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.

Aims: Eating disorder recovery is often supported by caregivers and mental health professionals. This research portfolio focuses on the experiences of supporting someone with an eating disorder from the perspective of the caregivers and also mental health professionals. The aims of this research portfolio are: Firstly, to systematically review the published qualitative literature relating to the experiences of caregivers supporting someone during eating disorder treatment; and secondly, to investigate the factors which may contribute to burnout, the factors which may protect against burnout and ways of managing work related stress for healthcare professionals who work in an eating disorder service. Method: A systematic review and meta-synthesis of caregiver experiences with eating disorder treatment was conducted. Searches identified 1927 studies of which 12 met the inclusion criteria for the study. Quality assessment revealed a number of strengths and also some limitations of the studies. For the research study ten healthcare professionals were interviewed on their experiences of supporting people with an eating disorder and ways of managing work related stress/burnout in this role. Interpretative Phenomenological Analysis was used to analyse the data. Results: Five major themes were identified from the systematic review: “access to treatment”, “key features of treatment”, “support for the caregiver”, “encounters with health care professionals” and “the future – hopes and fears”. The research study identified seven super-ordinate themes: “Dealing with Client Physical Health Risks”, “Working to Different Goals from the Client”, “Awareness of own Eating Patterns”, “Personal Accomplishment”, “Working Together as a Team”, “Working with Caregivers” and “Ways of Managing Work Related Stress”. Conclusions: The systematic review highlighted a number of clinical implications including the importance to caregivers of early intervention, the provision of practical, tailored information, support for the caregiver, the need for caregivers and professionals to work collaboratively and the importance of instilling hope in caregivers. The research study highlights potential contributors to burnout in eating disorder services as well as positive or protective factors to burnout. It also highlights ways of managing burnout through ensuring a work-life balance, utilising self-care strategies, self-reflection and realising recovery is not 'all or nothing'.

This thesis has been prepared in a paper based format and comprises of three stand-alone papers. Paper 1, a systematic review; Paper 2, an empirical study; and Paper 3, a critical appraisal and reflection of the work. Paper 1 has been prepared for submission to Appetite. The paper presents a systematic literature review of studies measuring or reporting potential psychological mechanisms within Night Eating Syndrome (NES). Databases were systematically searched and 20 studies were included in the review. The quality of evidence was mixed and NES was identified and diagnosed in a variety of ways. Studies utilised a variety of different instruments to identify thirteen psychological mechanisms. Syntheses of the studies suggest that there are distinct overlapping features within these mechanisms and five overarching themes were identified to accommodate these overlapping features. Suggestions are made relating to the potential function of the identified psychological mechanisms within NES.Paper 2 has been prepared for submission to Appetite. The paper is a qualitative study exploring the relationship between NES and the experience of emotion specifically from the perspective of patients identified as obese. Ten participants were interviewed and a constructivist grounded theory approach was used to analyse transcripts. A key category to emerge from the analysis was termed 'Emotional Hunger'; reflecting an urge or need to satiate a set of underlying unmet emotional needs. 'Emotional hunger' was underpinned by the following six interrelated themes: (1) The development of a relationship with food; (2) Loss; (3) The significance of night time; (4) A separation of the body and mind; (5) Why I eat, not what I eat; and (6) Consequences of night eating. The clinical implications of the findings are discussed with reference to existing literature. Paper 3 is not intended for publication. The paper provides a critical review of the research process, in which the strengths and weaknesses of the systematic review and empirical study are discussed. Personal and professional reflections on the experience of conducting a systematic review and an empirical study are explored. The clinical implications of the research are also discussed.

In this study we sought to compare eating disorder attitudes and behaviors, and proneness to an eating disorder (“ED proneness”), between gay men, lesbian women, and transgender and non-conforming (TGNC) adults. A further aim was to identify and compare risk and protective factors, and examine a mediational model based on the interpersonal theory of eating disorders (IPT-ED), whereby the association between interpersonal factors and ED proneness would be mediated by psychological constructs pertaining to the self and negative affect. Data was obtained from a larger national study of health risk and protective factors among sexual minority and gender diverse populations. The sample included 97 gay men, 82 lesbian women, and 138 TGNC adults. Participants completed the National College Health Assessment, Eating Disorders Screen for Primary Care, Patient Health Questionnaire Depression scale, Generalized Anxiety Disorder 7 scale, Self-Compassion Scale-Short Form, Negative Social Exchange subscale of the Multidimensional Health Profile, Interpersonal Needs Questionnaire, and Perceived Stigma Scale. There was a significant difference between groups in ED proneness, with lesbian women (66.7%) having a significantly higher percentage than gay men (47.6%). There was also a significant difference between groups in weight-based self-worth, with the lowest percentage in gay men (63%) and the highest percentage in lesbian women (82%), as well as dissatisfaction with eating patterns, with the highest percentage in TGNC adults (69.8%) and the lowest percentage in gay men (47.7%). There was a low percentage of inappropriate compensatory behaviors, with no significant difference between groups. Logistic regression analyses showed that the predictor variables of ED proneness were depression, perceived stigma, and self-compassion in gay men; depression in lesbian women; and self-compassion in the TGNC adults. Mediation analyses showed that thwarted belongingness (i.e., an unmet to belong) and perceived stigma had an indirect association with ED proneness that was mediated by self-compassion and depression (for perceived stigma alone) in gay men, depression in lesbian women, and self-compassion in TGNC adults. The interpersonal theory of eating disorders therefore extends to sexual minority and gender diverse populations; however, the results suggest a broadening of theoretical models and intervention programs to include the role of stigma and self-compassion.

