THOMAS E. JOINER, JR.
Overview

DAVID H. GLEAVES, MICHAEL R. LOWE, BRADLEY A. GREEN, MICHELLE B. CORORVE, AND TARA L. WILLIAMS.
Do Anorexia and Bulimia Nervosa Occur on a Continuum? A Taxometric Analysis

NANCY D. VOGELTANZ-HOLM, STEPHEN A. WONDERLICH, BETH A. LEWIS, SHARON C. WILSNACK, T. ROBERT HARRIS, RICHARD W. WILSNACK, AND ARLINDA F. KRISTJANSON.
Longitudinal Predictors of Binge Eating, Intense Dieting, and Weight Concerns in a National Sample of Women

CORRINA P. FERGUSON AND TERESA A. PIGOTT.
Anorexia and Bulimia Nervosa: Neurobiology and Pharmacotherapy

ANNA M. BARDONE, KATHLEEN D. VOHS, LYN Y. ABRAMSON, TODD F. HEATHERTON, AND THOMAS E. JOINER, JR.
The Confluence of Perfectionism, Body Dissatisfaction, and Low Self-Esteem Predicts Bulimic Symptoms: Clinical Implications

Special Series: Samples from Four Frontiers of Eating Disorders Research Overview

Thomas E. Joiner, Jr., Florida State University

This special series was designed to stimulate eating disorders research by sampling from four strands of particularly promising research directions: taxometric nosology; neuroscience and psychopharmacology; clinical/demographic risk prediction in epidemiologic samples; and psychological models of symptom development. In this overview, I highlight the series' import by puttting its papers in general contextt and also by highlighting key explanatory concepts from each paper. An additional purpose is to articulate areas not directly covered by this series that deserve careful attention in future research.



Do Anorexia and Bulimia Nervosa Occur on a Continuum?
A Taxometric Analysis

David H. Gleaves, Texas A&M University, The Renfrew Foundation, Michael R. Lowe, MCP Hahnemann University, The Renfrew Foundation, and Bradley A. Green, Michelle B. Cororve, and Tara L. Williams, Texas A&M University

We investigated the question of whether anorexia and bulimia nervosa occur on a continuum versus being discrete classes using two taxometric procedures: Mean Above Minus Below a Cut (MAMBAC) and Maximum Covariance (MAXCOV) analysis. Participants were N = 959 women diagnosed as having anorexia nervosa (n = 165), bulimia nervosa (n = 562) or atypical eating disorder (n = 18) or were nonclinical controls (n = 214). Indicators for the taxometric analyses were derived from the Eating Disorder Inventory, and we also included body mass index (BMI). Results replicated earlier taxometric findings in that both purging and nonpurging types of bulimia seemed qualitatively different from normative eating behavior. The distinction between restricting and binge-eating/purging types of anorexia nervosa also seemed to be qualitative rather than quantitative. However, results most consistently supported the conclusion that anorexia nervosa, binge-eating/purging type, occurs on a continuum with bulimia nervosa (both purging and nonpurging types) and that the two types of bulimia nervosa differ in degree rather than in kind. Overall, the results suggest that anorexia nervosa, binge-eating/purging type, is more qualitatively distinct from anorexia, restricting type, than from either type of bulimia nervosa, perhaps suggesting that these disorders should be reclassified in future editions of the Diagnostic and Statistical Manual of Mental Disorders.



Longitudinal Predictors of Binge Eating, Intense Dieting, and Weight Concerns in a National Sample of Women

Nancy D. Vogeltanz-Holm, Stephen A. Wonderlich, Beth A. Lewis, Sharon C. Wilsnack, T. Robert Harris, Richard W. Wilsnack, and Arlinda F. Kristjanson, University of North Dakota

As part of an ongoing longitudinal study of the antecedents and consequences of women's drinking in the U.S. adult female population, women who participated in a 1991 survey provided data in 1996 about their experiences of binge eating, intense dieting, and weight concerns (N = 709, ages 26 to 54 in 1996). Five percent of the women reported binge eating in the past 30 days, 29% reported that they had engaged in intense dieting or fasting in the past 3 months, and 1.5% of the women met criteria for nonpurging bulimia nervosa (binge eating and intense dieting). Forty-three percent reported that their weight and shape were either very important or more important than anything else. After controlling for 1991 occurrence of binge eating, predictors of binge eating in 1996 were past 12-month use of illicit drugs (mostly marijuana) and greater occurrence of drinking to intoxication. A body mass index (BMI) X 1991 binge eating interaction indicated that having a higher BMI in 1991 predicted the onset of binge eating by 1996, but it did not predict the continuation (chronicity) of binge eating 5 years later. Nineteen ninety-one predictors of intense dieting in 1996 were having weight concerns, being unmarried, having used illicit drugs in the past 12 months, and having parents who had more than a high school education. Only a younger age in 1991 and having a lower BMI predicted 1996 weight concerns, after controlling for weight concerns 5 years earlier. These results indicate that risk factors for the onset and chronicity of disordered eating behaviors and attitudes across longer time periods in adult women may differ considerably from predictors found in cross-sectional studies or studies of adolescent females.



