#)&(#./%-+(&#*$<%#/)*D-#/J%#/$('D)(#./$%9.'%&D(".'$%&/-%$D0$)'#5(#./%#/9.'6&(#./2
"((52WW,,,X#/9.'6&,.'*-X).6W$655W(#(*+Y)./(+/(Z(OBFGGGFQ?
ND60+'%.9%C#99+'+/(%HD'J#/J%[+"&8#.'$%7$+-%A6./J%M.6+/%M#("%L&(#/J
C#$.'-+'$2%H$1)".*.J#)&*<%[+"&8#.'&*<%T+*9SL99#)&)1%&/-%\D&*#(1%.9%;#9+
4D().6+$
C#&//%:X%A)]&'-
&0
^%=&("+'#/+%;X%='./+6+1+'
&
^%;#$&%:X%_'&/`+/
&
^%T&'&%AX%I#)"(+'
&
^%U&/+%N.'$('.6
)
&
%H&']%N#).**+(%:+*'.$+%K/$(#(D(+<%T(%;.D#$%H&']<%:#//+$.(&<%7TA%
0
%H'#8&(+%5'&)(#)+<%a.*-+/%b&**+1<
:#//+$.(&<%7TA%
)
%H&']%N#).**+(%_.D/-&(#./<%T(X%;.D#$%H&']<%:#//+$.(&<%7TA
4/*#/+%5D0*#)&(#./%-&(+2%?Q%_+0'D&'1%?@BB
!.%)#(+%("#$%A'(#)*+%A)]&'-<%C#&//%:X%<%='./+6+1+'<%=&("+'#/+%;X%<%_'&/`+/<%;#$&%:X%<%I#)"(+'<%T&'&%AX%&/-%N.'$('.6<
U&/+c?@BBd%eND60+'%.9%C#99+'+/(%HD'J#/J%[+"&8#.'$%7$+-%A6./J%M.6+/%M#("%L&(#/J%C#$.'-+'$2%H$1)".*.J#)&*<
[+"&8#.'&*<%T+*9SL99#)&)1%&/-%\D&*#(1%.9%;#9+%4D().6+$e<%L&(#/J%C#$.'-+'$<%BE2%?<%BPG%f%BOQ
!.%*#/]%(.%("#$%A'(#)*+2%C4K2%B@XB@g@WB@GQ@?GGX?@B@XPBBE@E
7I;2%"((52WW-hX-.#X.'JWB@XB@g@WB@GQ@?GGX?@B@XPBBE@E
Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf
This article may be used for research, teaching and private study purposes. Any substantial or
systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or
distribution in any form to anyone is expressly forbidden.
The publisher does not give any warranty express or implied or make any representation that the contents
will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses
should be independently verified with primary sources. The publisher shall not be liable for any loss,
actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly
or indirectly in connection with or arising out of the use of this material.
Page 1
Eating Disorders, 19:156–174, 2011
Copyright © Taylor & Francis Group, LLC
ISSN: 1064-0266 print/1532-530X online
DOI: 10.1080/10640266.2010.511909
Number of Different Purging Behaviors Used
Among Women With Eating Disorders:
Psychological, Behavioral, Self-Efficacy
and Quality of Life Outcomes
DIANN M. ACKARD
Park Nicollet Melrose Institute, St Louis Park; and Private practice,
Golden Valley, Minnesota, USA
CATHERINE L. CRONEMEYER, LISA M. FRANZEN, and
SARA A. RICHTER
Park Nicollet Melrose Institute, St Louis Park, Minnesota, USA
JANE NORSTROM
Park Nicollet Foundation, St. Louis Park, Minnesota, USA
The objective of this study was to examine differences between a
number of different purging behaviors used and outcome mea-
sures among eating disorder patients. Among 211 females who
received inpatient or partial hospitalization eating disorder treat-
ment, analyses of covariance and cross-tabulations identified
associations among a number of different purging behaviors (vom-
iting, laxative use, diuretic use) used and psychological, behav-
ioral, self-efficacy and quality of life measures at follow-up. Most
patients (80.1%) reported purging for weight control. Use of dif-
ferent pur ging behaviors was significantly associated at follow-up
with lower self-esteem, greater depression, higher state and trait
anxiety, higher BMI, poorer self-efficacy for normative eating and
body image, compromised quality of life, greater dietary restraint,
and eating, shape and weight concerns. Furthermore, a higher
percentage of those who used purging behaviors met criteria for
a subthreshold or threshold eating disorder at follow-up compared
to their non-purging peers. Eating disorder patients who use dif-
ferent purging behaviors are more compromised at follow-up than
Address correspondence to Diann M. Ackard, Ph.D., L.P., 5101 Olson Memorial Highway,
Suite 4001, Golden Valley, MN 55422, USA. E-mail: diann@diannackard.com
156
Downloaded By: [Optimised: University of Minnesota Libraries, Twin Cities] At: 17:44 20 April 2011
Page 2
Number of Purging Behaviors 157
patients who do not purge. Due to the severe medical complications
associated with different purging behaviors, future research should
address best practices for clinical intervention and prevention.
INTRODUCTION
Purging behaviors, such as the use of laxatives, diuretics, and self-induced
vomiting for weight control purposes, are common among eating disorder
patients (Edler, Haedt, & Keel, 2007; Haedt, Edler, Heatherton, & Keel, 2006)
and have also been documented in non-clinical, population-based studies.
For example, purging practices were assessed in adult men and women
responding to a 1998 U.S. National Health Interview Study (Kruger, Galuska,
Serdula, & Jones, 2004). In this nationally representative sample, 1.9% of
women and 1.4% of men r eported taking diuretics, 0.4% of women and
0.3% of men reported taking laxatives, and 0.1% of women and 0.1% of
men reported self-induced vomiting for weight control (Kruger et al., 2004).
The use of purging behaviors is not limited to populations within the United
States or to adults. For example, among an epidemiologic sample of over
5,000 young adult women in Australia, 1.4% r eported self-induced vomit-
ing, 1.0% reported laxative misuse and 0.3% reported diuretic misuse on at
least a weekly basis (Mond, Hay, Rodgers, Owen, & Mitchell, 2006). In addi-
tion, among a population-based study of adolescents in Minnesota, 22.1%
of adolescent girls and 6.5% of adolescent boys reported the use of extreme
weight-control behaviors (defined as self-induced vomiting, laxative use, diet
pill use, and/or diuretic use in order to lose weight or keep from gaining
weight) (Neumark-Sztainer et al., 2007).
These prevalence rates are worrisome because unhealthy means of con-
trolling weight have been found among adolescents in the United States to
predict overweight status, binge eating with loss of control, and partial and
full threshold eating disorders 5 years later (Neumark-Sztainer et al., 2006).
