Background: Eating disorder (ED) researchers continue to explore the effectiveness of e-therapy in improving symptoms and its treatment acceptability, however issues relating to poor uptake, adherence and dropout pose a challenge. Within this portfolio, the systematic review aimed to explore adherence to e-therapy for the treatment of ED, specifically exploring rates and predictors of uptake, completion, and dropout from randomised controlled trials (RCT) of ED e-therapy. The empirical project aimed to explore in-depth symptom change for ED cases engaged in blended internet-based cognitive behavioural therapy (ICBT) and face-to-face ED input. Acceptability of blended input was also explored. Methods: For the systematic review, literature searches were undertaken in March and September 2017 across EMBASE, PsycINFO, MEDLINE, Ovid and Cochrane Central Register of Controlled Trials (CENTRAL) and ProQuest databases. Key papers were assessed against five quality criteria (random assignment to groups, blinding to treatment allocation, quality of content, level of contact, sample size with sufficient power). Using a retrospective case series design, the empirical project explored changes over time of ED, anxiety, depression, quality of life (QoL), motivation for change, overall psychological functioning and clinician-rated/patient-rated improvement. Standardised health assessment measures captured symptoms over multiple time-points, and data was analysed using t-tests, multi-level modelling (MLM) and visual analysis. Acceptability of treatment was tentatively explored using an open feedback questionnaire. Results: Systematic review results identified intervention (content, acceptability, delivery method/location), participant (nature of symptoms, BMI, education, prior therapy, personality, views on e-therapy) and therapist-related factors (therapeutic support) were indicated in predicting uptake, completion and dropout across ED e-therapy. In the empirical project, study findings were inconclusive regarding symptom change attributable to blended input. Model fit improved when severity of ED symptoms predicted overall psychological functioning and patient-rated improvement over time, however findings were non-significant - potentially due to the study being underpowered. Conclusions: Promising evidence exists for ED e-therapy as an acceptable treatment option, however understanding which content nurtures engagement best is needed. Further research is needed into the factors predicting ED blended treatment outcome.

This study presents an in-depth case study of eight sessions of spiritually integrated psychotherapy with a 20-year-old woman recovering from an Eating Disorder. The inclusion and utility of session-to-session outcome data as well as systematic follow up data in conjunction with in-depth qualitative interviews are shown. The therapist and client's perspectives are highlighted over the course of treatment. Three clinical areas of focus (renewing identity, reducing self-contempt, and fostering hope) are extracted from the qualitative interviews and the therapeutic process of weaving them together is highlighted. The Tau-U and SMA single case study statistical analyses are used to highlight clinical gains and maintenance.

The age of onset for eating disorders (anorexia and bulimia nervosa) among females is typically late adolescence. In the present study, it was hypothesized that the onset of eating disorders is related to the late-adolescent developmental task of identity development. Thirty-three late adolescent and young adult females who met DSM-III-R criteria for an eating disorder (anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified) and 33 control females completed the Extended Objective Measure of Ego Identity status -- 2 (EOMEIS-2). Results of chi square analyses revealed no significant differences between eating disorder and control females with regard to status of identity development. However, when identity status subscale scores were treated as continuous variables, several significant between-group mean differences emerged. In line with expectations, eating disorder subjects scored higher on ideological diffusion and moratorium, and they scored lower on ideological achievement. Eating disorder subjects also scored higher on interpersonal diffusion and lower on interpersonal achievement. In addition, there were significant correlations between ideological diffusion and measures of depression and anxiety. Unexpectedly, there were also significant correlations between ideological moratorium and measures of depression, anxiety, social alienation, family discord, and borderline personality symptomatology. The possible implications of these results for understanding frequently occurring, co-morbid symptoms in eating disorder subjects are discussed.

