**Abstract**

The recognition of factors involved in the development and maintenance of eating disorders (EDs) may support the choice of therapeutic strategies and improve the prevention/treatment of eating pathologies and their outcomes. Based on this consideration, the overall purpose of the chapter is to investigate how some psychological characteristics link to EDs. It is organized as follows. First, the epidemiological aspects, risk, and maintaining factors for ED are outlined. Next, we present the findings from our two studies. The purpose of the first study was to identify predictors associated with the severity of eating symptomatology. Then, the objective of the second study was to provide an understanding of the relationship among perceived parental bonding, self-esteem, perfectionism, body shame, body mass index, and ED risk and mainly to test a predictive ED risk model in a non-clinical sample. In conclusion, the major findings and practical implications are discussed.

**Keywords:** perceived parental bonding, self-esteem, perfectionism, body shame, body mass index, eating disorders, risk factors

### **1. Eating disorder risk and maintaining factors: an overview**

Eating disorders (EDs) are highly prevalent psychological conditions characterized by abnormal eating behaviors that may lead to serious health problems and even cause death [1]. The existing diagnostic classifications of EDs include anorexia nervosa (AN), bulimia nervosa (BN), eating disorders not otherwise specified (EDNOS), avoidant/restrictive food intake disorder (ARFID), pica and rumination disorder. Additionally, the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) [2] supports binge eating disorder (BED) as a correct diagnosis on par with AN and BN.

In the framework of the European Study of the Epidemiology of Mental Disorders (ESEMeD) project, a lifetime prevalence rate of 0.93% for AN, 0.88% for BN, and 1.92% for BED have been found for females [3]. In a large population-based survey in the United States, Hudson and colleagues [4] have reported a lifetime prevalence of 0.9, 1.5, and 3.5% for AN, BN, and BED, respectively. More recently, a national survey has found a lifetime prevalence of DSM-5 defined AN, BN, and

BED of 0.80, 0.28, and 0.85%, respectively. Individuals with lifetime BED were found to have a later age of onset of ED and longer ED episodes duration [5].

Even though eating pathologies have been traditionally associated with females [6], males are also at risk for developing EDs [7, 8]. It was estimated that approximately 14% of AN [9], 10–15% of BN [10], and 40% of BED cases [11] were men. Prevalence rates of 0.3, 0.5, and 2.0% were found for AN, BN, and BED among men, who also accounted for approximately 25% of all EDs cases [4]. However, several studies have pointed out an upward trend in EDs prevalence rates among males [12–13]. Furthermore, empirical research shows that, in males, homosexual orientation is associated with higher body dissatisfaction and abnormal eating behaviors [14].

Adolescence to young adulthood is the peak risk period of onset for EDs symptomatology [15]. A recent longitudinal study, for instance, showed increases in weight preoccupation, body dissatisfaction, and bulimic behaviors from 11 to 25 years [16]. The Growing Up Today Study found that binge eating increased with age and peaked in late adolescence [17]. More generally, several authors have reported the presence of body dissatisfaction and drive for thinness even in children aged between 5 and 11 [18, 19] and have demonstrated that weight concerns, body dissatisfaction, and weight status increase with age [20, 21].

Some studies have found that the levels of EDs are highest in younger individuals [22]. Women with EDs with later age of onset (>25 years) might report less severe eating symptomatology compared with women with the typical age of onset (<25 years) [23].

In terms of the ED occurrence, several variables have been suggested as possible predisposing factors for these pathologies. In this section, we review some of the known risks and maintaining factors for the development of eating disturbances.

#### **1.1 Parental bonding**

It has long been recognized that family factors are essential features in the development, maintenance, and therapeutic outcome of EDs.

Selvini Palazzoli [24] was one of the first authors who observed some typical patterns in ED families functioning, such as an overprotective relationship with mother and a distant relationship with father.

Similarly, psychosomatic family model [25] suggested that a family environment characterized by enmeshment, overprotectiveness, and rigidity plays a key role in the etiology of AN. On the other hand, insecure attachment patterns were found to be prevalent in ED patients [26].

Overall, empirical evidence on parental bonding—generally assessed by the Parental Bonding Instrument [27]—highlights the importance of low paternal care and high maternal overprotection in the occurrence of ED symptomology in both clinical and non-clinical samples [28, 29]. Parental care refers to a continuum of behaviors ranging from affection and warmth to coldness and rejection. In contrast, parental protectiveness exists along a continuum that ranges from behaviors indicating encouragement of autonomy/independence as opposed to strict control with regulations and intrusiveness [27].