Of additional concern is that the use of diuretics has increased in prevalence
among American undergraduate women from 0.5% in 1990 to 2.1% in 2004;
the prevalence for other purging behaviors continues to be concer ning but
has essentially remained stable across the same time period, most recently
(2004) at 3.0% for self-induced vomiting and 2.7% for laxative use (Crowther,
Armey, Luce, Dalton, & Leahey, 2008). However, there has been an increase
in the disordered eating behaviors documented over a 10 year period among
adult males and females in Australia (Hay, Mond, Buttner, & Darby, 2008). It is
clear that purging behaviors are prevalent among clinical populations of eating
disorder patients as well as non-clinical samples, and among adolescents and
adults. Of significant concern is that many of the products used to “purge” are
readily available over the counter (Roerig et al., 2003; Steffen, Mitchell, Roerig,
Downloaded By: [Optimised: University of Minnesota Libraries, Twin Cities] At: 17:44 20 April 2011
Page 3
158 D. M. Ackard et al.
& Lancaster, 2007). These findings underscore the importance of examining
the use of different purging behaviors and associated consequences as they
are used as a means of weight control among adolescents and adults, and
can progress from occasional use to a full threshold eating disorder.
Although the use of multiple purging methods has been found to be
associated with greater eating disorder severity (Edler et al., 2007), less
is known about the factors associated specifically with purging behavior
over time. This is due, in part, to the dearth of research that has examined
the specific purging behaviors used across patients with any eating disor-
der diagnosis. One study investigated factors associated with diet pill use
and found that 32.3% of the sample, across all eating disorder diagnoses,
reported use of diet pills, and that 97.5% of diet pill users also reported
self-induced vomiting and/or some other type of purging (Reba-Harrelson
et al., 2008). For some eating disorder patients, purging behaviors are used
to compensate for binge eating episodes as is the case in patients diagnosed
with bulimia nervosa. For other patients, purging behaviors may be used
without any overeating as in cases of anorexia nervosa, purging subtype,
or in examples of “purging disorder” defined as recurrent use of purging
(self-induced vomiting, laxative use, or diuretic misuse) in the absence of
binge-eating behaviors (Keel, 2007). Regardless of diagnosis, the use of mul-
tiple purging methods among patients has been found to be associated with
greater severity of the eating disorder (such as frequency of objective and
subjective binge-eating episodes and greater concerns about eating, shape
and weight) and with greater psychopathology among young adult women
in the U.S. (Edler et al., 2007). Yet less is known about the longitudinal
factors associated with purging behavior use.
The vast majority of follow-up studies focus on outcome from spe-
cific eating disorder diagnoses being treated, not on the specific eating
disorder symptoms used (Fichter & Quadflieg, 2004; Fichter, Quadflieg,
& Hedlund, 2006; Grilo et al., 2007; Steinhausen, 2008; Thiels, Schmidt,
Treasure, & Garthe, 2003). However, it has been well-established that eating
disorder diagnoses are not stable over time and that some affected individ-
uals traverse from one constellation of eating disorder symptoms to another
(Fichter, Quadflieg, & Rief, 1994; Milos, Spindler, Schnyder, & Fairburn,
2005). Consequently, this study focuses on different purging behaviors
across all eating disorder diagnoses.
The current study expands on the extant literature by using a large
sample of treatment-seeking patients with eating disorders who have used
various purging behaviors, and comparing their outcome by number of
behaviors used. Patients were followed between 1 to 11 years after their
intake assessment at the treatment facility; this lengthy follow-up period
allows for a more accurate assessment of treatment outcomes than shorter
follow-up periods. Further more, there is a dearth of literature investigating
Downloaded By: [Optimised: University of Minnesota Libraries, Twin Cities] At: 17:44 20 April 2011
Page 4
Number of Purging Behaviors 159
multiple types of purging behaviors used by individuals with eating disor-
ders other than bulimia nervosa; the current study includes patients with all
eating disorder diagnoses in order to gain insight into the outcomes of all
patients who use purging behaviors. We hypothesized that patients with an
eating disorder who use multiple purging behaviors would be more psycho-
logically and behaviorally compromised at follow-up than patients with an
eating disorder who use none or one purging behavior.
METHODS
Participants
Females (N = 211) who received specialized treatment at the Park Nicollet
Melrose Institute, in St. Louis Park, MN participated in a study of treatment
outcomes and completed questions regarding self-induced vomiting, and
use of laxatives and diuretics. They were assessed at this facility and treated
in the inpatient or partial hospitalization program between the years of 1995
and 2005. They later completed self-report follow-up measures between
November of 2006 and May of 2007.
The following demographic characteristics describe the participating
female sample at intake assessment (see Table 1 for full demographic
description). Most were Caucasian (n = 196; 97.5%) and reported their mar-
ital status as single (n = 168; 85.7%). Their average age at intake was 20.8
years old (SD = 8.0), and the average age-of-onset of the eating disorder
was reported as 14.6 (SD = 4.6) years of age. Body Mass Index (BMI)
at intake was measured anthropometrically and calculated using the stan-
dard formula of weight in kilograms divided by the squared product of
height in meters, and the average BMI among study participants was 17.6
(SD = 3.2). Most patients received inpatient programming (n = 188; 89.1%).
TABLE 1 Description of Sample by Diagnosis at Intake Assessment
Description of s ample by diagnosis
AN-R
(n = 81)
AN-P
(n = 18)
BN
(n = 27)
EDNOS
(n = 85)
Age, average (standard deviation) 18.1 (6.2) 23.1 (8.8) 25.9 (10.0) 21.3 (7.7)
Age of eating disorder onset,
average (standard deviation)
14.7 (4.2) 13.7 (3.6) 15.2 (2.7) 14.9 (5.5)
Body Mass Index, average (standard
deviation)
15.8 (1.6) 15.7 (1.3) 21.4 (3.5) 18.6 (3.1)
% Caucasian 97.5% 100.0% 96.0% 97.5%
% Single 93.7% 88.9% 60.9% 84.2%
% Receiving inpatient treatment 96.3% 100.0% 88.9% 80.0%
Note: AN-R = Anorexia Nervosa Restricting subtype; AN-R = Anorexia Nervosa–Purging subtype)
BN = Bulimia Nervosa; EDNOS = Eating Disorder Not Otherwise Specified
Downloaded By: [Optimised: University of Minnesota Libraries, Twin Cities] At: 17:44 20 April 2011
Page 5
160 D. M. Ackard et al.
Diagnoses were determined by psychiatric clinical interview following DSM-
IV criteria; there was no standardized psychiatric assessment or inter-rater
reliability. The majority of patients were diagnosed with either Anorexia
Nervosa-Restricting Subtype (AN-R; n = 81; 38.4%) or Eating Disorder Not
Otherwise Specified (EDNOS; n = 85; 40.3%). Fewer patients were diag-
nosed with Bulimia Nervosa (BN; n = 27; 12.8%) or Anorexia Nervosa-
Purging Subtype (AN-P: n = 18; 8.5%).
