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Bariatric (Weight Loss) Surgery

▶ Surgery for Obesity and Impact on DisorderedEating

Bariatric Surgery

Melissa KalarchianSchool of Nursing, Duquesne University,Pittsburgh, PA, USA

Synonyms

Weight loss surgery

Definition

Bariatric surgery includes a number of differentprocedures to help individuals with severe obesitylose weight. The most common procedures in useinclude gastric bypass, sleeve gastrectomy, andadjustable gastric banding.

Context

Bariatric surgery has been effective for treatmentof severe obesity after nonsurgical approacheshave failed. It is considered for well-informed

# Springer Nature Singapore Pte Ltd. 2017T. Wade (ed.), Encyclopedia of Feeding and Eating DisorderDOI 10.1007/978-981-287-104-6

and motivated patients with a BMI>40 kg/m2 orfor individuals with a BMI of 35–40 kg/m2 andsignificant obesity-related comorbidities like type2 diabetes mellitus, obstructive sleep apnea, orhypertension. Patient selection involves a multi-disciplinary screening process including medical,nutritional, and psychological evaluations. Manypatients are also required to document completionof a physician-supervised diet and lifestyle mod-ification program.

Bariatric surgery includes a range of differentprocedures. All procedures restrict gastric capacityto reduce food intake (e.g., gastric sleeve, adjustablegastric banding). Some procedures also alter thedigestive tract to cause malabsorption (e.g., Roux-en-Y gastric bypass). In the general adult popula-tion, outcomes vary across patients and procedures.

Patients who undergo bariatric surgery with anexperienced surgeon in a high-volume hospitalhave lower mortality and fewer complications.Most individuals experience maximum weightloss within the first year post-surgery. In the lon-ger term, many regain some of the weight thatthey initially lost. Post-surgery weight and main-tenance are best when accompanied by healthylifestyle changes and lifelong follow-up.

Screening and Approval for Surgery

The routine screening and approval processincludes a psychological evaluation and clearanceby a licensed mental health professional. The

s,

50 Bariatric Surgery

psychological evaluation is not standardized, andproviders vary in how they assess candidates forbariatric surgery. Typical evaluations addressweight and dieting history; psychopathology,including eating disorders; social supports; andknowledge about surgery. In addition to a clinicalinterview, some providers utilize psychologicaltesting. Testing may include measures of eatingpathology, mood, substance use, personality,and/or cognitive functioning. However, manytests lack well-established psychometrics ornorms specifically for this patient population.

The vast majority of candidates are cleared forbariatric surgery on the basis of the psychologicalevaluation. For a relatively small proportion ofindividuals, bariatric surgery is denied or delayedon the basis of the psychological evaluation. Typ-ical reasons for denial included severe,uncontrolled psychiatric disorders (e.g., bipolardisorder) or a lack of understanding of the surgery(e.g., inability to provide informed consent).

With respect to eating disorders, it should benoted that binge eating is relatively commonamong individuals seeking treatment of obesity.Presurgery binge eating disorder tends to improveafter surgery and does not attenuate post-surgeryweight loss. Thus, binge eating disorder is not con-sidered acontraindication tobariatric surgeryper se.

Providers who screen and approve candidatesfor bariatric surgery should keep abreast of bestpractices in an evolving field. The American Soci-ety for Metabolic and Bariatric Surgery(ASMBS), the largest national society for thisspecialty, issues guidelines and recommendations,as well as position and consensus statements, rel-evant to all aspects of bariatric surgery (asmbs.org). In 2015, the ASMBS Integrated Health Clin-ical Issues and Guidelines Committee is currentlyupdating its recommendations for the presurgerypsychosocial evaluation.

Changes in Eating, Body Weight,and Nutrition

Patients are placed on a liquid diet immediatelyfollowing bariatric surgery. As solid foods aregradually reintroduced, patients are instructed to

limit portions, chew well, and stop as soon as theyfeel full. Eventually most individuals are able toconsume small quantities of a range of healthyfoods. Eating too much at one time or too quicklycan lead to gastrointestinal symptoms like nauseaand vomiting. For some, severe and persistentvomiting may contribute to the development ofnutritional complications like low iron, B12, orfolic acid. Eating patterns such as frequentsnacking on high-calorie foods can contribute toinadequate initial weight loss or significant regain.Technical problems with the surgical procedurecan also lead to complications.

Patients presenting with poor weight outcomesfollowing bariatric surgery should undergo medi-cal, nutritional, and psychological evaluations.This includes anatomic evaluation of the gastro-intestinal tract using upper gastrointestinal endos-copy and radiology. Depending on the results,some patients may be deemed candidates for asubsequent surgical procedure, known asrevisional or reoperative bariatric surgery. Itshould be noted that revisional bariatric surgeryhas been associated with lesser weight loss andgreater complications than initial procedures.Other patients may be referred for behavioraltreatment of obesity or eating disorders.

Post-surgery Eating Disorders

Providers who assess and treat problems witheating and weight following bariatric surgeryshould have accurate knowledge about bariatricsurgery and experience with this patient popula-tion. However, even among experts, there has notbeen consensus as to how to conceptualize andassess eating disorders after bariatric surgery.

The development of full-syndrome eating dis-orders like anorexia nervosa, bulimia nervosa, orbinge eating disorder is uncommon after bariatricsurgery. With respect to binge eating episodes,patients are generally unable to consume objec-tively large amounts of food at one time due to areduced gastric capacity. Nonetheless, some indi-viduals report the onset or persistence of episodesof loss of control over eating. (Loss of control isthe subjective experience that an individual

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cannot control what or how much one is eating,independent of the amount consumed.)A relatively large body of evidence now suggeststhat patients who experience recurrent loss ofcontrol over eating post-surgery have poorerweight outcomes. Thus, post-surgery loss of con-trol over eating may warrant clinical intervention.

Apart from loss of control over eating, there is adearth of information on other types of disorderedeating that may occur following bariatric surgery.One example is grazing, which is generally charac-terized by a repetitive eating pattern of smalleramounts throughout the day. Another example isnight eating, which is marked by evening hyper-phasia and/or nocturnal awakening to eat. Defini-tionsand terminologyhavevaried, andstandardizedinstrumentsdesignedspecifically for theassessmentof bariatric surgery patients are lacking.

Current Controversies

There has been debate about whether or not thepsychological evaluation or physician-superviseddiet should serve a gatekeeping function to deter-mine who can or cannot proceed to surgery. It isimportant to keep in mind that no robust pre-surgery predictors of post-surgery outcomeshave emerged from the literature. Moreover,there is a lack of effective nonsurgical treatmentsfor severe obesity. Ultimately, candidates andtheir health-care providers must weigh the poten-tial benefits and risks of bariatric surgery.

Another controversy has been the use of bar-iatric surgery in patients with a BMI below35 kg/m2 for treatment of type 2 diabetes. Increas-ingly, studies show that bariatric surgery can be aneffective treatment for type 2 diabetes in carefullyscreened patients for whom nonsurgical manage-ment has not been effective.

Finally, some have expressed concern aboutthe increasing use of bariatric surgery in youth.Current evidence suggests that extremely obeseteens who have achieved their adult stature canexperience weight loss and improvements inhealth following surgery. Nonetheless, questionsand concerns persist about the potential long-termimpact on growth and development.

Future Directions

Bariatric surgery is a rapidly changingfield. Emerg-ing research suggests that post-surgery weight lossis related to a complex interplay of neuronal, hor-monal, cognitive, and behavioral factors. In thefuture, a more complete understanding of mecha-nisms underlying changes in eating and bodyweight following the different procedures willimprove our ability to optimize patient outcomes.

More research is needed on how to define andtreat eating disorders in bariatric surgery patients.Assessments should include not only loss of controlover eating but also a broad range of eating behav-iors and other factors considered important bypatients andproviders.Hypothesis-driven, prospec-tive studies of large, diverse samples of bariatricsurgery patients will help move the field forward.

Cross-References

▶Obesity▶Obesity and Eating Disorders▶ Purpose of Assessment

References and Further Reading

Conceição, E. M., Mitchell, J. E., Engel, S. G., Machado,P. P. P., Lancaster, K., & Wonderlich, S. A. (2014).What is “grazing”? Reviewing its definition, frequency,clinical characteristics, and impact on bariatric surgeryoutcomes, and proposing a standardized definition.Surgery for Obesity and Related Diseases, 10(5),973–982.

Greenberg, I., Sogg, S., & M Perna, F. (2009). Behavioraland psychological care in weight loss surgery: Bestpractice update. Obesity, 17(5), 880–884.

Kalarchian, M. A., Marcus, M. D., Courcoulas, A. P.,Cheng, Y., & Levine, M. D. (2014). Self-report of gas-trointestinal side effects after bariatric surgery. Surgeryfor Obesity and Related Diseases, 10(6), 1202–1207.

Meany, G., Conceição, E., & Mitchell, J. E. (2014). Bingeeating, Binge eating disorder and loss of control eating:Effects on weight outcomes after bariatric surgery.European Eating Disorders Review, 22(2), 87–91.

Mitchell, J. E., King, W. C., Courcoulas, A., Dakin, G.,Elder, K., Engel, S., . . . Wolfe, B. (2015). Eatingbehavior and eating disorders in adults before bariatricsurgery. International Journal of Eating Disorders,48(2), 215–222.

52 Behavioral Affective Response

Parker, K., O’Brien, P., & Brennan, L. (2014). Measure-ment of disordered eating following bariatric surgery:A systematic review of the literature. Obesity Surgery,24(6), 945–953.

Wadden, T. A., Faulconbridge, L. F., Jones-Corneile, L. R.,Sarwer, D. B., Fabricatore, A. N., Thomas, J. G., . . .Williams, N. N. (2011). Binge eating disorder and theoutcome of bariatric surgery at one year: A prospective,observational study. Obesity, 19(6), 1220–1228.

Behavioral Affective Response

▶Emotion Expression in Individuals with Feed-ing and Eating Disorders

Binge Eating Disorder

▶Bipolar Disorder and Eating Disorders▶Eating Disorder Questionnaire (EDQ)▶ Impact of Psychiatric Comorbidity on EatingDisorder Outcomes▶ Starvation in Children, Adolescents, and YoungAdults: Relevance to Eating Disorders▶ Substance-Related Disorders in EatingDisorders

Binge Eating Scale (BES)

Elizabeth W. Cotter1 and Nichole R. Kelly2,31Department of Health Studies, AmericanUniversity, Washington, DC, USA2Department of Human Development and FamilyStudies, Section on Growth and Obesity, Programin Developmental Endocrinology and Genetics,Eunice Kennedy Shriver National Institute ofChild Health and Human Development ColoradoState University, Bethesda, MD, USA3Department of Medical and Clinical Psychology,Uniformed Services University of the HealthSciences, Bethesda, MD, USA

Synonyms

Loss of control eating; Objective binge eating

Definition

The binge eating scale (BES) is a 16-item self-report questionnaire designed to capture the behav-ioral (eight items, e.g., large amount of food con-sumed), as well as the cognitive and emotional(eight items, e.g., feeling out of control while eat-ing, preoccupation with food and eating), featuresof objective binge eating (OBE) in overweight andobese adults (Gormally et al. 1982). For each item,respondents are asked to select one of three or fourresponse options, coded zero to two or three,respectively. Individuals’ scores are summed andrange from 0 to 46, with higher scores indicatingmore severe binge eating problems. Marcuset al. (1988) created clinical cutoff scores for theBES representing none-to-minimal (<17 totalscore), moderate (18–26), and severe (>27) bingeeating problems. Importantly, the BES was createdbefore binge eating disorder (BED) was officiallyrecognized as a psychiatric diagnosis (AmericanPsychiatric Association 2013) and thus is notintended to detect the presence of this disorder.Rather, it has been suggested that this measure beused as a brief screening tool to identify the sever-ity of binge eating behavior in overweight andobese adults, to tailor obesity interventions, and totrack treatment outcomes (Gormally et al. 1982;Marcus et al. 1988). Although the BES has beenused with children and adolescents sparingly, weonly present data from adults in this chapter, as thismeasure was created specifically for this age group.

Reliability

Estimated internal consistency of the measure isgenerally acceptable (Cronbach’s alphas werereported above .8) across samples, includingmen and women from the community, collegestudents, treatment-seeking adults, racially/ethni-cally diverse groups, and adults from the UnitedStates and abroad (e.g., Celio et al. 2004; Freitaset al. 2006; Kelly et al. 2012; Minnich et al. 2014;Ricca et al. 2000; Timmerman 1999). Adequatetest-retest reliability has also been reported amongadult females’ samples over a ~2-week interval(e.g., Timmerman 1999).

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Validity

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Factor Structure The initial development of thescale (Gormally et al. 1982) yielded two eight-item factors representing the behavioral and cog-nitive/emotional aspects of binge eating. Morerecent examinations of the scale (e.g., Kellyet al. 2012) further support this two-factor solu-tion, suggesting that the existing subscales remainappropriate across a range of samples. Of interest,Kelly et al. reported measurement invariancebetween White/Caucasian and Black/AfricanAmerican female college samples, suggestingthat, while the same two-factor solution may beadequate for both racial/ethnic groups, the itemsmight be assessing different constructs (see Race/Ethnicity subsection for further discussion).

Concurrent Validity In support of the validityof the BES, numerous studies have identified sig-nificant associations with other questionnairesassessing related attitudes, behavior, and moodsymptoms. For instance, Mitchell and Mazzeo(2004) examined the BES in a sample of259 undergraduates, including 73 Black/AfricanAmerican women and 131 White/Caucasianwomen, and found that BES scores in both groupsof women were moderately to strongly correlatedwith a measure of general eating disorder symp-tomatology (r = 0.80 and 0.52, respectively). InRicca et al.’s (2000) research involving 344 outpa-tient men and women with obesity, BES scoreswere significantly associated with state (r = 0.25)and trait anxiety (r = 0.32), depressive symptoms(r = 0.30), and BMI (r = 0.13) providing furtherevidence of concurrent validity.

Gender Although the BES has primarily beenstudied in women, researchers have specificallyexamined the BES in men. For example, Minnichet al. (2014) examined the BES in a sampleof 302 primarily White/Caucasian (88.8%) under-graduate men. Concurrent validity was establishedwith significant correlations in the expected direc-tions at two separate time points with measures ofbody dissatisfaction (r = 0.52, 0.31), drive formuscularity (r = 0.19, 0.15), self-esteem

(r = 0.39, 0.25), depressive symptoms (r = 0.54,0.50), anxiety symptomatology (r = 0.33, 0.27),and BMI (r = 0.27, 0.32). BES scores also appearconsistent with established gender differences inBED prevalence, such that women endorse signif-icantly higher average BES scores than men (e.g.,Ricca et al. 2000).

Race/Ethnicity The BES has been used amongdiverse adult samples in both the United Statesand abroad and has been translated into severaldifferent languages (e.g., Freitas et al. 2006; Riccaet al. 2000). Because the BES was originallydeveloped and normed in a primarily White/Cau-casian sample, research has since investigatedwhether racial/ethnic variations in this measureexist. Data from Kelly et al. (2012) indicate thatWhite/Caucasian college women (n = 1467)reported a significantly stronger associationbetween body dissatisfaction and BES scoresthan Black/African American college women(n = 741). White/Caucasian women alsoendorsed higher scores on the BES than theirBlack/African American peers (M = 11.42,SD = 8.16 and M = 8.69, SD = 6.80, respec-tively). Taken together, data indicate that, on aver-age, binge eating behavior among Black/AfricanAmerican men and women may occur less fre-quently, may be less emotionally distressing, andmay be less associated with body image concernscompared to their White/Caucasian peers. Quali-tative data are needed to further clarify whetherbinge eating behavior manifests differentlyamong various racial/ethnic groups.

Clinical Usefulness to Assess BingeEating Episode Size

A core feature of BED according to DSM-5criteria (American Psychiatric Association 2013)is the presence of recurrent objective bulimic epi-sodes (OBEs), which involves the consumption ofunambiguously large amounts of food, in additionto a sense of loss of control (LOC) while eating.However, subjective bulimic episodes (SBEs), theconsumption of smaller amounts of food withLOC, are also associated with significant eating

54 Binge Eating Scale (BES)

disorder symptomatology and general psychopa-thology. While the BES was only designed tocapture OBEs, research has examined whetherthis measure adequately captures both types ofbinge eating episodes.

Timmerman (1999) compared BES scores todata from 28-day food records in a sample of56 healthy, primarily White/Caucasian (91%)women who engaged in OBEs at least twice permonth in the absence of regular compensatorybehaviors. Participants received training inmeasuring and recording food intake accuratelyprior to beginning the study. The BES demon-strated significant, moderate associations(r = 0.39–0.40) with several indicators of SBEs,including calories consumed during SBEs, numberof SBEs, and number of SBE days. Small-to-moderate, significant correlations (r = 0.29–0.32)were also noted between the BES and similar indi-cators of OBEs. Importantly, BES scores were notcorrelated with overall caloric intake. Timmerman(1999) also divided participants into groups basedon BES clinical cutoffs. Significant differencesemerged between the mild (�17) and severe(�27) groups, such that the severe group endorsedhigher levels of the following: number of caloriesconsumed during SBEs, number of calories con-sumed during SBEs and OBEs combined, numberof total SBEs, number of OBE days, number ofSBE days, and number of combined OBE and SBEdays. In Celio et al.’s (2004) research, the BES wasalso correlated with frequency of OBEs and num-ber of days, but no other form of overeating,including SBEs or objective overeating withoutLOC. Taken together, existing research indicatesthat the BES does not successfully discriminatebetween SBEs and OBEs, but appears to be agood indicator of severity of LOC eating.

Comparisons to Diagnostic Interviews

Although the BES was not developed with theintention of diagnosing BED, some researchershave examined the potential utility of this measureas a replacement for more costly, time-consumingdiagnostic clinical interviews that require trainedmental health staff. Therefore, it is important to

consider the concordance between the BES andstandard diagnostic clinical interviews.

Eating Disorder Examination (EDE, Fairburnand Cooper 1993) Celio et al. (2004) comparedthe BESwith the gold standard interview for eatingdisorder symptomassessment, theEDE, ina sampleof 157 primarily White/Caucasian (70.3%) womenseeking treatment for BED. Results suggested thatthe BES (using a severe cutoff score of 27) wasreasonably sensitive in detecting individuals withBED (85.1%), but demonstrated low specificity(20%), such that many women without BEDobtained BES scores above the severe cutoff.

Structured Clinical Interview for DSM Disor-ders (SCID; First et al. 2007) Freitas and col-leagues (2006) examined the clinical utility of thePortuguese version of the BES as a measure ofBED in a sample of 178 Brazilian women withobesity. Comparisons were made between theSCID, a semi-structured psychiatric interview,and a BES cutoff score of 17. Again, the BESdemonstrated higher sensitivity (97.8%) thanspecificity (47.7%); over half of the participantswho were not diagnosed with BED according tothe SCID scored above the clinical cutoff on theBES, while only ~2% of those diagnosed withBED scored below the cutoff. A large sample ofoutpatient men and women with obesity(N = 344; Ricca et al. 2000) completed theSCID and the BES; their data yielded a sensitivityof 84.8% and a specificity of 74.6%.

Based on the existing research, it appears thatthe BESmay demonstrate slightly stronger concor-dance with clinical interviews in community sam-ples compared to clinical samples, although thepotential for false positives remains a concern inthe majority of studies. As such, it is recommendedthat the BES not be used independently to diagnoseBED, but may be a useful initial screening tool(as originally suggested by Gormally et al. (1982)).

Summary and Future Directions

Overall, scores on the BES (Gormally et al. 1982)have demonstrated good reliability, and the

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measure appears to be valid for the assessment ofbinge eating severity for clinical, community, andcollege samples in the United States and abroad.Given discordance between the BES and clinicalinterviews, particularly the tendency to overdiag-nose BEDwhen using the BES clinical cutoffs, it issuggested that the BES be used as a brief screeningdevice rather than a diagnostic indicator. The BESmay also be more useful in terms of capturinggeneral LOC eating patterns rather than identifyingspecific binge episodes. Although the BES may beused with diverse patient and community samples,there remains a need to further examine the validityof this measure, particularly among Asian and His-panic/Latino groups. Additional research is alsoneeded with men outside of college samples,including community and clinical settings. Longi-tudinal studies are also needed to evaluate whetherthe BES is a prospective indicator of disorderedeating pathology as the majority of research citedherein reported cross-sectional data.

Cross-References

▶Binge Eating Disorder▶Choosing an Assessment Instrument/Method▶Eating Disorder Examination (EDE)/(EDE-Q)▶Obesity and Eating Disorders▶ Severity Dimensions▶ Structured Clinical Interview for DSM-IV(SCID)

References and Further Reading

American Psychiatric Association. (2013). The diagnosticand statistical manual of mental disorders: DSM 5.Washington, DC: American Psychiatric Association.bookpointUS.

Celio, A. A., Wilfley, D. E., Crow, S. J., Mitchell, J., &Walsh, B. T. (2004). A comparison of the binge eatingscale, questionnaire for eating and weight patterns-revised, and eating disorder examination questionnairewith instructions with the eating disorder examinationin the assessment of binge eating disorder and its symp-toms. International Journal of Eating Disorders, 36(4),434–444.

Fairburn, C., & Cooper, Z. (1993). The eating disorderexamination. In C. Fairburn & G. Wilson (Eds.),Binge eating: Nature, assessment and treatment (12thed., New York, NY : Guilford, pp. 317–360).

Freitas, S. R., Lopes, C. S., Appolinario, J. C., & Coutinho,W. (2006). The assessment of binge eating disorder inobese women: A comparison of the binge eating scalewith the structured clinical interview for the DSM-IV.Eating Behaviors, 7(3), 282–289.

First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B.(2007). SCID-I/P.

Gormally, J., Black, S., Daston, S., & Rardin, D. (1982).The assessment of binge eating severity among obesepersons. Addictive Behaviors, 7(1), 47–55.

Kelly, N. R., Mitchell, K. S., Gow, R. W., Trace, S. E.,Lydecker, J. A., Bair, C. E., & Mazzeo, S. (2012). Anevaluation of the reliability and construct validity ofeating disorder measures in white and black women.Psychological Assessment, 24(3), 608.

Marcus, M. D., Wing, R. R., & Hopkins, J. (1988). Obesebinge eaters: Affect, cognitions, and response to behav-ioral weight control. Journal of Consulting and Clini-cal Psychology, 56(3), 433.

Minnich, A. M., Gordon, K. H., Holm-Denoma, J. M., &Troop-Gordon, W. (2014). A test of an interactivemodel of binge eating among undergraduate men. Eat-ing Behaviors, 15(4), 625–631.

Mitchell, K. S., & Mazzeo, S. E. (2004). Binge eating andpsychological distress in ethnically diverse undergrad-uate men and women. Eating Behaviors, 5(2),157–169.

Ricca, V., Mannucci, E., Moretti, S., Di Bernardo, M.,Zucchi, T., Cabras, P., & Rotella, C. (2000). Screeningfor binge eating disorder in obese outpatients. Compre-hensive Psychiatry, 41(2), 111–115.

Timmerman, G. M. (1999). Binge eating scale: Furtherassessment of validity and reliability1. Journal ofApplied Biobehavioral Research, 4(1), 1–12.

Binge-Eating Disorder

Anja HilbertBehavioral Medicine, Integrated Research andTreatment Center Adiposity Diseases, Universityof Leipzig Medical Center, Leipzig, Saxony,Germany

Definition

Binge-eating disorder (BED) was first included asits own diagnostic entity in the Fifth Edition of theDiagnostic and Statistical Manual of Mental Dis-orders (DSM-5; American Psychiatric Associa-tion [APA], 2013). Listed as a Feeding andEating Disorder, the main characteristic of BED

Binge-Eating Disorder, Table 1 Diagnostic criteria ofbinge-eating disorder according to the Diagnostic andStatistical Manual of Mental Disorders, Fifth Edition(DSM-5; APA 2013)

Binge-eating disorder 307.51

A. Recurrent episodes of binge eating1. Definitely large amount of food2. Sense of lack of control over eating

B. At least 3 of the following: Eatingrapidly, eating until uncomfortably full,eating without hunger, eating alone,disgust after eating

C. Marked distress

D. At least 1 episode of binge eating perweek for 3 months

E. No recurrent compensatory behavior,not exclusively during bulimia nervosaor anorexia nervosa

56 Binge-Eating Disorder

is recurrent binge eating (A.): During binge-eatingepisodes an amount of food is consumed that isunambiguously larger than what others would eatunder comparable circumstances within a certaintime, coupled with a subjective sense of loss ofcontrol over eating (objective binge eating). Asopposed to binge eating in bulimia nervosa, bingeeating in BED occurs in the absence of regularinappropriate compensatory behaviors, such asself-induced vomiting, fasting, or laxative misuse,aimed at preventing weight gain (E.). For diagno-sis of BED, binge eating is required to occur atleast once per week over 3 months (D.) and inassociation with behavioral abnormalities (B.)and marked distress (C.) (Table 1).

DSM-5 offers two specifications for the diag-nosis of BED: (a) current severity according to thefrequency of binge-eating per week (mild, 1–3episodes; moderate, 4–7 episodes; severe, 8–13episodes; extreme, 14 or more episodes); and(b) remission status after full criteria have beenmet (partial remission, less than one binge-eatingepisode per week; full remission, no diagnosticcriterion met).

In addition, within the Other Specified Feedingor Eating Disorder section of DSM-5 (OSFED;307.59), a lower-threshold form of BED wasnewly defined, also associated with significantdistress or impairment in life functioning: Objec-tive binge eating can be classified as BED of low

frequency and/or limited duration if occurring lessthan once per week and/or for less than 3 months,the time criterion of BED (D.). For this diagnosis,all other DSM-5 criteria of BED are required tobe met.

According to the International Classificationof Diseases and Related Health Problems TenthEdition (ICD-10; World Health Organization1992), BED is subsumed under the Other EatingDisorders (F50.8), without any further specifica-tion of diagnostic criteria or guidelines. For theEleventh Edition of ICD (ICD-11), scheduled for2017, BED was designated as its own eating dis-order (Uher and Rutter 2012). However, deviatingfrom the DSM-5, the ICD-11 diagnosis of BEDwas proposed to be broadened and based onobjective or subjective binge eating. Thus, inaddition to objective binge eating, as defined inthe DSM-5, subjective binge eating, involving theconsumption of an amount of food that is subjec-tively larger than what others would eat undercomparable circumstances, combined with a sub-jective sense of loss of control over eating, couldbe used for diagnosis of BED, making the loss ofcontrol over eating the decisive criterion of bingeeating. Proposed for the other eating disorders aswell, the diagnostic time frame for BED wasshortened to 1 month, during which binge eatingis required to occur regularly and in the absence ofregular inappropriate compensatory behavior.

Historical Background

Stunkard first described the symptoms of BED in1959 in obese men and women who presentedwith recurrent episodes of binge eating but didnot purge. It was, however, only four decadeslater that BED was introduced in the DSM. Inthe Fourth Edition of the DSM (DSM-IV; APA1994), BED was included as a provisional eatingdisorder diagnosis in need of further study andsubsumed under the Eating Disorders Not Other-wise Specified. Even as a provisional diagnosis,the introduction of BED in the DSM was contro-versial, related to concerns about proliferation ofdiagnoses, lack of evidence on the specific diag-nostic criteria of BED, and potential overlap with

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bulimia nervosa. A major problem with DSM-IVwas that most cases in clinical settings were diag-nosed with the residual category Eating DisordersNot Otherwise Specified, leading to uncertaintiesin classification and treatment, and making a revi-sion of the DSM diagnostic system for eatingdisorders necessary. As guiding principles forthe revision, the DSM-5 Eating Disorders TaskForce aimed for maximum clinical utility, solidempirical evidence, and high continuity with theDSM-IV.

