Understanding relations between intolerance of uncertainty and body checking and body avoiding in anorexia nervosa

Springer Science and Business Media LLC
Jojanneke M. Bijsterbosch1, Anouk Keizer2, Paul A. Boelen1, Femke van den Brink1, Lot Sternheim1
1Department of Clinical Psychology, Utrecht University, PO Box 80140, 3508 TC, Utrecht, The Netherlands
2Department of Experimental Psychology, Utrecht University, Utrecht, The Netherlands

Tóm tắt

Abstract Background A key feature of anorexia nervosa is body image disturbances and is often expressed by dysfunctional body-related behaviours such as body checking and body avoiding. These behaviours are thought to contribute to both the maintenance and relapse of AN, yet empirical evidence is scarce. One variable that may contribute to the need for engaging in these behaviours is intolerance of uncertainty. This study aims to investigate body checking and body avoiding and its relations with intolerance of uncertainty in women with anorexia nervosa (AN-ill; 70), women recovered from AN (AN-rec; 85) and control group (127). Methods Three questionnaires were completed, measuring eating pathology, intolerance of uncertainty and body checking and body avoiding. One-way ANOVAS were used to test group differences. Moderation analyses were used to investigate associations between variables. Results Levels of intolerance of uncertainty, body checking and body avoiding were highest in AN-ill followed by AN-rec and, lastly, the control group, confirming group differences. Intolerance of uncertainty was associated with body checking in the AN-rec group and the control group but not in the AN-ill group. The association between intolerance of uncertainty and body avoiding was reported in the AN-rec group and only marginally in the control group. Conclusion Levels of intolerance of uncertainty, body checking and body avoiding were highest in AN-ill, however still elevated in AN-rec, confirming the presence of body image disturbances, even after recovery. The unique associations between intolerance of uncertainty and body checking and body avoiding within the studied groups may represent different stages of the illness. In the AN-rec group, the relation between intolerance of uncertainty, body checking and body avoiding may be driven by trait anxiety. For AN-ill group, body checking and body avoiding may eventually have grown into habitual patterns, rather than a strategy to ameliorate anxiety and uncertainty. Plain English summary Women with anorexia nervosa often experience disturbances in their body image and are expressed in body-related behaviours such as body checking and body avoiding. These behaviours are thought to contribute to both the maintenance and relapse of anorexia nervosa. Intolerance of uncertainty is defined as the incapacity to tolerate uncertainty and may contribute to the need for engaging in these behaviours. This study aims to investigate body checking and body avoiding and its relations with intolerance of uncertainty in women with anorexia nervosa (AN-ill; 70), women recovered from AN (AN-rec; 85) and control group (127). Three questionnaires were completed, measuring eating pathology, intolerance of uncertainty and body checking and body avoiding. Levels of intolerance of uncertainty, body checking and body avoiding were highest in AN-ill and still elevated in AN-rec, even after recovery. The associations between intolerance of uncertainty and body checking and body avoiding within the studied groups may represent different stages of the illness. In the AN-rec group, the relation between intolerance of uncertainty, body checking and body avoiding may be driven by trait anxiety. For AN-ill group, body checking and body avoiding may have grown into habitual patterns, rather than a strategy to ameliorate anxiety and uncertainty.

Từ khóa


Tài liệu tham khảo

Aardoom JJ, Dingemans AE, Slof-Op’t Landt MCT, Van Furth EF. Norms and discriminative validity of the eating disorder examination questionnaire (EDE-Q). Eat Behav. 2012;3:305–9. https://doi.org/10.1016/j.eatbeh.2012.09.002.

American Psychiatric Association. The diagnostic and statistical manual of mental disorders, Fifth Edition: DSM 5. Virginia: American Psychiatric Association; 2013.

Bailey N, Waller G. Body checking in non-clinical women: Experimental evidence of a specific impact on fear of uncontrollable weight gain. Int J Eat Disord. 2017;50:693–7. https://doi.org/10.1002/eat.22676.