Yet, up till now, few studies have investigated whether parental bonding might be correlated with the severity of disordered eating symptoms. Among ED patients, high parental overprotection is associated with suicidal behavior [30]. Body image disturbances, considered as one of the major clinical features of eating pathology [31], resulted in being predicted by low parental care and high parental overprotection [29, 32].

In the study by Canetti and colleagues [33], anorexic participants reported perceiving both parents as less caring and fathers as more controlling than control

**5**

*Risk and Maintenance Factors for Eating Disorders: An Exploration of Multivariate Models…*

group participants; moreover, maternal control and paternal care were associated with higher symptom severity. A recent cross-sectional study has shown that the quality of the father-daughter relationship (i.e., overprotective and avoidant) plays

Similar findings were reported by Rienecke and colleagues [34], the presence of paternal criticism—and not maternal—showed a significant predictive power for less psychological improvement in ED psychopathology at the end of family-based

Overall, the overprotective behavior of the parents might be a result of the ED and often starts as a consequence of the disorder [35]. Researchers suggest that eating pathology may influence family dynamics and environment, which in turn may

In terms of the psychological dynamics underlying the association between parental bonding and eating pathologies, several researchers have suggested the existence of potential mediating mechanisms involved in such association. Turner and colleagues [37], for instance, reported that paternal care and maternal overprotection had an indirect effect on ED symptoms through the mediating effect of maladaptive core beliefs (i.e., schemas related to defectiveness/shame and

Likewise, maladaptive perfectionism was found to mediate the pathway from parental psychological control and ED patterns [38]. In our previous study [28], on a large sample of adolescents, the link between the parental bonding pattern typified by low paternal care/maternal overprotection and dysfunctional eating attitudes were found to be mediated by self-concept. Our data were consistent with the study of Perry and colleagues [39] in which a parental bonding pattern characterized by low care and over-protection affected self-concept formation, which, in

The literature on EDs shows that a patient's self-concept is fundamentally characterized by low self-esteem, which is considered a critical vulnerability factor in the development of these diseases [40]. In a review focusing on causes of EDs, low self-esteem is one of the prominent features strongly implicated in the onset of

ship-based self-esteem were related to higher ED symptoms [42, 43].

In a series of interesting papers exploring the self-esteem dimensions, Geller and colleagues found that shape- and weight-based self-esteem and intimate relation-

It seems that white women are most at risk for having low self-esteem and difficulty with eating problems [44]. Still, several studies have shown that an impoverished sense of self is an essential contributor to ED symptomatology [45], and it is correlated with a negative treatment outcome [46]. Similarly, in a study carried out by Brechan and Kvalem [47], the effect of body dissatisfaction on restrained eating, binge eating, and compensatory behavior was completely mediated by self-esteem. However, some studies do not support the existence of a direct relationship between low self-esteem and eating pathology. In some studies, self-esteem did not emerge as a significant predictor of disordered eating [48, 49]. Moreover, some researchers suggest that future studies should focus on a more informative multifaceted construct of self-esteem [50] and investigate interactive effects with other predisposing factors for a better understanding of the link between self-esteem and eating problems [45]. In this regard, self-esteem has been suggested to predict disordered eating via body shame [51], also among obese youth [52]. A study by Goossens and colleagues [53] provided evidence for the hypothesis that an insecure

a critical role in understanding the ED onset and maintenance [29].

unconsciously affect ED symptoms maintenance and evolution [36].

turn, affected eating psychopathologies in adulthood.

*DOI: http://dx.doi.org/10.5772/intechopen.91063*

treatment for adolescents AN.

dependence/incompetence).

**1.2 Self-esteem**

the pathology [41].

#### *Risk and Maintenance Factors for Eating Disorders: An Exploration of Multivariate Models… DOI: http://dx.doi.org/10.5772/intechopen.91063*

group participants; moreover, maternal control and paternal care were associated with higher symptom severity. A recent cross-sectional study has shown that the quality of the father-daughter relationship (i.e., overprotective and avoidant) plays a critical role in understanding the ED onset and maintenance [29].

Similar findings were reported by Rienecke and colleagues [34], the presence of paternal criticism—and not maternal—showed a significant predictive power for less psychological improvement in ED psychopathology at the end of family-based treatment for adolescents AN.

