- Open access
- Published: 13 October 2021
![](http://sektorel.online/777/templates/cheerup/res/banner1.gif)
Stressful life events among individuals with a history of eating disorders: a case-control comparison
- Selma Ø. Lie 1 , 2 ,
- Cynthia M. Bulik 3 , 4 , 5 ,
- Ole A. Andreassen 6 , 7 ,
- Øyvind Rø 1 , 2 &
- Lasse Bang 1 , 8
BMC Psychiatry volume 21 , Article number: 501 ( 2021 ) Cite this article
5105 Accesses
17 Citations
3 Altmetric
Metrics details
Experiencing stressful life events (SLEs) can negatively impact mental health and increase risk for psychiatric disorders including eating disorders (EDs). Previous research has shown that childhood sexual abuse is associated with some EDs, but less is known about the association between other non-sexual SLEs and EDs.
A case-control study of individuals with ( n = 495, age mean ± SD = 29.1 ± 9.8 years) and without ( n = 395, age = 30.2 ± 11.7) self-reported lifetime history of EDs was conducted to compare history of self-reported SLEs. Participants reported history of sexual (e.g., rape, other sexual assault) and non-sexual (e.g., emotional abuse, assault, bereavement) life events using an adaptation of the Stressful Life Events Screening Questionnaire. Individuals with EDs were divided into ED subtypes along the restricting – binge eating/purging spectrum to examine subtype differences. Logistic regressions were conducted for each SLE and ED subtype to obtain odds ratios (ORs). We report p -values corrected for multiple comparisons.
Exposure to any SLE was significantly more common in individuals with EDs than in controls (OR = 2.47, p < .001). Specifically, rape, other sexual assault, and emotional abuse were significantly more common among individuals with a history of binge-eating/purging ED subtypes (ORs = 2.15–3.58, p ’s < .01) compared with controls. Furthermore, history of life-threatening disease and loss of a close relative/partner/friend were associated with some ED subtypes. The association between SLEs and EDs was stronger for individuals who had experienced multiple SLEs.
By investigating a range of different SLEs, we showed that both sexual and non-sexual SLEs were more common in individuals with a history of EDs (binge-eating/purging subtypes) than controls. Results highlight the importance of assessing a variety of past SLEs in risk assessment for different EDs.
Peer Review reports
Introduction
Anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED) are eating disorders (EDs) characterized by dysregulated food intake. Both genetic and environmental risk factors have been implicated in the development and maintenance of EDs [ 1 , 2 ]. Negative or stressful life events (SLEs) are among many environmental risk factors that have garnered interest in the ED field. In the context of this paper, we consider all negative and potential stressful life events together, including various forms of abuse, assault, bereavement, car accidents, being threatened, been diagnosed with a serious disease, etc. Many of these events are commonly referred to as ‘traumas’, but considering the diversity of events included we collectively refer to these as SLEs. Childhood maltreatment, particularly sexual abuse, is among those most studied and has been implicated as a risk factor for the development of EDs [ 3 , 4 , 5 ], and a predictor of treatment dropout [ 6 , 7 ]. A meta-analysis by Molendijk and colleagues [ 4 ] found that childhood maltreatment was two to four times more common among individuals with EDs than healthy controls, and was associated with more severe ED symptoms, earlier onset age, and more frequent binge-eating and purging behaviours.
To date, associations between SLEs and EDs are more consistent for binge-eating/purging subtypes (i.e., BN and BED) than restricting (i.e., AN) subtypes [ 3 , 4 , 8 , 9 , 10 , 11 , 12 ]. A recent review of published risk factor meta-analyses investigating a range of risk factors found evidence for childhood sexual abuse as a risk factor for BN, while the evidence was weaker for the other ED subtypes [ 13 ]. A stronger association between adverse events and binge-eating/purging behaviors has also been reported in individuals with AN, where both childhood and adult sexual abuse were more commonly associated with the binge-eating/purging subtype (AN-BP) than the restricting subtype (AN-R), and was associated with more posttraumatic stress disorder (PTSD) symptoms, emotion dysregulation, and treatment dropout [ 14 , 15 , 16 ]. Thus, converging evidence suggests that SLEs, both in childhood and later in life, may be selectively associated with binge-eating/purging EDs. The evidence is more mixed for AN, and few studies directly address differences between AN-R and AN-BP.
Although the majority of research on SLEs in EDs has focused on childhood sexual abuse [ 5 , 17 , 18 , 19 ], other types of childhood SLEs have also been associated with EDs, including physical and emotional abuse [ 4 , 20 , 21 ]. Studies investigating lifetime SLEs in different populations have found increased risk of ED symptoms in victims of sexual assault [ 22 , 23 , 24 ] and in female war veterans who have experienced traumatic events and/or assaults [ 25 ]. A range of relatively common childhood events such as parental illness, parental divorce, changing schools, and bullying, have also been asociated with EDs [ 26 , 27 , 28 ]. Despite a rich literature highlighting many different types of traumatic or stressful events as significant predictors of risk for mental problems [ 29 ], we know little of how common various SLE exposures are among individuals with EDs.
As such, exisiting research supports an association between different SLEs and some EDs, with the most conclusive evidence available for highly traumatic experiences such as sexual abuse. Less is known about other stressful life experiences, and studies investigating other types of SLEs throughout life and their potential associations with different EDs are scarce. Also, few studies have directly investigated how different SLEs are associated with specific EDs (including the two AN subtypes). This has been identified as an important topic for research in recent literature [ 13 , 30 ], and could have implications for our understanding of the etiology and treatment strategies for EDs.
The current study explored history of SLEs in individuals with a lifetime history of EDs and controls. Specifically, we investigated a) whether exposure to a variety of SLEs differed between individuals with a history of EDs and controls, and b) if the association was stronger for individuals who had experienced multiple types of events. Moreover, we explored differences in SLE exposure across different ED subtypes and report results separately for each subtype compared with controls. The main hypothesis was that SLEs would be more prevalent in individuals with EDs than in controls. We also hypothesised that the association between SLEs and EDs would be stronger for binge-eating/purging subtypes than restrictive subtypes, and that it is more common for individuals with EDs to experience multiple types of SLEs.
The present study used data from the Eating Disorders: Genes & Environment (EDGE) project; a cross-sectional study of Norwegian adults investigating a variety of risk factors for EDs. The study was approved by the Norwegian Regional Committee for Medical and Health Research Ethics (#2017/0606), and all procedures were performed in accordance with ethical guidelines and regulations. All participants provided written informed consent.
Participants and procedures
Norwegian residents over the age of 16 were invited to participate in the study by completing an online test battery including questions regarding ED history and experiences of SLEs. Individuals with and without lifetime EDs were invited to participate, and recruitment was targeted at user organisations for EDs and specialised ED treatment units in Norway to reach individuals with a lifetime ED. Recruitment through online/social media platforms (e.g., websites, Facebook), and flyers and posters at Norwegian universities targeted both case and control participants. Data were collected between June 2019 and January 2020.
The ED100K (see below) was used to classify cases and controls according to the presence or absence of lifetime DSM-5 EDs [ 31 ]. A total of 890 participants were classfied as either cases ( n = 495) or controls ( n = 395) according to DSM-5 criteria. Individuals with BN and/or BED (BN/BED n = 180) were combined in one group due to the considerable overlap between the two subtypes in lifetime diagnoses. In addition, previous research has found associations between SLEs and the shared symptomatology of these subtypes (i.e., binge-eating), suggesting that there may be underlying processes that are distinct for binge-eating/purging type disorders when compared to EDs characterised by restricting behaviours [ 4 , 32 ]. AN was divided into the two subtypes (AN-R n = 65 and AN-BP n = 114) to further explore this hypothesis. A mixed ED group (AN/BN/BED n = 133) included all individuals who at some point in their life had met criteria for both AN and BN and/or BED, further emphasising the high crossover between the ED diagnoses over time. We were unable to determine subtype for three individuals in the ED group who were excluded from the subtype analyses. We also calculated the ED onset age, defined as the earliest age of clinically significant symptoms (e.g., low weight, frequent binge eating, compensatory behaviours such as purging, etc.).
ED100K . The self-report measure ED100K (version 2) was used to assess lifetime history of AN, BN, and BED according to DSM-5 criteria [ 33 ]. The ED100K has shown good predictive validity for the different ED types when validated against the Structural Clinical Interview (SCID) for DSM-5 [ 33 ], The measure was adapted to fit the study design and was translated into Norwegian (then back-translated to ensure correspondence). The ED100K contains questions about frequency, duration, and severity of core ED features (e.g., weight history, binge eating, compensatory behaviors) and the age of onset for these features. This enabled us to distinguish between ED cases and controls as well as assigning the individuals with EDs to different subtypes.
Stressful life events screening questionnaire - adapted (SLESQ). The SLESQ is a validated instrument to assess history of different types of stressful events in clinical and non-clinical populations [ 34 ]. The current study used an adapted version of the Norwegian translation developed by Thoresen and Øverlien [ 35 ]. Twelve different items (SLEs) were included in the current study; disease (serious/life threatening), accident (serious/life threatening), assault (e.g., physical attack or robbery), bereavement (loss of a close relative, partner, or friend), rape, other sexual assault (unwanted sexual contact/touching), childhood physical abuse (before 18 years of age), adulthood physical abuse (after 18 years of age), emotional abuse, threatened (with a weapon or by threat of force), witnessed (witnessed a situation where another person was hurt, died, or was abused), and other (any other situations of serious threat to life, health, or safety; this item was not specified further). The complete list of questions is included in Table 1 . For each of these items, the participants indicated whether they had experienced the event (“yes” or “no”), and at what age (first occurrence). For some items (rape, other sexual assault, adulthood physical abuse, childhood physical abuse, emotional abuse, threatened), we also asked how many times the event in question had occured. In addition to the individual items, all participants who responded “yes” to one or more events were coded as “yes” on an overall “Any SLE” variable.
Eating disorder examination-questionnaire (EDE-Q). The EDE-Q is a self-report measure assessing ED psychopathology in the past 28 days [ 36 ], and a Norwegian translation has been previously validated [ 37 ]. For the present study, only the global EDE-Q sum scores were used to compare current ED symptoms and behaviours in cases and controls. The measure demonstrated good internal consistency: α = .96 for controls and α = .95 for the ED group.
For the main analysis, logistic regressions were performed for SLEs comparing each of the ED diagnostic groups with the control group. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported as a measure of effect for each comparison. In all regression models, ED outcome (subtype) was the dependent variable, and the specific SLE (e.g., rape) was entered as a dichotomous predictor (independent variable). We added gender, age, and education as covariates in all models as these variables have been associated with EDs [ 1 ], and to reduce recall bias. Unadjusted regression models were conducted without covariates, but these are not reported as the overall pattern of results was similar to the adjusted model.
To investigate whether individuals with EDs had experienced a higher number of SLEs than controls, three levels of SLE exposure were defined: none, one or two types, three or more types. As the measure of SLE number was heavily skewed (majority, > 75%, of participants had experienced between zero and four SLE types), this categorisation was preferred over the continuous measure to specifically compare low (0), medium (1 or 2), and high (≥3) exposure to SLEs while securing relatively even numbers in all groups. This variable was then used to perform logistic regressions comparing the different levels of SLE exposure as predictors for ED outcome (with gender, age, and education as covariates).
Separate analyses of variance (ANOVAs) were used to compare differences in continous variables between case and control groups.
In all models, alpha levels were adjusted using the Bonferroni-Holm correction for multiple comparisons within each family of tests. To ease interpretation, we report corrected p -values and p < 0.05 was considered statistically significant. All analyses were conducted using R version 4.0.3 [ 38 ].
Participant characteristics
Table 2 shows sample characteristics. The sample comprised individuals between the ages 16–78 years (M = 29.5 ± 10.6), and was predominantly female (95%). The lifetime ED group did not differ from controls on age or current body mass index (BMI, kg/m 2 based on self-reported weight and height). The majority (89%) of the ED group reported having received treatment for an ED, and they had a higher EDE-Q global score than controls ( p < .001). The control group had significantly higher completed education ( p = .002); more individuals had completed university education ≤4 years in the control group (28.9%) than the ED group (18.4%). The average age of ED onset was 15 years, and the average age reported for any SLE was between 10 and 14 years for the dfferent ED subtypes. Frequency and age for the different SLEs are listed in Table 3 .
Are SLEs more common in individuals with EDs than controls?
A total of 81% of all individuals with lifetime EDs had experienced one or more SLEs, compared to 65% in the control group. Many of the SLEs assessed were events that are commonly experienced throughout a lifetime (e.g., bereavement) and we therefore expected the majority of both cases and controls to report at least one SLE. Of the total ED sample, 56% had experienced one or more SLEs prior to ED onset. Of all the individuals in the ED group who reported a history of SLEs, 68% reported that at least one of the SLEs had occurred prior to ED onset age. The overall case-control comparison of exposure to any SLE in individuals with and without lifetime EDs yielded an OR of 2.47 (95% CI 1.80–3.40, p < .001). Individuals in the AN-BP, BN/BED, and AN/BN/BED groups had significantly higher frequency of any SLE than individuals in the control group (all p’ s < .05; see Table 4 ). Individuals with AN-R did not differ significantly from controls in overall SLE history ( p > .05).
What types of SLEs are associated with the different EDs?
The most commonly reported specified SLE in both ED and control groups was emotional abuse (43 and 21%, respectively). The second most common was other sexual assault (35% of ED group, 19% of controls), followed by rape for the ED group (28% of ED, 14% of controls) and child physical abuse for the controls (22% of ED, 16% of controls). This pattern was similar for each of the ED subtypes, except for AN-R where other sexual assault (26%) was more common than emotional abuse (23%). This is shown in Table 3 .
Of all the specified SLEs in the study, three events reached significance (all p < .05) for the three groups AN-BP, BN/BED, AN/BN/BED compared with controls: rape, other sexual assault, and emotional abuse (Table 4 ). Disease was significant for the AN-BP ( p = .029) and the AN/BN/BED ( p = .018) groups, and bereavement was significant for the BN/BED group only ( p = .038). In addition, individuals in all ED groups (including AN-R) scored significantly higher than the control group on the SLE category “other”, which was also the most commonly reported of all the SLE items across all groups.
Follow up analysis for the SLEs reaching significance for the three binge/purge ED groups (rape, other sexual assault, and emotional abuse) revealed no significant differences in age of event between groups except for a slightly lower age for rape in the mixed AN/BN/BED group (M = 12.3 ± 6.2) than controls (M = 16.3 ± 6.0; p = .028). The frequency of sexual assault was also higher in the BN/BED (M = 2.5 ± 1.19) group than in controls (M = 1.59 ± 0.86; p < .001). No other group differences in frequency were significant. In the ED sample as a whole, the proportion of reported SLEs that had occurred prior to ED onset age was 43.1% for rape, 56.6% for emotional abuse, and 49.4% for other sexual assault.
Is the association between SLEs and EDs stronger for individuals with a history of multiple SLEs?
Individuals with EDs reported experiencing a higher number of different SLEs (M = 2.6, M dn = 2) than individuals in the control group (M = 1.6, M dn = 1; p < .001). The overall case-control comparison showed that individuals in the ED group were significantly more likely to have experienced three or more SLEs (OR 2.08, 95% CI 1.49–2.90), than one or two SLE types (OR 1.82, 95% CI 1.30–2.57) compared with controls (see Table 5 ). Apart from the AN-R subtype, a pattern emerged that was consistent with a cumulative effect of multiple SLE types for all subtypes (AN-BP, BN/BED, AN/BN/BED). Thus, there was support for an association between binge-eating/purging EDs and SLEs that was stronger for individuals with more extensive SLE history.
The current study investigated the history of a variety of different lifetime SLEs in individuals with and without lifetime EDs, differentiated by subtype. Individuals with binge-eating/purging subtypes of EDs had experienced SLEs more often than controls, and it was more common for these groups to be exposed to multiple types of events. Rape, other sexual assault, and emotional abuse were significantly more common in the ED group as a whole than in the control group, and this held true for all ED subtypes with the exception of AN-R. This is consistent with previous research reporting a stronger association between a range of SLEs and binge-eating/purging EDs than restrictive AN [ 4 , 12 , 26 , 39 , 40 ]. The event category “other SLE” was significantly more common in all ED groups, and certain SLEs (bereavement and life-threatening disease) were more common for only some ED subtypes. The average onset age for both ED onset and SLE was during adolescence, and the majority of SLEs in the ED group occurred prior to ED onset. More than half of the ED group had experienced at least one SLE prior to developing significant ED symptoms, which raises the possibility that such events can be a trigger contributing to the onset of EDs. By assessing a number of different SLEs throughout life, we showed that both non-sexual and sexual SLEs are associated with binge-eating/purging EDs and thus add to the growing knowledge of sociocultural factors in EDs.
Our findings support the observation that exposure to SLEs is more prevalent among individuals with binge-eating/purging EDs than controls. These individuals were between two and three times more likely than controls to have experienced any SLE, with the highest individual associations being for sexual and emotional abuse. The association was also stronger for those with a higher number of different SLEs. This finding is consistent with other research showing a cumulative effect of multiple adversities on a range of negative health outcomes [ 41 ]. The strength of the associations in the present study is comparable to previous studies finding OR’s in the range of 2–3 for different types of adversities including emotional, physical and sexual child abuse, sexual assault, family disruption, parental psychiatric illness, parental teasing, and bullying [ 3 , 26 , 40 , 42 , 43 , 44 , 45 ]. We have previously reported associations between school-age bullying and EDs in the same sample as the present study, with a similar pattern of results [ 28 ]. Together, these findings indicate that history of SLEs is common among individuals with EDs, underscoring the importance of environmental factors in these patient groups.
Various SLEs were more common in individuals with AN-BP, BN/BED, and AN/BN/BED than controls, whereas this was not the case for the AN-R group. While we note that these analyses could be underpowered due to a relatively small sample size for the AN subtypes ( n = 65 for AN-R, n = 114 for AN-BP), other studies have found similar subtype differences regarding AN-R [ 14 , 16 ]. Why individuals with restricting ED subtypes would be less likely to have experienced SLEs is unclear. One interpretation is that SLEs and traumas cause behaviors that are characterized by impulsivity, as many studies have found associations between SLEs and other impulsive behaviours and maladaptive coping such as suicide attempts [ 46 ] and substance abuse [ 47 , 48 ] in addition to the more ED specific behaviours binge eating and purging [ 4 , 10 , 49 ]. Behavioural impulsivity has also been shown to mediate the relationship between childhood abuse and binge eating and purging in non-clinical populations [ 50 , 51 ]. Relatedly, personality traits such as sensation seeking and disinhibition have been associated with both BN/BED and victimisation experiences [ 52 ]. In addition, SLEs might differentially affect BN and BED – and different types of SLEs could be related to specific types of binge/purge symptoms. This would be obscured due to the combination of BN and BED in one group in the current study, and would need to be explored in future research.
In line with findings implicating an association between impulsive psychopathologies and SLEs, it has been suggested that AN-R in particular might have a different etiology than other EDs [ 1 , 26 , 53 ]. Different genetic pathways and interactions between genetic profile and traumatic events could thus account for the observed difference between restricting and binge-eating/purging EDs [ 54 , 55 , 56 ]. Genetic research on AN has also found both psychiatric and metabolic genetic correlations [ 57 ], and it is noteworthy that heritability estimates are higher in restricting than binge-eating/purging EDs, possibly suggesting a more biological etiology [ 58 ]. These observations along with the findings in the present study, may indicate that environmental stressors and triggers are more important in the etiology of binge/purge ED subtypes than restricting subtypes, which could have clinical implications for prevention and treatment.
In terms of specific SLEs, our results highlight that a range of SLEs are commonly experienced by individuals with EDs. This is in line with previous findings (e.g., [ 4 , 59 ]). Sexual traumas (rape and other sexual assault) were significantly associated with binge-eating/purging ED subtypes in the current study. This is consistent with previous literature highlighting sexual abuse in childhood [ 3 , 4 , 5 ] and sexual assault and harassment in adulthood [ 23 , 42 , 60 , 61 , 62 , 63 ] as risk factors for ED psychopathology and diagnosis. We also found that emotional abuse was significantly associated with binge-eating/purging EDs. This was common for both cases and controls (20–45%), and resulting ORs were particularly high (2.54–3.27). Emotional abuse has previously been studied mainly in childhood and adolescence and although fewer studies are available than for sexual abuse, the research supports a role of childhood emotional abuse in EDs [ 4 , 16 , 20 , 21 ]. Additionally, bereavement was significantly associated with BN/BED, which is consistent with a recent review highlighting non-abusive family-related risk factors [ 64 ]. Having a serious or life-threatening disease was significantly associated with AN-BP and AN/BN/BED. This could be consistent with previous research implicating immune system disturbances as risk factors for EDs [ 13 , 65 , 66 ], but we cannot rule out the possibility that some participants might have responded “yes” to this item because of their ED—for example in the case of somatically unstable AN or other complications. The final SLE category “other stressful life events” was also significant for all ED groups. This could include a range of different life experiences (for example divorce, financial difficulties, etc.), and indicates that there could be many more SLEs other than «typical» traumatic experiences that could be of interest to investigate in ED populations.
On average, most of the significant events occurred during early to middle adolescence in the present study. Thus, the average age for the significant SLEs associated with EDs was between 10 and 21 years for the different diagnostic groups, indicating that many of these events would have coincided with ED onset age (average 15 years). Indeed, in 68% of the individuals with EDs who reported SLEs, at least one event occured prior to our calculated ED onset age based on presence of symptoms. This is consistent with the notion that these events could be risk factors for the development of EDs [ 2 ], and in line with a handful of longitudinal studies finding increased risk of disordered eating in individuals who have experienced childhood maltreatment or other traumas [ 67 , 68 , 69 , 70 ]. Moreover, in a study by Brewerton et al. [ 71 ], history of victimisation and PTSD symptoms were associated with child onset binge eating, as opposed to adult onset. Thus, the timing of ED onset and SLE occurrence is an important factor to include in future studies. As there are still unanswered questions regarding the mechanisms of the associations between EDs and SLEs, further prospective studies are needed to explore this and extend to a wider range of lifetime experiences.
Although childhood physical abuse has previously been linked to EDs [ 3 , 4 ], both childhood and adulthood physical abuse were among the SLEs not significicantly associated with EDs in the present study. Some of these non-significant associations could be due to low power, as some events were infrequent in both ED and control groups. For example, being threatened was only experienced by 3–9% of individuals in all groups. The low prevalence for some events can be due to cultural and societal factors, as for example childhood maltreatment is less common in Scandinavian countries compared to the US and many other countries [ 72 , 73 , 74 ]. As such, we contribute to the current understanding of stressful life events and EDs by highlighting the role of sexual and emotional stressors, while not ruling out the possibility that other types of events may be important.
The current study used a convenience sample, and recruited participants mainly through online channels. Many of the participants were reached through ED-specific social media accounts and user-forums. This might have biased our sample towards more severe ED presentations, with a higher proportion of AN in the ED case group than what we would expect in the general population. In addition, this sampling method is likely to reach predominantly younger participants, and the sample had an average age of ≈ 30 yrs. (Mdn = 27). We therefore acknowledge that the ED case groups in the current study may not be representative of the ED population at large. However, as previous research has also found, there seems to be a subgroup of individuals with EDs who have a history of SLEs that may be related to the development, maintenance, severity, or clinical presentation of their symptoms. The co-occurrence and relationship between ED symptoms and SLE history has implications for treatment strategies for this group, and we refer to other studies providing in-depth discussions and experiences about the clinical interventions and treatment delivery for these individuals [ 75 , 76 , 77 ].
Our study has a number of limitations. First, we used self-report measures both for establishing ED status and for documenting SLEs. However, we used a comprehensive and previously validated measue (ED100K) for ED assessment and a validated measure for SLEs. Second, the retrospective nature of our study may introduce recall bias, which we attempted to account for by controlling for current age. This design also precludes us from drawing causal inferences, and further studies are needed to explore potential bi-directional relationships or third-variables that could affect the associations between SLEs and EDs. For example, we did not measure PTSD symptoms in the current study and we cannot determine whether the observed differences were influenced by such symptoms. Third, we did not consider events such as for example military experiences or natural disaster, and there could be other events that are associated with EDs not explored in the current study. Fourth, we did not include a psychiatric control group, and the sample was predominantly female. We also lack information regarding race or ethnicity of our sample, but note that the population of Norway is primarily of Northern European descent. Last, we did not directly compare ED subtypes as these comparisons would likely suffer from low power, and we combined BN and BED into one group which prevented us from investigating potential differences in SLE history for these two subtypes.
Conclusions
The current study showed that SLEs were more frequently reported by individuals with binge-eating/purging EDs than controls. While previous studies of SLEs have typically focused on sexual abuse, we queried a number of different events and found that both sexual (e.g., rape, other sexual assault) and non-sexual (e.g., emotional abuse, bereavement) events were more common among individuals with a history of EDs. These events may consistute risk factors, but prospective studies are needed to establish this further. Future studies are also needed to explore if timing of events is important, and whether there is a dose-response relationship between SLEs and EDs. In addition, an interesting avenue for further research is the exploration of potential gene – environment interactions, which may be relevant in the study of risk factor assessment for EDs [ 78 ]. Our results highlight that one or more SLEs are more commonly reported in individuals with ED subtypes marked by binge eating and purging than in controls, and encourage thorough assessment of SLEs to inform case conceptualization, treatment strategies, and risk assessment for this patient group.
Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Abbreviations
Anorexia nervosa binge-eating/purging subtype
Anorexia nervosa restricting subtype
- Binge-eating disorder
- Bulimia nervosa
- Eating disorders
Stressful life event
Mitchison D, Hay PJ. The epidemiology of eating disorders: genetic, environmental, and societal factors. Clin Epidemiol. 2014;6:89–97. https://doi.org/10.2147/CLEP.S40841 .
Article PubMed PubMed Central Google Scholar
Jacobi C, Hayward C, de Zwaan M, Kraemer HC, Agras WS. Coming to terms with risk factors for eating disorders: application of risk terminology and suggestions for a general taxonomy. Psychol Bull. 2004;130(1):19–65. https://doi.org/10.1037/0033-2909.130.1.19 .
Article PubMed Google Scholar
Caslini M, Bartoli F, Crocamo C, Dakanalis A, Clerici M, Carrà G. Disentangling the association between child abuse and eating disorders: a systematic review and meta-analysis. Psychosom Med. 2016;78(1):79–90. https://doi.org/10.1097/PSY.0000000000000233 .
Molendijk M, Hoek H, Brewerton T, Elzinga B. Childhood maltreatment and eating disorder pathology: a systematic review and dose-response meta-analysis. Psychol Med. 2017;47(8):1402–16. https://doi.org/10.1017/S0033291716003561 .
Article Google Scholar
Afifi TO, Sareen J, Fortier J, Taillieu T, Turner S, Cheung K, et al. Child maltreatment and eating disorders among men and women in adulthood: results from a nationally representative United States sample. Int J Eat Disord. 2017;50(11):1281–96. https://doi.org/10.1002/eat.22783 .
Rodríguez M, Pérez V, García Y. Impact of traumatic experiences and violent acts upon response to treatment of a sample of Colombian women with eating disorders. Int J Eat Disord. 2005;37(4):299–306. https://doi.org/10.1002/eat.20091 .
Mahon J, Bradley SN, Harvey PK, Winston AP, Palmer RL. Childhood trauma has dose-effect relationship with dropping out from psychotherapeutic treatment for bulimia nervosa: a replication. Int J Eat Disord. 2001;30(2):138–48. https://doi.org/10.1002/eat.1066 .
Article CAS PubMed Google Scholar
Spiegel J, Arnold S, Salbach H, et al. Emotional abuse interacts with borderline personality in adolescent inpatients with binge-purging eating disorders. Eat Weight Disord. 2021. https://doi.org/10.1007/s40519-021-01142-3 .
Kimber M, McTavish JR, Couturier J, Boven A, Gill S, Dimitropoulos G, et al. Consequences of child emotional abuse, emotional neglect and exposure to intimate partner violence for eating disorders: a systematic critical review. BMC Psychol. 2017;5(1):33.
Brewerton TD, Perlman MM, Gavidia I, Suro G, Genet J, Bunnell DW. The association of traumatic events and posttraumatic stress disorder with greater eating disorder and comorbid symptom severity in residential eating disorder treatment centers. Int J Eat Disord. 2020;53(12):2061–6. https://doi.org/10.1002/eat.23401 .
Palmisano GL, Innamorati M, Sarracino D, Bosco A, Pergola F, Scaltrito D, et al. Trauma and dissociation in obese patients with and without binge eating disorder: a case – control study. Cogent Psychol. 2018;5(1):1470483. https://doi.org/10.1080/23311908.2018.1470483 .
Palmisano GL, Innamorati M, Vanderlinden J. Life adverse experiences in relation with obesity and binge eating disorder: a systematic review. J Behav Addict. 2016;5(1):11–31. https://doi.org/10.1556/2006.5.2016.018 .
Solmi M, Radua J, Stubbs B, Ricca V, Moretti D, Busatta D, et al. Risk factors for eating disorders: an umbrella review of published meta-analyses. Braz J Psychiatry. 2020;43(3):314–23. https://doi.org/10.1590/1516-4446-2020-1099 .
Article PubMed Central Google Scholar
Carter JC, Bewell C, Blackmore E, Woodside DB. The impact of childhood sexual abuse in anorexia nervosa. Child Abuse Negl. 2006;30(3):257–69. https://doi.org/10.1016/j.chiabu.2005.09.004 .
Longo P, Bertorello A, Panero M, Abbate-Daga G, Marzola E. Traumatic events and post-traumatic symptoms in anorexia nervosa. Eur J Psychotraumatol. 2019;10(1):1682930. https://doi.org/10.1080/20008198.2019.1682930 .
Jaite C, Schneider N, Hilbert A, Pfeiffer E, Lehmkuhl U, Salbach-Andrae H. Etiological role of childhood emotional trauma and neglect in adolescent anorexia nervosa: a cross-sectional questionnaire analysis. Psychopathology. 2012;45(1):61–6. https://doi.org/10.1159/000328580 .
Wolf NM, Elklit A. Child maltreatment and disordered eating in adulthood: a mediating role of PTSD and self-esteem? J Child Adolesc Trauma. 2020;13(1):21–32. https://doi.org/10.1007/s40653-018-0224-x .
