Preoccupation with shape or weight, fear of weight gain, feeling fat and treatment outcomes in patients with anorexia nervosa: A longitudinal study

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Highlights

  • Little is known about the role of body-image concern in anorexia nervosa patients.

  • Preoccupation with shape or weight predicted improvement of eating concern.

  • Change in fear of weight gain was associated with improvement in dietary restraint.

  • BMI ≥18.5 at follow-up was predicted by body-image concern components.

  • It is important to address body-image concern in patients with anorexia nervosa.

Abstract

Objective

The study aimed to evaluate the trajectories of change over time in body-image concern components in patients with anorexia nervosa treated by means of intensive enhanced cognitive behavioural therapy. Moreover, it aimed to study the role of body-image concern components in changes in eating and general psychopathology as well as work and social functioning.

Method

Sixty-six adult patients with anorexia nervosa were recruited. Body mass index (BMI); Eating Disorder Examination ‘Dietary Restraint’ and ‘Eating Concern’ subscales; Brief Symptom Inventory (BSI); and Work and Social Adjustment Scale (WSAS) scores were recorded at admission, end of treatment, and at 6- and 12-month follow-ups. The trajectories of change of three components of body image concern, namely ‘preoccupation with shape or weight’, ‘fear of weight gain’ and ‘feeling fat’, were assessed.

Results

The treatment was associated with a significant improvement in outcome variables and body-image concern components. Baseline ‘preoccupation with shape or weight’ predicted improvement in Eating Concern, BSI and WSAS scores, while the change in ‘fear of weight gain’ was associated with improvement in dietary restraint. Baseline and end-of-therapy scores for all three measured body-image concern components predicted achievement of BMI ≥18.5 kg/m2 at 6- and 12-month follow-ups.

Discussion

These findings highlight the importance of assessing and addressing body-image concern in the management of patients with anorexia nervosa.

Introduction

Within the field of eating disorders, there is some disagreement as to whether or not body-image concerns are core characteristics of eating-disorder psychopathology or simply epiphenomenal. Although, this issue not been exhaustively addressed in the research, some authors have concluded that weight phobia should not be considered a central aspect of anorexia nervosa. This standpoint is based on a review of the history of the disorder, which revealed that this aspect of eating-disorder psychopathology was seldom reported until the 1930s (Nemiah, 1950; Nicolle, 1939; Russell, 1985; Waller, Kaufmann, & Deutsch, 1940), and may therefore be seen as a relatively recent addition to the psychopathology. However, others maintain that anorexia nervosa with weight phobia is clearly distinct from other groups of cases of extreme fasting without weight phobia in modern Western society, and therefore attempts to equate anorexia nervosa with any form of voluntary self-starvation that does not involve body image concerns are unjustified (Habermas, 2005). What is more, Phillipou, Castle, and Rossell (2018) have even proposed—very recently—that anorexia nervosa should be conceptualised as a body-image disorder, based on their conviction that this issue is at its core. This proposal, however, has sparked much debate, as other authors interpret this point of view as reductionist—an oversimplification of the multifactorial aetiology and nature of the disorder (Kaufmann & Russell, 2017).

Wherever the truth may lie, the fear of weight gain has been studied mostly in individuals with anorexia nervosa, and findings indicate that it is, in fact, associated with higher levels of eating-disorder psychopathology (Carter & Bewell-Weiss, 2011; Santonastaso et al., 2009). Furthermore, a recent systematic review has underscored the importance of body-image concerns as mechanisms that maintain eating disorders (Pennesi & Wade, 2016). In fact, the transdiagnostic theory upon which modern cognitive behavioural treatment is based (Fairburn, Cooper, & Shafran, 2003), it defines the overvaluation of shape and weight (i.e. judging self-worth largely, or even exclusively, in terms of shape and weight and the ability to control them) as the core psychopathology across most of the eating disorders, and considers the main clinical features seen in these disorders—such as the preoccupation with shape or weight, feeling fat, fear of weight gain (commonly included in the larger construct of body-image concern), body checking, body avoidance, and dietary restraint—as stemming directly from it (Fairburn, 2008). These clinical features, considered expressions of the overvaluation of shape and weight, are therefore specifically targeted by the “enhanced” form of cognitive behavioural therapy (CBT-E) for eating disorders (Fairburn, 2008), which is considered an effective evidence-based treatment, recommended for all eating disorders (National Institute for Health and Care Excellence, 2017). Although CBT-E directly addresses body-image concern, the research done to date has not yet clarified whether body-image concern is in fact a core characteristic of eating-disorder psychopathology or merely an epiphenomenon.

