Skip to main content
SpringerLink
Log in

Expressed emotion, family environment, and parental bonding in bulimia nervosa: A 6-year investigation

  • Original Research Paper
  • Published:
Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity Aims and scope Submit manuscript

Abstract

As part of a prospective, long-term treatment study, 30 in-patients with bulimia nervosa (BN) were divided into groups with high and low expressed emotion (EE) family backgrounds according to the Camberwell Family Interview, and followed for a period of six years. The high EE group initially showed significantly more psychopathology than the low EE group. No group x time interactions were found, but the high EE group showed a worse outcome on the “conflict” and “organisation” subscales of the Family Environment Scale. They also showed significantly more eating disorder pathology according to the Eating Disorder Inventory (EDI) and the Structured Interview for anorexia nervosa (AN) and BN before treatment, at discharge, after two years and, to some degree, even after six years. Depth of depression (Beck Depression Inventory) was significantly higher in the high EE group at admission (moderate depression), discharge and after the 6-year follow-up (still slight depression). The Parental Bonding Instrument (PBI) showed no differences between the high EE and low EE groups, but the individuals with “affectionless control” according to the PBI had more negative scores on three of the subscales of the Family Environment Scale (FES). In brief, the high EE individuals with BN were initially sicker and did not fully catch up over time in comparison with the symptomatic recovery of the low EE individuals. These data suggest that EE status upon admission to in-patient treatment is a relevant predictor of the severity and course of BN and depressive symptoms.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Fichter M.M., Quadflieg N.: Six-year course of bulimia nervosa. Int. J. Eat. Disord., 22, 361–384, 1997.

    Article  PubMed  CAS  Google Scholar 

  2. Keel P.K., Mitchell J.E.: Outcome in bulimia nervosa. Am. J. Psychiatry, 154, 313–321, 1997.

    PubMed  CAS  Google Scholar 

  3. Fichter M.M., Quadflieg N.: Comparing self- and expert rating: a self-report screening version (SIAB-S) of the Structured Interview for Anorexic and Bulimic Syndromes for DSM-IV and ICD-10 (SIAB-EX). Eur. Arch. Psychiatry Clin. Neurosci., 250, 175–185, 2000.

    Article  PubMed  CAS  Google Scholar 

  4. Johnson C., Flach A.: Family characteristics of 105 patients with bulimia. Am. J. Psychiatry, 142, 1321–1324, 1985.

    PubMed  CAS  Google Scholar 

  5. Dolan B.M., Lieberman S., Evans C., Lacey J.H.: Family features associated with normal body weight bulimia. Int. J. Eat. Disord., 9, 639–647, 1990.

    Article  Google Scholar 

  6. Ordman A.M., Kirschenbaum D.S.: Bulimia: Assessment of eating, psychological adjustment, and familial characteristics. Int. J. Eat. Disord., 5, 865–878, 1986.

    Article  Google Scholar 

  7. Shisslak C.M., McKeon R.T., Crago M.: Family dysfunction in normal weight bulimic and bulimic anorexic families. J. Clin. Psychol., 46, 185–189, 1990.

    Article  PubMed  CAS  Google Scholar 

  8. Waller G., Slade P., Calam R.: Family adaptability and cohesion: Relation to eating attitudes and disorders. Int. J. Eat. Disord., 9, 225–228, 1990.

    Article  Google Scholar 

  9. Blouin J.H., Carter J., Blouin A.G., Tener L., Schnare-Hayes K., Zuro C. et al.: Prognostic indicators in bulimia nervosa treated with cognitive-behavioral group therapy. Int. J. Eat. Disord., 15, 113–123, 1994.

    Article  PubMed  CAS  Google Scholar 

  10. Head S.B., Williamson D.A.: Association of family environment and personality disturbances in bulimia nervosa. Int. J. Eat. Disord., 9, 667–674, 1990.

    Article  Google Scholar 

  11. Moos R.H., Moos B.S. Family Environment Scale Manual. 2nd ed. Palo Alto, Consulting Psychologists Press, 1986.

    Google Scholar 

  12. Graber J.A., Brooks-Gunn J., Paikoff R.L., Warren M.P.: Prediction of eating problems: An 8-year study of adolescent girls. Dev. Psychol., 30, 823–834, 1994.

    Article  Google Scholar 

  13. Carney C.P., Yates W.R., Cizadlo B.: A controlled family study of personality in normalweight bulimia nervosa. Int. J. Eat. Disord., 9, 659–665, 1990.