The revisionwas based on a large body of empir-ical research, published since 1994 and compiledin state-of-the-art reviews (e.g., Striegel-Moore andFranko 2008; Wonderlich et al. 2009; Keel et al.2012). Herein, it was demonstrated that BED hasvalidity (i.e., demonstrable boundaries towardsnormality and neighboring syndromes) and clini-cal utility (i.e., nontrivial information aboutpsychobiological correlates, prognosis, and/ortreatment outcome; see Current Knowledge).Consequently, the DSM-5 adopted the DSM-IVdiagnostic criteria in a virtually identical form,with one exception: In order to match the thresh-olds proposed for bulimia nervosa, the diagnostictime frame was shortened from 6 to 3 months, andthe frequency threshold of objective binge-eatingepisodes required for diagnosis of BED wasdecreased from at least 2 per week to at least 1 perweek. Indeed, emerging evidence indicates that theuse of DSM-5 diagnostic criteria reduced the num-ber of cases with EDNOS, and led to an increase inthe prevalence rate of BED, similar to that of theother defined eating disorders.

Current Knowledge

Extant literature shows that individuals with BEDsuffer from increased eating disorder (e.g., shapeor weight concern) and general psychopathology(e.g., depressiveness, anxiety), high comorbiditywith Axis I (e.g., mood disorders, anxiety disor-ders, substance use disorders) and Axis II disor-ders (e.g., avoidant, borderline personalitydisorder), overweight and obesity, and impairedmental and physical quality of life, when com-pared to normal weight or overweight/obese

individuals without BED (Kessler et al. 2013).When compared to the other eating disordersanorexia nervosa and bulimia nervosa, BEDdisplayed a roughly similar psychological impair-ment. Empirical classification studies (e.g., latentstructure analyses) have shown that the clinicalprofile of BED is distinct from that of the othereating disorders, although a clear delineation fromobesity is still outstanding (Wonderlichet al. 2009). Laboratory test meal studies objec-tively demonstrated greater abnormalities in foodintake (e.g., greater consumption of calories in testmeal paradigms) in BED than in weight-matchedcontrols without BED, further speaking to thevalidity of this disorder. BED, with a lifetimeprevalence rate of 1.9% is the most prevalenteating disorder (DSM-IV) and presents with adistinct sociodemographic profile (e.g., later ageof onset, lower preponderance of female gender,higher rates of obesity), when compared toanorexia nervosa and bulimia nervosa.

Regarding etiology, BED seems to be precededby multiple mental, physical, and social correlatesof risk, most of which are shared with the othereating disorders. However, longitudinal evidenceon the development of BED is limited. A fewprospective studies indicated that childhood lossof control eating including both objective andsubjective binge eating, predicts a later develop-ment of full- or partial-syndrome BED andmay, invulnerable youth, precede excess weight gain andmetabolic dysfunction (Hilbert et al. 2013). For-mal genetic studies suggested the role of familialand genetic risk factors of binge eating. However,molecular genetic studies have not confirmed thecontribution of any specific gene or genetic path-way to the development of BED.

BED has been theorized to be maintainedthrough emotional, social, and cognitive dysfunc-tions. Emotional dysfunctions were found to besimilar to those in anorexia nervosa and bulimianervosa. Binge eating in BED has been found tobe preceded by negative affect in descriptive,laboratory, and ecological momentary assessmentstudies. However, no clear evidence exists thatbinge eating reduces negative affect, as stipulatedby the prominent affect regulation model. Nega-tive affect frequently arises from interpersonal

58 Binge-Eating Disorder

problems (e.g., social anxiety, poor social sup-port), characteristic of BED and similar to thoseof the other eating disorders, supporting the valid-ity of the interpersonal model of binge eating.This model posits that interpersonal problemsadversely impact affect, resulting in binge eating.Further, individuals with BED, as did individualswith anorexia nervosa and bulimia nervosa,displayed deficits in executive functioning whencompared to weight-matched controls, especiallyfor disorder-relevant cues (e.g., set-shifting diffi-culties with food stimuli; Kittel et al. 2015), likelyincreasing the probability of binge eating. Like-wise, preliminary studies of brain function in BEDsuggested a diminished activity in brain areasrelated to inhibitory control (e.g., ventromedialprefrontal cortex, inferior frontal gyrus, insula)compared to obese and normal weight controls.A greater striatocortical pathway dysfunction inreward processing, analogous to substance usedisorders, was suggested for BED; however, thefood addiction or eating addiction hypothesis inBED is awaiting definitive evidence.

Among evidence-based treatment approaches,cognitive-behavioral therapy and interpersonalpsychotherapy are standard specialty treatmentsfor BED, leading to large and long-lastingimprovements of binge eating and associated psy-chopathology (Hay 2013). Manualized self-helpapproaches, based on cognitive-behavioral princi-ples and guided by a coach, have further proven tobe efficacious, especially with lower levels ofpsychopathology. Overall, response to psycholog-ical treatment seems to be higher in BED than inanorexia nervosa and bulimia nervosa. In contrastto standard specialty treatments for BED, behav-ioral weight loss treatment for obesity yieldedonly moderate effects when treating obese indi-viduals with BED, lending clinical utility to thediagnosis of BED. In addition, the symptomatol-ogy of BED seems to impair long-term efficacy ofconservative and surgical approaches to weightloss treatment. It is of note that the rates of indi-viduals with BED receiving treatment for the eat-ing disorder are low, speaking for a necessaryimprovement in the provision of care. Consistentwith the substantial disease-related burden asso-ciated with BED, health care utilization and health

care costs are generally increased in individualswith BED. Recently, the first medication for BEDwas approved in the US (lisdexamfetaminedimesylate); however, the evidence on pharmaco-therapy for BED, especially regarding long-termoutcomes, remains limited.

Regarding long-term outcome, when comparedto anorexia nervosa or bulimia nervosa, the naturalcourse of BED seems to be more variable, withtendencies towards recovery and relapse likelyembedded in a chronic course. BED seems to beless prone than anorexia nervosa or bulimianervosa to migrate to another eating disorder. Theevidence is insufficient on the predictive value ofBED or binge eating for weight gain, or adversemedical outcomes including mortality, althoughBED may precede these outcomes.

Current Controversies

Currently, it remains unresolved, and this concernsother eating disorders as well, how to bestoperationalize binge eating – the core diagnosticcriterion of BED (A.) – and more specifically, howto define loss of control and demarcate an unusu-ally large amount of food. Concerns persist on thelack of evidence base for the behavioral indicatorsof binge eating (B.) and marked distress (C.). It hasbeen noted that no parallel of these criteria exists inthe diagnostic criteria of other eating disorders withbinge eating, especially bulimia nervosa. Thedetermination of illness severity is another diffi-culty that is beginning to be addressed empirically.The evidence is accruing that body image distur-bance, expressed as Undue influence of weight orshape on self-evaluation, is associated with greaterillness severity, while being unrelated to bodymassindex, and has potential relevance in the predictionof treatment outcome (Grilo 2013). Undue influ-ence of weight or shape on self-evaluation isrequired to diagnose both anorexia nervosa andbulimia nervosa according to the DSM and hasbeen recommended as a diagnostic specifier orcriterion of BED for forthcoming editions of diag-nostic systems. Further difficulties exist in the dif-ferentiation from other eating disorders such asbulimia nervosa, especially in case of nonpurging

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compensatory behaviors (e.g., Other SpecifiedFeeding or Eating Disorder Obesity, excessiveexercising) and in case of dietary restriction (e.g.,weight loss diets). In addition, symptom overlapexists with night eating syndrome, newly includedas an Other Specified Feeding or Eating Disorderin the DSM-5, which should not be diagnosed ifsymptoms can be better explained by BED.

Future Directions

Further evidence is needed on the reliability andvalidity of BED, taking into account the changes todiagnostic criteria in DSM-5 and ICD-11.A promising research avenue is the simplificationof diagnostic criteria for BED and other eatingdisorders, for example, as detailed in the BroadCategories for the Diagnosis of Eating Disorders(BCD-ED) approach (Walsh and Sysko 2009). Thedefinition of binge eating also warrants furtherconsideration. Further evidence is warranted onthe specification of restrictive eating in relation tothe maintenance of binge-eating episodes in BE-D. Future treatments should be closely informed bycurrent research on themaintenance of this disorder(e.g., cognitive dysfunction). Another major chal-lenge for research lies in the dissemination andimplementation of evidence-based approaches totreatment. More evidence is needed on the etiologyand long-term outcome of BED.

Cross-References

▶ Future Directions in Classification▶Loss of Control (LOC) Eating in Children▶Obesity▶Obesity and Eating Disorders▶Other Specified Feeding or Eating Disorder(OSFED)

References and Further Reading

Grilo, C. M. (2013). Why no cognitive body image featuresuch as overvaluation of shape/weight in the bingeeating disorder diagnosis? International Journal ofEating Disorders, 46, 208–211.

Hay, P. (2013). A systematic review of evidence for psy-chological treatments in eating disorders: 2005–2012.International Journal of Eating Disorders, 46,462–469.

Hilbert, A., Hartmann, A. S., Czaja, J., & Schoebi,D. (2013). Natural course of preadolescent loss ofcontrol eating. Journal of Abnormal Psychology, 122,684–693.

Keel, P. K., Brown, T. A., Holland, L. A., et al. (2012).Empirical classification of eating disorders. AnnualReview of Clinical Psychology, 8, 381–404.

Kessler, R. C., Berglund, P. A., Chiu, W. T., Deitz, A. C.,Hudson, J. I., Shahly, V., Aguilar-Gaxiola, S., Alonso,J., Angermeyer, M. C., Benjet, C., Bruffaerts, R.,de Girolamo, G., de Graaf, R., Maria Haro, J.,Kovess-Masfety, V., O’Neill, S., Posada-Villa, J.,Sasu, C., Scott, K., Viana, M. C., & Xavier,M. (2013). The prevalence and correlates of bingeeating disorder in the World Health OrganizationWorld Mental Health Surveys. Biological Psychiatry,73, 904–914.

Kittel, R., Brauhardt, A., & Hilbert, A. (2015). Cognitiveand emotional functioning in binge-eating disorder:A systematic review. International Journal of EatingDisorders, 48, 535–554.

Striegel-Moore, R. H., & Franko, D. L. (2008). Shouldbinge eating disorder be included in the DSM-V?A critical review of the state of the evidence. AnnualReview of Clinical Psychology, 4, 305–324.

Uher, R., &Rutter, M. (2012). Classification of feeding andeating disorders: Review of evidence and proposals forICD-11. World Psychiatry, 11, 80–92.

Walsh, B. T., & Sysko, R. (2009). Broad categories for thediagnosis of eating disorders (BCD-ED): An alterna-tive system for classification. International Journal ofEating Disorders, 42, 754–764.

Wonderlich, S. A., Gordon, K. H., Mitchell, J. E.,et al. (2009). The validity and clinical utility of bingeeating disorder. International Journal of Eating Disor-ders, 42, 687–705.

General ReferencesAmerican Psychiatric Association. (1994). Diagnostic and

Statistical Manual of Mental Disorders (4th Ed.).Arlington: American Psychiatric Association.

American Psychiatric Association. (2013). Diagnostic andStatistical Manual of Mental Disorders (5th Ed.).Arlington: American Psychiatric Association.

World Health Organization. (1992). International Classi-fication of Diseases and Related Health ProblemsTenth Edition (ICD-10). Geneva: World HealthOrganization.

Bipolar Affective Disorder (BAD)

▶Bipolar Disorder and Eating Disorders

60 Bipolar Disorder and Eating Disorders

Bipolar Disorder and EatingDisorders

Anna I. Guerdjikova1,2 and Susan L. McElroy1,21Lindner Center of HOPE, Mason, OH, USA2Department of Psychiatry and BehavioralNeuroscience, University of Cincinnati College ofMedicine, Cincinnati, OH, USA

Synonyms

Anorexia nervosa; Binge eating disorder; Bipolaraffective disorder (BAD); Bulimia nervosa; Eat-ing disorder not otherwise Specified; Manic-depressive illness (MAD)

Definitions

Bipolar disorder is also known as “manic-depres-sive illness” is defined by the American Psychiat-ric Association’s Diagnostic and StatisticalManual of Mental Disorders (DSM) 5 (A.P.A.2013) as a brain illness, characterized by periodsof elevated mood and periods of depression. Theelevated mood is significant; it impairs daily func-tioning and is known as mania or hypomania,depending on the severity of the episode or pres-ence of psychosis. During a manic episode, theindividual feels and/or acts abnormally and per-sistently elated, energetic, goal oriented, or irrita-ble and might make poorly thought out decisionswith little regard to the consequences. The needfor sleep is usually reduced, individuals are moretalkative than usual, and the disturbance in moodis observable by others. Periods of depression arecharacterized by low moods, pessimistic outlookfor the future, decreased energy, motivation, andinterest in hobbies and usual activities. Some indi-viduals cycle from low mood to elevated moodwithout periods of normalized stable mood, whileothers experience periods of stable mood inbetween manic and depressive episodes.Depending on the severity of the mooddysregulation, bipolar disorder is classified asbipolar I disorder (most severe mania,

characterized by the presence of manic episodesand depressive episodes), bipolar II disorder (lesssevere mania, characterized by the presence ofhypomanic episodes and depressive episodes)and bipolar disorder not otherwise specified.

DSM-5 outlines three types of eatingdisorders – anorexia nervosa, bulimia nervosa,and binge eating disorder. Anorexia nervosa ischaracterized with persistent restriction of foodintake leading to significantly low body weightalong with intense fear of gaining weight orbecoming fat. Individuals with bulimia nervosaengage in repetitive overeating (binge eating)followed by purging episodes (by vomiting orabusing laxative or diuretics), and their self-evaluation is unduly influenced by body shapeand weight. Binge eating disorder is characterizedwith at least weekly episodes of eating unusuallylarge amounts of food in a short period of timeaccompanied by the feeling of out of control dur-ing the binges and without engagement in anycompensatory behaviors.

Historical Overview

As early as fifth century BC, the HippocraticSchool used the terms “melancholia” and“mania” to define abnormal behavioral states dif-ferent from febrile illness. Early description ofmania as “yellow bile on the frontal portions ofthe brain, which alters the imagination and as aconsequence, reason” was provided byPosidonius (c. 135–51 BC). In the late seven-teenth century, Theophilus Bonet published“Sepuchretum,” a text that drew from his experi-ence performing 3000 autopsies, in which heconnected mania and melancholy in a conditioncalled “manico-melancolicus.” This was a sub-stantial step in defining bipolar illness becauseuntil then, mania and depression were usuallyconsidered separate states. However, it was notuntil the late eighteenth century when the Spanishphysician Andres Piquet wrote that “melancholiaand mania are terms denoting a single diseaseaccompanied by several disorders of mood.”Later in the nineteenth century, Esquirolcommented on the probable genetics of bipolar

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disorder by stating that “It would be difficult notto concede a hereditary transmission of mania,when one recalls that everywhere some membersof certain families are struck in several successivegenerations.” In 1854, the French psychiatristJean-Pierre Falret published an article describingwhat he called “la folie circulaire” (circular insan-ity). His article detailed patients switchingthrough severe depression and manic states, andis considered the first documented diagnosis ofbipolar disorder (Yildiz et al. 2015). The term“bipolar,” meaning “two poles,” and signifyingthe polar opposites of mania and depression, firstappeared in the third revision of American Psy-chiatric Association’s Diagnostic and StatisticalManual of Mental Disorders (DSM) in 1980.

Similarly, various presentations of eatingdysregulations, including historical notes on reli-gious fasting dating as far as BC, have beendescribed. The first anorexia nervosa casesappeared in medical literature in the early seven-teenth century with the work of the English phy-sician Dr. Morton. A century later, Sir W. Gull, theprominent physician to Queen Victoria published“Anorexia Hysterica,” and coined the termanorexia nervosa to distinguish the disorder fromthe umbrella term “hysteria.” While binging andpurging were both known through ancient historywith the Hebrew Talmud (A.D. 400–500) refer-ring to a ravenous hunger that should be treatedwith sweet foods (boolmot), and the Romansusing the word “vomitorium” (a special roomwhere the wealthy Romans would go to purgeafter a large meal), the term bulimia nervosa wasnot uniformly used until 1979 when it was intro-duced by Gerald Russel and then included as aformal diagnosis in DSM-III in 1987 (Gordon2000). Binge eating disorder was first formallydescribed in 1959 by Albert Stunkard as a formof abnormal eating among obese people. Overall,eating disorders received little systematic atten-tion until the middle of the twentieth century whenthey were conceptualized as mental illness andfurther included in formal disease classifications.As recently as 2013, binge eating disorder wasadded to DSM-5 as a standalone eating disorder.The anecdotal clinical observations on the overlapbetween mood and eating dysregulations and its

treatment implications sparked scientific interestand lead to systematic research starting in theearly 1990s.

Epidemiology and Course of Bipolarand Eating DisordersThe estimated worldwide prevalence of bipolardisorder is up to 2.4% (0.0% in Nigeria and3.3% in the Unites States) and it is considered tobe among the top 20 causes of disability. Whilebipolar illness is known to have a strong geneticcomponent with estimated heritability between60% and 85%, its complex genetic etiologyremains largely unknown. Like bipolar disorder,eating disorders are highly heritable illnessesassociated with decreased quality of life,increased disability, morbidity, and mortality.Both bipolar disorders and eating disorders startmost commonly in adolescence and the course ofillness can be acute, intermittent, or chronic.

Comorbidity of Bipolar Disorder and EatingDisordersPatients with bipolar disorder have been shown tohave elevated rates of co-occurring anorexianervosa, bulimia nervosa, and binge eating disor-der and conversely, patients with eating disordersare reported to have elevated rates of comorbidbipolar disorder (McElroy et al. 2011). Controlledfamily history studies have found elevated rates ofbipolar disorders in the first-degree relatives ofindividuals with anorexia nervosa, bulimianervosa, and binge eating disorder. Moreover,community studies found hypomania to be associ-ated with binge eating behaviors. The NationalComorbidity Survey Replication found that bipolarI and II disorders were associated with bulimianervosa and binge eating disorder, but not anorexianervosa (Hudsonet al. 2007). Bipolar patients witheating disorders are shown to have more weightdisturbance, more depressive episodes or recur-rences, and greater psychiatric comorbidity thanbipolar patients without eating disorders.

The precise pathophysiology of the overlapbetween eating disorders and bipolar disordersremains unknown. Growing research demon-strates that eating disorders are associated with

62 Bipolar Disorder and Eating Disorders

elevated familial rates of bipolar disordersuggesting certain genetic overlap. Moreover,dysregulation in some neurotransmitter andneurotrophin systems may play a role in the path-ophysiology of both illnesses. For example,abnormalities in brain-derived neurotrophic fac-tor, a protein involved in the regulation of moodand appetite, are found in individuals with bipolardisorder and those with eating disorders. Simi-larly, variants of the neurotrophic tyrosine kinasereceptor 3 gene are associated with early-onsetbipolar disorder and eating disorders.

Of interest, in both bipolar and eating disor-ders, similarly elevated comorbidity with anxiety,alcohol, and drug use disorders are observed,suggesting that bipolar disorders and eating disor-ders may be related by sharing a neurobiologicaldysregulation of mood, eating behavior, andimpulse control. Indeed, is has been hypothesizedthat certain impulsive behaviors, including bingeeating, may have mood stabilizing effects and thatsome patients with bipolar disorder might self-medicate their mood dysregulation with impul-sive overeating (e.g., binge eating). In this contextof shared neurobiology, it is not surprising thateating disorders respond to treatments with mood-improving properties (e.g., antidepressants and/orcognitive-behavioral therapy). For example, thebinge eating of bulimia nervosa and binge eatingdisorder responds to antidepressants and con-versely, interventions related to regulating foodintake and decreasing dysfunctional eating behav-iors can stabilize mood.

Treatment

Psychological TreatmentsThere have been no randomized, controlled trialsof any psychotherapy methods in the treatment ofpatients with bipolar disorder and a co-occurringeating disorder. Certain psychological interven-tions, briefly described below, hold promisewhen addressing mood and comorbid eatingdysregulations because they are effective in bipo-lar disorder alone or in eating disorders treatmentalone. In general, psychological treatments are not

recommended as a monotherapy when treatingbipolar disorder with a comorbid eating disorderand in most cases should be considered as anadjunct to pharmacotherapy.

PsychoeducationPsychoeducation is a behavioral training aimed atadjusting lifestyle to cope with mental and /orphysical illness by enhancement of illness aware-ness, early detection of relapse, and treatmentadherence. Psychoeducation empowers patientswith various tools, allowing them to be moreactive in their treatment, and is a widely usedmethod in addressing both mood and eatingdisorders.

Cognitive-Behavior Therapy (CBT)Cognitive-behavior therapy is considered the“gold standard” in the treatment of bulimianervosa and binge eating disorder. CBT has alsoshown promise in the treatment of acute bipolardepression and for relapse prevention when givento euthymic bipolar patients for up to 2 years. Themain goals in CBT when used for targeting bothmood and eating dysregulations is to enhancemedication adherence, to improve self-esteemand self-image, and to reduce maladaptive andhigh-risk behaviors associated with the comorbid-ity (Hofmannet al. 2012).

Dialectical-Behavior Therapy (DBT)In dialectical-behavior therapy (DBT), the maintreatment target is emotional dysregulation, whichis a core symptom in both bipolar and eatingdisorders. Skillful responses based on mindful-ness, distress tolerance, emotional regulation,and interpersonal effectiveness are used to replaceineffective and maladaptive behaviors, with par-ticular focus on managing impulsivity and inter-personal difficulties.

Family-Focused Therapy (FFT)Family-focused therapy is the “gold standard” in thetreatment of eating disorders, particularly anorexianervosa, in adolescents and young adults. Severalrandomized controlled trials support the effective-ness of FFT for adults with bipolar disorder

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(Milkowitz 2008). FFT is heavily focused on pro-viding solid psychoeducation about the eating ormood disorder for the whole family. Strategies forproblemsolving andcopingwith interfamilial stressare often learned through role-playing.

Pharmacological TreatmentsAs with psychological treatments, there have beenno randomized, controlled trials of a pharmaco-logic agent specifically in the treatment of patientswith bipolar disorder and a co-occurring eatingdisorder. When treating such patients, there areseveral therapeutic goals, including (ideally)selecting an agent effective in treating both syn-dromes, or at the minimum, selecting an agent thattreats one syndrome without exacerbating theother, either by therapeutic action or side effects(McElroy et al. 2006). For example, comorbidbinge eating disorder might be an important rea-son for weight gain and obesity in patients withbipolar illness and certain mood stabilizing andantimanic agents (e.g., clozapine, olanzepine, andvalproate) may further exacerbate comorbid bingeeating behavior and weight gain. Moreover,unrecognized bipolar disorder in patients witheating disorders could lead to development ofmanic symptoms if antidepressants are used forbulimia nervosa or binge eating disorder. Thus,careful diagnosis of presenting and comorbid con-ditions is the first step in successful pharmacolog-ical management of bipolar disorder whenco-occurring with an eating disorder.

Clinically, when treating bipolar illness comor-bid with anorexia nervosa, addressing the malnu-trition along with mood stabilization is theprimary treatment goal. When treating bipolarillness associated with bulimia nervosa or bingeeating disorder, targeting mood dysregulation andachieving euthymia is often the first step inaddressing the eating symptomatology as well.

Indeed, there are mostly case reports of suc-cessful pharmacotherapy of bipolar patients with aco-occurring eating disorder. Of note, the speci-ficities of the eating disorder, namely the need forweight restoration in anorexia nervosa or need forweight loss in binge eating disorder, should guidetherapeutic decisions, as detailed below.

LithiumLithium, the oldest and best researched agent inbipolar disorder, has been tested in placebo-controlled trials in the treatment of anorexianervosa and bulimia nervosa. While patientswith anorexia receiving lithium achieved signifi-cantly greater weight gain and displayed signifi-cantly greater improvement on a measure ofinsight compared to placebo, lithium was not effi-cacious in decreasing purging episodes in bulimianervosa patients. However, there are case reportsof bipolar patients with anorexia nervosa orbulimia nervosa responding well to lithium.There have been no randomized, controlled trialsof mood-stabilizing agents in the treatment ofbinge eating disorder.

Antipsychotic MedicationAntipsychotic medication is generally notrecommended when treating bipolar illnesscomorbid with bulimia nervosa or binge eatingdisorder because of the side effect of weight gainassociated with some of those agents. Sparse datasuggests, however, that second generation anti-psychotics might attenuate preoccupation withfood and weight of anorexia nervosa. Olanzepinewas superior to placebo and resulted in rapidweight gain and reduction in obsessive symptomsin a small controlled study. Quetiapine andaripiprazole have been investigated in open-labeltrials only but might hold promise for weightrestoration and reduction of obsessive-compulsive symptoms in a carefully selectedgroup of patients with anorexia nervosa.

Antiepileptic MedicationTopiramate and zonisamide, two novel anti-epileptic agents, have demonstrated efficacy inthe treatment of bulimia nervosa, binge eatingdisorder, and obesity. Topiramate was, however,not superior to placebo in the treatment of acutebipolar mania in a number of randomized, con-trolled trials and its efficacy in treating bipolardepression has been only partially supported.There have been no randomized, controlledtrials of zonisamide in the treatment of bipolardisorder, although some anecdotal data suggest

64 Bipolar Disorder and Eating Disorders

that this agent may have thymoleptic properties.Topiramate and zonisamide might thus offerpromise as adjunctive treatments along withmood-stabilizing agents for patients with bipolardisorder and comorbid bulimia nervosa or bingeeating disorder.

AntidepressantsThough commonly used in bipolar disorder, anti-depressant medication in bipolar illness treatmentis controversial (Kendall et al. 2014). Antidepres-sant monotherapy is contraindicated in bipolarI depression, but may be used in bipolar II depres-sion. Antidepressants from various classes haveproven efficacious in bulimia nervosa and bingeeating disorder in randomized, placebo-controlledtrials and could be used alongwithmood stabilizerswith a low risk of weight gain, appetite stimulation,or binge eating exacerbation in patients with bipo-lar II disorder and comorbid bulimia nervosa orbinge eating disorder. In contrast, trials of antide-pressants in anorexia nervosa have been almostuniformly negative and antidepressants should notbe considered the first line of treatment whenaddressing bipolar disorder comorbid withanorexia nervosa (Flament et al. 2012).

In summary, in regards to pharmacotherapy,mania and anorexia nervosa might improve onlithium and certain atypical antipsychotic medica-tion; if lithium is used, regular renal and thyroidfunction monitoring is mandated. Bipolar depres-sion and binge eating or bulimia nervosa mightimprove on antidepressants along with a mood-stabilizing agent. Stabilization of affective symp-toms in patients with bipolar disorder and aco-occurring eating disorder with a mood-stabilizing agent with a low risk of exacerbatingthe eating disorder is often the important first stepwhen treating this comorbidity.

Conclusion and Future Directions

Recognition of comorbid eating disorders inpatients with bipolar disorder and vice versa hasimportant implications for treatment. In routineclinical practice, if comorbidity is suspected, theadministration of a brief self-report measure like

the EatingAttitudes Test andMoodDisorder Ques-tionnaire (Rush et al. 2008) might assist the diag-nostic process. Comprehensive evaluation ofpatients with bipolar disorder should include asystematic assessment for eating disorders and con-versely, patients with eating disorder should bequestioned about mood instability to further informtreatment selection toward agents parsimoniouslyaddressing both syndromes, if present. Of note, inpatients with history of mood dysregulation pre-senting for obesity management a thorough psy-chiatric assessment might help uncover mood andeating disorder comorbidity and further guide treat-ment decisions. Patients with bipolar disorder and aco-occurring eating disorder present with multi-dimensional problems that most commonly cannotbe treated with a single intervention and benefitfrom a team approach to management to optimizeoutcomes. Ideally, a team of professionals, includ-ing a psychiatrist, a dietician, a social worker, and atherapist would be available to provide support forthe patient and their family. Despite significantscientific progress that was made in the last30 years, future research into the epidemiology,psychology, neurobiology, and treatment ofco-occurring bipolar disorder and eating disordersis greatly needed.

Cross-References

▶Anorexia Nervosa▶Binge Eating Scale (BES)▶Binge Eating Disorder▶Bulimia Nervosa▶Cognitive Behavioral Therapy▶Eating Disorder Examination (EDE)/(EDE-Q)▶Maudsley Model of Anorexia Nervosa Treat-ment for Adults (MANTRA)

▶ Structured Clinical Interview for DSM-IV(SCID)

References and Further Reading

A.P.A. (2013).Diagnostic and statistical manual of mentaldisorders (5th ed.). Washington, DC: A.P.A.