Bamford BH, Attoe C, Mountford VA, Morgan JF, Sly R. Body checking and avoidance in low weight and weight restored individuals with anorexia nervosa and non-clinical females. Eat Behav. 2014;15:5–8. https://doi.org/10.1016/j.eatbeh.2013.10.011.

Bardeen JR, Fergus TA, Orcutt HK. The moderating role of experiential avoidance in the prospective relationship between anxiety sensitivity and anxiety. Cog Ther Res. 2014;38:465–71.

Bardone-Cone AM, Harney MB, Maldonado CR, Lawson MA, Robinson DP, Smith R, Tosh A. Defining recovery from an eating disorder: conceptualization, validation, and examination of psychosocial functioning and psychiatric comorbidity. Behav Res Ther. 2010;48:194–202. https://doi.org/10.1016/j.brat.2009.11.001.

Bijsterbosch JM, Keizer A, Boelen PA, van den Brink F, Danner UN, Sternheim LC. How deep is your thought? The relations between intolerance of uncertainty, worry and weight and shape concerns in adolescent girls with anorexia nervosa. J Eat Disord. 2021;20:164. https://doi.org/10.1186/s40337-021-00523-4.

Bijsterbosch JM, van den Brink F, Vollmann M, Boelen PA, Sternheim LC. Understanding relations between intolerance of uncertainty, social anxiety, and body dissatisfaction in women. J Nerv Ment Diseas. 2020;208:833–5. https://doi.org/10.1097/NMD.000000000000120.

Boswell JF, Thompson-Hollands J, Farchione TJ, Barlow DH. Intolerance of uncertainty: a common factor in the treatment of emotional disorders. J Clin Psychol. 2013;69:630–45. https://doi.org/10.1002/jclp.21965.

Brown M, Robinson L, Campione GC, Wuensch K, Hildebrandt T, Micali N. Intolerance of uncertainty in eating disorders: a systematic review and a meta-analysis. Euro Eat Disord Rev. 2017;25:329–43. https://doi.org/10.1002/erv.2523.

Calugi S, Grave RD, Ghisi M, Sanavio E. Validation of the body checking questionnaire (BCQ) in an eating disorders population. Behav Cog Psychother. 2006;34:233–42. https://doi.org/10.1002/erv.2523.

Carleton RN. The intolerance of uncertainty construct in the context of anxiety disorders: theoretical and practical perspectives. Expert Rev Neurother. 2012;12:937–47. https://doi.org/10.1586/ern.12.82.

Carleton RN, Norton MA, Asmundson GJ. Fearing the unknown: a short version of the intolerance of uncertainty scale. J Anxiety Disord. 2007;21:105–17. https://doi.org/10.1016/j.janxdis.2006.03.014.

Castro TF, Miller K, Araújo MX, Brandão I, Torres S. Emotional processing in recovered anorexia nervosa patients: a 15 year longitudinal study. Eur Eat Disord Rev. 2021;29:955–68. https://doi.org/10.1002/erv.2858.

Craske MG, Kircanski K, Zelikowsky M, Mystkowski J, Chowdhury N, Baker A. Optimizing inhibitory learning during exposure therapy. Behav Res Ther. 2008;46(1):5–27.

Davis L, Walsh BT, Schebendach J, Glasofer DR, Steinglass JE. Habits are stronger with longer duration of illness and greater severity in anorexia nervosa. Int J Eat Disord. 2020;53:683–9. https://doi.org/10.1002/eat.23265.

Dawson L, Rhodes P, Touyz S. Defining recovery from anorexia nervosa: a delphi study to determine expert practitioners’ views. Adv Eat Disord. 2015;3(2):165–76. https://doi.org/10.1080/21662630.2015.1009145.

Dymond S. Overcoming avoidance in anxiety disorders: The contributions of pavlovian and operant avoidance extinction methods. Neurosc Biobehav Rev. 2019;1(98):61–70. https://doi.org/10.1016/j.neubiorev.2019.01.007.