Overall, the overprotective behavior of the parents might be a result of the ED and often starts as a consequence of the disorder [35]. Researchers suggest that eating pathology may influence family dynamics and environment, which in turn may unconsciously affect ED symptoms maintenance and evolution [36].

In terms of the psychological dynamics underlying the association between parental bonding and eating pathologies, several researchers have suggested the existence of potential mediating mechanisms involved in such association. Turner and colleagues [37], for instance, reported that paternal care and maternal overprotection had an indirect effect on ED symptoms through the mediating effect of maladaptive core beliefs (i.e., schemas related to defectiveness/shame and dependence/incompetence).

Likewise, maladaptive perfectionism was found to mediate the pathway from parental psychological control and ED patterns [38]. In our previous study [28], on a large sample of adolescents, the link between the parental bonding pattern typified by low paternal care/maternal overprotection and dysfunctional eating attitudes were found to be mediated by self-concept. Our data were consistent with the study of Perry and colleagues [39] in which a parental bonding pattern characterized by low care and over-protection affected self-concept formation, which, in turn, affected eating psychopathologies in adulthood.

#### **1.2 Self-esteem**

*Weight Management*

(<25 years) [23].

**1.1 Parental bonding**

BED of 0.80, 0.28, and 0.85%, respectively. Individuals with lifetime BED were found to have a later age of onset of ED and longer ED episodes duration [5].

dissatisfaction, and weight status increase with age [20, 21].

development, maintenance, and therapeutic outcome of EDs.

mother and a distant relationship with father.

be prevalent in ED patients [26].

with regulations and intrusiveness [27].

overprotection [29, 32].

Even though eating pathologies have been traditionally associated with females [6], males are also at risk for developing EDs [7, 8]. It was estimated that approximately 14% of AN [9], 10–15% of BN [10], and 40% of BED cases [11] were men. Prevalence rates of 0.3, 0.5, and 2.0% were found for AN, BN, and BED among men, who also accounted for approximately 25% of all EDs cases [4]. However, several studies have pointed out an upward trend in EDs prevalence rates among males [12–13]. Furthermore, empirical research shows that, in males, homosexual orientation is associated with higher body dissatisfaction and abnormal eating behaviors [14]. Adolescence to young adulthood is the peak risk period of onset for EDs symptomatology [15]. A recent longitudinal study, for instance, showed increases in weight preoccupation, body dissatisfaction, and bulimic behaviors from 11 to 25 years [16]. The Growing Up Today Study found that binge eating increased with age and peaked in late adolescence [17]. More generally, several authors have reported the presence of body dissatisfaction and drive for thinness even in children aged between 5 and 11 [18, 19] and have demonstrated that weight concerns, body

Some studies have found that the levels of EDs are highest in younger individuals [22]. Women with EDs with later age of onset (>25 years) might report less severe eating symptomatology compared with women with the typical age of onset

In terms of the ED occurrence, several variables have been suggested as possible predisposing factors for these pathologies. In this section, we review some of the known risks and maintaining factors for the development of eating disturbances.

It has long been recognized that family factors are essential features in the

Selvini Palazzoli [24] was one of the first authors who observed some typical patterns in ED families functioning, such as an overprotective relationship with

Overall, empirical evidence on parental bonding—generally assessed by the Parental Bonding Instrument [27]—highlights the importance of low paternal care and high maternal overprotection in the occurrence of ED symptomology in both clinical and non-clinical samples [28, 29]. Parental care refers to a continuum of behaviors ranging from affection and warmth to coldness and rejection. In contrast, parental protectiveness exists along a continuum that ranges from behaviors indicating encouragement of autonomy/independence as opposed to strict control

Yet, up till now, few studies have investigated whether parental bonding might be correlated with the severity of disordered eating symptoms. Among ED patients, high parental overprotection is associated with suicidal behavior [30]. Body image disturbances, considered as one of the major clinical features of eating pathology [31], resulted in being predicted by low parental care and high parental

In the study by Canetti and colleagues [33], anorexic participants reported perceiving both parents as less caring and fathers as more controlling than control

Similarly, psychosomatic family model [25] suggested that a family environment characterized by enmeshment, overprotectiveness, and rigidity plays a key role in the etiology of AN. On the other hand, insecure attachment patterns were found to

**4**

The literature on EDs shows that a patient's self-concept is fundamentally characterized by low self-esteem, which is considered a critical vulnerability factor in the development of these diseases [40]. In a review focusing on causes of EDs, low self-esteem is one of the prominent features strongly implicated in the onset of the pathology [41].