Flament, M. F., Bissada, H., & Spettigue, W. (2012).Evidence-based pharmacotherapy of eating disorders.

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International Journal of Neuropsychopharmacology,15(2), 189–207.

Gordon, R. A. (2000). Eating disorders: Anatomy of asocial epidemic. Malden: Blackwell Publishers.

Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., &Fang, A. (2012). The efficacy of cognitive behavioraltherapy: A review of meta-analyses.Cognitive Therapyand Research, 36(5), 427–440.

Hudson, J. I., Hiripi, E., Pope, H. G., Jr., & Kessler, R. C.(2007). The prevalence and correlates of eating disor-ders in the National Comorbidity Survey Replication.Biological Psychiatry, 61(3), 348–358.

Kendall, T., Morriss, R., Mayo-Wilson, E., Marcus, E., &Guideline Development Group of the National Institutefor Health Care and Excellence. (2014). Assessmentand management of bipolar disorder: summary ofupdated NICE guidance. BMJ, 349, g5673.

McElroy, S. L., Frye, M. A., Hellemann, G., Altshuler, L.,Leverich, G. S., Suppes, T., et al. (2011). Prevalence andcorrelates of eating disorders in 875 patients with bipolardisorder. Journal of Affective Disorders, 128(3),191–198.

McElroy, S. L., Kotwal, R., & Keck, P. E., Jr. (2006).Comorbidity of eating disorders with bipolar disorderand treatment implications. Bipolar Disorders, 8(6),686–695.

Milkowitz, D. J. (2008). Bipolar disorder: A family-focusedtreatment approach. New York: Guilford Press.

Rush, A. J., First, M. B., & Blacker, D. (2008). Handbookof psychiatric measures. Arlington: American Psychi-atric Association.

Yildiz, A., Ruiz, P., & Nemeroff, C. (2015). The bipolarbook. History, neurobiology, and treatment. New York:Oxford University Press.

Body Checking Questionnaire (BCQ)

Deborah Lynn ReasRegional Department of Eating Disorders(RASP), Division of Mental Health andAddiction, Oslo University Hospital, Oslo,Norway

Definition

The Body Checking Questionnaire (BCQ) (Reaset al. 2002) is a 23-item self-report inventorydesigned to assess the frequency of body checkingbehaviors. Body checking refers to the checkingof one’s body shape, weight, or size. The BCQitems measure the frequency of body checking

behaviors, such as measuring or pinching specificbody parts (e.g., thighs, waist, upper arms, etc.),using mirrors to monitor one’s shape, wearingspecial clothes or jewelry to gauge fit, or feelingfor bone protrusion. Each BCQ item is scored on a5-point Likert-type scale ranging from 1 (never) to5 (very often); thus, higher scores indicate higherfrequency of checking (total scores range from23 to 115). The BCQ is the first instrument devel-oped specifically to assess body checking behav-iors and has been translated into several languages,including Norwegian, Italian, German, and Portu-guese. Prior to its development in 2002, assessmentoptions for body checking were scant, limited tofew behavioral items on broader measures of bodyimage or eating disorders. The emphasis onrepeated body checking as a behavioral manifesta-tion of the “core psychopathology” of eating disor-ders (i.e., the overevaluation of weight and shapeand their control) (Fairburn 2008) within cognitive-behavioral models of eating disorders has greatlystimulated clinical and research attention to thisconstruct over the past decade.

Background and Development

The initial item pool of the BCQ consisted of38 items selected based on a literature review andclinical observations (Reas et al. 2002). Contentvalidity was assessed using patient feedback andexpert panel ratings for item relevance and repre-sentativeness. To examine the factor structure ofthe original 38 items, an exploratory factor analysis(EFA) was run using 244 female undergraduatesand 15 female outpatients with DSM-IV eatingdisorders being treated at a university clinic, witha total sample mean age of 21.8 years(15–51 years). Based on a principal componentanalysis using oblique rotation, 10 items wereremoved due to cross loadings or low loadings ona factor (<0.50). Three components with eigen-values >1 were retained. An overall appearancefactor comprised of 13 items (e.g., checking reflec-tion in mirror, using clothes to gauge fit, elicitingappearance-related judgments from others)accounted for 20.6% of the total variance, a factorcomprised of 9 items linked to specific body parts

66 Body Checking Questionnaire (BCQ)

(e.g., pinching stomach, checking for cellulite onthighs) accounted for 15.5% of the variance, and anidiosyncratic checking factor consisting of 6 items(e.g., feeling for bone protrusion, checking diame-ter of wrist, using jewelry) accounted for 15.2% ofthe total variance. A higher-order factor structurewas tenable based upon correlations ranging fromr = 0.56 to r = 0.85.

In a second study, a confirmatory factor analy-sis (CFA) using maximum likelihood factor anal-ysis was run for the 28-item version of theBCQ. The second sample was comprised of149 female college students and 16 female out-patients diagnosed with a DSM-IVeating disorder(ED) recruited from a university clinic. Resultsshowed strong and significant individual itemloadings as well as loadings of subfactors to thehigher-order factor, but the model showed mar-ginal fit due to within-factor correlated measure-ment error. Five items were deleted due toredundancy, and the resulting model showedgood fit (CFI = 0.90, IFI = 0.90, RMSEA =0.076), with three subfactors that are highly cor-related. A cross-validation of the 23-item BCQwas performed in the original sample of259 study participants, and fit indices confirmedthe adequacy of the model. The final 23-item BCQwas found to have satisfactory reliability andvalidity. Internal consistency was 0.88, 0.92, and0.83 for the overall appearance, specific bodyparts, and idiosyncratic checking subscales,respectively. Test-retest reliability was 0.94, indi-cating good temporal stability.

The total BCQ score was found to correlate sig-nificantly with measures of similar constructs,including the Body Shape Questionnaire (BSQ;r = 0.86), the Body Image Avoidance Question-naire (BIAQ; r = 0.66), and the Eating AttitudesTest-26 (EAT-26; r = 0.70). Additionally, a higherfrequency of body checking was associated withnegative attitudes toward weight and shape, as wellas eating disorder pathology. The BCQ score alsodiffered significantly between nonclinical, femalecollege students (M = 56.0, SD = 16.0) andpatients (M = 82.1, SD = 18.0). College femaleswithelevatedbodyshapeconcernsasdeterminedbythe Body Shape Questionnaire scored significantlyhigher than women with fewer concerns, and

similarly, dieters (M = 71.1, SD = 17.0) scoredhigher than non-dieters among nonclinical women(M = 54.2, SD = 16.0).

Current Knowledge

Since its publication, the BCQ has been studiedincreasingly in diverse clinical and nonclinicalpopulations worldwide. Despite long-standingclinical observations of checking behavior, bodychecking received scant research attention prior toits inclusion in cognitive-behavioral models ofeating disorders in the late 1990s. Body checkingbehaviors have been described as distressing,time-consuming, “noxious” behaviors (Shafranet al. 2004), which magnify perceived imperfec-tions, serving to worsen and maintain body sizepreoccupation. A landmark experimental studyusing manipulation trials in healthy controls hassince established a causal link between the level ofbody checking and body dissatisfaction, feelingsof fatness, and body-related self-critical thinking(Shafran et al. 2007).

More recent research has provided additionalsupport for the reliability and validity of the BCQas a measure of body checking behavior. Table 1summarizes normative data and sample character-istics from a selection of larger normative studiesconducted in nonclinical, female populations.Internal consistency data is also provided whereavailable. Consistent with the study describing theinitial development of the BCQ (Reas et al. 2002),research has consistently found the BCQ to dis-tinguish between women with high versus lowweight and shape concerns, dieters versusnon-dieters, and ED patients versus controls. Forexample, Calugi et al. (2006) investigated psycho-metric properties of the Italian version of the BCQusing a larger population (N = 422), including151 patients diagnosed with a clinical ED.Significant differences were observed betweencontrols and patients (M = 62.6, SD = 24.1 vsM = 44.2, SD = 14.7). Additional analysesacross diagnostic subgroups revealed that patientswith BN scored significantly higher than patientswith AN, with the lowest scores for EDNOS(M = 71.8, SD = 23.9; M = 58.3, SD = 23.9;

Body Checking Questionnaire (BCQ), Table 1 Selected larger normative studies of the Body Checking Questionnaire(BCQ) in university women

Reaset al. (2002)

Calugiet al. (2006) Campana et al. (2013)

Lydeckeret al. (2014)

Whiteet al. (2015)

Country USA Italy Brazil USA USA

N 149a 422 546b 1,011 650

Setting University University University University University

Gender Female Female Female Female Female

Age (M, SD,range)

20.8 (16–56) 24.1 (5.9) 18–55 years 18–25 19.64 (2.23)

BMI (M, SD,range)

22.1(16.3–37.7)

20.4 (2.2) N/A N/A 22.41 (4.13)

80.3% in normal BMIrange

Total BCQ (M,SD)

56.0 (16.0) 44.2 (14.7) 48.8 (14.9) 52.1 (17.9) 47.6 (15.8)

Cronbach’s alpha

Total N/A N/A N/A 0.94 0.96

Overallappearance

0.88 0.89 0.83

Specific bodyparts

0.92 0.83 0.87

Idiosyncratic 0.83 0.86 0.70

BCQ Body Checking Questionnaire, BMI Body Mass Index, N/A not availableaPlease see Reas et al. (2002) for Study 1 which provided test development data for an additionalN = 244 college femalesbPlease see Campana et al. (2013) for Study 2 which provided data for an additional N = 404 women recruited fromweight-loss centers/gyms

Body Checking Questionnaire (BCQ) 67

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M = 64.4, SD = 23.3). A Brazilian study of546 nonclinical college women scored signifi-cantly higher than ED patients (M = 48.28,SD = 13.68 vs M = 77.75, SD = 20.33)(Campana et al. 2013). This study also showedan inverse association between age and BCQ,such that younger age was associated withmore frequent checking. In a large and ethnicallydiverse nonclinical sample by Lydecker et al.(2014) of 1,011 university women, the averagetotal score was 52.14 (17.95). Additional analysesof racial influences on the BCQ revealed lowerscores for black women (N = 260; 25.7%) com-pared to white participants or Asian participants(Ms = 47.04, 53.59, and 55.69, p <0.01).A study of 650 college females by White andWarren (2013) similarly found lower mean scoresfor black women (M = 42.16, SD = 13.34) andLatina women (M = 44.88, SD = 14.69) in com-parison to Asian-Americans. Collectively, studiessuggest racial, ethnic, or cultural differences inbody checking behavior, and this represents aworthwhile area of further investigation.

Current Controversies

Several, but not all, factor analytic studies havesupported the original structural model purportinga higher-order factor with three related subfactors.Studies from Italy (Calugi et al. 2006), Brazil(Campana et al. 2013), and Norway haveprovided empirical support for the original model(Brazil, RMSEA = 0.064, CFI = 0.99; Italy,RMSEA = 0.056, CFI = 0.97, IFI = 0.97; Norway,RMSEA = 0.056, CFI = 0.91, NFI = 0.90).However, in a racially diverse sample of 1,011college women, Lydecker et al. (2014) identifiedan alternative three-factor structure that deviatedfrom the original structure. Specifically, one factorwas labeled “Feeling for fat” and contained sevenitems appearing related to feeling or checkingbody fat (i.e., “I rub or touch my thighs whilesitting to check for fatness”). A second factorwas labeled “Reassurance” and consisted of10 items that were described as behaviors to reas-sure oneself that the body had not become larger(“I check the diameter of my legs to make sure

68 Body Checking Questionnaire (BCQ)

they are the same size as before”). A third factor,“Thin ideal” consisted of six items and wasdescribed as body checking which appearedrelated to the pursuit of a thin ideal (e.g., “I com-pare myself to models on TV or magazines”).White et al. (2015) found initial evidence of analternate two-factor solution with items tappingvisual checking (e.g., “I check my reflection inglass doors or car windows”) and behavioralchecking (e.g., “I ask others about their weightor clothing size so I can compare my own weight/size”). Additional research is necessary to repli-cate these findings. Overall, however, the evi-dence of a higher-order model and the relativebrevity of the BCQ support the utility ofinterpreting and using the total score for mostresearch and clinical purposes.

Limitations of the BCQ are important to con-sider. The BCQ was not designed nor developedfor the assessment of male-specific body checkingbehaviors. Male body image concerns related to adrive for muscularity, for example, were notincluded during the development of the itempool. Additionally, the Body Checking Question-naire provides an assessment of body checkingbehaviors, rather than body checking cognitions,motivation, or various attitudinal aspects ofchecking behavior. Further, the items are wordedto assess frequency (never to very often) ratherthan the duration of body checking behaviors; inother words, the BCQ does not assess the amountof time (seconds, minutes, hours) spent engagedin specific body checking behaviors, which isvaluable information in clinical settings. Lastly,and as noted above, emerging data suggests racial,ethnic, or cultural differences in body checkingbehavior, as well as the potential effects of factorslike age and BMI on body checking in women.Sample and setting differences should necessarilybe taken into account in the interpretation of dataand the comparison of findings across studies.

Future Directions

The Body Checking Questionnaire is a 23-itemself-report measure of body checking behaviors.The BCQ can be administered in both group and

individual settings and requires approximately5–10 min. Nearly 15 years since its publication,the BCQ is increasingly used in clinical settingsand research protocols to investigate bodychecking behaviors in diverse settings andpopulations. The assessment and monitoring ofbody checking are recommended (Reas andGrilo 2004), and body checking is an importanttherapeutic target within behavioral (e.g., mirrorand in vivo exposure) and cognitive-behavioraltherapies for eating disorders. Future studiesinvolving the functional neuroanatomy of bodychecking are poised to advance our knowledgeof neurological correlates of this behavior.

Cross-References

▶Assessment▶Body Image

References and Further Reading

Calugi, S., Dalle Grave, R., Ghisi, R., & Sanavio,E. (2006). Validation of the body checking question-naire in an eating disorders population. Behaviouraland Cognitive Psychotherapy, 34(2), 233–242.

Campana, A. N., Swami, V., Onodera, C. M., da Silva, D.,& Tavares, C. Mda. (2013). An initial psychometricevaluation and exploratory cross-sectional study of thebody checking questionnaire among Brazilian women.PLoS One, 8(9), e74649. doi:10.1371/journal.pone.0074649.

Fairburn, C. G. (2008). Cognitive behavior therapy andeating disorders. New York: Guilford Press.

Lydecker, J. A., Cotter, E. W., & Mazzeo, S. E. (2014).Body checking and body image avoidance: Constructvalidity and norms for college women. Eating Behav-iors, 15(1), 13–16. doi:10.1016/j.eatbeh.2013.10.009.

Reas, D. L., & Grilo, C. M. (2004). Cognitive-behavioralassessment of body image disturbances. Journal ofPsychiatric Practice, 10(5), 314–322.

Reas, D. L., Whisenhunt, B. L., Netemeyer, R., &Williamson, D. A. (2002). Development of the bodychecking questionnaire: A self-report measure of bodychecking behaviors. International Journal of EatingDisorders, 31(3), 324–333.

Shafran, R., Fairburn, C. G., Robinson, P., & Lask,B. (2004). Body checking and its avoidance in eatingdisorders. International Journal of Eating Disorders,35(1), 93–101. doi:10.1002/eat.10228.

Shafran, R., Lee, M., Payne, E., & Fairburn, C. G. (2007).An experimental analysis of body checking. Behaviour

Body Distortion: Perceptual Measurement of Body Image Disturbance 69

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Research and Therapy, 45(1), 113–121. doi:10.1016/j.brat.2006.01.015.

White, E. K., & Warren, C. S. (2013). Body checking andavoidance in ethnically diverse female college students.Body Image, 10(4), 583–590. doi:10.1016/j.bodyim.2013.04.003.

White, E. K., Claudat, K., Jones, S. C., Barchard, K. A., &Warren, C. S. (2015). Psychometric properties of thebody checking questionnaire in college women. BodyImage, 13, 46–52. doi:10.1016/j.bodyim.2014.12.004.

Body Distortion: PerceptualMeasurement of Body ImageDisturbance

Leah Boepple, Emily Choquette andJ. Kevin ThompsonDepartment of Psychology, University of SouthFlorida, Tampa, FL, USA

Synonyms

Body size overestimation

Definition

Body size distortion, also known as body sizeoverestimation, is the difference between a per-son’s perceived and actual body size.

History

Overview. Body image disturbance is comprisedof two components, perception and attitude. Theperceptual component is commonly referred to asbody size distortion but is more accurately definedas the overestimation of size of a body site.

Bruch (1962) was the first person to proposebody size overestimation as a pathognomonic fea-ture of anorexia nervosa. In subsequent years,empirical studies provided mixed support for thisfinding. Slade and Russell (1973) reported that theprevalence of body size overestimation washigher in female participants with anorexianervosa than healthy controls. However, size

overestimation did not occur when participantsviewed physical objects, and researchers soonfound that a variety of factors affected what wasthought to be a purely “perceptual” dimension ofbody image.

For instance, Crisp and Kalucy (1974) foundthat demand characteristics affected size over-estimation in individuals with anorexia nervosa.Further research suggested that manipulatinginstructions altered the degree to which bodysize was overestimated. Additionally, a relation-ship exists between actual body size and body sizeoverestimation, such that smaller individuals tendto overestimate their bodies to a greater degreethan larger individuals. Indeed, Penneret al. (1991) found that when eating disorderedindividuals were matched on actual body size witha group of non-eating disordered individuals,levels of size overestimation were the same forboth groups. Perception of calorie intake also hasbeen found to impact body size estimation.Thompson et al. (1993) manipulated perceivedcaloric intake – participants who believed theyconsumed a high-calorie milk shake significantlyoverestimated their body size compared to partic-ipants who believed they consumed a low-caloriemilk shake.

During the 1980s and 1990s, research shiftedfrom acceptance that the perceptual componentalone contributed to body size estimation to inves-tigating whether more subjective componentswere involved, such as affect and attitude. Thisshift in focus produced studies indicating thatsubjective ratings of body image were morestrongly connected to clinical outcomes than per-ceptual ratings (Cash and Deagle 1997).

In the mid-1990s, Gardner and colleaguesstimulated a new wave of interest by using signaldetection methodology to measure body size esti-mation. This method greatly increased the accu-racy of body size estimation, and established, dueto the lack of differences in sensitivity to sensoryinformation detection between individuals witheating disorders and controls that body size over-estimation is largely caused by nonsensory, affec-tive factors (see Gardner 2011).

Measurement. There are two broad catego-ries of measurement strategies. First, techniques

70 Body Distortion: Perceptual Measurement of Body Image Disturbance

referred to as “body site” estimation techniquesmeasure one’s accuracy of perception of the sizeof specific body sites of the individual. An earlymethod called the visual size estimation apparatus(Slade and Russell 1973) requires individuals toadjust the distance between two lights until theymatch four body sites (face, chest, waist, andhips). A similar approach is the adjustable lightbeam apparatus (Thompson and Spana 1988).

The second category is referred to as “wholeimage” techniques. In whole image techniques,participants adjust the size of a self-image until itmatches their perceived body size. An early exam-ple of this approach was the distorted photographtechnique, in which participants select the imagethat corresponds to their perceived body size froma slide projector displaying images with varyinglevels of distortion. In recent years, researchersbegun to utilize up-to-date technology, such asdigital photographs (for a description of these,see Gardner 2011).

Reviews of these methods were rather criticalof the strategies, finding a good deal of variabilityin findings across assessment techniques andmethod limitations (Farrell et al. 2005). Forinstance, one source of variability was found toexist in the method of presentation of stimuli (i.e.,whether individuals were required to increase thesize of images or decrease the size of the stimuli tomatch perceived body size). It was found thatdecreasing images produced an overestimationof body size, while the opposite effect was foundwhen images were increased. This phenomenon iscalled “error of anticipation.” Researchers devel-oped a method (constant stimuli) to mitigate thisissue. In this method, individuals view distortedimages of themselves and identify if the image hasbeen altered (made larger or smaller) or remainsunaltered. Careful evaluation is given to the “pointof subjective equality” or the point at which 50%of images are perceived as larger or smaller. Thismeasurement also allows researchers to ascertainthe amount of distortion required for individualsto reliably detect change.

Measurement techniques have historicallyfailed to account for sensory (i.e., visual systemresponses) and nonsensory components (i.e., thebrain’s interpretation of visual information) of

body size estimation. Signal detection methodsallow for distinguishing between these compo-nents. These approaches require individuals toview an array of distorted self-images and indicatewhether an image is altered. Correct and incorrectresponses are recorded after each trial. Collectingthese data points allows for the calculation of“sensory sensitivity” (i.e., the ability to detectdistortion) and “response bias” (i.e., the tendencyto interpret the image as distorted). These methodsallowed researchers to conclude that body sizeoverestimation in individuals with eating disor-ders is related to nonsensory and not sensorycomponents.

Constant stimuli techniques require large num-bers of trials to accurately measure body size over-estimation. To address this concern, Gardner andcolleagues developed themethod of adaptive probitestimation. This technique is similar to constantstimuli; however, adaptive probit uses computersoftware, which requires fewer trails (for a thor-ough explanation, see Gardner and Boice 2004).

Current Knowledge and Controversies

As outlined above, a large body of research sug-gests that the initial belief that perception under-lies body size estimation is incorrect.Contemporary work (Kneipp et al. 2011) evensuggests that emotions like anger/irritability,avoidance, and impaired self-reference predictdegree of body size estimation in a trauma popu-lation. Greater clarity of emotion is linked to asmaller degree of body size overestimation,implying that affect has a role in body size esti-mation. Body size overestimation is linked to alack of clinical progress in individuals with eatingdisorders and decreases as symptoms improve,implying, due to the lack of stability, again indi-cating the involvement of subjective factors.

Overall, the literature suggests body size esti-mation is an amalgamation of cognitive, affective,and subjective mechanisms. The conjecture thatperception is responsible for these distortions isnot substantiated by evidence. However, despitethe literature, the “perceptual” component is stillcommonly cited, with researchers continuing to

Body Dysmorphic Disorder 71

endorse perceptual deficits, while the literaturesuggests actually overvaluation of thinness andaffective/cognitive factors largely contribute tosize estimation ratings.

B

Future Directions

Researchers continue to investigate the role of per-ception in body size estimation; however, much ofthe focus currently in the field of body image is onthe subjective nature of the phenomenon. From aclinical perspective, it is important to take a com-prehensive assessment approach, including themeasurement of multiple dimensions of bodyimage, including subjective, affective, cognitive,behavioral, and perceptual. In addition, if one isinterested in the perceptual component, it is impor-tant to potentially use more than one such strategyand also to adhere to established research method-ologies (e.g., Gardner 2011).

Cross-References

▶Body Checking Questionnaire (BCQ)▶Body Dysmorphic Disorder▶Body Image

References and Further Reading

Bruch, H. (1962). Perceptual and conceptual disturbancesin Anorexia Nervosa. Psychosomatic Medicine, 24(2),187–194.

Cash, T. F., & Deagle, E. A. (1997). The nature and extent ofbody-image disturbances in anorexia nervosa and bulimianervosa: A meta-analysis. International Journal of EatingDisorders, 22(2), 107–126. doi:10.1002/(SICI)1098-108X(199709)22:2<107::AID-EAT1>3.0.CO;2-J.

Crisp, A. H., & Kalucy, S. (1974). Aspects of the percep-tual disorder in anorexia nervosa. British Journal ofMedical Psychology, 47(4), 349–361.

Farrell, C., Lee, M., & Shafran, R. (2005). Assessment ofbody size estimation: A review. European Eating Dis-orders Review, 13(2), 75–88. doi:10.1002/erv.622.

Gardner, R. M. (2011). Perceptual measures of body imagefor adolescents and adults. In T. F. Cash & L. Smolak(Eds.), Body image: A handbook of science, practice,and prevention (2011th ed., Vol. 2, pp. 146–153). NewYork: Guilford Press.

Gardner, R. M., & Boice, R. (2004). A computer programfor measuring body size distortion and body

dissatisfication. Behavior Research Methods, Instru-ments, & Computers, 36(1), 89–95.

Kneipp, L., Kelly, K., &Wise, I. (2011). Trauma symptomsas predisposing factors for body image distortion. Indi-vidual Differences Research, 9(3), 126–137.

Penner, L., Thompson, J. K., & Coovert, D. L. (1991). Sizeoverestimation among anorexics: Much ado about verylittle? Journal of Abnormal Psychology, 100, 90–93.

Slade, P. D., & Russell, G. F. M. (1973). Awareness ofbody dimensions in anorexia nervosa: Cross-sectionaland longitudinal studies. Psychological Medicine,3(02), 188–199. doi:10.1017/S0033291700048510.

Thompson, J. K., & Spana, R. E. (1988). The Adjustablelight beam for assessment of size estimation accuracy:Description, psychometrics, and normative data. Inter-national Journal of Eating Disorders, 7, 521–526.

Thompson, J. K., Coovert, D. L., Pasman, L. N., & Robb,J. (1993). Body image and food consumption: Threelaboratory studies of perceived calorie content. Inter-national Journal of Eating Disorders, 14(4), 445–457.

Body Dysmorphic Disorder

Sharon Ridley1 and Karina Allen2,3,41Department of Health in Western Australia,Centre for Clinical Interventions, Perth, WA,Australia2The Eating Disorders Service, MaudsleyHospital, South London and Maudsley NHSFoundation Trust, London, UK3Institute of Psychiatry, Psychology andNeuroscience, King’s College London, London,UK4School of Psychology, The University ofWestern Australia, Crawley, WA, Australia

Definition and Diagnosis

Body dysmorphic disorder (BDD) is a psychiatricillness characterized by extreme preoccupationand distress with a part, or parts, of one’s bodybelieved to be defective in some way. This“defect” is often imperceptible to others or, ifnoticeable, only very slight. Individuals withBDD believe themselves to be immensely unat-tractive and may use such terms to describe them-selves as “ugly,” “deformed,” and “grotesque.”Asa result of their perceived ugliness, people withBDD will go to great lengths to conceal or modify

72 Body Dysmorphic Disorder

their appearance (e.g., excessive grooming,camouflaging) or avoid situations altogether,fearing negative judgment from others if their“true selves” were to be revealed. Concerns areoften focused on parts of the face (e.g., skin, nose,teeth, lips, chin) but can be about any body part orarea (e.g., breasts, genitals, hairline, symmetry,proportions). People may be concerned aboutmultiple body parts at the same time, or theirpreoccupation may shift from one body part toanother. Insight regarding body dysmorphicbeliefs can range from good to poor (overvaluedideation) to absent (delusional). It is very commonfor sufferers to have sought out cosmetic proce-dures such as plastic surgery, dentistry, or derma-tology to alter their physical appearance beforepresenting for psychological assistance regardingtheir body image.

Current DSM-5 Diagnostic Criteria for Body DysmorphicDisorder 300.7 (F45.22)

A. Preoccupation with one or more perceived defects or flawsin physical appearance that are not observable or appearslight to others

B. At some point during the course of the disorder, theindividual has performed repetitive behaviors (e.g., mirrorchecking, excessive grooming, skin picking, reassuranceseeking) or mental acts (e.g., comparing his or herappearance with that of others) in response to the appearanceconcerns

C. The preoccupation causes clinically significant distress orimpairment in social, occupational, or other important areasof functioning

D. The appearance preoccupation is not better explained byconcerns with body fat or weight in an individual whosesymptoms meet diagnostic criteria for an eating disorder

Individuals with BDD are more than just dis-satisfied by their appearance; they are signifi-cantly distressed or impaired by their disorder.Psychosocial functioning and quality of life tendto be poor. At the milder end of the spectrum,people may continue to function but with greatdifficulty, while at the more severe end, peoplemay be completely housebound. There is anincreased risk of suicide and some people willrequire psychiatric hospitalization.

BDD is classified as a somatoform disorder inDSM-5. In the International Classification of Dis-eases (ICD-10), BDD is subsumed under hypo-chondriacal disorder. However experts in the field

argue that there are important differences betweenhypochondriasis and BDD, which merit their clas-sification as distinct disorders.