Anorexia and Bulimia Nervosa: Neurobiology and Pharmacotherapy

Corrina P. Ferguson and Teresa A. Pigott, University of Texas Medical Branch at Galveston

This review provides an overview of some neurobiological factors that may contribute to the development and maintenance of eating disorders, and the psychopharmacological treatment of anorexia and bulimia nervosa. Various metabolic, physiologic, and neuroendocrine disturbances are associated with bulimia and anorexia nervosa, but it is often not clear whether they represent state or trait markers of the disorders. While most patients with bulimia nervosa who receive appropriate pharmacotherapy will experience significant short-term improvement, there is a substantial rate of relapse during long-term continuation treatment with medication. Strategies that appear to improve long-term outcome in bulimia nervosa include combination treatment with cognitive-behavioral therapy (CBT) and changing to an alternative antidepressant medication. The role for medication treatment in anorexia nervosa remains very limited, although the SSRI antidepressant fluoxetine may have a limited role in long-term treatment of anorexia.



The Confluence of Perfectionism, Body Dissatisfaction, and Low Self-Esteem Predicts Bulimic Symptoms: Clinical Implications

Anna M. Bardone, University of Wisconsin-Madison, Kathleen D. Vohs, Dartmouth College, Lyn Y. Abramson, University of Wisconsin-Madison, Todd F. Heatherton, Dartmouth College, and Thomas E. Joiner, Jr., Florida State University

We present a brief overview of empirically supported risk factors of bulimic behavior. We then propose an empirically supported, interactive, three-factor model of bulimic symptom occurrence from which we derive clinical implications for assessment, treatment, and prevention. Our research finds that perfectionism, body dissatisfaction, and self-esteem interact to predict bulimic symptoms. In particular, women who consider themselves overweight and who have elevated levels of perfectionism and lower levels of self-esteem show the greatest risk for bulimic symptoms. Thus, our model identifies three theoretically related targets for intervention: perfectionism, body dissatisfaction, and low self-esteem. Assessment of these factors is recommended. The extent to which cognitive-behavioral therapy for bulimia and interpersonal therapy for bulimia address these factors is reviewed and evaluated, and theory-based recommendations are made for prevention efforts.



Anger Management for Dementia Caregivers: A Preliminary Study Using Video and Telephone Interventions

Ann M. Steffen, University of Missouri–St. Louis

Data are presented on a preliminary study investigating the efficacy of an anger-management video series and workbook for dementia family caregivers. Materials from a previously developed intervention (Gallagher-Thompson & DeVries, 1994) were used to create a videotaped version of the treatment program. Women and men (N = 33) caring for a relative with dementia were randomly assigned to one of two formats for the video and bibliotherapy intervention (home-based viewing with weekly telephone sessions or class-based viewing) or to a wait-list comparison condition. The 8-week intervention focused on cognitive and behavioral skills to manage anger and frustration (i.e., relaxation training, cognitive restructuring, and assertion training). Compared to control participants, caregivers in both of the treatment conditions had lower posttreatment levels of anger and depression, and higher ratings of caregiving self-efficacy. Results from this preliminary study suggest that innovative multicomponent anger interventions can be effective for middle-aged and older caregivers of dementia patients; investigations using larger sample sizes are needed to confirm these findings.



Assessment of Culturally Related Anxiety in American Indians and Alaska Natives

Daniel W. McNeil, West Virginia University, Chebon A. Porter, Oklahoma State University, Michael J. Zvolensky, West Virginia University, John M. Chaney
Oklahoma State University, and Marvin Kee, West Virginia University

The present investigation was aimed at developing a means to measure culturally related anxiety in American Indians and Alaska Natives. Initial item selection and factor structure for a self-report instrument, the Native American Cultural Involvement and Detachment Anxiety Questionnaire (CIDAQ), were derived from samples of American Indian and Alaska Native college students representing numerous tribal groups. The factor structure then was replicated in a more homogeneous group of Navajo college students. The scale contains three factors, measuring anxiety about (a) social involvement with Native Americans and cultural knowledge, (b) economic issues, and (c) social involvement with the majority (Caucasian) culture. The scale showed high levels of item-total reliability, internal consistency, as well as convergent and divergent validity. We discuss the CIDAQ, and suggest it is a promising measure for researchers examining culturally related anxiety in American Indians and Alaska Natives, particularly in college counseling and other behavioral health-care centers.



