**2. Method**

#### **2.1 Participants**

This is a case control study which included 166 participants, pre-screened in three higher education institutions in a city in central Brazil, and with no self-reported diagnosis of mental disorders. 62 of these presented bulimic behaviors, according to the Eating Attitude Test (EAT) score. This instrument has been described as effective in the identification of eating disorders (Nunes & col., 2006; Tomáz & Zanini, 2009). Therefore, those individuals with raw scores in the general EAT range above 21 were considered cases (as standardization of the instrument made by Nunes & col., 2006), as well as a raw score higher than 3,9 on the scale for bulimia, taking into account the average score of non-clinical population (2.19) plus a standard deviation (1.71). The controls are represented by 88 individuals who have not had bulimic behaviors or any other behavior consistent with the diagnostic criteria for eating disorders, and had average scores on the EAT scale for bulimia below 2.19, as well as a general index on the EAT below 21.

#### **2.2 Instruments**

182 New Insights into the Prevention and Treatment of Bulimia Nervosa

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

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

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

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

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

This is a case control study which included 166 participants, pre-screened in three higher education institutions in a city in central Brazil, and with no self-reported diagnosis of mental disorders. 62 of these presented bulimic behaviors, according to the Eating Attitude Test (EAT) score. This instrument has been described as effective in the identification of eating disorders (Nunes & col., 2006; Tomáz & Zanini, 2009). Therefore, those individuals with raw scores in the general EAT range above 21 were considered cases (as standardization of the instrument made by Nunes & col., 2006), as well as a raw score higher than 3,9 on the scale for bulimia, taking into account the average score of non-clinical population (2.19) plus a standard deviation (1.71). The controls are represented by 88 individuals who have not had bulimic behaviors or any other behavior consistent with the diagnostic criteria for eating disorders, and had average scores on the EAT scale for bulimia

still unclear and could contribute to more effective interventions for this group.

stressful situation) ( Holahan, et al. 1996; Moos, 1993).

cognitive efforts and the last two to behavioral efforts).

suitable to the characteristics of the group studied.

below 2.19, as well as a general index on the EAT below 21.

**2. Method** 

**2.1 Participants** 

related to cognitive efforts and the last two to behavioral efforts).

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 satisfactory psychometric data and were published in the Brazilian literature.

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

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).

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 0-72.

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, Abuchaim, & Coutinho, 2006).

Personality and Coping in Groups With and Without Bulimic Behaviors 185

In the case group, the personality trait of extroversion is associated with coping strategies such as positive reappraisal (r = 0.28, p <0.05), social support (r = 0.36, p <0.05), problem solving (r = 0.31, p <0.05) and seeking alternative reward (r = 0.36, p <0.05). In the control group, however, the extroversion trait is only associated with coping strategies as social

Table 3 shows data from compared mean between case and control groups for problem

**F P** 

case 1,31 1,35 0,44 0,51

case 1,73 1,38 0,01 0,92

case 1,11 1,29 4,84 0,03

case 1,84 1,30 1,17 0,28

case 1,73 1,34 0,76 0,39

case 1,23 1,27 1,99 0,16

case 1,53 1,29 0,12 0,73

case 1,82 1,35 0,01 0,92

case 1,18 1,32 3,30 0,08

case 1,47 1,30 4,07 0,05

control 1,46 1,30

control 1,76 1,29

control 1,55 1,13

control 2,06 1,15

control 1,91 1,20

control 1,91 1,20

control 1,46 1,27

control 1,84 1,15

control 1,57 1,25

control 1,87 1,10

**Appraisal questions Group Mean SD** 

Table 3. Mean, Standard Deviation and Compared mean between case and controls for

control and case group respectively for everything is all right now).

The control group tends to evaluate having enough time to prepare to cope with the problem significantly more (p = 0.03) than the case group (m = 1.55 and 1.11, SD = 1.13 and 1,29 for the case and control group respectively). They also tend to evaluate that the problem was solved (p=0,08, F=3,30) and that everything is all right now (p=0,05, F=4,07) in levels higher than did the case group (m= 1,57 and 1,18, SD= 1,25 and 1,32 for control and case group respectively for if the problem was solved; m= 1,87 and 1,47, SD=1,10 and 1,30 for

support (r = 0.32, p <0.05) and seeking alternative reward (r = 0.31, p <0.05),.

appraisal.

the problem

person

problem

problem appraisal.

Previous experience with the problem

Knowing the problem would happened

Thinking on the problem as a threat

Thinking on the problem as a challenge

If the problem were caused by yourself

If the problem were caused by other

Positive consequences of facing the

If it were solved, is everything all right

If the problem were solved

Have enough time to prepare to cope with

## **2.3 Procedures**

The study was approved by the ethics in the human research committee and followed all the ethical procedures of the APA. The instrument application occurred collectively in the participants' classroom, coordinated by the researchers in charge. Data analysis was performed using the statistical package SPSS for Windows version 19.0.