It is important to differentiate BDD from theappearance preoccupation and distorted bodyimage that also characterizes the eating disorders.This becomes challenging when the appearanceconcerns are about weight or shape (i.e., a womanwho worries about her supposedly large thighsand proceeds to diet and exercise to make themslimmer). Katherine Phillips, a renowned authoron BDD, suggests that if a person’s concernsfocus on the hips, stomach, or thighs but notoverall body weight, and the person does nothave notably abnormal eating behavior, a diagno-sis of BDD is appropriate. People with BDD willtypically have other more specific appearanceconcerns (e.g., facial features) to assist the diag-nosis. If a person’s primary concern is with bodyweight/shape and being/becoming fat, and theyalso meet other required criteria for an eatingdisorder, an eating disorder should be diagnosed.Diagnosis is most difficult when there are appear-ance concerns in the context of abnormal eatingpatterns, but full criteria for anorexia or bulimianervosa are not met, as in the case of other spec-ified feeding and eating disorders (OSFED). Peo-ple can have both an eating disorder and BDDtogether; true comorbidity of BDD and eatingdisorder occurs when a person is preoccupied bya slight defect in their appearance unrelated toweight and shape and also meets criteria for aneating disorder.

There are validated screening measures toassist the clinician in diagnosing BDD accurately.The Yale- Brown Obsessive-Compulsive Scalefor BDD (YBOCS-BDD) is a 12-item, semi-structured, clinician-rated scale of symptomseverity and has become the gold standard forassessing severity of BDD as well as treatmentoutcome in randomized controlled trials.

Historical Background

Body dysmorphia was first described in 1891 bythe Italian psychiatrist Enrico Morselli. Morselliused the term “dysmorphophobia” to refer to

Body Dysmorphic Disorder 73

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significant worries and complaints about an imag-ined physical deformity, with associated distress,fear, and anxiety in the sufferer. Subsequent ref-erences to dysmorphophobia occur across the1900s. The earliest well-documented case is ofthe so-called “Wolf Man” because he also dreamtof white wolves outside his window. The WolfMan was described by Freud (1959) and Bruns-wick (1971) as being preoccupied with imagineddefects of his nose and obsessively checking hisnose using mirrors. Andy Warhol (1928–1987)was also preoccupied by his nose and is consid-ered to be a possible contemporary case of BDD.

Dysmorphophobia was included in DSM-III in1980 as an example of an atypical somatoformdisorder. Thus, it has been officially recognizedfor as long as bulimia nervosa (also included forthe first time in DSM-III). The DSM-III definitionof dysmorphophobia was of an individual whowas preoccupied with an imagined defect in phys-ical appearance, out of proportion to any actualphysical abnormality. The term was changed toBDD with the 1987 release of DSM-III-R.

Both DSM-III-R and DSM-IV kept BDD in thesomatoform disorder category and continued todefine the disorder by preoccupation with animagined defect in appearance, out of proportionto any actual physical anomaly. The major changefrom DSM-III-R to DSM-IV was the shift fromviewing BDD as incompatible with a diagnosis ofanorexia nervosa or delusional symptoms(DSM-III-R), to being a condition that couldco-occur with these disorders so long as symp-toms were not better accounted for by them(DSM-IV). Thus, from 1994, BDD could be diag-nosed alongside eating disorders and other psy-chiatric conditions if warranted. DSM-IV alsoadded the requirement that symptoms be associ-ated with clinically significant distress orimpairment.

The 2013 release of DSM-5 saw BDD move tothe new category of “obsessive-compulsive andrelated disorders.”DSM-5 also added the criterionof repetitive behaviors or mental acts performed inresponse to preoccupations with perceived defectsor flaws in appearance. Further, the “with muscledysmorphia” specifier was introduced. It is inter-esting to note that muscle-related concerns are

increasingly recognized as a feature of male eatingdisorders, which makes it important to distinguishbetween eating disorder psychopathology andBDD in males with a muscle focus.

Current Knowledge

Research into BDD is still in its relative infancy.However, available data suggest that 0.7–2.4% ofadults will experience BDD each year. For ado-lescents and young adults, prevalence rates arehigher and range from 2.2% to 13.0% (Veale andNeziroglu 2010). In contrast to eating disorders, asimilar number of men and women are affected.

The prevalence of BDD is greater in cosmeticsurgery settings (3.0–18.0%) and in psychiatricpopulations (3.0–5.0% for outpatients and12.0–15.0% for inpatients). There is considerableoverlap with eating disorders. Of those with BDD,4.0–22.0% may be expected to also meet thecriteria for an eating disorder. Conversely, ofthose with an identified eating disorder,39.0–45.0% may be expected to meet the criteriafor BDD.

Specific risk factors for BDD are largelyunknown. There is evidence to support a familialassociation between BDD and obsessive-compulsive disorder, suggesting shared geneticor environmental pathways for these disorders.Childhood adversity, an anxious/avoidant temper-ament, and poor parental bonding or insecureattachment have been identified as possible non-specific risk factors, relevant to BDD as well asother psychiatric disorders, including eating dis-orders. It has been suggested that aesthetic sensi-tivity (awareness and appreciation of beauty) maybe a specific risk factor for BDD, but moreresearch is needed to evaluate this possibility.

Key theoretical approaches to BDD includeneurobiological, learning, and cognitive-behavioral perspectives. These perspectives arecompatible, and all acknowledge a likely interac-tion between biological and environmentalexposures.

Neurobiological perspectives emphasize alikely role of the serotonergic system in BDD. Theserotonergic system is also implicated in other

74 Body Dysmorphic Disorder

obsessive-compulsive spectrum disorders,although whether serotonergic dysfunction is acause or consequence of BDD symptoms isunclear. Specific fronto-subcortical circuits arealso thought to be more active in individualswith BDD than in healthy controls, but the mech-anisms of action are not well understood.

Learning theory models may be seen as a pre-cursor to current cognitive-behavioral perspectiveson BDD. These models emphasize a combinationof operant conditioning and social learning in thedevelopment of BDD symptoms. For example, achild who is regularly praised for their appearancemay come to view appearance as a key determinantof worth or acceptability. From this background,classic or evaluative conditioning may result inlinks between appearance-related stimuli and neg-ative emotional or physiological responses. If ateenager is teased about their acne (stimuli), theymay come to experience anxiety and/or disgustwhen thinking about or viewing their face(response). The key difference between normativeappearance concerns and BDD is that, with BDD,conditioning processes result in marked distressand compulsive or avoidant behaviors that main-tain distress over time. For the teenager with acne,these behaviors could include compulsivelychecking for spots or completely avoiding mirrors.While these behaviors reduce distress in the shortterm, they do not allow the cause of distress to bechallenged or reappraised and ultimately maintaindifficulties over time.

Cognitive-behavioral models of BDD extendlearning theory approaches by placing greateremphasis on the role of cognition (beliefs aboutappearance) as well as biases in attention. Thesemodels emphasize the tendency for individualswith BDD to see themselves as an aestheticobject, i.e., to hold a visual image of themselvesas seen by other people. They also highlight therole of appearance-related assumptions or deep-seated beliefs about the importance of appearance.These may include beliefs such as “I must lookperfect to be accepted” or “If anyone sees the ‘realme’ they will be repulsed.” These assumptionsdrive the person to modify or conceal their

“ugly” appearance, avoid activities in whichtheir feature might be on display, check theirbody excessively, and seek reassurance fromothers. The tendency for individuals with BDDto hold a visual image of their body from anexternal perspective also drives heightened levelsof self-directed attention and self-consciousness.Negative appraisal of their image may producefeelings of shame, disgust or depression, and aruminative style replete with negative automaticthoughts that keep the person preoccupied withtheir perceived appearance flaws. This heightenedawareness and preoccupation can distort percep-tions and draw attention to minor imperfectionsthat would otherwise go unnoticed. This, togetherwith avoidance and checking behaviors, meanthat faulty appearance-related assumptions arecontinually reinforced.

Consistent with the cognitive-behavioral model,individuals with BDD spend more time looking atthe parts of their body they rate negatively thantheir counterparts without BDD. Rumination isalso well documented: individuals with BDD tendto fixate on perceived flaws and/or criticize them-selves for being unable to “fix” their flaws.

There is overlap between the cognitive-behavioral model of BDD and that of eating dis-orders. For eating disorders, cognitive-behavioralperspectives propose that overevaluation of theimportance of weight and shape is key to thepsychopathology of the disorders. This over-evaluation has paralleled with the appearanceassumptions seen in BDD. Moreover, cognitive-behavioral models of eating disorders proposethat body checking or avoidance may serve tomaintain weight and shape concerns, and, aswith BDD sufferers, individuals with eating dis-orders show biased attention toward the parts ofthe body they most dislike.

Current Treatment Approaches

The current evidence-based treatments for BDDinclude cognitive-behavioral therapy (CBT) andpharmacological treatment. Treatments that do

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not work include cosmetic interventions aimed ataesthetically modifying the feature of concern.Patients with BDD typically remain unhappywith their appearance perceiving the cosmeticintervention to have not worked or their BDDconcerns shift focus to another body part.

Engagement and motivation is a crucial part oftreatment. Clients typically arrive for treatmentfocusing on their appearance as the problem, andthe therapist’s task is to educate them about theprocesses involved in maintaining their preoccu-pation and distress via a shared formulation. Inthis regard, there is overlap with the early stages ofeating disorder treatment, where clients may pre-sent as ambivalent about change or unwilling togive up goals around weight loss.

CBT attempts to alleviate distress by targetingthe attentional biases, negative thought patterns,and unhelpful behaviors that maintain the preoc-cupation with one’s body and reinforceappearance-related assumptions.

Attentional retraining and mindfulness skillsare useful to help the client redirect their atten-tion away from their appearance and internalruminations. Behavioral experiments and expo-sure with response prevention are used to helpclients approach feared situations without safetybehaviors. For example, a behavioral experimentmay involve testing out the prediction “The shopassistant will stare at my acne and make a rudecomment about it,” to see if the feared outcomeactually happens. The client would be encour-aged to carry out the experiment without safetybehaviors (e.g., heavy makeup) and observewhat actually happens and reflect on this (e.g.,“They served me normally and did not mentionmy acne – perhaps it is not as noticeable asI think”). Exposure with response preventioninvolves gradually exposing the “defect” inplaces or situations that would normally beavoided and resisting the urge to engage in anycompulsive behaviors related to the defect (e.g.,using slightly lessmakeup over time).With repeatedexposure, the client becomes more comfortable insuch situations and can drop the compulsive behav-iors altogether.

Cognitive restructuring is a process of noticingnegatively biased thoughts and generating morerational, balanced ways of thinking. Clients learnthat BDD thoughts and appearance assumptionsare not necessarily true and may be replaced withmore rational thoughts that are more helpful. Overtime, with lots of practice thinking and behavingin a more functional way, clients will have newexperiences that start to weaken their convictionin their old appearance-related assumptions, andappearance will hold less importance in their self-evaluation. Other CBT strategies that are helpfulinclude mirror retraining, relaxation training,habit reversal, and imagery rescripting.

While the focus of CBT differs for BDD andeating disorders, the treatment techniques are sim-ilar. Cognitive restructuring and behavioral exper-iments also feature in CBT for eating disorders, aswell as other psychiatric disorders.

In terms of pharmacological treatment, selec-tive serotonin reuptake inhibitors (SSRIs) are cur-rently the medications of choice for BDD. SSRIsare a class of antidepressants with anti-obsessional properties that increase the level ofserotonin in the brain. Appearance-related preoc-cupations, as well as associated behaviors such ascompulsive mirror checking, usually diminishwith SSRI treatment and insight often improves.However, improvement is usually gradual withSSRIs taking up to 12–16 weeks to take full effect.It is extremely important that people (a) achieve ahigh enough dose and (b) remain on this thera-peutic dose for long enough. The dosage requiredto treat BDD can sometimes exceed therecommended dose range; hence, medicationshould be carefully monitored by a physician forresponse and side effects. When treating mildercases of BDD, it may be preferable to use a psy-chological treatment approach before prescribingmedication. In more severe cases, the patient maybe too severely depressed or anxious to engage inany meaningful therapy and may need to bestarted on an SSRI initially. It is common for acombination of psychological and pharmacologi-cal approaches to be employed. Again, this mir-rors approaches taken with eating disorders,

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particularly bulimia nervosa, where fluoxetine(an SSRI) may help complement psychologicaltreatment for bulimia nervosa.

Future Directions

There is a real need for additional research onrisk factors for BDD, as well as for clinical trialscomparing different treatment approaches (e.g.,CBT vs. medication vs. combined exposure plusmedication). There is also much to learn abouthow BDD and eating disorders interrelate,including optimal treatment approaches whenboth disorders are present. For example, it isunclear if BDD and eating pathology should betreated together or sequentially or whetherresponse to eating disorder (or BDD) treatmentis impacted by BDD (or an eating disorder) alsobeing present.

Cross-References

▶Body Distortion: Perceptual Measurement ofBody Image Disturbance

▶Obsessive-Compulsive Disorder and EatingDisorder Comorbidity

References and Further Reading

Corove, M. B., & Gleaves, D. H. (2001). Body dysmorphicdisorder: A review of conceptualizations, assessment,and treatment strategies. Clinical Psychology Review,21, 949–970.

Dingemans, A., van Rood, Y. R., de Groot, I., & van Furth,E. F. (2012). Body dysmorphic disorder in patients withan eating disorder: Prevalence and characteristics. Inter-national Journal of Eating Disorders, 45, 562–569.

Grant, J. E., Won Kim, S., & Eckert, E. D. (2002). Bodydysmorphic disorder in patients with anorexia nervosa:Prevalence, clinical features, and delusionality of bodyimage. International Journal of Eating Disorders, 32,291–300.

Phillips, K. A. (2005). The broken mirror –Understandingand treating body dysmorphic disorder, revised andexpanded edition. New York: Oxford University Press.

Phillips, K. A., Hollander, E., Rasmussen, S. A.,Aronowitz, B. R., DeCaria, C., & Goodman, W. K.

(1997). A severity rating scale for body dysmorphicdisorder: Development, reliability, and validity of amodified version of the Yale-Brown obsessive compul-sive scale. Psychopharmacological Bulletin, 33(1),17–22.

Veale, D., & Neziroglu, F. (2010). Body dysmorphicdisorder – A treatment manual. West Sussex: Wiley.

Body Image

Victoria A. Mountford1,2 and Antonia Koskina31Eating Disorders Unit, South London andMaudsley NHS Foundation Trust, London, UK2Eating Disorders Unit, Institute of Psychiatry,Psychology and Neuroscience, King’s CollegeLondon, London, UK3West London Mental Health Trust, London, UK

Definition

Body image can be seen as the perceptions andattitudes one holds toward one’s own body, espe-cially, but not exclusively, one’s physical appear-ance (Cash and Pruzinsky 2004). It is amultidimensional concept and encompasses:

1. Beliefs about appearance, including memoriesand assumptions

2. Feelings about the body, including its size andshape

3. Perception of the body and the sense ofembodiment

Body image is thought to be fluid and dynamicin nature and can be influenced by factors such asinterpersonal experience, personality, and socialand cultural norms.

Body image disturbance is defined as a “dis-turbance in the way in which body weight orshape is experienced, with undue influence ofbody weight or shape on self-evaluation or persis-tent lack of recognition of the seriousness of cur-rent low body weight” (DSM-5; AmericanPsychiatric Association 2013) and is a central

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diagnostic feature of anorexia nervosa, bulimianervosa, and eating disorders not otherwise spec-ified (EDNOS). Research into body image distur-bance generally distinguishes between twomodalities, which are separate but relatedconcepts:

1. Body image distortion, which occurs when anindividual experiences difficulty in perceivingor estimating their body size accurately

2. Body image dissatisfaction, which relates tocognitive-affective components of bodyimage and manifests as a negative subjectiveevaluation of one’s physical body

Historical Background

Body image has been conceptualized within avariety of models over the pastcentury – including genetic, neuroscientific, cog-nitive behavioral, sociocultural, and feminist. Theterm itself was coined in 1935 by Paul Schilder, anAustrian neurologist and psychoanalyst, in hisbook The Image and Appearance of the HumanBody. This early research into body image focusedon experiences of depersonalization (the sense ofalienation from one’s body) in individuals withschizophrenia. Other early influences to bodyimage theory came from surgeons’ accounts ofunusual body experiences in patients with ampu-tations, otherwise known as a “phantom limbsyndrome.” This phenomenon played a signifi-cant role in understanding how body perceptionis organized in the brain.

Body image distortion was first recognized ascentral to the psychopathology of eating disordersby Hilde Bruch in 1962. Body size overestimationhas generated a large amount of research over theyears; however, not all individuals experiencebody image distortion. In addition, it remainsunclear whether body image distortion is causedby a fundamental perceptual deficit or if thecognitive-affective components of body dissatis-faction indirectly exert influence upon sizeestimations.

In the present day, body image dissatisfactionis commonly reported in those with eating disor-ders and is a central diagnostic feature of anorexianervosa, bulimia nervosa, and atypical cases(American Psychiatric Association 2013). How-ever, early case descriptions of restrictinganorexia nervosa, together with evidence fromnon-Western cultures, suggest that not all individ-uals experience body dissatisfaction. For exam-ple, early nineteenth century clinical descriptionsof anorexia nervosa do not mention this as aclinical feature of the disorder. As such it appearsthat sociocultural factors, such as the internaliza-tion of the thin ideal in modern western cultures,may be associated with increased body imagedissatisfaction in individuals with eating disor-ders. Because of such factors, body image dissat-isfaction is also widely reported in womenwithout an eating disorder, to the extent that ithas been termed “normative discontent” in theresearch literature. Males with and without eatingdisorders may also experience body image distur-bance, although it is reported more frequently byfemales.

Current Knowledge

OverviewCognitive behavioral models of eating disorderscite the overevaluation of one’s body weight andshape and their control as the “core psychopathol-ogy” from which most other aspects of eatingdisorders arise, e.g., fear of fatness and dietaryrestraint (Fairburn 2008). While body image dis-turbance is not in itself a major risk factor in thedevelopment of eating disorders, body image dis-satisfaction is a predictor of dieting and restrictiveeating behaviors, which in turn appear to be aprecursor to the onset and maintenance of eatingdisorders. Body image disturbance has beenfound to be a predictor of symptom severity andone of the last aspects of psychopathology tochange during recovery. Furthermore, it may con-tribute to treatment dropout and appears to be asignificant predictor of relapse.

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Behavioral manifestations of a negative bodyimage arise in avariety ofways in individualswithan eating disorder and include body checking,body avoidance, body comparison, and body dis-play. Body checking involves repeated and ritual-istic monitoring and/or critical scrutiny of one’sbody, shape, and weight, e.g., frequent weighing,looking in themirror,measuring parts of the body,or using the fit of clothes to determine change inbody size. Body avoidance is the tendency toavoid exposure to viewing one’s body, e.g., bycoveringmirrors, refusing to beweighed, orwear-ing baggy clothes to conceal shape. Body com-parison involves the judgment of one’s own sizeor shape via repeatedly examining others’ bodies,and body display is the act of deliberately pre-senting one’s body size and shape, e.g., wearingtight clothing. These behaviors appear directlyrelated toweight and shape concerns and are asso-ciated with the severity of symptoms. Bodychecking and comparison behaviors may also actas an independentmaintaining factor of the eatingdisorder, by creating attention biases and increas-ing drive for thinness or by acting as a “safetybehavior.”

Social media have further increased opportu-nities for preoccupation with appearance. Youngpeople in particular may use many photo-sharingsites, photoshop their own pictures, or excessivelycompare themselves to friends or celebrities.Fitness- or diet-related apps may reinforce bodyimage dissatisfaction.

AssessmentBody image disturbance is multifaceted and it isimportant to assess and formulate difficulties care-fully when planning treatment. A thorough clini-cal interview incorporating personal history ofweight and shape concerns is vital in gaining anunderstanding of the idiosyncratic beliefs andassumptions attached to body image (Walleret al. 2007). In addition, several questionnaireand experimental measures have been developedto formally assess body image dissatisfaction anddistortion.

A relatively simple method of assessing bodydissatisfaction is to compare an individual’s actual

weight with their ideal weight. Experimental mea-sures have also used schematic outlines, contourdrawings, or silhouettes of human figures in var-ious sizes to assess the extent of body dissatisfac-tion. These methods usually require an individualto select the figures which represent their currentperceived and ideal size, and the extent of discrep-ancy is then compared. A number of self-reportquestionnaire measures have also been developed.Some of these measure the level of dissatisfactionwith specific parts of the body (e.g., the BodySatisfaction Scale), and others assess the emo-tions, beliefs, and behaviors related to body dis-satisfaction (e.g., the Appearance SchemasInventory and the Body Checking CognitionsScale).

Degree of body image distortion can beassessed using body size estimation tasks, inwhich participants’ perception of their individualbody parts and/or whole body size is compared totheir actual size (Cash and Pruzinsky 2004).Recently, techniques using virtual reality havebeen developed to assess both body image distur-bance and dissatisfaction. These methods gener-ate more realistic 3D scale figures of an individualusing actual body measurements. Body parts canthen be adjusted using computer software to cre-ate a perceived body image which is then com-pared to one’s actual or ideal size.

TreatmentUntil recently, the evidence base for empiricallyevaluated treatments for body image disturbancehas been sparse (Farrell et al. 2006). In the lastdecade, there has been an upsurge, both in theevaluation of treatment programs for body imagedisturbance and in research designed to betterunderstand mechanisms of change. Such treat-ments may address body image using a combi-nation of approaches, including developingacceptance, reducing perfectionism and chal-lenging sociocultural messages regarding the“thin ideal,” and targeting specific maintainingfactors (e.g., targeting selective attention todisliked body parts, the role of perceived oranticipated approval from others in evaluatingbody image).

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Cognitive Behavioral Treatment of Body ImageDisturbanceCognitive behavioral therapy (CBT) is perhapsthe therapy with the most empirical support todate. These interventions target three areas ofbody image disturbance – size perception(overestimation of body size), cognitive andaffective (negative thoughts, overvalued beliefsand the accompanying emotions, idealization ofthe “thin ideal”), and behavioral (body checking,excessive grooming, avoidance, comparing,social media usage). It is evident that once bodyimage disturbance develops, there are a range ofphenomena (e.g., body checking, avoidance, mis-interpretation of “feeling fat”) that serve to main-tain dissatisfaction through the reinforcement ofthe overevaluation of shape, weight, and theircontrol (Fairburn 2008). Core therapeutic tech-niques in this work include exposure, cognitiverestructuring, behavioral experiments, surveys,and graded hierarchies. Treatment may initiallybegin with the development of a formulation thatseeks to consider how early experiences, person-ality traits, physical appearance, and peer, family,and societal messages may have informed theindividuals appearance-based schemas. The for-mulation will highlight specific assumptionsregarding appearance (“if I am thin, I am moreacceptable”) and behaviors (checking, compar-ing) that may cause distress and reinforce negativebody image. The formulation may guide treatmenttargets and strategies, for example, an individualwhose negative body image is maintained bybody checking, and frequent mirror scrutiny maybenefit from behavioral experiments to target theirbeliefs about body checking and training and edu-cation regarding mirror use. Alternatively, for anindividual whose negative body image is drivenby high self-criticism and concern over othersjudgments, a mindfulness-based intervention pro-moting acceptance may be of benefit.Psychoeducation explores the role and functionof one’s body, weight, and energy requirementsand societal pressures on body shape and image,including enabling individuals to enhance theirmedia literacy. This may include exploring thepervasive sociocultural messages and developing

confidence in critiquing such messages. It is alsoimportant to explore the experience of “feelingfat,” which many patients can relate to. It hasbeen suggested that this is the result of mis-labelling certain emotions and bodily experiences(Fairburn 2008).

Encouraging patients to monitor body-relatedactions and judgments will alert both the therapistand patient to unhelpful thoughts and behaviorsand suggest targets for treatment, for example,reducing checking and avoidance or increasingself-care. Support exists for mirror exposure;however, the evidence suggests that the durationand manner of this work are important. Usingmirror exposure to enable cognitive restructuringmay be more beneficial than simply for anxietyreduction. Such work may focus on supportingpatients to view their whole body, rather thanselectively attending to disliked parts, often incor-porating elements of mindfulness such as stayingin the moment and being nonjudgmental. Patientsare also asked to describe their bodies in neutral,objective terms, rather than in a critical and sub-jective manner.

Treatment for body image disturbance is oftendelivered in a group format and there is someevidence to support this. Group-based treatmentsinclude psychoeducation groups, cognitivebehavioral groups, use of mindfulness, and mirrorexposure. All work in this area needs to be sensi-tively addressed and this is highly relevant togroup settings.

For some individuals, body image disturbancewill improve over a course of standard psycholog-ical therapy. For example, as patients with bulimianervosa reduce their binge and purge behaviors, thesignificant fluctuations in weight decrease, leadingto a subsequent decrease in anxiety and dissatisfac-tion. However, for a minority of patients, bodyimage disturbance may be more persistent andresistant to current treatment approaches. It is theauthors’ clinical experience that more pervasivebody image disturbance may be linked to trauma,particularly sexual or emotional abuse. Anapproach incorporating imagery rescripting (as forpost-traumatic stress disorder) has assisted inaddressing the complex interplay of factors.

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Alternative Treatment ApproachesA number of promising treatment approaches areemerging, at different stages of development.These include the use of virtual reality exposuretreatments, which have high ecological validity andmay be seen by patients as more reliable andimpartial than therapist feedback. Another researchgroup have explored evaluative conditioning(pairing an unconditioned stimulus – ownbody – with a conditioned stimulus – smilingface), finding that it increased body satisfactionand global self-esteem in women with high bodyconcern (Martijn et al. 2010).

Given that mindfulness-based treatments aim tofoster willingness to accept the present state non-judgmentally and to cultivate compassion, theyhave high levels of face validity in the treatmentof body image disturbance, with the driven pursuitof the thin ideal and the shameful nature of behav-iors such as checking and comparing. Acceptanceand Commitment Therapy (ACT) is a newer cog-nitive therapy that focuses on accepting critical orintrusive thoughts rather than attempting to reduceor change them. Behavioral components includemindfulness, cognitive defusion (changing theway one interacts with thoughts), and acceptance,which may be particularly valuable in addressingintrusive, appearance-related thoughts.

Many patients tell us of the value they place onyoga in helping them to accept their bodies, andthere is a small emerging evidence base in supportof this. Yogamay be recommended as an adjunct totherapy, helping to improve mind-body awareness.

PreventionAlongside the development of an eating disorder,body image dissatisfaction is associated with vari-ous other negative outcomes including depression,increased cosmetic surgery use, over- andunderexercising, obesity, and unhealthy weightloss behaviors. As such various prevention pro-grams have been developed to target risk factorsfor body image dissatisfaction, particularly ingroups of students and young people. Content mayfocus on developing media literacy and adopting acritical approach tomedia images thatmay promotebody dissatisfaction or focus on improving interac-tions between peers and limiting “fat talk.” Such

prevention programs have promising outcomesand have been found to improve body esteem andreduce internalizationof the thin ideal in thoseat riskof developing an eating disorder.

Current Controversies

Not all individuals with an eating disorder expe-rience difficulties in accurately estimating theirsize and shape, and many non-Western cases ofeating disorders often do not display body imagedissatisfaction. Furthermore, a minority ofpatients in western cultures present with eatingdisorders but deny body dissatisfaction at anypoint during the development of their difficulties.These individuals are typically diagnosed with an“atypical” eating disorder and may show littlebody checking, body avoidance, or fear of fatness.

As such, atypical and non-Western cases maypose some challenges for current cognitive behav-ioral models of eating disorders, which rest on theassumption that overvaluation of weight and shaperepresents the underlying core psychopathology.Where body image disturbance is absent, cliniciansmay need to seek alternative or more individual-ized approaches to formulation and treatment.

Future Directions

Although recent research has further contributedto the literature on body image, there remains anabsence of a clear and comprehensive modelthrough which to understand body image and todevelop and test interventions. In particular,newer approaches need empirical testing. Furtherwork is needed to understand when it is best toaddress body image disturbance and how to deter-mine which approach to use.

Cross-References

▶Anorexia Nervosa▶Bulimia Nervosa▶Overevaluation of Shape and Weight and ItsAssessment

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References and Further Reading

American Psychiatric Association. (2013). Diagnostic andstatistical manual of mental disorders (5th ed.). Wash-ington, DC: American Psychiatric Association.

