Families, Systems, & Health 2015, Vol. 33, No. 4, 405– 409
© 2015 American Psychological Association 1091-7527/15/$12.00 http://dx.doi.org/10.1037/fsh0000147
BRIEF REPORT
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Exploring the Association Between Partner Behaviors and Eating Disorder Symptomology Lisa Zak-Hunter, PhD
Lee N. Johnson, PhD
University of Georgia and Via Christi Family Medicine Residency, Wichita, Kansas
University of Georgia and Brigham Young University
Introduction: Research suggests an association between partner support and eating disorder (ED) symptomology in coupled women. However, no research describes whether time is a factor when examining routine partner behaviors that contribute to ED symptom severity. This study examined the relationship between supportive and unsupportive partner behaviors and ED symptom severity over a 3-month time period. Method: Fifty-eight women with anorexia nervosa (AN) and bulimia nervosa (BN) identified helpful and unhelpful partner behaviors and ranked relationship support and symptom severity for the past 3 months using an event history calendar. Regression analyses examined the relationship between symptom distress and partner-support variables over 3 months. Results: Higher levels of helpfulness and relationship quality positively predicted partner-support levels. Partner distancing was predictive of increases in symptom distress. Discussion: Emotional or physical distancing or neglect aggravates symptom severity, which highlights the importance of addressing couple relationships in treatment and research. Keywords: eating disorders, couples, symptomology, event history calendar
Eating disorders (EDs) have significantly high mortality rates, ranging from 1.93 in bulimia nervosa (BN) to 5.86 in anorexia nervosa (AN; Arcelus, Mitchell, Wales, & Nielsen, 2011), and partnered women tend to suffer from more severe symptomology (Bussolotti et al., 2002). Committed romantic relationships provide a distinct context for ED symptom manifestation, and there is growing understanding of these relationship chal-
This article was published Online First July 13, 2015. Lisa Zak-Hunter, PhD, Department of Human Development and Family Science, University of Georgia, and Via Christi Family Medicine Residency, Wichita, Kansas; Lee N. Johnson, PhD, Department of Human Development and Family Science, University of Georgia, and Department of Family Life, Brigham Young University. Lisa Zak-Hunter and Lee N. Johnson are no longer affiliated with University of Georgia. Correspondence concerning this article should be addressed to Lisa Zak-Hunter, PhD, Via Christi Family Medicine Residency, 1121 South Clifton, Wichita, KS 67218. E-mail: [email protected]
lenges (Arcelus, Yates, & Whiteley, 2012). Partnered women struggle with relationship concerns such as intimacy, physical and emotional closeness, sexuality, relationship conflict, and communication difficulties (Arcelus et al., 2012). Recent research examined specific supportive partner behaviors (such as acceptance/validation), and found that, in conjunction with patient motivation, these may facilitate working toward recovery (Fischer, Baucom, Kirby, & Bulik, 2015). One unexplored area is whether couple interaction changes with symptom severity. Follow-up studies on the course of EDs generally follow patients on an annual or biannual basis for several years. These indicate that recovery can take years, marked with periods of relapse, and sometimes crossover into different EDs (Fichter & Quadflieg, 2007). It is reasonable to assume partner behaviors may vary over time with these fluctuations. However, no studies have addressed this topic. To address these concerns, this study uses event history calendar
405
406
ZAK-HUNTER AND JOHNSON
(EHC) methodology to examine certain variables over 3 months: (a) whether ED thoughts and behaviors affect overall symptom distress and partner support and (b) whether helpful and unhelpful partner behaviors affect overall symptom distress and partner support.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Method Participants Sample criteria included (a) being female; (b) being age 18 years or older; (c) being clinically diagnosed with AN or BN; (d) being in a committed romantic relationship; and (e) having no Diagnostic and Statistical Manual of Mental Disorders (fourth edition; DSM–IV) Axis II disorders, per self-report. See Table 1 for demographic information. Materials and Procedure Participants were recruited via purposive sampling. Flyers with a link to the website and
Table 1 Mean Scores of Demographic and ED Variables Variable
M (SD) (%n ⫽ 58)
Demographics Participant age Partner age Length of relationship (years) Not married Cohabiting No children College degree Employed part-time Income ⬍$40,000 Caucasian
27.28 (8.0) 31.75 (10.58) 4.40 (5.16) 60.30% 70.70% 81.80% 65.90% 71.20% 51.2% 90.90%
Eating disorder Current diagnosis–BN First diagnosis–AN BMI–AN BMI–BN Other psychological diagnoses In treatment Outpatient treatment Individual treatment Length of current diagnosis (years)
55.20% 43.20% 19.52 (4.12)a 22.48 (4.39)a 55.80% 67.20% 70.40% 62.50% 8.78 (9.61)
Note. Although sexual orientation was not measured, one participant disclosed she was a lesbian. a Determined from self-reported most recent weight (if known) and height. Normal BMI range is 18.5–24.9 kg/m2.
