The main objective of the present study was to analyse the role of the ego-dystonicity and ego-syntonicity of eating disorder intrusive thoughts (EDITs) in the genesis and maintenance of eating disorders (EDs). Participants were 98 female patients with EDs, 56 Spanish and 42 English (27.19±9.59 years; body mass index (BMI): 18.72±2.87). All of them completed the eating attitudes test, the Eating Attitudes Test, the Eating Intrusive Thoughts Inventory, the Ego-Dystonicity Questionnaire-Reduced version, and the Ego-Syntonicity Questionnaire. Patients indicated that their EDITs were rational and also undesirable and immoral, suggesting that EDITs are not fully ego-syntonic or ego-dystonic. Multivariate analysis of variance (MANOVA) indicated no differences in ego-syntonicity and ego-dystonicity across ED subtypes. Path analyses were performed to investigate the mediating role of the EDITs’ ego-syntonicity and ego-dystonicity in their interference, dysfunctional appraisals and control strategies. They showed, first, that the more interference an EDIT caused, the more ego-syntonic and the less ego-dystonic it was and, second, that when the EDITs were assessed as ego-syntonic, patients tried to do what they indicated, whereas when they were assessed as ego-dystonic, patients made efforts to neutralise them. Clinical implications for the conceptualisation and treatment of ED are discussed.
One of the most intriguing characteristics of many individuals with eating disorders (EDs), especially those suffering from anorexia nervosa (AN), is the positive value they attach to their efforts to maintain symptoms such as their underweight and thinness under control (Vitousek et al., 1998). This is even true when they experience bothersome symptoms such as dizziness, hunger or concentration difficulties, since these symptoms are interpreted as a positive sign of control over their desired weight and thinness. This vicious cycle is considered a key point in the maintenance of EDs (Fairburn et al., 1999 and Schmidt and Treasure, 2006) and it reveals a dysfunctional identification of patients with their disorder. For Bulik and Kendler (2000, p. 1757), a chronic ED patient’s assertion that “a life without an eating disorder would be a life without an identity” exemplifies this dysfunctional identification. The ego-syntonicity of many ED patients with their symptoms makes them ambivalent and reluctant to undergo treatment (e.g., Vandereycken, 2006). In the context of self-determination theory, Mansour et al. (2012) demonstrate that, in bulimic patients, lower post-treatment scores on measures of eating preoccupations (shape, weight and eating concerns) were predicted by high autonomous motivation at pre-treatment. These results indicate the importance of increasing efforts to enhance motivation for treatment (Treasure and Schmidt, 2001 and Vitousek et al., 1998) and relapse prevention.
Nonetheless, some other ED symptoms are experienced as quite unpleasant and far from ego-syntonic, motivating the search for treatment (Garfinkel and Garner, 1982). The unwanted and repetitive intrusive thoughts, images and/or impulses about eating-related contents, or eating disorder intrusive thoughts (EDITs), frequently experienced by the vast majority of ED patients, are examples of symptoms that patients could value as negative. The intrusive nature and high frequency of the EDITs make them unpleasant, and patients can feel overwhelmed by their inability to keep them under control and by their interference in their daily activities (Fairburn, 2008 and Woolrich et al., 2008). In addition, EDITs fit the characterisation of an ego-dystonic thought formulated by Purdon et al. (2007, p. 200) as “one that is perceived as having little or no context within one’s own sense of self or personality. That is, the thought is perceived, at least initially, as occurring outside the context of one’s morals, attitudes, beliefs, preferences, past behaviour and/or one’s expectations about the kinds of thoughts one would or should experience.”
However, EDITs might also be ego-syntonic if ED patients interpret them as a motivating reminder of their valued goal, such as achieving a thin figure. Shafran et al. (2003) point out that the way patients interpret their symptoms determines how positively or negatively they value them. For example, feeling cold might be valued as positive because it can be interpreted as direct evidence of their control over their weight or thinness. The dual nature of some ED symptoms, ego-dystonic and also ego-syntonic, suggests that ego-dystonicity and ego-syntonicity are not the opposite ends of one unique dimension. Belloch et al. (2012), using a revised version of the Ego-Dystonicity Questionnaire from Purdon et al. (2007), found that, although related, ego-dystonicity and ego-syntonicity are best conceived as two separate dimensions in the case of both EDITs and unwanted intrusive thoughts with contents analogous to clinical obsessions.
In sum, ED symptoms may not always be considered ego-syntonic by ED patients. In the Yale–Brown–Cornell Eating Disorder Scale, Mazure et al. (1994) included two additional items that evaluated the ego-syntonicity/ego-dystonicity (consistency/inconsistency with their personality) of preoccupations and rituals. In a study of 40 women with an ED diagnosis, these authors found that more than half rated their eating-related preoccupations (28 women) and rituals (25 women) as ego-syntonic, whereas 10 women rated their preoccupations as ego-dystonic and 6 others rated their rituals in this way. Similar results were also found in recovered ED patients and restrained-eating control subjects (Sunday and Halmi, 2000).
The objective of this study is to examine in a group of women with ED to what extent the EDITs they experience are ego-dystonic or ego-syntonic, taking into account the subtype of the disorder. In addition, the mediating role of the ego-dystonicity and ego-syntonicity associated with the EDITs will be investigated with regard to the interference caused by the EDIT, the dysfunctional appraisals that this thought raises and the strategies used by the subjects to keep the thought under control.