In a series of interesting papers exploring the self-esteem dimensions, Geller and colleagues found that shape- and weight-based self-esteem and intimate relationship-based self-esteem were related to higher ED symptoms [42, 43].

It seems that white women are most at risk for having low self-esteem and difficulty with eating problems [44]. Still, several studies have shown that an impoverished sense of self is an essential contributor to ED symptomatology [45], and it is correlated with a negative treatment outcome [46]. Similarly, in a study carried out by Brechan and Kvalem [47], the effect of body dissatisfaction on restrained eating, binge eating, and compensatory behavior was completely mediated by self-esteem.

However, some studies do not support the existence of a direct relationship between low self-esteem and eating pathology. In some studies, self-esteem did not emerge as a significant predictor of disordered eating [48, 49]. Moreover, some researchers suggest that future studies should focus on a more informative multifaceted construct of self-esteem [50] and investigate interactive effects with other predisposing factors for a better understanding of the link between self-esteem and eating problems [45]. In this regard, self-esteem has been suggested to predict disordered eating via body shame [51], also among obese youth [52]. A study by Goossens and colleagues [53] provided evidence for the hypothesis that an insecure relationship with parents may act as a mediating variable in the pathway from selfesteem and dysfunctional eating patterns.

#### **1.3 Perfectionsim**

Perfectionism is a personality trait that is characterized by setting excessively high personal standards of performance [54]. Frost and colleagues [54] viewed perfectionism as being constituted of adaptive (healthy) and maladaptive (dysfunctional) perfectionism.

In a cross-sectional research designed to explore perfectionism across different stages of EDs recovery, ED patients scored significantly higher than healthy controls on the maladaptive perfectionism factor [55]. Further studies have reported that elevated levels of both adaptive and maladaptive perfectionism are strongly associated with body dissatisfaction [56] and ED psychopathology [57–59], including BN [60]. A percentage of about 40% of AN patients (Mage = 15.3 years) have a very high score on self-oriented perfectionism and perfectionistic selfpresentation. The authors concluded that in this subgroup of patients, it would be necessary to address these psychological characteristics to achieve a good outcome [61]. Several studies have highlighted that a higher level of perfectionism might be detrimental for disease duration and prognoses [62, 63], also among children and adolescents with EDs [64, 65]. Previous studies have shown that perfectionism predicts ED onset and maintaining [66]. Similarly, an experimental study has suggested that perfectionism represents a causal risk factor for ED pathology [67]. On the other hand, these findings are not systematically replicated in other studies: perfectionism—adaptive and maladaptive types—does not emerge as a risk factor for eating disturbances [68, 69], and the specific mechanism by which perfectionism uses its influence on eating psychopathology has, up till now, to be recognized.

In this regard, Bardone-Cone and colleagues [58] have reported that the investigation of mediating pathways from perfectionism to ED pathology was mostly absent from the literature. How perfectionism related to the EDs risk factors and potential mediating variables affecting the relationship between perfectionism and disordered eating remain mostly unknown.

Several studies support the association between low self-esteem, perfectionism, and varying degrees of ED patterns [70], "Indeed, the combination of low self-esteem and perfectionism is not unusual among those who binge, and especially those with BN, AN, or an atypical ED, and it may well contribute to the development of the problem" ([71], p. 65). Still, "as he was nearing the end of his life, Michelangelo began working on what many people believe to be his most important work, the Florentine Pietà. After working intensely for almost a decade, he entered his studio one day and took a sledgehammer to the sculpture. He broke away the hands and legs and nearly shattered the work before his assistants dragged him away. Why did Michelangelo attempt to destroy one of his greatest creations, a statue that has been described as among the finest works of the Renaissance? Disillusioned and isolated in the last decades of his life, Michelangelo had a heightened sense of perfectionism that was exarcebed by his failure to live up to the exceptions of his father, who viewed being a sculptor as akin to begin a manual laborer. Michelangelo, it seems, had self-esteem issues" ([72], p. 158).

Literature supports the hypothesis that a combination of low perception of control and low self-esteem moderates the effects of perfectionism on drive for thinness, BN, and body [73].