principal investigator contact information were placed in national and local ED treatment centers/ED specialist offices, university campuses, and ED or mental illness awareness social networking websites. Participants followed the link to an introduction, informed consent, calendar survey, and demographics form. They were given information about the purpose of calendar studies, instructions, and an example of how to fill out the calendar. They could enter a drawing for a $25 gift card. This study was approved by the Institutional Review Board at the University of Georgia. A self-administered online EHC (Belli, James, Van Hoewyk, & Alcser, 2009) was used to gather information about patients’ experiences of their ED and intimate relationship. EHCs have been used to research eating behaviors and family dynamics (Danford & Martyn, 2013), thus making them an ideal methodology for studying EDs within intimate relationships. EHC methods are also reliable for collecting retrospective data (Martyn & Belli, 2002). The EHC is a calendar grid wherein the columns represent time units (e.g., months) and the rows gather information regarding research-specific domains (e.g., ED symptoms). The first domains are the easiest to recall, the least threatening, and will cue memory recall of the remaining domains (e.g., age, relationship history, employment status, special events). EHCs are considered to be optimal for memory retrieval because of their ability to cue multiple mechanisms found in autobiographical memory. In this EHC, participants reported data for the past 3 months, starting with the most recent month. A 3-month time period was chosen for two reasons: (a) 1 year or longer may have been challenging for monthly memory recall and caused higher attrition and (b) to explore whether fluctuations occur on a smaller scale than is normally reported in ED literature. For each month, they first recorded the following domains: length of current relationship, cohabitation status, relationship status, employment status, and important life events and occurrences. This was followed by treatment-related domains: treatment type (inpatient, outpatient, residential, hospitalization) and treatment format (individual, couple, family, group). They then reported most and least frequent symptoms, including average monthly symptom severity (1–10; 10 ⫽ most distressing); weight (if
EXPLORING PARTNER BEHAVIORS
known); helpful and unhelpful partner behaviors; and average helpfulness of partner behaviors (1–10, 10 ⫽ most helpful), partner support, and relationship quality. They reported on all 3 months at once.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Statistical Analyses Symptoms and behaviors were coded on two dimensions; each dimension was broken into different codes. Symptoms included ED thoughts (five codes) and ED behaviors (four codes). Partner behaviors were coded on two dimensions: helpful behaviors and unhelpful behaviors. Each dimension was broken down into different five codes. Research questions were analyzed using multiple regression analyses in Mplus version 7, and missing data were deleted listwise. Results Of the 204 participants who visited the survey link, 58 completed the survey (response rate 28.4%). Of the 58 participants, 16 did not complete the demographic questionnaire at the end. An independent sample t test, t(55) ⫽ ⫺2.24, p ⬍ .05, indicated that those who filled out the calendar and demographics (n ⫽ 44; M ⫽ 5.59, SD ⫽ 2.99) experienced less overall partner support than those who did not complete the demographics (n ⫽ 14; M ⫽ 7.69, SD ⫽ 2.93). The most frequent ED thoughts were related to body image (12.3%; “feeling fat”) and the most frequent behavior was purging (24.6%). Providing emotional support (28.8%; “support me even though I started slipping”) and communication (24.4%; “talked to me”) were the most common helpful behaviors. The most common unhelpful behaviors were creating conflict (33.8%; “questioned and criticized”) and pulling away (27.5%; “seemed uninterested in me”). Results revealed that symptom type was not predictive of changes in symptom distress over 3 months. Symptom distress levels had no effect on level of partner support over 3 months. Lastly, no specific symptoms predicted partner support levels over 3 months (see Table 2). Two results were statistically significant. Increased levels of helpfulness of behaviors