At follow-up, which occurred between 1 and 11 years following intake
assessment depending on the year of intake, the average participant was
26.0 years of age (SD = 7.9) and had an average self-report BMI of 20.9
(SD = 3.6). The average length of follow-up was 5.7 years.
Procedure
Patients provided consent at their intake assessment to be contacted for
research and to have their medical records reviewed for research (as indi-
cated on the Park Nicollet Health Services Consent Form). For the current
study, eligible individuals were invited to participate in the study by a
mailed letter and consent form. If interested, they were asked to send back
the signed consent form in a postage-paid business reply envelope. After
the signed consent form was received, the follow-up questionnaires were
sent to the participant to be completed and mailed back in a postage-paid,
self-addressed, stamped envelope. In addition, a copy of the signed con-
sent was sent to the participant for their records. If the participant mailed
in the consent and did not return their questionnaires, the research team
sent three reminder letters. If the participant did not send in the completed
questionnaires after the three reminder letters, no further action was taken.
Two hundred and ninety-nine female patients consented to participate, of
which 211 completed the questionnaires, for a completion rate of 70.6%,
and were included in the current study.
This study was reviewed and approved by the Park Nicollet Health
Services Institutional Review Board; active consents and assents (for partici-
pants under 18 years of age) for all participants were used.
Measures
The following information was collected at the patient’s intake assessment
and extracted from her medical chart: race, date of birth, year of admis-
sion to the treatment facility, age at admission, treatment milieu, admission
diagnoses, and measured height and weight.
The following measures were collected as part of the mailed follow-
up assessment: self-reported height and weight, martial status, Eating
Disorders Inventory–3 Symptom Checklist, Eating Disorders Examination-
Questionnaire version, Rosenberg Self-Esteem Survey, Beck Depression
Downloaded By: [Optimised: University of Minnesota Libraries, Twin Cities] At: 17:44 20 April 2011
Page 6
Number of Purging Behaviors 161
Inventory–2, State-Trait Anxiety Inventory, the Eating Disorders Diagnostic
Scale, the Eating Disorders Quality of Life, and the Eating Disorders Recovery
Self-Efficacy Questionnaire.
The Eating Disorders Inventory-3 Symptom Checklist (EDI-3SC [Garner,
2004]) is self-report instrument that collects information on gender, cur-
rent age, martial status, and use of symptoms, such as: dieting; exercise
frequency, duration, and intention; binge-eating; self-induced vomiting; lax-
ative use; and diuretic use. Reliability and validity estimates are not available
for this measure.
Use of different purging behaviors was determined with a single ques-
tion per purging behavior on the EDI-3SC. Participants were asked to
respond yes or no to the following questions: “Have you ever used lax-
atives to ‘get rid of food’?”, “Have you ever taken diuretics (water pills) to
control your weight?”, and “Have you ever tried to vomit after eating in order
to get rid of the food eaten?”
The Beck Depression Inventory-2 (BDI-II [Beck, Steer, & Brown, 1996])
is a 21 item self-report instrument designed to measure the level of depres-
sion in adolescents and adults over the age of 13. Each of the 21 questions
requires the participant to make a choice from four options (e.g., 0 = I don’t
cry more than I used to; 1 = I cry more than I used to; 2 = I cry over
every little thing; 3 = I feel like crying, but I can’t.) Total scores range from
0 to 63, and a higher score indicates a higher level of depression. Clinical
severity categories are: 0–13 minimal; 14–19 mild; 20–28 moderate; 29–63
severe (Beck et al., 1996). Psychometric properties that assess the reliabil-
ity and validity of the BDI-II for measuring depression have been found to
be strong among adolescent (Osman, Kopper, Barrios, Gutierrez, & Bagge,
2004) and adult populations (Robinson, Shaver, & Wrightsman, 1991).
The State-Trait Anxiety Inventory (STAI [Spielberger, 2003]) is a 40 item
self-report assessment that includes separate measures of state and trait
anxiety. The total score ranges from 20 to 80 for each scale (trait versus
state anxiety), and higher scores indicate greater anxiety. Clinical severity
categories, based on score, are: 20–30 low; 31–40 low average; 41–48 aver-
age; 49–60 high average; 61–70 high; 71–80 very high (Spielberger, 2003).
Psychometric properties of the STAI are sound, with test-retest among male
and female high school and college students ranging from 0.65 to 0.86 for
trait anxiety and 0.16 to 0.62 for state anxiety. This low level of stability for
the state-anxiety scale is expected since responses to the items on this scale
are thought to reflect the influence of whatever transient situational factors
exist at the time of testing (Spielberger, 2003). The validity correlations are
0.80 with the Taylor Manifest Anxiety Scale, 0.75 with the IPAT Anxiety Scale,
and 0.52 with the Multiple Affect Adjective Check List (Spielberger, 2003).
Participants also completed the Rosenberg Self-Esteem Scale (RSES
[Rosenberg, 1965]). It is a 10-item questionnaire that assesses overall self-
esteem and self-worth; scores range from 10 to 40, and higher scores
Downloaded By: [Optimised: University of Minnesota Libraries, Twin Cities] At: 17:44 20 April 2011
Page 7
162 D. M. Ackard et al.
indicate greater self-esteem. Reliability and validity estimates have been pub-
lished elsewhere (Fleming & Courtney, 1984) and the measure demonstrates
adequate psychometric properties.
The Eating Disorders Examination–Questionnaire (EDE-Q [Fairburn &
Cooper, 1993]) is a 41-item self-report questionnaire that asks specific ques-
tions pertaining to the presence and frequency of eating disorder behaviors,
thoughts, and feelings about body over the past 28 days. The EDE-Q is
derived from the interview version of the Eating Disorders Examination
and has four subscales: Restraint; Eating Concern; Weight Concern; and
Shape Concern. Mean scale scores (and standard deviations) among young
Australian adult women are: 1.30 (1.40) for Restraint; 0.76 (1.06) for Eating
Concern; 1.79 (1.51) for Weight Concern; 2.23 (1.65) for Shape Concern
(Mond, Hay, Rodgers, & Owen, 2006); mean scores (and standard devi-
ations) among undergraduate women in the United States are similar:
1.29 (1.41) for Restraint; 0.87 (1.13) for Eating Concern; 1.89 (1.60) for
Weight Concern; 2.29 (1.68) for Shape Concern (Luce, Crowther, & Pole,
2008). Higher scores indicate greater pathology across the four subscales.
The EDE-Q has been found to have good concurrent validity and crite-
rion validity among community samples (Mond, Hay, Rodgers, Owen, &
Beaumont, 2004) and good internal consistency (Luce & Crowther, 1999;
Mond et al., 2004).