Bruch, H. (1962). Perceptual and conceptual disturbancesin anorexia nervosa. Psychosomatic Medicine, 24,187–194.

Cash, T. F., & Pruzinsky, T. (2004). Body image:A handbook of theory, research, and clinical practice.New York: Guilford Press.

Fairburn, C. G. (2008). Cognitive behavior therapy andeating disorders. New York: Guilford Press.

Farrell, C., Shafran, R., & Lee, M. (2006). Empiricallyevaluated treatments for body image disturbance:A review. European Eating Disorders Review, 14,289–300.

Martijn, C., Vanderlinden, M., Roefs, A., Huijding, J., &Jansen, A. (2010). Increasing body satisfaction of bodyconcerned women through evaluative conditioningusing social stimuli. Health Psychology, 29, 514–520.

Waller, G., Cordery, H., Corstorphine, E., Hinrichsen, H.,Lawson, R., Mountford, V., & Russell, K. (2007). Cog-nitive behavior therapy for eating disorders:A comprehensive treatment guide. New York: Cam-bridge University Press.

Body Image and Disordered Eatingin Midlife

Helena Lewis-Smith and Phillippa C. DiedrichsCentre for Appearance Research, University ofthe West of England, Bristol, UK

Definition

Use of the term “midlife” (also referred to as “mid-dle age”) has varied in body image and disorderedeating research. For example, McLean et al. (2010)defined it as 35–55 years of age, but other defini-tions have used 40–65 years. In order to reflect thisvariability, this entry will refer to researchconducted with adults aged 35–65 years of age.

Historical Background

Most research on body image and disordered eat-ing has focused on child, adolescent, and young

adult populations and the development of inter-ventions for these groups. This narrow focus hashistorically precluded knowledge on the preva-lence of, and risk factors for, body image concernsand disordered eating later on in life and particu-larly in midlife when appearance changes can bedrastic and uninvited. Weight gain is commonduring midlife, with an increase in fat mass anddecrease in muscle mass. Further, the biologicalmilestones of pregnancy and menopause can alterappearance. Pregnancy can cause women to put onweight, which may be retained following child-birth. Menopause can lead to the redistribution ofweight from the lower body to the torso, resultingin a rounder shape. In addition to alterations inbody weight and shape, unwanted changes to theskin and hair also occur. People can develop wrin-kles due to decreased skin elasticity and firmness,while also experiencing alterations to skin colora-tion. Their hair can also turn gray, become thin,and change texture duringmidlife. Finally, appear-ance can be altered indirectly due to the medicalmanagement of health conditions in midlife.

Changes to appearance during midlife reflectthe normal process of aging; however, they canmove adults further away from dominant socio-cultural ideals of beauty, which emphasize youth,and thinness for women and muscularity for men.These appearance alterations can therefore pro-voke adverse psychological consequences forpeople in midlife. A “double standard of aging”has also been proposed (e.g., Wilcox 1997), whichsuggests that aging-related changes are likely tobe more challenging for women than men. Thishas been attributed toward the belief that men andwomen gain status in society in different ways.While women gain status through a youthfulappearance, men gain status from a wider choiceof assets, such as wealth, power, or intelligence.These inevitable changes to appearance duringmidlife are consequently predicted to causegreater concern for women, than men, in midlife.

Current Knowledge on Prevalence

Existing research suggests that levels of bodydissatisfaction among women in midlife are

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similar to those of their younger counterparts.Indeed, concerns regarding weight and shapehave been consistently reported during midlife.For example, a study conducted by Gagneet al. (2012) with 1800 women above the age of50 years found that 40% of the sample reportedweighing themselves regularly and checking theirbody shape or size every day. In fact, weight andshape were indicated as important to self-perception by 80% of the women. Nonetheless,weight and shape are not the sole sources of con-cern for women in midlife, as participants in thisstudy indicated aspects of their appearance withwhich they felt less satisfaction with at midlifecompared with when they were younger, includ-ing their stomach (83.9%), shape (73.8%), skin(70.1%), weight (71.1%), arms (65.8%), face(54.1%), thighs (57.4%), and overall appearance(66.4%; Gagne et al. 2012).

Body image concerns among women in mid-life have been associated with disordered eating(McCabe et al. 2007). Longitudinal research sug-gests a prolonged risk for disordered eating fromyoung adulthood to midlife, and dangerousweight loss behaviors, including strict dieting,purging, and the use of laxatives, are prevalentand increasing among this older group of women(Ackard et al. 2013). For example, a study byFairweather-Schmidt et al. (2015) found thatalmost 11% of a sample of over 13000 womenaged between 45 and 50 years reported cognitiveand behavioral signs suggestive of disordered eat-ing. Further, research indicates 5% of this group todisplay symptoms congruent with DSM-IVcriteria for diagnosis of an eating disorder(Mangweth-Matzek et al. 2014). In fact, clinicaltreatment for disordered eating among women inmidlife has grown significantly (Ackardet al. 2013).

Studies investigating differences in the preva-lence of body image concerns and disorderedeating during midlife among women of differentethnic groups are conflicting. While one studyreported poorer body image and higher levels ofdisordered eating among European Americanscompared with African Americans, other researchidentified no difference in these outcomesbetween White and African American women.

Further, Hispanic women have been found toreport lower levels of preoccupation with weight,shape, and eating, compared with White women,and less binge eating than African Americanwomen. In contrast, another study identifiedpoorer body image and higher levels of eatingrestraint and concern among Hispanic womencompared with Black women. These inconsis-tencies may be related to different measures usedacross studies. Even so, more research is neededin this area, particularly to include other ethnicgroups within and outside of North America.

Less research attention has been directedtoward men in midlife. With regard to bodyimage, collectively the limited research to dateconcludes that while levels of body dissatisfactionare greater among women, it can still be an issuefor men in midlife. A review by McCabe andRicciardelli (2004) indicated that the emphasison increasing muscle size, which is prevalentamong adolescent boys and young adult men,shifts to a simultaneous aim to increase muscletone and lose weight among men in midlife. Fewresearchers have examined disordered eatingamong men in midlife and beyond; however, thefew studies suggest this does occur among thisgroup. For example, Mangweth-Matzeket al. (2016) found that 6.8% of 470 men agedbetween 40 and 70 years reported symptomsindicative of an eating disorder. Given that thereis little current knowledge on body image anddisordered eating among men in midlife, the restof this entry will focus specifically on women inmidlife.

Current Knowledge on Risk Factors

Increasing recognition of body dissatisfaction anddisordered eating among women in midlife hasinstigated research on associated influences andrisk factors. A review by Slevec and Tiggemann(2011) has consolidated these findings bydiscussing biological, psychological, and socio-cultural factors which have been associated withwomen’s body image and disordered eating inmidlife. The findings of this review are summa-rized below, although please see Slevec and

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Tiggemann (2011) for more detailed informationand citations for individual studies.

Biological influences include body mass index(BMI) and menopausal status. While both cross-sectional and longitudinal studies indicate ele-vated BMI as a predictor of body dissatisfactionand bulimic symptoms, the impact of menopauseis less clear. Cross-sectional research suggests thatpostmenopausal women are more dissatisfiedwith their bodies and exhibit greater levels ofdietary restraint than premenopausal women.A prospective study, however, identified greatersatisfaction with weight among postmenopausalwomen compared with premenopausal women.

Several psychological factors have been iden-tified as influences on body dissatisfaction anddisordered eating among women in midlife.Cross-sectional research indicates an associationbetween internalization of the thin youthful idealand body image concerns among this group, whilelongitudinal research found it to predict weightloss strategies. Appearance comparison (i.e., theextent to which an individual compares their ownappearance with that of others) has been found tobe associated with poor body image amongwomen in midlife. Cross-sectional studies alsosuggest an association between the importanceof appearance (i.e., an individual’s level of invest-ment in appearance for self-worth) and bodyimage concerns among this group, while prospec-tive research indicates this variable as a risk factorfor disordered eating. Self-objectification (i.e., theextent to which an individual considers their bodyan object to be viewed and appraised by others)has also been found to be correlated with bodyshame and disordered eating among women inmidlife.

With regard to more general psychological fac-tors, cross-sectional studies have found an associ-ation between negative affect (i.e., mood statessuch as depression, anxiety, and stress) and bodyimage concerns during midlife, while additionalresearch has shown support for its influence upondisordered eating in both clinical and nonclinicalsamples of women in midlife. Longitudinalresearch also identified depression and anxiety aspredictors of bulimic symptoms in a communitysample. In contrast, while cross-sectional research

indicates an association between both lower self-esteem and higher perfectionism and body imageconcerns among women in midlife, a longitudinalstudy failed to identify these variables as riskfactors for bulimic symptoms, despite cross-sectional research indicating a relationship. Thisraises the possibility that lower self-esteem andhigher perfectionism may be consequences of dis-ordered eating (and perhaps poor body image)rather than risk factors. The majority of identifiedpsychological influences upon body dissatisfac-tion and disordered eating are shared by bothyounger and midlife women; however, a distinctfactor associated with poor body image and dis-ordered eating among the latter group is aginganxiety. This is considered a concern regardingaging-associated changes to appearance. Cross-sectional support has been provided for an asso-ciation between aging anxiety and body shame,drive for thinness, and extreme dieting; however,longitudinal research is now needed.

Few sociocultural factors are shown to influ-ence the body image and eating practices ofwomen in midlife. The thin youthful ideal is astrong sociocultural influence which is theorizedto be transmitted primarily by three sources:media, family, and peers. While only cross-sectional research indicates an associationbetween perceived pressure to lose weight fromthe media, family, and peers and body dissatisfac-tion among women in midlife, a prospective studyidentified pressure felt from the media to loseweight as a predictor of drive for thinness andbulimic symptoms among this group. Other socio-cultural factors, such as weight-related teasing,have only received cross-sectional support.

Current Knowledge on Interventions

Given increasing evidence for the prevalence ofbody dissatisfaction and disordered eating amongwomen in midlife, the development and dissemi-nation of effective, evidence-based interventionsto ameliorate these concerns is warranted.A systematic review was conducted by Lewis-Smith et al. (2016) to identify interventions thatwere effective in improving the primary outcome

84 Body Image and Disordered Eating in Midlife

of body image and secondary outcome of disor-dered eating among women in midlife.

The systematic review found that the majority(64%, n = 7) of identified interventions (n = 11)resulted in significant improvements to bodyimage immediately post-intervention, three ofwhich reported maintained improvements mea-sured at 2 weeks (Pearson et al. 2012), 2 months(Smith et al. 2001), and 6 months (McLeanet al. 2011). In addition to improving bodyimage, two of these interventions were alsofound to improve disordered eating both at post-intervention and follow-up (McLean et al. 2011;Pearson et al. 2012). The studies evaluating theseinterventions with sustained improvements werealso judged to be of sound methodological qualityand are therefore recommended for use amongwomen in midlife. The three interventionsadopted two different therapeutic models: cogni-tive behavioral therapy (CBT) and acceptance andcommitment therapy (ACT).

Set Your Body Free, a CBT intervention eval-uated by McLean et al. (2011), was designedspecifically for women in midlife, with the inten-tion of targeting risk factors for body dissatisfac-tion and disordered eating. It was comprised ofeight weekly 2-h group sessions, with five to tenwomen with high levels of body dissatisfactionper group. The context of midlife was highlightedthroughout the intervention, while the contentdealt with age-related alterations to appearance,the importance of appearance for self-worth, self-care, and body acceptance. CBT techniques wereadopted in sessions to address different aspects ofthese topics in group activities. An example ses-sion comprised the following content: negativeself-talk (cognitive restructuring for alternativebalanced thoughts), body nurture with acceptingself-talk related to aging changes, body accep-tance (writing a letter to my body), and bodyimage avoidance (mirror exposure and responseprevention). The sessions were facilitated by twopsychology graduates, and an intervention man-ual consisting of psychoeducational material, cog-nitive and behavior change strategies, andactivities to be prepared before session wasgiven to participants.

ACT as a Workshop Intervention for BodyDissatisfaction, a 1-day (8-h) workshop evalu-ated by Pearson et al. (2012), was designed toexpand adult women’s lives beyond weightand shape concerns, as a means to targetbody dissatisfaction and disordered eating atti-tudes. The workshop was comprised of hour-long sessions which adopted core componentsof ACT, including creative hopelessness, con-trol as the problem/willingness as the solution,mindfulness and acceptance, clarification ofpersonal values, barriers to value, and commit-ted action. Participants completed differentactivities throughout the day so as to engagewith these components. They were encouragedto identify their challenges with body imageand to become aware of unsuccessful self-helpstrategies employed to change their appearanceor alter their self-perception. Mindfulness wastaught to participants, as a means by which toimprove acceptance of previously avoided cog-nitions and emotions. They were also encour-aged to clarify their values, in order to movetheir focus to other important aspects of theirlives. The workshop was led by two psychol-ogy graduates, and the group was comprised ofup to 15 women with elevated levels of bodydissatisfaction.

Smith and colleagues (2001) evaluated aCBT intervention designed to target body dis-satisfaction among adult women who werecompulsive or non-compulsive exercisers andof “normal” weight. The intervention was com-prised of eight weekly 1.5-h group sessions,with six to ten participants with high levelsof body dissatisfaction in each group. Sessionswere led by two clinical psychology graduates.A preexisting self-help book formed the basisof the intervention (Cash 1995), of whichincludes practical exercises to clarify distortedthoughts and change habitual behaviors whichtrigger body dissatisfaction. Readers areencouraged to challenge their negative “bodytalk,” to distance themselves from appearance-preoccupied behaviors, and to develop a posi-tive connection with their bodies through self-acceptance.

Body Image and Disordered Eating in Midlife 85

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Current Controversies

There are a number of methodological limitationsconcerning research exploring body image anddisordered eating in midlife. Firstly, nearly allresearch has focused on women, and our knowl-edge of body image and disordered eating amongmen is therefore limited. Given that the fewexisting studies indicate that the nature of bodyimage concerns among this group differs fromthat of women and that disordered eating is anissue, greater attention should be directed towardthe study of men in midlife. Secondly, the majorityof body image and disordered eating research moregenerally has concerned child, adolescent, andyoung adult women. Consequently, researchconducted with women in midlife has often reliedon measures developed for their younger counter-parts, which do not account for aging-relatedappearance concerns that are of unique relevanceto this age group. It is therefore important toemploy both age-specific and gender-specific mea-sures to assess body image concerns among bothwomen andmen inmidlife. Thirdly, the majority ofstudies exploring the prevalence of, and risk factorsfor, body dissatisfaction and disordered eating inmidlife are cross-sectional in nature. This increasesthe risk for cohort effects, and the adoption oflongitudinal designs in research is thereforeencouraged. Fourthly, existing studies which haveevaluated body image and disordered eating inter-ventions among women in midlife require greatermethodological rigor. For example, the majority ofsuch studies fail to conduct randomization, alloca-tion concealment, and blinding of research staff.Finally, evaluative studies must ensure the exami-nation of the possibility for long-term effects of theinterventions, rather than solely assessing post-intervention effects. A further conceptual issueconcerning research in the area of body imageand disordered eating in midlife is the definitionof midlife. The corresponding period of life differsaccording to the study, and greater consensus isneeded between researchers in order to facilitatecomparison and to increase the likelihood that thenature of body image concerns is actually relevantto “midlife.”

Future Directions

As previously discussed, future research shouldfocus its attention to the exploration of bodyimage and disordered eating among men in mid-life, a group of which are currently neglected inthe area. In addition to a greater necessity forstudies examining midlife, research investigatingthe trajectory of body image and disordered eatinginto older adulthood would be of interest. Relat-edly, future research should ensure a consider-ation of the functional aspects of body image, inaddition to the aesthetic aspects. As individualsmove through midlife and into later adulthood,their bodies change with regard to both appear-ance and functional capabilities. Alterations to thelatter might either be expected with age (e.g., jointand consequently movement limitations) or inrelation to illness or associated side effects (e.g.,fatigue in relation to cancer treatment), and theseare likely to impact on daily life, activities qualityof life, and potentially body image and eatingbehaviors. Greater examination of this aspect ofbody image is consequently needed. Finally, themajority of research in midlife has focused on theidentification of risk factors for body dissatisfac-tion and disordered eating. The area might benefitfrom expanding its focus to the exploration ofprotective factors for body dissatisfaction and dis-ordered eating and predictors of positive bodyimage. Related findings might have potentialimplications for intervention.

Cross-References

▶Cognitive Behavioral Approaches toPrevention

▶Dual-PathwayModel of Bulimic Spectrum Eat-ing Disorders

▶Mindfulness and Acceptance-Based Preventionof Eating Disorders

▶Objectification Theory Model of EatingDisorders

▶ Sociocultural Environment and Internalizationof the Thin Ideal as Eating Disorder RiskFactors

86 Body Image Attitudes – Body Image Beliefs

References and Further Reading

Ackard, D. M., Richter, S., Egan, A., & Cronemeyer,C. (2013). Eating disorder treatment among womenforty and older: Increases in prevalence over time andcomparisons to young adult patients. Journal of Psy-chosomatic Research, 74(2), 175–178.

Cash, T. F. (1995). What do you see when you look in themirror?: Helping yourself to a positive body image.New York: Bantam Books.

Fairweather-Schmidt, A. K., Lee, C., & Wade, T. D.(2015). A longitudinal study of midage women withindicators of disordered eating. Developmental Psy-chology, 51(5), 722–729.

Gagne, D. A., Von Holle, A., Brownley, K. A., Runfola,C. D., Hofmeier, S., Branch, K. E., & Bulik, C. M.(2012). Eating disorder symptoms and weight andshape concerns in a large web-based convenience sam-ple of women ages 50 and above: Results of the Genderand Body Image (GABI) study. International Journalof Eating Disorders, 45(7), 832–844.

Lewis-Smith, H., Diedrichs, P. C., Rumsey, N., &Harcourt, D. (2016). A systematic review of interven-tions on body image and disordered eating outcomesamong women in midlife. International Journal ofEating Disorders, 49(1), 5–18.

Mangweth-Matzek, B., Hoek, H. W., Rupp, C. I., Lackner-Seifert, K., Frey, N., Whitworth, A. B.,. . .Kinzl,J. (2014). Prevalence of eating disorders in middle-aged women. International Journal of Eating Disor-ders, 47, 320–324. doi:10.1002/eat.22232.

Mangweth-Matzek, B., Kummer, K. K., & Pope, H. G.(2016). Eating disorder symptoms in middle-aged andolder men. International Journal of Eating Disorders.doi:10.1002/eat.22550.

McCabe, M. P., & Ricciardelli, L. A. (2004). Body imagedissatisfaction among males across the lifespan:A review of past literature. Journal of PsychosomaticResearch, 56(6), 675–685.

McCabe, M. P., Ricciardelli, L. A., & James, T. (2007).A longitudinal study of body change strategies of fitnesscenter attendees. Eating Behaviors, 8(4), 492–496.

McLean, S. A., Paxton, S. J., & Wertheim, E. H. (2010).Factors associated with body dissatisfaction and disor-dered eating in women in midlife. International Jour-nal of Eating Disorders, 43, 527–536.

McLean, S. A., Paxton, S. J., & Wertheim, E. H. (2011).A body image and disordered eating intervention forwomen in midlife: A randomized controlled trial. Journalof Consulting and Clinical Psychology, 79(6), 751–758.

Pearson, A. N., Follette, V. M., & Hayes, S. C. (2012).A pilot study of acceptance and commitment therapy asa workshop intervention for body dissatisfaction anddisordered eating attitudes. Cognitive and BehavioralPractice, 19(1), 181–197.

Slevec, J. H., & Tiggemann, M. (2011). Predictors of bodydissatisfaction and disordered eating in middle-agedwomen. Clinical Psychology Review, 31(4), 515–524.

Smith, J. E., Wolfe, B. L., & Laframboise, D. E. (2001).Body image treatment for a community sample ofobligatory and nonobligatory exercisers. InternationalJournal of Eating Disorders, 30(4), 375–388.

Wilcox, S. (1997). Age and gender in relation to bodyattitudes is there a double standard of aging? Psychol-ogy of Women Quarterly, 21(4), 549–565.

Body Image Attitudes – Body ImageBeliefs

▶ Parent Influences on Body Image Attitudes andEating Patterns in Early Childhood

Body Image AvoidanceQuestionnaire (BIAQ)

Janet A. LydeckerDepartment of Psychiatry, Yale School ofMedicine, New Haven, CT, USA

Definition

The Body Image Avoidance Questionnaire(BIAQ) is a self-report measure of behavioralavoidance of experiences that could increasebody image-related distress or dissatisfaction.The questionnaire has 19 items across four behav-ioral themes: clothing (disguising or covering upthe body through clothing choices), social activi-ties (avoidance of social situations that involveeating or focus on appearance), restraint (dietaryrestriction), and grooming/weighing (checkingbehaviors such as scrutinizing oneself in the mir-ror and weighing). All items are scored on a6-point scale according to the frequency ofengagement in the behavior, from never (0) toalways (5). Because the BIAQ assesses behavioralavoidance across multiple domains, this scale hasutility helping clinicians understand patients’body image anxiety and guiding the developmentof behavioral exposures in the treatment of eatingdisorders.

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Historical Background

Rosen and colleagues initially developed theBIAQ in 1991, stemming from clinical observa-tions (Rosen et al. 1991). The purpose of thequestionnaire was to measure the extent to whichindividuals engage in behavioral avoidance ofsituations that can provoke distress about bodyimage, such as looking in the mirror. Examplesof behavioral avoidance measured by this instru-ment include wearing baggy clothing, avoidingsocial situations that focus on physical attraction,or eating.

Although the BIAQ was developed with spec-ificity for bulimia nervosa (DSM-III-R criteria),body image avoidance remains an indicator ofcore eating disorder psychopathology in theDiag-nostic and Statistical Manual of Mental Disor-ders, 5th edition (DSM-5). According to learningtheory, avoidance of body image stimuli may pro-vide temporary relief, but will likely increasebody image anxiety over time because avoidanceof stimuli prevents disconfirmation of body imagefears. Avoidance is diagnostically relevant to bothbulimia nervosa (self-evaluation undulyinfluenced by weight/shape) and anorexia nervosa(fear of gaining weight or becoming fat).

Current Knowledge

The BIAQ has shown evidence of good psycho-metric properties in diverse samples, includingAmerican college students (Lydeckeret al. 2014), eating disorder patients (Rosenet al. 1991), French adolescents (Maïanoet al. 2009), Italian students and adults (Riva andMolinari 1998), and Brazilian college students(Campana et al. 2009).

Reliability. Internal consistency has generallybeen good to excellent. The scale-developmentstudy reported an alpha of 0.89 (Rosenet al. 1991), and other studies have reported sim-ilar reliability values in the acceptable to excellentrange. Test-retest reliability for the BIAQ wasinitially established in the scale-developmentstudy: the correlation between individuals’ scores

at a 2-week interval was 0.87 (Rosen et al. 1991).Additionally, the French translation study con-firmed adequate 2-week temporal stability(Maïano et al. 2009).

Construct and Content Validity. The originalfactor structure in the scale-development study(Rosen et al. 1991) included four factors: clothing(nine items), social activities (four items), eatingrestraint (three items), and grooming/weighing(three items).

As a measure of eating disorder psychopathol-ogy, the BIAQ would be expected to have directassociations with other measures of eating disor-der psychopathology, particularly those withbehavioral elements and those focusing on bodyimage dissatisfaction or anxiety. Indeed, associa-tions with self-report questionnaires of eating dis-order behaviors (Body Checking Questionnaire;Bulimia Test, Revised), body dissatisfaction(Eating Disorder Inventory – Body Dissatisfac-tion subscale), and global measures of eating dis-order psychopathology (Eating DisorderExamination Questionnaire; Eating AttitudesTest-36) have been found. Additionally, theBIAQ has a strong relation with one itemaddressing behavioral avoidance related to cloth-ing on the Body Shape Questionnaire (Reaset al. 2005). This item has been used as a substi-tute for the full BIAQ; however, the use of a singleitem to assess body image avoidance could fail todetect nuances in the types of behavioral avoid-ance in which individuals engage. The BIAQ ismoderately associated with measures of psycho-pathology that are not specific to eating disordersor disordered eating, including a direct correlationwith the Beck Depression Inventory-II and aninverse correlation with the Rosenberg Self-Esteem Scale and SF-36 physical and mentalquality of life scores. The BIAQ also has anexpected, large inverse association with bodyimage acceptance (Body Image Acceptance andAction Questionnaire; Timko et al. 2014). Thispattern of associations supports the constructvalidity of the BIAQ to assess body imageavoidance.

The BIAQ also demonstrated evidence of threeimportant forms of criterion validity in the scale-

88 Body Image Avoidance Questionnaire (BIAQ)

development study. First, the BIAQ successfullydiscriminated patients with bulimia nervosa fromhealthy controls (N = 45 women;Mage = 26.29),both in the raw scores on the BIAQ, and aftercontrolling for other group differences includinggeneral psychopathology and body dissatisfac-tion. As noted previously, the BIAQ has implica-tions for clinical diagnoses of anorexia nervosaand bulimia nervosa. The scale-developmentstudy demonstrated that the BIAQ discriminatesbetween patients with bulimia nervosa andhealthy controls (Rosen et al. 1991), and a laterstudy demonstrated that the BIAQ distinguishesbetween low-weight patients with anorexianervosa, weight-restored patients with anorexianervosa, and both of these groups from healthycontrols (N = 160 women; Mage = 25.33;Bamford et al. 2014).

Second, BIAQ scores decreased followingcognitive-behavioral body image treatment(N = 37 women; Mage = 19; Rosen et al. 1991).The BIAQ also has implications for the clinicaltreatment of eating disorders. Mirror exposuresincorporated as part of treatment when there ishigh concern about body image show improve-ment in BIAQ scores from the start of treatment tothe end of treatment (N = 45 women; Mage =20.5; Delinsky and Wilson 2006). This is consis-tent with behavioral treatment of many anxietydisorders that incorporate in vivo exposures tofeared stimuli. Changes in BIAQ scores wereparalleled by changes in other body image vari-ables in that they occurred with mirror exposureintervention but not in control treatment.

Third, BIAQ scores were moderately corre-lated with a body size estimation task (N = 353women; Mage = 19.73; Rosen et al. 1991). Bodysize overestimation occurs in patients withanorexia and bulimia nervosa and is thought tobe driven by a lack of accurate feedback due toavoidance of body image stimuli. That is, becausepatients avoid looking at themselves (in the mir-ror, clothes shopping, in social situations focusedon appearance, etc.) or, alternatively, engage inchecking behaviors for parts of their body theywish to become smaller, they distort the informa-tion they have about their body and thereby distorttheir perception of their body. Because of these

theory-driven ties between body size over-estimation and body image avoidance, the scale-development study evaluated criterion validity byhaving participants estimate the size of their bust,waist, hips, and abdomen. There was an associa-tion between body size overestimation and avoid-ance in both the nonclinical and bulimia nervosasamples. This was particularly meaningful, asweight and concerns about weight/shape werenot associated with body size overestimation.

In addition to its relevance for clinical eatingdisorders, body image avoidance is also relevantin community populations. Of particular impor-tance is the association of body image avoidancewith impaired mental and physical quality of life(e.g., Latner et al. 2012). However, it is importantto recognize and distinguish between clinical eat-ing disorder behaviors such as those found inanorexia and bulimia nervosa and subthresholddisordered eating behaviors in community sam-ples. Comparing BIAQ scores with establishednorms, such as those in the scale-developmentstudy (Rosen et al. 1991) or the subsequent Amer-ican psychometric study (Lydecker et al. 2014),can help clarify how an individual’s frequenciesof engaging in body image behavioral avoidancecompares with peers.

The BIAQ has been translated into Italian(Riva and Molinari 1998), Brazilian Portuguese(Campana et al. 2009), German (Legenbaueret al. 2007), and French (Maïano et al. 2009).Information on the translation process is avail-able for the Portuguese and French versions;both of these studies included rigorous trans-lations followed by back translation to ensureclarity of language and constructs. Some differ-ences were made in the Brazilian version,including rephrasing “I do not go out” to “Iskip going out” because of comprehension dif-ficulties participants had responding negativelyto a negatively worded item. As well, two items(17, clothes shopping; 19, preparing to go out)were interpreted as having dual parts that par-ticipants would not necessarily answer in thesame way, and these were clarified to focus onthe intended content. The French version didnot have any differences from the originalversion.