Madowitz J, Matheson BE, Liang J. The relationship between eating disorders and sexual trauma. Eat Weight Disord. 2015;20(3):281–93. https://doi.org/10.1007/s40519-015-0195-y .
Vrabel KR, Hoffart A, Rø Ø, Martinsen EW, Rosenvinge JH. Co-occurrence of avoidant personality disorder and child sexual abuse predicts poor outcome in long-standing eating disorder. J Abnorm Psychol. 2010;119(3):623–9. https://doi.org/10.1037/a0019857 .
Kent A, Waller G, Dagnan D. A greater role of emotional than physical or sexual abuse in predicting disordered eating attitudes: the role of mediating variables. Int J Eat Disord. 1999;25(2):159–67. https://doi.org/10.1002/(SICI)1098-108X(199903)25:2<159::AID-EAT5>3.0.CO;2-F .
Waller G, Corstorphine E, Mountford V. The role of emotional abuse in the eating disorders: implications for treatment. Eat Disord. 2007;15(4):317–31. https://doi.org/10.1080/10640260701454337 .
Schou-Bredal I, Bonsaksen T, Ekeberg Ø, Skogstad L, Grimholt TK, Lerdal A, et al. Sexual assault and the association with health, quality of life, and self-efficacy in the general Norwegian population. J Interpers Violence. 2020;0886260520926307:088626052092630. https://doi.org/10.1177/0886260520926307 .
Fischer S, Stojek M, Hartzell E. Effects of multiple forms of childhood abuse and adult sexual assault on current eating disorder symptoms. Eat Behav. 2010;11(3):190–2. https://doi.org/10.1016/j.eatbeh.2010.01.001 .
Collins B, Fischer S, Stojek M, Becker K. The relationship of thought suppression and recent rape to disordered eating in emerging adulthood. J Adolesc. 2014;37(2):113–21. https://doi.org/10.1016/j.adolescence.2013.11.002 .
Arditte Hall KA, Bartlett BA, Iverson KM, Mitchell KS. Eating disorder symptoms in female veterans: the role of childhood, adult, and military trauma exposure. Psychol Trauma. 2018;10(3):345–51. https://doi.org/10.1037/tra0000301 .
Larsen JT, Munk-Olsen T, Bulik CM, Thornton LM, Koch SV, Mortensen PB, et al. Early childhood adversities and risk of eating disorders in women: a Danish register-based cohort study. Int J Eat Disord. 2017;50(12):1404–12. https://doi.org/10.1002/eat.22798 .
Darling KE, Ranzenhofer LM, Hadley W, Villalta D, Kasper V, Jelalian E. Negative childhood experiences and disordered eating in adolescents in a weight management program: the role of depressive symptoms. Eat Behav. 2020;38:101402. https://doi.org/10.1016/j.eatbeh.2020.101402 .
Lie SØ, Bulik CM, Andreassen OA, Rø Ø, Bang L. The association between bullying and eating disorders: A case–control study. Int J Eat Disord. 2021;54:1405–14. https://doi.org/10.1002/eat.23522 .
Cohen S, Murphy MLM, Prather AA. Ten surprising facts about stressful life events and disease risk. Annu Rev Psychol. 2019;70(1):577–97. https://doi.org/10.1146/annurev-psych-010418-102857 .
van Eeden AE, Oldehinkel AJ, van Hoeken D, Hoek HW. Risk factors in preadolescent boys and girls for the development of eating pathology in young adulthood. Int J Eat Disord. 2021;54(7):1–13. https://doi.org/10.1002/eat.23496 .
APA. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.
Google Scholar
Groth T, Hilsenroth M, Boccio D, Gold J. Relationship between trauma history and eating disorders in adolescents. J Child Adolesc Trauma. 2020;13(4):443–53. https://doi.org/10.1007/s40653-019-00275-z .
Thornton LM, Munn-Chernoff MA, Baker JH, Juréus A, Parker R, Henders AK, et al. The anorexia nervosa genetics initiative (ANGI): overview and methods. Contemp Clin Trials. 2018;74:61–9. https://doi.org/10.1016/j.cct.2018.09.015 .
Goodman LA, Corcoran C, Turner K, Yuan N, Green BL. Assessing traumatic event exposure: general issues and preliminary findings for the stressful life events screening questionnaire. J Trauma Stress. 1998;11(3):521–42. https://doi.org/10.1023/A:1024456713321 .
Thoresen S, Øverlien C. Trauma victim: yes or no?: why it may be difficult to answer questions regarding violence, sexual abuse, and other traumatic events. Violence Against Women. 2009;15(6):699–719. https://doi.org/10.1177/1077801209332182 .
Fairburn CG, Beglin SJ. Eating disorder examination questionnaire. Cognitive behavior therapy and eating disorders. New York: Guilford Press; 2008. p. 309–13.
Rø Ø, Reas DL, Lask B. Norms for the eating disorder examination questionnaire among female university students in Norway. Nord J Psychiatry. 2010;64(6):428–32. https://doi.org/10.3109/08039481003797235 .
R Core Team. R: a language and environment for statistical computing. Vienna: R Foundation for statistical Computing; 2019.
Carr CP, Martins CMS, Stingel AM, Lemgruber VB, Juruena MF. The role of early life stress in adult psychiatric disorders: a systematic review according to childhood trauma subtypes. J Nerv Ment Dis. 2013;201(12):1007–20. https://doi.org/10.1097/NMD.0000000000000049 .
Hicks White AA, Pratt KJ, Cottrill C. The relationship between trauma and weight status among adolescents in eating disorder treatment. Appetite. 2018;129:62–9. https://doi.org/10.1016/j.appet.2018.06.034 .
Hughes K, Bellis MA, Hardcastle KA, Sethi D, Butchart A, Mikton C, et al. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Public Health. 2017;2(8):e356–e66. https://doi.org/10.1016/S2468-2667(17)30118-4 .
Chen LP, Murad MH, Paras ML, Colbenson KM, Sattler AL, Goranson EN, et al. Sexual abuse and lifetime diagnosis of psychiatric disorders: systematic review and Meta-analysis. Mayo Clin Proc. 2010;85(7):618–29. https://doi.org/10.4065/mcp.2009.0583 .
Lie SØ, Rø Ø, Bang L. Is bullying and teasing associated with eating disorders? A systematic review and meta-analysis. Int J Eat Disord. 2019;52(5):497–514. https://doi.org/10.1002/eat.23035 .
Dahill LM, Touyz S, Morrison NMV, Hay P. Parental appearance teasing in adolescence and associations with eating problems: a systematic review. BMC Public Health. 2021;21(1):450. https://doi.org/10.1186/s12889-021-10416-5 .
Okada LM, Miranda RR, Pena GDG, Levy RB, Azeredo CM. Association between exposure to interpersonal violence and social isolation, and the adoption of unhealthy weight control practices. Appetite. 2019;142:104384. https://doi.org/10.1016/j.appet.2019.104384 .
Afifi TO, Enns MW, Cox BJ, Asmundson GJG, Stein MB, Sareen J. Population attributable fractions of psychiatric disorders and suicide ideation and attempts associated with adverse childhood experiences. Am J Public Health. 2008;98(5):946–52. https://doi.org/10.2105/AJPH.2007.120253 .
Khoury L, Tang YL, Bradley B, Cubells JF, Ressler KJ. Substance use, childhood traumatic experience, and posttraumatic stress disorder in an urban civilian population. Depress Anxiety. 2010;27(12):1077–86. https://doi.org/10.1002/da.20751 .
Ullman SE, Relyea M, Peter-Hagene L, Vasquez AL. Trauma histories, substance use coping, PTSD, and problem substance use among sexual assault victims. Addict Behav. 2013;38(6):2219–23. https://doi.org/10.1016/j.addbeh.2013.01.027 .
Brewerton TD, Dansky BS, O'Neil PM, Kilpatrick DG. The number of divergent purging behaviors is associated with histories of trauma, PTSD, and comorbidity in a national sample of women. Brunner-Mazel Eat Disord Monogr Ser. 2015;23(5):422–9. https://doi.org/10.1080/10640266.2015.1013394 .
Dworkin E, Javdani S, Verona E, Campbell R. Child sexual abuse and disordered eating: the mediating role of impulsive and compulsive tendencies. Psychol Violence. 2014;4(1):21–36. https://doi.org/10.1037/a0031779 .
Wonderlich S, Crosby R, Mitchell J, Thompson K, Redlin J, Demuth G, et al. Pathways mediating sexual abuse and eating disturbance in children. Int J Eat Disord. 2001;29(3):270–9. https://doi.org/10.1002/eat.1018 .
Brewerton TD, Cotton BD, Kilpatrick DG. Sensation seeking, binge-type eating disorders, victimization, and PTSD in the National Women's study. Eat Behav. 2018;30:120–4. https://doi.org/10.1016/j.eatbeh.2018.07.001 .
Monteleone AM, Cascino G, Ruzzi V, Pellegrino F, Patriciello G, Barone E, et al. Emotional traumatic experiences significantly contribute to identify a maltreated ecophenotype sub-group in eating disorders: experimental evidence. Eur Eat Disorders Rev. 2021;29(2):269–80. https://doi.org/10.1002/erv.2818 .
Duncan L, Yilmaz Z, Gaspar H, Walters R, Goldstein J, Anttila V, et al. Significant Locus and Metabolic Genetic Correlations Revealed in Genome-Wide Association Study of Anorexia Nervosa. Am J Psychiatry. 2017;174(9):850–8. https://doi.org/10.1176/appi.ajp.2017.16121402 .
Rozenblat V, Ong D, Fuller-Tyszkiewicz M, Akkermann K, Collier D, Engels RCME, et al. A systematic review and secondary data analysis of the interactions between the serotonin transporter 5-HTTLPR polymorphism and environmental and psychological factors in eating disorders. J Psychiatr Res. 2017;84:62–72. https://doi.org/10.1016/j.jpsychires.2016.09.023 .
Li D, Chang X, Connolly JJ, Tian L, Liu Y, Bhoj EJ, et al. A genome-wide association study of anorexia nervosa suggests a risk locus implicated in dysregulated leptin signaling. Sci Rep. 2017;7(1):3847. https://doi.org/10.1038/s41598-017-01674-8 .
Article CAS PubMed PubMed Central Google Scholar
Watson HJ, Yilmaz Z, Thornton LM, Hübel C, Coleman JRI, Gaspar HA, et al. Genome-wide association study identifies eight risk loci and implicates metabo-psychiatric origins for anorexia nervosa. Nat Genet. 2019;51(8):1207–14. https://doi.org/10.1038/s41588-019-0439-2 .
Yilmaz Z, Hardaway JA, Bulik CM. Genetics and epigenetics of eating disorders. Adv Genomics Genet. 2015;5:131–50. https://doi.org/10.2147/AGG.S55776 .
Brewerton TD. Eating disorders, trauma, and comorbidity: focus on PTSD. Eat Disord. 2007;15(4):285–304. https://doi.org/10.1080/10640260701454311 .
Wonderlich SA, Crosby RD, Mitchell JE, Thompson KM, Redlin J, Demuth G, et al. Eating disturbance and sexual trauma in childhood and adulthood. Int J Eat Disord. 2001;30(4):401–12. https://doi.org/10.1002/eat.1101 .
Romito P, Cedolin C, Bastiani F, Saurel-Cubizolles MJ. Disordered eating behaviors and sexual harassment in Italian male and Female University students. J Interpers Violence. 2019;34(14):2960–74. https://doi.org/10.1177/0886260516664315 .
Gomez F, Kilpela LS, Middlemass KM, Becker CB. Sexual trauma uniquely associated with eating disorders: a replication study. Psychol Trauma Theory Res Pract Policy. 2021;13(2):202–5. https://doi.org/10.1037/tra0000586 .
Dansky BS, Brewerton TD, Kilpatrick DG, O'Neil PM. The National Women's study: relationship of victimization and posttraumatic stress disorder to bulimia nervosa. Int J Eat Disord. 1997;21(3):213–28. https://doi.org/10.1002/(SICI)1098-108X(199704)21:3<213::AID-EAT2>3.0.CO;2-N .
Grogan K, MacGarry D, Bramham J, Scriven M, Maher C, Fitzgerald A. Family-related non-abuse adverse life experiences occurring for adults diagnosed with eating disorders: a systematic review. J Eat Disord. 2020;8(1):36. https://doi.org/10.1186/s40337-020-00311-6 .
Hedman A, Breithaupt L, Hübel C, Thornton LM, Tillander A, Norring C, et al. Bidirectional relationship between eating disorders and autoimmune diseases. J Child Psychol Psychiatry. 2019;60(7):803–12. https://doi.org/10.1111/jcpp.12958 .
Zerwas S, Larsen JT, Petersen L, Thornton LM, Quaranta M, Koch SV, et al. Eating disorders, autoimmune, and autoinflammatory disease. Pediatrics. 2017;140(6):e20162089. https://doi.org/10.1542/peds.2016-2089 .
Johnson J, Cohen P, Kasen S, Brook J. Childhood adversities associated with risk for eating disorders or weight problems during adolescence or early adulthood. Am J Psychiatry. 2002;159(3):394–400. https://doi.org/10.1176/appi.ajp.159.3.394 .
Romans SE, Gendall KA, Martin JL, Mullen PE. Child sexual abuse and later disordered eating: a New Zealand epidemiological study. Int J Eat Disord. 2001;29(4):380–92. https://doi.org/10.1002/eat.1034 .
Zelkowitz RL, Zerubavel N, Zucker NL, Copeland WE. Longitudinal associations of trauma exposure with disordered eating: lessons from the Great Smoky Mountains study. Eat Disord. 2021;29(3):208–25. https://doi.org/10.1080/10640266.2021.1921326 .
Sanci L, Coffey C, Olsson C, Reid S, Carlin JB, Patton G. Childhood sexual abuse and eating disorders in females: findings from the Victorian adolescent health cohort study. Arch Pediatr Adolesc Med. 2008;162(3):261–7. https://doi.org/10.1001/archpediatrics.2007.58 .
Brewerton TD, Rance SJ, Dansky BS, O'Neil PM, Kilpatrick DG. A comparison of women with child-adolescent versus adult onset binge eating: results from the National Women's study. Int J Eat Disord. 2014;47(7):836–43. https://doi.org/10.1002/eat.22309 .
Moody G, Cannings-John R, Hood K, Kemp A, Robling M. Establishing the international prevalence of self-reported child maltreatment: a systematic review by maltreatment type and gender. BMC Public Health. 2018;18(1):1164. https://doi.org/10.1186/s12889-018-6044-y .
Gilbert R, Widom CS, Browne K, Fergusson D, Webb E, Janson S. Burden and consequences of child maltreatment in high-income countries. Lancet. 2009;373(9657):68–81. https://doi.org/10.1016/S0140-6736(08)61706-7 .
Thoresen S, Myhre M, Wentzel-Larsen T, Aakvaag HF, Hjemdal OK. Violence against children, later victimisation, and mental health: a cross-sectional study of the general Norwegian population. Eur J Psychotraumatol. 2015;6(1):26259. https://doi.org/10.3402/ejpt.v6.26259 .
Trottier K, Monson CM. Integrating cognitive processing therapy for posttraumatic stress disorder with cognitive behavioral therapy for eating disorders in PROJECT RECOVER. Eat Disord. 2021;29(3):307–25. https://doi.org/10.1080/10640266.2021.1891372 .
Trottier K, Monson CM, Wonderlich SA, MacDonald DE, Olmsted MP. Frontline clinicians’ perspectives on and utilization of trauma-focused therapy with individuals with eating disorders. Eat Disord. 2017;25(1):22–36. https://doi.org/10.1080/10640266.2016.1207456 .
Brewerton TD. An overview of trauma-informed care and practice for eating disorders. J Aggress Maltreat Trauma. 2019;28(4):445–62. https://doi.org/10.1080/10926771.2018.1532940 .
Steiger H, Bruce K, Gauvin L, Groleau P, Joober R, Israel M, et al. Contributions of the glucocorticoid receptor polymorphism (Bcl1) and childhood abuse to risk of bulimia nervosa. Psychiatry Res. 2011;187(1):193–7. https://doi.org/10.1016/j.psychres.2010.10.021 .
Download references
Acknowledgements
The authors would like to thank all the participants for their willingness to contribute to this study, and to the Norwegian user organizations ROS and SPISFO for their support and assistance.
This study (via Dr. Bang) is funded by the South-Eastern Norway Regional Health Authority (#2017083). Dr. Bulik acknowledges funding from the Swedish Research Council (Vetenskapsrådet, award: 538–2013-8864). None of the funding bodies had any role in the design, data collection, data analysis, interpretation of data, or drafting the manuscript.
Author information
Authors and affiliations.
Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
Selma Ø. Lie, Øyvind Rø & Lasse Bang
Division of Mental Health and Addiction, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
Selma Ø. Lie & Øyvind Rø
Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
Cynthia M. Bulik
Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
NORMENT, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
Ole A. Andreassen
Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
Norwegian Institute of Public Health, Oslo, Norway
You can also search for this author in PubMed Google Scholar
Contributions
SØL contributed to data collection, data analysis, interpretation of results, and drafted/revised the manuscript. CMB contributed to the conception and planning of the study, interpretation of results, and in revising the manuscript. OAA contributed to the conception and planning of the study, interpretation of results, and in revising the manuscript. ØR contributed to the conception and planning of the study, interpretation of results, and in revising the manuscript. LB secured funding for the study, and contributed to the conception and planning of the study, data collection, interpretation of results, and in revising the manuscript. All authors read and approved the final manuscript.
Authors’ information
Affiliations: Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway (Selma Øverland Lie, Øyvind Rø, and Lasse Bang); Division of Mental Health and Addiction, Institute of Clinical Medicine, University of Oslo, Oslo, Norway (Selma Øverland Lie and Øyvind Rø); Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (Cynthia M. Bulik); Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA (Cynthia M. Bulik); Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA (Cynthia M. Bulik); NORMENT, Institute of Clinical Medicine, University of Oslo, Norway (Ole A. Andreassen); Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway (Ole A. Andreassen); Norwegian Institute of Public Health, Oslo, Norway (Lasse Bang).
Corresponding author
Correspondence to Selma Ø. Lie .
Ethics declarations
Ethics approval and consent to participate.
The study and all procedures were approved by the Regional Ethics Committee in Norway, South-East region (REK sør-øst, project id# 2017/1606). All participants signed informed consent to participate. All procedures were performed in accordance with ethical guidelines and regulations.
Consent for publication
Not applicable.
Competing interests
CM Bulik reports: Shire (grant recipient, Scientific Advisory Board member); Idorsia (consultant); Lundbeckfonden (grant recipient); Pearson (author, royalty recipient). OA Andreassen received speaker’s honorarium from Lundbeck and Sunovion. Consultant to HealthLytix. The other authors have no conflicts to declare.
Additional information
Publisher’s note.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Reprints and permissions
About this article
Cite this article.
Lie, S.Ø., Bulik, C.M., Andreassen, O.A. et al. Stressful life events among individuals with a history of eating disorders: a case-control comparison. BMC Psychiatry 21 , 501 (2021). https://doi.org/10.1186/s12888-021-03499-2
Download citation
Received : 28 May 2021
Accepted : 24 September 2021
Published : 13 October 2021
DOI : https://doi.org/10.1186/s12888-021-03499-2
Share this article
Anyone you share the following link with will be able to read this content:
Sorry, a shareable link is not currently available for this article.
Provided by the Springer Nature SharedIt content-sharing initiative
- Anorexia nervosa
- Stressful life events
- Risk factor
- Adverse events
- Sexual abuse
- Emotional abuse
BMC Psychiatry
ISSN: 1471-244X
- Submission enquiries: [email protected]
- General enquiries: [email protected]
Antonella: ‘A Stranger in the Family’—A Case Study of Eating Disorders Across Cultures
- Open Access
- First Online: 12 December 2020
Cite this chapter
You have full access to this open access chapter
- Vincenzo Di Nicola 6 , 7
7935 Accesses
2 Citations
7 Altmetric
The story of Antonella illustrates the way in which cultural and other values impact on the presentation and treatment of eating disorders. Displaced from her European home culture to live in Canada, Antonella presents with an eating disorder and a fluctuating tableau of anxiety and mood symptoms linked to her lack of a sense of identity. These arose against a background of her adoption as a foundling child in Italy and her attachment problems with her adoptive family generating chronically unfixed and unstable identities, resulting in her cross-cultural marriage as both flight and refuge followed by intense conflicts. Her predicament is resolved only when after an extended period in cultural family therapy she establishes a deep cross-species identification by becoming a breeder of husky dogs. The wider implications of Antonella’s story for understanding the relationship between cultural values and mental health are briefly considered.
You have full access to this open access chapter, Download chapter PDF
Similar content being viewed by others
![case study for eating disorders alexis case study for eating disorders alexis](https://media.springernature.com/w215h120/springer-static/image/art%3Aplaceholder%2Fimages/placeholder-figure-springernature.png)
Overlaps and Disjunctures: A Cultural Case Study of a British Indian Young Woman’s Experiences of Bulimia Nervosa
René girard and the mimetic nature of eating disorders, the rise of eating disorders in asia: a review.
- Eating disorders
- Anorexia multiforme
- Cultural values
- Uniqueness of the individual
- Role of animals
- Cross-species identification
- Cultural family therapy
1 Introduction
Eating disorders are a potentially fruitful area of study for understanding the links between values—in particular cultural values—and mental distress and disorder. Eating disorders show widely different prevalence rates across cultures, and much attention has been given to theories linking these differences with variations in cultural values. In particular, the cultural value placed on ‘fashionable slimness’ in the industrialised world has for some time been identified with the greater prevalence of eating disorders among women in Western societies [ 1 ]. Consistently with this view, the growing prevalence of eating disorders in other parts of the world does seem to be correlated with increasing industrialisation [ 2 , 3 ]. In my review of cultural distribution and historical evolution of eating disorders , I was so struck by its protean nature and its variability of clinical presentations of anorexia nervosa that I renamed this predicament ‘anorexia multiforme’ [ 4 , 5 ].
The story of Antonella that follows illustrates the potential importance of contemporary theories linking cultural values with eating disorders though also some of their limitations.
2 Case Narrative: Antonella’s Story
Ottawa in the early 1990s. Antonella Trevisan, a 24-year-old woman, was referred to me by an Italian psychiatrist and family therapist, Dr. Claudio Angelo, who had treated her in Italy [ 6 ] . When Antonella came to Canada to live with a man she had met through her work, Dr. Angelo referred her to me. Antonella’s presenting problems concerned two areas of her life: her eating problems, which emerged after her emigration from Italy, and her relationship with her partner in Canada.
2.1 Antonella’s Predicament
My initial psychiatric consultation (conducted in Italian) revealed the complexities of Antonella’s life. This was reflected in the difficulty of making an accurate diagnosis. Her food-related problems had some features of eating disorders , such as restriction of intake, the resulting weight loss, and a history of weight gain and being teased for it. What was missing was the ‘psychological engine’ of an eating disorder: a drive for thinness or a morbid fear of fatness. Her problem was perhaps better understood as a food-related anxiety arising from a ‘globus’ sensation (lump in the throat) and a learned avoidance response that generalized from one specific situation to eating in any context.
Although it was clear that her weight gain in late adolescence and the teasing and insults from her mother had sensitized her, other factors had to be considered. Antonella showed an exquisite rejection sensitivity that both arose from and was a metaphor for the circumstances of her birth and adoption. Her migration to Canada also seemed to generate anxieties and uncertainties, and there were hints of conflicts with her partner. Was she also re-enacting another, earlier trauma? In the first journey of her life, she was given up by her birth mother (or taken away?) and left on the steps of a foundry. In the first year of her life, Antonella had shown failure to thrive and developmental delays. And she had, at best, an insecure attachment to her adoptive family, predisposing her to lifelong insecurities.
2.2 A Therapeutic Buffet
After my assessment, we faced a choice: whether to treat the eating problem concretely, in purely behavioral terms, or more metaphorically, with some form of psychotherapy. Given the stabilization of her eating pattern and her weight and the larger context of her predicament, we negotiated to do psychotherapy. There were several components to her therapy. Starting with a psychiatric consultation, three types of therapy were negotiated, with Antonella sampling a kind of ‘therapeutic buffet’ over a period of some 2 years: individual therapy for Antonella, couple therapy for Antonella and Rick, and brief family therapy with Antonella’s adoptive family visiting from Italy.
The individual work with Antonella was at first exploratory, getting to know the complex bicultural world of the Italian Alps, how she experienced the move to Canada, examining her choices to move here and live with Rick. Sessions were conducted in a mix of Italian and English. At first, the Italian language was like a ‘transitional object’ in her acculturation process; slowly, as she gained confidence in her daily life, English began to dominate her sessions. Under stress, however, she would revert to Italian. I could follow her progress just by noting the balance of Italian and English in each session. This does not imply any superiority of English or language preferences; rather, it acknowledges the social realities of culture making its demands felt even in private encounters. This is the territory of sociolinguistics [ 7 , 8 ] . Like Italian, these individual sessions were a secure home base to which Antonella returned during times of stress or between other attempts to find solutions.
After some months in Canada and the stabilization of her eating problems, Antonella became more invested in examining her relationship to Rick. They had met through work while she was still in Italy. After communicating on the telephone, she daringly took him up on an offer to visit. During her holiday in Canada, a romance developed. After her return to Italy, Antonella made the extraordinary decision to emigrate, giving up an excellent position in industry, leaving her family for a country she did not know well. Rick is 22 years her senior and was only recently separated from his first wife.
In therapy she not only expressed ambivalence about her situation with Rick but enacted it. She asked for couple sessions to discuss some difficulties in their relationship. Beyond collecting basic information, couple sessions were unproductive. While Rick was frank about his physical attraction to her and his desire to have children, Antonella talked about their relationship in an oddly detached way. She could not quite articulate her concerns. As we got closer to examining the problems of their relationship, Antonella abruptly announced that they were planning their wedding. The conjoint sessions were put on hold as they dealt with the wedding arrangements.
Her parents did not approve of the marriage and boycotted the wedding. Her paternal aunt, however, agreed to come to Canada for the wedding. Since I was regarded by Antonella as part of her extended family support system, she brought her aunt to meet me. It gave me another view of Antonella’s family. Her aunt was warm and supportive of Antonella, trying to smooth over the family differences. A few months later, at Christmas time, her parents and sister visited, and Antonella brought them to meet me. To understand these family meetings, however, it is necessary to know Antonella’s early history.
2.3 A Foundling Child
Antonella was a foundling child. Abandoned on the steps of a foundry in Turin as a newborn, she was the subject of an investigation into the private medical clinics of Turin. This revealed that the staff of the clinic where she was born was ‘paid off to hide the circumstances of my birth.’ As a result, her date of birth could only be presumed because the clinic staff destroyed her birth records. She was taken into care by the state and, as her origins could not be established, she was put up for adoption.
Antonella has always tried to fill in this void of information with meaning that she draws from her own body. She questions me closely: ‘Just look at me. Don’t you think I look like a Japanese?’ She feels that her skin tone is different from other Italians, that her facial features and eyes have an ‘Asian’ cast. With a few, limited facts, and some speculation, she has constructed a personal myth: that she is the daughter of an Italian mother from a wealthy family (hence her hidden birth in a private clinic) and a Japanese father (hence her ‘Asian’ features). It is oddly reassuring to her, but also perhaps a source of her alienation from her family.
At about 6 months of age, Antonella was adopted into a family in the Italian Alps, near the border with Austria. This is a bicultural region where both Italian and German are spoken and services are available in both languages (much like Ottawa, which is bilingually English and French). Her father, Aldo, who is Italian, is a retired FIAT factory worker. Annalise, her mother, who is a homemaker, had an Italian father and an Austrian mother. About her family she said, ‘I had a wonderful childhood compared to what came afterwards.’ Years after her adoption, her parents had a natural child, Oriana, who is 15.
She describes her mother as the disciplinarian at home. Her mother, she said, was ‘tough, German.’ When she visited her Austrian grandmother, no playing was allowed in that strict home. Her own mother allowed her ‘no friends in the house,’ but her father ‘was my pal when I was a kid.’ Although she had a good relationship with her father, he became ‘colder’ when she turned 13. Her parents’ relationship is remembered as cordial, but she later learned that they had many marital problems. Mother told her that she married to get away from home, but in fact she was in love with someone else. Overall, the feeling is of a rigid family organization. Her father is clearly presented by Antonella as warmer and more sociable. She experiences her mother as being ‘tough’. But she is crying all the time, feeling betrayed by everybody.
2.4 A Family Visit from the Italian Alps
When her family finally came to visit, Antonella brought them to see me. At first, the session had the quality of a student introducing out-of-town parents to her college teacher. They were pleased that I spoke Italian and knew Dr. Angelo, who they trusted. I soon found that the Trevisans were hungry to tell their story. Instead of a social exchange of pleasantries, this meeting turned into the first session of an impromptu course of brief family therapy.
Present were Antonella’s parents, Aldo and Annalise, and her sister, Oriana. Annalise led the conversation. Relegating Aldo to a support role. Oriana alternated between disdain and agitation, punctuated by bored indifference. Annalise had much to complain about: her own troubled childhood, her sense of betrayal and abandonment, heightened by Antonella’s departure from the family and from Italy. I was struck by the parallel themes of abandonment in mother and daughter. Mother clearly needed to tell this story, so I tried to set the stage for the family to hear her, what narrative therapists call ‘recruiting an audience’ [ 9 ] . I used Antonella, who I knew best, as a barometer of the progress of the session, and by that indicator, believed it had gone well.
When I saw them again some 10 days later, I was stunned by the turn of events. Oriana had assaulted her parents. The father had bandages over his face and the mother had covered her bruises with heavy make-up and dark glasses. Annalise was very upset about Oriana, who was defiant and aggressive at home. For her part, Oriana defended herself by saying she had been provoked and hit by her mother. Worried by this dangerous escalation, I tried to open some space for a healthy standoff and renegotiation.
Somehow, the concern had shifted away from Antonella to Oriana. Antonella was off the hook, but I waited for an opening to deal with this. I first tried to explore the cultural attitudes to adolescence in Italy by asking how the Italian and the German subcultures in their area understood teenagers differently. What were Oriana’s concerns? Had they seen this outburst coming? The whole family participated in a kind of sociological overview of Italian adolescence, with me as their grateful audience. The parents demonstrated keen insight and empathy. Concerned about Oriana’s experience of the session, I made a concerted effort to draw her into it. Eventually, the tone of the session lightened. Knowing they would return to Italy soon, I explored whether they had considered family work. Since they had met a few times with Dr. Angelo over Antonella’s eating problems, they were comfortable seeing Dr. Angelo as a family to find ways to understand Oriana and her concerns and for Oriana to explore other, nonviolent ways to be heard in the family. I agreed to meet them again before their departure and to communicate with Dr. Angelo about their wishes. On their way out, I wondered aloud about the apparent switch in their focus from Antonella to Oriana. The parents reassured me that they were ready to let Antonella live her own life now.
