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This study considers and explores the relationship between eating disorders and the cognitive processes of attentional bias and cognitive avoidance. These processes are also considered in terms of their contribution to the current theoretical conceptualisations of eating disorders and how this may potentially inform treatment. Previous research in the field is limited yet indicates that attentional biases exist in eating disorders, at least for disorder-specific stimuli using well recognised experimental paradigms. The research into cognitive avoidance is scarce yet has indicated that those with bulimic tendencies may use this cognitive strategy. A modified emotional Stroop task and an anagram solution task were used to evaluate experimental hypotheses postulating that attentional bias to and cognitive avoidance of disorder relevant and self-esteem threat stimuli would be present in a group of patients with an eating disorder (N=23) in comparison with a control group (N=34). Using the emotional Stroop, the results showed limited support for the presence of attentional biases in eating disorders. For the anagram solution task, some limited evidence was found for the presence of cognitive avoidance in the clinical eating disorder sample. The limitations of the study were considered and discussed, with an emphasis on improvements for future research using these experimental paradigms. The findings of the study were also discussed in relation to the implications for eating disorder theory and treatment.

Thesis advisor: Barbara E. Wolfe / The core defining features of bulimia nervosa (BN) are repeated binge eating episodes and compensatory purging behavior. The biobehavioral aspects of binge eating are complex and not fully understood. One area of recent interest is the role of the satiety-signaling peptide cholecystokinin (CCK). Previous research observed a blunted postprandial plasma CCK response in those with BN, therefore suggesting this may be a cause, consequence, or maintenance factor in binge eating. It is unknown whether this altered response is due to a state versus trait phenomenon, thus having implications in the development of clinical treatment strategies. To examine the nature of this altered response, this study assessed whether CCK normalizes following remission from BN (RBN). This biobehavioral study utilized a comparative design to prospectively evaluate the biological CCK response and the corresponding behavioral ratings of satiety and other eating-related sensations in individuals with BN (n=10), RBN (n =14), and healthy controls (CON, n=13). CCK and behavioral ratings were assessed at baseline, +15, +30, and +60 minutes following the ingestion of a standardized liquid test meal. The BN group's CCK response was blunted and approached significance (p =.052) when compared to the RBN and CON groups. As predicted the RBN and CON groups' CCK response did not significantly differ. This finding supports the premise that CCK may normalize following abstinence from binge and purge (vomit) episodes and that this is a state versus trait related phenomenon. A significant positive relationship between CCK response and ratings of satiety occurred in the RBN group only (r=.59, p<.05). A new and unanticipated finding in the BN group was a significant relationship (r=.86, p < .01, two-tailed) between their CCK response and urge to vomit. A greater urge to vomit was reported by those individuals who had increased CCK response. Therefore, it is unknown whether the normalization of CCK functioning is a protective or liability factor in the stabilization and recovery process. Replication studies utilizing a larger sample size are needed to understand the role of CCK in recovery and the subsequent development of novel treatment strategies for those suffering with BN. / Thesis (PhD) — Boston College, 2012. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Esta tese teve por objetivo validar e pesquisar a confiabilidade da Sessão de Transtornos Alimentares do DAWBA (“Development and Well-Being Assessment"), um pacote de entrevistas e técnicas de avaliação planejado para ser aplicado por entrevistadores sem experiência clínica prévia, para rastrear e diagnosticar transtornos alimentares em crianças e adolescentes do sexo feminino, de 7 a 17 anos, em estudos epidemiológicos. Participaram deste estudo 174 crianças e adolescentes de 8 a 17 anos, do sexo feminino, procedentes de três grupos: (1) 48 meninas com transtornos alimentares; (2) 55 controles clínicos – 21 em tratamento para depressão unipolar, 14 em tratamento para transtorno obsessivo-compulsivo e 20 em tratamento para doença gastrointestinal – e (3) 71 controles comunitários. Um dos pais de cada menina também foi entrevistado com o instrumento. Foram eleitos sujeitos destes três grupos para pesquisar a validade discriminante do instrumento quanto à sua capacidade de diferenciar jovens com transtornos alimentares e outros transtornos físicos ou