407
Table 2 Research Question Results Independent variables
Est
SE
Variables predicting overall partner support Control variables Time ⫺0.33 0.18 Relationship quality 0.62 0.07 Helpfulness of behaviors 0.41 0.07 Unhelpfulness of behaviors ⫺0.01 0.07 Helpful behaviors Encouragement/support 0.06 0.61 Communicate 0.38 0.63 Physical affection/comfort 0.09 0.79 Directly attending to eating 0.01 0.72 Disorder symptoms Unhelpful behaviors Pull away 0.77 0.74 Create conflict ⫺0.26 0.75 Guilt 0.88 1.30 Focus on food ⫺0.21 0.76 Variables predicting overall symptom distress Control variables Time 0.13 0.20 BMI 0.15 0.04 Helpful behaviors Encouragement/support 0.81 0.56 Communicate ⫺0.39 0.49 Physical affection/comfort ⫺0.19 0.736 Directly attending to eating ⫺0.30 0.61 Disorder symptoms Unhelpful behaviors Pull away ⫺1.54 0.53 Create conflict ⫺0.70 0.56 Guilt ⫺0.55 1.31 Focus on food 0.60 0.55 ⴱ
z
⫺1.79 8.52ⴱ 5.50ⴱ ⫺0.10 0.09 0.60 0.12 0.02
1.04 ⫺0.35 0.68 ⫺0.28
0.06 3.58ⴱ 1.45 ⫺0.81 ⫺0.26 ⫺0.50 ⫺2.88ⴱ ⫺1.24 ⫺0.42 1.10
p ⬍ .01.
and relationship quality significantly predicted increased partner-support levels, with the model accounting for 62.2% of variance, p⬍.05. Second, body mass index (BMI) was included as a control variable when examining which helpful and unhelpful behaviors predict symptom distress levels over 3 months. Overall, the model was significant and accounted for 31% of variance in symptom distress, p ⬍ .05. Increased BMI and the unhelpful behavior of pulling away were predictive of increased symptom distress, but not over 3 months (see Table 2). Discussion This study explored how partner support and ED symptomology varied over 3 months.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
408
ZAK-HUNTER AND JOHNSON
Specifically, we examined the interplay among routine helpful and unhelpful partner behaviors, symptoms, and levels of partner support and symptom distress. Greater helpfulness of behaviors and higher relationship quality were indicative of higher partner support. This provides support to the idea that couple relationship functioning is important in the management of ED symptoms (Dick, Renes, Morotti, & Strange, 2013). Specific behaviors may not be as important as how satisfied the woman is with her relationship and partner help. This is somewhat in contrast to the findings of Fischer and colleagues (2015) that partner acceptance/validation is helpful. In our study, specific symptoms and symptom distress levels were not predictive of partner-support levels or behaviors over time. This is not surprising because women with EDs successfully hide symptoms and partners report difficulties responding appropriately because of the secrecy (Arcelus et al., 2012). Lastly, partner behaviors were related to higher ED distress; emotional and physical distancing in conjunction with high BMI contributed to higher overall symptom distress. This supports research that intimate relationships affect symptom severity (Bussolotti et al., 2002), and it identifies specific unhelpful behaviors. In previous research, partners admit to feeling powerless and uncertain how to manage EDs and can resort to using conflict or avoidance (Huke & Slade, 2006). There are some limitations to this study. One quarter of participants reported difficulties with recall or understanding the EHC. To address these concerns, the measure could be offered in person to clarify questions, include more probing questions, or the measure could be created with more advanced software. This study utilized an online survey site with preexisting design options. Second, although the study suggests that a 3-month time frame is not a factor, shorter time periods (i.e., days, weeks) may illustrate more variability in symptom distress and partner support. Third, there may be confounding variables (e.g., dual diagnoses) that directly or indirectly mediate or moderate perceptions of partner support. Fourth, the measure focused on patient perspectives and did not gather corresponding partner data. Future studies could use ad-