Participants were asked to complete the Eating Disorders Diagnostic
Scale (EDDS [Stice, Telch, & Rizvi, 2000]). The EDDS is a 22-item screening
tool based on DSM-IV (American Psychiatric Association, 2004) diagnostic
criteria and used to diagnose full threshold cases of anorexia nervosa (AN),
BN, and binge eating disorder (BED), subthreshold diagnoses of AN, BN and
BED, and EDNOS. The EDDS has demonstrated good reliability and validity
(Stice, Fisher, & Martinez, 2004; Stice et al., 2000).
The Eating Disorders Quality of Life (EDQOL [Engel et al., 2006]) is
a 25-item health-related quality of life instrument for use with clinical and
subclinical patients with AN, BN, and BED. The EDQOL has four subscales:
Psychological, Physical/Cognitive, Financial, and Work/School, as well as
a total score; higher scores indicate greater concerns across these quality
of life dimensions. Item scores range from 0 (never) to 4 (always). Mean
subscale score cutoffs (and standard deviations) and symptom severity cat-
egories across subscales are: 0.87 (0.82) minor, 2.20 (0.80) moderate, and
2.22 (1.18) severe for Psychological; 0.74 (0.58) minor, 1.52 (0.76) moderate
and 1.86 (1.10) severe for Physical/Cognitive; 0.12 (0.36) minor, 0.38 (0.69)
moderate, and 0.49 (0.87) severe for Financial; and 0.05 (0.26) minor, 0.24
(0.49) moderate, and 0.48 (0.73) severe for Work/School (Engel et al., 2006).
The instrument also demonstrates excellent validity and reliability (Engel
et al., 2006).
The Eating Disor der Recovery Self-Efficacy Questionnaire (EDRSQ
[Pinto, Guarda, Heinberg, & DiClemente, 2006]) is a 40-item self-report
measure of self-efficacy to recover from an eating disorder. The scale
Downloaded By: [Optimised: University of Minnesota Libraries, Twin Cities] At: 17:44 20 April 2011
Page 8
Number of Purging Behaviors 163
incorporates two 20-item scales of Normative Eating self-efficacy and Body
Image self-efficacy. Item scores range from 1 (not at all confident) to 5
(extremely confident), thus higher scores indicate greater self-efficacy. Means
(and standard deviations) for patients meeting full criteria versus those who
are in partial remission are: 2.2 (1.0) versus 2.8 (1.1) for Normative Eating;
and 2.0 (0.9) versus 2.3 (1.0) for Body Image self-efficacy (Pinto et al., 2006).
The developers of the instrument have documented good reliability and
validity (Pinto et al., 2006) and the scale has been shown to predict outcome
from inpatient eating disorders treatment (Pinto, Heinberg, Coughlin, Fava,
& Guarda, 2008).
Data Analysis
The results were stratified into three groups by number of different purging
behaviors used (None, One or Two or more). Differences on demographic
characteristics at intake assessment were evaluated using analyses of vari-
ance (ANOVA) for continuous and Chi-Square Tests for categorical variables.
Due to significant differences between groups on age and BMI at intake,
with greater number of different purging behaviors used being associated
with older age and greater BMI, all further analyses were adjusted to control
for these covariates. Mean scores on all continuous variables were compared
by purging group using analyses of covariance (ANCOVA), controlling for
age and BMI at intake. When the ANCOVA yielded significant results on
the outcomes studied, pairwise comparisons were calculated using the Least
Significant Difference method to identify specific group differences. The sig-
nificance level was set at p < .05. Statistical analyses were conducted with
SPSS 11.0 for Macintosh OS-X (SPSS, 2005).
RESULTS
Patients were stratified into three groups by number of different purging
behaviors used (none, one, two or more). A total of 169 eating disorder
patients (80.1%) reported ever using laxatives, diuretics or self-induced vom-
iting as a means of weight control or purging; 85 of the 169 (50.3%) reported
the use of one purging behavior and 84 (49.7%) reported the use of two or
more. The most common purging behavior reported was self-induced vom-
iting (71.1%), followed by laxative use (43.1%), and diuretic use (23.7%).
See Figure 1 for the number and type of purging behavior used across
the sample.
Demographic and Treatment Factors Associated With Number of
Different Purging Behaviors Used
A description of the sample stratified by number of different purging behav-
iors used, and differences among these categories, can be found in Table 2.
Downloaded By: [Optimised: University of Minnesota Libraries, Twin Cities] At: 17:44 20 April 2011
Page 9
164 D. M. Ackard et al.
FIGURE 1 Number and type of different purging behaviors used.
No significant differences were found between purging groups on race,
marital status, or treatment milieu received at intake. However, there were
significant differences by group on age and BMI at intake, with age and BMI
being positively and significantly associated with number of different purg-
ing behaviors used. Consequently, all subsequent analyses were adjusted for
age and BMI at intake. Furthermore, and as can be expected due to diagnos-
tic nosology, there were differences by purging group and eating disorder
diagnosis at intake, with greater numbers of different purging behaviors used
being more likely associated with BN and/or EDNOS. However, all eating
disorder diagnostic groups included some individuals who reported use of
different purging behaviors.
Outcomes by Number of Different Purging Behaviors Used
DEPRESSION AND ANXIETY
As shown in Table 3, the number of dif ferent purging behaviors used was
significantly and negatively associated with self-esteem, and positively asso-
ciated with scores on measures of depression and state and trait anxiety. This
means that as the number of different purging behaviors used increased,
self-esteem scores decreased and scores on measures of depression of anx-
iety increased. For depression, significant differences were found between
all three groups, with higher number of different purging behaviors used
associated with greater depression. Furthermore, self-esteem scores were
significantly lower and both state and trait anxiety scores were significantly
higher for those who reported the use of two or more different purging
behaviors than those who reported none or one purging behavior.
Downloaded By: [Optimised: University of Minnesota Libraries, Twin Cities] At: 17:44 20 April 2011
Page 10
TABLE 2 Differences in Demographic and Treatment Characteristics of Sample by Number of Different Purging Behaviors Used
Demographic and treatment characteristic N None (n = 42) One (n = 85)
Two or more
(n = 84) Test statistic; p-value
Age at intake, average (standard deviation) 211 17.8 (6.6) 19.9 (6.7) 23.3 (9.1) F = 8.15; p < .001
Body mass index at intake, average
(standard deviation)
202 15.9 (1.7) 17.0 (2.5) 19.0 (3.7) F = 18.41; p < .001
Race, percentages 201 Chi-square = 5.51 N.S.
Caucasian 100.0% 95.1% 98.7%
Asian 0.0% 1.3%
Hispanic 1.2%
Multiple races 3.7%
Marital status at intake, percentages 196 Chi-square = 12.91; p = .012.