In conclusion, as previously suggested [74], the role of perfectionism in the etiology and maintenance of EDs remains unclear.

**7**

**1.5 Body mass index**

*Risk and Maintenance Factors for Eating Disorders: An Exploration of Multivariate Models…*

relationship between shame and eating pathology has been found [76, 77].

sents a better concept than "body dissatisfaction" in work with EDs [80]. Body shame is a strong predictor of disordered eating [81, 82].

Eating pathologies have been described as "disorders of shame" [75]. A positive

However, several studies have concentrated upon shame explicitly associated

In a longitudinal study designed to explore the role of body shame and general shame in predicting increases in eating symptoms over 2.5 years in a sample of women with a past or current ED, body shame exclusively predicted an increase in AN symptoms [83]. Dorian and colleagues [84] have found that body shame is uniquely predictive of eating disturbance in a female clinical sample and in a male non-clinical sample. However, both body and characterological shame predicted eating psychopathology in a non-clinical female sample. In sum, body shame would

In addition, the severity of ED symptomatology has been linked to feelings of bodily shame in the eating context [81, 85]. Troop and colleagues [83], for instance, found that shame was uniquely associated with the severity of both AN and BN symptoms. Goss and Gilbert [79] proposed a model based on the functional role of eating disordered beliefs and behaviors in the management of shame. The authors offered a model process based on risk factors (i.e., genetic factors, personality, early attachment history, abuse or rejection experiences, and cultural factors) that might predispose people to develop both shame proneness and ED proneness. These factors cause shame, and to defend themselves against adverse social outcomes, individuals may attempt to change their body shape and weight. Then, they may feel around in their ability to manage their weight, but when they are not able to do so, they feel further shame. This leads to a shame-pride circle that maintains the pathology.

Overall, shame can be described both as cause and consequence of symptoms in eating pathology [80]. Unfortunately, there are few findings about body shame, and much is unknown about how it operates in ED development. Literature supports the suggestion that body shame may act as a mediator in the relationship between

Regarding the determinants of body shame, some research has provided evidence associating poor perceived parenting and subsequent shame [86]. The perception of low parental care and high parental protectiveness in childhood was found to be related to shame in young adulthood [87]. Murray and colleagues [88] suggested that dysfunctional parenting practices may lead to individuals' feelings of inadequacy and worthlessness, so it might be clinically essential to examine the psychological consequences of such a family experience, such as shame. Specifically, the authors found that paternal overprotection was related to bulimic symptoms through the mediation effect of shame. On the other hand, it has been shown that parenting practices failed to predict the vulnerability to body image shame, directly or indirectly. In a study examining the determinants of body shame, Markham and colleagues [89] found that body-image esteem, global self-worth, appearance comparison, and internalization of the thin ideal accounted for 62% of the variance in body-image shame.

It would seem that the body mass index (BMI) plays a more critical role in promoting the risk factors for EDs than indirectly maintaining eating pathology [90].

Body shame is the shame one feels about one's body or any part of it [78]. Moreover, body shame can also relate to how one's body functions [79], and it repre-

*DOI: http://dx.doi.org/10.5772/intechopen.91063*

with the body rather than to general shame.

seem to have a causal role in the ED onset.

self-esteem and disordered eating [51].

**1.4 Body shame**

*Risk and Maintenance Factors for Eating Disorders: An Exploration of Multivariate Models… DOI: http://dx.doi.org/10.5772/intechopen.91063*

#### **1.4 Body shame**

*Weight Management*

**1.3 Perfectionsim**

recognized.

functional) perfectionism.

esteem and dysfunctional eating patterns.

disordered eating remain mostly unknown.

relationship with parents may act as a mediating variable in the pathway from self-

Perfectionism is a personality trait that is characterized by setting excessively high personal standards of performance [54]. Frost and colleagues [54] viewed perfectionism as being constituted of adaptive (healthy) and maladaptive (dys-