When they returned to say goodbye, we had a brief session. Oriana and Antonella were oddly buoyant and at ease. The parents were relieved. Antonella had offered the possibility of Oriana returning to spend the summer in Canada with her. I tried to connect this back to the previous session, wondering how much the two sisters supported each other. I was delighted, I said emphatically, by the family’s apparent approval of Antonella’s marriage to Rick. It was striking that, even from a distance of thousands of miles away, Antonella was still a part of the Trevisan family. And Rick was still not in the room.
3 Discussion
In this section, I will consider the impact of cultural and other values on Antonella and those around her and then look briefly at the wider implications of her story for our understanding not only of eating disorders but of mental distress and disorders in general.
3.1 Antonella: Life Before Man
The key to understanding Antonella’s attachments was her passion for her Siberian huskies. In the language of values-based practice , it was above all her huskies that mattered or were important to her. And it is not hard to see why. From the beginning of her relationship with Rick, she used her interest in dogs as a way for them to be more socially active as a couple, getting them out of the house to go to dog shows, for example. As her interests expanded, she wanted to buy bitches for breeding and to set up a kennel. Rick was only reluctantly supportive in this. Nonetheless, they ended up buying a home in the country where she could establish a kennel. Her haggling with Rick over the dogs was quite instrumental on her part, representing her own choices and interests and a test of the extent to which Rick would support her.
Yet the importance to Antonella of her huskies rests I believe on deeper cultural factors, both negative and positive. As to negative factors , these are evident in the fact that from the first days of her life, Antonella was rejected by her birth parents, literally abandoned and exposed, and later adopted by what she experienced as a non-nurturing family. Positive cultural factors , on the other hand, are evident in the way that having thrown her net wider afield, she looked initially to Canada, and to Rick, for nurturance and for identity. Then, finding herself only partly satisfied, she turned to the nonhuman world for the constancy of affection she could not find with people. Her huskies gave her pleasure, a task, and an identity. She spent many sessions discussing their progress, showing me pictures of her dogs and their awards. As it happened, my secretary at the time was also a dog lover who raised Samoyed dogs (related to huskies) and the two of them exchanged stories of dog lore.
As to positive factors , again, is there something, too, in the mythology of Canada that helps us understand Antonella? Does Canada still hold a place in the European imagination as a ‘New World’ for radical departures and identity makeovers? Or does Canada specifically represent the ‘malevolent North,’ as Margaret Atwood [ 10 ] calls it in her exploration of Canadian fiction? Huskies are a Northern animal, close to the wolf in their origins and habits. Bypassing the human world, Antonella finds her identity within a new world through its animals. If people have failed her, then she will leave not only her own tribe (Italy), but skip the identification with Canada’s Native peoples, responding to the ‘call of the wild’ to identify with a ‘life before man’ (to use another of Atwood’s evocative phrases, [ 11 ]), finding companionship and solace with her dogs.
3.2 Wider Implications of Antonella’s Story
Antonella may seem on first inspection something of an outlier to the human tribe. Orphaned from her culture of origin, she finds her place not in another country but by identification with another and altogether wilder species, her husky dogs. Yet, understood through the lens of values-based practice Antonella’s story has, I believe, wider significance at a number of levels.
First, Antonella’s story is significant for our understanding of the role of values – of what is important or matters to the individual concerned – in the presentation and treatment of eating disorders , and, by extension, of perhaps many other forms of mental distress and disorder. Specifically, her story provides at least one clear ‘proof of principle’ example supporting the role of cultural values.
As noted in my introduction, much attention has been given in the literature to the correlations between the uneven geographical distribution of eating disorders and cultural values. Correlations are of course no proof of causation. But in Antonella’s story at least the role of cultural values seems clearly evident. They were key to understanding her presenting problems. And this understanding in turn proved to be key to the cultural family therapy [ 12 ] through which these problems were, at least to the extent of her presenting eating disorder, resolved.
The cultural values involved, it is true, were not those of fashionable slimness so widely discussed in the literature. But this takes us to a second level at which Antonella’s story has wider significance. For it shows that to the extent that cultural values are important in eating disorders , their importance plays out at the level of individually unique persons. In this sense, social stresses and cultural values are played out in the body of the individual suffering with an eating disorder, making her body the ‘final frontier’ of psychiatric phenomenology [ 13 ]. Yes, there are no doubt valid cultural generalisations to be made about eating disorders and mental disorders of other kinds. And yes, these generalisations no doubt include generalisations about cultural values—about things that matter or are important to this or that group of people as a whole. Yet, this does not mean that we can ignore the values of the particular individual concerned. It has been truly said in values-based practice that as to their values, everyone is an ‘ n of 1’ [ 14 ]. Antonella, then, in the very idiosyncrasies of her story, reminds us of the idiosyncrasies of the stories of each and every one of us, whatever the culture or cultures to which we belong.
Antonella’s identification with animals , furthermore, to come to yet another level at which her story has wider significance, was a strongly positive factor in her recovery. As with other areas of mental health, it is with the negative impact of cultural values that the literature has been largely concerned: the pathogenetic influences of cultural values of slimness being a case in point in respect of eating disorders . Antonella’s story illustrates what has been clear for some time in the ‘recovery movement’, that positive values are often the very key to recovery. Not only that, but as Antonella’s passion for her husky dogs illustrates, the particular positive values concerned may, and importantly often are, individually unique.
Not, it is worth adding finally, that Antonella’s values were in this respect entirely unprecedented. Animals , after all, are widely valued, positively and negatively, and for many different reasons, in many cultures [ 11 ]. Their healing powers are indeed acknowledged. Just how far these powers depend on the kind of cross-species identification shown by Antonella, remains a matter for speculation. But, again, her story even in this respect is far from unique. Elsewhere, I have described the story of a white boy with what has become known as the ‘Grey Owl Syndrome’ , wishing to be native [ 12 , chapter 5 ]. Similarly, in Bear , Canadian novelist Marion Engel [ 15 ] portrays Lou, a woman who lives in the wilderness and befriends a bear. Lou seeks her identity from him: ‘Bear, make me comfortable in the world at last. Give me your skin’ [ 15 , p. 106]. After some time with the bear, the woman changes: ‘What had passed to her from him she did not know…. She felt not that she was at last human, but that she was at last clean’ [ 15 , p. 137]. It was perhaps to some similarly partial resolution that Antonella came.
4 Conclusions
Antonella’s story as set out above goes to the heart of the importance of cultural values in mental health. Her presenting eating disorder develops when, displaced from her culture of origin in Italy, and in effect rejected by her birth family, she finds healing only through cross-species identification with the wildness of husky dogs in her adoptive country of Canada. Although somewhat unusual in its specifics, her story illustrates the importance of cultural values at a number of levels in the presentation and management of eating and other forms of mental distress disorder.
And Antonella? I met her again in a gallery in Ottawa, rummaging through old prints. She was asking about prints of dogs; I was looking for old prints of Brazil where my father had made a second life. How was she, I asked? ‘Well …,’ she said hesitantly. Was that a healthy ‘well’ or the start of an explanation? ‘Me and Rick are splitting up,’ she said without ceremony, ‘but I still have the huskies.’ For each of us, the prints represented another world of connections.
Makino M, Tsuboi K, Denerson L. Prevalence of eating disorders: a comparison of Western and non-Western countries. MedGenMed. 2004;6(3):49. Published online 2004 Sep 27 at: https://www.ncbi.nlm.nih.gov/pubmed .
PubMed PubMed Central Google Scholar
Erskine HE, Whiteford HA, Pike KM. The global burden of eating disorders. Curr Opin Psychiatry. 2016;29(6):346–53.
Article Google Scholar
Selvini Palazzoli M. Anorexia nervosa: a syndrome of the affluent society. Transcult Psychiatr Res Rev. 1985;22( 3 ):199–205.
Google Scholar
Di Nicola VF. Overview: anorexia multiforme: self-starvation in historical and cultural context. I: self-starvation as a historical chameleon. Transcult Psychiatr Res Rev. 1990;27(3):165–96.
Di Nicola VF. Overview: anorexia multiforme: self-starvation in historical and cultural context. II: anorexia nervosa as a culture-reactive syndrome. Transcult Psychiatr Res Rev. 1990;27(4):245–86.
Andolfi M, Angelo C, de Nichilo M. The myth of atlas: families and the therapeutic story. Edited & translated by Di Nicola VF. New York: Brunner-Routledge; 1989.
Douglas M. Humans speak. Ch 11. In: Implicit meanings: essays in anthropology. London: Routledge & Kegan Paul; 1975. p. 173–80.
Crystal D. The Cambridge encyclopedia of language. Cambridge: Cambridge University Press; 1987.
Parry A, Doan RE. Story re-visions: narrative therapy in the postmodern world. New York: Guilford Press; 1995.
Atwood M. Strange things: the malevolent north in Canadian literature. Oxford: Oxford University Press; 1995.
Atwood M. Life before man: a novel. New York: Anchor Books; 1998.
Di Nicola VF. A stranger in the family: culture, families, and therapy. New York: W.W. Norton & Co.; 1997.
Nasser M, Di Nicola V. Changing bodies, changing cultures: an intercultural dialogue on the body as the final frontier. Ch 9. In: Nasser M, Katzman MA, Gordon RA, editors. Eating disorders and cultures in transition. East Sussex: Brunner-Routledge; 2001. p. 171–93.
Fulford KWM, Peile E, Carroll H. A smoking enigma: getting and not getting the knowledge. Ch 6. In: Fulford KWM, Peile E, Carroll H, editors. Essential values-based practice: clinical stories linking science with people. Cambridge: Cambridge University Press; 2012. p. 65–82.
Chapter Google Scholar
Engel M. Bear: a novel. Toronto: Emblem (Penguin Random House Books); 2009.
Download references
Acknowledgements
The story of Antonella was first published in reference [ 12 ] (pp. 214–220) and presented at the Advanced Studies Seminar of the Collaborating Centre for Values-based Practice in Health and Social Care at St Catherine’s College, Oxford in October 2019. The names and other details of the case have been altered to maintain confidentiality. Parts of the discussion are adapted from that publication and the Oxford seminar. I am grateful to the publishers for permission to reproduce these materials here and to Professor Fulford and the members of the Advanced Studies Seminar for their stimulating exchanges. The subheading to the discussion of Antonella’s story (‘Life before Man’) was inspired by Margaret Atwood’s novel, Life Before Man [ 11 ].
Author information
Authors and affiliations.
Canadian Association of Social Psychiatry (CASP), World Association of Social Psychiatry (WASP), Department of Psychiatry and Addictions, University of Montreal, Montreal, QC, Canada
Vincenzo Di Nicola
Department of Psychiatry and Behavioral Sciences, The George Washington University, Washington, DC, USA
You can also search for this author in PubMed Google Scholar
Corresponding author
Correspondence to Vincenzo Di Nicola .
Editor information
Editors and affiliations.
Medical University Plovdiv, Plovdiv, Bulgaria
Drozdstoy Stoyanov
St Catherine’s College, University of Oxford, Oxford, UK
Bill Fulford
Department of Psychological, Health & Territorial Sciences, “G. D’Annunzio” University, Chieti Scalo, Italy
Giovanni Stanghellini
Centre for Ethics and Philosophy of Health Sciences, University of Pretoria, Pretoria, South Africa
Werdie Van Staden
Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
Michael TH Wong
Guide to Further Sources
For a more extended treatment of the role of culture in eating disorders and family therapy see:
Di Nicola VF (1990a) Overview: Anorexia multiforme: Self-starvation in historical and cultural context. I: Self-starvation as a historical chameleon. Transcultural Psychiatric Research Review, 27(3): 165–196.
Di Nicola VF (1990b) Overview: Anorexia multiforme: Self-starvation in historical and cultural context. II: Anorexia nervosa as a culture-reactive syndrome. Transcultural Psychiatric Research Review, 27(4): 245–286.
Di Nicola, V (1997) A Stranger in the Family: Culture, Families, and Therapy . New York & London: W.W. Norton & Co.
Nasser M and Di Nicola, V. (2001) Changing bodies, changing cultures: An intercultural dialogue on the body as the final frontier. In: Nasser M, Katzman M A, and Gordon R A, eds. Eating Disorders and Cultures in Transition . East Sussex, UK: Brunner-Routledge, pp. 171–193.
Rights and permissions
Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.
Reprints and permissions
Copyright information
© 2021 The Author(s)
About this chapter
Di Nicola, V. (2021). Antonella: ‘A Stranger in the Family’—A Case Study of Eating Disorders Across Cultures. In: Stoyanov, D., Fulford, B., Stanghellini, G., Van Staden, W., Wong, M.T. (eds) International Perspectives in Values-Based Mental Health Practice. Springer, Cham. https://doi.org/10.1007/978-3-030-47852-0_3
Download citation
DOI : https://doi.org/10.1007/978-3-030-47852-0_3
Published : 12 December 2020
Publisher Name : Springer, Cham
Print ISBN : 978-3-030-47851-3
Online ISBN : 978-3-030-47852-0
eBook Packages : Medicine Medicine (R0)
Share this chapter
Anyone you share the following link with will be able to read this content:
Sorry, a shareable link is not currently available for this article.
Provided by the Springer Nature SharedIt content-sharing initiative
- Publish with us
Policies and ethics
- Find a journal
- Track your research
Search by category
Popular searches.
![Priory Logo Blue text reading "Priory" with a red "0"](https://www.priorygroup.com/media/n3ijsj0r/priory-logo.png)
Eating disorder case study
![Banner Eating Disorders Case Study case study for eating disorders alexis](https://www.priorygroup.com/media/taciot1w/banner-eating-disorders-case-study.jpg)
Discover another eating disorder recovery story
"eating disorders tend to hide and they don't want to be seen, and if somebody else can see it ... it's a lot harder to hide".
![Charlie Carrol Living With An Eating Disorder case study for eating disorders alexis](https://www.priorygroup.com/media/meqleds4/charlie-carrol-living-with-an-eating-disorder.png)
Contact us to make an enquiry or for more information
![case study for eating disorders alexis U.S. flag](https://www.ncbi.nlm.nih.gov/coreutils/uswds/img/favicons/favicon-57.png)
An official website of the United States government
The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.
The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
- Publications
- Account settings
- My Bibliography
- Collections
- Citation manager
Save citation to file
Email citation, add to collections.
- Create a new collection
- Add to an existing collection
Add to My Bibliography
Your saved search, create a file for external citation management software, your rss feed.
- Search in PubMed
- Search in NLM Catalog
- Add to Search
Eating disorders and psychosis: a review and case report
Affiliations.
- 1 Department of Psychiatry and Mental Health, Baixo Vouga Hospital Centre, Aveiro, Portugal.
- 2 Psychiatry and Mental Health Clinic, São João University Hospital Centre, Porto, Portugal.
- PMID: 33331586
- DOI: 10.1590/1806-9282.66.12.1736
Introduction: The interplay between eating disorders and psychosis is a challenging field to which little attention has been paid. Its study raises conceptual and methodological questions in both areas, making the diagnosis and management of patients difficult. Such questions are addressed and illustrated with a review and case report.
Methods: The authors present the case of a woman with Anorexia Nervosa and with comorbid Shared Psychotic Disorder, based on a literature review regarding the comorbidity between eating disorders and psychosis. The authors conducted a non-systematic review by searching the PubMed database, using the Mesh Terms "anorexia nervosa", "bulimia nervosa", "comorbidity" and "psychotic disorders".
Results: The findings suggest that studies on the subject are limited by issues regarding data on the prevalence of comorbidities, phenomenological aspects of eating disorders, and the interface and integration with psychotic symptoms.
Conclusions: The case presented illustrates the difficulties in managing a patient with a comorbid eating disorder and psychosis. In order to ensure a rigorous assessment of both psychotic and eating disorder symptoms, the focus should be on the pattern of appearance or emergence of symptoms, their phenomenology, clinical and family background of the patient, and clinical status on follow-up.
PubMed Disclaimer
Similar articles
- Disordered eating: a defense against psychosis? Hugo PJ, Lacey JH. Hugo PJ, et al. Int J Eat Disord. 1998 Nov;24(3):329-33. doi: 10.1002/(sici)1098-108x(199811)24:3 3.0.co;2-r. Int J Eat Disord. 1998. PMID: 9741045
- Alcohol use disorder comorbidity in eating disorders: a multicenter study. Bulik CM, Klump KL, Thornton L, Kaplan AS, Devlin B, Fichter MM, Halmi KA, Strober M, Woodside DB, Crow S, Mitchell JE, Rotondo A, Mauri M, Cassano GB, Keel PK, Berrettini WH, Kaye WH. Bulik CM, et al. J Clin Psychiatry. 2004 Jul;65(7):1000-6. doi: 10.4088/jcp.v65n0718. J Clin Psychiatry. 2004. PMID: 15291691
- The prevalence of personality disorders in 210 women with eating disorders. Herzog DB, Keller MB, Lavori PW, Kenny GM, Sacks NR. Herzog DB, et al. J Clin Psychiatry. 1992 May;53(5):147-52. J Clin Psychiatry. 1992. PMID: 1592839
- Comorbidity of bipolar and eating disorders: distinct or related disorders with shared dysregulations? McElroy SL, Kotwal R, Keck PE Jr, Akiskal HS. McElroy SL, et al. J Affect Disord. 2005 Jun;86(2-3):107-27. doi: 10.1016/j.jad.2004.11.008. J Affect Disord. 2005. PMID: 15935230 Review.
- Eating disorders and schizophrenia in male patients: a review. Bou Khalil R, Hachem D, Richa S. Bou Khalil R, et al. Eat Weight Disord. 2011 Sep;16(3):e150-6. doi: 10.1007/BF03325126. Eat Weight Disord. 2011. PMID: 22290030 Review.
Publication types
- Search in MeSH
Related information
Linkout - more resources, full text sources.
- Scientific Electronic Library Online
- MedlinePlus Health Information
- Citation Manager
NCBI Literature Resources
MeSH PMC Bookshelf Disclaimer
The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.
Family sues Meta, blames Instagram for daughter’s eating disorder and self-harm
![case study for eating disorders alexis Alexis Spence holds her family dog, Draco.](https://media-cldnry.s-nbcnews.com/image/upload/t_fit-560w,f_auto,q_auto:best/rockcms/2022-06/220606-Alexis-Spence-ac-737p-fd868f.jpg)
A preteen girl’s “addictive” use of Instagram resulted in an eating disorder, self-harm and thoughts of suicide over several years, according to a lawsuit against the platform’s parent company, Meta.
The lawsuit, which was filed in U.S. District Court for the Northern District of California late Monday, heavily cites the Facebook Papers , a trove of internal Meta research documents leaked last fall that revealed that the tech giant knew Instagram was worsening body-image and other mental-health issues among teenage girls in particular .
The case was filed on behalf of Alexis Spence, who was able to create her first Instagram account at the age of 11 without her parents’ knowledge and in violation of the platform’s minimum age requirement of 13. The complaint alleges that Instagram’s artificial intelligence engine almost immediately steered the then-fifth grader into an echo chamber of content glorifying anorexia and self-cutting, and systematically fostered her addiction to using the app. The lawsuit was filed by the Social Media Victims Law Center , a Seattle-based group that advocates for families of teens harmed online.
Now 19, the formerly “confident and happy” Spence has been hospitalized for depression, anxiety and anorexia and “fights to stay in recovery every day” as a result of “the harmful content and features Instagram relentlessly promoted and provided to her in its effort to increase engagement,” the lawsuit states.
It is the first lawsuit of its kind to draw from the Facebook Papers while exposing the real human harm behind its findings, Spence’s attorneys say. The suit also features previously unpublicized documents from the leaks, including one in which Meta identified “tweens” as “herd animals” who “want to find communities where they can fit in.” The attorneys argue that such documents demonstrate Meta’s efforts to recruit underage users to its platforms.
“If you look at the extensive research that it [Meta] performed, they knew exactly what they were doing to kids, and they kept doing it,” said the founder of the Social Media Victims Law Center, Matthew P. Bergman, who is representing Spence and her family. “I wish I could say that Alexis’ case is aberrational. It’s not. The only aberration is that she survived.”
Bergman is also representing Tammy Rodriguez, an Enfield, Connecticut, woman who filed a lawsuit in January against Meta and Snap, the parent company of Snapchat, over the companies’ alleged roles in her 11-year-old daughter’s suicide last summer.
Liza Crenshaw, a spokesperson for Instagram, declined to comment on the Spence lawsuit, citing that it is “active litigation.”
But in a Facebook post that Meta CEO Mark Zuckerberg published on Oct. 5, 2021, following the early release of the Facebook Papers, he wrote, “I’ve spent a lot of time reflecting on the kinds of experiences I want my kids and others to have online, and it’s very important to me that everything we build is safe and good for kids.”
He also specifically referred to reporting that showed teenagers suffered more from “anxiety, sadness and eating issues” and noted that “more teenage girls who said they struggled with that issue also said Instagram made those difficult times better rather than worse.”
Katie Derkits, a spokesperson for Snap, said in part in a statement, “While we can’t comment on the specifics of active litigation, nothing is more important to us than the well-being of our community.” She added, “We work closely with many mental health organizations to provide in-app tools and resources for Snapchatters as part of our ongoing work to keep our community safe.”
![case study for eating disorders alexis The Spence family, from left, Jeffrey, Ryan, Alexis, Kathleen and their dog, Draco.](https://media-cldnry.s-nbcnews.com/image/upload/t_fit-760w,f_auto,q_auto:best/rockcms/2022-06/220606-Spence-family-ac-737p-ac5de0.jpg)
At the height of her addiction to Instagram, Spence said she had had multiple accounts and would access them for hours in the middle of the night so as not to alert her parents, who had grown concerned by her increasingly hostile and uncharacteristic behavior. One time, she punched a hole in the wall when they tried to take away her device, noted the suit, which attributed her conduct to Instagram’s “addictive design and product features.”
In an interview, Spence recalled how her algorithmically curated Instagram Explore page was brimming for years with “thinspo,” or “thin-spiration,” photos of emaciated young girls and models, which she would then save to look at for “motivation” whenever she was feeling hungry. Instagram also algorithmically recommended accounts for her to follow, including many offering instructions for bulimic purging and extreme dieting, the suit said.
At age 12, Spence drew a picture of herself crying on the floor next to her phone with the words “stupid ugly fat” on the screen and “kill yourself” in a thought bubble. By the time she was 15, she was receiving emergency psychiatric treatment for her anorexia, purging and suicidal ideation, according to the lawsuit.
“It was definitely really traumatizing,” Spence said in an interview. “It’s all images that are now ingrained into my head.”
The Facebook Papers, leaked by former Facebook product manager Frances Haugen, made public internal studies that Meta had conducted over the preceding three years. Meta conclusions contained in the documents included that Instagram makes 1 in 3 female teenage users feel worse about their bodies; the app is addictive by design; and it algorithmically drives vulnerable users toward pro-eating-disorder content.
Sen. Richard Blumenthal, D-Conn., reported similar findings amid the leaks when his office used a fake Instagram account to pose as a teenage girl.
“Our research has shown, in real time, Instagram’s recommendations will still latch on to a person’s insecurities, a young woman’s vulnerabilities about their bodies and drag them into dark places that glorify eating disorders and self-harm,” Blumenthal said at the time. “That’s what Instagram does.”
Haugen has argued that Instagram’s promotion of harmful content is part of what makes it so addictive.
“What’s super tragic is Facebook’s own research says as these young women begin to consume this eating-disorder content they get more and more depressed, and it actually makes them use the app more,” she said during a "60 Minutes" interview on CBS in October 2021, days before addressing Congress to warn of the damage Instagram has allegedly wrought on the mental health of its younger users.
Her testimony made Spence’s parents realize that Meta was driving their daughter toward this content. The Spences, who are both teachers, said they had long struggled to understand what had happened to her. The teen now lives with them on Long Island along with her therapy dog, Draco, who alerts them to her self-harm and disordered eating behaviors, and ensures that she is never alone.
“We started losing her slowly, piece by piece by piece,” Spence’s mother, Kathleen, said in an interview. “There was nothing that we could have done because we were fighting a multibillion-dollar corporation and we have two different interests at heart, and their interest is not my daughter.”
Jesselyn Cook is an investigative tech reporter for NBC News.
![case study for eating disorders alexis U.S. flag](https://www.ncbi.nlm.nih.gov/coreutils/uswds/img/favicons/favicon-57.png)
An official website of the United States government
The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.
The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
- Publications
- Account settings
Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .
- Advanced Search
- Journal List
- HHS Author Manuscripts
![case study for eating disorders alexis Logo of nihpa](https://www.ncbi.nlm.nih.gov/corehtml/pmc/pmcgifs/logo-nihpa.png)
Clinical Case Discussion: Binge Eating Disorder, Obesity and Tobacco Smoking
Marney a. white.
1 Department of Psychiatry, Yale University School of Medicine
Carlos M. Grilo
2 Department of Psychology, Yale University School of Medicine
Stephanie S. O'Malley
Marc n. potenza.
3 Child Study Center, Yale University School of Medicine
This clinical case involves an obese woman requesting treatment for her binge eating and obesity. The information is presented to expert clinicians who provide their thoughts regarding the case, assessment, treatment formulation, and associated clinical and research issues.
Case Description
A 48-year old African American woman presented for treatment for binge eating and weight loss. She presented for treatment following a recent routine physical examination during which her primary care physician noted concerns about her increasing weight. The physician recommended that she try to lose weight but did not provide any specific or further guidance. In light of her previous “failed” experiences with commercial weight loss programs, she decided to seek treatment at a university-based program. At initial evaluation, she was 64 inches tall and weighed 230 pounds yielding a body mass index (BMI) of 39.5, which reflects obesity. She had moderately elevated blood pressure and high cholesterol but was otherwise in good health. The patient completed college and a master's degree in education and had been employed as a special education teacher in the same job for 11 years. She lived with her husband of 24 years, and one of her two adult children. She reported that her relationships with her husband and family were good, that her job was enjoyable and rewarding, and that she had a good circle of close relationships.
Weight and dieting history
The patient reported an onset of overweight during adulthood. She reported having been involved in sports throughout childhood, and although she viewed herself as ‘big-boned’, she did not have body image concerns nor did she recall feeling dissatisfied with her weight or shape when younger. She denied any significant dieting behaviors until age 29. She reported maintaining a weight of approximately 150 pounds (BMI = 25.7) until age 28, at which age she became pregnant with her second child. She reported that she never fully lost the ‘baby weight’ and subsequently began to gradually gain weight throughout her 30s despite numerous dieting efforts. She reported a rapid weight gain of approximately 25 pounds in the past 6 months.
Binge eating
The patient reported an onset of “eating binges” at approximately age 16. The binge eating began soon after she began babysitting for neighborhood children. She estimated that she would engage in binge eating approximately 1-2 times per month which occurred during times that she babysat at night and had access to assorted snack foods. During those times she would ‘load up on junk food’ that the family had provided. She recalled that she would eat chips, cookies, and brownies “non-stop,” and that these eating episodes often lasted throughout the evening. She recalled feeling a loss of control during these episodes and stated that she would continue to eat despite not feeling physically hungry and that she would not stop until feeling physically ill. She reported that she was very embarrassed and secretive about these eating behaviors. She also recalled feeling embarrassed when worried that it was likely that the missing food was apparent to the family for whom she was babysitting. She denied any history of extreme inappropriate weight control or purging behaviors such as self-inducing vomiting or misusing laxatives.
The patient reported infrequent and sporadic binge eating throughout her late teens and early 20s, estimating a frequency of once per month which tended to correspond with social functions. During her 30s, however, the frequency of her binge eating increased considerably and became more regular except during periods of dieting efforts. The patient reported that she had enrolled in commercial weight loss programs approximately five different times, and had, in addition, tried to follow multiple self-help diets. She reported that when she was following a weight loss plan, she could successfully lose approximately 10 pounds, but that she would ‘hit a wall’ and discontinue after about one month of dieting. She reported that in-between diets, her binge eating would resume at a frequency of 2 to 3 times per week, and persist at that level until the next dieting attempt. The patient reported that she had not engaged any formal dieting in the past 18 months, although she frequently skipped meals in an effort to reduce her weight.
Recent course
The patient noted an increase in binge eating frequency approximately six months ago, corresponding with her mother's hospitalization and rapid physical decline. The patient was the primary caregiver for her mother, and noted that the months preceding her mother's death were extremely stressful. She reported that her binge eating increased in frequency to 3 to 4 times per week during her mother's illness, and increased to 6 to 7 times per week following her mother's death.
The patient described her typical binge episode as starting with an evening meal and extending for several hours. Her daily pattern of eating was to skip breakfast, and to consume a standard school cafeteria lunch at 11:30 a.m. She would then not eat again until preparing the evening meal, at which point she would ‘graze’ while cooking. The patient reported that most nights she would eat a ‘normal’ meal with her family, consisting of 5-6 ounces of meat, 2 or 3 types of vegetables, and bread. However, she would then eat the ‘leftovers’ while cleaning up after the meal, such that overall she would have consumed the equivalent of two full meals. She would then eat various foods throughout the rest of the evening until bedtime. During these episodes, she would alternate between salty and sweet snacks. One example binge episode, occurring approximately 30 minutes after the evening meal and spanning the two hours before bedtime, included: a roll of Ritz crackers with 6 ounces of cheese, 2 doughnuts, 4 handfuls of Chex mix, and ½ of a large (12 oz.) Cadbury candy bar.
![](http://sektorel.online/777/templates/cheerup/res/banner1.gif)
Smoking History and Cessation
The patient reported that she had recently quit smoking ‘cold turkey’ and had successfully maintained abstinence for four months. She reported quitting smoking following the death of her mother because she died of cancer. She quit smoking without any professional help and without the use of any nicotine replacements or medications to assist with the smoking cessation.