Body Image Avoidance Questionnaire (BIAQ), Table 1 Factor analytic results

ItemRosenet al. 1991

Riva and Molinari1998

Campanaet al. 2009

Maïanoet al. 2009

Lydeckeret al. 2014

1. Baggy clothes Clothing Clothing – Clothing Exposure

2. Disliked clothes Clothing – – Clothing Exposure

3. Dark clothes Clothing – Body exposure Clothing Exposure

4. Special clothes Clothing Clothing Body exposure Clothing Exposure

5. Restrict diet Restraint Restraint Hunger control Restraint –

6. Eat fruits,vegetables

Restraint Restraint Hunger control Restraint –

7. Fasting Restraint Restraint – Restraint Social

8. “Checked out” Social Social – Social Social

9. Discuss weight Social Social Refusal strategy Social Social

10. Others thinner Social – Refusal strategy Social Social

11. Involves eating Social – Refusal strategy Social Social

12. Weigh Weigh/groom

Weigh/groom Hunger control Weigh/groom –

13. Inactive Clothing Social Hunger control Clothing Exposure

14. Mirror Weigh/groom

Weigh/groom Hunger control Weigh/groom –

15. Physical intimacy Clothing Social – Clothing Exposure

16. Clothes divertattention

Clothing Clothing Body exposure Clothing Exposure

17. Clothes shopping Clothing – Refusal strategy Clothing Exposure

18. Revealing clothes Clothing Clothing – Clothing Exposure

19. Preparing to goout

Weigh/groom

– Body exposure Weigh/groom –

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The original factor structure of the BIAQ andevidence of alternative factor structures from sub-sequent studies are delineated in Table 1. Of note,many of the factor analytic studies come fromdifferent countries and languages than the scale-development study and may reflect cultural differ-ences in body image avoidance. In the Italiantranslation, multiple samples were evaluatedwith the BIAQ: high school students, universitystudents, and adults with obesity. Factor analysessuggested a four-factor model (clothing, eatingrestraint, social activities, weighing/grooming)had the best fit after removing six items (Rivaand Molinari 1998). In the Brazilian Portuguesetranslation, female university students were eval-uated, and their data suggested a three-factormodel (hunger control and shape concern, bodyexposure and accommodation strategies, refusalstrategies) after removing six items had the best fit(Campana et al. 2009). The French translation,which evaluated adolescents with the BIAQ,

found adequate fit with the same factor structureand set of items as the original version (Maïanoet al. 2009). They also determined all items as atotal score (i.e., a second-order factor) had goodfit. In a study of the psychometric properties of theBIAQ in a sample of American college students,factor analyses suggested a two-factor model(exposure discomfort, social discomfort) afterremoving five items had the best fit (Lydeckeret al. 2014).

Current Controversies

The primary controversy surrounding the BIAQconcerns the factor structure and included items,as described above and in Table 1. In addition, acriticism of the BIAQ is its focus on the avoidanceof overt behaviors rather than the avoidance ofinternal experiences (e.g., cognitions or feelings).A new measure, the Body Image Acceptance and

90 Body Image Avoidance Questionnaire (BIAQ)

Action Questionnaire, aims to evaluate the cogni-tive, affective, and behavioral expressions of bodyimage avoidance (Timko et al. 2014). The BIAQand the Body Image Acceptance and ActionQuestionnaire are highly, inversely correlated;that is, avoidance is negatively associated withacceptance. In a comparison of these measures,each measure explained a significant and uniqueproportion of variance in bulimic symptomatol-ogy, whereas only the Body Image Acceptanceand Action Questionnaire predicted drive for thin-ness. Further research is warranted on the con-structs these two measures capture and how theirsimilarities and differences are relevant for clini-cal treatment of eating disorders and prevention ofdisordered eating.

Future Directions

Because the scale-development study had partic-ipants who were young, female, and primarilyWhite, additional studies on psychometric prop-erties of the BIAQ in different demographicgroups are warranted. To date, two studies havebegun this research. The French translation studyevaluated psychometric properties across gendersand found that the measure was valid in both maleand female adolescents. However, girls scoredsignificantly higher than boys on the BIAQ(Maïano et al. 2009). The American study simi-larly examined psychometric properties and meandifferences by race (Lydecker et al. 2014). TheBIAQ had adequate fit for Black and Whitefemale college students (other racial groups wereunderpowered for factor analyses). White andAsian female college students scored higher onthe BIAQ than Black female college students.

Binge eating disorder, a diagnosis new to theDSM-5, is thought to be driven in part by a desireto deal with something concrete (i.e., food) andescape something abstract (i.e., distressing emo-tions). Because of the potential, conceptual fit of adesire to escapedistresswith body image avoidancebehaviors, research is needed to examine whetherbody image avoidance parallels dissociation fromstrong affect through binge behavior. This area isunderstudied, yet an important future direction

because body image concerns have been shown tooccur in individualswith binge eating disorder. Onestudy evaluated avoidance using one item from theBody Shape Questionnaire (avoiding wearingclothes that prompt awareness of shape) in a sampleof treatment-seeking patients with obesity andbinge eating disorder: avoidance was related tobinge eating and overvaluation of shape/weight(Reas et al. 2005). Evaluating body image avoid-ance using theBIAQcould expand on the complex-ities of the patterns of avoidance in this clinicalpopulation. Additionally, the Body Shape Ques-tionnaire avoidance item has predicted poorer per-formance in behavioral weight loss treatment(Latner 2008) andhas correlatedwithovervaluationof shape/weight in a presurgical bariatric population(Grilo et al. 2005). These associations suggest thatresearch with the BIAQ in these populations couldhave clinical utility in determiningwhether patternsof behavioral avoidance in these populations aresimilar to or different from patterns observed inpatients with eating disorders and implications forexposure-based treatment planning.

References and Further Reading

Bamford, B. H., Attoe, C., Mountford, V. A., Morgan, J. F.,& Sly, R. (2014). Body checking and avoidance in lowweight and weight restored individuals with anorexianervosa and non-clinical females. Eating Behaviors, 15(1), 5–8.

Campana, A. N., da Consolacao, M., Tavares, G. C., daSilva, D., & Diogo, M. J. (2009). Translation andvalidation of the Body Image Avoidance Questionnaire(BIAQ) for the Portuguese language in Brazil. Behav-ior Research Methods, 41(1), 236–243.

Delinsky, S. S., & Wilson, G. T. (2006). Mirror exposurefor the treatment of body image disturbance. Interna-tional Journal of Eating Disorders, 39(2), 108–116.

Grilo, C. M., Reas, D. L., Brody, M. L., Burke-Martindale,C. H., Rothschild, B. S., & Masheb, R. M. (2005).Body checking and avoidance and the core features ofeating disorders among obese men and women seekingbariatric surgery. Behavior Research and Therapy, 43,629–637.

Latner, J. D. (2008). Body checking and avoidance amongbehavioral weight-loss participants. Body Image, 5,91–98.

Latner, J. D., Mond, J. M., Vallance, J. K., Gleaves, D. H.,& Buckett, G. (2012). Body checking and avoidance inwomen: Associations with mental and physical health-related quality of life. Eating Behaviors, 13, 386–389.

Body Image-Acceptance and Action Questionnaire,Table 1 BI-AAQ items

Item

1. Worrying about my weight makes it difficult for me tolive a life that I value

2. I care too much about my weight and body shape

3. I shut down when I feel bad about my body shape orweight

4. My thoughts and feelings about my body weight andshape must change before I can take important steps inmy life

5.Worrying about my body takes up too much of my time

6. If I start to feel fat, I try to think about something else

7. Before I can make any serious plans, I have to feelbetter about my body

8. I will have better control over my life if I can controlmy negative thoughts about my body

9. To control my life, I need to control my weight

10. Feeling fat causes problems in my life

11. When I start thinking about the size and shape of mybody, it’s hard to do anything else

12. My relationships would be better if my body weightand/or shape did not bother me

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Legenbauer, T., Vocks, S., & Schütt-Strömel, S. (2007).Validierung einer deutschsprachigen Version des BodyImage Avoidance Questionnaire BIAQ. Diagnostica,53, 218–225.

Lydecker, J. A., Cotter, E. W., & Mazzeo, S. E. (2014).Body checking and body image avoidance: Constructvalidity and norms for college women. Eating Behav-iors, 15(1), 13–16.

Maïano, C., Morin, A. J., Monthuy-Blanc, J., & Garbarino,J. M. (2009). The Body Image Avoidance Question-naire: Assessment of its construct validity in a commu-nity sample of French adolescents. InternationalJournal of Behavioral Medicine, 16(2), 125–135.

Reas, D. L., Grilo, C. M., Masheb, R. M., & Wilson, G. T.(2005). Body checking and avoidance in overweightpatients with binge eating disorder. International Jour-nal of Eating Disorders, 37(4), 342–346.

Riva, G., & Molinari, E. (1998). Replicated factor analysisof the Italian version of the Body Image AvoidanceQuestionnaire. Perceptual and Motor Skills, 86(3),1071–1074.

Rosen, J. C., Srebnik, D., Saltzberg, E., & Wendt,S. (1991). Development of a Body Image AvoidanceQuestionnaire. Psychological Assessment, 3(1), 32–37.

Timko, C. A., Juarascio, A. S., Martin, L. M., Faherty, A., &Kalodner, C. (2014). Body image avoidance: An under-explored yet important factor in the relationship betweenbody image dissatisfaction and disordered eating. Journalof Contextual Behavioral Science, 3(3), 203–211.

Vossbeck-Elsebusch, A. N., Waldorf, M., Legenbauer, T.,Bauer, A., Cordes, M., & Vocks, S. (2015). Over-estimation of body size in eating disorders and itsassociation to body-related avoidance behavior. Eatingand Weight Disorders: Studies on Anorexia, Bulimiaand Obesity, 20(2), 173–178.

Body Image-Acceptance and ActionQuestionnaire

Mia L. PellizzerFaculty of Social and Behavioural Sciences,School of Psychology, Flinders University,Adelaide, SA, Australia

Synonyms

Body satisfaction; Positive body embodiment

Definition

The Body Image-Acceptance and Action Ques-tionnaire (BI-AAQ) is a 1-factor, 12-item self-

report scale designed to measure body image flex-ibility, the ability to accept and experiencethoughts, beliefs, perceptions, and feelings aboutone’s body (Sandoz et al. 2013). Items (seeTable 1) are rated on a seven-point Likert scalefrom 1 (never true) to 7 (always true) and arereverse scored and summed such that higherscores indicate greater body image flexibility.The BI-AAQ instructions and items are publishedin Sandoz et al. (2013).

Historical Background

Interest in body image flexibility emerged inresponse to the increasing use of Acceptance andCommitment Therapy (ACT) and mindfulness-based approaches in eating disorder treatment(Sandoz et al. 2013). Specifically, body imageflexibility was adapted from the ACT concept ofpsychological flexibility, defined as the opennessto experience (Sandoz et al. 2013). In addition,body image flexibility is considered to be positivebody image construct and a protective factor forphysical and psychological well-being (Webb

92 Body Image-Acceptance and Action Questionnaire

et al. 2015). It was noted in a recent review byWebb et al. (2015) that positive body imageassessment has largely been neglected in eatingdisorder prevention and intervention work. Nota-bly, positive body image is defined as distinctfrom negative body image, and attaining positivebody image may be a different outcome fromsimply the absence of negative body image(Webb et al. 2015). Given that positive bodyimage is conceptualized as a protective factor,ongoing assessment in eating disorder preventionand treatment is of particular relevance.

The BI-AAQ was adapted from three versionsof the Acceptance and Action Questionnaire(Bond et al. 2011), a measure of psychologicalflexibility. While early investigations find theBI-AAQ to be psychometrically sound and offerthe measurement of an important construct, todate the measure has not been widely used andremains novel, and further investigation iswarranted.

Current Knowledge

The unidimensional factor structure of theBI-AAQ has been replicated in several psycho-metric studies (Ferreira et al. 2011; Kurzet al. 2016; Pellizzer et al. 2016; Sandozet al. 2013; Timko et al. 2014). To date, theBI-AAQ has good reliability related to internalconsistency (Cronbach’s a = .91–.95, compositereliability = 0.96), item total (r = .50–82), andtest-retest (r = .80–.82) (Ferreira et al. 2011;Pellizzer et al. 2016; Sandoz et al. 2013; Timkoet al. 2014). It is correlated with measures ofeating disorder psychopathology, general psycho-pathology, self-compassion, self-esteem, socialcomparison, body dissatisfaction, body apprecia-tion, BMI, intuitive eating, distress tolerance,internalization of the thin ideal, psychologicalflexibility, body checking, and body image avoid-ance (Ferreira et al. 2011; Kelly et al. 2014;Pellizzer et al. 2016; Sandoz et al. 2013; Timkoet al. 2014). Furthermore, eating disorder anddieting samples, in addition to those classified“at risk” for eating disorders, have significantlylower BI-AAQ scores compared to controls

(Ferreira et al. 2011; Masuda et al. 2015; Pellizzeret al. 2016; Sandoz et al. 2013; Timko et al. 2014).In addition, a recent study found the BI-AAQ tobe the strongest predictor of disordered eating andquality of life when compared to measures ofbody checking and body avoidance (Pellizzeret al. 2016). Notably, a recent treatment studyused the BI-AAQ as part of their outcome moni-toring and found that improvements in bodyimage flexibility at the end of treatment wereassociated with reduced eating disorder psycho-pathology (Butryn et al. 2013).

Current Controversies

While the psychometric properties of the BI-AAQhave been consistently replicated across studies, ithas been noted that, because of the use of nega-tively worded items, conceptually the measuremay also be assessing the experiential avoidanceof body image (Timko et al. 2014; Webbet al. 2015). While the BI-AAQ was initiallydeveloped using a sample of men and women,the majority of participants were female (Ferreiraet al. 2011; Masuda et al. 2015), and subsequentpsychometric investigations have predominantlyused female samples. Recently the BI-AQQ wasstudied in an exclusively male sample whichsupported prior findings with women (Masudaet al. 2015). However, psychometric propertiesincluding factor structure and validity were notconducted (Masuda et al. 2015). Therefore, themeasure may be more relevant to body imageconcerns of women than those of men (Sandozet al. 2013; Webb et al. 2015). Webb et al. (2015)suggest that researchers consider the BI-AAQ tobe a preliminary measure of body image flexibil-ity and emphasize the importance of acknowledg-ing each limitation if the BI-AAQ is utilized.

Future Directions

In light of the limitations discussed, furtherresearch might investigate the use of more posi-tively worded items to determine whether thecurrent items accurately assess the concept of

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body image flexibility, rather than experientialbody image avoidance. Furthermore, it is unclearwhether the factor structure of the BI-AAQ issupported among males and individuals fromdiverse ethnic backgrounds. Thus far the psycho-metric properties of the BI-AAQ have only beenstudied in the USA, Australia, and Portugal(Ferreira et al. 2011; Kurz et al. 2016; Pellizzeret al. 2016; Sandoz et al. 2013; Timko et al. 2014).Further research may also seek to understand howbody image flexibility, as measured by theBI-AAQ, changes over time using longitudinaldesigns. Lastly, the use of the BI-AAQ in eatingdisorder treatment studies and case series is pre-liminary. Thus, future treatment studies may seekto include the BI-AAQ to inform treatment andmonitor outcomes.

Cross-References

▶Body Image▶Body Image and Disordered Eating in Midlife

References and Further Reading

Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M.,Guenole, N., Orcutt, H. K., . . . Zettle, R. (2011). Pre-liminary psychometric properties of the Acceptanceand Action Questionnaire II: A revised measure ofpsychological inflexibility and experiential avoidance.Behavior Therapy, 42, 676–688. doi:10.1016/j.beth.2011.03.007.

Butryn, M. L., Juarascio, A., Shaw, A., Kerrigan, S. G.,Clark, V., O’Planick, A., & Forman, E. M. (2013).Mindfulness and its relationship with eating disorderssymptomatology in women receiving residential treat-ment. Eating Behaviors, 14, 13–16. doi:10.1016/j.eatbeh.2012.10.005.

Ferreira, C., Pinto-Gouveia, J., & Duarte, C. (2011). Thevalidation of the Body Image Acceptance and ActionQuestionnaire: Exploring the moderator effect ofacceptance on disordered eating. International Journalof Psychology and Psychological Therapy, 11,327–345.

Kelly, A. C., Vimalakanthan, K., & Miller, K. E. (2014).Self-compassion moderates the relationship betweenbody mass index and both eating disorder pathologyand body image flexibility. Body Image, 11, 446–453.doi:10.1016/j.bodyim.2014.07.005.

Kurz, A. S., Flynn, M. K., & Bordieri, M. J. (2016). HowBayesian estimation might improve CBS measure

development: A case study with body-image flexibilityin Hispanic students. Journal of ContextualBehavioural Science, 5, 146–153. doi:10.1016/j.jcbs.2016.07.005.

Masuda, A., Hill, M. L., Tully, E. C., & Garcia, S. E.(2015). The role of disordered eating cognition andbody image flexibility in disordered eating behaviorin college men. Journal of Contextual Behavioral Sci-ence, 4, 12–20. doi:10.1016/j.jcbs.2015.01.001.

Pellizzer, M. L., Tiggemann, M., Waller, G., &Wade, T. D.(2016). Measures of body image: Confirmatory factoranalysis and association with disordered eating. Man-uscript submitted for publication.

Sandoz, E. K., Wilson, K. G., Merwin, R. M., & Kellum,K. K. (2013). Assessment of body image flexibility:The Body Image-Acceptance and Action Question-naire. Journal of Contextual Behavioral Science, 2,39–48. doi:10.1016/j.jcbs.2013.03.002.

Timko, C. A., Juarascio, A. S., Martin, L. M., Faherty, A.,& Kalodner, C. (2014). Body image avoidance: Anunder-explored yet important factor in the relationshipbetween body image dissatisfaction and disordered eat-ing. Journal of Contextual Behavioral Science, 3,203–211. doi:10.1016/j.jcbs.2014.01.002.

Webb, J. B., Wood-Barcalow, N. L., & Tylka, T. L. (2015).Assessing positive body image: Contemporaryapproaches and future directions. Body Image, 14,130–145. doi:10.1016/j.bodyim.2015.03.010.

Body Mass

▶Body Mass Index: Self and Parents

Body Mass Index: Self and Parents

Nadia Micali1,2 and Lauren Robinson11Institute of Child Health, University CollegeLondon, London, UK2Department of Psychiatry, Icahn School ofMedicine at Mount Sinai, New York, NY, USA

Synonyms

Body mass; Weight

Definition

Body mass index (BMI), also known as Quetelet’sindex, is calculated as one’s weight (in kg) divided

Body Mass Index: Self and Parents, Table 1 BMIcategories as identified by the WHO

BMI Weight category

<18.5 Underweight

18.5–24.9 Normal weight

25–29.9 Overweight

>30 Obese

94 Body Mass Index: Self and Parents

by height in meters squared: weight/height2. BMIis a well-known measure of adiposity and body fatin adults; it strongly correlates with direct mea-sures of body fat and is highly predictive of met-abolic risk and disease. High BMI indicateshigher fat mass and adiposity, and it is a relativelyeasy, valid, and cheap measure. However, BMI isnot a direct measure of body fat; the same BMImight index different levels of body fatness,depending on muscle mass, gender, and age.

BMI is often used to identify weight catego-ries, defined by the World Health Organization(WHO) (see Table 1) in adults.

Among children and adolescents, BMI needsto be used in the context of gender and age, giventhat body fat changes according to age and gender.BMI percentiles are commonly used for childrenand adolescents.

BMI is highly heritable although environmen-tal influences are important particularly inadulthood.

Historical Background

The relationship between individual BMI and eat-ing disorders (EDs) or disordered eating has beenwell studied over the years, although few studieshave investigated this relationship longitudinallyover time. Initial evidence of the relationshipbetween child and parental BMI and eating disor-ders comes from retrospective studies of patientswith ED (reviewed in Jacobi et al. 2004). Child-hood obesity was a retrospective correlate ofbinge eating disorder (BED) and bulimia nervosa(BN), and parental obesity was a retrospectivecorrelate of BN. Early longitudinal studies pro-vided inconsistent associations between BMI andED or disordered eating, with some studies

finding no associations and some finding a posi-tive association between higher BMI and higherED/ED symptoms (particularly binge eatingand/or purging) (reviewed in Jacobi et al. 2004).Inconsistencies in these longitudinal findings arelikely to be due to small sample size (leading tolow power to detect differences) or heterogeneityacross samples.

Given the strong association between BMI andbody weight of parents and offspring, and the roleof family factors in shaping the development ofED and disordered eating, there has been a grow-ing interest in the effect of parental BMI andoffspring ED/disordered eating. Early studiesinvestigated parental BMI using retrospectiveself-report in case-control studies.

Current Knowledge

BMI (Self)Following on from early studies, the recent liter-ature has focused on employing longitudinal pro-spective designs to understand both therelationship between BMI and ED and betweenBMI and adolescent ED precursors/early symp-toms, such as body dissatisfaction, dieting, andthin ideal internalization.

A causal relationship between child BMI andadolescent/young adult eating disorders has notbeen fully substantiated by prospective studies.There is some evidence, however, that higherBMI is prospectively associated with body dissat-isfaction, dieting, weight concern, and disorderedeating in adolescent boys and girls (Abebeet al. 2013; Field et al. 2001; Vincent and McCabe2000). Prospective associations between BMI andbody dissatisfaction might be similar acrossdevelopment in early and mid-adolescence(Paxton et al. 2006).

Contrasting findings are present in the litera-ture focusing on the relationship between BMIand ED or disordered eating in younger children.Although the association between higher BMI anddisordered eating is robust in cross-sectional stud-ies, only one longitudinal study has identified alongitudinal relationship between high BMI and

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dieting, eating, and weight and shape concern in amixed gender sample of primary school-age chil-dren (reviewed in Stemann Larsen et al. in press).

BMI (Parents)With respect to BMI of parents especiallymothers, higher maternal BMI was predictiveof late adolescence and early adult binge/purgedisorders in a prospective cohort study (Allenet al. 2014), but was not specific to ED versusother psychiatric disorders at earlier ages (Allenet al. 2009). In contrast, higher maternal BMIwas protective for adult anorexia nervosa(Nicholls and Viner 2009). No prospectiveassociations have been found between paternalBMI and ED (Allen et al. 2009; Nicholls andViner 2009).

Current Controversies

Understanding the relationship between BMI(both individual and parental) and ED and disor-dered eating is relevant not only to causal inves-tigations but also to the development ofprevention that adequately targets subjects atrisk. Disentangling the role of objective BMIand perceived weight (by the individual andothers) in contributing to ED and disorderedeating risk has been suggested as an importantarea of study in order to adapt current preventionstrategies.

Causal investigations have mostly focused onrisk factors; risk pathways have been less studied.A focus on risk pathways and mechanisms isparticularly relevant given (a) the importance oftiming of exposure and (b) the strong relationshipbetween BMI and related risk factors. Despite thewell-known time-varying effect of exposures toweight extremes across development on laterhealth outcomes, a focus on timing of exposureis lacking in the field.

Prevention programs for both obesity and EDare available and have been successfully tested,refining to target-specific population, and adapta-tion to different cultural/developmental contextsmight prove fruitful.

Future Directions

Methodological advances and the availability ofmultigenerational and large prospective studiesallow moving away from a focus on the role ofindividual or parental BMI in isolation and delv-ing deeper into investigating risk models andpathways. There is a need to study temporal rela-tionships and predictive factors across develop-ment and relevant risk pathways in causal models.

Growing interest in potential gender and agedifferences and differential risk mechanisms sug-gests child BMI might differentially interact withearly risk factors (body dissatisfaction) acrossgenders (Micali et al. 2015). Whether parentaland/or individual BMI influences risk differen-tially, cross gender, developmental stage, and eth-nicity/culture need to be fully explored to bettertarget prevention strategies. Given the high heri-tability of BMI, understanding the shared geneticvulnerability to both high/low BMI and ED/EDbehaviors might prove to be important.

Cross-References

▶Anorexia Nervosa▶Binge Eating Disorder▶Bulimia Nervosa▶Obesity▶Obesity and Eating Disorders

References and Further Reading

Abebe, D. S., Torgersen, L., Lien, L., Hafstad, G. S., & vonSoest, T. (2013). Predictors of disordered eatingin adolescence and young adulthood a population-based,longitudinal study of females and males in Norway. Inter-national Journal of Behavioral Development, 38(2),128–138. doi:10.1177/0165025413514871.

Allen, K. L., Byrne, S. M., Forbes, D., & Oddy, W. H.(2009). Risk factors for full-and partial-syndrome earlyadolescent eating disorders: A population-based preg-nancy cohort study. Journal of the American Academyof Child and Adolescent Psychiatry, 48(8), 800–809.

Allen, K. L., Byrne, S. M., Oddy, W. H., Schmidt, U., &Crosby, R. D. (2014). Risk factors for binge eating andpurging eating disorders: Differences based on age ofonset. International Journal of Eating Disorders, 47(7),802–812.

96 Body Satisfaction

Field, A. E., Camargo, C. A., Taylor, C. B., Berkey, C. S.,Roberts, S. B., & Colditz, G. A. (2001). Peer, parent, andmedia influences on the development of weight concernsand frequent dieting among preadolescent and adoles-cent girls and boys. Pediatrics, 107(1), 54–60.

Jacobi, C., Hayward, C., de Zwaan, M., Kraemer, H. C., &Agras, W. S. (2004). Coming to terms with risk factorsfor eating disorders: Application of risk terminologyand suggestions for a general taxonomy. PsychologicalBulletin, 130(1), 19–65.

Micali, N., De Stavola, B., Ploubidis, G., Simonoff, E.,Treasure, J., & Field, A. E. (2015). Eating disordersbehaviours and cognitions in adolescence: Gender-specific patterns in the prospective effect of child,maternal and family risk factors. British Journal ofPsychiatry, 206, 1–9. doi:10.1192/bjp.bp.114.152371.

Nicholls, D. E., &Viner, R.M. (2009). Childhood risk factorsfor lifetime anorexia nervosa by age 30 years in a nationalbirth cohort. Journal of the American Academy of Childand Adolescent Psychiatry, 48(8), 791–799.

Paxton, S. J., Eisenberg, M. E., & Neumark-Sztainer,D. (2006). Prospective predictors of body dissatisfac-tion in adolescent girls and boys: A five-year longitu-dinal study. Developmental Psychology, 42(5), 888.

Stemann Larsen, P., Strandberg-Larsen, K., Micali, N., &Nybo Andersen, A. M. (in press). Parental and childcharacteristics related to early-onset disordered eating:A systematic review.Harvard Review of Psychiatry, 23(6), 395–412.

Vincent, M. A., & McCabe, M. P. (2000). Gender differ-ences among adolescents in family, and peer influenceson body dissatisfaction, weight loss, and binge eatingbehaviors. Journal of Youth and Adolescence, 29(2),205–221.

Body Satisfaction

▶Body Image-Acceptance and ActionQuestionnaire

Body Shape Questionnaire

Tracey WadeSchool of Psychology, Flinders University,Adelaide, SA, Australia

Description

The Body Shape Questionnaire (BSQ) is a self-report questionnaire that was developed to

measure concerns about body shape (Cooperet al. 1987). In the manuscript that described thedevelopment and validation of the BSQ, the34 items (provided in Table 1) were included inthe appendix, thus the questionnaire is freelyavailable to use. The BSQ starts with the follow-ing phrase, “We should like to know how youhave been feeling about your appearance overthe PAST FOURWEEKS. Please read each ques-tion and circle the appropriate number to the right.Please answer all the questions.” Each item isanswered using a 6-point Likert scale: 1 (never),2 (rarely), 3 (sometimes), 4 (often), 5 (very often),and 6 (always). The maximum score is 204, and ahigher score indicates more dissatisfaction anddiscomfort with the body experience. It can becompleted in around 10 min.