vanced statistical techniques to examine the patient and partner’s influences on symptom severity, attachment, and intimacy. Lastly, there may be some limits to generalizability because of a predominant sample of unmarried, childless, cohabiting, heterosexual, Caucasian women, half of whom have BN and/or other mental health conditions. This study supports research indicating that partner interaction affects ED symptoms, and it illustrates partner-support variables that aggravate symptom severity. Overall, it may be useful for providers to include partners in treatment to address avoidance patterns and symptom distress. As our understanding of the dynamics between couple interactions and ED symptoms grows, interventionists will be well positioned to responsively provide care. References Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders. A metaanalysis of 36 studies. Archives of General Psychiatry, 68, 724 –731. http://dx.doi.org/10.1001/ archgenpsychiatry.2011.74 Arcelus, J., Yates, A., & Whiteley, R. (2012). Romantic relationships, clinical and sub-clinical eating disorders: A review of the literature. Sexual and Relationship Therapy, 27, 147–161. http://dx .doi.org/10.1080/14681994.2012.696095 Belli, R. F., James, S. A., Van Hoewyk, J., & Alcser, K. H. (2009). The implementation of a computerized event history calendar questionnaire for research in life course epidemiology. In R. F. Belli, F. P. Stafford, & D. F. Alwin (Eds.), Calendar and time diary methods in life course research (pp. 224 –238). Los Angeles, CA: Sage. http://dx.doi .org/10.4135/9781412990295.d19 Bussolotti, D., Fernández-Aranda, F., Solano, R., Jiménez-Murcia, S., Turón, V., & Vallejo, J. (2002). Marital status and eating disorders: An analysis of its relevance. Journal of Psychosomatic Research, 53, 1139 –1145. http://dx.doi.org/10.1016/S00223999(02)00336-7 Danford, C. A., & Martyn, K. K. (2013). Exploring eating and activity behaviors with parent-child dyads using event history calendars. Journal of Family Nursing, 19, 375–398. http://dx.doi.org/ 10.1177/1074840713491831 Dick, C. H., Renes, S. L., Morotti, A., & Strange, A. T. (2013). Understanding and assisting couples affected by an eating disorder. American Journal of Family Therapy, 41, 232–244. http://dx.doi.org/ 10.1080/01926187.2012.677728
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
EXPLORING PARTNER BEHAVIORS
Fichter, M. M., & Quadflieg, N. (2007). Long-term stability of eating disorder diagnoses. International Journal of Eating Disorders, 40, S61–S66. http://dx.doi.org/10.1002/eat.20443 Fischer, M. S., Baucom, D. H., Kirby, J. S., & Bulik, C. M. (2015). Partner distress in the context of adult anorexia nervosa: The role of patients’ perceived negative consequences of AN and partner behaviors. International Journal of Eating Disorders, 48, 67–71. http://dx.doi.org/10.1002/eat .22338 Huke, K., & Slade, P. (2006). An exploratory investigation of the experiences of partners living with
409
people who have bulimia nervosa. European Eating Disorders Review, 14, 436 – 447. http://dx.doi .org/10.1002/erv.744 Martyn, K. K., & Belli, R. F. (2002). Retrospective data collection using event history calendars. Nursing Research, 51, 270 –274. http://dx.doi.org/ 10.1097/00006199-200207000-00008
Received January 27, 2015 Revision received May 20, 2015 Accepted May 21, 2015 䡲
© 2015 American Psychological Association 1091-7527/15/$12.00 http://dx.doi.org/10.1037/fsh0000147
BRIEF REPORT
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Exploring the Association Between Partner Behaviors and Eating Disorder Symptomology Lisa Zak-Hunter, PhD
Lee N. Johnson, PhD
University of Georgia and Via Christi Family Medicine Residency, Wichita, Kansas
University of Georgia and Brigham Young University
Introduction: Research suggests an association between partner support and eating disorder (ED) symptomology in coupled women. However, no research describes whether time is a factor when examining routine partner behaviors that contribute to ED symptom severity. This study examined the relationship between supportive and unsupportive partner behaviors and ED symptom severity over a 3-month time period. Method: Fifty-eight women with anorexia nervosa (AN) and bulimia nervosa (BN) identified helpful and unhelpful partner behaviors and ranked relationship support and symptom severity for the past 3 months using an event history calendar. Regression analyses examined the relationship between symptom distress and partner-support variables over 3 months. Results: Higher levels of helpfulness and relationship quality positively predicted partner-support levels. Partner distancing was predictive of increases in symptom distress. Discussion: Emotional or physical distancing or neglect aggravates symptom severity, which highlights the importance of addressing couple relationships in treatment and research. Keywords: eating disorders, couples, symptomology, event history calendar
