Background: Hospitalizations including the diagnosis of an eating disorder (ED) have increased significantly in the pediatric population over the past few decades. Patients who are male, who areage, who receive an nasogastric (NG) tube, or who require admission to a residential treatment program often remain in the hospital for longer periods of time. Few studies examining LOS exist for children and adolescents with an ED. Longer lengths of stay have previously been associated with factors such as having Medicaid, a reduced body mass index (BMI) upon admission, and a diagnosis of anorexia nervosa (AN). Objective: The purpose of this study is to examine risk factors related to a longer LOS in children and adolescents admitted to a large urban pediatric hospital with AN or bulimia nervosa (BN). Participants/setting: A retrospective cohort study was conducted in 65 patients 9-20 years of age who were admitted to Children’s Healthcare of Atlanta (CHOA) between January 1, 2014 and December 31, 2015. Statistical Analysis: Frequency statistics were used to describe the demographic, anthropometric, and clinical characteristics of the population. A Mann Whitney U test or Kruskal-Walllis test was used to examine differences in LOS by demographic characteristics, mode of nutrition therapy, discharge treatment program location, and admission BMI category. The association between LOS category by demographic and clinical characteristics was determined using a Chi-square statistic. Results: A total of 65 patients (94% female, 89% Caucasian) with a mean age of 14.6 ± 2.4 years were admitted during the study period. The median LOS was 9 days (IQR; 6, 13) and was significantly longer in those who had an NG tube placed vs. oral diet (11 days (IQR; 7, 21) vs. 8 days (IQR; 5, 9.3), respectively; p Conclusion: The characteristics of hospitalized pediatric patients with an ED were consistent with those of other studies. Longer lengths of stay in those who had an NG tube placed may have been due to the patient’s lack of compliance, failure to gain weight, and severity of malnutrition since more time is needed for medical recovery. More treatment centers for children and adolescents with an ED are needed in the state of Georgia to potentially reduce LOS. Future studies should include a greater percentage of males and larger population of children and adolescents.

Though Cognitive Remediation Therapy (CRT) for anorexia nervosa shows promising evidence, questions remain regarding specific mechanisms of change. This mixed methods study aimed to explore both longitudinal patient data (neuropsychological and self-report measures, before and after CRT) and therapist experiences of delivering CRT and their perceptions regarding what it offers. All patients had received treatment in a specialist inpatient unit. Complete data were available for both individual (n=56) and group (n=43) CRT; clinical audit data were also available. Semi-structured interviews of 11 therapists were analysed using Thematic Analysis. Statistically significant improvements were found in cognitive flexibility task performance for individual CRT (medium effect) and in self-reported cognitive flexibility for group CRT (medium effect). Three main themes were identified from the therapist interviews: “Anorexia and its treatment”, “CRT - its characteristics and delivery” and “CRT and its effectiveness”. The quantitative findings replicated some previous results and the therapist interviews provided insights regarding not only CRT’s delivery but adaptations made according to individual need and complexity. Both individual and group CRT appear to be feasible interventions for future trials but questions remain around CRT’s specific effects. Recommendations are made for future research studies on this complex intervention.

Aims: Friendship plays an important and central role in adolescent life. This thesis was conducted in two parts to address two broad aims relating to friendship in adolescence. The first aim was to establish what is currently known about the impact of perfectionism on adolescent interpersonal relationships. Specifically, it was of interest to determine whether perfectionism exerts a negative influence on adolescent friendships. The second aim was to explore the friendship experiences of adolescents diagnosed with an eating disorder (ED) in order to address a significant gap in the current literature. Method: A systematic review of the literature relating to perfectionism and interpersonal functioning in adolescence was carried out with a view to addressing the first aim. With regards to the second aim a grounded theory study was conducted with adolescents currently in treatment for an eating disorder. The young people were asked about their experiences of friendship and emerging concepts were followed up in a concurrent process of data collection and analysis. Results: The systematic review highlighted an absence of research on interpersonal functioning and perfectionism in adolescence, with only seven studies identified that met inclusion criteria. The results were further complicated by inconsistencies in the conceptualisation of perfectionism in the identified studies. The empirical study uncovered the efforts that adolescents go to to achieve acceptance in their friendships. It also revealed that the development of an ED is experienced as creating distance in adolescent friendships. This affects both the actual amount of time that young people spend with their friends as well as the emotional connection that they are able to feel in their friendships. Conclusions: There is a need to reconsider the conceptualisation of perfectionism in future research with a consistent acknowledgement of the interpersonal dimensions of the concept. It is important to acknowledge the significant impact that ED development can have on adolescent relationships. Young people may require support to address these difficulties and preserve their friendships to avoid long term negative consequences.

