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Keywords:

  • body mass;
  • depression;
  • eating disorder;
  • gender;
  • obsession;
  • self-esteem

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIAL AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. REFERENCES

Abstract  The aim of this study was to examine the relationship between disordered eating and three psychological variables (obsessive and depressive symptoms, self-esteem) and body mass index (BMI) in a sample of male and female college students in Turkey. Maudsley Obsessive–Compulsive Inventory (MOCI), Beck Depression Inventory (BDI), Rosenberg Self Esteem Scale (RSES), Eating Attitude Test (EAT), and Bulimic Investigatory Test, Edinburgh (BITE) scales were administered to 408 college students (279 women; 129 men). By multiple regression analysis, the scales of MOCI, BDI, RSES and BMI were used as potential predictors of EAT and BITE scores for each gender. Obsessionality and BMI were the strongest predictors of bulimic and anorexic symptoms in women. In men, while the strongest predictors of bulimic symptoms were the depressive and obsessive symptoms, the best predictor of anorexic symptoms was obsession scores. There were significant differences and some similarities between male and female Turkish college students.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIAL AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. REFERENCES

The literature focusing on cultural aspects of eating disorders (ED) initially assumed them to be rare in non-Western societies. However, studies investigating the prevalence of disordered eating attitudes in non-Western societies show that these problems occur worldwide.1–4 However, cross-cultural studies should aim to do more than simply count cases. Understanding culture requires the consideration of its psychological counterparts and gender differences especially for eating disorders which are disproportionately more common among girls and women than boys and men.5 Turkey arguably occupies a pivotal position between East and West. Interestingly, the prevalence of abnormal eating attitudes reported in Turkish studies seems to be equivalent to or higher than those observed in Western countries in at least large cities.6,7 Obsessionality and body mass index (BMI) were found to be the best predictors in a study investigating the predicting variables (self-esteem, BMI, obsessionality, family functioning, depressive symptoms and locus of control) of Eating Attitude Test (EAT) scores of Turkish female college students.8

Low self-esteem is a widely recognized correlate of ED.9,10 Some studies have found that patients with ED have lower self-esteem than healthy control subjects.11–13 A prospective investigation revealed that low self-esteem significantly predicted the further occurence of the symptoms of ED.14,15 Silverstone claimed that chronic low self-esteem is the final common pathway of all risk factors of eating disorders.16 Low self-esteem at admission is found to be predictive in poor outcome for bulimic patients.17

Several studies have often reported an association between obsessive–compulsive disorder (OCD) and ED.18–20 The obsessive fear of gaining weight, extreme preoccupations with food and body image and an irresistable compulsion to binge and vomit have been seen as a manifestation of obsessive–compulsive symptom. Rothenberg proposed that ED are a modern variant of OCD in Western cultures.21 It has been shown that OCD symptoms persist after recovery from bulimia nervosa (BN).22 A strong connection was shown between obsessiveness and bulimic symptoms.23 Recovered female patients with BN and anorexia nervosa (AN) have a greater perfectionism than controls, and their most common obsessional target symptoms are the need for symmetry and ordering.24 An increased incidence of comorbid OCD has been observed in patients with BN.25,26 A hypothesis that ED should be included in obsessive–compulsive (OC) spectrum disorders was supported by the finding that the morbidity risk for OC spectrum disorders is significantly higher among the relatives of patients with ED than comparison individuals.27

The high prevalence of depressive symptoms in patients with ED has led many researchers to focus on relationship between ED and depression. Some theoretical models of ED etiology have emphasized the significant role of depression. The nature of this role is not yet clear (there are theories like ‘depression is a sequelae of ED’; ‘ED is a sequelae of depression’; ‘ED is an expression of depression’).28 Some researchers hypothesized that ED are a phenomenological variant of depression. Relatives of patients with an ED, AN and BN exhibit a high prevalence of mood disorders.29,30 High body mass is also considered to place individuals at risk for body dissatisfaction and consequent BN. Increased body mass is a known predictor of disordered eating, bulimic symptoms and the diagnosis of BN.31,32

Adolescent girls and young women are at the highest risk for ED.33 Particularly college women have the most striking prevalence of disordered eating behaviors. There exists a high number of abnormal eating attitudes among adolescent and young females who are neither anorexic nor bulimic. The aim of this study is to examine the relationship between disordered eating patterns and depression, obsessionality, self-esteem and BMI variables and to compare the gender differences in Turkish college students.