In terms of her smoking history, the patient reported that she began smoking at age 18, that she had successfully quit smoking upon becoming pregnant at age 24, but resumed when she returned to work 11 years ago. She reported a daily smoking frequency of 15 to 20 cigarettes per day. She reported no serious efforts to stop smoking during the past 11 years prior to this recent period of complete abstinence. The patient reported that since quitting smoking, she has experienced more frequent and intense urges to binge eat, and that in the few weeks prior to intake the urges to smoke had increased in frequency and intensity. She reported urges to smoke primarily in the evenings.
Diagnostic Instrument
In addition to a standard intake history, the patient was administered the Eating Disorder Examination (EDE; Fairburn and Cooper, 1993 ). The EDE is a semi-structured investigator-based interview that evaluates current eating behaviors and eating disorder psychopathology. The EDE focuses on the previous 28 days, except for diagnostic items – such as binge eating behaviors - which are assessed for the duration stipulations for each ED. More specifically, the EDE assesses the frequency of different forms of overeating, including objective bulimic episodes (binge eating defined as unusually large amounts of food with a subjective sense of loss of control) and various inappropriate weight control methods (e.g., purging, laxative abuse, etc). The EDE contains four scales reflecting different aspects of ED psychopathology (dietary restraint, eating concerns, weight concern, and shape concern). The EDE is considered the best-established method for assessing and tracking over time the behavioral and cognitive features of EDs and has psychometric support specifically with BED ( Grilo, Masheb, Lozano-Blanco, & Barry, 2004 ; Grilo, Masheb, & Wilson, 2001 ). The interview was administered before treatment and at treatment conclusion to evaluate treatment gains.
The patient was treated with 12 weekly individual sessions of cognitive behavioral therapy (CBT) for binge eating. Expert opinion ( Wilson, Grilo, & Vitousek, 2007 ) and quantitative meta-analytic reviews ( NICE, 2004 ) conclude CBT is the best-established and treatment-of-choice for BED. CBT, a focal and structured treatment, consists of three overlapping phases conducted in a collaborative and interactive method with patients. The first phase focused on educating the patient about the nature of binge eating. Standard behavioral strategies such as self-monitoring and record keeping were used to help the patient identify better her disordered eating patterns while working towards the central goal of normalizing and achieving a structured regular pattern of eating (i.e., not skipping meals). The second phase integrated cognitive procedures to help the patient identify and challenge maladaptive cognitions regarding her eating, possible triggers for dyscontrol, and associated eating/shape concerns. The final phase focuses on consolidating and maintaining the changes and relapse prevention issues.
During the overview of treatment and the ‘meal pattern prescription,’ the patient became tearful, stating that she is not organized enough to follow a meal pattern consisting of three meals and three snacks. She expressed a fear that eating more frequent meals would result in more weight gain, and stated that she was fearful of failing at another weight loss effort. The patient was encouraged to follow the meal and snack pattern as an ‘experiment’ for the first week of treatment. When the patient's fears were alleviated (i.e., disproved owing to weight maintenance during the first week of treatment), she moved through the treatment steps without difficulty. Although she initially voiced concern about the self-monitoring she eventually regarded it as one of the most essential tools that she gained during the treatment.
Overall, at treatment completion the patient's binge eating had remitted fully. She reported no objective bulimic episodes in the last 4 weeks of treatment. Her weight remained relatively stable, with a post-treatment weight loss of five pounds (final weight = 225; BMI = 38.6). Although the patient was pleased to have stopped binge eating, she reported continued distress over her weight and a persisting desire to lose weight.
Carlos M. Grilo, Ph.D.
This clinical case involves a combination of a behavioral (BED) and a physical medical problem (obesity) that often co-occur. This case is also notable for a positive lifetime history of a pharmacological addiction (nicotine) despite not being “active” at the time of presentation for treatment for the eating/weight concerns might nonetheless have important implications. In several respects, this case is fairly typical of BED in obese persons and serves to illustrate a number of important issues facing clinicians and researchers.
Background: Diagnosis, Distribution, and Clinical Features of BED
BED is a specific example of eating disorder not-otherwise-specified (EDNOS) and was included as a “research category” with provisional research diagnostic criteria in Appendix B of the DSM-IV ( American Psychiatric Association, 1994 ). BED is defined primarily by recurrent episodes of binge eating without the regular use of inappropriate compensatory weight control methods (such as purging) that characterize bulimia nervosa (BN). Binge eating is defined as eating unusually large amounts of food while experiencing a subjective sense of loss of control. The research criteria require marked distress about the binge eating and that the binge eating occurs on at least two days per week over the past six months. Unlike the two “formal” eating disorders (anorexia nervosa and bulimia nervosa), the DSM-IV does not include a cognitive criterion pertaining to disturbed body image (i.e., overvaluation of shape or weight) for the diagnosis of BED although such disturbances are present in many patients with BED ( Grilo, Hrabosky, White, Allison, Stunkard, & Masheb, 2008 ). Research has supported the distinctiveness of BED from both other eating disorders (BN) and from obesity without co-existing binge eating (Grilo, Crosby et al., in press; Grilo, Masheb, & White, in press ). A recent critical review of the literature concluded that there exists sufficient empirical evidence to support the inclusion of BED as a distinct and formal ED diagnosis in the DSM-V ( Striegel-Moore & Franko, 2008 ).
Recent epidemiological research has reported a prevalence rate for BED of roughly 3.5% in adult women, which is greater than anorexia nervosa and bulimia nervosa combined ( Hudson, Hiripi, Pope, & Kessler, 2007 ). The distribution of BED is much broader and more diverse than that of the other eating disorders. BED is evenly distributed throughout adulthood and is common in both men and women as well as across ethnic and racial groups ( Hudson et al., 2007 ; Grilo, Lozano, & Masheb, 2005 ). BED is strongly associated with obesity (which is not a required criterion) ( Hudson et al., 2007 ) and therefore with substantially increased morbidity associated with excess weight (e.g., diabetes, metabolic problems). The excess weight in patients with BED is attributable to a combination of binge eating in the absence of weight compensatory behaviors in addition to a general lack of dietary “restraint” that is salient and characteristic of the other eating disorders ( Grilo, 2010 ). Patients with BED who seek treatment are typically older than patients with other eating disorders despite the fact that many report a longstanding duration of the binge eating often dating back to adolescence ( Reas & Grilo, 2007 ). Moreover, unlike the case for the other eating disorders, which most frequently begin following intensive dieting attempts, nearly half of patients with BED report that the onset of their binge eating preceded their first diet ( Reas & Grilo, 2007 ). Regardless of the exact longitudinal sequence, the binge eating and the associated weight gain over time motivate multiple diet attempts over time many of which are not successful ( Reas & Grilo, 2007 ; Roehrig, Masheb, White, & Grilo, 2009 ).
Observations About the Specific Case
I will offer a number of observations regarding this specific case that are illustrative regarding selected issues of relevance to clinicians and researchers. This case is typical in a number of important respects yet it differs in several important ways that I will note with a view of characterizing the heterogeneity of this behavioral disorder. Evolving research has identified a number of treatments that have efficacy for a majority of such patients although two major challenges remain. First, many patients with BED do not get accurately identified, and few receive empirically-supported treatments ( Wilson, Grilo, & Vitousek, 2007 ).
Treatment-Seeking
Although obese patients with BED have elevated psychiatric and medical problems and greater health care utilization patterns relative to their obese peers who do not binge eat, they infrequently seek specialized psychological or psychiatric care for their binge eating. Obese persons who binge eat, along with many generalist health care providers, frequently see the binge eating problem as merely reflecting their obesity and need for better diet and weight loss. In this case, the patient and her physician discussed the need for weight loss, although her binge eating problem was not specifically addressed. Despite not being able to provide the patient with specific guidance, this interaction nonetheless represents an important first step. Many health care providers are uncomfortable in raising or discussing excess weight issues with their patients. This is likely due to a many reasons including, for example, negative biases or views about obesity, personal discomfort, perceived lack of expertise, and concerns about “harming” the therapeutic relationship ( Puhl & Heuer, 2009 ). The patient-physician interaction in this case seemed positive enough to support and motivate the patient to seek more specialized care. It is critically important for generalist health care providers to be receptive and open when discussing their patients' excess weight and potential treatment avenues.
Clinical Presenting Picture
This patient presented with co-occurring obesity and BED. Although she had moderately elevated blood pressure and high cholesterol, she had not yet developed metabolic syndrome although she was clearly at risk to do so along with other medical problems. Thus, her proactive treatment-seeking is certainly a very positive step. This is noteworthy because some research has suggested that black women who are obese and who binge eat are less likely to seek treatment than their white peers until both problems are substantially worse ( Grilo, Lozano, & Masheb, 2005 ; Pike, Dohm, Striegel-Moore, Wilfley, Fairburn, 2001 ). Her primary concern was her increasingly weight gain that started in her 30s despite numerous dieting attempts. More recently, her weight gain had increased markedly and this seemed related, in part, to her increased binge eating behaviors. Based on her clinical history, she did not seem to suffer from body image dissatisfaction or from body image disturbance that are characteristic of eating disorders. The EDE interview provides specific quantification of different aspects of body image disturbance and would yield detailed information regarding behavioral, affective, and cognitive aspects of body image to inform both treatment interventions and to assess changes over time ( Grilo et al., 2001 ). Although the absence of such body image problems in this specific patient signals a less disturbed variant of BED ( Grilo et al., 2008 ) with a positive prognosis ( Masheb & Grilo, 2008a ), treating the obese patient with BED will still remain challenging relative to treating obesity only ( Grilo et al., 2008 ). She did not appear to have significant psychosocial problems either independent or associated with the obesity and BED. Her psychosocial functioning seemed rather positive and this is not uncharacteristic of many patients with BED. Conversely, since it is not uncommon for many patients to have associated psychosocial problems, clinicians should routinely assess for any on-going difficulties as context for formulating and implementing treatment. Importantly, the patient did report a specific life stressor (her mother's death) which seemed associated with an intensification of her binge eating.
Psychiatrically, no additional lifetime or current problems were reported, although no formal structured diagnostic interview was administered. Patients with BED have elevated lifetime rates of psychiatric disorders, including most notably mood, anxiety, and substance use disorders ( Grilo, White, & Masheb, 2009 ), although roughly 25% have never experienced another psychiatric problem. For comprehensive treatment formulation and planning, the presence of other psychiatric disorders should be carefully ascertained. However, it is noteworthy that psychiatric co-morbidity has not emerged as a significant predictor or moderator of outcomes for BED treatments that have empirical support ( Masheb & Grilo, 2008b ; see Wilson et al., 2007 ).
The positive smoking history is especially noteworthy in this patient. Unfortunately, the significance of smoking in this patient group is still poorly understood and is often overlooked by clinicians and researchers alike. This case suggests some potentially important associations among smoking, eating, and weight domains. First, preliminary research suggests that smoking histories are not uncommon in patients with BED and, if present, signal increased risk for psychiatric problems, most notably anxiety disorders ( White & Grilo, 2006 ). Although this patient was not determined to have anxiety disorder co-morbidity, both binge eating and smoking may serve to regulate affect. The exacerbation of the patient's binge eating immediately following her mother's death and her smoking quit attempt can perhaps be conceptualized in this way (i.e., increased binge eating to cope with increased negative affect). Second, preliminary research also suggests that BED patients with smoking histories are characterized by heightened levels of maladaptive and rigid eating and dieting behaviors as well as heightened food “cravings” that must be addressed along with the binge eating ( White & Grilo, 2007 ). Third, weight gain following smoking cessation is common and may be especially problematic for obese patients with BED. A recent study found that obese patients with BED reported gaining significantly more weight following a smoking quit attempt than their non-binge-eating obese peers ( White, Masheb, & Grilo, in press ). This patient's rapid recent weight gain following her most recent smoking quit attempt is consistent with this finding and represents an important clinical challenge because it potentially represents a challenge to continued abstinence.
This patient's eating behavior and patterns are fairly representative of patients with BED. First, binge eating occurs most frequently during evenings, although many patients report having episodes at varying times throughout the day. The large amount consisting of mixed foods often based on availability and ease is typical. Also typical in this patient group is that the binge eating often follows eating behaviors or episodes that are occurring without a sense loss of control. Unlike bulimia nervosa where the binge eating episodes are very clear episodes following excessive restraint, patients with BED are characterized by a more chaotic and amorphous eating pattern. This patient attempts some dietary restraint (skipping breakfast, not eating for long period following lunch) but her eating is fairly continuous throughout the evening. Rather than eating a clear meal (dinner), she appears to eat continuously and during part of this time also experiences a sense of loss of control. Thus, these patients require assistance in several complex tasks including: normalizing and scheduling their eating (i.e., not skipping meals), lessening certain maladaptive restraint behaviors (i.e., not going long periods without eating), increasing certain adaptive restraint behaviors (i.e., not overeating during meals, not grazing or nibbling at odd times), in addition to eliminating the binge eating episodes (Allison, Grilo, Masheb, & Stunkard, 2006; Masheb & Grilo, 2006 ).
Treatment Options
Critical meta-analytic ( NICE, 2004 ) and qualitative reviews ( Wilson et al., 2007 ) of the treatment literature have concluded that cognitive behavioral therapy is the treatment of choice for BED. Studies of CBT for BED consistently report remission rates of 50% or greater along with broad improvements in associated psychological and psychosocial functioning, although weight loss tends to be minimal ( Wilson et al., 2007 ). Different research groups have documented that CBT is superior to other active treatments, including behavioral weight loss therapy ( Grilo & Masheb, 2005 ; Wilson et al., in press ) and pharmacotherapy with fluoxetine ( Grilo et al., 2005 ; Ricca et al., 2001 ), and that the benefits of CBT for BED are well-maintained through 24-months (Wilfley, Wilson, & Agras, 2008) following treatment. There is also some empirical support for two alternative psychotherapies (interpersonal psychotherapy and dialectical behavior therapy) which also produce substantial reductions in binge eating but, like CBT, fail to reduce weight ( Wilson et al., 2007 ). Finally, there is also empirical support for behavioral weight control therapy (structured manualized treatment delivered by professionals but not necessarily for the widely-available commercial programs or self-help diets) for reducing binge eating although findings regarding weight losses are also surprisingly mixed ( Grilo & Masheb, 2005 ; Wilson et al., 2007 ). Lastly, a critical meta-analysis of pharmacotherapy treatment research concluded that certain medications have a clinically significant advantage over placebo for producing short-term remission from binge eating and for reducing weight, although the weight losses tend to be quite modest and of uncertain clinical significance ( Reas & Grilo, 2008 ). The meta-analysis highlighted the potential efficacy of an anti-obesity agent (sibutramine) and anti-epileptic medications (particularly topiramate) but suggested more limited utility of SSRIs given their smaller effects on binge eating and essentially no effect on weight. Unlike the psychosocial treatments, the longer-term effects of these medications are unknown. The few available data from blinded ( Grilo, Masheb, & Wilson, 2005 ) and open-label ( Ricca et al., 2001 ) trials directly comparing the effectiveness of pharmacotherapy and psychological treatments indicate that CBT is significantly superior to SSRIs. In terms of combining approaches, most studies have found that adding pharmacotherapy to psychological approaches has generally not enhanced outcomes ( Reas & Grilo, 2008 ). Noteworthy exceptions are studies that reported adding orlistat ( Grilo, Masheb, & Salant, 2005 ) or topiramate ( Claudino et al., 2007 ) to CBT significantly enhanced the weight losses.
Treatment Course
Thus, it is fortunate that this patient sought treatment at a university-based program where she was offered an empirically-supported treatment. This patient's response to CBT was fairly typical in that she experienced an early and rapid response to the treatment ( Grilo, Masheb, & Wilson, 2006 ; Masheb & Grilo, 2007 ), stopped binge eating entirely by the end of treatment, but unfortunately did not lose weight. Many obese patients with BED fail to lose clinically meaningful amounts of weight despite the substantial reductions in binge eating achieved via CBT, which is not unlike the case for other psychological ( Wilson et al., 2007 ) and pharmacological treatments ( Reas & Grilo, 2008 ). Although the patient failed to lose significant weight (only five pounds), the CBT and presumably the cessation of binge eating were associated with a stabilization of weight. The patient entered treatment following a period of rapid and marked weight gain so the weight stabilization does represent a potentially important first step. Unfortunately, the failure to produce weight loss does leave this patient at risk for developing medical problems and given her frustration and distress about the weight may put her at heightened risk for relapse in both the binge eating and the smoking domains.
Future Directions
Finding ways to produce or enhance weight loss in obese patients with BED represents a major research priority ( Grilo, 2010 ). Interestingly, research has found that combining treatments, for example combining pharmacotherapy, has generally not enhanced outcomes ( Reas & Grilo, 2008 ). Possible notable exceptions have included findings from controlled trials suggesting that adding orlistat ( Grilo, Masheb, & Salant, 2005 ) or topiramate ( Claudino et al., 2007 ) may enhance weight losses achieved with CBT for BED. It has been suggested that greater attention to non-normative eating behaviors and patterns ( Masheb & Grilo, 2006 ) in addition to the CBT focus on normalization of eating meals and reducing binge eating may facilitate greater weight loss. Future treatment studies should include analyses of mediators of outcomes in order to guide the process of improving further our existing treatments ( Wilson et al., 2007 ).
Stephanie S. O'Malley, Ph.D.
This case history highlights the important interface between smoking and binge eating behavior and suggests how treatment of binge eating may have beneficial effects on maintenance of smoking abstinence.
Co-occurring Conditions and Complicating Factors
While smokers tend to be leaner compared to nonsmokers, a significant proportion of obese individuals smoke, placing them at increased risk of attendant health consequences such as diabetes and cardiovascular disease. Smoking related health consequences, experienced by the smoker or another family member, often motivate a smoker to quit as was the case for this patient. However, women compared to men are less likely to remain abstinent from smoking despite a motivating “health shock” for a variety of reasons, including concerns about weight gain. Smoking cessation can result in weight gain at one year of about 11 pounds on average, due to decreased energy expenditure, increased appetite and greater food intake. The degree of weight gain, however, is variable. Binge eating appears to be an important risk factor. In a retrospective study of overweight individuals who had quit smoking, those with significant binge eating problems gained substantially more weight in the year following smoking cessation (24.6 pounds) compared to those without binge eating (11 pounds) ( White, Masheb & Grilo, in press ).
Consistent with this report, this patient recently experienced rapid weight gain that initially began during the stressful period of her mother's illness and coincided with a four-month period of smoking abstinence. Her weight gain of 25 pounds over the recent six months, four of which followed smoking cessation, suggests that without intervention her binge eating is a major risk factor for continued weight gain.
Her maladaptive eating may also place her at risk of smoking relapse. Indeed, she reports that her urges to smoke had increased in recent weeks and were more intense in the evenings. Her pattern of depriving herself of food during the day and then binge eating in the evening could undermine maintenance of smoking abstinence in several ways. Food deprivation can increase the reinforcing effects of drugs, including nicotine, making any lapses to smoking more likely to promote continued smoking. Her efforts to resist eating may also tax her self-control resources and undermine her ability to resist smoking. The evening binge eating episodes she reports follow restricted eating during the day and may result in abstinence violation effects in which she experiences demoralizing recriminations over her loss of control. The resulting increase in negative affect and decreased self-efficacy could promote smoking urges and place her at risk of resorting to smoking to cope with negative affect, a common risk factor for smoking relapse. Finally, the expectation that smoking can limit binge eating is another risk factor for smoking relapse.
Treatment Considerations
Given this conceptualization, the treatment plan for her binge eating may help her also remain abstinent from smoking. The “meal prescription” of regular meals and several small snacks should prevent periods of food deprivation that could increase smoking urges, and diminished frequency of binge eating should increase feelings of self-efficacy and remove the compensatory need for smoking to limit binge eating. The remission of her binge eating and the resulting stabilization of her weight may remove the motivation to resume smoking in an effort to manage her weight.
Cognitive behavioral therapy for eating disorders, including binge eating, also addresses the development of alternative coping skills for handling negative affective states and other triggers of maladaptive eating patterns. Given that many smokers use smoking to cope with negative affective states, teaching her alternative coping skills for handling negative affect is likely to have benefits that generalize and help her maintain abstinence from smoking. The therapist could make this connection explicit by examining the circumstances that elicit the urge to smoke, noting any parallels with the circumstances that provoke binge eating as a coping strategy and emphasizing that the new coping skills learned as alternatives to maladaptive eating could serve as alternatives to smoking as a coping response. Evidence for coping skills therapy targeted to one maladaptive behavior generalizing to another behavior is evident in a study of cognitive behavioral therapy for alcoholism, in which improvements in eating disturbances occurred in addition to reductions in alcohol intake ( O'Malley et al., 2007 ). Learning new coping skills and introducing a regular pattern of eating during the day could ultimately minimize stress, a major precipitant of binge eating and smoking.
In the smoking literature, a recent meta-analysis concluded that smoking interventions that incorporate a weight control component result in short-term (< 3 months) improvements in smoking abstinence and reduced weight gain compared to smoking cessation interventions alone ( Spring et al., 2009 ). In one study, for example, a cognitive behavioral intervention designed to reduce over-concern with weight gain improved smoking quit rates and reduce weight gain compared to standard care or a weight control intervention ( Perkins et al., 2001 ). Further development of CBT interventions for weight concerned smokers may be well served by incorporating additional elements of CBT for binge eating, such as meal patterning, especially for those with a history of binge eating or other eating disorder that may predispose for the development or worsening of eating problems during a quit attempt. Likewise, the clinician should consider smoking history in the management of obese patients who present for treatment of binge eating disorder. As a group, these individuals have higher overall psychiatric co-morbidity and more severe binge eating pathology than overweight individuals without a history of smoking and may require specialized care ( White & Grilo, 2006 , 2007 ).
Marc N. Potenza, M.D., Ph.D.
Diagnostic considerations.
The current case describes the treatment of an individual who has demonstrated seemingly excessive engagement in two domains – tobacco use and food consumption. In anticipation of DSM-V, there exist discussions about how best to define and categorize disorders seemingly addictive in nature, and whether excessive engagement in non-drug behaviors (e.g., pathological gambling) might be grouped together with substance use disorders as addictions ( Petry, 2006 ; Potenza, 2006 ). The current case raises questions about whether excessive eating behaviors manifesting in BED and/or obesity might similarly be considered within an addiction framework, and, if so, how such a conceptualization might influence studies into the etiology, prevention and treatment of “behavioral” and drug addictions ( Grant et al., 2006 ; Holden, 2001 ).
Historically, the term “addiction” has undergone multiple changes in usage. Derived from the Latin word meaning “bound to” or “enslaved by”, the term was originally used independent of drug use. However, several hundred years ago the term became linked to excessive patterns of alcohol use and more recently drug use such that by the time when DSM-III-R was being generated, expert consensus was that “addiction” referred to compulsive drug-taking ( O'Brien et al., 2006 ). More recently researchers have proposed core elements of addiction (continued engagement despite adverse consequences, a compulsive quality, an appetitive urge typically preceding engagement in the behavior, and diminished self-control over the behavior) ( Potenza, 2006 ; Shaffer, 1999 ). If these features are seen as the defining qualities of addiction, then conditions like BED and obesity might be considered as addictions ( Volkow and O'Brien, 2007 ; Volkow and Wise, 2005 ).
Mechanisms and Treatment
Obesity, like addictions, appears to have multiple environmental and biological factors contributing to the disorder ( Gearhardt, Corbin, & Brownell, 2009 ; Gold et al., 2009 ). For example, food availability and advertising may increase the societal rates of obesity ( Brownell, 2004 ), and individual difference factors (e.g., specific genetic allelic variants) may predispose people to greater risks for obesity ( Paracchini et al., 2005 ; van Deneen et al., 2009 ). Arguably, a historical focus on the biological mechanisms underlying obesity has involved metabolism and imbalanced energy homeostasis (i.e., “energy in” and “energy out”) ( Abizaid et al., 2006 ). However, the application of motivational behavioral models to food consumption, like those that have been applied to drug use ( Chambers et al., 2003 ; Everitt and Robbins, 2005 ), may lead to identification of novel factors involved in the pathophysiology of obesity and BED ( Volkow and Wise, 2005 ; Hoebel et al.., 2009 ). Given that neurocircuity implicated in drug abuse appears similarly implicated in obesity (e.g., relatively diminished dopamine D2-like receptor availability in the striatum ( Wang et al., 2004 ; Wang et al., 2009 )), additional research is warranted to understand more completely the biological similarities and differences between drug addictions and obesity. The more complete and precise identification of these similarities and differences could help advance prevention and treatment strategies across disorders. Such a strategy has proven fruitful for pathological gambling, where proposed mechanisms underlying pathological gambling and substance addictions led to the hypothesis that opioid antagonists such as naltrexone, approved for the treatments of alcohol dependence and opioid dependence, would be efficacious in the treatment of pathological gambling ( Brewer et al., 2008 ; Grant et al., 2008 ; Tamminga and Nestler, 2006 ). Analogously, glutamatergic agents (e.g, N-acetyl cysteine) have demonstrated initial promise with respect to weight loss, tobacco smoking, pathological gambling and cocaine dependence ( Souza et al., 2008 ; Knackstadt et al., 2009; Grant et al., 2007 ; LaRowe et al., 2006 ), and further research is needed to further evaluate their efficacies and tolerabilities, particularly amongst dually diagnoses populations.
Specific aspects of the case also warrant mention as they relate to the relationship between disorders, like drug dependence, typically have been conceptualized as addictions and others, like obesity and BED, that typically have not. For example, it is noteworthy that the patient reports having recently quit smoking prior to entering treatment, as well as having had several periods of time of time when she was smoking regularly and others when she had quit for prolonged durations. This pattern raises questions about the natural history of smoking and eating behaviors, both individually and in conjunction. Addictions have historically been considered chronic relapsing conditions, a conceptualization based in considerable part on clinical samples. Epidemiological data suggest that both “behavioral” and drug addictions might follow less pernicious natural histories than originally thought, with many individuals recovering without formal interventions ( Slutske, 2006 ; Tamminga et al., 2006 ). Nonetheless, many individuals do require formal interventions, often on multiple occasions. Furthermore, how one behavioral domain might influence the other is incompletely understood. The phenomenon of “switching addictions”, as is suggested in other domains (e.g., alcoholism and problem gambling ( Potenza et al., 2005 )), may be reflected here in increased food cravings, food consumption and weight gain following smoking cessation, with multiple possible contributing mechanisms related to motivation, metabolic changes, stress reduction, or coping with uncomfortable or dysphoric states, as Dr. O'Malley indicates.
Life stressors appear to play an important role in the patient's clinical course, both with respect to smoking and eating. As such, therapies like CBT that include instruction in healthy coping strategies might be particularly relevant for the patient. From a biological perspective, the neural mechanisms underlying stress responses overlap with those implicated in impulse control and addiction ( Kalivas and Duffy, 1989 ; Piazza and Le Moal, 1996 ). Consistently, identification of specific intermediary phenotypes or endophenotypes in the domains of stress responsiveness and impulsivity would appear to have important implications across a broad range of disorders, including obesity, BED and nicotine dependence ( Blanco et al., 2009 ). As Dr. Grilo notes, combinations of pharmacological and behavioral therapies might be most helpful for BED, and consideration of pharmacological agents that target important intermediary phenotypes will represent important areas of future development.
Concluding Comments and Future Directions
The changes over time in the patient's smoking and eating behaviors highlight the importance of considering behaviors with addictive potential within a developmental framework, particularly as early problems have important implications for adult functioning ( Chambers et al., 2003 ). Early life interventions aimed at developing healthy eating, exercise, stress-coping skills, emotional regulation and general health behaviors at early ages, and particularly involving youth who might be considered high-risk, will be important in preventing the development of a broad range of addictive disorders including obesity ( Merlo et al., 2009 ). Public health interventions like those that appear effective in reducing youth smoking (e.g., increased taxation of cigarettes) warrant consideration for foods associated with obesity ( Brownell et al., 2009 ). It is likely that only through multiple interdisciplinary approaches will we be able to effectively target the public health concerns of obesity and drug addictions, ones that currently are estimated to cost US society hundreds of billions of dollars annually and impart significant personal and familial suffering ( Surgeon General, 2001 ; Uhl and Grow, 2004 ; Potenza and Taylor, 2009 ).
Acknowledgments
Acknowledgments and Disclosures: This work was supported by the NIH grants RL1 AA017539, UL1 DE19586, K23 KD071646, K24 DK070052, R01 DK49587, RC1 DA028279, P50 AA015632, NIH Roadmap for Medical Research/Common Fund, and the VA VISN1 MIRECC. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of any of the funding agencies. Dr. Potenza has received financial support or compensation for the following: Dr. Potenza consults for and is an advisor to Boehringer Ingelheim; has consulted for and has financial interests in Somaxon; has received research support from the National Institutes of Health, Veteran's Administration, Mohegan Sun Casino, the National Center for Responsible Gaming and its affiliated Institute for Research on Gambling Disorders, and Forest Laboratories, Ortho-McNeil, Oy-Control/Biotie and Glaxo-SmithKline pharmaceuticals; has participated in surveys, mailings or telephone consultations related to drug addiction, impulse control disorders or other health topics; has consulted for law offices and the federal public defender's office in issues related to impulse control disorders; provides clinical care in the Connecticut Department of Mental Health and Addiction Services Problem Gambling Services Program; has performed grant reviews for the National Institutes of Health and other agencies; has given academic lectures in grand rounds, CME events and other clinical or scientific venues; and has generated books or book chapters for publishers of mental health texts. Dr. Grilo has received research support from the National Institutes of Health, medical research foundations (Donaghue Foundation, American Heart Association, Borderline Personality Research Foundation), has delivered lectures and papers at scientific conferences, and has generated books and chapters for academic book publishers. Dr. O'Malley is a member of the ACNP workgroup, the Alcohol Clinical Trial Initiative, sponsored by Eli Lilly, Janssen, Schering Plough, Lundbeck, Glaxo-Smith Kline and Alkermes; a partner in Applied Behavioral Research; a Scientific Panel member, Butler Center for Research at Hazelden. Dr. O'Malley participates in studies in which Nabi Biopharmaceuticals and Sanofi Aventis donated medications, has given academic lectures at professional societies and has received grant support form the National Institutes of Health.
All authors report no conflicts of interest with the current manuscript.