Eating disorders (EDs) have significantly high mortality rates, ranging from 1.93 in bulimia nervosa (BN) to 5.86 in anorexia nervosa (AN; Arcelus, Mitchell, Wales, & Nielsen, 2011), and partnered women tend to suffer from more severe symptomology (Bussolotti et al., 2002). Committed romantic relationships provide a distinct context for ED symptom manifestation, and there is growing understanding of these relationship chal-
This article was published Online First July 13, 2015. Lisa Zak-Hunter, PhD, Department of Human Development and Family Science, University of Georgia, and Via Christi Family Medicine Residency, Wichita, Kansas; Lee N. Johnson, PhD, Department of Human Development and Family Science, University of Georgia, and Department of Family Life, Brigham Young University. Lisa Zak-Hunter and Lee N. Johnson are no longer affiliated with University of Georgia. Correspondence concerning this article should be addressed to Lisa Zak-Hunter, PhD, Via Christi Family Medicine Residency, 1121 South Clifton, Wichita, KS 67218. E-mail: [email protected]
lenges (Arcelus, Yates, & Whiteley, 2012). Partnered women struggle with relationship concerns such as intimacy, physical and emotional closeness, sexuality, relationship conflict, and communication difficulties (Arcelus et al., 2012). Recent research examined specific supportive partner behaviors (such as acceptance/validation), and found that, in conjunction with patient motivation, these may facilitate working toward recovery (Fischer, Baucom, Kirby, & Bulik, 2015). One unexplored area is whether couple interaction changes with symptom severity. Follow-up studies on the course of EDs generally follow patients on an annual or biannual basis for several years. These indicate that recovery can take years, marked with periods of relapse, and sometimes crossover into different EDs (Fichter & Quadflieg, 2007). It is reasonable to assume partner behaviors may vary over time with these fluctuations. However, no studies have addressed this topic. To address these concerns, this study uses event history calendar
405
406
ZAK-HUNTER AND JOHNSON
(EHC) methodology to examine certain variables over 3 months: (a) whether ED thoughts and behaviors affect overall symptom distress and partner support and (b) whether helpful and unhelpful partner behaviors affect overall symptom distress and partner support.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Method Participants Sample criteria included (a) being female; (b) being age 18 years or older; (c) being clinically diagnosed with AN or BN; (d) being in a committed romantic relationship; and (e) having no Diagnostic and Statistical Manual of Mental Disorders (fourth edition; DSM–IV) Axis II disorders, per self-report. See Table 1 for demographic information. Materials and Procedure Participants were recruited via purposive sampling. Flyers with a link to the website and
Table 1 Mean Scores of Demographic and ED Variables Variable
M (SD) (%n ⫽ 58)
Demographics Participant age Partner age Length of relationship (years) Not married Cohabiting No children College degree Employed part-time Income ⬍$40,000 Caucasian
27.28 (8.0) 31.75 (10.58) 4.40 (5.16) 60.30% 70.70% 81.80% 65.90% 71.20% 51.2% 90.90%
Eating disorder Current diagnosis–BN First diagnosis–AN BMI–AN BMI–BN Other psychological diagnoses In treatment Outpatient treatment Individual treatment Length of current diagnosis (years)
55.20% 43.20% 19.52 (4.12)a 22.48 (4.39)a 55.80% 67.20% 70.40% 62.50% 8.78 (9.61)
Note. Although sexual orientation was not measured, one participant disclosed she was a lesbian. a Determined from self-reported most recent weight (if known) and height. Normal BMI range is 18.5–24.9 kg/m2.