psiquiátricos mimetizantes. O diagnóstico da presença ou não de transtorno alimentar – anorexia e bulimia nervosas e síndromes parciais - em cada sujeito, foi gerado utilizando-se três métodos diferentes independentes: (1) diagnóstico padrão-ouro, baseado no DSM-IV e CID-10, estabelecido através de entrevista clínica livre do pai e da menina juntos, realizada por psiquiatra infantil especialista em transtornos alimentares, cego para o grupo de origem da menina; (2)diagnóstico preliminar do computador gerado por algoritmo específico baseado na CID-10 e DSM-IV levando em considerando a informação estruturada coletada pelo instrumento e (3) diagnóstico final DAWBA, estabelecido por especialista treinado, baseado na CID-10 e DSM-IV, através da revisão cuidadosa dos relatórios fornecidos pelo software DAWBA com o resumo das informações colhidas com o instrumento. A validade concorrente dos diagnósticos DAWBA (preliminar do computador e final) foi pesquisada mediante comparação com o diagnóstico padrão ouro. A confiabilidade teste-reteste foi pesquisada reaplicando o instrumento duas ou três semanas após a primeira utilização, em 55 sujeitos (7 com transtornos alimentares, 20 controles clínicos e 28 controles comunitários). Os aplicadores estiveram cegos (tanto no teste quanto no reteste) para o grupo de origem do sujeito. Pesquisou-se a consistência interna (Alfa de Crombach) e os melhores pontos de corte das cinco questões de rastreamento, bem como sua sensibilidade e especificidade. Houve diferença significativa na média de idade entre os grupos com transtornos alimentares (média de 16,0 anos) e controles clínicos (média de 14,5 anos). Para a detecção de qualquer transtorno alimentar segundo o DSM-IV e a CID-10, o diagnóstico final pelo DAWBA apresentou sensibilidade de 100% e especificidade de 94%. Houve boa concordância teste-reteste (Kappa de 0,81) e boa consistência interna das questões de rastreamento, sendo o Alfa de Crombach de 0,76 na entrevista com as meninas e 0,81 na entrevista dos pais. Os melhores pontos de corte nas questões de rastreamento foram de dois e três, observando que, para um ponto de corte de três a sensibilidade foi de 89,8% em ambas as entrevistas (meninas e pais) e a especificidade de 85,6% na entrevista das meninas e 85,5% na entrevista dos pais. Foram limitações do estudo a diferença significativa na média de idade entre os grupos ‘com transtornos alimentares’ e ‘controles clínicos’, a não inclusão de crianças com transtornos alimentares menores de 11 anos e a impossibilidade de estabelecer comparações entre os grupos com relação a variáveis sócio-econômicas. Desta forma, pode-se concluir com o presente estudo que a Sessão de Transtornos Alimentares do DAWBA apresenta boa validade e confiabilidade no rastreamento e diagnóstico de transtornos alimentares em crianças e adolescentes do sexo feminino e tem aplicabilidade tanto em pesquisa clínica quanto em estudos epidemiológicos comunitários. / This thesis concerns the validation and investigation of the reliability of The Eating Disorders Section of The Development and Well-eing Assessment (DAWBA), a package of interviews and assessment techniques designed to be administered by trained interviewers without previous experience in eating disorders, for screening and diagnosis in epidemiological studies of eating disorders in female children and adolescents, from 7 to 17 years old. This study was carried out with the participation of 174 female children and adolescents, from 8 to 17 years old, recruited from three groups: (1)48 girls with eating disorders; (2) 55 clinical controls – 21 in treatment for unipolar depression, 14 for obsessive compulsive disorder and 20 for gastrointestinal disease – and (3) 71 community controls. One of the parents of each girl was also interviewed with the measure. Subjects were recruited from the three groups to assess the discriminant validity of the measure concerning its ability in discriminate girls with eating disorders from other mimicking psychiatric or physic disorders. The diagnosis of the presence or not of eating disorder in each subject – anorexia, bulimia nervosa and partial syndromes – was made using three different independent methods – (1) gold standard diagnosis, based on DSM-IV and ICD-10, assigned through free clinical interview of the parent and the girl together, made by a child and adolescent psychiatrist specialized in eating disorders, blind to the group of origin of the girl; (2) preliminary computer diagnosis, generated by a specific algorithm based on ICD-0 and the DSM-IV, using the structured information collected with the measure and (3) final DAWBA diagnosis, established by a trained specialist, based on DSM-IV and ICD-10, through the careful review of the information on the reports provided by the DAWBA software, containing the abstracts of the information collected by the measure. The concurrent validity of the DAWBA diagnoses (computer preliminary and final) was assessed through the comparison with the gold