**1. Introduction**

178 New Insights into the Prevention and Treatment of Bulimia Nervosa

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Strober, M., Freeman, R., & Morrell, W. (1997). The long-term course of severe anorexia

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exercise, cognitive therapy, and nutritional counseling in treating bulimia nervosa.

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595-601.

Eating disorders have been increasing year by year, mainly due to social demands for anorexic standards of beauty (Cordás, 2004). Among the eating disorders, bulimia, described as episodes of binge eating followed by compensatory behaviors (Cordás, 2004), stands out.

Globalization and capitalism largely develop markets that explore beauty (for example, media, marketing strategies, chemical industries), and require their audience to follow a trend dictated by them (Souza & Santos, 2007). That makes Wolf (1991) postulate beauty as a monetary system similar to gold, a cult of beauty and thinness which intensified the development of eating disorders such as bulimia.

Since Hippocrates, in 467 BC, Boulos was the terminology used to describe a sick hunger. But it was in 1743, when James described binge eating as "true boulimus", and bulimic episodes as "caninus appetites", that bulimia started to be studied in its relation to health (Cordás, 2004). However, the recognition of an eating disorder called bulimia nervosa only occurred in 1979. In that year, Russell described cases of this disease linked to anorexia nervosa. Both diseases are similar and, in most cases, appear as concurrent or comorbidities. However, in bulimia there is not extreme weight loss as in anorexia (Busse, 2004).

Bulimia is characterized by an excessive consumption of food which does not aim for satiation. The DSM-IV emphasizes two factors related to binge eating: quantitative and qualitative. The quantitative factor is related to the excess of food intake, an amount of food superior than people are used to or need to consume. The qualitative factor would be the lack of control characteristic of binge eating, in which the individuals cannot stop eating. Both factors are common in the bulimia disease.

In general, after a gorging food intake, the person experiences guilt and fear of gaining weight that can trigger compensatory behaviors like self-induced vomiting, overuse of laxatives, diuretics, thyroid hormones, anorectic drugs, diets and excessive exercise in order to avoid weight gain. In addition to these behaviors there is an increased dissatisfaction with their bodies, often leading to body image distortion (Chemin & Milito, 2007).

Compensatory behaviors used by patients with bulimia generate considerable harm to their health. Among them we can mention severe changes in the central nervous system, changes in the cycle of satiation, metabolism and production of neurotransmitters (Chemin & Milito, 2007; Sicchieri, Bighetti, Borges, Santos, Ribeiro, 2006).

Personality and Coping in Groups With and Without Bulimic Behaviors 181

Reserved, serious, closed, aloof, task-oriented, selfless, quiet, speechless, non-assertive, non-bold, non-energetic, shy.

Conventional, reasonable, limited interests, nonartistic, non-analytical, non-imaginative, noncreative, non-inquisitive, non-reflective, nonsophisticated.

Cynical, rude, suspicious, uncooperative, vengeful, ruthless, irritable, manipulative, selfish,

Aimless, unreliable, lazy, careless, negligent, relaxed, weak, hedonistic,

irresponsible, impractical.

Folkman, 1984). Coping is characterized by a dynamic process of mutual influence between person and environment and can be classified according to their focus on problem-focused strategies (seeking to modify the problem in order to solve it), and emotion-focused strategies (which seek to transform the emotions caused by the problem and not the problem itself) (Lazarus & Folkman, 1984; Pesce, Assisi, Santos & Oliveira, 2004). There are

stingy.

disorganized,

Quiet, relaxed, unemotional, strong, secure, self-satisfied,

stable.

Low High

Worried, nervous, emotional, insecure,

hypochondriac, tense, unstable, unhappy.

Sociable, active, talkative,

Curious, broad interests, creative, original, imaginative,

nontraditional, curious, thoughtful, sophisticated.

Generous, kind, confident, helpful, forgiving, gullible, honest, cooperative,

Organized, reliable, hardworking, selfdisciplined, punctual, scrupulous, neat, ambitious, persevering, responsible, practical, detail-oriented.

altruistic.

people-oriented, optimistic, playful, affectionate, assertive, bold, energetic, fearless.

inadequate,

Big Five Factors

Neuroticism: evaluation of the adjustment versus emotional instability. Identifies individuals prone to psychological disorders, unrealistic ideas, excessive needs or cravings and maladaptive responses.

