Abstract
Purpose
Appearance-related stress may result from appearance-focused events such as seeing one’s reflection, seeing media images, and shopping for clothes. The purpose of this study was to examine the prospective association between momentary appearance-related stress and eating disorder (ED) behaviors (i.e., binge eating and vomiting) among women with anorexia nervosa (AN) using ecological momentary assessment (EMA). We hypothesized that appearance-related stress at Time 1 would predict binge eating and vomiting at Time 2, and that this prospective association would be mediated by momentary anxiety at Time 2 (controlling for anxiety at Time 1).
Methods
Women with AN completed a 2-week EMA protocol involving repeated daily assessments of experiences and behaviors.
Results
Momentary appearance-related stress preceded binge eating and vomiting, and momentary anxiety mediated the prospective association between appearance-related stress and ED behaviors.
Conclusions
Targeted momentary interventions delivered in the natural environment that address appearance-related stress may have utility in the treatment of ED behaviors.
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References
American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Association, Washington, DC
Hudson JI, Hiripi E, Pope HG, Kessler RC (2007) The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry 61:348–358. doi:10.1016/j.biopsych.2006.03.040
Mason TB, Heron KE (2016) Do depressive symptoms explain associations between binge eating symptoms and later psychosocial adjustment in young adulthood? Eat Behav 23:126–130. doi:10.1016/j.eatbeh.2016.09.003
Solmi F, Sonneville KR, Easter A, Horton NJ, Crosby RD, Treasure J, Rodriguez A, Jarvelin MR, Field AE, Micali N (2015) Prevalence of purging at age 16 and associations with negative outcomes among girls in three community-based cohorts. J Child Psychol Psychiatry 56:87–96. doi:10.1111/jcpp.12283
Stice E, Bearman SK (2001) Body-image and eating disturbances prospectively predict increases in depressive symptoms in adolescent girls: a growth curve analysis. Dev Psychol 37:597–607. doi:10.1037/0012-1649.37.5.597
DaCosta M, Halmi KA (1992) Classifications of anorexia nervosa: question of subtypes. Int J Eat Disord 11:305–313. doi:10.1002/1098-108X(199205)11:4<305::AID-EAT2260110403>3.0.CO;2-2
Fouladi F, Mitchell JE, Crosby RD, Engel SG, Crow S, Hill L, Le Grange D, Powers P, Steffen KJ (2015) Prevalence of alcohol and other substance use in patients with eating disorders. Eur Eat Disord Rev 23:531–536
Hartmann AS, Thomas JJ, Greenberg JL, Elliott CM, Matheny NL, Wilhelm S (2015) Anorexia nervosa and body dysmorphic disorder: a comparison of body image concerns and explicit and implicit attractiveness beliefs. Body Image 14:77–84. doi:10.1016/j.bodyim.2015.03.013
Bamford BH, Attoe C, Mountford VA, Morgan F, Sly R (2014) Body checking and avoidance in low weight and weight restored individuals with anorexia nervosa and non-clinical females. Eat Behav 15:5–8. doi:10.1016/j.eatbeh.2013.10.011
Vocks S, Legenbauer T, Wächter A, Wucherer M, Kosfelder J (2007) What happens in the course of body exposure? Emotional, cognitive, and physiological reactions to mirror confrontation in eating disorders. J Psychosom Res 62:231–239. doi:10.1016/j.jpsychores.2006.08.007
Cooper MJ, Fairburn CG (1992) Thoughts about eating, weight and shape in anorexia nervosa and bulimia nervosa. Behav Res Ther 30:501–511. doi:10.1016/0005-7967(92)90034-E
Spettigue W, Henderson KA (2004) Eating disorders and the role of the media. Can Child Adolesc Psychiatr Rev 13:16–19
Tiggemann M, Lacey C (2009) Shopping for clothes: body satisfaction, appearance investment, and functions of clothing among female shoppers. Body Image 6:285–291. doi:10.1016/j.bodyim.2009.07.002
Trautmann J, Worthy SL, Lokken KL (2007) Body dissatisfaction, bulimic symptoms, and clothing practices among college women. J Psychol 141:485–498. doi:10.3200/JRLP.141.5.485-498
Goldschmidt AB, Wonderlich SA, Crosby RD, Engel SG, Lavender JM, Peterson CB et al (2014) Ecological momentary assessment of stressful events and negative affect in bulimia nervosa. J Consult Clin Psychol 82:30–39. doi:10.1037/a0034974
Berg KC, Crosby RD, Cao L, Crow SJ, Engel SG, Wonderlich SA, Peterson CB (2015) Negative affect prior to and following overeating-only, loss of control eating-only, and binge eating episodes in obese adults. Int J Eat Disorder 48:641–653. doi:10.1002/eat.22401
Engel SG, Wonderlich SA, Crosby RD, Mitchell JE, Crow S, Peterson CB et al (2013) The role of affect in the maintenance of anorexia nervosa: evidence from a naturalistic assessment of momentary behaviors and emotion. J Abnorm Psychol 122:709–719. doi:10.1037/a0034010
Smyth JM, Wonderlich SA, Heron KE, Sliwinski MJ, Crosby RD, Mitchell JE, Engel SG (2007) Daily and momentary mood and stress are associated with binge eating and vomiting in bulimia nervosa patients in the natural environment. J Consult Clin Psychol 75:629–638. doi:10.1037/0022-006X.75.4.629
Deep AL, Nagy LM, Weltzin TE, Rao R, Kaye WH (1995) Premorbid onset of psychopathology in long-term recovered anorexia nervosa. Int J Eat Disorder 17:291–297. doi:10.1002/1098-108X(199504)17:3<291::AID-EAT2260170310>3.0.CO;2-#