MATERIAL AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIAL AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. REFERENCES

Subjects

The participants were 411 undergraduate college students attending Anadolu University in Eskisehir, midland city of Turkey. Total number of students in the univeristy was 18 546; participants were 2.2% of total. Students were recruited by random selection of classes. Subjects participated voluntarily after informed consent was obtained and the study was approved by the ethical committe of Anadolu University. Of the students who were contacted, all of them agreed to participate and submitted the scales. The mean age for 279 females and 129 males were 20.31 (SD = 1.73) and 21.53 (SD = 1.98), respectively. Questionnaires of three subjects were excluded due to insufficient completion.

Measures

Eating Attitudes Test

The EAT is widely used as a self-rating screening for abnormal eating attitudes and has proved to be efficient in detecting AN and BN.34 It contains 40 items with six possible answers for each statement ranging from ‘never’ (0) to ‘always’ (3). The cut-off score of 30 shows a potential risk of developing an ED. EAT was found to be a highly reliable measure with an internal consistency of 0.94 for a pooled sample of participants with AN and those in control groups. Savasir and Erol35 demonstrated the validity of the Turkish version of the questionnaire in distinguishing eating disordered patients with other psychopathology groups and healthy controls. Factorial validity was shown in population sample and reliability coefficients of the Turkish version of the test were found to be high.

Bulimic Investigatory Test, Edinburgh (BITE)

Bulimic Investigatory Test, Edinburgh is a brief questionnaire including questions on eating habits and concerns about eating, shape and weight as found in BN.36 The Turkish version of BITE has acceptable levels of concurrent validity and reliability in university students.37 Although the EAT is a proven, reliable questionnaire, it was not designed for use with binge eaters: the questions are specifically concerned with the behavior and feelings associated with anorexia nervosa.36 So, the authors assumed EAT scores as anorexic symptomatology and BITE scores as bulimic symptomatology.

Rosenberg Self-Esteem Scale (RSES)

The Rosenberg Self-Esteem Scale contains 10 items scored on a 4-point likert scale that is anchored by ‘strongly agree’ and ‘strongly disagree’.38 This 10-item questionnaire is probably the most commonly used measure of global self-esteem. The authors used the original method of scoring, which results in a score between 0 and 6, with higher scores indicative of lower self-esteem and above being Rosenberg’s criterion for low self-esteem. The scale has been shown to be valid and reliable for Turkish adolescents.39,40

Maudsley Obsessive–Compulsive Inventory (MOCI)

This 30-item instrument is designed to measure obsessional ritualization and was employed unamended from its original wordings.41,42 Subscales include checking, washing, doubt and slowness. Clarke and Bolton demonstrated the validity of the questionnaire in distinguishing adolescent patients with OCD from those with anxiety states. The Turkish version is translated and validated.43 Reliability of the Turkish form: Cronbach’s alpha was found to be 0.85 for all scales, and between 0.61 and 0.65 for subscales. Test–retest reliability was 0.88 for all scales, between 0.59 and 0.84 for subscales. Validity of the Turkish form: factor analysis was applied for constructive validity; instead of four, three factors were identified. These three factors were washing, obsessive thinking, slowness and control, respectively. Subscales were identified accordingly for the Turkish version.

Beck Depression Inventory (BDI)

A 21-item self-rated inventory measuring behavioral manifestations and depth of depression.44 Good internal consistency and reliability and a sensitivity to change have all been demonstrated. In a reliability study of the Turkish form, Cronbach’s alpha was found 0.81 and split-half reliability was found as 0.74. In establishing concurrent validity, BDI was correlated with Depression subscale of MMPI, and correlation between them was found to be 0.50. Factorial analysis was conducted for construct validity and six factors were found.45 It was stated that four out of six factors could be interpretable. These four factors include disparity, negative feelings toward one’s self, anxieties related with body, and guilt feelings, respectively.

Body mass index

Participants reported their height and weight. Based on these self-reported data, body mass index was calculated (BMI = weight (kg)/height2 (m2)).

