An examination of the transdiagnostic cognitive-behavioural model of eating disorders in adolescents
Introduction
Eating disorders impact physical, cognitive, and emotional development (Campbell & Peebles, 2014). In the transdiagnostic cognitive-behavioural model of eating disorders (Fairburn, Cooper, & Shafran, 2003), the core psychopathology of eating disorders (eating disorder symptoms) is a dysfunctional system of evaluating self-worth based on control over eating, shape, and weight. This evaluation of self-worth is maintained by core low self-esteem, clinical perfectionism, mood intolerance and interpersonal difficulties. Given eating disorders have a peak onset during adolescence (Mitchison et al., 2019), understanding how maintaining processes operate during this developmental period is important. Family-based treatment (FBT; Lock & Le Grange, 2015) is currently the most evidence-based treatment of choice for most adolescents with an eating disorder, however it is not without its limitations. FBT highlights the importance of the parents'/caregivers' involvment in therapy as necessary for successful treatment outcomes (Dalle Grave, Eckhardt, Calugi, & Le Grange, 2019), and is therefore difficult to use effectively when parent or caregiver involvement is limited. Enhanced cognitive-behavioural therapy (CBT-E; Fairburn, 2008), based on the transdiagnostic model, has demonstrated efficacy with adults (Linardon, 2018). There is emerging evidence that it is also efficacious with adolescents (e.g., Dalle Grave, Calugi, Doll, & Fairburn, 2013; Dalle Grave, Calugi, Sartirana, & Fairburn, 2015), and has been recommended for adolescents when FBT is not appropriate. For example, when parental involvement may be limited or FBT has not resulted in significant change.
Several studies have examined the validity of the transdiagnostic model of eating disorders and found core low self-esteem, clinical perfectionism, mood intolerance, and interpersonal difficulties were directly associated with eating disorders symptoms in non-clinical (Dakanalis, Timko, Clerici, Zanetti, & Riva, 2014; Hoiles, Egan, & Kane, 2012; Shanmugam, Jowett, & Meyer, 2011) and clinical adult samples (Lampard, Tasca, Balfour, & Bissada, 2013). To date, there has been limited evaluation of the transdiagnostic model of eating disorders in adolescents. Curzio et al. (2018) found that perfectionism, low self-esteem, and mood intolerance were associated with eating disorder symptoms across eating disorder diagnoses in a clinical sample of children and adolescents. These findings lend support for the validity of the transdiagnostic model of eating disorders in youth with eating disorders; however several limitations mean that further research is required to establish the validity of the model in adolescents. Curzio et al. (2018) used Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-4; American Psychiatric Association [APA], 1994) diagnostic criteria, and it would be useful for research to examine the validity of the transdiagnostic model using DSM-5 (APA, 2013) diagnostic criteria given the more inclusive diagnostic categories introduced (Limburg, Shu, Watson, Hoiles, & Egan, 2018).
In examining the validity of the transdiagnostic model of eating disorders in adolescents, it would be helpful to examine alternative pathways in addition to the pathways proposed in the model by Fairburn et al. (2003), specifically by testing the maintaining process of perfectionism as the central factor. Recent evidence suggests that perfectionism levels are increasing among adolescents (Curran & Hill, 2019), and given perfectionism has been demonstrated to be a robust predisposing and maintaining factor in eating disorder symptoms (Limburg, Watson, Hagger, & Egan, 2017), understanding how perfectionism may be associated with eating disorder symptoms during adolescence could be important for future prevention and treatment. Perfectionism predicts lower remission and poorer treatment outcomes for adolescents with eating disorders (Johnson et al., 2018). Perfectionism has also been found to have a direct relationship with eating disorders in adolescents, where higher perfectionism is related to higher eating disorder symptoms (Drieberg, McEvoy, Hoiles, Shu, & Egan, 2019; Morgan-Lowes et al., 2019) and CBT for perfectionism reduces eating disorder symptoms in adolescents (Hurst & Zimmer-Gembeck, 2015; Shu et al., 2019; Wilksch, Durbridge, & Wade, 2008). Therefore, there is a theoretical rationale to suggest that perfectionism may act as an earlier predictor for the other maintaining processes outlined by Fairburn et al. (2003), but such a model has not yet been tested in adolescents with eating disorders.
The aim of the present study was to examine the validity of the transdiagnostic model of eating disorders by examining the relationships between the four maintaining process outlined by Fairburn et al. (2003) and symptoms of eating disorders (represented by eating concerns, shape concerns, weight concerns, and dietary restraint) in a clinical sample of adolescents with eating disorders. It was hypothesised that perfectionism, core low self-esteem, mood intolerance, and interpersonal difficulties would account for a significant proportion of variance in eating disorder symptoms. A second exploratory model was also tested based on the literature outlining the importance of perfectionism in the development and maintenance of eating disorder pathology (Limburg et al., 2017). It was hypothesised that there would be direct and indirect positive associations between perfectionism and symptoms of eating disorders through self-esteem, mood intolerance, and interpersonal difficulties.
Section snippets
Participants
Participants were 270 adolescents (M = 14.86 years, SD = 0.83; 95.2% female) diagnosed with an eating disorder who attended an intake assessment at the Eating Disorders Program (EDP) at Perth Children's Hospital, Australia (Watson, McCormack, Hoiles, Forbes, & Potts, 2013). Based on the number of parameters in the model, and the recommended 10:1 ratio of participants to parameters (Kline, 2015), we estimated that 280 participants would be required to achieve 80% power to detect significant
Descriptive statistics
Eating disorder symptoms had significant, positive correlations with perfectionism, mood intolerance, and interpersonal difficulties, while self-esteem was negatively correlated with eating disorder symptoms. Age was negatively correlated with self-esteem, and positively correlated with mood intolerance, interpersonal difficulties, and eating disorder symptoms. Gender was negatively correlated with self-esteem, such that females reported lower levels of self-esteem. See Table 1 for descriptive
Discussion
The aim of the study was to examine the validity of the transdiagnostic cognitive-behavioural model of eating disorders in adolescents with eating disorders. The results provided partial support for the transdiagnostic model (Fairburn et al., 2003). In contrast to predictions, only self-esteem and mood intolerance were directly associated with eating disorder symptoms, while perfectionism and interpersonal difficulties were not directly associated with eating disorder symptoms. Perfectionism
Role of funding sources
The HOPE Project is supported by a Department of Health in Western Australia Targeted Research Fund grant. Emily Jones is supported by an Australian Government Research Training Program (RTP) Scholarship.
CRediT authorship contribution statement
EJJ drafted the manuscript. EJJ, JAH, SJE, KJH, and TGM reviewed and revised the manuscript. EJJ, JAH, SJE, KJH, and TGM conceived of and designed the study. All authors read, contributed to and approved the final manuscript. EJJ is the study coordinator and a Doctor of Philosophy candidate with Curtin University, Perth, Western Australia, being supervised by TGM, SJE, and JAH. TGM is chief investigator on the project. SJE, JAH, and KJH are co-investigators.
Declaration of competing interest
The authors declare no conflicts on interests.
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