In a cross-sectional research designed to explore perfectionism across different stages of EDs recovery, ED patients scored significantly higher than healthy controls on the maladaptive perfectionism factor [55]. Further studies have reported that elevated levels of both adaptive and maladaptive perfectionism are strongly associated with body dissatisfaction [56] and ED psychopathology [57–59], including BN [60]. A percentage of about 40% of AN patients (Mage = 15.3 years) have a very high score on self-oriented perfectionism and perfectionistic selfpresentation. The authors concluded that in this subgroup of patients, it would be necessary to address these psychological characteristics to achieve a good outcome [61]. Several studies have highlighted that a higher level of perfectionism might be detrimental for disease duration and prognoses [62, 63], also among children and adolescents with EDs [64, 65]. Previous studies have shown that perfectionism predicts ED onset and maintaining [66]. Similarly, an experimental study has suggested that perfectionism represents a causal risk factor for ED pathology [67]. On the other hand, these findings are not systematically replicated in other studies: perfectionism—adaptive and maladaptive types—does not emerge as a risk factor for eating disturbances [68, 69], and the specific mechanism by which perfectionism uses its influence on eating psychopathology has, up till now, to be

In this regard, Bardone-Cone and colleagues [58] have reported that the investigation of mediating pathways from perfectionism to ED pathology was mostly absent from the literature. How perfectionism related to the EDs risk factors and potential mediating variables affecting the relationship between perfectionism and

Several studies support the association between low self-esteem, perfection-

Literature supports the hypothesis that a combination of low perception of control and low self-esteem moderates the effects of perfectionism on drive for

In conclusion, as previously suggested [74], the role of perfectionism in the

ism, and varying degrees of ED patterns [70], "Indeed, the combination of low self-esteem and perfectionism is not unusual among those who binge, and especially those with BN, AN, or an atypical ED, and it may well contribute to the development of the problem" ([71], p. 65). Still, "as he was nearing the end of his life, Michelangelo began working on what many people believe to be his most important work, the Florentine Pietà. After working intensely for almost a decade, he entered his studio one day and took a sledgehammer to the sculpture. He broke away the hands and legs and nearly shattered the work before his assistants dragged him away. Why did Michelangelo attempt to destroy one of his greatest creations, a statue that has been described as among the finest works of the Renaissance? Disillusioned and isolated in the last decades of his life, Michelangelo had a heightened sense of perfectionism that was exarcebed by his failure to live up to the exceptions of his father, who viewed being a sculptor as akin to begin a manual laborer.

Michelangelo, it seems, had self-esteem issues" ([72], p. 158).

etiology and maintenance of EDs remains unclear.

**6**

thinness, BN, and body [73].

Eating pathologies have been described as "disorders of shame" [75]. A positive relationship between shame and eating pathology has been found [76, 77].

However, several studies have concentrated upon shame explicitly associated with the body rather than to general shame.

Body shame is the shame one feels about one's body or any part of it [78]. Moreover, body shame can also relate to how one's body functions [79], and it represents a better concept than "body dissatisfaction" in work with EDs [80].

Body shame is a strong predictor of disordered eating [81, 82].

In a longitudinal study designed to explore the role of body shame and general shame in predicting increases in eating symptoms over 2.5 years in a sample of women with a past or current ED, body shame exclusively predicted an increase in AN symptoms [83]. Dorian and colleagues [84] have found that body shame is uniquely predictive of eating disturbance in a female clinical sample and in a male non-clinical sample. However, both body and characterological shame predicted eating psychopathology in a non-clinical female sample. In sum, body shame would seem to have a causal role in the ED onset.

In addition, the severity of ED symptomatology has been linked to feelings of bodily shame in the eating context [81, 85]. Troop and colleagues [83], for instance, found that shame was uniquely associated with the severity of both AN and BN symptoms. Goss and Gilbert [79] proposed a model based on the functional role of eating disordered beliefs and behaviors in the management of shame. The authors offered a model process based on risk factors (i.e., genetic factors, personality, early attachment history, abuse or rejection experiences, and cultural factors) that might predispose people to develop both shame proneness and ED proneness. These factors cause shame, and to defend themselves against adverse social outcomes, individuals may attempt to change their body shape and weight. Then, they may feel around in their ability to manage their weight, but when they are not able to do so, they feel further shame. This leads to a shame-pride circle that maintains the pathology.

Overall, shame can be described both as cause and consequence of symptoms in eating pathology [80]. Unfortunately, there are few findings about body shame, and much is unknown about how it operates in ED development. Literature supports the suggestion that body shame may act as a mediator in the relationship between self-esteem and disordered eating [51].