Kaye WH, Bulik CM, Thornton L, Barbarich N, Masters K (2004) Comorbidity of anxiety disorders with anorexia and bulimia nervosa. Am J Psychiatry 161:2215–2221
Holtkamp K, Müller B, Heussen N, Remschmidt H, Herpertz-Dahlmann B (2005) Depression, anxiety, and obsessionality in long-term recovered patients with adolescent-onset anorexia nervosa. Eur Child Adolesc Psychiatry 14:106–110. doi:10.1007/s00787-005-0431-5
Yackobovitch-Gavan M, Golan M, Valevski A, Kreitler S, Bachar E, Lieblich A, Mitrani E, Weizman A, Stein D (2009) An integrative quantitative model of factors influencing the course of anorexia nervosa over time. Int J Eat Disorder 42:306–317. doi:10.1002/eat.20624
Lavender JM, De Young KP, Wonderlich SA, Crosby RD, Engel SG, Mitchell JE et al (2013) Daily patterns of anxiety in anorexia nervosa: associations with eating disorder behaviors in the natural environment. J Abnorm Psychol 122:672–683. doi:10.1037/a0031823
Hart TA, Flora DB, Palyo SA, Fresco DM, Holle C, Heimberg RG (2008) Development and examination of the social appearance anxiety scale. Assessment 15:48–59. doi:10.1177/1073191107306673
Reed DL, Thompson JK, Brannick MT, Sacco WP (1991) Development and validation of the physical appearance state and trait anxiety scale (PASTAS). J Anxiety Disord 5:323–332. doi:10.1016/0887-6185(91)90032-O
Veale D, Eshkevari E, Kanakam N, Ellison N, Costa A, Werner T (2014) The Appearance Anxiety Inventory: validation of a process measure in the treatment of body dysmorphic disorder. Behav Cogn Psychother 42:605–616. doi:10.1017/S1352465813000556
White EK, Warren CS, Cao L, Crosby RD, Engel SG, Wonderlich SA, Mitchell JE, Peterson CB, Crow SJ, Le Grange D (2016) Media exposure and associated stress contribute to eating pathology in women with AN: daily and momentary associations. Int J Eat Disord 49:617–621. doi:10.1002/eat.22490
First M, Spitzer R, Gibbon M, Williams J (1995) Structured clinical interview for DSM–IV axis I disorders: Patient Edition (SCIDI/P). Biometrics, New York
Lorr M, McNair DM, Droppleman LF (1971) Manual: profile of mood states. Educational and Industrial Testing Service, San Diego
Heron KE, Smyth JM (2013) Is intensive measurement of body image reactive? A two-study evaluation using Ecological Momentary Assessment suggests not. Body Image 10:35–44. doi:10.1016/j.bodyim.2012.08.006
Stein KF, Corte CM (2003) Ecologic momentary assessment of eating-disordered behaviors. Int J Eat Disorder 34:349–360. doi:10.1002/eat.10194
Preacher KJ, Zyphur MJ, Zhang Z (2010) A general multilevel SEM framework for assessing multilevel mediation. Psychol Methods 15:209–233. doi:10.1037/a0020141
Muthén K, Muthén BO (2015) Mplus user’s guide, 7th edn. Muthén & Muthén, Los Angeles
Heatherton TF, Baumeister RF (1991) Binge eating as escape from self-awareness. Psychol Bull 110:86–108. doi:10.1037/0033-2909.110.1.86
Wonderlich SA, Peterson CB, Smith TL, Klein MH, Mitchell JE, Crow SJ (2015) Integrative cognitive-affective therapy for bulimia nervosa: a treatment manual. Guilford Publication, New York
Heron KE, Smyth JM (2010) Ecological momentary interventions: incorporating mobile technology into psychosocial and health behaviour treatments. Br J Health Psychol 15:1–39. doi:10.1348/135910709X466063
Gale C, Gilbert P, Read N, Goss K (2014) An evaluation of the impact of introducing compassion focused therapy to a standard treatment programme for people with eating disorders. Clin Psychol Psychother 21:1–12. doi:10.1002/cpp.1806
Harrison A, Sullivan S, Tchanturia K, Treasure J (2009) Emotion recognition and regulation in anorexia nervosa. Clin Psychol Psychother 16:348–356. doi:10.1002/cpp.628
Key A, George CL, Beattie D, Stammers K, Lacey H, Waller G (2002) Body image treatment within an inpatient program for anorexia nervosa: the role of mirror exposure in the desensitization process. Int J Eat Disorder 31:185–190. doi:10.1002/eat.10027
Jansen A, Voorwinde V, Hoebink Y, Rekkers M, Martijn C, Mulkens S (2016) Mirror exposure to increase body satisfaction: should we guide the focus of attention towards positively or negatively evaluated body parts? J Behav Ther Exp Psychiatry 50:90–96. doi:10.1016/j.jbtep.2015.06.002
Sala M, Heard A, Black EA (2016) Emotion-focused treatments for anorexia nervosa: a systematic review of the literature. Eat Weight Disord 21:147–164. doi:10.1007/s40519-016-0257-9
Wildes JE, Marcus MD (2011) Development of emotion acceptance behavior therapy for anorexia nervosa: a case series. Int J Eat Disorder 44:421–427. doi:10.1002/eat.20826
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This work was supported by Grants R01MH059674 and T32MH082761 from the National Institute of Mental Health.
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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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Informed consent was obtained from all individual participants included in the study.
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Mason, T.B., Lavender, J.M., Wonderlich, S.A. et al. Examining a momentary mediation model of appearance-related stress, anxiety, and eating disorder behaviors in adult anorexia nervosa. Eat Weight Disord 23, 637–644 (2018). https://doi.org/10.1007/s40519-017-0404-y
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DOI: https://doi.org/10.1007/s40519-017-0404-y