Properties of the Childhood Anxiety Sensitivity Index in Children With Anxiety Disorders: Autonomic and Nonautonomic Factors

Bruce F. Chorpita, University of Hawaii, and Eric L. Daleiden, University of Tulsa

This study examined the item properties, factor structure, and convergent, discriminant, and incremental validity of items on the Childhood Anxiety Sensitivity Index (CASI). A large sample of children and adolescents with anxiety disorders (N = 228) was administered semistructured clinical interviews and self-report measures of anxiety sensitivity, anxiety, and depression. Overall, the CASI was found to exhibit good convergent and discriminant properties in relation to clinician-rated panic and generalized anxiety severity, respectively. Results identified a subset of items (autonomic items) that demonstrated psychometric properties superior to the full scale, in both child (7 to 11 years) and adolescent (12 to 17 years) subsamples. The findings point to strategies for continued investigation regarding the clinical assessment of AS in children and adolescents.



Relapse Prevention in the Treatment of Slot-Machine Pathological Gambling: Long-Term Outcome

Enrique Echeburúa, Universidad del País Vasco (España), Javier Fernández-Montalvo, Universidad Pública de Navarra (España), and Concepción Báez, Centro de Salud Mental de Rentería. Servicio Vasco de Salud (España)

The aim of this paper was, on the one hand, to determine the efficacy of stimulus control and exposure with response prevention in stopping pathological gambling and, on the other hand, to test the comparative effectiveness of two therapeutic modalities (individual and group) for relapse prevention, relative to a control group, in order to maintain abstinence. The sample consisted of 69 patients selected according to DSM-IV criteria. At the first part of the study, a one-group design with repeated measures of assessment (pre- and posttreatment) was used. At the second part, a multigroup experimental design with repeated measures (pretreatment, posttreatment, and 1-, 3-, 6-, and 12-month follow-up) was used. All treated patients gave up gambling at the end of the first part of the study. In the second part, results related to relapse showed a success rate higher in both individual and group relapse prevention than in the control group. These results raise the necessity of using relapse prevention programs in the treatment of pathological gambling. Implications of this study for clinical practice and future research in this field are discussed.



Use of Self-Management Strategies in a 2-Year Cognitive-Behavioral Intervention to Promote Physical Activity

Brian E. Saelens, Christine A. Gehrman, James F. Sallis, and Karen J. Calfas, San Diego State University, Julie A. Sarkin, University of Rhode Island, and Susan Caparosa, San Diego State University

Training in the use of self-management strategies (e.g., self-monitoring, positive self-talk) is common in behavioral and cognitive interventions, and participants' strategy use is a hypothesized mechanism for behavior change. However, reports of strategy use and the relation between strategy use and outcomes are rare. The use of cognitive and behavior strategies pertinent to increasing physical activity was assessed via survey at post-course, 1-year, and 2-year follow-up among 256 university seniors randomly assigned to either an intervention that promoted strategy use or to a nonbehavioral health course (control). Strategy use was higher among intervention relative to control women only at post-course, but was significantly related to women's leisure-time physical activity at post-course, 1-year, and 2-year follow-up after controlling for prior physical activity and condition. Men's strategy use did not differ by condition at any time point, but was associated with men's physical activity at 2-year follow-up. Strategy use was also assessed among intervention participants during ongoing phone contact. Participants' frequency of goal setting accounted for an additional 5.1% of women's physical activity variance at the 2-year assessment, but strategy use assessed on this ongoing basis was not related to men's physical activity. Examining proposed intervention mechanisms of change and the relation between these mechanisms and outcomes is paramount to improving cognitive-behavioral interventions.



Treatment of Hair Pulling and Hair Manipulation Maintained by Digital-Tactile Stimulation

John T. Rapp, University of Florida, Raymond G. Miltenberger, Tami L. Galensky, Sherry A. Ellingson, Jason Stricker, and Matthew Garlinghouse, North Dakota State University, and Ethan S. Long, West Virginia University

Treatment was provided for the hair pulling and hair manipulation of a 19-year-old woman (Kris) diagnosed with mental retardation across multiple settings in her home. Treatment probes conducted prior to our formal treatment evaluation indicated that hair pulling was suppressed when Kris wore either a 2.5-lb wrist weight or a golf glove. However, these interventions did not produce sustained reductions of hair pulling during the treatment evaluation. Therefore, a procedure involving response interruption and differential reinforcement for the absence of hair pulling and hair manipulation was implemented, which produced near-zero levels of hair pulling. The results of this intervention were socially validated and recommendations for further research are provided.