Extroversion: evaluation of the amount and quality of interpersonal interactions, activity level, need for stimulation, and ability to

Opening: evaluation of proactive activity and appraisal of the experience, tolerance and exploration,

Agreeableness: evaluation of the amount of interpersonal orientation over a continuum

Fig. 1. Description of the Big Five Factors

enjoyment of new experiences.

from compassion to antagonism in thoughts, feelings and actions.

Conscientiousness: evaluation of the grade of persistence, organization and motivation to achieve his/her

objectives.

rejoice.

The causes of this disorder are not well-known. Authors like Claudino and Zanella (2005), Castilho, Gonçalves, Milk, and Cordás Segal (1995) describe a relation between bulimia and personality factors, such as impulsivity and affective instability that may be associated to the behaviors of uncontrolled binge eating and purging to avoid weight gain. Even "low selfesteem, self-negative evaluation and greater vulnerability to stress are important risk factors for developing eating disorders" (p.19).

The relationship between personality factors and bulimia is based on an understanding of the disorder from a dynamic perspective, which considered the influence of personality traits over behaviors that can be associated with bulimia (Leonidas and Santos, 2010). In this sense, the Big Five model has been the most widely used in the investigations of personality traits and its relationship to psychopathology. This model refers to the Theory of Personality Factors based on the Big Five model composed by the factors: neuroticism, extroversion, openness, agreeableness and conscientiousness (Nunes, 2005). Figure 1 describes the personality factors according to the model of the Big Five factors.

The applicability to different cultures and the easy comprehensibility of the Big Five concepts can explain the large spread of studies based on it (Tani, Greenman, Schneider & Fregoso, 2003; & Ruiz Jiménez, 2004). The Big Five model also provides a measure of personality traits that has proved to be valid in different studies, both to predict the level of physical well being, mental and social health of individuals, and to predict the usage of coping strategies (Costa & Widiger, 1993).

For example, Furtado, Falcone and Clark (2003) found, in their studies, that dysfunctional personality factors such as perfectionism and obsessive-compulsive behavior interfere negatively in the way individuals cope with stress. In fact, we can postulate that the relation between personality and health can occur in at least two pathways. In the first one, by means of a direct effect, studies have shown a direct association between neuroticism and eating disorders (Tomaz & Zanini, 2009), anxiety and depression (Forns & Zanini, 2005), among others. In the second one, by means of an indirect effect, studies have demonstrated that individuals with high neuroticism scores have stronger tendencies to use avoidance as a way of coping with their problems, and that using this type of coping strategy is related to eating disorders (Tomaz & Zanini).

Thus, one can say that avoidance coping may influence the manifestation of psychiatric diseases such as bulimia (Margis, Picon, Cosner & Silveira, 2003; Nakahara, Yoshiuchi, Yamanaka, Sasaki, Suematsu, Kuboki, 2000), and that experiencing stressful situations can lead an individual to develop psychiatric disorders, such as posttraumatic stress, and depressive and anxiety symptoms, depending on the coping strategies they used (Blumenthal, Babyak, Carney, Keefe, Davis, Lacaille, Parekh, Freedland, Trulock Palmer, 2006, Sorkin & Rook, 2006).

On the other hand, patients with eating disorders such as bulimia tend to use less adaptive coping strategies than the general population (Nakahara, Yoshiuchi, Yamanaka, Sasaki, Suematsu, Kuboki, 2000). That can be explained by the availability of individual coping resources. To Claudino and Zanella (2005) the effect that stressful events have on the process of eating disorders "(...) depends on the resources that the individual has prior to use in response, as well as the social support network that he has access to and which can function as a protective factor "(p.21).