standard. The test-retest reliability was assessed reassessing 55 subjects (7 with eating disorders, 20 clinical controls and 28 community controls) with the measure two or three weeks after the first assessment. The DAWBA interviewers were blind (both in test and retest) for the origin group of the subject. Internal consistency (Crombach Alpha), best cutoffs in the screening questions, sensibility and specificity were assessed. There was a significant difference in mean age between the eating disorder (mean = 16 years) and clinical control (mean = 14,5 years) groups. For the detection of any eating disorder according the DSM-IV and ICD-10, the final DAWBA diagnosis presented sensibility of 100% and specificity of 94%. There was good test-retest agreement (Kappa = 0,81) and good internal consistency in the screening questions, being the Crombach Alpha of 0,76 in the girls interview and 0,81 in the parent interview. The best cutoffs on the screening questions were two and three, noting that for a cutoff of three the sensibility was 89,8% in both interviews (girls and parents) and the specificity was 85,6% for the girls interview and 85,5% for the parent interview. The significant difference in mean age between the eating disorder and clinical control groups, not including children with eating disorders younger than 11 years old and the absence of comparisons of social economic variables between groups were limitations of this study. In summary, the present study shows that The Eating Disorders Section of the DAWBA has good validity and reliability for the screening and diagnosis of female children and adolescents with eating disorders and has applicability both in clinical and community settings.

Este estudo apresenta a criação e análise da Sessão de Transtornos Alimentares do DAWBA, um instrumento construído para rastrear e fornecer, em estudos epidemiológicos, o diagnóstico de transtorno alimentar (TA) - anorexia e bulimia nervosas e síndromes parciais - em meninas de 8 a 17 anos. O estudo ocorreu em 3 fases: (1) criação do instrumento, (2) aprimoramento aplicando-o em 45 mulheres e seus familiares e (3) aprimoramento testando-o em 30 meninas e seus pais. Participaram das fases 2 e 3 sujeitos com TA, transtornos obsessivo-compulsivo e depressivo unipolar e com doenças de acometimento gastrintestinal. Dessa forma, produziu-se a versão final do instrumento, que está pronta para validação / This study presents the creation and analysis of The Eating Disorders Section of The DAWBA, a measure designed for epidemiological studies to screen and diagnose eating disorders (ED) - anorexia and bulimia nervosa and partial syndromes - in 8 to 17 year-old girls. The study was carried out in 3 phases: (1) measure creation, (2) refinement by applying it to 45 women and their relatives and (3) fine-tuning by testing it in 30 girls and their parents. Phases 2 and 3 involved subjects with ED, obsessive-compulsive and unipolar depression disorders and gastrointestinal disease, producing the final version of the measure, which is ready for validation

El presente estudio tiene como objetivo comprender cómo se han configurado el apego y la mentalización en mujeres con trastornos alimenticios (TA) y cómo esta experiencia particular teje una narrativa propia de la vivencia de la enfermedad. Para ello, se realizó una investigación cualitativa de corte narrativo. Se entrevistó a 6 mujeres con diferentes patologías alimentarias y en diferentes estadios del tratamiento en 2 oportunidades. La primera entrevista fue centrada en el tema y giró en torno a la vivencia del TA; la segunda, en torno a las experiencias tempranas con los cuidadores primarios. Se encontró en ellas dificultades para la elaboración de experiencias difíciles con sus figuras de apego. Asimismo, dificultades en la organización del discurso, la regulación del afecto, sus vínculos con los demás y una pobre función reflexiva. Se discute lo hallado hipotetizando que el tratamiento recibido puede haber actuado como una herramienta que les ha permitido progresar hacia apegos más organizados y un funcionamiento reflexivo más articulado. / Attachment styles and reflective function in women with eating disorders The present study aims to understand how attachment and reflective function have developed in women with eating disorders (ED) and how this particular experience itself weaves a singular narrative of the experience with the disease. In order to do this, a qualitative narrative study was conducted. Six women with various eating disorders at different stages of treatment were interviewed twice. The first interview focused on the experience of the ED and the second focused on early experiences with their primary caregivers. We found difficulties in the way they work through their distressing experiences with their attachment figures, in the coherence of their speech, in affect regulation, their interpersonal relations and their reflective function. Findings are discussed hypothesizing that treatment is a mean that enables them to progress to more organized attachment styles and improved reflective function. / Tesis