Evidence from multiple studies suggests that regulation of emotions and intensity of affect may be relevant to understanding disordered eating. Emotion regulation concerns the ways in which emotions are managed in daily life, whereas Affect Intensity (Larsen et al., 1986) refers to individuals‟ typical emotional reactivity. The thesis examines emotion regulation and affect in females with eating pathology (subclinical as well as clinical), and looks at ways dysfunctional regulatory strategies may be improved. The main objective of the present research was to look at the influence of experimentally-induced positive affect on the choice of emotion management strategies. Study 1 looked at typical Affect Intensity and emotion regulation in a sample of subclinically eating-disordered University of Edinburgh students. This study examined functionality of regulatory strategies, typical intensity of affect, and the effects of experimentally induced happiness and sadness on the two. Study 2 introduced the construct of creativity into the discourse on emotions and psychopathology, and looked at creative tendencies in relation to Affect Intensity, emotion regulation and psychopathology (anxiety, depression and sub-clinical eating pathology). Study 3 looked at the effects of Positive Psychology Interventions (PPIs) on emotion regulation, life satisfaction, anxiety and depression in a subclinically eating-disordered group and controls. Studies 4 and 5 were carried out in order to test and extend the results of Studies 1 and 3 with a clinical sample. In Study 4, emotion regulation, Affect Intensity and the immediate post-test effect of happiness on emotion regulation and life satisfaction were examined in females clinically diagnosed with eating disorders (i.e. anorexia nervosa, bulimia nervosa, and EDNOS). Study 5 looked at how longitudinal happiness induction influenced emotion regulation, eating behaviours and life satisfaction in eating-disordered individuals. One of the main findings across the studies was that females with subclinical and clinical forms of eating pathology tended to experience negative emotions of high intensity, and used predominantly dysfunctional regulatory strategies to manage them. Another important finding was that experimentally-induced positive emotions improved emotion regulation, and encouraged participants to choose healthier affect management strategies. The studies, their implications and contribution to theory and treatment of eating disorders are discussed.

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Due to the seriousness and prevalence of eating disorders, exploring the etiology of these disorders and identifying specific at-risk populations is crucial. One promising risk factor that has been linked to the development of eating disorders is competitiveness (Burckle, Ryckman, Gold, Thornton, & Audesse, 1999; Striegel-Moore, Silberstein, Grunberg, & Rodin, 1990). Additionally, specific populations of women have been shown to experience higher rates of eating disorders. Women in sororities are one such group identified with higher rates of disordered eating than their non-sorority counterparts (Basow, Foran, Bookwala, 2007; Crandall,1988; Schulken, Pinciaro, Sawyer, Jensen, & Hoban, 1997). Therefore this study will seek to understand more about how competitiveness may differentially impact this population of women and contribute to higher rates of eating disorder symptomatology. This project has several objectives. First, the prevalence of eating disorders, competition among women, and relational aggression among women in sororities will be addressed. In order to assess whether women in sororities differ from women who are not in sororities on measures of eating disorders symptomatology, a one-way analysis of variance (ANOVA) will be conducted. The constructs of competitiveness and relational aggression will be compared amongwomen in sororities and their non-sorority counterparts. A one-way multivariate analysis of variance (MANOVA) will be conducted to determine whether there are mean differences between women in sororities and those not on four constructs of competitiveness (hypercompetitiveness, personal development competitiveness, female competition for status competitiveness, and female competition for mates competitiveness). Finally, an ANOVA will be conducted to determine if there are mean differences between women in sororities and women not in sororities on a measure of relational aggression. The second focus of this project is to examine if different forms of competitiveness are better at predicting eating disorders. The constructs of competitiveness that have been individually demonstrated to predict eating disorder behavior will be included. Multiple regression will be used to examine how well knowing a participant’s type of competitive attitude will help explain eating disorder symptomatology. Lastly, because the literature has not yet explored how relational aggression relates to the development of eating disorders, the final purpose of this study will be to understand this relationship. In attempting to understand this relationship, a mediation model will be performed. Participants for this study will include 270 undergraduate women from the Educational Psychology subject pool. / text