The present study investigated perceptions, attitudes, and beliefs toward individuals with anorexia nervosa (AN) of varying weight. The primary aim was to examine the associations between eating disorder symptom level and stigma toward eating disorders, perceptions of acceptability/desirability of AN, and perceptions of severity of AN. The second aim was to investigate the impact of body weight on males’ and females’ perceptions and attitudes toward AN, specifically on their stigma toward eating disorders, perception of the severity of AN, and perception of acceptability or desirability of AN behaviors and characteristics. Two-hundred fifty-seven university students (187 females, 70 males, mean age = 22.5, SD = 6.59) in undergraduate courses participated in the online study, and were randomly assigned to view one of three underweight female figures (extremely thin, moderately thin, and mildly thin). Participants read a vignette describing an individual meeting full diagnostic criteria for anorexia and completed measures assessing stigma toward individuals with AN and eating disorder symptomatology. Regarding the first aim, it was hypothesized that an inverse relationship would emerge between eating disorder pathology in participants and stigmatizing attitudes and beliefs. In support of the hypothesis, findings revealed that increased acceptability of AN and greater perceptions of AN severity were associated with higher levels of eating disorder symptoms. In contrast to the hypothesis, current self-reported eating disorder symptoms were not significantly associated with lower levels of eating disorder stigma. It was also hypothesized that female participants would perceive AN as more positive and acceptable, and as less severe than male participants. The hypothesis was partially supported in that females indicated less stigma toward EDs and reported perceiving AN to be more serious than males. Greater acceptability was not more common among women. In regard to the second aim, there was no significant group differences found in eating disorder stigma, perceived acceptance of AN, and perceived severity of AN according to weight conditions, which was contrary to expectations. Implications of the study are discussed in terms of future research.

Doctor of Philosophy(PhD) / Research indicates that eating disorders and anxiety disorders frequently co-occur. The prevalence of anxiety disorders amongst anorexia nervosa and bulimia nervosa samples has been reported in a number of investigations. Despite the significant number of research papers investigating the comorbidity between eating disorders and anxiety disorders, many are plagued by methodological problems, limiting the usefulness of findings. Furthermore, there is a significant lack of research examining the prevalence of eating disorders among anxiety patients, and as a result, the frequency of eating disorder pathology among patients presenting to specialty anxiety clinics is unclear. The current research investigated the prevalence of comorbid eating and anxiety disorders amongst 152 women presenting for either eating disorder treatment or anxiety disorder treatment. The prevalence of anxiety disorders was determined from a sample of 100 women presenting for inpatient and outpatient eating disorder treatment. The prevalence of eating disorders was determined from a sample of 52 women presenting for outpatient treatment of an anxiety disorder. The current study found that 65% of women with eating disorders also met criteria for at least one comorbid anxiety disorder. Furthermore, 69% reported the onset of the anxiety disorder to precede the onset of the eating disorder. Of the anxiety disorders diagnosed, Social Phobia was most frequently diagnosed (42%) followed by PTSD (26%), GAD (23%), OCD (5%), Panic/Ag (3%) and Specific Phobia (2%). We also found that 13.5% of women presenting for anxiety treatment also met criteria for a comorbid eating disorder. The results of this study suggest that the prevalence of eating and anxiety disorder comorbidity is high. It is hoped that the present research will have significant etiological and therapeutic implications and further the understanding of the development and maintenance of eating disorder pathology.

Doctor of Clinical Psychology / Master of Science / Despite a number of different psychotherapeutic approaches having been examined for use with patients with eating disorders, there is still no established psychological treatment associated with acceptable levels of long-term recovery. These poor recovery rates are associated with the observation that eating disorder patients are often ambivalent, or even resistant, to treatment. As such, research has begun to explore the use of Motivational Enhancement Therapy (MET), a treatment approach that aims to engage ambivalent and change resistant patients in the treatment process, with these individuals. Poor motivation to recover is particularly prominent within the inpatient eating disorder setting. However, no previous study has examined the use of MET to foster willingness to engage in treatment with this group of patients. The objectives of the current study were twofold. Firstly, an examination of the effectiveness of an inpatient eating disorders unit affiliated was undertaken in order to further the research base upon which future inpatient interventions can be built and compared. The second objective was to develop and evaluate a brief MET group program for inpatient eating disorder sufferers. The goal of the intervention was to enhance patients’ motivation to more effectively utilise the inpatient program and to hence positively impact upon their psychological, physical and behavioural functioning. Forty-two consecutive inpatients meeting DSM-IV criteria for an eating disorder were recruited into the current study and sequentially allocated to groups. Twenty-three inpatients completed four MET groups in addition to routine hospital care. A control group of 19 participants in the standard hospital treatment program was also employed (TAU group). The inpatient unit was associated with significant improvements on a number of physical, behavioural and emotional outcome measures. Despite no significant differences between the MET and the TAU groups being found on the overall formal outcome measures, there were nevertheless differences between the groups. Specifically, the MET groups appeared to foster longer-term motivation and engagement, and to promote treatment continuation. This study hopes to start a constructive debate on the role of MET in the inpatient eating disorders unit.