Historical Background

A semi-structured interview was conducted with28 young women in order to understand their expe-rience of “feeling fat.” This subjective experienceis central to the maintenance of disordered eating,and targeted in eating disorder treatments. Fifty oneitems were derived from the interviews, and thisform of the BSQ was then administered to fourgroups of women, including women in treatmentfor bulimia nervosa, women attending a familyplanning clinic, occupational therapy students,and undergraduate students. Items were deletedfor one of two reasons: first, where two itemswere highly correlated, indicating that contentwas closely related, and second, items for which“often” was selected by less than 25% of womenbeing treated for bulimia nervosa and less than 5%of the community samples. The BSQ scores of thisformer group were found to be significantly higherthan the community sample, with a large between-group effect size (Cohen’s d) of 1.96 (95% confi-dence intervals, 1.62–2.31). A further indicator ofvalidity was significant correlations with the EatingAttitudes Test (EAT) (see entry “Eating AttitudesTest (EAT)” by Wade) and the Body Dissatisfac-tion subscale of the Eating Disorder Inventory(EDI) (see entry “Eating Disorder Inventory(EDI)” by Nyman-Carlsson and Garner).

Body Shape Questionnaire, Table 1 Body ShapeQuestionnaire items

# Item

1 Has feeling bored made you brood about yourshape?

2 Have you been so worried about your shape thatyou have been feeling you ought to diet?

3 Have you thought that your thighs, hips, or bottomare too large for the rest of you?

4 Have you been worried that you might become fat(or fatter)?

5 Have you been worried about your flesh not beingfirm enough?

6 Has feeling full (e.g., after eating a large meal)made you feel fat?

7 Have you felt so bad about your shape that youhave cried?

8 Have you avoided running because your fleshmight wobble?

9 Has being with thin women made you self-conscious about your shape?

10 Have you worried about your thighs spreading outwhen sitting down?

11 Has eating even a small amount of food made youfeel fat?

12 Have you noticed the shape of other women andfelt that your own shape compared unfavorably?

13 Has thinking about your shape interfered with yourability to concentrate (e.g., while watchingtelevision, reading, listening to conversations)?

14 Has being naked, such as when taking a bath, madeyou feel fat?

15 Have you avoided wearing clothes which makeyou particularly aware of the shape of your body?

16 Have you imagined cutting off fleshy areas of yourbody?

17 Has eating sweets, cakes, or other high-caloriefood made you feel fat?

18 Have you not gone out to social occasions (e.g.,parties) because you have felt bad about yourshape?

19 Have you felt excessively large and rounded?

20 Have you felt ashamed of your body?

21 Has worry about your shape made you diet?

22 Have you felt happiest about your shape when yourstomach has been empty (e.g., in the morning)?

23 Have you thought that you are the shape you arebecause you lack self-control?

24 Have you worried about other people seeing rollsof flesh around your waist or stomach?

25 Have you felt that it is not fair that other women arethinner than you?

26 Have you vomited in order to feel thinner?

(continued)

Body Shape Questionnaire, Table 1 (continued)

# Item

27 When in company have you worried about takingup too much room (e.g., sitting on the sofa or a busseat)?

28 Have you been worried about your flesh beingdimply?

29 Has seeing your reflection (e.g., in a mirror or shopwindow) made you feel bad about your shape?

30 Have you pinched areas of your body to see howmuch fat there is?

31 Have you avoided situations where people couldsee your body (e.g., communal changing rooms orswimming baths)?

32 Have you taken laxatives in order to feel thinner?

33 Have you been particularly self-conscious aboutyour shape when in the company of other people?

34 Has worry about your shape made you feel youought to exercise?

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Since its development, the BSQ has been usedin numerous research investigations and withdiverse populations, including men and womenwith body dysmorphic disorder, menopausalwomen, women who underwent abdominoplasty,female high-school students, obese patients enter-ing a weight loss program, female patients withanorexia nervosa, patients presenting for bariatricsurgery, and pregnant women. Although the BSQcan be helpful in the diagnostic process, it cannotbe used as an alternative for clinical diagnosis.

Current Knowledge

Factor analysis in a nonclinical female popula-tion suggests a hierarchical single factor model(Evans and Dolan 1993). This one-dimensionalscale has an inter-item correlation ranging from.14 to .76 and an alpha coefficient of 0.97. Thequestionnaire has also been validated in otherethnic groups, including Flemish (Probst et al.2008); Spanish (Warren et al. 2008), and Latinawomen in the United States (Franko et al. 2012).In the latter group, the 34-item version of theBSQ was used, evidencing Cronbach alphasbetween 0.82 and 0.88, with a test-retest corre-lation of 0.97. Findings across the studies sug-gest that the BSQ is reliable and valid with

98 Body Shape Questionnaire

respect to administration with different culturalgroups.

Shorter versions of the BSQ have been exam-ined and validated. Evans and Dolan presentedtwo 16-item “alternate forms” (items 1, 3, 5, 7,8, 9, 10–11, 15, 17, 20–22, 25, 28, 34 and items2, 4, 6, 12, 13–14, 16, 18, 19, 23, 24, 27, 29–31,32) and four 8-item versions of the BSQ (items1, 3, 7, 8, 9, 10, 17, 34; items 5, 11, 15, 20, 21, 22,25, 28; items 4, 6, 13, 16, 19, 23, 29, 33; items2, 12, 14, 18, 24, 27, 30, 31), which showedequivalent means and excellent internal consis-tency. The two 16-item scales were highly corre-lated (r = .96). The Pearson correlation betweenthe eight-item scales ranged from .92 to .94. Dow-son and Henderson (2001) developed a 14-itemversion of the BSQ (items 2, 9, 12, 14, 17, 19–21,23–25, 29, 33, 34).

These different versions of the BSQ were sub-sequently examined in two populations, Flemish(Probst et al. 2008) and Spanish (Warren et al.2008). The Flemish group consisted of 256 femalepatients consecutively admitted to a specializedinpatient unit for eating disorders (163 anorexianervosa patients and 93 bulimia nervosa patients)and 407 female students from the Catholic Uni-versity of Leuven. The Cronbach’s alpha of thefull BSQ in these two groups was .96 and .97. TheEvans and Dolan sixteen- and eight-item versionshad Cronbach alphas ranging from 0.82 to 0.94,and the Dowson and Henderson 14-item versionhad alphas ranging from 0.91 to 0.95. The BSQwas highly correlated with its alternate forms. Allversions were shown to differentiate people witheating disorders from healthy controls, but notpeople with anorexia nervosa versus bulimianervosa.

In the Spanish group there were 505 Euro-and 151 Hispanic-American (N = 656) under-graduates and 622 Spanish participants (445undergraduates and 177 women) receiving out-patient treatment for an eating disorder. A -one-factor solution for all four groups wastested for all versions of the BSQ: the 34-itemforms, the two 16-item forms, and the four8-items forms. Most factor loadings were

similar across the groups, but the authors alsofound that a 10-item version (items 1, 7, 8, 11,16, 14, 18, 19, 26, 28) showed the least differ-ences across all four groups.

In summary, this research indicates that thevalidity and reliability of the BSQ is stronglysupported, that it can be used with confidence indifferent ethnic groups, and that shorter versionsof the BSQ are robust.

Current Controversies

No particular controversies attached themselvesto the BSQ, as long as it is used in the way that itwas intended, i.e., not as a diagnostic tool but as asupplement to diagnosis, or to improve ourunderstanding of the prevalence of body shapeconcern in community populations.

Future Directions

In terms of participant burden, and robust evi-dence suggesting validity and reliability, use ofthe shorter versions of the BSQ in future researchis to be encouraged. Further research is requiredto develop a package of self-report question-naires that balance parsimony with validity andreliability in the assessment of aspects of bodysatisfaction that are considered to be of relevanceto eating disorders. For example, we now haveBody Checking Questionnaire (BCQ) (see entry“Body Checking Questionnaire (BCQ)” byReas), body avoidance (see entry by Lydecker),body acceptance (see entry “Body Image Accep-tance and Action Questionnaire” by Pellizzer),body self relations (see entry “MultidimensionalBody–Self Relations Questionnaire (MBSRQ)”by Cash), Overevaluation of Shape and Weightand shape and weight concern (see entries “Over-evaluation of Shape and Weight and Its Assess-ment,” “Eating Disorder Examination (EDE)/(EDE-Q),” and “Eating Disorder Questionnaire(EDQ)” by Murphy; Berg; Utzinger and Mitch-ell). The proliferation of questionnaires

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assessing this important aspect of eating disorderpsychopathology would benefit from somedegree of rationalization and specific recommen-dations about which are best used in what con-texts. Such work would be of benefit to clientsand clinicians alike.

Cross-References

▶Body Checking Questionnaire (BCQ)▶Body Image-Acceptance and ActionQuestionnaire

▶Body Image Avoidance Questionnaire (BIAQ)▶Eating Attitudes Test▶Eating Disorder Examination (EDE)/(EDE-Q)▶Eating Disorder Inventory▶Eating Disorder Questionnaire (EDQ)▶Multidimensional Body–Self Relations Ques-tionnaire (MBSRQ)

▶Overevaluation of Shape and Weight and ItsAssessment

References and Further Reading

Cooper, P., Taylor, M., Cooper, Z., & Fairburn, C. G.(1987). The development and validation of the BodyShape Questionnaire. International Journal of EatingDisorders, 6, 485–494.

Dowson, J., & Henderson, L. (2001). The validity of ashort version of the Body Shape Questionnaire. Psy-chiatry Research, 102, 263–271.

Evans, C., & Dolan, B. (1993). Body Shape Questionnaire:Derivation of shortened alternate forms. InternationalJournal of Eating Disorders, 13, 315–321.

Franko, D. L., Jenkins, A., Roehrig, J. P., Luce, K. H.,Crowther, J. H., & Rodgers, R. H. (2012). Psychomet-ric properties of measures of eating disorder risk inLatina college women. International Journal of EatingDisorders, 45(4), 592–596.

Probst, M., Pieters, G., & Vanderlinden, J. (2008). Evalu-ation of body experience questionnaires in eating dis-orders in female patients (AN/BN) and nonclinicalparticipants. International Journal of Eating Disor-ders, 41(7), 657–665.

Warren, C. S., Cepeda-Benito, A., Gleaves, D. H., Moreno,S., Rodriguez, S., . . . Pearson, C. A. (2008). Englishand Spanish versions of the Body Shape Questionnaire:Measurement equivalence across ethnicity and clinicalstatus. International Journal of Eating Disorders,41(3), 265–272.

Body Size Distortion

▶Neuroscientifically Informed Models of BodyImage Distortion in Eating Disorders

Body Size Overestimation

▶Body Distortion: Perceptual Measurement ofBody Image Disturbance▶Neuroscientifically Informed Models of BodyImage Distortion in Eating Disorders

Bone Density

▶Bone Health

Bone Health

Debra K. Katzman1,2 and Catherine M. Gordon31Division of Adolescent Medicine, Department ofPediatrics, The Hospital for Sick Children andUniversity of Toronto, Toronto, ON, Canada2Undergraduate Medical Education, University ofToronto School of Medicine, Toronto, ON,Canada3Division of Adolescent and Transition Medicine,Cincinnati Children’s Hospital Medical Center,University of Cincinnati College of Medicine,Cincinnati, OH, USA

Synonyms

Bone density; Bone mineral density; Low bonemineral density; Osteoporosis

Definition

Bone health is as a public health issue.Maintaining a healthy skeleton is an importantandcomplex process. Many things can interfere

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with the development of healthy bones. Forinstance, genetic abnormalities, nutritional defi-ciencies and hormonal disorders can affect theskeleton. In addition, lack of exercise, immobili-zation, alcohol use, certain medications andsmoking can also have negative effects on bonemass and strength. Many disorders can also affectthe skeleton. Anorexia nervosa, an eating disorderthat primarily affects adolescent girls and youngwomen, associated with low bone mineral densityand osteoporosis in adults. Anorexia nervosa ischaracterized by persistent restriction of energyintake leading to low body weight; an intensefear of gaining weight or of becoming fat or per-sistent behavior that impedes weight gain; anddisordered body image or lack of recognition ofthe seriousness of the low body weight. Anorexianervosa has significant physical consequences.Affected individuals can experience nutritional(low caloric intake, poor calcium and vitamin Dintake) and hormonal (hypothalamic hypo-gonadism) problems that negatively impact bonedensity, putting these individuals at risk forfractures.

Background

Adolescence is a critical window for bone accre-tion as adolescents gain 40–60% of peak bonemass during this developmental period. Havinganorexia nervosa (AN) is a major risk factor forlow bone mineral density (BMD). BMD andcompromised skeletal strength are common com-plications of a restrictive eating disorder(Katzman and Misra 2013; DiVasta et al. 2014).Among adolescent girls and young women withAN, decreased BMD at the lumbar spine, a skel-etal site rich in metabolically active trabecularbone, is highly prevalent when compared withage-matched controls (Katzman and Misra 2013;Misra and Klibanski 2014a, b). Among maleswith AN, low bone density is more common athip regions compared to age-matched controls(Misra and Klibanski 2014b). A startling statisticis that less than 15% of adult women with ANhave been found to have a normal BMD (Katzmanand Misra 2013). Further, studies have shown that

patients with a history of AN have a two- tothreefold increased risk of bone fracture.

Current Knowledge

Pathophysiology of Bone Lossand Determinants of Bone Health in AnorexiaNervosaDeterminants of low BMD and impaired bonemicroarchitecture in AN include nutritional fac-tors, body composition changes, and numerousendocrine alterations (Misra and Klibanski2014b; Anastasia et al. 2014; Fazeli and Klibanski2014).

Decreased body mass index (BMI) and leanmass: Both BMI and lean body mass are impor-tant determinants of BMD. Adolescents with ANhave lower BMI and lean mass than healthy peers,and each is strongly correlated with lower arealBMD. In girls with AN, increases in lean mass areassociated with increases in bone turnovermarkers and BMD.

Changes in bone marrow fat: Individuals withAN have been shown to have higher bone marrowfat content in both the central and peripheral skel-eton, despite diminished subcutaneous and vis-ceral fat. Bone marrow fat content and BMDappear to be inversely correlated. These findingssuggest that increased marrow fat may contributeto low BMD in patients with AN, a relationshipthat remains an area of active research (Misra andKlibanski 2014a, b).

Changes in Hormone ProfilesIn the setting of prolonged nutritional restriction,there are significant changes in many of the hor-monal axes that impact bone (Misra and Klibanski2014a, b; Fazeli and Klibanski 2014). In addition,other factors impacted by energy status includeleptin, adiponectin, ghrelin, and peptideYY. These combined alterations have deleteriousskeletal effects, leading to decreased bone forma-tion or increased bone resorption or both andultimately low bone density.

Hypothalamic–pituitary–gonadal axis: The stateof low energy intake in AN results in the suppres-sion of the hypothalamic–pituitary–gonadal axis,

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clinically manifested as menstrual dysfunction oramenorrhea. Decreased pulsatility of gonadotropin-releasing hormone causes immature secretory pat-terns of both follicle-stimulating hormone andluteinizing hormone and low levels of estrogenand testosterone. Young male and female adoles-cents with AN have lower levels of estradiol andtestosterone than controls, each a predictor of lowBMD. In adolescent girls with AN, a longer dura-tion of amenorrhea (>6 months in one study) andlater menarchal age are determinants of bone den-sity impairment.

Growth Hormone (GH) - Insulin-like growthfactor I (IGF-I) axis: Hepatic IGF-I secretiondecreases as body mass index (BMI) and bodyfat decline. IGF-I enhances bone formationthrough its action on mature osteoblasts, and cir-culating IGF-I is important for preservation ofcortical bone mass. IGF-I levels in patients withAN are positively correlated with BMD,irrespective of BMI levels. Adolescents with ANhave low IGF-I levels despite high GH levels,reflecting an acquired GH resistance. As such,bone formation rates are decreased, associatedwith decreased bone turnover. In one study, theadministration of supraphysiologic GH doses toadult women with AN was not shown to increaselevels of IGF-I or bone formation markers (Fazeliet al. 2010). This observation reinforces the rolethat GH resistance and low IGF-I levels play inimpaired bone metabolism in AN.

Hypothalamic–pituitary–thyroid axis: Thyroidfunction may also be altered, with low T3 and lowor low normal thyroxine which is thought to berelated to diminished peripheral conversion. Inaddition, thyroid-stimulating hormone is typicallylow or low normal. These findings are consistentwith a “sick euthyroid” state. The contribution ofthyroid axis alterations to bone loss in AN iscurrently unclear.

Hypothalamic–pituitary–adrenal axis: Indi-viduals with AN have higher serum and urinarycortisol levels than controls. Hypercortisolemiahas deleterious effects on bone strength and isdetrimental to the bone through enhanced osteo-blast and osteocyte apoptosis and reduced osteo-blast and osteoclast formation. Cortisol is alsoknown to increase the life span of osteoclasts

leading to a temporary increase in boneresorption.

Psychotropic medications: A common medica-tion used in individuals with AN is a selectiveserotonin reuptake inhibitor (SSRI). One studyreported that adolescents and young adults withAN taking SSRIs for more than 6 months hadlower BMD (Misra et al. 2010). In addition,SSRIs have been associated with accelerated hipbone loss in postmenopausal women, lower hipBMD in aged men, and increased risk for fragilityfractures in men and women over 50 years old.There is concern that SSRIs may have a harmfuleffect on bone mineral accrual if taken duringchildhood, a concerning finding as these agentsare prescribed for young adolescents with AN.

Measurement of Bone HealthThe most widely used imaging tool for the assess-ment of bone health is dual-energy x-ray absorp-tiometry (DXA), a measure of bone mineralcontent in a projected bone area (Gordonet al. 2014; Lewiecki et al. 2008). A BMDT-score (for adults) or Z-score (for adolescents)is generated by the scanner, which is then adjustedfor age, gender, and often ethnicity. The interpre-tation of DXA Z-scores, which provide atwo-dimensional assessment of bone density, canbe challenging due to potential confounding bybone size. In an adolescent with growth deficitsand short stature due to chronic AN, DXA resultsmay overestimate skeletal losses. Therefore, bonemineral content and BMD should be adjusted forheight in those with delayed growth or puberty, aserious complication of AN. Despite these limita-tions, DXA is a widely used densitometric tech-nique that is safe, rapid, and reproducible and haslow-radiation exposure. Individuals with ANshould have DXA scans obtained annually duringthe period of restrictive eating due to a knownhigh risk for low BMD and ongoing skeletallosses.

Different groups of investigators use varyingcriteria to define skeletal losses and states of bonehealth, and preferred terminology also variesbetween children/adolescents and adults. TheInternational Society for Clinical Densitometry(ISCD) recommends the term “osteopenia” not

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be used in pediatrics and should be reserved todescribe deficits in bone mass in adults. ISCD hasidentified “low bone mass or BMD” (defined asBMD Z-score <�2.0 SD) as the preferred termfor identifying children and adolescents withcompromised skeletal health. According to recentISCD guidelines, a diagnosis of osteoporosis mustinclude both a documented low bone mass byDXA and evidence of skeletal fragility (Gordonet al. 2014; Lewiecki et al. 2008). Recent technol-ogy has improved a clinician’s ability to evaluatebone health with greater accuracy in the form ofaxial and peripheral quantitative computedtomography (QCT). These assessment tools pro-vide a measurement of volumetric BMD and aremore accurate than DXA, particularly in growingadolescent patients whose bone size changes overtime and for individuals with chronic illness.However, the high radiation dose associated withaxial QCT has limited its utility in general clinicalpractice. In contrast, peripheral QCT, and espe-cially high-resolution peripheral QCT, examinesbone microarchitecture with increased precision.Although these technologies are often availableonly at academic centers, ongoing research con-tinues to consider whether computed tomographyshould be used as part of routine clinical practice.

Management of Low Bone Densityin Anorexia Nervosa

Weight Gain and Resumption of MenstrualFunctionIn patients with AN, the best approach to manag-ing bone health is treatment of the eating disorder,including normalization of weight and resumptionof menstrual function (Misra and Klibanski2014a, b). Studies in adolescents with AN haveshown that weight gain and menstrual restorationhalt skeletal losses. On the other hand, studies inadults have shown that while there is someimprovement in bone accrual with weight gain,BMD remains lower than in healthy controls andcatch-up does not occur.Weight restoration can bedifficult to achieve and sustain in patients withAN. Therefore, it is critical to identify effectivetherapies to counter low bone density in thispopulation.

CalciumSufficient calcium intake during adolescence isneeded to maximize skeletal growth during thepubertal growth spurt. Given the known beneficialeffects of calcium on bone mineralization amonghealthy youth, it is important to optimize intake ofthis micronutrient in patients with AN. Calciumrequirements are ideally achieved through thediet. The Institute of Medicine recommends1,000 mg/day of calcium for 4–8-year-olds and1,300 mg for those aged 9–18 years. In adoles-cents with AN, reaching these nutritional goalscan be challenging, and supplementation may beneeded.

Vitamin DVitamin D is necessary for efficient intestinal cal-cium absorption. Higher intake of vitamin D isassociated with lower risk for stress fracturesamong healthy adolescent girls (Sonnevilleet al. 2012). There are no randomized controlledtrials (RCTs) examining the use of vitamin Dsupplementation on bone density in AN.However, at least 600 IU of vitamin D per day isrecommended to optimize bone health.

Physical ActivityAmong healthy children, engaging in physicalactivity early in life improves bone mass. Further,regularly menstruating adolescents are known tohave a higher bone mass than sedentary controls.However, once young women become amenor-rheic, the protective effect of exercise is lost.There are also data to suggest that physical activ-ity may be detrimental in severely ill subjects withAN. Physical activity needs to be carefullyweighed against delayed weight gain, prolongedamenorrhea, and the risk of fractures in youngwomen with AN.

Estrogen Replacement TherapyThe hypoestrogenic state in adolescents with ANis a risk factor for reduced BMD. Studies suggestthat the use of oral contraceptives in these patientsis not beneficial for bone health. Klibanskiet al. conducted a randomized placebo-controlledtrial testing skeletal effects of estrogen replace-ment therapy in 48 adults with AN. Patients were

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followed for a mean of 1.5 years. The trial foundno significant difference in lumbar spine BMDbetween the two groups. Only the most severelymalnourished subjects (<70% of ideal bodyweight) exhibited protective effects from oralestrogen (Klibanski et al. 1995). A prospectiveobservational study of 50 adolescent femaleswith AN demonstrated no significant differencesin lumbar spine or femoral neck BMD betweengroups at 1 year. Despite treatment, reduction inBMD was persistent and, in some cases, progres-sive (Golden et al. 2002). In a multicenter, ran-domized, double-blind, placebo-controlled trialconducted on adolescent girls between 11 and17 years of age with AN, treatment with a tri-phasic oral contraceptive containing norgestimateand 35 mg of ethinyl estradiol did not increaselumbar spine or hip BMD after 1 year(Strokosch et al. 2006). Finally, a systematicreview and meta-analyses reviewing the effectsof oral estrogen preparations on bone health inwomen with AN concluded that there was inade-quate evidence to support the use of estrogen asmonotherapy for low bone density and that mostwomen with AN should refrain from its use (Simet al. 2010). Oral estrogen is not effective inincreasing BMD, likely due to the suppression ofthe hepatic synthesis of IGF-I. An 18-month RCTshowed that physiological estrogen replacementas transdermal 17b-E2 with cyclic progesteronecompared to placebo increased bone accrual ratesat the spine and hip in adolescents with AN (Misraet al. 2011). Transdermal estrogen avoids thehepatic first-pass effect and therefore has a neutraleffect on IGF-I secretion. Although these adoles-cents exhibited similar rates of increase in BMDas compared with healthy adolescents, physiolog-ical estrogen replacement did not lead to “catch-up” of BMD, as other hormonal abnormalitieslikely persisted.

Recombinant Human IGF-IIGF-I is important for promoting skeletal growthduring puberty and for bone maintenance. Thedeficiency of IGF-I may contribute to decreasedrates of bone formation and low bone density inAN. One trial showed that adult women random-ized to either placebo or supraphysiologic doses

recombinant human GH (rhGH) treatment for12 weeks did not differ with respect to IGF-Ilevels and bone formation markers, likely becauseof a relative GH resistance in AN. However,rhIGF-I replacement in doses that normalizeIGF-I levels led to an increase in bone formationmarkers in adults and adolescents with AN (Fazeliet al. 2010). Grinspoon et al. randomized 60 adultwomen with AN to one of four treatment groups:rhIGF-I alone, an oral contraceptive alone, thecombination of rhIGF-I and oral contraceptive,or placebo. Bone density was measured at base-line and 9 months. The investigators found thatbone density increased the most (1.8%) in womentaking both rhIGF-I and oral contraceptive com-pared to no treatment (Grinspoon et al. 2002).

TestosteroneAndrogens promote bone formation in AN. Bothmen and women with AN are deficient in testos-terone (Misra and Klibanski 2014b; Fazeli andKlibanski 2014). Increases in testosterone levelswith weight gain were predictive of increases inBMD. However, administration of a low-dosepatch of testosterone was not effective in increas-ing bone density over a 1-year period in adultswith AN, even though increases in lean body massand bone formation markers were seen. Theeffects of testosterone replacement on bone inadolescent boys and adult men with AN areunknown.

Dehydroepiandrosterone (DHEA)Young women with AN may have low circulatingDHEA concentrations that contribute to skeletaldeficits. Gordon et al. conducted a double-blind,randomized trial comparing the administrationof 50 mg/day of DHEA to a combinationestrogen–progestin pill (20 ug ethinyl estradiol/0.1 mg levonorgestrel) for 1 year in adolescentswith AN. There was no change in bone density ineither treatment group after controlling for weightgain. However, they observed a significantincrease in hip BMD in both treatment groupsthat correlated with weight gain and increases inIGF-I levels (Gordon et al. 2002). DiVasta et al.conducted an 18-month double-blind, random-ized, placebo-controlled trial, investigating the

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effects of the co-administration of oralDHEA with combined oral contraceptive versusplacebo on changes in bone geometry in youngwomen with AN (Divasta et al. 2012). The com-bined treatment resulted in the preservation ofBMD at the lumbar spine, hip, and whole body,while patients in the control group experiencedfurther bone loss. This combination treatment alsohad a beneficial impact on cortical thickness at thefemur and surrogate measures of hip bonestrength (DiVasta et al. 2014).

Recombinant Human LeptinThe administration of leptin to patients with AN, agroup known to be leptin deficient, has potentialincongruous effects. Leptin is bone anabolic, andits administration has been shown to restore men-ses in 60–70% of normal weight women withhypothalamic amenorrhea. On the other hand,leptin administration leads to reduction in appe-tite, body weight, and fat mass. To date, one 9-month RCT using metreleptin in adult womenwith hypothalamic amenorrhea showed increasesin bone mineral content (Sienkiewicz et al. 2011).This therapy has not been studied in adolescentswith AN.

BisphosphonatesBisphosphonates are known to inhibit boneresorption by decreasing osteoclast function. A 1-year RCT found a significant increase in BMD inadult women with AN treated with 5 mg ofrisedronate daily compared to placebo (Milleret al. 2011); spine and hip BMD increased by 3%and 2% in the treated group. However, an RCT inadolescents treated with alendronate compared toplacebo showed no improvement in spine BMDwith alendronate after 1 year (Golden et al. 2005).Bisphosphonates have a long half-life, which hasraised concerns about using these agents in youngwomen of reproductive age due to unknown sideeffects, including potential teratogenicity.

Current Controversies in Management

Weight gain and resumption of normal menstrualperiod remains the first-line goal, although it is

often difficult to achieve and sustain in individualswith AN. To date, there are limited well-studiedand effective therapeutic strategies that have beensuccessful in improving low bone density. Ifweight restoration is not possible, one might con-sider pharmacotherapy in women with AN whohave low bone density and a clinically significantfracture history (per ISCD guidelines) (Lewieckiet al. 2008). In adolescent females with AN whoare unable to gain or sustain a healthy bodyweight, have a prolonged illness, and havedecreasing BMD over time, one might considerhormone replacement therapy using transdermal17b-estradiol (100 mcg daily) with cyclic proges-terone (micronized progesterone 100 mg daily for10 days of every month).