Responding to strong indications in the research that anorexia and bulimia are reaching epidemic proportions in many Westernized nations, including the United States, Paul Garfinkel and David Garner have proposed a three-part model which implicates individual, familial, and sociocultural factors in the development of these multidetermined disorders. The present study uses Garfinkel and Garner's model to investigate factors related to the existence of an eating disorder in women between the ages of 18 and 38. Three groups of subjects were used in the study: an eating-disordered group (bulimics and anorexic bulimics; 18 women), a normal control group (26 women), and a second, depressed control group (24 women). The hypothesis that eating-disordered women were more impaired than normal controls, as measured by individual, familial, and socio-cultural factors, was largely supported, with the exception of the Bem Sex Role Inventory (socio-cultural measure), where little difference was found between groups. The hypothesis that depressed women would look healthier than women with an eating disorder but more dysfunctional than the normal controls was not supported; depressed women tended to look very much like bulimics and anorexic bulimics on the measures used in this study. Further exploration of socio-cultural factors by measures other than the Bem Sex Role Inventory, as well as further investigation of additional similarities--and differences--between depressed women and eating-disordered women would suggest more specific treatment strategies as well as possible prevention techniques for women afflicted by or at risk for an eating disorder.

Eating disorders can be viewed on a continuum, with disordered eating not reaching clinical diagnostic criteria but having potentially negative effects including increasing the risk of an eating disorder or obesity. This study investigated disordered eating in relation to emotional processing from an Acceptance and Commitment (ACT) perspective. Body image dissatisfaction is recognised as a risk factor in eating disorders and was therefore included in this study to investigate whether the ACT concept of inflexibility was associated with ‘less acceptance’ of body image and an increased eating disorder risk as well as general mood disturbance (i.e. depression and anxiety). A non-clinical sample of 96, 12-15 year old females at secondary schools in London was used. Eating disorder risk, inflexibility as well as depression and anxiety were measured. When comparing high, low and moderate eating disorder risk groups it was found that the low and moderate eating disorder risk groups had lower levels of inflexibility and the low eating disorder risk group had a higher body image acceptance than the moderate and the high risk groups as predicted. Inflexibility was also associated with higher rates of anxiety and depression and a negative association was found between depression and anxiety in relation to acceptance of body image. Thus providing supporting evidence for the transdiagnostic significance of ‘inflexibility’. Clinical implications of these findings in relation to prevention and treatment are discussed.

Objectives: To determine if emotion regulation mediates the link between emotional maltreatment and disordered eating behaviour in a community sample of adolescents. Design and method: Participants were 222 secondary school pupils (aged 14-18 years) from a state high school in a rural area in Scotland. Standardised questionnaire measures were used to gather data on history of emotional abuse and neglect using the Childhood Trauma Questionnaire (CTQ), emotion regulation strategies using the Regulation of Emotions Questionnaire (REQ) and subclinical disordered eating behaviour using the Eating Attitudes Test (EAT-26) and the Dutch Eating Behaviour Questionnaire (DEBQ). Pearson correlation and multiple mediation analyses were conducted to determine significant relationships and to identify whether dysfunctional emotion regulation was a mediator of the relationship between emotional maltreatment and disordered eating behaviour. Results: Multiple mediation analyses found both emotional abuse and emotional neglect to have a significant direct relationship with EAT-26 total score and DEBQ restraint scores - mediated by internal dysfunctional emotion regulation (with external dysfunctional emotion regulation also being a significant mediator in the analysis with emotional neglect and EAT-26 total). The direct relationship between emotional abuse/neglect and DEBQ emotional eating scores was non-significant, although a specific indirect effect through internal dysfunctional emotion regulation was observed. Conclusions: To the best of the author‟s knowledge, this is the first study which has looked at history of emotional maltreatment and disordered eating behaviour focussing on the influence of emotion regulation in particular. Results were indicative of significant indirect effects between emotional abuse and neglect and all measures of disordered eating through internal dysfunctional emotion regulation. Findings suggest the role of emotion regulation warrants further study in the research on childhood maltreatment and disordered eating behaviour.

M.A. / In this study an attempt is made to understand the phenomenological experience of girls in late adolescence who have had eating disorders, as well as the family dynamics that form part of this disorder. A developmental perspective regarding adolescence is discussed in this study. Eating disorders as a construct and the family of origin are broadly discussed in the literature chapter. Phenomenological research procedures are used to investigate three participants’ experience of eating disorders and their family of origin. Themes and sub themes that stood out in this study have been formulated and discussed. These main themes are the following: identity; emotionality; friendship relationships; compulsive behavior regarding food, body and weight; medical factors due to eating disorders; academic performance and competition; possible triggers for eating disorders; family factors; family patterns; family communication, and the road to recovery. The value of this study is illuminated. Some shortcomings of this study are recognized and suggestions for future research are made.