Procedure

Participants were asked to complete the MOCI, RSES, BDI, BITE, EAT and demographic information while at a lecture room in college. The students provided their responses while in a physical education class. BMI was calculated (kg/m2) based on self-reported height and weight.

Data analysis

One-way anova were conducted on scores of all measures by gender. Pearson product–moment correlation coefficients were computed to assess the relationship between variables for each gender. A linear regression analysis was carried out with EAT and BITE scores as the dependent variable for each gender. The independent variables were depression, obsession–compulsion, self-esteem scores and BMI values.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIAL AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. REFERENCES

Most of the subjects were unmarried (n = 404, 98.8%) except four married females (1.4%) and one married male (0.7%). Mean and standard deviations of age, BMI and psychological variables and gender differences are displayed in Table 1.

Table 1.  Mean scores of variables between genders
 FemaleMaleF
MeanSDMeanSD
  • *

    P < 0.05;

  • **

    P < 0.01.

  • BDI, Beck Depression Inventory; BITE, Bulimic Investigatory Test, Edinburg; BMI, body mass index; Checking, checking subscale of MOCI; Doubt, doubt subscale of MOCI; EAT, Eating Attitude Test; MOCI, Maudsley Obsessive–Compulsive Inventory; Obsess total, total score of MOCI; SD, standard deviation; Severity BITE, severity score of BITE; Slowness, slowness subscale of MOCI; Symptom BITE, symptom score of BITE; Washing, washing subscale of MOCI.

Age 20.31.7 21.51.9 39**
Height (cm)164.15.9175.66.3313**
Weight (kg) 54.87.0 67.28.4235**
Education year 13.40.8 13.40.7 13**
BMI 20.32.2 21.72.3 32.1**
EAT 15.78.3 12.25.7 17.7**
Symptom BITE 12.03.5 10.73.4 11.9**
Severity BITE 0.80.7 0.80.7 0.2
BDI 11.68.2 11.78.4 0.02
Self-esteem 1.11.2 1.41.4 3.3
Obsess total 14.35.6 12.95.8 5.0*
Checking 2.31.7 2.21.7 0.6
Washing 4.62.2 3.82.0 11.2**
Slowness 1.91.3 1.91.4 0.0
Doubt 2.91.4 2.81.4 0.7

Symptom scale scores of BITE were significantly different between men and women (F[1/400] = 11.9, P < 0.001). Severity scale scores of BITE were under the clinically non-significant score of 5 in both genders. Scores of EAT of females were significantly higher than EAT scores of males (F[1/399] = 17.75, P < 0.001). Comparisons of group means are displayed in Table 1. A total of 20.6% of females and 6.5% of males were underweight, while 6.5% of males and 1.8% of females were overweight. Distribution of weight and disordered eating scores are displayed in Table 2.

Table 2.  Weight and eating disorder symptom distributions of subjects
 Female n (%)Male n (%)Total N (%)
  •  18,5 > BMI, underweight; 18,5 < BMI < 25, normal; 25 < BMI < 30, overweight; 30 < BMI, obese; NHLBI, 1998.

  • BITE, symptom score of Bulimic Investigatory Test, Edinburg; EAT, Eating Attitude Test.

Underweight 56 (20.6) 8 (6.5) 64 (16.1)
Normal210 (77.2)107 (86.2)317 (80.0)
Overweight 5 (1.8) 8 (6.5) 13 (3.2)
Obese 1 (0.4) 1 (0.8) 2 (0.5)
BITE ≥ 20 5 (1.8) 2 (1.5) 7 (1.7)
10 ≥ BITE < 20202 (73.4) 76 (58.9)278 (68.8)
BITE < 10 68 (24.7) 51 (39.5)119 (29.4)
EAT ≥ 30 17 (6.1) 3 (2.4) 20 (5)
20 ≤ EAT < 30 55 (19.7) 10 (8.2) 65 (16.2)
EAT < 20206 (74.1)108 (89.2)314 (78.6)

There were no significant differences between women and men in depressive symptomatology and self-esteem scores. Females scored significantly higher than males on total score of obsession and subscale score of washing. The subscales of slowness, doubt and checking were not significantly different.