Blakey SM, Abramowitz JS. The effects of safety behaviors during exposure therapy for anxiety: critical analysis from an inhibitory learning perspective. Clin Psychol Rev. 2016;1(49):1–5.

Engel MM, Keizer A. Body representation disturbances in visual perception and affordance perception persist in eating disorder patients after completing treatment. Sci Rep. 2017;7:16184. https://doi.org/10.1038/s41598-017-16362-w.

Engel SG, Robinson MD, Wonderlich SJ, Meier BP, Wonderlich SA, Crosby RD, Steffen J, Mitchell JE. Does the avoidance of body and shape concerns reinforce eating disordered attitudes? Evidence from a manipulation study. Eat Behav. 2006;7:368–74. https://doi.org/10.1016/j.eatbeh.2005.12.002.

Eshkevari E, Rieger E, Longo MR, Haggard P, Treasure J. Persistent body image disturbance following recovery from eating disorders. Int J Eat Disord. 2014;47:400–9. https://doi.org/10.1002/eat.22219.

Fairburn CG, Beglin S. Eating disorder examination questionnaire (EDE-Q 6.0). In: Fairburn CG, editor. Cognitive behaviour therapy eating disorders. New York, NY: Guilford Press; 2008. p. 309–13.

Fairburn CG, Cooper Z, Shafran R. Cognitive behavior therapy for eating disorders: a “transdiagnostic” theory and treatment. Behav Res Ther. 2003;41:509–28. https://doi.org/10.1016/s0005-7967(02)00088-8.

Fairburn CG, Shafran R, Cooper Z. A cognitive behavioural theory of anorexia nervosa. Behav Res Ther. 1999;37:1–13. https://doi.org/10.1016/s0005-7967(98)00102-8.

Faul F, Erdfelder E, Buchner A, et al. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Meths. 2009;41:1149–60. https://doi.org/10.3758/BRM.41.4.1149.

Frank GK, Roblek T, Shott ME, Jappe LM, Rollin MD, Hagman JO, Pryor T. Heightened fear of uncertainty in anorexia and bulimia nervosa. Int J Eat Disord. 2012;45:227–32. https://doi.org/10.1002/eat.20929.

Godier LR, Park RJ. Compulsivity in anorexia nervosa: a transdiagnostic concept. Front Psychol. 2014;5:778.

Grogan S. Body image: understanding body dissatisfaction in men, women, and children, 4th ed. Routledge;2021. https://doi.org/10.4324/9781003100041.

Hartmann AS, Cordes M, Hirschfeld G, Vocks S. Affect and worry during a checking episode: a comparison of individuals with symptoms of obsessive-compulsive disorder, anorexia nervosa, bulimia nervosa, body dysmorphic disorder, illness anxiety disorder, and panic disorder. Psych Res. 2019;1(272):349–58.

Hayes AF. Introduction to mediation, moderation, and conditional process analysis second edition: a regression-based approach. New York, NY: Guilford Press; 2018.

Hedges LV, Pigott TD. The power of statistical tests for moderators in meta-analysis. Psychol Meth. 2004;9:426–45. https://doi.org/10.1037/1082-989X.9.4.426.

IBM Corp. Released. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp; 2019.

Kaye WH, Wierenga CE, Knatz S, Liang J, Boutelle K, Hill L, Eisler I. Temperament-based treatment for anorexia nervosa. Eur Eat Disord Rev. 2015;23:12–8. https://doi.org/10.1002/erv.2330.

Keizer A, Engel MM, Bonekamp J, et al. Hoop training: a pilot study assessing the effectiveness of a multisensory approach to treatment of body image disturbance in anorexia nervosa. Eat Weight Disord. 2019;24:953–8. https://doi.org/10.1007/s40519-018-0585-z.