- Abizaid A, Gao Q, Horvath TL. Thoughts for food: brain mechanisms and peripheral energy balance. Neuron. 2006; 51 :691–702. [ PubMed ] [ Google Scholar ]
- Allison KC, Grilo CM, Masheb RM, Stunkard AJ. Binge eating disorder and night eating syndrome: a comparative study of disordered eating. Journal of Consulting and Clinical Psychology. 2005; 73 :1107–1115. [ PubMed ] [ Google Scholar ]
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Fourth. Washington, DC: American Psychiatric Association; 1994. [ Google Scholar ]
- Blanco C, Potenza MN, Kim SW, Ibanez A, Zaninelli R, Saiz-Ruiz J, Grant JE. A pilot study of impulsivity and compulsivity in pathological gambling. Psychiatric Research. 2009; 167 :161–168. [ PMC free article ] [ PubMed ] [ Google Scholar ]
- Brewer JA, Grant JE, Potenza MN. The treatment of pathologic gambling. Addictive Disorders and Their Treatment. 2008; 7 :1–14. [ Google Scholar ]
- Brownell KD. Fast food and obesity in children. Pediatrics. 2004; 113 :132. [ PubMed ] [ Google Scholar ]
- Brownell KD, Farley T, Willett WC, Popkin BM, Chaloupka FJ, Thompson JW, Ludwig DS. The public health and economic benefits of taxing sugar-sweetened beverages. New England Journal of Medicine. 2009; 361 :1599–1605. [ PMC free article ] [ PubMed ] [ Google Scholar ]
- Chambers RA, Taylor JR, Potenza MN. Developmental neurocircuitry of motivation in adolescence: A critical period of addiction vulnerability. American Journal of Psychiatry. 2003; 160 :1041–1052. [ PMC free article ] [ PubMed ] [ Google Scholar ]
- Claudino AM, de Oliveira IR, Appolinario JC, Cordas TA, Duchesne M, Sichieri R, Bacaltchuk J. Double-blind, randomized, placebo-controlled trial of topiramate plus cognitive-behavior therapy in binge eating disorder. Journal of Clinical Psychiatry. 2007; 68 :1324–1332. [ PubMed ] [ Google Scholar ]
- Everitt B, Robbins TW. Neural systems of reinforcement for drug addiction: from actions to habits to compulsion. Nature Neuroscience. 2005; 8 :1481–1489. [ PubMed ] [ Google Scholar ]
- Fairburn CG, Cooper Z. The Eating Disorder Examination. In: Fairburn CG, Wilson GT, editors. Binge eating: nature, assessment, and treatment. 12th. New York: Guilford Press; 1993. pp. 317–360. [ Google Scholar ]
- Gearhardt AN, Corbin WR, Brownell KD. Food Addiction: An Examination of the Diagnostic Criteria for Dependence. Journal of Addiction Medicine. 2009; 3 :1–7. [ PubMed ] [ Google Scholar ]
- Gold MS, Graham NA, Cocores JA, Nixon SJ. Food addiction? Journal of Addiction Medicine. 2009; 3 :42–45. [ PubMed ] [ Google Scholar ]
- Grant JE, Kim SW, Hollander E, Potenza MN. Predicting Response to Opiate Antagonists and Placebo in the Treatment of Pathological Gambling. Psychopharmacology. 2008; 200 :521–527. [ PMC free article ] [ PubMed ] [ Google Scholar ]
- Grant JE, Brewer JA, Potenza MN. Neurobiology of substance and behavioral addictions. CNS Spectrums. 2006; 11 :924–930. [ PubMed ] [ Google Scholar ]
- Grant JE, Kim SW, Odlaug BL. N-Acetyl cysteine, a glutamate-modulating agent, in the treatment of pathological gambling: a pilot study. Biological Psychiatry. 2007; 62 :652–657. [ PubMed ] [ Google Scholar ]
- Grilo CM. What treatment research is needed for eating disorder not otherwise specified and binge eating disorder? In: Grilo CG, Mitchell JE, editors. The treatment of eating disorders: a clinical handbook. New York: Guilford Press; 2010. pp. 554–568. [ Google Scholar ]
- Grilo CM, Crosby RD, Masheb RM, White MA, Peterson CB, Wonderlich SA, Engel SG, Crow SJ, Mitchell JE. Overvaluation of shape and weight in binge eating disorder, bulimia nervosa, and subthreshold bulimia nervosa. Behaviour Research and Therapy [ PMC free article ] [ PubMed ] [ Google Scholar ]
- Grilo CM, Hrabosky JI, White MA, Allison KC, Stunkard AJ, Masheb RM. Overvaluation of shape and weight in binge eating disorder and overweight controls: refinement of a diagnostic construct. Journal of Abnormal Psychology. 2008; 117 :414–419. [ PMC free article ] [ PubMed ] [ Google Scholar ]
- Grilo CM, Lozano C, Masheb RM. Ethnicity and sampling bias in binge eating disorder: black women who seek treatment have different characteristics than those who do not. International Journal of Eating Disorders. 2005; 38 :257–262. [ PubMed ] [ Google Scholar ]
- Grilo CM, Masheb RM, Lozano-Blanco C, Barry DT. Reliability of the Eating Disorder Examination in patients with binge eating disorder. International Journal of Eating Disorders. 2004; 35 :80–85. [ PubMed ] [ Google Scholar ]
- Grilo CM, Masheb RM, Wilson GT. A comparison of different methods for assessing the features of eating disorders in patients with binge eating disorder. Journal of Consulting and Clinical Psychology. 2001; 69 :317–322. [ PubMed ] [ Google Scholar ]
- Grilo CM, Masheb RM. A randomized controlled comparison of guided self-help cognitive behavioral therapy and behavioral weight loss for binge eating disorder. Behaviour Research and Therapy. 2005; 43 :1509–1525. [ PubMed ] [ Google Scholar ]
- Grilo CM, Masheb RM, Salant SL. Cognitive behavioral therapy guided self-help and orlistat for the treatment of binge eating disorder: a randomized, double-blind, placebo-controlled trial. Biological Psychiatry. 2005; 57 :1193–1201. [ PubMed ] [ Google Scholar ]
- Grilo CM, Masheb RM, White MA. Significance of overvaluation of shape/weight in binge eating disorder: comparative study with overweight and bulimia nervosa. Obesity in press. [ PMC free article ] [ PubMed ] [ Google Scholar ]
- Grilo CM, Masheb RM, Wilson GT. Efficacy of cognitive behavioral therapy and fluoxetine for the treatment of binge eating disorder: a randomized double-blind placebo-controlled comparison. Biological Psychiatry. 2005; 57 :301–309. [ PubMed ] [ Google Scholar ]
- Grilo CM, Masheb RM, Wilson GT. Rapid response to treatment for binge eating disorder. Journal of Consulting and Clinical Psychology. 2006; 74 :602–613. [ PubMed ] [ Google Scholar ]
- Grilo CM, White MA, Masheb RM. DSM-IV psychiatric disorder comorbidity and its correlates in binge eating disorder. International journal of Eating disorders. 2009; 42 :228–234. [ PMC free article ] [ PubMed ] [ Google Scholar ]
- Hoebel BG, Avena NM, Bocarsly ME, Rada P. Natural addiction: a behavioral and circuit model based on sugar addiction in rats. Journal of Addiction Medicine. 2009; 3 :33–41. [ PMC free article ] [ PubMed ] [ Google Scholar ]
- Holden C. ‘Behavioral’ addictions: Do they exist? Science. 2001; 294 :980–982. [ PubMed ] [ Google Scholar ]
- Hudson JI, Hiripi E, Pope HG, Kessler RC. The prevalence and correlates of eating disorders in the NCS Replication. Biological Psychiatry. 2007; 61 :348–358. [ PMC free article ] [ PubMed ] [ Google Scholar ]
- Kalivas PW, Duffy P. Similar effects of daily cocaine and stress on mesocorticolimbic dopamine neurotransmission in the rat. Biological Psychiatry. 1989; 25 :913–928. [ PubMed ] [ Google Scholar ]
- Knackstedt LA, LaRowe S, Mardikian P, Malcolm R, Upadhyaya H, Hedden S, et al. The role of cystine-glutamate exchange in nicotine dependence in rats and humans. Biological Psychiatry. 2009; 65 :841–845. [ PMC free article ] [ PubMed ] [ Google Scholar ]
- LaRowe SD, Mardikian P, Malcolm R, Myrick H, Kalivas P, McFarland K, et al. Safety and tolerability of N-acetylcysteine in cocaine-dependent individuals. American Journal of Addictions. 2006; 15 :105–110. [ PMC free article ] [ PubMed ] [ Google Scholar ]
- Masheb RM, Grilo CM. Eating patterns and breakfast consumption in obese patients with binge eating disorder. Behaviour Research and Therapy. 2006; 44 :1545–1553. [ PubMed ] [ Google Scholar ]
- Masheb RM, Grilo CM. Rapid response predicts treatment outcomes in binge eating disorder: implications for stepped care. Journal of Consulting and Clinical Psychology. 2007; 75 :639–644. [ PubMed ] [ Google Scholar ]
- Masheb RM, Grilo CM. Prognostic significance of two sub-categorization methods for the treatment of binge eating disorder: negative affect and overvaluation predict, but do not moderate, specific outcomes. Behaviour Research and Therapy. 2008a; 46 :428–437. [ PMC free article ] [ PubMed ] [ Google Scholar ]
- Masheb RM, Grilo CM. Examination of predictors and moderators for self-help treatments of binge eating disorder. Journal of Consulting and Clinical Psychology. 2008b; 76 :900–904. [ PMC free article ] [ PubMed ] [ Google Scholar ]
- Merlo LJ, Klingman C, Malasanos TH, Silverstein JH. Exploration of food addiction in pediatric patients: a preliminary investigation. Journal of Addiction Medicine. 2009; 3 :26–32. [ PMC free article ] [ PubMed ] [ Google Scholar ]
- O'Brien CP, Volkow N, Li TK. What's in a word? Addiction versus dependence in DSM-V. American Journal of Psychiatry. 2006; 163 :764–765. [ PubMed ] [ Google Scholar ]
- O'Malley SS, Sinha R, Grilo CM, Capone C, Farren CK, McKee SA, Rounsaville BJ, Wu R. Naltrexone and cognitive behavioral coping skills therapy for the treatment of alcohol drinking and eating disorder features in alcohol dependent women: A randomized, double-blind, placebo controlled trial. Alcoholism: Clinical and Experimental Research. 2007; 31 :625–634. [ PubMed ] [ Google Scholar ]
- Pike KM, Dohm FA, Striegel-Moore RH, Wilfley DE, Fairburn CG. A comparison of black and white women with binge eating disorder. Am J Psychiatry. 2001; 158 (9):1455–60. [ PubMed ] [ Google Scholar ]
- National Institute for Clinical Excellence. Eating disorders – Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa, and related eating disorders (Clinical Guideline No 9) London: Author; 2004. available at www.nice.org.uk/guidance/CG9 . [ PubMed ] [ Google Scholar ]
- Paracchini V, Pedotti P, Taioli E. Genetics of leptin and obesity: a HuGE review. American Journal of Epidemiology. 2005; 162 :101–114. [ PubMed ] [ Google Scholar ]
- Perkins KA, Marcus MD, Levine MD, D'Amico D, Miller A, Broge M, Ashcom J, Shiffman S. Cognitive-behavioral therapy to reduce weight concerns improves smoking cessation outcome in weight-concerned women. Journal of Consulting and Clinical Psychology. 2001; 69 :604–13. [ PubMed ] [ Google Scholar ]
- Petry NM. Should the scope of addictive behaviors be broadened to include pathological gambling? Addiction. 2006; 101 (s1):152–160. [ PubMed ] [ Google Scholar ]
- Piazza PV, Le Moal M. Pathophysiological basis of vulnerability to drug abuse: Role of an interaction between stress, glucocorticoids, and dopaminergic neurons. Annual Review of Pharmacology and Toxicology. 1996; 36 :359–378. [ PubMed ] [ Google Scholar ]
- Potenza MN, Steinberg MA, Wu R. Characteristics of Gambling Helpline Callers with Self-Reported Gambling and Alcohol Use Problems. Journal of Gambling Studies. 2005; 21 :233–254. [ PubMed ] [ Google Scholar ]
- Potenza MN. Should addictive disorders include non-substance-related conditions? Addiction. 2006; 101 (s1):142–151. [ PubMed ] [ Google Scholar ]
- Potenza MN, Taylor JR. Found in Translation: Understanding Impulsivity and Related Constructs Through Integrative Preclinical and Clinical Research. Biological Psychiatry. 2009; 66 :714–716. [ PMC free article ] [ PubMed ] [ Google Scholar ]
- Puhl RM, Heuer CA. The stigma of obesity: a review and update. Obesity. 2009; 17 :941–964. [ PubMed ] [ Google Scholar ]
- Reas DL, Grilo CM. Timing and sequence of the onset of overweight, dieting, and binge eating in overweight patients with binge eating disorder. International Journal of Eating Disorders. 2007; 40 :165–170. [ PubMed ] [ Google Scholar ]
- Reas DL, Grilo CM. Review and meta-analysis of pharmacotherapy for binge eating disorder. Obesity. 2008; 16 :2024–2038. [ PMC free article ] [ PubMed ] [ Google Scholar ]
- Ricca V, Mannucci E, Mezzani B, Moretti S, Di Bernardo M, Bertelli M, Rotella CM, Faravelli C. Fluoxetine and fluvoxamine combined with individual cognitive-behavioral therapy in binge eating disorder: a one-year follow-up study. Psychotherapy and Psychosomatics. 2001; 70 :298–306. [ PubMed ] [ Google Scholar ]
- Roehrig M, Masheb RM, White MA, Grilo CM. Dieting frequency in obese patients with binge eating disorder: behavioral and metabolic correlates. Obesity. 2009; 17 :689–697. [ PMC free article ] [ PubMed ] [ Google Scholar ]
- Shaffer HJ. Strange bedfellows: a critical view of pathological gambling and addiction. Addiction. 1999; 94 :1445–1448. [ PubMed ] [ Google Scholar ]
- Slutske WS. Natural recovery and treatment-seeking in pathological gambling: results of two national surveys. American Journal of Psychiatry. 2006; 163 :297–302. [ PubMed ] [ Google Scholar ]
- Souza GA, Ebaid GE, Seiva FRF, Rocha KHR, Galhardi CM, Mani F, et al. N-acetylcysteine an Allium plant compound improves high-sucrose diet-induced obesity and related effects. eCAM. 2008 :1–7. [November 11, 2008]; doi: 10.193/ecam/neun070. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
- Spring B, Howe D, Berendsen M, McFadden G, Hitchcock K Rademaker, Hitchcock K, Rademaker AW, Hitsman B. Behavioral intervention to promote smoking cessation and prevent weight gain: a systematic review and meta-analysis. Addiction. 2009; 104 :1472–1486. [ PMC free article ] [ PubMed ] [ Google Scholar ]
- Striegel-Moore RH, Frank DL. Should binge eating disorder be included in the DSM-V? A critical review of the state of the evidence. Annual Review of Clinical Psychology. 2008; 4 :305–324. [ PubMed ] [ Google Scholar ]
- Surgeon General. The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity. United States Department of Health and Human Services. 2001. [11/22/06]. http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_glance.htm .
- Tamminga CA, Nestler EJ. Pathological gambling: Focusing on the addiction, not the activity. American Journal of Psychiatry. 2006; 163 :180–181. [ PubMed ] [ Google Scholar ]
- Uhl GR, Grow RW. The burden of complex genetics in brain disorders. Archives of General Psychiatry. 2004; 61 :223–229. [ PubMed ] [ Google Scholar ]
- van Deneen KM, Gold MS, Liu Y. Food addiction and cues in Prader-Willi syndrome. Journal of Addiction Medicine. 2009; 3 :19–26. [ PubMed ] [ Google Scholar ]
- Volkow ND, O'Brien CP. Issues for DSM-V: Should obesity be included as a brain disorder? American Journal of Psychiatry. 2007; 164 :708–710. [ PubMed ] [ Google Scholar ]
- Volkow ND, Wise RA. How can drug addiction help us understand obesity? Nature Neuroscience. 2005; 8 :555–560. [ PubMed ] [ Google Scholar ]
- Wang GJ, Volkow ND, Thanos P, Fowler J. Similarity between obseity and drug addiction as assessed by neurofunctional imaging: A concept review. Eating Disorders, Overeating, and Pathological Attachment to Food. 2004; 23 (3):39–53. [ PubMed ] [ Google Scholar ]
- Wang GJ, Volkow ND, Thanos PK, Fowler JS. Imaging of brain dopamine pathways: implications for understanding obesity. Journal of Addiction Medicine. 2009; 3 :8–18. [ PMC free article ] [ PubMed ] [ Google Scholar ]
- White MA, Grilo CM. Psychiatric comorbidity in binge eating disorder as a function of smoking history. Journal of Clinical Psychiatry. 2006; 67 :594–599. [ PubMed ] [ Google Scholar ]
- White MA, Grilo CM. Symptom severity in obese women with binge eating disorder as a function of smoking history. International Journal of Eating Disorders. 2007; 40 :77–81. [ PubMed ] [ Google Scholar ]
- White MA, Masheb RM, Grilo CM. Self-reported weight gain following smoking cessation: a function of binge eating behaviour. International Journal of Eating Disorders in press. [ PMC free article ] [ PubMed ] [ Google Scholar ]
- Wilson GT, Wilfley DE, Bryson S, Agras WS. A multi-site randomized controlled trial of interpersonal psychotherapy, behavioral weight loss, and guided self-help in the treatment of overweight individuals with binge eating disorder. Archives of General Psychiatry in press. [ Google Scholar ]
- Wilson GT, Grilo CM, Vitousek K. Psychological treatments for eating disorders. American Psychologist. 2007; 62 :199–216. [ PubMed ] [ Google Scholar ]
![case study for eating disorders alexis Image](https://div12.org/wp-content/uploads/2023/01/logo-white.png)
- Presidential Message
- Nominations/Elections
- Past Presidents
- Member Spotlight
- Fellow List
- Fellowship Nominations
- Current Awardees
- Award Nominations
- SCP Mentoring Program
- SCP Book Club
- Pub Fee & Certificate Purchases
- LEAD Program
- Introduction
- Find a Treatment
- Submit Proposal
- Dissemination and Implementation
- Diversity Resources
- Graduate School Applicants
- Student Resources
- Early Career Resources
- Principles for Training in Evidence-Based Psychology
- Advances in Psychotherapy
- Announcements
- Submit Blog
- Student Blog
- The Clinical Psychologist
- CP:SP Journal
- APA Convention
- SCP Conference
CASE STUDY Maria (binge eating disorder)
Case study details.
Maria is a 38-year-old divorced woman who works in a higher level administrative position for a large federal agency. She is well-established in her career and has several close friends with whom she enjoys spending time. She comes to you following years of unsuccessful attempts to get appropriate treatment for her binge eating. She reports a prior experience with counseling during college after she experienced a sexual assault. She shared with her counselor her concerns about binge eating but the counselor told her that they needed to remain focused on working through issues directly related to the sexual assault. Embarrassed for having brought up her binge eating behavior, she waited years to seek help again and, when she did on two other occasions, it was recommended that she meet with a dietitian to “learn how to eat healthily.” She explains to you that she needs help with binge eating and that it’s not a matter of knowledge – “I know what to do. I just can’t do it. I cannot control my eating.” She describes a pattern where she works hard to “get on track” with her eating but finds it difficult to maintain. She is 5’4”and weighs 180 lbs. She first started binge eating in college and her weight quickly increased from 135 lbs. as a freshman to 160 lbs. by graduation. She has been treated for hypertension and high cholesterol for the last 5 years. She is coming for help now at the recommendation of her physician after a recent visit where she reported increasing problems with back and knee pain due to her excess weight.
- Disordered Eating
- Obesity/Overweight
Diagnoses and Related Treatments
1. binge eating disorder.
Thank you for supporting the Society of Clinical Psychology. To enhance our membership benefits, we are requesting that members fill out their profile in full. This will help the Division to gather appropriate data to provide you with the best benefits. You will be able to access all other areas of the website, once your profile is submitted. Thank you and please feel free to email the Central Office at [email protected] if you have any questions
Information
- Author Services
Initiatives
You are accessing a machine-readable page. In order to be human-readable, please install an RSS reader.
All articles published by MDPI are made immediately available worldwide under an open access license. No special permission is required to reuse all or part of the article published by MDPI, including figures and tables. For articles published under an open access Creative Common CC BY license, any part of the article may be reused without permission provided that the original article is clearly cited. For more information, please refer to https://www.mdpi.com/openaccess .
Feature papers represent the most advanced research with significant potential for high impact in the field. A Feature Paper should be a substantial original Article that involves several techniques or approaches, provides an outlook for future research directions and describes possible research applications.
Feature papers are submitted upon individual invitation or recommendation by the scientific editors and must receive positive feedback from the reviewers.
Editor’s Choice articles are based on recommendations by the scientific editors of MDPI journals from around the world. Editors select a small number of articles recently published in the journal that they believe will be particularly interesting to readers, or important in the respective research area. The aim is to provide a snapshot of some of the most exciting work published in the various research areas of the journal.
Original Submission Date Received: .
- Active Journals
- Find a Journal
- Proceedings Series
- For Authors
- For Reviewers
- For Editors
- For Librarians
- For Publishers
- For Societies
- For Conference Organizers
- Open Access Policy
- Institutional Open Access Program
- Special Issues Guidelines
- Editorial Process
- Research and Publication Ethics
- Article Processing Charges
- Testimonials
- Preprints.org
- SciProfiles
- Encyclopedia
![Journal of Clinical Medicine jcm-logo](https://pub.mdpi-res.com/img/journals/jcm-logo.png?6922832c4f546280)
Article Menu
![case study for eating disorders alexis case study for eating disorders alexis](https://www.mdpi.com/profiles/1070273/thumb/Guillermo_Gervasini.jpg)
- Subscribe SciFeed
- Google Scholar
- on Google Scholar
- Table of Contents
Find support for a specific problem in the support section of our website.
Please let us know what you think of our products and services.
Visit our dedicated information section to learn more about MDPI.
JSmol Viewer
An umbrella review of body image concerns, disordered eating, and eating disorders in elite athletes.
![case study for eating disorders alexis case study for eating disorders alexis](https://www.mdpi.com/bundles/mdpisciprofileslink/img/unknown-user.png)
1. Introduction
2. materials and methods, 2.1. data extraction, 2.2. risk of bias assessment, 3.1. risk of bias assessment, 3.2. overlap analysis, 3.3. prevalence of disordered eating (including eating disorders) and body image concerns, 3.4. relative risk for disordered eating (including eating disorders) and body image concerns in elite athletes, 3.5. risk factors for disordered eating and body image concerns amongst elite athletes, 3.5.1. general risk factors, 3.5.2. sport-specific factors, 3.6. factors with emerging evidence, 4. discussion, 4.1. implications, 4.2. limitations, 4.3. conclusions, supplementary materials, author contributions, data availability statement, conflicts of interest.
- Hammerle, F.; Huss, M.; Ernst, V.; Bürger, A. Thinking dimensional: Prevalence of DSM-5 early adolescent full syndrome, partial and subthreshold eating disorders in a cross-sectional survey in German schools. BMJ Open 2016 , 6 , e010843. [ Google Scholar ] [ CrossRef ] [ PubMed ]
- Rodin, J.; Silberstein, L.; Striegel-Moore, R. Women and weight: A normative discontent. In Nebraska Symposium on Motivation ; University of Nebraska Press: Lincoln, NE, USA, 1984. [ Google Scholar ]
- Cash, T.F. Body image: Past, present, and future. Body Image 2004 , 1 , 1–5. [ Google Scholar ] [ CrossRef ] [ PubMed ]
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders , 5th ed.; American Psychiatric Publishing: Arlington, VA, USA, 2013. [ Google Scholar ]
- Wells, K.R.; Jeacocke, N.A.; Appaneal, R.; Smith, H.D.; Vlahovich, N.; Burke, L.M.; Hughes, D. The Australian Institute of Sport (AIS) and National Eating Disorders Collaboration (NEDC) position statement on disordered eating in high performance sport. Br. J. Sports Med. 2020 , 54 , 1247–1258. [ Google Scholar ] [ CrossRef ] [ PubMed ]
- Karrer, Y.; Halioua, R.; Mötteli, S.; Iff, S.; Seifritz, E.; Jäger, M.; Claussen, M.C. Disordered eating and eating disorders in male elite athletes: A scoping review. BMJ Open Sport Exerc. Med. 2020 , 6 , e000801. [ Google Scholar ] [ CrossRef ] [ PubMed ]
- de Bruin, A.; Oudejans, R.R.; Bakker, F.C.; Woertman, L. Contextual body image and athletes’ disordered eating: The contribution of athletic body image to disordered eating in high performance women athletes. Eur. Eat. Disord. Rev. 2011 , 19 , 201–215. [ Google Scholar ] [ CrossRef ] [ PubMed ]
- de Bruin, A.K. Athletes with eating disorder symptomatology, a specific population with specific needs. Curr. Opin. Psychol. 2017 , 16 , 148–153. [ Google Scholar ] [ CrossRef ] [ PubMed ]
- Williams, O. Eating for excellence: Eating disorders in elite sport–inevitability and ‘immunity’. Eur. J. Sport Soc. 2012 , 9 , 33–55. [ Google Scholar ] [ CrossRef ]
- Appolinario, J.C.; Sichieri, R.; Lopes, C.S.; Moraes, C.E.; da Veiga, G.V.; Freitas, S.; Nunes, M.A.; Wang, Y.-P.; Hay, P. Correlates and impact of DSM-5 binge eating disorder, bulimia nervosa and recurrent binge eating: A representative population survey in a middle-income country. Soc. Psychiatry Psychiatr. Epidemiol. 2020 , 57 , 1491–1503. [ Google Scholar ] [ CrossRef ] [ PubMed ]
- Udo, T.; Grilo, C.M. Psychiatric and medical correlates of DSM-5 eating disorders in a nationally representative sample of adults in the United States. Int. J. Eat. Disord. 2019 , 52 , 42–50. [ Google Scholar ] [ CrossRef ]
- Mountjoy, M.; Ackerman, K.E.; Bailey, D.M.; Burke, L.M.; Constantini, N.; Hackney, A.C.; Heikura, I.A.; Melin, A.; Pensgaard, A.M.; Stellingwerff, T. 2023 International Olympic Committee’s (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). Br. J. Sports Med. 2023 , 57 , 1073–1097. [ Google Scholar ] [ CrossRef ]
- Pensgaard, A.M.; Sundgot-Borgen, J.; Edwards, C.; Jacobsen, A.U.; Mountjoy, M. Intersection of mental health issues and Relative Energy Deficiency in Sport (REDs): A narrative review by a subgroup of the IOC consensus on REDs. Br. J. Sports Med. 2023 , 57 , 1127–1135. [ Google Scholar ] [ CrossRef ] [ PubMed ]
- Hausenblas, H.A.; Carron, A.V. Eating disorder indices and athletes: An integration. J. Sport Exerc. Psychol. 1999 , 21 , 230–258. [ Google Scholar ] [ CrossRef ]
- Torstveit, M.K.; Sundgot-Borgen, J. The female athlete triad: Are elite athletes at increased risk? Med. Sci. Sports Exerc. 2005 , 37 , 184–193. [ Google Scholar ] [ CrossRef ] [ PubMed ]
- Smolak, L.; Murnen, S.K.; Ruble, A.E. Female athletes and eating problems: A meta-analysis. Int. J. Eat. Disord. 2000 , 27 , 371–380. [ Google Scholar ] [ CrossRef ]
- Hausenblas, H.A.; Downs, D.S. Comparison of body image between athletes and nonathletes: A meta-analytic review. J. Appl. Sport Psychol. 2001 , 13 , 323–339. [ Google Scholar ] [ CrossRef ]
- Sundgot-Borgen, J.; Torstveit, M.K. Prevalence of eating disorders in elite athletes is higher than in the general population. Clin. J. Sport Med. 2004 , 14 , 25–32. [ Google Scholar ] [ CrossRef ] [ PubMed ]
- Torstveit, M.; Rosenvinge, J.H.; Sundgot-Borgen, J. Prevalence of eating disorders and the predictive power of risk models in female elite athletes: A controlled study. Scand. J. Med. Sci. Sports 2008 , 18 , 108–118. [ Google Scholar ] [ CrossRef ] [ PubMed ]
- Wu, A.D.; Zumbo, B.D. Understanding and using mediators and moderators. Soc. Indic. Res. 2008 , 87 , 367–392. [ Google Scholar ] [ CrossRef ]
- Bratland-Sanda, S.; Sundgot-Borgen, J. Eating disorders in athletes: Overview of prevalence, risk factors and recommendations for prevention and treatment. Eur. J. Sport Sci. 2013 , 13 , 499–508. [ Google Scholar ] [ CrossRef ]
- Burgon, R.H.; Beard, J.; Waller, G. Body image concerns across different sports and sporting levels: A systematic review and meta-analysis. Body Image 2023 , 46 , 9–31. [ Google Scholar ] [ CrossRef ]
- Chapa, D.A.; Johnson, S.N.; Richson, B.N.; Bjorlie, K.; Won, Y.Q.; Nelson, S.V.; Ayres, J.; Jun, D.; Forbush, K.T.; Christensen, K.A. Eating-disorder psychopathology in female athletes and non-athletes: A meta-analysis. Int. J. Eat. Disord. 2022 , 55 , 861–885. [ Google Scholar ] [ CrossRef ]
- Aromataris, E.; Fernandez, R.; Godfrey, C.M.; Holly, C.; Khalil, H.; Tungpunkom, P. Summarizing systematic reviews: Methodological development, conduct and reporting of an umbrella review approach. JBI Evid. Implement. 2015 , 13 , 132–140. [ Google Scholar ] [ CrossRef ]
- Page, M.J.; McKenzie, J.E.; Bossuyt, P.M.; Boutron, I.; Hoffmann, T.C.; Mulrow, C.D.; Shamseer, L.; Tetzlaff, J.M.; Akl, E.A.; Brennan, S.E. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. Int. J. Surg. 2021 , 88 , 105906. [ Google Scholar ] [ CrossRef ]
- Peters, M.D.; Marnie, C.; Tricco, A.C.; Pollock, D.; Munn, Z.; Alexander, L.; McInerney, P.; Godfrey, C.M.; Khalil, H. Updated methodological guidance for the conduct of scoping reviews. JBI Evid. Synth. 2020 , 18 , 2119–2126. [ Google Scholar ] [ CrossRef ]
- Shea, B.J.; Reeves, B.C.; Wells, G.; Thuku, M.; Hamel, C.; Moran, J.; Moher, D.; Tugwell, P.; Welch, V.; Kristjansson, E. AMSTAR 2: A critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 2017 , 358 , 1–9. [ Google Scholar ] [ CrossRef ]
- Hincapié, C.A.; Cassidy, J.D. Disordered eating, menstrual disturbances, and low bone mineral density in dancers: A systematic review. Arch. Phys. Med. Rehabil. 2010 , 91 , 1777–1789.e1771. [ Google Scholar ] [ CrossRef ]
- Varnes, J.R.; Stellefson, M.L.; Janelle, C.M.; Dorman, S.M.; Dodd, V.; Miller, M.D. A systematic review of studies comparing body image concerns among female college athletes and non-athletes, 1997–2012. Body Image 2013 , 10 , 421–432. [ Google Scholar ] [ CrossRef ]
- Werner, A.; Thiel, A.; Schneider, S.; Mayer, J.; Giel, K.E.; Zipfel, S. Weight-control behaviour and weight-concerns in young elite athletes–a systematic review. J. Eat. Disord. 2013 , 1 , 18. [ Google Scholar ] [ CrossRef ]
- Arcelus, J.; Witcomb, G.L.; Mitchell, A. Prevalence of eating disorders amongst dancers: A systemic review and meta-analysis. Eur. Eat. Disord. Rev. 2014 , 22 , 92–101. [ Google Scholar ] [ CrossRef ]
- Macdougall, H.; O’Halloran, P.; Shields, N.; Sherry, E. Comparing the well-being of para and Olympic sport athletes: A systematic review. Adapt. Phys. Act. Q. 2015 , 32 , 256–276. [ Google Scholar ] [ CrossRef ]
- Chapman, J.; Woodman, T. Disordered eating in male athletes: A meta-analysis. J. Sports Sci. 2016 , 34 , 101–109. [ Google Scholar ] [ CrossRef ]
- Rice, S.M.; Purcell, R.; De Silva, S.; Mawren, D.; McGorry, P.D.; Parker, A.G. The mental health of elite athletes: A narrative systematic review. Sports Med. 2016 , 46 , 1333–1353. [ Google Scholar ] [ CrossRef ]
- Mitchell, L.; Murray, S.B.; Cobley, S.; Hackett, D.; Gifford, J.; Capling, L.; O’Connor, H. Muscle dysmorphia symptomatology and associated psychological features in bodybuilders and non-bodybuilder resistance trainers: A systematic review and meta-analysis. Sports Med. 2017 , 47 , 233–259. [ Google Scholar ] [ CrossRef ] [ PubMed ]
- Mainwaring, L.M.; Finney, C. Psychological risk factors and outcomes of dance injury: A systematic review. J. Danc. Med. Sci. 2017 , 21 , 87–96. [ Google Scholar ] [ CrossRef ]
- Buckley, G.L.; Hall, L.E.; Lassemillante, A.-C.M.; Ackerman, K.E.; Belski, R. Retired athletes and the intersection of food and body: A systematic literature review exploring compensatory behaviours and body change. Nutrients 2019 , 11 , 1395. [ Google Scholar ] [ CrossRef ]
- Mancine, R.P.; Gusfa, D.W.; Moshrefi, A.; Kennedy, S.F. Prevalence of disordered eating in athletes categorized by emphasis on leanness and activity type–a systematic review. J. Eat. Disord. 2020 , 8 , 47. [ Google Scholar ] [ CrossRef ]
- Stoyel, H.; Slee, A.; Meyer, C.; Serpell, L. Systematic review of risk factors for eating psychopathology in athletes: A critique of an etiological model. Eur. Eat. Disord. Rev. 2020 , 28 , 3–25. [ Google Scholar ] [ CrossRef ]
- King, L.; Cullen, S.J.; McGoldrick, A.; Pugh, J.; Warrington, G.; Woods, G.; Losty, C. Mental health difficulties among professional jockeys: A narrative review. BMJ Open Sport Exerc. Med. 2021 , 7 , e001078. [ Google Scholar ] [ CrossRef ]
- Roberts, C.J.; Hurst, H.T.; Hardwicke, J. Eating disorders and disordered eating in competitive Cycling: A scoping review. Behav. Sci. 2022 , 12 , 490. [ Google Scholar ] [ CrossRef ]
- Woods, G.; McCabe, T.; Mistry, A. Mental health difficulties among professional footballers. Sports Psychiatry 2022 , 1 , 57–69. [ Google Scholar ] [ CrossRef ]
- Godoy-Izquierdo, D.; Ramírez, M.J.; Díaz, I.; López-Mora, C. A systematic review on exercise addiction and the disordered eating-eating disorders continuum in the competitive sport context. Int. J. Ment. Health Addict. 2023 , 21 , 529–561. [ Google Scholar ] [ CrossRef ]
- Zaccagni, L.; Gualdi-Russo, E. The Impact of Sports Involvement on Body Image Perception and Ideals: A Systematic Review and Meta-Analysis. Int. J. Environ. Res. Public Health 2023 , 20 , 5228. [ Google Scholar ] [ CrossRef ]
- Smith, A.; Buadze, A.; Colangelo, J.; Liebrenz, M. A review of mental health issues in high-performance and elite-level cycling. Int. J. Sports Med. 2023 , 44 , 1034–1042. [ Google Scholar ] [ CrossRef ]
- Pieper, D.; Antoine, S.L.; Mathes, T.; Neugebauer, E.A.; Eikermann, M. Systematic review finds overlapping reviews were not mentioned in every other overview. J. Clin. Epidemiol. 2014 , 67 , 368–375. [ Google Scholar ] [ CrossRef ]
- de Bruin, A.K.; Oudejans, R.R. Athletes’ body talk: The role of contextual body image in eating disorders as seen through the eyes of elite women athletes. J. Clin. Sport Psychol. 2018 , 12 , 675–698. [ Google Scholar ] [ CrossRef ]
- Krane, V.; Choi, P.Y.; Baird, S.M.; Aimar, C.M.; Kauer, K.J. Living the paradox: Female athletes negotiate femininity and muscularity. Sex Roles 2004 , 50 , 315–329. [ Google Scholar ] [ CrossRef ]
- Stirling, A.E.; Cruz, L.C.; Kerr, G.A. Influence of retirement on body satisfaction and weight control behaviors: Perceptions of elite rhythmic gymnasts. J. Appl. Sport Psychol. 2012 , 24 , 129–143. [ Google Scholar ] [ CrossRef ]
- Mitchison, D.; Basten, C.; Griffiths, S.; Murray, S.B. Beneath the tip of the iceberg: Why so many people with eating disorders are not referred for treatment. Aust. Fam. Physician 2017 , 46 , 539–540. [ Google Scholar ]
- Torstveit, M.K.; Ackerman, K.E.; Constantini, N.; Holtzman, B.; Koehler, K.; Mountjoy, M.L.; Sundgot-Borgen, J.; Melin, A. Primary, secondary and tertiary prevention of Relative Energy Deficiency in Sport (REDs): A narrative review by a subgroup of the IOC consensus on REDs. Br. J. Sports Med. 2023 , 57 , 1119–1126. [ Google Scholar ] [ CrossRef ]
- Pope, Z.; Gao, Y.; Bolter, N.; Pritchard, M. Validity and reliability of eating disorder assessments used with athletes: A review. J. Sport Health Sci. 2015 , 4 , 211–221. [ Google Scholar ] [ CrossRef ]
- Buckley, G. Furthering the Conceptualisation of Disordered Eating in Current and Former Athletes for the Development, Validation and Evaluation of the Athletic Disordered Eating (ADE) Scale Swinburne University of Technology]. Swinburne Research Bank. 2021. Available online: http://hdl.handle.net/1959.3/462290 (accessed on 1 July 2023).