Single 92.7% 92.5% 74.7%
Married 7.3% 5.0% 17.3%
Divorced 2.5% 8.0%
Treatment milieu, percentages 211 Chi-square = 3.63; N.S.
Inpatient 95.2% 90.6% 84.5%
Partial hospitalization 4.8% 9.4% 15.5%
Eating disorder diagnosis at intake,
percentages
211 Chi-square = 22.73; p = .001
Anorexia Nervosa–Restricting Subtype 61.9% 42.4% 22.6%
Anorexia Nervosa–Purging Subtype 0.0% 9.4% 11.9%
Bulimia Nervosa 2.4% 12.9% 17.9%
Eating Disorder Not Otherwise Specified 35.7% 35.3% 47.6%
165
Downloaded By: [Optimised: University of Minnesota Libraries, Twin Cities] At: 17:44 20 April 2011
Page 11
TABLE 3 Psychological Outcomes by Number of Different Purging Behaviors Used; Means (and Standard Deviations)
Adjusted for Age and BMI at Intake Assessment
Psychological outcomes N None (n = 42) One (n = 85)
Two or more
(n = 84) Test Statistic; p-value
Rosenberg Self-Esteem 202 28.5 (6.3)
a
27.8 (5.2)
a
24.9 (5.3)
b
F = 5.45; p < .001
Beck Depression Inventory–2 202 8.7 (10.1)
a
14.5 (12.4)
b
21.4 (14.1)
c
F = 9.70; p < .001
State-Trait Anxiety
Inventory–State Anxiety
201 37.7 (13.2)
a
42.8 (12.7)
a
48.6 (14.4)
b
F = 5.16; p = .001
State-Trait Anxiety
Inventory–Trait Anxiety
199 42.6 (13.6)
a
44.5 (13.4)
a
52.5 (12.8)
b
F = 5.72; p < .001
Note: Different superscripts indicate statistically significant differences between groups (p < .05).
166
Downloaded By: [Optimised: University of Minnesota Libraries, Twin Cities] At: 17:44 20 April 2011
Page 12
Number of Purging Behaviors 167
Eating Disorder Behaviors, Concerns and Diagnostic Criteria
Regarding eating disorder behaviors and concerns, the number of dif-
ferent purging behaviors used was significantly and positively associated
with all subscales on the EDE-Q at follow-up (see Table 4). Specifically,
scores for dietary restraints and for eating, shape and weight concerns were
significantly higher for those who reported the use of two or more dif-
ferent purging behaviors than those who reported none or one purging
behavior.
Inspection of the percentage meeting eating disorder criteria at follow-
up shows that 42.4% of those reporting use of one purging behavior and
42.9% of those reporting use of two or more purging behaviors still met
criteria for subthreshold or full threshold eating disorder diagnosis at follow-
up, compared with only 16.6% of those reporting no purging behaviors.
Furthermore, those reporting the use of two or more purging behaviors
had a higher BMI at follow-up than those reporting none or one purging
behavior.
Self-Efficacy for Normative Eating and Body Image
Self-efficacy for normative eating and body image at follow up decreased
with increasing number of different purging behaviors; significant differ-
ences were found among all three groups.
Quality of Life
Quality of life concerns in psychological, physical and cognitive, and
financial areas at follow-up increased with greater number of different
purging behaviors. Specifically, scores for quality of life in psychologi-
cal, physical/cognitive and financial domains were significantly higher for
those who reported the use of two or more purging behaviors than those
who reported none or one purging behavior. No statistically significant dif-
ferences were found between purging groups pertaining to work/school
quality of life.
DISCUSSION
The current study found that eating disorder patients who reported multiple
purging behaviors (laxative use, diuretic use, and/or self-induced vomit-
ing) fared more poorly at follow-up than those using one or no purging
behaviors. Specifically, the number of different purging behaviors used was
significantly associated with poorer self-esteem, greater depression, higher
anxiety, more severe dietary restraint, greater concerns about eating, shape
Downloaded By: [Optimised: University of Minnesota Libraries, Twin Cities] At: 17:44 20 April 2011
Page 13
TABLE 4 Behavioral, Self-Efficacy, and Quality of Life Outcomes by Number of Different Purging Behaviors Used; Analyses Adjusted for
Age and BMI at Intake Assessment
Behavioral, Self-Efficacy and Quality of Life
Outcomes N None (n = 42) One (n = 85)
Two or more
(n = 84) Test statistic; p-value
BMI at follow-up, means (standard deviations) 182 20.4 (2.4)
a
20.2 (3.1)
a
21.8 (4.3)
b
F = 17.0; p < .001
Eating Disorders Examination, scale score
means (standard deviations)
Dietary restraint 202 1.4 (1.6)
a
2.0 (1.6)
b
2.7 (1.8)
b
F = 5.96; p = .001
Eating concern 202 1.5 (1.6)
a
1.7 (1.3)
a
2.7 (1.6)
b
F = 7.32; p = .002
Shape concern 202 2.5 (1.9)
a
3.2 (1.6)
b
4.2 (1.6)
c
F = 9.15; p < .001
Weight concern 202 2.1 (1.8)
a
2.5 (1.7)
a
3.5 (1.5)
b
F = 7.88; p < .001
Eating Disorder Diagnostic Scale, percentages 211
Subthreshold ED diagnosis 9.5% 21.2% 19.1%
Full threshold ED diagnosis 7.1% 21.2% 23.8% Chi-sq = 10.50, p = .040
Eating Disorders Recovery Self-Efficacy, scale
score means (standard deviations)
Normative eating 202 3.6 (1.2)
a
3.1 (1.1)
b
2.6 (1.1)
c
F = 8.29; p < .001
Body image 202 2.9 (1.2)
a
2.4 (1.0)
b
1.9 (0.7)
c
F = 10.82; p < .001
Eating Disorder Quality of Life, scale score
means (standard deviations)
Psychological 202 1.2 (1.0)
a
1.6 (1.0)
a
2.1 (1.0)
b
F = 10.24; p < .001
Physical and cognitive 202 0.9 (0.8)
a
1.0 (0.9)
a
1.5 (1.1)
b
F = 7.86; p < .001
Financial 201 0.3 (0.6)
a
0.3 (0.6)
a
0.6 (0.9)
b
F = 2.51; p = .043
Work and school 199 0.2 (0.6) 0.3 (0.6) 0.5 (0.8) F = 2.21; N.S.
Note: Different superscripts indicate statistically significant differences between groups (p < .05).