Kesby A, Maguire S, Brownlow R, Grisham JR. Intolerance of Uncertainty in eating disorders: an update on the field. Clin Psychol Rev. 2017;56:94–105. https://doi.org/10.1016/j.cpr.2017.07.002.

Keski-Rahkonen A, Hoek HW, Susser ES, Linna MS, Sihvola E, Raevuori A, Bulik CM, Kaprio J, Rissanen A. Epidemiology and course of anorexia nervosa in the community. Am J Psychiatry. 2007;164:1259–65. https://doi.org/10.1176/appi.ajp.2007.06081388.

Legenbauer T, Martin F, Blaschke A, Schwenfeier A, Blechert J, Schniker K. Two sides of the same coin? A new instrument to assess body checking and avoidance behaviors in eating disorders. Body Image. 2017;21:39–46. https://doi.org/10.1016/j.bodyim.2017.02.004.

Legenbauer T, Müller A, de Zwaan M, Herpertz S. Body image and body avoidance nine years after bariatric surgery and conventional weight loss treatment. Front Psychiatry. 2020;10:945. https://doi.org/10.3389/fpsyt.2019.00945.

Levinson CA, Byrne M. The fear of food measure: a novel measure for use in exposure therapy for eating disorders. Int J Eat Disord. 2015;48:271–83. https://doi.org/10.1002/eat.22344.

McFadden E, Jones ME, Schoemaker MJ, Ashworth A, Swerdlow AJ. The relationship between obesity and exposure to light at night: cross-sectional analyses of over 100,000 women in the breakthrough generations study. Am J Epidemiol. 2014;180:245–50.

Mond JM, Hay PJ, Rodgers B, Owen C. Eating disorder examination questionnaire (EDE-Q): norms for young adult women. Behav Res Ther. 2006;44:53–62. https://doi.org/10.1016/j.brat.2004.12.003.

Montoya AK, Hayes AF. Two-condition within participant statistical mediation analysis: a path-analytic framework. Psychol Meth. 2017;22:6–27. https://doi.org/10.1037/met0000086.

Mountford V, Haase A, Waller G. Body checking in the eating disorders: associations between cognitions and behaviors. Int J Eat Disord. 2006;39:708–15. https://doi.org/10.1002/eat.20279.

Nikodijevic A, Buck K, Fuller-Tyszkiewicz M, de Paoli T, Krug I. Body checking and body avoidance in eating disorders: Systematic review and meta-analysis. Eur Eat Disord Rev. 2018;26:159–85. https://doi.org/10.1002/erv.2585.

Olsavsky AK, Shott ME, DeGuzman MC, Frank GKW. Neural correlates of taste reward value across eating disorders. Psychiatry Res Neuroimaging. 2019;30:76–84. https://doi.org/10.1016/j.pscychresns.2018.08.010.

Pallister E, Waller G. Anxiety in the eating disorders. Underst Overlap Clin Psychol Rev. 2008;28:366–86.

Piccolo M, Milos GF, Bluemel S, Schumacher S, Mueller-Pfeiffer C, Fried M, Ernst M, Martin-Soelch C. Behavioral responses to uncertainty in weight-restored anorexia nervosa - preliminary results. Front Psychol. 2019;10:2492. https://doi.org/10.3389/fpsyg.2019.02492.

Radix AK, Rinck M, Becker ES, Legenbauer T. The mediating effects of specific social anxiety facets on body checking and avoidance. Front Psychol. 2019. https://doi.org/10.3389/fpsyg.2018.02661.

Reas DL, Grilo CM, Masheb RM, Wilson GT. Body checking and avoidance in overweight patients with binge eating disorder. Int J Eat Disord. 2005;37:342–6. https://doi.org/10.1002/eat.20092.

Rosen JC, Srebnik D, Saltzberg E, Wendt S. Development of a body image avoidance questionnaire. Psychol Assess: J Consult Clin Psychol. 1991;3:32–7. https://doi.org/10.1037/1040-3590.31.32.