- Stice, E. A prospective test of the dual-pathway model of bulimic pathology: Mediating effects of dieting and negative affect. J. Abnorm. Psychol. 2001 , 110 , 124. [ Google Scholar ] [ CrossRef ] [ PubMed ]
- Fairburn, C.G.; Cooper, Z.; Shafran, R. Cognitive behaviour therapy for eating disorders: A “transdiagnostic” theory and treatment. Behav. Res. Ther. 2003 , 41 , 509–528. [ Google Scholar ] [ CrossRef ] [ PubMed ]
- Stice, E.; Chase, A.; Stormer, S.; Appel, A. A randomized trial of a dissonance-based eating disorder prevention program. Int. J. Eat. Disord. 2001 , 29 , 247–262. [ Google Scholar ] [ CrossRef ] [ PubMed ]
- Becker, C.B.; McDaniel, L.; Bull, S.; Powell, M.; McIntyre, K. Can we reduce eating disorder risk factors in female college athletes? A randomized exploratory investigation of two peer-led interventions. Body Image 2012 , 9 , 31–42. [ Google Scholar ] [ CrossRef ] [ PubMed ]
- Stewart, T.M.; Pollard, T.; Hildebrandt, T.; Wesley, N.Y.; Kilpela, L.S.; Becker, C.B. The Female Athlete Body project study: 18-month outcomes in eating disorder symptoms and risk factors. Int. J. Eat. Disord. 2019 , 52 , 1291–1300. [ Google Scholar ] [ CrossRef ] [ PubMed ]
- Gorrell, S.; Schaumberg, K.; Boswell, J.F.; Hormes, J.M.; Anderson, D.A. Female athlete body project intervention with professional dancers: A pilot trial. Eat. Disord. 2021 , 29 , 56–73. [ Google Scholar ] [ CrossRef ] [ PubMed ]
- Perelman, H.; Schwartz, N.; Yeoward-Dodson, J.; Quiñones, I.C.; Murray, M.F.; Dougherty, E.N.; Townsel, R.; Arthur-Cameselle, J.; Haedt-Matt, A.A. Reducing eating disorder risk among male athletes: A randomized controlled trial investigating the male athlete body project. Int. J. Eat. Disord. 2022 , 55 , 193–206. [ Google Scholar ] [ CrossRef ] [ PubMed ]
- Becker, C.B.; Smith, L.M.; Ciao, A.C. Peer-facilitated eating disorder prevention: A randomized effectiveness trial of cognitive dissonance and media advocacy. J. Couns. Psychol. 2006 , 53 , 550. [ Google Scholar ] [ CrossRef ]
- Becker, C.B.; Stice, E. From efficacy to effectiveness to broad implementation: Evolution of the Body Project. J. Consult. Clin. Psychol. 2017 , 85 , 767. [ Google Scholar ] [ CrossRef ]
- Sandgren, S.S.; Haycraft, E.; Plateau, C.R. Nature and efficacy of interventions addressing eating psychopathology in athletes: A systematic review of randomised and nonrandomised trials. Eur. Eat. Disord. Rev. 2020 , 28 , 105–121. [ Google Scholar ] [ CrossRef ]
Click here to enlarge figure
Author | Objective of Review | Type of Review | Unique Participant Details or Context * | Inclusion Criteria | Number of Reviewers | Number of Databases | Date of Database Searching | Publication Date Range | Number of Studies | Instrument for Quality Appraisal |
---|---|---|---|---|---|---|---|---|---|---|
Hausenblas and Carron (1999) [ ] | (1) MA of DE in athletes; (2) moderators: age, BMI, sport type, competition level | MA | Mixed competition level—separate syntheses for elite athletes | Athlete sample; comparison with control; measure of DE; data sufficient for effect size | Unclear | 6; Dissertation Abstracts Online, Educational Research in Completion, MEDLINE, PsychINFO, Sociofile, SPORTDiscus | Unclear | 1978–1998 | 92 studies | Nil reported |
Smolak et al. (2000) [ ] | (1) MA of eating problems in female athletes; (2) moderators: sport type, elite vs. non-elite | MA | Females; mixed competition level—separate syntheses for elite athletes | Female athletes sample compared with female non-athletes; data sufficient for MA | Unclear | 2; FirstSearch and PsychLit | Unclear | 1975–1996 (elite) | 33 studies (19 elite samples) | Nil reported |
Hausenblas and Downs (2001) [ ] | (1) MA of BD in athletes; (2) moderators: gender, age, sport type, competition level, ethnicity, body composition | MA | Mixed competition level—separate syntheses for elite athletes | Athlete sample and non-athlete comparison; body image measure; data sufficient for effect size | 2 | 5; Dissertation Abstracts Online, Educational Resources in Completion, MEDLINE, PsycINFO, Sportdiscus | Unclear | 1975–2000 (unclear of elite) | 78 studies (19 elite) | Nil reported |
Hincapie and Cassidy (2010) [ ] | Summarise the epidemiology, diagnosis, prognosis, and treatment of disordered eating, menstrual disturbances, and low bone mineral density in dancers | SR | Mostly female; dancers; mixed competition level—separate syntheses for elite dancers | Dancer sample; prevalence, correlates or intervention for DE, menstrual disturbances, or low bone density in dancers, in English, include at least 20 participants | 2 | 8; MEDLINE, CINAHL, PsycINFO, Embase, Cochrane Central Trials Registry, MANTIS, Index to Chiropractic Literature, EBSCO | 2010 | 1980–2010 (DE) | 8 studies focused on disordered eating (2 professional, 2 pre-professional, 2 university, 2 young student) | Based on Carroll et al. (2008) |
Varnes et al. (2013) [ ] | (1) SR of body image in female collegiate athletes vs. non-athletes; (2) moderators: sport type, competition level | SNR | Females; collegiate athletes; USA and Canada only; mixed competition level—separate syntheses for elite athletes | Collegiate female sample and non-athlete comparison; measure of body image; peer-reviewed in English | Unclear | 5; Dissertation Abstracts Online, Educational Resources in Completion, MEDLINE, PsychINFO, and SPORTDiscus | 1997–July 2012 | 1998–2012 | 10 studies | Nil reported |
Werner et al. (2013) [ ] | (1) SR of pathogenic weight -control behaviours in young elite athletes vs. non-athletes; (2) moderators: sport type, gender | SR | Young athletes (≤25 years old) | Elite current athletes (<25 years); measure of weight concerns or weight control behaviour; peer reviewed published | 2 | 3; PubMed, PsycINFO, Spolit | Feb 2012 | 1993–2011 | 15 studies | Nil reported |
Arcelus et al. (2014) [ ] | (1) Summarise the prevalence of ED in dancers; (2) moderators: methodology, dance type, change in diagnosis over time | MA | Mostly female; dancers; mixed competition (mostly elite) | Dancer sample (at least 10 participants); diagnosis or symptoms to establish caseness for ED; English journal articles | 2 | 3; MEDLINE/PubMed, PsycINFO, Embase | Jul 2013 | 1985–2012 (elite) | 33 studies (27 elite sample) | Nil reported |
Macdougall et al. (2015) [ ] | (1) Comparing para- and Olympic sport athletes for well-being | MA | Para athletes | Para-athlete sample with Olympic sport athlete comparison; peer-reviewed in English | 2 | 8; MEDLINE, PsycINFO, Embase, AMED, CINAHL. SPORTDiscus, Scopus, and Web of Science | Sep 2014 | 1989–2012 | 12 studies (2 relating to body image) | Adapted from McMaster University guidelines and Effective Public Health Practice Project |
Chapman and Woodman (2016) [ ] | (1) MA of disordered eating in male athletes; (2) moderators: sport type, competitive level, measurement tool | MA | Males; mixed competition level—separate syntheses for elite athletes | Male athlete sample and non-athlete comparison; data sufficient for meta-analysis | Unclear | 9; PsycINFO, PsychLit, SPORTDiscus, Science Direct, Web of Knowledge, PubMed, Ingenta-Connect, First Search, Google Scholar | 1 January 2014 | 1986–2013 (elite) | 31 studies (12 elite samples) | Nil reported |
Rice et al. (2016) [ ] | (1) SR of psychological wellbeing among elite-level athletes | SR | + | Adult elite athlete sample; measures of mental wellbeing; English articles | 3 | 5; PubMed, EMBASE, SPORTDiscus, PsycINFO, Cochrane; Google Scholar | May 2015 | 1994–2008 (elite) | 60 studies (10 relating to ED and body image) | Based on Glasziou et al. and Brown et al. |
Mitchell et al. (2017) [ ] | (1) MA and SR of muscle dysmorphia symptomatology in body builders; (2) investigating correlates | MA | Body builders; mixed competition level—comparisons between elite and non-elite athletes | Body builder sample with non-body builder resistance trainer comparisons; psychometrically validated measure of MD; peer-reviewed journal articles | 1 | 8; MEDLINE, PsycINFO, CINAHL, ProQuest 5000, Scopus, PubMed, SPORTDiscus, Web of Science | Feb 2015 | 2002–2013 (elite) | 31 studies (6 elite) | Modified scale by Downs and Black |
Mainwaring and Finney (2017) [ ] | (1) SR of psychological factors associated with dance injuries | SR | Dancers; mixed competition level (mostly elite) | Dancer sample; measure of injury relating to dance; measure of psychological factor related to the injury | 2 | 4; SPORTDiscus, MEDLINE, CINAHL, PsycINFO | 7 July 2014 | 2001–2015 (ED related) | 13 studies (3 relating to DE) | Custom assessment based on Finney et al. and Lagerveld et al. |
Buckley et al. (2019) [ ] | (1) SR of athletes’ relationships with food and bodies after retirement from elite sport | SR | Retired elite athletes | Retired elite athlete sample; measures of eating behaviours or body image; English peer-reviewed articles | 2 | 6; Web of Science, Scopus, PubMed, EBSCO Host, SPORTDiscus, CINAHL | Aug 2018 | 1996–2018 | 16 studies | Pluye et al. (2009) |
Mancine et al. (2020) [ ] | (1) SR of DE in athletes; (2) moderators: sport type | SR | Mixed levels—separate syntheses for elite athletes | Sample of athletes; standardised tool or interview for risk of DE; English peer-reviewed published work | 2 | 1; PubMed | Jul 2019 | 2007–2019 | 12 studies (at least 7 elite) | Nil reported |
Stoyel et al. (2020) [ ] | (1) SR of evidence for a model of DE in athletes; (2) assess mediators for DE | SR | + | Sample of elite athletes; measure of DE; measure of a mediator from the model; quantitative peer-reviewed articles published after 2000 | Unclear | 4; Ovid-MEDLINE, PsycINFO, JSTOR, EBSCOhost | Nov 2018 | 2002–2017 | 37 studies | Effective Public Health Practice Project assessment tool |
Karrer et al. (2020) [ ] | (1) SR of DE in male elite athletes | SSR | Males | Adult elite male athlete sample; measure of DE; English or German language | 2 | 4; PsycINFO, PubMed, SPORTDiscus, Web of Science | May 2020 | Not stated | 80 studies (14 controlled, 47 uncontrolled, 1 intervention, 18 reviews) | None used |
King et al. (2021) [ ] | (1) SR of jockeys’ mental health | SR | Professional jockeys | Professional jockey sample; data of mental health disorders or help-seeking; English language | 2 | 2; PubMed, Google Scholar | Jan 2021 | 1987–2019 (DE) | 16 studies (12 relating to DE) | Nil reported |
Roberts et al. (2022) [ ] | (1) SR of DE and EDs in competitive cyclists | SNR | Competitive cyclists; mixed competition level (majority elite) | Competitive cyclist sample; reference to ED or DE, eating patterns and attitudes, race weight, leanness; English peer-reviewed articles | 2 | 4; PubMed, SPORTDiscus, Web of Science, Google Scholar | Sep 2022 | 2003–2022 | 14 studies | None used |
Woods et al. (2022) [ ] | (1) SR of prevalence of mental health symptoms among professional footballers | SNR | Professional football players | Elite footballers sample; data on mental health disorders or their symptoms; English language | 3 | 1; MEDLINE | Unclear | 2015–2021 (DE) | 13 studies (5 relating to DE) | Nil reported |
Chapa et al. (2022) [ ] | (1) MA of ED psychopathology (i.e., DE and BIC) in female athletes; (2) moderators: sport type, age, competition level | MA | Females; mixed competition level—included as moderating variable | Female athlete sample and non-athlete comparisons; sufficient data for meta-analysis; English studies (including dissertations) | 2 | 2; PubMed and PsycINFO | Jan 2022 | 2001–2021 (elite) | 56 studies (18 elite) | Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-sectional Studies |
Burgon et al. (2023) [ ] | (1) MA and SR of BIC in adult athletes; (2) moderators: sport type, competition level, gender | MA | Mixed competition level—separate syntheses for elite athletes | Elite adult (>16 years) athlete sample and non-athlete comparisons; quantitative measure of BIC; sufficient data for effect sizes; English quantitative study | 2 (2nd checked 10%) | 3; Scopus, PsycINFO; PubMed | Mar 2023 | 1989–2021 | 21 studies | Critical Appraisal Skills Programme |
Godoy-Izquierdo et al. (2023) [ ] | (1) SR of association between exercise addiction and DE in competitive athletes | SR | Mixed competition level—separate syntheses for elite athletes | Competitive athlete sample; measure of DE and exercise addiction; English or Spanish peer-reviewed and grey literature | 4 | 5; Web of Science, Scopus, ProQuest, EBSCOhost (including SportDiscus and Psicodoc databases), and Cochrane Library | Apr 2020 | 1998–2019 (higher competition) | 22 studies (10 higher competition level) | Nil reported |
Zaccagni and Gualdi-Russo (2023) [ ] | (1) MA and SR of BIC in athletes; (2) compare general vs. sport BIC; (3) moderators: gender, sport type, competition level; body composition | MA | Mixed competition level—comparisons of elite versus non-elite athletes | Competitive athlete sample (non-clinical sample); including body silhouette scale measure of BIC and anthropometric measurements; English journal articles | 2 | 2; PubMed and Web of Science | 2012–2022 | 2012–2021 | 15 studies | Adapted Newcastle–Ottawa Scale for observational studies |
Smith et al. (2023) [ ] | (1) SR of mental health of cyclists | SR | Cyclists | Cyclists; psychiatric concerns; peer-reviewed articles; in English | 2 | 3; PsychINFO, PubMed, Scopus | March 2023 | 2003–2022 | 10 studies (8 relating to ED) | Nil reported |
Review or Meta-Analysis | Key Risk of Bias Concerns | |||||
---|---|---|---|---|---|---|
Pre-Registration | Search Procedures | Justification for Excluded Studies | Risk of Bias in Interpretation of Results | Meta-Analytic Statistical Methods (Meta-Analysis) | Consideration of Publication Bias (Meta-Analysis) | |
Systematic Reviews without Meta-Analyses | ||||||
Hincapie and Cassidy (2010) [ ] | X | X | X | |||
Varnes et al. (2013) [ ] | X | X | X | |||
Werner et al. (2013) [ ] | X | X | X | |||
Rice et al. (2016) [ ] | X | X | X | |||
Mainwaring and Finney (2017) [ ] | X | X | ||||
Buckley et al. (2019) [ ] | X | X | ||||
Mancine et al. (2020) [ ] | X | X | X | X | ||
Stoyel et al. (2020) [ ] | X | X | X | X | ||
Karrer et al. (2020) [ ] | X | X | ||||
King et al. (2021) [ ] | X | X | X | X | ||
Roberts et al. (2022) [ ] | X | X | X | |||
Woods et al. (2022) [ ] | X | X | X | X | ||
Godoy-Izquierdo et al. (2023) [ ] | X | X | ||||
Smith et al. (2023) [ ] | X | X | X | |||
Systematic Reviews with Meta-Analyses | ||||||
Hausenblas and Carron (1999) [ ] | X | X | X | X | ||
Smolak et al. (2000) [ ] | X | X | X | X | X | |
Hausenblas and Downs (2001) [ ] | X | X | X | |||
Arcelus et al. (2014) [ ] | X | X | X | |||
Macdougall et al. (2015) [ ] | X | X | X | X | ||
Chapman and Woodman (2016) [ ] | X | X | X | |||
Mitchell et al. (2017) [ ] | X | X | X | X | X | |
Chapa et al. (2022) [ ] | X | X | X | |||
Burgon et al. (2023) [ ] | ||||||
Zaccagni and Gualdi-Russo (2023) [ ] | X | X | X | X |
Elevated risk of disordered eating for athletes | MA (1978–1998) of elite female athletes. DE higher in athletes than non-athletes (small effect) (Hasuenblas and Carron, 1999) [ ] | MA (1975–1996) of female elite athletes. DE higher in athletes than non-athletes (small effect) (Smolak et al., 2000) [ ] | * MA (1985–2012) of dancers. ED risk, including AN and EDNOS but not BN, higher in dancers than non-dancers. DE higher in dancers than non-dancers (Arcelus et al., 2014) [ ] | * MA (1986–2013) of male athletes. DE higher for athletes than non-athletes for the Eating Attitudes Test (small effect) (Chapman and Woodman, 2016) [ ] | * MA (1986–2013) of male athletes. DE higher for male wrestlers than non-athletes (small effect) (Chapman and Woodman, 2016) [ ] |
SR (1994–2008) of elite athletes. DE and BIC higher in athletes than non-athletes (Rice et al., 2016) [ ] | MA (2002–2013) of competitive body builders. MD higher in body builders than non-body builder resistance trainers (medium to large effects) (Mitchell et al., 2017) [ ] | SR (2002–2017) of elite athletes. DE higher in athletes than non-athletes in 5/9 studies (no difference in 4/9) (Stoyel et al., 2020) [ ] | SR (1996–2018) of retired elite athletes. DE higher in retired athletes than non-athletes (Buckley et al., 2019) [ ] | SR (dates unclear) of male elite athletes. DE higher in athletes than non-athletes in 7/11 studies (Karrer et al., 2020) [ ] | |
No significant difference in disordered eating | SR (1993–2011) of elite young (under 25 years) athletes. Mixed findings with no conclusive evidence of elevated risk of DE for athletes (Werner et al., 2013) [ ] | MA (1986–2013) of male elite athletes. No difference between athletes and non-athletes for DE (Chapman and Woodman, 2016) [ ] | * MA (2001–2021) of female athletes. No difference between athletes and non-athletes for DE, drive for thinness, restricting, binge eating (Chapa et al., 2022) [ ] | ||
Lower risk of disordered eating for athletes | * MA (2001–2021) of female athletes in non-lean sports. Drive for thinness lower in athletes than non-athletes (Chapa et al., 2022) [ ] |
Lower risk of body image concerns for athletes | * MA (1975–1996) of female athletes. EDI-BD lower in athletes than non-athletes (medium effect), despite higher EDI-DT scores (small effect) (Smolak et al., 2000) [ ] | MA (1975–2000) of elite athletes. BD lower in elite athlete than non-athletes (small effect) (Hausenblas and Downs, 2001) [ ] | SR (1998–2012) of elite female collegiate athletes (USA). BIC lower for athletes than non-athletes (Varnes et al., 2013) [ ] | SR (dates unclear) of male elite athletes. BD lower in athletes than non-athletes in 6/14 studies (no difference in 8/14) (Karrer et al., 2020) [ ] |
* MA (2001–2021) of female athletes. BD lower in athletes than non-athletes (Chapa et al., 2022) [ ] | * MA (2001–2021) of female athletes in non-lean sports. BD lower in athletes than non-athletes (Chapa et al., 2022) [ ] | * MA (1990–2021) of athletes. BIC lower in athletes than non-athletes (medium effect) (Burgon et al., 2023) [ ] |
General Risk Factors | Sport-Specific Factors | |||||||||
---|---|---|---|---|---|---|---|---|---|---|
Demographics | Psychological Factors | Sport Categories | Pressures within Sport | Sport-Specific Psychological Factors | Career Changes | |||||
Gender | Age | BD | Negative Affect | Injuries | Performance Changes | Retirement | ||||
* MA of athletes (Hausenblas and Carron, 1999) [ ] | RR vs. non-athletes: male (female) | RR vs. non-athletes: aesthetic (ball) in females | ||||||||
MA of elite female athletes (Smolak et al., 2000) [ ] | RR vs. non-athletes: lean (non-lean) | |||||||||
SR of young elite athletes (Werner et al., 2013) [ ] | Female (male) | = | Lean (non-lean) | |||||||
* MA of dancers (Arcelus et al., 2014) [ ] | Ballet (other dancers) | |||||||||
* MA of male athletes (Chapman and Woodman, 2016) [ ] | = | |||||||||
SR of elite athletes (Rice et al., 2016) [ ] | Female (male) | Younger (older) | Lean (non-lean) | Risk of injury | ||||||
SR of dancers (Mainwaring and Finney, 2017) [ ] | Risk of injury | |||||||||
SR of retired elite athletes (Buckley et al., 2019) [ ] | Self-objectification | High energy consumption | Internalisation of athletic ideals | Injury during career | Career dissatisfaction | Retirement | ||||
SR of elite athletes (Mancine et al., 2020) [ ] | Lean (non-lean) | |||||||||
SR of elite athletes (Stoyel et al., 2020) [ ] | BD; overvaluation of weight and shape | Negative affect | Lean (non-lean) | High performance climate; Pressure from coaches and teammates | Drive for leanness in sport | |||||
SR of elite male athletes (Karrer et al., 2020) [ ] | RR vs. non-athletes: adults (younger) | BD | Depression | Lean (non-lean) | Career dissatisfaction | |||||
SR of elite jockeys (King et al., 2021) [ ] | Changes across competitive seasons | |||||||||
* SR of cyclists (Robert et al., 2022) [ ] | High energy consumption | Power-to-weight ratios | Internalisation of ideal cyclist body | |||||||
SR of professional footballers (Woods et al., 2022) [ ] | = | Retirement | ||||||||
* MA of female athletes (Chapa et al., 2022) [ ] | = | Lean (non-lean) | ||||||||
* SR of elite athletes (exercise addiction) (Godoy-Izquierdo et al., 2023) [ ] | = | = | Weight-sensitive | |||||||
SR of elite cyclists (Smith et al., 2023) [ ] | Pressure from coaches and teammates; changes across competitive seasons | Drive for leanness in sport |
General Risk Factors | Sport-Specific Factors | |||
---|---|---|---|---|
Demographics | Sport Categories | |||
Gender | Age | Para-Athletes | ||
* MA of athletes (Hausenblas and Downs, 2001) [ ] | RR vs. non-athletes: = | RR vs. non-athletes: = | = | |
* SR of female collegiate athletes (Varnes et al., 2013) [ ] | ||||
MA of elite para-athletes (Macdougall et al., 2015) [ ] | Para-athletes (non-para-athletes) | |||
* MA of female athletes (Chapa et al., 2022) [ ] | = | Mixed findings between SR and MA | ||
* MA of athletes (Burgon et al., 2023) [ ] | Lean (non-lean) in females | |||
* MA of athletes (Zaccagni and Gualdi-Russo, 2023) [ ] | Females (males) | = |
Article | Risk Factor |
---|---|
SR of elite athletes (Rice et al., 2016) [ ] | Commencement of training at an earlier age |
SR of retired elite athletes (Buckley et al., 2019) [ ] | Athletic identity |
SR of retired elite athletes (Buckley et al., 2019) [ ] | Comparison with other athletes |
SR of retired elite athletes (Buckley et al., 2019) [ ] | Involvement in sport following retirement |
SR of dancers (Hincapie & Cassidy, 2010) [ ] | Body fat outside of “normative” range for dancers |
SR of dancers (Hincapie & Cassidy, 2010) [ ] | Lower bone mineral density |
SR of dancers (Hincapie & Cassidy, 2010) [ ] | Male-typified gender role |
SR of dancers (Hincapie & Cassidy, 2010) [ ] | Living alone |
SR of cyclists (Roberts et al., 2022) [ ] | Lack of nutritional support |
SR of elite male athletes (Karrer et al., 2020) [ ] | Other-oriented perfectionism |
SR of elite athletes (Stoyel et al., 2020) [ ] | Internalisation of appearance ideals |
The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
Share and Cite
Fatt, S.J.; George, E.; Hay, P.; Jeacocke, N.; Gotkiewicz, E.; Mitchison, D. An Umbrella Review of Body Image Concerns, Disordered Eating, and Eating Disorders in Elite Athletes. J. Clin. Med. 2024 , 13 , 4171. https://doi.org/10.3390/jcm13144171
Fatt SJ, George E, Hay P, Jeacocke N, Gotkiewicz E, Mitchison D. An Umbrella Review of Body Image Concerns, Disordered Eating, and Eating Disorders in Elite Athletes. Journal of Clinical Medicine . 2024; 13(14):4171. https://doi.org/10.3390/jcm13144171
Fatt, Scott J., Emma George, Phillipa Hay, Nikki Jeacocke, Emily Gotkiewicz, and Deborah Mitchison. 2024. "An Umbrella Review of Body Image Concerns, Disordered Eating, and Eating Disorders in Elite Athletes" Journal of Clinical Medicine 13, no. 14: 4171. https://doi.org/10.3390/jcm13144171
Article Metrics
Article access statistics, supplementary material.