Stepwise multiple regression analysis was conducted to determine the best predictors of disordered eating in females and males. The independent variables were BMI, self-esteem, depression and obsession scores. Stepping method criteria is the F-value which the enter F is 3.84 and the removal F is 2.71. Dependent variables were BITE and EAT scores. Regression analyses were conducted separately for each gender.

Predictors of bulimic symptomatology (BITE scores): The independent variables were depression scores, self-esteem, obsession scores and BMI values. Regression analysis was conducted separately for each gender. Stepwise regression analysis was conducted to determine the best predictors of BITE symptom scores. The best predictors of bulimic symptoms of females were total score of obsession and subscale score of slowness and BMI. These three variables accounted for 16% of the variability in bulimic symptoms. The best two predictors of bulimic symptoms for males were depressive symptoms and checking obsession scores. Depression and checking obsessive symptoms scores accounted for 14% of the variability in bulimic symptoms of males. Summary of the regression equation of females and males is displayed in Table 3.

Table 3.  Variables entered in regression equation of Bulimic Investigatory Test, Edinburg scores
 RR2BR2 change
  1. BDI, Beck Depression Inventory; BMI, body mass index; Obsession Total, total score of Maudsley Obsessive–Compulsive Inventory.

Female
 Obsession total0.270.070.150.07
 BMI0.370.140.270.06
 Slowness0.400.160.190.02
Male
 BDI0.340.110.280.11
 Checking0.380.140.180.02

Predictors of anorexic symptomatology (EAT scores): Stepwise regression analyses were conducted to determine the best predictors of EAT scores. The best predictors of EAT score of females were total obsession score and BMI. These two variables accounted for 7.7% of the variability in EAT scores. For males the best predictor of EAT scores were obsession total scores. Obsession total scores of males accounted for 4% of the variability in EAT scores. Summary of the regression equations of females and males is displayed in Table 4.

Table 4.  Variables entered in regression equation of Eating Attitude Test scores
 RR2BR2 change
  1. BMI, body mass index; Obsession total, total score of Maudsley Obsessive–Compulsive Inventory.

Female
 Obsession total0.240.060.240.06
 BMI0.270.070.130.01
Male
 Obsession total0.190.040.190.04

The authors have found a significant positive correlation (r = 0.25, P < 0.001) between anorexic and bulimic symptoms of females (Table 5). In contrast, there was no significant correlation (r =−0.002, P = 0.98) between anorexic and bulimic symptoms of males. Self-esteem scores of females were not significantly correlated with anorexic (r = 0.10, P > 0.05) and bulimic (r = 0.11, P > 0.05) symptoms. Anorexic symptoms of males were significantly correlated with only total obsession (r = 0.19, P < 0.05) scores and subscale scores of checking (r = 0.179, P < 0.05).

Table 5.  Correlations between variables of men and women
 12345678910
  • *

    P < 0.05;

  • **

    P < 0.01.

  • BDI, Beck Depression Inventory; BITE, symptom score of Bulimic Investigatory Test, Edinburg; BMI, body mass index; Check, checking subscale of MOCI; Doubt, doubt subscale of MOCI; EAT, Eating Attitude Test; MOCI, Maudsley Obsessive–Compulsive Inventory; ObsT, obsession total score of MOCI; RSES, Rosenberg Self-Esteem Scale; Slow, slowness subscale of MOCI; Wash, washing subscale of MOCI.

Female
 1. BITE         
 2. EAT0.25**        
 3. BMI0.25**0.13*       
 4. BDI0.16**0.14*0.07      
 5. RSES0.110.010.080.43**     
 6. ObsT0.28**0.24**−0.000.31**0.17**    
 7. Check0.24**0.13*0.000.21**0.12*0.78**   
 8. Wash0.090.14*−0.030.03−0.050.66**0.32**  
 9. Slow0.27**0.19**−0.070.24**0.18**0.60**0.43**0.32** 
10. Doubt0.19**0.15*0.020.22**0.12*0.67**0.47**0.24**0.27**
Male
1. BITE         
2. EAT0.00        
3. BMI−0.020.01       
4. BDI0.34**0.10−0.15      
5. RSES0.30**−0.05−0.130.66**     
6. ObsT0.29**0.19*−0.150.47**0.26**    
7. Check0.27**0.17*−0.1*0.34**0.24**0.76**   
8. Wash0.080.170.020.12−0.040.71**0.40**  
9. Slow0.25**0.12−0.160.42**0.25**0.76**0.49**0.43** 
10. Doubt0.17*0.14−0.2*0.45**0.26**0.78**0.50**0.46**0.59**