Several studies have evaluated the influence of perceptual components of body image (Boehm et al., 2016; Roy & Meilleur, 2010) and generic body dissatisfaction (Schlegl, Quadflieg, Lowe, Cuntz, & Voderholzer, 2014) on treatment outcome in anorexia nervosa, but little research has examined the role of the different cognitive expressions of the overvaluation of shape and weight in this regard. For example, the role of ‘preoccupation with shape and weight’—a characteristic expression of the overvaluation of shape and weight—has only been investigated in one cross-sectional non-clinical study; this found an association between this characteristic with distress, dietary restraint, and binge eating in female secondary students (Mitchison et al., 2017), but no data in other populations has yet been reported. Similarly, no study has yet evaluated the role of ‘fear of weight gain’ in influencing outcomes in anorexia nervosa, although a meta-analysis of studies did reveal a significantly higher level of eating-disorder psychopathology in patients with anorexia nervosa with respect to patients who met all diagnostic criteria for anorexia nervosa (APA, 2006) except for fear of weight gain (Thomas, Vartanian, & Brownell, 2009). Finally, only a few cross-sectional studies have reported significant associations between the experience of ‘feeling fat’ and eating-disorder psychopathology (i.e., loss of control over eating, emotional eating) in clinical and non-clinical samples (Cooper, Deepak, Grocutt, & Bailey, 2007; Striegel-Moore, McAvay, & Rodin, 1986), and no study has yet assessed the influence of ‘feeling fat’ on outcomes in anorexia nervosa.

In other words, although body-image concern is considered by the transdiagnostic cognitive behavioural theory (Fairburn et al., 2003) to play a key role in maintaining eating disorder psychopathology no study has yet examined the respective roles of its three main components, namely ‘preoccupation with shape and weight’, ‘fear of weight gain’ and ‘feeling fat’ in influencing the long-term outcomes of patients with eating disorders treated by means of CBT-E. Hence, the aims of this study were to evaluate the trajectories of change in body-image concern components (i.e., ‘preoccupation with shape or weight’, ‘fear of weight gain’, and ‘feeling fat’) over time in patients with anorexia nervosa treated via intensive CBT-E. We set out to assess the relationship between the change over time in these body-image concern components and changes in BMI, eating-disorder and general psychopathology, and work and social functioning, by assessing measures of each before, after treatment, and at 6- and 12-month follow-up. Moreover, we endeavoured to determine whether or not baseline measures of these components of body-image concern could in fact be predictors of the change in outcome measures of CBT-E, namely BMI, eating (i.e., dietary restraint and eating concern) and general psychopathology, and work and social functioning.

Section snippets

Participants

The sample comprised 66 adult patients with anorexia nervosa, referred from across Italy by eating disorder specialists or general practitioners and admitted to the inpatient Eating Disorder Unit of Villa Garda Hospital (Northern Italy). To qualify for admission, patients had to be between 18 and 65 years of age; to fully meet the DSM-IV diagnostic criteria for anorexia nervosa (with the exception of the amenorrhea criterion) (APA, 2006); and to require inpatient treatment—either due to

Participant characteristics

The 66 patients with anorexia nervosa had a mean age of 26.1 years (SD = 5.9), and a mean baseline BMI of 14.7 kg/m2 (SD = 2.1). The vast majority of patients were women (97%) and single (86.4%). The mean age of their eating-disorder onset was 18.4 years (SD = 4.2), and the mean duration of illness across the entire sample was 7.7 years (SD = 5.7). Fifty-six participants (84.8%) completed the treatment, whereas 10 (15.2%) interrupted the treatment before its end. There was no significant

Discussion

This study, which aimed to assess the body image concern components, namely ‘preoccupation with shape or weight’, ‘fear of weight gain’, and ‘feeling fat’, in patients with anorexia nervosa treated via an intensive version of CBT-E, their change over time, and to evaluate their interaction with changes in BMI, eating and general psychopathology and work and social functioning, yielded six main findings. The first concerned the relationships among the baseline variables. In particular, ‘feeling

Conflicts of interest

The authors declare no conflict of interest regarding the material discussed in this manuscript.

Funding source

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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