principal investigator contact information were placed in national and local ED treatment centers/ED specialist offices, university campuses, and ED or mental illness awareness social networking websites. Participants followed the link to an introduction, informed consent, calendar survey, and demographics form. They were given information about the purpose of calendar studies, instructions, and an example of how to fill out the calendar. They could enter a drawing for a $25 gift card. This study was approved by the Institutional Review Board at the University of Georgia. A self-administered online EHC (Belli, James, Van Hoewyk, & Alcser, 2009) was used to gather information about patients’ experiences of their ED and intimate relationship. EHCs have been used to research eating behaviors and family dynamics (Danford & Martyn, 2013), thus making them an ideal methodology for studying EDs within intimate relationships. EHC methods are also reliable for collecting retrospective data (Martyn & Belli, 2002). The EHC is a calendar grid wherein the columns represent time units (e.g., months) and the rows gather information regarding research-specific domains (e.g., ED symptoms). The first domains are the easiest to recall, the least threatening, and will cue memory recall of the remaining domains (e.g., age, relationship history, employment status, special events). EHCs are considered to be optimal for memory retrieval because of their ability to cue multiple mechanisms found in autobiographical memory. In this EHC, participants reported data for the past 3 months, starting with the most recent month. A 3-month time period was chosen for two reasons: (a) 1 year or longer may have been challenging for monthly memory recall and caused higher attrition and (b) to explore whether fluctuations occur on a smaller scale than is normally reported in ED literature. For each month, they first recorded the following domains: length of current relationship, cohabitation status, relationship status, employment status, and important life events and occurrences. This was followed by treatment-related domains: treatment type (inpatient, outpatient, residential, hospitalization) and treatment format (individual, couple, family, group). They then reported most and least frequent symptoms, including average monthly symptom severity (1–10; 10 ⫽ most distressing); weight (if
EXPLORING PARTNER BEHAVIORS
known); helpful and unhelpful partner behaviors; and average helpfulness of partner behaviors (1–10, 10 ⫽ most helpful), partner support, and relationship quality. They reported on all 3 months at once.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Statistical Analyses Symptoms and behaviors were coded on two dimensions; each dimension was broken into different codes. Symptoms included ED thoughts (five codes) and ED behaviors (four codes). Partner behaviors were coded on two dimensions: helpful behaviors and unhelpful behaviors. Each dimension was broken down into different five codes. Research questions were analyzed using multiple regression analyses in Mplus version 7, and missing data were deleted listwise. Results Of the 204 participants who visited the survey link, 58 completed the survey (response rate 28.4%). Of the 58 participants, 16 did not complete the demographic questionnaire at the end. An independent sample t test, t(55) ⫽ ⫺2.24, p ⬍ .05, indicated that those who filled out the calendar and demographics (n ⫽ 44; M ⫽ 5.59, SD ⫽ 2.99) experienced less overall partner support than those who did not complete the demographics (n ⫽ 14; M ⫽ 7.69, SD ⫽ 2.93). The most frequent ED thoughts were related to body image (12.3%; “feeling fat”) and the most frequent behavior was purging (24.6%). Providing emotional support (28.8%; “support me even though I started slipping”) and communication (24.4%; “talked to me”) were the most common helpful behaviors. The most common unhelpful behaviors were creating conflict (33.8%; “questioned and criticized”) and pulling away (27.5%; “seemed uninterested in me”). Results revealed that symptom type was not predictive of changes in symptom distress over 3 months. Symptom distress levels had no effect on level of partner support over 3 months. Lastly, no specific symptoms predicted partner support levels over 3 months (see Table 2). Two results were statistically significant. Increased levels of helpfulness of behaviors