    Article  Google Scholar 

  14. McNamara K., Loveman C.: Differences in family functioning among bulimics, repeat dieters, and nondieters. J. Clin. Psychol., 46, 518–523, 1990.

    Article  PubMed  CAS  Google Scholar 

  15. Walsh B.T., Roose S.P., Glassman A.H., Gladis M., Sadik C.: Bulimia and depression. Psychosom. Med., 47, 123–131, 1985.

    PubMed  CAS  Google Scholar 

  16. Villejo R.E., Humphrey L.L., Kirschenbaum D.S.: Affect and self-regulation in binge eaters: Effects of activating family images. Int. J. Eat. Disord., 21, 237–249, 1997.

    Article  PubMed  CAS  Google Scholar 

  17. Boumann C.E., Yates W.R.: Risk factors for bulimia nervosa: A controlled study of parental psychiatric illness and divorce. Addict. Behav., 19, 667–675, 1994.

    Article  PubMed  CAS  Google Scholar 

  18. Grissett N.I., Norvell N.K.: Perceived social support, social skills, and quality of relationships in bulimic women. J. Consult. Clin. Psychol., 60, 293–299, 1992.

    Article  PubMed  CAS  Google Scholar 

  19. Reiss D., Johnson-Sabine E.: Bulimia nervosa: 5- year social outcome and relationship to eating pathology. Int. J. Eat. Disord., 18, 127–133, 1995.

    Article  PubMed  CAS  Google Scholar 

  20. Parker G., Tupling H., Brown L.B.: A parental bonding instrument. Br. J. Med. Psychol., 52, 1–10, 1979.

    Article  Google Scholar 

  21. Leung N., Glyn T., Waller G.: The relationship between parental bonding and core beliefs in anorexic and bulimic women. Br. J. Clin. Psychol., 39, 204–213, 2000.

    Article  Google Scholar 

  22. Calam R., Waller G., Slade P., Newton T.: Eating disorders and perceived relationships with parents. Int. J. Eat. Disord., 9, 479–485, 1990.

    Article  Google Scholar 

  23. Steiger H., Van der Feen J., Goldstein K., Leichner P.: Defense styles and parental bonding in eating-disordered women. Int. J. Eat. Disord., 8, 131–140, 1989.

    Article  Google Scholar 

  24. Fairburn C.G., Welch S.L., Doll H.A., Davies B.A., O’Connor M.E.: Risk factors for bulimia nervosa. A community-based case-control study. Arch. Gen. Psychiatry, 54, 509–517, 1997.

    Article  PubMed  CAS  Google Scholar 

  25. Kent, J.S., Clopton, J.R.: Bulimic women’s perceptions of their family relationships. J. Clin. Psychol., 48, 281–292, 1992.

    Article  PubMed  CAS  Google Scholar 

  26. Leff J., Vaughn C.: Expressed emotion in families. Its significance for mental illness. New York, Guilford Press, 1985.

    Google Scholar 

  27. Kavanagh D.J.: Recent developments in expressed emotion and schizophrenia. Br. J. Psychiatry, 160, 601–620, 1992.

    Article  PubMed  CAS  Google Scholar 

  28. MacMillan J.F., Gold A., Crow T.J., Johnson A.L., Johnstone E.C.: Expressed emotion and relapse. Br. J. Psychiatry, 148, 133–143, 1986.

    Article  PubMed  CAS  Google Scholar 

  29. Mintz J., Mintz L., Goldstein M.: Expressed emotion and relapse in first episodes of schizophrenia. Br. J. Psychiatry, 151, 314–320, 1987.

    Article  PubMed  CAS  Google Scholar 

  30. Vaughn C., Leff J.: The measurement of expressed emotion in the families of psychiatric patients. Br. J. Soc. Clin. Psychol., 15, 157–165, 1976a.

    Article  PubMed  CAS  Google Scholar 

  31. Hooley J.M., Orley J., Teasdale J.D.: Levels of expressed emotion and relapse in depressed patients. Br. J. Psychiatry, 148, 642–647, 1986.

    Article  PubMed  CAS  Google Scholar 

  32. Miklowitz D.J., Goldstein M.J., Nuechterlein K.H., Snyder K.S., Doane J.A.: Expressed emotion, affective style, lithium compliance, and relapse in recent onset mania. Psychopharmacol. Bull., 22, 628–632, 1986.