168
Downloaded By: [Optimised: University of Minnesota Libraries, Twin Cities] At: 17:44 20 April 2011
Page 14
Number of Purging Behaviors 169
and weight, and a higher likelihood to be struggling with a subthreshold
or full threshold eating disorder diagnosis at follow-up. A higher number
of different purging behaviors was also associated with poorer quality of
life in psychological, physical/cognitive, and financial domains, and lower
self-efficacy for normative eating and body image. These results suggest that
patients who present for eating disorder treatment and who have used multi-
ple purging behaviors may have more serious psychological and behavioral
concerns as well as poorer outcomes than those who used one or no purging
behaviors. It is possible that purging directly affects this poorer outcome, or
that purging may be a marker of a temperament trait that is influencing poor
outcome. Regardless, emphasis in treatment should be placed on abstinence
from purging behaviors. Public health efforts should focus on the prevention
of the use of these behaviors and products among the general public, as they
are readily available and globally used by adolescents (Neumark-Sztainer &
Hannan, 2000; Neumark-Sztainer et al., 2006) and adults (Crowther et al.,
2008; Mond et al., 2006; Neumark-Sztainer, Sherwood, French, & Jeffery,
1999).
Scores across groups stratified by number of different purging behaviors
used indicate clinically significant differences between groups. For exam-
ple, depression scores ranged from minimal depressive symptoms for those
patients using no purging behaviors, to mild depression for those report-
ing one, and moderate depression for those reporting two or more purging
behaviors. Scores at follow-up on the EDE-Q subscales of restraint, and
eating and weight concern approximated the mean scores for norms of
young women in Australia (Mond et al., 2006) and the United States (Luce
et al., 2008) for those using no purging behaviors, whereas scores for
those reporting the use of two or more purging behaviors were greater
than one standard deviation above the means. Furthermore, patients using
two or more purging behaviors reported poorer self-efficacy across nor-
mative eating and body image subscales, approximating scores for patients
who meet full criteria for an eating disorder (Pinto et al., 2006). Finally,
patients reporting the use of two or more purging behaviors scored at
or above the “severe” range on the EDQOL Psychological, Financial, and
Work/School subscales, and in between “moderate” and “severe” on the
EDQOL Physical/Cognitive subscale; in comparison, those reporting the use
of no or one purging behavior approximated norms for those with “minor” to
“moderate” impairment (Engel et al., 2006). These statistically and clinically
significant differences underscore the association between use of different
purging behaviors and later compromised functioning and well-being among
those who have sought treated for an eating disorder.
To the best of the authors’ knowledge, this is the first study to inves-
tigate outcomes based on number of different purging behaviors used and
not based on eating disorder diagnosis. Furthermore, the use of a follow-
up period is significant as improvements in symptomatology and related
Downloaded By: [Optimised: University of Minnesota Libraries, Twin Cities] At: 17:44 20 April 2011
Page 15
170 D. M. Ackard et al.
psychopathology may not be evident until years following treatment (Fichter
& Quadflieg, 2004; Fichter et al., 2006; Steinhausen, 2008). Poorer outcomes
from an eating disorder have been predicted by psychiatric comorbidity,
childhood obesity, older age at eating disorder onset, higher binge-eating
frequency, longer duration of eating disorder (Fichter & Quadflieg, 2004;
Fichter et al., 2006; Steinhausen, 2008) and personality disorders (Grilo et al.,
2007; Steinhausen, 2008), but no studies to date have specifically investigated
whether a higher number of different purging behaviors is a poor prognostic
factor for outcome from an eating disorder.
Of particular interest in the current study is that purging behaviors
were not restricted to those patients diagnosed with an eating disorder sub-
type that suggests or specifies purging behavior. For example, 55 (68%) of
patients diagnosed at intake with AN-R reported the use of one or more
purging behaviors at follow-up. It is possible that the different purging
behaviors reported at follow-up were not in current use when the diagno-
sis was made at intake, or that these patients may have migrated from one
constellation of eating disorder symptoms to another as has been reported
to occur (Shisslak, Crago, & Estes, 1995). It is also possible that patients may
be embarrassed by the use of purging behavior, or may wish to deny or
hide the use of these behaviors from their treatment team in the interest of
wanting to continue to use these behaviors. Regardless, clinicians working
in the field of eating disorders should routinely assess for the use of different
purging behaviors regardless of the presenting diagnosis of the patient.
Strengths and Limitations
There are several noteworthy strengths of the current study that speak to
its added value to the extant literature. First, the follow-up study used a
large sample of eating disorder patients, with diverse diagnoses and symp-
tom constellations. These patients were treated in a clinical environment, not
part of a controlled treatment trial, and thus our final sample includes those
who did and did not complete all treatment recommendations; according to
one study those who prematurely terminate treatment fare similarly to those
who complete treatment (Bjork, Bjorck, Clinton, Sohlberg, & Norring, 2009)
and are important to include in investigations. Second, the measures used at
follow-up assessment capture a broad range of behavioral and psychologi-
cal health outcomes, thus allowing a more comprehensive understanding of
how patients using multiple purging behaviors compare to patients who
do not. In addition, the outcome measures used in the study demon-
strate good psychometric properties, and this allows for generalizability to
other samples.
There are several limitations of this study that should be considered
when applying the current study results to other samples. First, the cur-
rent study sample included only treatment-seeking patients, predominantly
Downloaded By: [Optimised: University of Minnesota Libraries, Twin Cities] At: 17:44 20 April 2011
Page 16
Number of Purging Behaviors 171
diagnosed with AN-R or EDNOS as determined by non-structured clini-
cal interview (thus having no inter-rater reliability), and caution should be
taken when generalizing these findings to females using purging behaviors
that are not seeking treatment, those who do not have an eating disorder,
and those with AN-P or BN diagnoses. Second, there were no male par-
ticipants. Although the authors believe that purging behaviors would be
harmful and predict unfavorable long-term outcomes among males sim-
ilarly to that found among females, this question remains unanswered.
Furthermore, there was little diversity among participants on sociodemo-
graphic characteristics. The current study findings are most generalizable to
unmarried Caucasian females receiving inpatient treatment. Future research
should investigate long-term outcomes of individuals diagnosed with an
eating disorder from broader socioeconomic backgrounds, diverse ethnic-
ities, and across both treatment-seeking and non-treatment-seeking groups.
Fourth, we must mention the high probability of a response bias in this sam-
ple: for example, those who chose to participate in the study could have
been more compliant, healthier, or further along in recovery than those
that elected not to participate, and treatment for an eating disorder is often
a distressing experience so it may deter people from wanting to partici-
pate. We attempted to address this issue by sending multiple invitations to
participate in the study, but future research may seek to investigate other
recruitment strategies that could attract a more diverse group of participants.