El trastorno de la conducta alimentaria es considerado como una de las patologías que cobra mayor importancia debido a su número creciente de víctimas a lo largo de los últimos años. Recientes estudios han demostrado que tanto la anorexia como la bulimia nerviosa han aumentado su incidencia en la población masculina, lo que antes era prácticamente desconocido. La presente investigación tuvo como finalidad hacer un estudio de la validez y confiabilidad del Inventario Sobre Trastornos Alimentarios (ITA) de Joan Hartley, para saber si es posible utilizarlo en una población masculina. El inventario de 50 ítems con seis alternativas de respuesta tipo Likert, se administró a un grupo de 164 varones adolescentes pertenecientes a un centro universitario y pre universitario privados de Lima. La edad comprendida de los participantes fue entre 16 y 20 años. Luego de la administración, se inició el proceso de análisis, resultado que este inventario a pesar de tener una confiabilidad dentro de rangos adecuados (α=,591-, 901), tiene una pobre validez de contenido y de constructo debido a que las áreas no logran funcionar como se planteó por la autora original en la muestra seleccionada. Es así, que a modo tentativo se hace una propuesta de un inventario reorganizado que consiste en 21 ítems que conforman 4 áreas. Cabe resaltar que esta última versión tiene única función de servir como una base altamente estructurada, para que a partir de ésta, se puedan realizar futuras investigaciones y construir una versión mejorada y completa / Tesis

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Binge eating is a harmful, maladaptive behavior associated with comorbid psychopathology. Theory posits that increases in maladaptive, transdiagnostic emotions following binge eating in individuals with BN may predict the experience of comorbid symptoms. The current study served as a laboratory test of the first part of this theory: whether state increases in maladaptive emotions occur following engagement in binge eating behavior in women with BN compared with healthy controls. Women (n = 51) were recruited from the community if they met DSM-5 criteria for BN or OSFED BN (of low frequency) (n = 21) or were free of lifetime disordered eating and current psychopathology (n = 30). Participants completed questionnaires assessing eating disorder symptoms (preoccupation with weight and shape, urge to vomit), state shame, and state negative affect before and after consuming a test meal in which they were instructed to binge. Women with BN endorsed significantly greater preoccupation with weight and shape and urge to vomit following test meal consumption compared with controls. Women with BN reported significant increases in state shame, but not state negative affect, following test meal consumption, compared with controls. Results are consistent with a model indicating binge eating precipitates increases in state shame among women with BN. Given shame’s status as a transdiagnostic risk factor, future work should clarify whether state shame following binge eating predicts increases in comorbid symptoms.

Explica los procesos psicológicos implicados en la atribución de significados al trastorno de conducta alimentaria en mujeres diagnosticadas con anorexia y bulimia nerviosa usuarias de una clínica privada en la ciudad de Lima Metropolitana. Para ello, se realizó una investigación empírica con metodología cualitativa, desde una perspectiva constructivista, usando el diseño o tradición de la teoría fundamentada. Las participantes fueron 16 mujeres diagnosticadas con trastorno de conducta alimentaria según criterios del manual de Clasificación Internacional de las Enfermedades, CIE-10 (OMS, 1992). Las técnicas de recolección de datos empeladas fueron la entrevista individual, grupo focal y documentos personales, recabándose así 33 recursos o textos entre trascripciones de entrevistas y cartas. El procesamiento de información se realizó siguiendo las estrategias sugeridas por el método de la teoría fundamentada, con apoyo del programa Nvivo 10. Los resultados sugieren que la atribución de significados al trastorno de conducta alimentaria se realiza a través de procesos psicológicos interpretativos constructivos, donde las participantes asumen un rol activo y son motivadas por sus proyectos personales o intencionales. Asimismo, el trastorno de conducta alimentaria significa para las participantes estrategias, medios o planes de acción implementadas en el trascurso de sus experiencias de vida que le permiten adaptarse a su contexto personal y social. Los hallazgos constituyen un aporte para la comprensión del problema pues se proponen modelos teóricos sustentados en los datos. A la vez, este aporte representa evidencia empírica para la implementación de estrategias psicoterapéuticas pues enfatiza el rol activo y constructivo de la persona en el marco de su contexto personal y social. / Tesis