    PubMed  CAS  Google Scholar 

  33. O’Farrell T., Hooley J., Fals-Stewart W., Cutter H.S.G.: Expressed emotion and relapse in alcoholic patients. J. Consult. Clin. Psychol., 66, 744–752, 1998.

    Article  PubMed  Google Scholar 

  34. Fichter M.M., Glynn S.M., Weyerer S., Liberman R.P., Frick U.: Family climate and expressed emotion in the course of alcoholism. Fam. Process, 36, 203–221, 1997.

    Article  PubMed  CAS  Google Scholar 

  35. Chambless D.L., Steketee G.S.: Expressed emotion and the outcome of treatment for agoraphobia and obsessive-compulsive disorder. Annunal Conference of the Association for Advancement of Behavior Therapy. Miami, FL, 1997.

    Google Scholar 

  36. Chambless D.L., Steketee G.: Expressed emotion and behavior therapy outcome: A prospective study with obsessive-compulsive and agoraphobic outpatients. J. Consult. Clin. Psychol., 67, 658–665, 1999.

    Article  PubMed  CAS  Google Scholar 

  37. Butzlaff R.L., Hooley J.M.: Expressed emotion and psychiatric relapse. Arch. Gen. Psychiatry, 55, 547–552, 1998.

    Article  PubMed  CAS  Google Scholar 

  38. King S., Dixon M.J.: The influence of expressed emotion, family dynamics, and symptom type on the social adjustment of schizophrenic young adults. Arch. Gen. Psychiatry, 53, 1098–1104, 1996.

    Article  PubMed  CAS  Google Scholar 

  39. Peter H., Hand I., Wilke C.: Einfluß der Paarbeziehung auf Symptomatik und Therapieeffekte bei Agoraphobie: Eine empirische Studie unter Anwendung des Camberwell Familiy Interview. [Influence of relationships on symptoms and therapy outcome in agoraphobia: An empirical study using the CFI.] Verhaltenstherapie, 3, 120–130, 1993.

    Article  Google Scholar 

  40. Szmukler G.I., Eisler I., Russell G.F.M., Dare C.: Anorexia nervosa, parental ‘Expressed Emotion’ and dropping out of treatment. Br. J. Psychiatry, 147, 265–271, 1985.

    Article  PubMed  CAS  Google Scholar 

  41. Le Grange D., Eisler I., Dare C., Hodes M.: Family criticism and self starvation: A study of expressed emotion. J. Fam. Therapy, 14, 177–192, 1992.

    Article  Google Scholar 

  42. van Furth E., van Strien D.C., van Son M.J.M., van Engeland H.: The validity of the five-minute speech sample as an index of expressed emotion in parents of eating disorder patients. J. Child Psychol. Psychiatry 34, 1253–1260, 1993.

    Article  PubMed  Google Scholar 

  43. Dare C., Le Grange D., Eisler I., Rutherford J.: Redefining the psychosomatic family: Family process of 26 eating disorder families. Int. J. Eat. Disord., 16, 211–226, 1994.

    Article  PubMed  CAS  Google Scholar 

  44. Vaughn C.E., Leff J.P.: The influence of family and social factors on the course of psychiatric illness: A comparison of schizophrenic and depressed neurotic patients. Br. J. Psychiatry, 129, 125–137, 1976.

    Article  PubMed  CAS  Google Scholar 

  45. van Furth E.F., van Strien D.C., Martina L.M.L., van Son M.J.M., Hendrickx J.J.P., van Engeland H.: Expressed emotion and the prediction of outcome in adolescent eating disorders. Int. J. Eat. Disord., 20, 19–31, 1996.

    Article  PubMed  Google Scholar 

  46. Flanagan D.A.J., Wagner H.L.: Expressed emotion and panic-fear in the prediction of diet treatment compliance. Br. J. Clin. Psychol., 30, 231–240, 1991.

    Article  PubMed  Google Scholar 

  47. Fischmann-Havstad L., Marston A.R.: Weight loss maintenance as an aspect of family emotion and process. Br. J. Clin. Psychol., 23, 265–271, 1984.

    Article  PubMed  Google Scholar 

  48. Fichter M.M., Elton M., Engel K., Meyer A.E., Mall H., Poustka F.: Structured Interview for Anorexia and Bulimia Nervosa (SIAB): Development of a new instrument for the assessment of eating disorders. Int. J. Eat. Disord., 10, 571–592, 1991.

    Article  Google Scholar 

  49. Garner D.M., Olmsted M.P., Polivy J.: Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and bulimia. Int. J. Eat. Disord., 2, 15–34, 1983.