There has been a growing interest in eating disorders among Singaporean medical professionals since the 1990s, and the Singaporean public is also starting to become aware of the risks of these conditions. This ethnographic research on eating disorders in Singapore, conducted in 2001, however, found that the majority of the informants with these conditions have struggled with a lack of understanding from others. This thesis aims to increase understanding by bringing these under-represented sufferers' voices to the forefront. This thesis focuses on the immense fear and guilt about gaining weight that are shared by these individuals. Unlike medical science, which usually considers such fear and guilt to be pathological, this thesis looks at these emotions as cultural by using the anthropological theory of feelings as well as the theory of the body politic. By illustrating how thinness has become an ideal image for Singaporean women in the past twenty years, cultural components of these feelings become readable to those without eating disorders. This thesis recommends two ways to increase understanding of the informants' inner struggles. First, medical science should consider culture a possible cause of eating disorders, since the exclusion of culture from the etiology legitimizes a lack of understanding on the part of those without eating disorders. Secondly, instead of asserting that appearance is unimportant, those without eating disorders should acknowledge that appearance plays an important role in human lives across every culture. Furthermore, they need to understand that while society superficially encourages people to accept themselves as they are, it stigmatizes fatness more forcefully. Lastly, they need to consider that the dieting industry often exploits medical science to justify its image of the ideal female body. / Graduation date: 2003

Binge is a multi-media installation consisting of dangling IV bags looming over a large table of food. Monitors on the table show live online chats about thinness, depression and eating disorders. On the rear wall, interview footage describing the gruesome experiences of the eating disorder sufferer intercut with the newest development of the disease, the online presence. The installation confronts the viewer with the horrible dualities of the disease: discipline and madness, reason and passion, and suffering and indulgence. The work references the philosophic mind/body struggle as well as the grim reality of these afflicted young women.

Many studies reported that childhood abuse and stress play contributory roles in the development and maintenance of disordered eating behaviors. However, these studies made no mentioned efforts to validate their self-report data, and thus failed to separate the effects of actuality versus perception of childhood abuse. Thus, the current study examined how perceptions of childhood abuse and life stress affect binge eating behavior among university students. Participants for the current study included 173 undergraduate students, recruited via Study Board. After giving verbal consent, participants completed a series of surveys and questionnaires that collected demographic data, and measured perception of abuse, perceived stress levels and binge eating activity. Upon completion, participants were given either course credits or extra credits, to be given at the discretion of their professors. Results indicated that all of the hypotheses were supported. There were significant differences between the perception of abuse and the perceived life stress conditions (respectively). Furthermore, both of the independent variables were shown to be predictive of binge eating behavior. However, there was no interaction effect between the two independent variables. Moreover, these two variables did not moderate each other in terms of predicting binge eating behavior among university students. Findings from this study indicated that perceptions of childhood abuse and recent life stress are both predictive of binge eating activity among university students, which was highest among individuals with a perceived history of childhood abuse. While findings from this study showed a correlation between perception of abuse and binge eating behavior, they did not show a correlation between reporting of actual incidents of childhood abuse and binge eating behavior. There were a number of limitations to the study, including limited generalizability of the findings, limited reliability of self-report measures, and any confounding of analyzed data due to order effect. Future studies are encouraged to further explore the relationship between perception and actuality of childhood abuse.

Eating disorders and borderline personality disorder involve several overlapping features, such as impulsivity, negative affectivity, and dissociation. However, few studies have specifically assessed how eating pathology and borderline personality may be related. The present study sought to evaluate this relationship by focusing on one particular area of overlap, negative affectivity. A pilot study assessed the psychometric properties of a dietary restraint measure among undergraduate women (N = 149). In the main study, undergraduate women (N = 307) completed a baseline mood assessment, then viewed a 39-minute sad film either with or without concurrent food presentation. Participants then completed a second mood assessment, and those who received food completed a third mood assessment following a 10-minute post-reflection delay. Results suggest that women reporting more borderline features exhibited greater negative affect across three different time points (baseline, post-movie/food, and post-reflection period), and were more reactive to the sad film. Food presentation appeared to have a small tempering effect on sadness, such that individuals who received food reported relatively less sadness after viewing the film when compared to those who did not receive food. However, actual quantity of food consumption was associated with improvements in mood only for women reporting higher levels of borderline features. Finally, highscorers on dietary restraint measures consumed greater quantities of food than their lowscoring counterparts. In sum, these data suggest that women with borderline personality features may be at elevated risk for developing problems with binge-eating, as consuming larger quantities of food appeared to have a tempering effect on their negative mood and specific feelings of sadness. Further, results are consistent with earlier findings in that reported efforts to restrain dietary intake were associated with greater food consumption in response to negative affect, and this relationship may need to be addressed in treating individuals with problematic eating behaviors.