ZIP-Document (ZIP, 88 KiB)
Further Information
Mdpi initiatives, follow mdpi.
![MDPI Open Access Journals MDPI](https://pub.mdpi-res.com/img/design/mdpi-pub-logo-white-small.png?71d18e5f805839ab?1721815055)
Subscribe to receive issue release notifications and newsletters from MDPI journals
- Open access
- Published: 15 July 2024
A peer mentoring program for eating disorders: improved symptomatology and reduced hospital admissions, three years and a pandemic on
- Anita Raspovic 1 , 2 , 3 , 4 ,
- Rachael Duck 1 , 3 ,
- Andrew Synnot 1 ,
- Belinda Caldwell 1 ,
- Andrea Phillipou 5 , 6 , 7 , 8 , 9 ,
- David Castle 10 ,
- Richard Newton 11 ,
- Leah Brennan 12 ,
- Zoe Jenkins 9 ,
- Michelle Cunich 4 , 13 , 14 , 15 , 16 ,
- Sarah Maguire 2 , 4 , 17 na1 &
- Jane Miskovic-Wheatley 2 , 4 , 17 na1
Journal of Eating Disorders volume 12 , Article number: 99 ( 2024 ) Cite this article
404 Accesses
4 Altmetric
Metrics details
Peer support involves people (mentors) using their own experiences to assist others (mentees). The impetus to include peer support in eating disorder recovery is high, however research on implementation of peer roles in eating disorder management is limited. A previous pilot study found positive but preliminary results for a Peer Mentor Program (PMP) for eating disorders. The PMP has since developed over time, including broadening its eligibility criteria and shifting to predominantly online delivery during COVID-19. This study aimed to evaluate the updated version of the PMP, on a larger and more diverse group of mentees.
Previously collected PMP service data from July 2020 to April 2022 (during COVID-19 lockdowns) was evaluated for fifty-one mentees using mixed methods. Data from program start (baseline), mid-point (3-months) and end (6-months) for measures of eating disorder symptoms as measured by the Eating Disorder Examination Questionnaire (EDE-Q) and psychological wellbeing as measured by the Depression, Anxiety and Stress Scale (DASS) was evaluated. Frequency of eating disorder-related hospital admissions during PMP participation versus the 6 months prior, direct program costs and qualitative mentee feedback were also analysed. One way ANOVA’s with post hoc tests were used to evaluate symptom change and thematic analysis was conducted on qualitative data.
Program attendance averaged 12.12 ( SD ± 1.57) of a possible 13 sessions. Statistically significant and clinically meaningful improvements were demonstrated across all subscales of the eating disorder and psychological wellbeing symptom measures. EDE-Q Global score and DASS scores decreased significantly by program end. Fewer eating disorder-related hospital admissions were reported during PMP than the 6-months prior. Qualitative findings were positive and themed around the unique benefits of lived experience connection, a new kind of space for recovery, hope and motivation for change. Challenges with the time limited nature of the mentee-mentor relationship were expressed.
Conclusions
The important benefits of a PMP for individuals with eating disorders are further supported. There is a pressing need for high quality, co-produced research, utilising a mixture of designs and fidelity to core peer work principles, to inform further implementation of peer work into eating disorder policy and practice.
Plain English summary
Peer mentoring involves people using their personal lived experiences to support others. A pilot Peer Mentoring Program for eating disorders (PMP) offered through Eating Disorders Victoria (EDV) was evaluated previously, showing positive findings. Subsequent demand for the program was high. As a result, the PMP has been running and evolving over time. Key changes included a broadening of program eligibility to all individuals with an eating disorder (versus only people recently discharged from hospital), larger participant numbers and a shift to largely online delivery due to COVID-19. This study evaluated this current version of the PMP. Five rounds of anonymised PMP data, from July 2020 to April 2022, were evaluated with mentee prior consent. Individuals in recovery from an eating disorder (mentees), had been paired with individuals recovered from an eating disorder for 2-years minimum (mentors). PMP rounds were 6-months, with fortnightly meetings. Mentees overall showed improvements in eating disorder symptoms and psychological wellbeing. Fewer mentee eating disorder-related hospital admissions during PMP participation were reported, compared to the 6-months prior. Feedback from mentees identified many positive benefits and some challenges. Overall, the results provide further support for the use of peer mentoring in eating disorder recovery.
Eating Disorders are common, costly and disabling [ 1 , 2 , 3 ]. All eating disorder diagnoses are associated with elevated psychosocial and medical comorbidity, with anorexia nervosa having the highest mortality rate of all mental illnesses [ 4 , 5 ]. Eating disorders occur irrespective of age, gender, cultural background, sexual orientation and body size, with important groups being at elevated risk including Aboriginal and Torres Strait Islander Peoples (First Australians) [ 6 ], LGBTIQA + individuals [ 7 ], neurodiverse individuals [ 8 ] and people experiencing certain physical conditions such as diabetes [ 9 ]. As many as 80% of people with an eating disorder do not seek eating disorder-specific interventions, and for those who do, treatment can be substantially delayed, poorly co-ordinated, or inadequately aligned to individual needs [ 10 ]. Treatment relapse rates are high, averaging between 30% and 50% depending on diagnosis when followed for 10 years [ 11 ]. Taken together, there is a clear and urgent need for diversification, innovation and improved accessibility of person-focussed eating disorder treatments.
Peer support, the sharing of related lived experience in order to connect, support and learn with and from others, offers significant benefits within mental health [ 12 ]. Based on “a system of giving and receiving help founded on key principles of respect, shared responsibility and mutual agreement of what is helpful” [ 13 ], (p 135), peer support is relational in nature. Whilst underpinned by complex mechanisms, peer support operates through mutual challenge and personal growth, it mirrors naturally occurring peer support relationships and aims to build hope, empowerment, social inclusion and self-management [ 12 , 14 ]. Positive outcomes from peer support in mental health have been demonstrated, including in early psychosis intervention [ 15 ], for reducing psychiatric admissions [ 16 ] and assisting people with complex needs to engage in services [ 17 ]. With the current policy landscape advocating for lived experience in the co-production and co-delivery of eating disorder services, there is strong impetus to build an evidence base to support safe and effective implementation [ 18 ]. Eating Disorders Peer Workforce Guidelines have recently been released in Australia, which is a promising advancement [ 19 ]. Research in the context of peer support programs in eating disorders is, however, currently limited and outcomes have been mixed [ 18 , 20 ].
In terms of the extant literature, Ramjan et al. (2017) ran a proof-of-concept study on a mentoring support program for people with any eating disorder (n = 10 mentees) [ 21 ] . They reported statistically significant improvements in hope for recovery in the domains of social relationships, romantic relationships, family life, work and overall scores. Ramjan et al. (2018) followed by using a mixed methods, participatory action research design to study a 13-week face-to-face community-based peer mentoring program for anorexia nervosa ( n = 6 mentees ) [ 22 ]. They reported on the importance of connecting people in recovery with “someone who understands” to facilitate hope, grow relationships and build quality of life. A randomised controlled trial of a face-to-face hospital-based peer mentoring program for a range of eating disorder diagnoses (anorexia nervosa, bulimia nervosa and binge-eating disorder) ( n = 60 ), showed reductions in body dissatisfaction, symptoms of depression and anxiety, and frequency of binge eating and restriction [ 23 ]. Peer-mentorship did not impact re-entry into higher level of care or body mass index. Finally, a 6-month community-based Peer Mentoring Program (PMP) in eating disorders was piloted by a research team in collaboration with Eating Disorders Victoria (EDV), the largest community-based organisation providing eating disorder specific services in Victoria, Australia [ 24 , 25 , 26 ]. A further evaluation of EDVs PMP is the focus of this current study.
The PMP was designed to address a service gap for people requiring additional support after an eating disorder-related hospital admission [ 24 ]. The PMP uses a peer support model, harnessing the experience of people who had recovered from an eating disorder (mentors) to support people in recovery (mentees) as an adjunct to their eating disorder treatment. The initial pilot PMP evaluation engaged mentees ( n = 22 ) who had recently been discharged from a high acuity eating disorder-related admission and showed promising preliminary results, indicating “moderate feasibility” [ 25 ]. By program end, mentees demonstrated on average modest improvements in body mass index, quality of life, eating disorder symptomatology, depression, anxiety, stress and perceived disability. Important qualitative themes arose from program participation including hope for recovery, greater personal agency and inspiration from first-hand interaction with another person who had recovered from an eating disorder [ 26 ]. With additional funding, EDV went on to run their highly sought after PMP in the community for over four years with the current evaluation arm possible by translational research funding (MRFF Million Minds - MAINSTREAM).
Since the initial pilot, EDV’s PMP has evolved. Over 150 mentees have now completed the program. PMP improvements include enhanced mentor training and supervision, refined program systems and procedures, and greater staff expertise using intentional peer support in eating disorder recovery. PMP eligibility broadened to include anyone in the community 18 years of age or over seeking support for eating disorder recovery, rather than only those with a recent hospital stay only. Furthermore, the PMP shifted to predominantly online delivery (i.e., fully online or online with minimal in-person meetings outdoors) in response to COVID-19 lockdowns imposed by the Victorian State Government during the 2020–2021 pandemic years, which also increased geographical reach.
The primary aim of this study was to evaluate the updated PMP for eating disorders. We hypothesised that this program would be associated with reductions in mentee eating disorder symptomatology and lowered symptoms of depression, anxiety and stress, when delivered online as part of community-based eating disorder management. We further aimed to compare the frequency of mentee eating disorder-related hospital admissions in the 6-months prior to the PMP, versus during the PMP period, and to report direct program costs. A secondary study aim was to continue to build our understanding of mentee experiences of the PMP from their feedback, using qualitative thematic analysis.
Study design, time frame and setting
This study employed a single-site, retrospective, pre-post, uncontrolled, service evaluation design using mixed methods [ 27 ]. Retrospective ethical approval was granted by the Bellberry Human Ethics Research Committee (HREC 2022_04_374). Service delivery and evaluation data collected across 5 rounds of the PMP (from July 2020 to April 2022) were pooled for analysis. The PMP ran from the EDV offices in Melbourne, Australia and sessions were conducted across various formats and locations in keeping with COVID-19 lockdown rules, including online and at times suitable outdoors locations (e.g., parks). Meetings were not permitted in mentor or mentee homes.
Participants and procedures
Participants were mentees who undertook EDV’s PMP during the study timeframe. PMP recruitment was from a broad range of sources where the program was promoted, including hospital and medical/mental health practitioners, as well as EDV’s website, social media and newsletter. PMP staff, that is EDV staff who oversaw administration of the program, assessed program eligibility based primarily on verbal self-reported information from potential participants. PMP staff were all trained in mental health and eating disorders, with some having related lived experience. Mentors are not the focus of this current evaluation, however they were individuals who had recovered from an eating disorder for a minimum of two years duration and acted as peer mentors in the program. All mentors had undergone three days of intensive training and an induction run by EDV, prior to being matched with a mentee. EDV provided all mentors with regular de-briefing and bi-monthly group supervision throughout each of the rounds of the PMP in this study.
Inclusion criteria for PMP participation (and the study) were: being 18 years or older; a self-reported current eating disorder diagnosis as indicated by their health care team (including anorexia nervosa, bulimia nervosa, binge eating disorder, atypical anorexia nervosa or avoidant restrictive food intake disorder); and actively engaged in community-based eating disorder management including a treating general practitioner, a mental health practitioner and a personal support person for the duration of the PMP. A personal support person is someone who a mentee nominates that is aware of their diagnoses and who they would be comfortable with EDV contacting if there was a concern about their health or wellbeing. Once nominated, it was assumed that this person would be available for the mentee for the duration of the PMP . A personal support person can be a family member, loved one or friend. Exclusion criteria (for PMP enrolment and thus for this evaluation) were past participation in the program, serious acute risk of harm to oneself or another (e.g., individuals at high risk of suicide) and/or being a current inpatient at the time of program start. Mentees were not excluded from the PMP if they underwent a hospital admission during the program, mentees were offered the option to continue, or pause, mentor sessions whilst an inpatient.
In total, 117 people were assessed for eligibility for EDV’s PMP running between July 1, 2020 to April 31, 2022 (i.e., the five rounds of PMP being retrospectively analysed in this study) and 87 were deemed eligible and enrolled. Six people did not proceed, with baseline program data subsequently collected for 81 people (i.e., mentees). Seventeen mentees (21%) withdrew for a variety of personal, clinical and program reasons (e.g., insufficient time, alternative treatments or deeming program ‘fit’ was not right). One significant outlier was removed for analysis due to invalid questionnaire scores.
Of the remaining 63 mentees, complete data were available for 51 (81%) as primary outcome data were missing at either one or two time points for 12 (19%). A comparison between baseline characteristics of mentees with complete data ( n = 51) versus missing data ( n = 12) identified a possible difference in eating disorder diagnostic profile, suggesting data may not be missing at random. For example, in those with missing data there was a relatively higher rate of bulimia nervosa (25% compared to 7.8%) and eating disorder duration was on average five years longer. Data imputation was not deemed appropriate and therefore the 51 cases with full data on all primary outcome measures were included for analysis (Fig. 1 ).
![case study for eating disorders alexis figure 1](https://media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs40337-024-01051-7/MediaObjects/40337_2024_1051_Fig1_HTML.png)
Flowchart of mentees through the Peer Mentoring Program (PMP) across the study timeframe.*NB - 87 participants (mentees) in total were enrolled into the Peer Mentoring Program (PMP) between July 1 2020 and April 31, 2022. This flow chart shows the process followed for each of the 5 rounds over this time period, with total participants numbers (n) summed
Program details
EDV’s PMP involved fortnightly individual mentoring sessions over 6 months. Mentees attended an average of 12.1 ( SD ± 1.6) PMP sessions out of a possible 13 sessions (range 6 to 13) indicating overall high attendance (87% attended over 75% of PMP sessions). A detailed program description is provided in Additional File 1 . Robust consent processes are in place at EDV for collection, analysis and reporting of service user data. Prior written approval was given by all mentees whose data was subsequently de-identified and pooled in the current analysis. Service data was not collected anonymously but was de-identified by EDV staff prior to analysis commencing. No mentees opted out, or requested withdrawal, of their de-identified data for service evaluation and publication. Program evaluation data was collected using FormAssembly, an online secure data storage system. All data were stored in EDV’s online, secure data storage system.
Program evaluation approach
Demographic and clinical information.
Demographic and clinical information, including age, identified gender, work status, education status and eating disorder diagnosis and duration, were collected via online self-report prior to PMP commencement.
Quantitative evaluation: eating disorder symptomatology and psychological wellbeing questionnaires
Mentees completed two questionnaires to evaluate change in eating disorder symptomatology and psychological wellbeing across PMP participation. These were utilised in two ways: (1) to monitor mentee wellbeing to guide if program modifications were needed, and (2) for program evaluation. Questionnaires were administered via automated email at program start, mid and end (i.e., baseline, 3-months and 6-months). The questionnaires were the Eating Disorder Examination Questionnaire (EDE-Q) [ 28 ] and the Depression, Anxiety and Stress Scale (DASS-21) [ 29 ]. Both have acceptable to good psychometric properties and are described elsewhere in detail [ 30 , 31 , 32 , 33 ]. Higher scores indicate higher symptomatology.
Eating disorder-related hospital admission data before vs during PMP
Self-reported, eating disorder-related inpatient hospital admission rates (medical or psychiatric admissions specific to the eating disorder) for the 6-months prior to PMP participation were collected during mentee online registration. Inpatient eating disorder-related admission rates during the 6-months of program participation were recorded by EDV program staff.
Peer mentoring program (PMP) direct costs
Direct costs of the PMP for the study period were derived from EDV operating budgets from July 2020 to April 2022. Expense categories included: general administration, infrastructure and information technology and program-related costs.
Qualitative evaluation: mentee feedback
Mentees provided online written feedback at mid-program and program end. The questions asked were what mentees (1) enjoyed most and found the least challenging, and (2) enjoyed the least and found most challenging, about PMP participation. Mentee feedback was used to optimise program responsiveness to their expressed needs and for service evaluation and quality improvement.
Statistical analysis
IBM SPSS Statistics (version 28.0) was used for quantitative analyses. Descriptive statistics were calculated. One-way repeated measures analyses of variance (ANOVA) tests evaluated change on EDE-Q and DASS scores across the 3 time points. Statistical assumptions were met for the one-way repeated measures ANOVA tests, except for the sphericity assumption for the EDE-Q Shape Concern and EDE-Q Weight Concern subscales, where a Greenhouse–Geisser correction was applied [ 34 ]. Bonferonni adjusted post-hoc tests evaluated specific time frames in which scores EDE-Q or DASS scores changed (i.e., baseline and 3-months or 3-months and 6-months). A t -test was used to compare differences in frequency of mentee eating disorder-related hospital admissions in the 6 months prior compared to during the PMP period. All tests were conducted using an alpha of 0.05.
Qualitative analysis
Qualitative analysis followed a six-stage approach of thematic analysis [ 35 ] to identify key themes in mentee feedback data. This analysis involves six phases: 1. familiarisation with the data, 2. generating initial codes, 3. searching for themes, 4. reviewing themes, 5. defining and naming themes and 6. producing the report. Qualitative analysis was overseen by the first author (AR) in collaboration with co-authors (RD & AS). Initial coding was undertaken manually by the first author on the entire data set, drawing on inductive approaches. This stage involved deep engagement with the data, to identify repeated patterns in mentee feedback. Codes were constructed around the two key feedback questions posed (i.e., 1. What were the most enjoyed/least challenging aspects of the PMP? and 2. What were the least enjoyed/most challenging aspects of the PMP?) and codes were generated in response patterns which were conceptualised from the data, strongly grounded in mentees’ accounts. Codes were grouped into themes and subthemes based on all feedback provided by the 51 mentees. The coding framework was refined over iterations in consultation between AR, RD & AS, as coded material was re-considered, similar codes merged and obsolete codes were deleted. Themes were therefore reviewed and amended to ensure they formed a consistent and authentic representation of both coded extracts and the entire feedback data set. This research was conducted primarily out of Eating Disorders Victoria (EDV), in conjunction with the MAINSTEAM collaboration and the research team, whom seek to improve care offered to people in recovery from an eating disorder. EDV’s vision is of “a future where individuals and communities thrive through empowered and safe relationships to food, eating, body and movement” and EDV’s services are strongly informed by people who have lived experienced of eating disorders and their loved ones.
First author AR, is a researcher, academic and mental health clinician working in the field, she did not work or have direct involvement with running the PMP at any stage of this evaluation (i.e., program delivery, data collection and analysis). AR contributed qualitative and quantitative research methods and service evaluation experience to the current study. As senior EDV staff members, authors RD and AS bought backgrounds in mental health work, including experience in peer work, program design & implementation and in overseeing the coordination of the PMP. They were both senior staff members in the PMP at the time of data collection, analysis and manuscript editing. Overall, the multidisciplinary research team broadly bring a range of different perspectives to this evaluation, including clinical, research, service provision (public community, hospital & private sector) and translation backgrounds. This is the first formal evaluation study of the PMP that AR, RD and AS have been involved in. Several of the authors were involved in the conduct and publication of the original PMP pilot studies (AP, DC, RN, LB, ZJ) [ 25 , 26 ].
Mentee baseline characteristics are provided in Table 1 . Mentees averaged 27 years of age ( SD ± 8.7) and predominantly identified as women (94.1%). The primary self-reported eating disorder diagnosis was anorexia nervosa (AN; 76.5%), followed by binge eating disorder (BED; 11.8%) and bulimia nervosa (BN; 7.8%) being the next most frequent eating disorder diagnoses.
Quantitative evaluation: changes in eating disorder symptomatology and psychological wellbeing
Overall, there was a statistically significant decrease in scores (improvement) across the 6-months of PMP for all primary outcome measures - the Global EDE-Q score, as well as its constituent subscales Restraint, Eating Concern, Weight Concern & Shape Concern, and the Depression, Anxiety and Stress subscales of the DASS. Effects sizes found were mostly in the statistically large range according to Cohen (1988). Refer to Table 2 . The EDE-Q Global score and EDE-Q Restraint and Eating Concern sub-scale scores had decreased significantly by 3-months of the PMP and between baseline and 6-months. The EDE-Q Shape Concern sub-scale reduced by 3-months, between 3-months and 6-months and between baseline and 6-months. All three DASS subscales reduced significantly but only between baseline and 6-months (i.e., program end), except DASS-Stress which also decreased significantly between 3- and 6-months. DASS-Anxiety and DASS-Depression each reduced from the ‘severe’ to the ‘moderate’ category and stress scores changed from ‘moderate’ to ‘mild’ [ 36 ]. Refer to Table 3 and Fig. 2 a & 2b.
![case study for eating disorders alexis figure 2](https://media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs40337-024-01051-7/MediaObjects/40337_2024_1051_Fig2_HTML.png)
Change in eating disorder (EDE-Q) and wellbeing (DASS) symptoms across participation in the Peer Mentoring Program (PMP) (n = 51). a Changes in Eating Disorder Examination Questionnaire (EDE-Q) subscales and global score across PMP participation. b Changes in Depression, Anxiety and Stress (DASS) subscales across PMP participation
Eating disorder-related hospital admissions before v’s during PMP
Thirty-one eating disorder-related hospital admissions were self-reported in the 6 months prior to participation in the PMP across 25 individuals, with 21 mentees reporting one admission (41.2% of mentees) and the remainder reporting two or more admissions (7.8% of mentees). Fewer eating disorder-related hospital admissions occurred during PMP, with 11 admissions in total (i.e., 20 less admissions). Of those 11 admissions, nine mentees reported one admission (17.6% of mentees), and the remainder reported two or more admissions (2.0% of mentees). It was the first eating disorder-related admission for a small number of mentees and a re-admission for eight.
Regarding hospital admissions before versus during the PMP, twenty-four mentees (47.1%) did not report a hospital admission in either the 6-months before or during PMP participation and eight mentees (15.7%) reported a hospital admission in both the 6-months before and during PMP participation (i.e., no change). Two mentees (3.9%) had a hospital admission during PMP participation yet not before PMP (i.e., increase in hospital admissions), however, seventeen mentees (33.3%) reported a hospital admission in the 6-months before but not during PMP (i.e., decrease in hospital admissions). Overall, there were 31 admissions between 51 participants in the 6-months prior to PMP, (representing a 0.61 likelihood of hospital admission), however only 11 admissions during PMP (0.22 likelihood of hospital admission).
Direct costs of the PMP totalled $840,090 AUD across the study period. This equated to an average of $168,018 per round and $10,372 per mentee. Average cost per mentee was calculated for the 81 mentees who commenced the PMP in the study period, to also account for costs incurred by the service for those participants who withdrew from the program early (n = 17). This figure for direct costs included general administration costs, such as office costs, infrastructure and IT including rent and internet, program specific costs for mentees such as the costs of mentee-mentor activities undertaken and program specific costs for mentors including remuneration and supervision, staff costs and program administration. While the majority of the PMP was delivered online for the rounds of the PMP reported herein, office space, IT and internet costs for staff were still incurred. Of note is that the biggest expense of running the PMP, was for PMP staff (program & administrative), mentee and supervisor remuneration costs. A breakdown of costs for the Peer Mentoring Program according to key categories is provided in Table 4 . Additional costs (such as hospital stays) were beyond the scope of this study.
Below are findings and sample quotes from a cross-section of mentee responses (using initial-based pseudonyms), derived from the thematic analysis of PMP mentee written feedback. A summary of the feedback questions with a collated list of themes can be found in Table 5 .
Feedback Question 1 - Most enjoyed/least challenging aspects of the PMP
Theme 1.1: power of the lived experience connection.
Mentees reflected personal benefit from connecting first-hand with someone who had recovered from an eating disorder and was open to sharing their experiences.
“Hearing my mentor’s story helped me see that there is a life outside of an eating disorder and that full recovery is possible”(FT)
Mentees further described positive impact from feeling heard, understood, validated and guided in a nuanced way.
“Spending time talking to someone else who understands completely what I'm going through and is empathetic, sharing experiences, doing things that I would have been scared to try alone but have been really beneficial for me (e.g. yoga), having a supportive person who cares about me.”(DE).
Some mentees identified value in someone understanding and caring about their daily struggles with an eating disorder, and who in turn was there to support them trying new experiences.
“I enjoyed being able to talk to my peer mentor about struggles and difficulties I was experiencing and gaining support from a person with lived experience. I also enjoyed being able to try new things, challenge myself in a safe and supportive environment.”(NJ).
Theme 1.2: A new kind of recovery space
Mentees identified that the PMP offered a different kind of therapeutic space to explore recovery. This included authenticity from mentors and a safe space to explore any topic without fear of judgement or shame.
“Having someone with lived experience to talk to about my fears, concerns and eating disorder behaviours without fear of judgement. I felt as though I could ask anything and together we would work towards a solution.”(NY).
Mentees welcomed the opportunity to discuss experiences with someone who had firsthand experience of the challenges of living with an eating disorder.
“My mentor’s incredible understanding of living with an eating disorder. Laughing! The feeling of looking forward to our meetings and comfort, when I have felt hopeless, that I was not alone.”(TI).
More equal power dynamics, connecting with someone to whom mentees could relate (e.g., closer in age and interests), were reflected as helpful and additional to past treatment set ups.
“Having the opportunity to connect with a peer of similar age and positionality who also has the capacity and understanding to support me in the contexts of dining out and more day-to-day eating disorder recovery factors than I have had the opportunity to delve into in other treatment contexts.”(MH).
Theme 1.3: Strengthening the foundations for recovery
Themes of inspiration and hope for recovery were relayed by mentees.
“Getting out and about which I never really do, and having someone to chat to that has somewhat recovered from an eating disorder gives hope that it might be possible for me to improve my quality of life in that area too.”(TG).
Greater connection to others, belonging to a group, increased positive social engagement and reduced isolation, were factors identified in enabling positive change.
“It's also been really nice to feel part of something, and part of some kind of community through the program.”(OQ)
Key messages towards re-discovering sense of self-identity, self-worth and connecting with life motivations for recovery were relayed, for example, “finding myself again(WO)“ , “feeling like a normal person”(IY) and “seeing there is a life outside of an eating disorder”(FT).
Theme 1.4: Reaping the rewards of “going there”
Mentees commented on the power of mentor support to help drive positive change and the subsequent rewards, as akin to being pushed out of the comfort zone but in a helpful way.
“Getting to experience some real-world activities outside of my comfort zone with lots of support and having someone to share anything with and get advice without feeling like I am being forced to do anything.”(FF). “Having moral support and a friend for challenging situations outside of my comfort zone, which I never would have otherwise tried on my own.”(TU)
Help with goal setting and problem solving the ‘how to’ practical aspects of eating disorder recovery were valued by mentees (e.g., planning for social events, cooking together and help undertaking food challenges).
“Making challenges to complete between sessions became a really useful tool and accelerated my progress in recovery.”(NY)
Additionally, positive impacts of building motivation experientially, with persistence and help, was relayed as beneficial.
“The feeling of quiet accomplishment after trying something that previously scared me, like eating out socially in such a "normal" way.”(TU)
Feedback Question 2–Least enjoyed/most challenging aspects of the PMP
Theme 2.1: the double-edged sword of ‘going there’.
Whilst mentees clearly reported benefits from increased engagement with the tasks of recovery, this was also reflected as one of the greatest challenges of the PMP.
“Sort of the reverse of the above, pushing myself to open up has been incredibly challenging however, it's also been incredibly rewarding thus a huge positive for me.”(FJ)
Translating learnings into life, choosing recovery and doing the work were commonly relayed concepts that were expressed as very difficult, however potentially reflect a strength of the program in supporting individuals enact change.
“The parts that I enjoyed the least were the struggles of choosing recovery and doing activities that challenged my eating disorder, however it always ended up being beneficial.”(KI).
Theme 2.2: Trust and vulnerability
A consistent theme was around the challenges of allowing oneself to trust the program as a safe space to be open and vulnerable, despite a time limited arrangement.