Purging Disorder (PD) is characterized by purging after normal or small amounts of food among individuals who are not underweight. Several studies indicate that PD is associated with distress and impairment, underscoring the need for intervention. However, little is known about factors that trigger and maintain purging in PD. This study examined antecedents and consequences of purging using Ecological Momentary Assessment (EMA), a design that involved repeated assessments of current psychological states in participants' natural environments. Women with PD (N = 24) were recruited from the community to make multiple daily ratings of affect, shape/weight concerns, violation of dietary rules, and stomach discomfort using random-, interval-, and event-contingent recordings over a two-week period. Multilevel model analyses were used to examine between-day differences (purge versus non-purge day) and within-day changes in psychological variables relative to purging behavior. Results supported study hypotheses that negative affect and shape/weight concerns would be higher and positive affect would be lower on days when participants purged compared to days they did not purge. In addition, antecedent analyses supported within-day increases in negative affect, shape/weight concerns, and stomach discomfort prior to purging; however, only changes in positive affect and shape/weight concerns on purge days differed from naturally-occurring changes observed on non-purge days. For consequence analyses, negative affect, shape/weight concerns, and stomach discomfort decreased following purging on purge days, and trajectories of change were significantly different from non-purge days. Finally, exploratory analyses suggested that lower levels of impulsivity enhanced associations between antecedent affect and purging. These data are crucial to understand why women with PD purge after consuming normal or small amounts of food and may point to specific targets for the development of effective interventions.

Eating-disorder clients show low motivation, poor follow-through, and inordinate premature dropout rates in treatment. To date, little research has been conducted that might provide clinicians with an understanding of the critical factors that may aid clients' recovery. Such factors may be used by clinicians to better motivate clients to collaborate in treatment. The purpose of this study was to identify some of the critical factors that women with eating disorders believed were crucial in prompting or facilitating their recovery. Identification of these factors was accomplished through a systematic content analysis of semistructured interviews with recovered or recovering bulimics and anorexics. This study may contribute significantly to future research into the development of motivational supplements to eating disorder therapy ( e.g., psychoeducational materials or therapy orientation programs). Of interest were what personal, interpersonal, or environmental factors anorexic and bulimic clients reported increased their motivation to recover, and prompted them to begin the recovery process, maintain recovery, and cope with the threat of relapse. Also, factors that subjects reported hindered their progress in recovery were examined. The anorexic and bulimic subjects reported social support as a critical factor across three stages of recovery, including beginning recovery, maintaining recovery, and coping with relapse. Being "tired" of the disorder and therapy were indicated to be relevant to beginning recovery. Improved self-esteem was deemed significant in helping subjects both maintain recovery and cope with the threat of relapse. Establishing healthy eating habits and attitudes was a necessary factor required to maintain recovery. Subjects shared that developing healthy ways to deal with emotions enabled them to deal successfully with the threat of relapse. Anorexic subjects reported that people and societal expectations, fear of becoming fat, incentive to numb emotions, and poor eating habits and attitudes impeded their recovery. Bulimic subjects indicated that people and societal expectations, incentive to numb emotions, lack of understanding, and poor eating habits and attitudes hindered their recovery.