    Article  Google Scholar 

  50. Fichter M.M., Quadflieg N.: Six-year course and outcome of anorexia nervosa. Int. J. Eat. Disord., 26, 359–385, 1999.

    Article  PubMed  CAS  Google Scholar 

  51. Fichter M.M., Quadflieg N., Gnutzmann A.: Binge eating disorder: Treatment outcome over a 6-year course. J. Psychosom. Res., 44, 385–405, 1998.

    Article  PubMed  CAS  Google Scholar 

  52. American Psychiatric Association: Diagnostic and statistical manual of mental disorders. 3rd ed., revised. Washington, APA, 1987.

    Google Scholar 

  53. Fichter M.M.: Bulimia nervosa: Basic research, diagnosis and therapy. Chichester, John Wiley & Sons, 1990.

    Google Scholar 

  54. Fichter M.M.: Psychological therapies in bulimia nervosa. In: Fichter M.M. (Ed.), Bulimia nervosa: Basic research, diagnosis and therapy. Chichester, John Wiley & Sons, 1990, pp. 273–293.

    Google Scholar 

  55. Rief W., Stock C., Fichter M.M.: Das Anti-Diät Programm als integrativer Therapiebaustein bei anorektischen, bulimischen und adipösen Patienten. [The anti-diet-approach as an integrative therapeutic element with anorectic, bulimic and overweight patients.] Verhaltenstherapie, 1, 47–54, 1991.

    Google Scholar 

  56. Fichter M.M., Herpertz S., Quadflieg N., Herpertz-Dahlmann B.: Structured Interview for Anorexic and Bulimic Disorders for DSM-IV and ICD-10: Updated (third) revision. Int. J. Eat. Disord., 24, 227–249, 1998.

    Article  PubMed  CAS  Google Scholar 

  57. American Psychiatric Association: Diagnostic and statistical manual of mental disorders. 4th ed. Washington, APA, 1994.

    Google Scholar 

  58. Beck A.T., Ward C.H., Mendelson M., Mock J., Erbaugh J.: An inventory for measuring depression. Arch. Gen. Psychiatry, 4, 561–571, 1961.

    Article  PubMed  CAS  Google Scholar 

  59. Hiller W., Zaudig M., Mombour W.: Development of diagnostic checklists for use in routine clinical care. Arch. Gen. Psychiatry, 47, 782–784, 1990.

    Article  PubMed  CAS  Google Scholar 

  60. Hiller W., Zaudig M.: MDCL — Münchner Diagnosen-Checklisten für DSM-III-R und ICD-10. Handbuch und Checklisten (MDCL — Munich Diagnostic Checklists for DSM-III-R and ICD-10. Handbook and checklists. Bern, Huber, 1992.

    Google Scholar 

  61. Moos R.H., Moos B.S.: Family environment scale manual. Palo Alto, Consulting Psychologists Press, 1981.

    Google Scholar 

  62. Schneewind K.A., Beckmann M., Hecht-Jackl A.: Familiendiagnostisches Testsystem. Das FKTestsystem. Testmanual. [Testing system for family diagnosis. The FES.] Forschungsberichte aus dem Institutsbereich Persönlichkeitspsychologie und Psychodiagnostik 8.1. Munich, Germany, Universität München, 1985.

    Google Scholar 

  63. Welch S.L., Doll H.A., Fairburn C.G.: Life events and the onset of bulimia nervosa: A controlled study. Psychol. Med., 27, 515–522, 1997.

    Article  PubMed  CAS  Google Scholar 

  64. Bailey C.A.: Family structure and eating disorders: The family environment scale and bulimic-like symptoms. Youth & Society, 23, 251–272, 1991.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Roseneck Center for Behavioral Medicine, University of Munich (LMU), 83209, Prien/Chiemsee, Germany

    S. Hedlund Ph.D., M. M. Fichter & C. Brandl

  2. Department of Psychiatry, University of Munich (LMU), Germany

    M. M. Fichter & N. Quadflieg

Authors
  1. S. Hedlund Ph.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. M. M. Fichter
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. N. Quadflieg
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. C. Brandl
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Hedlund, S., Fichter, M.M., Quadflieg, N. et al. Expressed emotion, family environment, and parental bonding in bulimia nervosa: A 6-year investigation. Eat Weight Disord 8, 26–35 (2003). https://doi.org/10.1007/BF03324986

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF03324986

Key words

Search

Navigation