407
Table 2 Research Question Results Independent variables
Est
SE
Variables predicting overall partner support Control variables Time ⫺0.33 0.18 Relationship quality 0.62 0.07 Helpfulness of behaviors 0.41 0.07 Unhelpfulness of behaviors ⫺0.01 0.07 Helpful behaviors Encouragement/support 0.06 0.61 Communicate 0.38 0.63 Physical affection/comfort 0.09 0.79 Directly attending to eating 0.01 0.72 Disorder symptoms Unhelpful behaviors Pull away 0.77 0.74 Create conflict ⫺0.26 0.75 Guilt 0.88 1.30 Focus on food ⫺0.21 0.76 Variables predicting overall symptom distress Control variables Time 0.13 0.20 BMI 0.15 0.04 Helpful behaviors Encouragement/support 0.81 0.56 Communicate ⫺0.39 0.49 Physical affection/comfort ⫺0.19 0.736 Directly attending to eating ⫺0.30 0.61 Disorder symptoms Unhelpful behaviors Pull away ⫺1.54 0.53 Create conflict ⫺0.70 0.56 Guilt ⫺0.55 1.31 Focus on food 0.60 0.55 ⴱ
z
⫺1.79 8.52ⴱ 5.50ⴱ ⫺0.10 0.09 0.60 0.12 0.02
1.04 ⫺0.35 0.68 ⫺0.28
0.06 3.58ⴱ 1.45 ⫺0.81 ⫺0.26 ⫺0.50 ⫺2.88ⴱ ⫺1.24 ⫺0.42 1.10
p ⬍ .01.
and relationship quality significantly predicted increased partner-support levels, with the model accounting for 62.2% of variance, p⬍.05. Second, body mass index (BMI) was included as a control variable when examining which helpful and unhelpful behaviors predict symptom distress levels over 3 months. Overall, the model was significant and accounted for 31% of variance in symptom distress, p ⬍ .05. Increased BMI and the unhelpful behavior of pulling away were predictive of increased symptom distress, but not over 3 months (see Table 2). Discussion This study explored how partner support and ED symptomology varied over 3 months.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
408
ZAK-HUNTER AND JOHNSON
Specifically, we examined the interplay among routine helpful and unhelpful partner behaviors, symptoms, and levels of partner support and symptom distress. Greater helpfulness of behaviors and higher relationship quality were indicative of higher partner support. This provides support to the idea that couple relationship functioning is important in the management of ED symptoms (Dick, Renes, Morotti, & Strange, 2013). Specific behaviors may not be as important as how satisfied the woman is with her relationship and partner help. This is somewhat in contrast to the findings of Fischer and colleagues (2015) that partner acceptance/validation is helpful. In our study, specific symptoms and symptom distress levels were not predictive of partner-support levels or behaviors over time. This is not surprising because women with EDs successfully hide symptoms and partners report difficulties responding appropriately because of the secrecy (Arcelus et al., 2012). Lastly, partner behaviors were related to higher ED distress; emotional and physical distancing in conjunction with high BMI contributed to higher overall symptom distress. This supports research that intimate relationships affect symptom severity (Bussolotti et al., 2002), and it identifies specific unhelpful behaviors. In previous research, partners admit to feeling powerless and uncertain how to manage EDs and can resort to using conflict or avoidance (Huke & Slade, 2006). There are some limitations to this study. One quarter of participants reported difficulties with recall or understanding the EHC. To address these concerns, the measure could be offered in person to clarify questions, include more probing questions, or the measure could be created with more advanced software. This study utilized an online survey site with preexisting design options. Second, although the study suggests that a 3-month time frame is not a factor, shorter time periods (i.e., days, weeks) may illustrate more variability in symptom distress and partner support. Third, there may be confounding variables (e.g., dual diagnoses) that directly or indirectly mediate or moderate perceptions of partner support. Fourth, the measure focused on patient perspectives and did not gather corresponding partner data. Future studies could use ad-