Recent research indicates that 2% to 4% of the population meet diagnostic criteria for the newly proposed binge eating disorder, and that it is much more common (30%) among the treatment-seeking obese. Although recognized as a significant problem, binge eating disorder is l1l not well understood, and there is debate about whether binge eating disorder is a distinct disorder. It has been argued that binge eating disorder is simply a variant or milder form of bulimia nervosa and not a separate and distinct disorder. Researchers have begun to study this population in greater depth in order to assess the characteristics of individuals with binge eating disorder, the similarities and differences between individuals with binge eating disorder, bulimia nervosa, and obese individuals who do not engage in binge eating, and the effectiveness of various treatments for binge eating disorder. Previous reviews of the literature (using non-meta-analytic strategies) have examined these areas and have yielded inconsistent conclusions. Therefore, a more comprehensive, current, and empirical integration of the data was conducted. In total, 297 studies of individuals with binge eating disorder, bulimia nervosa and/or obese individuals who do not engage in binge eating were collected, coded, and statistically analyzed across studies (by calculating standardized mean difference effect sizes). The key characteristics of individuals with binge eating disorder were assessed, diagnostic groups were systematically compared, and treatment outcomes (from 19 studies) were evaluated. The results indicated that individuals with binge eating disorder have a number of differences from both bulimia nervosa and obese non binge eating individuals. However, the extent of these differences was not great, and there was a general trend for binge eating disorder individuals to fall between the two groups on most measures of disturbed eating and psychopathology. These findings tend to support the continuum/variant conceptualization of binge eating disorder rather than that of a distinct disorder. In addition, data from primary research studies on the treatment of binge eating disorder indicated that, overall, psychosocial interventions were helpful in decreasing binge eating and psychopathological symptoms, but were less effective at reducing weight. The clinical implications of these findings are discussed, as are suggestions for future research.

Research has shown that body image plays a principle role in predicting the occurrence and extent of eating disordered symptomatology. The term 'body image' has multiple definitions but is most commonly used to refer to self-perceptions of body weight and shape. Evidence shows that Western socio-cultural beliefs encourage females to strive for an extremely thin, unrealistically small figure. The difficulties obtaining this thin-ideal have lead to the development of body image dissatisfaction (BID). Because the thin-ideal is a Western construct, BID was thought to effect only Western, White women, however, research shows that body image concerns and consequently eating pathology are appearing in non-Western, ethnic minority groups where they were once unknown. This has been attributed to increasing contact between ethnic minority groups and Western cultural mores. This would suggest that the degree of attachment a minority individual feels towards their ethnic identity is likely to moderate the development of BID and thus eating concerns. This thesis compared levels of body image dissatisfaction amongst ethnic groups in New Zealand, focussing particularly on Māori and Pakeha. No differences were found to exist amongst these groups with regards to body image dissatisfaction and eating pathology regardless of ethnic attachment. The information found has consequences for clinicians working with clients of Māori extraction and those researching body image dissatisfaction in New Zealand.

Ortorexia Nervosa (ON) är ett idag relativt okänt fenomen och detfinns skilda åsikter angående vilken typ av problem det är. Det finns desom menar på att det kan vara en ätstörning eller ett tvångssyndrom.Studien genomfördes med syfte att undersöka hur utbrett ON är hosträningsintresserade människor samt undersöka om bassjälvkänsla ochförvärvad självkänsla kunde relateras på olika sätt till graden av ONsamt se ifall kön och ålder har någon inverkan på detta.Undersökningen genomfördes med enkäter som mätte graden av ONoch självkänsla på 102 deltagare. Det visade sig att 33% av antaletdeltagare hade poäng över tröskelvärdet för ON. Studiens äldre ochyngre deltagare visade sig vara de som fick högst poäng på testet förON, dock hittades ingen skillnad beträffande kön. Inga signifikantasamband mellan ON och de två typerna av självkänsla kunde hittas.Idag är forskningen bristfällig inom ON och fler studier behövs.

The current dissertation is comprised of two studies that examined the relationship between group dynamics, attachment anxiety, and post-treatment outcomes in a sample of women (N = 102) with binge eating disorder (BED) who received Group Psychodynamic Interpersonal Psychotherapy. The first study explored the relationship between the development of group cohesion, the individuals’ level of attachment anxiety, and frequency of binge eating, symptoms of depression, and self-esteem at post-treatment. The second study explored the relationship between the interpersonal learning, individuals’ level of attachment anxiety, and outcomes. Interpersonal learning was conceptualized as the convergence between multiple perspectives of group cohesion: one’s own and the group’s perception of one’s cohesion to the group. Parallel measures of individual self-rated cohesion (CQ-I) and mean group-rated cohesion (CQ-G) were developed based on the original Cohesion Questionnaire (CQ; Piper et al., 1983) for this study. Participants were assigned to homogeneous groups composed of either high or low attachment anxiety to assess the impact of pre-treatment attachment anxiety. Findings indicated significant growth in cohesion over time, and a significant convergence in multiple ratings of cohesion. These processes did not differ significantly based on level of attachment anxiety. Growth in cohesion was related to greater reductions in binge eating for those high in attachment anxiety, while the convergence in ratings of cohesion (i.e., interpersonal learning) was related to improvements in self-esteem for individuals in both attachment anxiety conditions. The findings support the importance of group interventions for BED that are sensitive to individuals’ attachment anxiety, and that emphasize cohesiveness, and interpersonal learning to improve outcomes.