According to the transactional theory, coping can be defined as a person's ability to cope with a stressful situation, which exceeds its own resources (Compas, 1987; Lazarus &

The causes of this disorder are not well-known. Authors like Claudino and Zanella (2005), Castilho, Gonçalves, Milk, and Cordás Segal (1995) describe a relation between bulimia and personality factors, such as impulsivity and affective instability that may be associated to the behaviors of uncontrolled binge eating and purging to avoid weight gain. Even "low selfesteem, self-negative evaluation and greater vulnerability to stress are important risk factors

The relationship between personality factors and bulimia is based on an understanding of the disorder from a dynamic perspective, which considered the influence of personality traits over behaviors that can be associated with bulimia (Leonidas and Santos, 2010). In this sense, the Big Five model has been the most widely used in the investigations of personality traits and its relationship to psychopathology. This model refers to the Theory of Personality Factors based on the Big Five model composed by the factors: neuroticism, extroversion, openness, agreeableness and conscientiousness (Nunes, 2005). Figure 1 describes the

The applicability to different cultures and the easy comprehensibility of the Big Five concepts can explain the large spread of studies based on it (Tani, Greenman, Schneider & Fregoso, 2003; & Ruiz Jiménez, 2004). The Big Five model also provides a measure of personality traits that has proved to be valid in different studies, both to predict the level of physical well being, mental and social health of individuals, and to predict the usage of

For example, Furtado, Falcone and Clark (2003) found, in their studies, that dysfunctional personality factors such as perfectionism and obsessive-compulsive behavior interfere negatively in the way individuals cope with stress. In fact, we can postulate that the relation between personality and health can occur in at least two pathways. In the first one, by means of a direct effect, studies have shown a direct association between neuroticism and eating disorders (Tomaz & Zanini, 2009), anxiety and depression (Forns & Zanini, 2005), among others. In the second one, by means of an indirect effect, studies have demonstrated that individuals with high neuroticism scores have stronger tendencies to use avoidance as a way of coping with their problems, and that using this type of coping strategy is related to

Thus, one can say that avoidance coping may influence the manifestation of psychiatric diseases such as bulimia (Margis, Picon, Cosner & Silveira, 2003; Nakahara, Yoshiuchi, Yamanaka, Sasaki, Suematsu, Kuboki, 2000), and that experiencing stressful situations can lead an individual to develop psychiatric disorders, such as posttraumatic stress, and depressive and anxiety symptoms, depending on the coping strategies they used (Blumenthal, Babyak, Carney, Keefe, Davis, Lacaille, Parekh, Freedland, Trulock Palmer,

On the other hand, patients with eating disorders such as bulimia tend to use less adaptive coping strategies than the general population (Nakahara, Yoshiuchi, Yamanaka, Sasaki, Suematsu, Kuboki, 2000). That can be explained by the availability of individual coping resources. To Claudino and Zanella (2005) the effect that stressful events have on the process of eating disorders "(...) depends on the resources that the individual has prior to use in response, as well as the social support network that he has access to and which can function

According to the transactional theory, coping can be defined as a person's ability to cope with a stressful situation, which exceeds its own resources (Compas, 1987; Lazarus &

for developing eating disorders" (p.19).

coping strategies (Costa & Widiger, 1993).

eating disorders (Tomaz & Zanini).

2006, Sorkin & Rook, 2006).

as a protective factor "(p.21).

personality factors according to the model of the Big Five factors.


Fig. 1. Description of the Big Five Factors

Folkman, 1984). Coping is characterized by a dynamic process of mutual influence between person and environment and can be classified according to their focus on problem-focused strategies (seeking to modify the problem in order to solve it), and emotion-focused strategies (which seek to transform the emotions caused by the problem and not the problem itself) (Lazarus & Folkman, 1984; Pesce, Assisi, Santos & Oliveira, 2004). There are

Personality and Coping in Groups With and Without Bulimic Behaviors 183

The instruments were: a Brazilian experimental scale to assess personality traits based on the Big Five theory; the Coping Response Inventory - Adult Form (CRI - A) for the evaluation of the perception of the problem and coping strategies; and the Eating Attitudes Test (EAT- 26) to assess behaviors consistent with eating disorders. All instruments have

The scale of personality was used to evaluate two factors in our sample: neuroticism and extraversion. This test was based on the Personality Factor Inventory created by Pasquali, Ghesti and Azevedo (1997), which measures 15 psychological characteristics. The factors are divided into 25 phrases that participants should answer based on a Likert scale ranging from 1 (extremely uncharacteristic) to 5 (extremely characteristic). The items were preceded by a paragraph that asked participants to express their degree of agreement with each statement contained in the scale. This scale presents satisfactory psychometric