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIAL AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. REFERENCES

In the present study, 6.1% of female college students rated abnormal eating attitudes by EAT-40; this ratio appears to be similar to the findings of other studies performed in Turkey. A total of 8% of 253 female university students displayed abnormal eating attitudes as measured by EAT-40 in Turkey.1 In a previous study which did not include male college students, it was found that 9.9% of 532 female university students scored over 30 on the EAT.7

The authors have found that females had more bulimic and anorexic eating attitudes than males. Depression and self-esteem scores were not different between men and women. Self-esteem was not a good predictor of disordered eating of Turkish women and was surprisingly not even correlated with disordered eating. Low self-esteem is one of the consistent predictors of disordered eating among girls in Western countries.9,46 The authors have also found that obsession-total and washing scores of women were significantly higher than of men.

Both EAT and BITE scores of males were not correlated with BMI. Therefore, bulimic and anorexic behavior of men is not a result of weight-related sensitivity. However, not surprisingly, the bulimic and anorexic behaviors of Turkish females were strongly related with BMI. In addition, BMI was a strong predictor in regression equation of BITE and EAT scores of women. This result is consistent with the findings of previous studies in which the relationships between BMI and psychological variables differed between men and women in Western countries.47

The relationship with obsessionality and disordered eating was obvious in both women and men. The current finding which indicated a relationship with obsessionality and disordered eating (bulimic and anorexic) was congruent with the findings of Rogers and Petrie’s investigation of college female students.23 Predictors and correlates of EAT and BITE scores of Turkish men and women were different except for obsessionality. Bulimic symptoms of men were best predicted by depression and obsession-checking scores. Anorexic symptoms (EAT scores) of men were best predicted by obsession-total scores. EAT scores of men were correlated with only obsession total and checking scores, while EAT scores of men were not correlated with self-esteem, depression and BMI.

The present study showed a strong relationship between disordered eating attitudes and obsessionality and BMI in young Turkish women. This was not the same for young Turkish men. Bulimic attitudes of young Turkish men were strongly related with depressive and obsessive symptomatology. Anorexic attitudes of young Turkish men were related with obsessionality. The authors can conclude that the gender differences were more obvious than similarities in the association between psychological functioning and disordered eating. The authors may suggest that these findings in Turkish females can not be generalized to Turkish males. In comparison to the findings of previous Western studies, the authors have found some similarities and differences in psychological and disordered eating patterns.46–48

The cross-sectional design that can not assess the progression of symptoms over time and the absence of structured diagnostic interviews to diagnose eating disorders are the limitations of this study. The authors have not included other variables in the current study which might also be predictors of these disordered eating behaviors.

CONCLUSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIAL AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. REFERENCES