In addition, the use of self-report instruments does not allow for clarification
of some areas of interest as would be possible during interviews. A fifth
limitation is that the current study only investigates three purging behaviors
(self-induced vomiting, laxative use, diuretic use) and there are other forms
of purging available, such as chewing and spitting out food, the use of ene-
mas and suppositories, and misuse of or omitting insulin in patients with
insulin-dependent diabetes mellitus. The eating disorders field would bene-
fit from a more comprehensive examination of the long-term consequences,
physical and psychological, of a wide variety of purging behaviors. Finally,
the study was not able to differentiate between purging behavior use ver-
sus abuse. However, the current study still found less favorable outcome
results among individuals who had ever used purging behaviors, regard-
less of whether or not they abused them. Future research may seek to use a
measure that differentiates between use and abuse, has established reliability
and validity values, and reduces limitations of self-report instruments.
CONCLUSIONS
Findings from the current study indicate that eating disorder patients who
use multiple purging behaviors (laxative use, diuretic use and/or self-
induced vomiting) reported poorer self-esteem, higher levels of depression
and anxiety, greater dietary restraint, more concerns about eating, shape and
Downloaded By: [Optimised: University of Minnesota Libraries, Twin Cities] At: 17:44 20 April 2011
Page 17
172 D. M. Ackard et al.
weight, poorer quality of life (psychological, physical and cognitive, and
financial domains) and lower self-efficacy for normative eating and body
image at follow-up than patients reporting use of one or no purging behav-
iors. Furthermore, a higher percentage of those who used multiple purging
behaviors met subthreshold and full threshold eating disorder diagnostic cri-
teria at follow-up than their nonpurging peers. Due to the severe medical
complications associated with these extreme forms of weight control, studies
investigating the prevention of the use and abuse of these readily available
products warrant significant consideration. In addition, future research in the
area of purging behavior use among patients with eating disorders should
include a more diverse patient population (e.g., by gender, race, age) to
more fully address the clinical implications of treating individuals who use
these behaviors, and continue to evaluate the long-term impact of purging
behavior use on overall health.
REFERENCES
American Psychiatric Association (2004). Diagnostic and statistical manal for mental
disorders (4th ed.). Washington, DC: American Psychiatric Association.
Beck, A. T., Steer, R. A., & Brown, G. K. ( 1996). Manual for the Beck Depression
Inventory - II. San Antonio, TX: Psychological Corporation.
Bjork, T., Bjorck, C., Clinton, D., Sohlberg, S., & Norring, C. (2009). What happened
to the ones who dropped out? Outcome in eating disorder patients who com-
plete or prematurely terminate treatment. European Eating Disorders Review,
17, 109–119.
Crowther, J. H., Armey, M., Luce, K. H., Dalton, G. R., & Leahey, T. (2008). The
point prevalence of bulimia disorders from 1990 to 2004. International Journal
of Eating Disorders, 41, 491–497.
Edler, C., Haedt, A. A., & Keel, P. K. (2007). The use of multiple purging meth-
ods as an indicator of eating disorder severity. International Journal of Eating
Disorders, 40, 515–520.
Engel, S. G., Wittrock, D. A., Crosby, R. D., Wonderlich, S. A., Mitchell, J. E., &
Kolotkin, R. L. ( 2006). Development and psychometric validation of an eating
disorder-specific health-related quality of life instrument. International Journal
of Eating Disorders, 39, 62–71.
Fairburn, C. G., & Cooper, Z. (1993). The Eating Disorder Examination (12th ed.).
In C. G. Fairburn & G. T. Wilson (Eds.), Binge eating: Nature, assessment and
treatment (pp. 317–360). New York, NY: Guilford Press.
Fichter, M., Quadflieg, N., & Rief, W. (1994). Course of multi-impulsive bulimia.
Psychological Medicine, 24, 591–604.
Fichter, M. M., & Quadflieg, N. (2004). Twelve-year course and outcome of bulimia
nervosa. Psychological Medicine, 34, 1395–1406.
Fichter, M. M., Quadflieg, N., & Hedlund, S. (2006). T welve-year course and out-
come predictors of anorexia nervosa. International Journal of Eating Disorders,
39, 87–100.
Downloaded By: [Optimised: University of Minnesota Libraries, Twin Cities] At: 17:44 20 April 2011
Page 18
Number of Purging Behaviors 173
Fleming, J., & Courtney, B. (1984). The dimensionality of self-esteem: Hierarchical
facet model for revised measurement scales. Journal of Personality and Social
Psychology , 46, 404–442.
Garner, D. M. (2004). The Eating Disorders Inventory-3 symptom checklist:
Professional manual. Lutz, FL: Psychological Assessment Resources, Inc.
Grilo, C. M., Pagano, M. E., Skodol, A. E., Sanislow, C. A., McGlashan, T. H.,
Gunderson, J. G., & Stout, R. L. (2007). Natural course of bulimia nervosa and of
eating disorder not otherwise specified: 5-year prospective study of remissions,
relapses, and the effects of personality disorder psychopathology. Journal of
Clinical Psychiatry , 68, 738–746.
Haedt, A. A., Edler, C., Heatherton, T. F., & Keel, P. K. (2006). Importance of multiple
purging methods in the classification of eating disorder subtypes. International
Journal of Eating Disorders, 39, 648–654.
Hay, P. J., Mond, J., Buttner, P., & Darby, A. (2008). Eating disorder behaviors are
increasing: findings from two sequential community surveys in South Australia.
PLoS One, 3(2), e1541.
Keel, P. K. (2007). Purging disorder: Subthreshold variant or full-threshold eating
disorder? International Journal of Eating Disorders, 40, 589–594.
Kruger, J., Galuska, D. A., Serdula, M. K., & Jones, D. A. (2004). Attempting to lose
weight: Specific practices among U.S. adults. American Journal of Preventive
Medicine, 26, 402–406.
Luce, K. H., & Crowther, J. H. (1999). The reliability of the Eating Disorder
Examination Self-Report Questionnaire Version (EDE-Q). International Journal
of Eating Disorders, 25, 349–351.
Luce, K. H., Crowther, J. H., & Pole, M. (2008). Eating Disorder Examination
Questionnaire (EDE-Q): Norms for undergraduate women. International
Journal of Eating Disorders, 41, 273–276.
Milos, G., Spindler, A., Schnyder, U., & Fairburn, C. G. (2005). Instability of eat-
ing disorder diagnoses: Prospective study. British Journal of Psychiatry, 187,
573–578.
Mond, J. M., Hay, P. J., Rodgers, B., & Owen, C. (2006). Eating Disorder Examination
Questionnaire (EDE-Q): Norms for young adult women. Behavior Research
Therapy, 44(1), 53–62.
Mond, J. M., Hay, P. J., Rodgers, B., Owen, C., & Beaumont, P. J. (2004). Temporal
stability of the Eating Disorders Examination Questionnaire. International
Journal of Eating Disorders, 36, 195–203.
Mond, J. M., Hay, P. J., Rodgers, B., Owen, C., & Mitchell, J. E. (2006). Correlates
of the use of purging and non-purging methods of weight control in a commu-
nity sample of women. Australian and New Zealand Journal of Psychiatry, 40,
136–142.