vanced statistical techniques to examine the patient and partner’s influences on symptom severity, attachment, and intimacy. Lastly, there may be some limits to generalizability because of a predominant sample of unmarried, childless, cohabiting, heterosexual, Caucasian women, half of whom have BN and/or other mental health conditions. This study supports research indicating that partner interaction affects ED symptoms, and it illustrates partner-support variables that aggravate symptom severity. Overall, it may be useful for providers to include partners in treatment to address avoidance patterns and symptom distress. As our understanding of the dynamics between couple interactions and ED symptoms grows, interventionists will be well positioned to responsively provide care. References Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders. A metaanalysis of 36 studies. Archives of General Psychiatry, 68, 724 –731. http://dx.doi.org/10.1001/ archgenpsychiatry.2011.74 Arcelus, J., Yates, A., & Whiteley, R. (2012). Romantic relationships, clinical and sub-clinical eating disorders: A review of the literature. Sexual and Relationship Therapy, 27, 147–161. http://dx .doi.org/10.1080/14681994.2012.696095 Belli, R. F., James, S. A., Van Hoewyk, J., & Alcser, K. H. (2009). The implementation of a computerized event history calendar questionnaire for research in life course epidemiology. In R. F. Belli, F. P. Stafford, & D. F. Alwin (Eds.), Calendar and time diary methods in life course research (pp. 224 –238). Los Angeles, CA: Sage. http://dx.doi .org/10.4135/9781412990295.d19 Bussolotti, D., Fernández-Aranda, F., Solano, R., Jiménez-Murcia, S., Turón, V., & Vallejo, J. (2002). Marital status and eating disorders: An analysis of its relevance. Journal of Psychosomatic Research, 53, 1139 –1145. http://dx.doi.org/10.1016/S00223999(02)00336-7 Danford, C. A., & Martyn, K. K. (2013). Exploring eating and activity behaviors with parent-child dyads using event history calendars. Journal of Family Nursing, 19, 375–398. http://dx.doi.org/ 10.1177/1074840713491831 Dick, C. H., Renes, S. L., Morotti, A., & Strange, A. T. (2013). Understanding and assisting couples affected by an eating disorder. American Journal of Family Therapy, 41, 232–244. http://dx.doi.org/ 10.1080/01926187.2012.677728
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
EXPLORING PARTNER BEHAVIORS
Fichter, M. M., & Quadflieg, N. (2007). Long-term stability of eating disorder diagnoses. International Journal of Eating Disorders, 40, S61–S66. http://dx.doi.org/10.1002/eat.20443 Fischer, M. S., Baucom, D. H., Kirby, J. S., & Bulik, C. M. (2015). Partner distress in the context of adult anorexia nervosa: The role of patients’ perceived negative consequences of AN and partner behaviors. International Journal of Eating Disorders, 48, 67–71. http://dx.doi.org/10.1002/eat .22338 Huke, K., & Slade, P. (2006). An exploratory investigation of the experiences of partners living with
409
people who have bulimia nervosa. European Eating Disorders Review, 14, 436 – 447. http://dx.doi .org/10.1002/erv.744 Martyn, K. K., & Belli, R. F. (2002). Retrospective data collection using event history calendars. Nursing Research, 51, 270 –274. http://dx.doi.org/ 10.1097/00006199-200207000-00008
Received January 27, 2015 Revision received May 20, 2015 Accepted May 21, 2015 䡲