Regarding the determinants of body shame, some research has provided evidence associating poor perceived parenting and subsequent shame [86]. The perception of low parental care and high parental protectiveness in childhood was found to be related to shame in young adulthood [87]. Murray and colleagues [88] suggested that dysfunctional parenting practices may lead to individuals' feelings of inadequacy and worthlessness, so it might be clinically essential to examine the psychological consequences of such a family experience, such as shame. Specifically, the authors found that paternal overprotection was related to bulimic symptoms through the mediation effect of shame. On the other hand, it has been shown that parenting practices failed to predict the vulnerability to body image shame, directly or indirectly. In a study examining the determinants of body shame, Markham and colleagues [89] found that body-image esteem, global self-worth, appearance comparison, and internalization of the thin ideal accounted for 62% of the variance in body-image shame.

#### **1.5 Body mass index**

It would seem that the body mass index (BMI) plays a more critical role in promoting the risk factors for EDs than indirectly maintaining eating pathology [90]. Obese individuals are at higher risk for developing an eating pathology [91]. Indeed, a low BMI represents a protective factor against the development of disturbed eating in adolescent girls [92, 93]. Moreover, BMI in childhood is a significant predictor of restrained eating in early adolescence [94].

BMI at admission can be considered as a significant predictor of outcome in AN [95]. The link between BMI and mortality in BN has also been investigated. Severe BN patients may be at higher risk of death, especially if suicide has been attempted previously or in case of a low minimum BMI at admission [96].

In terms of the underlying mechanisms that linked BMI and eating psychopathology, in a study by Fan and colleagues [97], BMI was not found to have a direct influence on ED symptoms, and the authors concluded that weight control concerns and behaviors could mediate this relationship. To answer the question of what causes a high BMI, risk factors for obesity included parental fatness—although only a few longitudinal studies have investigated the parent-child fatness association social factors, birth weight, timing or rate of maturation, physical activity, dietary factors, and other behavioral and psychological factors [98, 99].

Parental overweight is one of the main predictors for the development of childhood overweight and obesity [100], but parents can influence child body weight through specific feeding behaviors and practices, such as restriction, pressure to eat, and monitoring [101, 102], or more broadly through their general parental attitudes and style of interacting with children (for a review, see [103]). In a study about the influence of parental care in childhood on the risk of obesity in young adulthood, parental neglect was found to significantly affect the risk of adult obesity, independent of age and body mass index in childhood, sex, and social background. Instead, receiving overprotective parental support did not affect [104].

In terms of the psychological dynamics underlying parental-child relationship, possible mediating factors are considered. Overall, a growing body of research has focused on maternal sensitivity and emotion regulation. A poor quality of the early maternal-child relationship, characterized by low levels of maternal sensitivity, may be linked to childhood overweight and obesity through the development of potential difficulties in children's ability to regulate emotions [105]. In this regard, emotion dysregulation in early childhood is implicated in the development of obesity in early adolescence [106]. Similarly, empirical research suggested that authoritarian parenting (high control and low levels of emotionally responsiveness) may influence children's self-regulation skills [107] and, in turn, to be positively associated with child weight status [108, 109]. A longitudinal study showed that more inadequate maternal emotional regulation abilities during pregnancy were able to predict, at 7 months of age of the baby, the quality of the early mother-child feeding patterns [110], and the body mass index of the child at three years of age [111].

#### **1.6 Multivariate etiologic models**

Most of the studies about the ED onset have focused on the risk factors unconnectedly, precluding understanding about interactive effects.

In one of the few research in this area studies, Bardone-Cone and colleagues [112] found that perfectionism, body dissatisfaction, and self-esteem interact to predict bulimic symptoms. Specifically, women who perceived themselves to be overweight and who had elevated levels of perfectionism and lower levels of self-esteem were most at risk for bulimic symptoms. However, this interactive model has received mixed support [113–115], for example, it has been considered valid concerning maintenance and exacerbation, but not with the onset of bulimic symptoms [116]. Expanding the model to EDs patients under psychotherapy treatment, Watson and colleagues [74] found that binge eating and purging were not

**9**

*Risk and Maintenance Factors for Eating Disorders: An Exploration of Multivariate Models…*

significantly predicted by the three-way interaction term neither in concurrent nor in prospective analyses (i.e., examined as a moderator of treatment outcome). The authors concluded raising concerns about the robustness of the three-way model. Otherwise, it could have been affected by an inadequate conceptualization of the