The Coping Response Inventory-Adult Form (Moos, 1993) measures eight specific coping strategies defined as Logical analysis, Positive Reappraisal, Seeking guidance and support, Problem solving, Cognitive avoidance, Acceptance-resignation, Seeking alternative rewards, and Emotional discharge. Each specific coping strategy comprises a six-item rating using a four-point Likert-type scale, ranging from 0 (No, not at all) to 3 (Yes, fairly often). The Cronbach alpha coefficients for Brazilian subjects are acceptable and ranged from 0,68 to 0,72. Similar Cronbach alpha coefficients are described in international coping literature

Moos (1993) classified these specific strategies on the basis of Method or Focus of coping. The focus reflects the approach (directly coping with problems) versus avoidance coping (coping with the emotion elicited by the problem rather than the problem). Approach is composed of Logical Analysis, Positive Reappraisal, Seeking Guidance, and Problem Solving. Avoidance is composed of Cognitive Avoidance, Acceptance Resignation, Seeking Alternative Rewards, and Emotional Discharge. The method reflects a theoretical differentiation of cognitive versus behavioral efforts to cope. Cognitive method is composed of Logical Analysis, Positive Reappraisal, Cognitive Avoidance and Acceptance Resignation. Behavioral method is composed of Seeking Guidance, Problem Solving, Seeking Alternative Rewards and Emotional Discharge. These classifications allow to consider four typologies of coping: Approach, Avoidance, Cognitive and Behavioral coping, each of them rated from

To assess eating attitudes and behaviors characteristic of people suffering from eating disorders, we used the Eating Attitudes Test (EAT-26). This instrument has good psychometric qualities and has been used in several studies to assess behaviors related to eating disorders as well as diagnostic criteria for them (Cordás & Neves, 2000). In this study we used the reduced version, which contains 26 items, divided into three ranges: diet; bulimic behaviors; and preoccupation with food and oral control (Freitas, Appolinario & Gorenstein, 2002). Items are rated using a scale from 0 to 3, in which the responses "always," "often" and "sometimes" punctuate 3, 2 and 1, respectively, but the responses "rarely", "almost never "and" never "do not give scores. Thus, individuals who achieve a score above 21 are classified as individuals with eating disorder behaviors (Nunes, Apollinario,

satisfactory psychometric data and were published in the Brazilian literature.

characteristics, as described in Tomaz and Zanini (2009).

**2.2 Instruments** 

(Moos, 1993).

0-72.

Abuchaim, & Coutinho, 2006).

other categories to measure coping strategies such as classifying coping responses, according to their method, in cognitive responses (when using cognitive efforts to cope with a stressful situation) and behavioral responses (when using behavioral efforts to cope with a stressful situation) ( Holahan, et al. 1996; Moos, 1993).

Moos (1993) built the Coping Response Inventory (CRI) linking method to focus, to conceptualize and measure coping strategies. The CRI classify coping strategies in cognitive and behavioral responses, and also in approach and avoidance coping. In the group classified as approach coping strategies are those that employ cognitive and behavioral responses as a way to solve the problem. This group is similar to that described by Lazarus and Folkman (1984) as problem-focused coping. Examples of these strategies are logical analysis, positive reappraisal, seeking guidance and problem solving (the first two refer to cognitive efforts and the last two to behavioral efforts).

In the group of avoidance strategies there are other specific strategies that can also be classified as cognitive and behavioral efforts to avoid the problem by manipulating the emotions that cause the problem without confronting the stressful situation. Again, this classification is similar to the emotion-focused coping described by Lazarus and Folkman (1984). Examples of this type of avoidance coping would be cognitive avoidance, acceptance and resignation, seeking alternative reward, and emotional discharge (again, the first two related to cognitive efforts and the last two to behavioral efforts).

Among the various factors related to eating disorders, literature has pointed to personality traits and coping strategies towards the problem as factors that may influence the occurrence, perpetuation and adherence to treatment (Binford, 2003; Gongora, Guedes, Albuquerque, Troccoli, Noriega, JJ & Guedes, 2006; Rebelo & Leal, 2007). However, the differential analysis of this influence on bulimic subjects in comparison to other groups is still unclear and could contribute to more effective interventions for this group.

This chapter discusses the relationship between personality and coping in a group of people with bulimic behavior (cases) compared with a group without bulimic behavior (controls), highlighting the implications of these differences for intervention proposals which are more suitable to the characteristics of the group studied.