Salkind NJ, editor. Encyclopedia of research design, vol. 1. Thousand Oaks, CA: Sage; 2010.

Shafran R, Fairburn CG, Robinson P, Lask B. Body checking and its avoidance in eating disorders. Int J Eat Disord. 2004;35:93–101.

Slof-Op’t Landt MCT, Dingemans AE, de la Torre Y, Rivas J, van Furth EF. Self-assessment of eating disorder recovery: absence of eating disorder psychopathology is not essential. Int J of Eat Disord. 2019;52:956–61. https://doi.org/10.1002/eat.23091.

Schmidt U, Adan R, Böhm I, Campbell IC, Dingemans A, Ehrlich S, Elzakkers I, Favaro A, Giel K, Harrison A, Himmerich H, Hoek HW, Herpertz-Dahlmann B, Kas MJ, Seitz J, Smeets P, Sternheim L, Tenconi E, van Elburg A, van Furth E, Zipfel S. Eating disorders: the big issue. Lancet Psychiatry. 2016;3:313–5. https://doi.org/10.1016/S2215-0366(16)00081-X.

Steinglass JE, Glasofer DR, Walsh E, Guzman G, Peterson CB, Walsh BT, Attia E, Wonderlich SA. habits in anorexia nervosa: a proof-of-concept randomized trial. Psychol Med. 2018;48:2584–91. https://doi.org/10.1017/S003329171800020X.

Steinhausen HC. The outcome of anorexia nervosa in the 20th century. Am J Psychiatry. 2002;159:1284–93. https://doi.org/10.1176/appi.ajp.159.8.1284.

Sternheim L, Harrison A. The acceptability, feasibility and possible benefits of a group-based intervention targeting intolerance of uncertainty in adolescent inpatients with anorexia nervosa. Psychology. 2018;5:1. https://doi.org/10.1080/23311908.2018.1441594.

Sternheim L, Konstantellou A, Startup H, Schmidt U. What does uncertainty mean to women with anorexia nervosa? An interpretative phenomenological analysis. Eur Eat Disord Rev. 2011;19:12–24. https://doi.org/10.1136/bmj.a288.

Sternheim L, Danner U, van Elburg A, Harrison A. Do anxiety, depression, and intolerance of uncertainty contribute to social problem solving in adult women with anorexia nervosa? Brain Behav. 2020. https://doi.org/10.1002/brb3.1588.

Treasure J, Willmott D, Ambwani S, Cardi V, Clark Bryan D, Rowlands K, Schmidt U. Cognitive interpersonal model for anorexia nervosa revisited: The perpetuating factors that contribute to the development of the severe and enduring illness. J Clin Med 2020;9(3):630.

Vandereycken W, Van Humbeeck I. Denial and concealment of eating disorders: a retrospective survey. Eur Eat Disord Rev. 2018;16:109–14. https://doi.org/10.1002/erv.857.

Verplanken B. Psychology of habit. Cham: Springer; 2018.

Walker DC, Gorrell S, Hildebrandt T, Anderson DA. Consequences of repeated critical versus neutral body checking in women with high shape or weight concern. Behav Ther. 2021;52:830–46. https://doi.org/10.1016/j.beth.2020.10.005.

Walker DC, White EK, Srinivasan VJ. A meta-analysis of the relationships between body checking, body image avoidance, body image dissatisfaction, mood, and disordered eating. Int J Eat Disord. 2018;51:745–70. https://doi.org/10.1002/eat.22867.

Walsh BT. The enigmatic persistence of anorexia nervosa. Am J of Psychiatry. 2013;170:477–84.

Wilhelm L, Hartmann AS, Cordes M, Waldorf M, Vocks S. How do you feel when you check your body? Emotional states during a body-checking episode in normal-weight females. Eat Weight Disord-Stud Anorex Bulim Obes. 2020;25:309–19.

Thông tin
Thông tin xuất bản

Springer Science and Business Media LLC

Thông tin tác giả