“At first it was hard to be open and honest as we didn’t know each other”(KT) “It was challenging to open up because I hate being vulnerable.”(CU)”
Opening up to big emotions involving sharing feelings, values, fears and wants, came with trepidation, but also built hope for some mentees. Leaning into confronting experiences such as “ realising how far I had to go”(CO), managing “perfectionis tic personal challenges ”(UQ) and “ drawing comparisons to others in the program”(MQ) were reflected as valuable but challenging aspects of participation.
Theme 2.3: Navigating closeness with a trusted stranger
The unique mentee-mentor relationship was portrayed by mentees as a beneficial and fundamental program feature. This relationship, however, came with challenges around learning to navigate a new kind of relationship - one which was neither completely personal, nor clinical. Seeking to understand the boundaries of the mentee-mentor relationship (e.g., what can I ask, what can I say) and learning to maximise the available time, were two of the issues raised.
“I've found it a bit challenging to ask more personal questions, such as how to navigate an eating disorder in a relationship or how to talk about it with my partner, because it's a personal question and because I don't want to overstep my mentor's boundaries.”(TU). “Sometimes I feel I am imposing when I call or text at challenging times.”(WO)
The inevitable parting of ways with a mentor instilled sadness and a sense of vulnerability in some mentees, reflected in their feedback.
“The wave of sadness, grief and loss that has come with the end of the program and trying to navigate my way through these emotions.”(MQ)
Theme 2.4: Logistics matter
The shift to predominantly online delivery of the PMP due to COVID-19 raised a unique situation in the program’s history. No single preferred delivery mode was identified, but a greater variety of delivery options provided versatility to individual mentee needs and preferences. Some reported the online only mode reduced capacity for connection with their mentors, while others reported that flexible delivery enabled them to participate even if geographically constrained (e.g., if in hospital or outside of the metropolitan area).
“I found it challenging being confined to zoom and phone calls only. I would have loved to of met my mentor face to face but that didn't end up happening due to a variety of reasons.”(FT) versus “Flexibility of sessions and allowing it to fit into my lifestyle with work.”(FJ).
The overarching purpose of this study was to further build understanding of the effectiveness and acceptability of EDV’s PMP, a now well-established community program. We utilised a mixed method design, that is, an approach which utilised the available program quantitative and qualitative data [ 27 ], to gain a fuller understanding of the ways in which mentees experienced the PMP. An additional aim was to interpret the impact of a shift of PMP to online delivery, in context of the significant challenges of extended COVID-19 lockdowns on the physical and mental wellbeing of local communities [ 37 ]. The diversity of ages and eating disorder diagnosis duration in the mentees included is wider, suggesting good program adaptability and inclusivity. Acceptability of the program was high, as reflected by consistent mentee attendance, expressed program enjoyment and the range of benefits experienced.
The first study aim was to evaluate whether program participation was associated with changes in eating disorder symptomatology and psychological wellbeing. The EDE-Q Global score and the DASS subscales reduced around 20% on average, representing both statistically significant and clinically meaningful improvements [ 36 , 38 ]. These outcomes are particularly important given the data was collected across the very challenging time of COVID-19 lockdowns when the risk of eating disorder, depression and anxiety symptoms worsening was significantly elevated [ 39 ].
A further feature of this study was the access to three data points (i.e., baseline, 3-months and 6-months), providing information on the timing of symptom changes. Regarding the EDE-Q, the Restraint subscale showed the largest change particularly in the first 3-months, with the Eating Concern subscale changing in a similar pattern but to a lesser magnitude. It may be that eating concerns potentially reduced, as behavioural changes around restraint provided corrective experiences via challenging eating anxiety. The Shape Concern subscale appeared to improve a modest amount by 3-months and 6-months, but this equated to a statistically significant change by program end. The Weight Concern subscale demonstrated the least change and appeared to take longer to show improvements, albeit reaching significance by program end. This is not unexpected as body image often takes time to change particularly in clinical level eating disorders [ 40 ].
Statistically significant reductions in symptoms of depression, anxiety and stress, occurred in a pattern of reduction across the entire program. The exception was the Stress subscale, which also indicated a pattern of change between program mid-point and end. We interpreted this change as a clinically meaningful, as according to symptom severity scores for the DASS [ 36 ], depression and anxiety scores in the current study reduced from the ‘severe’ to the ‘moderate’ category and stress scores reduced from the ‘moderate’ to ‘mild’ category. Taken together, we believe these reductions in symptomatology are also likely to represent meaningful positive improvements to mentees lives and capacity for recovery, given there is a well-documented link between increased mental health concerns and eating disorder symptomatology, and consequently improved mental health with eating disorder recovery [ 41 ].
Of note is that the reported changes in eating disorder and psychological wellbeing symptom scores represent average improvements. There were a range of responses to the program; some participant scores did not improve to this degree, while others improved more (refer to Table 2 for 95% confidence intervals of the mean difference). Further research should seek to assess for whom this program works most effectively.
Eating disorder-related hospital admissions and costing data related to PMP adds another domain on which to evaluate the program. Fewer hospital admissions were reported during PMP participation, compared to the 6-months prior, which likely represents an important cost saving. We postulate that the intentional peer support offered during the PMP is likely to explain some of this marked decrease at a program level, but further research is required to confirm this and further explore individual variations in response to PMP participation, irrespective of hospital admission. Long hospital waiting lists during COVID-19 may also have had an impact on the lower hospital admission found [ 42 ]. This finding offers evidence however that hospital admissions may reduce during PMP, regardless of the broader eligibility criteria for the program from the original pilot which included only people transitioning out of intensive treatment programs [ 25 ].
The themes from the qualitative analysis of the PMP feedback questions helped to elucidate mentees experiences of intentional peer support within the current program, thereby improving fidelity of this evaluation. Researchers in the field have acknowledged the importance of using diverse methodology when seeking to understand the complex nature of peer work in recovery [ 14 ]. Past in-depth qualitative analysis has been conducted on the initial PMP pilot [ 26 ] and main themes were re-confirmed in the current version of the program. Mentees identified the therapeutic nature of empathy, validation, normalisation of experiences and feeling truly seen and understood by another who has ‘walked in their shoes’. The difficult nature of making changes, but the benefit accruing therefrom, highlights the juxtaposition of up and down sides. Similarly, the challenge of mentees allowing themselves to be vulnerable and open in order to benefit as much as possible from the mentor relationship, was also challenged by sadness when the relationship came to an end at program completion. The quantitative and qualitative findings from our current study, taken together, support contemporary dialogues that eating disorder recovery is personal and multi-dimensional, encompassing both the reduction of eating disorder symptoms and building psychological well-being though multiple avenues including fostering meaningful relationships, self-adaptability, resilience and positive personal growth [ 41 ]. The current study confirmed outcomes from the initial PMP pilot study [ 25 , 26 ] and shows efficacy for a broader group of individuals with eating disorder problems, at various stages of their wellness journey. The acceptability of the online delivery was made pressing by the COVID-19 pandemic but has longer-term applicability in expanding availability of the program. We provisionally conclude that peer support during eating disorder recovery can offer significant benefits towards symptomatic improvement, when the quantitative and qualitative data are considered together, and await this being examined in high quality research including embedded lived experience co-production.
Results of the study must be interpreted in light of key limitations. The absence of a control group is a key limitation for understanding whether and to what degree the improvements in symptoms and reductions in hospital admissions might be attributable to non-program effects. This issue should be addressed as a priority for studies moving forward considering a range of contemporary research methodologies and approaches to explore the mechanisms and effectiveness of peer mentoring given the complexities of eating disorder recovery [ 43 ]. Furthermore, the impact of prior hospitalisation and limited access to hospital during COVID may both be alternative explanations for our findings. It is also important to note that while average data are presented in this paper, there is inherent variation in the degree of symptom response from individual to individual. We do not yet know characteristics or predictors of whom will benefit significantly from engagement with a peer mentoring program. Other limitations include the potential for selection bias and lack of generalisability. The accuracy of self-reported data and recall bias is also a limitation. Further high quality, co-designed, prospective research utilising a range of study designs and long-term follow up is urgently required on a range of forms of peer support for eating disorder management, to inform implementation into policy and practice.
In conclusion, the findings of this work add to the under-researched but important area of peer mentoring programs in eating disorder management. The current research reports novel findings on the further evaluation of EDV’s PMP for eating disorders, as a matured program, with a larger and more diverse sample, adapted for online delivery. While participating in the program the mentees experienced a significant reduction in eating disorder symptomatology, improved psychological wellbeing and reduced hospital admissions. Thematic analysis showed key benefits experienced by mentees through connecting with people with lived experience of an eating disorder (the mentors), accessing a different kind of space for recovery, building hope, motivation and social engagement, and gaining practical help with the ‘work’ of recovery. Given growing research and anecdotal evidence for the benefits of peer support in eating disorder recovery, and wide-spread government and societal shifts calling for greater lived experience inclusion into mental health programs, targeted research in peer mentoring programs in eating disorder management is likely to have large-scale benefits for society.
Availability of data
The data are not publicly available due to privacy.
Abbreviations
Peer Mentoring Program
Eating Disorders Victoria
Eating Disorder Examination Questionnaire
Depression Anxiety Stress Scale - 21 (also known as Short Form)
Hay P, Mitchison D, Lopez Collado AE, Gonzalez-Chica DA, Stocks N, Touyz S. Burden and health-related quality of life of eating disorders, including Avoidant/Restrictive Food Intake Disorder (ARFID), in the Australian population. Journal of Eating Disorders. 2017;5.
Mitchison D, Mond J, Bussey K, Griffiths S, Trompeter N, Lonergan A, et al. DSM-5 full syndrome, other specified, and unspecified eating disorders in Australian adolescents: prevalence and clinical significance. Psychol Med. 2020;50(6):981–90.
Article PubMed Google Scholar
Demmler JC, Brophy ST, Marchant A, John A, Tan JOA. Shining the light on eating disorders, incidence, prognosis and profiling of patients in primary and secondary care: national data linkage study. Br J Psychiatry. 2020;216(2):105–12.
van Eeden AE, van Hoeken D, Hoek HW. Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa. Curr Opin Psychiatry. 2021;34(6).
Guinhut M, Godart N, Benadjaoud M-A, Melchior J-C, Hanachi M. Five-year mortality of severely malnourished patients with chronic anorexia nervosa admitted to a medical unit. Acta Psychiatr Scand. 2021;143(2):130–40.
Burt A, Mannan H, Touyz S, Hay P. Prevalence of DSM-5 diagnostic threshold eating disorders and features amongst Aboriginal and Torres Strait islander peoples (First Australians). BMC Psychiatry. 2020;20(1):449.
Article PubMed PubMed Central Google Scholar
Nagata JM, Ganson KT, Austin SB. Emerging trends in eating disorders among sexual and gender minorities. Curr Opin Psychiatry. 2020;33(6):562–7.
Boltri M, Sapuppo W. Anorexia nervosa and autism spectrum disorder: a systematic review. Psychiatry Res. 2021;306:114271.
Abbott S, Dindol N, Tahrani AA, Piya MK. Binge eating disorder and night eating syndrome in adults with type 2 diabetes: a systematic review. J Eat Disord. 2018;6(1):36.
Hart LM, Granillo MT, Jorm AF, Paxton SJ. Unmet need for treatment in the eating disorders: a systematic review of eating disorder specific treatment seeking among community cases. Clin Psychol Rev. 2011;31(5):727–35.
Sala M, Keshishian A, Song S, Moskowitz R, Bulik CM, Roos CR, et al. Predictors of relapse in eating disorders: a meta-analysis. J Psychiatr Res. 2023;158:281–99.
Gillard S. Peer support in mental health services: where is the research taking us, and do we want to go there? J Ment Health. 2019;28(4):341–4.
Mead S, Hilton D, Curtis L. Peer support: a theoretical perspective. Psychiatr Rehabil J. 2001;25(2):134–41.
King AJ, Simmons MB. A systematic review of the attributes and outcomes of peer work and guidelines for reporting studies of peer interventions. Psychiatr Serv. 2018;69(9):961–77.
Galloway A, Pistrang N. “We’re stronger if we work together”: experiences of naturally occurring peer support in an inpatient setting. J Ment Health. 2019;28(4):419–26.
Lawn S, Smith A, Hunter K. Mental health peer support for hospital avoidance and early discharge: an Australian example of consumer driven and operated service. J Ment Health. 2008;17(5):498–508.
Article Google Scholar
Rowe M, Bellamy C, Baranoski M, Wieland M, O’Connell M, Benedict P, et al. A peer-support, group intervention to reduce substance use and criminality among persons with severe mental illness. Psychiatr Serv. 2007;58(7):955–61.
Lewis HK, Foye U. From prevention to peer support: a systematic review exploring the involvement of lived-experience in eating disorder interventions. Mental Health Rev. 2022;27(1):1–17.
Utpala R, Squire S, Farrar-Rabbidge M. Eating disorders peer workforce guidelines. Sydney: Butterfly Foundation; 2023.
Google Scholar
Pellizzer ML, Wade TD. The effectiveness of lived experience involvement in eating disorder treatment: a systematic review. Int J Eat Disord. 2023;56(2):331–49.
Ramjan LM, Hay P, Fogarty S. Benefits of a mentoring support program for individuals with an eating disorder: a proof of concept pilot program. BMC Res Notes. 2017;10(1):709.
Ramjan LM, Fogarty S, Nicholls D, Hay P. Instilling hope for a brighter future: a mixed-method mentoring support programme for individuals with and recovered from anorexia nervosa. J Clin Nurs. 2018;27(5–6):e845–57.
PubMed Google Scholar
Ranzenhofer LM, Wilhelmy M, Hochschild A, Sanzone K, Walsh BT, Attia E. Peer mentorship as an adjunct intervention for the treatment of eating disorders: a pilot randomized trial. Int J Eat Disord. 2020;53(5):767–79.
Beveridge J, Phillipou A, Edwards K, Hobday A, Hilton K, Wyett C, et al. Peer mentoring for eating disorders: evaluation of a pilot program. Pilot Feasibility Stud. 2018;4:75.
Beveridge J, Phillipou A, Jenkins Z, Newton R, Brennan L, Hanly F, et al. Peer mentoring for eating disorders: results from the evaluation of a pilot program. Journal of Eating Disorders. 2019;7.
Hanly F, Torrens-Witherow B, Warren N, Castle D, Phillipou A, Beveridge J, et al. Peer mentoring for individuals with an eating disorder: a qualitative evaluation of a pilot program. J Eat Disord. 2020;8(1):29.
Creamer EG, Reeping D. Advancing mixed methods in psychological research. Methods Psychol. 2020;3:100035.
Fairburn CG, Beglin SJ. Assessment of eating disorders: interview or self-report questionnaire? Int J Eat Disord. 1994;16(4):363–70.
Lovibond P, Lovibond S. The structure of negative emotional states: comparison of the depression anxiety stress scales (DASS) with the beck depression and anxiety inventories. Behav Res Ther. 1995;33(3):335–43.
Black CMD, Wilson GT. Assessment of eating disorders: Interview versus questionnaire. Int J Eat Disord. 1996;20(1):43–50.
Carey M, Kupeli N, Knight R, Troop NA, Jenkinson PM, Preston C. Eating Disorder Examination Questionnaire (EDE-Q): norms and psychometric properties in U.K. females and males. psychological assessment. 2019;31(7):839–50.
Antony MM, Bieling PJ, Cox BJ, Enns MW, Swinson RP. Psychometric properties of the 42-item and 21-item versions of the depression anxiety stress scales in clinical groups and a community sample psychological assessment. 1998;10(2):176–81.
Ng F, Trauer T, Dodd S, Callaly T, Campbell S, Berk M. The validity of the 21-item version of the Depression Anxiety Stress Scales as a routine clinical outcome measure. Acta Neuropsychiatr. 2007;19(5):304–10.
Pallant J. SPSS Survival Manual. Crows Nest, NSW: Allen & Unwin; 2011.
Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101.
Lovibond S, Lovibond P. Manual for the depression anxiety stress scales. 2nd ed. Sydney: Psychology Foundation; 1995.
Phillipou A, Meyer D, Neill E, Tan EJ, Toh WL, Van Rheenen TE, et al. Eating and exercise behaviors in eating disorders and the general population during the COVID-19 pandemic in Australia: initial results from the COLLATE project. Int J Eat Disord. 2020;53(7):1158–65.
Velkoff EA, Brown TA, Kaye WH, Wierenga CE. Using clinical cutoff scores on the eating disorder examination-questionnaire to evaluate eating disorder symptoms during and after naturalistic intensive treatment. Eat Disord. 2023:1–15.
Vitagliano JA, Jhe G, Milliren CE, Lin JA, Spigel R, Freizinger M, et al. COVID-19 and eating disorder and mental health concerns in patients with eating disorders. J Eat Disord. 2021;9(1):80.
Eshkevari E, Rieger E, Longo MR, Haggard P, Treasure J. Persistent body image disturbance following recovery from eating disorders. Int J Eat Disord. 2014;47(4):400–9.
de Vos JA, LaMarre A, Radstaak M, Bijkerk CA, Bohlmeijer ET, Westerhof GJ. Identifying fundamental criteria for eating disorder recovery: a systematic review and qualitative meta-analysis. J Eat Disord. 2017;5(1):34.
Lin JA, Hartman-Munick SM, Kells MR, Milliren CE, Slater WA, Woods ER, et al. The impact of the COVID-19 pandemic on the number of adolescents/young adults seeking eating disorder-related care. J Adolesc Health. 2021;69(4):660–3.
Hower H, LaMarre A, Bachner-Melman R, Harrop EN, McGilley B, Kenny TE. Conceptualizing eating disorder recovery research: Current perspectives and future research directions. J Eat Disord. 2022;10(1):165.
Download references
Acknowledgements
We wish to thank the myriad of people who have played a role in developing Eating Disorder Victoria’s (EDV’s) Peer Mentoring Program (PMP) since its inception. The authors would like to thank EDVs Board, Senior Management and PMP staff, for their commitment to facilitating lived experience eating disorder support for our communities and whose collaboration has allowed the conduct of this work. Importantly, we wish to thank and acknowledge the essential contributions of the mentees and mentors of the PMP, who make the program and this work possible.
Individual members of the Mainstream Center are: Associate Professor Sarah Maguire, Professor Stephen Touyz, Professor Natasha Nassar, Dr Michelle Cunich, Professor Ian Hickie, Professor Jan Russell, Associate Professor Sloane Madden, Associate Professor Warren Ward, Danielle Maloney, Claire Diffey, Dr Jane Miskovic-Wheatley, Dr Ang Li, Bronny Carroll, Genevieve Dammery, Belinda Caldwell, Belinda Chelius, Amanda Davis, Michelle Roberton, Dr Andrew Wallis, Dr Lyn Chiem, Rachel Knight, Dr Phillip Aouad, Dr Morgan Sidari, Dr Sumedha Verma, Dr Anita Raspovic, Dr Moin Uddin Ahmed, Dr, Lorraine Ivancic, Dr Diana Bond, Dr Francisco Schneuer Brahm, Amy Hannigan, Kelly Dann, Emma Bryant , Dr Shu Hwa Ong, Dr Sabina Vatter
This research is funded by the National Health and Medical Research Council Medical Research Future Fund Million Minds Mission Grant (APP1178922), grant activity coordinated by the InsideOut Institute for Eating Disorders, a partnership between the University of Sydney and Sydney Local Health District.
Author information
Sarah Maguire and Jane Miskovic-Wheatley have contributed equally to this work.
Authors and Affiliations
Eating Disorders Victoria, Abbotsford, Victoria, 3067, Australia
Anita Raspovic, Rachael Duck, Andrew Synnot & Belinda Caldwell
InsideOut Institute for Eating Disorders, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, 2006, Australia
Anita Raspovic, Sarah Maguire & Jane Miskovic-Wheatley
School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, 3086, Australia
Anita Raspovic & Rachael Duck
MAINSTREAM The Australian Centre for Health System Research and Translation in Eating Disorders, Sydney, New South Wales, 2006, Australia
Anita Raspovic, Michelle Cunich, Sarah Maguire & Jane Miskovic-Wheatley
Orygen, Melbourne, Victoria, 3052, Australia
Andrea Phillipou
Centre for Youth Mental Health, The University of Melbourne, Melbourne, Victoria, 3000, Australia
Department of Psychological Sciences, Swinburne University of Technology, Melbourne, Victoria, 3182, Australia
Department of Mental Health, St Vincent’s Hospital, Melbourne, Victoria, 3065, Australia
Department of Mental Health, Austin Health, Melbourne, Victoria, 3084, Australia
Andrea Phillipou & Zoe Jenkins
University of Tasmania and Tasmanian Centre for Mental Health Service Innovation, Hobart, Tasmania, 7000, Australia
David Castle
Peninsula Mental Health Service, Monash University, Frankston, Victoria, 3199, Australia
Richard Newton
School of Psychology and Public Health, La Trobe University, Wodonga, Victoria, 3689, Australia
Leah Brennan
Boden Initiative, Charles Perkins Centre, Faculty of Medicine and Health (Central Clinical School), The University of Sydney, Camperdown, New South Wales, 2006, Australia
Michelle Cunich
Sydney Health Economics Collaborative, Sydney Local Health District, Camperdown, New South Wales, 2050, Australia
Sydney Institute for Women, Children and Their Families, Sydney Local Health District, Camperdown, New South Wales, 2050, Australia
Cardiovascular Initiative, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, 2006, Australia
Faculty of Medicine and Health (Central Clinical School), The University of Sydney, Sydney, New South Wales, 2050, Australia
Sarah Maguire & Jane Miskovic-Wheatley
You can also search for this author in PubMed Google Scholar
Contributions
AR contributed to study conceptualisation, methodology, formal analysis, writing (original draft and review and editing), supervision and project administration. RD and AS contributed to conceptualisation, investigation, writing (review and editing) and project design and administration. BC, AP, RN, DC, LB, ZJ significantly and substantially contributed to conceptualisation and methodology, and contributed to writing (reviewing and editing). MC contributed to methodology, formal analysis and writing (reviewing and editing). JMW and SM contributed to conceptualisation, methodology, formal analysis, resources, writing (original draft and review and editing) and supervision. Four authors (AR, SM, JMW & MC) conducted the project under the auspices of the Mainstream Centre. All authors have read and approved the final manuscript.
Corresponding author
Correspondence to Anita Raspovic .
Ethics declarations
Ethics approval and consent to participate.
This study received ethical approval from the Bellberry Human Ethics Research Committee (HREC 2022_04_374) after a full board review (approval date 09-August-2022). This study analysed previously collected service evaluation data and prior written consent had been given from all people whose de-identified mentee data was pooled for analysis in the current study.
Consent for publication
Not applicable.
Competing interests
At the time of publication, Belinda Caldwell was Chief Executive Officer of Eating Disorders Victoria and Rachael Duck and Andrew Synnot were employed by Eating Disorders Victoria as Peer Mentoring Program (PMP) staff. Sarah Maguire and Richard Newton sit on the panel of Senior Editors for the Journal of Eating Disorders.
Additional information
Publisher's note.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Additional file 1, rights and permissions.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Reprints and permissions
About this article
Cite this article.
Raspovic, A., Duck, R., Synnot, A. et al. A peer mentoring program for eating disorders: improved symptomatology and reduced hospital admissions, three years and a pandemic on. J Eat Disord 12 , 99 (2024). https://doi.org/10.1186/s40337-024-01051-7
Download citation
Received : 21 October 2023
Accepted : 19 June 2024
Published : 15 July 2024
DOI : https://doi.org/10.1186/s40337-024-01051-7
Share this article
Anyone you share the following link with will be able to read this content:
Sorry, a shareable link is not currently available for this article.
Provided by the Springer Nature SharedIt content-sharing initiative
- Peer mentoring
- Lived experience
- Eating disorders
- Intervention
- Hospitalisations
- Implementation
Journal of Eating Disorders
ISSN: 2050-2974
- General enquiries: [email protected]
![](http://sektorel.online/777/templates/cheerup/res/banner1.gif)
IMAGES
VIDEO
COMMENTS
Study with Quizlet and memorize flashcards containing terms like Often, several factors contribute to the development of an eating disorder. In addition to her own desire for thinness, which of the following hypothetical outside influences would exacerbate Alexis's disordered eating habits?, Some of the symptoms associated with various eating disorders are summarized in the following table.
Dr. Lazaro V. Zayas (Psychiatry): An 11-year-old girl was seen in an outpatient clinic of this hospital because of difficulty eating solid food and associated weight loss after an acute choking ...
Anorexia nervosa is a chronic eating disorder which primarily affects adolescent girls and young women. 1 The prevalence of anorexia nervosa varies between 0.1-1%. 1 Although the prevalence is low, the morbidity is high and the mortality varies between 0.1-25%. 2 Relapse is common and chances of recovery are less than 50% in 10 years while 25% ...
Terms in this set (44) Two major types of DSM-5 eating disorders. Anorexia NervosaBulimia Nervosa- Severe disruptions in eating behavior- Weight and shape have disproportionate influence on self-concept- Extreme fear and apprehension about gaining weight- Strong sociocultural origins- westernized views- Emphasize on thinness.
The majority of studies focusing on eating disorders have found higher levels of alexithymia in individuals with eating disorders and disturbed eating compared to healthy controls [2-8]. When the individual characteristics of alexithymia are examined, individuals with eating disorders have specific deficits in identifying and communicating ...
This case study involved the treatment of a young adult female, referred to as "Marie," who presented for treatment seeking help with her eating disorder. Marie evinced symptoms of dietary restriction, amenorrhea, low weight, and low body mass index (BMI); she was subsequently diagnosed with anorexia nervosa.
Most individuals with eating disorders will either recover, settle into an unrecovered but self-defined acceptable quality of life, or continue to cycle from crisis to relative stability over time. However, a minority of those with severe and enduring eating disorders recognize after years of trying that recovery remains elusive, and further treatment seems both futile and harmful.
Risk factors represent a range of complex variables associated with the onset, development, and course of eating disorders. Understanding these risk factors is vital for the refinement of aetiological models, which may inform the development of targeted, evidence-based prevention, early intervention, and treatment programs. This Rapid Review aimed to identify and summarise research studies ...
Experiencing stressful life events (SLEs) can negatively impact mental health and increase risk for psychiatric disorders including eating disorders (EDs). Previous research has shown that childhood sexual abuse is associated with some EDs, but less is known about the association between other non-sexual SLEs and EDs. A case-control study of individuals with (n = 495, age mean ± SD = 29.1 ± ...
Eating disorders are a potentially fruitful area of study for understanding the links between values—in particular cultural values—and mental distress and disorder. Eating disorders show widely different prevalence rates across cultures, and much attention has been given to theories linking these differences with variations in cultural values.
Case study 1 for eating disorders - Alexis . Case study 2 for eating disorders - Bianca Case study for sleeping disorders - Martha . Mastery Training 30 3 . 16 ; 1 . 3 . 3 . 3 30 . Chapter 9 All Chapter 9 assignments are due on or before 11/2 at 11:59 p.m. Physical Disorders and Health Psychology Quiz 9.1
avoidant restrictive food intake disorder. just avoids eating all together. pica. eating odd objects that aren't food at all. rumination disorder. eating food and then regurgitating and potentially re swallowing. Study with Quizlet and memorize flashcards containing terms like etiology, risk factors, anorexia nervosa def and more.
eating disorder studies (Lebow et al., 2019; Murray et al., 2017; Rodgers et al., 2018; Vo, Lau, & Rubinstein, 2016). These findings suggest that a primary care-based approach to eating disorder identification and treatment could be more accessible for patients from diverse backgrounds. Here, we describe one case in greater detail to provide a
Emma's* journey through an eating disorder: From struggle to recovery, detailing support, therapy, and a promising future. Live your life. ... Eating disorders ; Eating disorder case study. Eating disorder case study. Call 0330 056 6041. Call Us. Tap on a number to call. Treatment enquiries. 0330 056 6041 . General enquiries.
Alexis Jimenez is a licensed mental health therapist in Washington State. She works both in community mental health and private practice, focusing primarily on trauma, somatic work, and sex therapy. She received a master's degree in Existential-Phenomenological Psychology from Seattle University and a certificate in Sex Therapy from Antioch University.
Abstract. Introduction: The interplay between eating disorders and psychosis is a challenging field to which little attention has been paid. Its study raises conceptual and methodological questions in both areas, making the diagnosis and management of patients difficult. Such questions are addressed and illustrated with a review and case report.
Anorexia Nervosa (AN) poses significant therapeutic challenges, especially in cases meeting the criteria for Severe and Enduring Anorexia Nervosa (SE-AN). This subset of AN is associated with severe medical complications, frequent use of services, and the highest mortality rate among psychiatric disorders. In the present case series, 14 patients were selected from those currently or previously ...
This case study illustrates the administration of this evidence-based intervention in a clinical setting, highlighting how the best available research was used to make clinical decisions at each stage of treatment delivery. ... Twin studies of eating disorders: A review. International Journal of Eating Disorders. 2000; 27:1-20. [Google ...
The case was filed on behalf of Alexis Spence, who was able to create her first Instagram account at the age of 11 without her parents' knowledge and in violation of the platform's minimum age ...
This clinical case involves an obese woman requesting treatment for her binge eating and obesity. The information is presented to expert clinicians who provide their thoughts regarding the case, assessment, treatment formulation, and associated clinical and research issues. Case Description. A 48-year old African American woman presented for ...
Case Study Details. Maria is a 38-year-old divorced woman who works in a higher level administrative position for a large federal agency. She is well-established in her career and has several close friends with whom she enjoys spending time. She comes to you following years of unsuccessful attempts to get appropriate treatment for her binge eating.
These findings align with a population-based case-controlled study, with male and female elite Norwegian athletes meeting DSM-IV eating disorder diagnostic criteria across all sporting categories ... The Female Athlete Body project study: 18-month outcomes in eating disorder symptoms and risk factors. Int. J. Eat. Disord. 2019, 52, 1291-1300.
Case study 1 for eating disorders - Alexis (Explore each "Master Training" chapter activity. Use your knowledge of eating disorders to identify symptoms and provide a diagnosis based on the details presented in the following case summary and physical exam: Case Summary: Name: Alexis ; Age: 19 ; Sex: Female ; Family: Lives with room mates
Background Peer support involves people (mentors) using their own experiences to assist others (mentees). The impetus to include peer support in eating disorder recovery is high, however research on implementation of peer roles in eating disorder management is limited. A previous pilot study found positive but preliminary results for a Peer Mentor Program (PMP) for eating disorders. The PMP ...