Future Directions

Bone health in individuals with AN may deterio-rate rapidly during the course of this debilitatingdisease. Threats to skeletal health can be mini-mized with early identification of illness, aggres-sive weight restoration, and ongoinginterdisciplinary management of the diseasethrough psychiatric, medical, and nutritional sup-port. However, ongoing efforts to refine boneassessment technologies and the identification ofboth anabolic and anti-resorptive skeletal agentsmay help to preserve bone health in these patients.Further research is needed to establish treatmentoptions that best preserve bone density and skel-etal strength during the often slow process ofweight gain and psychological recovery.

Cross-References

▶Anorexia Nervosa▶Avoidant/Restrictive Food Intake Disorder(ARFID)

▶Binge Eating Disorder▶Bulimia Nervosa▶Childhood Anorexia Nervosa andDevelopment

▶Eating Disorders in Boys and Men▶Exercise/Physical Activity

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▶ Feeding Disorders, Assessment of▶Medical Complications: Adults (pregnancy)▶Nasogastric Refeeding▶ Pubertal Development and Timing▶ Purging Behaviors▶Refeeding▶ Special Considerations in the Assessment ofChildren and Adolescents

▶ Starvation in Children, Adolescents, and YoungAdults: Relevance to Eating Disorders

References and Further Reading

Anastasia, D., Lyritis, G. P., & Tournis, S. (2014). Bonedisease in anorexia nervosa. Hormones, 13(1), 38–56.

Divasta, A. D., Feldman, H. A., Giancaterino, C., Rosen,C. J., Leboff,M. S., &Gordon, C.M. (2012). The effectof gonadal and adrenal steroid therapy on skeletalhealth in adolescents and young women with anorexianervosa. Metabolism, 61(7), 1010–1020. Epub 2012/01/20.

DiVasta, A. D., Feldman, H. A., Beck, T. J., LeBoff, M. S.,& Gordon, C. M. (2014). Does hormone replacementnormalize bone geometry in adolescents with anorexianervosa? Journal of Bone andMineral Research, 29(1),151–157. Epub 2013/06/08.

Fazeli, P. K., & Klibanski, A. (2014). Anorexia nervosa andbone metabolism. Bone, 66, 39–45. Epub 2014/06/03.

Fazeli, P. K., Lawson, E. A., Prabhakaran, R., Miller, K. K.,Donoho, D. A., Clemmons, D. R., et al. (2010). Effectsof recombinant human growth hormone in anorexianervosa: A randomized, placebo-controlled study.Journal of Clinical Endocrinology and Metabolism,95(11), 4889–4897. Epub 2010/07/30.

Golden, N. H., Lanzkowsky, L., Schebendach, J., Palestro,C. J., Jacobson, M. S., & Shenker, I. R. (2002). Theeffect of estrogen-progestin treatment on bone mineraldensity in anorexia nervosa. Journal of Pediatric andAdolescent Gynecology, 15(3), 135–143.

Golden, N. H., Iglesias, E. A., Jacobson, M. S., Carey, D.,Meyer, W., Schebendach, J., et al. (2005). Alendronatefor the treatment of osteopenia in anorexia nervosa:A randomized, double-blind, placebo-controlled trial.Journal of Clinical Endocrinology and Metabolism,90(6), 3179–3185. Epub 2005/03/24.

Gordon, C. M., Grace, E., Emans, S. J., Feldman, H. A.,Goodman, E., Becker, K. A., et al. (2002). Effects oforal dehydroepiandrosterone on bone density in youngwomen with anorexia nervosa: A randomized trial.Journal of Clinical Endocrinology and Metabolism,87(11), 4935–4941. Epub 2002/11/05.

Gordon, C. M., Leonard, M. B., & Zemel, B. S. (2014).2013 pediatric position development conference: Exec-utive summary and reflections. Journal of ClinicalDensitometry, 17(2), 219–224. Epub 2014/03/25.

Grinspoon, S., Thomas, L., Miller, K., Herzog, D., &Klibanski, A. (2002). Effects of recombinant humanIGF-I and oral contraceptive administration on bonedensity in anorexia nervosa. Journal of Clinical Endo-crinology and Metabolism, 87(6), 2883–2891.

Katzman, D. K., & Misra, M. (2013). Bone health inadolescent females with anorexia nervosa: What is aclinician to do? International Journal of Eating Disor-ders, 46(5), 456–460. Epub 2013/05/10.

Klibanski, A., Biller, B. M., Schoenfeld, D. A., Herzog,D. B., & Saxe, V. C. (1995). The effects of estrogenadministration on trabecular bone loss in young womenwith anorexia nervosa. Journal of Clinical Endocrinol-ogy and Metabolism, 80(3), 898–904. Epub 1995/03/01.

Lewiecki, E. M., Gordon, C. M., Baim, S., Leonard, M. B.,Bishop, N. J., Bianchi, M. L., et al. (2008). Interna-tional society for clinical densitometry 2007 adult andpediatric official positions. Bone, 43(6), 1115–1121.Epub 2008/09/17.

Miller, K. K., Meenaghan, E., Lawson, E. A., Misra, M.,Gleysteen, S., Schoenfeld, D., et al. (2011). Effects ofrisedronate and low-dose transdermal testosterone onbone mineral density in women with anorexia nervosa:A randomized, placebo-controlled study. Journal ofClinical Endocrinology and Metabolism, 96(7),2081–2088. Epub 2011/04/29.

Misra, M., & Klibanski, A. (2014a). Anorexia nervosa andbone. Journal of Endocrinology, 221(3), R163–R176.Epub 2014/06/06.

Misra, M., & Klibanski, A. (2014b). Endocrine conse-quences of anorexia nervosa. The Lancet Diabetesand Endocrinology, 2(7), 581–592. Epub 2014/04/16.

Misra, M., Le Clair, M., Mendes, N., Miller, K. K.,Lawson, E., Meenaghan, E., et al. (2010). Use ofSSRIs may impact bone density in adolescent andyoung women with anorexia nervosa. CNS Spectrums,15(9), 579–586. Epub 2010/09/01.

Misra, M., Katzman, D., Miller, K. K., Mendes, N.,Snelgrove, D., Russell, M., et al. (2011). Physiologicestrogen replacement increases bone density in adoles-cent girls with anorexia nervosa. Journal of Bone andMineral Research, 26(10), 2430–2438. Epub 2011/06/24.

Sienkiewicz, E., Magkos, F., Aronis, K. N., Brinkoetter,M., Chamberland, J. P., Chou, S., et al. (2011). Long-term metreleptin treatment increases bone mineral den-sity and content at the lumbar spine of lean hypo-leptinemic women. Metabolism, 60(9), 1211–1221.Epub 2011/07/12.

Sim, L. A., McGovern, L., Elamin, M. B., Swiglo, B. A.,Erwin, P. J., & Montori, V. M. (2010). Effect on bonehealth of estrogen preparations in premenopausalwomen with anorexia nervosa: A systematic reviewand meta-analyses. International Journal of EatingDisorders, 43(3), 218–225. Epub 2009/04/08.

Sonneville, K. R., Gordon, C. M., Kocher, M. S., Pierce,L. M., Ramappa, A., & Field, A. E. (2012). Vitamin D,calcium, and dairy intakes and stress fractures among

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female adolescents. Archives of Pediatrics and Adoles-cent Medicine, 166(7), 595–600. Epub 2012/03/07.

Strokosch, G. R., Friedman, A. J., Wu, S. C., & Kamin, M.(2006). Effects of an oral contraceptive (norgestimate/ethinyl estradiol) on bone mineral density in adolescentfemales with anorexia nervosa: A double-blind,placebo-controlled study. Journal of AdolescentHealth, 39(6), 819–827.

Bone Mineral Density

▶Bone Health

Brain Stimulation Treatments

▶Neuromodulation Treatments

Brain-Directed Interventions

▶Neuromodulation Treatments

Brief Analytic Therapy

▶ Psychodynamic Model

Brief Eating Disorder Assessment

▶Eating Disorder Screening Measures

Bulimia Nervosa

Carol B. Peterson, Emily M. Pisetsky andKelly C. BergDepartment of Psychiatry, The University ofMinnesota, Minneapolis, MN, USA

Definition

The current diagnosis of bulimia nervosa in theDiagnostic and Statistical Manual of Mental

Disorders, Fifth Edition (DSM-5; APA 2013)and the International Classification of Diseases-10 (1992) is characterized by repeated episodesof binge eating, accompanied by compensatorybehaviors to prevent weight gain, including self-induced vomiting, laxative/diuretic misuse,fasting, and compensatory exercise. TheDSM-5 also includes severity specifiers basedon current average frequency of inappropriatecompensatory behaviors per week (e.g.,mild = 1–3; moderate = 4–7; severe = 8–13;extreme = 14 or greater).

Historical Background

Although historical records suggest that overeat-ing and purging were observed several centuriesago and case histories were reported in the early1900s, Gerald Russell first described bulimianervosa in the scientific literature as an “ominousvariant” of anorexia nervosa in 1979. In currentnomenclature, “bulimia” was first included inDSM-III, which emphasized only the occurrenceof binge eating. In DSM-III-R, compensatorybehaviors and overconcern with weight andshape were added to the criteria. DSM-IV revisedthe definition of binge eating to require the con-sumption of a “clearly” large amount of foodalong with the subjective experience of a lack ofcontrol over eating. In addition, DSM-IV speci-fied that binge eating must occur along with com-pensatory behavior at least twice a week for3 months, that the diagnosis required an overvalu-ation of shape and weight, and that individualswith bulimic symptoms who met the criteria foranorexia nervosa should not be given the concur-rent diagnosis of bulimia nervosa (i.e., DSM-IVspecified that individuals meeting criteria for bothanorexia nervosa and bulimia nervosa should beclassified as having the binge-eating/purging sub-type of anorexia nervosa). Finally, DSM-IVaddeda subtyping classification of purging (i.e., self-induced vomiting, misuse of laxatives/diuretics)and non-purging (i.e., fasting, excessive exercise)bulimia nervosa. Most recently, DSM-5 (APA2013) reduced the average frequency thresholdto weekly episodes of binge eating and

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compensatory behaviors for 3 months in order tobroaden the criteria and reduce the prevalence ofnot otherwise specified and unspecified eatingdisorder diagnoses (Call et al. 2013). DSM-5also eliminated the purging/non-purging sub-typing because of the lack of data supporting itsvalidity (van Hoeken et al. 2009).

Current Knowledge

The 12-month prevalence of bulimia nervosa isestimated at 0.9–1.5%, and bulimia nervosa isslightly more prevalent in females than males(APA 2013; Hudson et al. 2007; Sminket al. 2012; Swanson et al. 2011). Both geneticand environmental factors are associated with therisk of developing bulimia nervosa (APA 2013).The onset occurs typically during adolescence oryoung adulthood and, although the clinicalcourse is variable, most remain symptomatic forseveral years (APA 2013; Swanson et al. 2011).Bulimia nervosa in adolescents and adults ishighly comorbid with several psychiatric disor-ders, including depression, anxiety, and sub-stance use disorders, as well as elevated suiciderisk (APA 2013; Hudson et al. 2007; Swansonet al. 2011). Although diagnostic crossover fromanorexia nervosa to bulimia nervosa is common,the transition from bulimia nervosa to anorexianervosa occurs less frequently (APA 2013). Mor-tality is elevated in individuals with bulimianervosa due to both medical complications andhigh rates of suicide (APA 2013; Sminket al. 2012). Less than half of adult individualswith BN seek specialized treatment (Hudsonet al. 2007). Although rates of treatment-seekingindividuals have been found to be slightly higheramong adolescents with BN, they nonetheless donot typically receive specialized care (Swansonet al. 2011). A number of evidence-based outpa-tient psychotherapies have been found to behelpful in the treatment of bulimia nervosaincluding cognitive-behavioral therapy(Fairburn 2008) and interpersonal therapy. Theempirical support of pharmacological interven-tions including selective serotonin reuptakeinhibitors is more modest.

Current Controversies

One of the most significant ongoing challenges inthe context of classification is to establish thevalidity of the bulimia nervosa criteria. Perhapsthe most controversial criterion is the requirementthat binge-eating episodes consist of the con-sumption of a large amount of food. A numberof studies have found that “subjective” episodes,in which the amount of food is not objectivelylarge by clinical rating but the individual experi-ences a sense of loss of control and believes thathe or she has overeaten (Fairburn 2008), are asso-ciated with similar features, comorbidity, and dis-tress as DSM-5 defined episodes (Wolfeet al. 2009). For this reason, whether the criteriafor bulimia nervosa should require a threshold forwhat is considered an objectively large amount offood has been debated. Additionally, whetherthere are valid distinctions among bulimianervosa (characterized by large binge-eating epi-sodes accompanied by compensatory behaviors),purging disorder (characterized by purging in theabsence of self-reported binge eating), and “sub-threshold” bulimia nervosa (characterized by sub-jective episodes of binge eating accompanied bycompensatory behaviors) remains controversial(Keel and Striegel-Moore 2009). A related con-troversy is the extent to which DSM-5 andICD-10 criteria can be validated using empiricalclassification.

An additional problem with the bulimianervosa diagnostic criteria that influenced thedecision to broaden the DSM-IV criteria in theDSM-5 is that many individuals with bulimicsymptoms seeking treatment for eating disordersdid not meet strict criteria for the bulimia nervosadiagnosis (Call et al. 2013). These strict criteriaresulted in a preponderance of individuals witheating disorders who were given “not otherwisespecified” and/or “subthreshold” diagnosesdespite comparable levels of associated eatingdisorder and comorbid psychopathology. Thevalidity of the new criteria and the extent towhich they will be more inclusive and usefulclinically requires further investigation.

Finally, although diagnostic criteria have tradi-tionally relied on categorical definitions,

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dimensional methods of conceptualization andclassification are indicated (APA 2013). Alongwith the severity specifiers included in DSM-5,dimensional approaches along with empiricalclassification will potentially improve the reliabil-ity, validity, and utility of bulimia nervosaclassification.

Future Directions

Further validation of the diagnostic criteria forbulimia nervosa, particularly the binge-eatingsize criterion, is needed, along with assessmenttechniques that maximize reliability and validity.In addition, future investigations are needed tobetter integrate bulimia nervosa phenotypic clas-sification with neurobiological correlates as wellas state-of-the-art classification techniques,including empirical and dimensional approaches.

Cross-References

▶Bipolar Disorder and Eating Disorders▶Classification: The Transdiagnostic Perspective▶Eating Disorder Questionnaire (EDQ)▶Empirical Approaches to Classification▶Epidemiology of Eating Disorders▶ Future Directions in Classification▶ Impact of Psychiatric Comorbidity on EatingDisorder Outcomes

▶ Starvation in Children, Adolescents, and YoungAdults: Relevance to Eating Disorders

▶ Substance-Related Disorders in EatingDisorders

Reference and Further Reading

American Psychiatric Association. (2013). Diagnostic andstatistical manual of mental disorders (5th ed.). Wash-ington, DC: American Psychiatric Association.

Call, C., Walsh, B. T., & Attia, E. (2013). From DSM-IV toDSM-5: Changes to eating disorder diagnoses. CurrentOpinion Psychiatry, 26, 532–536.

Fairburn, C. G. (2008). Cognitive behavioral therapy andeating disorders. New York: Guilford.

Hudson, J., Hiripi, E., Pope, H. G., Jr., & Kessler, R. C.(2007). The prevalence and correlates of eating

disorders in the National Comorbidity Survey Replica-tion. Biological Psychiatry, 61, 348–358.

Keel, P. K., & Striegel-Moore, R. H. (2009). The validityand clinical utility of purging disorder. The Interna-tional Journal of Eating Disorders, 42, 706–719.

Smink, F. R. E., van Hoeken, D., & Hoek, H. W. (2012).Epidemiology of eating disorders. Current PsychiatryReport, 14, 406–414.

Swanson, S. A., Crow, S. J., Le Grange, D., Swendsen, J.,& Merikangas, K. R. (2011). Prevalence and correlatesof eating disorders in adolescents: Results from theNational Comorbidity Survey Replication AdolescentSupplement. Archives of General Psychiatry, 68,714–723.

van Hoeken, D., Veling, W., Sinke, S., Mitchell, J. E., &Hoek, H. W. (2009). The validity and utility of sub-typing bulimia nervosa. International Journal of Eat-ing Disorders, 42, 595–602.

Wolfe, B. E., Baker, C. W., Smith, A. T., & Kelly-Weeder,S. (2009). Validity and utility of the current definitionof binge eating. International Journal of Eating Disor-ders, 42, 674–686.

World Health Organization. (1992). International Classi-fication of Diseases-10 classification of mental andbehavioral disorders: Clinical descriptions and diag-nostic guidelines. Geneva: World HealthOrganization.

Bulimia Nervosa (BN)

▶Multifamily Interventions with Adolescent Eat-ing Disorders

Bulimia Test-Revised (BULIT-R)

Tracey WadeSchool of Psychology, Flinders University,Adelaide, SA, Australia

Definition

The Bulimia Test-revised (BULIT-R) is a self-report questionnaire that contains 28 scoreditems covering all of the DSM-III-R criteria (seeTable 1) and 8 unscored items referring to specificweight-control behaviors. All items are presentedin a five-point, forced-choice, Likert format, inwhich responses were mutually exclusive.

Bulimia Test-Revised (BULIT-R), Table 1 Bulimia Test-revised items

Item Five-point rating scale

I am satisfied with my eatingpatterns

Agree Neutral Disagree a little Disagree Disagreestrongly

Would you presently callyourself a “binge eater?”

Yes, absolutely Yes Yes, probably Yes,possibly

No,probably not

Do you feel you have controlover the amount of food youconsume?

Most or all ofthe time

A lot of thetime

Occasionally Rarely Never

I am satisfied with the shape andsize of my body

Frequently oralways

Sometimes Occasionally Rarely Seldom ornever

When I feel that my eatingbehavior is out of control, I try totake rather extreme measures toget back on course (strict dieting,fasting, laxatives, diuretics, self-induced vomiting, or vigorousexercise)

Always Almostalways

Frequently Sometimes Never

I am obsessed about the size andshape of my body

Always Almostalways

Frequently Sometimes Seldom ornever

There are times when I rapidlyeat a very large amount of food

More than twicea week

Twice aweek

Once a week Two tothree timesa month

Once amonth orless

How long have you been bingeeating (eating uncontrollably tothe point of stuffing yourself)?

I do not bingeeat

Less than3 months

3 months–1 year 1–3 years 3 or moreyears

Most people I know would beamazed if they knew how muchfood I can consume at one sitting

Without a doubt Veryprobably

Probably Possibly No

Compared with women at yourage, how preoccupied are youabout your weight and bodyshape?

A great dealmore thanaverage

Muchmore thanaverage

More thanaverage

A littlemore thanaverage

Average orless thanaverage

I am afraid to eat anything forfear that I would not be able tostop

Always Almostalways

Frequently Sometimes Seldom ornever

I feel tormented by the idea thatI am fat or might gain weight

Always Almostalways

Frequently Sometimes Seldom ornever

How often do you intentionallyvomit after eating?

Two or moretimes a week

Once aweek

Two to threetimes a month

Once amonth

Less thanonce amonth

I eat a lot of food when I am noteven hungry

Very frequently Frequently Occasionally Sometimes Seldom ornever

My eating patterns are differentfrom the eating patterns of mostpeople

Always Almostalways

Frequently Sometimes Seldom ornever

After I binge eat, I turn to one ofseveral strict methods to try tokeep from gaining weight(vigorous exercise, strict dieting,fasting, self-induced vomiting,laxatives, or diuretics)

Never or I donot binge eat

Rarely Occasionally A lot of thetime

Most or allof the time

When engaged in an eatingbinge, I tend to eat foods that arehigh in carbohydrates (sweetsand starches)

Always Almostalways

Frequently Sometimes Seldom ornever

(continued)

Bulimia Test-Revised (BULIT-R) 109

B

Bulimia Test-Revised (BULIT-R), Table 1 (continued)

Item Five-point rating scale

Compared to most people, myability to control my eatingbehavior seems to be

Greater thanothers’ ability

About thesame

Less Much less I haveabsolutelyno control

I would presently label myself a“compulsive eater” (one whoengages in episodes ofuncontrolled eating)

Yes, absolutely Yes Yes, probably Yes,possibly

No,probably not

I hate the way my body looksafter I eat too much

Seldom ornever

Sometimes Frequently Almostalways

Always

When I am trying to keep fromgaining weight, I feel that I haveto resort to vigorous exercise,strict dieting, fasting, self-induced vomiting, laxatives, ordiuretics

Never Rarely Occasionally A lot of thetime

Most or allof the time

Do you believe that it is easierfor you to vomit than it is formost people?

Yes, it is noproblem at allfor me

Yes, it iseasier

Yes, it is a littleeasier

About thesame

No, it is lesseasy

I feel that food controls my life Always Almostalways

Frequently Sometimes Seldom ornever

When consuming a largequantity of food, at what rate ofspeed do you usually eat?

More rapidlythan mostpeople haveever eaten intheir lives

A lot morerapidlythan mostpeople

A little morerapidly thanmost people

About thesame rateas mostpeople

More slowlythan mostpeople/notapplicable

Right after I binge eat, I feel So fat andbloated.I cannot stand it

Extremelyfat

Fat A little fat Okay abouthow mybody looks/never bingeeat

Compared to other people of mysex, my ability to always feel incontrol of how much I eat is

About the sameor greater

A little less Less Much less A great dealless

In the last 3 months, on theaverage, how often did youbinge eat (eat uncontrollably tothe point of stuffing yourself)?

Once a monthor less(or never)

Two tothree timesa month

Once a week Twice aweek

More thantwice aweek

Most people I know would besurprised at how fat I look afterI eat a lot of food

Yes, definitely Yes Yes, probably Yes,possibly

No,probablynot, orI never eat alot of food

110 Bulimia Test-Revised (BULIT-R)

Responses are scored by giving up to five pointsfor each where a higher score indicates greaterfrequency or strength of bulimic behaviors.BULIT-R scores are computed by summingresponses to the 28 scored items, and scores canrange from 28 (no symptoms) to 140 (elevatedsymptoms), where scores >104 can be used as acutoff to indicate caseness.

Historical Background

The BULIT was first developed in 1984 to assessbulimia nervosa based on the DSM-III criteria. In1991, an evaluation of the BULIT-R appeared,with the self-report items updated to assessDSM-III-R criteria for bulimia nervosa. It wasdeveloped over four stages with a number of

Bulimia Test-Revised (BULIT-R) 111

B

different groups of women, including womenbeing treated for bulimia nervosa and healthycontrols (Thelen et al. 1991). Further investiga-tion suggests that it appears to be a valid instru-ment with which to identify individuals who meetDSM-IV criteria for bulimia nervosa (Thelenet al. 1996).

The original factor structure of the BULIT-Rrevealed five similar, yet inconsistent factors, attwo different stages of scale development. At thefirst stage of data analysis, the five factors identi-fied for females were (1) binging and control,(2) radical weight loss and body image, (3) laxa-tive and diuretic use, (4) self-induced vomiting,and (5) exercise. A similar five-factor structurewas evident in the second study, with the excep-tion of body image which loaded on the bingingand control factor. Additionally, laxative use fac-tored with vomiting rather than diuretic use.

Current Knowledge

Two examinations of the BULIT-R in communityadolescent populations have been conducted. Inthe first study (Vincent et al. 1999), 603 secondaryschool students participated, which included306 girls aged between 11 and 17 years(M = 13.66, S.D. = 1.12) and 297 boys agedbetween 11 and 18 years (M = 13.89,S.D. = 1.13). In the second study (McCarthyet al. 2002), data were collected annually onthree occasions from two samples of 12–18-year-old females, one recruited from three publicmiddle schools (n = 239; mean age 12.8 years)and one from two public high schools (n = 119;mean age 15.9 years).

A factor analysis in the first study identifiedfour similar factors for adolescent boys and girls:binging, control, normative weight loss (dietingand exercise), and extreme weight loss behaviors(vomiting, diuretics, and laxatives). The four-factor structure extracted for girls accounted for61.4% of the total variance, and for boys, the four-factor structure accounted for 54.4% of the totalvariance. In this sample, the BULIT-R also dem-onstrated good reliability and adequate concurrent

validity with five questions measuring binge eat-ing as defined by the DSM-IV criteria for bingeeating.

The second study also gave results that pro-vided strong evidence for the reliability and sta-bility of the BULIT-R. Mean levels of the BULIT-R were remarkably consistent over 3 years, andthis lack of change raised questions about thedevelopmental trajectory of bulimic behaviorsthrough adolescence. Given that larger epidemio-logical studies show that binge eating and purgingare more likely to emerge in later adolescence,through to early adulthood, it may be that thesefindings simply reflect the lack of growth in thesebehaviors over that developmental period.

Current Controversies

There has been some difficulty experienced inobtaining a stable factor structure of the BULIT-R across different groups. A review of factoranalyses of the BULIT-R (Berrios-Hernandezet al. 2007) concluded that a number of solutionshad been identified, the four- and five-factor struc-ture previously outlined, as well as a one- andsix-factor structure. The authors conducted a con-firmatory factor analysis of the BULIT-R between200 European-American women from a south-western public university in the United Statesand 204 Spanish white women attending collegeat the University of Granada, Spain. They testedthe different BULIT-R models reported previ-ously by various investigators: a one-factormodel, a four-factor model, a five-factor model,and a six-factor model. All the models fit poorly,and therefore an exploratory factor analysis wasused to examine the structure in the cross-culturalsample. In the American sample, six factors wereidentified, but only four in the Spanish sample.Only two factors were the same between the twosamples and also were consistent with previousresults from other studies: binge eating and bodyconcerns.

An investigation of a subset of the 23 BULIT-R items which assess the binge eating, loss ofcontrol, and body image factors identified by

112 Burnout

Thelen et al. (1991) has shown it to be an excel-lent overall measure of binge eating disorder inobese populations (Vander Wal et al. 2011). Thismeasure, called the Binge Eating Disorder Test(BEDT), does not include items loading on fac-tors associated with purging behaviors, includingradical weight loss measures, laxative/diureticabuse, self-induced vomiting, and inappropri-ate/excessive exercise. The only exception wasthe addition of the item that assesses how theperson feels right after binge eating, designed tomeasure disgust with oneself after binge eating,one of the features of binge eating disorder. Thesensitivity, specificity, and positive and negativepredictive values of the BULIT-R, BEDT, andthe subscales of the Eating DisorderExamination-Questionnaire (EDE-Q) have beencompared with respect to the BEDT diagnosis(Vander Wal et al. 2011). Results indicated thatthe BEDT performed best across all these indi-ces, achieving 100%.

Future Directions

The usefulness of the BULIT-R with adolescentand young adult community samples requires fur-ther investigation. Therefore, it may be that its useis best limited to clinical populations at this time,but further work is required to ascertain its uniquecontribution compared to other self-report instru-ments which assess diagnostic criteria, such as theEating Disorder Examination.

Cross-References

▶Eating Disorder Questionnaire (EDQ)

References and Further Reading

Berrios-Hernandez, M. N., Rodriguez-Ruiz, S., Perez, M.,Gleaves, D. H., Maysonet, M., & Cepeda-Benito,A. (2007). Cross-cultural assessment of eating disor-ders: Psychometric properties of a Spanish version ofthe Bulimia Test-Revised. European Eating DisordersReview, 15(6), 418–424.

McCarthy, D.M., Simmons, J. R., Smith, G. T., Tomlinson,K. L., & Hill, K. K. (2002). Reliability, stability, andfactor structure of the Bulimia Test-Revised and eatingdisorder inventory-2 scales in adolescence. Assessment,9(4), 382–389.

Thelen, M. H., Farmer, J., Wonderlich, S., & Smith,M. (1991). A revision of the bulimia test: The BULIT-R. Psychological Assessment, 3, 119–124.

Thelen, M. H., Mintz, L. B., Vander, W., & Jillon,S. (1996). The Bulimia Test-Revised: Validation withDSM-IV criteria for bulimia nervosa. PsychologicalAssessment, 8(2), 219–221.

Vander Wal, J. S., Stein, R. I., & Blashill, A. J. (2011). TheEDE-Q, BULIT-R, and BEDT as self-report measuresof binge eating disorder. Eating Behaviours, 12(4),267–271.

Vincent, M. A., McCabe, M. P., & Ricciardelli, L. A.(1999). Factorial validity of the Bulimia Test-Revisedin adolescent boys and girls. Behaviour Research &Therapy, 37(11), 1129–1140.

Burnout

▶Assessment Burden