A study by Ghaderi [117] suggested that a combination of low self-esteem, high

body concern, low perceived support from the family, and more relative use of escape avoidance coping constitute a risk profile that later would lead to the development of ED. However, the author did not investigate if and how the predictor

In terms of the mechanism that perpetuates EDs, according to the cognitivebehavioral theory of the maintenance of BN [118], a dysfunctional system for evaluating self-worth is central to the continuation of the pathology. People with eating disturbances judge themselves principally based on their eating behaviors, shape, or weight and their ability to control them. Most of the other clinical features can be considered as stemming directly from this overvaluation of eating, shape, and weight that represents the "core of psychopathology". This original theory of continuance on BN could embrace four additional maintaining mechanisms, which concern the influence of clinical perfectionism, low core self-esteem, mood intolerance, and interpersonal difficulties. However, a common mechanism is involved in the persistence of BN, AN, and the atypical EDs resulting in the transdiagnostic theory of the maintenance of the full range of eating disturbances [119]. Moving from this theory, Lampard and colleagues [120] concluded that a mixture of factors (i.e., transdiagnostic and disorder-specific) might be involved in the maintaining mechanism of ED disorder symptomatology. The transdiagnostic model of EDs might be applied to improve our understanding of muscle dysmorphia, additionally

**2. Identifying predictors associated with the severity of eating concerns** 

Investigating factors that contribute to the onset and development of EDs has been the focus of previous studies. Several variables have been suggested as possible predisposing and perpetuating factors for EDs pathologies: perceived parental bonding, self-esteem, perfectionism, and body shame are among the factors that have been investigated separately. However, studies explicitly evaluating different predictors associated with the risk and severity of eating symptoms are limited in

Based on this consideration, we have conducted a study [124] to identify predictors associated with the severity of disordered eating symptomatology. Identifying which of the individual variables (self-esteem, perceived parental care and protectiveness, body shame, and perfectionism) significantly predicted the severity of eating symptomatology for ED patients was the main research question that has

The study was approved by the ethics committee of the Faculty of Psychology

We gathered data from inpatients and outpatients referred to specialized residential ED treatment units in Northern, Central, and Southern Italy. At intake, a clinical interview was administered by ED clinicians for the assessment of diagnosis. All participants had a primary ED diagnosis DSM-IV [125]. Participants were tested at early stages—in order to avoid strong treatment effects—and at variables

variables interact with each other in explaining ED onset.

*DOI: http://dx.doi.org/10.5772/intechopen.91063*

perfectionism construct.

to eating psychopathology [121].

the literature [122, 123].

points during the treatment.

driven our work.

**in females with eating disorders**

(University of Campania "Luigi Vanvitelli").

#### *Risk and Maintenance Factors for Eating Disorders: An Exploration of Multivariate Models… DOI: http://dx.doi.org/10.5772/intechopen.91063*

significantly predicted by the three-way interaction term neither in concurrent nor in prospective analyses (i.e., examined as a moderator of treatment outcome). The authors concluded raising concerns about the robustness of the three-way model. Otherwise, it could have been affected by an inadequate conceptualization of the perfectionism construct.

A study by Ghaderi [117] suggested that a combination of low self-esteem, high body concern, low perceived support from the family, and more relative use of escape avoidance coping constitute a risk profile that later would lead to the development of ED. However, the author did not investigate if and how the predictor variables interact with each other in explaining ED onset.

In terms of the mechanism that perpetuates EDs, according to the cognitivebehavioral theory of the maintenance of BN [118], a dysfunctional system for evaluating self-worth is central to the continuation of the pathology. People with eating disturbances judge themselves principally based on their eating behaviors, shape, or weight and their ability to control them. Most of the other clinical features can be considered as stemming directly from this overvaluation of eating, shape, and weight that represents the "core of psychopathology". This original theory of continuance on BN could embrace four additional maintaining mechanisms, which concern the influence of clinical perfectionism, low core self-esteem, mood intolerance, and interpersonal difficulties. However, a common mechanism is involved in the persistence of BN, AN, and the atypical EDs resulting in the transdiagnostic theory of the maintenance of the full range of eating disturbances [119]. Moving from this theory, Lampard and colleagues [120] concluded that a mixture of factors (i.e., transdiagnostic and disorder-specific) might be involved in the maintaining mechanism of ED disorder symptomatology. The transdiagnostic model of EDs might be applied to improve our understanding of muscle dysmorphia, additionally to eating psychopathology [121].