The authors obtained quite interesting gender-related results in this study. There were significant differences and some common features between male and female Turkish students. Self-esteem was not correlated with disordered eating of Turkish women. Bulimic and anorexic behaviors of women were strongly related with BMI but not for men. Obsessionality was the strong predictor of disordered eating of both genders.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIAL AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. REFERENCES
  • 1
    Miller NM, Pumariega AJ. Culture and eating disorders: a historical and cross-cultural review. Psychiatry 2001; 64: 93110.
  • 2
    Elal G. Abnormal eating attitudes and disorders in Turkey: feminine attractiveness or liberal modernity? In: RuggieroGM (ed.). Eating Disorders in the Mediterranean Area: An Exploration in Transcultural Psychology. Nova Biomedical Books, New York, 2003; 5778.
  • 3
    Le Grange D, Telch CF, Tibbs J. Eating attitudes and behaviors in 1435 South African caucasian and non-caucasian college students. Am. J. Psychiatry 1998; 155: 250254.
  • 4
    Lee S, Katzman MA. Cross-cultural perspectives on eating disorders. In : FairburnCG, BrownellKD (eds). Eating Disorders and Obesity: A Comprehensive Handbook, 2nd edn. Guilford Press, New York, 2002; 260264.
  • 5
    Striegel-Moore RH, Smolak L. Gender, Ethnicity, and eating disorders. In : FairburnCG, BrownellKD (eds). Eating Disorders and Obesity: A Comprehensive Handbook, 2nd edn. Guilford Press, New York, 2002; 251255.
  • 6
    Altug A, Elal G, Slade P, Tekcan A. The Eating Attitude (EAT) in Turkish University students: relationship with sociodemographic, social and individual variables. Eat. Weight. Disord. 2000; 5: 152160.
  • 7
    Elal G, Sabol E, Slade P. The relationship between abnormal eating attitudes and sexual abuse in Turkish university students. 30th Congress of the European Association for Behavioural and Cognitive Therapies, Granada, Spain, 2000.
  • 8
    Erol A, Toprak G, Yazici F. Predicting factors of eating disorders and general psychological symptoms in female college students. Turk. Psikiyatri Derg. (Turk. J. Psychiatry) 2002; 13: 4857 (in Turkish).
  • 9
    Button EJ. Self-esteem in girls aged 11–12: baseline findings from a planned prospective study of vulnerability to eating disorders. J. Adolesc. 1990; 13: 407413.
  • 10
    Fairburn CG, Welch SL, Doll HA, Davies BA, O’Connor ME. Risk factors for bulimia nervosa. Arch. Gen. Psychiatry 1997; 54: 509517.
  • 11
    Dykens EM, Gerard M. Psychological profiles of purging bulimics, repeat dieters and controls. J. Consult. Clin. Psychol. 1986; 54: 283288.
  • 12
    Silverstone PH. Low self-esteem in eating disordered patients in the absence of depression. Psychol. Rep. 1990; 67: 276278.
  • 13
    Laessle RG, Tuschl RJ, Waadt S, Pirke KM. The specific psychopathology of bulimia nervosa: a comparison with restrained and unrestrained eaters. J. Consult. Clin. Psychol. 1989; 57: 772775.
  • 14
    Button EJ, Sonuga-Barke EJS, Davies J, Thompson M. A prospective study of self-esteem in the prediction of eating problems in adolescent schoolgirls: questionnaire findings. Br. J. Clin. Psychol. 1996; 35: 193203.
  • 15
    Leon GR, Keel PK, Klump KL, Fulkerson MA. The future of risk factor research in understanding the etiology of eating disorders. Psychopharmacol. Bull. 1997; 33: 405411.
  • 16
    Silverstone PH. Is chronic low self-esteem the cause of eating disorders? Med. Hypotheses 1992; 39: 311315.
  • 17
    Van Der Ham T, Van Strien DC, Van Engeland H. Personality characteristics predict outcome of eating disorders in adolescents: a 4-year prospective study. Eur. Child Adolesc. Psychiatry 1998; 7: 7984.
  • 18
    Palmer HD, Jones MS. Anorexia nervosa as a manifestation of compulsive neurosis. Arch. Neurol. Psychiatry 1939; 41: 856860.
  • 19
    Hsu LK, Kaye W, Weltzin T. Are the eating disorders related to obsessive compulsive disorder? Int. J. Eat. Disord. 1993; 14: 305318.
  • 20
    Polivy J, Herman CP. Causes of eating disorders. Annu. Rev. Psychol. 2002; 53: 187213.
  • 21
    Rothenberg A. Eating disorder as a modern obsessive–compulsive syndrome. Psychiatry 1986; 49: 4553.