Neumark-Sztainer, D., & Hannan, P. (2000). Weight-related behaviors among ado-
lescent girls and boys: Results from a national survey. Archives of Pediatric and
Adolescent Medicine, 154, 569–577.
Neumark-Sztainer, D., Sherwood, N. E., French, S. A., & Jef fery, R. W. (1999). Weight
control behaviors among adult men and women: Cause for concern? Obesity
Research, 7
, 179–188.
Downloaded By: [Optimised: University of Minnesota Libraries, Twin Cities] At: 17:44 20 April 2011
Page 19
174 D. M. Ackard et al.
Neumark-Sztainer, D., Wall, M. M., Guo, J., Story, M., Haines, J. I., & Eisenberg, M. E.
(2006). Obesity, disordered eating, and eating disorders in a longitudinal study
of adolescents: How do dieters fare 5 years later? American Dietetic Association,
106, 559–568.
Neumark-Sztainer, D., Wall, M. M., Haines, J. I., Story, M. T., Sherwood, N. E., & van
den Berg, P. A. (2007). Shared risk and protective factors for overweight and
disordered eating in adolescents. American Journal of Preventive Medicine, 33,
359–369.
Osman, A., Kopper, B., Barrios, F., Gutierrez, P., & Bagge, C. (2004). Reliability
and validity of the Beck depression inventory - II with adolescent psychiatric
inpatients. Psychological Assessment, 16, 120–132.
Pinto, A. M., Guarda, A. S., Heinberg, L. J., & DiClemente, C. O. (2006). Development
of the Eating Disorder Recovery Self-Efficacy Questionnaire. International
Journal of Eating Disorders, 39, 376–384.
Pinto, A. M., Heinberg, L. J., Coughlin, J. W., Fava, J., & Guarda, A. S. (2008). The
Eating Disorder Recovery Self-Ef ficacy Questionnaire (EDRSQ): Change with
treatment and prediction of outcome. Eating Behaviors, 9, 143–153.
Reba-Harrelson, L., Von Holle, A., Thornton, L. M., Klump, K. L., Berrettini, W. H.,
Brandt, H., . . . Bulik, C.M. (2008). Features associated with diet pill use in
individuals with eating disorders. Eating Behaviors, 9, 73–81.
Robinson, J. P., Shaver, P. R., & Wrightsman, L. S. (1991). Measures of personality
and social psychological attitudes (Vol. 1). San Diego, CA: Academic Press.
Roerig, J. L., Mitchell, J. E., de Zwaan, M., Wonderlich, S. A., Kamran, S., Engbloom,
S., . . . Lancaster, K. (2003). The eating disorders medicine cabinet revisited: A
clinician’s guide to appetite suppressants and diuretics. International Journal
of Eating Disorders, 33, 443–457.
Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton
University Press.
Shisslak, C. M., Crago, M., & Estes, S. (1995). The spectrum of eating disturbances.
International Journal of Eating Disorders, 18, 209–219.
Spielberger, C. D. (2003). Manual for the State-Trait Anxiety Inventory. Palo Alto,
CA: Consulting Psychologists Press.
SPSS, I. (2005). SPSS 11.0 for the Macintosh OS-X. Chicago, IL: SPSS, Inc.
Steffen, K. J., Mitchell, J. E., Roerig, J. L., & Lancaster, K. L. (2007). The eating
disorders medicine cabinet revisited: A clinician’s guide to Ipecac and laxatives.
International Journal of Eating Disorders, 40, 360–368.
Steinhausen, H.-C. (2008). Outcome of eating disorders. Child and Adolescent
Psychiatric Clinics of North America, 18, 225–242.
Stice, E., Fisher, M., & Martinez, E. (2004). Eating Disorder Diagnostic Scale:
Additional evidence of reliability and validity. Psychological Assessment, 16,
60–71.
Stice, E., Telch, C. F., & Rizvi, S. L. (2000). Development and validation of the Eating
Disorder Diagnostic Scale: A brief self-report measure of anorexia, bulimia, and
binge eating disorder. Psychological Assessment, 12, 123–131.
Thiels, C., Schmidt, U., Treasure, J. L., & Garthe, R. (2003). Four-year follow-up
of guided self-change for bulimia nervosa. Eating and Weight Disorders, 8,
212–217.
Downloaded By: [Optimised: University of Minnesota Libraries, Twin Cities] At: 17:44 20 April 2011
Page 20
  • [Show abstract] [Hide abstract] ABSTRACT: Abstract Objective: To examine correlates of compensatory weight control behaviors among women in transition between adolescence and adulthood. Participants: The authors recruited a sample of undergraduate women (N = 759) at a large northwestern university during the 2009-2010 academic year. Methods: Logistic regression was used to assess relations among childhood abuse, psychosocial functioning, adult dating relationship factors, and women's endorsement of compensatory weight control behaviors. Results: The final model reliably distinguished between participants who endorsed versus denied use of compensatory behaviors (χ(2)[5, N = 747] = 36.37, p < .001), with global psychosocial functioning and relationship avoidance accounting for the most variance. Conclusions: These findings illustrate the importance of considering childhood abuse histories and adult relationships while assessing young women's compensatory weight control behaviors.
    No preview · Article · Nov 2013 · Journal of American College Health
  • [Show abstract] [Hide abstract] ABSTRACT: The aim of this study was to compare quality of life in anorexia nervosa patients to that of subjects without eating disorders, with other eating disorders, or with other psychiatric disorders. Results showed reduced quality of life for eating disorder patients, including anorexia nervosa, as compared to normal controls and individuals with other psychiatric disorders; however, whether anorexia nervosa treatment resulted in improved quality of life remains controversial. Furthermore, anorexia nervosa had a modest impact in the physical domain, although this may reflect self-report limitations as well as the psychopathology of the disorder rather than healthy functioning.
    No preview · Article · May 2013 · Eating disorders
  • Source
    [Show abstract] [Hide abstract] ABSTRACT: Sociocultural norms pertaining to an ideal of thinness for women likely play a role in the development and maintenance of disturbance in body image, and by extension, disordered eating. However, competing norms associated with feminism may buffer women from pressures associated with achieving the thin ideal. The present study explored the relationship between feminist ideology, empowerment, and self-efficacy relative to body image and eating behavior with a sample of U.S. undergraduate women (N=318) attending a southeastern U.S. mid-sized university. In planned hierarchical multiple regression analyses, endorsement of feminist ideology predicted perceptions of positive body image, but did not appear to predict disordered eating. Self-efficacy emerged as a robust predictor of positive body image and lower disordered eating even after controlling for perceptions of personal empowerment and feminism. Results, although limited by correlational data, suggest that self-efficacy may protect college-aged women from disordered eating and negative body image.
    Full-text · Article · Sep 2013 · Body image
Show more