  • 22
    Ranson KM, Kaye WH, Weltzin TE, Rao R, Matsunaga H. Obsessive-Compulsive Disorder symptoms before and after recovery from bulimia nervosa. Am. J. Psychiatry 1999; 156: 17031708.
  • 23
    Rogers RL, Petrie TA. Psychological correlates of anorexic and bulimic symptomatology. J. Couns. Dev. 2001; 79: 178187.
  • 24
    Kaye WH, Klump KL, Frank GKW, Strober M. Anorexia and bulimia nervosa. Annu. Rev. Med. 2000; 51: 299313.
  • 25
    Leassle RG, Kittl S, Fichter MM, Wittchen HU, Pirke KM. Major affective disorder in anorexia nervosa and bulimia. Br. J. Psychiatry 1987; 151: 785789.
  • 26
    Braun DL, Sunday SR, Halmi KA. Psychiatric comorbidity in patients with eating disorders. Psychol. Med. 1994; 24: 859867.
  • 27
    Bellodi L, Cavallini MC, Bertelli S, Chiapparino D, Riboldi C, Smeraldi E. Morbidity risk for obsessive-compulsive spectrum disorders in first-degree relatives of patients with eating disorders. Am. J. Psychiatry 2001; 58: 563569.
  • 28
    Bulik CM. Anxiety, depression and eating disorders. In : FairburnCG, BrownellKD (eds). Eating Disorders and Obesity: A Comprehensive Handbook, 2nd edn. Guilford Press, New York, 2002; 193198.
  • 29
    Wade TD, Bulik CM, Neale M, Kendler KS. Anorexia nervosa and major depression: shared genetic and environmental risk factors. Am. J. Psychiatry 2000; 157: 469471.
  • 30
    Hudson JI, Laird NM, Betensky RA, Keck PE, Pope HG. Multivariate logistic regression for familial aggregation of two disorders. II. Analysis of studies of eating and mood disorders. Am. J. Epidemiol. 2001; 153: 506514.
  • 31
    Keel PK, Fulkerson JA, Leon GR. Disordered eating precursors in pre-and early adolescent girls and boys. J. Youth Adolesc. 1997; 26: 203216.
  • 32
    Patton GC. The spectrum of eating disorder in adolescence. J. Psychosom. Res. 1988; 32: 579584.
  • 33
    Striegel-Moore RH, Silberstein LR, Frensch P, Rodin J. A prospective study of disordered eating among college students. Int. J. Eat. Disord. 1989; 11: 121131.
  • 34
    Garner DM, Garfinkel PE. Eating attitudes test: an index of the symptoms of anorexia nervosa. Psychol. Med. 1979; 9: 273279.
  • 35
    Savasir I, Erol N. Eating attitude test: anorexia nervosa symptom index. Psikoloji Dergisi 1989; 7: 1925 (in Turkish).
  • 36
    Henderson M, Freeman CPL. The BITE: a self-rating scale for bulimia. Br. J. Psychiatry 1987; 150: 1824.
  • 37
    Kiran SG, Agargun MY, Kara H, Kutanis R. Eating attitudes and dissociative experiences in college students. 36th National Psychiatry Congeress, Antalya, Turkey, 3–7 October 2000 (in Turkish).
  • 38
    Rosenberg M. Society and the Adolescent Self-Image. Princeton University Press, Princeton, NJ, 1965.
  • 39
    Cuhadaroglu F. Self-esteem and its relation to various psychopathologies in adolescence. Dusunen Adam 1990; 3: 7175.
  • 40
    Cuhadaroglu F. Self-esteem in adolescents. Doctoral Dissertation, Hacettepe University, Ankara, Turkey, 1986 (in Turkish).
  • 41
    Hodgson RJ, Rachman S. Obsessional-compulsive complaints. Behav. Res. Ther. 1977; 15: 389395.
  • 42
    Strenberger LG, Burns GL. Maudsley Obsessional-Compulsive Inventory: obsessions and compulsions in a nonclinical sample. Behav. Res. Ther. 1990; 28: 337340.
  • 43
    Erol N, Savasir I. The Turkish version of the Maudsley Obsessional-Compulsive Questionnaire. Presented in the 2nd Regional Conference of the International Association of Cross-Cultural Psychology, Amsterdam, 1989.
  • 44
    Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch. Gen. Psychiatry 1961; 4: 561571.
  • 45
    Hisli N. Validity and reliability of Beck Depression Inventory for college students. Psikoloji Dergisi 1989; 7: 313 (in Turkish).
  • 46
    McCabe MP, Vincent MA. The role of biodevelopmental and psychological factors in disordered eating among adolescent males and females. Eur. Eat. Disord. Rev. 2003; 11: 315328.
  • 47
    Faith MS, Flint J, Fairburn CG, Goodwin GM, Allison DB. Gender differences in the relationship between personality dimensions and relative body weight. Obes. Res. 2001; 10: 647650.
  • 48
    Keel PK, Klump KL, Leon GR, Fulkerson JA. Disordered eating in adolescent males from a school-based sample. Int. J. Eat. Disord. 1998; 23: 125132.